DAWN M. CLEVENGER, Employee/Appellant, v. INDEPENDENT SCH. DIST. #252, SELF-INSURED/BERKLEY RISK ADM’RS CO., Employer, and BLUE CROSS BLUE SHIELD OF MINN., MAYO CLINIC, and FAIRVIEW RED WING CLINIC, Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
OCTOBER 23, 2008
TEMPORARY BENEFITS - FULLY RECOVERED. Where it was supported by the employee’s medical record, including the opinions of medical experts, the compensation judge’s conclusion, that the employee’s work injury was limited to a fully resolved left ankle sprain and contusion and left thenar contusion, was not clearly erroneous and unsupported by substantial evidence.
CAUSATION - PSYCHOLOGICAL CONDITION. Where there was evidence including the opinion of medical experts that the employee’s psychological problems might be related to her workers’ compensation litigation but were not related to any physical pain consequent to her work injury, the compensation judge’s denial of benefits directly related to the employee’s psychological condition was not clearly erroneous and unsupported by substantial evidence.
PRACTICE & PROCEDURE - MATTERS AT ISSUE. Where it was apparent that the nature and extent of the employee’s left ankle injury were clearly at issue before the compensation judge, and where the judge concluded that the employee’s ankle injury had fully resolved by a given date, the fact the employer had voluntarily paid benefits subsequent to that date did not preclude the judge’s finding that the employee’s work injury had fully resolved by a date prior to that on which the employer stopped voluntarily paying benefits, nor was the judge’s finding to that effect unnecessarily broad or unfairly prejudicial to the employee’s future entitlement to benefits.
Determined by: Pederson, J., Wilson, J., and Stofferahn, J.
Compensation Judge: James F. Cannon
Attorneys: Charles A. Bird, Bird, Jacobsen & Stevens, Rochester, MN, for the Appellant. Charlene K. Feenstra, Heacox, Hartman, Koshmrl, Cosgriff & Johnson, St. Paul, MN, for the Respondent.
WILLIAM R. PEDERSON, Judge
The employee appeals from the compensation judge’s finding that she had fully recovered from her January 27, 2005, work-related left ankle injury as of September 23, 2005, with no need for work restrictions or ongoing medical care and treatment, and from the judge’s finding that she did not sustain a consequential psychological injury. We affirm.
On January 27, 2005, Dawn Clevenger [the employee] sustained a work-related left ankle injury and associated injuries to her left side, when she misstepped and fell on stairs in the school library in the course of her job as a special education paraprofessional with the Cannon Falls school district, Independent School District #252 [the employer], which was at the time self-insured against its workers’ compensation liability. At the time of her injury, the employee was forty-five years old, having worked for the employer for about twelve years, and was working in the elementary school, providing personal care and supervision on a one-on-one basis for physically challenged students. About two weeks before her injury, the employee had submitted a letter of resignation to the employer, in which she indicated her intent to change careers to work with her husband in his insurance and financial planning business. She had intended her last work day with the employer to be February 18, 2005.
The employee sought medical treatment on the day of her injury with Dr. Mark Sprangers at Fairview Red Wing Medical Center. X-rays of the left ankle showed mild degenerative change at the ankle joint but no fracture. Dr. Sprangers diagnosed a contusion and sprain of the left ankle and recommended that she apply ice packs to the medial side of the ankle. The employee declined pain medication, and Dr. Sprangers restricted her from working, with instructions to use an ankle support for comfort and protection. The employer admitted liability for the employee’s injury and commenced payment of temporary total disability benefits effective January 28, 2005.
The employee began physical therapy and started using a CAM walker support on February 3, 2005, and she returned to see Dr. Sprangers on February 10. At that visit, she described a marked reduction in her left lower leg and ankle symptoms, with less swelling and less pain and no numbness or tingling into any of the digits of her left foot. The doctor recommended that she remain off work, continue with therapy, and use Tylenol if needed for discomfort.
On March 1, 2005, the employee reported to Dr. Sprangers that she had been wearing the left leg CAM support and that her pain was reduced, and on examination Dr. Sprangers observed that “[s]he has essentially resolved the swelling previously present in the left lower extremity at the ankle.” She no longer had any erythema at the ankle, but she did have some pain with palpation at the lateral distal tibia. The doctor released her to return to full-time work, with restrictions against more than occasional standing and against walking more than four hours in an eight-hour day.
