DALLAS S. RUSS, JR., Employee, v. PENNINGTON COUNTY HIGHWAY DEP=T, SELF-INSURED/MINNESOTA COUNTIES INS. TRUST-RSKCO, Employer, and INDEPENDENT SCH. DIST. NO. 564, SELF-INSURED/BERKLEY RISK ADMIN. CO., Employer/Appellant, and ALTRU HEALTH SYS., RURAL RADIOLOGICAL CONSULTANTS, and RIVERVIEW HEALTHCARE, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
MARCH 26, 2008
CAUSATION - PERMANENT AGGRAVATION; CAUSATION - PRE-EXISTING CONDITION; EVIDENCE - EXPERT MEDICAL OPINION. Where, subsequent to the work incident, the employee=s left shoulder restrictions had been increased and his employment consequently terminated, where the employee had testified that symptoms in the shoulder had grown more severe ever since the incident, and where the judge=s decision was not improper for being based on the medical record as a whole instead of on formal expert medical opinion, the compensation judge=s finding of a work injury on the date alleged was not clearly erroneous and unsupported by substantial evidence.
APPORTIONMENT - EQUITABLE; CAUSATION - CONSEQUENTIAL INJURY. Where the recent work injury was an aggravation of a preexisting left shoulder condition, where any causal relationship between that preexisting condition and the employee=s earlier right shoulder work injury was irrelevant as a matter of law, where the employee=s left shoulder symptoms were currently more severe than his right shoulder symptoms, and where the appellant second employer offered no expert medical opinion apportioning any liability to the earlier employer, the compensation judge=s award placing sole liability on the second employer for benefits subsequent to the left shoulder injury was not clearly erroneous and unsupported by substantial evidence, notwithstanding the fact that the employee had permanent restrictions related to both shoulders.
Determined by: Pederson, J., Johnson, C. J., and Rykken, J.
Compensation Judge: James F. Cannon
Attorneys: John P. Bailey, Bailey Law Office, Bemidji, MN, for the Respondent Employee. Elizabeth Benson Powell, Johnson & Condon, Minneapolis, MN, for Respondent Pennington County Highway Dep=t. Michael J. Koshmrl, Heacox, Hartman, Koshmrl, Cosgriff & Johnson, St. Paul, MN, for the Appellant.
WILLIAM R. PEDERSON, Judge
Self-insured employer Independent School District No. 564 and its insurance administrator, Berkley Risk Administrators Company, appeal from the compensation judge's conclusion that the employee sustained a substantial work-related aggravation of a pre-existing left shoulder condition and that the employee was subsequently temporarily totally disabled solely due to that aggravation. We affirm.
The medical history of Dallas Russ, Jr., that is here relevant spans six years and involves claims based on three different work-related injuries. On February 27, 2001, Mr. Russ [the employee] sustained an injury to his right shoulder in the process of hurling some heavy logs to another worker in the course of his employment as a maintenance worker with the Pennington County Highway Department [Pennington County]. The employee was forty-eight years old on that date and was earning a weekly wage of $469.20, and Pennington County was self-insured against workers= compensation liability. Eventually, on April 12, 2001, the employee saw orthopedic surgeon Dr. Brian Briggs regarding the injury, who diagnosed a right rotator cuff tear and, on June 13, 2001, performed a right rotator cuff repair with acromioplasty. On July 5, 2001, Dr. Briggs recommended permanent restrictions against use of the arm at or above shoulder level and against doing any lifting or carrying of more than twenty or thirty pounds. He indicated also at that time that Athese restrictions also apply to the left shoulder where there is a 1/3rd risk for sustaining a rotator cuff tear on the contralateral side in the future.@ About two months later, on September 13, 2001, Dr. Briggs increased those restrictions to preclude lifting or carrying more than fifteen pounds with the right arm or more than thirty pounds with the left. Effective October 29, 2001, the employee was terminated from his job with Pennington County because work with the county was not available for him within those physical restrictions. On December 13, 2001, while finding no major problems and almost full range of motion, Dr. Briggs reiterated his earlier permanent restrictions for the employee, indicating again that the restrictions on the left were issued because the employee had at least a thirty percent chance of sustaining a rotator cuff tear on that side in the future.
