JULIE KROMSCHROEDER, Employee/Appellant, v. ME INT=L, SELF-INSURED, Employer-Insurer, and MINNESOTA DEP=T OF LABOR & INDUS./VRU, BLUE CROSS/BLUE SHIELD, ST. LUKE=S CLINIC, and MINNESOTA DEP=T OF EMPLOYMENT & ECON. DEV., Intervenors.

 

WORKERS= COMPENSATION COURT OF APPEALS

DECEMBER 21, 2004

 

No. WC04-209

 

HEADNOTES

 

CAUSATION - AGGRAVATION; CAUSATION - PRE-EXISTING CONDITION.  Where they were supported by expert medical opinion and were not otherwise unreasonable, the compensation judge=s conclusions that the only work-related injuries proven to be at issue were the admitted carpal and cubital nerve tunnel injuries in the employee=s wrists and elbows and that those injuries were effectively resolved upon the employee=s post-surgical release to return to work without restrictions were not clearly erroneous and unsupported by substantial evidence, notwithstanding the fact that the employee had been initially diagnosed with wrist tendonitis and also with symptoms of arguably transient or pre-existing shoulder problems.

 

Affirmed.

 

Determined by: Pederson, J., Johnson, C. J., and Wilson, J.

Compensation Judge: Rolf G. Hagen

 

Attorneys: Raymond R. Peterson, McCoy, Peterson, Jorstad Ltd., Minneapolis, MN, for Appellant.  Edward Q. Cassidy and Timothy J. Pramas, Felhaber, Larson, Fenlon & Vogt, St. Paul, MN, for Respondents.

 

 

OPINION

 

WILLIAM R. PEDERSON, Judge

 

The employee appeals from the compensation judge's conclusion that the employee failed to prove that her bilateral carpal tunnel and cubital syndromes were a substantial contributing factor in her overall disability and need for medical care after September 11, 2001, or that her work activities either caused or aggravated the osteoarthritis condition in her wrists and hands bilaterally or the degenerative joint disease/arthritis or tendinitis condition in her left shoulder.  We affirm.

 

BACKGROUND

 

Julie Kromschroeder [the employee] began working for ME International [the employer] in 1985, first, for about a year, as a switchboard operator and payroll clerk and then, for about four years, as a casting specialist.  The casting specialist position was a multi-station job that regularly entailed lifting up to fifty pounds, using a sledge hammer to install clamps to hold pieces of molds together, pouring molten metal into molds, removing those molds, and chipping away extraneous hardened metal using an ice chopper or pick hammer.  In about 1990, the employee evidently switched to a different position with the employer, as a warehouse or maintenance clerk.  Some nine years later, in August of 1999, many employees of the employer, including the employee, went on a strike that lasted for about a year.  When she was among the minority of workers invited back to work on August 7, 2000, the employee was reassigned to the casting department, where she worked at what she described in testimony as Athe molding table,@A[h]ammering the clamps@ eight to twelve hours a day, five or six days a week, without option of rotation to other tasks.  Within about a week, the employee=s arms evidently began to ache, and she requested but was initially denied an option of rotating tasks.  Eventually, evidently thanks to influence by the employer=s company nurse, she was switched to the pouring station, where continued sledge hammer work, some of it overhead, resulted in continuing upper extremity pain.  On December 13, 2000, the employee notified the employer of work injuries in the nature of Abilateral shoulder strain@ and Abilateral wrist tendonitis,@ identifying their date as Acumulative trauma for past 6 months.@  The employee was fifty-one years old at the time and was earning a weekly wage of $643.20. 

