The employee petitions to vacate the 1998 Award on Stipulation based on a substantial change in medical condition.  We grant the petition.

On June 9, 1995, Sheila Jech Dehn, the employee, sustained an admitted work-related injury to her left hand and wrist while working as a depot manager for Star Tribune, the employer, which was insured for workers’ compensation liability at that time by Kemper National Insurance Company.  The employee also worked as a bus driver for Hunts Bus Company.  The employer and insurer paid various benefits including temporary partial and temporary total disability benefits.  The employee treated at the Unity Hospital emergency department and later with Dr. Randall Norgard at Orthopaedic Partners, P.A.  In October 1995, Dr. Norgard assessed persistent left carpal tunnel syndrome and referred her to a hand surgeon, Dr. Mark Holm, who diagnosed torn triangular fibrocartilage complex and a partial tear of the scapholunate ligament.  On December 7, 1995, the employee underwent surgery on her left wrist, including debridement and a left open carpal tunnel release.  The employee was released for limited work activities in April 1996.  The employee attempted to return to her job as a bus driver, but she experienced pain in her left wrist while bus driving.  In May 1996, Dr. Holm recommended that the employee permanently stop bus driving.

On August 20, 1996, the employee underwent a dorsal capsulorrhaphy surgery on her left wrist to stabilize the scapholunate ligament.  In September 1996, the employee was released to work for the employer, but with a restriction of not using her left hand.  In November 1996, the employee developed right carpal tunnel syndrome symptoms and was given a five-pound lifting restriction for the right hand.  A January 1997 EMG indicated moderately severe right carpal tunnel syndrome.  Dr. Holm opined that this condition was caused by overuse of the employee’s right hand as a result of her restrictions on left-handed work.  On January 17, 1997, the employee slipped and fell in a non-work-related incident, landing on both hands and experiencing more pain in her left wrist.  In February 1997, the employee underwent right carpal tunnel release surgery.  She returned to light-duty work in April 1997.  In August 1997, the employee began experiencing symptoms with soreness in her left thumb and significant pain.  Dr. Holm recommended a pisiform bone excision.

The employee underwent independent medical evaluations by Dr. Jeffrey Groner in April and August 1997.  Dr. Groner opined that the employee’s left carpal tunnel syndrome was causally related to the June 1995 work injury and that her right carpal tunnel syndrome was a Gillette injury resulting from the repetitive use of her right hand at work and also of her overuse of the right hand due to her left hand condition.  He also opined that the employee’s surgeries were reasonable, necessary, and causally related to the June 1995 injury.  After this examination, the surgery recommended by Dr. Holm was approved.  On September 10, 1997, the employee underwent an excision of the ulnar sesamoid bone on the left thumb with Dr. Holm.  The employer was no longer able to accommodate the employee’s restrictions of no lifting over ten pounds and to avoid repetitive pinching, gripping, or grasping, and her employment was terminated in October 1997.

In January 1998, the employee slipped and fell in a non-work-related incident, injuring her right wrist.  The employee also continued to treat for her left wrist.  In March 1998, Dr. Holm recommended arthrodesis of the employee’s left thumb MP joint.  On May 7, 1998, the employee underwent a right ulnar osteoplasty and repeat debridement by Dr. Holm.  Dr. Holm opined the employee’s right wrist condition and recent surgery were not causally related to the employee’s work injury.  Around that time, the parties entered into a stipulation for settlement, and an Award on Stipulation was served and filed May 20, 1998.  Under the settlement, the employee was paid $15,000.00 for a full, final, and complete settlement with medical expenses left open.  At the time of the settlement, the employee acknowledged that she may have future entitlement to temporary partial, temporary total, or even permanent total disability benefits.  The employer and insurer asserted that the employee would not have any future entitlement to temporary total or temporary partial disability benefits “as she is fully capable of working, without significant restriction, in her present capacity.”  The employee also claimed that she required a left wrist arthrogram after the 1998 fall, but agreed not to make a claim for that surgical procedure. In 1998, sometime after the settlement, the employee applied for and began receiving Social Security disability benefits of $744.00 per month.

Dr. Holm released the employee for light-duty work at a service station on May 21, 1998.  The employee attempted to work in this position, but could not continue.  Since that time, the employee has worked part time running bingo games in social halls.

In September 1998, the employee underwent a left thumb arthrodesis.  She continued to have pain in her left wrist.  The employee fell again in November 1998, landing on both forearms. Dr. Holm noted that the employee had not damaged her thumb in the fall.  In February 1999, the employee reported left wrist radial and ulnar pain and an inability to bend her left wrist.  Dr. Holm recommended a left wrist fusion, which the employee underwent in May 1999.  In September 1999, the employee was involved in a motor vehicle accident and twisted her left wrist and fingers in the steering wheel.  She treated with Dr. Holm, who diagnosed sprained ligaments.  The employee had some improvement, and continued to treat with Dr. Holm.  The employee underwent a right wrist hardware removal in May 2000.  A month later, the employee fell and landed on her right wrist.  The employee’s left wrist hardware was removed in October 2000.

