The self-insured employer appeals the compensation judge’s determination that the employee’s work activities over the years for the employer were substantial contributing factors in the employee’s development of a lumbar spine Gillette injury and bilateral Achilles tendon Gillette injuries.  They also appeal the compensation judge’s determination that the employee did not retire or voluntary withdraw from the labor market and that the employee was permanently and totally disabled as of December 5, 2011.  We affirm.

The compensation judge’s findings of fact are largely unappealed.  The employee, Linda Hellgren, began working for the self-insured employer, St. Mary’s Medical Center,^[1] in March 1984 as a food service worker in the employer’s nutrition services department.  She worked there until December 5, 2011, which is the alleged culmination date for her Gillette injuries.

Over the years, the employee’s duties included washing dishes, pots, pans, trays, and other utensils and serving items, doing pre-cooking and preparation activities, serving meals in the dining room, and working in the salad area.  Physically, the employee described a number of movements during her workday, including bending and twisting, lifting, and carrying dishes, pots and pans, and food service items, walking, and being on her feet during her entire shift.  She also described a number of incidents in which she slipped on a wet floor surface but was able to continue working.^[2]

The employee contends that her work activities over the years, as well as certain specific incidents, have caused low back pain, right hip pain, knee pain, and Achilles tendon problems resulting in permanent injuries to her low back, knees, right hip, and Achilles tendons.  She has also claimed that she has been permanently and totally disabled since December 5, 2011.

The employee’s medical treatment for low back symptoms is first documented in 1983.  Medical records show that on February 7, 1983, the employee was seen at Skyline Medical Center complaining of back pain for the last three days with no specific trauma.^[3]  The employee received some additional low back treatment in 1992, and by September 1995, the employee’s medical records indicate that she had “chronic” low back pain.^[4]

In July 2002, the employee was treating for low back pain, which she associated with work activities such as washing pots and pans.^[5]

The employee underwent lumbar MRIs in March 2003 and December 2004.^[6]  The December 2004 report indicates that there was no significant change since March 2003.  Mild degenerative disc disease was noted at the L4-5 level, with a small left posterior paracentral and posterolateral disc bulge.  This was unchanged since the prior study, with minimal narrowing of the left neural foramen.  There were degenerative changes noted in the lower lumber facet joints as well.

The employee underwent another MRI in 2005, which showed substantial degenerative disc disease in the low back.^[7]

In 2006, the employee continued to treat for ongoing low back pain.  Records indicate that the employee needed to use Ultram during her work day to continue to function.^[8]  She also went through a course of physical therapy and injection treatments.

In January 2008, the employee saw Dr. John Holcomb.  Dr. Holcomb noted that gainful employment was possible for the employee with medications, but not without, because she was on her feet all day.^[9]

In September 2009, the employee sustained an injury to her low back when she slipped on some water at work.  The employee did not fall, but she caught herself using her left arm and twisting to the right.  The self-insured employer accepted liability for the injury, and the employee was seen a couple of days later in the employer’s occupational medicine department for low back pain.  The employee was given sedentary work restrictions.  She was also referred for physical therapy and prescribed a TENS unit.  The employee underwent a course of physical therapy sessions.  On October 19, 2009, she was released to return to work without restrictions.

On October 3, 2010, the employee was seen by Dr. James Butcher in the orthopedics department at the employer’s medical center for a new problem that had developed over several weeks.^[10]  She was reporting bilateral heel pain that was more bothersome when the employee was on her feet for long periods of time.  Dr. Butcher assessed the employee with bilateral Achilles tendinitis.  She was referred for physical therapy.  In late November 2010, the employee returned to see Dr. Butcher and reported some improvement from the therapy.  However, she was having significant heel pain after a long shift at work.  The employee was given heel lifts and a Bledsoe boot.  Therapy continued.

On June 30, 2011, the employee returned to see Dr. Butcher for low back pain.^[11]  The employee was referred to occupational medicine and physical therapy.  She also filed a work injury report relating to her current low back symptoms, and the employer initially accepted her claim as work related.