 

On January 25, 2001, the employee saw Physician=s Assistant Kelsy Kuehn, complaining that she had been experiencing Abilateral shoulder and wrist pain since August.@  Ms. Kuehn diagnosed bilateral shoulder strain and bilateral wrist tendonitis and issued work restrictions against pushing, pulling, twisting, turning, or lifting more than ten pounds with either arm.  She limited the employee also to light duty with no firm grasping or overhead work and prescribed six sessions of physical therapy. The following day, on January 26, 2001, the employer=s workers= compensation insurer was notified of an injury now identified, by another First Report of Injury filed with the Department of Labor and Industry on January 30, 2001, of a work injury in the nature of Abilateral shoulder and wrist pain@ sustained by the employee on August 1, 2000.  On February 7, 2001, Dr. Jacob Kammer diagnosed bilateral shoulder strain, bilateral wrist sprain, and A[w]rist nodules@ and referred the employee for evaluation of the nodules.  The employer, which was self-insured against workers= compensation liability at the time and had had proper notice of the injuries, commenced payment of benefits.

 

On March 2, 2001, the employee was examined by neurologist Dr. David McKee, who diagnosed moderate to severe bilateral carpal tunnel syndrome, together with bilateral ulnar neuropathy at the elbow.  Dr. McKee stated that, A[g]iven the type of work that the [employee] describes, I suspect that her median and ulnar nerve problems relate to her work but the development of multiple focal neuropathies does raise a question of underlying predisposing condition, especially diabetes.@  Dr. McKee recommended certain medication but supposed that Ait probably isn=t going to be enough to prevent her needing surgery.@

 

On March 14, 2001, the employee saw neurosurgeon Dr. Stefan Konasiewicz, with complaints of A[b]ilateral hand pain, numbness, tingling, weakness and shoulder pain, elbow pain.@  Upon neurological examination, and after noting that the employee=s AEMG=s, nerve conduction studies show evidence of significant carpal tunnel syndrome bilaterally@ together with Aevidence of significant ulnar neuropathy on both sides,@ Dr. Konasiewicz recommended that the employee undergo carpal tunnel release as well as ulnar nerve decompression transposition, concluding that the employee had Ainjuries that are work related.@  On March 23, 2001, Dr. Konasiewicz performed surgery on the employee=s right wrist and elbow, in the nature of endoscopic carpal tunnel release and ulnar nerve decompression and transposition at the cubital tunnel, and two months later, on May 10, 2001, he performed similar surgery on the employee=s left wrist and elbow.  On May 16, 2001, the employee reported to Ms. Kuehn that her surgeries had gone well and that the pain in her hands was resolving.  Physical therapy records for July 6, 2001, indicate that the employee was still, on that date, Anot quite strong enough or conditioned to d[o] a full days work,@ but by August 3, 2001, she was reported to be Afunctioning at a very high level,@ and three days later Dr. Konasiewicz released her to return to work four hours a day beginning August 7, 2001.  Apparently about a month later, by a signed but undated memo ATo Whom it May Concern,@ Dr. Konasiewicz released the employee to return to work Awithout restriction@ on September 11, 2001, qualified only by the note  Afulltime @ eight (8) hours per day.@

 

Upon her return to work, the employee was assigned again to work at the molding table, but about a week later, on September 17, 2001, she was laid off  for economic reasons unrelated to any work injury.  On about January 24, 2002, she was recalled back to her job at the molding table, from which she was now allowed to rotate to the other stations in the casting department.  On that same date, Mark Pendleton, a human resources officer at the employer, evidently called Dr. Konasiewicz=s office to inquire into the employee=s restrictions, since her return-to-work letter had Amentioned full-time work OK, but no mention of overtime.@  Mr. Pendleton was evidently informed that Ait was OK from a neurosurgical standpoint, but [the employee] needs to be careful not to reinjure herself,@ since A[apparently, [the employee] was telling HR she couldn=t work overtime.@  On February 13, 2002, on referral from Dr. Konasiewicz=s office, the employee was seen by physical medicine and rehabilitation specialist Dr. Daniel Wallerstein, who restricted her from working overtime, recommending that she alternate positions when working overhead, limiting overhead work to fifteen minutes at a time and allowing a minimum of an hour between activities performed above waist height.  The employer apparently accommodated those restrictions until it terminated the employee in May of 2002.

