DEBRA K. MATTICK, Employee/Appellant, v. HY-VEE FOOD STORES, SELF-INSURED/EMC RISK SERVS., INC., Employer/Respondent, and MAYO CLINIC and HARTFORD LIFE, Intervenors.

The employee appealed the compensation judge’s denial of benefits arising from the finding that her January 18, 2014, work injury was temporary and resolved. The employer maintained that the compensation judge’s decision was adequately supported by the report of the independent medical examiner admitted into the record of this proceeding.

As the findings of the compensation judge are not supported by substantial evidence and consistent with the law, we reverse. As there are issues remaining regarding the requested benefits, this matter is remanded.

The employee, Debra Mattick, has worked for the employer, Hy Vee Food Stores, since 2001 as a cake decorator. The employee’s work requires standing all day, with walking and light lifting. On January 18, 2014, the employee suffered an admitted work injury to her right ankle in the course and scope of her employment. Prior to the work injury, the employee worked 40 to 45 hours per week.

On March 14, 2000, the employee was walking down stairs at church, missed a step, and fractured her right ankle. The employee was diagnosed with an unstable bimalleolar fracture. The employee underwent surgery to install hardware for repair of the fracture.

The employee experienced nonunion of the right ankle fracture. On June 27, 2000, the employee underwent open reduction and internal fixation of the right ankle at the fracture site. The employee’s medical records following the reduction surgery indicated that the fracture was healed and the employee was not reporting pain. Range of motion was somewhat limited and the employee was warned against high risk twisting activities. Use of orthotics to protect the right ankle was continued.

Following the second surgery, the employee returned to work without restrictions. The employee engaged in organized sporting activities including golf, sand volleyball, and league bowling. The employee commonly took five mile recreational walks.

At a follow-up examination on April 12, 2004, the employee discussed right ankle pain that had gone on for about one month which was attributed to post-traumatic arthritic pain arising from the fracture. The employee did not recall this pain to be either lengthy or severe.^[1] The employee experienced right heel pain, diagnosed as Achilles tendinitis following plantar fasciitis release, in 2007. The employee’s pain was limited to her right Achilles tendon and heel. That condition resolved after two months of physical therapy.

From 2004 to January 18, 2014, the employee experienced no significant pain symptoms or swelling in her right ankle. The employee noted occasional pain and minor swelling often coincident with changes in the weather. The only orthotic device used by the employee was a simple ankle brace while playing volleyball. The employee experienced a trip and twisted right ankle in the summer of 2013 while at work. The employee did not experience any injury from the incident and did not seek any medical treatment. The employee’s supervisor was aware of the incident, but no injury report was filed.^[2]

On January 18, 2014, the employee tripped over a pallet at work and twisted her right ankle. The employee iced and rested her right ankle, noticing swelling and pain symptoms. The employee next worked on Monday, January 20, 2014, and the pain and swelling continued. After work on January 20, 2014, the employee was examined by Cynthia Gilbert, PA-C, who noted no bruising and some swelling. Imaging was performed which showed mild degenerative changes, no fracture, intact hardware, spurring in the calcaneus (heel bone), and soft tissue swelling. PA-C Gilbert diagnosed an ankle sprain and directed conservative treatment. Work restrictions were issued for standing, as tolerated.^[3]

A follow-up examination was conducted on January 28, 2014, by Steven J. Schulz, M.D. Dr. Schulz noted that the employee’s ankle swelling was improving. A lace-up ankle brace was prescribed with instructions to reduce weight bearing on the right ankle as much as possible, but no restriction against walking or standing was imposed. The employee continued working at her usual duties.

On March 11, 2014, the employee was examined on follow-up by Dr. Schulz, who noted that the employee’s condition was “about the same.” Dr. Schulz prescribed four weeks of physical therapy and released the employee to work without restrictions.

