ELVIRA O. RAMIREZ, Employee, v. MARATHON ASHLAND OIL and ACE INS. CO./FRANK GATES SERVS. CO., Employer-Insurer/Appellants, and REGINA MED. CTR., ALLINA, SUMMIT ORTHOPEDICS, WALGREEN CO., ST. PAUL RADIOLOGY, THERAPY PARTNERS, INC., CENTER FOR DIAGNOSTIC IMAGING, and PRIMARY BEHAVIORAL HEALTH CLINIC, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 17, 2008
CAUSATION - PSYCHOLOGICAL CONDITION. Where there was evidence including the opinion of medical experts that the employee=s psychological condition was related to her work injuries, the compensation judge=s award of benefits related to the employee=s psychological condition, including temporary total disability benefits and medical expenses, was not clearly erroneous or unsupported by substantial evidence.
Determined by: Rykken, J., Johnson, C.J., and Stofferahn, J.
Compensation Judge: Harold W. Schultz, II
Attorneys: Jackson S. Baehman, Attorney at Law, Woodbury, MN, for the Respondent. Edward Q. Cassidy, Fredrikson & Byron, Minneapolis, MN, for the Appellants. Todd J. Thun, Hitesman and Assocs., Maple Grove, MN, for the Intervenor, Regina Medical Center.
MIRIAM P. RYKKEN, Judge
The employer and insurer appeal from the compensation judge=s determination that the employee=s work injuries represented substantial contributing factors to the employee=s disability from work and need for medical treatment, including psychological and psychiatric care. We affirm.
Elvira Ramirez [the employee] began working for Marathon Ashland Oil [the employer] in July 1986. But for a brief period of time, she continued working for the employer until May 2004. The employee=s earlier work history includes employment in a meat packing plant, as a restaurant server, as an assembler at manufacturing plants, and as a hair dresser. The employee=s work for the employer included working in various units and on the loading docks, and later as a laboratory technician.
The record includes extensive medical records that document the employee=s treatment predating her work injuries and extending through December 2007, with numerous records and opinions from her treating and consulting physicians and from independent medical examiners. In February 1991, she experienced pain in her neck and shoulders after pulling a chain valve at work and obtained medical treatment following that incident. The employee complained of hand and wrist symptoms in 1991 and 1992, and attributed those symptoms to her work activities. The employee claimed she sustained an injury in the nature of a bilateral hand and wrist condition in September 1992. The employer and insurer denied liability for that claim. The employee also consulted a physician in 1992 and 1993 regarding upper back pain for which she received physical therapy. In early 1993, she was diagnosed with probable bilateral carpal tunnel syndrome, underwent therapy for those symptoms and, for a time, was limited to part-time restricted work. In the mid-1990's, she also reported symptoms in her upper extremities, and on occasion between 1986 and 1998, the employee worked on a light duty basis due to her hand and wrist condition.
The employee=s first injury at issue on appeal occurred on October 16, 1998, when the employee experienced pain in her neck and lower back while trying to pry open a stuck cover on an oil tanker. The employer and its insurer at that time admitted liability for the employee=s injury and paid medical expenses on the employee=s behalf. The employee evidently did not miss time from work immediately after this injury. She consulted Dr. Marlin Rosin, at the Allina Medical Clinic [Allina], on October 20, 1998, reporting that when she lifted the dome off a tanker at work, she felt a snap in her neck, and later felt pain in both arms, her upper and lower back and neck. Dr. Rosin diagnosed a bilateral trapezius muscle spasm and bilateral sacroiliac strain, and prescribed physical therapy, pain medication, and work restrictions. In November 1998, Dr. Rosin added a diagnosis of a Apossible early carpal tunnel,@ and ordered continued physical therapy, work restrictions and prescription medications for the employee.
The employee also consulted Dr. Vijay Eyunni at the Minnesota Occupational Health on October 28, 1998. Dr. Eyunni commented that A[i]f the alleged history is correct, then the employee sustained a cervical and lumbar strain following the work-related incident@ on October 16. Dr. Eyunni advised that the employee could continue to work within restrictions, and recommended continued physical therapy as well as a formal strengthening program to help avoid a recurrence of her symptoms.
