RYAN SCHADT, Employee/Appellant, v. DENT WIZARD INT’L, and LIBERTY MUT. INS. CO., Employer-Insurer/Respondents, and SUMMIT ORTHOPEDICS, LTD., Intervenor.

The employee appeals from the compensation judge’s findings that the employee’s rheumatoid arthritis diagnosis is not related to his July 15, 2020, work injury, that his work injury did not involve his neck or right shoulder, that his left shoulder injury resolved as of July 29, 2020, and that he is not entitled to temporary partial disability benefits and payment of his medical expenses.  We affirm.

The employee, Ryan Schadt, began working for the employer, Dent Wizard International, in 2017 as a sales representative.  At the time of the hearing, he was working for the employer as a business development executive.  On July 15, 2020, the employee was holding up a nine-foot by six-foot wall weighing approximately 150 to 200 pounds while it was being secured by coworkers.  He held the wall in place for three to four minutes.  When he put his arms down, he felt a tingling sensation in his left shoulder.  He reported the incident to his project leader and stopped work for the day.  

The next day, on July 16, 2020, the employee was seen at Summit Orthopedics for left shoulder pain and weakness.  He gave a history of having had sharp and sudden discomfort in his left shoulder as he was trying to lift a stainless-steel wall at work the day before.  He denied any radiation of pain down his arm and had no complaints of tingling or numbness in his hand.  He was prescribed prednisone and an MRI scan was ordered for a suspected rotator cuff injury.  A July 28, 2020, MRI scan showed significant bony edema/inflammation involving the acromioclavicular joint, but no rotator cuff tear or pathology.  The employee reported that his symptoms had markedly improved and that functionally, he was “pretty much able to do most of his normal activities.”  (Ex. D at 259.)  The employee was advised that he just needed time to heal and that he should return in one month if he did not continue to improve.  

The employee returned to Summit Orthopedics on September 11, 2020, reporting that he woke up in the middle of the previous night with a sudden onset of severe pain in his right shoulder, without any injury or trauma.  Regarding his left shoulder, he reported that his symptoms had resolved.  On September 22, 2020, the employee was seen again, reporting bilateral global shoulder pain that radiated down his arms into his wrists and forearms, as well as numbness, tingling, and weakness.  He received subacromial cortisone injections, which improved his symptoms, but he did have ongoing intermittent paresthesia in both arms.  At a medical visit on October 20, PA-C Emily Peterson opined that the employee’s shoulder symptoms may be caused by cervical radiculopathy and recommended a cervical MRI scan, which was performed on October 26, 2020.  The cervical MRI scan showed left-sided foraminal stenosis at C6-7 as well as other degenerative changes.  On October 29, 2020, the employee saw Dr. Nicholas Wills at Summit Orthopedics and reported symptoms in his left wrist that improved when he wore a wrist splint.  Dr. Wills explained that the employee’s wrist symptoms could not be related to his neck if wearing a splint improved his symptoms, and he referred the employee to a hand specialist.  On November 13, 2020, the employee was seen by Dr. David Falconer at Summit Orthopedics for a hand evaluation.  Dr. Falconer felt that the employee had early left carpal tunnel symptoms, however, an EMG performed on July 21, 2021, ruled that condition out.

The employee was evaluated by Dr. Andrew Clary at Summit Orthopedics on November 17, 2020.  Dr. Clary recommended an epidural steroid injection to rule out cervical involvement.  On January 12, 2021, Dr. Clary suggested that the employee’s symptoms could be caused by an acquired hypersensitivity after an injury.  In follow up on March 22, 2021, it was discussed that he had both discogenic neck pain and hypersensitivity.  Another injection was recommended in conjunction with physical therapy, which commenced on April 15, 2021, and continued through June 2021.  On June 2, 2021, the employee reported to Dr. Clary that he was having symptoms in his neck, shoulders, hands, and feet, and that his symptoms were getting worse with therapy.  Dr. Clary recommended medication and another cervical MRI.  A repeat cervical MRI scan on June 15, 2021, showed C6-7 disc bulging.  On June 17, 2021, the employee reported that in the past he could hit a golf ball 300 yards, but now he could not even tie his own shoelaces.  Dr. Clary noted swelling in both hands and felt that the employee had ongoing nerve hypersensitivity. The employee underwent an EMG on July 20, 2021, which suggested right ulnar entrapment at the elbow.

