The employer and insurer appeal the compensation judge’s findings that the employee’s work injury aggravated her pre-existing cervical, right shoulder, and lumbar conditions, that the employee’s RSD condition is related to the work injury, that the employee’s medical expenses were reasonable and necessary, and that the employee is entitled to temporary total and temporary partial disability benefits.  We affirm.

On March 6, 2013, Allison Weigand, the employee, was working as finance manager for Independent School District No. 2342, the employer, which was insured for workers’ compensation liability by RAM Mutual Insurance.  On that day, the employee slipped and fell while stepping from the employer’s parking lot to the sidewalk, falling with her right arm behind her, and landing on her right hand and right buttock.  After the fall, she experienced pain in her right hand, the right side of her neck, and her right buttock.  The employee notified the employer of the injury, and sought treatment that day from her chiropractor, Dr. Michael Kastner.  The next day, the employee began having difficulty holding a pen and had increased right hand pain, and returned to Dr. Kastner for treatment.  On March 8, 2013, the employee treated with her family doctor, Dr. James Halvorson, at the Sanford Medical Center in Fargo, North Dakota.  He noted that the employee was markedly impaired and took the employee off work, and referred the employee to a Minnesota provider for the work-related injuries.

On April 17, 2013, the employee treated with Dr. Michael Bristow at the Alexandria Clinic.  The employee reported right arm weakness and numbness, right shoulder pain, and low back pain.  Dr. Bristow referred the employee for neck, low back, and right shoulder MRIs and recommended physical therapy.  The employee’s shoulder MRI indicated mild subscapular tendinosis, interstitial longitudinal tear, mild intra-articular biceps tendinosis, and subacromial subdeltoid bursitis.  In May 2013, the employee began experiencing swelling and redness in her right hand as well as ongoing shoulder pain.  Dr. Bristow indicated that the employee had RSD-type symptoms and recommended work restrictions, physical therapy, an EMG, a pain management consultation, and a neurological consultation.  The EMG showed early mild carpal tunnel syndrome and no radiculopathy, and the employee was found not to be a surgical candidate.  At the employee’s request, Dr. Bristow recommended a graduated return to work, and the employee returned to work within her restrictions on May 22, 2013.  When the employee attended medical appointments or left early from work for reasons related to her work injury, she used compensatory time, vacation time, or sick leave.  The employee continued to treat with Dr. Kastner through July 2013.

At Dr. Bristow’s referral, the employee was evaluated by Dr. Sam Elghor at the Center for Pain Management on August 21, 2013.  Dr. Elghor assessed cervical facet joint injury and recommended diagnostic C2-7 nerve blocks.  The nerve blocks had a positive result, and Dr. Elghor recommended radiofrequency rhyzotomies.  These procedures were performed in October 2013 and provided relief of the employee’s neck pain.  In September 2013, the employee treated with Dr. Elghor for increased right hand pain and swelling.  Dr. Elghor recorded symptoms of pain, swelling, color changes, temperature changes, decreased range of motion, and hypersensitivity in the employee’s right hand and arm, and diagnosed reflex sympathetic disorder (RSD).  Dr. Elghor referred the employee for occupational therapy for her right hand and arm in 2013.  During treatment, the occupational therapist recorded symptoms of allodynia, swelling, changes in nail growth, joint stiffness, and weakness in her right hand.  The therapy increased the employee’s dexterity and range of motion.  The employee later underwent stellate ganglion blocks which reduced her pain and increased her ability to work.  The employee has been unable to return to other personal activities since the work injury.

On September 26, 2013, the employee was examined by Dr. David Fey, orthopedic surgeon, at the employer and insurer’s request.  Dr. Fey noted that the employee had pre-existing cervical degenerative disc disease that was unrelated to the work injury, and opined that there was no objective basis to indicate any current diagnosis, disability, or need for treatment related to her March 2013 work injury.  He concluded that the employee’s medical treatment more than one month after the work injury was not related to the work injury and that she did not need any further medical treatment or restrictions.

The employee’s treating physicians determined that the employee’s work injury was a substantial contributing cause of her conditions.  In January 2014, Dr. Elghor opined that the employee had reached maximum medical improvement for her cervical facet joint syndrome and spondylolistheses diagnoses.  He also opined that the employee had RSD in her right arm which had not reached maximum medical improvement.^[1]  Dr. Elghor concluded that the employee’s work injuries were a substantial contributing cause of her conditions.  In February 2014, Dr. Bristow stated that the employee had been diagnosed with cervical strain, intractable back pain, lumbar strain, RSD of the right arm, disc bulges at C6-7, L3-4, and L4-5, and mild rotator cuff tendinosis with possible small longitudinal tear.  He opined that the employee’s work injury was a substantial contributing factor of these conditions and that the employee was not at maximum medical improvement.  The employee continued to treat for RSD, cervical facet joint dysfunction, and low back pain with Dr. Bristow and Dr. Elghor.

