CAUSATION – SUBSTANTIAL EVIDENCE. The compensation judge’s determination that the additional medical care rendered to the employee’s bilateral knees was not causally related to the work injury is supported by substantial evidence in the record showing that the symptoms and objective findings were the same as those found to be unrelated in a prior proceeding.
EVIDENCE – EXPERT MEDICAL OPINION. The compensation judge did not err in accepting and relying upon the opinions of medical experts that it is not clear that the employee suffers from CRPS in denying the employee’s claim for medical benefits to the right ankle.
Compensation Judge: William J. Marshall
Attorneys: Jeremiah W. Sisk, Mottaz & Sisk Injury Law, Coon Rapids, Minnesota, for the Appellant. Karen M. Charlson, Littler Mendelson, P.C., Minneapolis, Minnesota, for the Respondent.
Affirmed.
SEAN M. QUINN, Judge
The employee appeals from the compensation judge’s finding that his admitted work injury did not result in complex regional pain syndrome (CRPS), and from the finding that medical care for the employee’s bilateral knee injuries provided after January 22, 2022, was not causally related to his admitted work injury. We affirm.
On February 27, 2018, the employee, Ray Appleby, slipped on ice and twisted his right knee and right ankle while in the course of his employment as a park keeper for the employer, the Minneapolis Park & Recreation Board. He had no prior right ankle issues, but had prior issues with his knees, including 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 those surgeries.
Following the 2018 work injury, the employee was referred to Dr. Eric Khetia of Summit Orthopedics, who performed a right knee arthroscopic partial medial meniscectomy, partial lateral meniscectomy, and patellofemoral chondroplasty on March 23, 2018. By late 2018, the employee reported he was doing well and he had no significant symptoms, almost full range of motion, full motor strength, no swelling, and well-healed scars. 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.
Around the same time that he treated for his right knee, the employee also treated with Dr. Michael Castro of Summit Orthopedics for his right ankle complaints. 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 surgery of the right ankle. 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.
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. A January 2019 MRI scan of the left knee 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 January 24, 2019, Dr. Castro performed a second surgery on the right ankle. The employee consequently suffered a postoperative hematoma and underwent another surgery to evacuate it on February 1, 2019.
On February 18, 2019, the employee underwent a left knee arthroscopic partial medial meniscectomy, partial lateral meniscectomy, loose body removal, and patellofemoral chondroplasty by Dr. Khetia. 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 full-duty work relative to both knees.
Due to ongoing right ankle symptoms, the employee saw Dr. Fernando Pena of TRIA Orthopaedic Center for a second opinion on April 29, 2019. By September 2019, Dr. Pena suspected the source of the employee’s pain was not the ankle itself. 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 CRPS and was treated with physical therapy and sympathetic nerve blocks.
The employee returned to Dr. Khetia in October 2019 for additional care to the right knee, and later for the left knee. These were his first visits to Dr. Khetia for his right knee since October 2018, and since April 2019 for his left knee.
At the request of the employer, 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. She concluded that both injuries had resolved within two to four weeks.
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. The employee returned to Dr. Khetia in 2020 and 2021 for additional bilateral knee treatment.
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 his treatment the employee, 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. Due to the complexity of the employee’s condition, Dr. Pena could not form an opinion regarding the etiology of the employee’s pain, and consequently, could not opine with any degree of medical certainty that the February 27, 2018, work injury was related to the employee’s current complaints of right ankle pain. In the same report, however, Dr. Pena stated 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. The employer admitted the right knee and right ankle injuries, but asserted those injuries had resolved according to the opinion of Dr. Happe, and they denied the claimed consequential left knee injury. No claims were asserted by the employee based on the CRPS diagnosis.
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 was not persuaded by Dr. Happe’s opinion. He awarded benefits, including PPD benefits, for the bilateral knees and right ankle, but found the medical care for each of those body parts was no longer causally related to the work injury after October 8, 2018, for the right knee, April 8, 2019, for the left knee, and February 1, 2021, for the right ankle.
