The employer and insurer appeal from the compensation judge’s decision to award disputed medical expenses based on a finding that the employee’s initial left hand injury, which occurred on February 10, 2010, was aggravated by continuing repetitive work activities with her left hand, resulting in the need for continuing medical treatment.  We affirm.

The employee, Tiffany House, was 42 years old at the time of the hearing in this matter.  She began working for the employer, Heartland Homecare, in September 2006.  About one year after starting with the employer, she became a full-time team coordinator in the medical records department.  She continued in that position through her injury date, February 10, 2010.

The employee’s job duties varied throughout the day, including making charts, filing, sorting, placing orders for medical supplies, handling cell phone repair requests, answering phones, greeting patients, gathering forms, and distributing mail.  The employee testified that she had a wide variety of tasks during her workday, and she was able to switch tasks and do things as she saw fit or as her symptoms warranted.

When the employee was hired in 2006, she did not recall having any problems with her left hand, wrist, or arm.  She did admit to having some prior problems with her hands while working for a different employer previously, but she could not recall specifically what her symptoms were and whether she saw a doctor.

Records from Allina Forest Lake Clinic indicate that on September 13, 2005, the employee was seen for complaints of bilateral wrist pain that had been going on for a while and had worsened recently.  The employee was diagnosed with bilateral hand, wrist, and forearm pain, probably carpal tunnel syndrome, and she was referred for an EMG.  The employee underwent the EMG, and when she saw her doctor again on September 27, 2005, she was informed that the EMG was unremarkable.  The employee underwent a physical exam on April 27, 2006, and she reported having no complaints relative to her hands.

The employee had also previously treated with Ottomeyer Chiropractic for neck and shoulder pain at various times dating back to 1994.  On January 25, 2010, the employee had treated with the chiropractor for shoulder pain.  She was given a diagnosis code of 729.1, which, according to the employer and insurer, represented a diagnosis of fibromyalgia:  myalgia and myositis, unspecified; fibromyositis “NOS.”

However, the employee denied having any problems or symptoms with either of her hands or wrists while working as a team coordinator for the employer before the February 2010 injury date.  The employee testified that although she could not remember exactly how she was injured, she said it occurred while she was either “putting a chart back on the shelf or I was removing it from the shelf.”  The employee said that she had her left hand up by the chart, and she felt pain between her index finger and the middle finger on the left hand.  The pain was on the top portion of her left hand in between the index finger and the middle finger.  On the date of injury, the employee said that her pain did not go into her wrist, but the symptoms that she was having in the back of her hand were difficult for her to explain.  She felt as though it was similar to “when you stretch a rubber band and it blings back like a vibrating thing.”  She denied ever having any similar symptoms in her left hand before.

The employee stated that her left hand symptoms came on suddenly on the date of injury, as described above, and she reported the injury six days later.  The first report of injury noted that the employee sustained a strained/sprained left hand.

The employee’s initial treatment after her work injury occurred on February 17, 2010, when she presented to the Allina Clinic.  She reported feeling strain in her left hand while putting a chart onto a shelf.  She described pain in the area between her index finger and middle finger.  This radiated up the hand and was occasionally felt in the dorsum of the forearm.  She was diagnosed with an “acute left hand strain.”  She was given a wrist brace for immobilization.

The employee saw Dr. Andrew Thomas in the Hand Center at Summit Orthopedics on March 24, 2010.  She noted a history of sudden onset of pain in the dorsal aspect of her hand radiating up to the middle finger and index finger.  The employee was reporting minimal benefit with the use of her splint.  Dr. Thomas felt the employee could possibly have Wartenberg syndrome, which related to “inflammation of the dorsal sensory branch of the radial nerve.”  Ibuprofen was recommended along with continuous use of the splint.  An injection was also attempted, but it provided no relief.

The employee returned to see Dr. Thomas on May 17, 2010.  She was reporting symptoms that were reportedly consistent with medial nerve irritation at the antecubital fossa.  Dr. Thomas felt they may represent a lesion, perhaps in the shoulder or even in the spinal cord.

The employee underwent an EMG at Neurological Associates on June 3, 2010, which was reportedly normal.