On February 19, 2002, having been cleared for the work by Dr. Judith Campbell, the employee began working as a school bus driver with Independent School District No. 564 [School District 564]. On March 21, 2002, QRC Linda Thiem, from whom the employee had been receiving rehabilitation assistance related to his right shoulder injury since July 5, 2001, noted that the employee had been reporting increased symptoms in his left upper extremity, which the employee attributed at the time to his using his left upper extremity more than his right in compensation for his right upper extremity limitations. After completing the school year as a school bus driver, the employee worked full time during the summer of 2002 as Director of Shooting Sports at a Boy Scouts camp. On September 19, 2002, he was served with Dr. Briggs= report of maximum medical improvement [MMI] with regard to his right shoulder. The employee returned to school bus driving that fall, and by December of 2002 he was averaging at least thirty hours of work a week at that job, some weeks working a full forty hours.
On July 11, 2003, seven months later, QRC Thiem indicated in her report that the employee had continued to work as a school bus driver through May 28, 2003, normally without aggravation of his symptoms, and that he planned to return to that job again in the fall. QRC Thiem indicated that the employee was planning also to apply for an additional job during the school year that fall, to work an additional six hours a day as a full-time bus driver also with the Head Start program. On August 5, 2003, Dr. Briggs again reiterated his restriction of the employee from lifting over fifteen pounds with the right shoulder or over thirty pounds with the left and from doing any arm activity at or above shoulder level, again indicating that those restrictions were permanent. Later that month, on August 25 and 26, 2003, the employee underwent also a functional capacity evaluation [FCE], diagraming pain at the time in both of his shoulders and in his left knee. The evaluation resulted in a finding that he was able to do light to medium lifting and carrying, that he was able to frequently tolerate static positions like sitting, and that he was able to use both of his arms frequently for nonresistive reaching.
On September 30, 2003, the employee, who has weighed well over three hundred pounds during all time periods here relevant, fractured his right foot while stepping down from the bus that he had been driving in the course of his work as a school bus driver for School District 564. On the date of his injury, the employee was earning a weekly wage of $274.20, and School District 564 was self-insured against worker=s compensation liability. The union of the fractured bone in the employee=s foot was delayed, and, for about a year after the injury, the employee was continuously treated with multiple casts and crutches, which repeatedly wore out. The cast on his right foot during much of this period was about two inches higher than the shoe on his left foot, and he was made to walk with an uneven gait. Eventually the employee, who had no previous record of any problems with his cervical, thoracic, or lumbar spine, began to experience problems at all levels of his back.
On September 2, 2004, the employee, having not sought or received any treatment for any right shoulder symptoms since June of 2002, was reexamined by Dr. Briggs, to whom he complained of having experienced a Asnap@ in his right shoulder two months earlier, while reaching overhead to dry his back after a shower. X-rays revealed some degenerative changes but no other abnormality, and Dr. Briggs prescribed anti-inflammatories and icing and recommended that the employee Acarefully back off his physical activities@ and refrain from overhead reaching, anticipating a possible need for an injection or an MRI scan if symptoms persisted. The following day, September 3, 2004, the employee was examined by chiropractor Dr. Larry Stember, at his attorney=s request for opinions and recommendations regarding the employee=s right foot injury of September 30, 2003. In his report on that date, Dr. Stember opined that the employee=s September 2003 right foot injury had resulted in consequential injuries to all levels of the employee=s spine, due to the uneven gait that resulted from his year of treatment with casts and crutches. The report makes no mention of any left shoulder problems.
