The employee appeals the compensation judge’s findings and order denying: (1) Gillette^[1] injuries in April 2009 and in June 2010; (2) a consequential psychological injury; and (3) reimbursement of medical treatment expenses.^[2]  We affirm.

On November 18, 2005, Eric Gunderson, the employee, sustained a work-related injury to his low back while working as a composite technician for McNeilus Companies, the employer, which was insured for workers’ compensation liability by Travelers Group.  The employee was working on the inside front discharge chute of a rotating fiberglass drum when his foot caught on a cleat as he was trying to exit.  He fell approximately six feet landing on a concrete floor directly onto his tailbone and he felt a painful popping sensation in the right side of his lower back.  He continued to work that day and developed progressive back pain, spasms and radiating pain into the right lower extremity.  That night he was seen at the Austin Medical Center emergency room where he was treated.  The employee was off work for approximately five days and then released to return to light duty work.  He received chiropractic treatments and attempted to increase his physical activity but with the increased activity, his back and right leg pain returned.

When the employee’s condition did not improve, he underwent an MRI on February 1, 2006.  The MRI revealed a large protruding disc on the right at the L5-S1 disc with possible extrusion and significant compression of the right thecal sac and neuroforaminal narrowing on both the right and left.  At the L4-5 level, a disc bulge and osteophyte complex caused mild spinal canal narrowing and neuroforaminal narrowing on both the right and left.

The employee had temporary relief from an epidural steroid injection and underwent a surgical consultation with Dr. Bryan Lynn at the Institute for Low Back and Neck Care.  Dr. Lynn assessed right lower extremity pain consistent with right S1 radiculopathy, right L5-S1 herniated nucleus pulposus, and moderate disc degeneration at L4-5 and L5-S1.  On March 29, 2006, Dr. Lynn performed a L5-S1 disc excision for a right herniated disc and right S1 radiculitis.  Following surgery, the employee’s symptoms improved and Dr. Lynn released him to return to light duty work.  The employee returned to work as an assembler, which involved standing on a concrete floor next to a bench that reached thigh height, working on electrical wiring of remote control devices, and assembling small parts in cab boxes.^[3]  The employee testified he was able to perform the modified job, but experienced fluctuating symptoms that left him tired and sore in his low back at the end of the day.

A July 10, 2006, MRI indicated a recurrent right L5-S1 posterior disc protrusion.  A few weeks later, Dr. Lynn performed a second lumbar surgery involving an excision of a recurrent right L5-S1 herniated disc.  The employee had a good recovery after surgery and returned to the same modified work in September of 2006.  In a report of workability, Dr. Lynn defined modified work as 30 pounds lifting frequently, 15 pounds bending and lifting, 30 pounds pushing and pulling, or 75 pounds on wheels.

The employee treated again with Dr. Lynn on May 4, 2007.  The doctor noted the employee had been doing well until April when he experienced a significant increase in pain that required a substantial increase in prescription medications.  Dr. Lynn removed the employee from work and recommended an MRI, which revealed a moderate-sized recurrent right posterolateral disc herniation at L5-S1 with moderate disc degeneration and impingement on the right S1 nerve root.  Dr. Lynn performed a third right L5-S1 disc excision on May 24, 2007.  The employee was released for light duty work on June 9, 2007.

Over the next two months, the employee was in and out of work, performing various duties in modified subassembly.  The employee needed intermittent breaks from work during this period as he recovered from the surgery.  On August 3, 2007, Dr. Lynn found the employee at maximum medical improvement and in need of permanent light duty work restrictions.  The employee continued to perform subassembly duties, but was moved to a different part of the plant where he could stand on a cushioned mat and sit or stand alternately as needed.  The bench in the new area was at waist height, which reduced the amount of bending for the employee while he assembled and wired electrical boxes.  In December 2007, Dr. Lynn assigned the employee a 13 percent permanent partial disability rating, which included 9 percent under Minn. R. 5223.0390, subp. 4.D., 2 percent under Minn. R. 5223.0390, subp. 4.D.(2), and 2 percent under Minn. R. 5223.0390, subp. 4.D.(3).

The employee sought chiropractic care beginning in April 2009.  He returned to Dr. Lynn, now at Summit Orthopedics, in September 2009, reporting low back pain and right leg symptoms.  A November 6, 2009, MRI indicated moderate to advanced degenerative disc disease at L5-S1, residual recurrent midline disc herniation at L5-S1, small midline disc herniation at L4-5, and foraminal narrowing at L5-S1 on both sides.  The employee was treated with right L5-S1 transforaminal epidural steroid injections, but had no substantial relief.  A January 29, 2010, discogram indicated concordant pain at L5-S1 and L4-5.  The next month, the employee reported substantial pain even in sedentary activities of daily living.  Dr. Lynn recommended fusion surgery at L5-S1.

