CELENE M. GUNDERSON, Employee, v. GOLDEN LIVING CTR. DELANO and AMERICAN. HOME ASSURANCE CORP./CONSTITUTION STATE SERVS., Employer-Insurer/Appellants, and CERVICAL SPINE SPECIALISTS, ANESTHESIA FOR SURGERY, RIDGEVIEW MED. CTR., and MERIDIAN RECOVERY SERVS., Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
JULY 5, 2012
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including lay testimony, medical records, and expert medical opinion, supported the compensation judge’s finding of a Gillette injury and his award of benefits resulting from that injury.
Determined by: Stofferahn, J., Johnson, J., and Milun, C.J.
Compensation Judge: James F. Cannon
Attorneys: William G. Laak, McCollum, Crowley, Moschet, & Miller, Minneapolis, MN, for the Respondent. Christine L. Tuft and Aaron D. Schmidt, Arthur, Chapman, Kettering, Smetak & Pikala, Minneapolis, MN, for the Appellants.
DAVID A. STOFFERAHN, Judge
The employer and insurer appeal from the compensation judge’s determination that the employee sustained a work-related Gillette injury culminating on or about August 6, 2009. We affirm.
The employee, Celene M. Gunderson, has worked for the employer, Golden Living Center Delano, since 2003 maintaining the facility’s medical records. Generally about 40 percent of the employee’s time was occupied with computer data entry, and the rest of her time she handled binders and files holding patient records and charts.
During early August 2009, the Minnesota Department of Health was on site performing its annual review of the facility’s medical records. The employee had postponed thinning out patient charts kept in large binders at the nurses’ station pending this review, so that all the records needed in that review would be accessible to Department of Health staff in one place.
Following the review, the employee began thinning out the patient charts on August 5, 2009, to remove records no longer required to be kept in the chart binders and to move them to other file locations. This was done so that the nursing station binders contained only the currently needed records and did not grow beyond a manageable size. Thinning out the charts involved taking each three-inch wide binder down from shelving at the nursing station, placing it on the nurse’s desk, then repeatedly opening and closing the binder rings while going through the various tabbed sections in each binder to remove non-current portions of the records, and then replacing the binder in the shelving racks.
The employee testified that the nursing station had recently been remodeled and the desk was now higher than it had been in prior years when she had done prolonged periods of chart thinning. She could not get the chair at the station to go up high enough to do this job at a normal “desk level.” As a result, the employee, who is 5’ 3” tall, stated that she found it necessary to do the work with her arms raised higher than before. She testified that she felt discomfort in her shoulders while doing this task.
The employee began this assignment on August 5, 2009, and continued to perform it for her full eight-hour shift on August 6, 2009. At the end of each work day she felt sore and stiff in both shoulders. On Thursday, August 6, she noticed that her neck was becoming increasingly stiff. When she woke up the following morning, August 7, the employee stated that her neck was tilted to the right and was too stiff and sore to move. Nonetheless, she went to work, where she spent that day filing the various records that had been thinned from the chart binders into folders in file cabinets.
On Saturday, August 8, the employee noted her symptoms had gotten worse and she was starting to have a burning pain down her right shoulder. She was not able to drive because of her neck pain and stiffness and so had a family member take her to the Ridgeview Westonka Clinic in Spring Park, Minnesota, where she was seen by Dr. Sheila N. Seats. The employee gave a history of gradual onset of her symptoms with filing over the past three days. Dr. Seats noted that the employee was tender in the right medial scapular area with a trigger point and tight musculature. She had normal range of arm motion but neck flexion and extension were limited and triggered right upper back pain. The employee was given two trigger point injections in the right medial scapular area.