 

On July 8, 2002, the employee saw Dr. Lynn MacLean Aregarding hypersensitivity to cold in both arms and continued pain in elbows when she leans her elbows on a table.@  Dr. MacLean diagnosed A[h]ypersensitivity to bilateral hands, likely secondary to prior ulnar damage prior to surgeries,@A[e]lbow pain, likely exacerbated by prior ulnar neuropathy,@ and A[l]umps in left hand, likely exacerbated by osteoarthritic changes to left hand, possibly secondary to ganglionic formations around tendons of left hand,@ and he referred the employee to a rheumatologist to evaluate the lumps on the employee=s left hand.  On July 23, 2002, on referral from Dr. MacLean, the employee was seen by rheumatologist Dr. Charles Moore, complaining chiefly of A[s]tiffness and pain in hands@ but also of Asome trouble with her left shoulder for about the last two years.@  X-rays were read to reveal, in the left hand, mild degenerative change at the base of the thumb and mild to moderate degenerative change at the DIP joints of the first and fifth fingers, and, in the right hand, mild degenerative change involving multiple PIP joints, in particular the lateral aspect of the right fourth PIP joint, without evidence of bone destruction or erosion.  The x-rays also revealed  moderate degenerative arthritic change of the AC joint in the left shoulder.  After examining the employee and reviewing her personal and medical histories, Dr. Moore diagnosed in part Atypical osteoarthritis findings [in the] small joints of her hands,@ with significantly decreased range of motion in her left shoulder and left wrist, its A[e]tiology to be determined,@ though he did Anot think this problem is directly related to [the employee=s] previous median, ulnar nerve problems.@

 

On July 29, 2002, the employee underwent additional EMG and nerve conduction studies of her median and ulnar nerves, conducted by Dr. McKee, all of which studies were essentially normal.  With regard to the employee=s median nerves bilaterally, Dr. McKee found as follows:

 

There is very mild residual slowing for the right median nerve through the carpal tunnel with no evidence for residual slowing for the left median nerve though the carpal tunnel.  It is noted that the patient showed electrodiagnostic changes of severe grade carpal tunnel syndrome on the right prior to surgery.  Typically, in cases such as this, there is not [a] complete return to normal conduction speed and the very mild residual slowing seen for the right median nerve is not suggestive of recurrent carpal tunnel syndrome or failed surgical release.

 

With regard to the employee=s left and right ulnar nerves, Dr. McKee found as follows:

 

The findings related to left ulnar neuropathy seen on the [employee=s] 3/2001 study have resolved.  There is still very mild slowing for the right ulnar nerve across the elbow.  This is of questionable significance and the conduction speed and the amplitudes of the wave forms have improved significantly compared to her earlier study.

 

On August 2, 2002, Dr. Moore added the diagnoses of A[i]mpingement left shoulder,@ which he indicated A[m]ay in part be related to degenerative joint disease AC joint,@ and A[e]xtender tendon abnormalities left wrist.@  Dr. Moore asserted that the left shoulder and left wrist problems were Amost likely related to the type of work that [the employee] did,@ that A[t]he osteoarthritic change[s] in her hands, although not caused by the work she was doing, clearly have been made worse.@  On September 19, 2002, the employee was discharged from physical therapy that Dr. Moore had prescribed, with a note that the employee had been Agiven home exercise and given [ultrasound] and mobilization to the [left] shoulder,@ that the goals of her therapy had been met, and that she was now Aable to reach over head and reach behind her back with much less pain.@

 

On October 18, 2002, the employee filed a claim petition, alleging entitlement to various wage loss, medical, and rehabilitation benefits, consequent to a work injury on August 1, 2000, in the nature of Abilateral upper extremity overuse with multiple medical conditions diagnosed.@

 

