The employer and insurer appeal the compensation judge’s finding that the employee’s April 2009 work injury was a substantial contributing cause of his bilateral arm condition and total disability from and after March 12, 2010.  We affirm.

On April 7, 2009, Bobby Raaen, the employee, sustained a work-related injury to both arms when he slipped on ice, falling and landing on the underside of his forearms near his elbows.  At the time he was working as a sales manager for Inventive Health, Inc., the employer, which was insured for workers’ compensation liability by Sentry Insurance Company, the insurer.  The employee was able to continue working and drove to his next client’s location, but felt numbness and tingling in his hands.  The next day the employee observed bruising on his arms where they hit the ground.  Although the employee experienced persistent bilateral elbow pain, as well as numbness and tingling into his fingers, he did not seek medical treatment for this condition or report the injury until June 9, 2009, because he thought the symptoms would resolve on their own.  At that time, he reported numbness in his fingers and stiffness around his elbows while being examined by Dr. Craig Smith, who assessed a “[d]ifficult problem with range of motion and ulnar neuritis of the elbows after trauma; Underlying congenital trigger.”  Dr. Smith referred the employee to Dr. R. Blake Curd, an orthopedic specialist, and also recommended EMG studies to evaluate the ulnar neuritis.

A June 25, 2009, EMG indicated bilateral ulnar neuropathy.  On August 27, 2009, after conservative treatment measures provided no symptomatic relief, Dr. Curd performed an ulnar nerve transposition surgery on the employee’s left arm.  The employee continued to experience pain in both arms.  Dr. Curd referred the employee to Dr. Thomas Ripperda, a physical medicine and rehabilitation specialist.  Dr. Ripperda recommended work restrictions and prescribed topical steroids for pain relief.  He questioned the etiology of the employee’s condition and ongoing symptoms and noted a discrepancy between the employee’s symptoms and his findings on examination.

The employee also has a pre-existing condition, which is a congenital fusion of the radius and ulna, identified as bilateral congenital proximal radial ulnar synostosis.  According to a chart note from a November 23, 2004, physical examination at the Mayo Clinic, this condition limited the employee’s elbow and wrist rotation and his functional capacity, and he reportedly was starting to have problems with this condition and noted intermittent pain and stiffness.  Dr. Kirk Rodysill and Ann M. Thompson, R.N., who examined the employee, advised that “it would certainly be worthwhile to check radiographs of both upper extremities and have him be seen by a hand and elbow specialist,” but also recommended that the employee focus on certain other medical issues, stating that “evaluation of this lifelong condition can certainly wait until a later date.”  There is no indication in the record that the employee sought further treatment for this condition following this 2004 appointment.  The employee testified that he noticed no problems with his elbows in 2004 and that the examination of his arms at that time was incidental to a physical examination.

On March 2, 2010, the employee was examined by Dr. Richard Lemon at the employer and insurer’s request.  Dr. Lemon concluded that the employee had sustained bilateral elbow contusions after the April 7, 2009, work injury, which had resolved as of May 7, 2009, and that the employee had developed bilateral ulnar neuropathies due to the aging process and his congenitally limited range of motion of his elbows, which were not related to his work injury.  Dr. Lemon also stated that, in his opinion, it is nearly impossible to sustain bilateral ulnar neuropathies due to a fall on both elbows since in such a fall, “one lands on the point of the elbow and does not land on the ulnar nerve or the cubital tunnel.”

During this same time period, Dr. Curd referred the employee to the Mayo Clinic for evaluation of his bilateral hand weakness and numbness and his bilateral elbow pain.  Dr. Bassem Elhassan initially examined the employee on March 8, 2010, and diagnosed ulnar and median neuropathy and “significant bilateral elbow symptomatic arthritis.”  Dr. Elhassan concluded that the employee’s April 7, 2009, work injury was a substantial contributing factor to his ongoing pain and disability and his need for carpal tunnel surgery to relieve the pain and numbness.  A March 24, 2010, EMG was negative for nerve entrapment, but Dr. Elhassan noted that the employee had a significant positive Tinel finding and significant changes in his hand, and recommended surgery.  On May 4, 2010, the employee underwent a left carpal tunnel release and revision of the left cubital tunnel release/transposition surgery, performed by Dr. Elhassan.  The surgery note stated that the ulnar nerve was embedded in a significant amount of scar tissue and was released.  The employee later reported that the surgery relieved his pain and numbness on the left side but that he continues to have pain and numbness on the right side.

