TERRI BESTE, Employee/Appellant, v. CENTRACARE HEALTH LONG PRAIRIE and SFM MUT. INS. CO., Employer-Insurer/Respondents, and FAIRVIEW HEALTH SERVS. - ALL ENTITIES, ALLINA MED. CTR., and RAYUS RADIOLOGY, Intervenors.

The employee appeals the compensation judge’s determination that the employee sustained an injury that resolved after February 2021, relying upon the opinion of the employer and insurer’s medical experts.  We affirm.

Terri Beste, the employee, worked as a registered nurse for CentraCare Health Long Prairie, the employer.  Her past medical history included a motor vehicle accident in 1987 or 1988, resulting in two years of chiropractic treatment and sports medicine therapy.  She had no issues with her neck and had no restrictions on her activities at the time she was hired by the employer in December of 2013.

On February 15, 2020, the employee was assisting in the transfer of a patient from a wheelchair to a cart when the patient fainted.  The employee caught the patient with a transfer belt and moved him to a cart.  She immediately felt her left shoulder strain and jarring pain but was able to finish her shift.  The next day at work, as she helped transfer a patient out of the backseat of a car, she again felt pain in her shoulder as well as in her clavicle, scapula, and left arm.  On her next scheduled day of work, February 18, 2020, she was unable to lift an empty food tray with her left arm.  She reported the injury and was seen at the emergency room of the employer.  She was released to return to work with restrictions and an MRI was recommended.

A February 24, 2020, MRI of the employee’s left shoulder showed calcific bursitis of the subacromial and subdeltoid space with no partial or full thickness tear, AC joint arthritis, nondisplaced tearing at the base of the superior labrum and no significant glenohumeral arthrosis.  She began physical therapy and underwent an injection to her left shoulder on July 29, 2020, which provided little relief.

The employee subsequently underwent a left shoulder arthroscopic surgery performed by Dr. David Edgerton on November 19, 2020.  The operative report shows a post-surgical diagnosis of left shoulder subacromial subdeltoid bursitis, labral degeneration, and rotator cuff fraying without full thickness defect.  (Ex. B.)  Eight weeks post-surgery, she reported the pain had returned and she had additional symptoms of pain, numbness, and tingling in her left hand and wrist.  On examination she had decreased range of motion.  Recommendations included a cortisone injection, additional physical therapy, and an EMG.

The employee sought treatment at the Long Prairie Hospital emergency room on February 1, 2021, for thoracic pain and possible diverticulitis.  (Ex. A.)  Two weeks later, she again saw Dr. Edgerton with continued decreased range of motion in the shoulder.  A new MRI was recommended, which showed very minimal residual calcification of the anterior footprint of the supraspinatus, no full thickness tear, peritendinous edema, or bursitis, and AC joint arthrosis.  The employee saw Dr. Pierce McCarty on April 15, 2021, for a second opinion on referral and was diagnosed with AC joint arthritis “aggravated by work injury,” still symptomatic, as well as possible pectoralis minor syndrome and possible thoracic outlet syndrome.  (Ex. C.)  Dr. McCarty recommended a pectoralis minor block/injection, which greatly improved her symptoms for a short period.  He then referred the employee to Dr. Kamran Karimi for an evaluation of possible thoracic outlet syndrome.  Dr. Karimi suspected left upper extremity post-traumatic neurogenic thoracic outlet syndrome and recommended interscalene blocks to confirm the diagnosis, which took place on July 12 and August 24, 2021.

Dr. McCarty also recommended a left shoulder distal clavicle excision with pectoralis minor release which was performed on November 3, 2021.  At her post-operative visit following this procedure, the employee reported continued pain in the left shoulder, worsened numbness and tingling in the last three digits of her left hand, pain in her left elbow, and tightness through the forearm.  She was diagnosed with post-operative adhesive capsulitis and lateral and medial epicondylitis.

