CAUSATION – TEMPORARY INJURY. The record as a whole, including testimony and medical record evidence, supports the compensation judge’s finding that the employee suffered a temporary injury to her low back as a result of the work injury, even in the absence of expert medical opinion.
EVIDENCE – MEDICAL EXPERT OPINION. It was an abuse of the compensation judge’s discretion to rely upon medical records with no causation discussion or analysis in finding that the employee’s current right knee injury was ongoing and causally related to the work injury.
Compensation Judge: Kirsten M. Marshall
Attorneys: James A. Reichert, James A. Reichert, LLC, Minneapolis, Minnesota, for the Respondent. Tracy M. Borash, Brown & Carlson, P.A., Minneapolis, Minnesota, for the Appellants.
Affirmed in part, modified in part, and reversed in part.
SEAN M. QUINN, Judge
The employer and insurer appeal the compensation judge’s determinations that the employee suffered a temporary work injury to her low back and that the work injury to her right knee is ongoing. We affirm in part, modify in part, and reverse in part.
The employee, Linder Konneh, claimed to have suffered an injury to her low back and bilateral knees on April 23, 2021, while working as a home health aide for the employer, Sundog Enterprises.
Prior to the work injury, the employee had treated for her low back and knees. In 2005, the employee reported bilateral knee pain to her family doctor who suspected chondromalacia of the patella and referred her to physical therapy. In September 2015, the employee reported bilateral knee pain. X-rays and a physical examination revealed patellofemoral arthritic changes and the employee underwent physical therapy. By December 2015, the employee reported improvement in strength and symptoms. The employee was noted to have discogenic pain and right-sided SI joint dysfunction in 2016. In May 2018, the employee fell walking down a ramp. Lumbar x-rays revealed minimal degenerative changes and she underwent physical therapy. In June 2018, the employee was in a motor vehicle accident which caused back pain. In 2020, the employee was diagnosed with mechanical low back pain, with likely deconditioning.
On April 23, 2021, while sweeping stairs at a client’s home, the employee slipped. Her right foot slid down one or two stairs and forcefully landed on the next step. She felt pain in her legs and up through her spine to her head. On April 28, 2021, she presented at HealthPartners Clinic complaining of right knee pain, stating that the pain began the day after the injury and that swelling started a few days later. Her pain worsened with standing, walking, and bending. The employee explained the stair slip incident but stated the knee pain was not related to that incident. Swelling and a popliteal cyst[1] were noted on examination and a sprain was suspected. She was told to take a day off work. A few days later, the employee called the clinic and asked that it be noted that her knee pain was related to her work injury.
On May 3, 2021, the employee was examined at TRIA Orthopedics by Dr. Leslie Ellis. The employee described the work injury to Dr. Ellis and explained she had twisted both knees in her fall. Concerned that the employee might have a right meniscus injury, Dr. Ellis ordered an MRI scan and recommended a hinged knee brace for stability and symptom relief.
The employee completed an incident report dated May 3, 2021. She described having misstepped and landing hard on her right foot on the next stair. She reported pain in both knees. On a diagram, the employee indicated her knees as the only area of injury. (Ex. 17.)
The employee returned to Dr. Ellis on May 9, 2021. At this visit, she complained of right hip and low back pain that she associated with her work injury, which had worsened since the date of injury. She also continued to have right knee pain. Dr. Ellis recommended physical therapy for the low back. The employee underwent strengthening, motion exercises, and aquatic therapy over the next several months.
An MRI scan of the employee’s right knee was done on May 13, 2021. The scan revealed no evidence of an acute injury, with both menisci and the cruciate and lateral ligaments intact. The scan showed advanced chondromalacia of the patella and articular cartilage loss along the undersurface of the medial femoral condyle. Dr. Ellis recommended ongoing bracing or use of a knee sleeve.
