The employer appeals from the finding that the employee’s work injury on June 19, 2006, is a substantial contributing cause of her current disability and from the award of temporary total disability compensation.  The employee cross-appeals the denial of her request for a change of physician.  We affirm.

The employee, Kathleen Jerikovsky, began working for Lakes & Pines Community Action Council in April 1989.  She worked as a weatherization technician, installing weatherization materials at homes which qualified under the employer’s weatherization programs.  The employee worked for the employer until April 22, 2011.  During her employment, the employee sustained numerous work injuries to multiple body parts.  The record contains First Reports of Injury for 21 injuries between January 16, 1990, and December 29, 2010.  The most recent hearing involved employee’s claim for benefits arising out of a right shoulder injury that she alleged had occurred either on June 19, 2006, or April 22, 2008.  To the extent possible, this review will focus only on those two injuries and on the employee’s right shoulder complaints and treatment.

The employee began treating with Dr. John A. Benson, a chiropractor in Cloquet in February 1996.  His treatment notes from that time on indicate that the employee saw him for a variety of symptoms, primarily for pain in her cervical, thoracic, and lumbar spine, but also including treatment for her right trapezius.

On June 19, 2006, the employee missed a step while descending a ladder and fell about five feet to the ground, landing on her right side with her right arm extended.  She saw Dr. Benson on June 21 with symptoms of upper and low back pain as well as right shoulder pain.  She began a program of chiropractic treatment at that time and saw Dr. Benson a number of times in the ensuing months.

On July 24, 2006, the employee saw Dr. Patrick Hall at Orthopedic Associates of Duluth.  She reported that she had experienced right shoulder, right wrist, and right knee pain since a fall from a ladder on June 19.  She had not had any treatment in the form of therapy, medications, or injections for her symptoms.  She had found that overhead reaching and drilling at work was aggravating her right shoulder pain.  Examination showed the employee was tender to palpation over the anterolateral acromion and rotator cuff.  The AC joint was prominent but non-tender. Dr. Hall diagnosed right shoulder impingement, right wrist pain, and right hip trochanteric bursitis.  He recommended that the right shoulder be treated conservatively with physical therapy and anti-inflammatory medications.  Diagnostic radiology and conservative treatment modalities were recommended for the wrist, knee, and hip symptoms.  The employee was advised that she avoid overhead reaching and drilling and limit lifting and carrying to 40 pounds no more than four to six hours of her work day.

The employee returned to Dr. Hall on October 2, 2006, for evaluation of her right shoulder. She had been in physical therapy and felt that her symptoms were improving but she still had some right shoulder pain.  The employee noted that she had been avoiding overhead reaching and drilling at work and that this had also helped her symptoms.  Dr. Hall recommended that the employee continue physical therapy and remain on work restrictions to avoid overhead drilling.

The employee had continued to treat with Dr. Benson from time to time for neck, upper back, lower back, and right shoulder symptoms through the summer of 2007. She returned on December 28, 2007, with recurrent spinal complaints and was seen again on January 25, 2008, with her principal complaint being recent episodes of increased upper back and neck symptoms.  On February 11, 2008, Dr. Benson signed a Health Care Provider Report regarding the June 19, 2006, injury in which he indicated that maximum medical improvement (MMI) was reached on that date with no permanency and that no further treatment was anticipated.

On April 22, 2008, the employee sustained a repetitive motion injury resulting in bilateral carpal tunnel syndrome.

The employee began treating with Dr. Michael Momont at Orthopedic Associates of Duluth after she had another fall from a ladder on October 30, 2008, with injuries to her left ankle, left leg, and left shoulder.  Later, she also saw Dr. Momont for her carpal tunnel syndrome.  The employee had an open right carpal tunnel release done by Dr. Momont on April 22, 2011, and an open left carpal tunnel release on May 17, 2011.  The employee has been off work since her first carpal tunnel surgery.

At the appointment with Dr. Momont for her left shoulder problems on June 23, 2011, the employee asked the doctor about the pain in her right shoulder.  She noted that she had previously been seen for her right shoulder pain in 2006.  Her symptoms in that shoulder had now advanced to a point where they had become similar to those she had in the left shoulder after the October 2008 injury.  Dr. Momont told the employee that he would arrange to obtain x-rays of her right shoulder on her next return visit.

