The employer and insurer have appealed the compensation judge’s finding that the employee’s neuropathic pain has transferred to her left upper extremity and that the medical treatment received for that condition was reasonable, necessary, and causally related to the employee’s May 3, 2005 work injury.  We affirm.

Wendy Ruby was employed by Casey’s General Store when she was injured on the job on May 3, 2005.  Ms. Ruby injured her left foot and ankle, which later developed into reflex sympathetic dystrophy (RSD) or, as used interchangeably, complex regional pain syndrome (CRPS).  Within a few months, the employee experienced diffuse pain in various places in her body, but primarily the left arm.  The employee sought and was awarded medical care for neuropathic pain in her left arm.  That award was appealed by the employer and insurer and this court upheld the award.^[1]  The court determined that substantial evidence supported the compensation judge’s conclusion that neuropathic pain had migrated from the RSD/CRPS affected limb to the upper left limb and that the May 3, 2005, work injury was the cause of the upper left symptoms.  That decision was appealed and affirmed without opinion by the Minnesota Supreme Court.^[2]

The employee began using a spinal cord stimulator in January 2010 to address her left side neuropathic pain.  The employee described getting significant relief from the device.  None of the leads were installed to address any portion of the employee’s right side extremities.  On June 29, 2012, the stimulator was reprogrammed to improve pain coverage on the employee’s left leg and left arm.

On September 5, 2013, the employee was examined by her treating physician, Kanya Vanadurongvan, M.D.  The employee complained of a burning sensation from her right elbow to her wrist and pain up to the right shoulder joint.  Dr. Vanadurongvan noted that the employee’s right elbow was swollen and that her right arm had a somewhat mottled appearance.  Dr. Vanadurongvan diagnosed tendinitis and tenosynovitis of the right elbow, possibly related to the employee’s underlying RSD/CRPS.  (Employee Ex. N.)

In September and October 2013, the employee underwent physical therapy treatment to address the right elbow condition and to desensitize her right arm as part of an RSD treatment protocol.  The employee described several RSD symptoms which she had been experiencing and these symptoms were charted in the employee’s physical therapy treatment notes.  (Employee Ex. S.)

On October 10, 2013, the employee was again examined by Dr. Vanadurongvan.  The employee described the symptoms that she recently experienced regarding her right arm.  Dr. Vanadurongvan diagnosed possible RSD/CRPS in the right arm and he proposed testing the hypothesis with a stellate ganglion block.  The employee noted that her spinal cord stimulator had been providing inconsistent relief and Dr. Vanadurongvan arranged for reprogramming of the device.  (Employer/Insurer Ex. 5.)

On November 23, 2013, the employee underwent a stellate ganglion block administered by Sam Elghor, M.D.  Dr. Elghor listed his pre-operative diagnosis as RSD and right upper extremity pain.  Dr. Elghor noted that “the affected upper extremity was at least 5 degrees warmer than the opposite side and there was also a positive Horner syndrome.”^[3]  (Employee Exhibit B.)  The employee experienced pain relief from the procedure and it was repeated on May 16, 2014.  At that time, the right and left hand temperatures were recorded and the employee’s left hand was about one degree warmer post-procedure.  The employee also exhibited Horner syndrome after the procedure.  On May 23, 2014, the employee underwent an injection to address her right elbow pain (diagnosed as medial epicondylitis).  On May 30, 2014, the employee underwent another stellate ganglion block.  No specific temperature was recorded, but the chart noted that upper left extremity was at least 5 degrees warmer.

On January 14, 2014, the employee underwent an independent medical examination (IME) conducted by Jack Hubbard, M.D.  Dr. Hubbard noted no signs consistent with RSD/CRPS (mottling, edema, temperature differences, allodynia, and hair and nail growth).  Dr. Hubbard noted that the employee could ambulate without the walker that she had been using, and that her gait was “minimally unsteady.”  (Employer/Insurer Ex. 1, Attachment B at 6.)  Dr. Hubbard opined that the employee was not suffering from RSD/CRPS in any extremity, that the spinal cord stimulator should be discontinued, and that the employee was suffering from tendonitis to her right elbow but that this condition was unrelated to the May 5, 2005, work injury.

