The employer SuperValu, Inc./Cub Foods and Risk Enterprise Management, Ltd., appeal from the compensation judge’s conclusion that the employee sustained a work-related bilateral carpal tunnel injury while working at Cub Foods on August 4, 2008, and from the judge’s award of a rehabilitation consultation.  We affirm.

In 1995, Anita Neff [the employee] began working in the deli section of a SuperValu, Inc./Cub Foods store [Cub], by whom she had been employed cleaning grocery store floors and bathrooms since 1993.  The employee’s work in the deli section entailed assignment in either the salad, the meat and cheese, the pizza, or the chicken area, work that sometimes entailed lifting and carrying up to forty pounds.  In 1996, the employee developed wrist symptoms that resulted in numbness in her hands that caused her to drop things.  On November 15, 1996, she saw family practitioner Dr. Christine Swenson, who diagnosed possible carpal tunnel syndrome, prescribed wrist splints, and referred the employee for an EMG.  The EMG was conducted on November 22, 1996, and was read to be consistent with mild to moderate right carpal tunnel syndrome, with no evidence of carpal tunnel symptoms in the left upper extremity.  Following her diagnosis, the employee did not treat for her right carpal syndrome for a number of years, except to wear splints or braces at night.

On January 29, 2001, the employee was seen in the Walk-in Care Center at St. Mary’s Medical Center, regarding pain that she had been having in her left arm for the past month.  Nurse practitioner Greta Martin diagnosed left lateral epicondylitis, prescribed Naprosyn, and recommended use of a forearm band, ice or heat, and avoidance of lifting.  Pain eventually returned in the employee’s right arm as well, and on June 20, 2003, on referral by Dr. Joy Magruder, the employee underwent another EMG study of her upper extremities, which was read to confirm mild to moderate carpal tunnel syndrome bilaterally, right greater than left.  Following this study, the employee apparently returned to work without additional treatment.

In May of 2005, the employee began working about sixteen hours a week - - two eight-hour days - - in the salad and dessert department at Olive Garden restaurant, a job that sometimes required her to lift twenty-five-pound cases of tomatoes and lettuce.  In July of that same year, she fell on her left elbow in the course of her work at her main job at Cub.  She evidently had elbow symptoms for about a month afterward, but she did not seek any medical treatment for an injury at that time.

In March of 2006, the employee was transferred by Cub from the deli department to the bakery, where her duties cleaning the bakery oven and washing dishes and pots and pans were substantially more physical than they had been in the deli department and involved more repetitive use of her hands and arms.

On August 28, 2007, when her left elbow started to bother her again, the employee completed a first report of injury at Cub, reporting an injury on that date based on her fall in the deli kitchen in July of 2005.  About two weeks later, on September 10, 2007, she saw Dr. Robert McDonald with complaints also of right wrist pain, which Dr. McDonald noted were “long standing and associated with her work at Cub Foods and Olive Garden,” “especially when she has been working with heavy things.”  The employee complained to Dr. McDonald also of her left elbow pain, which the doctor concluded was probably not due to the employee’s fall two years earlier but instead to overuse, “perhaps related to some of the same lifting difficulties.”  Dr. McDonald prescribed medication, recommended use of ice, and restricted the employee from lifting more than twenty pounds.  About four months later, on January 25, 2008, the employee saw Dr. McDonald again, to whom she reported, in addition to her elbow and wrist pain, joint pain in her shoulders and knees, and Dr. McDonald referred her to rheumatologist Dr. Charles Moore.

The employee saw Dr. Moore on February 18, 2008.  Dr. Moore’s diagnoses on that date included multiple joint problems, including problems in the right wrist, exacerbated by obesity and working two physical jobs, and he recommended physical therapy.  Upon follow-up on March 31, 2008, the employee reported that the physical therapy was of no benefit, complaining specifically of problems in her shoulders and elbows, and Dr. Moore issued a work excuse, recommending that she change from washing dishes to packaging bread and that she be restricted from lifting over twenty pounds.  About this time, in the spring of 2008, the employee’s hours at Olive Garden were evidently reduced from about sixteen hours a week to about five or six hours a week - - five days a week for something over an hour each morning, before the beginning of her shift at Cub.