From about October 28 through November 17, 2004, with his right foot fracture finally going on to union, the employee underwent work hardening therapy. Records of the commencement of that therapy do not reference any left shoulder pain. On the final day of that therapy, the employee underwent another FCE, in the summary of which the examining therapist indicated in part that A[o]verall test findings, in combination with clinical observations, suggest [that a] question be drawn as to the reliability/accuracy of [the employee=s] subjective reports of pain/limitation.@ The therapist was quick to state, however, that he was Aby no means implying intent,@ only Athat [the employee] can do more at times than he currently states or perceives.@ On November 29, 2004, the primary doctor attending to the employee=s right foot injury, Dr. David Schall, noted, AFrom my standpoint, [the employee] really has no restrictions. Our big issue is getting him back to functional activities.@ On December 9, 2004, Dr. Schall declared the employee=s foot fracture Aessentially healed,@ and about that same time, after having been away from it ever since his September 2003 foot injury, the employee returned to his job as a bus driver.
On June 20, 2005, the employee was examined for Pennington County by physiatrist Dr. Paul Biewen. In his report on June 30, 2005, after physically examining the employee and reviewing his medical records, Dr. Biewen diagnosed (a) status post right rotator cuff tear and status post right rotator cuff repair with good result, (b) right acromioclavicular joint osteoarthritis, (c) resolved right fifth metatarsal fracture, (d) low back pain of undetermined etiology, with no evidence of relationship to a work injury, and (e) obesity, status post gastric bypass. It was Dr. Biewen=s opinion that the employee=s work-related shoulder and foot conditions did not require any additional evaluation or treatment and did not warrant the employee=s participation in a chronic pain program. It was his further opinion that the employee did not require an additional FCE, in that his shoulder surgeon had already clearly established permanent restrictions relative to his shoulder, he did not require any specific restrictions for his foot based on the treating physician=s documentation, and an earlier FCE had already established appropriate restrictions. Finally, Dr. Biewen opined that A[a]pportionment for a whole body program or chronic pain program is not applicable to the situation, as they are not medically necessary.@
On September 1, 2005, the employee was examined again by Dr. Briggs, complaining of increasing difficulties with his left shoulder over the past three or four months. X-rays were essentially normal, and Dr. Briggs diagnosed left shoulder pain and weakness with probable rotator cuff tear, instructing the employee Ato carefully protect this area, to avoid any abduction or overuse activities and to consider obtaining a MRI scan.@
About two weeks later, on September 16, 2005, in the course of his work as a bus driver with School District 564, the employee felt his driver=s seat suddenly collapse under him and tip to the right. In an effort to support himself and still keep control of the bus, the employee thrust his right arm and hand down onto the floor while keeping his left arm and hand stretched up and grasping the steering wheel. On September 19, 2005, three days after this incident, the employee was seen by Dr. Cory Rathgeber, complaining of pain on the upper left side of his neck and pain and significantly reduced range of motion in his left shoulder, which the employee related to the incident of September 16, 2005. X-rays revealed roughening of the distal left clavicle and evidence of degeneration in the glenohumeral joint and acromioclavicular joint, but no visible acute fracture. In his record on that date, Dr. Rathgeber indicated a finding of positive impingement and concluded that he could not determine whether the incident of September 16, 2005, had caused the employee=s symptoms or whether those symptoms were due to a pre-existing left shoulder condition. Dr. Rathgeber restricted the employee from driving, from lifting over five pounds, and from doing any overhead lifting, pending an appointment with Dr. Briggs in about a week for further treatment. The following day, September 20, 2005, School District 564 informed the employee that it no longer had work available for him within his new restrictions. On the date of the seat collapse, the employee had been earning a weekly wage of $303.40, and School District 564 remained self-insured.
