The employee appeals from the compensation judge’s findings that the employee did not have carpal tunnel syndrome, that the employee failed to establish that her work activities were a substantial contributing cause of her claimed bilateral carpal tunnel syndrome, and that the carpal tunnel release surgeries performed on the employee were not reasonable or necessary.  The employee also appeals from the compensation judge’s denial of temporary total disability benefits, payment of medical expenses, and a rehabilitation consultation.  We affirm.

Kim M. Nord, the employee, was employed for seven years, from 2004 until May 4, 2011, as a dishwasher and bus person at the Downtown Diner, the employer, in Alexandria, Minnesota.  The employee worked from 8:00 a.m. to 2:00 p.m. on Saturdays and Sundays.  Her duties included clearing tables, washing and putting away the dishes, filling the refrigerator, cutting up potatoes, making pancake batter, cleaning the floor and the racks above the deep fryer, and taking out the garbage.

In January 2011, the employee began to experience numbness and tingling in her right arm and fingers.  On February 9, 2011, the employee was seen by Dr. Warzecha at the Alexandria Clinic, complaining of right wrist numbness over the past month.  She described numbness in the forearm, wrist, and hand and sometimes the third and fourth fingers.  The doctor noted a positive Tinel’s and a positive Phalen’s test, diagnosed right carpal tunnel syndrome and provided a wrist brace.

The employee was seen by Dr. Leutmer at the Alexandria Clinic for left wrist pain on April 14, 2011.  The employee described shooting nerve pain, tingling and numbness.  On examination, the doctor noted a postive Tinel’s sign and a positive Phalen’s sign.  Dr. Leutmer diagnosed left carpal tunnel syndrome and prescribed a wrist brace, Ibuprofen for discomfort, and a nine-day course of prednisone.

On April 20, 2011, the employee was examined by Dr. Patrick Hurley at Heartland Orthopedic Specialists.  The employee complained of bilateral hand and wrist pain with pain and numbness from the left elbow to her shoulder.  On examination of the left wrist, Dr. Hurley noted a positive carpal compression test with paresthisias along the median nerve course up the forearm, but not into the hand, and a positive Phalen’s sign into the forearm.  Tinel’s sign along the median nerve course gave the employee radiating pain into the forearm and upper arm with pain along the ulnar nerve at the wrist radiating up the forearm.  With respect to the right wrist, the doctor noted a positive carpal compression test with parathesias along the median nerve course into the forearm and Tinel’s sign along the median nerve at the wrist radiating into the forearm.  Dr. Hurley assessed mononeuritis of the upper limb, mononeuritis multiplex, and carpal tunnel syndrome bilaterally.  The doctor observed that although the employee had compression of the median nerve she “presents a little differently as her symptoms radiate up the forearm and upper arm instead of into the hand and fingers bilaterally.”  (Pet. Exh. J.)  Dr. Hurley concluded early surgery was an option as there was clinical evidence of median nerve denervation.  The employee elected to proceed with a carpal tunnel release on the left.

The surgery was performed by Dr. Hurley on May 5, 2011.  By June 10, 2011, Dr. Hurley noted negative Tinel’s sign and negative Phalen’s sign along the median nerve at the left wrist.  The employee stated her symptoms on the left had diminished but she continued to have occasional tingling along the dorsum of the hand.  Examination of the right wrist revealed a positive carpal compression test, positive Phalen’s sign, and positive Tinel’s sign along the median nerve.  The employee wanted to proceed with a right carpal tunnel release.  Dr. Hurley performed the surgery on July 6, 2011.  Following the surgery, the employee’s right wrist symptoms completely resolved.

In a report dated July 7, 2011, Dr. Hurley stated the employee’s diagnosis was bilateral mononeuropathies/carpal tunnel syndrome with “classic distribution of paresthesia for median nerve compression and text book positive findings of a positive carpal tunnel compression, Tinel’s and Phalen’s signs.”  (Pet. Exh. H.)  In Dr. Hurley’s opinion, the employee’s work as a dishwasher at the Downtown Diner, requiring repetitive use of her hands, substantially contributed to the development of carpal tunnel compression of the median nerve.