Before that surgery, and on the basis of Dr. Lemon’s report, the employer and insurer sought to discontinue the employee’s temporary total disability benefits as of March 12, 2010.  The employee filed an objection to discontinuance on April 20, 2010, and an evidentiary hearing was held on July 20, 2010.  The sole issue in dispute at the hearing was whether the employee’s work injury represented a substantial contributing cause of his bilateral upper extremity condition.  In her findings and order of August 13, 2010, the compensation judge found that the employee had been temporarily totally disabled from March 12, 2010, as a result of his bilateral elbow pain and numbness and tingling into his fingers, and that his April 7, 2009, work injury was a substantial contributing factor in that disability.  The employer and insurer appeal.

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 (2008).  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 compensation judge found that the employee’s April 7, 2009, work injury was a substantial contributing cause of the employee’s ongoing bilateral elbow condition, and based her conclusions on the employee’s lack of similar symptoms before the injury, the abrupt appearance of symptoms after the injury, the persistence of the employee’s symptoms, and the positive findings on the EMG study that were suggestive of bilateral ulnar neuropathy.  The compensation judge took into account the opinion of Dr. Lemon, but found Dr. Elhassan’s opinion to be more persuasive on the issue of the cause of the employee’s bilateral elbow condition.

The employer and insurer argue that the employee’s pre-existing conditions, bilateral congenital proximal radial ulnar synostosis and degenerative arthritis, limited the employee’s functional capacity before the injury occurred.  They also argue that other medical opinions, including those of Dr. Ripperda and Dr. Lemon, support their position that the employee’s work injury was not a substantial contributing cause of his ongoing elbow condition and temporary total disability.

We acknowledge there is evidence in the record that would support the employer and insurer’s position.  Dr. Lemon opined that the employee’s ongoing condition was not related to his work injury, but that it had developed due to the aging process and due to the employee’s congenitally limited range of motion of his elbows.  Dr. Ripperda questioned the etiology of the employee’s condition and whether there was a discrepancy between his symptoms and findings on examination.  The employer and insurer argue that the compensation judge erred by ignoring Dr. Ripperda’s opinion and that she made no reference whatsoever to Dr. Ripperda’s opinion.  The fact that the compensation judge did not mention all the evidence favoring the employer and insurer's position, however, does not establish that she overlooked that evidence, as a compensation judge is not required to specifically mention in a decision every piece of evidence or opinion that is part of the record.  See  Weiland v. Tiedemann Farms, slip op. (W.C.C.A. Nov. 3, 2003) (citing Rothwell v. Minnesota Dep't of Natural Resources, slip op. (W.C.C.A. Dec. 6, 1993); Pelto v. USX Corp., slip op. (W.C.C.A. Dec. 16, 1993)).

In addition, under this court’s standard of review, the issue is not whether the evidence will support alternative findings but whether substantial evidence supports the compensation judge’s findings.  Where evidence conflicts or more than one inference can be drawn from the evidence, the judge’s findings are to be affirmed.  Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).  The judge's decision centered on her choice between the medical opinions and she adopted Dr. Elhassan’s opinion over that of Dr. Lemon.

The judge disagreed with Dr. Lemon’s conclusion that the two month gap between the employee’s injury and his initial treatment proved that the injury was minor and temporary given the employee’s later treatment.  She also disagreed with the employer and insurer’s argument that the employee’s pre-existing conditions resulted in his symptoms, and disputed their argument that because the employee fell on the points of his elbows, as presumed by Dr. Lemon, the injury could not have resulted in bilateral ulnar neuropathies.  The compensation judge accepted the employee’s testimony concerning the circumstances of his slip and fall on the ice - - that he fell on his forearms - - and we will defer to the compensation judge’s finding in that regard.  Brennan v. Joseph G. Brennan, M.D., 425 N.W.2d 837, 839-40, 41 W.C.D. 79, 82 (Minn. 1988) (assessment of a witness’s credibility is the unique function of the trier of fact).

The employer and insurer also argue in their appellate brief that the compensation judge committed reversible error by “misstating the extent of the employee’s pre-existing medical condition and concomitant functional limitations.”  In her memorandum, the compensation judge addressed the employee’s preexisting condition and enumerated the reasons that she found Dr. Lemon’s opinion to be less persuasive than that of Dr. Elhassan, stating that:

Dr. Elhassan, on whose opinion the compensation judge relied, acknowledged that the employee had pre-existing conditions and that his EMG study conducted before surgery was negative, but he relied on other evidence to support his opinion that the employee’s work injury exacerbated his preexisting elbow arthritis and the triggering of cubital tunnel and carpal tunnel conditions, and that the injury necessitated surgery.  Because Dr. Elhassan had adequate foundation for his medical opinion, we find no basis to reverse.  See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).  Based on our review of the record as a whole, we conclude that substantial evidence, including expert medical opinion, supports the compensation judge’s finding that the employee’s work injury was a substantial contributing cause of his bilateral upper extremity condition and total disability from and after March 12, 2010.  Accordingly, we affirm.