THOMAS A. JOHNSON, Employee/Appellant, v. AMERIPRIDE SERVS., INC., and CNA/RISK ENTER. MGMT., Employer-Insurer, and TWIN CITY BAKERY DRIVERS H & W FUND, SUMMIT ORTHOPEDICS, HEALTHEAST ST. JOSEPH’S HOSP., ASSOCIATED ANESTHESIOLOGISTS/ PMSI, MINNESOTA DEP’T OF EMPLOYMENT & ECON. DEV., and MINNESOTA DEP’T OF LABOR & INDUS./VRU, Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
OCTOBER 6, 2008
CAUSATION - SUBSTANTIAL EVIDENCE; EVIDENCE - EXPERT MEDICAL OPINION. Substantial evidence, including well-founded medical opinion, supports the compensation judge’s finding that the employee did not sustain an injury in the nature of right ulnar neuropathy as a result of his work activities.
Determined by: Rykken, J., Johnson, C.J., and Stofferahn, J.
Compensation Judge: James F. Cannon
Attorneys: James T. Hansing, Minneapolis, MN, for the Appellant. Gregg A. Johnson and Joseph P. Mitchell, Heacox, Hartman, Koshmrl, Cosgriff & Johnson, St. Paul, MN, for the Respondents. Kathryn Hipp Carlson, Miller & Carlson, Minneapolis, MN, for Intervenor, Twin Cities Bakery Drivers Health & Welfare Fund.
MIRIAM P. RYKKEN, Judge
The employee appeals from the compensation judge’s denial of the employee’s claim that he sustained ulnar neuropathy as a result of his work activity and from the related denial of his claim for benefits related to that condition. We affirm.
Thomas A. Johnson [the employee] worked as a route delivery person for AmeriPride Services, Inc. [the employer] for over 26 years, between February 1979 and September 2005. As a customer service representative, he drove a truck or van, and picked up and delivered linens, rugs and clothing from various clients. According to the employee, from 2004 to 2006 he worked 4 days per week Monday through Thursday, from 5:30 a.m. until approximately 3:00 to 5:00 p.m., averaging 42 to 46 work hours per week. The employee estimated that on each day, he drove approximately 2 hours, made 16 - 24 stops and at each stop worked between 15 minutes and up to 1-2 hours. Most of the products he delivered were garments on hangers, but he also delivered rugs, bundles of towels, and soap products. He retrieved soiled linen from clients in either garment bags or four-wheeled baskets and returned those items to the employer’s location. At the end of each workday, after completing his various stops, he spent 30-40 minutes performing office duties, including updating his account information. In addition, the employee occasionally performed collection work and customer surveys.
The dispute on appeal involves an injury to his right upper extremity the employee claims to have sustained on or about September 15, 2005. He has been adjudicated to have sustained a Gillette injury in the nature of right carpal tunnel syndrome as of September 15, 2005; the parties have not appealed that determination. The dispute on appeal relates to a claimed right ulnar nerve injury, for which the employer and insurer have denied primary liability.
Between February 7, 1979, when he began working for the employer, and his last date of employment in September 2005, the employee was able to perform his job duties as a delivery driver. Prior to September 2005, the employee had experienced numbness and tingling in his right hand for about 4 or 5 years, but had not sought treatment for that condition. He also had experienced numbness in all of his fingers of his right hand while driving during the day time, and he was often awakened at night from those symptoms.
On Sunday, September 11, 2005, the employee bumped his right elbow on a shelf at home. The next day, he reported to work and performed his usual job, and initially did not seek medical treatment as he hoped his symptoms would soon subside. On Tuesday, September 13, the employee advised his supervisor of his home elbow injury. By mid-week, his right elbow exhibited swelling and numbness, and he requested some help with his job, which he received on Thursday, September 15. After that date, the employee felt unable to perform his job and realized that he should consult a physician.
That Friday, a day on which he was not scheduled to work, the employee consulted his family physician, Dr. William Schroeder, at the East Metro Family Clinic. Dr. Schroeder diagnosed a sprained and bruised elbow, provided the employee with a right arm sling, and prescribed medication. On the following Monday, the employee still felt unable to return to work. Later that week, Dr. Schroeder referred the employee for a CT scan which showed a potential intraarticular loose body.
