DEBORAH A. VIEHAUSER, Employee/Appellant, v. FUNCTIONAL INDUSTRIES, INC., SELF-INSURED/BERKLEY RISK ADM=RS CO., Employer.
WORKERS= COMPENSATION COURT OF APPEALS
JUNE 18, 2008
CAUSATION - GILLETTE INJURY. Substantial evidence, including the adequately founded opinion of a medical expert, supports the compensation judge=s determination that the employee failed to prove a Gillette injury in the nature of an aggravation or acceleration of her pre-existing osteoarthritis in both hands.
CAUSATION - PSYCHOLOGICAL INJURY. Substantial evidence, including medical expert opinion, supports the compensation judge=s finding that the employee did not sustain an aggravation of her underlying psychological condition as a result of her work injury.
CAUSATION - REFLEX SYMPATHETIC DYSTROPHY. Where the compensation judge=s finding is confusing and inconsistent, where it appears the judge improperly applied the criteria set forth in Minn. R. 5223.0400, sub.6, in determining the nature and existence of the claimed reflex sympathetic dystrophy condition, and where the judge incorrectly found the treating and examining doctors had not concluded or explained how the work injury resulted in RSD, the issue of the employee=s sympathetic dystrophy condition and related benefits must be remanded for reconsideration.
Affirmed in part and vacated and remanded in part.
Determined by: Johnson, C.J., Rykken, J., and Pederson, J.
Compensation Judge: Cheryl LeClair-Sommer
Attorneys: John J. Horvei, New Brighton , MN, for the Appellant. Timothy P. Jung, Lind, Jensen, Sullivan & Peterson, Minneapolis, MN, for the Respondent.
THOMAS L. JOHNSON, Judge
The employee appeals from the compensation judge=s decision finding the employee failed to prove she sustained a work-related injury in the nature of a Gillette injury to her bilateral hands, a consequential psychological injury, and reflex sympathetic dystrophy in both hands. We affirm in part, and vacate and remand in part.
Deborah A. Viehauser, the employee, sustained a personal injury on April 21, 2005, when an upset client grabbed both hands, squeezing and twisting them. At the time of the injury, the employee was a lead production supervisor at Functional Industries, Inc., the self-insured employer. The employer provides work rehabilitation services for physically and mentally handicapped adults. The employer admitted liability for the personal injury and paid various workers= compensation benefits.
The employee saw Dr. Brett Oden at the Buffalo Clinic on the day of her injury, reporting a Asmashed finger@ when a client grabbed her finger and squeezed. The employee gave a history of arthritis, but stated the joint had not bothered her much until the incident. An x-ray showed extensive degenerative changes about the interphalangeal joint spaces of the right index finger with no evidence of fracture. Dr. Oden diagnosed arthritis with a squeezing injury to the finger, placed the right index finger in a splint and released the employee to return to work with restrictions. The employee returned to the Buffalo Clinic on May 9 with continued complaints regarding her right index finger. On examination, Dr. Rajan Jhanjee noted an obviously swollen finger with limited range of motion. The diagnosis was finger pain superimposed on previous degenerative arthritis. Dr. Jhanjee recommended physical therapy and anti-inflammatory medication. On May 27, Dr. Jhanjee restricted the employee to 10 pounds lifting at work. On June 27, noting the employee=s continuing pain, Dr. Jhanjee referred the employee for a surgery consultation.
The employee saw Dr. Robert Anderson at Metropolitan Hand Surgery Associates on July 12, 2005. The doctor took a history of someone grabbing and twisting the employee=s right index finger resulting in severe pain and swelling through the joint. An x-ray showed complete destruction of the proximal interphalangeal (PIP) joint with a substantial valgus deformity through the joint with erosive arthritic changes. Dr. Anderson recommended joint replacement surgery which he performed on August 17, 2005. In a post-surgery follow-up on October 4, 2005, the doctor noted the employee was making slow progress with substantial loss of range of motion and moderate swelling in the finger. The employee stated she was moving to Austin, Minnesota, and asked for a referral. Dr. Anderson recommended Dr. Robert Beckenbaugh at the Mayo Clinic.