The employee obtained a second opinion on the proposed surgery from Dr. Paul M. Huddleston, an orthopedic surgeon at Mayo Clinic.  Dr. Huddleston diagnosed lumbar spondylosis, chronic low back pain, history of multiple discectomies, and degenerative disc disease at L4-5 and L5-S1.  He found that the employee was a reasonable candidate for a two-level fusion surgery.  An April 16, 2010, MRI showed no significant change from the last MRI in 2009, and a June 14, 2010, CT scan indicated a disc and osteophyte complex at L5-S1 with possible contact of the right S1 nerve root.  On June 15, 2010, the employee underwent an anterior discectomy and fusion at L4-5 and L5-S1, performed by Dr. Huddleston.  The employee’s surgery was successful, with almost complete relief of his low back pain.  He had some leg pain and tingling, which was treated with medication.  A month later, an MRI showed partial healing at the fused spinal levels.

The employee was evaluated by Dr. Robert Wengler, an orthopedic surgeon, in August 2010, at the request of the employee’s attorney.  Dr. Wengler opined that the employee had sustained exacerbations of his 2005 work injury in 2007 and 2009 and that his recurrent disc herniations were caused by prolonged standing at work after the first surgery.  He also opined that the employee sustained a Gillette injury culminating on June 15, 2010, the date of the last surgery, and rated the employee at 34 percent permanent partial disability, attributing 14 percent to the 2005 injury and 20 percent to the Gillette injury.  Dr. Wengler recommended work restrictions of no lifting over 10 pounds and no repetitive bending, stooping, heavy pushing or pulling, or prolonged postural stress.

The employee returned to the Mayo Clinic in September 2010, reporting occasional right buttock and posterior thigh pain.  A work-hardening program was recommended after the fusion healed in three months.  A December 29, 2010, X-ray showed a solid fusion at L4-5 and L5-S1.  The employee began a daily work rehabilitation program in January 2011.  The employee returned to part-time work for the employer in February 2011 and worked up to full time by March 2011 in about a month.  In August 2011, the employee was treated for sacroiliac joint pain at the Mayo Clinic.  The employee underwent a radiofrequency denervation procedure on the right lumbrosacral region a month later.  A November 18, 2011, MRI was read as largely unchanged from the last MRI, and a December 27, 2011, EMG was normal with no evidence of radiculopathy.  In February 2012, the employee’s treating physician indicated that the employee was at maximum medical improvement and had permanent restrictions.  The restrictions were noted again in September 2012, and included working 10 hours per day, 4 days per week, no heavy torquing or use of an impact wrench, and no continuous repetitive bending.

The employee was evaluated by Dr. Norman Cohen, a licensed psychologist, for an expert psychological opinion at his attorney’s request.  In a May 5, 2012, report, Dr. Cohen diagnosed anxiety disorder as a result of the work injury and rated the employee at 40 percent permanent partial disability under Minn. R. 5223.0360, subp. 7.D.(3).  Dr. Paul Arbisi, a clinical psychologist, conducted an independent psychological evaluation of the employee.  In a September 4, 2012, report, Dr. Arbisi diagnosed the employee with pain disorder due to psychological factors and generalized anxiety disorder in remission.  He opined that the employee’s generalized anxiety disorder pre-existed his work injury.  He also found that the employee had sustained an exacerbation of his anxiety disorder in 2009, but that it was not causally related to the work injury.  He noted that the employee was able to function independently in the community and in the workplace.  Dr. Arbisi found no evidence that the employee required assistance to live independently or that he had significant psychological impairment, and would rate the employee at zero percent permanent partial disability for his anxiety disorder.

The employee’s claims of work-related cumulative micro-trauma injuries to his low back in the spring of 2007, the spring of 2009, and in June of 2010 were heard by Compensation Judge Penny Johnson on October 12, 2012.  On cross-examination at the hearing, the employee was asked if he had any other injuries with the employer after November of 2005.  The employee replied, “. . . it’s the same injury over and over and over. . . . I didn’t have no other injuries.  I mean it’s the back injury that keep[s] reoccurring.”^[4]  Concluding that the significant effects from the November 18, 2005, work injury were the multiple surgeries, recurrent disc herniations, post-surgical instability and degeneration in the spine, the compensation judge determined that the employee temporarily exacerbated his low back condition at work in the spring of 2007 and found the evidence insufficient to prove Gillette injuries culminating in the spring of 2009 or in June of 2010.  The judge awarded a closed period of temporary total and temporary partial benefits attributable to the effects of the 2007 temporary exacerbation and further awarded an additional permanent partial disability of 9 percent to the low back under Minn. R. 5223.0390, subp. 4.D. over the 23 percent previously paid for the November 18, 2005, work injury.  The employee’s additional claims for wage loss benefits, a consequential psychological injury with permanent partial disability, and medical expenses were denied by the compensation judge.  The employee appeals.