On July 21, 2011, Dr. Momont saw the employee for the right shoulder pain.  Her left shoulder had been doing well post surgery.  Dr. Momont noted that the right AC joint was exquisitely tender to palpation.  X-rays revealed a Type 3 acromion morphology with advanced degenerative changes.  He diagnosed an impingement syndrome of the right shoulder, with acromioclavicular joint arthrosis.  He recommended an MRI of the right shoulder and stated that the employee should not return to work until a follow up appointment in four to six weeks.

The employee was seen by Dr. Janus D. Butcher in the orthopedics department at Essentia Health on September 16, 2011, for her right shoulder.  Dr. Butcher’s assessment was right shoulder AC arthrosis, probably posttraumatic, with a possible labral tear and rotator cuff injury.  Right shoulder x-rays on that day showed acromioclavicular joint arthrosis.  He referred her for an MRI.  The MRI of the right shoulder was done on October 5, 2011, and was read as showing synovitis in the rotator interval suggesting adhesive capsulitis.  There was moderate acromioclavicular joint narrowing.

The employee returned to Dr. Butcher the following day, October 6, 2011. Dr. Butcher reviewed the MRI scan and noted that it showed some intrasubstance tearing of the supraspinatus tendon.  He saw evidence of a significant impingement as well as a probable superior labral tear.  He referred the employee to Dr. Troy Erickson for consideration of surgical intervention.  He released the employee to work with limitations on use of the right arm in overhead work.

The employee was seen by Dr. Erickson on October 26, 2011. The employee gave a history of right shoulder pain since she fell off a ladder at work in 2006.  She stated that her ankle and knee were initially more bothersome than her shoulder, but that her shoulder symptoms worsened over time.  Dr. Erickson noted that a large protuberance was present over the right AC joint. The employee had good reflexes and a full range of motion, but “she does struggle with the motions” and there was weakness on testing the supraspinatus at shoulder height.  Dr. Erickson reviewed the MRI scan, which he noted showed what appeared to be a labral tear with rotator cuff tendinitis, impingement signs, and AC arthritis.  Dr. Erickson discussed conservative and surgical treatment options, and the employee indicated she would like to proceed with surgery.

Dr. Erickson scheduled the employee for right shoulder arthroscopic surgery with subacromial decompression, distal clavicle excision, and labral repair.  However, the employee, who no longer had medical insurance, cancelled the surgery after the workers’ compensation insurer denied liability for the right shoulder condition.  Dr. Momont saw the employee in follow-up in November and December 2011 and continued to recommend that the employee undergo right shoulder arthroscopy with decompression and distal clavicle excision.

At a hearing on December 21, 2011, before Compensation Judge John Baumgarth, the primary issue was the employee’s entitlement to temporary total disability benefits for the bilateral carpal tunnel syndrome related to the April 22, 2008, work injury.  A subsidiary issue was noted as being whether the employee had also injured her right shoulder in April 2008.  In Findings and Order issued January 11, 2012, the compensation judge awarded the employee ongoing temporary total disability benefits and deferred the question of whether the right shoulder had been injured in April 2008.  There was no appeal from this decision.

On January 31, 2012, Dr. Momont concluded that that employee had reached MMI from her April 22, 2008, work injury. Temporary total disability benefits were discontinued after an administrative conference on May 9, 2012.

The employee had seen Dr. Mark Gregerson at the request of her attorney in October 2011 for evaluation of the medical issues then in dispute.  The employee saw Dr. Gregerson again on April 9, 2012, for evaluation of her right shoulder pain.  With respect to the right shoulder, Dr. Gregerson noted that x-ray studies he had examined of the right shoulder were normal and he concluded that the employee's shoulder symptoms were secondary to a cervical disc herniation that had been shown in a December 2011 MRI.  However, he also concluded that all of the employee's conditions were due to work activities in her job with the employer.  He offered permanency ratings for the employee's cervical disc herniation, left shoulder, and bilateral knee injuries.  He provided no permanency rating for the right shoulder, based on his opinion that this problem was related to her cervical disc herniation.  He recommended that the employee avoid repetitive bending or twisting of the neck, as well as working overhead, repetitive bending, kneeling or squatting, and lifting be more than 10 pounds with the right arm or 20 pounds overall.

