The employee appeals from the compensation judge’s findings that the employee had no restrictions or need for treatment as a result of the employee’s admitted left hand injury.  We affirm.

The employee, Scott Polzin began working for the employer, Canterbury Park, as a poker dealer in July 2007.  The job required him to deal cards to nine or ten players at his table throughout his shift.  He dealt the cards by holding the deck in his right hand, “peeling off” cards from the deck one at a time, and “pitching” them to the players using his left hand.  Occasionally, he was required to shuffle cards, although this was normally done with a shuffle machine.

The employee had no history of left hand symptoms or treatment before starting work for the employer.  Beginning in mid-November 2008, he began to experience discomfort in his left hand while dealing cards.  While at work on December 19, 2008, the employee had burning pain in the left hand and numbness and tingling in the left pinky and ring fingers.  He stopped working midway through his shift.

On December 20, 2008, the employee was seen at the Allina Medical Clinic by Dr. Robert Goodwin.  He gave a history of three to four weeks of tightness on the back of his left hand in the area of the fourth and fifth metacarpals, followed on December 19 by the development of pain and tingling from this area into the fourth and fifth fingers and along the volar aspect of his forearm.  Dr. Goodwin diagnosed an overuse injury related to the employee's job, but the exact nature of the injury was uncertain.  He gave the employee restrictions which limited repetitive use of his left hand, and referred him to see an orthopedist or sports medicine specialist.

The employer and its insurer, SFM, accepted liability for the employee’s left hand injury.  The employee’s weekly wage on December 19, 2008, was $1,135.21, an amount which included substantial tip income.  The employer provided the employee with light duty work in accordance with Dr. Goodwin’s restrictions.  The employee was assigned to pick up “chip racks” over the next two months.  This job paid a lower wage, so the employee received temporary partial disability benefits.

The employee was seen by Dr. Scott Koehler, a sports medicine specialist, on December 22, 2008.  X-rays taken on that date showed no fractures, dislocations, osseous lesions or significant arthrosis.  Dr. Koehler noted that the employee’s hand appeared normal on observation.  No muscle atrophy or edema was noted and there was a full range of motion.  The employee was tender over the flexor carpi ulnaris tendon (“FCU”) as well as over the triangular fibro cartilage complex (“TFCC”).  He reported increased pain when stressing the FCU tendon with resistance.  Dr. Koehler diagnosed work related flexor carpi ulnaris tendonitis with mild extensor carpi ulnaris tendon (“ECU”) and TFCC involvement.  He recommended that the employee use a wrist brace while sleeping and dealing cards, and take a work break of 20 minutes every two hours to ice the wrist.

After a return visit to Dr. Koehler in January 2009, the employee was referred for physical therapy and a wrist brace.  On February 4, 2009, the employee reported some improvement in his pain.  He was now tender to palpation only over the ECU sheath.  Tinel’s, Phalen’s and DeQuervain’s signs were all negative.  Dr. Koehler gave the employee an ECU tendon sheath injection.  He authorized the employee to deal cards with his right hand, holding the deck with his left.

The employee returned full time to his job as a poker dealer using his right hand to distribute cards.  When seen again by Dr. Koehler on February 27, 2009, the employee reported his symptoms were unchanged since his last visit.  Dr. Koehler recommended that the employee continue occupational therapy and have an MRI scan of his left wrist.

The MRI was performed on March 10, 2009.  The extensor carpi ulnaris tendon was seen as within normal limits at the skin marker the employee had used to represent the location of his pain.  There was no significant thickening, tearing or splitting, and no significant tenosynovitis.  The mid to radial portion of the triangular fibro cartilage (TFC) was also unremarkable.  Mildly attenuated intermediate signal intensity was present at the mid to ulnar portion of the TFC, which the radiologist suggested could represent mild chronic sprain.  There was no evidence of a discrete tear and no abnormal distal radioulnar effusion.  The intrinsic ligaments of the wrist were intact.

When seen by Dr. Koehler on May 8, 2009, the employee was still noted to be significantly tender over the musculoskeletal junction of the ECU, with less tenderness over the insertion point.  Dr. Koehler’s diagnosis was of an improving left lateral wrist tendonitis.  The employee was continued on the same restrictions.