On March 16, 2005, Dr. Sprangers concluded that the employee’s contusion to her left ankle had resolved, but because of continued sprain symptoms he recommended an orthopedic consultation with Dr. Everett Hughes. When she saw Dr. Hughes on April 4, 2005, the employee reported some improvement in her left ankle but that she still had considerable discomfort on the medial side. Dr. Hughes was concerned about a possible posterior tibial tendon tear and requested an MRI of the ankle to evaluate this possibility. The MRI was performed on April 26, 2005, and, upon review with the employee the following week, the doctor noted that the ligaments appeared intact but that there appeared to be some increased fluid surrounding the distal tibialis posterior tendon. He concluded that this could represent tenosynovitits, but he saw no distinct tear.
Almost two months later, on June 27, 2005, Dr. Hughes noted that the employee was still reporting a “gnawing” pain mostly on the medial side of her ankle around in the area of “a leftover hemosiderin staining from a bruise.” He noted that the employee complained of tenderness to palpation along the medial aspect of the ankle and that there was some minimal diffuse swelling in this region. Dr. Hughes had no explanation for the employee’s persistent ankle pain, and he recommended a referral to foot and ankle specialist Dr. J. Chris Coetzee at TRIA Orthopaedic Center in Bloomington.
On July 8, 2005, the employee was seen by her primary care physician, Dr. John Walsh. She reported longstanding problems with her ankle of moderate severity, and she described symptoms of depression evidently exacerbated by “work comp complications.” Dr. Walsh diagnosed depressive disorder and started the employee on Lexapro. About a month later he referred the employee to psychologist and clinical nurse specialist Dr. Judith Scott.
In the meantime, the employee continued with physical therapy as prescribed by Dr. Hughes. On Tuesday July 26, 2005, the therapist noted that the employee had described an increase in her ankle pain in the past week, including a constant burning on the medial side, but that it had gotten better by the weekend and was now gone. The therapist observed that the employee was wearing an ankle brace and that her range of motion was within normal limits.
The employee met with Dr. Scott on August 11, 2005. Under a section of her report entitled, “current stressors,” Dr. Scott described the employee as “in the midst of a very difficult workman’s compensation case. She has been laid off due to an injury sustained last March. Money is tight and she is quite fearful.” Dr. Scott diagnosed generalized anxiety disorder with depressed mood, and she modified the employee’s medications. She also referred the employee to Dr. David Roseen, a psychotherapist, for one-to-one counseling, “in order to manage some of the stress that is upon her.” Dr. Scott continued periodically to see the employee for medication management up to the time of the hearing.
The employee was seen by Dr. Roseen on August 15, 2005. In the initial intake note, the employee described herself as having trouble coping with all of the people that were then in her life and the fact that she had to keep sharing information about herself that she would rather not share. Dr. Roseen’s diagnosis was adjustment disorder with anxiety and depression.
The employee was examined by Dr. Coetzee on September 1, 2005. Dr. Coetzee obtained a history, performed a physical examination, and reviewed the employee’s MRI scan and x-rays. On examination, the doctor noted that the employee had 5/5 strength in all muscle groups of the lower extremity bilaterally and that sensation was also intact bilaterally. The doctor also observed a hemosiderin deposit on the left medial aspect of the leg consistent with her injury, with some tenderness to palpation and mild swelling over this area. He noted that the employee’s MRI revealed no obvious muscular tenderness or ligamentous or bony injuries and that her plain x-rays appeared essentially normal. Dr. Coetzee diagnosed an injury to the left lower extremity in January with no significant improvement, and he recommended a CT scan to further evaluate the structure of the ankle. He also diagnosed depression and recommended that the employee seek some psychiatric help.
The employee underwent a CT scan of the left ankle and distal tibia at the Center for Diagnostic Imaging [CDI] on September 9, 2005. The radiologist at CDI issued a report to Dr. Coetzee on the CT scan, as well as an addendum report regarding the employee’s April 26, 2005, MRI of the left ankle. In a chart note dated September 23, 2005, Dr. Coetzee stated the following:
I reviewed the MRI that was done September 9, 2005. The MRI was available for review. It confirms the previous sprain to the left ankle that has healed completely. There is no osteochondral injury to the ankle joint itself. There is also no ongoing soft tissue or bony abnormality.
This confirms the clinical impression that she sustained direct injury to her distal tibia at the time of her fall. This, however, healed completely and there is no sign of ongoing injury or any inflammatory response at the ankle.
There is, therefore, nothing that I can offer at this stage. I would suggest that she go through a work hardening program to improve her strength and endurance, and return to work as soon as she reaches a comfortable level. It might also be worthwhile to do a functional capacity evaluation to assess her current capacity.
There is nothing that I can offer from an orthopaedic point of view.
