CAROLYN M. STEINDEL, Employee, v. AMERIPRIDE LINEN & APPAREL SERVS. and CNA/RISK ENTER. MGMT., Employer-Insurer/Appellants.
WORKERS’ COMPENSATION COURT OF APPEALS
MARCH 15, 2010
CAUSATION - GILLETTE INJURY. Substantial evidence, including the employee’s testimony, medical records, and expert medical opinion, supports the finding of a Gillette injury to the employee’s fingers.
MEDICAL TREATMENT & EXPENSE - SURGERY. Substantial evidence, including the employee’s testimony, medical records, and expert medical opinion, supports the finding that surgery to the specific fingers awarded is reasonable and necessary.
Determined by: Stofferahn, J., Wilson, J., and Pederson, J.
Compensation Judge: Paul V. Rieke
Attorneys: David B. Kempston, Law Office of Thomas D. Mottaz, Coon Rapids, MN, for the Respondent. Gregg A. Johnson and Joseph P. Mitchell, Heacox, Hartman, Kosmrl, Cosgriff & Johnson, St. Paul, MN, for the Appellants.
DAVID A. STOFFERAHN, Judge
The employer and insurer appeal from the compensation judge’s determination that the employee sustained Gillette injuries to the fingers of both hands, culminating on or about December 21, 2005, and that surgery proposed by the employee’s treating doctor is reasonable and necessary. We affirm.
The employee, Carolyn Steindel, graduated from high school in 1977. She began working for the employer, AmeriPride Linen & Apparel Services, in July 1978. The employer provides and repairs linen products for commercial clients.
The employee initially worked in the employer’s flat ironing department. Her work there involved feeding aprons into a machine. After a few months doing this job, she was assigned to load and remove shirts on a sheet machine. She next returned to the apron department where she worked wrapping irons and doing paperwork. For about a year, the employee worked in an area known as the “the cage,” where she filled soaps, bagged mops and wrapped items such as gloves and blankets. At other times, she counted shirts, specially washed and folded certain items, and sewed or hemmed continuous rolls of cloth towels. Thereafter, the employee continued to work in various positions for the employer through 1992, mostly in the flat ironing department working the apron machine and in the press department hanging up garments.
The employee has sustained several injuries while working for AmeriPride. The first was on March 29, 1984, while the employer was still known as American Linen. The employee treated with Dr. A.B. Sundberg, at Orthopaedic Medicine and Surgery. She was evaluated for left elbow radial humeral bursitis and given a cortisone injection. The next injury was on March 7, 1986, when she pulled some muscles in her arms while hanging garments.
In 1992, the employee began working in the flat mending department. Her job there involved inspecting table linen to determine whether the linen should be re-washed, ragged or used for some other purpose. The employee used a machine to cut up those garments which were to be ragged; she did not use a scissors.
On December 22, 2000, the employee reported right elbow pain associated with repetitive work activities. She treated with Dr. Vijay Eyunni, who diagnosed right-sided lateral epicondylitis. Because of ongoing right elbow symptoms, Dr. Eyunni eventually referred her to an orthopedic surgeon, Dr. Jack Drogt. On May 8, 2002, Dr. Drogt performed a right-sided epicondylectomy with repair to the extensor carpe radialis brevis. The employee was eventually able to resume her regular work activities and returned to work full time. On March 19, 2004, the employee struck her right elbow at work. She saw Dr. Drogt who diagnosed lateral epicondylar pain secondary to contusion. X-rays were taken but were unremarkable. The employee again returned to Dr. Drogt on October 13, 2004, for symptoms in her left elbow. Dr. Drogt recommended conservative treatment.
In October 2005 the employee was transferred back to the flat department. She was not having any difficulties with her hands or wrists when she began working in this department. She worked a sheet machine, which required her to grab sheets with her fingers and slide them into the machine at a rate of 200 to 250 sheets per hour.
