SHAROLYN MORRISON, Employee/Appellant, v. HORMEL FOODS CORP., SELF-INSURED/REM, Employer, and DOWNTOWN ORTHOPEDICS, BOLLINGBERG CHIROPRACTIC, BLUE CROSS & BLUE SHIELD OF MINN., SPORTS & ORTHOPAEDICS SPECIALISTS, P.A., and HORMEL FOODS CORP., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
JULY 31, 2006
PRACTICE & PROCEDURE - ADEQUACY OF FINDINGS; CAUSATION - GILLETTE INJURY. Where the medical record was notably complex, where the judge clearly referenced specific elements of the expert testimony on which she relied in finding no medical causation, where absent medical causation there was no reason for the judge to have cited or applied any law regarding consequential injury, and where there was no reason to presume that the judge had erroneously applied the overruled Reese standard of proof for Gillette-type injuries, there was no basis for remanding the case to the compensation judge for fuller findings or application of other law.
CAUSATION - SUBSTANTIAL EVIDENCE; EVIDENCE - EXPERT MEDICAL OPINION. Where the expert on whose opinion the judge relied was board certified, had examined the employee on two separate occasions, and at each examination had obtained a history from the employee, had reviewed the relevant medical records, and had performed a physical examination, the expert medical opinion on which the compensation judge relied was not without proper foundation and the judge=s decision based on that opinion was not clearly erroneous and unsupported by substantial evidence, notwithstanding the fact that the opinion may not have been elicited in response to a hypothetical question.
Determined by: Pederson, J., Johnson, C.J., and Rykken, J.
Compensation Judge: Nancy Olson
Attorneys: Mark Fellman, St. Paul, MN, for the Appellant. Dean K. Adams, Adams, Rizzi & Sween, Austin, MN, for the Respondent.
WILLIAM R. PEDERSON, Judge
The employee appeals from the compensation judge=s determination that the employee did not sustain a work-related injury to her cervical or thoracic spine and from the judge=s corresponding denial of all claimed benefits. We affirm.
On November 2, 1993, Sharolyn Morrison [the employee] sustained an injury to her right hand and wrist while working for Hormel Foods Corporation [the employer]. The employee, who was thirty-eight years old at the time, caught her right hand in a Askinning machine@ and suffered a Adegloving@ or avulsion skin injury. She was taken to the hospital emergency room and then transferred immediately to the Mayo Clinic, where a skin grafting procedure was performed by hand surgeon Dr. R. A. Berger. Postoperatively, the employee underwent fairly extensive physical therapy at the employer=s medical facility to regain strength and motion in her hand and wrist.
The employee evidently returned to work in a light duty capacity on December 27, 1993, at a largely left hand job. The employee=s right wrist remained painful, however, and on September 19, 1995, she underwent a vascularized bone graft of the right lunate bone.
Following her second surgery, the employee was again released to light duty and returned to the employer=s medical facility for therapy. The employee continued to complain of right wrist pain while attempting to perform her light duty jobs with the employer. At a March 21, 1996, therapy visit, the employee complained also of neck and Aright upper quarter@ symptoms. In a visit the following week, therapist Mike Gosha noted that the employee had been experiencing Aprogressive not dysfunctional pain over the right lower cervical area into the upper trapezius and parascapular areas.@ He felt that her symptoms were more than likely Acompensatory due to peripheral dysfunction secondary to limited right wrist range of motion.@ The employee=s therapy led to some improvement in the employee=s shoulder and neck but not in her wrist.
In January 1997, the employee was seen by Dr. Mark Hecimovich at Austin Chiropractic regarding complaints of neck and right parascapular pain and stiffness Athat has been bothering her for the past year and a half.@ Dr. Hecimovich commented that, A[d]ue to the [employee=s] wrist/hand disability [the employee] seems to be overcompensating by using her right shoulder/periscapular [sic] region more than usual.@ Dr. Hecimovich diagnosed Acervical/thoracic/periscapular [sic] myofacitis with possible right shoulder tendonitis.@ The employee was evidently given treatment for about one month.