The employee was evaluated at the Mayo hand surgery clinic on October 20, 2005. The employee described pain and loss of motion in the index finger, along with pain, swelling and stiffness in the whole hand. The impression was possible reflex sympathetic dystrophy (RSD) following index finger PIP arthroplasty. Dr. Beckenbaugh noted the employee originally did well post-op, but as time went by developed an extension lag in the index finger and swelling and discomfort in the remainder of the hand. The doctor noted apparent dystrophic change to the adjacent three digits. He prescribed daily physical therapy with an initial goal of decreasing swelling and regaining full extension of the right index finger. On October 26, Dr. Beckenbaugh noted improvement in the appearance and movement of the finger. The doctor discussed pain dysfunction syndrome with the employee, and ordered continued physical therapy focusing on rehabilitation of the entire hand. On November 9, Dr. Beckenbaugh stated the employee=s dystrophy appeared to be resolving. He noted the employee still had some limitation of motion in the long finger, but her hand pain was generally much better and the passive position of the index finger was much improved. Physical therapy was continued, and the doctor suggested the employee could return to work using only the left hand in a week or so.
On November 11, 2005, the employee complained of pain in all of her joints, stating her arthritic symptoms were too bad for her to return to work. Dr. Beckenbaugh recommended a work capacity evaluation. On December 6, Dr. Beckenbaugh stated the employee was doing pretty well, with decreasing swelling but some continuing sensitivity. He recommended the employee return to see a therapist every other week to avoid recurrence of the dystrophic changes. The employee was also seen by Dr. Jeffrey Brault, at the same clinic, who concurred with a functional capacity evaluation (FCE) and with continued monitoring for autonomic changes. Following the FCE in January 2006, Dr. Brault stated the assessment demonstrated Afairly significant limitations of her ability to use her right hand, particularly her right index finger,@ and recommended a work hardening program. (Ee Ex. G-3.)
On January 30, 2006, Dr. Stephen Olmsted, a hand surgeon, examined the employee at the request of the self-insured employer. The employee described pain, swelling and stiffness in her right index finger and pain, numbness and paresthesia in both hands. Following examination, Dr. Olmsted diagnosed bilateral advanced osteoarthritis in the PIP and distal interphalangeal (DIP) joints of the hands, noting significantly limited range of motion in the right index finger. The doctor opined the April 21, 2005, work injury was a temporary symptomatic aggravation of the employee=s underlying, pre-existing osteoarthritis in the PIP joint of the right index finger. He maintained the injury did not result in any change in the underlying condition of the index finger joint and would have resolved within 4 to 6 weeks. Dr. Olmsted stated the restricted motion, pain and swelling in the employee=s hands and fingers was consistent with the natural history of an arthritic condition, and opined the employee=s work injury was not a substantial contributing cause of the employee=s arthritis, including that of the right index finger. Dr. Olmsted rated zero permanent partial disability and stated the employee had reached maximum medical improvement.
The employee was referred by Dr. Scott Holtz, her family physician, to Dr. Eric Schned for a second opinion regarding her hand pain. When seen on January 31, 2006, the employee described patchy and intermittent numb or burning sensations into her fingers that had steadily worsened in the fall. On examination, Dr. Schned noted positive Tinel=s signs bilaterally along with nodes and tenderness in all finger joints. His impression was underlying osteoarthritis of the hands, asymptomatic until her work injury in April 2005, along with bilateral carpal tunnel syndrome. Dr. Schned noted the employee=s diabetes was a possible underlying risk factor, but stated the injury and work assessment seemed to have aggravated the carpal tunnel. He did not believe the employee had reflex sympathetic dystrophy or other inflammatory arthritis.
Dr. Beckenbaugh re-examined the employee on February 24, 2006, noting bilateral carpal tunnel syndrome had been confirmed by EMG. The doctor noted a positive carpal tunnel compression test and Tinel=s sign, as well as some increased heat involving the right hand and symptoms in the left hand. Dr. Beckenbaugh observed that
[i]n a situation where [the employee] has had intermittent swelling, diffuse pain which has been interpreted as being related to a chronic pain syndrome, we are always reluctant to consider further surgical intervention[.] * * * I have emphasized with her that because of the overlying characteristics and findings compatible with . . . that of a pain dysfunction syndrome [t]his could conceivably be worsened with surgery. On the other hand, if we do not correct the source of her pain (presumed to be carpal tunnel . . .), it will be difficult to get her over the dystrophy.
