STEPHEN C. LAPANTA, Employee/Appellant, v. MYRON=S CARDS & GIFTS, INC., and CNA INS. CO., Employer-Insurer, and MYRON=S CARDS & GIFTS, INC., and PHARMACISTS MUT. INS. CO., adm=d by DOUGLAS CLAIMS SERVS., Employer-Insurer.
WORKERS= COMPENSATION COURT OF APPEALS
OCTOBER 14, 2005
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence supports the compensation judge=s finding that the employee=s work-related injuries did not substantially contribute to his current condition, claimed disability, and need for right knee surgery, but that his condition, claimed disability and need for surgery were causally related to his significant preexisting degenerative arthritis of the right knee.
Determined by: Rykken, J., Johnson, C.J., and Stofferahn, J.
Compensation Judge: Paul D. Vallant
Attorneys: David R. Vail, Soderberg & Vail, Minneapolis, MN, for the Appellant. Philip C. Warner, Law Office of Joseph M. Stocco, Edina, MN, for Respondents Myron=s Cards, and CNA. Mark A. Wagner and Steven E. Sullivan, Johnson & Condon, Minneapolis, MN, for Respondents Myron=s Cards and Pharmacists Mutual.
MIRIAM P. RYKKEN, Judge
The employee appeals the compensation judge=s finding that his work-related injuries did not substantially contribute to his current condition, claimed disability and need for right knee surgery, but that the employee=s condition, claimed disability and need for surgery were causally related to his significant preexisting degenerative arthritis of the right knee. We affirm.
Stephen LaPanta, the employee, sustained two admitted work injuries to his right knee while working for Myron=s Cards & Gifts, Inc., the employer. The first right knee injury occurred on June 26, 1990, while the employer was insured by CNA Insurance Company. On that date, as he checked a load of fixtures in the back of a truck, a wooden display fixture fell down onto his right knee. The employee testified that his knee "hyperextended" and felt as if it were forced the wrong way and as if something tore in the knee. He initially consulted his family physician, Dr. Cyril Kapsner, who prescribed ibuprofen and advised the employee to apply ice and to rest his knee as much as possible. Because his pain did not subside, the employee consulted an orthopedist, Dr. Lewis Gramer, who recommended a support brace as well as an MRI scan.
An August 6, 1990, MRI scan of the employee=s right knee showed the following: (1) a large right knee joint effusion; (2) no evidence for ligament derangement; (3) myxoid degeneration suspected involving the medial and lateral menisci, without demonstration of articular surface tear; and (4) mild chondromalacia suspected involving the articular cartilage of the medial femoral condyle with marked degenerative changes involving cartilage of the patellofemoral joint. Dr. Gramer initially recommended conservative treatment, but later considered arthroscopic debridement of the right knee due to the employee=s report of continued pain and tenderness in the right knee. Prior to surgery, Dr. Gramer diagnosed a Aprobable degenerated medical meniscus.@ On February 12, 1991, he performed a right knee arthroscopy in the nature of a chondroplasty of the medial femoral condyle. Post-operatively, Dr. Gramer diagnosed chondromalacia of the medial femoral condyle.
The employee later consulted Dr. Jack Bert, due to his continued pain and swelling in his right knee, which he especially noticed after he "spent the day on the floor in the stores or doing anything strenuous." He reported to Dr. Bert that he felt aching pain with ambulation, walking more than one-half block, climbing or descending stairs, climbing, crawling and kneeling. Dr. Bert recommended anti-inflammatory medication and possible steroid injections, and an upper tibial osteotomy if needed. By September 1993, Dr. Bert diagnosed bilateral early medial gonarthrosis. Dr. Bert opined that the employee had reached maximum medical improvement (MMI) from his right knee injury by November 1, 1993; the employer and insurer served notice of MMI, along with Dr. Bert's report, on the employee on March 9, 1994. In April 1994, based upon ratings assigned by Dr. Bert, CNA Insurance paid permanency benefits to the employee, based on one percent permanent partial disability of the body as a whole, under Minn. R. 5223.0170, subp. 5B(12), for the procedure of patellar shaving, and two percent under Minn. R. 5223.0170, subp. 5B(2), for a partial meniscectomy.
The employee testified that his right knee symptoms never completely resolved after his 1990 work injury. On November 13, 2001, the employee sustained another right knee work injury while the employer was insured by Pharmacists Mutual Insurance Company. As he reached into a van through the side doors, his knees were situated against the bed rail of the van. The employee testified that as he tried to lift some heavy metal framework for a card display, he lifted and "put pressure on [his] knees and the right knee just collapsed," causing him to fall into the van. The employee noted pain in the same area of his right knee where he earlier felt pain, although he admitted that this pain was more severe than he had earlier experienced. The employee was transported by ambulance to the emergency room at United Hospital where the attending physician diagnosed torn cartilage. A November 13, 2001, MRI indicated the following: (1) a tear of the posterior horn of the medial meniscus; (2) degenerative changes of the medial compartment; (3) mild to moderate generalized thinning of the retropatella cartilage over the median eminence and medial facet; (4) mild knee joint effusion; and (5) small osteochondral loose body within the supra patellar recess medially.
