EVELYN TANNER, Employee/Appellant, v. PARK NICOLLET HEALTH SERVS., SELF-INSURED/GALLAGHER BASSETT SERVS., INC., Employer, and BLUE CROSS & BLUE SHIELD OF MINN. and WAUSAU BENEFITS, INC./J.W. HUTTON, INC., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
JULY 25, 2006
CAUSATION - SUBSTANTIAL EVIDENCE. Although the compensation judge erroneously found the evidence failed to show the employee's treating doctors understood the employee had been diagnosed with carpal tunnel syndrome in 1996, there is substantial evidence, including the adequately founded opinion of the independent medical examiner, to support the finding that the employee failed to prove that her work activities for the employer were a substantial contributing cause to the development of bilateral carpal tunnel syndrome.
Affirmed as modified.
Determined by: Johnson, C.J., Wilson, J. and Rykken, J.
Compensation Judge: Cheryl LeClair-Sommer
Attorneys: James M. Gallagher, James M. Gallagher & Assocs., Minneapolis, MN, for the Appellant. Karen M. Charlson, Felhaber, Larson, Fenlon & Vogt, St. Paul, MN, for the Respondent.
THOMAS L. JOHNSON, Judge
The employee appeals the compensation judge's determination that the employee failed to prove her work activities for the self-insured employer were a substantial contributing cause of her bilateral carpal tunnel syndrome. We affirm as modified.
Evelyn Tanner, the employee, began working as a third-party workers' compensation billing coordinator for Park Nicollet Health Services, the self-insured employer, on November 3, 2003. The employee's job included a variety of activities including making and receiving phone calls, pulling and reviewing medical charts, typing, writing and handling mail. The employee testified she spent a lot of time, every day, typing on the computer and hand writing notes.
In about February 2004, the employee began to experience swelling and pain in her hands. She reported her symptoms to her supervisor who referred her to Dr. Robert Gorman at the Park Nicollet occupational medicine clinic. When seen on March 8, 2004, the employee described bilateral carpometacarpal (CMC) joint pain, left index finger pain and pain in the dorsum of the hand. Dr. Gorman's records indicate the employee's symptoms occurred during and after work, and that her job duties included typing and writing. The employee stated her current symptoms began in mid-February, and also gave a history of carpal tunnel syndrome in 1996, treated with splints, that resolved. On examination, Dr. Gorman noted a positive spring test, and negative Tinel and Phalen's tests. X-rays of the hands and wrists showed some degenerative changes and the doctor noted a family history of arthritis. Dr. Gorman stated it was difficult to say, at that point, whether the employee's problem was work related. He prescribed thumb spica splints and Aleve, and released the employee to return to work without formal limitations.
The employee returned to Dr. Gorman in three weeks complaining of persistent CMC joint pain and bilateral hand swelling and pain, and right forearm extensor pain. On examination, Dr. Gorman noted tenderness in the CMC joint of the right hand and over the forearm extensor musculature, an inconsistent Finkelstein's test, and grossly normal grip strength. The doctor referred the employee for hand therapy and set up an appointment with Dr. Thomas Walsh, a hand surgeon at Park Nicollet.
The employee was seen by Dr. Walsh on April 16, 2004, reporting bilateral thumb pain, right forearm and elbow pain and bilateral hand pain and swelling. She also noted a past history of carpal tunnel syndrome. On examination, the doctor noted tenderness over the right lateral epicondyle, tenderness over the finger flexor tendons, through the palm and into the base of the fingers, no visible swelling, bruising or deformity in the hands, a "softly present" Tinel's sign over the median nerves at the wrist, no intrinsic atrophy or weakness, and tenderness over the basilar joints of both thumbs. (Jt. Ex. 1.) Dr. Walsh's impression was right lateral epicondylitis, bilateral basilar thumb synovitis, and bilateral hand pain consistent with digital flexor tendon soreness. Dr. Walsh opined the employee's hand and arm condition was aggravated by work.
The employee returned to see Dr. Walsh on May 7, 2004. She reported persistent symptoms and also noted tingling in the ring and small fingers of each hand that typically occurred while she was typing. The doctor diagnosed bilateral hand pain and prescribed continuing hand therapy. Dr. Walsh also completed a work ability report, requiring five to ten minute breaks every hour when typing, and recommended the employee spend as little time as possible with elbows bent.
