SHEILA S. GRABOSKY, Employee/Appellant, v. ISD 720 and SFM, Employer-Insurer/Respondents, and PREFERRED ONE ADMIN. SERVS. and MADISON NAT’L LIFE INS. CO., Intervenors.

The employee appeals from the compensation judge’s finding that her February 9, 2016, work injury was a temporary aggravation of her pre-existing condition and that it resolved by March 1, 2016. We affirm.

The employee, Sheila Grabosky, began working for the employer, ISD 720, as a math teacher in 2006. She sustained a work injury on February 9, 2016, that she claimed aggravated her pre-existing condition. At the hearing, the employee claimed that the work-related aggravation continued to the date of the hearing, July 6, 2017.

The employee has an extensive medical history which predates her work injury. In 2007, the employee sought treatment at Minnesota Gastroenterology for what was then described as heartburn. Because of continuing symptoms, she eventually had an upper GI endoscopy on November 25, 2008, with normal results. By 2008, the records of the employee’s family physician, Dr. Anthony Ferrara, show that the employee was frequently complaining of episodes of left chest pain into her back, sometimes up to her left shoulder. The employee stated that her chest pain was accompanied by pain down her left shoulder and down the back of her arm to her fingers. A number of pain medications were prescribed for these symptoms, including Vicodin, Oxycodone, and a Fentanyl patch.

In August 2008, the employee was seen at the emergency room at St. Joseph’s Hospital for chest pain which she had experienced on and off over a three-week period. A cardiology consultation was subsequently performed. The diagnostic impression was of pain that was non-cardiac in nature. The employee had a normal neurological examination at that time, as well, and a neurologist opined that the employee’s chest symptoms did not appear to represent radicular pain.

The employee’s pain symptoms persisted and in 2009 she was seen at the Mayo Clinic for multiple gastroenterology consultations, a consultation at the thoracic surgery clinic, and a pain rehabilitation center evaluation. The physicians at Mayo Clinic concluded that her pain was not of gastroenterological or esophageal origin. She was diagnosed with atypical chest pain and chronic pain. She was considered a good candidate for a comprehensive pain rehabilitation program.

On July 7, 2010, the employee was seen by her family physician, Dr. Ferrara, for sharp chest pain. She reported she had tried acupuncture without success and needed to use 30 Percocet per month to get some relief. Dr. Ferrara refilled the employee’s Percocet and recommended referral to a pain clinic. The employee continued treating with Dr. Ferrara for her chest and left upper extremity pain, in addition to other complaints. In 2011, Dr. Ferrara recommended a thoracic spine MRI and an EMG study of the left upper extremity and left paraspinal muscles. The MRI study failed to show any clear deformation of the spinal cord and the sternum was unremarkable. The EMG was normal. The employee continued to take Vicodin for her chronic chest pain, which she reported could reach an 8/10 pain level and last variously from one minute to three days.

In 2012 the employee was seen by Dr. Abhiram Prasad at the Mayo Clinic’s cardiovascular disease clinic for her symptoms. No cardiological explanation was found for her symptoms.

Dr. Ferrara referred the employee to Allina Health’s United Pain Center, where she was evaluated by Dr. Todd M. Hess on January 17, 2013. The employee reported pain ranging from 1/10 to 9/10 during the day, with the average at 5/10. Costochondral/intercostal pain was present on palpation. No inciting trauma was reported. Dr. Hess suggested that the employee have a bone scan to rule out any fracture. The employee was also given a psychological assessment at the United Pain Center by Dr. Robert Tolles. She was diagnosed with a chronic pain disorder.

The employee’s bone scan came back negative for any changes except left ankle arthritis. Dr. Hess recommended a series of chest wall injections. An intercostal nerve block and costochondral injections at T2, T3, T4 and T5 were administered on February 5, 2013. The employee immediately reported severe pain and was given IV Fentanyl. The pain was so severe that the employee was returned to the injection room and nerve blocks were given at the T5 intercostal nerve and the costochondral junction. Dr. Hess observed that he had never before seen this reaction to this type of injection.

