TED KNABLE, Employee/Cross-Appellant, v. PIES, INC., and CIGNA INS. CO., Employer-Insurer/Appellants, and MANUS PRODS., INC., and ST. PAUL FIRE & MARINE INS. CO., Employer-Insurer, and ORTHOPAEDIC CONSULTANTS, P.A., Intervenor.
WORKERS' COMPENSATION COURT OF APPEALS
APRIL 28, 2000
HEADNOTES
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including lay testimony, medical records, and expert medical opinion, supported the compensation judge=s determination that the employee did not sustain a Gillette injury in the nature of bilateral carpal tunnel syndrome and ulnar neuritis arising out of and in the course of his employment the employer Manus Products, Inc.
Affirmed.
Determined by Wilson, J., Pederson, J., and Wheeler, C.J.
Compensation Judge: William R. Johnson
OPINION
STEVEN D. WHEELER, Judge
The employer, PIES, Inc., and its insurer appeal, and the employee cross-appeals, from the compensation judge's determination that the employee did not sustain a Gillette injury[1] or aggravation in the form of bilateral carpal tunnel syndrome and ulnar neuritis arising out of and in the course of his employment with employer Manus Products, Inc. We affirm.
BACKGROUND
The employee, Ted Knable, was born on September 27, 1971. In 1991 he began working for the employer, PIES, Inc., working variously on four different production lines. On one line, the Acobbler line,@ the employee performed either Acrimping@ or Apackaging.@ Crimping involved pinching foil lids onto aluminum foil pans of frozen cobblers using his fingers. Packaging involved lifting five-pound trays of frozen cobblers from a belt two at a time and putting them into boxes, then lifting the boxes onto pallets. On the ASchwan=s@ line, the employee lifted 30-pound boxes of pies onto a conveyor and a pallet. Sometimes on the Schwan=s line he was also required to fold in the sides of boxes and push them into a machine. He also worked on the Ameringue@ and on the Acream@ lines, either lifting pies and sliding them into a machine, putting plastic domes over pies, or catching packaged pies off the line and wrapping them. Approximately a couple of times each week, the employee put pricing codes on stickers using a pricing gun with a trigger. The employee testified that this work was fast-paced, and that he initially worked 40-hours per week in eight-hour days, but later worked ten-hour days. His weekly wage at PIES for the dates relevant to this matter was $252.52. (T. 18-28; Finding 1.)
The employee began to notice problems with his forearms, wrists, hands and fingers in the spring of 1992, in the form of stiffness, tenderness, and cracking and popping in the joints. In May 1992 he reported this to the employer and his supervisor took him to the Chanhassen Medical Center. The records for the Chanhassen Medical Center on May 13, 1992, state that the employee was seen on that date and reported that his wrists had started hurting at work about two months before and had progressively bothered him. The employee also reported problems with grabbing and grasping and that he had been dropping things. He was found to have tenderness of the dorsal surface of the wrist mostly on the radial side. There was weakness of the thumb in abduction and adduction, and the abductor pollicis brevis and the extensor tendons of the first and second fingers on both hands were quite tender. The employee was diagnosed with a bilateral wrist strain with tendinitis due to cumulative trauma disorder. He was instructed to ice his wrists frequently and to wear bilateral wrist splints. He was restricted to modified light-duty work with no lifting beyond ten pounds as Aan intensive treatment designed to get this patient back to normal in a very short period of time so he can do a more efficient job.@ (T.28-31; Exh. C.2: 5/13/92.)
The employee returned to the Chanhassen Medical Center without improvement on May 20, 1992 and again on June 3, 1992. At that time Phalen=s test was slightly positive on both sides and the Tinel=s sign was slightly positive on the left. The employee was advised to undergo EMG and nerve conduction studies to rule out possible carpal tunnel syndrome. The employee returned again on June 17, 1992. On that date, his physician noted that the nerve conduction study had been negative but that the employee had been placed in a workers= compensation off-work status by his employer since June 12, 1992 because his symptoms had continued. The employee was prescribed intensive physical therapy. The employee was off work about five weeks and then returned to work for his employer in the production line jobs. He continued to treat at the Chanhassen Medical Center through September 10, 1992, on which date he was referred to Dr. Mark D. Fischer. (T.31-32; Exh. C.2: 5/20/92 - 9/10/92; Exh. D.1: 12/9/92 letter.)
