NORMA J. JOTBLAD, Employee, v. CITY OF ST. PAUL, SELF-INSURED, Employer/Appellant, and REGIONS HOSP., PRIMARY BEHAVIORAL HEALTH, HEALTHPARTNERS, THERAPY PARTNERS, and ST. PAUL RADIOLOGY, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
JUNE 11, 2007
CAUSATION - PSYCHOLOGICAL INJURY. Substantial evidence of record supports the compensation judge=s finding that the employee=s work injury of June 7, 1996, was a substantial contributing factor in causing or significantly aggravating her psychological condition and diagnosis.
PERMANENT TOTAL DISABILITY - SUBSTANTIAL EVIDENCE. Substantial evidence supports the compensation judge=s finding that the employee is permanently and totally disabled as a result of her work-related psychological condition.
CAUSATION - GILLETTE INJURY. Substantial evidence, including expert medical opinion, supports the compensation judge=s finding that the employee sustained a Gillette injury to her right wrist in the nature of carpal tunnel syndrome.
Determined by: Rykken, J., Stofferahn, J., and Pederson, J.
Compensation Judge: Kathleen Behounek
Attorneys: Thomas D. Mottaz, Law Office of Thomas D. Mottaz, Anoka, MN, for the Respondent. Timothy S. Crom and Matthew P. Bandt, Jardine, Logan & O=Brien, Lake Elmo, MN, for the Appellant.
MIRIAM P. RYKKEN, Judge
The self-insured employer appeals from the compensation judge=s finding that the employee sustained a work-related carpal tunnel injury on June 22, 1995, that the employee=s work injury of June 7, 1996, was a substantial contributing factor in causing or significantly aggravating her psychological condition and diagnosis, that the employee has sustained permanent partial disability of the body as a whole as a result of her June 7, 1996, work injury, and that the employee has been permanently totally disabled since February 11, 2005, as a result of her work-related psychological condition. We affirm.
Norma J. Jotblad, the employee, began working for the City of St. Paul, the self-insured employer, on August 1, 1978. She worked for the employer on a full-time basis, first as a clerk typist, working with the St. Paul school district and later in the city=s Public Works Department. The disputed issues addressed on appeal arise from three admitted or claimed injuries: an injury on June 22, 1995, in the nature of right-sided carpal tunnel syndrome; an admitted injury on June 7, 1996, to the low back, left hip, neck and right arm; and an April 21, 2003, claimed injury to the low back and left hip. The employer disputes that the employee=s carpal tunnel syndrome or right wrist condition is causally related to her work activities. The employer also disputes that the employee=s injury of June 7, 1996, which allegedly led to the employee=s low back pain, sacroilliac joint dysfunction and an altered gait, is causally related to the employee=s current psychological condition, and disputes that the employee has sustained any permanent partial disability relative to her psychological condition. In addition, the employer disputes that the employee is permanently totally disabled as a substantial result of any work related injuries or conditions.
From January 1986 until January 1995, the employee worked in the Public Works Department, where the majority of her work duties involved typing or keying. She spent approximately six hours each day typing, and noted no physical problems performing that job until 1995, when she developed pain in her right wrist and thumb. The employee sought treatment at United Hospital, and in August 1995 was referred to Dr. Paul Donahue. The employee reported that she had undergone a right-sided carpel tunnel release approximately 25 years earlier. Dr. Donahue initially treated the employee=s trigger finger symptoms with a cortisone injection and later a trigger release in November 1995. By January 1996, Dr. Donahue noted that the employee had mild symptoms of carpal tunnel with symptoms of swelling in her hand with work.
In October 1998, due to her ongoing symptoms, Dr. Donahue referred the employee for an EMG, which showed some abnormalities in the median nerve. On November 19, 1998, based on the results of that EMG, he performed a right carpal tunnel release. During surgery, Dr. Donahue noted and removed a small amount of fatty tissue on top of the median nerve, which was later shown to be fibroadipose tissue with some fibrosis. As a result of her hand and wrist condition, Dr. Donahue assigned restrictions for the employee=s work, including avoidance of keying over 30 minutes per hour, no lifting over five pounds, and no heavy pinching with her right hand. In Dr. Donahue=s opinion, the employee=s work activities from 1979 to 1995 were a substantial contributing cause to her carpal tunnel syndrome, and he opined that she sustained a Gillette injury as a result of her work activities between 1979 and 1995.
The employer initially admitted liability for a June 22, 1995, injury and later paid the employee permanent partial disability benefits based on a 3.08% whole body impairment rating as assigned by Dr. Donahue. The employer later retroactively denied primary liability for the employee=s carpal tunnel syndrome, and, as part of the current appeal, seeks a credit for the permanency benefits paid to the employee for that condition.