Dr. Schroeder also referred the employee to Summit Orthopedics for a consultation, where he initially was seen by Dr. Amy Stromwell on October 3, 2005. She diagnosed a right elbow osteoarthritis with a possible associated loose body. Dr. Stromwell commented that if the employee did in fact have a loose body in his elbow, he would benefit from arthroscopy by her colleague, Dr. Mark Holm. She referred the employee for an MRI scan of his right elbow to assess whether the right elbow injury was acute or chronic and to delineate his level of osteoarthritis. The MRI scan, performed on October 3, 2005, was interpreted as being abnormal, with findings that included joint effusion possibly indicating synovitis, collagen fiber microtearing of the distal biceps tendon and extensor tendon, and findings expected to represent residua of a sprain injury that occurred at an indeterminate time.
Later in October, Dr. Holm examined the employee, and diagnosed ulnar neuritis, which he did not believe to be related to the employee’s right elbow injury. Dr. Holm referred the employee for an EMG to evaluate his right upper extremity. Dr. Laura Li, who interpreted the EMG, commented that the EMG findings “could suggest a borderline carpal tunnel syndrome. This does not seem to explain all of the patient’s clinical symptoms . . . . EMG study cannot rule out a pure dorsal root radiculopathy. Clinical correlation is recommended.”
Over the course of the next two years, the employee experienced symptoms in his right wrist and right elbow area, and was evaluated for and diagnosed at various times with right carpal tunnel syndrome and right ulnar neuropathy. In a chart note of November 1, 2005, Dr. Holm noted that the employee reported continued pain in his right elbow and some paresthesias in the median nerve distribution of the right hand. Dr. Holm provided steroidal injections in both the employee’s right elbow and right carpal tunnel, and referred the employee to hand therapy. The employee underwent hand therapy on a periodic basis between November 2005 and March 2006.
In mid-December 2005, the employee slipped on icy steps and grabbed onto the railing for support; he reported that the force of that effort increased his right elbow pain, even though he did not strike his elbow on anything at that time. A chart note from the employee’s physical therapist, dated December 19, 2005, noted significant right hand swelling due to his recent injury. The therapist also noted that surgery was to be scheduled on the employee’s right elbow, to treat for a bone chip. The employee consulted Dr. Holm on December 20, 2005; the employee’s right hand was red and swollen, and the employee reported tenderness around his right wrist. Dr. Holm aspirated fluid from employee’s right wrist; evaluation of the fluid suggested gout or pseudogout, a condition for which the employee had been earlier diagnosed and treated. Dr. Holm provided the employee with a short arm fiberglass splint and Ace bandage.
On January 10, 2006, Dr. Holm noted a positive Tinel’s sign of the median nerve over the right wrist as well as diminished sensation in the median nerve distribution. On January 26, 2006, Dr. Holm performed a right carpal tunnel release. By March 8, 2006, Dr. Holm restricted the employee to light-duty work, with a five-pound lifting restriction. In a Work and Activity Release form completed on March 17, 2006, Dr. Holm released the employee to full work activities as of March 20, 2006.
The employer advised the employee that he would be able to return to work only if released to work with no restrictions. Evidently in response to Dr. Holm’s full release of the employee, the employer and insurer requested that the employee be evaluated by Dr. Vijay Eyunni, Minnesota Occupational Health. On March 21, Dr. Eyunni performed a “fitness for duty evaluation.” He then prepared a report outlining his opinion, stating that he had spoken with Dr. Holm and the employee’s treating therapist, and concluded that the employee could work within restrictions of avoiding heavy repetitive gripping with his right hand and repetitive lifting beyond 50 pounds, or, alternatively, those restrictions to be determined from completion of a functional capacities evaluation (FCE). The employee underwent an FCE, which demonstrated the need for work restrictions.
On March 26, 2006, Dr. Thomas Jetzer, Occupational Consultants, Inc., also examined the employee at the request of the employer and insurer, evidently for the express purpose of determining whether the employee could return to work at his regular job with the employer. Dr. Jetzer concluded that the employee continued to require some work limitations because he had not yet fully recovered from his carpal tunnel surgery. In Dr. Jetzer’s opinion, the employee had not yet reached maximum medical improvement (MMI) and would benefit from exercise, anti-inflammatory medication, and physical therapy. Dr. Jetzer commented that there was “a real good chance that [the employee] will be able to return to regular duties, as his elbow does not appear to be a problem at this point in time nor does his shoulder. Also, his gout is in remission and under reasonably good control.”