On March 23, 2014, the employee suffered a non-work fall in which she injured her right knee and suffered a mild concussion. The employee described her right ankle as having some new swelling. Dr. Schulz conducted a follow-up examination on April 3, 2014, after the employee tripped on a crack in the sidewalk and suffered an aggravation of her right ankle condition. Dr. Schulz directed that the employee take ibuprofen and continue physical therapy. The employee noted a slight increase in pain symptoms after these two incidents which returned to her baseline of symptoms within a couple of weeks.^[4]

On April 17, 2014, Dr. Schulz referred the employee to a foot and ankle clinic due to continued pain in her right ankle. The referral form describes the employee’s condition as a “right ankle sprain.”^[5]

On April 30, 2014, the employee was examined by Robert L. Collier, D.P.M. Imaging taken showed a healed fracture, properly aligned hardware, small bony ossicle ununited at medial malleolus, and severe degenerative lateral ankle joint space narrowing with bone on bone. Dr. Collier diagnosed the employee’s condition as “lateral ankle sprain with exacerbation of arthritis.”^[6] Dr. Collier administered a Kenalog (steroid) injection and directed that the employee to use a CAM (controlled ankle movement) boot whenever she was weight bearing. A second injection was performed on May 19, 2014.

On October 15, 2014, Dr. Collier examined the employee on follow-up. The employee’s use of an AFO (ankle foot orthosis) was noted. Dr. Collier assessed the employee as having significant degenerative arthritis of the right ankle. The chart note indicates that the employee “had a secondary injury at work which has led to the most recent episode of pain.”^[7] The possibility of undergoing an ankle fusion was discussed and work restrictions were imposed.

On February 3, 2015, the employee underwent an independent medical examination (IME) conducted by David Fey, M.D. Dr. Fey conducted a physical examination where the employee exhibited limited passive range of motion in her right ankle compared to her left ankle. Dr. Fey assessed the employee’s January 18, 2014, work injury as a temporary lateral ankle sprain that would naturally resolve within a two-month period. Dr. Fey maintained that there was “no reasonable subjective basis or objective basis by which to support that [the employee] accelerated or otherwise in any way modified her pre-existing degenerative arthritis.” Dr. Fey opined that the employee’s existing ankle condition was “in no way related to her claimed work injury of January18, 2014.” Dr. Fey assessed reasonable care for the employee’s January 18, 2014, work injury to be two visits to a physician and up to six physical therapy sessions within two months of the work injury. Dr. Fey opined that ankle fusion was not a reasonable treatment for a mild ankle sprain.^[8]

On June 2, 2015, the employee was examined by Daniel B. Ryssman, M.D. Dr. Ryssman noted that the employee had undergone open reduction and fixation of her right bimalleolar ankle fracture, which had healed. Dr. Ryssman noted that the employee has been in continual and constant pain since the January 18, 2014, work injury.

On August 31, 2015, the employee underwent removal of right ankle hardware and a right ankle arthrodesis. From the time of the January 18, 2014, work injury to the fusion surgery, the employee experienced right ankle pain and swelling every day. During the last four months prior to the fusion, the employee described the right ankle pain as 10 [of 10] and excruciating. The employee was unable to participate in volleyball, bowling, golf, or recreational walking since the January 18, 2014, work injury.^[9]

On September 24, 2015, Dr. Collier provided a narrative report at the request of the employee’s counsel. Dr. Collier noted his initial impression that the employee had experienced an ankle sprain which had exacerbated the employee’s degenerative arthritis. Dr. Collier stated: “I do feel that her injury, while not the primary cause of the arthritis, certainly led to the flare up along with the ankle sprain that [the employee] received.”^[10] Dr. Collier also completed a Health Provider Form in which he checked the box indicating that in his opinion, the employee’s work injury “caused, aggravated or accelerated” the employee’s condition.

On October 30, 2015, Dr. Fey provided a supplement to his IME opinion. Dr. Fey noted the diagnosis by Dr. Collier on October 14, 2014, of “probable lateral ankle sprain with exacerbation of degenerative arthritis.” Dr. Fey assessed the employee’s medical documentation as consistent with that of a mild ankle sprain. Dr. Fey stated “If she would have sustained an injury on January 18, 2014 to the level that resulted in the need for a fusion procedure, as ultimately performed, it would be expected that she would have significant swelling and at least some bruising . . . .”^[11]

On November 23, 2015, the employee underwent an IME conducted by Jack M. Bert, M.D., at the request of the employee’s counsel. Dr. Bert conducted a physical examination and reviewed the employee’s medical records. Dr. Bert noted the absence of limitations on the employee’s activities prior to the January 18, 2014, work injury. Dr. Bert opined that the employee’s right ankle condition was the result of a permanent aggravation by the January 18, 2014, work injury to the employee’s underlying and preexisting arthritis. Dr. Bert opined that the employee had “certainly . . . sustained a permanent partial disability directly causally related to the January 18, 2014 aggravation of her preexisting condition.”^[12]