The employee was seen for a medical examination by Dr. Loren Vorlicky on April 27, 2012, on behalf of the employer and insurer.  The employee reported right shoulder pain and continuing pain and dysesthesias in her right wrist and hand.  Dr. Vorlicky acknowledged that the October 2011 MRI of the right shoulder showed findings consistent with acromioclavicular joint arthritis and impingement syndrome with an intact rotator cuff, as well as a slight labral tear.  He also stated that the employee might benefit from right shoulder arthroscopy as proposed by Dr. Erickson.  However, he did not consider the employee's right shoulder condition to be causally related to the June 2006 or April 2008 work injuries, or to any other specific work injury.  Instead, he attributed the employee's right shoulder problems to an impingement syndrome and acromioclavicular joint arthritis which he considered was the result of the aging process, the activities of daily living, “and possibly accumulation of work-related events.”  Dr. Vorlicky also concluded that the employee could work without restrictions.

A hearing was held before Compensation Judge Baumgarth on September 25, 2012.  Among the issues presented were whether the employee was entitled either to permanent total disability benefits from April 22, 2011, through the date of hearing, or to temporary total disability benefits from April 30, 2012, through the date of hearing; whether the employee was entitled to payment of permanent partial disability benefits; and whether the employee was entitled to a change of treating physician from Dr. Momont to Dr. Gregerson.  Following the hearing, the compensation judge determined that the employee had sustained an injury to her right shoulder on June 19, 2006, that the right shoulder injury was a substantial contributing cause of her current disability and wage loss, and that the employee was entitled to temporary total disability compensation from May 1, 2012, through the date of hearing.  The judge also found that the employer and insurer were liable for the treatment expenses for the employee’s right shoulder, and granted authorization for the right shoulder arthroscopy proposed by Dr. Erickson and Dr. Momont.  Finally, the judge denied a change of treating physician to Dr. Gregerson, on the basis that the change of physicians was not in the employee’s best interests.

The employer and insurer appeal from the findings pertaining to the employee’s right shoulder injury and entitlement to temporary total disability compensation.  The employee cross-appeals the denial of the request for a change of physician.

The employer and insurer have appealed the compensation judge’s finding that the 2006 injury is a substantial contributing factor in the employee’s right shoulder condition and argue that this finding is unsupported by substantial evidence.  They point out that the employee returned to work without restrictions for a period of time following the 2006 work injury and that she thereafter worked at more onerous duties than before the injury.  In addition, the employee’s chiropractor, Dr. Benson, signed an MMI form in 2008 referencing the 2006 work injury which did not place any restrictions on the employee.  Finally, they submit that right shoulder complaints do not appear again in the medical records until 2011.  Taken together, they contend, this evidence precludes the conclusion that there was any causal nexus between the 2006 work injury and the employee’s current right shoulder symptoms.  Accordingly, they argue, the compensation judge should have accepted the opinion of Dr. Vorlicky, their medical examiner, who opined that the employee did not sustain a permanent injury to the right shoulder in 2006, and attributed the employee’s current right shoulder condition to other causes.  They further argue that the opinion of Dr. Gregerson, who thought that the employee’s right shoulder and right upper extremity symptoms were related to a cervical disc injury, lends further support to the denial of any link between the 2006 work injury and the employee’s current conditions.

We note, however, that the employee testified that she continued to have right shoulder symptoms following the 2006 work injury through the date of hearing.  The employee testified that she did not seek medical attention for her right shoulder until the pain worsened in 2011 and that between 2006 and 2011 her medical treatment was focused on other conditions and injuries.  The compensation judge found the employee’s testimony credible and this court must give due weight to the compensation judge’s opportunity to observe the witness and judge her credibility.  Brennan v. Joseph G. Brennan, M.D., 425 N.W.2d 837, 839-40, 41 W.C.D. 79, 82 (Minn. 1988); Baker v. T. Maxwells Inc., No. WC09-5003 (W.C.C.A. Feb. 8, 2010).  Where there is conflicting evidence or evidence from which more than one inference may reasonably be drawn, we must affirm the compensation judge.  Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988).