Dr. Briggs examined the employee on September 22, 2005. Examination of the right shoulder revealed mild tenderness over the acromioclavicular joint with no suggestion of instability, while mild crepitus with flexion and abduction and weakness with abduction and external rotation was noted in the left shoulder. Dr. Briggs found it probable that the employee had a rotator cuff tear of his left shoulder and that he Awould be wise to initially protect this area and stay away from any significant use.@ Dr. Briggs again recommended an MRI scan of the left shoulder, to check for a rotator cuff tear, but he did not provide an opinion as to the cause of the left shoulder condition, and he did not issue any new restrictions.
On October 6, 2005, the employee filed an amended claim petition, alleging entitlement to temporary total disability benefits continuing from September 16, 2005, rehabilitation benefits, and medical expenses, consequent to bilateral shoulder injuries sustained while working for Pennington County on February 27, 2001, to right foot and spine injuries sustained while working with School District 564 on September 30, 2003, and to left shoulder and neck injuries sustained while working with School District 564 on September 16, 2005. Also on October 6, 2005, the employee filed a medical request, seeking authorization for an MRI scan of his left shoulder, based on the same alleged injuries.
On October 18, 2005, the employee was examined again at the request of his attorney by Dr. Stember. It was Dr. Stember=s opinion that the work-related incident of September 16, 2005, had resulted in an exacerbation of a pre-existing cervical condition together with an acute traumatic left shoulder rotator cuff injury with possible tearing, superimposed on a pre-existing Aless involved@ injury, which had in turn resulted in restricted joint motion, left shoulder and arm weakness, and pain.
In its Answer to the claim petition, filed October 21, 2005, School District 564 admitted liability for a right foot injury on September 30, 2003, but it denied liability for any spine injury consequent to that injury or for any left shoulder or other injury on September 16, 2005. On those grounds it disputed the employee=s claim to temporary total disability, permanent partial disability, rehabilitation, and medical benefits, alleging that the employee=s claimed disability was due to a pre-existing condition. In its Answer to the claim petition and its Medical Response, both filed October 24, 2005, Pennington County admitted liability for a right shoulder injury on February 27, 2001, but it denied liability for any consequential left shoulder injury, disputed the employee=s entitlement to temporary total disability, rehabilitation, and medical benefits, and declined to pay for an MRI scan. In a Medical Response filed October 28, 2005, School District 564 also denied the employee=s request for a left shoulder MRI scan.
On January 10, 2006, in an attempt to move the still unemployed employee=s case forward, QRC Moberg wrote to Drs. Briggs and Rathgeber, stating in part as follows:
I realize it is difficult to coordinate restrictions based on the past surgical repair of the right rotator cuff and a potential left rotator cuff tear, but I am hoping it can be realized. In reviewing the Functional Capacities Evaluation and Dr. Rathgeber=s restrictions, I am wondering if an accurate transitional Report of Work Ability would be appropriate when factoring both the right and left shoulder restrictions, such as sedentary work, lifting less than 10 pounds (both right and left shoulders), primarily seated, and no overhead lifting for either the right or left. If so, please sign below so that we can move forward or modify accordingly.
Dr. Briggs signed off on the request on January 16, 2006. On February 13, 2006, the employee filed another Medical Request, again seeking authorization for an MRI scan of his left shoulder. On February 20, 2006, and February 28, 2006, respectively, both Pennington County and School District 564 again refused to authorize the MRI scan, for the same reasons.
