The employer and insurer appeal the compensation judge’s finding that the employee’s carpal tunnel syndrome is a substantial contributing cause of the employee’s ongoing disability and need for restrictions.  We affirm.

Rosemary Baker, the employee, sustained a work-related carpal tunnel syndrome injury to her right arm which culminated on November 24, 2004, when she was working as a central load controller for Northwest Airlines, the employer.  On that date, the employer was insured for workers’ compensation liability by Liberty Mutual Insurance Company, the insurer.  The employee underwent right carpal tunnel release surgery, performed by Dr. William Simonet, on February 14, 2005.  The surgery relieved the employee’s numbness in her arm, but she continued to note numbness in one fingertip at an examination on March 8, 2005.  The employee was released to return to work without restrictions on March 11, 2005.

The employee developed similar symptoms in her left arm and was taken off work by her primary care physician, Dr. Albert Salazar, from August 23, 2005, through September 2, 2005.  On August 30, 2005, the employee returned to Dr. Simonet, reporting similar symptoms in her left arm and non-specific pain in her right hand and forearm.  Dr. Simonet diagnosed left carpal tunnel syndrome and recommended surgery for the left arm, but no further treatment on the right arm.  The employee then consulted with Dr. Deborah Bohn, who confirmed the left carpal tunnel syndrome diagnosis.  The employee also indicated that her right hand had not returned to full function and sensation after the surgery, and that she experienced intermittent pain and numbness in the right palm.  Dr. Bohn also recommended left carpal tunnel surgery.

On October 5, 2005, the employee underwent left carpal tunnel syndrome release surgery, performed by Dr. Jeffrey Husband, a colleague of Dr. Bohn, since she was unavailable.  The employee’s numbness and tingling in her left arm resolved after the surgery.  The employee returned to Dr. Husband on October 19, 2005, and reported occasional residual numbness and tingling and persistent pain on the right side.  Dr. Husband recommended therapy and released the employee to return to work with restrictions from October 20 through November 17, 2005.  The employee did not return to work at that time.  The employee underwent a hand therapy evaluation on October 27, 2005, which indicated issues of bilateral palmar hypersensitivity post carpal tunnel release, decreased strength and decreased function.  The employee reported minimal progress with therapy.

The employee returned to Dr. Husband again on November 16, 2005, reporting volnar burning in the left arm and persistent numbness and tingling in the median nerve distribution of the right upper extremity.  Dr. Husband diagnosed status post left carpal tunnel release and persistent right carpal tunnel symptoms and indicated that the employee was demonstrating subjective symptoms which were not substantiated by objective findings.  Dr. Husband took the employee off work from November 16, 2005, through December 5, 2005, and then released the employee to work without restrictions on December 5, 2005.  The employee had been receiving physical therapy since late October, and was discharged from therapy on December 13, 2005.

On January 5, 2006, the employee consulted with Dr. Bohn, who noted that the employee had normal median nerve sensation in both arms, the numbness in her fingertips was essentially gone, and recent EMG studies indicated mild slowing of the ulnar nerve at the wrist and chronic appearing median neuropathy at the wrist.  The employee reported that she was experiencing a persistent burning sensation in her palms and pain at the base of her thumbs.  Dr. Bohn assessed that the employee was within normal limits of healing for carpal tunnel syndrome and that “a good deal” of her pain came from carpometacarpal arthritis bilaterally.  The employee returned to Dr. Husband, her surgeon, on January 26, 2006, reporting bilateral arm pain, numbness and tingling.  Dr. Husband opined that these symptoms were not consistent with residual carpal tunnel syndrome, and diagnosed bilateral chronic upper extremity pain, possible ulnar neuropathy of the right elbow, and status post bilateral carpal tunnel release.  Dr. Husband recommended indefinite restrictions of rare lifting over 5 pounds and repetitive wrist motions, keyboarding, or writing less than 10% of time; these restrictions prevented the employee from returning to her regular job with the employer.  In a work ability report dated January 26, 2006, Dr. Husband noted that the employee’s diagnoses are bilateral carpal tunnel syndrome and right ulnar neuropathy, and that the injury was work related.  In a letter dated January 20, 2006, the employee’s primary care physician, Dr. Salazar, also indicated that the employee was restricted from repetitious work, and that she should use splints and would need breaks from her routine work every 15 minutes.

In March 2006, the employee treated with Dr. Ann VanHeest, reporting pain in both hands in the volnar aspect of her wrists with radiation into her elbows and difficulty with gripping and grasping objects.  Dr. VanHeest ordered a diagnostic bone scan, which was performed on March 23, 2006, and which showed degenerative disease in both arms and symmetric abnormalities in both wrists indicative of arthritis.  An x-ray taken the same day indicated a cyst or erosion at the distal aspect of the scaphoid bone in the right wrist.  Dr. VanHeest concluded that the results of the bone scan could account for some of the employee’s symptoms, and referred the employee to Dr. Marie-Christine Leisz for a physical medicine and rehabilitation consultation. Dr. Leisz indicated that Phalen’s test and Tinel’s test were positive, and suggested that the employee’s symptoms were related to tightness of the soft tissue surrounding her ulnar and median nerves.  Dr. Liesz  recommended physical therapy to reduce the employee’s upper extremity symptoms and to help improve her posture.  The employee started the therapy, but by May 2006 it was discontinued after the employee reported no significant improvement from the therapy.

