GREGORY E. KELLETT, Employee/Appellant, v. BREEZY POINT RESORT and DOTSON INS./MINNESOTA INS. GUARANTY ASSOC., Employer-Insurer, and ST. MARY’S DULUTH CLINIC HEALTH SYS., MINNESOTA DEP’T OF LABOR & INDUS./VRU, and BLUE CROSS BLUE SHIELD OF ILL., Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
MARCH 27, 2012
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including expert opinion, supported the compensation judge’s conclusion that the employee’s left knee condition and need for treatment were not a compensable consequence of the employee’s work-related right knee injury.
Determined by: Wilson, J., Stofferahn, J. and Milun, C.J.
Compensation Judge: William R. Johnson
Attorneys: Robert C. Falsani and Stephanie M. Balmer, Falsani, Balmer, Peterson, Quinn & Beyer, Duluth, MN, for the Appellant. Michael D. Miller and Jeffrey R. Homuth, McCollum Crowley, Minneapolis, MN, for the Respondents.
DEBRA A. WILSON, Judge
The employee appeals from the compensation judge’s decision that the employee’s work-related right knee injury did not contribute to his need for left knee replacement surgery. We affirm.
The employee has a history of right knee symptoms and treatment dating back to at least 1982, when he underwent arthroscopic surgery after injuring his knee in a high school basketball game. He testified that he subsequently had no trouble with his knee over the next six years.
On January 12, 1988, the employee sustained a right knee injury arising out of and in the course of his employment with Breezy Point Resort [the employer]. The employer and insurer admitted liability for the injury and paid various benefits, including medical expenses. The employee underwent and the employer and insurer ultimately paid for six surgeries to the employee’s right knee: an arthroscopic surgery in January 1988, another arthroscopy in October 1988, a July 1990 osteotomy, a January 1996 total knee replacement, a September 1998 revision of the total knee replacement, and a February 2007 second revision of the total knee replacement. Medical records indicate that the employee had psuedogout, a nonwork-related condition, which caused the artificial knee to wear prematurely.
After each of the right knee surgeries, the employee used assistive devices, such as crutches and canes, for periods ranging from weeks to months. Records of Dr. Thomas Kaiser, the employee’s treating surgeon, indicate that the employee at times altered his gait and sometimes limped in an effort to protect his right knee. Records also indicate that the employee had a valgus deformity of the knee, or knock knee, on both sides.
By 2007, the employee had begun to complain of pain in his left knee. He testified that, for the next few years, he favored his left knee, and Dr. Kaiser expressed concern that the added stress created by the employee’s effort to protect his left knee would adversely affect the employee’s total right knee replacement. Tests revealed substantial degenerative changes in the employee’s left knee, and, on September 20, 2010, the employee underwent a total left knee replacement.
The employee claimed that his work-related right knee injury had substantially contributed to his need for left knee surgery, and the matter came on for hearing before a compensation judge on May 20, 2011. The primary issue was causation. Evidence included the employee’s medical records and testimony; several reports from Dr. Larry Stern, the employer and insurer’s independent examiner; reports from Dr. Robert Wengler, the employee’s independent examiner; and medical journal articles dealing with degenerative knee conditions in patients who had undergone amputation of a lower extremity.
In a decision issued on June 24, 2011, the compensation judge concluded that the employee’s left knee condition was not causally related to the employee’s work-related right knee injury. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.” Minn. Stat. § 176.421, subd. 1 (2010). Substantial evidence supports the findings if, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.” Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
The issue in this matter is whether the employee’s work-related right knee injury substantially contributed to the employee’s left knee condition and need for left total knee replacement surgery. The employee’s theory of the case was that his use of assistive devices, such as canes and crutches, after surgery, and his other efforts to protect his right knee, caused an “overuse kind of scenario” with respect to his left knee. Drs. Stern and Wengler offered narrative opinions on the issue, and the records of Dr. Kaiser, the employee’s treating surgeon, contain causation opinions as well. The compensation judge ultimately accepted the opinion of Dr. Stern, and the judge denied the employee’s claims on that basis.
On appeal, the employee contends that the compensation judge erred in accepting the opinion of Dr. Stern, arguing that Dr. Stern relied on an incorrect history of the development of the employee’s left knee symptoms and that Dr. Stern “deliberately disregarded accepted medicine so as to protect [a previous] opinion on the employee’s consequential injury claim.” We are not persuaded by these arguments.