On November 16, 2001, Dr. Bert performed arthroscopic surgery to repair the employee=s right knee. In late November, following post-surgery recovery, the employee returned to work for the employer. By December 11, 2001, Dr. Bert released the employee to work without restrictions. On April 2, 2002, as more fully explained below, Dr. Bert performed surgery on the employee=s left knee. The employee continued to consult Dr. Bert for both knees. In November 2002, Dr. Bert prescribed a course of Synvisc injections for both knees; the employee underwent at least three of those injections into both knees.
In a letter dated April 15, 2003, Dr. Bert advised that the employee had reached maximum medical improvement with respect to his right knee injury, and assigned a rating of four percent permanent partial disability to the body as a whole, pursuant to Minn. R. 5223.0510, subp. 3B(3), for a meniscectomy of the right knee. On April 29, 2003, the employer and Pharmacists Mutual served notice of MMI on the employee. Pharmacists Mutual paid permanency benefits to the employee based upon Dr. Bert=s rating.
The employee also has undergone significant medical treatment for his left knee and right hip. He has undergone two surgeries to his left knee and also a right hip arthroplasty, none of which were related to his work injuries; his medical records refer to the employee=s medical treatment for osteoarthritis in his left knee and right hip, and contain similar findings in the employee=s left knee as were observed in his right knee. On January 27, 1994, Dr. Bert performed arthroscopic surgery on the employee=s left knee with debridement and partial medial meniscectomy for degenerative posterior horn tear medial meniscus with degenerative arthritis medial compartment left knee. On May 28, 1996, Dr. Bert performed a right total hip arthroplasty on the employee for coxarthrosis, which is defined as Adegenerative joint disease or osteoarthritis of the hip joint.@ On April 2, 2002, the employee underwent a left cemented unicompartmental replacement on his left knee for left medial gonarthrosis. By May 2003, Dr. Bert concluded that the employee would need a revision of his unicompartmental replacement on his left knee; he also advised that the employee eventually would need a right total knee replacement.
On October 29, 2003, the employee=s employment with Myron=s Cards & Gifts was terminated due to reasons unrelated to his work injury, and he began working as a realtor in December 2003. Dr. Bert reexamined the employee on April 29, 2004, when he reported pain in his left knee. Dr. Bert recommended physical therapy and anti-inflammatory medication, and concluded that the employee may need a total left knee revision. He also again diagnosed severe right medial gonarthrosis. Dr. Bert reiterated that recommendation in his chart note dated November 11, 2004.
On May 10, 2004, the employee filed a claim petition against both insurers, seeking payment of medical expenses, rehabilitation benefits, and temporary disability benefits relative to his right knee injuries. On August 25, 2004, the employee was evaluated by Dr. Thomas J. Raih at the employer and Pharmacist Mutual=s request. Dr. Raih opined that the employee=s work injuries were temporary aggravations of the employee=s preexisting degenerative right knee condition, that the employee had reached maximum medical improvement for those injuries, and that they did not substantially contribute to the employee=s current impairment. He concluded that although the employee remains subject to restrictions related to his right knee, those limitations are related to his underlying osteoarthritis and not to his work injuries. Dr. Raih also concluded that any disability the employee experienced after six to eight weeks following his November 2001 surgery was unrelated to his work injuries. Dr. Raih based his opinion, in part, on the employee=s radiographic studies that showed significant degenerative osteoarthritis that preexisted the employee=s 1990 injury and his 2001 meniscal injury.
On October 21, 2004, the employee was evaluated by Dr. Joel L. Boyd at the employer and CNA Insurance=s request. Dr. Boyd concluded that the employee sustained a right knee contusion on June 26, 1990, but had reached MMI from that injury within six weeks of that injury. He also concluded that the employee=s November 13, 2001, injury resulted in an aggravation of his underlying degenerative right knee osteoarthritis, but that he had reached MMI from that injury within eight weeks following his arthroscopic surgery performed on November 16, 2001. Dr. Boyd expressed his opinion that the employee=s 1990 and 2001 injuries did not substantially contribute to the employee=s disability after October 29, 2003, that those injuries bore no relationship to his ongoing need for restrictions, and that, instead, those restrictions were related to the employee=s underlying degenerative bilateral knee osteoarthritis.
In a letter dated November 8, 2004, Dr. Bert stated that, in his opinion, the employee=s ongoing right knee condition was work-related, noting that the employee was asymptomatic before June 1990, and that his June 1990 and November 13, 2001, work injuries represented substantial contributing factors to his right knee condition. In his chart note of November 11, 2004, Dr. Bert recommended that the employee undergo a total knee arthroplasty on the right and a revision total knee arthroplasty on the left.