On January 10, 2003, the employee was examined for the employer by orthopedic surgeon Dr. William Simonet.  In the history section of his report on January 13, 2003, Dr. Simonet noted expressly that he had Aasked the [employee] about [her March and May 2001] surgeries and she tells me that they helped in that she regained her strength and grasp and no longer had pain.  The records indicate that she was improved.@  The doctor noted also in his report that the employee did Anot know of any specific restrictions with regard to use of her hands or arms,@ although she did inform him that Ashe was once told to find a job that didn=t require her to use her arms over a waist level.@  After noting almost entirely normal findings on physical examination, including entirely normal range of motion in both shoulders, Dr. Simonet diagnosed A[s]tatus post bilateral carpal tunnel release and ulnar nerve decompression with excellent clinical results@ (noting that the preoperative diagnosis had been carpal tunnel syndrome and cubital tunnel syndrome), A[b]ilateral hand stiffness likely secondary to age appropriate osteoarthritis,@A[n]onspecific arm aches secondary to deconditioning syndrome,@ and A[s]econdary gain factors with pending litigation.@  It was Dr. Simonet=s opinion that the employee=s carpal and cubital tunnel syndromes had been successfully treated, that they had resolved with no residual symptomology, that any ongoing symptoms were not related to the employee=s work activities or work injury, and that the employee did not require any restrictions regardless of causation.  He also reported that the employee had been instructed in a fitness and exercise program for her shoulders but that she had chosen not to do the exercises and that no other treatment for her shoulders was necessary.  He concluded also that the employee had reached maximum medical improvement [MMI] with regard to her carpal and cubital tunnel syndrome work injuries, and his report to that effect was served on the employee on January 16, 2003.

 

On January 13, 2003, on referral from Dr. MacLean, the employee commenced a thirty-day program of physical therapy for what was described in initial therapy evaluation records as primarily Asignificant crepitus and pain in the left wrist, and bilateral hand weakness,@ together with some tightness in her neck and left shoulder.  On the following day, January 14, 2003, the employee underwent an MRI scan of her cervical spine to help in the diagnosis of her pain.  On January 24, 2003, Dr. MacLean reported to the employee that the scan had revealed no evidence of compromise in her spine that could explain the pains in her arms but that it did reveal certain thickening of one of the bones that was Aconsistent with arthritic changes.@  By February 3, 2003, physical therapy records indicate that the employee=s Acrepitus and pain have decreased significantly,@ but further therapy was recommended, and on February 10, 2003, a new therapy program was initiated, focused primarily on the employee=s neck pain.  Discharge therapy records on March 21, 2003, indicate that the employee Adid continually improve,@ that she had Areported doing very well,@ and that A[a]ll goals have been met.@

 

On January 27, 2003, the employee had begun receiving job search and other rehabilitation assistance from QRC Dale Kinnunen, with whose help she located and began working on March 25, 2003, at a job selling used hotel and motel furniture full time and sometimes overtime with Kenlor Enterprises, where she was initially paid $9.00 an hour and eventually earned $12.00 an hour.  On May 6, 2003, the employee=s rehabilitation assistance was terminated.

 

On December 8, 2003, on referral from Dr. MacLean, the employee was examined by neurologist Dr. Ed Crisostomo, primarily with regard to paresthesia in her thighs, but the employee=s neck was also examined, and Dr. Cristostomo reported to Dr. MacLean that the employee=s Aneurological examination is completely normal.@  On March 2, 2004, Dr. Simonet testified by deposition, essentially reiterating the conclusions that he had reached in his report of January 13, 2003, to the effect that the employee was no longer subject to any work-related restrictions and that there was nothing in medical literature to suggest that mild osteoarthritis of the DIP joints and basilar thumb joints of the hand, such as that to which the employee is subject, is in any way related to repetitive work activity or potentially ever a consequence of carpal or cubital tunnel syndrome.

 

The matter came on for hearing on March 5, 2004.  Issues at hearing included the following:  (1) whether, as a result of her work for the employer on or about August 7, 2000, the employee had sustained injury to her wrists and left shoulder in the nature of tendonitis and to her hands in the nature of osteoarthritis; (2) the nature and extent of the employee=s admitted and alleged August 7, 2000, work injuries; (3) whether the employee had reached MMI with regard to those injuries; (4) whether the employee was entitled to temporary total disability benefits during any of various periods subsequent to August 7, 2000, without disqualification by resolution of her injury prior to September 6, 2001, or by any failure to conduct a reasonably diligent job search; (5) whether the employee was entitled to temporary partial disability benefits during any of various periods subsequent to August 7, 2000; and (6) whether any of four intervenors, whose claims totaled $13,160.00, were entitled to any payment or reimbursement and, if so, in what amount.  With regard to the latter issue, the parties stipulated at hearing that all medical care and treatment relating to the employee=s admitted bilateral carpal tunnel and cubital syndromes was reasonable and necessary through September 6, 2001.  In the course of the employee=s testimony at hearing, the following exchange took place between the employee and her attorney regarding her release to return to work on September 11, 2001:

 

Q.  So you went back to work.  Did your doctor have you on any restrictions at that point?

A.  Yes.

Q.  What were the restrictions?

A.  Eight hours a day.

Q.  Okay.

A.  And to be very careful not to reinjure myself (indiscernible) the restriction.

 

By findings and order filed May 19, 2004, the compensation judge concluded in part that the employee=s work-related bilateral carpal tunnel and cubital syndromes were substantial contributing factors in the employee=s disability and need for medical care from August 7, 2000, through September 11, 2001, but not after that date.  In express reliance on the opinions of Dr. Simonet, and even while finding the employee to be Aa highly credible and motivated individual,@ the judge found that the employee had reached MMI with regard to her work injuries with service of Dr. Simonet=s report on January 16, 2003, that she had failed to prove that her work activities with the employer had either caused or aggravated the osteoarthritis in her wrists and hands or the degenerative joint disease/arthritis or tendonitis in her left shoulder, and that Aany and all claims of the employee to workers= compensation benefits from and after 09/17/2001 should be denied.@  The employee appeals.

 

STANDARD OF REVIEW

 

In reviewing cases on appeal, the Workers= Compensation Court of Appeals must determine whether Athe 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 (1992).  Substantial evidence supports the findings if, in the context of the entire record, Athey 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, A[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).  Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless 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

 

The compensation judge concluded in his memorandum that the employee Awas ultimately released to return to work without restriction by her primary treating neurosurgical physician, on 09/11/2001," that A[b]ased upon this release, and upon the strength of the opinion of Dr. Simonet (IME), this Compensation Judge believes that the employee=s bilateral carpal [tunnel] and bilateral cubital syndromes resolved completely without residual [symptomology] and without the need for restrictions no later than 09/11/2001,@ and that Athe employee=s prior osteoarthritic/arthritic conditions were neither caused nor aggravated by the work activities while in the employ of the employer.@  Citing expressly the opinions of Dr. Moore, the employee contends on appeal in part that A[t]he medical evidence in combination with the Employee=s credible testimony regarding her pre-August 2000 condition and her post-August 2000 condition and condition following surgery, provides adequate evidence to support a finding of a compensable work-related injury to the shoulder and/or wrists.@  She asserts that an increase in symptoms after a work injury Aalone is sufficient evidence to support a strong inference of cause and effect@ and that A[b]oth common sense and/or an employee=s testimony alone is sufficient basis for a finding,@ arguing that A[n]o evidence, let alone substantial evidence, supports the conclusion that [the employee] returned to pre-injury status following the release surgeries.@  She contends further that the compensation judge Aseems to deny benefits based on the fact that [the employee=s] scans show degenerative changes,@ arguing that Asubstantial evidence does not support the compensation judge=s reliance on the determination of adverse examiner Dr. William Simonet,@ on whose opinion, she suggests, the judge relied A[a]pparently by default.@  We are not persuaded.

 

We concede, initially, that there may well be, as the employee has asserted, substantial evidence, both medical and testimonial, that the employee sustained an aggravation of the osteoarthritis in her hands and/or tendonitis in her left shoulder and/or in her wrists bilaterally, consequent to her work for the employer by August 2000 or to her work-related carpal and cubital tunnel syndromes sustained by that date.  The existence of such evidence supportive of a decision contrary to that reached by the compensation does not, however, render insubstantial the evidence that might also be found to support the decision actually reached by the judge; it is the substantiality of the latter evidence that our standard of review requires us to assess.  See Land v. Washington County Sheriff=s Dep=t, slip op. (W.C.C.A. Dec. 23, 2003).^[1]