On June 7, 1996, as a result of slipping and falling on a damp floor in a bathroom, the employee sustained an injury to her low back, left hip, head, neck and right arm. She was seen by Dr. Julia Halberg, at United Occupational Health, reporting pain in the left side of her low back extending through her left SI joint, her left hip and left knee. The employee also noticed neck pain and right arm tingling as a result of this injury, but those symptoms eventually resolved. Dr. Halberg diagnosed a lumbar strain, cervical strain, and multiple contusions related to the employee=s fall at work. The employer admitted liability for this injury and paid various workers= compensation benefits to the employee, including periodic temporary total disability benefits.
The employee was disabled from employment for approximately six weeks following her June 1996 injury and later returned to work on a light-duty basis. For approximately two years thereafter, she worked on a light-duty basis and occasionally was off work entirely as a result of her 1996 injury. The primary symptoms that have persisted ever since the employee=s 1996 injury include hip pain and pain in her SI joint area, in addition to problems with her gait. Medical records reflect that the employee=s gait abnormality persisted; the employee described her need to internally rotate her left hip or, in a way, swivel her pelvis to alter her gait, in order to alleviate pain and to assist with walking. As a result of her ongoing pain, she underwent continued, periodic and extensive consultations with various specialists, including physicians in the speciality areas of occupational medicine, physical medicine, orthopedics, neurology, osteopathy and pain management. Within a few months of her June 1996 injury, the employee developed symptoms of depression. At Dr. Halberg=s recommendation, the employee consulted Dr. Todd Hess at the United Pain Center, where she reported difficulty with sitting, changing positions and weight bearing. She was observed to have an antalgic gait, and a Alisting@ to the right. Dr. Hess assessed acute low back strain resulting from the 1996 injury. At Dr. Hess=s referral, the employee underwent an L5-S1 facet denervation, which temporarily resolved the pain in her sacroiliac joint.
In October 1996, the employee consulted a physical medicine specialist, Dr. Teresa Gurin, who assessed sacroiliac joint pain with small right hemipelvis and a short right leg, and noted that the employee=s leg length discrepancy could be exacerbating the back pain from her work injury and could be preventing that pain from improving. Drs. Halberg and Gurin provided follow-up treatment for the employee. On December 5, 1996, at Dr. Gurin=s referral and due to her tearful and depressed affect, the employee also underwent a neuropsychology consultation with Kerri Lamberty, Ph.D., L.P. Dr. Lamberty noted that the employee=s pain was contributing to Areduced social functioning and to a mild to moderate level of depression,@ and recommended antidepressants, pain medication and counseling. Dr. Gurin restricted the employee from work.
On December 27, 1996, the employee underwent an orthopedic evaluation with Dr. Jonathan Biebl. He diagnosed low back and left hip pain secondary to the work injury along with probable sacroiliitis, and found the employee=s pain and gait patterns to be Abizarre.@ In January 1997, Dr. Gurin prescribed a cane to assist with the employee=s significantly abnormal gait; the employee has used a cane since that time. Also in January 1997, both Dr. Todd Hess and Winnie Lilly-Taylor, Ph.D., L.P. evaluated the employee from a chronic pain program perspective, and concluded that the employee would benefit greatly from participation in such a program. She also received follow-up treatment in 1997, with Drs. Halberg and Gurin, as well as with Dr. Vijay Eyunni, director of United Occupational Health, and Dr. Terrance Capistrant, a neurologist. Dr. Capistrant assessed localized pain in the SI joint, and an exaggerated limp and a Avery grotesque externally rotated leg.@ Dr. Capistrant expressed concern that the employee might have developed pain behaviors and might require a psychological evaluation to discern whether these behaviors indicated a conversion reaction. Dr. David Gilbertson, D.O., evaluated the employee and assessed mechanical low back strain, weakness in the left leg, and lumbar disc degeneration. He felt that the employee=s gait was a function of her lumbar and pelvic problem which was probably mechanical, and also concluded that x-rays showed some degenerative changes which may have contributed to the employee=s long-standing problem.
At Dr. Eyunni=s referral, the employee underwent aquatic therapy at the Courage Center. In August 1997, she also consulted Dr. James Ogilvie at Fairview-University Medical Center. He assessed an unusual gait disturbance from a painful dysfunction of the left SI joint, and provided a repeat facet injection in the SI joint which provided some pain relief.