On February 20, 2006, the employee had also been examined again for Pennington County by Dr. Biewen. In his report on March 2, 2006, Dr. Biewen noted that the employee had exhibited a great deal of subjective pain behavior once physical examination had begun and had responded inconsistently, particularly in active shoulder motion. He indicated that, aside from healed surgical scars on the employee=s right shoulder and abdomen and the employee=s morbid obesity, the employee manifested no abnormal findings on physical examination. He noted that the employee=s left shoulder symptoms were not his chief complaint and were only referenced at the direct query of Dr. Biewen. Dr. Biewen acknowledged that the employee=s x-ray findings demonstrated a degree of degenerative change in his left shoulder, but he went on to note that the employee=s physical examination findings consisted primarily of pain behavior upon which no specific diagnosis could be based. He noted further that Dr. Briggs= record of September 1, 2005, referenced left shoulder pain of three or four months duration but without reference to any specific or Gillette-type injury. Dr. Biewen found no evidence in the medical record or elsewhere that the incident of September 16, 2005, even exacerbated a preexistent left shoulder condition or that it in any way caused injury to either the employee=s right shoulder or his low back. He noted that the employee=s subjective complaints of neck pain, right hip pain, and right knee pain, in addition to his left shoulder complaints, were not supported by objective physical findings. He reiterated his opinion that the employee did not require another FCE, but he did recommend a left shoulder MRI scan, concluding that the only necessary restrictions to be observed by the employee pertained to the employee=s earlier right shoulder work injury and that any restricted ability to work experienced by the employee was also due in part to the employee=s obesity and self-imposed sedentary lifestyle.
On March 3, 2006, the employee was examined also, for School District 564, by orthopedic surgeon Dr. John Dowdle. In his report on March 6, 2006, Dr. Dowdle similarly concluded that there was no indication that the incident of September 16, 2005, had caused the employee=s left shoulder complaints. He opined that the employee=s left shoulder condition was instead a manifestation of a chronic impingement syndrome and possible rotator cuff tendonitis or tear, together with age-related osteoarthritic changes of the acromioclavicular joint. He concluded that the employee=s subjective complaints were in excess of objective findings and that the employee was capable of working full time with restrictions against overhead lifting and prolonged single-position activities. As had Dr. Biewen, Dr. Dowdle recommended an MRI scan of both his left shoulder and his low back for further direction of his potential care and treatment but that neither of these would be related to the event of September 16, 2005. He opined further that, although subject to a 2% whole-body permanent partial disability relative to his right shoulder, the employee had reached MMI relative to both his right shoulder and his right foot injuries, that the employee was capable of working full time within restrictions against overhead lifting and prolonged single position activities, and that any restricted ability to work was due in part also to the employee=s obesity and self-imposed sedentary lifestyle and was not due to any work injury. Dr. Dowdle=s report was served on the employee on March 17, 2006.
In a report on August 12, 2006, QRC Ken Moberg, the employee=s QRC since his right foot injury, noted that the employee continued at that time to complain of several symptoms unrelated to his foot and shoulder injuries, including frequent headaches, low back and hip pain, and bilateral knee pain. On September 20, 2006, Dr. Maile Roper, a partner of Dr. Rathgeber, indicated that they would be attempting to get authorization for an MRI scan of the employee=s left and right shoulders.
On January 29, 2007, without reexamining the employee but after reviewing various notes of the employee=s QRC and records of Dr. Briggs, Dr. Stember issued an addendum report regarding the employee=s current condition. In his report, Dr. Stember opined that the employee=s current left shoulder rotator cuff condition was the result of a Gillette-type injury Aincurred from driving the school bus for a number of years while at the same time using [the left shoulder] in a compensatory fashion given the right rotator cuff surgery@ and that A[t]he inciden[t] which occurred on 9-16-05 with the seat breaking added further insult to an already weakened left shoulder,@ rendering it Aa substantial contributing factor to an already preexisting Left shoulder Gillette injury.@
The employee=s amended claim petition and his two medical requests had been consolidated for hearing, and they came on for that hearing on March 15, 2007. Issues at the hearing included whether the employee=s work-related right shoulder injury on February 27, 2001, had caused a consequential left shoulder condition due to overuse of the left shoulder, whether the employee had sustained a specific work-related left shoulder injury on September 16, 2005, and whether the employee had been temporarily totally disabled ever since September 16, 2005, due substantially to any admitted or alleged work-related injury or injuries.