The employee=s symptoms persisted, however, and the employee consulted Dr. Peter Daly, orthopedic surgeon, on July 28, 2000. He diagnosed bilateral subacromial bursitis with positive impingement findings, and commented that the employee might have some component of fibromyalgia; MRI scans confirmed Dr. Daly=s diagnosis, including advanced degeneration of the AC joints. After the employee experienced unsuccessful results from conservative treatment, including steroidal injections, Dr. Daly recommended surgery and, on November 17, 2000, he performed right shoulder surgery on the employee in the nature of an arthroscopic subacromial decompression, distal clavicle excision and rotator cuff repair.
On March 6, 2001, Dr. Daly performed the same type of surgery on the employee=s left shoulder, and also performed a manipulation of her right shoulder, under anesthesia, to alleviate stiffness and limited range of motion. By May 22, 2001, following a period of recuperation, Dr. Daly released the employee to return to work within certain restrictions. He later assigned a 6% whole body impairment rating to each of the employee=s shoulders; the employer and insurer paid benefits based upon those ratings. The employer and insurer also paid temporary total disability benefits to the employee from November 17, 2000, to May 21, 2001. By October 16, 2001, Dr. Daly removed all restrictions related to the employee=s shoulders.
On December 21, 2001, the employee fell in the laboratory work area, and reported that she struck her right knee and right wrist and jammed her left shoulder. The employer, however, admitted liability only for a right wrist and left shoulder injury, and denied liability for any injury to the employee=s right knee, right ankle, or left arm. The employee evidently did not miss any time from work immediately after this incident.
It appears that the first notation in the employee=s medical records of a December 2001 injury was made on January 23, 2003, when the employee consulted Nurse Practitioner Linda Auleciems, at Allina, and reported a history of falling on her right knee a year earlier. She advised that her knee continued to bother her, and also reported she had felt pain in her hands and arms for the last six months along with symptoms in her neck and low back. N.P. Auleciems referred the employee to Dr. Joseph Haber, also at Allina, who evaluated the employee for her hand symptoms. X-rays of the employee=s hands detected a bone cyst on her left little finger, which was surgically treated in April 2003. Dr. Haber also ordered an EMG nerve conduction study due to the employee=s reported numbness and tingling in both hands. The EMG was interpreted to be normal.
The employee has received treatment for various conditions since 2003, including treatment and surgery for her shoulders and for carpal tunnel syndrome, and psychological and psychiatric treatment. In April 2003, the employee reported symptoms of depression to N. P. Auleciems, who referred her to counseling with Richard E. Close, LICSW, at Allina. The employee consulted him in April 2003, reporting that she was Afeeling stressed,@ in part due to family, marital and workplace concerns. She reported anger due to an employment situation and that, in the past, she had experienced suicidal impulses. Mr. Close diagnosed dysthymic disorder, based on the employee=s depressive symptoms, and referred the employee back to N.P. Auleciems, who prescribed a trial of anti-depressant medication. During the summer of 2003, the employee=s depressive symptoms worsened; she continued to consult with her physicians and nurse at Allina for that condition.
In early 2003, the employee again consulted Dr. Daly, reporting symptoms in her right knee, left shoulder, and left upper extremity. Dr. Daly referred the employee for MRI scans. A left shoulder MRI scan was interpreted as being negative for recurrent tearing in the left shoulder; Dr. Daly recommended home exercises for her left shoulder. A right knee MRI scan showed a posterior horn medial meniscus horizontal cleavage tear, and so on June 5, 2003, Dr. Daly performed a right knee arthroscopic surgery including a partial medial meniscectomy. Dr. Daly restricted the employee from work until July 10, 2003, when he released her to a four-hour work day, with restrictions. Dr. Daly ultimately released the employee to full-duty work on July 21, 2003. In August 2003, due to ongoing pain in her right knee and leg, Dr. Daly provided the employee with a steroid injection to treat her right trochanteric bursitis.
The employee also continued to consult with Dr. Haber for ongoing hand and wrist symptoms. On June 26, 2003, Dr. Haber diagnosed bilateral carpal tunnel syndrome, and linked that condition to the employee=s work in a lab that included gripping, grasping, and repetitively handling small objects. After attempting to treat her condition conservatively, including by steroidal injections, Dr. Haber recommended carpal tunnel release surgery. Dr. Peter Badroos, in the occupational health department at Allina, concurred with Dr. Haber=s treatment recommendations and assessment of the causal relationship between the employee=s work activities and her carpal tunnel syndrome. In November 2003 and January 2004, Dr. Haber performed a right and left carpal tunnel release, respectively. The employee underwent post-operative physical therapy.