The employee returned to Dr. Koehler for a follow up appointments in June, 2009.  Dr. Koehler suggested that he consult with an orthopedic physician to consider a TFCC injection, an MRI with wrist arthrogram, or some other form of treatment.

On July 7, 2009, the employee was seen by Dr. Robert W. Shepley at the Orthopaedic and Fracture Clinic at Northfield Hospital.  The employee reported that he no longer had left wrist pain, but continued to have aching in the wrist in the same distribution.  Dr. Shepley noted tenderness over the ulnar styloid and over the triangular fibro cartilage complex.  There was no catching or locking.  He read the MRI as showing chronic attenuation in the triangular fibro cartilage complex, with the remainder of the ligaments in the wrist, and bone and articular cartilage structures, showing as normal.  Dr. Shepley’s assessment was ulnar sided left wrist pain with possible attenuation of triangular fibro cartilage complex.  He recommended that the employee try a wrist cast for six weeks, or, in the alternative, that he be referred to a hand specialist.  He agreed that the employee should continue to restrict the use of the left hand.

The employee was seen in consultation by Dr. David P. Falconer at Summit Orthopedics on August 24, 2009, at the request of Dr. Shepley.  The employee gave a history of coordination problems, pain and discomfort over the dorsal ulnar aspect of the left wrist and the base of the fifth metatarsal.  His pain was seen to localize over the dorsal ulnar pronator a bit distal to the TFC, and Dr. Falconer noted a possible synovitic snap located over the fifth CMC or triquetral hamate (“TH”) joint.  Although no gross deformity was seen on x-ray, Dr. Falconer noted irregularity and widening at the TH joint suggesting a possible anatomic abnormality in this area.  He diagnosed left wrist pain with synovitis and performed a steroid injection to the employee’s left wrist.  On September 28, 2009, the employee returned and was given another injection.

When the employee returned to Dr. Falconer on October 26, 2009, he reported that he had received no lasting benefit from the injections.  His pain had recurred and was persistent.  Dr. Falconer suggested that an MRI arthrogram and open exploration of the dorsal triquetral ligament complex might be attempted in order to further investigate the possible source of the employee’s problem and determine if instability, synovitis, or erosive changes in the tip of the hamate were present.  Dr. Falconer suggested that if the MRI arthrogram were normal, surgical exploration of the pain spot could be warranted, although no guarantees could be made as to whether surgery might or might not improve the employee’s condition.  He noted that surgery could also leave him stiff and tender with scar tissue with no change in symptoms.  Dr. Falconer further opined that the employee might have to go on long term disability to get away from card dealing or repetitive motion, and that a permanent job change might be indicated.

The MRI left wrist arthrogram was performed on December 21, 2009.  There were no abnormalities in carpal alignment.  Mild contrast migration was seen from the radio carpal joint into the midcarpal space, and there was a small focal fenestration of the membranous portion of the scapholunate ligament without widening of the scapholunate interspace.  The TFCC was intact.  Mild tendinosis of the extensor carpi ulnaris was present, but no other tendinous injury was seen.  There was no evidence for a ganglion cyst.

Dr. Falconer saw the employee twice more in follow up in January and February 2010.  He noted that the MRI arthrogram was negative in the dorsal ulnar wrist with the exception of a pinhole tear of uncertain significance.  The objective findings did not entirely correlate with the employee's symptoms.  He noted, however, that the employee had a type II hamate, touching the lunate, which sometimes could be painful.  He suggested a further injection.  If the employee's symptoms continued to persist, he suggested an arthroscopic inspection and possible debridement of the tip of the hamate.

The employee decided to seek an opinion on his symptoms at the Mayo Clinic, where he was seen on March 16, 2010 by Dr. Steven Giuseffi.  The employee presented with left dorsal hand pain, with symptoms largely localized to the dorsal aspect of the left fourth and fifth metacarpals.  On examination, there was no obvious deformity.  Sensation was intact and the range of motion of the fingers was full.  There was mild subjective hypesthesia in a left ulnar nerve distribution.  Review of the prior imaging showed no evidence of a carpal fracture, metacarpal fracture, scapholunate dissociation or lunotriquetral ligament injury.  Tendons were intact.  Dr. Giuseffi considered the etiology of the employee's symptoms unclear and suggested an EMG and bone scan.