Dr. Stern examined the employee and issued opinions for the employer and insurer on several occasions over the years. In a December 2010 report, Dr. Stern concluded that the employee had “certainly not sustained a consequential injury to his left knee as the result of his right knee work injury,” explaining as follows:
The notion that because of his right total knee surgeries over the years his left knee was subjected to increased stress and strain leading to an acceleration or progression of his left knee degenerative arthritis has absolutely no credibility whatsoever in orthopedic thought or practice. The concept is wrong from several different points of view. First off, unless one is talking about crutch use, postoperative rehabilitation from total knee arthroplasty, or just having a very painful right knee, requires full weightbearing to both the right and the left knee irrespective of any surgery having been done on the right knee. In other words, when one uses a walker, it is a well understood principle that one cannot go “partial weightbearing status” with a walker unless the patient “hops.” Mr. Kellett confirmed that has not been the case. Hopping requires far too much energy and the use of a walker, which allows easier ambulation after knee surgery, still requires that both the left and the right legs bear the patient’s full body weight with ambulation. It is true that when the patient stops walking, he might put more of his weight on the left side than on the right, if weightbearing was hurting on the right, but the minute that the patient walked again, he would be placing his full body weight on both knees. As I think most people are aware of, it is a common occurrence that people who have had osteoarthritis in one knee develop it on the other side, and the observation that many patients require bilateral total knee arthroplasties is readily apparent and quite common. The fact that this gentleman should require a left total knee arthroplasty because of his 18 degree of valgus in his left knee has nothing whatsoever to do with the problem involving his right knee.
Concluding his discussion on this point, Dr. Stern wrote,
Perhaps no “real world” example can be more demonstrative of the fallacy that a right knee condition would lead to a left knee condition as a consequence of overuse in the observation that patients who have above the knee or below the knee amputations and ambulate with a prosthesis, do not have an increased risk of having a total joint replacement of their remaining good leg.
After reviewing Dr. Stern’s report, the employee’s attorney apparently used the internet to find medical studies bearing on the issue. Counsel then submitted these articles to Dr. Wengler for consideration in conjunction with his request for Dr. Wengler’s opinion on causation. Dr. Wengler responded in a one-page report dated March 3, 2011, addressing causation as follows:
It is my opinion that the deterioration of left knee of the joint occurred as a function of stresses to which it was subjected by virtue of his favoring the right and that these stresses ultimately led to the need for the total knee arthroplasty. The articles that you cite support the thesis of compensatory deterioration of otherwise healthy joints on sides opposite injured (amputated) members.
Dr. Wengler offered no further explanation for his opinion connecting the employee’s need for left knee treatment to his work-related right knee condition.
The employer and insurer’s attorney then submitted the journal articles to Dr. Stern for comment. In his report dated May 19, 2011, Dr. Stern indicated that the journal articles in no way changed his prior opinions, because “not one of them denotes a statistical increase in amputees requiring a total knee replacement on the opposite side.”
The employee contends that Dr. Stern misread the articles in question and that he relied on “junk science” to support his position. There is an argument to be made that at least one of the studies did indeed deal with amputee patients’ development of osteoarthritis in the contralateral, or opposite, leg, contrary to Dr. Stern’s analysis. However, Dr. Stern offered another reason for discounting the relevancy of the journal articles, and it was apparently this theory that the compensation judge found most persuasive: that is, that amputation is not comparable to shorter-term use of crutches, walkers, or canes. As the judge explained in his memorandum,
The articles cited by Dr. Wengler as supporting his opinions in this case are not persuasive evidence. The articles deal with “secondary complications among people with lower-limb loss who are long-term prosthesis wearers.” See, Petitioner’s Exhibit B. That situation is not at all analogous to the situation here. The employee had a knee replacement in one leg and while he may have spent a few months after each surgery on crutches this is not the same situation as outlined in the articles cited by Dr. Wengler. Also, as Dr. Stern notes “it is a common occurrence that people who have had osteoarthritis in one knee develop it on the other side, and the observation that many patients require bilateral total knee arthroplasties is readily apparent and common.” See, Respondent’s Exhibit 3. The employee had his osteoarthritis aggravated or accelerated in the right knee by the work injury. However, he then surely and inevitably developed the same progressive degenerative condition in the left knee, albeit at a slower pace, without the right knee problem playing any significant role.
Finally, we note that the compensation judge was not in any event required to accept the journal articles as authoritative.
The question in this case is not whether this court accepts the premise that a work-related knee injury might lead to additional joint stress on the opposite knee sufficient to cause injury. Rather, the issue is whether the compensation judge was entitled to reject the employee’s claim in view of the record before him. We conclude that he was. Because the judge’s decision is supported by substantial evidence in this record as a whole, we affirm his denial of benefits related to the employee’s left knee condition.
 As expressed in the employee’s counsel’s letter to Dr. Wengler.
 The employee also takes issue with several other aspects of Dr. Stern’s opinion, complaining, for example, that Dr. Stern never “mentioned or explained the multiple findings of [right leg] atrophy in other records.” Whether or not true, allegations of this kind furnish no basis to reverse the judge’s decision.
 In connection with a previous claim, Dr. Stern agreed with the employee’s contention that the work-related right knee injury substantially contributed to the employee’s ongoing right knee problems and need for treatment.
 According to the employee’s appeal brief.
 For this reason, cases affirmed on substantial evidence grounds have little or no bearing on our analysis of the present matter.