The employee appealed that decision to this court. In an October 10, 2022, decision, this court concluded that despite the bilateral knees and right ankle injuries being found to be permanent, substantial evidence supported the conclusion that there was no longer a causal link to the need for ongoing care to each body part after the specific date, per body part, as determined by the compensation judge. With respect to the knees, substantial evidence showed that there were gaps in care after the employee recovered from the right and left knees surgeries, respectively, before new care commenced many months later. With respect to the right ankle, the compensation judge was within his discretion to accept Dr. Pena’s opinion that he could not determine a diagnosis or etiology of the employee’s ongoing ankle pain. As such, this court affirmed the compensation judge’s decision. Appleby v. Minneapolis Park & Recreation Bd., No. WC22-6454 (W.C.C.A. Oct. 10, 2022).
Following this court’s decision in 2022, the employee filed a new claim petition alleging entitlement to medical benefits for treatment to his bilateral knees rendered after the 2021 hearing. He also claimed entitlement to medical benefits for CRPS treatment that had been rendered prior to the 2021 hearing.
The employee had returned to Dr. Khetia for ongoing bilateral knee pain on February 7, 2022. The employee’s subjective complaints and objective findings were similar to those made and observed in previous visits with Dr. Khetia. Dr. Khetia again assessed the employee with ongoing chondromalacia and provided cortisone injections. A similar visit occurred on January 30, 2023.
The employee reported having suffered an injury at work on November 16, 2023. The employee underwent an MRI of his left knee on November 30, 2023, and a follow-up visit with Dr. Khetia on December 8, 2023.[2] The employee’s subjective complaints and Dr. Khetia’s objective observations were similar to those occurring on prior visits, with the exception of swelling of the knee joint noted by Dr. Khetia. Another cortisone injection was administered.
There is no evidence in the record of the employee having received medical treatment for CRPS of the right ankle since the 2021 hearing. The employee received medical care for his ongoing ankle pain from Dr. Castro, and later from Dr. Pena in 2019, as well as care from the TRIA pain program. At least one provider in the pain program felt the employee had CRPS, and Dr. Agre opined the same. Dr. Pena, however, was unsure of the employee’s diagnosis or the etiology of his symptoms and need for care.
In his current claim, the employee submits these same medical records and bills, seeking compensation based upon the CRPS diagnosis as opposed to an ongoing right ankle injury which was denied in the 2021 hearing.
Dr. Agre examined the employee a second time on May 21, 2023, at the request of the employee’s attorney. In his report, dated the same day, Dr. Agre opined the employee had ongoing chondromalacia to his bilateral knees. He explained that while there may have been a gap in care for the employee’s knee, there was no explanation other than that the work injury remained a substantial contributing factor to the need for medical care to both knees. Dr. Agre opined that the medical care to the employee’s bilateral knees after the 2021 hearing was causally related to the work injury. Dr. Agre also opined that the employee continued to suffer from CRPS which was a consequence of the ankle surgeries related to the work injury.
The employer had the employee examined by Dr. Ifran Altafullah on January 30, 2023. In his March 16, 2023, report, Dr. Altafullah opined that the employee had “fragments of neurogenic pain syndrome,” but “not full-blown” CRPS. He believed the employee was at MMI and needed no further care or work restrictions related to the neurological complaints. He did not express a causation opinion. (Ex. 4.)
The employee’s new claims came on for hearing before a compensation judge on January 22, 2024. A Findings and Order was issued on April 4, 2024. The compensation judge found the employee’s work injury did not substantially cause CRPS or the need for medical treatment for such a diagnosis. He also found that the work injury did not substantially cause the need for medical care for the employee’s bilateral knees on the three new claimed dates of service with Dr. Khetia. 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 argues on appeal that substantial evidence fails to support the compensation judge’s finding that the medical care the employee received after January 22, 2022, for his bilateral knee injuries was not causally related to his admitted work injury of February 27, 2018. He further argues that substantial evidence fails to support the compensation judge’s finding that the admitted work injuries did not cause his CRPS diagnosis. We are not persuaded.
The employee argues that the compensation judge failed to review the new medical evidence from treatment that occurred after the 2021 hearing. The compensation judge, in his memorandum, stated that “[n]othing new has happened” relative to the knees since the 2021 hearing. (Mem. at 7.) The employee asserts that this statement shows that the compensation judge failed to consider the medical records of Dr. Khetia for the three visits claimed from 2022 and 2023. We disagree.
