SHARLENE L. NAGLE, Employee/Appellant, v. LIFEWORKS SERVS., SELF-INSURED, adm=d by BERKLEY RISK ADM=RS CO., Employer, and THE MINNEAPOLIS CLINIC OF NEUROLOGY, BLUE CROSS/BLUE SHIELD OF MINN., UNITED PAIN CTR., and UNITED HOSPS., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
APRIL 27, 2007
CAUSATION - MEDICAL TREATMENT; EVIDENCE - EXPERT MEDICAL OPINION. Substantial evidence, in the form of a well-founded medical opinion, supports the compensation judge=s determination that the employee=s work injury was not a substantial contributing factor to her need for medical care.
Determined by: Stofferahn, J., Johnson, C.J., Pederson, J.
Compensation Judge: Gary M. Hall
Attorneys: Gregg B. Nelson, Nelson Law Offices, Inver Grove Heights, MN, for the Appellant. Timothy P. Jung and Kathleen M. Daly, Rider & Bennett, Minneapolis, MN, for the Respondent.
DAVID A. STOFFERAHN, Judge
The employee appeals from the compensation judge=s determination that her work injury was not a substantial contributing factor in her need for medical care. We affirm.
On March 12, 1996, Sharlene L. Nagle, the employee, was working at Lifeworks Services, a company that provided various services to physically and mentally challenged individuals. She was walking with a client and holding on to the client=s belt when the client had a seizure and began to fall. Ms. Nagle tried to support the client and in doing so felt a pulling-type of pain in her right arm, shoulder, and the right side of her neck. Ms. Nagle had also had a similar occurrence about six months previously.
After the more recent incident, Ms. Nagle sought medical care at the Allina Clinic in Plymouth. She was referred from there to the Minneapolis Clinic of Neurology where she saw Dr. Jessica Heiring on April 15, 1996. The employee=s primary complaints were of numbness in forearm and hand, and she also noted coldness and discoloration in her right arm. She had some shooting pain in her right elbow. After examining the employee, Dr. Heiring concluded the employee,
. . . is suffering from a cervical myofascial pain syndrome along with right arm pain, temperature change and swelling. Given the type of injury she suffered, one would wonder if she could have stretched her brachial plexus as she is having numbness in the hand. I do think an EMG should be done to look for evidence of underlying nerve injury. She appears to be developing symptoms consistent with reflex sympathetic dystrophy given the way she avoids using the right arm and the color and temperature changes she describes.
Medication, physical therapy and an EMG to look for nerve injury were recommended. The EMG was done on April 22, 1996, and was interpreted by Dr. Heiring as being within normal limits. Dr. Heiring saw the employee twice more in 1996 and provided Lidocaine injections with continuing physical therapy.
The employee testified that she continued to work at Lifeworks with restrictions until March 1997 when she moved to Shakopee and discontinued her job with Lifeworks because of the commute. The nature of the employee=s employment from that point to the date of hearing is not clear from the record. The employee did not make a claim for wage loss benefits.
The employee returned to Allina in January 1997 when she complained of worsening symptoms in her right arm. Exercises were recommended. The employee did not treat again for her right arm until she returned to Dr. Heiring on August 11, 1998. The employee reported that her symptoms since 1996 had come and gone on an intermittent basis but that over the previous month or so her symptoms were more steady with an aching in her right shoulder which intensified with activity. She told Dr. Heiring that her present symptoms were aching in the right lateral neck and shoulder. After the examination, Dr. Heiring concluded:
Ms. Nagle continues to suffer from cervical myofacial pain syndrome with intermittent symptoms of referred pain into the right arm. She does not seem to be having any significant RSD-type symptoms any longer, though she does describe an occasional cool feeling going into the arm. I do not see any new neurologic problems, only the disuse atrophy of the upper shoulder girdle muscles, which I believe is from using her left arm much more than her right as her reflexes and strength testing appear normal.
Dr. Heiring recommended physical therapy.