The employee testified that the injections gave her only a few hours relief, and so later the same day, she went to the emergency room at the Ridgeview Medical Center in Waconia, Minnesota where she reported sharp, shooting pain originating in the right neck/back/shoulder region and radiating down the arm to the elbow and around to the front of the chest. The pain was worse with rotation and flexion of the head. The chart note states the employee has had this pain “for at least five days.” The attending physician, Dr. Lisa Larson, diagnosed spasmodic torticollis. She advised the employee to ice affected areas four times daily for 15 minutes per time over two days, and prescribed Norco and Valium. The employee was told to follow up with a nurse practitioner on Monday, August 10, 2009.
The employee returned to the Ridgeview Westonka Clinic on August 10, 2009, and was seen by Dr. Jerry R. Petersen. The employee reported that she had gotten about a day’s relief from the trigger point injections. Her symptoms were mainly pain in the right side of her neck and her right shoulder, but she also had some numbness into her hand and fingers. The employee could recall no recent trauma, other than having slipped and fallen the previous winter. The employee was told to remain off work for the rest of the week and to continue her medications.
The employee was seen by a physician’s assistant at the Ridgeview Delano Clinic on August 27, 2009. She continued to have right shoulder pain which she stated had started after “separating charts” at work. The employee was referred for an orthopedic evaluation.
On September 1, 2009, the employee saw Dr. Daniel Rotenberg at the Ridgeview Western Orthopedic Clinic for evaluation of pain in her neck going down her right arm that had lasted several weeks. Dr. Rotenberg diagnosed cervical radiculopathy involving the right arm. He recommended that the employee undergo an MRI of the cervical spine. The MRI was performed on September 4, 2009, and was read as showing a small right lateral disc herniation at C5-6 compressing the right C6 nerve root. Mild central stenosis and a mild flattening of the ventral spinal cord were also present at this level. At C6-7, there was a moderate right lateral disc herniation compressing the right C7 nerve root, but without cord compression. No disc herniation or stenosis were seen at C4-6 and C7-T1, and C2-3 and C4-5 were read as normal.
The employee was then seen on September 9, 2009, by Dr. Michael Smith at the Cervical Spine Specialists Clinic on referral by Dr. Rotenberg. Dr. Smith recorded a history that the employee had been experiencing severe pain in her cervical spine for about a month which “began insidiously in early August where as while [sic] she had preexisting cervical and trapezial pain, her arm pain began to become predominant.” The employee explained that she had experienced an abrupt onset of symptoms on repetitively using her hands to accommodate lifting and thinning medical charts at a desk which had been too high. Dr. Smith’s diagnosis was of acute cervical radiculopathy. He recommended that the employee first try conservative treatment including a cervical collar, medication, physical therapy and traction. In the event this did not provide improvement, he considered it likely that the employee would need surgery.
The employee completed five sessions of physical therapy at Ridgeview Rehab. Her symptoms failed to respond well to conservative treatments of mechanical traction, physical therapy modalities, and a stretching and strengthening program. On October 21, 2009, Dr. Smith performed a two-level anterior discectomy and fusion at C5-6 and C6-7.
Following the surgery, the employee was kept off work until early November 2009, when she was able to return to work part time on light restrictions. By November 19, 2009, she was able to work full time. The employee testified the surgery relieved her right arm pain, leaving only some numbness in two fingers of her right hand.
The employee was evaluated on behalf of the employer and insurer on August 20, 2010, by Dr. Nolan Segal. Dr. Segal diagnosed multilevel degenerative disease of the cervical spine, with status post operative anterior cervical discectomies and fusions at two levels. His opinion was that her condition was caused by idiopathic arthritis in the cervical spine, and did not result from her employment activities. Dr. Segal further speculated that the disc disease at the C3-4 and C4-5 disc levels might have been the pain-producing levels, but that it was impossible to be certain as provocative discography was not done prior to the fusion surgery. Dr. Segal recommended that the employee observe permanent restrictions, but did not consider the need for the restrictions to be due to a work injury or work-related condition. He believed that the employee had reached maximum medical improvement.
