STEVEN D. WRIGHT, Employee/Cross-Appellant, v. VIKING COCA COLA BOTTLING CO. SELF-INSURED/BERKLEY RISK ADM’RS CO., LLC, Employer/Appellant, and NORAN NEUROLOGICAL CLINIC, NAT’L DIZZY & BALANCE CTR., MINN. DEP’T OF HUMAN SERVS., CIGNA HEALTH CARE, CENTRACARE SURGERY CTR., CENTRACARE ST. CLOUD HOSP., CENTRACARE RIVER CAMPUS CLINIC, CTR. FOR DIAGNOSTIC IMAGING, ABBOTT NW. HOSP., SUMMIT ORTHOPEDICS, REG’L DIAGNOSTIC RADIOLOGY, and AM. ACCOUNTS, C/O EMERGENCY PHYSICIANS, Intervenors.

The self-insured employer appeals the compensation judge’s finding that the employee was entitled to temporary total disability (TTD) through maximum medical improvement (MMI) plus 90 days. The employee cross-appeals the judge’s finding that his claimed head, spine, and concussive injuries were not compensable. Because substantial evidence supports the compensation judge’s findings, we affirm.

Steven Wright, the employee, has worked as a delivery truck driver for Viking Coca Cola since 2012. His job required him to deliver soft drink products to businesses, including bars, restaurants, and convenience stores. On February 25, 2015, while delivering product to a gas station, he slipped and fell on an icy sidewalk. He landed on his left side with his left arm extended overhead and felt immediate pain in his left shoulder and arm. The employee called his supervisor, finished delivering the product, and returned to the employer’s distribution facility. He met with Lisa Zolin, Viking’s Director of Human Resources, who talked to him about the incident and completed a First Report of Injury. Ms. Zolin asked the employee if he hit his head as a result of the fall, and he said he had not.

The employee sought treatment the same day at the St. Cloud Medical Group with Kalina C. Skillingstad, PA-C, and Gary Kolle, M.D. At the initial visit, he complained of left forearm, left shoulder, and left upper arm pain and numbness. He denied headaches and lightheadedness. He underwent an x-ray of the cervical spine which showed severe right-sided foraminal stenosis at the C3-4 level and it was noted that the employee complained of neck pain and right-, not left-, sided radicular pain. A subsequent CT scan of the cervical spine in June 2016 was unremarkable. Dr. Kolle restricted the employee to light duty work and the employer accommodated the employee’s restrictions with no lost time. The employee continued to have left arm and shoulder symptoms. He also complained of neck and low back pain in May 2015. After undergoing multiple scans and diagnostic tests for the left shoulder and neck, all of which showed no significant abnormalities, the employee’s condition did not improve.

Sixteen months after the work injury, in June 2016, the employee first sought care and treatment for severe headaches at St. Cloud Hospital’s Emergency Department. No connection between the headaches and the work injury is apparent in the emergency room notes. In July 2016, the employee consulted with Steven Noran, M.D., at the Noran Neurological Clinic complaining of left upper extremity pain, debilitating light sensitive headaches, balance, sleep, and paralysis issues. The notes from this appointment reflect that the employee attributed his complaints to the work-related injury of February 25, 2015. To give the employee a chance to rest and to get a complete work-up, Dr. Noran took the employee off work and ordered diagnostic studies including MRI scans of the head, cervical spine, and left shoulder. The MRI scans were again unremarkable. An EMG and nerve conduction study of the left upper extremity was found to be normal. Dr. Noran referred the employee to a number of doctors who diagnosed the employee with convergence insufficiency, post-concussive syndrome, and traumatic brain injury, among other conditions. The employee continued to see Dr. Noran through August 2017, primarily for neurological issues, however, Dr. Noran also continued to note the employee’s left upper extremity condition.