(Ee Ex. G-3.) Dr. Beckenbaugh further stated, Athere has always been a question of the workman=s relationship to her symptom levels and I felt that in the past that much of this has been related to her arthritis although the fact that her symptoms were precipitated by grapping [sic] incident while she was at work would tend to suggest that the whole current process is, in fact, work related and we could consider it so.@ (Ee Ex. G-3.)
On March 18, 2006, following a medical record review, Dr. Olmsted agreed the employee had bilateral carpal tunnel syndrome. The doctor opined, however, that the employee had idiopathic, non-work-related carpal tunnel consistent with risk factors including being female, obesity, and age-related, pre-existing osteoarthritis.
On April 5, 2006, Dr. Beckenbaugh noted the employee=s hands were cold and sweaty. The doctor stated he was concerned the employee was pre-dystrophic with increased sweat patterns etc., but believed the employee had little chance of getting over the dystrophy until the pain from the carpal tunnel syndrome was addressed. The doctor stated the proper approach was to release the carpal tunnel and then work on the employee=s hand symptoms. Dr. Beckenbaugh performed bilateral carpal tunnel releases on April 6, following which the employee again received physical therapy.
Dr. Robert Wengler examined the employee on June 9, 2006, on referral by her attorney. The employee complained of painful limitation of motion of both hands, attributing the onset of her hand pain to her personal injury. The doctor noted the skin of the hands was shiny and dystrophic, which along with posturing, suggested the possibility of a regional pain syndrome. Dr. Wengler diagnosed degenerative osteoarthritis of both hands and bilateral carpal tunnel syndrome. The doctor stated the employee=s osteoarthritis pre-existed her work injury, but opined the work incident was a material aggravation of the employee=s condition, causing the arthritis to become symptomatic, and further stating the Awhole current process,@ including the carpal tunnel, was work related. Dr. Wengler assigned permanent disability for loss of motion of the joints of the four fingers of each hand under Minn. R. 5223.0480, subp. 4, and opined the employee was totally disabled from any activity that involved the use of her hands.
The employee returned to see Dr. Holtz at the Austin Medical Center on September 25, 2006. On examination, the doctor noted the employee=s hands had a shiny appearance with inflammation of the PIP joints in both hands. The doctor diagnosed osteoarthritis and possible rheumatoid arthritis or underlying reflex-type dystrophy and suggested a trial of Neurontin along with Vicodin for pain control. In October and November 2006, Dr. Holtz diagnosed on-going reflexive-type sympathetic dystrophy secondary to a work injury. He noted improvement with the Neurontin and increased the dose. By report dated April 11, 2007, Dr. Holtz stated the employee Asuffered an injury to her hand while at work and was found to have a rather rapidly [sic] progression of osteoarthritis and carpal tunnel syndrome of both hands thereafter. She has since that period of time not been able to work secondary to chronic pain syndrome and a suspected feeling of mild reflex sympathetic dystrophy in the hands.@ (Ee Ex. G-2.)
On April 3, 2007, the employee was seen in the emergency department of the Austin Medical Center reporting depression starting several days previously when she had an altercation with her mother and was thrown of out of her parents= house where she had been staying. She was hospitalized until April 6, 2007, and was diagnosed with a major depressive disorder, recurrent, undifferentiated somatization disorder, and anxiety disorder. She continued to receive individual psychotherapy after her discharge.
Dr. Wengler re-examined the employee on April 12, 2007. The doctor observed the employee=s hands had deteriorated since the carpal tunnel surgery. On examination, Dr. Wengler noted both hands were exquisitely tender to touch, the skin was reddened, shiny and dystrophic, the palms were sweaty and dyshidrotic, and motion of the joints was markedly limited. Dr. Wengler stated the symptoms and findings were characteristic of autonomic dysfunction or RSD. The doctor provided a permanent partial disability rating of 27% to the right and left upper extremity under Minn. R. 5223.0400, subp. 6.B., for RSD. Dr. Wengler further opined the employee=s work activities for the employer, requiring rapid, repetitive and strenuous use of the hands, contributed to the development of the employee=s degenerative osteoarthritis in the nature of a Gillette injury, and that the April 21, 2005, incident materially aggravated the pre-existing arthritis.