In late March 2006, the employee reported right shoulder symptoms to his therapist, and later reported the same to Drs. Schroeder and Holm. Dr. Holm reimposed a lifting restriction for the employee’s right hand. He reexamined the employee in late April, and detected some mild loss of motion and reduced grip strength in his right hand. As of May 1, 2006, Dr. Holm released the employee to full duty work.
On June 8, 2006, Dr. Schroeder provided his opinion concerning the cause of the employee’s right wrist condition, stating that “I believe that Mr. Johnson’s right carpal tunnel problem is work related from repetitive use of his hand and wrist at work. The repetitive use was compounded, and the magnitude greater, because of his injury to his elbow.”
The employee again consulted Dr. Holm on October 30, 2006, reporting increasing weakness of his right hand and increased numbness of his right fourth and fifth fingers. Dr. Holm referred the employee for a NeuroMetrix test to evaluate for ulnar neuritis, which revealed mild residual median neuropathy at the right wrist as well as right ulnar neuropathy at the wrist. Based on those test results, Dr. Holm diagnosed ulnar neuritis at the right wrist, and recommended a submuscular transposition of the ulnar nerve and decompression of the ulnar tunnel at the right wrist. It appears that the employee has never undergone that recommended surgery.
On November 13, 2006, Dr. William Call, orthopedist, conducted an independent medical examination of the employee. In his report of November 22, 2006, Dr. Call concluded that the employee had not sustained a Gillette injury to his right wrist in September 2005, either in the nature of a carpal tunnel syndrome or ulnar neuropathy. Based on the contemporaneous medical records, Dr. Call found no evidence that the employee sustained any wrist injury in September 2005, and concluded that any diagnosed carpal tunnel syndrome had not resulted from the employee’s September 2005 injury but instead resulted from his gout and “the usual idiopathic developmental carpal tunnel syndrome.” He based that opinion, in part, on the lapse in time between the employee’s last date of employment in September 2005 and the first report of related symptoms in medical records from December 2005. Dr. Call also determined that the employee had no permanent partial disability and required no ongoing medical treatment for his right wrist condition.
The employee never returned to work for the employer after September 2005. Following his injury, the employee received disability benefits through the intervenor, Twin City Bakery Drivers Health and Welfare Fund, through at least February 2006. His position with the employer was ultimately terminated, on the basis of the employer’s policy that he could not return to work unless all of his work restrictions were lifted; by May 2006, the employee began receiving unemployment compensation; the record does not indicate for how long he received such benefits.
The employee sought rehabilitation assistance through the Vocational Rehabilitation Unit of the Department of Labor and Industry, and on March 12, 2007, the employee underwent a rehabilitation consultation. Mr. Fred Charlton, the qualified rehabilitation consultant (QRC) who conducted that evaluation, determined that the employee was qualified for statutory rehabilitation assistance, and provided him with such assistance.
In the course of his work with Mr. Charlton, the employee applied for and interviewed with Old Dutch Foods for a delivery position. On March 26, 2007, the employee consulted Dr. Holm, in part to obtain his opinion on whether the duties required of that position were compatible with his restrictions. At that appointment, the employee reported continued aching in his right elbow at night, some improvement from wearing a long arm splint, and continued numbness in his right fingers. Dr. Holm provided permanent work restrictions, including frequent lifting of 10 pounds or less, occasional lifting of 25 pounds or less, and avoidance of frequent heavy gripping and grasping. Dr. Holm also advised that the employee could proceed with a trial attempt at the Old Dutch route.
In a letter dated March 29, 2007, Dr. Holm outlined his opinion on the causation of the employee’s wrist condition. Dr. Holm opined that the employee’s ulnar neuritis more likely than not was significantly aggravated by his work activities. He also opined that the employee’s right carpal tunnel syndrome was related to his gout condition, but his work activities had aggravated his carpal tunnel syndrome. Dr. Holm based his opinions on his testing and examinations of the employee and on the type of work activities the employee had performed for the employer.
The employee was not offered the anticipated delivery position with Old Dutch Foods however, due to that company’s hiring freeze. His QRC continued to provide the employee with job search assistance, and in June 2007 the employee began working with Auto Uplink through a temporary placement agency, where he continued to work at the time of the hearing in August 2007. He also worked on a part-time basis for a catering company for whom he had worked over the past years.