As part of the work-up, the employee was evaluated for sleep difficulties in July and August 2016 by Eric Hernandez, M.D., Ph.D., at the Noran Clinic. Dr. Hernandez was concerned that the employee’s shoulder injury could change his sleep position and cause acute symptomatic obstructive sleep apnea. After testing, treatment for mild sleep apnea was recommended. The employee also underwent a neuropsychological evaluation with Kerri Lamberty, Ph.D., in December 2016. Dr. Lamberty noted the employee’s MMPI suggested “possible over reporting of an unusual combination of responses associated with non-credible memory complaints.” (Joint Ex. 8.) She concluded that her findings “suggest that feigned cognitive impairment remains within the realm of possibility.” Id.

The employer retained two medical experts, Irfan Altafullah, M.D., and David Fey, M.D., to examine the employee. Dr. Altafullah, a neurologist, found no basis to relate any of the employee’s neurological complaints to the incident of February 25, 2015. He noted a normal neurologic examination, with normal imaging and EMG studies. The first notation of neurological symptoms in the medical record was not until July 2016 which, he explained, would be inconsistent with the employee’s claim that he developed a neurological injury on February 25, 2015. In concluding that the employee had reached MMI, Dr. Altafullah also saw no need for work restrictions or additional medical treatment. MMI for this condition was served on the employee on August 31, 2017.

Likewise, Dr. Fey, an orthopedic surgeon, examined the employee in November 2016 and found no reasonable orthopedic explanation for the employee’s ongoing subjective complaints of pain and no reasonable medical basis to support an opinion that his orthopedic condition is related to the claimed work injury of February 25, 2015. Dr. Fey opined that the employee had reached MMI with respect to the orthopedic condition. MMI for this condition was served on the employee on November 21, 2016.

The employee filed a claim petition and the matter was heard on December 21, 2017. At issue was primary liability for the spine, head, and concussion claims; the nature and extent of the February 25, 2015, injury; TTD from July 1, 2016, forward; and the reasonableness, necessity, and causal relationship between the employee’s medical treatment and the injury.

The employee’s spouse testified that the employee suffered behavioral and cognitive changes since the February 25, 2015, injury. She testified that before the injury, the employee was active. He served the community as the captain of the fire department, played softball, and had time to work on the family farm. She testified that after the injury, the employee became moody, forgetful, and depressed and suffered severe headaches. The employer’s Human Resources Director, Ms. Zolin, testified that the employee did not notify her of any head trauma injury, nor did he display difficulty performing his job from the date of injury until Dr. Noran took him off work.

In a Findings and Order issued on February 27, 2018, the judge denied the employee’s claim that he suffered a spine, head, and/or concussive injury as a result of the February 25, 2015, work injury and also denied medical treatment for these conditions. The judge awarded TTD benefits from July 1, 2016, to February 19, 2017, 90 days post-MMI. The employer appeals the award of TTD. The employee cross-appeals the denial of the spine, head, and concussive injuries and associated medical treatment.

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).

The employee appeals the compensation judge’s award of temporary total disability (TTD) benefits. On appeal, the employer argues that the judge erred in awarding TTD benefits during a time when the employee was off work for treatment of the non-compensable injury of the spine and head/concussion. The employer argues that the employee was working without wage loss for sixteen months before Dr. Noran took the employee off work for a non-compensable injury. As a result, the employer asserts that the employee is not entitled to TTD benefits during that time because Dr. Noran was not treating the work-related shoulder injury.

A general requirement in awarding TTD benefits is to prove that a work-related injury is causally related to the employee’s inability to work. See Kautz v. Setterlin Co., 410 N.W.2d 843, 845, 40 W.C.D. 206, 208 (Minn. 1987); see also Schulte v. C. H. Peterson Constr. Co., 278 Minn. 79, 153 N.W.2d 130, 24 W.C.D. 290 (1967). In awarding TTD benefits here, the judge explained that the employee was taken off work by Dr. Noran due to ongoing symptoms attributable, in part, to the work-related injury to the upper extremity. Substantial evidence supports the judge’s reasoning.

