The employee appeals from the compensation judge’s finding that the insurer is entitled to a credit for temporary total benefits paid following the filing of a Notice of Intention to Discontinue Benefits on April 2, 2013, up to May 1, 2013.  We find the credit is not supported by the evidence and reverse.

James Beekman, the employee, was 51 years old at the time of the hearing.  He began working for JPS Lawn Service, the employer, in 1998.  Prior to working for the employer, the employee had no problems with or injury to his left shoulder.  The employer was insured for workers’ compensation liability by Farmers Insurance Group.

The employee was hired to perform basic lawn services for the employer.^[1]  The employee’s day-to-day job involved operating self-propelled lawn mowers and riding lawn mowers, loading and unloading equipment into trucks and trailers, lifting ramps on trailers and tailgates, general yard clean-up, weed treatment, blowing leaves using a backpack blower, operating a fertilizer spreader, shoveling debris out of a truck, spreading mulch around trees, and some branch removal and hand raking.^[2]  On days when lawn service could not be performed, the employee would sharpen mower blades and perform general maintenance on machines.

On October 18, 2011, the employee was operating a riding lawn mower on an incline when the lawn mower tipped over backwards and landed on top of him.  The employee testified that the lawn mower weighed over 850 pounds and he was pinned underneath the mower for approximately ten minutes.  He was subsequently transported to Fairview Southdale Hospital for emergency treatment, underwent x-rays, and was diagnosed with a displaced midshaft fracture of the left clavicle.  He was discharged with a sling and medication.

The employee was first seen by treating orthopedic surgeon, Dr. John Kearns, on October 24, 2011.  Dr. Kearns performed an examination, reviewed the x-rays from the hospital, and diagnosed a minimally displaced closed midshaft left clavicle fracture.  He advised the employee to remain in a sling and return for a second evaluation in two weeks.

On November 7, 2011, the employee returned to see Dr. Kearns.  Dr. Kearns re-examined the employee, took x-rays, and concluded that the clavicle fracture was significantly displaced and in need of surgical stabilization by placing a steel plate with screws under the clavicle.  The employee elected to proceed with the open reduction and internal fixation of the midshaft clavicle fracture.  Surgery was performed by Dr. Kearns on November 9, 2011.

The employee gradually improved after surgery, progressing from a shoulder immobilizer to a sling and then instructed to perform gentle range-of-motion exercises.  X-rays taken at each visit showed the position of the clavicle fracture fragments and a gradual consolidation.  On December 22, 2011, Dr. Kearns noted on examination that the employee had markedly limited shoulder motion and referred the employee for physical therapy.  The employee had his first physical therapy evaluation on December 23, 2011.  At the evaluation, the employee indicated a pain level of two out of ten, stiffness and reduced range of motion in his shoulder, numbness at the surgical site along with his left fingers, and irregular shooting pain.

At a medical visit with Dr. Kearns on January 16, 2012, an x-ray taken revealed a lateral midshaft fracture between the 4th and 5th screws of the fixation plate.  Dr. Kearns renewed a narcotic presciption and the employee continued with physical therapy.

By February 2012, the employee was having umbilical hernia symptoms.  But he continued to perform the recommended physical therapy treatment and showed improvement in range-of-motion tests while avoiding lifting weights.  Medical notes indicated ongoing numbness along the anterior chest but improvement in overall pain.  The employee was again evaluated by Dr. Kearns on February 27, 2012.  Dr. Kearns advised the employee to continue with his overall exercise activities and recommended another prescription for physical therapy.  Chart notes indicated the employee would return for an evaluation in approximately one month to consider a return to work by April 1.

Dr. Kearns saw the employee on April 1, 2012, and noted some weakness in the left upper extremity with mild reduced range of motion.  On the basis of this examination, the employee remained off work for the next two months and continued with physical therapy.

The employee was seen by Dr. Doreen McEvoy at Park Nicollet Family Medicine Clinic on April 30, 2012, for an evaluation of an umbilical lump.  The employee was taking prescription pain medications for both shoulder and abdominal pain and gave Dr. McEvoy a history of worsening hernia pain while trying to extract himself from underneath the lawn mower on October 18, 2011.  Dr. McEvoy diagnosed an umbilical hernia and advised the employee to have it repaired.  Dr. McEvoy would not provide an opinion that the umbilical injury was caused by the work accident.

Hernia surgery was scheduled in May of 2012 but then cancelled after the insurer denied liability.  The hernia continued to limit the employee’s mobility to such a degree that by May 31, 2012, the employee had significant discomfort with movement and performance of day-to-day functions.  The hernia was noted to be larger than the previous month and surgery was again recommended.