On June 9, 2010, the employee saw Dr. Thomas and reported an improvement in symptoms, with only some slightly reduced sensation at the dorsal aspect of the thumb and index finger.  However, the employee continued to follow up with Dr. Thomas, reporting pain in the dorsal radial aspect of the left hand and discomfort over the radial forearm.  She reported only minimal benefit with the prior injection, and she said splinting was somewhat more beneficial.

The employee saw Dr. Thomas again on August 18, 2010.  He noted that the employee had presented, at times, with symptoms consistent with Wartenberg syndrome and paresthesia radiating through the distribution of the radial nerve with focal percussion.  At other times, the employee had symptoms of generalized, diffuse achy wrist, forearm, elbow, and upper arm pain.  On examination, the employee reported that the focal paresthesia in the distribution of the radial sensory nerve had largely dissipated.  However, she had achiness in the hand, wrist, forearm, elbow, and arm.  Attempts to better delineate the area pain were largely unsuccessful, and the pain was essentially described as being “everywhere.”  Dr. Thomas noted that the pain appeared to be fairly mild, present at some times and not others, and reasonably well controlled with splinting. Dr. Thomas diagnosed the employee with generalized left arm achiness without focal anatomical positioning.  She was performing her work activities adequately, and the pain was not debilitating or particularly influential on her life activities.  Dr. Thomas recommended that the employee continue to use her splint and to work within restrictions.

Dr. Jeffrey Husband conducted an independent medical examination at the request of the employer and insurer, and he issued a report on September 27, 2010.  Dr. Husband indicated that the employee’s examination findings were inconsistent with the known anatomical cutaneous distribution of the superficial radial nerve.  The employee was reporting symptoms that were not supported by objective findings on examination.  She also had no findings supporting Wartenberg syndrome.  Dr. Husband opined that the employee had somatization, with symptoms for which there was no pathophysiologic basis.  He felt there was no reason to believe that the February 10, 2010 injury could account for the employee’s ongoing subjective complaints.  He also opined that the employee reached maximum medical improvement without any permanency, restrictions, or need for ongoing treatment relating to the February 2010 injury.

The employee returned to see Dr. Thomas on September 29, 2010.  She was again noted to have examination findings that could not be replicated and which were diffuse and without anatomic correlate.  She reported mild achiness through the left forearm, but Dr. Thomas was not able to determine an anatomic correlate.  The employee’s discomfort was mild enough that she was able to perform most of her work and recreational activities.  The employee was allowed to discontinue splinting.  Dr. Thomas indicated that there was no organic cause of the current complaints, and there did not appear to be any reason to restrict the employee’s work activities.  Dr. Thomas was not able to determine a diagnosis for the employee’s condition, what was causing the employee’s pain, or what would be an effective treatment for her.

The employee then returned to the Allina Clinic where she saw Dr. Steven Semmler on October 15, 2010.  The employee was complaining of intermittent left arm pain for the last six months, along with some current upper arm pain.  Her symptoms were worse after a full workday.  The employee had a relatively normal examination, and she was started on Neurontin.  The employee saw Dr. Semmler again on November 12, 2010, and she reported that her symptoms were unchanged on the Neurontin.

The employee saw Dr. Jawad Bajwa with Neurological Associates of St. Paul on November 22, 2010.  During an examination of her left hand, the employee described pain in the medial side of the hand that ranged up over the wrist into the forearm and occasionally above the elbows.  She noted that her pain was aggravated by things such as brushing her hair, combing her hair, holding a dryer, writing, and typing.  The employee was thought to have possible carpal tunnel syndrome.  It was noted, however, that the prior EMG had been normal.  The employee’s dose of Neurontin was increased, and she was instructed to follow up in six months.

On December 15, 2011, the employee returned to Allina for an annual exam.  She noted that she was taking both Neurontin and using Lidocaine patches.  However, she was continuing to report some pain.

The employee saw Dr. Bajwa again on April 5, 2011.  She also reported feeling “funky” because of her medications.  The examination was reportedly unremarkable, and an additional EMG was recommended.  Dr. Bajwa wanted to wean the employee off the Neurontin and prescribe Lyrica instead.