On May 3, 2007, the employee was seen by Dr. Matthew Kumar at the Austin Medical Center pain clinic. The doctor noted both hands appeared swollen, the skin stretched, shiny and erythmatic. Dr. Kumar recommended further evaluation to rule out neuropathy, rheumatoid arthritis and RSD.
Dr. John Cronin, a licensed psychologist, examined the employee in May 2007 at the request of her attorney. Dr. Cronin diagnosed a pain disorder with psychological factors and a general medical condition (RSD), along with a dysthemic disorder which the doctor defined as long- standing depression. Dr. Cronin noted, despite a history of psychological problems, the employee was able to function until the personal injury. In his opinion, the employee=s personal injury was a substantial contributing factor to her depression and chronic pain syndrome. Dr. Cronin provided a 35% permanent partial disability for the employee=s psychological impairments under Weber.
Dr. John Rauenhorst, a psychiatrist, examined the employee on May 30, 2007, at the request of the self-insured employer. The doctor diagnosed a depressive disorder which he opined began long before the April 21, 2005, personal injury. In his opinion, the employee=s psychological and emotional problems were not related to the April 21, 2005, personal injury to her hands but were the result of various personal stressors in her life.
Dr. Olmsted again saw the employee on June 28, 2007. At that time, the employee continued to complain of burning pain, numbness and tingling in all digits, and stated she obtained no relief from the carpal tunnel surgeries. The doctor stated there was no dystrophic appearance to the hand on examination and concluded there were no objective physical findings to suggest an ongoing regional pain syndrome.
The employee filed a claim petition contending she sustained a Gillette personal injury in the nature of bilateral osteoarthritis of the hands and or bilateral carpal tunnel syndrome culminating on April 21, 2005. The employee further claimed a specific injury on April 21, 2005, in the nature of an aggravation of her osteoarthritis in both hands, reflex sympathetic dystrophy and carpal tunnel syndrome, along with a consequential psychological condition. The employee sought temporary total and permanent partial disability benefits together with medical expenses and a rehabilitation consultation. Following a hearing, the compensation judge found (1) the employee sustained a permanent injury to her right index finger as a result of the April 21, 2005, work injury, and that the work injury was a substantial contributing factor to her joint replacement surgery; (2) the April 21, 2005, incident did not result in an injury to the hands in the nature of an aggravation of the employee=s pre-existing osteoarthritis; (3) the employee did not sustain a Gillette injury in the nature of an aggravation or acceleration of her pre-existing osteoarthritis or bilateral carpal tunnel syndrome; (4) the employee failed to prove her work injury caused an aggravation of an underlying psychological condition; and (5) the employee failed to prove she was entitled to permanent partial disability for reflex sympathetic dystrophy. Finally, the compensation judge found the employee failed to conduct a reasonably diligent search for employment from April 4, 2006, to the date of the hearing. Based upon these findings, the compensation judge denied the employee=s claims for wage loss benefits and permanent partial disability benefits. The employee appeals the compensation judge=s denial of her claim for wage loss and permanent partial disability benefits.
1. Gillette Injury
Accepting the opinion of Dr. Olmsted, the compensation judge found the employee did not sustain a Gillette injury in the nature of an aggravation or acceleration of her underlying osteoarthritis. The employee asserts the opinion of Dr. Olmsted was inconsistent with the evidence and lacked foundation, and that there was no legal basis for the judge=s rejection of Dr. Wengler=s opinion. We disagree.
The employee contends the evidence establishes her work for the employer was hand intensive and strenuous. She testified she used her hands repeatedly in her job as lead production supervisor, including daily and weekly lifting, pushing and pulling. She described handling materials requiring significant hand strength on a daily basis and described her job as very hard work. Rodney Peterson, the president of the employer, disagreed with the employee=s characterization of the frequency of lifting and moving weight, stating the job primarily involved supervising and observing clients and some paperwork. While different inferences could be drawn from the evidence, the compensation judge could reasonably conclude the employee=s duties were not as strenuous or hand intensive as claimed by the employee.