In August 1998, the employee returned to work on a full-time basis, working under restrictions assigned by Dr. Eyunni. She continued to work in a clerk typist III position in the Public Work Department, and continued to receive periodic treatment for her persistent low back and left hip symptoms and consultations for her psychological or emotional condition. In October 1998, the employee underwent a psychological consultation with Dr. John Hung, Ph.D., LP. Dr. Hung concluded that the employee displayed many classic features of a somatoform pain disorder which he felt was superimposed on a long-standing personality style marked by salient histrionic and some dependent features. Dr. Hung concluded that the employee might not be a candidate for a comprehensive chronic pain management program because her physical complaints were not limited to chronic pain but were also focused on her SI dysfunction and altered gait. He recommended instead that the employee=s case management be coordinated by a physician in the area or chronic pain and disability management, such as Dr. Eyunni.
The employee=s treating physicians had varying opinions as to the nature of her symptoms, and the record contains varying medical opinions concerning her diagnosis and the etiology of her physical symptoms and altered gait, and also contains varying psychological and psychiatric opinions concerning her emotional or psychological condition. In March 1999, her family physician at HealthPartners, Dr. Robert Koch, diagnosed a probable left SI joint instability. He felt this was not a pain control issue, but instead concluded that A[T]his is an issue of a very clear and obvious gait dysfunction which has not been addressed and it is very clearly related to a work related injury of June 19, 1996.@ However, Dr. Frank Wei, a specialist in physical medicine and rehabilitation, whom the employee consulted on August 5, 1999, was not convinced that the SI joints were the primary problem, and recommended a treatment of the employee=s muscular problem. He commented that the employee might have some radiculopathy, but that proper use of a cane as well as physical therapy and pool therapy could assist in relieving the muscular tightness in her pelvic girdle.
On April 12, 2000, the employee underwent an independent orthopedic examination with Dr. Mark Friedland, at the employer=s request. Dr. Friedland diagnosed a non-anatomic bizarre gait pattern that could not be explained based on any anatomic or physical findings nor diagnostic studies, and a histrionic personality disorder, and concluded that the employee=s right upper extremity condition was unrelated to her work and instead was related to a lipomatous tumor of the media nerve found at the time of her 1998 surgery. Dr. Friedland recommended no restrictions on the employee=s work or recreational activities as a result of her low back or hip complaints, but recommended limitations on her use of her right hand.
On August 20, 2001, Dr. Suzanne Proudfoot, D.O., Fairview Health Service, conducted a pain management evaluation of the employee at the referral of Dr. Koch. Her examination findings were suggestive of an underlying left SI dysfunction but she commented that Athere is significant difficulty secondary to possible overlay vs. simply inhibition from abnormal joint mechanics.@ She also diagnosed chronic low back pain, chronic pain syndrome and sleep disruption. Dr. Proudfoot recommended rehabilitative therapy and biofeedback therapy. As part of the pain management evaluation, Dr. Patrick O=Laughlin, Ph.D., conducted a psychosocial evaluation of the employee. The employee reported longstanding low back and leg pain, and expressed her desire to understand the physical dimension of her pain. The employee also expressed resistance to pain management in part because she did not want her pain to be Aidentified as psychological.@ Dr. O=Laughlin diagnosed pain disorder with emotional features and adjustment disorder, with aspects of depression. He noted that the employee acknowledged times of feeling depressed and discouraged, but was reluctant to enter into psychologically-oriented care to address those conditions. The treatment he recommended included biofeedback training to assist with pain modulation or reduction. The employee did undergo biofeedback therapy and additional physical therapy in 2001 and 2002.
In 2003, the employee transferred from working at the Public Works Department to the Asphalt Plant; she testified that she transferred because of her ongoing problems with her right upper extremity, although she continued to work as a clerk typist III. On April 21, 2003, the employee sustained an injury while working when she slipped on gravel and an oily surface as she closed a swinging cyclone fence gate. Her left leg skidded forward and she twisted and grabbed the fence, aggravating or re-injuring her low back and left hip. She consulted Dr. Koch on May 1, 2003, reporting an increase in her left low back pain radiating into her left groin area and down her leg. Dr. Koch assigned work restrictions and referred her to physical therapy. Her symptoms persisted, and, on September 3, 2003, Dr. Koch diagnosed a left SI joint instability, left SI strain and questionable left glutenous medius myopathy and strain. Dr. Koch concluded that her condition was work-related, with an original date of injury being June 7, 1996, and a re-injury at work on April 21, 2003. In December 2003, Dr. Koch concluded that the employee=s work restrictions were permanent; those included a five-pound lifting limit with no bending more than 45 degrees.
The employee continued to consult with Dr. Koch at Health Partners, and reported that she felt easily fatigued, limited in her motivation and concerned about responses to her recent stressors. Dr. Koch diagnosed depression and anxiety, prescribed Prozac, and recommended that she follow up with a counselor at Behavioral Health at HealthPartners. She consulted a counselor, Janet Baum, in March 2004, and periodically consulted her until at least April 2006. According to Ms. Baum=s report of October 5, 2004, the employee=s anxiety had increased to the point of possible agoraphobia, in that she did not leave her home except to go to work. Ms. Baum diagnosed depressive disorder with a component of anxiety.