Subsequently, Dr. Hess recommended a new MRI of the employee’s chest in case something had changed since the negative MRI two years previously. The MRI was performed on March 13, 2013, and was also negative. On March 29, 2013, the employee told Dr. Hess that she had now recalled that she had been struck in the chest with a hockey stick at age 24 and taken to the hospital with loss of consciousness.^[1] The employee was started with physical therapy at Viverant Physical Therapy. When she returned to the United Pain Center in May 2013, she reported that her physical therapist had suggested that she might have thoracic outlet syndrome, and she wanted to pursue evaluation for this condition.

The employee was seen by Dr. Robert W. Thompson at Barnes-Jewish Hospital in Saint Louis, Missouri in July 2013 for evaluation of a possible thoracic outlet syndrome (“TOS”). Dr. Thompson concluded she had a relatively strong clinical diagnosis of TOS. On December 3, 2013, the employee underwent a left supraclavicular thoracic outlet decompression with anterior and middle scalenectomy, brachial plexus neurolysis, resection of the first rib, and left pectoralis minor tenotomy. During the surgery, inspection of the brachial plexus nerve roots revealed a moderate amount of inflammatory scar tissue surrounding the nerve roots; this scar tissue was removed.

Following the surgery, the employee continued to treat at Viverant Physical Therapy. She returned to work part time in January 2014 and noted some increase in her pain. In February 2014, she returned to an eight-hour workday, again with some increase in soreness. On August 5, 2014, the employee told her physical therapist that she had done some preparatory class work and had an increase in pain. This increase in her pain level continued for at least three weeks, as it was mentioned again in physical therapy notes through August 26, 2014. The employee also reported increased symptoms with overhead writing, recorded on September 11, 2014, and again on September 18, 2014, and with having gone hiking on the weekend before November 6, 2014. On December 3, 2014, physical therapy notes indicate that driving, shutting off a light, and opening a door remained factors which aggravated the employee’s pain.

The employee’s physical therapist referred her to the TRIA Orthopaedic Center for an evaluation. She was seen there by Dr. Donald A. Asmussen on January 26, 2015. The employee told Dr. Asmussen that her TOS surgery had moderately helped her symptoms in that it had largely alleviated her anterior chest pain, but that she still had pain along the left trapezius and left scapula down the left arm. Dr. Asmussen suspected that much of the employee’s pain might be originating from the shoulder, and recommended a post arthrogram MRI of the left shoulder to rule out a rotator cuff tear or labral tear. The MRI was performed on February 23, 2015 and showed no evidence of either condition.

The employee was again see by Dr. Hess at the United Pain Center on March 30, 2015. Dr. Hess noted that the employee had not been seen there in two years, and in the interval had undergone surgery for TOS. She reported continuing to have “really bad” headaches and left shoulder and arm pain. She reported a new symptom, numbness in the thumb of the left hand, which Dr. Hess noted could be due to nerve damage during the surgery. The employee stated that using a laptop, reading, grading papers, teaching, classroom duties, driving more than two hours, biking, walking and household duties were triggers for her pain. The employee was scheduled for occipital injections for her headaches and for trigger point injections for her shoulder and arm pain. These injections were initiated on April 1, 2015. The employee was also continued on a variety of medications including narcotic pain relievers.

The employee continued in ongoing physical therapy at Viverant Physical Therapy and returned about once a month to United Pain for injection therapy which typically included occipital nerve blocks and multiple trigger point injections.

On September 10, 2015, the employee was given a cervical epidural steroid injection at United Pain by Dr. Sena Ayse Kihtir for her left-sided neck pain. At that visit, the employee reported that she was having headaches that radiated to the front of her head and caused nausea and photophobia, with each headache lasting from six hours to as long as two to three days. Dr. Kihtir discussed Botox injections with the employee as an option which the employee might try in the future.

On October 14, 2015, when seen at United Pain for scheduled injections, the employee noted that her pain level had been higher after returning to work. She told the doctor that she felt the interval between the injections was too long. On November 11, 2015, Dr. Hess advised the employee that she might look into Botox injections if her trigger point injections were not offering long term relief.

