MICHAEL W. BURKETT, Employee/Cross-Appellant, v. RANDSTAD N. AM. and ACE USA/ESIS, INC., Employer-Insurer/Respondents, KEYSTONE AUTO. PARTS and SEDGWICK CLAIMS MGMT. SERVS., INC., Employer-Insurer/Appellants, ALLINA MED. CLINIC, N. MEM’L HEALTH CARE, BLUE CROSS BLUE SHIELD OF MINN. & BLUE PLUS and SUMMIT ORTHOPEDICS, Intervenors.

The employer appeals the compensation judge’s findings that the employee suffered bilateral carpal tunnel syndrome due to his work activities and not to a pre-existing diabetes mellitus condition. The employee cross-appeals the compensation judge’s finding that the employee was not entitled to wage loss benefits due to a withdrawal from the labor market. Because the judge’s findings are supported by substantial evidence, and the judge did not err in the application of the law to the facts of the case, we affirm.

Michael Burkett, the employee, was diagnosed with diabetes mellitus in 2007. In June 2014, he complained of numbness and tingling in both hands and fingers. In October 2014, he was hired by a temporary employment agency, Randstad North America (“Randstad”),^[1] and assigned to warehouse work at Keystone Automotive Parts (“Keystone”).^[2] Keystone used temporary workers from Randstad and if they worked out, Keystone would offer them permanent employment. As a warehouse worker in the returns department, the employee gripped, lifted, and moved auto parts weighing between 50 and 200 pounds.

Shortly after he began working for Randstad, the employee noticed pain and swelling in both hands in late fall of 2014. He underwent an insulin pump placement in December 2014 and lost time from work because he believed the insulin pump had caused his hands to swell. On January 18, 2015, the employee sought care in the emergency department at North Memorial Hospital for swelling, pain, numbness and tingling in his hands bilaterally. The employee’s diagnosis was bilateral hand pain. The next day, he told his supervisor that his hands were too swollen and painful to come to work.

On January 20, 2015, the employee was hired by Keystone as a full time employee. As an employee for Keystone, he worked the same job and the same hours as he did as a temporary employee, but the work increased in intensity. Over the course of the next two months, the employee noticed that the pain and numbness in both hands worsened. He was taken off work for a few days in February 2015 due to severe hand pain and swelling. By March 19, 2015, the pain became unbearable and the employee stopped working.

At the time the employee stopped working for Keystone in March 2015, he claimed that his hands were so painful that he was unable to dress himself or take care of basic needs due to the inability to use his hands. He testified that the pain made it impossible for him to work. Consequently, he did not look for work, even though, at the time, no doctor restricted him from working.

The employee sought medical treatment for his symptoms through Scott Reichel, M.D., who had treated the employee’s diabetic condition since 2007. On January 30, 2015, Dr. Reichel examined the employee and took a history of the employee’s complaints noting that, “[h]e has been having a lot of trouble with hands tingling over the last 3 months. No Injury. Had started a new job about that time that requires a lot of heavy lifting and gripping.”^[3] Dr. Reichel reported that the employee had made “awesome” progress with controlling his diabetes using an insulin pump. He described the employee’s condition as “most like carpal tunnel syndrome with his new work exacerbating the symptoms.”^[4] He ordered an EMG which showed bilateral carpal tunnel and bilateral cubital tunnel syndrome, and no evidence of peripheral neuropathy indicative of diabetic neuropathy.^[5]

Dr. Reichel referred the employee to orthopedic surgeon, Mark Fischer, M.D., who, on May 4, 2015, confirmed the diagnosis of CTS and recommended surgery. The employee chose not to pursue surgery. Between May 4, 2015, and May 20, 2016, the employee remained off work, did not seek treatment, was under no restrictions, and did not look for work.^[6]

About a year after he last sought medical care for his bilateral CTS, the employee sought care again with Dr. Reichel in May 2016. Dr. Reichel referred the employee to Elizabeth Plocher, M.D., an orthopedic hand surgeon at Sports and Orthopedic Specialists. Dr. Plocher saw the employee on June 21, 2016, with continuing complaints of bilateral hand numbness and tingling. She ordered another EMG which confirmed carpal tunnel syndrome. She administered an injection to the employee’s upper extremity which mostly resolved his symptoms. Due to his recovery, the employee was determined to have reached maximum medical improvement (MMI) and Dr. Plocher released him to work without restrictions on September 19, 2016. By October 21, 2016, during his last visit in hand therapy, the employee reported no symptoms.