On February 12, 1997, the employee returned to see Dr. Berger at the Mayo Clinic for problems related to her right upper extremity. She reported that her symptoms were exacerbated by cold exposure and by her tasks at work. Dr. Berger issued absolute restrictions against use of her right upper extremity and against exposure to inside temperatures lower than sixty-eight degrees. He also requested that the employee undergo a functional capacity evaluation [FCE].
The employee underwent the FCE on April 24 and 25, 1997. Her job at that time required the employee to visually inspect bacon slices and to remove slices that did not meet quality standards, and the evaluator concluded that, given its requirement of repetitive movements, the job was not physically appropriate for the employee. He recommended that the employee limit repetitive movement of her right hand and that she frequently stretch her upper back and shoulder region, because she had Asignificant compensation of use of shoulder and upper back to compensate for right upper extremity limitations.@
The employee continued to be seen at the employer=s medical facility for her right upper extremity complaints as well as for her upper back and neck pain. On September 3, 1997, she returned to the Mayo Clinic and was seen by physiatrist Dr. K.A. Bengston. The employee reported to Dr. Bengston that she was working on the Spam processing line where she lifts nine- to eighteen-pound boxes of Spam and tries to do this with only her left hand. Dr. Bengston noted changes in the employee=s most recent right wrist MRI and referred her back to Dr. Berger. Tomograms of the employee=s right wrist showed collapse and fragmentation of the central aspect of the lunate, and Dr. Berger recommended a wrist fusion, which was performed on October 28, 1997.
In November 1997, the employee met with qualified rehabilitation consultant [QRC] Nancy Johnson for a rehabilitation consultation. The QRC found the employee eligible for rehabilitation services and assisted the employee in returning to restricted duty work in January 1998. About four months later, the employee began working on a depalletizing line. Although it evidently aggravated her shoulders, she worked at this depalletizing job for about fourteen months.
On May 11, 1999, accompanied by her QRC, the employee was seen for right shoulder pain by Dr. Daniel Buss. She advised Dr. Buss of her fused right wrist and her restrictions against use of her right arm. She complained of having a dull ache continuously and of shooting pain with activity. Dr. Buss recommended an MRI scan, which was performed on June 16, 1999. The scan showed moderate ill-defined tendinopathy of the rotator cuff, moderate degenerative changes of the acromioclavicular [AC] joint that caused narrowing of the subacromial space, and some labial irregularities. On August 18, 1999, Dr. Buss recommended arthroscopic surgery, which was performed on October 28, 1999. The surgery included arthroscopic debridement of a type 1 SLAP lesion, arthroscopic decompression for impingement syndrome, and arthroscopic AC joint resection for AC joint osteolysis.
Following her right shoulder surgery, Dr. Buss started the employee on a series of exercises and strengthening procedures. When she was seen on February 7, 2000, the employee reported right posterior shoulder and neck pain, pain over the AC joint on the right side, and increasing left shoulder pain and discomfort. She attributed her left shoulder discomfort to her doing a one-armed job with her left arm at the employer=s plant. Dr. Buss diagnosed left shoulder pain and recommended ongoing restrictions for the employee=s bilateral shoulders and continuance of a home exercise program for her shoulders and neck.
The employee returned to see Dr. Buss on March 28, 2000, and reported that approximately fifty percent of her pain was gone from her preoperative status on the right side. She still had some left shoulder discomfort, but she felt that it was improving. Dr. Buss diagnosed left shoulder bursitis rotator cuff tendinitis and continued the employee=s restrictions for both shoulders.