On June 28, 2021, the employee reported to Dr. Ellis that physical therapy was not improving her symptoms. Dr. Ellis again reviewed the imaging and examined the employee. She diagnosed chondromalacia of the right knee and a lumbar strain with radiculopathy and ordered an MRI scan of the low back. Dr. Ellis administered a corticosteroid injection to the employee’s right knee and advised the employee to continue with physical therapy.
The employee returned to TRIA on July 2, 2021, and saw Dr. Chad Griffith, an orthopedic surgeon, regarding her right knee. He took a history, reviewed the various scans, and examined the employee’s right knee. Dr. Griffith diagnosed osteoarthritis and a popliteal cyst which he noted were exacerbated by the work injury. He recommended continued physical therapy and home exercises, as well as ongoing use of the brace for stabilization and pain relief, and he updated the employee’s work restrictions. He further stated that total knee replacement surgery was not indicated at that time given the employee’s young age.
On September 1, 2021, the employee underwent an MRI scan of the low back. The scan showed no significant disc bulges or stenosis, but indicated multilevel disc disease, including some facet arthropathy and foraminal narrowing.
The employee returned to Dr. Griffith on September 21, 2021. She reported ongoing throbbing pain in her right knee and that it was painful to walk. She also reported about 50 percent improvement in her symptoms since the work injury. Dr. Griffith reviewed the employee’s MRI scan and recommended ongoing physical therapy.
The employee was seen on November 1, 2021, by Dr. Ellis who reviewed the MRI scan of the low back and recommended the employee continue her exercise program. By December 20, 2021, Dr. Ellis noted the employee was improving but was not yet back to baseline.
The employee returned to Dr. Griffith on November 30, 2021, for her right knee symptoms. She told Dr. Griffith that her right knee was improving and that she was working within restrictions of no lifting, pushing, or pulling more than 40 pounds, but that her symptoms had worsened in the past week. Dr. Griffith increased her work restrictions and recommended returning to physical therapy.
On January 28, 2022, a physical therapist at TRIA noted improvement in the employee’s right knee and low back pain, that she no longer walked with a limp, and that she had full range of motion of her lumbar spine. The employee was to be discharged from physical therapy and transitioned to a low back strengthening program at TRIA from February 8 to July 19, 2022.
On February 10, 2022, the employee was seen by Dr. Jess Olson, an occupational medicine doctor at HealthPartners Neuroscience Center. The employee described her work injury and reported that while her knees were getting better, her low back pain was persisting. Dr. Olson examined the employee and reviewed the September 2021 MRI scan of the low back. She diagnosed a lumbar strain with foraminal narrowing and recommended ongoing physical therapy, home exercise, and a trial of acupuncture.
On February 25, 2022, at the request of the employer and insurer, the employee was examined by Dr. Paul Wicklund. Dr. Wicklund performed an examination of the employee’s knees and took a history from the employee. He did not have any pre-injury medical records to review, but reviewed medical records for treatment rendered following the work injury. In his March 13, 2022, report, Dr. Wicklund diagnosed the employee as suffering from tri-compartmental osteoarthritis of her right knee that was permanently aggravated by the work injury. Dr. Wicklund opined that the employee needed further care including viscosupplementation injections, that she was not at maximum medical improvement (MMI), and that she required a work restriction of no kneeling with the right knee.
On November 3, 2022, the employee returned to TRIA with a flare-up of right knee pain that had started approximately one week prior. She stated that there was no new injury. She was referred to occupational medicine and was seen by Dr. Daniel Lussenhop, an occupational medicine doctor at HealthPartners, the following day. He diagnosed a strain of the right knee, encouraged her to fill her medication prescription, and advised her to return if the symptoms persisted. After the employee reported that she had suffered a work injury to her right knee in April 2021, Dr. Lussenhop stated that, “Based on this evaluation, [the employee’s] work injury as described … is the most likely causal explanation for her condition.” (Ex. 7.)
The employee returned to HealthPartners Occupational Medicine on November 14, 2022. She reported ongoing right knee pain which had worsened to the point of needing a cane to walk, as well as difficulty working. It was noted that the cyst on her posterior knee could be the source of her symptoms.