On December 28, 2015, Dr. Fey provided an addendum to his two earlier IME opinions. Dr. Fey noted the assessment by Dr. Bert of a permanent aggravation. Dr. Fey repeated his contention that the January 18, 2014, work injury resulted only in a mild sprain that would have resolved within two months. Dr. Fey stated that “While I appreciate and respect [the employee]’s history that she had ankle problems at times subsequent to her claimed work injury of January 18, 2014, there is no objective basis by which to support any opinion that these ongoing problems were related to anything other than her long-standing degenerative arthrosis of the ankle which developed subsequent to the March 2000 bimalleolar ankle fracture.” Dr. Fey later referred to the employee describing “having difficulties at some point in time after [the January 18, 2014 work injury]. . . .” Dr. Fey opined that Dr. Bert’s opinions were not reasonably supported in the employee’s medical records. Dr. Fey repeated his contention that fusion surgery is not required to treat ankle sprains. Nothing in Dr. Fey’s addendum addresses the assessment by Dr. Bert based on the employee’s abilities before and after the work injury.^[13]

On January 20, 2015, the employee filed a Claim Petition seeking approval of the right ankle arthrodesis. The employee added claims of temporary total disability, permanent partial disability and out-of-pocket medical expenses. These claims, together with two intervention claims, came on for hearing before the compensation judge on February 5, 2016. The compensation judge issued a Findings and Order that was filed and served on April 4, 2016. The compensation judge rejected the opinions of Dr. Collier as being insufficiently definite regarding permanence, and of Dr. Bert for not having reviewed all of the employee’s medical records. The compensation judge found that the employee’s right ankle injury that was incurred on January 18, 2014, was temporary and had resolved. The judge also found that the January 18, 2014, work injury was not a significant or substantial contributing factor to the right ankle fusion surgery performed on August 31, 2015. The judge denied the claims by the employee and the two intervenors. The employee appealed.

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 (2014). 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). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. 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.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

Where a work injury aggravates or accelerates a pre-existing condition, the employer and insurer are responsible for the resulting condition. Vanda v. Minn. Mining & Mfg. Co., 300 Minn. 515; 218 N.W.2d 458; 27 W.C.D. 379 (1974)(1974). The employee argues that the employer and insurer’s medical expert failed to follow this longstanding rule. The employee contends that her preexisting medical condition only required medical treatment because of the January 18, 2014, work injury (citing Johnson v. Northern Pride, 59 W.C.D. 494 (W.C.C.A. 1995); Buford v. Ford Motor Co., 52 W.C.D. 723 (W.C.C.A. 723)). The employee also contends that the six factors established to assess whether an aggravation is temporary or permanent were not followed by the compensation judge. McClellan v. Up North Plastics, slip op. (W.C.C.A. Oct. 18, 1994).

The employer emphasized that the employee did not miss significant time from work and that substantial evidence, in the form of the IME of Dr. Fey, supported the compensation judge’s findings. The employer described the choice of expert by the compensation judge as “sacrosanct” and “unassailable.” The employer responded to each of the McClellan factors, contending that the lack of prior restrictions was not relevant because she was not taken off work after the injury. The employer relied heavily on Dr. Fey’s assessment of the employee’s January 18, 2014, ankle sprain in contending that the aggravating incident was “mild in nature.” The employer did acknowledge that fact findings could be set aside where “manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.” Northern States Power Co., 304 Minn. at 201, 229 N.W.2d 521 at 524.

Six factors have been identified that a compensation judge may consider to determine whether an aggravation is temporary or permanent. These factors are: (1) the nature and severity of the preexisting condition and the extent of restrictions and disability resulting therefrom; (2) the nature of the symptoms and extent of medical treatment prior to the aggravating incident; (3) the nature and severity of the aggravating incident and the extent of restrictions and disability resulting therefrom; (4) the nature of the symptoms and extent of medical treatment following the aggravating incident; (5) the nature and extent of the employee's work duties and non-work activities during the relevant period; and (6) medical opinions on the issue. McClellan, slip op. (W.C.C.A. Oct. 18, 1994).

