RAY APPLEBY, Employee/Appellant, v. MINNEAPOLIS PARK & RECREATION BD. and SFM MUT. INS. CO., Employer-Insurer/Respondents, and SUMMIT ORTHOPEDICS, LTD, TRIA ORTHOPAEDIC CTR. and MEDICA HEALTH PLANS, Intervenors.

The employee appeals from the compensation judge’s denial of payment for medical treatment after specified dates upon finding that the employee failed to meet his burden of proof to demonstrate causation with the work injury.  We affirm with a modification of a clerical error.

Prior to his employment with the employer, Ray Appleby, the employee, had sustained injuries to both his knees.  In 1998, he injured his right knee when he fell down some stairs while working for a different employer.  He conservatively treated for this injury and his symptoms resolved.  He underwent a left knee arthroscopic partial medial meniscectomy in 2007, and a right knee arthroscopic partial medial meniscectomy and minimal debridement of the patella in 2015.  The employee had no permanent restrictions to either knee following recovery from these surgeries.

On February 27, 2018, the employee slipped on ice and twisted his right knee and ankle while in the course of his employment as a park keeper for the employer, the Minneapolis Park & Recreation Board.

In the days that followed the injury, the employee was diagnosed with right knee and right ankle sprains and was given work restrictions.  X-rays of the knee and ankle showed no fracture.  A right knee MRI scan showed narrowing of the right knee joint related to the prior surgery and an acute posterior horn medial meniscal tear. The employee was referred to Dr. Eric Khetia of Summit Orthopedics, who performed an arthroscopic partial medial meniscectomy, partial lateral meniscectomy, and patellofemoral chondroplasty on March 23, 2018.

On October 8, 2018, the employee was seen by Dr. Khetia for a six-month follow-up from the right knee surgery.  The employee reported he was doing well, he had no significant symptoms, almost full range of motion, full motor strength, no swelling, and well-healed scars.  He had an altered gait which was noted to possibly be due to the right ankle.  Dr. Khetia found the employee to be at maximum medical improvement (MMI) with a 4 percent permanent partial disability (PPD) rating.  The employee was released to return to work without restrictions relative to the right knee.

Just over two months following the work injury, on May 10, 2018, the employee began treating with Dr. Michael Castro of Summit Orthopedics for ongoing right ankle symptoms.  An MRI scan of the right ankle showed a chronic anterior talofibular ligament sprain and subacute/chronic anterior tibiofibular ligament sprain.

On June 28, 2018, Dr. Castro performed an arthroscopic debridement of the right ankle with resection of an anterior tibial osteophyte, a repair of a peroneus brevis tendon rupture, reconstruction of the superior peroneal retinaculum, and excision of the peroneus quartus.  The employee continued to follow up with Dr. Castro postoperatively and underwent physical therapy for the right ankle from July 2018 through the rest of that year without any significant improvement.  He was also regularly taking prescription narcotics for his right ankle pain.

On January 24, 2019, Dr. Castro performed a second surgery on the right ankle, a gastrocnemius recession, based upon the diagnosis of an isolated gastrocnemius contracture.  The employee consequently suffered a postoperative hematoma and underwent surgery to evacuate it on February 1, 2019.

The employee saw Dr. Fernando Pena of TRIA Orthopaedic Center for a second opinion regarding his right ankle on April 29, 2019.  Injections were performed by Dr. Pena on June 10 and July 15, 2019, with mixed results.  He recommended an MRI scan to determine the source of the employee’s pain, which was not approved.

On September 23, 2019, the employee again saw Dr. Pena for ongoing right ankle pain and swelling.  He suspected the source of the employee’s pain was not the ankle itself.  The employee told Dr. Pena that his right ankle pain was so severe that his right knee often buckled as a result, and that such an event occurred while working on September 19, 2019.  The employee was later seen at the TRIA pain program at the request of Dr. Pena for consideration of a spinal cord stimulator.  There, the employee was diagnosed with complex regional pain syndrome (CRPS) and treated with physical therapy and sympathetic nerve blocks.  The employee participated in physical therapy from January 2020 until it was denied by the employer and insurer in late 2020 or early 2021.  The employee returned to TRIA on April 29, 2021.  He reported that he had done well after a lumbar sympathetic block and physical therapy.