The employee testified at hearing in part that he felt something snap in his left arm at the time of the September 16, 2005, incident and that he did not feel as though he had sustained any permanent injury at the time of the incident drying himself after a shower, just prior to his seeing Dr. Briggs on September 2, 2004. He testified also that he had had some stiffness and soreness in his left shoulder and neck prior to the September 16, 2005, incident but that just after the seat broke he had not been able to extend his arm all the way up. He testified also that he was currently using his right shoulder more than his left because Afor right now it has less pain in it than my left shoulder does.@ He testified that, while he was driving bus, he mainly used his left arm to steer and that therefore his left shoulder pain would increase whenever he drove bus. He testified also that he understood his current lifting restriction on his left upper extremity to have been increased from thirty pounds to ten to twelve pounds. He testified that he still feels a Asnapping@ sensation in his right shoulder if he=s not careful and that on the left side he sometimes feels - - sharp now whereas before September 16, 2005, it had been dull - - running down both the inside and the outside of his arm down to his elbow and also up the side of his neck. He testified that he also hears a snapping noise sometimes in his left shoulder now, which had never happened before the incident of September 16, 2005.
By findings and order filed July 13, 2007, the compensation judge concluded in part that the employee=s work-related right foot injury of September 30, 2003, did not cause any consequential injury or ongoing disability and so was not a substantial contributing factor in the employee=s disability or need for medical treatment after September 16, 2005. The judge further found that the employee=s right shoulder injury of February 27, 2001, did not cause a consequential left shoulder condition and was not a substantial contributing factor in the employee=s disability and need for medical treatment after September 16, 2005. With regard to the latter conclusion, he acknowledged that, prior to the incident of September 16, 2005, the employee had had a left shoulder problem and related permanent work restrictions. But he noted also that the employee was able to return to work as a bus driver after the 2001 injury, that he sought no treatment for his right shoulder during the more than two-year period from June of 2002 to August of 2004, and that he sought no treatment for his left shoulder for fully four and a half years after the 2001 right shoulder injury, right up until September 2005. The judge concluded that the employee=s work-related incident of September 16, 2005, had caused a substantial aggravation of a pre-existing left shoulder condition and was a substantial contributing factor in the employee=s subsequent disability and need for medical treatment. In related findings, the judge concluded that the employee had been cooperating with rehabilitation efforts and looking for work within his restrictions since September 2005, that he was not yet at maximum medical improvement related to his September 2005 left shoulder injury, and that the recommended MRI scan and the expenses related to treatment of that shoulder were reasonable and necessary and causally related to that injury. On those findings, the judge ordered School District 564 to pay for the recommended MRI scan, to pay for all medical treatment related to the left shoulder as claimed, and to pay the employee temporary total disability benefits continuing from September 16, 2005. School District 564 appeals from the judge=s finding of a work injury on September 16, 2005, and from his finding the school district solely liable.
STANDARD OF REVIEW
In reviewing cases 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 (2006). 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, A[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, Aunless 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.
1. Personal Injury on September 16, 2005
At Finding 24, the compensation judge concluded that the employee=s incident at work on September 16, 2005, caused a substantial aggravation of a pre-existing left shoulder condition that constituted a specific work-related injury. On that finding, the judge ordered School District 564 to pay the employee temporary total disability benefits continuing from September 16, 2005, together with the costs of the recommended left shoulder MRI scan and other medical expenses and reimbursement to the medical intervenors related to the left shoulder. School District 564 contends that the judge=s conclusion is clearly erroneous and unsupported by substantial evidence. It argues that the employee=s restrictions were essentially the same before September 16, 2005, as they were after that date and that there exists no credible and properly founded medical opinion to support the judge=s conclusion, while the opinions of Drs. Biewen and Dowdle support a conclusion to the contrary. We are not persuaded.