The employee continued to complain of left ankle pain, and Dr. Hughes arranged for an evaluation by a second foot and ankle specialist, Dr. Fernando Pena, at the University of Minnesota Medical Center. Dr. Pena examined the employee on April 4, 2006, and reviewed the employee’s MRI and CT scans. He diagnosed “ankle pain of unknown etiology” and recommended a bone scan to eliminate any possibility of a bony source for the employee’s pain. A week later, after undergoing the bone scan, Dr. Pena explained to the employee that the test was negative for any type of increased uptake along the medial malleolus of the left ankle, where she reported her pain. His assessment remained “left ankle pain of unknown etiology,” but he added that her pain was possibly neurogenic in nature. Dr. Pena noted that “[i]t was discussed with the patient in the presence of her QRC for no less than half an hour that at this point I do not have any significant theory for the source of her pain.”
Two months later, on June 12, 2006, the employee returned to see Dr. Hughes, complaining of numbness and tingling in her foot and pain at the ankle region. Dr. Hughes indicated that he thought “her injury [was] difficult to complete[ly] ascertain.” Considering the employee’s complaint of numbness and tingling, he concluded that a neurology consultation would be appropriate before she underwent any further treatment. He also agreed with a plan to take a more comprehensive approach to her treatment by having her see a physical medicine and rehabilitation doctor at the Mayo clinic and perhaps consider the possibility of a chronic pain management clinic.
On July 27, 2006, the employee was examined at the request of the employer by orthopedic specialist Dr. Scott McGarvey. In a report dated August 4, 2006, Dr. McGarvey indicated that he found it difficult to provide a specific diagnosis in this case. He stated that the employee exhibited behavior of a chronic pain syndrome, but he found no evidence of reflex sympathetic dystrophy. She had localizing tenderness along the posterior tibialis muscular insertion of the distal tibia. He felt that she would benefit from a pain clinic evaluation with the possibility of trigger point injections for her medial leg and ankle pain. He did not believe that the employee had reached maximum medical improvement [MMI] from her injury, but he felt that she was capable of working full-time at a sedentary job.
Throughout this time, the employee continued to be seen by Drs. Scott and Roseen at Fairview Behavioral Health Services. In a brief letter responding to the employee’s attorney on September 12, 2006, Dr. Scott stated, “I think that my most honest statement about [the employee’s] condition is that situational stressors worsened her depression and anxiety.” And on October 31, 2006, Dr. Scott wrote, “I do see [the employee’s work-related injury] as a cause of increased social stressors and a cause in terms of her seeking treatment.”
The following week, on November 6, 2006, Dr. Hughes referred the employee to the Mayo Clinic for evaluation and treatment. In his referral letter, Dr. Hughes noted that MRI and CT scan evaluations of the employee’s left ankle “demonstrate what appear to be old degenerative changes but nothing related to an acute injury.” He noted that most of the employee’s pain was slightly proximal to the ankle, in an area where she had a hemosiderin staining from a bruise related to the injury which had not resolved completely, together with a dent in this region on the medial aspect of her ankle. He stated that he had no further options to offer the employee and that he was looking for help in treating her symptoms.
On November 10, 2006, the employee was seen by Mayo Clinic neurologist Dr. Gregory Cascino. On examination, Dr. Cascino noted that the employee walked with an antalgic gait and limped on the left leg. He indicated that she had diffuse tenderness involving the left ankle and left foot but that he found no outward signs of swelling, redness, or infection in the ankle. His neurologic examination did not reveal any specific abnormality, but examination of the left foot was limited because of pain. Dr. Cascino’s diagnosis included the following: chronic left leg pain, etiology indeterminate; headaches, etiology indeterminate; chronic pain syndrome with associated behavioral changes; anxiety and depression. On November 27, 2006, the employee was seen also by Dr. Jeffrey Rome at the Mayo Pain Rehabilitation Center. Dr. Rome obtained a history from the employee and noted that “[t]he involvement of her left leg appears to have been triggered by an on-the-job injury almost two years ago.” He noted that the possibility of chronic regional pain syndrome [CRPS] had been raised regarding her left leg. After conducting a mental status examination, Dr. Rome diagnosed bilateral lower extremity pain, chronic daily headache, and unspecified depression. He concluded that the employee was a good candidate for intensive, multidisciplinary pain rehabilitation. The employee expressed her concern about privacy issues and her anxiety about becoming involved in a group process.
Around this same time, the employee filed a medical request seeking payment for the psychological treatment provided by Drs. Scott and Roseen, as well as payment for medications and associated medical mileage. The employer denied liability for a psychological injury and for the claimed treatment and expenses. On January 29, 2007, the employer served a notice of intention to discontinue the employee’s temporary total disability benefits, on grounds that it had paid compensation for the statutory maximum of 104 weeks. Also in late January 2007, the employee, who had been working for her husband on a voluntary basis, began working for her husband on a paid basis, ten hours per week at $10.00 per hour.
