The employee appeals from the compensation judge’s finding on remand that the employee failed to prove she developed reflex sympathetic dystrophy as a result of her work injury to the right index finger on April 21, 2005.  We affirm.

Deborah A. Viehauser, the employee, sustained an injury on April 21, 2005, when an upset client grabbed her hands, squeezing, and twisting them.  At the time of the injury, the employee was a lead production supervisor at Functional Industries, Inc., the self-insured employer.  The employer admitted liability for the personal injury.

The employee was seen at the Buffalo Clinic on the day of her injury, reporting a “smashed finger” when a client grabbed her finger and squeezed. The employee gave a history of arthritis, but stated the joint had not bothered her much until the incident.  An x-ray showed extensive degenerative changes about the interphalangeal joint spaces of the right index finger.  The diagnosis was arthritis with a squeezing injury to the finger.  The finger was placed in a splint and the employee was released to return to work with restrictions. She returned to the Buffalo Clinic on May 9 with continuing complaints regarding her right index finger.  An obviously swollen finger with limited range of motion was noted on examination.  The diagnosis was finger pain superimposed on previous degenerative arthritis.  Physical therapy and anti-inflammatory medication was prescribed.

The employee was referred to Dr. Robert Anderson at Metropolitan Hand Surgery Associates who saw the employee on July 12, 2005.  The doctor took a history of someone grabbing and twisting the employee’s right index finger resulting in severe pain and swelling through the joint. An x-ray showed complete destruction of the proximal interphalangeal (PIP) joint with a substantial valgus deformity through the joint with erosive arthritic changes.  Dr. Anderson recommended joint replacement surgery which he performed on August 17, 2005.  In a post-surgery follow-up on October 4, 2005, the doctor noted the employee was making slow progress with substantial loss of range of motion and moderate swelling in the finger.

The employee moved to Austin, Minnesota, and was referred to Dr. Robert Beckenbaugh at the Mayo Clinic.  She was seen on October 20, 2005.  The employee described pain and loss of motion in the index finger, along with pain, swelling and stiffness in the whole hand.  The impression was possible reflex sympathetic dystrophy (RSD) following index finger PIP arthroplasty.  Dr. Beckenbaugh noted the employee originally did well post-op, but as time went by developed an extension lag in the index finger and swelling and discomfort in the remainder of the hand.  The doctor noted apparent dystrophic change to the adjacent three digits.  He prescribed daily physical therapy with an initial goal of decreasing swelling and regaining full extension of the right index finger.  On October 26, Dr. Beckenbaugh noted improvement in the appearance and movement of the finger.  The doctor discussed pain dysfunction syndrome with the employee, and ordered continued physical therapy focusing on rehabilitation of the entire hand.  On November 9, Dr. Beckenbaugh stated the employee’s dystrophy appeared to be resolving.  He noted the employee still had some limitation of motion in the long finger, but her hand pain was generally much better and the passive position of the index finger was much improved.

On November 11, 2005, the employee complained of pain in all of her joints, stating her arthritic symptoms were too bad for her to return to work.  On December 6, Dr. Beckenbaugh stated the employee was doing pretty well, with decreasing swelling but some continuing sensitivity. He recommended the employee return to see a therapist every other week to avoid recurrence of the dystrophic changes.  The employee was also seen by Dr. Jeffrey Brault, at the same clinic, who concurred with continued monitoring for autonomic changes.

On January 30, 2006, Dr. Stephen Olmsted, a hand surgeon, examined the employee at the request of the self-insured employer.  The employee described pain, swelling and stiffness in her right index finger and pain, numbness and paresthesia in both hands.  Following examination, Dr. Olmsted diagnosed bilateral advanced osteoarthritis in the PIP and distal interphalangeal (DIP) joints of the hands, noting significantly limited range of motion in the right index finger.  The doctor opined the April 21, 2005, work injury was a temporary symptomatic aggravation of the employee’s underlying, pre-existing osteoarthritis in the PIP joint of the right index finger.  He maintained the injury did not result in any change in the underlying condition of the index finger joint and would have resolved within 4 to 6 weeks.  Dr. Olmsted stated the restricted motion, pain and swelling in the employee’s hands and fingers was consistent with the natural history of an arthritic condition, and opined the employee’s work injury was not a substantial contributing cause of the employee’s arthritis, including that of the right index finger.