Dr. Husband examined the employee again on March 13, 2012.  She reported that Neurontin did little to relieve her symptoms.  She noted switching to Lyrica, and said her symptoms were “somewhat improved.”  Dr. Husband also noted that the employee’s current symptoms were the same as they had been at the time of the prior examination in September 2010.  Dr. Husband opined that the employee was continuing to report subjective complaints of pain without any objective findings on examination.  He did not feel that any additional medical treatment was reasonable, necessary, or causally related to the work injury, and he specifically noted that the use of Lyrica was not reasonable, necessary, or causally related to a work injury.

The employee’s attorney scheduled an evaluation with Dr. Kenneth Britton, which took place on March 20, 2012.  The employee reported having had symptoms over the past two years, and she specifically noted that her symptoms “had not significantly improved or worsened” over the past two years.  She was continuing to work in her regular job on a full-time basis.  She was also going to school on essentially a full-time basis and maintaining her household and family responsibilities.  Dr. Britton diagnosed the employee with superficial sensory nerve pain, most likely due to myofascial compression in the dorsal forearm.  He stated that the employee’s history and physical examination findings were “consistent with overuse syndrome” related to her work activities.  Dr. Britton felt that the employee’s work activities constituted a substantial contributing factor in her current complaints.

Dr. Britton also indicated that the employee reached maximum medical improvement on November 30, 2010, about two weeks after her last visit with Dr. Bajwa and six weeks after her last visit with Dr. Thomas.  Dr. Britton opined that it was “doubtful” that the employee would have complete resolution of her overall symptoms.  However, she may be able to find some qualitative improvements in the amount of her discomfort with an increase in her Lyrica dosage, up to a maximum of three 150 mg doses three times per day, and “symptom-limited activity,” meaning that when her symptoms increased, she should stop whatever activity she was doing and rest.  She could also use the splint if it helped.  She could continue her regular work activities, but the doctor recommended “symptom-limited restrictions” and avoiding extended repetitive use, particularly involving strong gripping or grasping.  Dr. Britton opined that all previous treatment had been reasonable and necessary to treat the employee’s symptoms.

Dr. Britton issued a subsequent report on May 8, 2012.  He did not examine the employee at that time, but he reviewed additional records, including the chiropractic records and the re-evaluation report from Dr. Husband.  Dr. Britton continued to opine that the employee was at maximum medical improvement as of November 30, 2010.  He suggested that medication, including Lyrica, and desensitization activities, including potential assistance from a hand therapist, could maximize the desensitization process and may decrease the discomfort the employee was experiencing when active.  “The goal of this treatment would be to decrease the discomfort that she experiences and increase her capacity for activity before experiencing excessive discomfort.”  Dr. Britton continued to opine that the “symptom-oriented treatment is the direct result of the injuries sustained in this work-related injury.”

On May 31, 2012, the matter came on for hearing to address a medical request that the employee filed on July 7, 2011.  At hearing, the compensation judge was asked to decide whether claimed medical expenses were reasonably required as a result of the work injury and whether those expenses were in compliance with the medical treatment parameters.  At issue were dates of service at Allina, ranging from October 15, 2010, through November 10, 2010, dates of service at Neurological Associates of St. Paul, ranging from November 22, 2010, through December 13, 2010, and various co-pays, mileage, and prescriptions, including Lyrica and Lidocaine patches.  The compensation judge summarized the issues for decision as follows:

With regard to the treatment parameter issue, the compensation judge asked counsel for the employer and insurer which specific parameters or rules were being raised with regard to the treatment at issue.  Counsel for the employer and insurer cited Minn. R. 5221.6300, subp. 10, arguing that none of the doctors involved had been able to establish that the medications involved had been effective in treating the employee’s condition and that the treatment was not providing “any great relief or increase in her activity.”

The employee admitted that during the course of her treatment, she had told her providers that she was having symptoms in about seven different parts of her left arm during various times in her treatment.  However, none of her doctors and treating physicians had ever advised her that she had fully recovered from the effects of her work injury.