When seen by Dr. Fischer on September 10, 1992, the employee described distal volar forearm pain, aggravated by his job. On the right side, the pain was localized to an area just ulnar to the flexor carpi radialus tendon. The employee also reported some cramping pain between his fingers. On examination, the employee exhibited a mildly positive Phalen=s test bilaterally. Thumb compression and Tinel=s test were negative. Dr. Fischer diagnosed wrist flexor tendinitis and Aintrinsic muscle pain secondary to overuse as well as transverse compression.@ Dr. Fischer recommended a program of tendon and gliding exercises as well as exercises to stretch and strengthen the intrinsic muscles. Restrictions were written to gradually return the employee to full strength lifting while engaged in the rehabilitation program. On December 10, 1992, the employee returned to Dr. Fischer with mild tenderness in the flexor pronator muscles and no focal area of discomfort. Phalen=s and Tinel=s tests were negative. The employee complained of some mild clicking in the right wrist. Dr. Fischer released the employee to return to work without restrictions. (Exh. C.5: 9/10/92, 12/10/92.)
The employee continued to work for PIES as a production worker performing the same duties until some time in 1995 or 1996 when he was promoted to a line lead. As a line lead, the employee performed the same kinds of work as he had previously performed, but to a lesser degree, as he also spent part of the day on administrative tasks, such as keeping records of production on his line. While working as a line lead, the symptoms in the employee=s arms and wrists did not subside. He was, however, able to remove his wrist braces while engaged in his lighter work. (T. 33-34.)
After about a year as a line lead the employee was returned to work as a line worker. In this position the problems with his hands and wrists became worse and the employee reported a return of pain as he increased the use of his hands. (T. 34-36.)
On March 21, 1997, the employee returned to the Chanhassen Medical Center reporting that he had experienced an increase in aching and pain in his wrists and arms since he was taken off the line lead position and returned to full-time line work. He also told the doctor that he had begun to drop things after periods of repetitive work. On examination, Tinel=s sign was equivocal on the left and negative on the right, and Phalen=s sign was equivocal with some dysesthesias in the middle finger bilaterally. He was diagnosed with a bilateral wrist overuse syndrome, was placed in wrist splints and referred for occupational therapy. Restrictions were imposed. (Exh. C.2: 3/21/97.)
The employee returned to the Chanhassen Medical Center on April 11, 1997. He stated that he felt Aa little bit better@ but was still having crunching and creaking in his tendons. The doctor noted that the employee=s physical therapists Adon=t feel that he has typical carpal tunnel syndrome.@ Tinel=s sign was negative. There was some crepitus laterally over the ulnar-sided flexor tendons. He was continued in physical therapy and permitted to work with restrictions. The employee again returned to the Chanhassen Medical Center on May 1, 1997. Physical therapy reports showed improvement, although the employee had experienced some return of aching in his wrists which he associated with doing some work beyond his restrictions during the prior two days. The employee also reported tenderness along the extensor tendon of the thumb, mostly on the left. The employee informed the doctor that he had been fired from his job at PIES that morning. (Exh. C.2: 4/11/97 - 5/1/97.)
Later in May 1997, the employee found work with the employer Manus Products packaging caulking tubes. His weekly wage at Manus Products for the dates relevant to this matter was $339.75. His job primarily involved catching caulking tubes as they came out of an automatic machine, placing them in boxes and moving pallets of boxes. In conjunction with this job the employee underwent a pre-employment physical examination conducted by a physician=s assistant, Julie Frank, on May 16, 1997. Among other findings, Ms. Frank noted that Phalen=s and Tinel=s signs were negative. She released the employee for work for Manus Products without limitations. (T. 39-40, 47-51; PIES Exh. 2; Finding 2)
The employee next returned to the Chanhassen Medical Center on July 8, 1997. The records from that visit state that he was Arequesting evaluation of chronic persistent bilateral wrist pain@ and that the symptoms had persisted since his last visit to the clinic in May. The employee reported chronic pain, as well as Apins and needles@ and occasional numbness in the second and third fingers of the right hand. The pain in the wrist, however, was more severe on the left. The employee stated that Ahis job at this time does not require him to use his wrist for any type of heavy lifting or repetitive movement. He is concerned about the persistence, which is the reason for this visit. No recent trauma since leaving PIES.@ He was diagnosed with chronic tendinitis of the left and right wrists. An EMG was scheduled to rule out carpal tunnel syndrome. The EMG, however, was apparently not performed. (Exh. C.2: 7/8/97.)