In October 2004, upon referral from Dr. Koch, the employee consulted an orthopedist, Dr. John Stark. He assessed unusual mechanical back symptoms without objective confirmation. CT scans were taken of the employee=s pelvis, in two positions described by the employee as demonstrating the type of hip adjustment she needed to make while walking in order to alleviate her pain. Those positions, described as showing her hip to be Apopped in@ and Apopped out,@ were both examined. The CT scans were interpreted as showing no definite evidence of subluxation of the SI joints but showing a more pronounced external rotation of the left proximal femur and also a pronounced degenerative disc disease at the L5-S1 level. Based on these results, Dr. Stark had difficulty determining a working diagnosis of the employee=s physical condition and the sensation of hip Ashifting@ or rotation. Acknowledging the employee=s continued symptoms, Dr. Stark periodically examined the employee in 2004 and 2005, in conjunction with Dr. Koch, but by July 2005 had no recommendations for treating an orthopedic condition. He concluded that, in his opinion, the employee Ahad a disabling orthopedic injury in 1996 which has manifested itself as a conversion disorder.@
On November 8, 2004, Dr. Mark Friedland re-examined the employee. His opinions on the employee=s condition remained the same, that is, that there was no causal connection between her work activities and her low back and hip condition, nor her right hand and wrist condition. He also found no objective evidence of an anatomical injury resulting from the April 21, 2003, incident.
The employee again consulted Dr. Stark on February 11, 2005, reporting pain in her low back, advising that extending her left leg in order to walk was very painful and she could only alleviate that pain by rotating her pelvis up to the left. Dr. Stark could not provide a plausible explanation for the employee=s Abizarre shifting sensation.@ He restricted her from work at that time, for at least a three-month period, although the employee never returned to work after February 10, 2005.
On April 20, 2005, the employee underwent an evaluation with Dr. Alford Karayusuf, for purposes of a Social Security disability evaluation. According to Dr. Karayusuf=s report of that date, the employee cried throughout the interview, had a moderately to severely depressed mood, and he diagnosed depression, NOS (not otherwise specified), and a severe somatization disorder, along with a personality disorder, NOS, with dependent and histrionic features. In Dr. Karayusuf=s opinion, the employee=s condition was Asimply not going to work out in a job setting and, therefore, she is not able to maintain pace and persistence.@ The employee was ultimately awarded Social Security disability income, with benefit payments commencing in August 2005.
The record contains opinions from various medical providers addressing the employee=s diagnosis and the cause of her symptoms, including a July 12, 2005, report from Dr. John Stark, in which he concluded that the employee did not have a treatable orthopedic problem but that she had a Asignificant conversion of her previous 1996 injury@ that had resulted in unusual complaints of pelvic instability. He concluded that this was a work-related problem, and that, but for her work injury, she would not be in her current psychological condition. In summary, Dr. Stark concluded that the employee had a disabling orthopedic injury in 1996 which had manifested itself in a conversion disorder, that her disability was not a conscious decision, and that her remarkably disabling psychological condition disqualified her from employment and therefore she was permanently and totally disabled as a result of her 1996 injury.
At the request of the self-insured employer, the employee was examined by Dr. Sean Flood, on July 28, 2005. Dr. Flood diagnosed, among other things, chronic left hip and low back pain. He concluded that the employee suffered from carpal tunnel syndrome and right thumb weakness and dexterity problems, but opined that those symptoms and that condition were not related to work. Dr. Flood also concluded that the employee Amay have sustained a lumbosacral/SI strain superimposed on top of some degenerative lumbar disc disease@ but felt there was nothing in the medical records to support a true physiological or anatomical dysfunction of her hemipelvis and left SI joint. He concluded that the employee=s history of a personality and somatoform disorder, coupled with her depression and anxiety, limited her ability Ato deal appropriately with the problem in her left SI hip area, resulting in symptom magnification and the very strange and bizarre gait pattern that she demonstrates on examination.@
On August 30, 2005, Dr. Koch, with whom the employee had continued to receive follow-up treatment, completed a PERA Disability Medical application form. Dr. Koch opined that the employee=s condition was musculoskeletal in nature consisting of SI joint pain and hip dysfunction, and that despite extensive physical therapy, physiatry and orthopedic evaluations, she had disability with ambulation and her chronic pain had persisted. Dr. Koch expected no improvement, and answered Ayes@ to the question whether the employee was Atotally and permanently disabled from engaging in any substantial gainful activity for at least one year. @ In response to the question of the time period for which the employee would be unable to work, Dr. Koch stated Apermanent.@
On September 8, September 14, October 5 and October 24, 2005, and upon referral from her attorney, the employee was evaluated and tested by Dr. John Patrick Cronin, Ph.D., MPH, LP, for purposes of a chronic pain evaluation. She also received follow-up treatment with Dr. Cronin. He assessed a pain disorder associated with both psychological factors and a general medical condition along with dysthymic disorder, and psychosocial environmental problems, such as problems with occupation and economic problems. Dr. Cronin concluded that the employee was exhibiting an emotional reaction to her work-related injuries, in the form of depression, and that she met the criteria for chronic pain syndrome as defined by the DSM-IV. He felt that the current symptoms were directly and causally related to the employee=s June 7, 1996, and April 21, 2003, work injuries. He assigned a 35% whole body impairment rating, on the basis of the Weber decision, using as a guideline the rating set forth in Minn. R. 5223.0360, subp. 7.D., subcategories 2 and 3. Dr. Cronin also concluded that the employee was permanently and totally disabled from employment.