On February 20, 2007, the employee returned to the Mayo Clinic to be examined by orthopedist Dr. Ryan Pitts. At that visit, the employee complained of “extreme” pain and a burning and tingling sensation at all times in her left leg. On examination, Dr. Pitts found only very mild swelling of the left lower extremity, but he noted that the leg was pale and cool to the touch compared to the right and that the employee exhibited “some early skin changes consistent with CRPS.” He noted no instability of the left ankle and found that the employee had full, pain-free range of motion in it. Dr. Pitts concluded by stating:
I think [the employee] clearly has CRPS on the left. There are no significant physical exam findings or x-ray findings to suggest any problem that could be helped with any surgical intervention. She has MRI and CT scans from the outside hospital which are essentially normal. She has multiple questions and concerns. She is obviously very depressed and anxious and has behavioral changes associated with her pain syndrome. She is very interested in someone “looking around in her ankle and cutting out the problem.” I think at this point that would be a very bad idea. I think she should continue with pain rehabilitation as planned and hopefully she can get some relief of her symptoms.
On February 26, 2007, the employee filed a claim petition seeking payment of temporary partial disability benefits or, in the alternative, permanent total disability benefits continuing from January 29, 2007, as a result of her January 27, 2005, left ankle injury, her chronic pain, and a psychological injury. In its answer to the petition, the employer denied that the employee had sustained a psychological injury causally related to her left ankle injury, and it disputed “the nature and extent of the left ankle injury claimed by the Employee,” together with the employee’s claim to either temporary partial or permanent total disability benefits. On March 21, 2007, a compensation judge issued an order consolidating the employee’s medical request and claim petition for purposes of hearing.
On May 21, 2007, the employee was examined by neurologist Dr. Joel Gedan. Dr. Gedan obtained a history from the employee, reviewed her medical records, and performed a physical examination. In a report on that same date, Dr. Gedan opined that on January 27, 2005, the employee sustained a left ankle sprain and contusion and a left thenar contusion. He reported that her neurological examination was normal and that he was unable to explain the employee’s generalized pain complaints on the basis of any injuries sustained on January 27, 2005. Dr. Gedan did not find any evidence of a medical or a neurological dysfunction, and he stated that the employee’s diagnosis and symptoms were primarily psychiatric and related to severe depression. Nor did he believe that the employee had reflex sympathetic dystrophy or chronic regional pain syndrome. He placed no restrictions on the employee’s ability to work. Because of the employee’s persistent complaints of left ankle pain, Dr. Gedan found the employee’s medical treatment relative to the left ankle and distal lower extremity to be reasonable, necessary, and related to the 2005 injury. He opined, however, that ongoing treatment would no longer be reasonable, necessary, or indicated with regard to injuries sustained on January 27, 2005. Finding the employee’s primary problem to be marked depression, Dr. Gedan recommended that further discussion of treatment be addressed by a psychiatrist. He did not agree with the recommendation of a chronic pain program.
Psychologist Paul Arbisi performed a psychological assessment of the employee at the request of the employer on August 6 and September 10, 2007, issued a report on September 14, 2007, and testified at the hearing. In addition to his interviews of the employee and review of her medical records, Dr. Arbisi administered a Beck Depression Inventory and an MMPI-2. Dr. Arbisi diagnosed “depressive disorder, NOS [not otherwise specified], by history, and R/O [rule out] malingering.” In his opinion, the employee’s work injury was not a substantial contributing cause of her current psychological/psychiatric status. He found her treatment with Dr. Scott and Dr. Roseen to be reasonable but not causally related to the work injury. He did not believe that the employee required any restrictions related to her psychological condition, and he did not agree that a chronic pain program was indicated. Although he had not confirmed a diagnosis of malingering, he felt that the employee presented herself in a non-credible fashion and “appears to have engaged in a deliberate attempt to appear more physically ill than she actually is.” At trial, Dr. Arbisi testified that the employee’s alleged psychological diagnoses had no relationship to a physical injury. If malingering were to be ruled out, he believed that the employee’s depression and emotional disturbances were due to stress surrounding the workers’ compensation process as opposed to being a direct consequence of the work injury. Dr. Arbisi testified also that the employee did not qualify for a permanent impairment rating under the permanent partial disability schedule because she had a functional overlay, which disqualified her for a rating pursuant to Minn. R. 5223.0360, subd. 7D.