The employee was asked about her Lyrica usage, and she stated, “I think it has actually helped me a little bit.”  At the time of the hearing, the employee indicated that her treatment included taking two 75 mg doses of Lyrica per day.  The employee also testified that she had used a Lidocaine patch about three times per month.  She testified that the Lidocaine would numb her hand so she does not feel it.  She only used the Lidocaine patch when her symptoms were very bad because of “overwork.”

The compensation judge reviewed the medical evidence and the testimony presented.  She also reviewed both independent medical examiners’ opinions.  The compensation judge specifically found the employee to be a credible witness.  The compensation judge also concluded that the employee’s primary symptoms and aggravating activities did not significantly change over time following the February 2010 injury.  The judge felt that the employee’s injury was “never truly just an acute specific injury that occurred that day.”  The judge opined that the employee’s injury “may have felt like a strain on that particular day, but it was the repetitive grasping in the employee’s daily work duties that caused the employee to continue to have left hand problems that did not easily resolve.”  The compensation judge noted that the employee’s symptoms were not always exactly the same in the hand and forearm, complicating the diagnosis and treatment of her condition.

The compensation judge credited the opinion of Dr. Britton over the opinion of Dr. Husband, and she concluded that the employee’s “initial injury on February 10, 2010 was aggravated by continuing repetitive work activities with her left hand that resulted in the need for continuing medical treatment of her overuse syndrome.”  Consequently, the compensation judge found that the disputed medical treatment was reasonably required to treat the February 2010 work injury.  The compensation judge also found that because Lyrica had been “effective and cost effective” in treating the employee’s symptoms, Minn. R. 5221.6300, subp. 10, did not bar the treatment at issue.

The employer and insurer argue that because of the varied diagnoses and varied complaints regarding the employee’s symptoms, location, and timing, the employee has failed to establish that her current complaints and her need for treatment were reasonable, necessary, and causally related to the admitted February 2010 left hand injury.

The employee has the burden of proving that the claimed medical expenses were reasonable, necessary, and causally related to her work injury or injuries.  See, e.g., Adkins v. University Health Care Ctr., 405 N.W.2d 231, 39 W.C.D. 898 (Minn. 1987).  The reasonableness and necessity of medical treatment under Minn. Stat. § 176.135 is a question of fact for the compensation judge.  See Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993).  Questions of medical causation fall within the province of the compensation judge.  Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994).  It is the function of the compensation judge to resolve conflicts in expert medical testimony, and his or her choice of expert opinion is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence.  Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).  Where evidence is conflicting or more than one inference may reasonably be drawn from the evidence, the findings of the compensation judge are to be upheld.  Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 40 W.C.D. 948 (Minn. 1988).

Here, the compensation judge credited the opinion of Dr. Britton in finding that the claimed treatment was reasonable, necessary, and causally related to the employee’s work injury.  The employer and insurer do not challenge the foundation of Dr. Britton’s opinions.  Rather, they argue that the employee’s injury was in the nature of a temporary strain.  Therefore, her current complaints and need for treatment are related to her varied complaints, the number of different potential causes cited by the various doctors and providers involved, her underlying conditions, or something else, but not her February 2010 work injury.

A lack of specific diagnosis or anatomical explanation for the employee’s symptoms is not a bar to compensability.  See Wegner v. American Legion Post 50, No. WC11-5240 (W.C.C.A. June 22, 2011) (notwithstanding the lack of a clear anatomical explanation, substantial evidence supported the compensation judge’s choice to adopt the treating physician’s opinion that the work injury was a substantial contributing cause of the disability and need for care).  The issue is not the diagnosis of the employee’s condition but whether that condition was caused, aggravated, or accelerated by the employee’s work.  Id. (citations omitted).

The compensation judge addressed the various diagnoses here, and she found that the employee’s injury was “never truly just an acute specific injury that occurred that day.”  The judge opined that the employee’s injury “may have felt like a strain on that particular day, but it was the repetitive grasping in the employee’s daily work duties that caused the employee to continue to have left hand problems that did not easily resolve.”