In July of 2008, the employee requested a letter from Dr. Moore relating her symptoms to her work, and Dr. Moore advised her to come in to be examined, which she did on August 4, 2008.  In his office notes on that date, Dr. Moore indicated that the employee’s “[m]ost bothersome [problems] are her upper extremities, i.e., her shoulders, elbows and wrists,” and he diagnosed “periarthritic complaints.”  In a separate report on that same date, apparently after obtaining from the employee a more detailed description of her work, the doctor certified that the employee had “been felt chiefly to have polyarticular type complaints (i.e. tendinitis/bursitis).  Currently, these symptoms are worse in her upper extremities.  In reviewing her job description that she provided I believe that her work compounds these problems to a significant degree.”

On April 20, 2009, the employee filed a claim petition, alleging entitlement to certain medical and rehabilitation benefits consequent to a Gillette-type work injury^[1] on August 4, 2008, and/or to specific fall injuries at work on September 4, 2008, and/or October 23, 2008.

On May 7, 2009, the employee returned to see Dr. McDonald, complaining of ongoing joint pain, particularly in the upper arms, wrists, elbows, and hands.  Dr. McDonald suspected degenerative arthritis and referred the employee back to Dr. Moore, whom the employee saw on May 20, 2009.  Dr. Moore diagnosed “[o]veruse type syndrome upper extremities.  Probably periarthritis shoulders.  Lateral epicondylitis elbows.  ? carpal tunnel,” noting that the employee’s “worst problem now is cleaning angel food pans which she has to do manually,” and he referred the employee to physiatrist Dr. Jennifer Weinman.  The employee saw Dr. Weinman on June 17, 2009, regarding chiefly pain in her right arm from the wrist to just above the elbow, which had increased for the past two and a half years, and also left shoulder and left elbow pain, together with numbness and tingling in both of her hands, especially in the morning.  Dr. Weinman’s diagnosis on that date included “chronic bilateral carpal tunnel syndrome with increased symptoms lately,” and she recommended continued use of carpal tunnel splints at night, occupational therapy for six weeks, carpal tunnel massage, and myofascial release of wrist extensor and flexor muscles.  The doctor also continued the employee’s restriction against lifting over twenty pounds, recommended that she avoid repetitive tasks with her right arm, and ordered another EMG study, which, when eventually conducted on August 5, 2009, confirmed moderate to severe bilateral median neuropathy at the wrist.

On July 30, 2009, the employee was examined for Cub and its insurer by orthopedic surgeon Dr. Tilok Ghose.  In his report on August 13, 2009, Dr. Ghose diagnosed diffuse pain syndrome, for which he could identify no cause, concluding that the employee’s work activities were not in any way related to the symptoms in her hands, wrists, elbows, shoulders, or knees.  He concluded that the employee had reached maximum medical improvement from any purported injury, without any permanent partial disability, and was capable of working without any restrictions.

The employee saw Dr. Weinman again on September 8, 2009, on which date Dr. Weinman verified the diagnosis of chronic moderate to severe bilateral carpal tunnel syndrome, for which the employee had recently been issued new carpal tunnel splints by her occupational therapist.  In her plan for the employee, Dr. Weinman indicated in part that the employee “should continue to lift up to 20 pounds rarely and avoid repetitive tasks with either arm,” “should not do scrubbing-type work,” and should “consider surgical consultation for evaluation for carpal tunnel release surgery.”

On December 8, 2009, QRC NancyJo Ferguson conducted for Cub and its insurer an onsite analysis of the employee’s bakery job with Cub, and her report was sent both to Dr. Weinman and to Dr. Moore, who deferred to Dr. Weinman.  In an eventual letter dated June 2, 2010, to the attorney for Cub and its insurer, Dr. Weinman, after reviewing QRC Ferguson’s report, concluded that the employee “should be able to perform her job [in the bakery department at Cub] adequately overall.”  Noting that the employee had deferred a surgical consultation for evaluation for carpal tunnel release surgery, Dr. Weinman indicated that the employee “may continue to wear carpal tunnel splints to stabilize her wrists,” although trying to perform her job ‘[w]earing the splints may cause some difficulty with her ability to grasp objects firmly, . . . so she may wish to wear them primarily when she is not working.”  Apparently about this same time, Rehabilitation Consultant Suanne Grobe, at the request of Olive Garden, prepared a physical job description of the employee’s position at Olive Garden, after conducting telephone interviews with the employee’s manager and the culinary manager at the restaurant.^[2]  Ms. Grobe concluded that the job fell between the sedentary and light duty categories, based on lifting and standing requirements.