The compensation judge outlined the new medical visits in the 2024 findings and order. (Findings 2-4.) We do not read the compensation judge’s memorandum, stating “there is nothing new” here, to mean anything more than the medical care at issue was no different than the visits preceding those three dates. That medical care was determined in the 2021 hearing to be not related to the work injury. The subjective and objective observances of these three new medical visits, as well as the treatment, were identical to the previous treatment which had been determined to be unrelated. There was “nothing new” to show that the need for the recent care was related to the work injury.
Moreover, there is no new expert medical opinion evidence. Dr. Khetia did not provide an additional or updated opinion, and Dr. Agre’s most recent opinion is identical to his first with the exception that he disagrees with the compensation judge’s conclusions from the 2021 hearing. While the employee did suffer a permanent work injury to his knees, as was previously found by the compensation judge, the aggravation from that work injury did not require a need for additional care. Substantial evidence supports the compensation judge’s finding that the employee’s treatment after January 22, 2022, was not causally related to his February 27, 2018, injury, and we affirm.
At the 2021 hearing, the employee did not claim entitlement to workers’ compensation benefits for a CRPS condition. He did claim medical benefits for treatment to his right ankle, including medical care received at TRIA. That care was determined to be payable through February 1, 2021, the date Dr. Pena opined that he could not come to a definitive diagnosis of the employee’s right ankle pain, nor the etiology of that unspecified condition. Care after that date for the right ankle was found to be unrelated to the work injury given Dr. Pena’s opinion.
At the 2024 hearing, the employee sought payment of that same TRIA medical care rendered after February 1, 2021, under a new theory, that the care was not for the specific ankle injury, but was due to CRPS which developed as a consequence of his work-related ankle surgeries performed by Dr. Castro. The compensation judge found that the evidence failed to show that the employee’s diagnosis of CRPS was caused by the work injury.
The employee argues that the medical evidence is uncontroverted, that whether labeled CRPS, as was done by Dr. Agre and some of the providers at TRIA, or labeled as something less than “full-blown” CRPS, as was done by Dr. Altafullah, the employee has a neurogenic condition, and as such the medical care to treat the condition must be awarded. Consequently, on appeal, the employee asserts that the compensation judge’s denial of this medical care is clearly erroneous. We are not convinced.
The compensation judge was presented with conflicting medical opinions. Dr. Agre opined the employee has CRPS that was caused by treatment the employee received for his admitted right ankle injury. As noted, some providers at TRIA agreed with the diagnosis, but expressed no causation opinions. Dr. Altafallah opined that while the employee did not have “full-blown” CRPS, he did present “fragments” of such a condition. He did not express a causation opinion. (Ex. 4.) Dr. Pena opined that the diagnosis and its causation were uncertain.
The compensation judge adopted the opinion of Dr. Altafallah as persuasive, and also relied upon Dr. Pena’s opinion that the diagnosis and etiology of the employee’s right ankle complaints are unclear.[3] The compensation judge was within his discretion to accept these opinions. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). Thus, even if we agreed that the employee has a neurogenic condition, regardless of the diagnostic label, there is evidence to support the compensation judge’s finding that the employee had not proven that his February 27, 2018, injury was a substantial contributing factor to the diagnosis of CRPS or any treatment for that condition. As such, the compensation judge did not err in denying compensability of the treatment for the condition, and we affirm.
Lastly, we note that the employer raised a res judicata/collateral estoppel defense at the hearing and on appeal, arguing that the employee’s claims for the medical care to treat the CRPS condition, raised in the 2023 hearing, had been denied in the 2021 litigation, when brought under the theory that the care was to treat the orthopedic ankle injury. Given his findings, the compensation judge did not address this argument. Given our affirmance of the compensation judge, we also need not address those arguments.
[1] Further, in at least one workability report, Dr. Pena checked a box stating that the work injury was the cause of the employee’s right ankle symptoms and need for medical care.
[2] No claims were raised at the hearing based on a November 16, 2023, injury. See Ex. E (date of service Dec. 8, 2023.)
[3] As we noted in our prior decision, while Dr. Pena provided conflicting opinions regarding causation and necessity of medical care, the compensation judge reasonably adopted Dr. Pena’s explanation contained in his treatment notes and narrative report that he was not able to state with certainty the nature and etiology of the employee’s ankle condition. Appleby v. Minneapolis Park & Recreation Bd., No. WC22-6454 (W.C.C.A. Oct. 10, 2022).