The employee returned to see Dr. Hurley on July 27, 2011, reporting shooting pain down the left forearm with certain movements of her elbow.  The doctor noted a positive tennis elbow test and diagnosed mild lateral epicondylitis, stating it was an overuse injury.  The employee then returned to Dr. Luetmer with complaints of left upper arm pain.  The doctor noted some pain in the biceps tendon and diagnosed tendinopathy of the upper extremity.  The employee was seen again for arm pain by Dr. Zwach at the Alexandria Clinic on September 14, 2011.  She reported a gradual onset occurring in an intermittent pattern for months with mild pain mostly in the left arm, shoulder, and neck.  An MRI scan of the cervical spine was taken on September 29, 2011, to rule out disc disease.  No significant findings were noted.

An independent medical examination was performed by Dr. William Call, an orthopedic surgeon, at the request of the employer and insurer on October 12, 2011.  Dr. Call reviewed Dr. Hurley’s records, noting the employee previously had seen Dr. Warzecha and had received prednisone and splints from Dr. Leutmer.  Dr. Call asserted that Dr. Hurley’s “positive” findings on examination were in fact negative, explaining that to be positive, Tinel’s sign and the carpal compression test must radiate distally, that is downward into the hand, in the distribution of the sensory branch of the nerve being tested.  Dr. Call maintained the employee’s symptoms and physical examination were not consistent with carpal tunnel syndrome, and that absent an EMG, there was no objective confirmation of the diagnosis of carpal tunnel syndrome.  Dr. Call also noted Dr. Hurley did not wait for completion of the prednisone course but scheduled the first surgery after only one visit.  In Dr. Call’s opinion, the employee never had carpal tunnel syndrome, although there was some indication of minimal thoracic outlet irritation on the left.  Dr. Call further opined the employee’s work at the Downtown Diner was not a significant contributing factor to carpal tunnel syndrome.  Finally, Dr. Call opined that neither of the carpal tunnel release surgeries was indicated.

The case was heard by a compensation judge at the Office of Administrative hearings on March 8, 2012.  In a Findings and Order served and filed March 19, 2012, the compensation judge found that the employee did not have carpal tunnel syndrome; the carpal tunnel release surgeries were not reasonable and necessary, and that the employee failed to establish that her work activities were a substantial contributing cause of carpal tunnel syndrome.  The employee appeals.

The appellant moved to strike certain exhibits attached to the respondents’ brief together with references to the exhibits within the brief.  The exhibits marked F through J consist of a page from a medical treatise or journal and articles from various internet sites about carpal tunnel syndrome.  These documents were not offered into evidence at the hearing below.  On appeal, this court is limited to examination of evidence submitted to and considered by the compensation judge.  See Minn. Stat. § 176.421, subd. 1 (“in view of the entire record as submitted”); Gollop v. Shale H. Gollop, D.D.S., 389 N.W.2d 202, 38 W.C.D. 757 (Minn. 1986); Glasgow v. Franciscan Health Cmty., No. WC04-434 (W.C.C.A. May 2, 2005).  The employer and insurer argue the articles are not evidence, but merely supplement their legal argument.  We disagree.  Treatises, periodicals and articles on a medical subject are substantive evidence.  Compare, for example, Minnesota Rules of Evidence, Art. 8, Rule 803(18).  In this case, the medical experts disagreed on points addressed in the articles.  We, therefore, have not considered Exhibits F through J or those portions of the respondents’ brief referencing these exhibits.

The employee argues the compensation judge erred in finding that the employee did not have carpal tunnel syndrome.  She contends the evidence submitted at trial overwhelmingly establishes that she had carpal tunnel syndrome.  There was, however, conflicting medical expert opinion on this point.  Dr. Hurley concluded the employee had a “classic distribution of paresthesia for median nerve compression and text book positive findings of a positive carpal tunnel compression, Tinel’s and Phalen’s signs.”  (Pet. Exh. H.)  Dr. Call concluded that Dr. Hurley’s test results were actually negative rather than positive, stating that best practices would have indicated an EMG to confirm the diagnosis of carpal tunnel syndrome, and that without an EMG, there was no objective evidence of carpal tunnel syndrome in the record.^[1]  The employee testified that she had had pain and tingling in her left arm from the shoulder to the fingers since the beginning, that these symptoms had never changed, and that the surgery did not help these symptoms at all.  The judge was persuaded by Dr. Call’s opinion and found the employee did not have carpal tunnel syndrome.