The employee was seen by Dr. Manoj Doss at HealthPartners Occupational Medicine on November 28, 2022. Dr. Doss noted the cyst appeared to be larger than what was first seen on the MRI scan 18 months prior. He aspirated the cyst and suggested the employee was likely at MMI. He also referred to the right knee condition as being related to the employee’s work injury without further explanation. On the same day, the employee also saw Dr. Todd Johnson at TRIA who opined that the employee’s symptoms were not from the popliteal cyst.
The employee was seen in the emergency room on January 14, 2023, reporting right leg pain. She had a small amount of swelling in the right knee with pain upon flexion in the popliteal region of the knee. An ultrasound showed the popliteal cyst, as well as fluid about the knee.
On January 24, 2023, the employee returned to Dr. Griffith with increased right knee pain and swelling. He aspirated the cyst but did not consider it to be the source of the employee’s pain. He suggested that no surgery would help other than a total knee replacement, which was not necessarily indicated given her young age.
On February 1, 2023, the employee returned to the HealthPartners Orthopedic Clinic with low back pain. She was diagnosed with low back pain and spondylosis and a facet joint injection was recommended.
The employee returned to Dr. Griffith on April 4, 2023. She described an acute exacerbation of her right knee with no new injury. Swelling was noted and Dr. Griffith aspirated fluid from the knee. He also ordered a new MRI scan of her right knee. The May 16, 2023, scan showed radial tearing of the inner portion of the posterior horn medial meniscus. There was also a second smaller tear peripherally within the posterior horn of the meniscus, and a possible tear in the medial meniscus. The scan also showed the previously seen medial and patellofemoral chondromalacia and the popliteal cyst.
The employee saw Dr. Griffith again on May 30, 2023. Dr. Griffith reviewed the recent MRI scan and noted changes from the May 2021 scan. He stated that the meniscal damage was too severe to be repaired surgically and reiterated that the only surgical option was a total knee replacement, which was premature given her age. Instead, he prescribed an unloader brace for the employee’s right knee to provide stability and symptom relief. He also aspirated her knee of fluid. In addition, he wrote:
The patient states she [has] not had any new injury since her initial injury in 2021. I reviewed her prior MRI scan and there is no evidence of a medial meniscal root tear. There is clearly a catabolic environment causing destruction where now she has a large root tear with extrusion . . . .
(Ex. 9.)
On July 11, 2023, the employee was reexamined by Dr. Wicklund at the employer and insurer’s request. Dr. Wicklund reviewed additional medical records from before and after the work injury. He diagnosed the employee with minimal degenerative disc disease of the low back and moderate osteoarthritis of the right knee with patellofemoral crepitation, tri-compartmental disease, and a popliteal cyst. Dr. Wicklund opined that the work injury did not cause or aggravate the employee’s low back degenerative disc disease. As to the right knee, he opined that he no longer felt that the work injury permanently aggravated her knee condition. Rather, given the new information he had, he opined that the degenerative changes in the employee’s right knee were neither caused nor aggravated by the work injury, but the twisting nature of the fall temporarily aggravated her right knee symptoms. According to Dr. Wicklund, the employee had recovered and reached MMI when she was discharged from physical therapy on July 19, 2022. Dr. Wicklund noted that there was no meniscus tear after the work injury as seen on the 2021 MRI scan and opined that the meniscus tear seen on the 2023 MRI scan was unrelated to the work injury.
On referral from Dr. Griffith, the employee was seen on August 22, 2023, by Dr. Der Chen Huang for her ongoing right knee symptoms. Dr. Huang agreed that an unloader brace was appropriate care until total knee replacement surgery.
The employee again saw Dr. Griffith on December 19, 2023. He aspirated her right knee and offered other non-surgical options beyond an unloader brace, including foam rolling, physical therapy, NSAIDs, and cortisone injections. He also noted that “[w]orkability [was] not needed.” (Ex. 9.) On June 18, 2024, Dr. Griffith recommended a cortisone injection which was administered on July 9, 2024.