On July 19, 2011, the employee saw occupational medicine specialist Dr. Brian Konowalchuk for low back pain.^[12]  Dr. Konowalchuk assessed the employee with chronic low back pain with “temporary exacerbations due to prolonged standing.”  He suggested anti-fatigue work mats to help with the employee’s daily discomfort.  Dr. Konowalchuk commented that

On August 1, 2011, the employee returned to see Dr. Konowalchuk complaining of intermittent back pain on a daily basis.^[14]  Dr. Konowalchuk suggested additional mat placement and ordered a wireless TENS unit for the employee.  The employee saw Dr. Konowalchuk again on August 15, 2011.  She indicated that leg pain had dissipated, but she was continuing to have low back pain while standing at work.  The employee was to continue previous recommendations.  She continued working without restrictions.

On September 16, 2011, the employee saw Dr. Konowalchuk again complaining of diffuse low back pain with walking and standing at work.  A SpineX program was recommended for reconditioning.  Dr. Konowalchuk agreed to the employee’s request to continue working without restrictions.

The employee began the SpineX program and participated from October 3, 2011, through November 8, 2011.^[15]  Dr. Konowalchuk noted that the employee was making slow progress, and he extended the program to a total of 10 weeks.

The employee underwent a lumbar MRI on November 22, 2011.  A small disc protrusion was noted at L1-2, with no nerve root or spinal canal impingement.  Facet arthropathy was noted at L4-5 and L5-S1.^[16]

The employee continued with the SpineX program through the end of November 2011.  The employee presented to Dr. Konowalchuk on December 5, 2011.^[17]  She reported that she could no longer tolerate her standing job.  Dr. Konowalchuk imposed light-duty work restrictions, including two hours standing or walking per day maximum.  The employee was also given an application for disability parking.  The restrictions and disability parking were related to facet arthritis.

Since December 5, 2011, the employee’s light-duty restrictions have prevented her from continuing to work in her current position.  She testified that she did look for other jobs within the employer’s system, but she found that none were available to her.  As of the date of hearing, the employee had not returned to work.

The employee returned to see Dr. Konowalchuk on March 13, 2012.^[18]  She was reporting chronic low back pain and an inability to tolerate standing.  The employee was in the process of applying for Social Security disability, and she asked Dr. Konowalchuk for assistance.  In response to her request, Dr. Konowalchuk wrote a medical note as follows:

Dr. Konowalchuk took the employee off work, stating that the employee’s disability would be permanent in nature.

The employee received a letter dated April 13, 2012, awarding her Social Security disability benefits.^[19]

At the self-insured employer’s request, the employee underwent an independent medical examination with Dr. Nolan Segal on September 14, 2012.^[20]  Dr. Segal opined that the employee had not sustained Gillette injuries to her lumbar spine, knees, hip, or Achilles tendons culminating on or about December 5, 2011.  He was of the opinion that the employee would be able to work full time, provided she avoid lifting more than 30 pounds, and was able to change from standing and walking positions as needed.  He was also of the opinion that the employee had a lumbar permanency rating of 10 percent.

The employee underwent an independent medical examination of her own with Dr. Mark Gregerson on February 6, 2013.^[21]  Dr. Gregerson found that the employee had degenerative arthritis of the lumbar spine, bilateral Achilles tendinitis, and degenerative changes in the knees.  Dr. Gregerson opined that the employee’s many years of work activities that included lifting, bending, twisting, and being on her feet all day were substantial contributing factors in the employee’s back, knee, and lower extremity conditions.  He agreed with Dr. Konowalchuk’s permanent work restrictions of light duty, with no standing or walking for more than two hours of an eight-hour day and no more than 15 minutes in an hour.

Dr. Segal issued a supplemental report in August 2013 indicating that he had reviewed additional information, including the employee’s deposition.  Dr. Segal reiterated his opinions that the employee had not sustained Gillette injuries and that she was not permanently and totally disabled as of December 5, 2011.

On September 6, 2013, the case came on for hearing before Compensation Judge Jerome Arnold.  The employee testified and presented medical records, including the report from Dr. Gregerson.  The employee testified that as of December 5, 2011, she was physically unable to continue working.  She was asked about that timeframe, and she stated as follows:

The employee also offered a post-hearing deposition from an independent vocational expert, Fran Williams.  Ms. Williams opined that given the employee’s physical condition in combination with her age, training, experience, and the type of work available in her community, she was unable or unlikely to secure employment and that any employment would not be gainful, suitable employment.  Therefore, Ms. Williams opined that the employee was permanently and totally disabled.

The self-insured employer presented medical records that included Dr. Segal’s report on workability and causation and cross-examined the employee under oath.