On April 24, 2006, the employee was examined by Dr. David Falconer at the employer and insurer’s request.  Dr. Falconer noted some moderate residual parasthesias and tingling with minor abnormalities on the right EMG and that recent x-rays indicated moderate age-related degenerative arthritis of the STT joints (scaphoid-trapezium-trapezoid joint of the thumb).  He concluded that the employee’s ongoing symptoms and restrictions were not related to carpal tunnel syndrome or residual carpal tunnel, but were caused by her osteoarthritis of the STT joints, and also concluded that she could return to work in her load controller position.  On June 15, 2006, Dr. VanHeest confirmed the STT arthritis and scaphoid bone cyst diagnoses, and also confirmed that a recent EMG ruled out significant nerve involvement.

On May 16, 2006, the employee underwent a general health examination with Dr. James Young, who noted marked bilateral pain through the carpal tunnel and positive Tinel’s and Phalen’s tests, and diagnosed carpal tunnel syndrome and reflex sympathy dystrophy of the upper limb.

After completing physical therapy, on May 30, 2006, the employee returned to Dr. Leisz, reporting no significant improvement.  Dr. Leisz referred the employee to Dr. VanHeest for surgical evaluation.  Dr. VanHeest reviewed the employee’s EMG studies and determined that surgery was not required, and also concurred that some of the employee’s symptoms were consistent with STT arthritis.  At a follow-up in August 2006, Dr. Salazar, the employee’s primary care physician, referred the employee for a consultation with an orthopedic surgeon, Dr. Matthew Putnam.  At an examination on September 27, 2006, Dr. Putnam concluded that the employee had ongoing pain syndrome in the left and right wrist region, that the prior carpal tunnel release unsuccessfully alleviated the employee’s discomfort, and that a portion of the employee’s symptoms were due to STT degenerative joint change.  Dr. Putnam recommended a functional capacities evaluation before proceeding with additional care, to assess her work restrictions and capabilities.  He recommended additional therapy, and also commented that it might be possible that the employee would benefit from surgical intervention to reduce her discomfort secondary to arthritis. Dr. Putnam completed a report of work ability dated November 22, 2006, stating that the employee’s diagnosis was right/left median nerve injury, which was work-related and likely would result in permanent disability, and assigned permanent work restrictions.  No functional capacities evaluation was completed.

The employee filed a claim petition for temporary total disability benefits from August 19 through September 13, 2005, temporary partial disability benefits from August 30, 2006, through the present, and rehabilitation services.  A hearing was held on November 29, 2006.  In her Findings and Order served and filed December 22, 2006, the compensation judge found that the employee continued to have pain in her palms of her hands and wrists and numbness in her fingers, that the employee was restricted from repetitive wrist motions, heavy lifting, and excessive writing, that the employee’s job was outside of her restrictions, that the employee’s November 24, 2004, work injury was a substantial contributing factor to the employee’s disability, and that the employee’s work absence from August 19, 2005, through September 13, 2005, was not due to her work injury.  The compensation judge denied the employee’s claim for temporary total disability benefits from August 19, 2005, through September 13, 2005,^[1] and awarded temporary partial disability benefits and ongoing rehabilitation services.  The employer and insurer appeal.

When an appeal is taken from a compensation judge’s factual findings, this court’s review on appeal is limited to a determination of whether the 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).  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 once 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.

The compensation judge found that the employee’s November 2004 work injury was a substantial contributing cause of her temporary partial disability.  The employer and insurer argue that substantial evidence does not support this finding.  The compensation judge specifically found that “[w]hile it may be that wrist arthritis is a significant factor in the employee’s current condition, the weight of the evidence indicates that the residuals of the employee’s carpal tunnel syndrome continue to play a substantial role in her condition as well.”  The compensation judge based her conclusion on the employee’s ongoing symptoms, on her permanent partial disability attributable to the carpal tunnel syndrome, and on Dr. Husband’s opinion, as outlined in his report assigning the employee restrictions, that the employee’s diagnosis included bilateral carpal tunnel syndrome.

The employer and insurer argue that the employee’s symptoms have not been consistent from the onset of her carpal tunnel syndrome through the hearing, and that her current complaints are not indicative of ongoing carpal tunnel syndrome, but involve symptom magnification and underlying arthritis.  While several doctors expressed concerns over the employee’s subjective complaints being disproportionate to her objective findings, the employee had been assigned restrictions due to her work injury which prevented her from returning to her pre-injury job.  Dr. Husband recommended indefinite restrictions of rare lifting over 5 pounds and repetitive wrist motions, keyboarding, or writing less than 10% of time, and noted that the employee’s diagnoses are bilateral carpal tunnel syndrome and right ulnar neuropathy, and that the injury was work related. Dr. Falconer, who examined the employee at the employer and insurer’s request, assigned the employee a 3% permanent partial disability rating based upon moderate residual parathesias and tingling with minor residual abnormalities on her right EMG.

Further, Dr. Young noted marked bilateral pain through the carpal tunnel upon examination and positive Tinel’s and Phalen’s tests, and diagnosed carpal tunnel syndrome and reflex sympathy dystrophy of the upper limb.  Dr. VanHeest and Dr. Putnam concluded that some of the employee’s pain could be due to the employee’s STT arthritis.  An employee need not prove that the employment was the sole cause, only a substantial contributing cause of the disability for which benefits are sought.  Swanson v. Medtronics, Inc., 443 N.W.2d 534, 536, 42 W.C.D. 91, 94-95 (Minn. 1989).  Based on the record as a whole, including the employee’s medical records and her testimony, which the compensation judge found to be credible, the judge could reasonably conclude that the employee’s carpal tunnel syndrome had not completely resolved, and remained a significant contributing factor of the employee’s disability along with her arthritis condition.  “Where more than one inference may reasonably be drawn from the evidence, the compensation judge’s findings shall be upheld.”  Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 371 (Minn. 1985).  Substantial evidence supports the compensation judge’s findings, and we affirm.