During a physical therapy session for the right ankle on December 18, 2018, the employee felt a pop in his left knee while performing a squatting exercise.  On January 15, 2019, he saw Dr. Khetia, who took the employee off work and ordered an MRI scan, which showed a small superimposed radial tear along the free margin of the posterior horn of the meniscus, as well as a low grade MCL sprain.

On February 18, 2019, Dr. Khetia performed a left knee arthroscopic partial medial meniscectomy, partial lateral meniscectomy, loose body removal, and patellofemoral chondroplasty on the employee.  Following the procedure, the employee was placed on sedentary-only work restrictions.  The employee returned to therapy in late February 2019 for both his right ankle and left knee.

By April 8, 2019, the employee reported that his left knee was feeling pretty good although he was still experiencing some difficulties with planting, twisting, kneeling, and walking on uneven surfaces.  The employee was released to work at full-duty relative to his knees.

On October 8, 2019, the employee returned to Dr. Khetia, who noted “right knee pain, secondary to medial femoral and patellofemoral chondromalacia, status post work-related injury.”  (Ex. E.)  Dr. Khetia performed a right knee cortisone injection to help with inflammation and recommended exercises and sedentary work restrictions for six weeks.

The employee returned to Summit Orthopedics on November 15, 2019, and reported good relief from the right knee injection, but that the pain had gradually come back.  The employee was walking awkwardly due to right knee and ankle pain and was compensating by putting more weight on the left knee which was also bothering him.  It was noted that the employee had an “exam and history consistent with exacerbation of his underlying medial compartment and patellofemoral chondromalacia seen during arthroscopy.”  (Ex. E.)  The employee was given a cortisone injection for his left knee, he was to continue physical therapy, and his work restrictions remained.  Dr. Khetia ordered more physical therapy in January 2020.

On July 14, 2020, the employee was seen by Dr. Khetia for an exacerbation of his chondromalacia.  The cortisone injections had been providing good relief and Dr. Khetia noted that the employee would likely need repeat injections every three to four months as needed but did not otherwise require work restrictions related to the knees.

The employee last saw Dr. Khetia on September 13, 2021, with right and left knee pain secondary to his chondromalacia.  Dr. Khetia noted that the employee had not received an injection since the summer of 2020 and had good results until an increase in pain, stiffness, and swelling prior to the visit.  X-rays showed joint space narrowing consistent with the employee’s symptoms.  Dr. Khetia provided bilateral cortisone injections on that date and advised returning every three to four months for additional cortisone injections as needed.

At the request of the employer and insurer, the employee was examined by Dr. Julie Happe, who issued a report dated April 13, 2020.  It was Dr. Happe’s opinion that the employee suffered a temporary aggravation of a mild, self-limiting right ankle strain on February 27, 2018, and a minimal right knee strain “possibly” occurring on the same date.  (Ex. 2.)  She concluded that both injuries had resolved within two to four weeks and called into question much of the employee’s medical care, including the bilateral knee operations and multiple ankle procedures, as well as causation for the claimed left knee injury.

On July 23, 2020, Dr. Khetia wrote a report to the employee’s attorney.  The employee had been released with no current restrictions and no current follow-ups for his bilateral knees.  Dr. Khetia opined that the work injury aggravated the employee’s preexisting right and left knee findings of chondromalacia.  He considered all treatment provided by his office to be reasonable, necessary, and causally related to the work injury and he provided a 4 percent PPD rating under Minn. R. 5223.0510, subp. 3B(3) for each of the employee’s knees.