On December 2, 2005, the employee underwent a psychiatric evaluation with Dr. Thomas Gratzer at the employer=s request. In his report of December 13, 2005, he diagnosed the employee with a somatoform disorder, NOS; a history of adjustment disorder with mixed anxiety and depressed mood, resolved; and a histrionic personality disorder with compulsive and dependent features. He concluded that the employee=s somatoform disorder reflected a psychiatric condition, and not a physical condition, and that her adjustment disorder and depressed mood had substantially resolved. He found none of those conditions to be related to her work injury. Dr. Gratzer also concluded that the employee was not disabled from a psychiatric perspective, and disagreed with the permanency rating assigned by Dr. Cronin, opining that the employee did not have symptoms or psychiatric impairments relative to depression rising to the level of a 35% Weber rating.
Dr. Stark addressed the opinions of Dr. Gratzer and Dr. Cronin, and, in a letter dated July 25, 2006, summarized his opinion as follows:
I believe this patient has an injury to her SI joint. I believe she has a significant psychosocial overlay. I believe that her psychosocial overlay makes evaluation, conservative, and surgical treatment difficult.
I have reviewed the additional reports of Dr. Grazer and Dr. Cronin. I believe that in some specifics, there are some underlying disagreements about the definition of certain terms, but I believe we all agree on the basic premise that she has psychosocial overlay, which is complicating her recovery. Both the underlying problem and the psychosocial overlay are work related, because they are very tightly and densely interconnected. The psychosocial overlay is a direct result of her injury and the injury is, of course, the result of a work-related mechanism. I believe that, to a reasonable degree of medical certainty, all of this is a result of the June 1996 injury and that she is permanently and totally disabled because of the injury and its secondary effects.
On March 24, 2005, the employee filed a claim petition, seeking the following benefits as a result of her 1996 and 2003 work injuries: temporary total or permanent total disability benefits as of February 11, 2005, medical expenses, and permanent partial disability benefits based on a Weber rating of 35% whole body impairment, related to her psychological condition. The self-insured employer denied liability for the employee=s claims. An evidentiary hearing was held before a compensation judge on August 3, 2006. Evidence included the employee=s extensive medical records and reports from medical consultations, deposition testimony by Drs. Donahue, Friedland, Gratzer, and Cronin, testimony by the employee, and testimony by two of the employee=s co-workers or supervisors employed by the City of St. Paul.
In a decision issued on October 10, 2006, the compensation judge found that the employee had sustained a Gillette injury to her right hand and wrist on June 22, 1995; that she sustained an injury to her low back, left hip, head, neck and right arm on June 7, 1996, as well as an aggravating injury to her low back and left hip in April 21, 2003; and that the employee=s June 7, 1996, injury was a substantial contributing factor in causing or significantly aggravating her psychological condition and diagnosis. The compensation judge awarded payment of medical expenses related to her low back and left hip complaints, reimbursement of the employee=s out-of-pocket expenses, and payment for the treatment rendered by Dr. Cronin. In addition, the compensation judge awarded payment of permanent partial disability benefits based on a Weber rating of 35% whole body impairment. The compensation judge found that the employee had been permanently and totally disabled from employment since February 11, 2005, and awarded benefits between February 11, 2005, and February 17, 2006.