On August 5, 2021, the employee reported to Dr. Clary ongoing neck and shoulder pain radiating into his hands along with swelling in his hands.  Dr. Clary recommended a stellate ganglion block at right C6 and discussed a potential spinal cord stimulator trial, and the employee consented to both.  Neither the block nor the spinal cord stimulator improved the employee’s symptoms.  By August 23, 2021, Dr. Clary suspected an autoimmune process as the cause of the employee’s symptoms and referred him to both neurology and rheumatology.

The employee’s father took him to the emergency room at M Health Fairview on October 6, 2021.  The employee’s father testified at the hearing below that on that day, the employee’s hands had swollen so much they looked like catcher’s mitts.  He also testified that his son had no physical problems prior to the work injury.  Following a neurology and rheumatology work up at the hospital it was determined that the employee’s symptoms were most consistent with bilateral symmetric polyarthritis in the setting of rheumatoid arthritis.  He was prescribed medication and was advised to follow up with rheumatology.

The employee was evaluated by Dr. Ana Patricia Groeschel at Noran Neurology on October 20, 2021.  Dr. Groeschel felt that the employee had two conditions, neck pain as explained by the cervical MRI, and rheumatoid arthritis as diagnosed at M Health Fairview.  She noted that he was feeling better with medication and planned to follow up with rheumatology.  

On December 21, 2021, the employee was seen by Dr. Maren Hilton at Arthritis and Rheumatology Consultants and continued to treat with her through the date of hearing.  He was treated with various medications and infusions, which have significantly improved his symptoms.  Dr. Hilton, as well as other medical providers, encouraged the employee to cease smoking to help manage his symptoms.  

Several medical experts have issued opinions regarding the nature and extent of the employee’s July 15, 2020, work injury and whether the employee’s rheumatoid arthritis and neck symptoms were caused by the injury.  On January 22, 2021, Dr. Jeffrey Dick performed an independent medical examination and issued a report at the request of the employer and insurer.  In his report, Dr. Dick opined that the July 15, 2020, work injury caused a temporary aggravation of the employee’s left acromioclavicular joint arthrosis which resolved by July 29, 2020, at which time the employee reached maximum medical improvement.  It was also Dr. Dick’s opinion that the employee’s neck and neurological symptoms were not related to the work injury since the employee did not complain of those symptoms until several months after the injury.   

Dr. Clary issued a narrative report dated March 14, 2022.  In that report, Dr. Clary opined that the work injury was a substantial contributing factor to the employee’s bilateral upper extremities and cervical spine condition, as well as to his chronic regional pain syndrome (CRPS).  He explained that the employee’s work injury was a “stretch injury from overextension of his neck working overhead on July 15, 2020,” which can cause an insidious onset of nerve irritation that has unpredictable frequency of pain and swelling.  (Ex. B at 140.)  He further stated that the medical treatment received to date had been reasonable and necessary and he recommended ketamine treatments.  Finally, Dr. Clary outlined why he did not agree that the employee sustained a temporary left shoulder injury, as opined by Dr. Dick, pointing out the complex symptoms reported by the employee at the time of injury.  

Following a June 6, 2023, independent medical examination at the employer and insurer’s request, Dr. Mark Martin at Physical Medicine & Rehabilitation issued a medical report.  Dr. Martin opined that the employee had rheumatoid arthritis and that the July 15, 2020, work injury appeared to “unmask” the underlying autoimmune disease.  (Ex. 2 at 122.)  He explained that while CRPS and rheumatoid arthritis can be difficult to differentiate, rheumatoid arthritis was indicated because the employee responded to treatment for rheumatoid arthritis and not for CRPS. 