The compensation judge found that (1) the employee’s work activities over a period of more than 25 years, which involved extensive bending, twisting, lifting, and being on her feet all day on hard floors, were substantial contributing factors in the employee’s development of a lumbar spine Gillette work injury culminating on the last day of work at her employer, December 5, 2011; (2) the employee’s work activities were also substantial contributing factors in the development of Gillette injuries in the nature of bilateral Achilles tendinitis, culminating on December 5, 2011; (3) the employee’s separation from employment “did not represent a retirement within the meaning of Minn. Stat. § 176.101, subd. 8, and it was not a voluntary withdrawal from the labor market;” (4) the employee had rebutted the retirement presumption contained in Minn. Stat. § 176.101; (5) once the employee ceased employment on December 5, 2011, she was released at that time only with light-duty work restrictions, and as of April 12, 2013, Dr. Konowalchuk took the employee off work permanently; (6) any job search by the employee from December 5, 2011 to the date of hearing, given her medical condition and vocational factors, would have been futile in securing suitable gainful employment; and (7) the employee’s physical condition as of December 5, 2011 in combination with her age, training and experience and the type of work available in the community prevents her from securing anything more than sporadic employment resulting in insubstantial income.  Based on the findings above, the compensation judge determined that the employee had been permanently and totally disabled since December 5, 2011, and ordered the self-insured employer to pay permanent total disability benefits from December 5, 2011, to the date of hearing to continue as warranted, as well as 10 percent permanent partial disability as related to the lumbar spine.

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.”^[23]  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.”^[24]  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.^[25]  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.”^[26]

The self-insured employer argues that the evidence does not support the compensation judge’s determination that the employee sustained Gillette injuries to her lumbar spine and bilateral Achilles tendons culminating on December 5, 2011.  We are not persuaded by the self-insured’s arguments.

A Gillette injury is the result of repetitive minute trauma brought about by the performance of ordinary job duties.^[27]  To establish a Gillette injury, the employee must demonstrate “a causal connection between [the employee’s] ordinary work and ensuing disability.”^[28]  Proof of a Gillette injury principally depends on medical evidence^[29] and that medical evidence must be based on adequate foundation.^[30]

“Whether an employee has proved a Gillette injury is a question of fact for the compensation judge.”^[31]  As the trier of fact, it is the compensation judge’s responsibility to resolve conflicts in expert medical testimony, and, where there is adequate foundation for the opinions adopted by the judge, this court normally upholds the compensation judge’s choice among medical experts.^[32]

The self-insured employer first argues that the compensation judge’s conclusion that the employee sustained a Gillette injury to her low back was unreasonable and contrary to the weight of the evidence.  It argues that the employee’s medical records chronicle a long history of chronic back complaints that predate her employment with the employer.  In particular, the self-insured employer points to the fact that by 1992, the employee was reporting “multiple back pains,” and by 1995, her back pain was being described as “chronic.”  In light of the employee’s longstanding history of smoking, obesity, and deconditioning, it argues that the fact that the employee’s low back symptoms manifested while working does not necessarily mean that her work activities caused a Gillette injury.  The self-insured employer also points to Dr. Konowalchuk’s earlier opinion that there was no long-term attributable workers’ compensation injury.

By contrast, the employee related her low back symptoms and condition to her day-to-day job duties and work activities.  Over the years, her physical duties required a number of different movements during her workday, including bending and twisting, lifting, and carrying dishes, pots and pans, and food service items, walking, and being on her feet during her entire shift.  She also described a number of incidents in which she slipped on a wet floor surface but was able to continue working.  The medical evidence in the record indicates that the employee began relating her low back symptoms to her daily work activities as early as July 2002.  Dr. Gregerson opined that the employee’s lengthy work history and her work activities were a substantial contributing factor in the employee’s low back condition.  While Dr. Gregerson did not use the specific legal term “Gillette injury,” he did find that the employee’s work activities were a substantial contributing factor in the development of her present condition.^[33]  Furthermore, even though Dr. Konowalchuk did not agree on the theory that there was a long-term workers’ compensation injury, he did indicate that the employee had sustained work-related exacerbations, and he opined that the employee was permanently disabled from work when he saw her in March 2012.  Given the totality of the evidence, there is sufficient proof of a Gillette injury to the low back, and we affirm.^[34]

The self-insured employer next argues that the compensation judge’s conclusion that the employee sustained a Gillette injury in the nature of bilateral Achilles tendinitis was unreasonable and contrary to the weight of the evidence.  The self-insured employer maintains that the record does not support a conclusion that the employee sustained any kind of “ultimate breakdown” on December 5, 2011, with regard to her Achilles tendons or that her Achilles tendinitis had anything to do with her decision to stop working at that time.  Again, we are not persuaded by the self-insured employer’s argument.