On September 1, 2005, two weeks before his left shoulder work injury, the employee came to Dr. Briggs with a three- or four-month history of increasing symptoms in his left shoulder, and Dr. Briggs instructed him Ato carefully protect this area, to avoid any abduction or overuse activities and to consider obtaining a[n] MRI scan.@ The employee at that point went back to work as a school bus driver. Subsequently, on September 22, 2005, about one week after the September 16, 2005, work incident, Dr. Briggs reexamined the employee and instructed him Ato initially protect this area and stay away from any significant use,@ again recommending an MRI scan. It is true that these two very informal restriction recommendations by Dr. Briggs are fairly similar in their import. During the intervening three-week period, however, on September 19, 2005, three days after the incident, the employee had been examined by Dr. Rathgeber, who had temporarily restricted him from all driving and from lifting over five pounds, and, unable to comply with these restrictions, the employer had terminated the employee=s employment. Moreover, while acknowledging that he had had some preexisting stiffness and soreness in the left shoulder prior to September 16, 2005, the employee testified at hearing that he had felt something snap in his left arm at the time of the September 16, 2005, incident and that immediately after that incident he had become unable to extend his arm all the way up. And he testified further that he continues to hear a snapping noise in the left shoulder now, which he had never heard prior to the September 16, 2005, incident. Further, on January 16, 2006, in an admittedly less than formal assertion of new permanent restrictions, Dr. Briggs, the physician most closely attending to the employee=s bilateral shoulder conditions, signed off on QRC Moberg=s proposal of increased working restrictions that would embrace the employee=s total ongoing shoulder condition, and the employee=s testimony at hearing essentially supports the ongoing effectiveness of those increased restrictions. It is evident that the School District 564 driver job is no longer available to the employee and that that nonavailability resulted most directly from the incident on September 16, 2005, as a result of which the employee=s left-shoulder complaints substantially increased and prior to which the employee had for years been able not only to drive a bus but also to work as a shooting instructor. Given the sum of this evidence, it was not unreasonable for the compensation judge to conclude, even without consideration of further medical evidence, that an event substantially injurious to the employee=s left shoulder occurred on September 16, 2005, in the course of the employee=s employment.
With regard to the alleged absence of medical opinion supporting the judge=s decision, we would note initially that even the case cited by School District 564 - - Himmer v. Pace Dairy, slip op. (W.C.C.A. April 3, 1996) - - does not require that every judge=s award be supported by a formal and properly founded medical opinion as to causation. Nor, as the school district itself acknowledges on page 23 of its brief, does the judge indicate definitive or otherwise material reliance on any particular medical opinion or opinions as to causation, including the opinion of Dr. Stember, which would then be subject to increased foundational scrutiny. To quote the case cited by the school district, an employee is generally required only to support his claim with Aobjective medical evidence@ (underscoring added). Cf., Himmer v. Pace Dairy, slip op. (W.C.C.A. April 3, 1996), citing Steffen v. Target Stores, 517 N.W.2d 579, 581, 50 W.C.D. 464, 467 (Minn. 1994). Moreover, while a judge may not be free to disregard even unopposed formal medical opinion contrary to the judge=s decision, see Flansburg v. Giza, 284 Minn. 199, 201-02, 169 N.W.2d 744, 746, 25 W.C.D. 3, 6 (1969), such opinion is not necessarily conclusive upon the trier of fact. See Tuomela v. Reserve Mining Co., 299 Minn. 203, 204, 216 N.W.2d 638, 639, 27 W.C.D. 312, 313 (1974).