The employee was also seen on the same date, March 16, 2010, by another Mayo Clinic physician, Dr. Richard A. Berger.  The employee described pain in the ulnar aspect of his left, non-dominant hand, which began when dealing cards.  There was occasional numbness and tingling in the ulnar nerve distribution but no cramping, and he was otherwise asymptomatic.  On examination, there was tenderness at the level of the fifth CMC joint.  No instability or crepitance was present.  There was moderate discomfort on palpation in the fourth web space.  The employee’s hand was not tender over the hook of the hamate.  Some mild tenderness was present at the level of the pisotriquetral joint but the employee did not relate this to his current complaint.  Compression of the ulnar nerve throughout Guyon’s canal failed to replicate the employee's symptoms.  Dr. Berger diagnosed left ulnar wrist and hand pain of uncertain etiology.  He recommended that the employee undergo electro diagnostic studies, as well as a technetium 99 bone scan to rule out an osseous or arthritic etiology.

The employee returned to Dr. Berger on March 22, 2010. His left hand was tender just distal to the hook of the hamate and deep pressure in this region replicated his pain, including production of referred pain to the dorsal aspect of the hand.  Dr. Berger noted that the bone scan was largely unremarkable.  He suspected that there might be some issue with the deep branch of the ulnar nerve just distal to the hook of the hamate, although nothing demonstrating this was seen on the imaging or diagnostic tests.  He recommended a high resolution MRI of the left wrist, and referred the employee to Dr. A.T. Bishop for a provisional second opinion.

The MRI was performed on June 1, 2010.  It showed mild extensor carpi ulnaris tendinopathy with associated surrounding tissue swelling and edema.  There was no abnormality involving the ulnar nerve or branches, including the hook of the hamate.  No abnormality was seen underlying a marker placed over the dorsal ulnar aspect of the wrist.  A bone scan showed increased uptake in the right third MCP joint, consistent with post-traumatic or degenerative change, but was otherwise normal.

Dr. Bishop saw the employee for a second opinion at the Mayo Hand Clinic on June 1, 2010.  The employee’s current symptoms were of an “icy hot sensation” located on the dorsal ulnar aspect of the hand, distal to the wrist joint, and spreading into the ring and small fingers.  These symptoms typically lasted from a few minutes to a few hours, but sometimes for a day or two.  Point tenderness was present in the inter metacarpal space along the radial border of the fifth metacarpal shaft distal to the CCMC joint and proximal to the MP joints.  The employee denied any tenderness over the wrist.  The ECU was benign; the fourth and fifth carpometacarpal joints were painless and stable; and the ulnar midcarpal joint was stable and painless.  The pisotriquetral joint and the insertion of the flexor carpi ulnaris on the pisiform were both normal.  There was no tenderness over the hamate hook.  The employee had no volar tenderness.  Dr. Bishop noted that the MRI had shown no focal abnormalities, and that the small findings on the scan did not correlate with the employee's symptoms.  He diagnosed dorsal ulnar hand pain at the radial border of the fifth metacarpal shaft, with unknown etiology.  In Dr. Bishop’s opinion, the employee had been provided with extensive conservative care without benefit and no workup had demonstrated any identifiable lesions.  He opined that there was no further treatment to offer him at this time.

Dr. Berger saw the employee again at the Mayo Hand Clinic on June 10, 2010.  The employee was now pointing to the mid-shaft of the fifth metacarpal on the left side as the source of his pain, which was a location more distal than the employee had previously identified.  Exam showed focal tenderness on the radial aspect of the mid-shaft of left fifth metacarpal.  There was no pain with resisted abduction and adduction of the ring or small fingers, no evidence of intrinsic contracture, and no evidence of tenosynovitis.  Dr. Berger characterized the MRI findings as essentially normal.  He had no further recommendations and opined that the employee could engage in activities of any nature without jeopardy to his hand.