In a letter opinion dated November 1, 2010, Dr. Smith provided his opinions and commented on Dr. Segal’s IME report. He provided a diagnosis of acute cervical radiculopathy secondary to an acute disc herniation. With respect to whether there was a causal connection between the employee’s work activities occurring or culminating on or about August 5, 2009, Dr. Smith stated that the employee had “a crescendo [of] symptoms around the August 5, 2009, timeframe consistent with an acute cervical disc herniation.” He noted that the employee had experienced an onset of neck pain while performing repetitive and strenuous movements to thin out charts from heavy medical folders and place them in racks. He concluded that “her reported mechanism of injury secondary to her work activities is consistent with the genesis of a disc herniation.” He expressly opined that the alleged August 5, 2009, work injury was a substantial contributing cause of the employee’s condition. Although Dr. Smith agreed that the employee did have some mild degenerative disc disease, he noted that this was simply consistent with her age, and nothing out of the ordinary for her age group. He did not see any indications of a diffuse symmetric or systemic degenerative condition, and did not agree with Dr. Segal that the employee had idiopathic arthritis of the cervical spine. Dr. Smith rated the employee with a 23 percent permanent partial disability.
On November 3, 2010, at a one year postoperative follow up appointment, Dr. Smith noted that the employee was functioning at a reasonably high level, with no radicular pain or symptoms. She was able to perform her usual job duties without significant problems other than some increased discomfort at the end of the day when doing repetitive tasks. Dr. Smith considered the employee’s postoperative status to be satisfactory.
In a supplemental report dated February 14, 2011, Dr. Segal opined that “the employment activities as described by Ms. Gunderson . . . would not result in significant disc herniations.” Dr. Segal did note, however, that the employee’s chiropractic treatments, if true chiropractic adjustments were done, “could result in more acute disc changes.” He reiterated his opinion that the employee’s disc herniations were not due to her work activities, but instead were the result either of “idiopathic disease or some related factor other than her work in medical records.” Dr. Segal also disagreed with Dr. Smith’s rating of permanency, rating the employee with a 15 percent permanent partial disability.
A hearing was held before Compensation Judge James Cannon on October 25, 2011. At the hearing, the employee alleged either a specific injury to her cervical spine on August 6, 2009, or a Gillette injury culminating on or about August 6, 2009, as the result of her work activity in thinning medical charts on August 5 and 6, 2009. In his findings and order, the compensation judge found that the employee had sustained a work-related Gillette injury culminating on August 6, 2009. The employee was awarded temporary total disability compensation for the dates she was off work due to her cervical spine condition, and reimbursement for medical expenses was awarded to the employee and intervening medical providers. The compensation judge further found that the employee had sustained a 15 percent permanency. The employer and insurer appeal from the finding of causation and the awards of benefits following from that finding.
On appeal, the employer and insurer dispute the finding of a Gillette injury. A Gillette injury is a gradual process resulting in a breakdown of a body part or an aggravation of a pre-existing condition as the result of repetitive, minute trauma in the performance of an employee’s ordinary work activities. Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960). To establish a Gillette injury, the employee must “prove a causal connection between her ordinary work and ensuing disability.” Steffen v. Target Stores, 517 N.W.2d 579, 581, 50 W.C.D. 464, 467 (Minn. 1994). While evidence of specific work activities causing specific symptoms leading to disability “may be helpful as a practical matter,” the determination of a Gillette injury “primarily depends on medical evidence.” Id. (citing Marose v. Maislin Transp., 413 N.W.2d 507, 40 W.C.D. 175 (Minn. 1987)).
The compensation judge noted that the medical experts whose opinions had been offered in the case had reached contradictory opinions as to whether the employee’s work activities were a substantial contributing cause of her disc herniations or whether they were due to an idiopathic process wholly separate from the employee’s work. He treated the question before him as primarily a medical one, turning on which medical expert opinion he found more persuasive in the light of the facts and other evidence taken as a whole.
