LYNN M. MELLGREN, Employee/Appellant, v. MINN. DEP’T OF CORR., STATE OF MINN., Self-Insured Employer/Respondent.

The employee appeals the compensation judge’s finding that the employee’s January 2016 work injury was not a substantial contributing factor to her current right knee condition or need for treatment. We affirm.

Lynn M. Mellgren, the employee, has worked as a guard for the Minnesota Department of Corrections, the self-insured employer,^[1] for 19 years. In February 2000, the employee injured her right knee in a non-work-related incident. An MRI scan indicated a tear of the anterior cruciate ligament (ACL), a medial meniscus tear, and degenerative changes of the medial compartment of her right knee. The employee underwent arthroscopic surgery, including medial meniscus tear repair and ACL reconstruction with a graft. The employee returned to her regular job without restrictions and did not experience additional symptoms for several years. In 2006, the employee experienced pain in her right knee and was treated with a cortisone injection. An x-ray image at that time indicated degenerative joint disease on the medial side of her knee. The employee did not have any symptoms, restrictions, or medical treatment for her right knee from 2006 through early 2016.

On January 29, 2016, the employee was involved in an altercation with an inmate. At the end of her shift, the employee’s knee was sore, and overnight she experienced severe pain in her right knee. The employee treated with Dr. William Brunnel, who recommended rest, medication, and an MRI scan, which indicated severe chondromalacia, moderate osteoarthritis, signs of ACL graft failure, and moderate degeneration or partial tearing of the posterior cruciate ligament. The employee was taken off work. The employer admitted liability for the employee’s injury and paid wage loss and medical expenses.

The employee was referred to Dr. Gregory Folsom, an orthopedic surgeon, in March 2016. An x-ray taken at that time indicated significant arthritis in the right knee, especially in the medial compartment. Dr. Folsom opined that the employee’s symptoms were related to a flare-up of arthritis or a minor knee sprain. He reviewed the employee’s MRI scan and stated that the ACL graft had failed. He recommended conservative care and a cortisone injection. Dr. Brunnel opined that the employee’s ongoing pain was from a torn ACL graft, not a degenerative deficiency of the graft.

In April 2016, the employee sought another opinion from Dr. Glenn Cielger, who stated that the employee had sustained a work-related right knee injury but also had pre-existing severe post-traumatic tricompartmental arthrosis of the right knee. A total knee replacement was discussed. Dr. Marc Tompkins, an orthopedic surgeon, evaluated the employee on May 18, 2016. He assessed medial compartment arthritis status post ACL reconstruction. Surgical options were discussed, but the employee pursued conservative care and underwent a Synvisc injection performed by Dr. Tompkins. After physical therapy, the employee returned to her pre-injury job. A metal brace was recommended but the employee could not wear it at work for security reasons.

On July 27, 2016, the employee underwent an independent medical examination with Dr. Rajan Jhanjee, who diagnosed the employee with advanced osteoarthritis and a chronically deficient ACL. He opined that these conditions were not caused by the work injury. Given the delay in her severe symptoms until later in the night after the injury, Dr. Jhanjee did not think the employee had sustained an acute ACL tear during the work injury. He further opined that the employee’s pre-existing osteoarthritis was temporarily aggravated by the work injury but that she had returned to baseline and the aggravation had resolved. He concluded that the employee was at maximum medical improvement, had no permanent partial disability, and needed no further treatment or restrictions. The employee was released to work without restrictions in August 2016.

On February 15, 2017, the employee returned to Dr. Tompkins for treatment of her right knee, reporting that her symptoms had gradually returned and that she had never returned to her pre-2016 injury level. Dr. Tompkins noted that the employee could not wear the brace at work and suggested a knee compression sleeve instead. Another Synsvisc injection was recommended, and the employee requested approval of the injection. The employer denied the request based on Dr. Jhanjee’s opinion that the employee’s work injury was a temporary aggravation of her pre-existing condition and had resolved. In a supplemental report dated June 26, 2017, Dr. Jhanjee opined that the employee had not likely sustained an acute ACL tear in January 2016 and that it was likely she had a chronic failure of a non-healing previous graft. He also stated that while the initial Synvisc injury was appropriate to help resolve any inflammation or aggravation from the injury in the area of pre-existing arthritis, any further treatment would be for the underlying pre-existing arthritis and unrelated to her work injury.