A hearing was held at the Office of Administrative Hearings on January 7, 2005. At the time of the hearing, the employee claimed entitlement to payment of medical expenses, rehabilitation benefits, temporary total disability benefits from October 29 to December 1, 2003, and temporary partial disability benefits on an ongoing basis after December 1, 2003. The compensation judge found that the employee=s work injuries were temporary aggravations of the employee=s significant preexisting degenerative arthritis of his right knee and did not substantially aggravate, exacerbate or accelerate that preexisting condition. The compensation judge also found that although the employee has work restrictions of lifting, bending, stooping, squatting, and use of ladders, those restrictions were necessitated by the employee=s underlying degenerative osteoarthritis of both knees and right hip, and were not causally related to the employee=s work injuries. Based on these findings, the compensation judge denied the employee=s claim for benefits. The employee appealed from the compensation judge=s findings that his 1990 and 2001 work injuries no longer represented substantial contributing causes of the employee=s current right knee condition, claimed disability and need for medical treatment to the right knee.
STANDARD OF REVIEW
On appeal, the Workers' Compensation Court of Appeals must determine whether "the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted." Minn. Stat. ' 176.421, subd. 1. Substantial evidence supports the findings if, in the context of the entire record, "they are supported by evidence that a reasonable mind might accept as adequate." Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, "unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
The employee argues that substantial evidence does not support the compensation judge=s decision. The compensation judge accepted Dr. Raih=s opinion that the employee=s work injuries do not substantially contribute to the employee=s current impairment. Dr. Raih noted that the employee=s right knee MRI scan taken six weeks after the June 27, 1990, work injury indicated suspected myxoid degenerative changes of the medial and lateral meniscus and significant marked degenerative changes in the medial femoral condyle and patellofemoral joint and opined that these degenerative changes were severe and therefore preexisted the June 1990 injury. In addition, after the November 13, 2001, injury, another MRI scan of the right knee indicated a medial meniscus tear but also significant degenerative changes in the medial compartment and the retropatellar cartilage which preexisted the right meniscal injury. Dr. Raih also noted that the employee has already undergone a total joint arthroplasty of his right hip and a unicompartmental arthroplasty of his left knee, and expressed his opinion that the employee has obvious preexisting underlying degenerative osteoarthritis. Dr. Raih concluded that the employee was a candidate for right total knee replacement arthroplasty, but that the need for the total knee replacement was precipitated by his preexisting underlying degenerative osteoarthritis, and not by his 1990 or 2001 work injury. Dr. Raih did not apportion any liability to the employee=s work injuries, stating that those injuries primarily involved meniscus issues that were treated appropriately with surgery, were assessed for permanent partial disability, and from which the employee had reached maximum medical improvement. Dr. Raih agreed that the employee remained subject to work restrictions, but that these restrictions were due to the employee=s underlying osteoarthritis, not his work injuries.
The compensation judge accepted Dr. Raih=s opinion that the employee=s work injuries do not substantially contribute to the employee=s current impairment. It is the compensation judge's responsibility, as trier of fact, to resolve conflicts in expert testimony, see Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985). The compensation judge noted that the employee had been assessed permanent partial disability ratings specifically for his right knee surgeries performed after the work injuries, but concluded that these ratings alone did not establish that the employee=s current impairment was the result of those work injuries. The compensation judge found that the employee=s work injuries were temporary aggravations of the employee=s significant preexisting degenerative arthritis of the right knee and did not substantially aggravate, exacerbate, or accelerate his preexisting right knee condition.
The employee argues that his work injuries cannot be considered to be Atemporary@ aggravations since they resulted in permanent partial disability. The determinative issue before the compensation judge was not whether the injuries were Atemporary@ or Apermanent@ in nature. The issue was whether the employee=s work-related right knee injuries represent substantial contributing factors in the employee=s current condition, claimed disability and need for additional medical treatment to the right knee. Dr. Raih noted that the employee=s work injuries primarily involved meniscus issues of the right knee. The surgeries required for these injuries related to those meniscus issues, and the permanent partial disability ratings that the employee was assessed were based upon those surgeries. Dr. Raih also noted that the employee had already required surgery for arthritis-related conditions on his left knee and his right hip. In addition, the employee=s MRI scans after his work injuries indicated preexisting degenerative changes in the right knee. Dr. Raih concluded that the employee=s current disability and need for treatment for his right knee were caused by his arthritic condition, not his work injuries. Based on the evidence in the record, the compensation judge could reasonably conclude that the employee=s work injuries were not a substantially contributing cause of the employee=s claimed disability through the date of the hearing, nor did they substantially contribute to his need for additional treatment for his right knee osteoarthritis condition. Accordingly, we affirm.
 Gonarthrosis is defined as an Aarthritic affection of the knee joint, due to degeneration or trauma.@ See Dorland=s Illustrated Medical Dictionary, 763 (29th Ed., 2000).
 Synvisc (hylan G-F 20) is a fluid administered by intra-articular injection, typically once a week for a total of three injections, and Ais indicated for treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, e.g., acetaminophen.@ See Physicians= Desk Reference, 3404 (55th Ed., 2005).
 See Dorland=s Illustrated Medical Dictionary, 415 (29th Ed., 2000).