Also during the summer of 2003, the employee noted a worsening in her depression, and in August 2003, she also reported low back and hip pain. On September 9, 2003, she consulted Dr. Walid Mikhail, who diagnosed a Amajor depressive disorder, severe.@ He modified the employee=s antidepressant medication, and discussed with her the option of taking a short-term leave from her work. Dr. Mikhail and N.P. Auleciems provided follow-up treatment to the employee for her depression, including continued prescriptions for antidepressant medication.
In November 2003, the employee also consulted a psychologist, Marilyn Mason, Ph.D., L.P., at Primary Behavioral Health Clinic, where she underwent extensive testing and participated in therapy sessions. The employee reported long-term and constant hand pain in her hands, as well as chronic pain, and expressed her frustration that she was unable to perform her job due to her hand and wrist pain.
The employee returned to work after recuperating from her January 2004 left carpal tunnel release surgery. She continued to treat with Dr. Haber for her left wrist condition; he prescribed physical therapy and pain medication, as well as an injection to her wrist. The employee also continued to receive counseling treatment at Primary Behavioral Health Clinic.
On May 7, 2004, John Patrick Cronin, Ph.D., L.P., clinical director at Primary Behavioral Health Clinic, who had treated the employee along with Dr. Mason, restricted the employee from work, recommending that she cease work for three weeks due to her Acurrent psychological condition and increased pain levels.@ In a May 11, 2004, letter to Ms. Cathy Pipcorn, R.N., a nurse with the employer, Dr. Cronin provided his rationale for restricting the employee from work. He advised that the employee had reported increased swelling of her hands, and that she continued to treat with Drs. Haber and Mikhail, who provided cortisone shots in her right wrist and prescribed pain medication. Dr. Cronin stated that at her most recent appointment, the employee was Afar more depressed than [he] had seen her in several weeks@ and that he Adecided she needed some time off to rest and recuperate and let the effects of the various treatments work.@
In his chart report dated May 21, 2004, Dr. Mikhail referred to Dr. Cronin=s recommendation that the employee temporarily remain off work. Dr. Mikhail listed the employee=s diagnosis as Amajor depressive exacerbation@ related to pain, and also described the employee=s subjective symptoms as Achronic pain syndrome.@
On May 19, 2004, N.P. Auleciems conducted a routine health care maintenance examination on the employee, who reported that she had not felt well for several weeks. Ms. Auleciems noted that the employee reported that she was off work, Adue to problems with pain in her back, neck, legs and shoulders. She is feeling increasingly depressed.@ At a follow-up appointment on May 21, 2004, with Dr. Haber, the employee reported constant pain in her neck, back and hands, and attributed her worsening depression to her ongoing pain and swelling in her hands.
The employee has not returned to work since May 7, 2004. She has not conducted any job search since then, nor has she been released to return to work by her medical providers. The employee eventually applied for and began receiving Social Security disability insurance in December 2004. The employee continued to receive medical treatment and psychological counseling after discontinuing work in May 2004. She continued to report symptoms in her neck, back, shoulders, upper extremities and lower extremities.
During the course of her treatment, the employee has undergone various independent medical examinations at the request of the employer and insurer. The first was on May 27, 2004, when the employee was examined by Dr. Gary Wyard, orthopedic surgeon. She reported symptoms in her hands, back and legs. In his report, Dr. Wyard outlined his diagnoses as follows: (1) post-bilateral carpal tunnel surgery for apparently normal EMGs on both sides; (2) vague upper extremity symptoms; (3) neurologically intact, shakiness and hyperreflexia; (4) post-lateral shoulder rotator cuff repairs; and (5) post-right knee surgery. Dr. Wyard concluded that the employee=s Awork activities at [the employer] were not a substantial contributing factor in the development of any carpal tunnel syndrome diagnosis.@ He commented that the employee Adid not get validation of her carpal tunnel syndrome by EMGs prior to surgical intervention@ and that the results from carpal tunnel surgery had been Avariable.@
On June 25, 2004, the employee underwent an independent psychiatric evaluation with Dr. Thomas Gratzer. Dr. Gratzer reviewed the employee=s medical records, including the results from her psychological testing. He noted that the employee=s medical records reflected her chronic depression and anxiety, and assessed the employee as having a Amajor depressive disorder, recurrent, in partial remission.@ Dr. Gratzer found insufficient evidence in the employee=s medical records to show either a psychiatric disability or the need to be restricted from work since May 7, 2004. He noted that the employee had identified pain complaints as the precipitant for her removal from work, and that he did not have an opinion as to whether the employee was unable to work from a physical standpoint. He recommended that employee return to work incrementally, over an eight week period, and concluded that the employee did not need any psychiatric restrictions.
