The employer and insurer appeal from the judge’s finding that the employee sustained consequential injuries to her hip and low back as a result of her 1997 work-related right ankle injury.  We affirm.

The employee was working for Greater Lake Country Food [the employer] on October 30, 1997, when she sustained a work-related injury to her right ankle.  The injury was initially diagnosed as an ankle strain, and the employee treated with medication, physical therapy, and an injection.  In physical therapy notes in December of 1999, the employee mentioned right hip pain.  In early 2000, she was noted to have acute tenderness about the right lateral ankle, with swelling and postural dysfunction.

The employee underwent an independent psychological exam in April of 2001 with Dr. Robert Clift.  At that time, the employee reported that she continued to have right ankle pain, was unable to dorsiflex her foot, and could walk no more than 30 minutes.

The employee subsequently moved to Wisconsin.  At an independent medical examination on November 3, 2003, with Dr. Ahmad Haffar, for a different injury, the employee reported that, in 1998, she had lost flexibility in her right foot and had also developed what she described as drop foot.

The employee began treating with Dr. Stephen Arbes on April 6, 2006.  At that time, the employee indicated that she had experienced pain in the right ankle for 9 to 10 years, and Dr. Arbes diagnosed an “old injury” to the right peroneal.

Dr. Paul Cederberg performed an independent medical examination on November 1, 2006.  Noting mild swelling of the anterior talofibular region and decreased dorsiflexion of the right ankle, Dr. Cederberg diagnosed stiffness and heel cord contracture and stated that “the problems she has with her right ankle date back to the injury in 1997.”

Subsequently, an MRI revealed a longitudinal tear of the peroneus longus tendon.  Dr. Arbes reviewed the MRI with the employee on January 31, 2007, and told her that the aches and pains in her hips, back, and neck were “most likely coming from her altered gait because her foot is so painful.”  At his recommendation, the employee underwent a right peroneal tendon repair on July 3, 2007.  She continued to receive treatment after that surgery.  In September of 2007, she sought care at Bellin Health System for complaints that included ankle pain, hip pain, and back problems.  In March of 2009, she treated for chronic pain affecting multiple body parts, including the back, ankle, and hips.

On November 11, 2009, the employee was seen by Dr. David Kaufman, who noted that the employee had “chronic right ankle pain that interferes with her ability to ambulate [e]ffectively.”  It was Dr. Kaufman’s impression that the employee’s chronic hip pain and bursitis were “secondary to altered body mechanics from a right ankle injury dated 10/30/97.”

On October 17, 2011, the employee was seen in consultation by Dr. Brian Knapp, who recorded that the employee had sustained a severe right lateral ankle sprain in 1997.  He diagnosed, in part, right ankle osteoarthritis and valgus positioning with plantar fasciitis, and bilateral trochanteric bursitis and right piriformis syndrome.  He related the trochanteric bursitis and right piriformis syndrome to the employee’s gait abnormality, and he recommended that the employee use a wedge in her shoe.

The employee treated with Carol Rafferty, APNP, at Bellin Health System on February 9, 2012.^[1]  At that time, the wedge had not yet been approved by the workers’ compensation carrier, and the employee’s primary complaint was pain in her hips, low back, and ankles.  It was Ms. Rafferty’s impression that the employee’s ongoing discomfort and chronic symptoms all related to the work injury.

Dr. Cederberg examined the employee again on August 28, 2012, and diagnosed a sprain and ligament tear to the right ankle due to the 1997 work injury.  He opined that the employee “did not sustain a consequential injury to her lumbar spine or hips due to an altered gait” arising from the 1997 injury.  He explained, “I am not aware of any published reports or textbooks that relate an ankle injury or sprain as a causative factor causing bursitis at a later date in a patient’s hips or low back disorder.”

Dr. Knapp reviewed Dr. Cederberg’s report and responded by letter of November 9, 2012.  According to Dr. Knapp, the employee’s right ankle surgery in 2007 was performed “with the express purpose of improving the patient’s hip and back pain.”  Quoting from a Physical Medicine and Rehabilitation text book, he went on to explain his opinion that gait dysfunction can cause secondary musculoskeletal symptoms and diseases such as trochanteric bursitis.

When the matter proceeded to hearing, the sole issue was whether the employee’s hip and low back conditions were causally related to the 1997 right ankle injury.  The judge found that the employee had sustained consequential injuries to her hips, legs, and low back caused by the altered gait resulting from the 1997 injury.  The employer and insurer appeal.

On appeal, 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.”  Minn. Stat. § 176.421, subd. 1 (2012).  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.”  Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  Similarly, 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 evidence or not reasonably supported by the evidence as a whole.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

The employer and insurer contend that medical evidence does not support the judge’s finding of consequential injuries to the employee’s hip and low back, arguing that the judge “erroneously accepted the opinions of the Employee’s treating physician, Dr. Knapp.”  The employer and insurer contend that the Dr. Knapp’s opinions are faulty because Dr. Knapp assumed that the employee had sustained a “serious” injury to her right ankle in 1997, he was not aware of the gap in medical treatment from 2000 to 2006, and he did not have access to the employee’s full medical history.  We are not persuaded.

The employee testified that she had ongoing pain in her right ankle after the 1997 injury.  The medical records establish that, between the date of injury and March of 2000, she was treated with physical therapy, medications, and injections.  While there was no evidence that the employee sought care for her ankle between 2000 and 2006, the reports from Dr. Clift and Dr. Haffar, issued during that period, reflect that the employee had ongoing pain in her right ankle and limited dorsiflexion and that disputes with the insurer may have been limiting the employee’s ability to receive treatment.

In 2006, Dr. Cederberg diagnosed stiffness and heel cord contracture and opined that the employee’s right ankle symptoms at that time were related to her 1997 work injury.  Torn ligament and tendon were not diagnosed until 2007, and when Dr. Cederberg re-examined the employee in 2012, he related the ligament tear to the 1997 injury.

A judge’s choice between expert witnesses is generally 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).  Other than contending that Dr. Knapp wrongly assumed that the 1997 right ankle injury was “serious,” the employer and insurer point to no facts assumed by Dr. Knapp that were not supported by the evidence.  And Dr. Knapp’s characterization of the right ankle injury as “serious” was not improper given that the injury required treatment over a number of years and eventually necessitated surgery.

We would also note that the judge did not rely solely on the opinions of Dr. Knapp.  Rather, the judge specifically found that Dr. Kaufman, Dr. Yeatman, and Dr. Arbes also opined that the chronic pain in the employee’s legs, hips, and low back was related to the employee’s altered gait.  Those doctors tied the employee’s altered gait to right ankle pain from the 1997 work injury.

The employee’s medical records reflect ongoing pain, stiffness, and decreased dorsiflexion in the employee’s right ankle after the 1997 injury.  There are also multiple references to the employee’s difficulty walking and that her difficulty walking caused discomfort in her hips and low back.  The compensation judge was entitled to accept the opinions of the employee’s treating doctors over the contrary opinion of Dr. Cederberg.  Substantial evidence supports the judge’s finding that the 1997 work-related ankle injury caused a consequential injury to the employee’s hips and low back, and we therefore affirm the judge’s decision in its entirety.