Use of the McClellan factors is not mandatory, even in aggravating injury cases such as this one. Lambert v. City of Duluth, No. WC11-5268 (W.C.C.A. Nov. 18, 2011); Calbillo v. MG Waldrum, No. WC05-235 (W.C.C.A. Jan. 31, 2006). Nevertheless, the factors are useful in assessing the totality of the record regarding whether the employee has met her burden to demonstrate that she suffered a permanent aggravation, caused by her work injury, to a pre-existing condition.

We consider the facts of this case in light of the McClellan factors. The employee had no restrictions or disability arising out of her preexisting condition. The employee had only limited and temporary symptoms on an infrequent basis and no medical treatment to her right ankle for ten years prior to the work injury at issue. The aggravating incident required medical treatment that escalated over time when a minor injury would have healed. The employee experienced pain at all times following the aggravating incident, required use of an orthotic at all times following the incident, and it resulted in a right ankle fusion. The employee experienced limited impairment in her ability to work and complete cessation of her sports activities following the aggravating incident. Medical opinions of a treating physician and the employee’s IME concluded that the January 18, 2014, work injury was a cause of the employee’s need for the fusion surgery.

Five of the six McClellan factors unambiguously support finding that the January 18, 2014, work injury was a permanent aggravation of the employee’s underlying right ankle arthritis which required that the employee undergo the right ankle fusion. While the employee experienced only limited disability from employment until she underwent the fusion surgery, she was totally disabled from her sporting activities. The sixth factor, medical opinions, is split, with opinions on both sides of the issue. Assessment of which of the factors are significant and the weight to be given to any factor is generally left to the compensation judge. Wold v. Olinger Trucking, Inc., slip op. (W.C.C.A. Aug. 29, 1994). In this matter, the only factor that supports a conclusion that the aggravation was temporary is the opinion of the employer’s IME, Dr. Fey.

A compensation judge’s choice between conflicting expert opinions is usually upheld unless the facts assumed by the expert are not supported by substantial evidence. Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985)(citing Klapperich v. Agape Halfway House, Inc., 281 N.W.2d 675, 679-80, 31 W.C.D. 641, 650 (Minn. 1979); McDonald v. MTS Sys. Corp., 43 W.C.D. 83 (W.C.C.A. 1990), summarily aff’d (Minn. July 13, 1990). The employee contended that Dr. Fey ignored the employee’s actual treatment records and the employee’s actual condition. The employer and insurer contended that the compensation judge’s choice of medical opinion was “sacrosanct” and could not be altered on appeal.

Where, as here, the employee is seeking to demonstrate causation through aggravation of an allegedly asymptomatic condition, there must be an assessment of the employee’s condition before and after the work injury. Dr. Fey relies on the employee’s “expected natural history of [the employee’s preexisting condition] is progression of the arthritic condition with chronic waxing and waning and generally progressive symptoms.”^[14] The employee’s medical record has no evidence whatsoever of such symptoms. The only instance of significant pain in the employee’s medical record relating to the employee’s preexisting condition was in 2004 and resolved promptly through conservative treatment. Further, the employee was unimpaired by her preexisting condition, to the extent the she could participate in golf, bowling, sand volleyball and recreational walking over significant distances. The ten-year absence of any progressive symptoms and the lack of limitations on use of the ankle prior to the January 18, 2014, work injury are not mentioned in Dr. Fey’s opinion.

After the January 18, 2014, work injury, the employee’s medical records are consistent, showing that her right ankle condition did not improve. Dr. Fey opined that the employee’s ankle sprain required no more than conservative treatment and the condition resolved within two months of the work injury. However, as of April 30, 2014, over three months after the work injury, the employee’s diagnosis was “lateral ankle sprain with exacerbation of arthritis” and the employee was placed in a CAM boot.

Dr. Fey’s opinions suggest that the employee’s condition improved and at some point the employee’s diagnosis somehow changed. These descriptions appear almost verbatim in the compensation judge’s memorandum. There is no basis in the employee’s medical record or the employee’s testimony to support these suggestions. The employee’s treatment records are clear that the employee’s pain symptoms did not significantly improve from the time of the January 18, 2014, work injury until the employee’s right ankle arthrodesis. While the description of the employee’s condition occasionally refers only to arthritis, the causation of the condition, which is the ultimate issue to be decided in this matter, plainly refers to the right ankle sprain on January 18, 2014.^[15]