Dr. Wicklund wrote a third report, dated September 19, 2024, after the employer and insurer provided additional medical records. The opinions he expressed regarding causation of the employee’s low back and right knee conditions remained essentially unchanged. He added, relative to Dr. Griffith’s May 30, 2023, treatment note:
Dr. Griffith describes this change on her MRI scan and describes the large root tear with degenerative changes. It is my opinion that the cause of her root tear was the gradual progression of pre-existing degenerative arthritis of her right knee. His notes on May 30, 2023, do not describe any new injury. He uses the word catabolic environment when he describes this large root tear with an extrusion. It is my opinion this was not a small metabolic (i.e. catabolic) problem; however, it was the natural progression of medial compartment degenerative osteoarthritis seen on the MRI scan done on May 13, 2021, which showed an area of full-thickness cartilage loss involving the central weightbearing portion of the medial femoral condyle. This area of cartilage loss was the primary force causing tearing of the medial meniscus. It is my opinion that this tearing of the medial meniscus resulting in a large posterior root tear was due to the larger area of grade 4 chondromalacia of the medial femoral condyle causing pressure on the medial meniscus with ambulation. I see no evidence for a “catabolic” environment.
With regard to the term catabolic, it refers to small metabolic changes with the breakdown of large, complicated molecules into smaller ones. The best known catabolic reaction would be the digestion process.
(Ex. 15.)
From the time of the 2021 work injury through the summer of 2024, the employee continued to work for the employer within restrictions set by her doctors, resulting in a reduction of pay compared to her wage at the time of the work injury. On August 29, 2024, the employee was notified that she had failed to complete required online training and was told by the employer, “we can only assume that you are resigning your employment.” (Ex. 12.)
In November 2023, the employee requested a formal hearing after her rehabilitation benefits were discontinued by an October 13, 2023, administrative decision. In December, she filed a claim petition seeking wage loss, rehabilitation, and medical benefits. The two pleadings were consolidated and a hearing before a compensation judge took place on September 24, 2024. The issues included whether the employee suffered a low back injury on April 23, 2021, entitlement to wage loss and vocational rehabilitation benefits, and the reasonableness of the employee’s request for a knee unloader brace.
At hearing, the employee testified that prior to the work injury, although she had some right knee care and symptoms, she never had the need for work restrictions or long-term care, whereas after the work injury, she had ongoing symptoms of pain, swelling, and stiffness, the functional use of the right knee was limited, and she needed work restrictions.
On October 17, 2024, the compensation judge issued her Findings and Order, finding that while the employee was an unreliable historian regarding her medical care pre-dating the work injury, she was a credible witness regarding the work injury itself and her right knee symptoms and dysfunction after the work injury. She found that the employee suffered a work injury to her low back, but that injury was temporary and had resolved by January 28, 2022. She concluded that the employee’s right knee injury was ongoing and awarded temporary total disability (TTD) and temporary partial disability (TPD) benefits. She found that the employee remained eligible for rehabilitation benefits. Finally, the compensation judge found the an unloader brace was reasonable and necessary treatment for her ongoing right knee condition and ordered payment for the brace.
The employer and insurer appeal.
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). When the findings are supported by substantial evidence, the Workers’ Compensation Court of Appeals must defer to the compensation judge. Lagasse v. Larry Horton, 982 N.W. 2d 189, 202 (Minn. 2022). 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); see also Smith v. Carver Cnty., 931 N.W. 2d 390, 79 W.C.D. 495 (Minn. 2019).
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); see also Busch v. Advanced Maint., 659 N.W.2d 772, 778-779 (Minn. 2003).
The employer and insurer appeal from the compensation judge’s determination that the employee suffered a compensable work injury to her low back, and that the employee’s work injury to her right knee was ongoing.