In November 2000, the employee fell and landed on her left hand.  An x-ray indicated a fracture by the screw hole in the third metacarpal.  Dr. Holm placed a cast on the employee’s left arm.  The employee reported some improvement in January 2001 until a dog bit her wrist.  In February 2001, Dr. Holm noted a nonunion at the base of the left third metacarpal.  In April 2001, Dr. Holm performed a bone graft and internal fixation as well as a left wrist arthrodesis, third carpal/metacarpal trapezium excision of tendon, and arthroplasty of the left thumb.  The employee bruised her left hand when she fell in June 2001.  In January 2002, Dr. Holm performed an extensor tenolysis and neurolysis of the left thumb.

The employee fell again in February 2002, landing hard on her right wrist.  A right wrist arthrogram was negative for ligament tears in June 2002.  Later in 2002, the employee cut her left hand, once with a sheet rock knife and once on a piece of glass.  Exploratory surgery indicated the nerves were intact.  In November 2002, Dr. Holm recommended bilateral distal ulnar hemi-resections.  The right arm was done first in December 2002, with an extensor tenolysis.  In February 2003, the employee fell and landed on her right wrist.  The left arm was done next in November 2003; the cast was removed in January 2004.  Another resection of the left distal ulna was required in March 2004.  In June 2004, the employee fell again on her left wrist, and in August 2004, she again cut her hand, this time on a car door.  In December 2004, a neuroma was excised from her left wrist.

The employee continued to have problems with her right wrist and injured her right wrist in another fall in April 2005.  The employee also underwent several additional surgeries on her right arm, including carpal tunnel release and distal ulna resection in August 2005, proximal row carpectomy in January 2006, right wrist arthrodesis and ulnar nerve transposition at the right elbow in June 2007, extensor tenolysis in October 2007, and ulnar tunnel release in February 2008.  The employee continued to have left arm symptoms, and underwent a left carpal tunnel release and ulnar tunnel release in September 2008.  Her right wrist was injured again in a fall and she continued to have right wrist symptoms.  She underwent right wrist arthrodesis revision in January 2009 and again in July 2009 with hardware replacement and ulnar nerve transposition revision.  In November 2009, the employee developed left elbow tenderness.  A March 2010 MRI of the left elbow indicated partial tearing of the extensor tendon on the lateral epicondyle.  Dr. Holm performed a left elbow epicondylectomy in April 2010.  In July 2010, the employee again had pain in her left wrist, and she underwent a revised distal ulnar resection in August 2010.  In December 2010, Dr. Holm removed the hardware from her healed left wrist fusion.  The employee fell in February 2011, spraining her left wrist, and fell again in September 2011, landing on her left elbow and forearm.

Dr. Holm opined in a May 2012 narrative report that the employee had undergone a substantial change in her left wrist condition since May 1998 that was not anticipated.  He stated that “further degeneration of the left wrist occurred through a combination of normal wear-and-tear on the left wrist from the activities of daily living and also other injuries such as further slip-and-fall accidents.”  (Employee’s Ex. C.)  He noted that the stabilization procedure was unsuccessful in 1998 and that a full wrist fusion was necessary, and assigned 20 percent permanent partial disability under Minn. R. 5223.0470.  He also assigned permanent restrictions of no lifting over ten pounds and to avoid repetitive firm gripping and grasping with her left hand.  Dr. Holm concluded that the employee’s ongoing left wrist problems were the result of the employee’s 1995 work injury.

In April 2013, QRC Ken Askew performed a vocational evaluation of the employee.  He found that the employee was permanently and totally disabled and that her 1995 work injury was a substantial contributing cause of the employee’s disability.  He also opined that the employee’s income from working bingo at social halls did not result in substantial income.

On July 8, 2013, the employee filed a petition to vacate the 1998 award on stipulation based on Dr. Holm’s opinion.  The employer, self-insured at that time, objects to the petition.

The Workers’ Compensation Court of Appeals has the authority to vacate an award on stipulation “for cause.”  Minn. Stat. §§ 176.461, 176.521, subd. 3.  “Cause” to set aside an award exists if (1) the award was based on a mutual mistake of fact, (2) there is newly discovered evidence, (3) the award was based on fraud, or (4) there is a substantial change in medical condition since the time of the award that was clearly not anticipated and could not reasonably have been anticipated at the time of the award.  Minn. Stat. § 176.461; see also Franke v. Fabcon, Inc., 509 N.W.2d 373, 376, 49 W.C.D. 520, 523 (Minn. 1993).  When evaluating a petition to vacate, this court compares the employee’s condition at the time of the settlement award to the condition at the time the petition was filed.  See Virnig v. Carley Foundry, Inc., slip op. (W.C.C.A. Nov. 14, 2000).