On May 31, 2006, the employee filed a claim petition, seeking benefits based on his right carpal tunnel syndrome and right ulnar nerve condition. That claim was amended on May 2, 2007, and was addressed at hearing on August 20, 2007. At issue at the hearing was the employee’s claim that he sustained a Gillette injury culminating on or about September 15, 2005, in the nature of right carpal tunnel syndrome and right ulnar neuropathy. The employee sought payment of temporary disability benefits extending from September 16, 2005, through the date of the hearing, and also sought payment of medical expenses related to treatment of both his carpal tunnel syndrome and right ulnar condition. The employee, his QRC, and two representatives from the employer testified at the hearing. Records submitted into evidence at the hearing included the employee’s medical records, rehabilitation and job search records, a DVD documenting surveillance conducted on the employee in May and June 2007, and employment records.
In his findings and order served and filed on November 7, 2007, the compensation judge found that the employee had sustained a Gillette injury to his right wrist in the nature of carpal tunnel syndrome, with that injury culminating on or about September 15, 2005, and that the employee had provided proper notice of that injury. The judge awarded a portion of the employee’s claims for temporary total disability benefits, from the date of his carpal tunnel surgery on January 27, 2006, until May 1, 2006, the date on which he was released to full-duty work by Dr. Holm. The judge also awarded medical expenses related to treatment for carpal tunnel syndrome, incurred during that same time period. In addition, the judge awarded payment to certain intervenors for disability benefits and medical expenses they had paid during the awarded time periods.
The compensation judge denied the employee’s claim that he also sustained a right ulnar nerve injury culminating on September 15, 2005, and denied the employee’s claim for temporary total disability benefits between his injury date and his carpal tunnel surgery on January 27, 2006. The compensation judge determined that the employee had not been temporarily totally disabled from employment during that period of time as a result of his work-related carpal tunnel syndrome, because the work restrictions placed on him during this period were related to his right elbow and not to his carpal tunnel syndrome. The judge also denied the employee’s claims for benefits and payment of medical expenses after May 1, 2006, on the basis that any disability and need for medical treatment after that date was unrelated to his work or work injury.
The employer and insurer did not appeal the finding that the employee’s carpal tunnel condition was work-related nor from the related awards of benefits and medical expenses. The employee appeals from the denial of his claims related to his ulnar nerve condition.
STANDARD OF REVIEW
In reviewing cases on appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.” Minn. Stat. § 176.421, subd. 1. Substantial evidence supports the findings if, in the context of the entire record, “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 evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, “[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). Findings of fact should not be disturbed, even though the reviewing 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.
The compensation judge found that the employee did not sustain an ulnar nerve injury as a result of his work, basing that conclusion on the opinion of Dr. Call. The employee argues that substantial evidence does not support this finding, contending that Dr. Call did not have adequate foundation for his opinion and that it was error for the compensation judge to rely on that opinion. The employee contends that Dr. Call’s testimony “was not credible and lacked a proper foundation because he inexplicably admitted that the employee exhibited all the symptoms of [an ulnar nerve] condition but yet denied that he had the condition.” The employee also contends that Dr. Call ignored the employee’s reports of ulnar nerve symptoms that had been documented in initial records generated by Summit Orthopedics.
The employee’s arguments go to the weight to be accorded to Dr. Call’s medical opinion rather than its foundation. Karakash v. Superior Rock Bit Co., slip op. (W.C.C.A. May 3, 2001). See also Heitz v. Par 30 Restaurant & Lounge, Inc. 60 W.C.D. 98 (W.C.C.A. 2000), summarily aff’d (Minn. May 4, 2000); Drews v. Kohl’s, 55 W.C.D. 33 (W.C.C.A. 1996); and Stuhr v. Northwestern Travel Servs., Inc., 57 W.C.D. 352 (W.C.C.A. 1997). Foundation is established by the competency of a witness to provide expert opinion. Competency of a medical expert depends both on the extent of the scientific knowledge of the witness and “the witness’s practical experience with the matter which is the subject of the offered testimony.” Reinhardt v. Colton, 337 N.W.2d 88, 93 (Minn. 1983). Sufficient knowledge of the subject matter can be obtained through personal knowledge, a hypothetical question, or testimony at the hearing. Scott v. Southview Chevrolet Co., 267 N.W.2d 185, 188, 30 W.C.D. 426, 430 (Minn. 1978). Dr. Call took a history from the employee, reviewed his medical records and examined the employee. The employer and insurer provided additional information to Dr. Call, based on testimony provided by the employee at his deposition in 2006. The information provided to Dr. Call in addition to his examination of the employee and his medical background and experience, provided sufficient foundation for his opinion.