At the request of the employee’s attorney, Dr. Pena wrote an undated narrative report following his February 1, 2021, examination of the employee.  Dr. Pena maintained, as he had throughout the employee’s medical records, that he was unable to determine the source of the employee’s pain, and therefore had been unable to provide any solutions, surgical or otherwise, for his ankle joint issues.  Dr. Pena indicated that the diagnosis continued to be “right ankle pain of unknown etiology.”  (Ex. D.)  Due to the complexity of the employee’s condition, and the unknown etiology of the employee’s pain, Dr. Pena could not opine with any degree of medical certainty that the February 27, 2018, work injuries were related to the employee’s current complaints of right ankle pain.  In the same report, however, Dr. Pena opined that the medical care he had provided was reasonable, necessary, and causally related to the February 27, 2018, work injury.^[1]

The employee was also seen by Dr. Mark Agre at the request of his attorney on September 17, 2021.  Dr. Agre diagnosed causalgia/CRPS type II of the right ankle area.  He opined that CRPS type II was a rare, but real complication of the ankle surgeries performed by Dr. Castro.  He was of the opinion that the employee would continue to have problems particularly with the right ankle but had done well with his knees.  He assessed the right foot and ankle with a total of 2.73 percent PPD rating under Minn. R. 5223.0420, subp. 2I(4) and 5223.0430, subps. 5, 2G(2), and H.  He agreed with Dr. Khetia’s opinion of 4 percent PPD ratings for the bilateral meniscectomies.  He also opined that the right knee and ankle injuries were caused by the work injury while the left knee injury was a consequential injury resulting from the medical care to the right knee and ankle.

The employee asserted a claim for various workers’ compensation benefits as a result of the injuries sustained on February 27, 2018, including PPD benefits for a 4 percent rating for the left knee^[2] and a 2.73 percent rating for the right ankle, payment of outstanding medical bills, and approval for recommended therapies and ongoing treatment.  The employer and insurer admitted the right knee and right ankle injuries and asserted those injuries had resolved according to the opinion of Dr. Happe.  They denied the claimed consequential left knee injury.

The disputed claims came before a compensation judge on December 2, 2021.  In his Findings and Order, the judge found the employee sustained a consequential injury to the left knee.  He awarded the claimed PPD benefits and awarded claims for medical treatment for the right knee through October 8, 2018, for the left knee through April 8, 2019, and for the right ankle through February 1, 2021.^[3]  The compensation judge found that the February 27, 2018, work injury was a substantial contributing factor to the employee’s symptoms and need for treatment only through those specified dates.  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).

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 from the compensation judge’s determination that the work injury was not a substantial contributing factor for medical treatment of the employee’s right knee condition after October 8, 2018, his left knee condition after April 8, 2019, and his right ankle condition after February 1, 2021.

The employee argues that the compensation judge erred by denying medical treatment after specific dates while simultaneously awarding PPD benefits.  He argues that because his injuries are permanent, treatment after the dates specified by the compensation judge necessarily were causally related to the permanent injuries.  While we agree with the employee that payment of PPD is equivalent to a finding that the injuries sustained by the employee were permanent,^[4] the fact that an employee has sustained a permanent injury “does not in itself establish that the . . . injury is a substantial contributing factor” for medical treatment.  Younghans v. Johnson Bros. Liquor, No. WC16-6017 (W.C.C.A. May 12, 2017).  Rather, the employee bears the burden of proving that medical expenses are reasonable, necessary, and causally related to the work injuries.  Minn. Stat. § 176.021, subd. 1; Heikkila v. Allied Staffing, LLC, No. WC22-6447 (W.C.C.A. July 18, 2022).

Here, the compensation judge found that the preponderance of the evidence showed the employee’s work injury remained a substantial contributing factor in his need for treatment only through specified dates for his three conditions.  An employee need not show that the work injury was the sole cause of disability, but that it was a substantial contributing cause.  Swanson v. Medtronics, Inc., 443 N.W.2d 534, 42 W.C.D. 91 (Minn. 1989).  Whether a work injury is a substantial contributing factor in the employee’s need for medical treatment is a question of causation and a question of fact for the compensation judge.  See Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994).  We will not disturb the compensation judge’s determination unless clearly erroneous and not supported by the record as a whole.  See Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993).

