DAWN ENGLUND, Employee/Respondent, v. PRESBYTERIAN HOMES & SERVS. and BERKLEY RISK ADMIN’S, Self-Insured Employer/Appellant, and CAMBRIDGE MED. CTR., ALLINA MED. CLINIC, and MINN. DEP’T OF HUM. SERVS., Intervenors.

The self-insured employer appeals from the compensation judge’s determination that the employee sustained a work-related injury and from the award of benefits.  We affirm.

On June 28, 2020, the employee, Dawn Englund, sustained a right shoulder and mid-back injury while employed as a trained medication aide for the self-insured employer, Presbyterian Homes & Services, doing business as Boutwells Landing.  On the date of injury, the employee was pushing a large cart stocked with medication to be administered to patients.  The employee estimated the cart to have weighed a couple hundred pounds.  (T. 20.)  She pushed the cart over commercial carpeting and did not need to maneuver it around sharp corners at any time.  (T. 49.)  The cart had a handle (T. 42-43; Ex. B, p. 8) at the height of the employee’s chest (T. 59-60) or shoulder (Ex. B, p. 9).  The employee found the cart heavy, hard to push, and difficult to maneuver.  (T. 60.)  Approximately mid-shift, the employee began noticing her back and right shoulder were getting sore.  (T. 22.)  She testified that she felt as though she had “pulled a muscle” in her mid-back, and that she felt pain when moving her shoulder and raising her arm.  (T. 24.)  She continued working and finished her shift, but had discontinued use of the cart due to pain.  Following her shift, she took Tylenol and applied ice to attempt to alleviate the pain.

The following day, the employee did not go in to work.  She was seen by Alex Bendickson, PA-C, at Allina Health for right shoulder and back pain related to pushing a cart at work.  She reported that on June 28, 2020, she was pushing a med cart and had symptoms of right shoulder and low back pain.  PA-C Bendickson’s examination revealed tenderness in the employee’s anterior right shoulder extending to the deltoid.  The employee was diagnosed with a right shoulder and low back strain and was given work restrictions of a limit of ten-pound lifting and a limit of ten-pound pushing/pulling.  PA-C Bendickson, throughout his medical records, on and after June 29, 2020, noted that the employee’s injury was work-related.

The employee continued working under PA-C Bendickson’s restrictions, which gradually eased to lifting up to 20 pounds, pushing/pulling up to 50 pounds, and working eight hours per day.  This continued until July or August 2020, when the employer could no longer provide work within the restrictions.  The employee continued to treat with PA-C Bendickson for her right shoulder and back conditions.  On August 17, 2020, the employee’s lumbar spine was assessed as normal on x-ray examination, and thoracic spine scans revealed minor degenerative findings.  A negative bone density scan was completed.  She underwent physical therapy from July 22 to November 5, 2020.  On September 14, 2020, a right shoulder injection was administered and provided temporary pain relief.

The employee underwent an independent medical examination at the request of the employer conducted by Dr. Thomas Raih on October 15, 2020.  He opined that the employee’s back symptoms were the result of mild underlying degenerative thoracic disc disease and that she had some mild rotator cuff tendinitis.  Dr. Raih reviewed a video, provided by the employer.^[1]  The video depicts a male individual, 5’8” tall, weighing 150 pounds, and 29 years old, pushing a cart similar to the cart used by the employee on the date of injury for a short period of time.^[2]  The weight of the cart and its contents is unknown.  Upon his review of the video, Dr. Raih opined that “[t]he cart appeared to roll easily over the carpet, with minimal effort,” that “[t]here was no overhead activity, nor anything that would appear to particularly stress the right shoulder,” and that “pushing this type of cart is not an activity that would result in injury to the back or shoulder.”  (Ex. 2.)  He opined that the employee’s back and shoulder complaints could not be related to an injury on June 28, 2020.

The employee continued physical therapy and underwent a work hardening program.  Her restrictions were eased to 35 pounds lift/carry and push/pull up to 75 pounds.  She found part-time work within her restrictions on November 16, 2020.  By January 4, 2021, the employee struggled with lack of strength in the right shoulder with her arm extended and overhead.  X-rays of the right shoulder revealed no fracture or degenerative changes.  She received a second right shoulder injection from which she experienced ten days of relief.  PA-C Bendickson’s assessment was strain of the right rotator cuff.  A functional capacity evaluation (FCE) was conducted on January 19, 2021, which demonstrated that the movement within the employee’s spine was within functional limits.  Per the FCE, the employee could perform only light-duty work and her pushing ability was restricted to 35 pounds.  Her functional limitations were found to be consistent with her impairments and diagnosis, and the objective signs were consistent with her reports of discomfort.