Dr. Fey’s opinion relies on assumptions about the employee’s medical condition that are not supported by substantial evidence. As a result, this opinion does not meet the standard for reliability set in Nord. There is no basis for denying compensation for a consequential injury simply because the injury which aggravated an underlying condition seemed somewhat minor. The employee need only demonstrate that the work injury did cause the need for the subsequent medical treatment. The employee has shown that her underlying and preexisting arthritis was asymptomatic. The employee has shown that she did not need a right ankle arthrodesis prior to the January 18, 2014, work injury. The effects of the work injury included rendering the employee’s preexisting arthritis symptomatic, ongoing severe pain, and precluding the employee from participating in physical activities that she had enjoyed until the date of the work injury. This constitutes causation under the applicable case law and the employee has met her burden of proof on that issue.

We are cognizant of the discretion afforded the compensation judge in the choice of expert and that discretion is rarely intruded upon. But here, as in Nord, the expert relied upon by the compensation judge overlooked significant aspects of the employee’s condition both before and after her work injury. As the Minnesota Supreme Court stated: “While the trier of fact's choice between experts whose testimony conflicts is usually upheld, that choice is not upheld where the facts assumed by the expert in rendering his opinion are not supported by the evidence.” Nord, 360 N.W.2d at 342-3. As this rare occurrence is the case in this proceeding, we conclude that the opinion of Dr. Fey is not supported by the evidence in this proceeding and cannot be relied upon.

The employee’s treatment records, the medical opinions of the treating physician, and the employee’s testimony all demonstrate that the employee’s pain symptoms were caused by an aggravation of a preexisting condition. The aggravation was caused by the employee’s January 18, 2014, work injury. The aggravation caused a loss of use of the employee’s right ankle. The aggravation was permanent, in that the employee’s ongoing pain condition did not resolve after the January 18, 2014, work injury until the employee underwent surgery. The right ankle arthrodesis was necessary and reasonable to cure and relieve the employee from the effects of the January 18, 2014, work injury. The Findings and Order of the compensation judge served and filed April 4, 2016, is reversed. As the record is disputed regarding some of the requested benefits, most notably the request for permanent partial disability, this matter is remanded for further proceedings consistent with this decision.

The compensation judge relied on the opinion of the employer and insurer’s IME to conclude that the employee’s need for a right ankle arthrodesis was not caused by the employee’s right ankle sprain on January 18, 2014. As the IME opinion in this matter was based on assumed facts that are not supported by substantial evidence, the IME opinion does not meet the Nord standard for the choice of expert. Overwhelming evidence in the record demonstrates that the employee’s January 18, 2014, work injury was the cause of her preexisting arthritis becoming symptomatic. The subsequent right ankle arthrodesis was reasonably required to treat the symptoms which arose out of that injury. As the employer and insurer also disputed whether a permanent partial disability rating was premature, the Findings and Order of the compensation judge is REVERSED, and this matter is REMANDED for determination as to what benefits are appropriate.

In determining if the work injury was temporary or permanent in nature, the majority begins its analysis by relying on the six factors outlined in McClellan and Wold.^[16] It argues that five of the six factors support the appellant’s position, leaving only one, the medical opinions on the issue, as “ambiguous.” The majority ultimately concludes that the judge erred in relying on the Dr. Fey’s medical opinion because it was not supported by substantial evidence.

I respectfully disagree with the majority’s reversal of the findings and order. I would affirm the compensation judge in that substantial evidence supports the temporary nature of the employee’s work injury.

In Wold, this court stated:

I disagree with the majority’s conclusion that five of the six McClennan and Wold factors support the appellant’s position. The record as a whole appears to support the temporary nature of work injury in some of the six factors, and support the permanent nature of the work injury in others. First, the employee’s preexisting condition was significant. She was diagnosed with “severe degeneration of the ankle joint.” She treated for the right ankle and heel conditions in 2000, 2004, and 2007. In 2013, she twisted her ankle at work. She testified that between 2004 and 2014, she had intermittent swelling, and three to four times a year she would get ankle pain and take anti-inflammatories. She wore an ankle brace when playing sports. These facts support that the pre-existing condition was severe, yet the employee seemed to get along, work, and participate in active sports. They could be interpreted to support either conclusion about the nature of the work injury.

Second, the medical treatment for 10 years before the work injury was not regular, yet it was significant. She suffered a non-union fracture which required two surgeries and the placement of hardware which tends to support the temporary nature of the 2014 work injury.