A hearing was held on August22, 2017. The employer argued that the employee’s work injury was a temporary aggravation and asserted that the requested injection was reasonable and necessary medical treatment for the employee’s underlying arthritis condition, not for her work injury. The compensation judge found that the employee’s January 2016 work injury was not a substantial contributing factor to the employee’s current right knee condition or need for treatment. 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.”^[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] 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.”^[5]

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.^[6]

The compensation judge found that the employee’s January 29, 2016, work injury was not a substantial contributing factor to her current knee condition or need for treatment. The employee argues that substantial evidence does not support this finding. The employee does not dispute that her work injury aggravated her pre-existing right knee condition, but argues that the aggravation has not resolved and that therefore the need for an additional Synvisc injection is related to her work injury. The employee points to six factors this court has used to assess whether a work injury aggravated an underlying condition. These factors include: 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. ^[7] Which factors are significant in a particular case and the weight to be given to each factor is generally a question of fact for the compensation judge.^[8]

The employee claims that her symptoms have gradually returned since the first Synsvisc injection. The employee argues that her pre-existing medical condition only required medical treatment because of the January 29, 2016, work injury and therefore the judge erred in finding that the employee’s work injury was not a substantial contributing factor to her ongoing need for treatment. The employee emphasizes that she had not missed time from work due to her right knee condition until after the work injury and also that she had not needed medical treatment for her right knee except for conservative care in 2006. After the January 2016 work injury, the employee was off work for six months. The employee was treated with physical therapy and a Synvisc injection in June 2016 before being released to work at her pre-injury job with no restrictions. While she was prescribed a brace, she did not wear it at work. The employee’s arguments here regarding the analysis of the Wold factors primarily consist of weighing the evidence at hearing differently than the compensation judge did in her decision.

As to medical opinions in the matter, the employer argues that the compensation judge’s finding is supported by Dr. Jhanjee’s opinion that the employee’s pre-existing osteoarthritis had been temporarily aggravated by her work injury but that the aggravation had resolved. A compensation judge’s choice among conflicting expert opinions is upheld unless the opinion lacked adequate factual foundation.^[9] A compensation judge has considerable discretion in determining the adequacy of foundation for an expert opinion, which is subject to review for abuse of discretion by this court.^[10] Dr. Jhanjee examined the employee, took her history, and reviewed her medical records, noting in his report that the employee had reported being symptom free before 2016. In this case, the information provided to Dr. Jhanjee is adequate foundation for his expert medical opinion.^[11]

An expert opinion may lack adequate foundation “when the facts assumed by the expert in rendering an opinion are not supported by the evidence . . . .”^[12] The employee asserts that her ten-year lack of symptoms and lack of restrictions on her right knee were not mentioned by Dr. Jhanjee and therefore his opinion was not reliable. Dr. Jhanjee opined that the initial Synvisc injection was appropriate to help resolve any inflammation or aggravation from the employee’s work injury in the area of the knee with pre-existing arthritis, but that any further treatment would be for the underlying pre-existing arthritis and unrelated to her work injury. His opinion was “not based on speculation or conjecture . . . .”^[13] The compensation judge did not err by relying on Dr. Jhanjee’s opinion.

In addition, as the compensation judge noted, none of the doctors involved gave an opinion stating that the employee’s work injury continued to be a substantial contributing factor to the employee’s current condition or need for the Synvisc injection. While Dr. Tompkins recommended another Synvisc injection in February 2017, he did not address the causation of the employee’s condition at that time. Further, the compensation judge relied on other evidence in determining that the employee had not shown that her work injury remained a substantial contributing factor to her current knee condition and her need for treatment, including the February 2016 MRI scan which did not show acute findings resulting from the work injury, the employee’s release to return to work without restrictions in August 2016, and the employee’s uncontroverted current diagnosis of osteoarthritis.

We recognize that there is evidence in the record which supports the employee’s arguments. The issue for this court, however, is not whether there is substantial evidence in the record to support the employee’s claim which is contrary to a compensation judge’s findings but whether there is substantial evidence supporting the findings the judge made.^[14] Where more than one inference may reasonably be drawn from the evidence, the compensation judge’s findings are to be affirmed.^[15] In this case, substantial evidence supports the compensation judge’s finding that the employee’s January 2016 work injury was no longer a substantial contributing factor to her current right knee condition or need for treatment. Accordingly, we affirm.