On April 2, 2012, the employee was again evaluated by Dr. Kearns who noted ongoing weakness in the left upper extremity and mild decreased range of motion.  Dr. Kearns recommended ongoing physical therapy and home exercises.  Dr. Kearns indicated the employee was to remain off work.  The employee was instructed to return for an evaluation in two months or “sooner if problems arise.”^[3]  The employee scheduled an office visit on May 4, 2012, to recheck the left clavicle fracture.  He again questioned Dr. Kearns about removing the broken metal plate.  On physical examination, the employee had near full abduction passively but lacked some internal rotation.  The employee indicated improvement of the range of motion in his shoulder but noted lack of full strength.  The employee also indicated his commitment to continue ongoing exercises including strength building and range of motion.  X-rays taken showed “satisfactory position of the fracture fragments and the fixation plate and screws”^[4] as well as progressive consolidation.  Dr. Kearns was of the opinion that it was too early to consider removing the plate and instructed the employee to continue physical therapy.  The employee remained off work.  On May 24, 2012, Dr. Kearns signed off on a purchase order for a medical device described as a “Shoulder Range Of Motion Device”^[5] to treat the diagnosis of muscle weakness and joint stiffness in his neck and shoulder.

On May 31, 2012, the employee was again seen by Dr. Kearns and, after the examination, Dr. Kearns recorded in a chart note the following:

The examination of the left shoulder revealed approximately 150 degrees of elevation of the left shoulder and the employee could abduct his left shoulder past 90 degrees.  Dr. Kearns recommended the employee remain off work and continue physical therapy.  The employee was given a prescription for a narcotic analgesic and told to return to the office in four weeks, “or sooner if problems arise.”^[7]

On June 8, 2012, the employee was again evaluated by Dr. Kearns and, after the office visit, Dr. Kearns recorded in a chart note the following:

Dr. Kearns recommended the employee remain off work and talk with his boss to see if he could return to work with restrictions and in lighter duties.  The employer, however, did not have any light duty work available.

On June 28, 2012, the employee was again evaluated by Dr. Kearns.  Dr. Kearns noted improvement in the employee’s left shoulder symptoms, strength, and range of motion.  Dr. Kearns noted the employee was “getting close to returning to work”^[9] and recommended additional physical therapy and continuing with an exercise program.  The employee remained off work.

Throughout the summer, the employee continued to experience pain at the surgical incision site and continued to pursue the removal of the broken plate.  Dr. Kearns advised the employee to wait until November.  At the recommendation of Dr. Kearns, the employee remained off work and continued strength training and range-of-motion exercises.  On July 26, 2012, Dr. Kearns met with the employee’s Qualified Rehabilitation Counselor (QRC) to discuss the employee’s progress and restricted activities.  Dr. Kearns indicated that a work-hardening or work-evaluation program would be of benefit to the employee after the surgery to remove the broken plate.

The employee sought a second opinion regarding his right shoulder treatment from Dr. Michael Freehill on August 28, 2012.  On examination, Dr. Freehill noted a trace of atrophy in the supraspinatus muscle at the right shoulder, some scapulothoracic winging and dyskinesis, and numbness in the chest.  Dr. Freehill was also of the opinion that hardware removal should not be done until one year after the first surgery and, like Dr. Kearns, recommended the employee continue with physical therapy.  Dr. Freehill noted that if the employee transferred his future medical treatment under his care, Dr. Freehill would likely recommend work restrictions of 20 pounds lifting, and no repetitive overhead or outstretched reaching for a period of time with a follow-up check in November, for consideration of possible hardware removal.

The employee was again seen by Dr. Kearns on October 18, 2012.  Although the employee noted improvement in shoulder pain, muscle strength, and motion, he once more indicated that his left shoulder was not at the point where he could handle unrestricted work.  A range-of-motion examination of the left shoulder revealed approximately 150 degress of abduction and flexion with some limitation of internal rotation.  Muscle strength was noted as adequate.  Dr. Kearns recommended additional physical therapy and advised the employee to return for an evaluation in one month to assess a return to work without restrictions.  By recommendation of Dr. Kearns, the employee remained off work.