The employee was assigned to sew straps on laundry bags in the flat mending department full time for a couple of weeks in December 2005. She had done this job only on an intermittent basis in the past. To sew the straps on the bags, she would stand with her hands out in front of her with her fingers bent at about a 90-degree angle to her hands pinching the bag and strap between the thumb and index fingers of both hands. She would then start the machine with a foot pedal and it would sew the strap on. After sewing the strap, she removed the bag from the sewing machine and cut the thread. The employee performed this job at the rate of 150 to 200 bags per hour. While working at this job, the employee began experiencing soreness in both thumbs. She also noticed that her right index finger was sore and would “lock up.”
The employee was off work for the last week in 2005. She hoped her symptoms would improve during this time off work, but they did not, and she reported a work injury on January 9, 2006, involving bilateral thumb pain. That same day, she sought medical treatment at Minnesota Occupational Health, where she was seen by Dr. James Anderson. She told him she had been having pain at the base of the thumb over the past few weeks. The doctor diagnosed tendinitis with a borderline “trigger thumb” condition, right greater than left. He restricted the employee to light duty work.
The employee continued to treat with Dr. Anderson through January 2006 with ongoing complaints of pain at the base of both thumbs. Conservative treatment, including cortisone injections and physical therapy, gave brief relief but failed to otherwise improve the employee’s symptoms, and on January 30, 2006, Dr. Anderson referred the employee to Dr. Edward Su, a hand specialist at Summit Orthopedics.
Dr. Su saw the employee on February 6, 2006. At this visit, the employee complained of pain and tingling in the bilateral thumbs, right greater than left, as well as triggering in the right index finger, present for the past week. The employee told the doctor that her symptoms began after a change in her work duties, and that she had been doing a lot of sewing and cutting fabric and feeding a sewing machine with large amounts of cloth. On examination, there was tenderness at the Al pulleys in the bilateral thumbs and left middle finger, but no tenderness over the pulley in the right index finger. A palpable nodule was present over the left middle finger; no other nodules were noted. Dr. Su’s diagnosis was bilateral trigger thumbs and left middle trigger finger, bilateral mild de Quervain’s tenosynovitis and mild left-sided carpal tunnel syndrome. The employee was kept under restrictions and referred to physical therapy. Dr. Su believed it was too early to determine whether the previously administered injections would provide lasting relief. He advised the employee to return for reevaluation in one month.
The employee followed up with Dr. Su on March 6, 2006. Surgery was recommended as a possible option on the left side, where the employee’s symptoms were greatest. Dr. Su restricted the employee from lifting more than 10 pounds or performing repetitive work longer than 20 minutes. The employee returned to light duty work with the employer. On April 18, 2006, the employee again saw Dr. Su, who noted that based on her history, her problems “stemmed from repetitive use at work.” The employee’s restrictions were continued. Dr. Su gave her a brace for her right thumb. He continued to recommend surgery.
When next seen by Dr. Su on May 15, 2006, the employee told the doctor that her symptoms on the right side were getting much worse, with numbness and tingling in the right hand. Dr. Su added an additional diagnosis of right carpal tunnel syndrome. Although the employee had been working light duty, she stated that the employer did not seem very clear what her restrictions were, and that she did not receive a break between alternating job duties. Dr. Su imposed more restrictive work restrictions, requiring that the employee take a 20 minute break after every 20 minutes worked. He recommended a right-sided EMG study.
A right upper extremity EMG was performed at Neurological Associates of St. Paul on June 1, 2006, and was read as normal.
On June 9, 2006, Dr. Su performed surgery in the form of a right endoscopic carpal tunnel release, right trigger thumb release and right de Quervain’s release. The employee was off work following the surgical procedure through June 21, 2006, at which time she returned to light duty inspection work. However, she continued to have pain in the right wrist and hand and was again taken off work on June 29, 2006.
When seen by Dr. Su on July 13, 2006, the employee reported that her pain had improved significantly since being taken off work, though her right index finger had locked twice recently. Her left upper extremity symptoms remained the same. Dr. Su recommended further surgery for the left hand.
On July 28, 2006, the employee underwent a left endoscopic carpal tunnel release, left trigger thumb release and left de Quervain’s release. On August 10, 2006, the employee reported some increased right hand symptoms. Dr. Su thought this was probably was due to overuse of the right hand following her left upper extremity surgery. She was referred to physical therapy.