On August 6, 2004, the employee underwent an independent medical examination with Dr. Paul Dworak, orthopedic surgeon. Dr. Dworak concluded that there were no objective findings in the employee=s upper extremities, back or right knee on which to assess restrictions. Dr. Dworak concluded that the employee=s complaints of pain were subjective and that they far outweighed her objective physical findings. Dr. Dworak concluded that the employee=s bilateral rotator cuff injuries and need for surgery were unrelated to the employee=s work, specifically relying on the employee=s agreement that she did very little activity at work Aabove the horizontal.@ Instead, he related the employee=s shoulder condition and need for surgery to her pre-existing anatomic condition variation that predisposed her shoulder to develop as it had.
Dr. Dworak also concluded that the employee=s bilateral carpal tunnel surgeries were not causally related to her work, and that she had undergone surgeries even though her EMG results had been negative. Concerning the employee=s right knee condition, Dr. Dworak found no causal relationship between the employee=s work activities and her right knee condition. He found no contemporaneous reference in the employee=s medical records to a knee injury in 2001, and concluded that Aif she had any significant injury to her right knee resulting in a medial meniscal tear, she would have had ongoing symptoms of medical knee pain with any pivoting, walking, etc.@ Dr. Dworak concluded that, from an orthopedic standpoint, the employee had not been temporarily totally disabled since May 2004, that she required no physical restrictions, that she had not sustained any work-related injury, and that she had reached maximum medical improvement.
Between 2003 and at least July 2007, the employee has received psychological and psychiatric treatment at Primary Behavioral Health Clinic. She has undergone psychotherapy treatment, and was recommended breathing exercises and clinical biofeedback treatment as part of that treatment. At Dr. Cronin=s referral, Dr. John Curran, M.D., psychiatrist, consulted with the employee between July 2004 and February 2005, and prescribed medication for the employee. In addition, Dr. Mikhail continued to treat the employee for her depression between May 2004 and May 2006. Drs. Mikhail, Cronin and Mason all related the employee=s psychological condition to her work injuries. In his report of March 27, 2007, Dr. Cronin diagnosed a chronic pain condition and depression that were directly and causally related to her work-related injuries, and specifically noted that her pain disorder was associated with both psychological factors and a general medical condition.
Dr. Dworak again examined the employee on November 2, 2007. He again found that the employee continued to report cervical, bilateral shoulder, arm, lumbar, right ankle, and knee pain without any significant objective physical findings. He opined that the employee had a significant psychiatric history of depression, but that her depressive disorder was not orthopedic in nature. Dr. Dworak=s conclusions concerning causation of the employee=s multiple conditions remained the same; he found no causal relationship between the employee=s work activities and her condition and multiple pain complaints. Likewise he found no anatomic basis for the employee=s ongoing pain. He concluded that the employee Ahas multiple somatic complaints which are not substantiated by objective physical findings.@
On three occasions, in August 2004, June 2005, and December 2007, the employee underwent independent psychiatric evaluations with Dr. Michael Farnsworth. He diagnosed the employee with recurrent major depression and pain disorder that was associated with psychological factors alone. He found no evidence to support the employee=s claim that her difficulties were the result of injuries she had sustained in the workplace. Although in 2004 Dr. Farnsworth concluded that the employee was disabled as a result of her chronic pain syndrome, by the time he examined her in 2007 he did not believe that the employee had been disabled from work since May 2004 as a result of her work injuries. He concluded that the employee did not have Aany significant restrictions regarding her psychiatric condition and could participate, at least part-time, in volunteer work or work for pay as permitted by the level of pain that she subjectively experiences.@ He commented that the employee reported a reduction in her depressive symptoms, and he recommended no further psychiatric treatment.