We note, also, that the medical records show that the employee consistently related her right shoulder symptoms by history to her 2006 injury.  The employee’s treating physicians, Dr. Momont, Dr. Erickson, and Dr. Butcher, all attributed the employee’s right shoulder complaints to her work injury.  The compensation judge’s memorandum specifically indicates that he gave greater weight to the opinions of Dr. Momont and Dr. Erickson than to those of Dr. Vorlicky and Dr. Gregerson.  A compensation judge’s choice between conflicting medical opinions is generally upheld unless the facts assumed in rendering the opinion are not supported by the evidence.  Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985).  As we have held in other cases as well, this court will generally affirm a compensation judge’s decision which is based on a choice between competing medical opinions.  Perry v. ADB Constr., Inc., 68 W.C.D. 491 (W.C.C.A. 2008).

We conclude that the finding of a causal link between the employee's 2006 work injury and her current right shoulder symptoms had substantial support in the record, and affirm.

The employer and insurer also argue that the employee is ineligible for temporary total disability compensation pursuant to Kautz v. Setterlin Co., 410 N.W.2d 843, 40 W.C.D. 206 (Minn. 1987).  In Kautz, the court noted that liability for workers’ compensation benefits continues only while an employee continues to have some form of disability from a work injury.  The argument here relies on Dr. Vorlicky’s opinion that the employee sustained no permanent disability and requires no work restrictions due to her work injuries.  The compensation judge, however, left open the questions of permanent work restrictions and permanent partial disability, noting that these issues could not be resolved until the completion of further medical testing and treatment, including the arthroscopic surgery recommended by Drs. Erickson and Momont.  The judge explicitly found that the right shoulder injury remained a substantial contributing cause of the employee's wage loss through the date of hearing.  We have already discussed this finding in the context of its causation aspect. Among the evidence supporting the disability aspect of the finding, we note that the medical records of Drs. Momont and Erickson show that they have recommended work restrictions which fairly clearly relate to the right shoulder condition and not solely to the employee's other conditions; as, for example, the restrictions on overhead use of the right upper extremity.

We conclude that the compensation judge’s finding that the right shoulder condition remains a substantial contributing cause of disability is supported by substantial evidence.

The appellants further argue that the employee lost entitlement to temporary total compensation pursuant both to Minn. Stat. § 176.101, subd. 1(h) and 1(j).  Subdivision 1(h) provides that temporary total disability compensation ceases if an employee has been released to return to work without restrictions from the work injury.  Subdivision 1(j) provides that once maximum medical improvement has been reached, temporary total disability compensation ceases 90 days following service of a medical report indicating the attainment of maximum medical improvement.

Specifically, the employer and insurer argue that, as the employee was able to return to work without restrictions for a period of time following the 2006 work injury, her entitlement to temporary total disability compensation was suspended pursuant to §176.101, subd. 1(h).  In the alternative, the employer and insurer argue that the employee became ineligible for temporary total disability compensation 90 days after February 28, 2008, when the MMI form signed by Dr. Benson and referencing the 2006 work injury was served on her.

With respect to the MMI claim, we first note that the compensation judge specifically discounted Dr. Benson’s report and found that the employee had not in fact reached maximum medical improvement for her right shoulder in 2008.  The compensation judge was not required to accept an MMI report as determinative that MMI was in fact reached; rather, maximum medical improvement is an issue of ultimate fact to be determined by the compensation judge after considering medical records, medical opinions, and other relevant evidence.  Hammer v. Mark Hagen Plumbing & Heating, 435 N.W.2d 525, 528-29, 41 W.C.D. 634, 639 (Minn. 1989).

Here, the compensation judge reviewed the employee’s history of treatment with Dr. Benson and concluded that Dr. Benson was primarily treating the employee’s spinal injuries, so that it was not clear that the MMI form Dr. Benson signed in February 2008 was even intended to express an opinion on MMI for the employee’s shoulder condition.  The judge noted that he gave significant weight to the surgical recommendations and causation opinions of Drs. Erickson and Momont.  These aspects of those medical opinions provide further support to the conclusion that MMI had not yet been reached for the 2006 injury, in that these physicians attributed the need for further medical treatment to the effects of that injury.  The judge could also reasonably take into account the employee’s testimony as to the continuation of her symptoms following the 2006 injury.