Moreover, even if the compensation judge had concluded the employee=s job duties were hand intensive, a finding of causation does not necessarily follow. The employee, in a Gillette case, has the burden of proving a causal connection between her ordinary work activities and her disability. This is a question of fact for the judge and depends, primarily, on the medical evidence. Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D.181 (Minn. 1994); Steffen v. Target Stores, 517 N.W.2d 579,50 W.C.D. 464 (Minn. 1994). Dr. Wengler opined the employee=s work activities for the employer, requiring rapid, repetitive and strenuous use of the hands, contributed to the development or aggravation of the employee=s degenerative osteoarthritis in the nature of a Gillette injury. Dr. Olmsted diagnosed bilateral advanced osteoarthritis of the hands. He maintained the restricted motion, pain and swelling in the employee=s hands and fingers was consistent with the natural history of an arthritic condition involving the hand, and opined the employee=s arthritis was idiopathic, likely not directly related to physical activity, and not consistent with a Gillette injury. The employee testified she noticed no change in her knuckles, was not having problems with her hands and wrists doing the job, and did not have regular hand pain while working for the employer. Dr. Olmsted reviewed the employee=s medical records, took a history, examined the employee, and reviewed the employee=s position descriptions. We have on many occasions stated this level of experience with the subject matter provides sufficient foundation for an expert opinion. See Grunst v. Immanuel‑St. Joseph Hosp., 424 N.W.2d 66, 40 W.C.D. 1130 (Minn. 1988). It is the function of the compensation judge to choose between conflicting expert opinions. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). There is substantial evidence of record to support the compensation judge=s finding and it must be affirmed.
2. Psychological Condition
The employee contends the compensation judge=s finding that the employee did not sustain an aggravation of her underlying psychological condition as a result of her work injury, erroneously assumes the employee had an Aunderlying psychological condition@ and ignores the employee=s unrefuted testimony. We are not persuaded.
The resolution of this issue rests on the compensation judge=s choice of experts. Both Dr. Cronin and Dr. Rauenhorst agreed the employee had a long-standing psychological condition. Dr. Cronin diagnosed a pain disorder with psychological factors and a general medical condition and a dysthemic disorder. He stated the employee had been doing well before the injury but, after the injury, obviously went downhill. Dr. Cronin explained it was not just the pain and inability to respond to treatment, but the financial and social consequences as well - - the loss of her home, having to move in with her parents - - that lead to a reactive depression. In his opinion, the work injury precipitated or exacerbated her existing psychological condition and was a substantial contributing factor to her current depression and chronic pain syndrome.
Dr. Rauenhorst, on the other hand, diagnosed a depressive disorder which began long before the April 21, 2005, injury, further noting the employee had not sought any treatment for emotional symptoms until nearly two years after the personal injury. In his opinion, the employee=s depressive disorder was the result of personal stressors in her life, including a difficult childhood, her current financial difficulties, her conflict with her parents, dissatisfaction with her living situation and worries about her financial future, and was not caused by or related to the work injury.
The compensation judge adopted the opinion of Dr. Rauenhorst. It is not the role of this court to re-evaluate the credibility and probative value of expert witness testimony. Whether we might have viewed the evidence differently is not the point. Rather the question on appeal is whether the finding of the compensation judge is supported by evidence that a reasonable mind might accept as adequate. Redgate v. Sroga's Standard Serv., 421 N.W.2d 729, 40 W.C.D. 948 (Minn. 1988). There is substantial evidence in the form of well-founded medical expert opinion to support the compensation judge=s finding, and we must, accordingly, affirm. See Nord, id.
3. Reflex Sympathetic Dystrophy
The employee argues the compensation judge made errors of fact and law in finding the employee failed to prove her reflex sympathetic dystrophy symptoms were a consequence of the April 21, 2005, injury to the right index finger. We agree. The compensation judge=s finding on the RSD claim and her memorandum on this issue are confusing at best. The judge found:
The evidence fails to prove that the work injury of April 21, 2005, a permanent injury to the right index finger, is a substantial contributing factor to the symptoms diagnosed by some physicians as reflex sympathetic dystrophy. The medical records document persistent signs and symptoms of edema and reduced range of motion to the bilateral hands. On occasion, the medical records document excessive sweating, local skin color change, local alteration of skin texture due to shiny skin, and local abnormality of skin temperature regulation (by the employee=s report) to the bilateral hands. The lack of persistent objective evidence of five of the eight conditions required by Minn. Rule 5223.0430, subp. 6, results in the conclusion the condition cannot be rated for a permanent partial disability. In addition, maximum medical improvement has not been achieved for the RSD since additional medical treatment may lead to significant recovery.