The compensation judge found that on April 23, 2021, the employee suffered a temporary work injury to her low back. The employer and insurer argue that substantial evidence does not support a finding of any injury to the employee’s low back. The employee bears the burden to prove that she suffered a compensable work injury. See Swanson v. Fairway Foods, 439 N.W.2d 722, 41 W.C.D. 1010 (Minn. 1989). On appeal, this court will affirm the compensation judge’s findings of a compensable work injury if supported by substantial evidence. Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
The employer and insurer argue that the employee did not report low back pain until several days after the work injury and failed to include the low back as an initial claim on her first report of injury. The employee testified that her low back symptoms were less severe than her right knee symptoms, but that they were still present from the time of the injury. The medical records demonstrate that the employee began a course of care for her low back pain by May 9, 2021, about 16 days after the work injury, and that she treated for her low back symptoms consistently with doctors and physical therapists until discharged from physical therapy in January 2022.
No doctors’ narrative opinions nor treatment notes were offered to support the claim that the employee’s work incident caused her low back injury. The treatment notes from the employee’s many providers contain only rote statements that the employee was seeking treatment related to a work injury, with no causation analysis or opinion. Nevertheless, the record as a whole supports the compensation judge’s finding that the employee suffered a temporary injury to her low back on April 23, 2021. The employee slid on the stairs and jammed her foot onto the second or third step down. She credibly testified that she felt pain all the way up her entire spine at that moment. A course of treatment started shortly thereafter for ongoing symptoms which resolved within nine months at the completion of physical therapy. The evidence in this case, from the testimony and the medical records, is sufficient to support the compensation judge’s finding of a temporary low back injury even in the absence of expert medical opinion. See Bender v. Dongo Tool Co., 509 N.W.2d 366, 49 W.C.D. 511 (Minn. 1993); Carroll v. Univ. of Minn., slip op. (W.C.C.A. May 4, 1999) (medical causation opinions are necessary except for cases involving “commoner afflictions” where a compensation judge can rely upon his or her own lay expertise without medical opinion evidence). We affirm the compensation judge’s finding that the employee sustained a work-related injury to her low back which had resolved by January 28, 2022.[2]
In awarding benefits to the employee, the compensation judge determined that the employee’s right knee injury was ongoing and that the work injury remained a substantial contributing factor in the employee’s need for restrictions and treatment. While the employer and insurer have admitted the compensability of the right knee injury through July 19, 2022, they argue on appeal that substantial evidence in the record does not support the compensation judge’s award of benefits after that date.
In support of her conclusions, the compensation judge explained that she was persuaded by “[t]he opinions of Dr. Griffith, Dr. Huang, and the occupational medicine physicians as expressed throughout the medical records.” (Mem. at 13.) The compensation judge did not identify which specific opinions or medical records she was relying upon in reaching her conclusions. This court has reviewed the entirety of the medical evidence in the record and no doctor proffered an adequate causation opinion linking the employee’s current right knee condition to the work injury.
It is within the discretion of the compensation judge to weigh medical evidence and choose between competing medical expert opinions. Giannoti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 803, 77 W.C.D. 117, 126 (Minn. 2017). This court will uphold a compensation judge’s choice of expert opinion if the opinion is adequately founded and in the absence of an abuse of discretion. Mattick v. Hy-Vee Foods Stores, 898 N.W.2d 616, 621, 77 W.C.D. 617, 624 (Minn. 2017). While formal medical opinions as to causation are not necessarily required to support a finding of compensability in those cases which involve “commoner afflictions,” as noted above regarding the employee’s low back injury, in most cases, a properly founded medical opinion providing a causal relationship is required. Bender, 509 N.W.2d at 367, 49 W.C.D. at 513; Miller v. Abbott Northwestern Hosp., slip op. (W.C.C.A. July 17, 2001); Reeder v. Metro Transit, slip op. (W.C.C.A. Sept. 11, 2003).