On June 25, 2014, Dr. Elghor provided his opinion regarding the employee’s care at the request of the employee’s counsel.  Dr. Elghor identified his diagnosis for the employee’s right upper extremity as complex regional pain syndrome and right elbow epicondylitis.  Dr. Elghor opined that the CRPS condition had spread from the employee’s left arm and left leg to her right arm.  Dr. Elghor based this opinion on the observation of hypersensitivity, color changes, temperature changes, and the employee’s response to the stellate ganglion blocks.  Regarding the right elbow epicondylitis, Dr. Elghor attributed the condition to overuse arising out of the inability of the employee to use her left arm for many tasks and the employee’s need for a cane.

The employee filed a Medical Request for payment of the treatment provided for the pain symptoms in her upper right extremity.  A hearing was held regarding the medical dispute.  The employee testified regarding her symptoms and specifically the pain that she was experiencing in her upper right extremity.  The compensation judge’s findings and order were issued on February 27, 2015.  The compensation judge determined that the employee’s right upper extremity condition was neuropathic pain that transferred from her upper left side and was caused by the employee’s RSD/CRPS condition that arose out of the May 3, 2005. work injury.  The compensation judge awarded payment of the medical expenses in dispute.  The employer and insurer have appealed that decision.

An employer is obligated to provide an injured worker with medical care that may “reasonably be required” to cure and relieve from the effects of the work injury.  Minn. Stat. § 176.135.  The issue of whether specific medical treatment is reasonable and necessary is a question of fact for the compensation judge to determine.  Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993); Richardson v. Hot Shot Prods., 72 W.C.D. 113 (W.C.C.A. 2012).  The question for this court is whether the decision of the compensation judge is supported by substantial evidence.  If so, the decision is to be affirmed. Minn. Stat. § 176.421, subd. 1; Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984).

The employer and insurer maintained that the medical evidence offered was insufficient to support the compensation judge’s decision because that evidence was unduly subjective.  The employee responded that observable, objective symptoms, specifically, temperature differences, mottling, color changes, and edema were observed affecting the employee’s right arm at various times from September 5, 2013, and onward.  These symptoms were set out in the employee’s medical records and described by the employee in her hearing testimony.  In addition, the employee noted that her subjective complaint of pain in her right arm (apart from the elbow condition) was alleviated by the blocks applied.  The employee contended that this was sufficient evidence to support the compensation judge’s decision.

The employee’s medical record contains observed, objective symptoms affecting her right upper extremity that are consistent with those of RSD/CRPS.  While the employee’s medical record does not reflect that she experienced all of the symptoms of RSD/CRPS, such a demonstration is not required to support a conclusion that the employee experienced neuropathic pain in her right upper extremity that originated from the employee’s left side RSD/CRPS.  See Stone v. Harold Chevrolet, 65 W.C.D. 102 (W.C.C.A. 2004), summarily aff’d. (Minn. Feb. 2, 2005); Ellsworth v. Days Inn/Brutgers Equities, No. WC06-276 (W.C.C.A. June 8, 2007)(failure to manifest a majority of the symptoms of RSD not a bar to a diagnosis of the condition).

The employer and insurer maintained that there is a distinction between neuropathic pain and RSD/CRPS and that the compensation judge erred in awarding medical benefits because not all of the RSD/CRPS symptoms were present.  This argument misstates the basis on which the compensation judge awarded benefits.  The compensation judge carefully distinguished between neuropathic pain and RSD/CRPS.  The award was based solely on the migration of neuropathic pain from the employee’s left side to her right upper extremity.  The IME relied upon by the employer and insurer, Dr. Hubbard, indicated that such pain migrates in up to 10 percent of cases and follows a pattern.  (Employer/Insurer Ex. 1 at 13-14.)  The migration pattern identified by Dr. Hubbard is consistent with the pattern displayed by the employee herein.  Both of the employee’s treating physicians identified the right upper extremity condition as having been caused by the RSD/CRPS which arose out of the May 3, 2005, work injury.  (Employee Exs. L and N.)

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 (2010).  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).  On the issue of causation of the employee’s right upper extremity condition, the record contains sufficient evidence, including expert medical opinion, to support the compensation judge’s finding and for that reason we affirm.  Id. at 60, 37 W.C.D. at 240.

Considering the evidence available from the employee’s medical record and her testimony, there is a sufficient basis to conclude that the employee experienced neuropathic pain in her right upper extremity that migrated from her left side.  The evidence in the record is sufficient to establish the chain of causation running from the work injury to the right side neuropathic pain experienced by the employee.  The employee testified as to the relief that she experienced from the medical care received from her treating physicians, which provides a sufficient basis to determine that the medical care was appropriate to cure and relieve the effects of the work injury.  For these reasons, we conclude that the decision of the compensation judge is supported by substantial evidence and the decision is affirmed.