On December 16, 2015, the employee submitted a request to the employer for FMLA leave, seeking intermittent leave for “chronic health issues” requiring weekly physical therapy and regular visits to medical specialists.

On January 20, 2016, Dr. Hess noted that a three-week injection schedule was keeping the employee’s pain well-controlled.

From April 1, 2015, when Dr. Hess started the employee on a program of injection therapy, through January 20, 2016, the last visit with Dr. Hess before the work injury, the employee received approximately 116 trigger point injections and twelve bilateral occipital nerve blocks. During this period, the records of United Pain and of Viverant Physical Therapy document waxing and waning pain symptoms, with pain aggravations lasting up to a few weeks and frequently associated with a triggering physical activity such as driving, painting, shoveling or moving some furniture. On January 27, 2016, when seen at her physical therapy appointment, the employee was having more chest pain and pain in the top of her left shoulder and back of the arm. She stated, however, that her neck pain was much better.

On February 9, 2016, the employee slipped backwards while walking down a staircase at work. She caught herself and did not fall. She testified that she felt pain in her left shoulder and upper neck, developed a migraine headache and had numbness and tingling in some of the fingers of her left hand. She testified at the hearing that she had experienced the same symptoms in the past.

The employee saw Dr. Hess the next day, February 10, 2016, for a regularly scheduled injection therapy appointment. Dr. Hess recorded that the employee had been doing well overall but that “unfortunately, she slipped yesterday and this has exacerbated her left shoulder and chest pain.”

At a physical therapy session on February 18, 2016, the therapist wrote that the employee noted being worse over the past week “secondary to inactivity and recent fall,” but that she was much better overall and continued to “move in the right direction” even with this setback. The same notation was made again in the physical therapy note for February 25 and March 11, 2016.

On March 23, 2016, Dr. Hess noted that, “Since our last visit, the employee has continued to do poorly.” Muscle spasms had remained high despite injections and physical therapy. Dr. Hess wrote, “She is unsure what caused this, but it may be due to her slip on the steps. This flare of pain lasted about three weeks, but she reports ‘yesterday was the first day I felt normal.’” The employee was provided with occipital nerve blocks, trigger point injections, and a left cervical plexus block.

When the employee was seen by Dr. Hess for her regularly scheduled injections on April 13, 2016, he noted that she had been doing well since her last visit, but had experienced a flare up of pain after she returned from a vacation in Florida and started teaching again. The employee reported that ongoing injections had been a “tremendous help” for her overall pain management. She was again given occipital nerve blocks, trigger point injections and a left cervical nerve block.

The employee telephoned United Pain on April 29, 2016, to inquire about whether she could be changed to a different muscle relaxer. She stated that her neck was painful and tight after riding in a tow truck. The records quote her as stating, “This [is a] typical flare up, but this time nothing is helping.” She was given an increase in her Valium dosage. A few days later, May 4, 2016, the employee was seen for her scheduled injections by Dr. Hess. He wrote, “Since our last visit she has been doing great. She’s been feeling well since return from Florida. Notes last week she had a really bad headache and a strong flare of neck pain, she believes it was due to a bumpy ride in a tow truck.”

Subsequent treatment records include ongoing treatment continued with injections. There was variation in the employee’s pain levels, partly associated with aggravations from various triggering events. The employee started Botox injections with Dr. Kihtir on June 22, 2016, and additional injections were scheduled for about every three months.

The employee underwent physical performance testing on August 12, 2016. She gave a history which stated she was having increased pain and paresthesias in her left upper extremity and hand following slipping at work in February and that she needed to determine her restrictions to see if she would be able to continue working. She reported that her symptoms had been worsened by trying to prepare her classroom for the upcoming school year. The physical therapist performing the assessment recorded that the employee appeared to put forth full effort in testing but her performance was limited by pain focus behavior. He noted that her performance “gives an indication of her pain tolerance rather than her physical maximum” and that the limitations suggested represented “the patient’s safe capabilities as she perceives them.”