On January 29, 1998, the employee was seen in the Chanhassen Medical Center for reassessment of his wrists. Tinel=s sign was negative but Phalen=s sign was positive. The employee was referred to occupational therapy for carpal tunnel assessment and evaluation. He returned on March 4, 1998. The chart note of that date states the employee Adoes have bilateral carpal tunnel. He has been diagnosed with that in the past.@ The employee was referred for an orthopedic consultation. An EMG was again ordered, and was performed the next day, March 5, 1998. It was read as showing Aborderline evidence of bilateral carpal tunnel syndrome.@ (Exh. C.2: 1/29/98 - 3/4/98; 3/6/98 EMG report.)
The employee was seen by Dr. Mark E. Friedland on March 10, 1998, at which time the doctor recorded the following history:
Ted Knable is a 26-year old white male referred by Jane Anderson, RNP, for bilateral wrist pain with numbness and tingling, primarily in the middle and ring fingers and to a lesser degree in the little fingers of both hands. This has been going on since 1992, ever since the patient began working at Pies, Incorporated packing pies. For a period of time he had been placed in a lead position, where he didn=t have to do the packing, and his problems resolved. However, he was then returned to the packing position and he had recurrent symptomatology of carpal tunnel syndrome. When he could not do the work he was terminated. Nine months ago he began working at Manus Products packing caulking tubes. He denies any specific injuries while working at Manus Products.
On examination, Tinel=s sign was mildly positive bilaterally at the carpal tunnel for the median nerve but negative for the ulnar nerve at the wrist. Dr. Friedland diagnosed a work-related bilateral carpal tunnel syndrome, unresponsive to conservative treatment. He recommended staged bilateral carpal tunnel release surgery, about a week apart. The employee underwent the surgery on March 20, 1998 and on April 17, 1998. (T. 55-56; Exh. 5: 3/10/98; Exh. 6.)
On May 21, 1998 the employee filed a claim petition alleging an injury in the nature of carpal tunnel syndrome with an injury date of May 13, 1992, while employed by employer PIES. PIES and its insurer answered by denying liability. (Judgment Roll.)
The employee was seen for a medical evaluation on behalf of employer PIES and its insurer on August 17, 1998 by Dr. Chris Tountas. Dr. Tountas diagnosed a decompression bilateral carpal tunnel syndrome. He opined that the employee had sustained a temporary aggravation of his a preexisting tendinitis condition in March 1997 while working at PIES, Inc., and that the employee had sustained a Gillette-type injury culminating when there was EMG evidence and conclusive findings for carpal tunnel syndrome during the time the employee was working for Manus Products. He further opined that the employee=s ongoing tendinitis was an underlying factor for the eventual bilateral carpal tunnel syndrome, and that both the work at PIES, Inc. and the work activities at Manus Products were substantial contributing factors to the employee=s need for surgery and resulting wage loss. Dr. Tountas estimated apportionment of liability at 1/3 for PIES and 2/3 for Manus Products. (PIES Exh. 1.)