In deciding to adopt Dr. Smith’s opinion over that of Dr. Segal, the compensation judge specifically noted in Finding 19: (1) that there was no dispute between the experts that the employee had two cervical disc herniations with impingement; (2) that there was no evidence of significant medical treatment or lost time from work for a neck or shoulder condition prior to the work activity on August 5 and 6, 2009; (3) that the employee had engaged in work activity during that period that was more strenuous than usual; and (4) that there was no evidence that the employee had sustained a specific non-work injury to her neck or shoulders prior to or during the period when she first experienced the onset of her symptoms.
On appeal, the employer and insurer offer a number of arguments which they contend demonstrate that the evidence was insufficient to sustain the judge’s finding. First, they contend that “these types of injuries [i.e., cervical disc herniations] just do not occur from the duties that the employee has described.” While this argument essentially restates the view of Dr. Segal, Dr. Smith reached a different conclusion. It is not this court’s role to choose between medical experts on matters of disputed medical opinion. It is the compensation judge’s responsibility, as trier of fact, to resolve conflicts in expert testimony. Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985). As we have repeatedly held in other cases, this court will generally affirm a compensation judge’s decision which is based on a choice between adequately founded competing medical opinions. Perry v. ADB Constr., Inc., 68 W.C.D. 491 (W.C.C.A. 2008).
The employer and insurer next claim that Dr. Smith’s opinion lacked foundation in that he “lacked appreciation of the actual nature of the employee’s work duties.” We do not find this contention persuasive. We note that Dr. Smith had treated the employee since September 9, 2009, and performed the employee’s surgery. His chart notes from September 9, 2009, when he first saw the employee, reveal that she had described her job duties to him and had also described how her symptoms came on after repetitive use of her hands and arms doing lifting and thinning of medical charts at a desk that was too high. Also in evidence was the letter provided to Dr. Smith by the employee’s attorney in soliciting his medical opinion. That letter sets forth the employee’s work activities in great detail, and is fully consistent with the employee’s testimony about those duties and with the compensation judge’s findings describing the duties. Dr. Smith also reviewed the medical records of the other physicians who had treated the employee prior to providing his letter opinion. He had a sufficient factual understanding of the employee’s work activities, symptoms and medical history to render a well-founded expert medical opinion. Grunst v. Immanuel-St. Joseph’s Hosp., 424 N.W.2d 66, 40 W.C.D. 1130 (Minn. 1988); Polfliet v. Northern Lights Distrib., No. WC10-1572 (W.C.C.A. April 13, 2011).
The appellants contend, however, that Dr. Smith’s opinion fails to provide a sufficient medical basis for the compensation judge’s finding on causation. First, they argue that Dr. Smith’s opinion was legally insufficient in that the doctor failed to give a detailed explanation of the mechanics by which the employee’s specific work activities would have caused the employee’s injury. In particular, they note that the doctor did not explain why performing repetitive tasks at an elevated work station would have any effect on the employee’s neck and shoulders. We have held however, that while a detailed explanation of the process of injury may be helpful in evaluating the respective merits of divergent medical opinions, it is not a prerequisite for the adoption of an expert opinion by the compensation judge. Henschal v. Federal Express Corp., No.WC07-212 (W.C.C.A. Jan 30, 2008); Vandenbosch v. Waste Mgmt of the Twin Cities, No. WC08-258 (W.C.C.A. July 9, 2009 ).
Secondly, they argue that Dr. Smith’s diagnosis of “acute” cervical disc herniations inherently contradicts the finding that the employee sustained a Gillette injury rather than a specific injury. Thus, they argue, in finding a Gillette injury, the compensation judge actually implicitly rejected Dr. Smith’s opinion, so that the judge could not then rely on that opinion to support his causation findings. We disagree. A Gillette injury differs from a specific injury in that a Gillette injury involves repetitive minute trauma rather than a single more powerful trauma as the process by which an injury culminates in a disabling condition. The distinction is one of process rather than of result. There is no inherent contradiction in an opinion which contemplates an acute injury as the culmination of a Gillette-type process.