On August 29, 2016, the employee saw Dr. Hess and reported that she had experienced severe left-handed hand and arm cramping and swelling in the shoulder when she started teaching that week. He wrote that, “she feels ready to retire as a result of her disability,” that she, “has an opportunity to file for Workmen’s compensation,” and that she had inquired about his opinion, “which I cannot give.”

On September 10, 2016, the employee sought treatment with Dr. Tara Kelly at the Entira Family Clinic for a slip and fall injury that she sustained at home. When she fell, she struck her head on the lid of a garbage can. Her forehead was cut and she reported significant bleeding. She told Dr. Kelly that “she has chronic neck issues due to thoracic outlet syndrome and that has been worse since this injury.”

The employee filed a claim petition on November 22, 2016. The employer and insurer answered denying liability.

On November 29, 2016, the employee was seen by Dr. Mark A. Winkler at United Pain Center for chronic pain follow up and medication management. Her chief complaint was chronic neck pain. She stated that she had experienced increased pain in the left side of the neck, left upper chest and left arm since February when she slipped on stairs at work. The employee stated that she was unable to work due to her pain. She had brought “insurance paperwork regarding the work injury to be filled out.” Dr. Winkler noted that she was a patient of Dr. Hess and he recommended she follow up with Dr. Hess and continue with her ongoing treatment. He reported that he had filled out her “workability paperwork” but handed it to Dr. Hess for review.

On December 5, 2016, Dr. Hess signed a Health Care Provider Report and a Report of Workability. The health care provider report stated the employee had slipped on a stairs at school exacerbating her neck and shoulder pain, with pre-existing thoracic outlet syndrome and cervical plexus neuropathy as contributing conditions. The workability form stated she was unable to work from September 8, 2016, to February 1, 2017.

The employee was seen for an IME by Dr. Howard Saylor on April 6, 2017. In his report dated April 26, 2017, Dr. Saylor diagnosed the employee with chronic pain syndrome in the left shoulder and upper extremity of uncertain etiology. He did not believe the employee’s TOS was a component of her current pain complex, in light of the decompression of the thoracic outlet performed in December 2013. With respect to the February 9, 2016, work injury, Dr. Saylor opined that it was a substantial contributing factor to a temporary aggravation of the employee’s preexisting left TOS complaints and need for medical treatment, but did not significantly aggravate the preexisting condition or need for treatment, since the employee’s pain complaints and treatment before and after the work injury remained little changed. Dr. Saylor reiterated that in his opinion, there was no objective evidence of a permanent injury as a result of the 2016 work injury. He stated that “in my opinion, the incident of February 8, 2016, caused a temporary aggravation of Ms. Grabosky’s preexisting condition and left thoracic outlet syndrome complaints, which has not yet resolved.”

A hearing was held on the employee’s claim petition before a compensation judge of the Office of Administrative Hearings on July 6, 2017. The employee relied primarily on the employee’s testimony, her post-injury medical records, and on Dr. Saylor’s report, which, in her opinion, supported the view that the effects of the employee’s work aggravation had not yet resolved. The employer and insurer introduced the employee’s medical records from before the work injury, and argued that the judge should adopt Dr. Saylor’s opinion, which they characterized as stating that the work injury did not permanently aggravate or accelerate the employee’s long term condition or affect her treatment.

The compensation judge found that the employee’s work injury was a temporary aggravation of her preexisting condition and that it resolved by March 1, 2016. The employee 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).

The compensation judge found that the employee’s work injury was a temporary aggravation of her preexisting condition and that it resolved by March 1, 2016. The employee argues that this finding is clearly erroneous and unsupported by substantial evidence. She points to a number of factors that she contends should have led the judge to conclude that the work injury had caused a significant aggravation of her pre-existing condition which remained ongoing through the date of the hearing.