On April 27, 2000, the employee was examined at the request of the employer by Dr. Thomas Litman. Dr. Litman obtained a history from the employee, performed a physical examination, and reviewed pertinent medical records. In a report issued April 27, 2000, Dr. Litman related the employee=s avascular necrosis of the lunate bone to her avulsion skin injury of November 2, 1993, and he considered the 1995 bone graft of the right lunate bone and the 1997 fusion to be consequent to that same injury. Dr. Litman also found the employee=s right shoulder condition to be consequent to that injury, although he assigned an injury date of July 1, 1994, concluding that the employee=s loss of motion in the shoulder was secondary to not moving the shoulder during the healing process after multiple surgical procedures. While that would not have actually led to degenerative changes, he explained, it did lead to tendinous changes and tendonitis. Finally, Dr. Litman found a consequent Gillette-type injury to the employee=s left shoulder on the basis of overuse, to which he assigned a date of February 7, 2000.
On July 13, 2000, the parties submitted a stipulation for settlement for approval to the Office of Administrative Hearings. In that stipulation, the parties agreed that the employee had sustained an injury to her right hand, right wrist, and right shoulder on November 2, 1993. By way of compromise, the employer agreed to accept liability for the employee=s alleged left shoulder injury, with an agreed upon injury date of February 10, 2000. An award on stipulation was issued on July 24, 2000.
About this same time, the employer offered the employee a full time position entitled West/Freezer/Locker Room Janitor/Laundry Aide, and QRC Marsha Ellingson assisted the employee in making sure that the proposed job duties were within the employee=s restrictions. On August 1, 2000, Dr. Buss saw the employee, accompanied by QRC Ellingson, for a recheck of both of her shoulders. Dr. Buss noted at that time that the employee was maintaining good motion in both of her shoulders and that her new job involved below-chest-level janitorial activities. On September 27, 2000, Dr. Buss assigned permanent work restrictions related to both shoulders, including restrictions against lifting more than five pounds above the shoulder, against repetitive work above shoulder level, and against repetitive outstretched reaching.
On July 26, 2001, QRC Ellingson filed a closure report indicating the employee had returned to suitable gainful employment. She indicated that both the employee and the employer had reported that the west freezer/locker room job was going well. She indicated further that, because the employee had been working successfully for a number of months in a permanent job, because her medical treatment had been placed on an as-needed basis, and because her work restrictions had been finalized, it seemed to her that it was time to close the case.
On November 15, 2001, the employee was seen at the Austin Medical Center with complaints of upper back and neck pain. A review of her x-rays revealed degenerative disc disease, and she was treated with medication. When seen in follow-up on December 17, 2001, by Dr. Saleh Alrajhi, the employee reported that her pain was localized mostly between her shoulder blades, and she related its onset initially to her injury with the skinning machine. Dr. Alrajhi diagnosed upper back pain secondary to degenerative disc disease in the cervical and thoracic spine area and recommended an MRI of the cervical and thoracic spine to rule out any herniated discs. The employee underwent the cervical and thoracic MRI scans on April 15, 2002. The cervical scan was read to reveal advanced degenerative disc disease at C4-5 and C5-6, with broad-based bulges at both levels, as well as moderate degenerative bulging at C6-7. The thoracic scan was read to reveal some degenerative endplate changes at T11-T12, with anterior osteophyte formation from T10-L1. The employee reviewed the scans with Dr. Alrajhi three days later, and the doctor recommended a referral to a neurosurgeon. The following week, the employee saw a neurosurgeon at the Mayo Clinic, who evidently saw no evidence for cancer or neoplastic processes and did not recommend surgical intervention.
