The employee appeals from the compensation judge’s decision that the employee’s treatment of various conditions after May 1, 2009, was not causally related to the employee’s admitted 1986 low back injury.  We affirm.

The employee was 71 years old on the date of the hearing giving rise to the current appeal.  In 1986, she sustained a work-related injury to her low back while employed as a home health aide by Lake County Home Health Service [the employer].  As a result of that injury, she underwent a posterolateral fusion at L4-5 in 1988 and a posterolateral fusion at L5-S1 in 1989.  The employee’s treating surgeon, Dr. Richard Salib, issued restrictions that precluded her return to her pre-injury employment.  Dr. Salib also indicated that the employee had reached maximum medical improvement [MMI] from her low back injury effective September 5, 1990, and he rated the employee as having a 22.5% whole body impairment.

In late 1990, the parties entered into a settlement agreement, settling all claims for benefits related to the employee’s 1986 injury, except claims for non-chiropractic medical expenses, on a full, final, and complete basis.  Subsequent to the settlement, the employee, with her husband, ran a business called Window Ware, a window treatment sales and installation operation.  The employee took window measurements; the employee’s husband installed the curtains and blinds.

The employee received little or no care for her low back condition for the next twelve years.  Then, in late 2003 or early 2004, she was seen for complaints of left hip and leg pain.  This marked the beginning of an extensive course of medical treatment for numerous, seemingly unrelated conditions.

The employee eventually underwent three more low back surgeries: a fusion at L3-4 in July of 2005; removal of the pedicle screw and fixation device at that same level in July of 2006; and a right sacroilliac joint fusion in October of 2006.  Liability for these surgeries is undisputed.  The employee also received medical care for left shoulder, right shoulder, right foot, neck, and mid back pain as well as psychological and chronic pain issues.  Specific treatment included several shoulder surgeries, a vast number of trigger point injections,^[1] epidural steroid injections, diagnostic blocks and scans, aquatic therapy, medications, occupational therapy, and at least several years of physical therapy.^[2]  Well over a dozen physicians have participated in the employee’s treatment.^[3]  Diagnoses for conditions other than the employee’s low back have included rotator cuff tears; atypical reflex sympathetic dystrophy [RSD] of the right lower extremity; cervical and thoracic degenerative changes; possible neuroma or neuritis of the employee’s right foot; AC arthritis with impingement and tendonosis of the employee’s right shoulder; adjustment disorder; T4 disc herniation; and depression.

During the course of the employee’s treatment for all of these maladies, some of her physicians, especially Dr. Salib, have related the need for that treatment to the 1986 work injury.  For example, the employee’s shoulder conditions allegedly resulted from the employee’s need to use crutches and canes while in a body brace following her sacroilliac fusion surgery, and the employee’s diagnosed atypical RSD allegedly resulted from that surgery as well.  Similarly, because the employee and some of her physicians associated all of her musculoskeletal conditions and symptoms, and the RSD, with the 1986 work injury, the employee’s need for psychological and chronic pain treatment was, in their opinions, related as well.

The employer and its insurer apparently paid for all of the employee’s treatment for all of these conditions until May 1, 2009.  At that point, the employer and insurer indicated that they would pay only for treatment specifically directed at the employee’s low back condition.

The employer and insurer eventually had the employee’s medical records reviewed by Dr. Mark Johnson.  In an eighteen-page report issued on January 19, 2010, Dr. Johnson indicated that the employee’s treatment after May 1, 2009, had not been necessitated by the 1986 work injury, either because the conditions in question had been temporary and had resolved by that date, or because those conditions were simply unrelated to the original injury.

The matter came on for hearing before a compensation judge on April 26, 2011, for resolution of the employee’s claim for medical expenses related to treatment she received after May 1, 2009.  The employee claimed that that treatment was related to conditions she had developed as a substantial consequence of the 1986 work injury.  Evidence included several hundred pages of treatment records, the report of Dr. Johnson, and the employee’s testimony.  To aid the court in resolving the primary issue - - causation - - the employee’s attorney prepared a fifty-page summary of the employee’s medical records, containing more than 340 entries, and a synopsis of the medical opinion evidence.  The employer and insurer relied primarily on the opinion of Dr. Johnson.

In a decision issued on June 10, 2011, the compensation judge denied the employee’s medical expense claim, in its entirety, on causation grounds.  The employee appeals.