Dr. Asim Khan performed an independent medical examination and issued a report at the request of the employer and insurer on October 11, 2023.  Dr. Khan agreed with the  diagnosis of rheumatoid arthritis and noted that he had been previously diagnosed with multilevel cervical disc disease and degenerative disease along with left acromioclavicular arthritis.  With regard to the rheumatoid arthritis, he explained that the condition is an autoimmune disorder which was not caused by the July 15, 2020, work injury.  He also agreed that the work injury caused a temporary flare-up of the left shoulder arthritis that resolved after taking anti-inflammatory medications.  Dr. Khan noted that other joint involvement was related to the employee’s underlying rheumatoid arthritis and not to the work injury.  He felt that all treatment related to the left shoulder was reasonable and necessary up to the time the diagnosis of rheumatoid arthritis was established.  

The employee’s treating rheumatologist, Dr. Hilton, did not author a narrative report. By way of signing specific interrogatories, Dr. Hilton affirmed that the employee did not have symptoms or a diagnosis of rheumatoid arthritis before the work injury of July 15, 2020, and that the work injury “could be” a contributing factor to the onset of rheumatoid arthritis symptoms.  (Ex. A at 136.)

The employee filed a claim petition asserting that his work injury of July 15, 2020, was a substantial contributing cause of his rheumatoid arthritis condition as well as his cervical and right shoulder issues.  He claimed temporary partial disability benefits and payment of out-of-pocket medical expenses.  Summit Orthopedics filed a motion to intervene seeking payment of medical bills for various dates of service between September 2020 and 2021.

The employee’s claims came on for hearing on September 4, 2024.  In the findings and order, the compensation judge found that the July 15, 2020, work injury caused a temporary aggravation of the employee’s left acromioclavicular joint arthrosis which resolved by July 29, 2020, that the work injury did not substantially contribute to the employee’s diagnosis of rheumatoid arthritis, and that the employee did not sustain a work-related injury to his neck or right shoulder.  As a result, the compensation judge denied the claims for payment of wage loss and medical benefits and denied the intervention claim of Summit Orthopedics.  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).  When the findings are supported by substantial evidence, the Workers’ Compensation Court of Appeals must defer to the compensation judge. Lagasse v. 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, 778-79 (Minn. 2003).

The employee argues on appeal that the compensation judge’s findings are not supported by substantial evidence because he relied on the medical opinions of Dr. Dick and Dr. Khan, which lack adequate foundation.  The employee specifically appeals the findings that his rheumatoid arthritis condition is not related to his July 15, 2020, work injury, that his work injury did not involve his neck or right shoulder, that his left shoulder injury was temporary and had resolved as of July 29, 2020, and that he is not entitled to temporary partial disability benefits or payment of his medical expenses.  

The employee appeals from the compensation judge’s finding that his July 15, 2020, work injury was not a substantial contributing cause of his rheumatoid arthritis condition, arguing that the compensation judge erred in relying on the expert opinion of Dr. Khan because he assumed facts not supported by substantial evidence in the record.  We disagree.  The employee contends that Dr. Khan’s opinion lacks foundation because he “assumes rheumatoid arthritis is never related to a work injury . . . .   In other words,. . . there is never a scenario where [rheumatoid arthritis] is a compensable condition.”  (App. Brief at 5.)  The employee’s position is misguided for a number of reasons.

First, the report of Dr. Khan does not specifically state that rheumatoid arthritis can never be related to a work injury.  His report notes that rheumatoid arthritis is an autoimmune disorder, and he opined that the employee’s “injury of July 15, 2020, is not a contributing cause for rheumatoid arthritis.”  (Ex. 3 at 131.)  Dr. Khan further stated that the employee’s “work injury is not a contributing cause of his diagnosis as this is an autoimmune disease not related to any work injury.”  (Id.)  Dr. Khan’s opinion, read in context, refers to any injury of the employee’s, not any injury whatsoever.  We decline to accept the employee’s overly broad interpretation of Dr. Khan’s statement.