Following surgery, Sarah Conrad, P.A., noted that the employee’s symptoms were likely the result of thoracic outlet syndrome.  The employee returned to work with restrictions eight weeks after surgery.  In a follow-up visit on January 27, 2022, the employee reported pain and swelling in her elbow and wrist.  There was also concern that she was developing adhesive capsulitis in the shoulder.  The employee underwent occupational therapy for her left elbow beginning in February 2022.  An EMG of the left upper extremity was positive only for carpal tunnel syndrome. On March 1, 2022, the employee had a left shoulder arthrography, which showed no evidence of rotator cuff tear with mild calcification of the distal rotator cuff tendon.  She had two more injections into her shoulder and had improved range of motion.  By May 2022, P.A. Conrad stated that the employee had recovered well from her surgery and noted that her ongoing pain and limitations were caused by her compensatory mechanisms and thoracic outlet syndrome.

On July 11, 2022, the employee assisted a patient out of a SUV at work.  According to the employee, she grabbed the jacket lapels of the patient and pulled forward while another employee pushed the patient forward from the back.  The patient wrapped her arms around the employee’s neck and the employee guided the patient to a walker.^[1]  After the incident, the employee had redness, swelling, and pain in her left arm.  The employee did not return to work until July 15, 2022.  The employee did not seek medical attention immediately because she was already scheduled for a follow-up appointment for her ongoing left shoulder symptoms with P.A. Conrad on July 28, 2022.  At that appointment, the employee reported increased pain since the July 11 incident with pain in the clavicle, shoulder, neck, and axilla, and radiating pain from her biceps down her arm.  She also reported right shoulder pain worsening over the past two months.  A cervical MRI was recommended, which showed multilevel spondylosis, moderate front to back central stenosis with cord flattening at C5-6 and C6-7, osteophyte and bulge flattening the cord at C4-5, and multilevel left foraminal stenosis, severe at C3-7.

On September 1, 2022, the employee was diagnosed with lateral and medial epicondylitis of the left elbow, compensatory right shoulder pain, carpal tunnel syndrome of the left wrist, thoracic outlet syndrome, cervicalgia, and cervical foraminal stenosis.  The employee was referred for second opinions for her thoracic outlet syndrome and cervical conditions.  She was seen for her cervical spine by Dr. Matthew Hunt on October 7, 2022, and given an epidural steroid injection.  On January 18, 2023, she had another MRI of the left shoulder which indicated improved appearance with no complications observed.  (Ex. C at 443.)  The medical records again noted that her symptoms were likely from thoracic outlet syndrome and cervical spine pathology.

On February 27, 2023, the employee was seen again by Dr. Karimi, who diagnosed her with neurogenic thoracic outlet syndrome related to the February 15, 2020, injury.  He recommended left first rib resection surgery after the employee’s cervical issues were addressed.  On March 10, 2023, Dr. Hunt recommended a C5-7 anterior fusion and discectomy.

He indicated in his office note that the July 11, 2022, work injury was an exacerbation of an underlying condition.  At the time of the hearing, the employee was scheduled to undergo this procedure.

The employee was seen by two medical experts at the request of the employer and insurer.  The employee was first seen by Dr. Randal Wojciehoski on August 23, 2021.  After reviewing medical records from St. Gabriel’s Little Falls Orthopedics, CentraCare Center, and from Allina Clinic, Dr. Wojciehoski opined that the employee sustained a left shoulder strain on February 15, 2020, which would have resolved three months after the first shoulder surgery, on approximately February 19, 2021.  Any treatment after that, he opined, was related to her preexisting personal health condition.  He explained that the MRI findings, which showed no acute injury but only degenerative conditions, were successfully addressed with the November 2020 surgery.  He did not think that the thoracic outlet syndrome diagnosis was related to the February 11, 2020, injury based on the mechanism of injury, but instead to her personal anatomy.  He opined that she did not need any additional medical treatment or restrictions related to her left shoulder work injury.

The employee was examined by another independent medical expert, Dr. William Simonet, on November 22, 2022.  Dr. Simonet opined that there was no evidence that the employee sustained an injury as a result of the February 12, 2020, incident.  He noted that the MRI degenerative findings seen nine days post-injury indicated a condition which preexisted the incident.  With regard to the July 11, 2022, incident, he opined that she did not sustain an injury to any body part.  Dr. Simonet did not find any objective evidence of any injury and stated that the results of the cervical and shoulder MRIs were age appropriate.  Finally, Dr. Simonet could not confirm the thoracic outlet syndrome diagnosis, but opined that if it exists, it was related to a congenital variation of anatomy and not any work injury.  He also expressed concern of the reliability of her subjective complaints and of her lack of improvement despite excessive treatment from several providers.