The employee filed a claim petition on May 3, 2013, for injuries related to a slip and fall in the employer’s parking lot.  The employer and insurer objected, claiming that the employee’s injuries were temporary and had resolved after one month.  After a hearing on February 11, 2014, the compensation judge found that the employee’s work injury aggravated her pre-existing cervical, right shoulder, and lumbar conditions, that the employee’s RSD condition was related to the work injury, that the medical treatment submitted was reasonable, necessary, and causally related to the work injury, and that the employee was entitled to temporary total disability benefits and temporary partial disability benefits.  The judge denied the employee’s claim for penalties.  The employer and insurer appeal the compensation judge’s determinations that the employee’s work injury aggravated her pre-existing cervical, right shoulder, and lumbar conditions, that the employee’s RSD condition is related to the work injury, and that the employee is entitled to temporary total and temporary partial disability benefits.

The Workers’ Compensation Court of Appeals will uphold the factual findings of the compensation judge if they are supported by substantial evidence and were reached through application of the correct legal standard.^[2]  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.”^[3]  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.^[4]  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.”^[5]

This case presents five issues for determination:  (1) whether the employee sustained a work injury; (2) whether she suffered a substantial aggravation of her pre-existing cervical, right shoulder, and lumbar conditions from the work injury; (3) whether the work injury was a substantial contributing cause to her neuropathic condition and need for medical treatment; (4) whether her medical treatment post-injury was reasonable, necessary, and causally related to the work injury; and (5) whether the employee sustained an actual loss of earning capacity.  We affirm the findings of the compensation judge for the reasons addressed below.

The compensation judge found the employee injured herself when she slipped and fell while stepping from the employer’s parking lot to the sidewalk.  In making this finding, the judge accepted the employee’s testimony as credible and adopted the medical opinions of Dr. Elghor and Dr. Bristow.  It was this finding which in turn raised two issues for the compensation judge:  what was the nature and what was the extent of the injuries.  Appellants argue on appeal that the factual findings by the compensation judge on the nature and the extent of the employee’s injuries are not supported by substantial evidence in the record.  First, appellants claim the evidence, at best, supports a finding that the employee experienced a continuation of her pre-existing conditions after the injury.  Second, even if the employee sustained work-related injuries, appellants claim the injuries were temporary and resolved within 30 days.

In support of their contention, appellants rely on Dr. Fey’s October 9, 2013, and February 10, 2014, medical reports in which he concluded there was no work injury from the fall because the employee’s complaints were not supported by any objective findings to support any diagnosis that would be related to a work injury.  By contrast, Dr. Elghor and Dr. Bristow provided medical opinions that the March 6, 2013, incident was a substantial contributing cause of the employee’s neuropathic pain, reflex sympathetic dystrophy, and need for treatment.  In Dr. Bristow’s reports, he recorded the onset and development of symptoms after the work injury which he found to be valid indicators of neuropathic pain and need for treatment.  Dr. Elghor treated the employee on multiple occasions and recorded symptoms of reflex sympathetic dystrophy including swelling, color changes, temperature changes, decreased range of motion, and hypersensitivity in the employee’s right hand and arm.  These findings were present on multiple examinations with both Dr. Elghor and Dr. Bristow.  Unlike Dr. Fey, Dr. Elghor and Dr. Bristow viewed the employee’s objective findings as consistent with a neuropathic type of condition and not out of proportion to her subjective complaints.  Drs. Elghor and Bristow were also of the opinion that the symptoms and related pain from the neuropathic condition were the result of the work injury.

In his memorandum cited below, the judge explained his rationale for choosing Dr. Elghor’s and Dr. Bristow’s opinions over that of Dr. Fey regarding the employee’s onset and development of RSD and the causal link between the condition and the work injury:

Appellants point out that since the employee’s attorney’s summary of medical treatment sent to the doctors did not include the employee’s chiropractic treatment after 2010, those doctors do not have adequate foundation for their opinions.  We disagree.  The employee was first evaluated by her primary care provider, Dr. Bristow, in April of 2013.  Four months later the employee was seen at the Center for Pain Management from a referral by Dr. Bristow.  Both Dr. Bristow and Dr. Elghor examined and treated the employee numerous times.  As a general rule, this level of knowledge establishes a doctor’s competence to render an expert opinion.^[10]  The foundation for Dr. Bristow’s and Dr. Elghor’s medical opinions was based on their personal knowledge of the employee’s symptoms and conditions.  We find no basis to conclude their opinions lack foundation and the compensation judge did not err by relying on their opinions.