On July 7, 2010, the employee was examined for Olive Garden and its insurer by orthopedic surgeon Dr. Joel Boyd, pursuant to Olive Garden’s June 30, 2010, queries as to injuries alleged to have been sustained by the employee at either Olive Garden or Cub on August 4, 2008, September 4, 2008, and/or October 23, 2008.  In his report on July 30, 2010, Dr. Boyd indicated his opinion that the employee’s carpal tunnel syndrome pre-existed her work with Cub and Olive Garden on any of those dates and that she had sustained “no real injury” as a result of her work at either of those employers on any of those dates.  He concluded therefore that neither her work at Cub nor her work at Olive Garden was a substantial contributing factor in the employee’s carpal tunnel symptoms, which he related to a possible rheumatologic condition.

On August 6, 2010, the employee’s attorney wrote to Dr. Weinman, requesting her formal opinion on various issues pertaining to causation of the employee’s symptoms, the role of “overuse” in her employment in that regard, the employee’s restrictions, the reasonableness and necessity of the employee’s treatment for those symptoms, and the suitability of the employee’s job at Cub in light of her condition.  In her reply on August 30, 2010, Dr. Weinman noted that the employee had been having left wrist pain when the doctor last saw her in June and that, at that time, “[i]t appeared that she would be able to perform [her job] duties, with the exception of repetitious use of her arms bilaterally.”  Dr. Weinman then went on to opine as follows:

The matter came on for hearing on August 31, 2010, on which date the employee was continuing to perform her job within the restrictions approved by Dr. Weinman.  Issues at hearing were as follows: (1) whether the employee had suffered bilateral carpal tunnel injuries with Cub and/or Olive Garden; (2) whether the employee’s musculoskeletal problems other than her carpal tunnel conditions represented injuries related to the employee’s work activities at Cub and/or Olive Garden; (3) whether the employee was entitled to a rehabilitation consultation; (4) the employee’s entitlement to mileage reimbursement and payment of medical expenses related to her carpal tunnel conditions and/or other musculoskeletal problems; and (5) the intervenors’ entitlement to payment or reimbursement.

By findings and order filed November 1, 2010, the compensation judge concluded in part that the employee’s repetitive work activities in the bakery at Cub had worsened her carpal tunnel symptoms and had resulted in minute trauma to her wrists, causing bilateral carpal tunnel injuries “culminating in a Gillette injury on August 4, 2008, when employee’s work activities were considered by a treating physician, Dr. Moore, to be a cause of her bilateral carpal tunnel syndrome.”  The judge found further that the employee’s work at Olive Garden was not a substantial contributing factor in or cause of her carpal tunnel syndrome and that the employee had failed to show that her work activities at either Cub or Olive Garden were substantial contributing factors in any of her symptoms other than those related to her bilateral carpal tunnel syndrome.  On those findings, the judge ordered Cub and its insurer to pay all reasonable and necessary expenses related to treatment of the employee’s bilateral carpal tunnel syndrome and to satisfy the intervenors’ interests related to that condition, granting also the employee’s claim for a rehabilitation consultation.  Cub and its insurer appeal.

In reviewing cases 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.  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, “[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 Foods 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, “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 sustained a bilateral carpal tunnel Gillette-type injury on August 4, 2008, consequent to her work for Cub, and that she was entitled to related medical benefits and a rehabilitation consultation based thereon.  Cub and its insurer contend that these conclusions are unsupported by substantial evidence.  Even if this court should affirm an injury on August 4, 2008, they argue, the compensation judge’s award of a rehabilitation consultation should still be reversed, since there is no evidence that the employee is subject to any restrictions related to her carpal tunnel syndrome.