The employee, however, testified that he did not feel able to resume dealing cards with his left hand.  He was still working full time dealing cards with his right hand.  However, he testified that during June 2010, his left hand pain returned to the point that he felt unable even to deal cards right-handed.  He asked that the employer give him lighter work.  The employer agreed to this request and assigned the employee to work at a reception desk for the rest of the summer.  This assignment paid the employee less than he earned as a card dealer.

The employee returned to Dr. Falconer at Summit Orthopedics on June 29, 2010.  He told the doctor that he continued to have localized pain over the ulnar carpus, which was worse when dealing cards.  Dr. Falconer again recommended a diagnostic midcarpal arthroscopy.  In his view, should this procedure not be approved, the employee should undergo a functional capacities evaluation to set permanent restrictions, and he should avoid card dealing.  He provided the employee with written restrictions against working with the left hand pending possible surgery.

The employee filed a claim petition on July 20, 2010, seeking wage loss benefits, a vocational rehabilitation consultation, and approval of the surgical procedure recommended by Dr. Falconer.

On July 19, 2010, the employee was seen by Dr. Mark E. Friedland for an examination on behalf of the employer and insurer.  Dr. Friedland noted that the employee’s current reported symptoms were constant pain over the mid to distal aspects of the left fourth and fifth metacarpals, with the pain greater on the dorsal than the volar aspect of his hand.  The employee stated that the numbness and tingling he previously had in December 2008, had resolved.  Physical examination showed tenderness in the fourth interosseous space, greater over the dorsal than the volar aspect.  Slight tenderness was present over the mid shaft of the fifth metacarpal, with greater subjective symptoms reported on dorsal palpation.  There was tenderness over the dorsal aspect of the left wrist just distal to the ulnar styloid.  No tenderness was present over the hamate on the volar ulnar aspect of the wrist.

Dr. Friedland diagnosed left hand pain without objective anatomic corroborating findings on examination or radiographic studies.  In his opinion, the employee’s subjective complaints were without any verifiable objective anatomic etiology.  He noted that no aberrations were ever identified on MRI scans in the locations where the employee claimed to have pain; in fact all examinations and radiological findings were within normal limits.  In his view, the employee had never had symptoms consistent with any abnormalities of the hook of the hamate, which he noted to be on the volar rather than dorsal aspect of the wrist.  He opined that the employee was not in need of any additional medical care, and that there was no reason for any work restrictions.  He did not agree with Dr. Falconer’s recommendation for surgery, which he believed was neither reasonable nor necessary.  Dr. Friedland further concluded that the employee had reached maximum medical improvement by June 1, 2010, at the latest, and that there was no ratable disability.

In September 2010, the employee was promoted to floor supervisor at an hourly wage of about $22.00 an hour.  This hourly wage was markedly higher than the hourly rate the employee received as a poker dealer; however, the employee's weekly earnings in this job remained less than he was making as a poker dealer because he no longer received tips.

In a report dated November 11, 2010, prompted by a letter from the employee’s attorney, Dr. Falconer responded to Dr. Friedland’s opinion.  He felt that Dr. Friedland had mischaracterized his surgical recommendation, noting that he was merely proposing arthroscopy as another tool to investigate the etiology of the employee’s hand pain and soreness, because of the x-ray evidence of a type 2 lunate and the theoretical potential for hamate lunate impaction.  Dr. Falconer acknowledged that any severe joint irritation or arthritic damage would usually be frankly evident either on MRI or on a nuclear scan.  He further acknowledged that the fact that the nuclear scan done at the Mayo Clinic was completely normal in this area suggested that the proposed arthroscopic investigation of the tip of the hamate might find it to be normal.  However, given the diagnosis of unexplained hand pain with apparent temporary symptomatic improvement from cortisone injections in the midcarpal joint; and given the theoretical potential for lunate hamate impaction with a type 2 lunate, Dr. Falconer still believed that diagnostic arthroscopy was appropriate.  He noted, however, that if the hamate was found to be normal there might be no lasting or therapeutic benefit from the procedure.