 

Nor does our standard of review require that substantial evidence Asupport the compensation judge=s reliance on@ a particular medical opinion; it requires only that a medical opinion on which a judge relies be premised on accurate facts.  See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) ("the trier of fact's choice between experts whose testimony conflicts is usually upheld [unless] the facts assumed by the expert in rendering his opinion are not supported by the evidence").  The employee does argue, more materially under the Nord standard and in addition to her contention that Dr. Simonet Adisregarded@ certain evidence, that ADr. Simonet based his opinion on the mistaken idea that all of [the employee=s] pain was relieved following the surgeries@ and Athat she had no numbness or tingling in her hands after the surgeries.@  She argues further, moreover, that, at the time of her work injury,

 

Some of her symptoms were attributable to the admitted bilateral carpal tunnel and cubital tunnel syndromes while others [we]re more directly attributable to shoulder and wrist difficulties.  For example, the initial diagnosis from the company doctor was bilateral shoulder strain and wrist strainBthe Employee=s arm and elbow difficulties were not specifically addressed.  The restrictions provided by the company doctor reflected a need to adjust her work because of her shoulders and wrists.  Later, when she sought treatment outside of the company, the Employee=s carpal tunnel and elbow syndromes were placed at the forefront and addressed.

 

Still, we are not persuaded.

 

Just as the judge was entitled to credit generally the employee=s hearing testimony, Dr. Simonet was entitled to credit the employee=s materially contrary assertions to himBAshe tells me that [the surgeries] helped in that she regained her strength and grasp and no longer had pain.@  We conclude that, even while crediting the employee=s hearing testimony in general, the judge was also entitled to credit the more specific factual account reported in the doctor=s examination records.  Particularly qualified as the doctor=s report was by his less definitive follow-up comment that A[t]he records indicate that she was improved@ (emphasis added), and together with the very subjective nature of the fact at issue, we cannot conclude that the doctor=s opinion was based on any premises sufficiently false to disqualify the doctor=s opinion as expert medical evidence.

 

The compensation judge=s decision in this case, reliant as it is on the properly founded opinions of Dr. Simonet, is based on the conclusion that the only work-related injuries proven to be at issue in this case are the admitted carpal and cubital nerve tunnel injuries in the employee=s wrists and elbows and that those injuries were effectively resolved by September 11, 2001, when the employee=s surgeon, Dr. Konasiewicz, released the employee to return to work expressly Awithout restriction,@ qualified only by the note Afulltime @ eight (8) hours per day.@  That the employee=s wrist symptoms may have been initially diagnosed as tendonitis or that she may have been diagnosed at that time also with arguably nonwork-related and perhaps transient symptoms in her shoulder is not here dispositive, given Dr. Simonet=s specific related opinions.  Regarding the factual accuracy of the judge=s finding that the employee was released on September 11, 2001, to work restricted only to an eight-hour work day, we would note that the employee herself testified at hearing only that she was restricted at that time to A[e]ight hours a day@ and to being Avery careful not to reinjure myself.@  Dr. Simonet reported unambiguously his opinion that any ongoing osteoarthritis or tendonitis condition in the employee=s hands, wrists, or shoulders was unrelated either to the employee=s work activities or to her repaired carpal and cubital tunnel syndromes, and he subsequently testified to his conviction that there was nothing in medical literature to sustain a causal connection between such a condition and such syndromes.  There being no evidence that Dr. Simonet=s opinion was based on any false premises, the compensation judge was entitled to choose and to rely on the opinion of Dr. Simonet rather than on the apparently contrary opinion of Dr. Moore.  See Nord, 360 N.W.2d at 342-43, 37 W.C.D. at 372-73.  Because the judge was entitled to rely on the expert opinion of Dr. Simonet, and because the judge=s decision does not appear to us to have been otherwise unreasonable in light of the entire medical and other record, we affirm the compensation judge=s denial of all claims for benefits or reimbursement based on the employee=s condition from and after September 17, 2001.  See  Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.