A condition resulting from repeated minute trauma at work becomes a compensable personal injury - - a Gillette-type injury - - when its effect is sufficiently serious to disable the employee from further work.  Carlson v. Flour City Brush Co., 305 N.W.2d 347, 350, 33 W.C.D. 594, 598 (Minn. 1981).  Such an injury normally occurs when the employee experiences an “ultimate breakdown” in the body member that has been under prolonged minute trauma.  Id. at 350, 33 W.C.D. at 599, citing Jensen v. Kronick’s Floor Covering Serv., 29 W.C.D. 61, 66 (W.C.C.A. 1975), aff’d, 309 Minn. 541, 245 N.W.2d 230, 29 W.C.D. 69 (1976).  Proof of such an injury is dependent primarily on medical evidence.  Marose v. Maislin Transp., 413 N.W.2d 507, 512, 40 W.C.D. 175, 182 (Minn. 1987).  In Schnurrer v. Hoerner-Waldorf, 345 N.W.2d 230, 36 W.C.D. 504 (Minn. 1984), the supreme court expanded the rule in Carlson, indicating that the holding there did not necessarily require that the date of disability by a Gillette-type injury be determined solely by the date on which the employee went off work, but rather “should be determined on all the evidence bearing on the issue.”  Schnurrer v. Hoerner-Waldorf, 345 N.W.2d 230, 233, 36 W.C.D. 504, 509 (Minn. 1984).  The court in Schnurrer noted several “ascertainable events” in its case that evidenced a Gillette-type injury prior to the date on which the employee actually went off work - - including that the employee had earlier been relieved of his regular work, a doctor’s opinion that surgery was needed, and the employee’s discussion of his pain with his foreman.  Id., 345 N.W.2d at 233, 36 W.C.D. at 508; but cf. Ellingson v. Thriftway, Inc., 42 W.C.D. 565 (W.C.C.A. 1989) (where there were no “ascertainable events” indicative of actual disability prior to January 1984, the judge’s finding of a Gillette-type injury in December 1983 was reversed).

In his memorandum, the compensation judge indicated that the employee’s carpal tunnel condition qualified her for benefits based on the fact that “[t]he duties of [her] position reflect extensive use of the hands and forearms to accomplish the tasks assigned” and that, in carrying out those tasks, “the employee had to use her hands, wrists and forearms in positions known to be precipitators of a carpal tunnel problem” - - positions such as “forearm supination, wrist flexion, power gripping, fingertip loading and fist grasping.”  The judge indicated further that his decision was made also in part in reliance on the opinions of the employee’s treating doctors, Dr. Moore and Dr. Weinman.  He indicated finally that August 4, 2008, had been selected as the culmination date of the injury “as it represents the date wherein treating physician Dr. Moore connected the employee’s work activities to the employee’s carpal tunnel symptoms.”  Cub and its insurer deny primary liability for the employee’s carpal tunnel condition, arguing that it was diagnosed already in 1996, long before August of 2008, and that there is no evidence of any “ultimate breakdown” or other properly applicable “ascertainable event” occurring on August 4, 2008.  We are not persuaded.

It is uncontested that the employee’s carpal tunnel syndrome was diagnosed already in 1996.  What was at issue in this case was whether or not the employee, in the course of her work for Cub and/or Olive Garden, sustained an aggravation of that pre-existing condition that was substantial enough to constitute a new injury in August of 2008.  We conclude that it was not unreasonable for the compensation judge to find that the employee did sustain such an aggravation in the course of her work for Cub.  The record, including the testimony of the employee, is replete with details of the employee’s work washing pots and pans of various sizes and weights in the bakery at Cub.  That work was apparently continuous throughout the employee’s work day, and the judge reasonably related it to the repetitive “forearm supination, wrist flexion, power gripping, fingertip loading and fist grasping” that are reasonably “known to be precipitators of a carpal tunnel problem.”  Moreover, the record clearly indicates that the employee’s carpal tunnel syndrome was not simply, as Cub argues, a chronic pre-existing condition, but a condition that clearly worsened after her transfer to the bakery department in 2006.  The EMG conducted in November of 1996, upon order of Dr. Swenson, confirmed only mild to moderate carpal tunnel syndrome, and only on the right side, and the EMG conducted in June of 2003, upon order of order Dr. Magruder, still confirmed only mild to moderate carpal tunnel syndrome, although now bilaterally.  But the EMG conducted in August of 2009, upon order of Dr. Weinman, confirmed a bilateral condition that was now moderate to severe.