In a follow-up appointment on May 11, 2004, Dr. Gorman noted that Dr. Walsh believed the employee's condition was work-related. The employee reported tingling into her left little, right and middle fingers and right lateral epicondyle forearm discomfort in addition to her previous symptoms. Dr. Gorman observed the employee had missed a day of work that week due to severe hand pain. Dr. Gorman's impression was bilateral hand pain and swelling, unclear etiology, and bilateral CMC joint pain.
The employee returned to Dr. Walsh in June 2004. The doctor noted the employee continued to have symptoms when typing for extended periods that appeared to be ulnar nerve related. Stating "[a]lthough she has no evidence of muscular atrophy or weakness, and paresthesias are intermittent," the doctor ordered an EMG to rule out "any" surgically significant pathology. (Jt. Ex. 1.) The July 6, 2004, EMG study was interpreted by Dr. Paul Biewen as consistent with moderately severe bilateral median nerve entrapment at the wrist.
In follow-up on July 16, 2004, Dr. Walsh reviewed the EMG study. He noted the employee was awakening every night with numbness and tingling in both hands and that symptoms recurred regularly during the daytime. On exam, he again noted a softly present Tinel's sign. Dr. Walsh's impression was bilateral arm pain with a component of carpal tunnel syndrome (CTS). Based on the consistency and duration of her symptoms and the EMG findings, the doctor felt the employee was a reasonable candidate for bilateral CT releases. He additionally noted, however that while the aching discomfort in her wrist and numbness and tingling in her fingers were most likely caused or significantly contributed to by her carpal tunnel condition, the more proximal forearm pain and other arm discomforts might very well be distinct from the carpal tunnel condition.
In September 2004, the employee was examined by Dr. William Call, an orthopedic surgeon, at the request of the self-insured employer. The employee stated her symptoms began in February 2004 with swelling in the hands and wrist and, later, included pain going up the forearm. She also gave a history of carpal tunnel syndrome "years ago" treated in Evanston, Illinois. (Jt. Ex. 3.) The employee reported she had symptoms all the time, all day, at rest and at night. Her job, Dr. Call reported, included checking claims, documenting cases, hand writing and taking calls, and involved typing on a computer all day long. According to the doctor, the employee demonstrated a functional wrist neutral position, with an arm at the side, for typing. On examination, Dr. Call noted essentially normal objective findings. The doctor concluded the employee's history, examination and medical records were consistent with subjective discomforts in the upper extremity of either a myofascial or fibromyalgic nature. Dr. Call maintained the employee did not have clinical findings consistent with carpal tunnel syndrome, that her work activities would not be irritative, causal or exacerbatory to a carpal tunnel syndrome, and that her condition was not work-related. In October 2005, Dr. Call reviewed the employee's EMG study. In his opinion, the EMG was consistent with a mild right carpal tunnel syndrome and a moderate left carpal tunnel syndrome by electrical determination. Dr. Call stated, however, that as there was no evidence of carpal tunnel syndrome on clinical examination his opinions had not changed.
In February 2005, the employee was seen by Dr. Matthew Putnam, a hand surgeon at the University of Minnesota, for a second opinion. He reviewed Dr. Walsh's chart notes and the EMG study and took a patient history. The employee stated her symptoms began about one year previously when she began to have numbness and tingling into her hands and aching in her forearms. The doctor further noted the employee's EMG study was abnormal for the median nerve bilaterally. Dr. Putnam concurred with Dr. Walsh's diagnosis of bilateral carpal tunnel syndrome and agreed the employee would likely benefit from a surgical release.
The self-insured employer initially accepted liability and paid for the employee's medical treatment. Following receipt of Dr. Call's opinion, however, the employer denied primary liability for the employee's hand and wrist condition. In November 2004, the employee filed a Claim Petition alleging a work injury to the bilateral arms, hands and wrists (CTS) and seeking payment of medical expenses and approval of the carpal tunnel surgery recommended by Dr. Walsh. The matter came on for hearing before a compensation judge at the Office of Administrative Hearings on October 18, 2005. In a decision issued on January 26, 2006, the judge found the employee had failed to prove that her work activities for the self-insured employer were a substantial contributing factor to the development of carpal tunnel syndrome. The employee appeals.
The employee contends the compensation judge erred in determining the employee's carpal tunnel syndrome was not causally related to her work activities for the employer. In particular, the employee asserts the compensation judge erred in finding that the treating physicians were not aware of her previous treatment for carpal tunnel syndrome, and in concluding that her treating physicians failed to document a detailed understanding of the employee's job duties.