The employee argues that the compensation judge failed to look at the evidence as a whole, and in particular, the employee’s own testimony, portions of the medical records, and the compensability of his claim for PPD benefits.^[5]  We have reviewed the voluminous record in this case and agree with the employee that there is evidence that could support inferences different than those made by the compensation judge.  However, the role of this court is not to assess whether substantial evidence might support a conclusion contrary to that reached by the compensation judge, but rather, this court must assess whether substantial evidence exists to support the findings reached by the compensation judge.  Emam v. Cmty. Action P’ship of Ramsey, No. WC21-6406 (W.C.C.A. Sept. 1, 2021); see also Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 40 W.C.D. 948 (Minn. 1988) (substantial evidence is evidence that a reasonable mind might accept as adequate).

As to the right knee, substantial evidence in the record supports the compensation judge’s determination that the employee’s work injury was no longer a substantial contributing factor in his need for treatment after October 8, 2018.  On October 8, 2018, the employee had been seen by Dr. Khetia for a follow-up six months after the surgery.  At that visit, the employee reported he was doing well and Dr. Khetia released him from treatment.  Dr. Khetia also opined that the employee was at MMI.^[6]  It was not until September 23, 2019, nearly one year later, that the employee reported right knee symptoms.  These symptoms may have been due to a new injury on September 19, 2019, which the employee also mentioned at the pain clinic when seen on October 21, 2019.  Dr. Khetia’s treatment records do contain references to treating the employee’s underlying chondromalacia, however, this condition existed prior to the work injury and at no time did Dr. Khetia state whether the chondromalacia being treated was due to the work injury or due to the preexisting chondromalacia.  There is sufficient evidence that a reasonable mind could accept that the employee failed to prove that the treatment to his right knee after October 8, 2018, was causally related to his work injury.

Regarding the left knee, substantial evidence in the record supports the compensation judge’s determination that the employee’s work injury was no longer a substantial contributing factor in his need for treatment after April 8, 2019.  On April 8, 2019, the employee had been seen by Dr. Khetia and reported feeling pretty good.  Dr. Khetia noted that the employee was able to perform normal activities with the exception of kneeling and determined the employee had reached MMI.  The employee was released without restrictions to the left knee.  Also, as with the right knee symptoms, the left knee symptoms returned following the September 2019 injury with the employee favoring his right knee and ankle.

For the right ankle. substantial evidence in the record supports the compensation judge’s determination that the employee’s work injury was no longer a substantial contributing factor in his need for treatment after February 1, 2021.  On appeal, the employee argues that Dr. Pena concluded that all treatment to the right ankle was related to the work injury.  We disagree.  Throughout his treatment records, Dr. Pena stated that he could not find a causal link to the employee’s symptoms and the work injury.  Dr. Pena has provided no diagnosis for the employee’s ankle condition, nor has he made a determination of its etiology.  His narrative report states that he “cannot assure with any degree of medical certainty that the injuries sustained on February 27, 2018, are related to the current complaints of [the employee] regarding his right ankle,” and he “cannot create any relationship or causation between the injury and his current complain [sic] of ankle pain given the fact that [he did] not understand the source of his pain.  The statement would apply to both the etiology of his pain as well as the anatomic location for his pain.”  (Ex. D.)  We acknowledge that Dr. Pena made contrary indications when completing health care provider reports indicating that there was a causal link between the employee’s work injury and his need for care, and that he also stated in the last part of his narrative report that the care he provided was reasonable, necessary, and causally related to the employee’s work injury.  It was within the purview of the compensation judge to reconcile these inconsistencies, and his adoption of the more detailed opinion and explanation contained in the treatment notes and narrative report, and rejection of the check boxes on the health care provider reports and the single sentence at the end of the narrative report, was reasonable.

The findings of the compensation judge must be affirmed because, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.”  Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.  The record in this case contains conflicting evidence, and evidence from which more than one inference may reasonably be drawn.  The inferences made and conclusions drawn by the compensation judge from this conflicting evidence are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  We affirm with the clerical modification noted above.