The employee was referred to Dr. Eric Schned for a second opinion regarding her hand pain.  When seen on January 31, 2006, the employee described patchy and intermittent numb or burning sensations into her fingers that had steadily worsened in the fall.  On examination, Dr. Schned noted positive Tinel’s signs bilaterally along with nodes and tenderness in all finger joints.  His impression was underlying osteoarthritis of the hands, asymptomatic until her work injury in April 2005, along with bilateral carpal tunnel syndrome.  Dr. Schned did not believe the employee had reflex sympathetic dystrophy or other inflammatory arthritis.

Dr. Beckenbaugh re-examined the employee on February 24, 2006, noting bilateral carpal tunnel syndrome confirmed by EMG.  The doctor noted a positive carpal tunnel compression test and Tinel’s sign, as well as some increased heat involving the right hand and symptoms in the left hand.  Dr. Beckenbaugh observed “there has always been a question of the workman’s relationship to her symptom levels and I felt that in the past that much of this has been related to her arthritis although the fact that her symptoms were precipitated by grapping [sic] incident while she was at work would tend to suggest that the whole current process is, in fact, work related and we could consider it so.”  (Ee Ex. G-3.)

On March 18, 2006, following a medical record review, Dr. Olmsted agreed the employee had bilateral carpal tunnel syndrome.  The doctor opined, however, that the employee had idiopathic, non-work-related carpal tunnel consistent with risk factors including being female, obesity, and age-related, pre-existing osteoarthritis.

On April 5, 2006, Dr. Beckenbaugh noted the employee’s hands were cold and sweaty.  The doctor stated he was concerned the employee was pre-dystrophic with increased sweat patterns etc., but believed the employee had little chance of getting over the dystrophy until the pain from the carpal tunnel syndrome was addressed.  The doctor stated the proper approach was to release the carpal tunnel and then work on the employee’s hand symptoms.  Dr. Beckenbaugh performed bilateral carpal tunnel releases on April 6, following which the employee again received physical therapy.

Dr. Robert Wengler examined the employee on June 9, 2006, on referral by her attorney.  The employee complained of painful limitation of motion of both hands, attributing the onset of her hand pain to her personal injury.  The doctor noted the skin of the hands was shiny and dystrophic, which along with posturing, suggested the possibility of a regional pain syndrome.  Dr. Wengler diagnosed degenerative osteoarthritis of both hands and bilateral carpal tunnel syndrome.  The doctor stated the employee’s osteoarthritis pre-existed her work injury, but opined the work incident was a material aggravation of the employee’s condition, causing the arthritis to become symptomatic, and further stating the “whole current process,” including the carpal tunnel, was work related.  Dr. Wengler assigned permanent disability for the loss of motion of the joints of the four fingers of each hand and opined the employee was totally disabled from any activity involving the use of her hands.

The employee returned to see Dr. Holtz at the Austin Medical Center on September 25, 2006.  On examination, the doctor noted the employee’s hands had a shiny appearance with inflammation of the PIP joints in both hands.  The doctor diagnosed osteoarthritis and possible rheumatoid arthritis or underlying reflex-type dystrophy and suggested a trial of Neurontin along with Vicodin for pain control.  In October and November 2006, Dr. Holtz diagnosed on-going reflexive-type sympathetic dystrophy secondary to a work injury.  He noted improvement with the Neurontin and increased the dose.  By report dated April 11, 2007, Dr. Holtz stated the employee “suffered an injury to her hand while at work and was found to have a rather rapidly [sic] progression of osteoarthritis and carpal tunnel syndrome of both hands thereafter.  She has since that period of time not been able to work secondary to chronic pain syndrome and a suspected feeling of mild reflex sympathetic dystrophy in the hands.”  (Ee Ex. G-2.)