In May 2003, the employee began a series of chiropractic treatments with Dr. Faye Bollingberg. Dr. Bollingberg restricted the employee from working from June 23, 2003, through July 29, 2003, and again on August 19, 2003, and then referred the employee to Dr. Robert Wengler for an orthopedic consultation. When he saw the employee on October 6, 2003, Dr. Wengler obtained a history from the employee, performed a physical examination, reviewed x-rays of the employee=s cervical spine taken on December 28, 1998, and April 12, 2002, and reviewed the employee=s April 15, 2002, MRI scan. Dr. Wengler diagnosed advanced degenerative disc disease at C4-5, C5-6, and to a lesser degree at C6-7, with right-side foraminal stenosis at the first two levels, and he recommended a repeat MRI of the cervical spine with contrast. The employee underwent the repeat MRI on November 21, 2003, and reviewed the findings with Dr. Wengler that same day. Dr. Wengler noted that the MRI revealed reversal of the normal cervical curvature, together with multilevel degenerative disc disease with Modic changes in the 5th, 6th, and 7th vertebral bodies. He noted also a right-side disc herniation at C5-6 that was flattening the ventral lateral aspect of the cord on the right side. Dr. Wengler=s assessment was degenerative disc disease of the cervical spine at multiple levels, with probable symptomatic herniation at C5-6 on the right side. Surgical treatment options were discussed with the employee at that time.
On December 15, 2003, the employee filed a claim petition for additional workers= compensation benefits. She alleged that on November 2, 1993, in addition to her right hand, right wrist, and right shoulder injury, she also injured her neck. Similarly, she alleged that on February 10, 2000, she injured not only her left shoulder but her neck as well. Further, the employee alleged that she sustained injuries to her neck and upper back also on November 6, 2001, and May 5, 2003.
The employee was next seen in consultation by neurosurgeon Dr. Mahmoud Nagib on December 23, 2003. Dr. Nagib reviewed the employee=s history, performed a physical examination, and reviewed her MRI. He noted that the employee=s pain was so overwhelming that an examination was difficult. He recommended surgery and proceeded with an anterior cervical fusion from C4 through C7 on December 31, 2003. Subsequent to her surgery, the employee remained off work until April 4, 2004, when she returned to her job in the west freezer/locker room. She subsequently resumed treatment with Dr. Bollingberg on June 28, 2004, who eventually restricted her from working from September 17, 2004, through March 20, 2005.
On April 1, 2005, counsel for the employee prepared detailed letters to Drs. Bollingberg, Wengler, Nagib, and Buss, summarizing the employee=s medical treatment and work history for the employer following her injury of November 2, 1993. Counsel also solicited their opinions concerning diagnosis, prognosis, causation, extent of disability, and the reasonableness and necessity of medical treatment.
In a response dated April 15, 2005, Dr. Nagib stated that the employee=s diagnosis was cervical spondylosis with multilevel degenerative discogenic disease. He recommended that the employee avoid work activities requiring repetitive neck motions. With regard to causation, Dr. Nagib stated, AThe only way I can address your question is by saying that we feel the patient=s ailment is work related. I cannot tell you which accident caused the patient=s condition when we saw her back in December of 2003.@
In a letter dated May 12, 2005, Dr. Wengler opined that the employee=s right upper quadrant symptoms were a consequence of altered biomechanics of the right arm secondary to problems associated with the employee=s hand and wrist injury. He related the deterioration of the employee=s cervical discs and her need for surgery to her injury of November 2, 1993. He stated that, A[w]ith the benefit of hindsight, it is apparent that she was developing symptoms associated with the multiple level degenerative disc disease at that time [March of 1996] and that the symptoms progressed to the point where the surgical treatment of December 2003 was necessary.@ In addition, Dr. Wengler further stated that the employee=s functional impairment Aresidual to her 3 cervical disc herniations with a multiple level fusion is [a] 35% whole body impairment.@
Similarly, on May 27, 2005, in response to counsel=s letter, Dr. Bollingberg too was of the opinion that altered biomechanics caused injury to the employee=s cervical and thoracic regions, Abased on her poor body mechanics and overcompensation.@ She opined that the employee=s employment was a significant contributing factor in her cervical and upper thoracic complaints. Dr. Bollingberg also rated the employee=s whole body impairment relative to her cervical spine at 35%, also rating the employee=s whole body thoracic spine impairment at 5%.