The analysis of a Gillette injury is built from the evidence of repetitive or cumulative minor trauma caused by performing ordinary duties and work activities.  Selection of a date of injury of a Gillette injury is a question of fact for the compensation judge to be determined on all the evidence in the record.^[35]  A compensation judge is not required to make an automatic determination that the employee sustained Gillette-type injuries on the day he or she stopped working.^[36]

In this case, Dr. Gregerson conducted an examination of the employee on February 6, 2013.  At that time, he opined that the employee continued to have a diagnosis of bilateral Achilles tendinitis.  He related this condition to the employee’s work activities over the years, including being on her feet all day, and he opined that the Achilles tendinitis was a substantial contributing factor in the employee’s overall disability.  The compensation judge chose to credit Dr. Gregerson’s opinion in that regard.  He also found the employee’s testimony credible with regard to the development of her Achilles condition and her ongoing symptoms.

The compensation judge chose the date the employee stopped working as the culmination date for her Achilles condition.  Although he may have chosen a different culmination date, there is sufficient medical support for the conclusion that the employee’s work activities were a substantial contributing factor in the development of Achilles tendinitis and that this condition was a substantial contributing factor in the employee’s disability by December 5, 2011.  Therefore, we affirm.

Finally, the employer and insurer argue that the compensation judge’s findings on the low back and Achilles tendons are inconsistent with the findings on the hips and knees and his denial of the employee’s claimed Gillette injuries involving those body parts.  As such, the self-insured employer argues that the findings and order should be reversed.  We disagree.

The parties do not challenge the foundation for either Dr. Gregerson’s opinions or Dr. Segal’s opinions.  Generally, in such circumstances, the compensation judge’s decision, based upon a choice of medical opinions, will not be reversed.^[37]  Moreover, a compensation judge is not obligated to accept all of a medical opinion and may accept only part of it.^[38]  Here, the compensation judge chose to credit Dr. Gregerson’s opinions and determined that the employee sustained Gillette injuries to her low back and Achilles tendons.  Indeed, the compensation judge chose to credit Dr. Segal’s opinion that the employee did not sustain injuries to her knees and hips and denied that portion of her claim under the analysis that those conditions were the result of conditions personal to the employee.  The choice of well-founded medical opinions is within the compensation judge’s discretion, and, therefore, we affirm.

On appeal, the self-insured employer argues that the compensation judge erred in finding that the employee did not voluntarily retire or voluntarily withdraw from the labor market.  The self-insured employer contends that the compensation judge’s findings and order failed to consider the factors set out in Dillemuth v. Owatonna Tool Co.^[39] and goes on to argue that the factors outlined in Dillemuth weigh in favor of finding that the employee voluntarily retired or withdrew from the labor market.

Generally, retirement is the voluntary withdrawal from one’s position or occupation or from active working life.^[40]  Retirement can be financial independence where one no longer needs to work for a living or what follows after one is no longer capable of working.^[41]  Retirement from the labor market or a voluntary withdrawal from the labor market may preclude a finding of permanent total disability benefits if the retirement is not the involuntary result of a compensable disability.^[42]  Whether an employee has retired from the labor market is dependent upon the facts of each case, and several factors are relevant to this consideration, including the intent of the employee in retiring or withdrawing from the labor market.^[43]  Ultimately, “[w]hether an employee has removed himself from the labor market is a question of fact, the resolution of which will not be disturbed on appeal unless manifestly contrary to the evidence.”^[44]

In Dillemuth v. Owatonna Tool Co., this court specifically identified six factors to consider when analyzing retirement, including:

On review, we conclude that the compensation judge cited evidence that is sufficient to support his determination that the employee had not voluntarily withdrawn or retired.  The compensation judge stated that the employee testified credibly “to the effect that she left her employment because of symptom aggravation in continuing the work she had done for most of her adult life.”  As the compensation judge pointed out in his memorandum of law, “no doctor including several independent medical examiners have said that the employee could return to the work duties she had as of December 5, 2011.”  The employee did not seek work after December 5, 2011, and the compensation judge found, based in part on the employee’s medical records, her present condition, and the evidence presented regarding the vocational factors present, that a job search would have been futile.  After the employee stopped working, she did collect short-term disability, and she approached her employer about accessing her pension.  The employee testified that she elected to “resign” so that she could access her pension, as instructed by the employer.^[46]  The compensation judge also noted that the employee subsequently applied for and was awarded Social Security disability benefits, which required a showing that she was unable to perform any substantial gainful activity because of her physical impairment for a continuous period of more than one year.^[47]  We conclude that even in the absence of a written factor-by-factor analysis outlined in Dillemuth, a complete review of the compensation judge’s findings and order establishes that he did consider the necessary Dillemuth factors in reaching his retirement determination.

Here, a critical factor in the retirement analysis is not only the employee’s disability status at retirement but also the employee’s intent in withdrawing from the labor market, that is, whether the retirement or withdrawal was the involuntary result of a compensable disability.^[48]  Any statement by an employee that he or she would have continued to work but for the disability is of particular significance in establishing an intent not to retire.^[49]  Here, the employee testified that she stopped working on December 5, 2011, because she was physically unable to continue due to her injuries.^[50]  The compensation judge credited that testimony, and we conclude, on review, that there is sufficient evidence to support the conclusion that the employee did not voluntarily retire or withdraw from the labor market but involuntarily retired because she was no longer capable of working as a result of her work-related injuries.^[51]

Permanent and total disability means that the employee’s physical condition and disability causes the employee to be unable to secure anything more than sporadic employment resulting in an insubstantial income.^[52]  Other factors to consider in determining whether an employee is totally and permanently incapacitated include the employee’s age, education, training, and experience.^[53]  It is well established that the concept of “total disability” depends primarily upon the employee’s ability to obtain or maintain gainful employment rather than his physical condition.^[54]  To recover compensation benefits, the employee must establish that the work injury is a substantial contributing cause of the injury.^[55]

On review, we conclude that there is substantial evidence to support the compensation judge’s determination that the employee was permanently and totally disabled as of December 5, 2011.  As indicated above, the employee testified that she was unable to continue working as of December 5, 2011 because of her work injuries.  The compensation judge found this testimony credible.  This determination is further supported by the medical opinions of Dr. Konowalchuk^[56] and Dr. Gregerson^[57] and the vocational opinions of Fran Williams.^[58]

The self-insured employer challenges the “foundation” for the employee’s vocational expert, Fran Williams.  The self-insured employer, however, did not object to the admission of Ms. Williams’s independent vocational report at hearing, and it had the opportunity to cross-examine Ms. Williams during her deposition.  The arguments raised here on appeal with regard to Ms. Williams’s opinions go to the weight to be afforded those opinions.  The challenge here is to the adequacy of the labor market analysis, which primarily consisted of an Internet search for positions available in the employee’s area, and the lack of any vocational aptitude testing.  The ultimate argument is that the vocational expert was operating from an assumption that any job search by the employee would have been futile.

The self-insured employer, however, offered no vocational evidence to rebut the employee’s expert.  The compensation judge was free to accept or reject Ms. Williams’s opinions as he saw fit.  He explained in his memorandum of law that he considered her vocational opinions in combination with the medical opinions contained in the medical records, thereby accepting Ms. Williams’s conclusion that the employee would not be able to find work given her situation.  Even Dr. Konowalchuk, when he saw the employee in March 2012, indicated that the employee would be permanently disabled and that she was not likely to find work given her physical condition and limitations.  The compensation judge concluded that the “employee herein has not done any job search but given her physical limitations when taken together with her age, transferable skills, experience and work available in her community it is clear that any job search would have been futile in that if the employee found any employment which is highly unlikely, it would be sporadic employment and would produce an insubstantial income.”^[59]

The compensation judge is the fact finder who is required to evaluate the credibility and probative value of witness testimony, and it is not the role of this court to choose different inferences from the evidence than the compensation judge.^[60]  Because substantial evidence, including the employee’s testimony and the opinions of Dr. Gregerson, Ms. Williams, and Dr. Konowalchuk support the compensation judge’s determination that the employee was permanently and totally disabled as of December 5, 2011, we affirm.