At some point not disclosed in the record, the employer and insurer accepted liability for the trigger finger conditions in both the employee’s thumbs. The insurer paid for the employee’s surgeries in 2006 and neither causation nor benefits related to the employee’s thumbs are at issue in the present appeal.
Following her surgeries, the employee remained off work until seen by Dr. Su on September 13, 2006. She was given left-sided restrictions; none were given on the right side, although there was mild tenderness at the Al pulley in the right index finger. She returned to light duty work in the employer’s press department, scanning garments and applying clips with the right hand.
On November 9, 2006, the employee told Dr. Su that her left hand symptoms were significantly worse. The doctor gave her a steroid injection in the left wrist and thumb. The employee continued to follow up with Dr. Su throughout October and November of 2006, with some modifications made to her restrictions. She continued to report symptoms associated with repetitive activities.
When seen by Dr. Su on December 7, 2006, the employee reported no improvement following the previously administered injections. She was still having some ongoing symptoms. However, she wanted to see whether she could return to her old job, and Dr. Su released her to work with no restrictions. She then returned to full duty work on a “table cloth” machine shortly after being released by Dr. Su. In this job, the employee grabbed two hundred to two hundred and fifty tablecloths per hour. She also occasionally performed sewing in the flat mending department. The employee did not report any problems while performing the sewing activities.
On January 24, 2007, the employee told Dr. Su that her hands were continuing to improve. Objective physical examination of the employee’s hands was normal, with full range of motion and no evidence of locking or catching in any of the bilateral digits. The employee reported that the employer was having her alternate her work in various jobs. She stated that she sometimes had some left hand pain, especially at the end of a busy day at work, but that her right hand was not giving her significant problems. The doctor decided that she could continue to work full duty without restrictions.
The employee returned to Dr. Su on March 22, 2007. She reported that her right hand was almost 100 percent better, but that her left hand continued to experience some pain when working a lot. After a recent work assignment that involved sewing for four eleven-hour days per week, she had significant pain in her left thumb. Dr. Su noted that his physical examination revealed mildly tender flexor tendon nodules in the right index, ring and small fingers and left index finger, but without locking or catching. He thought she might have some possible early trigger fingers in these fingers, but not yet so severe as to limit her function. The employee was again released to return to work with no restrictions, but was counseled to avoid working more than two 11-hour workdays in a week and to try to work in different job tasks on a rotating schedule if possible.
In a Health Care Provider Report dated April 2, 2007, Dr. Su opined that Ms. Steindel had reached maximum medical improvement. He rated her permanent partial disability at 0.5% for each hand pursuant to Minn. R. 5223.0130, subp. 3.E.
The employee did not return to see Dr. Su until October 29, 2007. She reported that she had developed pain in both hands, especially in the left ring and index fingers and right ring finger, beginning in about July of 2007. She said that the left hand was worse than the right, and that the left index finger occasionally would lock up. Examination revealed tender flexor tendon nodules in the left ring, middle, index and small fingers. On the right side there was a nodule in the employee’s right ring finger. She also had a tender nodule in the palm of her left hand which was diagnosed as a Dupuytren nodule. Tenderness was present over the Al pulleys of the index, middle, and small fingers in the right hand. Dr. Su diagnosed multiple trigger fingers in both hands. He injected the left index and ring flexor tendon sheaths at the Al pulleys. The employee was allowed to continue working without restrictions.
The employee next saw Dr. Su on December 10, 2007. She reported that the injections six weeks earlier had reduced her symptoms somewhat but had not resolved them. She was still having swelling and catching of the fingers in the mornings. The biggest problem at that time was with her right middle finger.