In addition to her consideration of the medical opinions, the compensation judge also based her decision, in part, on the employee’s testimony, which she found to be credible with regard to her description of the injury, her ongoing symptoms, and her need for ongoing treatment.  A compensation judge may base his or her conclusions on other reliable evidence in the record beyond the medical records.  See Reimer v. Minnit Tool/M.I.T. Tool Corp., 520 N.W.2d 397, 51 W.C.D. 153 (Minn. 1994).  Assessment of a witness’s credibility is the unique function of the trier of fact.  See Even v. Kraft, Inc., 445 N.W.2d 831, 42 W.C.D. 220 (Minn. 1989).  The existence of a personal injury may be established based on subjective complaints of an employee coupled with the opinion of a medical expert that the employee sustained a work-related injury or aggravation.  See Shayda v. Minnesota Mining & Mfg. Co., 46 W.C.D. 350 (W.C.C.A. 1991), summarily aff’d (Minn. Mar. 27, 1992).  The employee is the person most familiar with the severity of his or her symptoms, and we conclude that the compensation judge did not err in relying, in part, on the employee’s testimony regarding causation and her current condition and need for treatment.  See Brening v. Roto-Press, Inc., 306 Minn. 562, 237 N.W.2d 383, 28 W.C.D. 225 (Minn. 1975).

There is substantial evidence, including Dr. Britton’s opinion and the employee’s testimony, to support the compensation judge’s decision the employee’s current symptoms and need for treatment are related to the injury of February 10, 2010.  Therefore, we will not disturb that decision on appeal.

The employer and insurer argue that the compensation judge erred in finding that the treatment involved is appropriate pursuant to Minn. R. 5221.6300, subp. 10.  In particular, the employer and insurer argue that the employee’s medical records do not substantiate any progressive improvement in the employee’s functional status or pain complaints.

Minn. R. 5221.6300, subp. 10, addresses medication usage to treat upper extremity conditions, stating as follows:

As the compensation judge noted, the medications at issue have been prescribed by the employee’s treating physicians, including Dr. Semmler and Dr. Bajwa, for symptom control.  In addition, Dr. Britton recommended continued medication use, and even an increased dosage, because it would be effective in maintaining the employee’s functional level and pain management for her nerve-related symptoms, which he feels are not likely to resolve.  Therefore, substantial evidence supports the compensation judge’s decision not to apply Minn. R. 5221.6300, subp. 10.

In their appeal brief, the employer and insurer also cite Minn. R. 5221.6050 as the basis for their argument that the employee’s treatment has not progressively improved her condition since the injury and is, therefore, inappropriate under the treatment parameters.  However, this court has indicated that a party must specifically identify which treatment parameters it claims to be applicable, and a party must make these specific arguments at the trial level to the compensation judge.  Pinc v. Stepping Out, Inc., 69 W.C.D. 181, 187 (W.C.C.A. 2009) (citing Lewis v. St. Therese Home, Inc., slip op. (W.C.C.A. Mar. 31, 2004); Boryca v. Marvin Lumber & Cedar, slip op.  n.3 (W.C.C.A. Nov. 10, 1999)).  The employer and insurer only raised Minn. R. 5221.6300, subp. 10, at the hearing, and their pretrial statement only states the following general issue:  “Whether the treatment provided complies with the treatment parameters.”  As such, we will not address Minn. R. 5221.6050 on appeal.

Regardless of the treatment parameter issues discussed above, cases addressing reasonableness and necessity have developed a series of factors that a compensation judge may consider when assessing whether certain medical treatment was reasonable and necessary, including the following:  the employee’s opinion as to relief obtained; the provision of services on a scheduled rather than an as-needed basis; the duration of relief from symptoms and whether symptoms recur; the use of alternative medical care; whether the employee is psychologically dependent on treatment; evidence as to a reasonable treatment plan; documentation of the details of treatment; whether the frequency of treatment is warranted; the cost of treatment in light of the relief obtained; an employee’s overall activities and the extent of his ability to work; and the potential for aggravation of an underlying condition.  See Horst v. Perkins Restaurant, 45 W.C.D. 9 (W.C.C.A. 1991).  Not all factors apply in all cases, and the weight to be attached to any given factor will vary from case to case.  Olson v. Allina Health System, 59 W.C.D. 37 (W.C.C.A. 1999).  The reasonableness and necessity of treatment is a question of fact, and a compensation judge’s decision will not be overturned unless it is clearly erroneous and unsupported by the record as a whole.  Id.