Third, the nature and extent of the 2014 work injury was not severe at first. The employee presented with mild soft tissue swelling, but no bruising. On examination, her ankle joint showed good range of motion. X-rays showed no fracture, and no movement of the ankle hardware. She appeared to be improving through March 2014. She twisted her ankle once in March and again in April causing more swelling. These facts appear to support the compensation judge’s finding that the work injury was probably temporary in nature.

Fourth, the nature and extent of medical treatment after the work injury would tend to support the permanent nature of the work injury. The employee continued to treat with ongoing pain and swelling until she underwent an ankle joint fusion in August 2015.

Fifth, the nature and extent of the employee’s work duties after the 2014 work injury tend to support the temporary nature of the condition. The employee was released to return to work without restrictions. She spent the work day on her feet until her surgery in August 2015. However, with respect to the employee’s non-work related activities, the facts tend to support the permanent nature of the work injury. The employee testified that she was unable to engage in the sport activities she had before the work injury. Finally, the medical opinions on the issue appear to support the temporary nature of the employee’s condition.

The medical opinion upon which the judge relied was the IME, Dr. Fey, who concluded that the 2014 work injury was an ankle sprain which was temporary in nature. The majority discounts Dr. Fey’s opinion as being unsupported by substantial evidence. I disagree. Dr. Fey based his opinion on objective findings of long standing degenerative arthrosis of the ankle which the employee developed subsequent to the March 2000 bimalleolar ankle fracture. He opined that the 2014 work-related ankle sprain did not result in the need for surgery. Rather, it was the underlying arthritic condition that led to the fusion of the ankle joint in August 2015.

Dr. Fey supported his opinion in three separate IME reports. He reviewed the medical records. He outlined a medical history consistent with the record. He also discussed the long term care of the employee post work injury. He acknowledged the employee’s ongoing symptoms and stated “while I appreciate that Ms. Mattick described having difficulties at some point in time after the incident of January 18, 2014, which led to further evaluation and ultimately a fusion procedure dated August 31, 2015, .the medical information available for review including all subjective information but also objective information simply does not reasonably support she sustained any injury on January 18, 2014, which resulted in any change in condition or diagnosis which would result in the need for a later fusion surgery.”^[17] Dr. Fey considered the evidence and concluded that the work injury was temporary in nature.

Other medical opinions also appear to support Dr. Fey’s conclusions. Dr. Rysmann, the orthopedic surgeon who performed the ankle joint fusion in August 2015, chose not to address the causal connection between the ankle joint fusion and the work injury in his narrative report.^[18] Yet, he noted in the operative report that based on what he could see, “most of her symptoms were coming from the arthritis in the ankle . . . .”^[19] Even the opinion of the employee’s podiatrist, Dr.Collier, is not unequivocal. He stated that “I feel that the [work] injury, although not the primary cause of the arthritis, certainly led to the flare-up along with the ankle sprain that she received.” The fact that he used the word “flare-up” to describe the work injury’s effect on the underlying severe arthritis warrants some analysis. A definition of “flare-up” is a “transient worsening in severity of a disease or condition that eventually subsides or lessens.”^[20] If a condition is transient and eventually subsides or lessons, it is not necessarily permanent. Under this analysis, Dr. Collier’s medical opinion appears to support the temporary nature of the work injury. While a “flare-up” may mean different things to different doctors, what is clear is that the opinion of the employee’s medical expert is not clear.

In adopting Dr. Fey’s opinion, the compensation judge chose a clearly spoken conclusion based on the employee’s medical history, examination findings, subjective complaints, and Dr.Fey’s knowledge as a board certified orthopedist. The majority may disagree with Dr.Fey’s opinion, but that is not an acceptable basis for reversing the compensation judge’s findings.

Discerning which of the Wold factors are significant in a particular case, and the weight to be given to any factor, is generally a question of fact for the compensation judge.^[21] In this case, the facts outlined could reasonably be interpreted to support Dr. Fey’s conclusions. The majority’s analysis requires substituting different inferences from the evidence and giving different weight to portions of the evidence than did the compensation judge. Doing so would not comport with the scope of our review as an appellate court and would require that we ignore the Hengemuhle standard. Substantial evidence supports the compensation judge’s factual determination that the January 18, 2014, work injury was temporary. I would decline to adopt the majority’s decision.