The employer appeals the compensation judge=s finding that the employee=s June 7, 1996, work injury was a substantial contributing factor in causing or significantly aggravating the employee=s psychological condition. Where a work‑related physical injury causes, aggravates, accelerates, or precipitates a mental injury, that mental injury is compensable. See Hartman v. Cold Spring Granite Co., 243 Minn. 264, 271, 67 N.W.2d 656, 660, 18 W.C.D. 206, 212 (1954) (Atraumatic neurosis is compensable if it is the proximate result of the employee's injuries and results in disability"); see also Dotolo v. FMC Corp., 375 N.W.2d 25, 38 W.C.D. 205 (Minn. 1985) (depression that was causally related to a work-related condition of tinnitus was held to be compensable). In order for a mental injury to be compensable, it is not necessary that the work‑related physical injury that caused it is its sole cause; it is sufficient if the work‑related physical injury is a substantial contributing factor. See Miels v. Northwestern Bell Tel. Co., 355 N.W.2d 710, 715, 37 W.C.D. 164, 170 (Minn. 1984).
The employer argues that there is no medical opinion that the employee=s medical condition is causally related to her work injuries, and that substantial evidence does not support the compensation judge=s finding that the employee=s psychological condition is causally related to the employee=s work injury. We are not persuaded.
The employer argues that the employee=s current chronic pain syndrome is not related to the employee=s work injuries and that there is no medical opinion to support the conclusion that they are related. The employer argues that in this medically complex case, the employee must produce a properly founded medical opinion providing a causal relationship between work and the employee=s disability. See Bender v. Dongo Tool Co., 509 N.W.2d 366, 367, 49 W.C.D. 511, 513 (Minn. 1993); Westling v. United Vegetable Farms, slip op. (W.C.C.A. Apr. 29, 2004) (where there was no medical opinion connecting the employee=s pain condition to his work injury, there was no foundation for an opinion that related the employee=s psychological condition from the pain condition to the work injury). In March 1999, however, Dr. Koch, the employee=s primary care physician for a number of years, diagnosed a probable left SI joint instability. He felt this was not a pain control issue, but instead concluded that Athis is an issue of a very clear and obvious gait dysfunction which has not been addressed and it is very clearly related to a work related injury of June 19, 1996.@ Dr. Koch continued to oversee the employee=s treatment and maintained his opinion that the employee=s left SI joint instability or condition, and related symptoms, were causally related to her 1996 work injury. In his report of July 16, 2004, Dr. Koch reiterated that he had been kept apprised of the employee=s ongoing difficulties with her work-related injury, and that he had made evaluations and recommendations himself. He diagnosed a chronic sacroiliac joint strain, and referred to the possibility that the employee also had some injury to her hip musculature as well.
Dr. Stark also concluded that a causal relationship existed between the employee=s June 1996 injury and her ongoing symptoms and condition. In July 2005, Dr. Stark concluded that the employee did not have a treatable orthopedic problem but that she had a Asignificant conversion of her previous 1996 injury,@ that had resulted in unusual complaints of pelvic instability. In his report of July 25, 2006, he concluded that the employee had both Aan injury to her SI joint@ and a Asignificant psychosocial overlay,@ both of which were work-related and were Avery tightly and densely interconnected.@ Dr. Stark=s opinion was well-founded. As he commented in his report of July 12, 2005, Dr. Stark had seen the employee for several consultations and imaging techniques and had been made aware of the opinions generated by various physicians and Athe very complex, long-standing history that she has had over multiple visits and multiple orthopedic complaints with multiple practitioners.@ There are adequately founded medical opinions in the record, including those of Drs. Stark and Koch, that the employee=s chronic pain condition is causally related to her work injuries.
The employer also argues that substantial evidence does not support the compensation judge=s finding that the employee=s psychological condition is causally related to the employee=s work injuries. There is conflicting evidence in the record on this issue. Dr. Flood concluded that the employee Amay have sustained a lumbosacral/SI strain superimposed on top of some degenerative lumbar disc disease@ but felt there was nothing in the medical records to support a true physiological or anatomical dysfunction of her hemipelvis and left SI joint. He concluded that the employee=s history of a personality and somatoform disorder, coupled with her depression and anxiety, limited her ability to deal with the problem in her left SI/hip area. Dr. Gratzer diagnosed the employee with a somatoform disorder, NOS; a history of adjustment disorder with mixed anxiety and depressed mood, resolved; and a histrionic personality disorder with compulsive and dependent features. He concluded that the employee=s somatoform disorder reflected a psychiatric condition, and not a physical condition, and that her adjustment disorder and depressed mood had substantially resolved, and that none of those conditions to be related to her work injury. Dr. Gratzer opined that the employee was not disabled from a psychiatric perspective.
Dr. Cronin, a psychologist, assessed a pain disorder associated with both psychological factors and a general medical condition along with dysthymic disorder, and psychosocial environmental problems, including problems with occupation, economic problems and problems related to the interaction with the legal system. Dr. Cronin concluded that the employee was exhibiting an emotional reaction to her work-related injuries, in the form of depression, that she met the criteria for chronic pain syndrome, and that her current symptoms were directly and causally related to the employee=s June 7, 1996, and April 21, 2003, work injuries.