The employee was examined at the request of the employer on June 14, 2004, and April 11, 2005, by Dr. Paul Wicklund. On both occasions, Dr. Wicklund obtained a history from the employee, reviewed the employee=s medical records, and performed an examination. Dr. Wicklund prepared reports dated June 15, 2004, and April 13, 2005, summarizing his examinations, and he prepared a brief addendum on April 26, 2005, following his second exam. At his deposition, taken on June 8, 2005, Dr. Wicklund testified that he found no evidence that the employee had sustained an injury to her cervical spine or to her thoracic spine in the course of her employment with the employer. He disagreed with the opinions of the treating doctors, explaining that, in his opinion, Ayou cannot biomechanically explain [the multilevel changes in her neck] based on the use of her neck that she did, and the way she used her neck in the course of her employment.@ He rated the employee=s neck-related whole body impairment at 15%. He found no ratable permanency related to the employee=s thoracic spine.
The employee=s claims came on for a hearing before a compensation judge on July 6, 2005, and the record closed on August 17, 2005. The primary issue presented to the judge was whether the employee had sustained an injury to her cervical and/or thoracic spine arising out of and in the course of her employment. In a findings and order issued October 6, 2005, the compensation judge found that the employee had failed to prove that she sustained a cervical and/or a thoracic injury on any of the injury dates claimed. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers= Compensation Court of Appeals must determine whether Athe 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 (2004). Substantial evidence supports the findings if, in the context of the entire record, Athey 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, Aunless 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).
On appeal, the employee contends that the compensation judge=s findings and order were inadequate as a matter of law, that the judge applied an improper standard of proof with regard to her claim of a Gillette-type injury, that Dr. Wicklund=s opinions were without adequate foundation, and that her finding that the employee did not sustain an injury to her cervical and/or thoracic spine is clearly erroneous and unsupported by substantial evidence in the record.
1. Adequacy of the Findings/Standard of Proof
The primary issue presented to the compensation judge was whether the employee sustained an injury to her cervical and/or thoracic spine, either as a consequence of her admitted injury of November 2, 1993, or as a result of subsequent Gillette-type injuries on November 6, 2001, and/or May 5, 2003. The compensation judge=s decision on this issue is brief. At Finding 1, the only finding on the issue, the judge stated as follows:
The employee has failed to prove by a preponderance of the evidence that she sustained a cervical and/or thoracic injury arising out of and in the course and scope of employment on any of the above claimed dates of injuries. The compensation judge accepted the opinions of Dr. Wicklund that the employee=s cervical and thoracic problems were not caused, aggravated, or accelerated by her work activities (Exhibit 11, pages 14-19). The compensation judge rejected the opinions of Dr. Nagib, Dr. Bollingberg, and Dr. Wengler, on causation.
The judge=s memorandum reads, in its entirety, as follows:
This case was decided based on the medical opinions offered. The compensation judge believed that Dr. Wicklund=s opinion was more consistent with the type of degenerative changes the employee had throughout her cervical spine, for which she required the claimed surgery, th[a]n the opinions of the treating doctors. Although both Dr. Wengler and Dr. Bollingberg related the employee=s cervical problems to working one-handed there was no real good explanation given by them for why this would cause, aggravate, and/or accelerate the degenerative changes on so many levels of the cervical spine simultaneously. The treating doctors did not relate the employee=s need for surgery at the specific levels of the cervical spine to specific work activities. Dr. Nagib did not relate the employee=s cervical condition to any specific injury. Under the Minnesota Workers= Compensation Law the employee has the burden of proof to establish entitlement to benefits by a preponderance of the evidence, Minn. Stat. 176.021, subd 1 and 1(a). The employee=s treating doctors= opinions were not sufficiently persuasive to meet that burden of proof.