On January 25, 2021, PA-C Bendickson examined the employee and opined that she had reached maximum medical improvement (MMI) with no permanent partial disability (PPD) rating.  She was discharged from care and was released to return to work with the permanent restrictions recommended in the FCE findings.

The employee underwent an independent medical examination at the request of her attorney with Dr. Jack Bert on April 19, 2021.  He opined that the employee sustained a work-related injury to her mid-back and right shoulder on June 28, 2020, and that the activity of pushing the cart aggravated a pre-existing degenerative condition in the employee’s mid-back.  Upon examination, Dr. Bert found the employee had right shoulder pain with abduction and flexion, and had reduced strength.  He also noted a positive Hawkins impingement sign.  He stated that “[t]he fact that she did not have symptoms prior to that time leaves me to the conclusion that she had a permanent aggravation of her pre-existing condition with respect to her thoracic spine and a new condition with respect to her right shoulder.”  (Ex. I.)  Dr. Bert stated that the employee had not yet reached MMI and that she required ongoing work restrictions, and he recommended that the employee undergo an MRI of her right shoulder.

An MRI scan of the employee’s right shoulder performed on May 12, 2021, showed a full-thickness supraspinatus tendon tear extending to the anterior infraspinatus tendon, distal subscapularis tendinosis with partial tearing and fraying superiorly, tendinosis of the long biceps tendon, minor glenohumeral joint degenerative changes, and AC joint degenerative changes.  On May 18, 2021, Dr. Richard Birdwell of Allina Health conducted a surgical evaluation of the employee.  Dr. Birdwell noted that the employee’s symptoms began 11 months ago with a reported mechanism of injury of pushing a med cart.  The examination revealed that the employee had limited range of motion, measurable loss of strength, disabling pain, and loss of function in the right shoulder.  On palpation, the employee was tender at the right rotator cuff insertion.  Dr. Birdwell observed a number of tests (including Hawkins-Kennedy, Jobe’s/empty can, and Speed’s) were all positive.  Dr. Birdwell diagnosed the employee as having a chronic right shoulder supraspinatus tendon rupture which occurred at work in June 2020.  Dr. Birdwell noted that the employee’s MRI scans showing a full-thickness rotator cuff tear correlated with her reported symptoms and physical exam findings.

On June 14, 2021, the employee underwent an arthroscopic right rotator cuff repair performed by Dr. Birdwell at Cambridge Medical Center.  The postoperative diagnoses were listed as: 1) right shoulder injury 06/2020, 2) work comp injury, 3) right shoulder supraspinatus tendon rupture, 4) impingement syndrome, 5) infraspinatus tendon rupture, 6) extensive synovitis, and 7) mild acromioclavicular joint DJD.  (Ex. J.)

The employee filed a claim petition on August 13, 2020, seeking various workers’ compensation benefits.  The employer denied primary liability arguing that the employee did not sustain an injury arising out of and in the course and scope of her employment.  The matter was heard before a compensation judge on November 19, 2021.  At issue was whether the employee suffered a work injury on June 28, 2020, and if so, whether the work injury remained a substantial contributing factor in her need for medical treatment and entitlement to benefits.  In his Findings and Order served and filed on January 14, 2022, the compensation judge adopted the opinion of Dr. Bert and found that the employee suffered work injuries to her right shoulder and mid-back on June 28, 2020, and that those injuries remained a substantial contributing factor in her need for medical treatment.  The employee’s claims for payment of medical treatment and for wage loss benefits, as well as intervention claims, were awarded.  The employer 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 self-insured employer appeals from the compensation judge’s determination that the employee sustained a work injury on June 28, 2020, from which she is suffering ongoing effects, arguing that the judge erred by relying upon the opinion of Dr. Bert and that substantial evidence does not support the decision.  We disagree.

Dr. Bert performed an examination of the employee, took a recorded history from her, and reviewed extensive medical records.  Dr. Bert’s reports were accepted into evidence over the self-insured employer’s objections to foundation and to Dr. Bert’s qualifications.  (T. 7-8.)  The compensation judge adopted the opinion of Dr. Bert, stating that those opinions were detailed and consistent with the employee’s hearing testimony and with the medical records.  (Mem. at 5.)

Generally, this court will defer to a compensation judge’s choice between competing medical expert opinions.  Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985).  A compensation judge may rely on an expert opinion if it has “an adequate factual foundation.”  Hudson v. Trillium Staffing Solutions, 896 N.W.2d 536, 77 W.C.D. 437 (Minn. 2017) (citation omitted.)  The expert opinion “need only be based on ‘enough facts to form a reasonable opinion that is not based on speculation or conjecture.’”  Mattick v. Hy-Vee Foods Stores, 898 N.W.2d 616, 621, 77 W.C.D. 617, 624 (Minn. 2017) (quoting Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 802, 77 W.C.D. 117, 124 (Minn. 2017)).