(Finding 6.) In her memorandum, the judge stated, in part,
The evidence is not conclusive on a finding of RSD. . . . According to the opinions of the various physicians, it is possible the employee has a mild sympathetic component to her condition.
Dr. Wengler diagnosed RSD through skin discoloration, a purplish complexion, sweaty palms, marked passive limitation of all joints of the fingers, shiny skin and Athe x-ray showed a severe demineralization of the bones of the fingers and the carpal bones.@ The RSD occurred as a cascade of complications after the particular traumatic event, Dr. Wengler concluded. But the x-ray reports do not support a conclusion of demineralization of the bones to support the opinion of Dr. Wengler.
* * *
The evidence does not prove that the right finger injury resulted in the possible mild sympathetic component. The treating and examining physicians do not conclude or explain how the right index finger injury resulted in RSD. Permanent partial disability cannot be rated since physicians at Mayo Clinic recommend additional medical treatment.
Although the judge made an apparent finding of causation [A[t]he evidence fails to prove that the work injury . . . is a substantial contributing factor to the symptoms diagnosed by some physicians as reflex sympathetic dystrophy@], she made no clear finding as to whether the employee does or does not have an RSD-type condition, an issue clearly raised by the parties. Where the issue of causation arises from a dispute over the nature of an injury, it is necessary first to answer the question of whether the employee has the condition claimed, including the nature of that condition.
Moreover, in addressing the employee=s RSD claim, it appears the compensation judge erroneously applied criteria set forth in Minn. R. 5223.0400, subp. 6. Under this rule, for the purpose of a permanency rating, a diagnosis of reflex sympathetic dystrophy is deemed to occur in a member if five of eight specified conditions persist concurrently. This court held, in Stone v. Harold Chevrolet, 65 W.C.D. 102, 111-12 (W.C.C.A. 2004), that while the criteria may be useful as Adiagnostic tools with which to establish a diagnosis of RSD,@ an employee=s failure to satisfy five of the eight conditions does not preclude an award of permanency benefits. More importantly, as this court observed in Ellsworth v. Days Inn/Brutgers Equities, No. WC06-276 (W.C.C.A. June 8, 2007), the permanency rule does not dictate the existence, or not, of a compensable injury or medical condition, nor does it apply to preclude an individual doctor=s diagnosis of a sympathetic pain syndrome. In any event, it is not the diagnosis of the injury that is the ultimate issue. Rather the issue is the nature of the employee=s medical condition or injury, whether the diagnosis is labeled reflex sympathetic dystrophy, pain dysfunction syndrome, autonomic changes or something else. Haley v. Kwik Trip, Inc., No. WC06-200 (W.C.C.A. Jan. 10, 2007).
In this case, the compensation judge found the medical records document persistent signs and symptoms of edema and reduced range of motion to the bilateral hands. On occasion, the medical records document excessive sweating, local skin color change, local alteration of skin texture due to shiny skin, and local abnormality of skin temperature regulation to the bilateral hands. In her memorandum, the judge noted that according to the opinions of the various physicians, the employee may have a mild sympathetic component. Dr. Beckenbaugh variously referred to and treated the employee for Adystrophy@ or Adystrophic changes,@ Apain dysfunction syndrome,@ and Apre-dystrophic@ symptoms. Dr. Brault used the term Aautonomic changes.@ Dr. Wengler referenced a Aregional pain syndrome,@ Aautonomic dysfunction@ and Areflex sympathetic dystrophy.@ Dr. Holtz diagnosed Areflexive-type sympathetic dystrophy.@ Dr. Olmsted, while agreeing the employee exhibited subjective Atouch-me-not@ behaviors, stated the employee had no physical objective findings on his examination consistent with Areflex sympathetic dystrophy@ and concluded the employee did not have RSD.
