SHIRLEY GUNDERSON, Employee/Appellant, v. CENTER FOR DIAGNOSTIC IMAGING and THE HARTFORD INS. CO., Employer-Insurer, and RICE MEM’L HOSP. and BLUE CROSS/BLUE SHIELD OF MINN., Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
FEBRUARY 19, 2013
CAUSATION - SUBSTANTIAL EVIDENCE. Given the length of time before back pain was noted in the employee’s treatment records, inconsistencies as to the onset of the employee’s symptoms, as well as conflicting expert opinions, substantial evidence supported the compensation judge’s conclusion that the employee did not injure her low back in a fall at work.
Determined by: Wilson, J., Hall, J., and Stofferahn, J.
Compensation Judge: Catherine A. Dallner
Attorneys: Rodney C. Hanson, Anderson Larson Hanson & Saunders, Willmar, MN, for the Appellant. Kassi Erickson Grove, Law Offices of Steven G. Piland, Eagan, MN, for the Respondents.
DEBRA A WILSON, Judge
The employee appeals from the compensation judge’s decision that she did not injure her low back in a fall at work. We affirm.
The employee is employed as an x-ray technician by Diagnostic Imaging Holdings, Inc., also known as Center for Diagnostic Imaging [the employer]. In September 2009, she injured her right knee at work, necessitating arthroscopic repair of her medial meniscus, but she missed little or no time from work as a result of this injury.
The following year, on November 22, 2010, the employee sustained another work injury when she slipped on melted snow or ice on the floor of the x-ray room. She was holding an expensive piece of equipment at the time, and, in order to protect this equipment and also to avoid striking her head, she fell straight down onto her knees on the cement floor, with her buttocks collapsing on her feet as she landed. She returned to her work but completed a first report of injury shortly thereafter, describing the fall and indicating that “both knees hurt and between shoulder blades.” The employee subsequently testified that the pain between her shoulder blades was temporary, lasting only about a week.
The employee sought treatment for knee symptoms on November 30, 2010, from Dr. Dennis Peterson, a physician in the medical clinic in which the employee worked. Dr. Peterson recommended pain relievers and directed the employee to follow up in two weeks. In a December 7, 2010, treatment note, a nurse practitioner observed that the veins on the employee’s left leg were somewhat distended, and she ordered a Doppler study, which was negative for deep vein thrombosis. The employee then saw Dr. Peterson again about a month later, on January 6, 2011, complaining of “persistent knee pain left greater than right.” Dr. Peterson found good range of motion bilaterally and no obvious effusion but “puffy swelling of the left medial pes anserine bursa.” He administered an injection of the left bursa, which “completely relieved [the] pain.”
The employee sought no further treatment until March 18, 2011, when she was evaluated by Dr. Anthony Amon, a colleague of Dr. Peterson. In his note from this examination, Dr. Amon wrote as follows:
1. knee pain patient has had ongoing knee pain and now it is affecting down her leg. The patient fell on November 22 slipping on water from a patient x-ray room and landing on her knees with all of her weight in the flexed position. She had intense pain at that time. The back of her knees turned black and blue and she had swelling. She has been seen multiple times without improvement. She had a right knee partial medial meniscectomy in February of 2010 in Alexandria. She had no ongoing her [sic] chronic pain since the surgery up until the injury. She has had an injection into the anserine bursa on the left knee on January 6 with no improvement. Her left knee is worse since the fall, both of her legs and knees are sore and they feel like they would give out. She has had an ultrasound without clots. She had a free consult from Dr. Sult because of pain and lower leg venous US showed prominence of varicose vein of her left leg. She has not had this problem prior to the fall. 2 blockages and incompetent valves were noted of the L leg. Patient will take 6 Advil every 4 hours and she still will get up at night. She has no history of prior back or hip pain. She has some mild discomfort in her left hip and low back since the injury. No change in bowel or bladder function.
(Emphasis added.) In a note dated March 29, 2011, Dr. Amon again indicated that the employee was experiencing pain on the left, writing that he was “hopeful that the hip and low back pain are related to the knee pain” and that those symptoms would improve as the employee’s knee pain improved. The employee continued to treat with Dr. Amon for knee and low back symptoms, and she was also seen by Dr. John Geiser, an orthopedic surgeon, and Dr. Christopher Roark, a neurosurgeon.
According to the July 12, 2011, report from the employee’s evaluation by Dr. Geiser, in “April or May of this year [the employee] noticed that she was having some low back pain, ‘primarily on the left side.’” The report also indicated that the employee “feels that the limping due to her knee pain has caused her back pain” but that the employee was “unsure whether or not the fall she took injured her back as well.” X-rays of the lumbar spine taken on that date were described as “unremarkable,” and Dr. Geiser’s physician assistant wrote,
[a]t this time Dr. Geiser states that [the employee’s] back pain is probably not related to her fall in November. It is seemingly unrelated at this point. Dr. Geiser stated that really there is no evidence to link her injury at work with her current low back condition.