The employer asserts that Dr. Bert lacked adequate foundation because he made no mention of the video demonstration offered by the employer.  This demonstration lasted 21 seconds depicting someone other than the employee using a cart which differed from that used by the employee on the date of injury.  Without consideration of this video, the employer argues, Dr. Bert did not sufficiently understand the employee’s job duties.  Whether Dr. Bert was provided this video is not clear on this record.  What is clear is that Dr. Bert was provided a background letter describing the employee’s job duties in terms that are consistent with the employee’s credible testimony.  Dr. Bert obtained a history from the employee, reviewed the employee’s medical records, and performed a physical examination.  This level of knowledge affords an examining physician adequate foundation to render an expert opinion.  See Drews v. Kohl’s, 55 W.C.D. 33 (W.C.C.A. 1996), summarily aff’d (Minn. July 11, 1996); see also Gianotti, 889 N.W.2d at 803, 77 W.C.D. at 126.

The employer maintains that Dr. Bert is not competent to offer an opinion with regard to the employee’s shoulder condition because he is a knee specialist.  This court has rejected similar arguments seeking to discredit the opinion of a medical expert relied upon by a compensation judge.  In Johnson v. A&B Welding & Constr., Inc., slip op. (W.C.C.A. July 21, 2000), we held that a compensation judge could reasonably rely on the expert medical opinion of a board-certified orthopedist regarding causation of a thumb condition, even though the doctor was not a hand specialist.  Similarly, in Branstad v. FedEx Freight East, No. WC08-263 (W.C.C.A. June 11, 2009), we held that an orthopedic surgeon was competent to render an expert medical opinion on an employee’s disability and need for disc replacement surgery, even though the doctor did not himself have experience performing the type of surgery being contemplated.  The competency of a witness to provide an expert opinion “depends upon both the degree of the witness’ scientific knowledge and the extent of the witness’ practical experience with the matter which is the subject of the offered testimony.”  Reinhardt v. Colton, 337 N.W.2d 88, 93 (Minn. 1983).  Where the doctor has sufficient expertise and foundation to render an opinion, these factors go to the weight of the opinion, and not to its admissibility.  See Reuther v. State, 455 N.W.2d 475, 42 W.C.D. 1118 (Minn. 1990).  Dr. Bert is competent to render an opinion in this matter and we conclude that the compensation judge was well within his discretion to give significant weight to those well-founded opinions.

On appeal, the employer also takes issue with a statement made by Dr. Bert in his April 19, 2021, report, that “[t]he fact that [the employee] did not have these symptoms prior to June 28, 2020 in her mid back and right shoulder, is indicative of the fact that the work activity obviously permanently aggravated the thoracic spine osteoarthritis and caused her right shoulder pain.”  (Ex. I.)  The employer argues that this situation is analogous to that presented in Rindahl v. Brighton Wood Farms, 382 N.W.2d 855, 38 W.C.D. 473 (Minn. 1986), where the supreme court rejected a causal link between the employee’s injury and claimed mental health condition.  The compensation judge had found a causal link between the employee’s physical injury and the mental health issues, reasoning that “‘the anxiety, pain and disability resulting from her work-related injury are logically a substantial cause of the depression.’”  Id. at 856, 38 W.C.D. at 475.  The supreme court reversed, stating that “[w]e do not think causation in this complex and subtle area of emotional distress is entirely a matter of logic, for it does not necessarily follow that because the depression came after the injury that the injury caused the depression.”  Id.  The court held that something more than the employee attributing her depression to her injury was needed, and that “some medical opinion causally relating the depression to [the] employee’s physical injuries is required before the depression can be found compensable under the workers’ compensation system.”  Id. at 856-57, 38 W.C.D. at 476.

In Rindahl, the “logical” causation statement was made connecting a claimed psychological injury to a physical injury.  By contrast, there was no claim of a psychological injury in this case.  Dr. Bert’s opinion was based on his own findings on examination, his discussion of the employee’s medical history, and the employee’s reports of the chronology and development of her symptoms.  The severity of symptoms prior to the date of the work injury is a long-standing factor in assessing causation through permanent aggravation of physical injuries.  See Wold v. Olinger Trucking, Inc., slip op. (W.C.C.A. Aug. 29, 1994).  These are all aspects of a typical, well-founded opinion by a competent medical expert.  We are not persuaded that Dr. Bert’s causation opinion was the type of “logical” opinion rejected in Rindahl.

The decision of the compensation judge in this case is supported by the well-founded and competent opinions of Dr. Bert, the medical records in evidence, and the credible testimony of the employee.^[3]  Because substantial evidence in the record supports the decision, we affirm.