The employee’s carpal tunnel complaints, although perhaps secondary at times to her elbow and shoulder complaints, have remained an increasingly present subject of her medical consultations over the course of her employment in the bakery at Cub.  Already in September of 2007, a little over a year after the employee was transferred into that job, Dr. McDonald noted that the employee’s wrist complaints were “associated with her work at Cub Foods.”  It is true that Dr. Moore, to whom the employee had been referred by Dr. McDonald, makes no specific reference to the carpal tunnel condition in particular in his August 4, 2008, causation opinion relating the employee’s work to her “polyarticular type” upper extremity complaints in general.  And it is true that he makes only passing reference to it, along with other upper extremity problems, in his office notes on that same date.  Nevertheless, it remains clear, from his treatment notes already on February 18, 2008, six months earlier, and from his notes on May 20, 2009, nine months later, that Dr. Moore was well aware of the employee’s carpal tunnel condition as an active part of her upper extremity problems.

The progress in the worsening of the employee’s carpal tunnel condition is even more evident in the record of her treatment with Dr. Weinman.  When the employee first saw Dr. Weinman in June of 2009, her chief complaint was of pain in her right arm from the wrist to the elbow, and this pain had increased for the past two and a half years - - or since about half a year after her transfer into the bakery department at Cub.  Dr. Weinman recommended at that time that the employee avoid repetitive tasks with her right arm, and, when she saw the employee about three months later, in September of 2009, after verifying that the employee’s condition had now progressed from mild-to-moderate to moderate-to-severe bilaterally, she recommended avoidance of repetitive tasks with either arm and consideration of a surgical consultation.  Although she had continued to defer on the surgical option, the employee was continuing to have disabling wrist pain in her work when she saw Dr. Weinman in June of 2010, and Dr. Weinman continued to recommend at least the use of wrist splints.  And this history was formally reiterated by Dr. Weinman in her causation opinion in August of 2010.

Given this record of worsening in the employee’s carpal tunnel condition under medical supervision over the course of her work in the bakery at Cub, beginning with Dr. McDonald in 2007 and continuing with Dr. Moore in 2008 and Dr. Weinman in 2009, and supported as that record of worsening is by the testimony of the employee herself, which was directly observed by the judge at hearing, we cannot say that it was unreasonable for the compensation judge to find a work-related carpal tunnel injury.  Nor, given Dr. McDonald’s association of the condition with the employee’s work at Cub nearly a year earlier, can we say that it was unreasonable for the judge to choose August 4, 2008, as the effective date of that injury - - particularly given that only medical and rehabilitation benefits, and not wage replacement, were at issue in this proceeding.  Because they were not unreasonable, we affirm those conclusions of the judge.  See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.

In his memorandum, the compensation judge cited case law to the effect that, having suffered the personal injury alleged, the employee is entitled to a rehabilitation consultation “if she establishes a need for [related] work restrictions.”  Citing Wagner v. Bethesda Hospital, slip op. (W.C.C.A. January 5, 1995).  The judge implied that that requirement was satisfied by the fact that “the employee is presently working in a somewhat modified position due to her carpal tunnel injuries.”  Cub and its insurer suggest that whatever modification has occurred in the employee’s job is due to her shoulder, elbow, and other physical complaints, which the judge specifically found unrelated to the employee’s work for Cub.  They argue that the restrictions issued by Dr. Moore on March 31, 2008, were unrelated to, and issued without mention of, the employee’s carpal tunnel syndrome.  Even the restrictions issued by Dr. Weinman, they argue, were not specifically related to the employee’s carpal tunnel syndrome, the employee herself testifying that she understood them to be related primarily to her shoulders and elbows.  We are not persuaded.

The employee’s bilateral upper extremity joint problems are many, complex, and apparently interrelated, and, beginning already with her first treatment by Dr. Moore, on February 18, 2008, she has been followed with regard to shoulder and elbow problems as well as carpal tunnel problems.  For this reason, it is not a transparent issue as to whether, even in the doctor’s own mind, Dr. Moore’s weight restrictions from that date forward pertain to one or two or all three areas of the employee’s upper extremity joint pain.  We do not agree that Dr. Weinman’s restrictions were not even more specifically related to the employee’s carpal tunnel syndrome, in that she more than once reiterated her recommendation that the employee avoid repetitive use of her arms bilaterally.  This is certainly a restriction as clearly applicable to a carpal tunnel condition as to an elbow or shoulder condition, and Dr. Weinman continued to recommend use of wrist splints for wrist support.  Because it was not unreasonable for the judge to conclude that the employee’s restrictions pertained at least in part to her carpal tunnel condition, we affirm the compensation judge’s award of a rehabilitation consultation.  See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.