The employee contends that Dr. Call’s medical opinion is unreliable and insufficient to support the compensation judge’s finding because the doctor did not review all of the employee’s medical records and contains inaccurate facts.  While the records reviewed by Dr. Call apparently began with the first visit to Dr. Hurley, the chart notes reference the employee’s prior treatment by Dr. Warzecha and Dr. Leutmer.  Dr. Call additionally reviewed the employee’s surgical records and deposition testimony, examined the employee, and took her medical history.  As such, he had adequate foundation for his opinion.  See Grunst v. Immanuel-St. Joseph Hosp., 424 N.W.2d 66, 40 W.C.D. 1130 (Minn. 1988).  Nor do we find facts in the report so significantly inaccurate as to require reversal.  See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) (a trier of fact's choice between experts whose testimony conflicts is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence).  We find no basis for reversal on the ground of any inadequacy in Dr. Call’s opinion.

The employee also argues the compensation judge erred in failing to make a specific finding that the employee did not have right carpal tunnel syndrome.  While the compensation judge found the employee had had pain and tingling down her left arm since before the surgery, did not have a good result from the left carpal tunnel release, and that the left wrist surgery did not help these symptoms (Finding 7), the judge did not make a specific finding that the employee did not have left carpal tunnel syndrome.^[2]  Similarly, the compensation judge did not make a separate finding that the employee did not have right carpal tunnel syndrome.  Rather, the compensation judge found the employee “did not have carpal tunnel syndrome” and that “the carpal tunnel release surgeries were not reasonable and necessary.”  (Finding 8, emphasis added.)  Since the employee claimed bilateral carpal tunnel syndrome, we conclude the compensation judge’s finding is sufficient to address the employee’s claim in this case.

The employee appealed the compensation judge’s finding that the employee failed to establish that the employee’s work activities were a substantial contributing cause of carpal tunnel syndrome.  Dr. Hurley concluded the employee’s work activities, involving repetitive use of her hands, was substantial enough to have contributed to the development of carpal tunnel in both upper extremities.  Dr. Call concluded that the employee’s work at the Downtown Diner was not a significant contributing factor to carpal tunnel syndrome, even if she had carpal tunnel syndrome.

The employee worked two days a week (Saturday and Sunday), from 8:00 a.m. to 2:00 p.m.  Her job duties included a variety of activities including bussing tables, washing and drying dishes, putting dishes away, stocking the refrigerator, cutting up potatoes, making pancake batter, cleaning the floor and racks over the deep fryer, and taking out the garbage.  The employee argues that Dr. Call relied on an incorrect fact - - that the employee made pancake batter with a two pound bag of dry ingredients when it was a five pound bag.  This was only one activity of the many the employee performed in the course of a shift and there was no evidence that the size of the dry ingredients bag was a significant factor in the opinion of either doctor.

Dr. Call reviewed the employee’s description of her work activities in her deposition and reviewed work duties with her at the time of his examination.  He had an adequate foundation for his opinion, and the compensation judge could reasonably find, based on Dr. Call’s opinion, that the employee’s work duties were not a substantial contributing cause of carpal tunnel syndrome.  See Nord, 360 N.W.2d 337, 37 W.C.D. 364.

The employee asserts the compensation judge failed to comprehend and address the employee’s claim, contending the employee claimed a Gillette injury to her left upper extremity that included left carpal tunnel syndrome and “an additional injury as well.”  (App. Brief p. 18.)  The employee’s claim petition lists bilateral carpal tunnel syndrome.  It is unclear from the record of the hearing whether the employee was alleging some additional or different condition or what that condition might be.  Although the employee was seen for left arm pain, the location, symptoms, and diagnosis were different with each doctor she saw.  Nor, as noted by the compensation judge, was it clear what might be causing the employee’s left arm pain and symptoms.  Under these facts, the compensation judge concluded it was premature to determine whether the employee had suffered some other work-related injury to the left arm and limited his determination to the employee’s carpal tunnel syndrome claim.  Given the vagueness of the employee’s claim, we agree with the compensation judge and affirm.

As we have affirmed the compensation judge’s findings that the employee did not have carpal tunnel syndrome and that the employee failed to establish that her work activities were a substantial contributing cause of carpal tunnel syndrome, we affirm the compensation judge’s denial of temporary total disability benefits, payment of medical expenses, and a rehabilitation consultation.