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.^[5]  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.^[6]  Fact findings are clearly erroneous if the reviewing court, looking at the entire evidence, is left with a definite and firm conviction that a mistake has been committed.^[7]  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.”^[8]

The employee contends the compensation judge erred when she found the employee failed to establish through medical evidence and testimony that he suffered Gillette injuries in April 2009 and in June 2010.  The employee maintains that the record “unequivocally demonstrates” that the employee’s subsequent herniations after November 18, 2005, were the result of cumulative trauma caused by prolonged standing and postural stress from the work activities.  The employee further argues, “[t]he lack of evidence supporting the Compensation Judge’s denial is not that which a reasonable mind would find adequate if the entirerecord is considered.”^[9]  We are not persuaded by the employee’s arguments.

Whether an injury occurs as a result of repetitive minute trauma caused by the performance of work-related duties is an ultimate question of fact for the compensation judge to determine.^[10]  Proof of a Gillette injury principally depends on medical evidence^[11] that is based on adequate foundation.^[12]  The employee’s testimony alone is generally not sufficient to establish this connection.^[13]  Here, the employee relied on the medical opinions contained in the narrative report of Dr. Wengler to connect a date of disablement to the performance of job duties.  However, the determination of whether an employee sustained a Gillette injury is not solely dependent on medical testimony, and the compensation judge should consider the nature and extent of the employee’s work duties in deciding whether those activities caused the disability.^[14]  Given the medical evidence on the issue of causation, the judge found the employee could not prove that his day-to-day work-related duties supported his Gillette injury claims.

In her findings and order, the compensation judge detailed the multiple surgeries, recurrent disc herniations, post-surgical instability, and spinal degeneration described in the medical records.  The judge compared the employee’s medical conditions to his work-related duties and reviewed the medical opinion on causation contained in Dr. Wengler’s report.  The judge noted the lack of detail in Dr. Wengler’s report when describing the employee’s work duties and how they affected the employee’s medical condition.  In finding 37, the judge explained the deficiency:

In finding 38 of her decision, the judge again addressed the medical opinion of Dr. Wengler as failing to establish a 2010 Gillette injury:

The employee contends the compensation judge committed an error of law by determining that the employee did not sustain a consequential psychological condition due to his work-related injury and by failing to award permanent partial disability benefits to the employee for the psychological condition.

We recognize the compensability of a claim where the physical injury results in a consequential mental condition.^[17]  Here, the judge was presented with two conflicting opinions on mental impairment and causation.  The employee submitted the medical report of Dr. Cohen.  Dr. Cohen was of the opinion that the employee’s work-related physical injury was a substantial contributing factor in producing his anxiety condition and assigned a 40 percent rating under Minn. R. 5223.0360, subp. 7.D.(3).  That rule requires a finding that the employee has moderate emotional disturbance present at all times and can live independently but requires some supervision on a daily basis.  The employer and insurer submitted the medical report of Dr. Arbisi who was of the opinion that the employee did not suffer from depression, anxiety, or any symptoms consistent with a mental disorder caused by the physical injury.  Dr. Arbisi was also of the opinion that the mental condition did not meet the requirements of Minn. R. 5223.0360, subp. 7.D.(3), stating that there was no evidence that the employee required assistance to live independently or that he had significant psychological impairment.

A compensation judge has the discretion as the trier of fact to choose between competing and conflicting medical experts, reports, and opinions.^[18]  A compensation judge’s choice between conflicting medical expert opinions is generally upheld unless the facts assumed by the expert are not supported by the record.^[19]  If more than one doctor has adequate foundation to render opinions, the Workers’ Compensation Court of Appeals must affirm the compensation judge’s choice between conflicting expert medical opinions.^[20]  In the present case, the compensation judge found the employee’s increased anxiety symptoms beginning in 2009 were more closely related to socio-economic factors than the effects of the work injury and also found Dr. Cohen’s opinion on the 40 percent permanency rating “not persuasive.”^[21]  Given our standard of review, we affirm the compensation judge’s findings on this issue.