The employee returned to Dr. Heiring in April 1999 and reported that the physical therapy had helped her symptoms. Dr. Heiring recommended that the employee try to progress to the Back to Fitness conditioning program by increasing her work on the upper back and shoulder. When the employee returned to Dr. Heiring in December 1999, however, she advised the doctor that physical therapy had caused her symptoms to flare up. She still had constant tightness in the right lateral neck and shoulder with aching in the right arm as well as headaches. She still had coolness and swelling in the right hand at times. Dr. Heiring commented,
Ms. Nagle continues to suffer from cervical myofascial pain syndrome with intermittent RSD-type symptoms into the right arm. Her neurologic exam remains normal and I really think at this point and time she has reached maximum medical improvement. She really has plateaued in terms of the conservative interventions that we can try. At this point she states she is aware that she has a chronic pain problem.
Dr. Heiring recommended medication to help the employee deal with the pain and also rated her as having a 7% permanent partial disability.
In November 2000 and March 2001, the employee treated at the Allina Clinic in Shakopee for her right arm, shoulder, and neck symptoms. She received cortisone injections on both occasions. She saw Dr. Aubrey Schock at Allina Clinic in Hastings in September 2001 for additional injections. On exam, Dr. Schock found tightness in the mid trapezial region and right paracervical region. The employee returned to Dr. Schock in February 2002 for additional steroid injections. Similar appointments with injections took place in July and December 2002 and in July 2003.
Dr. Heiring saw the employee on September 15, 2003, for the first time since January 2000. Dr. Heiring noted the continuing headaches as well as neck and shoulder pain and also referenced a Anew complaint over the last month of numbness and tingling radiating down the right arm starting in the elbow region and radiating down to the fingers.@ Dr. Heiring=s conclusion was that the employee was Asuffering from right upper extremity numbness of unclear etiology.@ An EMG was recommended. Dr. Heiring did not prescribe physical therapy since that had previously aggravated the employee=s symptoms. Instead, Dr. Heiring recommended medication and referred the employee back to Dr. Schock for continuing care. The EMG of the right upper extremity was normal.
The employee saw Dr. Schock in April 2004 and April 2005 for her right neck, shoulder and arm pain. She was given steroid injections. Follow-up appointments with injections were in September and November of 2005.
The employee consulted with Dr. Jonathan Braman at University Orthopedics on December 5, 2005, at the recommendation of Dr. Schock. The employee=s symptoms of right neck, arm and shoulder pain were those that she had reported previously to her doctors. She also reported to Dr. Braman that she had pain in her scapula. The radiographic studies were non-diagnostic. Dr. Braman=s assessment was of RSD. He stated that she had a Apretty profound@ problem which was outside of his area of expertise. He recommended pain management and referred her back to Dr. Schock.
The employee was referred to the United Pain Center on February 6, 2006, where she saw Dr. Edrie Kioski. Dr. Kioski=s conclusion was that the employee had myofascial pain syndrome involving muscles of the cervical paraspinal area and trapezius supraspinatus. For this condition, Dr. Kioski recommended muscle relaxant medication and other pain treatment modalities such as the use of TENS unit. Dr. Kioski also stated that the employee had a history of complex regional pain syndrome. He made this diagnosis from Dr. Heiring=s notes, but stated that he could find no evidence for it on examination. Medication was recommended for what he perceived as some intermittent symptoms connected to this syndrome. Trigger-point injections were also prescribed for both conditions.
Dr. Joel Gedan evaluated the employee on behalf of the self-insured employer on May 22, 2006. Dr. Gedan took a history from the employee, conducted an examination, and reviewed medical records. Dr. Gedan concluded that the March 1996 work injury was a right cervical, upper trapezius, and shoulder strain. He found no indication in the records or on examination that the employee had any type of neurologic abnormality, including RSD. Dr. Gedan further opined that the soft-tissue work injury had resolved by December 1999, based on Dr. Heiring=s records and that after that date, the employee was not in need of medical care or work restrictions.