The compensation judge further commented in her memorandum that the evidence did not establish the right finger injury resulted in the possible mild sympathetic component, stating the treating and examining physicians did not conclude or explain how the finger injury resulted in RSD. This is simply incorrect.
This court has stated on a number of occasions that a medical expert need not provide an explanation for his or her opinion, and that the lack of an explanation, while it may affect the persuasiveness of an opinion, is not a sufficient basis to disqualify a medical expert=s opinion. See, e.g., Henchal v. Federal Express Corp., No. WC07-212 (W.C.C.A. Jan. 30, 2008). That said, the treating and examining doctors did conclude the RSD condition was related, and/or explained the relationship between the finger injury and the dystrophic hand condition.
The diagnosis following the initial evaluation at Mayo Clinic on October 20, 2005, was possible RSD following index finger PIP arthroplasty. On February 24, 2006, Dr. Beckenbaugh stated the employee was originally seen for a stiff finger following a work-related traumatic injury to the joint that resulted in a PIP arthroplasty. Post-operatively, the doctor stated, the employee developed a pain dysfunction syndrome. Dr. Beckenbaugh expressed his concern that, because of the characteristics and previous finding of a pain dysfunction syndrome, the syndrome could conceivably be worsened by further surgery, and felt Athe whole current process@ could be considered work related. Dr. Holtz diagnosed RSD secondary to the trauma and stress of the finger injury, and specifically stated the employee had reflexive-type sympathetic dystrophy secondary to her workers= compensation injury. Dr. Olmsted explained that RSD is a sympathetic nervous system mediated pain response that is typically induced by trauma, surgeries or injuries. Dr. Wengler similarly stated RSD is generally believed to develop secondary to a relatively innocuous blunt trauma. The most simplistic theory, he stated, is that there is a short-circuiting between neural impulses from the sympathetic nervous system into the efferent nervous system which then feeds back into the brain. Dr. Wengler stated RSD usually develops slowly, and opined the time frame in this case was not unreasonable for the development of the problem at issue. In his opinion, the employee=s RSD occurred as a cascade of physiologic complications following the twisting and squeezing injury.
We conclude the compensation judge made material errors of law and fact in addressing the employee=s RSD claim. This court is not, however, a fact-finding court, and as differing inferences could be drawn from the evidence, we vacate finding 6 and remand the issue of the employee=s sympathetic dystrophy claim and related benefits to the compensation judge for reconsideration.
 Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).
 Additional findings and issues were listed in the notice of appeal but were not addressed in the appellant=s brief. These issues are deemed waived and have not been decided by the court. Minn. R. 9800.0900, subp. 1.
 Weber v. City of Inver Grove Heights, 461 N.W.2d 918, 43 W.C.D. 471 (Minn. 1991).
 The compensation judge and the self-insured employer mistakenly cite Minn. R. 5223.0430, subp. 6, rating the lower extremities. Dr. Wengler, in fact, rated the employee=s sympathetic dystrophy symptoms under Minn. R. 5223.0400, subp. 6.B., relating to the upper extremities, but the provision is otherwise identical.
 The eight listed conditions are: edema, local skin color change of red or purple, local dyshidrosis, local abnormality of skin temperature regulation, reduced passive range of motion in contiguous or contained joints, local alteration of skin texture of smooth or shiny, osteoporosis in underlying bony structures demonstrated by radiograph, or typical findings of reflex sympathetic dystrophy on bone scan. The self-insured employer argued at the hearing and on appeal that the employee does not qualify for a Adiagnosis of RSD@ based on the lack of persistent, objective evidence of five of the eight conditions.
 In Ellsworth, this court concluded that the term Aconcurrently@ may reasonably be read to imply appearance over a general period of time, rather than all together at a specific moment in time.
 We further note that while objective findings are necessary for a permanent partial disability rating, the existence of a personal injury may be established based on an employee=s subjective complaints coupled with the opinion of a medical expert. Brown v. State, Dep=t of Transp. 54 W.C.D. 60 (W.C.C.A. 1996).
 Dr. Olmsted did not directly give a causation opinion on RSD as he did not believe the employee had RSD. He also concluded the employee=s work injury was a temporary sprain/strain and that the right index finger arthroplasty was a consequence of the underlying arthritis, not the work injury, an opinion rejected by the compensation judge.