The employee first argues that the judge committed an error of law in not providing more detailed factual findings. She contends that by failing to issue findings regarding the nature of the employee=s original work injury, her medical condition, the types of work she performed with the employer after her 1993 injury, her documented reports of cervical and thoracic symptoms following that injury, and her treatment for those problems, it is virtually impossible to discern the basis for Finding 1. Citing to this court=s decision in Mendez-Merino v. Farmstead Foods, slip op. (W.C.C.A. Aug. 7, 2001), the employee asserts the judge failed to set forth sufficient facts she found essential to her ultimate decision to enable a reviewing court to determine from the record whether the facts support the judge=s decision. We find the judge=s findings and order minimally sufficient for appellate review.
We acknowledge that the complexity and extent of the record in this case may have warranted a more detailed and explanative findings and order. That being said, however, it is not entirely clear what additional factual findings the employee seeks. The nature of the employee=s original work injury is undisputed, and detailing the employee=s subsequent work history and documented medical complaints would merely represent a recitation of the evidence and not true findings of fact. Moreover, as we have stated on many occasions, a compensation judge has no obligation to acknowledge specifically in her decision every item of medical evidence received. See Rothwell v. State, Dep=t of Natural Resources, slip op. (W.C.C.A. Dec. 6, 1993). Here, the judge=s findings included a determination of each contested factual issue. With respect to the primary issue of medical causation, the judge clearly stated that she accepted the opinions of the employer=s expert Dr. Paul Wicklund, and she referenced specific pages in the transcript of Dr. Wicklund=s testimony. We find no reversible error in the brevity of the judge=s findings.
The employee next argues that, because the judge=s findings and order do not make any reference to the law concerning consequential injuries, Aone is left to speculate if she properly considered whether the cervical and/or thoracic conditions constituted the >natural consequence= flowing out of the original injury as is the standard.@ She argues that the failure to articulate, or even to reference, the law by which the claim was to be decided, and to then apply the law to the facts of this case, constitutes an error of law and requires, at a minimum, a remand. We do not agree.
We note, first of all, that the direct and natural consequence rule is applicable only in those cases in which the consequences for which benefits are sought did not result from a second work injury. Heinemann v. Independent School District #279, 63 W.C.D. 312, 320 (2003). Here, although the employee undoubtedly claims that her 1993 injury is a substantial contributing factor in her cervical and thoracic conditions, those cervical and thoracic conditions were allegedly also caused, at least in substantial part, by the effects of subsequent work activities with the employer. Regardless of the legal theory advanced by the employee, medical causation must be established. In this case, the judge rejected the medical causation opinions of the treating physicians and accepted the medical causation opinions of Dr. Wicklund. Dr. Wicklund did not find the employee=s cervical and thoracic conditions to be causally related to her 1993 injury or to subsequent work activities for the employer. In the absence of established medical causation, we see no reason for the judge to have referenced in her findings and order the law concerning Aconsequential injuries.@ The judge=s failure to do so was not an error of law or grounds for remand.
The employee contends also that the judge applied an improper standard of proof with regard to the employee=s claim of a Gillette injury. In her memorandum, the compensation judge stated that Athe treating doctors did not relate the employee=s need for surgery at the specific levels of the cervical spine to specific work activities.@ This statement, the employee contends, implies a standard which requires proof that specific work activities caused specific symptoms leading to disability. Citing this court=s decision in Scharber v. Honeywell, Inc., and the supreme court=s decision in Steffen v. Target Stores, she contends that application of this standard, originally outlined in Reese v. North Star Concrete, constitutes reversible error and that the issue of her Gillette claim must be remanded for reconsideration. See Scharber v. Honeywell, Inc., slip op. (W.C.C.A. May 22, 2000). We are not persuaded.
In Reese v. North Star Concrete, this court had held that, in order to prove a Gillette injury, an employee must be able to demonstrate Athat specific work activity caused specific symptoms leading to disability@ and Awhat activities affected the employee in what specific manner, forming a basis for medical opinion of causal relationship.@ Reese v. North Star Concrete, 38 W.C.D. 63, 65 (W.C.C.A. 1985). In 1994, the supreme court held that, A[w]hile that kind of evidence may be helpful@ in proving a Gillette injury, Athe question of a Gillette injury primarily depends on medical evidence.@ Steffen v. Target Stores, 517 N.W.2d 579, 581, 50 W.C.D. 464, 467 (Minn. 1994). Pursuant to the supreme court=s standard in Steffen, an employee is still required to Aprove a causal connection between her ordinary work and ensuing disability,@ but she may no longer be required to document an actual pattern of specific activities leading to specific symptoms in order to demonstrate that causal connection. Id.