The parties disputed the reasonableness and causation of medical expenses incurred by the employee for treatment of her right neck, shoulder and arm symptoms. The employer paid for no medical expenses after October 1999. The dispute was heard by Compensation Judge Gary Hall on October 18, 2006. In his findings and order of November 6, 2006, the compensation judge concluded,
Based on a preponderance of the evidence it is determined that the disputed medical treatment was not reasonable, necessary or causally related to any work related condition. Dr. Gedan=s opinion was found to be most persuasive and is adopted by this court.
The employee appeals.
1. Foundation For Dr. Gedan=s Opinion.
The employee argues that the opinion of Dr. Gedan lacked foundation and that, as a result, it was error for the compensation judge to rely on that opinion in making his determination. Specifically, the employee argues foundation was lacking because the medical records which were referenced in his report and which would have been relied upon by Dr. Gedan were not introduced into evidence by the employer.
The employee does not identify the records reviewed by Dr. Gedan which were not introduced into evidence. This argument was not made before the compensation judge and from a review of Dr. Gedan=s report it appears that medical records he referred to are included in the record. According to the employee, however, Dr. Gedan states in his report that the employee=s medical records do not contain a firm diagnosis of RSD. The employee argues that this statement is incorrect. First of all, we do not find any such statement by Dr. Gedan in his report. Dr. Gedan stated, that in his opinion, there were no objective findings in the records to support a diagnosis of RSD. In his review of the records, however, he did refer to such a diagnosis being made at times by some of the employee=s treating doctors. Second, while a medical opinion must be based on evidence, we do not believe that an alleged failure by a party to place into evidence every piece of paper in the medical records makes the opinion one without foundation.
We conclude Dr. Gedan=s opinion had adequate foundation and that it was not error for the compensation judge to rely on the opinion in making his determination. Cull v. Wallmart Stores, Inc., 64 W.C.D. 262 (W.C.C.A. 2004).
2. Nature of the Employee=s Injury.
The employee also argues that the compensation judge placed an improper burden on her in establishing her case. According to this argument, the compensation judge=s decision was based on his determination that the employee=s claim depended on the establishment of a diagnosis of RSD. The compensation judge=s conclusion that the employee did not have RSD led to his denial of the employee=s claim. We think this is a misreading of the compensation judge=s decision.
The question in a case such as this is whether the work injury is a substantial contributing factor to the need for treatment. While an appropriate diagnosis is important for appropriate medical care, the question for a compensation judge is not whether the employee=s doctors have correctly diagnosed the employee=s condition but, instead, whether the employee has established a causal relationship between the work injury and the condition. Fisher v. Saga, 463 N.W.2d 501, 43 W.C.D. 559 (Minn. 1990). The employee points out that she has had virtually the same symptoms ever since her injury but that does not relieve the employee of the obligation to establish the causal connection between the injury and the need for treatment. Determining whether the employee has made that connection is a fact question for the compensation judge which this court will affirm if supported by substantial evidence. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984).
In Findings 6, 7, and 8, the compensation judge noted the differing opinions among the treating doctors as to the employee=s condition, including the possible diagnosis of RSD. He also noted Dr. Gedan=s disagreement with those opinions. Dr. Gedan based his opinion on the lack of objective findings on examination, the lack of abnormalities in the EMGs, and the fact that the employee=s symptoms had continued for more than 10 years since the work injury with no improvement from any type of treatment. We find substantial evidence in the record, in the form of Dr. Gedan=s opinion, to support the compensation judge=s determination that the employee failed to establish a relationship between her work injury and her medical treatment.
The decision of the compensation judge is affirmed.
 The terms RSD, reflex sympathetic dystrophy, and complex regional pain syndrome are used interchangeably in the employee=s records.
 3.5% under 5223.0370, subp. 3.B. for cervical pain syndrome and 3.5% under 5223.0370, subp. 4.B. for radicular pain or paresthesia associated with the cervical condition.