As of January 3, 2008, Dr. Farnsworth testified that the employee had Amajor depression, recurrent in partial remission and the second is pain disorder with psychological factors.@ Dr. Farnsworth did not render an opinion as to the cause of the employee=s depression.
In a letter dated November 21, 2007, Dr. Mikhail outlined his opinions on the employee=s disability, diagnosis, and causation of her injuries. He concluded that the employee was totally disabled and that he had monitored her for the last several years due to her severe major depressive disorder. He related her depression directly to her multiple work-related injuries and her chronic pain. He assigned whole body impairment ratings based upon the employee=s cervical and lumbar pain syndromes, medial meniscus removal in her right knee, the chronic numbness and weakness in both hands, and her bilateral shoulder injuries.
In November 2003, the employee filed a claim petition, seeking payment of medical expenses and intermittent wage loss due to three injuries on September 19, 1992; October 16, 1998; and December 21, 2001; she later amended her claim to include a May 7, 2004, injury. The employer and insurer in 1992, ACE USA, alleged that the employee=s claims related to the September 1, 1992, injury were barred by the statute of limitations provision of the Minnesota workers= compensation law. By agreement, that portion of the employee=s claim was dismissed without prejudice.
The employer, through its insurer and also as a self-insured employer, admitted primary liability for a neck and back injury on October 16, 1998, admitted a left shoulder and right wrist injury on December 21, 2001, but denied that the employee sustained a right knee, right ankle or left arm injury in December 2001. The employer and insurer also denied liability for a May 7, 2004, injury and denied that the employee was entitled to the claimed benefits.
A hearing was held on January 8, 2008, to address the employee=s amended claims for temporary disability benefits and medical expenses. The employee claimed that she had been disabled from work due to chronic pain and depression that had resulted from her carpal tunnel condition and her injuries to her back, neck, right knee and ankle, and right arm. Evidence at the hearing included the employee=s medical records; causation opinions from multiple medical personnel; deposition and live testimony from the employee, and deposition testimony from Dr. Dworak and Dr. Farnsworth.
In his findings and order, the compensation judge concluded that on October 16, 1998, the employee had sustained a bilateral shoulder injury, neck injury, lumbar strain, and bilateral carpal tunnel syndrome, but no permanent back injury, and that on December 21, 2001, she had sustained an injury to her right knee as well as injuries to her upper extremities. He determined that there was a causal relationship between the employee=s work injuries and her depression and chronic pain syndrome, and therefore awarded temporary total disability benefits between May 7, 2004, and May 4, 2006, and payment for medical expenses, including psychological and psychiatric treatment. The employer and insurer appeal.
STANDARD OF REVIEW
On appeal, the Workers= Compensation Court of Appeals must determine whether Athe 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 (2008). 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). 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, findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
The compensation judge determined that the employee=s October 16, 1998, personal injury was a substantial contributing factor to her chronic pain and depression. He concluded that the medical treatment claimed by the employee, including her psychological and psychiatric care, represented reasonable and necessary treatment, and awarded payment of the medical treatment expenses in dispute at the hearing. The compensation judge also concluded that the employee was disabled from employment from May 7, 2004, through May 4, 2006, as a substantial result of her October 16, 1998, injury, and awarded payment of the statutory maximum of 104 weeks of temporary total disability benefits. See Minn. Stat. ' 176.101, subd. 1(e).
In arriving at his conclusions, the compensation judge accepted the opinions of Dr. Mikhail and the employee=s other treating physicians. The judge stated that he carefully considered the testimony presented by the medical witnesses on behalf of the employer and insurer, that those witnesses had some legitimate points to make, and that he appropriately weighed those opinions. The judge explained the basis for his conclusions as follows:
Especially critical to the determination of this case is [Dr. Mikhail=s] opinion that the multiple work-related injuries are a substantial contributing factor to the employee=s chronic pain and depression. He has treated the employee for a long period of time for a number of conditions including depression. He has prescribed medication to address that.
The employee provided credible testimony. She did have issues at work other than the challenges she had with her physical injuries. However, this compensation judge is convinced that she had pain resulting from the personal injuries and that was a substantial contributing factor to her depression. The employee has had a number of surgeries.