In this case, it is clear, from his detailed findings and substantial memorandum, that the compensation judge considered and weighed the medical opinions of Drs. Biewen and Dowdle, along with those of Dr. Stember and the records of Drs. Rathgeber, Briggs, and Schall, in reaching his conclusion. The judge=s decision is not rendered improper as a matter of law by the mere fact that the judge granted more weight to contrary evidence in the medical record as a whole than to the formal causation opinions of Drs. Biewen and Dowdle. Moreover, while expert medical opinion is relevant and may be determinative, it is not the only evidence a compensation judge may consider. Larson v. Mark J. Wells, Inc., slip op. (W.C.C.A. May 4, 2005) (the compensation judge properly considered and relied upon the employee=s testimony regarding the severity of his pain and symptoms and the limitations the personal injury placed on his ability to work). Because it was not improper for being unsupported by sufficient medical opinion, and because it was not otherwise unreasonable, we affirm the compensation judge=s conclusion that the employee suffered a work-related injury on September 16, 2005. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
2. Sole Liability
At Finding 28 the compensation judge concluded that the employee had been temporarily totally disabled since September 16, 2005, due to a left shoulder work injury on that date. At Finding 29 the judge concluded that the recommended left shoulder MRI scan and other medical expenses at issue were made necessary by that same work injury. Then, at Order 3, the judge denied the employee=s claim that his left shoulder condition was in substantial part a consequence of his right shoulder injury of February 27, 2001, due to overuse of the left shoulder in compensation for the right shoulder limitations. School District 564 contends that these conclusions of the judge are unsupported by substantial evidence. It argues that the employee=s right shoulder restrictions are essentially the same as his left shoulder restrictions, that the employee has not been actively treating for either shoulder condition for the past two years, that the employee has meanwhile been subject to a plethora of other nonwork-related potentially disabling problems, including problems with his neck, his back, his feet, and numerous complications stemming from his obesity. The school district contends that, A[i]f the employee has indeed been disabled, a conclusion we clearly think is wrong, then the evidence, taken as a whole, shows that this period of disability is caused equally by the employee=s right and left shoulder problems, not solely by the employee=s left shoulder problems.@ We are not persuaded.
At Finding 7, the compensation judge concluded that the employee=s work-related right shoulder injury in February of 2001 did not cause a consequential left shoulder condition due to compensatory overuse of the left shoulder. Although School District 564 has nominally appealed from this finding, they have not addressed it in their brief as a basis for their appeal - - and rightly so, in that, as this court has previously indicated, Minnesota workers= compensation law does not recognize a consequential injury that is also work-related. See Heinemann v. Independent Sch. Dist. #279, 63 W.C.D. 312 (W.C.C.A. 2003). It is true that nonwork-related Anatural consequence[s] flowing from the primary injury@ are compensable under that injury, see Eide v. Whirlpool Steeger Co., 260 Minn. 98, 102, 109 N.W.2d 47, 50, 21 W.C.D. 437, 441 (1961), but here the employee=s left shoulder injury, whether or not consequentially related to his right shoulder work injury, happened in the course of his employment with School District 564.
While arguing that the employee=s right foot condition and several nonwork-related aspects of the employee=s condition contribute to any disability from work to which he might be subject, School District 564 bases its appeal for apportionment only on the employee=s right shoulder condition and its related permanent restrictions. The school district did not, however, offer any expert medical opinion in support of its position on this issue of apportionment, and we conclude that it was not unreasonable for the judge to have implicitly concluded that any official permanent restrictions related to the employee=s right shoulder did not correlate with sufficient actual disability to be factored into any award. We acknowledge that, after not being the subject of any treatment for over two years ending three and a half years after his February 27, 2001, injury the employee=s right shoulder problems were monitored again for the nine months between about September 2004 and about June of 2005, when he was examined by Dr. Biewen. But it would not have been unreasonable for the compensation judge to conclude that any actual functional disability directly attributable to the February 2001 right shoulder injury with Pennington County had reasonably resolved by June 2002, when commenced about a twenty-five-month period during which the employee was apparently without any symptoms disabling enough to compel his seeking treatment. The employee clearly testified that since September 16, 2005, his left shoulder symptoms have been more severe than any right shoulder problems to which he is subject, the left side problems sometimes including very sharp pain. Without clearer evidence of actual functional limitation related to the right shoulder restrictions, and without any medical opinion at all in that regard, we cannot conclude that the judge was unreasonable in his placing sole liability on School District 564 for all of the employee=s temporary total disability and medical expenses after September 16, 2005. Therefore we affirm that decision of the judge. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
 See Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).