On December 16, 2007, the employee was examined by Dr. William Call on behalf of the employer and insurer. The employee described her symptoms on this date as including clicking and snapping in the left index finger with occasional numbness and tingling in both thumbs and ring fingers. Examination revealed multiple nodules over the Al pulleys of both hands, with no active triggering. Dr. Call diagnosed a pre-tendinous Dupuytren’s nodule on the left finger without contracture. The doctor did not think the employee’s work had caused or affected her Dupuytren’s nodule, nor did he think that the Al pulley nodules, or any trigger symptoms the employee had subjectively claimed, were related to her work activities. He suggested that these symptoms more likely were related to the employee’s hypothyroidism and aging, and to hysterectomy surgery the employee had undergone in 2005. He did not think the employee ever had carpal tunnel syndrome.
The employee saw Dr. Su on February 18, 2008. He recorded that her right index finger was locking all the time and was regularly bothersome for her, although the right middle finger was the one she thought the most painful. The employee reported that the small fingers in both hands had recently also started to lock and catch. Her left index, middle and ring fingers were stiff and sore in the morning, but did not lock; the left hand was worse than the right. Examination showed nodules in the index, middle, and small fingers at the Al pulley in the right hand, and over the index, middle, ring, and small fingers at the Al pulley in the left hand. Dr. Su diagnosed multiple trigger fingers in both hands and recommended injections.
Based on Dr. Call’s opinion, the employer and insurer denied liability for the employee’s hand conditions with the exception of the trigger thumb conditions for which it had previously accepted liability. The employee filed a claim petition on April 4, 2008, alleging injuries on or about January 9, 2006, to the employee’s “bilateral upper extremities.” The employer and insurer answered reiterating their denial of liability.
On April 17, 2008, the employee told Dr. Su that her right index finger locked up every day. Her left index and right middle fingers were beginning to lock up, but not as much as the right index finger. The ring and small fingers in the left hand were the most painful and problematic. Nodules were again present at the Al pulleys of the left index, ring, and small fingers and the right index, middle, and small fingers. Dr. Su again diagnosed multiple bilateral trigger fingers. Injections were given at the left ring, index, and small fingers.
The employee was deposed on May 21, 2008. She testified that she continued to experience discomfort in the first, third, and fourth fingers on her left hand. The discomfort would tend to come and go on a daily basis. She claimed occasional swelling at the base of her right and left wrist, and to a lesser extent in the index, second, and fourth fingers on the right hand. Her right index finger would occasionally lock. She was still working fulltime for the employer without restrictions, and believed that she could continue working in this capacity.
In a report dated August 11, 2008, Dr. Su offered his opinion that the employee’s work activities were a substantial contributing factor in aggravating her bilateral hand conditions. Dr. Su noted that the employee had “reported multiple times that her symptoms became significantly worse while at work when she was gripping and pinching things with her hands.” Dr. Su recommended further injections, and possibly surgery if the symptoms persisted.
The employee again returned to Dr. Su on September 11, 2008. She told the doctor that both her hands were quite painful. She was interested in surgery for the left hand. Examination again showed tenderness over the Al pulleys of the index, ring, and small fingers in both hands. Dr. Su indicated some concern over surgery because the employee’s prior surgeries had necessitated quite prolonged recovery periods.
The employee was last seen by Dr. Su on February 12, 2009. She reported her symptoms were generally about the same and perhaps getting worse. There were bilateral flexor tendon nodules at the Al pulleys of the index, ring, and small fingers. Dr. Su noted that since steroid injections did not provide lasting relief, the employee’s only option was surgery. The employee told him that she wanted to proceed with trigger finger release surgery.
The employer and insurer had the employee reexamined by Dr. Call on March 26, 2009. She complained of “sticking” in the left index finger and right index and long fingers, which she could not relate to any particular activities. Dr. Call’s examination of the fingers of the right hand was entirely normal. On the left hand, nodules were present on the long, ring, and small fingers at the Al pulleys. Dr. Call failed to find any active triggering. In his report, he repeated his prior opinions. He did not consider the employee’s symptoms as she described them to be typical of trigger fingers. He further opined that the surgery recommended by Dr. Su was not reasonable or necessary in the absence of objective documentation that a physician had observed the employee’s fingers actually triggering. He also expressed concern that the employee could develop chronic pain syndrome or reflex sympathetic dystrophy if she underwent the surgeries. Dr. Call reiterated and explained these opinions again in his testimony at a July 21, 2009, deposition.