In a letter to the employee=s attorney dated January 4, 1999, Dr. Friedland offered the opinion that the employee had sustained Gillette injuries to his wrists as a result of his repetitive work activities at PIES, Inc. culminating in disability on May 13, 1992, resulting in bilateral wrist flexor tendinitis which in turn predisposed him to the development of bilateral carpal tunnel syndrome. He explained that Athe usual clinical course for carpal tunnel syndrome is development of flexor tenosynovitis which frequently results in median neuropathy (carpal tunnel syndrome). This is a clinical spectrum along which the diagnosis frequently progresses from tendinitis to carpal tunnel syndrome if the tendinitis cannot be fully controlled.@ Dr. Friedland opined that the employee also sustained a Gillette injury at Manus Products culminating in disability on March 20, 1998, on the basis that A[i]t was not until Mr. Knable began work at Manus Products that his EMGs were noted to be frankly positive for carpal tunnel syndrome even though he had symptomology of carpal tunnel syndrome and wrist flexor tendinitis prior to that.@ He thus considered the employee=s work activities at both employers to have been substantial contributing factors to the need for his medical care and treatment, including surgery, since May 1997, and to the work disability related to the employee=s diagnoses and treatment. (Exh. D.2.)
On February 9, 1999, employer PIES and its insurer filed a motion seeking to join employer Manus Products, Inc. and its insurer. An order for joinder was served and filed on February 18, 1999. (Judgment Roll.)
The employee was examined by Dr. William H. Call on behalf of employer Manus Products and its insurer on May 7, 1999. Dr. Call noted that the employee told him that Ahis symptoms began in 1992@ and summarized the history given to him by the employee as consistent with the employee=s deposition testimony, which had been furnished to the doctor:
. . . since he left PIES his wrist stayed about the same. He decided to get medical treatment for his hands because they weren=t getting any better and he was tired of dealing with the pain. He also stated the work at Manus was not aggravating his symptoms since he returned . . . the patient felt that his wrist injuries related back to PIES.
Dr. Call opined that Athe employee did not sustain an objectively supported work related injury as a substantial result of his work activities at Manus Products@ and that all of his symptoms were well-established for years prior to working for Manus and were merely a continuation of the previous symptoms at PIES, Inc. He apportioned all medical treatment, disability and work restrictions 100 percent to PIES, Inc. (Manus Exh. 1.)
A hearing was held before a compensation judge of the Office of Administrative Hearings on July 21, 1999. As of the date of hearing, the employee had changed his position to assert a separate injury at Manus Products in addition to the 1992 injury at PIES. (T. 13.)
On direct examination, the employee testified that his hand, wrists and arms did not initially bother him very much when he began working at Manus Products, but that by the fall of 1997, he noticed that his wrists and forearms Astarted swelling up more.@ He testified that the pain in his wrists and arms just prior to his termination by PIES had been mostly during heavier work, and that by March 1998 he was having the pain every day, and it had become intolerable. (T. 52-54, 57-59.)
However, on cross-examination by counsel for Manus Products, the employee acknowledged that it had been his deposition testimony on July 15, 1998 that his problems with his hands and arms had started in 1992, that he had never been symptom free since 1992, and that the specific symptoms that started prior to termination by PIES included numbness in the hands, numbness in the fingers, loss of strength in the wrists, forearm pain, tingling and numbness, and muscle pain and tenderness. The employee acknowledged that at his first deposition, he had testified that his symptoms had stayed about the same after leaving PIES, and prior to the surgery, and that he had not noticed that anything he was doing while at Manus Products aggravated his condition. On cross-examination by counsel for PIES the employee acknowledged that, in his deposition testimony, he had stated that he had not had any change in the nature of his symptoms after beginning work at Manus Products, only an increase in the frequency of the symptoms and in his ability to tolerate the pain. He was asked to account for any change in his current testimony that might suggest the development of new symptoms. He responded that, AI listened to what my doctor says, and that=s what he thought.@ (T. 108-109, 123, 129-133.)
Following the hearing, the compensation judge found that the employee had not sustained a Gillette injury in the form of bilateral carpal tunnel syndrome and ulnar neuritis arising out of his employment at Manus Products. He found that the employee=s complaints were all causally related to the work activities at PIES. Employer PIES and its insurer appeal, and the employee cross-appeals joining the appeal by PIES.
STANDARD OF REVIEW
On appeal, this court must determine whether the compensation judge's findings and order are "clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted." Minn. Stat. ' 176.421, subd. 1(3) (1992). Substantial evidence supports the findings if, in the context of the record as a whole, 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 the evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings must be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, "[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed." Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Factfindings may not be disturbed, even though this court might disagree with them, "unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole." Id.