An employer must furnish such medical and surgical treatment for a work-related injury “as may reasonably be required at the time of the injury and any time thereafter to cure and relieve from the effects of the injury.”  Minn. Stat. § 176.135, subd. 1(a).  It is long and well established that "cure and relieve" means "cure or relieve" (emphasis added).  See, e.g., Hall v. Midway Hospital, slip op. (W.C.C.A. Aug. 13, 1991).^[2]  Thus, there need not be a complete cure from the effects of the injury, only an indication that the treatment provides relief.

Here, the compensation judge discussed Minn. R. 5221.6300, subp. 10, and in doing so, discussed many of the factors above.  She found that the treatment at issue was both effective and cost effective.  As she noted, the employee’s treating physicians had prescribed the employee’s medication to treat the employee’s nerve-related symptoms.  Dr. Britton had also recommended continuing the treatment and even increasing the dosage.  The compensation judge also pointed out that the employee “has not required any extensive medical care since the medication was prescribed.”  In her memorandum, the compensation judge noted that although the employee had ongoing symptoms, the medication allowed the employee to manage her condition and she had improved to a point where she was “fairly stable.”  Therefore, she determined that the employee’s treatment, including Lyrica, had been in compliance with Minn. R. 5221.6300, subp. 10, and had been reasonable and necessary to treat the employee’s condition.  Because there is substantial evidence, including Dr. Britton’s opinion and the employee’s testimony, to support the compensation judge’s finding that the treatment has been effective in managing her condition, we will not disturb it on appeal.

The employer and insurer argue that the compensation judge erred in finding that the employee is suffering from an “overuse syndrome” because it is a new Gillette injury that was never alleged by the employee or admitted by the employer and insurer.  The compensation judge was asked to decide whether the disputed medical treatment was reasonable, necessary, and causally related to the February 10, 2010 injury.  Thus, the employer and insurer do not argue that the compensation judge inappropriately issued a decision regarding the causation and nature and extent of the employee’s current symptoms.  Instead, they argue that the judge found a new injury that the employee had not raised as a part of her pleadings.

A compensation judge’s decision shall include a determination of “all contested issues of fact and law” but may not resolve matters that are not at issue.  See Minn. Stat. § 176.371; Carroll v. Honeywell, Inc., slip op. (W.C.C.A. Mar. 31, 1992).  Fundamental fairness requires that parties be afforded reasonable notice and an opportunity to be heard before decisions concerning entitlements to benefits can be made.  Kulenkamp v. TimeSavers, Inc., 420 N.W.2d 891, 40 W.C.D. 869 (Minn. 1988).

We disagree that the compensation judge found that the employee had sustained a Gillette injury.  Rather, the compensation judge chose the same language Dr. Britton used while discussing the employee’s ongoing symptoms and the fact that she continues to work and experience some increased symptoms with increased activity or “overuse.”  In addition, the employee testified at hearing that she had an increase in her symptoms with “overwork.”  The compensation judge also pointed out that none of the doctors involved, including the employer and insurer’s independent medical examiner, have opined that the employee’s current issues are related to any prior injury, condition, or underlying issues.  She then found that the employee’s “initial injury on February 10, 2010 was aggravated by continuing repetitive work activities with her left hand that resulted in the need for continuing medical treatment of her overuse syndrome.”  The compensation judge also noted that the employee’s primary symptoms, and the activities that aggravate her symptoms, have not changed significantly over time.

The compensation judge’s credit of Dr. Britton’s opinion is also instructive.  Dr. Britton opined that the employee has a nerve-related condition that will not likely resolve.  As discussed above, the employee’s injury was difficult to diagnose, which does not bar compensability.  See Wegner, No. WC11-5240.  The compensation judge also cited the activity-related symptoms that Dr. Britton discussed.  Ultimately, the compensation judge determined that the employee’s symptoms following the initial injury on February 10, 2010 had not resolved and that her current symptoms and need for treatment are the result of the employee’s initial injury, her ongoing nerve issues, and her continued work activities.  Because substantial evidence supports that determination, as discussed above, we affirm.