The employee returned to Dr. Falconer on November 18, 2011.  He testified that he had gone to see Dr. Falconer because the doctor had not provided a letter report requested by his attorney.  Dr. Falconer noted that he had reviewed the Mayo Clinic records provided by the employee’s attorney as well as Dr. Friedland’s report.  He reiterated that he believed that the employee’s symptoms were consistent with a possible impingement of the hamate lunate on the employee's type 2 lunate facet.  He again noted that he found it “concerning” for his theory that the MRI scan at Mayo was negative, but still felt that further diagnostic testing in form of diagnostic arthroscopy was a reasonable approach.  He advised that the employee continue to avoid highly repetitive painful use of his left hand.

The employee’s claims came on for a hearing before a compensation judge of the Office of Administrative Hearings on April 12, 2012.  Summit Orthopedics had by this time intervened seeking payment for certain medical expenses, which were also now at issue.

Following the hearing, the judge found that the employee no longer had restrictions on his work activities after June 1, 2010.  Accordingly, the judge denied temporary partial disability compensation from that date through the date of hearing.  The judge further found that the arthroscopic surgery recommended by Dr. Falconer was not reasonable or necessary.  Finally, the judge found that the employee’s office visit with Dr. Falconer on November 18, 2011, was not reasonably necessary to cure or relieve the employee's work-related injury, but was instead for the purpose of obtaining a report from the doctor for litigation purposes.  The claim for payment of the expenses of this office visit was denied.  The employee appeals.

On appeal, the employee argues that substantial evidence does not support the compensation judge’s decision.  He refers to his testimony regarding the level of his pain from June 2010 and continuing which made it necessary to quit dealing cards at that time.  He contends that this testimony, along with the records and opinion of Dr. Falconer, who advised him to restrict the repetitive use of his left hand, constitute substantial evidence supporting his claim that his medical condition restricted him from continuing in the job he held at the time of injury and qualified him for temporary partial disability benefits.

The compensation judge found that the employee was not under restrictions from his work injury during the period for which wage loss benefits were sought, from June 1, 2010, through the date of hearing.  In her memorandum, the compensation judge discussed in detail the evidence on which she relied.  In particular, she noted that, despite thorough examinations and exhaustive diagnostic testing, no abnormalities were found that correlated with the employee’s symptoms.  The judge accepted the medical opinions of Dr. Berger and of Dr. Friedland, both of whom found no basis for any medical restrictions.

The employee states that Dr. Berger was unaware of the subjective increase in his symptoms which began in June 2010, after the date that Dr. Berger had expressed the opinion that the employee could engage in any activities with his left hand, and which led the employee to discontinue dealing cards even with the right hand, his left hand pain having reached “11” on a scale of 10.  The employee argues that, since the compensation judge made no express finding discounting the credibility of his testimony of increased symptoms in June 2010, the opinions of Dr. Berger and Dr. Bishop were without adequate foundation, in that they were rendered prior to and without knowledge of his increase in symptoms.

We note, first, that we do not find the employee’s foundation argument here particularly convincing, since the wording of Dr. Berger’s medical opinion reasonably supports the interpretation that it was based primarily on the absence of objective medical findings rather than on the nature of the employee’s subjective symptoms.  Thus, the compensation judge could have concluded that an increase in reported symptoms without any objective evidence of physical abnormality would not have been a change in the foundation of the doctor’s opinion.

We also note that the employee testified that his symptoms, after increasing in June 2010, had remained unchanged at the increased level.  Even if we were to accept the employee’s argument that a medical opinion rendered without knowledge of the increased symptoms lacked adequate foundation, that argument does not apply to the opinion of Dr. Friedland, who saw the employee in mid-July 2010, and who also concluded that the employee was not in need of work restrictions.

It is the function of the compensation judge to consider competing medical opinions and the judge’s decision in that regard will be affirmed so long as the accepted medical opinion has adequate foundation.  Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Smith v. Quebecor, 63 W.C.D. 566 (W.C.C.A. 2003). After a review of the record, we conclude the opinions of Drs. Bishop and Friedland had adequate foundation and it was not error for the compensation judge to rely on those opinions.