Neither Randstad nor Keystone admitted primary liability. Each retained a medical expert who similarly opined that the employee suffered from CTS and trigger finger which was not related to work activities at the warehouse. Rather, each medical expert related the condition to the employee’s diabetes mellitus. Keystone retained Steven Meletiou, M.D., who restricted the employee to no repetitious forceful gripping activities. Randstad retained Jeffrey Husband, M.D., who examined the employee after his symptoms had resolved in September 2016. Dr. Husband concluded that the employee was capable of working after March 19, 2015, but he was to avoid repetitive forceful gripping and repetitive forceful wrist flexion and extension.

The employee filed an amended claim petition on April 15, 2016, claiming wage loss benefits from March 19, 2015, medical benefits, and fees against both Randstad and Keystone. The matter was heard on February 23, 2017, by Compensation Judge Stephen Daly. At issue was the nature and extent of the injury, compensability and liability of the employee’s CTS and trigger finger condition, wage loss and medical benefits. The judge found that the employee suffered a Gillette-type^[7] injury on March 19, 2015, which arose out of and in the course of employment with Keystone. He awarded temporary total disability (TTD) benefits from March 19, 2015, through May 4, 2015. He denied further TTD because the employee removed himself from the labor market and did not seek further medical treatment for over a year. Keystone appeals and the employee cross-appeals.

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(3). 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).

A decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which the Workers’ Compensation Court of Appeals may consider de novo. Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).

Keystone appeals from the compensation judge’s decision based upon two arguments. First, Keystone argues that the judge’s finding that the employee’s diabetes was not responsible for bilateral CTS and trigger finger was unsupported by substantial evidence. Keystone claims that Dr. Reichel drew an incorrect factual inference in that the employee had no pre-existing upper extremity diabetic neuropathy thereby making his opinion unreliable. Keystone argues that the judge’s adoption of Dr. Reichel’s opinion in finding a Gillette injury should not be upheld. Second, Keystone argues that the judge erred as a matter of law in finding that the Gillette injury culminated on March 19, 2015. Keystone argues that the correct culmination date should be January 18, 2015, because the employee sought treatment for the condition and lost time during Randstad’s employment. In the alternative, Keystone maintains that the employee worked the identical job for Randstad as he did for Keystone, and therefore, the judge erred in not apportioning liability between them.

The employee cross-appeals from the compensation judge’s decision on the issue of entitlement to ongoing TTD benefits.

In its appeal, Keystone argues that substantial evidence does not support the compensation judge’s finding that the employee’s CTS and trigger finger condition is not a result of his diabetes. To establish a Gillette-type injury, the employee must prove a causal connection between his ordinary work and ensuing disability. Steffen v. Target Stores, 517 N.W.2d 579, 50 W.C.D. 464 (Minn. 1994). Whether an employee has sustained a Gillette injury primarily depends on medical evidence. Id. Although, this determination is not solely dependent on medical testimony, but may also include all the evidence in determining whether the work activities caused the disability. Lindelof v. Sylva, No. WC16-5933 (W.C.C.A. Nov. 1, 2016).

Here the judge made no finding that the diabetic condition was or was not responsible for the employee’s bilateral CTS. Instead, the judge found that the preponderance of the evidence proved that the employee sustained a Gillette injury which arose out of and in the course of his employment with Keystone.^[8] Whether diabetes may have contributed was not decided here, and may nevertheless be of little consequence. Generally, when the usual tasks of an employee’s work substantially aggravate, accelerate, or combine with a pre-existing disease to produce a disability, the entire disability is compensable. Vanda v. Minn. Mining & Mfg. Co., 218 N.W.2d 458, 27 W.C.D. 379 (Minn. 1974).

The judge determined that the employee’s prior symptoms were not of the nature and magnitude he experienced as a warehouse worker. He determined that the employee credibly testified that his job required repetitive lifting, grasping and gripping of heavy auto parts. He also determined that the employee credibly testified that the nature of the duties, and increase in those duties while working with Keystone, led to the worsening of symptoms until they became unbearable. We give due weight to the opportunity of the judge to evaluate the credibility of the witness. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).