Work injuries are compensable if the employment is a substantial contributing factor not only in causing a new condition but also in aggravating or accelerating a preexisting condition.^[11]  The compensation judge discussed the evidence relating to the employee’s pre-existing conditions and her pre-injury medical treatment for these conditions.^[12]  While this evidence was persuasive to the independent medical examiner, it did not persuade the compensation judge the same way.  In reaching his conclusion on the compensability of the employee’s claim, the judge cited several pieces of evidence.  He identified the nature and extent of the employee’s conditions and treatment before the date of injury and also made findings citing the medical providers and treatment on and after the date of injury.  A review of this evidence on appeal illustrates a pre- and post-injury change in the employee’s conditions that the compensation judge found credible, reasonable and significant.^[13]  In reviewing for substantial evidence to support the judge’s findings, we do not make credibility determinations.  The judge found the employee a credible witness and chose Dr. Elghor’s and Dr. Bristow’s opinions over that of Dr. Fey.

For all the reasons addressed above, we reject the appellants’ argument that the record lacks substantial evidence to support the compensation judge’s findings on the employee’s nature and extent of her injuries and conditions.  Substantial evidence in the record supports the judge’s findings that the employee sustained work-related injuries and that the neuropathic diagnosis was not a continuation of a pre-existing non-work-related condition.  Accordingly, we affirm the compensation judge’s determinations that the employee sustained a work injury, that she suffered a substantial aggravation of her cervical, right shoulder, and lumbar conditions from the work injury, and that the work injury was a substantial contributing cause to her neuropathic condition and need for medical treatment.

Appellants contend the compensation judge erred when he found the medical treatment post-injury was reasonable, necessary, and causally related to the work injury.  Appellants argue that 80 medical appointments within a six-month period is excessive and “well past the number of appointments Dr. Fey stated would have been reasonable following the injury.”^[14]  We are not persuaded by this argument.

A charge for a medical service is excessive if it is for a service provided at a level, duration, or frequency that is excessive based upon accepted medical standards.^[15]  Appellants ask us to follow their logic and to agree that “[t]he extensive list of appointments and the ongoing treatment demonstrates that the Employee has been unable to cure or relieve her injuries, illustrating that the treatment she has received is not reasonable.”^[16]  We note that the frequency of a particular medical expense or service when measured against the accepted standards of medical practice may be excessive.  However, appellants fail to cite in their brief any particular expense or treatment which they claim as excessive or unreasonable, citing only to Dr. Fey’s medical opinions contained in his medical reports.  Conflicts in expert medical testimony must be resolved by the compensation judge.^[17]  The compensation judge adopted the medical opinions of Dr. Bristow and Dr. Elghor over the medical opinions of Dr. Fey on the employee’s medical treatment.  In doing so, the judge found the medical appointments and treatment likely to produce results as to the diagnosis and treatment of the employee’s work-related conditions.  We find the relevant evidence adequate to support the compensation judge’s determination that the medical treatment awarded was reasonable, necessary, and causally related to the work injury.

The appellants also contend the compensation judge committed an error of law when he found the employee entitled to temporary partial disability benefits, arguing that the employee has no actual loss of earning capacity since she received her full wage with use of vacation time and sick leave.  We reject this argument based on the reasons addressed below.

The employee used her vacation time and sick time to cover her wage loss for medical appointments and lost time for reasons related to her work injury.  Appellants argue that the employee received her full wages and therefore did not sustain any wage loss and so is not entitled to temporary partial disability benefits for that time.  Appellants maintain that payment of temporary partial disability benefits compensates the employee twice under the theory of double recovery since she was already paid for the time off.

This court considered this argument in Ellingson v. City of Fergus Falls.^[18]  In Ellingson, we noted that workers’ compensation benefits are primary.  We also noted that not allowing the employee to receive temporary partial disability benefits for vacation leave and sick time would be tantamount to employees “paying workers’ compensation benefits to themselves from their acquired vacation and sick leave.”^[19]  Here, the employee used vacation time and sick leave while she waited for her claim to proceed to hearing.  Once her claim was determined compensable, the portion of wages received under vacation or sick leave became the portion of wages paid as temporary partial disability at the compensation benefit rate.  The judge in this case did not err in awarding the employee temporary partial disability benefits for vacation time or sick leave used to cover the time lost from work since the workers’ compensation insurer was adjudicated the primary payor.  Accepting appellants’ argument would in effect transfer the employer’s obligation to provide workers compensation benefits over to an employee entitled to workers’ compensation benefits.  For the foregoing reasons, we affirm.