The employee notes that the compensation judge did not discuss in detail the employee’s testimony about the flare up of his symptoms in June 2010.  He argues that this suggests that the compensation judge simply failed to consider the record as a whole.  We disagree.  The compensation judge stated in her memorandum that she carefully reviewed and considered all of the evidence, including the employee’s testimony.  In fact, she directly quoted the portion of the employee’s testimony stating that in June 2010, his left hand pain was at 11 on a scale of 10.  In any event, a compensation judge need not comment on every piece of evidence introduced at hearing.  See, e.g., Engels v. City of Delano, 65 W.C.D. 497 (W.C.C.A. 2005); Winkel v. Jacobson Transp., slip op. (W.C.C.A. Oct. 12, 2004).

The employee also points out that the compensation judge did not make an express finding as to the date that the employee no longer required work restrictions.  He contends that a remand is necessary in light of the failure to make such a finding.  We disagree.  The compensation judge’s findings, orders and memorandum, taken as a whole, make it clear that the compensation judge found no restrictions in effect during the specific time period for which benefits were sought.  It was not necessary for the judge to establish a precise date when the date had no relevance to the employee’s claim.

Since substantial evidence supports the compensation judge’s finding that the employee had no restrictions during the period during which benefits were sought, we affirm that finding.  Where an employee is able to work without any restrictions from the work injury, the employee is ineligible for wage loss benefits.  Kautz v. Setterlin Co., 410 N.W.2d 843, 40 W.C.D. 206 (Minn. 1987).  Accordingly, we also affirm the denial of temporary partial disability compensation.

In January 2010, after no other condition had been found to explain the employee’s ongoing left wrist pain, Dr. Falconer proposed that the employee undergo diagnostic arthroscopy to determine whether the employee's symptoms might be related to irritation of the upper midcarpal joint, possibly related to the employee’s type II hamate.  The employee then went to the Mayo Clinic for a second opinion.  While there, he had an enhanced MRI scan which failed to show any focal abnormalities, and in particular, no abnormalities in the region where the employee's pain was localized.  The Mayo physicians offered the opinion that no further treatment or diagnostic study was warranted.

The employee then returned to Dr. Falconer, who continued to recommend the arthroscopic surgery procedure, although any severe joint irritation or arthritic damage would usually be evident on an enhanced MRI scan.  Dr. Falconer also acknowledged that because the scan done at the Mayo Clinic was completely normal, the proposed arthroscopic investigation of the tip of the hamate might find it to be normal, and if so, there would be no benefit to the surgery.  However, given the employee’s unexplained hand pain, his apparent temporary symptomatic improvement from cortisone injections in the midcarpal joint, and the theoretical potential of lunate hamate impaction associated with a type 2 lunate, Dr. Falconer still believed that diagnostic arthroscopy was appropriate.

The reasonableness and necessity of medical treatment under Minn. Stat. § 176.135 is a question of fact for the compensation judge.  Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993).  “The employee bears the burden of proving that health provider services were reasonable and necessary.”  Wylie v. Dan's Plumbing & Heating, 47 W.C.D. 235, 238 (W.C.C.A. 1992) (citing Wright v. Kimro, Inc., 34 W.C.D. 702 (W.C.C.A. 1982)).

On reviewing the evidence, the compensation judge accepted the expert medical opinion of Dr. Friedland, who considered the proposed surgery neither reasonable nor necessary.  Dr. Friedland stated that the employee’s subjective complaints were without any verifiable objective anatomic etiology, and that no aberrations were ever identified on MRI scans in the locations where the employee claimed to have pain; in fact all examinations and radiological findings were within normal limits.  He further did not see any basis to conclude that the employee’s symptoms were consistent with an abnormality of the hook of the hamate, which he noted to be on the volar rather than dorsal aspect of the wrist, where the employee’s pain was localized.

The employee argues on appeal that the compensation judge should have accepted Dr. Falconer’s opinion, because Dr. Falconer was the only physician to suggest any further treatment or testing to diagnose the employee’s problems.  The employee also argues that Dr. Friedland misunderstood or mischaracterized the diagnostic purpose of Dr. Falconer’s suggested procedure.  Neither of these arguments provides a basis for reversing the compensation judge’s determination.

The question here was decided primarily on the compensation judge’s choice between expert medical opinions.  We see no foundational defect in Dr. Friedland’s opinion sufficient to make the compensation judge’s reliance on his opinion unreasonable.  We therefore affirm.  Nord v. City of Cook, supra, 360 N.W.2d 337, 37 W.C.D. 364.