On October 29, 2012, the employee was admitted to Fairview Southdale Hospital after complaining of language difficulty and right-sided weakness.  A brain MRI revealed an infarct in the posterior left middle cerebral artery distribution.  The employee remained in the hospital for treatment until November 6, 2012.  During the hospitalization, the employee had recurring episodes of syncope with bradycardia which required a pacemaker.  The employee also had atrial fibrillation which the doctors treated with prescribed medication.  A CT scan performed during the hospitalization confirmed two ventral hernias in the right periumbilical region.

On December 20, 2012, the employee treated with Dr. Alexander Zubkov at the Minneapolis Clinic of Neurology.  Dr. Zubkov indicated in his evaluation that the employee was unable to work due to his poor balance, noting that the employee used a cane for stability and walked with a slight wide-based gait.  He also noted the employee’s stroke secondary to atrial fibrillation and multiple other risk factors including high cholesterol, high blood pressure, and obesity.  He recommended a change in some of the employee’s medications and advised him to return in six months.

The employee returned to see Dr. Kearns on February 8, 2013.  On examination the employee’s left shoulder abduction had decreased since his last visit to approximately 90 degrees as compared to 180 degrees on the right.  The employee indicated that, since the stroke, he had been unable to go to physical therapy or exercise “as well as he would like.”^[10]  The employee also expressed a decrease in strength in his right upper extemity and loss of balance that required the use of a cane.  Dr. Kearns advised additional physical therapy and did not release the employee to return to work.

Dr. Kearns examined the employee again on April 1, 2013.  At that time, the employee was using his left upper extremity for most of his normal activities.  Examination of the left shoulder revealed 150 degrees of abduction and Dr. Kearns indicated the left shoulder internal rotation “is possible to midthoracic region with minimal pain.”^[11]  The employee indicated significant improvement in the pain and range of motion of his shoulder to such a degree he now believed he could return to work with some restrictions.  In the April 1, 2013, office note under the caption “RECOMMENDATION” Dr. Kearns wrote the following:

On the same day, the QRC filled out a return-to-work form releasing the employee to return to work with no work restriction effective April 1, 2013.^[13]  The form was signed by Dr. Kearns.  The next day, the insurer filed a Notice of Intention to Discontinue Benefits.

On April 2, 2013, the QRC sent an email to the insurer and counsel stating her recollection of a meeting between her, the employee, and Dr. Kearns the day before.^[14]  The QRC stated the employee had completed physical therapy for his shoulder, he had not yet had his hernia and hardware removal surgeries, and he was awaiting clearance for surgery from his primary doctor with whom he had scheduled an examination on April 4, 2013.  The QRC email characterized Dr. Kearns’ opinion that, from an orthopedic standpoint, the employee did not have ongoing restrictions, but if he had hardware removal surgery, he would be off work for a recovery period followed by a functional capacitites evaluation to determine his abilities.  Finally, the QRC noted that the employee was released to work concerning the shoulder, but was uncertain whether or not the employee would be able to work because of other health issues.

The employee again requested surgery to remove the broken plate.  In a faxed form letter dated April 10, 2013, Dr. Kearn’s office sent the insurer a request to perform surgery at Abbott Northwestern Hospital on May 5, 2013, “for Removal of painful fixation plate of the left clavicle.”^[15]  The surgery occurred on May 1, 2013.

In a post-surgical evaluation on May 16, 2013, Dr. Kearns completed a work disability slip indicating the employee was not cleared to return to work until a work-hardening evaluation was completed.  In the QRC’s email to the insurer and counsel on the same day, she relayed the employee’s reported decrease in numbness and tingling in the surgical site and improvement of the range of motion in the shoulder.  Dr. Kearns restricted the employee from work for two more weeks followed by a work-hardening program.

The employee underwent surgery for the hernias on May 30, 2013.  Post surgery, the employee was given restrictions on lifting for four weeks.

On July 1, 2013, the employee underwent a work-hardening evaluation at Saunders Physical Therapy.  The evaluation indicated the employee had left shoulder stiffness, weakness, and discomfort, and some residual problems with his leg and foot from the stroke.  He had good strength in both shoulders, but his external rotation was slightly weaker on the right, and he had a decrease in gleno-humeral joint mobility in the right shoulder greater than the left due to his stroke.  He had discomfort reaching up with the left arm, particularly overhead.  He had general deconditioning, slight loss of left shoulder range of motion, and some weakness and increased discomfort at maximum heights.  The physical therapist recommended two-hour work-hardening sessions every other day with increasingly longer hours for four to six weeks.  At the July 12, 2013, work-hardening session, the employee experienced occasional discomfort in his left collarbone, but the pain did not limit his activity.