We agree the compensation judge's finding that "the evidence fails to substantiate that the treating physicians understood the employee was diagnosed with carpal tunnel syndrome in 1996 on the left and wore a splint for a period of time" is incorrect. (Finding 3.) The chart notes and records of Dr. Gorman and Dr. Walsh clearly include a previous history of carpal tunnel syndrome, either bilateral or left-sided, in 1994-95 or 1996. Dr. Gorman's notes specifically reference treatment with a splint. Both treating doctors described the employee's previous CTS history with at least as much specificity as, if not more than, Dr. Call. Moreover, the relevance of the finding is unclear. The only evidence of the employee's prior CTS was the history she gave to the doctors and her testimony at the hearing. That evidence indicated her previous symptoms had resolved, and, as noted by the employee, neither the treating doctors nor Dr. Call indicated that her previous treatment for CTS had any bearing on the employee's current condition. We modify the Findings and Order accordingly.
The employee argues, additionally, that the compensation judge erred in concluding the employee's treating doctors did not demonstrate a sufficiently detailed understanding of the employee's job duties. We agree. On March 8, 2004, Dr. Gorman noted the employee's job duties included typing and writing, and the employee thought her problems were possibly related to her work activities. On March 30, 2004, the employee reported to Dr. Gorman that her hand pain and swelling occurred two hours into her work shift, aggravated by keying, and again stated she felt her problems were related to her work. In follow-up in May 2004, Dr. Gorman noted the employee wanted to keep her job, but it involved more keying than previous jobs.
On April 16, 2004, the employee reported to Dr. Walsh that the more keying and writing she did, the worse her symptoms seemed to be. Stating, "in light of the fact that I am not able to identify any activities outside of work that may precipitate these symptoms, and that working activities have been aggravating for her," Dr. Walsh opined the employee's condition was aggravated by her work. (Jt. Ex. 1.) On May 7, 2004, the employee reported to Dr. Walsh tingling in the ring and small fingers of each hand that occurred more commonly when she was typing. The doctor then imposed work restrictions of a 5-10 minute break every hour when typing. The information contained in the doctors' chart notes reflects an understanding of the employee's work activities that, in combination with their medical expertise and practical experience, is sufficient to provide adequate foundation for a medical opinion as to causation. See, e.g., Steffen v. Target Stores, 517N.W.2d 579, 50 W.C.D. 464 (Minn. 1994).
Nevertheless, the dispositive issue in this case is whether substantial evidence supports the compensation judge's determination that the employee failed to prove she sustained a personal injury in the nature of bilateral carpal tunnel syndrome as a result of her work activities for the self-insured employer. Certainly, on the record in this case, the compensation judge could have drawn different inferences and reached a different conclusion. On appeal, however, it is not the role of this court to make an independent evaluation of the probative value of the testimony or to reweigh the evidence submitted. "The point is not whether we . . . might have viewed the evidence differently, but whether the findings of the compensation judge are supported by evidence that a reasonable mind might accept as adequate." Redgate v. Sroga's Standard Service, 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988).
Here, the compensation judge accepted the opinion of Dr. Call that the employee, by history and examination, had no objective findings consistent with bilateral carpal tunnel syndrome and that her condition was not related to her work activities. Dr. Call took a statement from the employee describing her symptoms, medical history and her work activities for the employer, reviewed the employee's medical records, and performed an examination. As a general rule, this level of knowledge is sufficient to afford foundation for the opinion of a medical expert. Drews v. Kohl's, 55 W.C.D. 33 (W.C.C.A. 1996). The decision concerning the weight to be given to evidence submitted at the hearing, and whether to accept or reject an expert's opinion is for the compensation judge, not this court. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). Ultimately, the question becomes which medical expert the compensation judge finds more persuasive. In Golob v. Buckingham Hotel, the Minnesota Supreme Court observed:
[U]ntil the time comes when medical knowledge has progressed to such a point that experts in the field of medicine can agree, causal relation in determining compensable injury or disease will have to remain in the province of the trier of fact. 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 Reuther v. State, Mankato State Univ., 455 N.W.2d 475, 478-79, 42 W.C.D. 1118, 1123-24 (Minn. 1990).
The compensation judge accepted Dr. Call's opinion. The doctor's opinion was adequately founded and the compensation judge could reasonably rely upon it. On this record we cannot say the compensation judge's decision was manifestly contrary to the evidence, and we must, therefore, affirm.
 The sole condition at issue at the hearing was the employee's alleged bilateral carpal tunnel syndrome. No claim with respect to any other hand, wrist, arm or upper extremity condition was raised, considered or determined at the hearing. (T. at 5-6, 11-12.) To the extent the Findings and Order suggests otherwise, it is hereby modified.