Unlike the judge in Scharber, the judge in the present case made no specific reference to the Reese decision or otherwise indicate reliance on the Reese holding as a continuing standard. We do not read the judge=s remark in her memorandum to suggest that she was requiring the employee to prove that specific work activity caused specific symptoms or that she was unmindful of the requirement that a finding of a Gillette injury depends primarily on medical evidence. It appears rather that she was looking for an explanation from the treating physicians as to how the employee=s need for a three-level cervical fusion was related to the employee=s work activities. This inquiry by the judge is consistent with Steffen, and we find no basis for a remand on the issue for misapplication of the law.
2. Substantial Evidence/Foundation
The ultimate question for this court is whether substantial evidence supports the compensation judge=s finding that the employee did not sustain a cervical and/or thoracic injury arising out of and in the course of her employment on any of the claimed dates of injuries. The judge accepted the opinions of Dr. Wicklund on this issue, while specifically rejecting the opinions of Dr. Nagib, Dr. Bollingberg, and Dr. Wengler. A trier of fact=s choice between experts whose testimony conflicts is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence. Nord v. City of Cook, 360 N.W.2nd 337, 37 W.C.D. 364 (Minn. 1985).
The employee contends that the compensation judge=s finding that the employee did not sustain a cervical and/or thoracic injury arising out of and in the course of her employment is unsupported by substantial evidence. Her primary argument is that Dr. Wicklund=s opinions regarding causation were based on an inadequate factual foundation and should not have been relied upon by the judge. She contends that, prior to his evaluations of the employee, Dr. Wicklund was never provided with any written job descriptions of the type of work that the employee had performed for the employer, nor was this information provided to him as part of background letters from the employer. Dr. Wicklund=s reports, she asserts, contain only the briefest narrative regarding his understanding of the employee=s work activities. She further contends that, while Dr. Wicklund was provided with a written job description of the west freezer locker room job at the time of his deposition, he was not asked to assume that the tasks described in that description were of the type the employee performed prior to her cervical surgery. She argues that he was not provided with a hypothetical providing him with a background regarding the employee=s work activities or her medical history. Finally, she argues, even though Dr. Wicklund was shown videotapes of three separate jobs, the videotapes were not a comprehensive review of all of the employee=s job activities, they did not accurately depict how the employee performed the job, and Dr. Wicklund was not specifically asked whether the jobs were of the type that could cause, aggravate, or accelerate the employee=s cervical and/or thoracic condition. Because, the employee argues, Dr. Wicklund=s opinions were therefore without proper foundation, the judge=s decision on causation in reliance on those opinions was clearly erroneous and reversal of Finding 1 is required. We disagree.
The employee objected on foundational grounds to Dr. Wicklund=s causation opinion at his deposition and at trial. The compensation judge admitted Dr. Wicklund=s opinion into evidence, stating that she would consider the objection in terms of the weight to be given the opinion. The competency of a medical expert to provide an expert opinion depends upon both the extent of the scientific knowledge of the witness and the witness=s practical experience with the matter which is the subject of the expert opinion. Reinhardt v. Colton, 337 N.W.2d 88 (Minn. 1983). Dr. Wicklund is a board certified orthopedic surgeon, and he examined the employee on two separate occasions. On both occasions, he obtained a history from the employee, reviewed the relevant medical records, and performed a physical examination. As a general rule, this level of knowledge is sufficient to afford foundation for the opinion of a medical expert. See e.g., Caizzo v. McDonald=s, 65 W.C.D. 378 (W.C.C.A. 2005).