In a letter responding to an inquiry from the employee’s attorney on October 11, 2007, Dr. Hughes stated that he agreed that the employee carried a diagnosis of chronic regional pain syndrome causally related to her injury of January 27, 2005. He rated her permanent partial disability at 14% of the whole body under Minn. R. 5223.0420, subp. 6B. He recommended restrictions on her normal daily activities, including limiting her ability to walk, stand, or sit for prolonged periods of time because of pain in her foot and ankle. He concurred also in the suggestion that the employee should be followed by a pain management clinic to help with her chronic pain secondary to the chronic regional pain syndrome.
On October 16, 2007, psychologist David Roseen testified by deposition. He testified that he began seeing the employee in conjunction with Dr. Scott on August 15, 2005, with her last session taking place on October 9, 2007. At the time of his deposition, Dr. Roseen diagnosed the employee with social phobia, neurotic depression, and conversion disorder. Dr. Roseen opined that the employee’s diagnoses were precipitated by the accident that she had experienced on January 27, 2005, and he agreed that the physical injury and restrictions related to that injury played a direct role in the onset and continuing progress of her depression. He did not believe that the employee was malingering. He opined that she suffered from a permanent impairment as a result of her diagnosed conditions, and he rated that impairment at 30% of the body as a whole, splitting the difference between the 20% rating provided by subpart 7D(2) and the 40% allowed by subpart 7D(3) of Minnesota Rules 5223.0360. He found, under the rule, that the employee had a moderate rather than mild emotional disturbance and that she was capable of living independently and relating to others. On cross-examination, Dr. Roseen agreed that the main source of the employee’s anxiety and depression was her fear, worry, and concern over the entire workers’ compensation process. He acknowledged that the employee’s psychological status was directly affected by increased stress, which in turn had a direct affect on her physical status.
On October 21, 2007, Dr. Gedan issued a supplementary report in response to Dr. Hughes’ report of October 11, 2007. Dr. Gedan reiterated his opinion that the employee does not have reflex sympathetic dystrophy and does not qualify for a permanent partial disability rating “in the absence of any objective clinical or radiological findings in the left lower extremity.” In his opinion, the employee does not satisfy any of the criteria necessary for the diagnosis of reflex sympathetic dystrophy.
The employee’s claims came on for hearing before a compensation judge on October 23, 2007. Issues presented to the judge at hearing included the following: (1) the nature and extent of the employee’s left ankle injury of January 27, 2005; (2) whether the employee was temporarily partially disabled from January 29, 2007, and continuing through the date of hearing, due to the work-related left ankle injury; (3) whether the employee was permanently and totally disabled from January 29, 2007, and continuing through the date of hearing, due to the work-related left ankle injury; (4) whether the employee sustained a consequential psychological injury due to the work-related left ankle injury; (5) whether the employee sustained a 14% permanent partial disability as a result of RSD, or chronic regional pain syndrome, and a 30% permanent partial disability as a result of a consequential psychological injury; and (6) whether the employee’s claim for medical expenses, including a recommended chronic pain program, and the claims of the intervenors constitute medical treatment that is reasonable, necessary, and causally related to the employee’s left ankle injury. Evidence submitted at trial included the employee’s voluminous medical and rehabilitation records and testimony from the employee, Russ Clevenger, QRC Roxanne Tarrant, vocational-expert David Berdahl, and Dr. Paul Arbisi.
In a findings and order issued February 5, 2008, the compensation judge concluded that the employee’s left ankle injury was a contusion and sprain of the ankle and a left thenar contusion, which had fully resolved as of September 23, 2005, with no permanent partial disability, no need for ongoing work restrictions, and no need for further medical treatment. He concluded also that the employee did not sustain a consequential psychological injury due to her work-related left ankle injury of January 27, 2005. Consequently, the judge denied the employee’s claims for temporary partial and/or permanent total disability benefits, permanent partial disability benefits, and payment of medical expenses. The employee appeals from the judge’s findings regarding the nature and extent of her left ankle injury, from the judge’s denial of a consequential psychological injury, and from his denial of her claim for medical and mental health care benefits.
STANDARD OF REVIEW
When an appeal is taken from a compensation judge’s factual findings, this court’s review on appeal is limited to a determination of whether the judge’s findings and order are “clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.” Minn. Stat. § 176.421, subd. 1(3) (1992). If, on the other hand, the judge’s factual determinations are adequately supported by substantial evidence, and not clearly erroneous, we must affirm. This court is not a finder of fact, and on appeal the court will not “retry” the factual issues which were before the lower court; thus, it is irrelevant whether different conclusions than those found by the compensation judge could also be reached on the evidence. Substantial evidence supports the findings if, in the context of the record as a whole, they “are supported by evidence that a reasonable mind might accept as adequate.” Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where the evidence conflicts or more than once inference may reasonably be drawn from the evidence, the findings must be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, “[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Factfindings may not be disturbed, even though this court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.” Id.