Second, this case does not present circumstances where a medical expert cannot negate causation by disagreeing with a theory of compensability, such as a statutory presumption of causation or a legal concept of a Gillette injury.  See, e.g., Courtney v. City of Orono, 424 N.W.2d 295, 40 W.C.D. 1117 (Minn. 1988); Linnell v. City of St. Louis Park, 305 N.W.2d 599, 33 W.C.D. 602 (Minn. 1981) (if a firefighter or police officer develops various coronary diseases or pneumonia, the disease is presumptively work related and cannot be rebutted by a medical opinion denying the correctness of the presumption); Christ v. Berwald Roofing, slip op. (W.C.C.A. Mar. 6, 2002) (where the employee asserts a Gillette claim, an expert opinion that states a Gillette injury is not a legitimate medical concept cannot be used to dispute causation of an injury).  In this case, Dr. Khan’s purported disagreement with the employee’s theory of compensability does not affect the foundation of his opinion nor does it preclude the compensation judge from relying on that opinion.

Third, the opinion of Dr. Khan is adequately founded and the compensation judge did not err in relying on that opinion.  The compensation judge, as trier of fact, has discretion to choose between competing and conflicting medical experts’ reports and opinions.  Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 803, 77 W.C.D. 117, 126 (Minn. 2017).  A compensation judge’s decision to adopt the opinion of an expert must be upheld if the opinion has adequate foundation, absent an abuse of discretion.  Mattick v. Hy-Vee Foods Stores, 898 N.W.2d 616, 621, 77 W.C.D. 617, 624 (Minn. 2017).  “An expert opinion lacks adequate foundation when the opinion does not include the facts upon which the expert is relying in forming the opinion, there is no explanation of the basis for the opinion, or the facts assumed by the expert are not supported by the evidence.”  Erickson v. Grand Itasca Clinic & Hosp., No. WC21-6413 (W.C.C.A. Nov. 16, 2021) (citing Hudson v. Trillium Staffing, 896 N.W.2d 536, 540, 77 W.C.D. 437, 442 (Minn. 2017)).  Dr. Khan reviewed medical records from numerous medical providers and prior independent medical evaluation reports, performed a physical examination of the employee, and took the employee’s history.  In his brief, the employee acknowledges that Dr. Khan reviewed the medical records and does not identify incorrect facts assumed or missing from Dr. Khan’s report that would show foundation for his opinion is lacking.  Because there is adequate factual foundation for Dr. Khan’s expert medical opinion, it was not an abuse of discretion for the compensation judge to rely on that medical opinion.

Further, the compensation judge rejected the medical opinions submitted by the employee in support of his claims.  The employee relied on the signed interrogatories of Dr. Hilton in which she agreed that the work injury “could be” a contributing factor to the onset of rheumatoid arthritis symptoms, and on Dr. Martin’s opinion that the work injury appeared to “unmask” an underlying rheumatoid arthritis disease.  A medical provider must be “of the opinion that it was not merely possible that the employee’s work injury could have caused the employee’s injury, but that it was probable that it did in fact cause the injury.”  McBride v. Anderson Power & Equip., Inc., slip op. (W.C.C.A. Feb. 21, 2002); see also Goss v. Ford Motor Co., 55 W.C.D. 316 (W.C.C.A. 1996), summarily aff’d (Minn. Oct. 18, 1996).  Neither of these opinions rise to the level of stating that the work injury probably caused, aggravated, or accelerated the employee’s rheumatoid arthritis condition.  Substantial evidence, including Dr. Khan’s expert medical opinion, supports the compensation judge’s finding that the employee’s work injury was not a substantial contributing cause of his rheumatoid arthritis condition, and we affirm.