In substantial part, the employee relies on her own testimony as to the nature and extent of her pain symptoms. Although she admits that she experienced essentially the same symptoms both before and after the work injury, she contends that the pain symptoms became more frequent, more intense, and of longer duration after the work injury. She argues, for example, that while she had headaches before the work injury, the headaches after the injury were different. She characterizes the post-injury headaches as migraines, stating she never had migraine headaches before the work injury. She further points out that she did not have Botox injections for her headaches until after the work injury. We note, however, that when seen by Dr. Kihtir for her headaches on September 10, 2015, the employee described headaches that radiated to the front of her head and caused nausea and photophobia, with each headache lasting from six hours to as long as two to three days. Dr. Kihtir provided a cervical steroid epidural injection and also discussed Botox injections with the employee as an option which the employee might try in the future if the headaches continued to be a problem.

We note that the compensation judge expressly concluded that the medical records did not provide confirmation for the employee’s claims of increased symptoms, since the conditions listed, the treatment provided, and the objective findings on examination remain largely unchanged both before and after the work injury. We cannot conclude that the judge erred in giving less weight to the employee’s testimony and recollection of the waxing and waning of her symptoms than to the contemporaneous medical records.

The employee also argues that there was in fact a substantial change in the nature and duration of treatment after the work event, stating that her injections from Dr. Hess before the injury occurred roughly monthly while after the work injury they were provided on a more frequent schedule. She also contends that the work restrictions that were imposed based on the post-injury physical capacities evaluation in August 2016 were somewhat stricter than her pre-injury restrictions. However, on October 14, 2015, almost four months before the work injury, the employee complained to Dr. Hess that the interval between the monthly injections was too long. The interval was then shortened, before the work injury, and on January 20, 2016, Dr. Hess stated that a three-week injection schedule was keeping the employee’s pain well-controlled.

The employee’s primary argument on appeal is her contention that the compensation judge misinterpreted the expert opinion of Dr. Saylor. In the employee’s reading of that opinion, Dr. Saylor offered the opinion that the employee’s work-related aggravation had not yet resolved as of the date of his examination in 2017. The employee bases this interpretation on the phrase, “the incident of February 9, 2016 caused a temporary aggravation of Ms. Grabosky’s preexisting left thoracic outlet syndrome complaints and need for medical treatment, which has not yet resolved.” She argues that as no other medical expert opinion was in evidence, the judge was not free to “ignore” this opinion by finding that the employee’s aggravation had resolved.

When read as a whole, Dr. Saylor’s report does not support the interpretation given by the employee. Dr. Saylor clearly states in his report that the employee’s current symptoms as of the date of his examination were due to a pre-existing chronic pain syndrome of unknown etiology. He further opined that while the February 9, 2016, work injury did temporarily aggravate the employee’s pre-existing left thoracic outlet complaints and need for treatment, it was not a significant aggravation since she continued to have similar symptoms and the injury resulted in little change in her medical care following the incident. The compensation judge could reasonably conclude that the phrase “which has not yet resolved” in the sentence cited by the employee was intended to refer not to the temporary aggravation but to the pre-existing condition.

The medical records in this case are voluminous and it is apparent that the compensation judge reviewed those records. In his memorandum, the judge set out the evidence he found persuasive in reaching his decision: 1) the continuous and ongoing care the employee received for neck, shoulder and chest pain which had existed since 2008; 2) Dr. Hess’ conclusion a month before the work injury that the employee was a candidate for long-term opioid analgesics because of her pain; 3) the employee’s symptoms waxed and waned in a similar pattern both before and after the injury; 4) entries in the medical records both before and after the work injury which refer to exacerbations from the employee’s work and other activities; 5) the employee received trigger point injections after the work injury in the same locations and at nearly the same rate as before the injury; 6) the employee’s testimony that she had a significant increase in symptoms after the work injury is not supported by the medical records; 7) the opinions of Dr. Saylor were persuasive as to the resolution of the flare-up of symptoms after the work injury and that opinion was consistent with the records of Dr. Hess.

We conclude that substantial evidence supports the judge’s findings. The factors listed by the compensation judge in his memorandum are in accord with the evidence in the case and are sufficient to support the judge’s findings.

The compensation judge’s decision is affirmed.