At Finding 14, the compensation judge found that the employee’s work-related left ankle injury of January 27, 2005, had fully resolved by September 23, 2005, the date of Dr. Coetzee’s follow-up report. At Finding 24, the judge found that the employee did not sustain a consequential psychological injury due to her work-related left ankle injury. And at Finding 29, the judge found that the employee’s claim for payment of medical expenses, including the recommended chronic pain program, her claim for medical mileage, and the claims of the intervenors were not reasonable and necessary and causally related to the work injury. The employee contends that the judge’s conclusions and findings of fact supporting those conclusions are manifestly contrary to the weight of the evidence and must be reversed.
Before addressing the employee’s arguments, we would first note that 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). In the present case, the findings on appeal as identified above revolve substantially around the judge’s resolution of such conflicts. We reiterate that it is not this court’s function to assess whether substantial evidence might support a conclusion contrary to that reached by the compensation judge; our function on factual review is only to assess whether substantial evidence exists to support the conclusion actually reached by the judge. See Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988), quoting Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239 (“whether [the appellate court] might have viewed the evidence differently is not the point, but whether the findings of the compensation judge are supported by evidence that a reasonable mind might accept as adequate”).
1. Nature and Extent of Injury
In finding that the employee’s left ankle injury had fully resolved by September 23, 2005, the compensation judge relied in part on the opinions of foot and ankle specialist Dr. J. Chris Coetzee, to whom the employee had been referred by Dr. Hughes. In his report of September 23, 2005, Dr. Coetzee opined that the employee had “healed completely” from her January 27, 2005, left ankle injury. He found no sign of ongoing injury or any inflammatory response at the ankle, and he stated that he had no treatment to offer from an orthopaedic point of view. The employee argues that the judge’s interpretation of Dr. Coetzee’s September 23, 2005, report is overly broad. She contends as follows: (1) that there is no proof that Dr. Coetzee reviewed the CT scan performed by CDI on September 9, 2005; (2) that CDI’s interpretations of the April 26, 2005, MRI scan and of the September 9, 2005, CT scan show an injury at areas other than the distal tibia; (3) that Dr. Coetzee did not say that the employee was released to return to work without restrictions; (4) that Dr. Coetzee did not say that the employee needed no further medical treatment; (5) that Dr. Coetzee did not say that the employee’s injury fully resolved with no permanent partial disability by September 23, 2005; and (6) that both of the employer’s independent medical examiners - - Dr. McGarvey in August of 2006 and Dr. Gedan in May of 2007 - - found either that ongoing medical treatment was required or that treatment up to the date of his examination had been reasonable and necessary. We are not persuaded.
First of all, it is evident from his office note following his examination of the employee on September 1, 2005, that Dr. Coetzee did review a previous MRI scan, the only previous MRI scan of the employee’s left ankle having been performed on April 26, 2005. At that same September 1, 2005, office visit, Dr. Coetzee ordered a CT scan of the employee’s left ankle and distal tibia, and that CT scan was performed on September 9, 2005, the report on it from the radiologist being addressed to and evidently sent to Dr. Coetzee. While Dr. Coetzee’s office note of September 23, 2005, refers to “the MRI that was done September 9, 2005,” it is apparent when comparing the doctor’s office note to the reported conclusions by the radiologist that Dr. Coetzee was reviewing the CT scan. Dr. Coetzee specifically referred to the absence of an osteochondral injury to the ankle joint itself and the absence of ongoing soft tissue or bony abnormality. These were the same conclusions drawn by the radiologist on the CT scan report. Nor is it reasonable to suppose that Dr. Coetzee would prepare a follow-up report to assess a CT scan that he had not reviewed. While there are other findings reported in the “interpretation” section of CDI’s report, Dr. Coetzee evidently did not find any other findings to be clinically significant. We note also that either the reports of or the actual MRI and CT scans themselves were subsequently reviewed by Drs. Pena, Hughes, Pitts, and Gedan, and no mention was made of any significant scan findings or their relationship to the employee’s injury and her pain complaints.