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 (2010).  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 contended that, as a result of her 1986 low back injury, she developed conditions necessitating treatment to both shoulders, her right foot, her neck, and her thoracic spine.  She also contended that her need for psychological and chronic pain treatment was ultimately caused by the 1986 injury and was therefore compensable.  We acknowledge that there is more than enough evidence in the employee’s medical records to support the employee’s claim, including the opinions of Dr. Salib and some other treating physicians.  However, the issue on appeal is whether substantial evidence supports the compensation judge’s decision to the contrary.

The compensation judge’s decision contains 101 findings describing the employee’s medical treatment.  Also in those findings, the judge expressly accepted the opinion of Dr. Johnson, the employer and insurer’s independent medical examiner, on the issue of causation.  In another finding, the judge concluded that, while the employee had developed an atypical RSD condition as a result of the work injury, she had fully recovered from that condition as of October 15, 2007, and that the treatment for the employee’s right foot thereafter was necessitated by a neuroma, unrelated to the employee’s low back condition.  The judge further concluded that the employee’s use of crutches and a cane after her October 2006 low back surgery had caused a “temporary aggravation of the employee’s pre-existing cervical spine, thoracic spine and left shoulder conditions which all fully resolved” by May 1, 2009, as had any depression related to either the employee’s low back condition or to the enumerated temporary aggravations.  As for the employee’s right shoulder condition, for which the employee first under went arthroscopic surgery in April of 2006, the judge concluded that the employee had failed to connect that condition to the 1986 work injury.  In his memorandum, the judge further explained his decision on causation as follows:^[4]

On appeal, the employee argues that the judge’s causation findings are erroneous because the judge mistakenly concluded that the opinions of Dr. Salib and Dr. Johnson were in accord on the issue.  The compensation judge did indicate in his memorandum that “[t]he opinions of Dr. Johnson are in accord with those of the treating back surgeon Dr. Salib whose opinions the Court accepted,” and clearly the two doctors differed on the issue of causation for some of the conditions at issue.  However, as to other conditions, the two doctors did in fact agree as to cause; where they differed was on the question of whether the employee had recovered from the effects of those conditions prior to May 1, 2009.  We note also that, in treatment notes, Dr. Salib specifically indicated that the employee had recovered from the atypical RSD she had developed following her sacroilliac fusion, an opinion also consistent with the conclusion reached by Dr. Johnson.  For these reasons, we reject the employee’s contention that the compensation judge erred in characterizing the opinions of Drs. Johnson and Salib as consistent.  At the very least, the judge’s statements to that effect are explainable and provide no grounds for reversal.

The employee next argues that the compensation judge erred by basing his decision as to psychological injury on the opinion of Dr. Johnson, in that Dr. Johnson did not expressly address that condition or the employee’s chronic pain treatment in his January 2010 report.  However, it is evident from his decision as a whole that the judge rejected the employee’s psychological and chronic pain treatment claims on grounds that the employee’s psychological and chronic pain issues were the result of her thoracic, neck, and shoulder condition, which the judge found unrelated to the employee’s back injury after May 1, 2009.  And it is evident from the record that the employee’s pain complaints and depression over pain and functional loss were focused primarily on symptoms other than back pain.^[5]  In fact, the employee’s low back surgeries appeared, in the end, to be largely successful in resolving the employee’s low back symptoms.  Given the severity of the employee’s other complaints, the compensation judge could reasonably conclude that the employee’s low back condition was not a substantial cause of the employee’s need for chronic pain and psychological treatment after May 1, 2009.

Finally, the employee argues that the judge erred in concluding that the employee’s right lower extremity condition and treatment were no longer related to the employee’s sacroilliac fusion surgery.  However, as noted previously, the judge’s opinion on this issue is supported by a treatment note by Dr. Salib, and it is reasonably inferable from other treatment records that the employee was subject to more than one foot condition: an atypical RSD resulting from the sacroilliac fusion, which resolved prior to May 1, 2009, and a neuroma unrelated to the employee’s 1986 low back injury and/or resulting treatment.

The record in this matter is immense.  The employee has received a massive amount of treatment since 2004, and her condition is complicated, to say the least.  It is evident from his detailed findings that the compensation judge reviewed the evidence thoroughly.  As indicated earlier, the record would have supported the conclusion that the claimed treatment was all substantially necessitated by the employee’s 1986 work injury.  However, also in view of the record, and particularly the opinion of Dr. Johnson, we cannot say that the judge’s denial of the employee’s claim is clearly erroneous or unsupported by substantial evidence.  We therefore affirm the judge’s decision in its entirety.