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Overall, this compensation judge is convinced by the opinions of the treating physicians. Dr. Daly tied in the shoulder surgeries and the knee surgery to the work injuries. Drs. Haber, Badroos and Mikhail tied in the carpal tunnel surgeries to her employment. Dr. Mikhail relates her chronic pain/depression to her injuries. Two other medical providers also do that: Psychologists John Patrick Cronin and Marilyn Mason.
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In the instant case, the employee proved by a preponderance of the evidence what was awarded. Accordingly, those benefits must be paid.
(Memo. at 11.)
The employer and insurer argue that no physician has identified a physical basis for the employee=s pain complaints. They contend that in May 2004, when the employee was restricted from work, there was no physiological basis for the employee=s chronic pain syndrome and the depression and therefore no causal relationship exists between the employee=s work-related injuries and her chronic pain and depression. As a result, the employer and insurer contend that the employee=s disability from work between May 2004 and May 2006, and her treatment for psychiatric and psychological condition, are not compensable.
A primary focus of the employer and insurer=s argument rests in the conflict between the diagnoses for the employee=s pain disorder assigned by Drs. Gratzer and Farnsworth and those assigned by Dr. Cronin. Each used diagnostic criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), a classification system used by psychologists, psychiatrists and mental health workers. According to that reference manual, the essential feature of a pain disorder is pain that is the predominant focus of the clinical presentation and is sufficiently severe to warrant clinical attention. The DSM-IV divides pain disorders into two basic types:
1. Diagnostic Code 307.80: Pain disorder associated with psychological factors. This subtype is used when psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. In this subtype, general medical conditions play either no role or a minimal role in the onset or maintenance of the pain.
2. Diagnostic Code 307.89: Pain disorder associated with psychological factors and a general medical condition. This subtype is used when both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain.
Dr. Farnsworth, one of the medical experts on whom the employer and insurer rely concerning the employee=s pain disorder diagnosis, limited his diagnosis of the employee=s condition to that of a pain disorder associated with a psychological condition only. Dr. Gratzer ruled out any general medical condition associated with the employee=s pain disorder. They both recognized that the employee had major depression and anxiety disorder, but neither attributed the employee=s pain disorder, and therefore her psychological condition, to her work-related injuries. By contrast, Dr. Cronin, the medical expert on whom the employee relies concerning her pain disorder, diagnosed a psychological condition associated with psychological factors and a general medical condition, and determined that the employee=s pain disorder was related to her work injuries.
Citing to Westling v. United Vegetable Farms, slip op. (W.C.C.A. April 29, 2004), the employer and insurer argue that the employee=s claim is not compensable, as there is no physical basis for the employee=s pain disorder. The employer and insurer also rely on the opinions of Drs. Wyard and Dworak, orthopedic surgeons, who both concluded that the employee=s orthopedic conditions are not related to the employee=s work injuries. In Westling, this court determined that when an employee seeks to recover workers= compensation benefits based on allegations that he or she has chronic pain disorder associated with both psychological factors and a general medical condition, a clear medical opinion is necessary to connect this psychological condition to a work injury. An employee therefore must establish that there is a physical basis for his or her pain in order to establish a causal connection to a workplace injury.