With respect to the conclusions drawn by the judge from Dr. Coetzee’s September 23 report, we believe the record as a whole supports the judge’s findings. We find no inconsistency between Dr. Coetzee’s statement that the employee’s injury had “healed completely” and the judge’s conclusion that the employee’s injury had resolved with no permanent partial disability, no need for ongoing work restrictions, and no need for further medical treatment. In addition to Dr. Coetzee’s evaluation, the judge noted in his memorandum that he was also influenced by Dr. Pena’s diagnosis of “left ankle pain of unknown etiology,” and the employee’s normal bone scan in April 2006. While Dr. McGarvey thought that the employee might benefit from additional treatment, Dr. McGarvey, too, was unable to provide a specific diagnosis in this case. Moreover, Dr. Gedan opined that the employee had sustained a left ankle sprain and contusion and a left thenar contusion, but he did not find any evidence of a continuing medical or a neurological dysfunction. He was unable to explain the employee’s generalized pain complaints on the basis of any injuries sustained on January 27, 2005. Both Dr. McGarvey and Dr. Gedan concluded that the employee did not have RSD.
We conclude that there is ample evidence in the record, including the medical opinions referenced above, to support the judge’s determination that the employee’s left ankle injury of January 27, 2005, was limited to a sprain and contusion and left thenar contusion that had fully resolved by September 23, 2005. Accordingly, the judge’s determination in this regard is affirmed.
2. Causation - 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, 67 N.W.2d 656, 18 W.C.D. 206 (1954). It is not necessary that the physical injury be the sole cause of the mental injury; it is sufficient if the work-related physical injury is a substantial contributing factor in the mental injury. Miels v. Northwestern Bell Tel. Co., 355 N.W.2d 710, 715, 37 W.C.D. 164, 170 (Minn. 1984). It does not necessarily follow, however, that the physical injury caused the mental injury just because the mental injury followed the physical injury.
In the present case, the employee’s diagnosis has included generalized anxiety disorder with depressed mood, adjustment disorder with anxiety and depression, depressive disorder, social phobia, neurotic depression, and conversion disorder. The issue in this case is whether the employee’s physical injuries have substantially contributed to this psychological condition. While Dr. Roseen and Dr. Arbisi may have agreed that a major source of the employee’s psychological condition is her fear and concern over the workers’ compensation process, these doctors did not agree that the work injury was a substantial contributing factor in that psychological condition. Dr. Arbisi quite clearly did not relate the employee’s psychological condition to the work injury, and the compensation judge was entitled to rely on that opinion. See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) (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). While Dr. Roseen did relate the employee’s psychological injury to the employee’s pain and related loss of function, the judge was not required to accept that opinion. Moreover, the judge noted that Dr. Roseen conceded in his deposition that the employee’s main source of anxiety was her fear, worry, and concern over the workers’ compensation process. This conclusion is also supported by Dr. Scott’s letter of September 12, 2006, wherein Dr. Scott stated that “situational stressors worsened [the employee’s] depression and anxiety.”
We have carefully reviewed the record from Fairview Red Wing Behavioral Health and the testimony of Dr. Roseen. The record as a whole more than adequately supports the judge’s conclusion that the employee’s psychological problems are not substantially related to her work-related physical pain. This conclusion is also supported by the expert testimony of Dr. Arbisi. Although there is arguably a kind of chain of causation between the employee’s work injury and her need to cope with complications that typically accompany the litigation process, conditions resulting from such indirect causal relationships are generally not compensable as workers’ compensation injuries. See, e.g., Koenig v. Northern Insulation Co., 358 N.W.2d 644, 37 W.C.D. 266 (Minn. 1984) (aggravation of ulcer condition was not compensable where it was a result of employee’s experience with his QRC, the requirements of job search and reporting, and the necessity of litigation); Hendrickson v. George Madsen Constr. Co., 281 N.W.2d 672, 31 W.C.D. 608 (Minn. 1979) (heart attack sustained while pursuing workers’ compensation claim in court was not compensable); Melartin v. Mavo Sys. Inc., No. WC04-328 (W.C.C.A. May 5, 2005) (aggravation of pre-existing alcoholism by time off after work injury was not compensable). We find this case factually similar to the cases cited above. Substantial evidence supports the compensation judge’s decision that the employee’s work injury was not a substantial contributing factor in the development of the employee’s psychological condition. That decision must, therefore, be affirmed. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).
3. Medical Benefits
We have affirmed the compensation judge’s conclusion that the employee’s left ankle injury of January 27, 2005, had fully resolved by September 23, 2005, with no need for further medical treatment. The employee contends on appeal that this finding by the judge went beyond the issues being litigated and was unnecessary to support his denial of the vast majority of the employee’s claims for benefits litigated at the hearing. If allowed to stand, she asserts, this finding will have a preclusive effect on any future benefits arising out of the employee’s admitted ankle injury. See Kautz v. Setterlin Co., 410 N.W.2d 843, 40 W.C.D. 206 (Minn. 1986) (if the employee recovers without residual disability, restrictions, or need for continuing medical care or treatment, there is no further liability for benefits). The employee contends also that she did not have reasonable notice that the employer was seeking to terminate all medical care as of September 23, 2005. Concluding that the nature and extent of the employee’s injury was clearly an issue submitted to the compensation judge at the hearing, we are unpersuaded by the employee’s arguments.