Further, the compensation judge clearly did not accept the argument that the employee had no restrictions in early 2008 from the 2006 injury.  As noted previously, he accepted as credible the employee’s testimony of ongoing pain in her right shoulder, especially when trying to do the various physical aspects of her job.  We conclude the provisions of Minn. Stat. § 176.101, subd. 1(f) or 1(j) do not apply here.

The employee had requested authorization for a change of physicians from Dr. Momont to Dr. Gregerson.  Under the facts of this case, authorization for a change of physician is governed by Minn. R. 5221.0430, subp. 4.  Whether a change of physicians should be permitted is a question of reasonableness under the circumstances in each case.  Hernandez v. Heartland Foods, 53 W.C.D. 372, 378 (W.C.C.A. 1995).

The employee first contends that the denial of her request to change physicians resulted primarily from a misreading of Dr. Gregerson’s opinion by the compensation judge.  Specifically, the employee argues that the compensation judge had misread Dr. Gregerson’s report as denying that the employee’s right shoulder condition was causally related to the 2006 work injury.  The employee submits, however, that “Dr. Gregerson clearly stated in his report of October 27, 2011, he did believe that Ms. Jerikovsky’s right shoulder condition was work-related.”  The employee further argues that, even if Dr. Gregerson had not found the employee’s right shoulder condition to be work related, the doctor’s opinion on causation does not constitute a sufficient reason to deny a change of physicians.

The compensation judge explained his denial of the employee’s request in detail in his memorandum:

It is clear that the judge did not deny the change of physicians on the basis of whether or not Dr. Gregerson considered the right shoulder condition to be work related.  Rather, the judge's decision was based primarily on the fact that Dr. Gregerson was attributing the employee’s symptoms to a cervical disc herniation instead of the shoulder condition diagnosed by Drs. Momont and Erickson.  The compensation judge found that the arthroscopic surgery which these other physicians had recommended to diagnose and treat these shoulder conditions was reasonable and necessary.  It is not unreasonable under the circumstances for the compensation judge to have also concluded that treatment should not be transferred to the one physician who did not agree with the diagnoses on which the surgical recommendation was based.

The employee argues that no provision of the rule explicitly makes this kind of consideration a basis for denial of a change of physicians, and that the compensation judge in effect has created a new basis for denying a change of physicians beyond those provided in the rule.  The compensation judge, however, applied subpart F of the rule, having considered that, based on the evidence and findings, and his reasoning above, it was not in the parties’ best interests for the employee’s physician to be changed to Dr. Gregerson.  Subpart F is, in a sense, a kind of “catch-all” provision which allows a compensation judge to consider factors not otherwise specifically set forth in the rules in determining whether to grant a change of physicians.  We cannot say that it was unreasonable here for the compensation judge to conclude that the situation before him met the requirements of this subpart.

The employee makes two further arguments which we will deal with very briefly here.  First, the employee contends that the change of physicians was unopposed in that the employer and insurer did not specifically reiterate their opposition to that request during the course of the hearing.  We note, however, that the issue was in fact joined both by their denial of the request and by the fact that they reiterated their opposition to it in closing written arguments.

The employee also argues that the compensation judge erred in failing to consider as a factor that the geographic distance the employee needed to travel to see Dr. Gregerson was less than that needed to see Dr. Momont.  While no specific evidence seems to have been offered on the relative distances need to travel to each physician, the employee made a generalized relative distance argument in her post-hearing memorandum to the compensation judge, and referred the judge to the employee’s testimony that she had experienced discomfort while driving to Duluth for the hearing (Duluth also being the location of Dr. Momont’s offices).  We see no reason to assume that the compensation judge failed to take this argument and testimony into consideration.  That he did not discuss them is not a basis for reversal.  A judge need not discuss every piece of evidence introduced at hearing.  Regan v. VOA Nat’l Housing, 61 W.C.D. 142 (W.C.C.A. 2000).