The compensation judge addressed the employer=s contention that the employee=s medical condition does not qualify her for a diagnosis that relates her pain disorder to a general medical condition. The judge relied, in part, on Dr. Mikhail=s opinion that the employee=s multiple work-related injuries substantially contributed to the employee=s chronic pain and depression. The judge also relied on the opinions of Drs. Cronin and Mason concerning the causal relationship between the employee=s injuries and her chronic pain and depression, and accepted Dr. Cronin=s diagnosis. The judge also distinguished the facts of this case from those in Westling, stating in his memorandum that A[i]n this case, the employee=s evidence is stronger than what was submitted in the case of Westling v. United Vegetable Farm, et al, (cite omitted).@ The judge commented that in Westling, Athe employee lost his case based on insufficient evidence. He relied on the testimony of one psychologist to support his claim. That is not the situation here.@
It is the role of the compensation judge to consider the competing medical opinions and the judge=s decision in that regard will not be reversed so long as the accepted opinion has adequate foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Smith v. Quebecor, 63 W.C.D. 566 (W.C.C.A. 2003). Resolution of the issue at hand required the compensation judge to address the conflicting medical opinions and also the extent of the interrelationship between the employee=s physical injuries and her chronic pain syndrome and depression. The compensation judge reasonably relied on the opinions of Drs. Mikhail, Cronin and Mason in arriving at his conclusion that the employee=s pain and depression were causally related to her work injuries. As substantial evidence supports those conclusions, we must affirm. Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
The employer and insurer also argue that Dr. Cronin=s opinion lacked foundation and that he disqualified himself, and therefore the compensation judge=s reliance on his opinion rendered his finding clearly erroneous and unsupported by substantial evidence of record. The employer contends that because Dr. Cronin deferred the assignment of physical work restrictions to the employee=s treating physicians, he disqualified himself from rendering an opinion on whether there was a general medical condition causing the employee=s pain. The employer and insurer also argue that Dr. Cronin, as a psychologist and not a medical doctor, is not qualified to render an opinion as to whether there is a general medical condition causing the employee=s pain. The employer and insurer rely on Dr. Farnsworth=s explanation that a psychologist is not qualified to make a determination about whether pain is caused by a general medical condition because he is not a medical doctor and does not have the same type of training and would not perform a physical examination in order to make a diagnosis of a physical condition. However, we note that Dr. Farnsworth also testified that a psychologist Amay be able to make that diagnosis if [he has] supportive evidence from a physician that [he=s] working with that there=s an anatomical lesion.@
The competency of a medical expert to provide an expert opinion depends upon both the extent of the scientific knowledge of the expert and the expert=s practical experience with the matter that is the subject of the expert opinion. Drews v. Kohl=s, 55 W.C.D. 33 (W.C.C.A.1996) (citing Reinhardt v. Colton, 337 N.W.2d 88, 93 (Minn. 1983)). There is no dispute as to Dr. Cronin=s scientific expertise concerning the employee=s pain disorder and depression. In addition, Dr. Cronin has examined the employee, has taken a history from her concerning her injury and physical and psychological symptoms, reviewed her chart notes and assessment by Dr. Mason, and reviewed testing results. As a general rule, this level of knowledge is sufficient to afford foundation for the opinion of a medical expert. See, e.g., Caizzo v. McDonald=s, 65 W.C.D. 378 (W.C.C.A. 2005). The fact that Dr. Cronin deferred the assessment of the employee=s physical restrictions does not render his causation opinion to be without foundation, not does it disqualify him from rendering an opinion on the causal connection between the employee=s injuries and her chronic pain and depression. See, e.g., Stuhr v. Northwestern Travel Servs., Inc., 57 W.C.D. 352 (W.C.C.A. 1997). These concerns go to the persuasiveness or weight to be afforded his medical opinion, but are insufficient to establish lack of foundation. We therefore find no grounds for reversal on the basis of any foundational defect. Wacek v. Hy-Vee Food Stores, No. WC05-275 (W.C.C.A. June 5, 2006).
We have carefully reviewed the employee=s medical records and the witness testimony, and conclude that the record as a whole more than adequately supports the judge=s conclusion that the employee=s psychological condition is substantially related to her work-related physical pain. This conclusion is also supported by the expert opinions of Drs. Mikhail, Cronin and Mason. Although the employer and insurer presented medical support for their position that there is no causal relationship between the employee=s work injuries and her depression and chronic pain syndrome, the compensation judge relied on the medical support presented by the employee. Substantial evidence supports the compensation judge=s decision that the employee=s work injuries were substantial contributing factors in the development of the employee=s psychological condition. That decision must, therefore, be affirmed. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239 (Minn. 1984).
 The record includes references to an injury on October 15 and 16, 1998; the compensation judge refers to the date of October 16, 1998, and there is no dispute that these dates refer to the same injury, so we have used the October 16 date throughout this decision.
 According to information presented at the hearing, two separate insurers were on the risk at the time of the employee=s injuries in 1998 and 2001. However, Marathon ACE has agreed to indemnify the 1998 insurance carrier for any liability. For that reason, we have referred generally to the Aemployer and insurer@ throughout this decision, with that reference being to the employer and ACE Insurance Company, administered by Frank Gates Services Company.
 Diagnostic and Statistical Manual of Mental Disorders, Text Edition, 499 (4th Ed. 2000).