Dr. Noran removed the employee from work in order to conduct a full neurological work-up which included the left shoulder and left upper extremity. At that time, Dr. Noran assessed a cervical injury with symptoms into the left arm and wanted to rule out disc or bony abnormalities versus chronic cervical myoligamentous injury and facet injuries. Dr. Noran also ordered diagnostic tests and scans for the employee’s head, neck, and left shoulder, and in each office visit note from July 2016 to August 2017, Dr. Noran recorded ongoing problems with the left upper extremity. The MRI scans were unremarkable and the EMG and nerve conduction study of the left upper extremity was found to be normal. Further, the employee was evaluated for sleep difficulties by Dr. Hernandez as part of the overall work-up. Dr. Hernandez expressed concern over the possibility that the employee’s shoulder injury could change his sleep position and cause acute symptomatic obstructive sleep apnea. After testing, the employee was diagnosed with mild sleep apnea and treatment was recommended. Substantial evidence supports the judge’s determination that Dr. Noran took the employee off work due to ongoing symptoms due, in part, to the work-related left upper extremity injury.

Four months after the employee was taken off work, the employer’s medical expert, Dr. Fey, examined the employee’s left upper extremity and determined that he had reached MMI.^[1] Upon service of Dr. Fey’s report finding MMI, the employee would be entitled to TTD benefits as claimed from July 1, 2016, through 90 days post-MMI.^[2] See Minn. Stat. § 176.101. Consequently, we affirm the compensation judge’s award of TTD benefits.

The employee, in his cross-appeal, alleges the compensation judge erred by relying upon the employer’s medical expert in denying his claim of a neurological injury. The judge found that the employee did not establish by a preponderance of the evidence that he sustained spine and/or head/concussion injuries arising out of and in the course and scope of his employment with the employer on February 25, 2015. The employee argues that the judge erred in accepting the medical opinion of Dr. Altafullah that the employee did not sustain the claimed neurological injury.

The employee claims that Dr. Altafullah’s opinion was based on a faulty factual foundation. Citing the record, the employee argues that there was objective evidence of a neck injury as early as the initial visit at St. Cloud Hospital when the cervical spine x-ray showed abnormalities. The employee argues that Dr. Altafullah chose to disbelieve the history given by the employee that headaches began shortly after the injury and did not take into consideration his spouse’s account. The employee asserts that Dr. Altafullah’s failure to consider other relevant evidence renders his opinion inadequate.

It is well established that a compensation judge’s choice of expert opinion must be upheld unless the opinion lacked adequate factual foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). An expert opinion which includes the facts upon which the expert relied and the basis for the opinion is generally sufficient to establish foundation. An opinion need only be based on “enough facts to form a reasonable opinion that is not based on speculation or conjecture.” Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 802, 77 W.C.D. 117, 124 (Minn. 2017) (citing Wenner v. Gulf Oil Corp., 264 N.W.2d 374, 381 (Minn. 1978)). Here, the record supports the factual foundation upon which Dr. Altafullah relied. In addition, Dr. Altafullah physically examined the employee, took a history from the employee, and reviewed multiple medical records. His opinion is adequately founded.

In reaching his decision, the judge explained that he relied upon a number of significant facts. The judge relied on the employee’s testimony that he fell and landed with his left arm extended over his head, and did not know if he hit his head in the fall. He also relied on the employer’s human resource director, Ms. Zolin, determining she was credible in her testimony that the employee did not mention hitting his head and replied in the negative when she specifically asked if he struck his head in the fall. He further relied upon the report of Dr. Lamberty, who noted that the employee’s overall profile suggested feigned cognitive impairment. The judge also considered the paucity of neurological complaints in the medical records for 16 months post-injury. Ultimately, he adopted Dr. Altafullah’s opinion that the employee did not suffer a neurological injury on February 25, 2015.

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, 385 N.W. 2d at 59, 37 W.C.D. at 239. Here, because substantial evidence supports the judge’s findings, we affirm.