The employer argues that there must be a Amedical opinion@ as opposed to a psychological opinion to connect a psychological condition to a work injury, citing Westling v. United Vegetable Farms, slip op. (W.C.C.A. Apr. 29, 2004). In that case, this court concluded that an opinion from a psychologist did not support a finding that the employee=s psychological condition was causally related to the employee=s work injury. However, that opinion was not rejected by the court because it was made by a psychologist, but because the opinion lacked foundation. There is no case law indicating that the required medical opinion connecting a psychological condition to a work injury must be made by a medical doctor instead of a psychologist. Dr. Cronin met with the employee on at least nine occasions for evaluation, testing and consultation, and, as documented in his report, reviewed multiple medical records documenting the employee=s medical history. Dr. Cronin=s opinion had adequate foundation, and the compensation judge could reasonably rely on his opinion when reaching her conclusions. In addition, as outlined above, the record contains medical opinions, from the employee=s treating physicians, that her psychological condition was causally related to her work injury.
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 addition, it is the compensation judge's responsibility, as trier of fact, to resolve conflicts in expert testimony. Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985). The compensation judge accepted Dr. Cronin=s opinion concerning the causal relationship between the employee=s work injury and her psychological condition. In addition, Dr. Stark opined that the employee=s underlying problem and the psychosocial overlay are work-related, because the psychosocial overlay is a direct result of her injury and the injury is the result of a work-related mechanism. Dr. Koch agreed with that assessment. We acknowledge that the record contains medical opinions that support the position and defenses raised by the self-insured employer. The issue on appeal, however, is whether there is adequate evidence in the record to support the compensation judge=s resolution of this factual issue. This court must determine whether the findings of fact and the 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, 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). Under the court=s standard of review, a compensation judge=s findings of fact should not be disturbed 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, 229 N.W.2d. 521 (1975). Upon review of the record as a whole, we conclude that substantial evidence of record supports the compensation judge=s finding that the employee=s June 7, 1996, work injury was causally related to her psychological condition, and we affirm.
Permanent total disability
The compensation judge found that the employee has been permanently totally disabled since February 11, 2005, as a result of her work-related psychological condition. An employee is permanently totally disabled if his or her physical condition, in combination with his or her age, training, and experience, and the type of work available in the community, causes the employee to be unable to secure anything more than sporadic employment resulting in an insubstantial income. Schulte v. C. H. Peterson Constr., 278 Minn. 79, 83, 153 N.W.2d 130, 133-34, 24 W.C.D. 290, 295 (1967). A determination of permanent total disability therefore has both a medical and a vocational component. See McClish v. Pan-O-Gold Baking Co., 335 N.W.2d 538, 36 W.C.D. 133 (Minn. 1983).
The employer argues that since the employee was able to work over nine years after her 1996 work injury with no significant change in her condition, substantial evidence does not support the compensation judge=s finding that the employee is permanently and totally disabled as a result of her work-related psychological condition. Whether an employee has met the burden of proving permanent total disability is ultimately a question of fact for the compensation judge. See Atkinson v. Goodhue County Co-op Elec. Ass=n, 55 W.C.D. 150, 160 (W.C.C.A. 1996). Dr. Koch opined that the employee=s condition was musculoskeletal in nature consisting of SI joint pain and hip dysfunction, and that despite extensive treatment, her disability with ambulation and her chronic pain had persisted. Dr. Koch expected no improvement, and, in August 2005, concluded that the employee was Atotally and permanently disabled from engaging in any substantial gainful activity.@ He related the employee=s conversion reaction to her work-related injury of June 7, 1996. Dr. Karayusuf diagnosed the employee with depression, a severe somatization disorder, along with a personality disorder with dependent and histrionic features, and opined that the employee=s condition would not Awork out in a job setting.@ Dr. Stark concluded that the employee had a disabling orthopedic injury in 1996 which had manifested itself in a conversion disorder and that her remarkably disabling psychological condition disqualified her from employment, and therefore she was permanently and totally disabled as a result of her 1996 injury. Based on the extensive medical records in evidence, we conclude that evidence in the record amply supports the compensation judge=s finding that the employee is permanently and totally disabled, and we affirm.