Dr. Su was deposed on July 9, 2009. He testified that the employee’s work activities for the employer substantially contributed to the development of her trigger finger, with repetitive pinching and gripping over an extended period of time resulting in inflammation and pain. He continued to recommend surgery on the index, ring, and small fingers of both hands to alleviate the trigger symptoms.
By the date of the hearing below, July 28, 2009, the employee had limited her claims so that the sole issues before the judge were the causation of the employee’s condition, and the reasonableness and necessity of the surgical treatment proposed by Dr. Su. At the hearing, the employee testified to pain in the index, ring, and small fingers in both hands. She reported that she was still experiencing occasional locking in the right middle and index fingers and the left middle finger, but most recently had not been having locking or catching in the bilateral ring fingers on either hand. The compensation judge found that the employee had sustained Gillette injuries to both hands on December 21, 2005, with intermittent aggravations by work activities thereafter, resulting in triggering in various fingers. The compensation judge found that trigger surgeries were reasonable for the index and small fingers of the right hand and the index, ring, and small fingers of the left hand, but that surgery on the middle and ring fingers on the left hand was not shown to be reasonable and necessary. The employer and insurer appeal.
1. Scope of the Issues
The employer and insurer first argue that the compensation judge exceeded the scope of the issues set for hearing by finding that the employee’s work activities had caused Gillette injuries to the fingers of both her hands. They contend that the judge’s consideration on the issue of causation should have been limited solely to those specific fingers for which surgery was recommended by Dr. Su. Since Dr. Su had not recommended surgery for the middle digit of either of the employee’s hands, they submit on appeal that the judge could not properly consider whether the employee’s symptoms in those fingers were causally related to her work activities. By similar reasoning, they argue that the compensation judge’s findings should not have mentioned the admitted injury to her thumbs, as the thumbs also were not among the digits for which surgery was currently under consideration. They contend that the judge’s findings with respect to these digits was not only improper, but denied them adequate notice or opportunity to defend against a claim of injury to the employee’s bilateral middle fingers, and similarly precluded them from subsequently litigating causation for a bilateral thumb injury, should they choose later to withdraw their voluntary acceptance of that injury.
We disagree. There was, first, no lack of notice as to the claim. The employee’s claim petition asserted an injury to the “bilateral hands,” which would certainly include all her fingers and both thumbs. Further, the exact components of the employee’s claim, including which symptoms were present and in which fingers, were well known to the employer and insurer through the full medical records which were provided to them, through the employee’s deposition, and through the reports of their own medical examiner. They cannot claim to have been unfamiliar with the specifics of the employee’s claimed condition as of the date of the hearing.
In the employee’s opening statement, her counsel set out by way of medical history that the employee had alleged that she sustained injuries in the nature of bilateral trigger thumbs, carpal tunnel syndrome, de Quervain’s syndrome, and had been diagnosed with trigger fingers in the all fingers of both hands. He then summarized the employee’s current claim as follows: “. . . no benefits are at issue today with respect to the carpal tunnel, the de Quervain’s, or the bilateral trigger thumbs. Those have been paid for and there’s no pending claim for treatment on those. So we’re left with eight fingers.” (T. 16, emphasis added.)
Counsel for the employer and insurer did not object to the statement that the claim was for a work-related injury to all the fingers. Instead, pointing out that the record was unclear as to which fingers were under consideration for surgery, he specifically argued that the judge should carefully examine the records about each of the employee’s fingers, noting that the evidence for active triggering in each of the eight was inconsistent for recent periods and that triggering in some fingers, including the right middle finger, had resolved but in others had started only recently. He asked the judge to consider that Dr. Su and Dr. Call had both agreed that triggering in all ten digits is rare. Finally, he requested that the judge find that “. . . the trigger fingers, whichever ones are being claimed here today, are not a result of work activities performed at AmeriPride.”