The employee appeals the compensation judge’s finding that the employee did not sustain a work injury to his neck, arguing it was error to rely on the opinion of Dr. Dick.  After reviewing the medical records and radiographs through the date of his report, Dr. Dick opined that the employee had multilevel cervical disc and facet degeneration which were not related to the July 15, 2020, work injury.  His opinion was based on the fact that the employee did not report neck symptoms until January 21, 2021, six months after the injury, and that the October 26, 2020, cervical MRI scan did not show evidence of a neck injury.  Dr. Dick’s opinion regarding the employee’s neck condition is based on adequate foundation.  See Hudson, 896 N.W.2d at 540, 77 W.C.D. at 442.  The compensation judge did not abuse his discretion in relying on that opinion and we affirm this finding.  See Mattick, 898 N.W.2d at 621, 77 W.C.D. at 624.

The employee appeals the compensation judge’s finding that he did not sustain an injury to his right shoulder on July 15, 2020.  The only medical opinion related to the employee’s right shoulder in the record is a March 14, 2022, report from Dr. Clary who opined that the employee’s bilateral extremities and cervical spine conditions were caused by CRPS related to the trauma sustained on July 15, 2020.  He opined that the employee sustained a “stretch injury from overextension of his neck working overhead” on that date, which can cause an insidious onset of nerve irritation that has unpredictable frequence of pain and swelling.  (Ex. B at 140.)  However, it was determined that the employee did not, in fact, have CRPS, but suffered from rheumatoid arthritis.  Due to the incorrect diagnosis, the compensation judge found the opinion of Dr. Clary to be neither credible nor persuasive.  The only other evidence on the right shoulder injury was the testimony of the employee, who testified that he “woke up one morning and [his] right shoulder was acting up.”  (T. 51.)  The employee bears the burden of proving, by a fair preponderance of the evidence, the compensability of his or her claims.  Fischer v. Saga Corp., 463 N.W.2d 501, 501, 43 W.C.D. 559, 560 (Minn. 1990); Swanson v. Fairway Foods, 439 N.W.2d 722, 723, 41 W.C.D. 1010, 1013 (Minn. 1989).  The compensation judge’s determination that the employee did not meet his burden of proof regarding a right shoulder injury is supported by substantial evidence in the record, and we affirm. 

The employee appeals from the compensation judge’s finding that his left shoulder injury was a temporary aggravation of his left acromioclavicular joint arthrosis which resolved as of July 29, 2020, arguing that the compensation judge erred in relying on the expert opinion of Dr. Dick, as the opinion lacked foundation because it relies upon facts not supported by substantial evidence.  We are not persuaded.

On appeal, the employee argues that Dr. Dick’s opinion lacks foundation as it relies on a “misinterpretation” of the July 29, 2020, medical record from Summit Orthopedics.  (App. Brief at 4.)  He contends that since the medical record demonstrates that the employee was not symptom free as of that date, the evidence does not support a finding that the employee’s left shoulder injury resolved by July 29, 2020. 

Dr. Dick reviewed medical records and radiographs, took and summarized the employee’s medical history, and performed a physical examination.  In his report, he noted that the July 29, 2020, medical record included the history that “currently [the employee’s] shoulder symptoms were minimal” and that the provider recommended ibuprofen and an injection into the acromioclavicular joint.  (Ex. 1.)  Dr. Dick was aware that the employee was not completely symptom free as of July 29, 2020, but found the temporary aggravation had resolved as of that date given the minimal nature of the employee’s symptoms.  The medical note does not negate the foundation of Dr. Dick’s opinion.  See Hudson, 896 N.W.2d at 540, 77 W.C.D. at 442.  The compensation judge did not abuse his discretion in relying on the expert medical opinion of Dr. Dick in concluding that the employee’s left shoulder injury was temporary and had resolved as of July 29, 2020.  See Mattick, 898 N.W.2d at 621, 77 W.C.D. at 624.

Accordingly, we affirm the compensation judge’s denial of the employee’s claims for wage loss and payment of medical expenses and affirm the denial of the intervention claim of Summit Orthopedics.