There is no requirement that an expert opinion be elicited through a hypothetical question to have adequate foundation. Grunst v. Immanuel St. Joseph=s Hospital, 424 N.W.2d 66, 40 W.C.D. 1130 (Minn. 1988). At the time of both of his exams, Dr. Wicklund asked the employee what activities at work seemed to cause her problems. He was provided with all of the employee=s medical records, including the records from the employer=s medical facility where the employee was seen for cervical and thoracic complaints. At his deposition, Dr. Wicklund was provided with and had an opportunity to review reports from Dr. Wengler, Dr. Bollingberg, and Dr. Nagib, setting forth their opinions regarding the issue of causation. The question here is not whether Dr. Wicklund was familiar with every relevant detail surrounding the employee=s medical conditions and work activities but whether he had sufficient knowledge of the underlying facts. See Bossey v. Parker Hannifin, slip op. (W.C.C.A. Mar. 14, 1994). We believe that a fair reading of Dr. Wicklund=s deposition testimony establishes adequate foundation, and we conclude that the judge could reasonably rely on the doctor=s causation opinion.
In her memorandum, the compensation judge explained why she chose the opinions of Dr. Wicklund over those of the treating doctors. First, she found Dr.Wicklund=s opinion Amore consistent with the type of degenerative changes the employee had throughout her cervical spine, for which she required the claimed surgery, th[a]n the opinions of the treating doctors.@ In this regard, Dr Wicklund testified that his opinion was based in part on,
. . . the MRI evidence that shows age-related multi level degenerative disk problems that were treated appropriately, but were not work related. And, I think when you see those kind of multi level changes in the neck, which involve, at least, four levels of the cervical spine, that include osteophyte formation, narrowing of openings for nerves, disk space narrowing, disk space bulging, small disk herniations at multi levels, you cannot biomechanically explain that based on the use of her neck that she did, and the way she used her neck in the course of her employment at Hormel. Those sorts of disk problems at all those levels can=t happen doing the kind of work activities she was doing.
He further testified,
I don=t think there=s any way you can postulate any kind of work she did at Hormel as causing, aggravating, or accelerating the age-related degenerative problems which were seen on several MRIs that were done in the course of her evaluation of her spine. The one I=m looking at, 11-21-03, done at CDI, shows mild to moderate multi level degenerative disk problems. And the word degenerative, by itself, means a gradual age-related wearing out of a disk. I don=t think that happened because of activities she did at Hormel.
The judge also noted that, A[a]lthough both Dr. Wengler and Dr. Bollingberg related the employee=s cervical problems to working one-handed there was no real good explanation given by them for why this would cause, aggravate, and/or accelerate the degenerative changes on so many levels of the cervical spine simultaneously.@
Ultimately, as noted by the judge, Athis case was decided based on the medical opinions offered.@ The judge found Dr. Wicklund=s opinion to be more persuasive than those offered by the treating doctors. Questions of medical causation fall within the province of the compensation judge. Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994). In Golob v. Buckingham Hotel, the Minnesota Supreme Court stated,
Where qualified medical witnesses differ as they do here, it ordinarily is not for us on appeal to say that one is so eminently right and the other so clearly wrong that the fact finder was obliged to accept the opinion of one and discard the opinion of the other. The determination of this question is like the determination of any other question of fact, and it must depend to a large extent upon the credibility attached by the trier of facts to the opinion and testimony of the various witnesses who are expressing their opinions.
244 Minn. 301, 304-05, 69 N.W.2d 636, 639, 18 W.C.D. 275, 278 (1955), quoted in Ruether v. State, 455 N.W.2d 475, 478-79, 42 W.C.D. 1118, 123-24 (Minn. 1990).
Finding that Dr. Wicklund=s causation opinion is adequately founded and that his opinion provides substantial evidence to support the judge=s decision, we affirm the judge=s decision in its entirety.
 See Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).