In her findings and order, the compensation judge cited the April 1 release form authorizing a full release without restrictions, and, on the basis of this evidence, awarded a credit for temporary total benefits paid following the filing of a Notice of Intention to Discontinue Benefits on April 2, 2013, up to May 1, 2013.  The employee appeals.

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.”^[16]  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.”^[17]  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.^[18]  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 the evidence or not reasonably supported by the evidence as a whole.”^[19]

The compensation judge concluded the employer and insurer did not owe temporary total disability benefits from April 3 through April 30, 2013, and allowed a credit from future wage loss benefits for the overpayment made.^[20]  In doing so, the judge found the April 1 work slip persuasive and consistent with the employer and insurer’s argument that by April 1, the employee fully recovered from the effects of his October 18, 2011, injury and had no work-related disability preceding the May 1 surgery.  The compensation judge further discussed and determined the residuals from the stroke and other non-work-related health conditions^[21] were the cause of this thirty-day period of disability and need for work restrictions.

The employee contends the compensation judge erred in finding no disability from his work-related shoulder injury during the disputed period.  The employee asserts there is not substantial evidence in the record to support the compensation judge’s findings.  The employee argues the April 1 medical form releasing the employee to return to work with no restrictions until the second surgery “is an aberration inconsistent with the physician’s chart-note and inconsistent with the employee’s continuing medical treatment.”^[22]  We agree.  In view of the entire record, we find substantial evidence does not support the compensation judge’s conclusion and we reverse.

The ultimate issue before the compensation judge was whether the effects of the work-related injury^[23] remained a substantial contributing cause of the employee’s inability to work.  Temporary total disability benefits cease if an employee is released to work without any physical restrictions caused by the work injury.^[24]  Temporary total disability benefits may be discontinued when a period of unemployment is not causally related to the work injury.^[25]

In finding 17, captioned “Re-evaluation Dr. Kearns February 2013,” the compensation judge found that Dr. Kearns released the employee to begin physical therapy he had previously recommended, “and he planned to release the employee to return to work in April, but advised he should not work in the meantime.”^[26]  In review of the February 2013 medical records we find no such statement in Dr. Kearns’ February report and consider the finding of fact a factual error that was used by the judge to reach her ultimate conclusion.

In her memorandum, the compensation judge stated that Dr. Kearns did not “recant his earlier release to unrestricted work” “[e]ven after plans were made for hardware removal surgery.”^[27]  Such indirect inferential evidence was entitled to very little weight in light of the QRC’s direct evidence to the contrary.  The compensation judge’s statement relies on the QRC’s interpretation in her email to the insurance representative and counsel on April 2, 2013.  This email was negated by the testimony of the QRC at hearing:

Essentially, this case boils down to reconciling inconsistency in one medical expert’s opinion.  The April 1, 2013, chart note from Dr. Kearn’s office recommends a return to work following a work-hardening program or a functional capacity evaluation.  A work slip signed the same day releases the employee to work with no restrictions.

On appeal, this court reviews whether substantial evidence exists to support the compensation judge’s findings.  Here, in every chart note from October 24, 2011, to April 1, 2013, where Dr. Kearns references the release to return to work, the release was considered in combination with physical limitations caused by the work injury or a functional capacities evaluation.  Nothing in the doctor’s April 1, 2013, chart note provides an explanation as to why, after fourteen months, the employee’s work-related medical condition had changed so dramatically that he went from a no release to a full release without restrictions before surgery.

Whether an employee’s work injury substantially contributes to a period of disability is a question of fact for the compensation judge.^[29]  While generally the weight given to such expert medical opinions is for the finder of fact, that weight must be balanced against the weight of all the other evidence.  We find an unrestricted release inconsistent with the very medical history documented by Dr. Kearns’ chart notes.  In view of the entire record, the work slip is lacking in objective support.  Given this context, there is insufficient evidence to support the finding that the employee was released to return to work with no restrictions 29 days before the second surgery.  Accordingly, we reverse the award of a credit from April 2 to May 1, 2013.

I respectfully dissent.  I would affirm the compensation judge’s determination based on substantial evidence.  The records show that Dr. Kearns was considering a release without restrictions within a month of the October 18, 2012 visit.  Shortly after that visit, the employee had his stroke.  Although the records from Dr. Kearns seem somewhat inconsistent at times, on April 1, 2013, he signed a release to return to work without restrictions.  That, together with the Respondent’s Exhibit 7, and the ORC’s testimony at hearing regarding her meeting with Dr. Kearns, should be sufficient to affirm the compensation judge’s decision.