In early August 2011, the employee underwent a lumbar MRI. That scan showed degeneration and dehydration with a small tear disc herniation, without impingement, at L5-S1, mild disc dehydration and annular bulging at L4-5, with a small tear that “may possibly correlate with left-sided pain complaints,” and facet joint effusion at L4-5 on the left.
The employee was seen by Dr. Roark on November 17, 2011, nearly a year after her fall at work. In the history portion of his report, Dr. Roark indicated that the employee had been experiencing low back pain for “about the last year.” He diagnosed chronic low back pain and referred the employee for physical therapy, but he offered no opinion as to the cause of the employee’s low back condition.
On December 20, 2011, Dr. Amon issued a narrative report in response to questions from the employee’s attorney. In contrast to some of his earlier treatment notes, in which he tied the employee’s low back condition to altered gait related to the employee’s knee injury, Dr. Amon wrote that the “accident and her knee injuries directly caused her back injury.” He explained that he had based his opinion on the fact that the employee had no prior back problems and had been very active prior to the incident at work.
In June of 2012, the employee was seen for an independent medical evaluation by Dr. Robert Wengler. In contrast to most prior treatment records, the employee apparently described her low back and radiating leg symptoms as being primarily on the right side. Dr. Wengler concluded that the employee was suffering from discogenic low back pain and right lower extremity sciatica, with “clinical evidence of segmental instability over the lower lumbar segments and MRI documentation of rather marked narrowing of L5-S1 disc with a central and left-sided prolapse.” On the issue of causation, Dr. Wengler wrote as follows:
I consider her current back symptoms and need for treatment to have been consequentially caused if not directly the result of the fall that occurred on November 22, 2010. It is not unusual for damage to the annular fibers of a disc to occur at the time of an injury and the disc not become symptomatic until it decompensates at the later date. I have no major issues with assigning direct causation.
The employer and insurer admitted liability for a knee injury but denied that the employee’s low back condition was work-related, and the matter came on for hearing before a compensation judge on July 11, 2012. At that time, the employee was claiming that she had either injured her low back in the November 22, 2010, fall or that her low back condition had been caused by the altered gait resulting from her knee injuries. In a decision issued on August 13, 2012, the compensation judge concluded that the employee had not sustained a work-related low back injury under either theory. 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 (2012). 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 employee appeals from the compensation judge’s decision that the employee did not injure her low back in the November 22, 2010, fall at work, arguing, in part, that the compensation judge erred in accepting Dr. Geiser’s opinion on causation. We note initially that the compensation judge never expressly accepted the opinion of Dr. Geiser but rather noted that neither Dr. Geiser nor Dr. Roark supported the employee’s claim. In any event, to the extent that the compensation judge may have accepted the opinion of Dr. Geiser, we find no clear error in this regard. The report from Dr. Geiser’s evaluation, completed by his assistant, indicates that Dr. Geiser reviewed the employee’s medical records in conjunction with the exam, and, contrary to the employee’s suggestion, we see no basis to support the conclusion that Dr. Geiser failed to review all of the relevant records. As such, also contrary to the employee’s argument, the judge was not required to reject Dr. Geiser’s opinion on foundation grounds. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 351 (Minn. 1985).
It appears to us, however, that the compensation judge based her decision primarily on her rejection of the evidence supporting the employee’s claim, including the employee’s testimony as to the onset and course of her symptoms. In explaining her decision, the judge cited a number of inconsistencies. For example, the employee testified that her low back pain began about a week or so after the November 22, 2010, fall and that she told her providers about the symptoms. As the judge noted, however, there is no mention of low back pain in the employee’s medical records until Dr. Amon’s exam of March 18, 2011, four months after the incident at work. We acknowledge that the employee had a possible explanation for this discrepancy, namely, that the employee’s initial treatment was informal, essentially occurring in the hallway when she could catch a provider between appointments. This, the employee suggests, resulted in mistakes or omissions in her treatment records. However, the compensation judge was not required to accept this explanation, plausible or not. The judge also noted that Dr. Geiser’s evaluation indicates that the employee’s back pain began in April or May of 2011, not November or December of 2010, and, as the judge observed, Dr. Wengler did not explain how or why the employee’s symptoms shifted from her left side to her right. As for Dr. Amon, the compensation judge was unpersuaded by his opinion in part because he appeared to shift his diagnosis from a consequential injury due to altered gait to a direct injury from the fall, all without explanation.
The evidence in this case is susceptible to differing interpretations. As such, given this court’s standard of review, we must affirm the compensation judge’s decision.
 The employee’s work station is located in the clinic, but the employee is employed by the employer, not the clinic.
 The employee originally also appealed from the compensation judge’s denial of the claimed consequential low back injury, but, in her brief, she expressly withdrew her appeal from the compensation judge’s finding on that issue.