Carpal tunnel injury
The employer also claims that substantial evidence does not support the compensation judge=s finding that the employee sustained a work-related carpal tunnel injury. The compensation judge found that the employee sustained a work-related Gillette injury to her right hand and wrist on or about June 22, 1995, as a result of her work activities with the employer. A Gillette injury is an injury resulting from repeated trauma or aggravation of a preexisting medical condition. Such a condition becomes compensable when the cumulative effect is sufficiently serious to disable an employee from further work. Gillette v. Harold, Inc., 257 Minn. 313, 321-22, 101 N.W.2d 200, 205-06, 21 W.C.D. 105, 111-13 (1960); Carlson v. Flour City Brush Co., 305 N.W.2d 347, 350, 33 W.C.D. 594, 598 (Minn. 1981). A finding as to a Gillette injury is primarily dependent on the medical evidence. See Marose v. Maislin Transp., 413 N.W.2d 507, 40 W.C.D. 175 (Minn. 1987).
In 1998, the employee underwent a right carpal tunnel release performed by Dr. Donahue. The operative report indicated that a lipomatous tumor was growing over the median nerve, which was removed. She returned to work after the surgery, but had ongoing symptoms. In May 2000, Dr. Donahue performed a tendon transfer in the employee=s thumb. Dr. Flood concluded that the employee suffered from carpal tunnel syndrome and right thumb weakness and dexterity problems, but opined that those symptoms and that condition were not related to work. The employee reportedly had undergone right carpal tunnel release 25 years earlier. Dr. Friedland opined that the employee could not redevelop carpal tunnel after having prior carpal tunnel release surgery, unless she developed scars or a fibrotic reaction, which was not noted, and that the employee=s symptoms were caused by the lipoma pressing on the carpal nerve, which also caused damage requiring the tendon transfer, and that therefore this condition was not work-related.
Dr. Donahue indicated that during the carpal tunnel release surgery in 1998, he had excised fatty tissue from the surface of the nerve, but that the pathologic diagnosis was fatty degeneration with fibrosis, not a discrete lipoma or cyst. He opined that repetitive motion could cause fibrosis and subsequent degeneration of median nerve function causing carpal tunnel syndrome, and that the employee=s repetitive work activities were a significant aggravating factor in her recurring carpal tunnel syndrome. After the surgery, the employee had weakness in her right thumb. Dr. Donahue opined that weakness and atrophy of the thenar muscle is a later stage symptom of carpal tunnel syndrome and that this was a continuation of her original problem.
The court was presented with opposing medical opinions as to whether the employee sustained a Gillette injury in 1995, and it is the responsibility of the compensation judge, as the trier of fact, to resolve such conflicts in expert testimony. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). The compensation judge adopted Dr. Donahue=s opinion and concluded that although Dr. Donahue had removed fatty tissue at the time of the employee=s carpal tunnel release, the tissue was found not to compress the carpal tunnel, and that the type of tissue found was consistent with chronic irritation of the area and carpal tunnel syndrome. Based on the medical evidence in the record documenting the employee=s symptoms and medical treatment, the compensation judge reasonably relied on Dr. Donahue=s causation opinion. Substantial evidence supports the compensation judge=s finding that the employee sustained a work-related Gillette injury to her right hand and wrist on or about June 22, 1995, as a result of her work activities with the employer. Accordingly, we affirm.
 The record contains no contemporaneous reports of that earlier surgery.
 A Aconversion@ is defined as an unconscious defense mechanism by which the anxiety that stems from intrapsychic conflict is converted and expressed in a symbolic somatic (bodily) manifestation. Dorland=s Illustrated Medical Dictionary 400, 1663 (29th ed. 2000).
 The term Asomatoform@ denotes physical symptoms that can not be attributed to organic disease and appear to be of psychic origin. Dorland=s Illustrated Medical Dictionary 1663 (29th ed. 2000).
 A histrionic personality disorder is defined, in part, as a personality disorder marked by excessive emotionality and attention-seeking behavior. Dorland=s Illustrated Medical Dictionary 1361 (29th ed. 2000).
 See Weber v. City of Inver Grove Heights, 461 N.W.2d 918, 43 W.C.D. 471 (Minn. 1990) and Minn. Stat. ' 176.105, subd. 1(c).
 Medical records in evidence included those cited in the background section as well as records from multiple other providers, including various medical personnel at HealthPartners, United Occupational Health, Fairview University Medical Center, Spectrum Physical Therapy, St. Anthony Park Clinic, Orthopaedic Sports, University EN&T, Courage Center, Dr. Victor Corbett, St. Paul Radiology, BodyWorks Physical Therapy, Suburban Imaging, Dr. Walter Bailey, NovaCare, Therapy Partners, Preferred WorkCare, and Dr. John Wilson.
 The employee=s claim for permanent total disability (PTD) benefits was limited to this time period. Due to the employee=s receipt of Social Security disability income and PERA retirement benefits, the employee=s PTD benefits would be entirely offset after receipt of $25,000.00 in PTD benefits, a level that would be reached by February 17, 2006. See Minn. Stat. ' 176.101, subd. 4a.