The employee also argues that the compensation judge’s conclusion that the employee did not sustain an ulnar nerve condition as a result of his work is not supported by the evidence in the record. The employee points out that, at the time of his examination of the employee in 2006, Dr. Call concluded that the employee had symptoms which could be related to ulnar neuropathy. However, Dr. Call explained that these symptoms could be the result of other conditions, and ruled out the employee’s work activity as a cause of the symptoms because he had not worked for the employer since September 2005. We acknowledge that the employee reported continuing right upper extremity symptoms after September 2005, but the compensation judge was presented with opposing opinions on the cause of the employee’s ulnar condition. In assessing the cause of that condition, the compensation judge considered the medical opinions of the employee’s treating physician, Dr. Holm, who concluded the condition was work-related, and the opinions of the independent medical examiner, Dr. Call, who found no causal connection to the employee’s work.
As noted in his chart note of October 26, 2006, Dr. Holm diagnosed the employee with ulnar neuritis of the right elbow after noting that the employee had diminished sensation in the right fourth and fifth fingers, weakness of abduction of the fingers, mild tenderness at the right elbow, and a positive Tinel’s sign over it. In November 2006, Dr. Holm opined that the employee’s neuropathy tests indicated ulnar neuritis at the wrist and symptoms at the elbow. He recommended that the employee undergo surgery, specifically a submuscular transposition of the ulnar nerve and deep compression of the ulnar tunnel at the right wrist, although it appears that the employee has never undergone that surgery. In a letter dated March 29, 2007, Dr. Holm concluded that the employee’s ulnar neuritis more likely than not was significantly aggravated by his work activities.
By contrast, Dr. Call opined that the employee did not have ulnar neuropathy at the right wrist or elbow, noting that the employee’s December 27, 2005, EMG was normal regarding ulnar neuropathy at the elbow or wrist. The employee contends that these EMG testing results were not dispositive, referring to Dr. Holm’s statement that ulnar neuritis can go undetected by EMG testing. The compensation judge inferred from Dr. Holm’s opinion that “the logical conclusion from this statement is that more often, or on most occasions, ulnar neuritis is detected by EMG testing.” (Emphasis in original.) That inference by the compensation judge was not unreasonable, in view of all the medical evidence presented to him.
The employee also contends that the compensation judge erred by relying on the video surveillance tape submitted into evidence and relied upon by Dr. Call. The compensation judge referred to this evidence, and concluded that the activities in May and June 2007, as demonstrated on the DVD, appeared to be outside of the restrictions assigned by Dr. Holm during that time period. The employee argues that the “video surveillance tape is of no probative use or value and does not somehow invalidate, contradict or undermine Dr. Holm’s testimony that the employee has an ulnar nerve condition.” Dr. Call reviewed this video, and was asked at his deposition whether the information contained therein was significant. Dr. Call testified that the information reinforced his position that the employee required no restrictions. To the extent that he considered this portion of Dr. Call’s opinion or the surveillance tapes, the compensation judge did not err.
The record contained extensive medical information concerning the employee’s carpal tunnel syndrome and ulnar nerve condition, including varying opinions on the diagnosis and potential causes of that condition. The judge relied on the opinion of Dr. Call and concluded that the employee did not have ulnar neuropathy at the right wrist or elbow. The judge also noted that Dr. Schroeder, Dr. Eyunni, and Dr. Jester did not diagnose ulnar neuropathy or an ulnar nerve condition. In view of the record as a whole, we cannot conclude that the compensation judge’s finding that the employee did not sustain a work-related injury to his right ulnar nerve was unreasonable or erroneous. 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); see also Tuomela v. Reserve Mining Co., 299 Minn. 203, 204, 216 N.W.2d 638, 639, 27 W.C.D. 312, 313 (1974). We therefore affirm the compensation judge’s finding that the employee did not sustain an injury to his right ulnar nerve as a result of his work with the employer, and affirm the denial of the employee’s claims related to that condition.
 Due to a failure in recording equipment, the hearing held on August 10, 2007, was not recorded. On April 23, 2008, the parties filed a Stipulation and Summation of August 10, 2007, Hearing Testimony. As a result, background information in this decision has been obtained from that stipulation as well as from documents submitted into evidence at the hearing.
 Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).
 The employee’s later medical records show that medication prescribed for the employee’s gout seemed to reduce or resolve his gout-related symptoms.