Contrary to the compensation judge’s statement, the treatment notes from occupational medicine physicians do not support a conclusion that the employee’s current condition is causally related to her work injury. Any mention of causation from an occupational medicine physician was noted in conclusory statements in November 2022,[3] months before the meniscus tear was discovered in May 2023. These occupational medicine records repeat the history provided by the employee that she suffered a work injury with no causation analysis or discussion. Likewise, the employee was seen only once by Dr. Huang on August 22, 2023, and he did not provide a causation opinion or analysis in his treatment note.
The employee’s claim is also not supported by an opinion from Dr. Griffith.[4] Though not specifically identified or discussed by the compensation judge, the employee on appeal points to Dr. Griffith’s May 30, 2023, treatment note as an adequate causation opinion. In that note, Dr. Griffith described the MRI scan of May 16, 2023, as having shown a meniscus tear as well as significant cartilage loss compared to her previous MRI scan. He then wrote, “[t]here is clearly a catabolic environment causing destruction where now she has a large root tear.” (Ex. 9.) As conceded by the employee during oral argument, Dr. Griffith does not define or explain a “catabolic environment.” “Catabolic” refers to the destructive metabolic process.[5] Dr. Wicklund defined “catabolic” as referring to “small metabolic changes with the breakdown of large, complicated molecules into smaller ones.” (Ex. 15.) Dr. Griffith’s treatment note implies that the employee’s right knee condition, including the new meniscus tear, was caused by a metabolic process. This statement, with no further discussion or analysis, does not adequately address whether the employee’s current condition is causally related to the work injury.
We conclude that the compensation judge abused her discretion in relying upon the records of Dr. Griffith, Dr. Huang, and the employee’s occupational medicine physicians as none provide an adequately founded opinion that relates the employee’s current right knee condition to the work injury.
While a right knee condition with a meniscus tear may be considered a “commoner affliction” in some situations, the employee’s right knee condition here is complicated by the amount of time between the employee’s injury and the occurrence of the meniscus tears, and therefore an adequately founded medical opinion relating the work injury to the employee’s current right knee condition was necessary. See Powers v. Bachman’s, Inc., 65 W.C.D. 263, 267 (W.C.C.A. 2005). As such, the employee did not meet her burden of proving her current right knee condition was causally related to her work injury. The compensation judge’s finding that the employee’s testimony regarding her right knee condition after the work injury was credible, without other supporting medical opinion evidence, does not support a causation determination in this case.
Substantial evidence in the record as a whole, including the medical evidence cited by the compensation judge, does not support a determination that the employee’s right knee condition, which was admitted through July 19, 2022, remained causally related to the work injury after that date. Accordingly, we modify Finding 53 to read, “The treatment provided by the intervenors was causally related to the employee’s work-related right knee injury through July 19, 2022. The preponderance of the evidence fails to prove treatment provided by the intervenors after July 19, 2022, was causally related to the employee’s work-related right knee injury.” We modify Finding 57(c) to read “April 25, 2022, through July 19, 2022.” We strike the time periods set forth in Findings 57(d) through 57(f). Findings 58 and 59 and Orders 3 and 4, regarding ongoing eligibility to rehabilitation benefits and the award of an unloader brace, are reversed.
[2] While we affirm the compensation judge on this issue, we modify Finding 55 to read, “The preponderance of the evidence fails to prove treatment to the employee’s low back provided by the intervenors after January 28, 2022, was causally related to the work injury.”
[3] The employee was examined, on a single occasion each, by three different occupational medicine doctors in November 2022. None of these doctors reviewed past medical records or had any understanding of the employee’s right knee history or work injury other than the limited details she shared.
[4] We acknowledge that Dr. Griffith expressed a causation opinion in his July 2, 2021, treatment note. However, this opinion was expressed long before the employee developed a torn meniscus and thus has no relevance as to whether the employee’s current right knee condition is causally related to the work injury.
[5] Dorland’s Illustrated Medical Dictionary 298 (33rd ed. 2020).