The employer and insurer could reasonably have anticipated that the compensation judge would, as they had themselves requested, consider whether the problems of pain, inflammation, nodules, or triggering in each of the employee’s fingers were due to a work-related injury. Their principal defense, raised in their answer, was a denial of causation. This defense necessarily extended to each of the fingers of both hands, inasmuch as the employee’s medical records reveal that each was, to a greater or lesser extent, symptomatic, and because the employee’s case relied for its support on Dr. Su’s opinion, which posited a single mechanism of injury as causing the employee’s condition in all her fingers.
The employer and insurer relied on Dr. Call’s opinion, on the variations in the employee’s symptoms, and on the timing of the symptoms in the employee’s fingers as compared to the various work activities she was doing since 2005. On reviewing the evidence offered by the employer and insurer, the cross-examination they conducted of the employee, and the arguments made before the judge, the employer and insurer were not denied an opportunity to defend against the claims relating to all the employee’s fingers, and in fact the record reveals that they fully availed themselves of the opportunity to do so.
2. Sufficiency of Evidence
The employer and insurer next contend that the compensation judge’s findings on causation were not supported by substantial evidence, and that the employee failed to provide evidence showing how specific work activities contributed to the development of the employee’s symptoms on a finger by finger basis.
In order to establish a Gillette injury, an employee must demonstrate a causal relationship between the employee’s ordinary work activity and the disablement. Steffen v. Target Stores, 517 N.W.2d 579, 581, 50 W.C.D. 464, 467 (Minn. 1994). Further, “the question of a Gillette injury primarily depends on medical evidence.”
Dr. Su, the employee’s treating physician, provided a medical opinion supporting the employee’s claim. He opined that the employee’s work activities, involving repetitive grasping and pinching over many years, had been a substantial contributing cause of the development of trigger fingers in both of the employee’s hands. Dr. Call, testifying for the employer and insurer, offered a contrary opinion. While he acknowledged the presence of multiple nodules over the Al pulleys of both hands, Dr. Call did not think the Al pulley nodules, or any trigger symptoms the employee claimed, were related to her work activities. The compensation judge accepted Dr. Su’s opinion over that of Dr. Call. The trier of fact’s choice between the disparate opinions of experts is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence. Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985).
We have previously held that a well-founded medical opinion can serve as the basis for a compensation judge’s finding of a Gillette injury. Stevens v. AAA Cooper Transp., 65 W.C.D. 431 (W.C.C.A. 2005); Walsh v. Dassel Lakeside Comty. Home, slip op. (W.C.C.A. June 21, 2005). The competency of a medical expert to provide an expert opinion depends upon both the extent of the expert’s scientific knowledge and the expert’s practical experience with the matter that is the subject of the expert opinion. Reinhardt v. Colton, 337 N.W.2d 88 (Minn. 1983). Dr. Su is an orthopedic surgeon specializing in upper extremity conditions. He has been the employee’s treating physician for the conditions at issue since February 2006, and in that capacity had repeatedly examined the employee and was well familiar with her medical history, the nature of her work duties, and the effects of her various duties and restrictions on her symptoms. Such information generally establishes adequate foundation for a medical opinion. Scott v. Southview Chevrolet Co., 267 N.W.2d 185, 30 W.C.D. 426 (Minn. 1978).
The employer and insurer contend that Dr. Su’s opinion was without sufficient foundation in that he relied on the employee’s subjective description of pain and accepted her accounts of locking in her fingers, which he had not himself observed. They point out that Dr. Call, their medical consultant, testified that he does not diagnose a “trigger finger” without having personally observed the patient’s fingers locking up. The difference between Dr. Su and Dr. Call with respect to how much consideration each give to a patient’s description and history of their symptoms is simply a difference in medical philosophy and practice. We note, also, that Dr. Su relied not just on the employee’s reported history and subjective pain, but on the presence of palpable nodules in the employee’s fingers and on other objective examination findings.
The appellants also object to Dr. Su’s opinion as “too equivocal” because at one point in a chart note he expressed uncertainty over why there had been a progression of triggering into more of her fingers, and because he agreed with Dr. Call that the employee’s age, sex, and prior hysterectomy were factors that had put the employee at increased risk for the development of trigger fingers. However, Dr. Su stated specifically that, notwithstanding the presence of the other risk factors, it was his opinion that the employee’s work activities, involving repetitive grasping and pinching, were a substantial contributing cause of the development of a Gillette injury to all ten of her thumbs and fingers. We conclude that his opinion had the requisite degree of medical certainty.