Dr. Wengler re-examined the employee on April 12, 2007.   The doctor observed the employee’s hands had deteriorated since the carpal tunnel surgery.  An x-ray showed demineralization of the bones of the fingers and the carpal bones of both hands.  On examination, Dr. Wengler noted both hands were exquisitely tender to touch, the skin was reddened, shiny and dystrophic, the palms were sweaty and dyshidrotic, and motion of the joints was markedly limited.  Dr. Wengler stated the symptoms and findings were characteristic of autonomic dysfunction or RSD. The doctor provided a permanent partial disability rating of 27% to the right and left upper extremity under Minn. R. 5223.0400, subp. 6.B., for RSD.

On May 3, 2007, the employee was seen by Dr. Matthew Kumar at the Austin Medical Center pain clinic.  The doctor noted both hands appeared swollen, the skin stretched, shiny and erythmatic.  Dr. Kumar recommended further evaluation to rule out neuropathy, rheumatoid arthritis and RSD.

Dr. Olmsted re-examined the employee on June 28, 2007.  At that time, the employee continued to complain of burning pain, numbness and tingling in all digits, and stated she obtained no relief from the carpal tunnel surgeries.  On examination, the doctor found a normal skin turgor, normal wrinkles, a normal sweat pattern, no excessive edema, and typical swelling as seen in osteoarthritis.  The doctor diagnosed bilateral osteoarthritis, status post proximal interphalangeal orthroplasty with ankylosed arthroplasty of 45 degrees, status post carpal tunnel releases with no symptomatic relief, and functional overlay.  Dr. Olmstead again opined the employee’s injury was a temporary aggravation of her underlying osteoarthritis which did not change the natural progression of that condition.  The doctor stated there was no dystrophic appearance to the hand on examination and concluded there were no objective physical findings to suggest an ongoing regional pain syndrome.

The employee filed a claim petition contending she sustained a Gillette^[2] personal injury in the nature of bilateral osteoarthritis of the hands and or bilateral carpal tunnel syndrome culminating on April 21, 2005.  The employee further claimed a specific injury on April 21, 2005, in the nature of an aggravation of her osteoarthritis in both hands, reflex sympathetic dystrophy, and carpal tunnel syndrome.  The employee sought temporary total and permanent partial disability benefits together with medical expenses and a rehabilitation consultation.  Following a hearing, the compensation judge found (1) the employee sustained a permanent injury to her right index finger as a result of the April 21, 2005, work injury, and that the work injury was a substantial contributing factor to her joint replacement surgery; (2) the April 21, 2005, incident did not result in an injury to the hands in the nature of an aggravation of the employee’s pre-existing osteoarthritis; (3) the employee did not sustain a Gillette injury in the nature of an aggravation or acceleration of her pre-existing osteoarthritis or bilateral carpal tunnel syndrome; and (4) the employee failed to prove she was entitled to permanent partial disability for reflex sympathetic dystrophy.  Based upon these findings, the compensation judge denied the employee’s claims for wage loss benefits and permanent partial disability benefits.  The employee appealed.

On appeal, this court affirmed the compensation judge’s finding that the employee did not sustain a Gillette injury in the nature of an aggravation or acceleration of her underlying osteoarthritis and vacated the compensation judge’s finding regarding the employee’s claim of  reflex sympathetic dystrophy.  The case was remanded to the compensation judge for reconsideration of the issue of entitlement to benefits for the claimed RSD.   In a findings and order on remand, the compensation judge made the following finding:

The employee appeals the compensation judge’s findings on remand and the subsequent denial of benefits.