The judge explained that his findings were also based on the medical causation opinions of two doctors--Dr. Reichel and Dr. Plocher. Dr. Reichel had treated the employee since 2007 for diabetes and other ailments. During the course of treatment, Dr. Reichel noted once, on June 20, 2014, that the employee had experienced numbness and tingling in his fingers.^[9] When Dr. Reichel noted in his narrative report^[10] that the employee had not experienced problems with tingling or numbness in his hands, he was, therefore, not entirely accurate. The employee had experienced numbness and tingling in his fingers in June 2014. However, there was no ongoing reference.^[11] It was only after the employee began working for Keystone when Dr. Reichel noted, on January 30, 2015, that the employee had been having trouble with his hands tingling over the last 3 months. Dr. Reichel suspected CTS with the employee’s new work exacerbating the symptoms,^[12] and explained that the employee had no other signs of neuropathy in his feet or toes which would be common with diabetes. The CTS and cubital tunnel syndrome diagnoses were also confirmed by the 2015 and 2016 EMG studies. Because the record substantially supports the judge’s finding of a Gillette injury, we affirm.

In its appeal, Keystone also argues that the judge erred as a matter of law in finding that the employee’s Gillette injury culminated on March 19, 2015. Because the employee had already lost time from work and treated for the condition in December 2014 and in January 2015, during Randstad’s employment, Keystone argues that the judge erred by misinterpreting the standard as to when a Gillette injury culminates.

Generally, injuries resulting from repeated trauma, or aggravations of a pre-existing condition, result in a compensable personal injury when their cumulative effect is sufficiently serious to disable the employee from further work. Carlson v. Flour City Brush Co., 305 N.W.2d 347, 33 W.C.D. 594 (Minn. 1981). A Gillette injury occurs when there is an “ultimate breakdown.” Jensen v. Kronick’s Floor Covering Serv., 29 W.C.D. 61, 66 (W.C.C.A. 1975), aff’d, 309 Minn. 541, 245 N.W.2d 230, 29 W.C.D. 69 (1976). Identification of when that breakdown occurs is subject to varying interpretations. Schnurrer v. Hoerner-Waldorf, 345 N.W.2d 230, 36 W.C.D. 504 (Minn. 1984) (a modification of job duties due to a doctor’s restrictions was held to be the culmination date); Shaffer v. Minn. Orchestra, 53 W.C.D. 341 (W.C.C.A. 1995) (the date upon which an employee initiates medical attention was the date of culmination of a Gillette injury); Plaster v. Palani Constr., slip op. (W.C.C.A. May 15, 1996) (the date of an MRI scan giving a definitive diagnoses was accepted as the date of a Gillette injury).

The most obvious date is the date when the cumulative effect of the repetitive trauma is “sufficiently serious to disable the employee from further work.” Carlson, 305 N.W.2d at 350, 33 W.C.D. at 598. While no doctor disabled the employee by restricting activity at that time he stopped working, the employee’s own self-imposed restrictions are sufficient here. Gagnon v. Richard Capp, D.D.S., 58 W.C.D. 327 (W.C.C.A. 1998). The judge concluded that the employee credibly testified that he was disabled and the judge chose the date when the employee last worked, March 19, 2015, as the ultimate breakdown. The judge appropriately applied the law to the facts here and we affirm. Because we affirm the judge’s findings, there is no need to address Keystone’s argument whether apportionment of liability is appropriate here.

In his cross-appeal, the employee argues that, in denying TTD benefits from May 5, 2015, the judge relied too heavily upon the lack of job search. We disagree.

The judge found that the employee was entitled to TTD from March 19, 2015, (the date the employee stopped working) to May 4, 2015 (the date Dr. Fischer recommended surgery). Over a year later, on May 20, 2016, the employee sought treatment again with Dr. Reichel. During that year, the employee had not looked for work, sought no medical treatment, and obtained no medical restrictions. Yet, his symptoms had improved.^[13] Generally, an employee who is able to work must conduct a reasonably diligent job search to establish entitlement to TTD benefits. Redgate v. Sroga's Standard Serv., 421 N.W.2d 729, 40 W.C.D. 948 (Minn. 1988). Here, the judge correctly found that the employee failed to conduct a diligent job search and had removed himself from the labor market. Because the judge correctly applied the law in denying TTD benefits after May 4, 2015, we affirm.