The appellants contend that Dr. Su’s opinion provided insufficient support for the employee’s Gillette injury claims in that he failed to explain precisely how specific work activities contributed to the development of employee’s symptoms on a finger by finger basis. We disagree. This argument is based on a standard for proving a Gillette injury which was rejected by Steffen, supra, 517 N.W.2d 579, and is no longer the law. Under Steffen, an employee is required to “prove a causal connection between her ordinary work and ensuing disability” but is not required to document an actual pattern of specific activities leading to specific symptoms in order to do so. And we note that there was extensive testimony by the employee about her specific work activities for the employer over the years that did provide additional support for the judge’s findings.
Finally, in a related argument, the employer and insurer object to the fact that the compensation judge did not make specific findings discussing each finger individually. We do not agree that the failure to consider each finger separately in this case constitutes error or provides any basis for reversal. Rather, we conclude that it was not unreasonable for the compensation judge to consider the employee’s finger injuries as the result of a single, unitary process, in which repetitive gripping and pinching which at first affected the employee’s thumbs and dominant forefinger could cause changes in the dynamics of the employee’s grip and thus to have resulted over time in similar symptoms arising in the other fingers.
Overall, we conclude that the employee’s testimony, medical records, and the opinion of Dr. Su provided substantial evidence supporting the compensation judge’s findings as to causation for a Gillette injury to the employee’s fingers, and affirm.
3. Reasonableness of Surgery
The employer and insurer offer several arguments why the compensation judge should not have found the surgery proposed by Dr. Su to be reasonable and necessary. Most of these arguments rely on portions of the opinion of Dr. Call; specifically, that he did not consider surgery appropriate in the absence of a physician’s own observations of triggering; that he felt that further conservative treatment might be tried prior to surgery, that he considered the employee’s extended recovery from the prior thumb surgery as a contraindication to similar surgery, and that he listed several potential adverse consequences that might follow such surgery. In each of these areas, Dr. Su came to a different conclusion in weighing the risks against the need for surgery. The compensation judge accepted the opinion of Dr. Su on this issue, and the fact that Dr. Call’s opinion was different does not provide a basis to reverse the compensation judge.
As their next objection to the determination that surgery is reasonable and necessary, the employer and insurer argue that surgery cannot be reasonable and necessary because the employee is able to work and perform tasks of daily living in her present condition. We disagree. Minn. Stat. § 176.135 requires the employer to provide such medical care “as may reasonably be required at the time of the injury and any time thereafter to cure and relieve from the effects of the injury.” Included under the statute is palliative care to prevent pain and discomfort. Castle v. City of Stillwater, 235 Minn. 502, 51 N.W.2d 370, 17 W.C.D. 103 (1952). Nothing in the statute limits medical treatment to situations where an employee is unable to work or perform activities of daily living.
Finally, the appellants point out that, as of the date of hearing, the employee’s symptoms had changed as compared to those she had at her last visit to Dr. Su, and she testified that she was not having triggering in one of the fingers Dr. Su recommended for surgery, but was now having more trouble with one which Dr. Su had not recommended for surgery. They contend that, in a situation where the employee’s symptoms may wax and wane and the specific fingers needing surgery may change from time to time, surgery is entirely inappropriate. The compensation judge dealt with the waxing and waning of symptoms in the fingers by denying surgery both for the finger Dr. Su had contemplated operating on but which was not currently triggering frequently, and for the finger the employee complained had worsened, but for which Dr. Su had not previously considered surgery. We think this approach was a reasonable one. And with respect to the other fingers, for which surgery was awarded, we note that the evidence of ongoing, continuous problems, together with Dr. Su’s recommendations, sufficiently supported the award.
 See Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).
 The A1 pulley is located in the palm at the base of the thumb. It creates a tunnel through which the flexor tendon passes. (Dr. Su Depo. p. 8)