Finally, the employer and insurer assert that certain language in Dr. Smith’s opinion is too “unclear” to “meet the statutory requirement for a founded causation opinion.” Specifically, Dr. Smith stated that he based his opinion in part on the employee having sustained “a crescendo [of] symptoms around the August 5, 2009, timeframe consistent with an acute cervical disc herniation.” Noting that the primary dictionary meaning of “crescendo” is merely “a gradual increase in volume of a musical passage,” the employer and insurer contend that Dr. Smith’s medical opinion fails to support the compensation judge’s finding of a Gillette injury that culminated in two acute disc herniations. We note, however, that writers and speakers in common parlance frequently employ “crescendo” as synonymous with the term “climax,” regardless of whether to do so is technically accurate. The compensation judge in this case could reasonably interpret the doctor’s wording in a manner which is consistent with the findings in this case.
The employer and insurer further contend that the compensation judge improperly shifted the burden of proof so as to require them to prove an alternative cause for the employee’s injury. In support of this claim, they point to Finding 19, in which the compensation judge discussed the factors which he considered significant in choosing between the expert medical opinion offered by the employee and that offered by the employer and insurer.
The compensation judge appropriately considered the timing of the emergence of the employee’s symptoms in relation to the timing and nature of the specific work duties the employee performed, and it was not improper for him to note that there was no evidence of a non-work injury or activity that might have been a factor in the development of the employee’s cervical condition. In addition, the compensation judge in Finding 18 specifically acknowledged the employer and insurer’s point that the employee had the burden of proof to establish that her medical condition was caused by her work activity. On the record before us we see no basis to conclude that the compensation judge failed to properly apply that burden of proof.
In addition to the foregoing, we will address two further arguments from the appellants’ brief. Quoting from the medical records, the appellants argue that the compensation judge’s causation finding must be reversed because, they contend, the employee failed to give a consistent medical history to all medical providers regarding the development of her neck problems, and on some occasions the records fail to show any mention of her chart thinning duties as causing the onset of her symptoms. The examples given involve instances where the employee was unable to recall any specific trauma that might have caused the injury. The employer and insurer made this argument at the hearing and the compensation judge clearly found the employee credible despite these minor lapses in the records. The compensation judge determined that the employee’s work injury was in the nature of a Gillette injury, that is to say, it did not arise from a single traumatic event, but from the effects of repetitive minute trauma. We see no reason why an employee whose injury occurred as the result of a Gillette process would necessarily respond in the affirmative to a physician’s question about having had any recent physical trauma.
Nor do we find any merit in the contention that the compensation judge simply disregarded Dr. Segal’s opinion in considering the evidence, or that his failure to adopt that opinion was improper because it was the “key opinion” in the case. The compensation judge’s findings make it abundantly clear that the compensation judge carefully considered the competing medical opinions on the primary issue and, for the reasons he set out in his findings, found the opinion of Dr. Smith to be more persuasive than the opinions of Dr. Segal.
We find ample evidence in the record which supports the determination of the compensation judge on the issue of causation.
The employer and insurer have also appealed from the compensation judge’s awards of temporary total and temporary partial disability, and from the award of permanent partial disability compensation for a 15 percent permanency. However, the appeal from these awards is predicated solely on the causation argument that we have addressed above. We therefore affirm the awards of temporary benefits and of permanent partial disability compensation.
The decision of the compensation judge is affirmed.
 Gillette v. Harold, Inc., 257 Minn. 313,101 N.W.2d 200, 21 W.C.D. 105 (1960).
 Cf., e.g., Burchfeld, R.W., Fowler’s Modern English Usage (3rd ed. 1996); Encarta World English Dictionary(1999); The American Heritage New Dictionary of Cultural Literacy, (3rd ed. 2005).