The employee, on appeal, contends that her personal injury is a substantial contributing cause of the development and progression of her hand and wrist symptoms collectively referred to by various names, all of which are considered to be within the definition of reflex sympathetic dystrophy.  The employee contends the compensation judge’s decision fails to acknowledge the nature of RSD as an evolving, variable, condition unique to each sufferer.  The employee notes the medical records document excessive sweating, local skin color change, local alteration of skin texture due to shiny skin, and local abnormality of skin temperature regulation in both hands.  All of these symptoms are consistent with a diagnosis of RSD.  An x-ray of the employee’s hands ordered by Dr. Wengler in April 2007 showed demineralization of the bones of the fingers and the carpal bones.  Dr. Wengler unequivocally diagnosed the employee’s condition as RSD.  The employee contends that physicians at the Mayo Clinic and the Austin Medical Center also concluded the employee had RSD and provided treatment for that condition.  The employee asserts the compensation judge failed to consider all of the facts, adhered to an erroneous standard of proof, and failed to properly consider our June 18, 2008 decision.  The employee asks this court to vacate the compensation judge’s findings and make factual findings consistent with our prior decision.

This case is both medically and factually very complex.  The case is further complicated by the fact that different doctors provided different labels and/or diagnoses to describe the employee’s condition.  Dr. Beckenbaugh variously referred to and treated the employee for “dystrophy” or “dystrophic changes,” “pain dysfunction syndrome,” and “pre-dystrophic” symptoms. Dr. Brault used the term “autonomic changes.”  Dr. Wengler referenced a “regional pain syndrome,” “autonomic dysfunction,” and “reflex sympathetic dystrophy.”  Dr. Holtz diagnosed “reflexive-type sympathetic dystrophy.”  Dr. Olmsted, while agreeing the employee exhibited subjective “touch-me not” behaviors, opined the employee had no physical objective findings on examination consistent with reflex sympathetic dystrophy.  Whether the employee’s condition is called reflex sympathetic dystrophy or something else is not, however, the issue.  Rather, the issue is whether the employee’s condition is causally related to her work injury.  In our June 18, 2008, decision, we concluded the compensation judge made no clear finding as to whether the employee does or does not have an RSD-type condition and we remanded the case to the compensation judge to make that factual finding.

In the Findings and Order on Remand, the compensation judge found the employee failed to establish her April 21, 2005, work injury was “a substantial contributing factor to the symptoms diagnosed by some physicians as reflex sympathetic dystrophy.”  The compensation judge further found the “preponderance of the evidence fails to establish that the employee has developed reflex sympathetic dystrophy as a result of the work injury to the right index finger on April 21, 2005.”  (Finding 6.)  The issue on appeal is whether the compensation judge’s factual findings are supported by substantial evidence.

There is no question there exists substantial evidence of record to support the employee’s position that she developed an RSD-type condition as a direct result of her April 21, 2005, work injury.  Under this court’s standard of review, however, the issue is not whether the evidence will support alternative findings but whether “the findings of fact and order were 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 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 the 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.

Dr. Stephen Olmstead examined the employee on two occasions, June 30, 2006, and June 11, 2007.  On both occasions, the doctor obtained a history from the employee, reviewed medical records, and performed a physical examination.  Dr. Olmstead diagnosed bilateral osteoarthritis which he opined was temporarily aggravated by the April 21, 2005, injury.  The doctor opined this temporary aggravation resolved within six weeks and stated the injury would not have changed the natural history or the condition of the employee’s osteoarthritis.  In his June 11, 2007, physical examination, the doctor reported the employee had a normal skin turgor, normal sweat pattern, no excessive edema of the digits, no thenar wasting or intrinsic atrophy, a normal sweat pattern and profusion, and no dystrophic appearance of the hand to suggest any reflex sympathetic dystrophy.  The doctor explained that RSD encompasses a constellation of symptoms that can vary from mild to severe.  However, Dr. Olmstead testified the employee showed no objective clinical findings of RSD.

The opinions of Dr. Olmstead provide substantial evidentiary support for the compensation judge’s finding that the employee did not develop reflex sympathetic dystrophy as a result of her work injury to the right index finger on April 21, 2005.  We acknowledge that Dr. Wengler expressed an opinion to the contrary.  It is, however, the responsibility of the compensation judge as the trier of fact to resolve conflicts in expert testimony.  See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).  Because substantial evidence supports the compensation judge’s decision, the decision must be affirmed.