DECISION
On appeal, the appellant/employer PIES and its insurer and the cross-appellant[2] employee (hereinafter, Aappellants@) argue that a finding of a Gillette injury at Manus Products was supported by the absence of EMG evidence for carpal tunnel syndrome prior to the inception of the employee=s job at Manus, by the fact that the employee=s pain worsened at Manus such that he was no longer able to tolerate it, by the fact that later work the employee performed for Manus Products subsequent to his surgery worsened his symptoms and by the opinions of Dr. Friedland and Dr. Tountas.
The compensation judge stated that the employee=s testimony was Acritical@ to understanding the outcome in the case. The judge found that A[a] careful reading of the employee=s testimony clearly indicates that he believed that his work activities at PIES, Inc., had already culminated in a Gillette-type injury by the time he left their employment in May of 1997 . . . The employee never testified that his pain grew worse at Manus, simply that his tolerance for the pain, which dated back long before he started at Manus, finally reached the breaking point,@ such that the employee Aalready had the problem and just decided to have it surgically addressed while at Manus.@ The judge indicated that the employee=s testimony supported the conclusion that the work activities that the employee performed at Manus did not aggravate his problems. Accordingly, the compensation judge adopted the view of Dr. Call that the employee=s symptoms were solely related to his work duties at PIES. (Finding 5; Mem. at 11.)
The appellants do not directly dispute the compensation judge=s interpretation of the employee=s testimony, but argue on appeal that the compensation judge erred in accepting the opinion of Dr. Call. Specifically, they note that the compensation judge stated that A[a]s Dr. Call notes in his report the employee had a long history of positive Phalen=s test and his Tinel sign was positive on the left as early as June 3, 1992.@ (Finding 5. ) The appellants argue that the statement that the employee had a Along history@ of a positive Phalen=s test is contradicted by the medical records, in that although the employee did have positive Phalen=s findings as early as 1992, these findings were not consistently made thereafter, with long periods of negative Phalen=s findings on examinations between then and 1998. They suggest that the compensation judge=s statement indicates that he did not read the medical records, but only relied upon Dr. Call=s recapitulation of the medical evidence.
We disagree. The compensation judge did not state that the employee had a long and continuous history of positive Phalen=s findings, and his statement clearly refers not to the continuity of the findings but the length of time since an initial positive Phalen=s finding. This is consistent with the compensation judge=s reasoning as set forth in the remainder of Finding 5, which indicates that he based his choice among the medical opinions on the fact that each of the employee=s hand and wrist symptoms had already been noted prior to the employment with Manus Products, as opposed to relying entirely on the date at which EMG testing first was positive for a carpal tunnel condition. This court will assume that the compensation judge examined all of the evidence in the case unless it is manifestly clear that something was overlooked. Here, the compensation judge=s findings and memorandum reflect instead his familiarity with the contents of the medical records.
The appellants further argue that Dr. Call=s opinion should be deemed without adequate foundation because that doctor had not reviewed the contents of the pre-employment physical examination on May 16, 1997, conducted just prior to the employee beginning work with Manus Products. The significance of this examination is that Phalen=s and Tinel=s signs on that date were seen as negative. However, Dr. Call specifically based his opinion on the history of the employee=s symptomology, rather than the specific dates of the various test results. There is nothing in the doctor=s report to suggest that he relied upon the view that the employee exhibited, or should necessarily have exhibited, positive Phalen=s findings in May 1997. There is no basis to conclude that Dr. Call=s opinion would have been changed had he been provided with the notes from the pre-employment examination.
Generally, this court must affirm a compensation judge=s determination based upon the judge=s choice between the conflicting opinions of medical experts unless the opinion on which the judge relied was clearly without adequate foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). We cannot say that Dr. Call=s opinion lacked adequate foundation under the specific facts and circumstances of this case. Substantial evidence, as reasonably interpreted by the compensation judge, supported the judge=s determination which was not clearly erroneous. We, therefore, affirm.