It is apparent from a review of the judgement roll and the record in this matter that the nature and extent of the employee’s left ankle injury was clearly being disputed by the employer. The issue was raised by the employer both in its answer to the employee’s claim petition and in its pretrial statement, and it was also identified in the employee’s own pretrial statement. At the outset of the trial, the compensation judge invited counsel to present opening statements as to the issues for determination. Both attorneys identified the nature and extent of the employee’s left ankle injury as one of the issues to be decided by the judge. Counsel for the employee stated that the first issue for determination would be, “does this employee really have an injury to her left ankle that continues to be disabling and to identify what that injury is.” He then went on to state, “[A]nd depending on what findings you make on those issues, the rest of it is going to fall into place as to whether or not she has a disability, what’s the nature of that disability, and what wage loss or other medical benefits, if any, are going to get paid as a result of this . . . mountain of evidence that we have.” Counsel for the employer then contended that the employee’s injury was a sprain of the ankle and left thenar contusion, that “contemporaneous medical records indicate . . . healed by no later than the fall of 2005.”
We acknowledge that the employer paid medical treatment expenses on behalf of the employee after September 23, 2005, but this fact alone does not preclude the employer’s later assertion that the employee’s injury had already resolved by that date. See Parker v. University of Minn., 66 W.C.D. 373, 377 (W.C.C.A. 2006) (the voluntary payment of benefits by an employer to an injured employee does not bar the employer from later changing its position and asserting defenses to continuing liability). The issue in dispute was the nature and severity of the employee’s left ankle injury, and both parties were fully aware of that dispute and introduced evidence in support of their respective positions. Not only was the employee’s claim for payment of medical expenses dependent on the judge’s findings on this issue, but so too were the employee’s claims for temporary partial, permanent total, and permanent partial disability benefits. If the nature and extent of the employee’s injury was at issue before the judge - - as clearly it was - - then total resolution of that injury was clearly a finding available to the judge. And if total resolution was the finding of the judge - - as here it was - - the preclusive effect on any future benefits is the same regardless of the date of that resolution. We conclude that the compensation judge was correct in ruling on the issue of the nature and extent of the employee’s injury. The issue was clearly submitted by the parties for determination, and, as we have already affirmed, the judge’s determination was supported by substantial evidence in the record.
This was a medically complex case coupled with an extensive record, and we acknowledge that some of the evidence would support contrary findings. However, the issue on appeal is not whether there is evidence that supports alternative findings but rather whether substantial evidence supports the findings of the compensation judge. Concluding that the record as a whole reasonably supports the judge’s decision, we affirm the judge’s decision in its entirety.
 In his report on the CT examination of the employee’s left ankle and distal tibia, the radiologist offered the following conclusion:
1. Chronic-appearing irregularity of the distal medial and lateral malleoli, which may relate to prior sprain injuries. No acute bony abnormalities of the distal tibia or fibula can be seen.
2. No osteochondral injuries of the talar dome or tibial plafond are seen.
3. No definite bony abnormalities of the midfoot are present.
4. No soft tissue abnormalities are identified.
 Dr. Coetzee’s reference to a September 9, 2005, MRI is clearly a transcription error. Dr. Coetzee requested a CT scan after having already reviewed the employee’s earlier MRI. The reference to scan findings in the doctor’s September 23, 2005, chart note mirrors findings reported by CDI in its September 9, 2005, CT scan report.
 The employee has not appealed from the judge’s denial of her claims for temporary partial disability benefits, permanent total disability benefits, or permanent partial disability benefits.
 See Roseen deposition pp. 44-46.
 According to the employee’s reply brief, unpaid nonpsychiatric medical bills, for treatment of the employee’s ankle, consisted of a $101.00 charge for treatment by Dr. Sprangers on March 16, 2005, and an unspecified amount paid for medication prescribed by Dr. Pena in April 2006. The employee has also referenced charges incurred at the Mayo Clinic. We note, however, that on October 17, 2007, the Mayo Clinic advised the compensation judge that it had no outstanding balance at that time for treatment of the employee’s left ankle.
 It would appear that the judge’s failure to order payment for treatment provided by Dr. Sprangers on March 16, 2005, was an oversight. If that bill remains outstanding, it should be paid by the employer.