The employee claims the May 20, 1998, award on stipulation should be vacated based on a substantial change in medical condition.  The party seeking to vacate an award has the burden of proof to show such cause exists.  Groshung v. The Light Depot, 65 W.C.D. 349, 355 (W.C.C.A. 2005); Mehta v. Meldisco, slip op. (W.C.C.A. Oct. 26, 1995) (burden of proving good cause rests with the party petitioning to vacate an award); see also Stewart v. Rahr Malting Co., 435 N.W.2d 538, 539, 41 W.C.D. 648, 649 (Minn. 1989).  A substantial change in the employee’s medical condition requires that the change in the condition occurred after the time of the award, was clearly unanticipated at the time of the award, and could not reasonably have been anticipated at the time of the award.  Minn. Stat. § 176.461(4).  Substantial change may be demonstrated by a number of factors such as a change in diagnosis, a change in the employee’s ability to work, additional permanent partial disability, the necessity of more costly and extensive medical care than initially anticipated, the causal relationship between the work injury and the worsened condition, and the contemplation of the parties at the time of the settlement.  Fodness v. Standard Cafe, 41 W.C.D. 1054, 1060-61 (W.C.C.A. 1989).

The employer admits that the employee’s diagnosis changed after the settlement as a result of her subsequent surgeries.

The employee claims that she expected to return to work after the settlement, and the agreement states that the employee had returned to work without a wage loss at the time of the settlement.  The employer and insurer asserted at the time of the settlement that the employee was fully capable of working, without significant restriction, in her present capacity.  The employee was released to light-duty work at a service station after the settlement, but was only able to work there about a month.  It is not clear from the exhibits if this was the job referred to in the settlement agreement.  She had a five-pound lifting restriction at that time.  At the time of the petition, the employee had a ten-pound lifting restriction but also had additional restrictions of avoiding repetitive firm gripping and grasping.  The employee conducted a job search, but only found limited part-time work running bingo games.  The employee has experienced a change in her ability to work since the time of the settlement.

At the time of the settlement, the employee had not been assigned any permanent partial disability.  In 2012, Dr. Holm assigned the employee 20 percent permanent partial disability under Minn. R. 5223.0470.  The employer argues that even though the employee had not been assigned a permanent partial disability rating at the time of the settlement due to ongoing treatment, she would have been entitled to a rating for her condition and treatment at the time.  However, given the employee’s extensive treatment and fusion surgery since the settlement, the employee would be entitled to a higher permanent partial disability rating after the settlement that she would have been entitled to at the time of the settlement.

Where medical expenses are left open by the stipulation for settlement, this court has stated that the need for additional medical care carries less weight in determining whether a substantial change in medical condition has occurred.  Burke v. F-M Asphalt, 54 W.C.D. 363, 368-69 (W.C.C.A. 1996), summarily aff’d (Minn. May 30, 1996).  However, even in such cases, the need for more costly and extensive medical care remains useful evidence.  See e.g., Hughes v. Medcor, Inc., 69 W.C.D. 258, 269 (W.C.C.A. 2009).  In this case, there is no dispute the employee has incurred substantial medical costs since the award on stipulation.  The employee has undergone many additional surgeries, including arthrodesis, resection of the distal ulna, and revision of the arthrodesis.  The employer argues that additional treatment and surgery was anticipated at the time of the settlement, including the left thumb arthrodesis that was recommended in March 1998.  The employer also claims that, “given her ongoing pain the possibility of a future wrist fusion would have been very real.”  (Employer’s brief, p. 17.)  There is no evidence in Dr. Holm’s records of any mention of a future wrist fusion.  Dr. Holm specifically stated that he had not anticipated that the 1998 stabilization procedure would be unsuccessful or that a full wrist fusion would be necessary.  The parties did not anticipate that the employee would require such extensive additional treatment, which supports the employee’s assertion that she has sustained a substantial change in her medical condition.

The employer asserts that the employee’s numerous falls are the cause of the employee’s current left wrist condition, arguing that the employee received similar treatment for her right arm, which had also been injured in falls.  There is no medical causation opinion to support this argument.  While Dr. Holm noted that the employee’s left wrist had degenerated further due to the activities of daily living and the employee’s slip-and-fall accidents, he concluded that the employee’s ongoing left wrist problems were the result of the employee’s 1995 work injury.  Further, the work injury need not be the sole cause of the employee’s disability or need for medical treatment, but a substantial contributing cause.  See Roman v. Minneapolis St. Ry. Co., 268 Minn. 367, 129 N.W.2d 550, 23 W.C.D. 573 (1964); see also Smith v. Timberland, No. WC06-106 (W.C.C.A. Aug. 23, 2006).  The employee has shown medical support of a causal relationship between her work injury and her current condition.

Considering all of the above factors, the employee has shown a substantial change in medical condition since the time of the settlement.  In addition, the employee received a relatively small amount of compensation, $15,000.00, in the award on stipulation.  The employee has established good cause to vacate the award on stipulation.  We therefore grant the employee’s petition to vacate the award on stipulation.