A combined hearing was held on the employee’s claim petition and the employer and insurer’s petition to discontinue on July 10, 2023.  In his findings and order, the compensation judge adopted the opinions of Dr. Wojchehoski that the employee reached maximum medical improvement for her left shoulder three months following the first surgery and awarded medical treatment through three months following the November 2020 surgery.  He also adopted Dr. Simonet’s opinion that that the employee did not sustain any injury as a result of the July 11, 2022, incident.  The judge further found that the employee’s current left shoulder complaints, right shoulder complaints, cervical condition, and thoracic outlet syndrome are not causally related to any work injury and denied wage loss, vocational rehabilitation, and ongoing medical benefits.  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 the findings that her left shoulder, cervical, and thoracic outlet syndrome conditions are not causally related to her injury of February 15, 2020, and the denial of benefits for her claimed injury of July 11, 2022.  She argues that the medical opinions relied upon by the compensation judge lack adequate foundation and that substantial evidence of record does not support the compensation judge’s findings.  Further, she asserts that the judge improperly expanded the issues without notice by finding that the employee’s left shoulder injury was temporary and had resolved.  We disagree.

The employee bears the burden of proving, by a fair preponderance of the evidence, the compensability of his or her claims.  See Swanson v. Fairway Foods, 439 N.W.2d 722, 723, 41 W.C.D. 1010, 1013 (Minn. 1989).  The compensation judge, as trier of fact, has discretion to choose between competing and conflicting medical experts’ reports and opinions.  Ruether v. State of Minn., 455 N.W.2d 475, 478, 42 W.C.D. 1118, 1121 (Minn. 1990); Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364 (Minn. 1985); Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 803, 77 W.C.D. 117, 126 (Minn. 2019).  The nature and extent of an injury is an issue of ultimate fact to be decided by a compensation judge.  Abed v. Era Venture Capital, slip op. (W.C.C.A. Feb. 22, 2019) (citing Felton v. Chevrolet, 513 N.W.2d 457, 459, 50 W.C.D. 181, 184 (Minn. 1994)); Domarus v. Yule Transp., No. WC20-6387 (W.C.C.A. June 29, 2021).  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)).

Here, the compensation judge relied upon the expert medical opinions of Dr. Wojciehoski and Dr. Simonet in finding that treatment for the left shoulder after February 2021 was not related to the work injury and that her cervical, thoracic outlet syndrome, and upper extremity conditions are not related to the work injuries of February 15, 2020, and July 11, 2022.  We find that the medical opinions are based on adequate foundation and the findings are supported by substantial evidence in the record, therefore we affirm.

The compensation judge found that the employee’s February 15, 2020, injury was a sprain and soft tissue injury that aggravated and accelerated a preexisting degenerative change in the employee’s left shoulder condition.  He also found that she reached maximum medical improvement for that injury three months after her November 1, 2020, surgery, and that her need for medical treatment and restrictions after that point were not related to her February 15, 2020, injury.  In making those findings, the compensation judge relied in part on the medical opinion of Dr. Wojciehoski.

At hearing, the employee objected to the report of Dr. Wojciehoski on the basis that it lacked foundation.  As noted above, Dr. Wojciehoski had sufficient foundation for his opinions.  He detailed the history provided by the employee, reviewed and summarized medical records, and detailed his examination findings.  His medical expert opinion regarding causation, the reasonableness and necessity of treatment, restrictions, permanent partial disability, and the nature and extent of the injury is supported by evidence in the record.

In addition to the expert opinion of Dr. Wojciehoski, the compensation judge’s findings regarding the left shoulder are also supported by the medical records in evidence.  The surgical record from the November 2020 surgery showed extensive degenerative changes.  An MRI taken subsequent to the surgery showed that the left shoulder had recovered appropriately.  Physical therapy and office records reflect improvement to the shoulder despite ongoing subjective complaints associated with other physical conditions.  These records, as well as Dr. Wojciehoski’s adequately founded medical opinion, provide ample support for the compensation judge’s findings regarding the left shoulder.

The employee argues that “Dr. Wojciehoski’s opinion on this issue taken together with the . . . medical records . . . and Dr. McCarty’s opinion all lead to the inescapable conclusion that the left shoulder injury with the extensive preexisting degenerative changes are all part and parcel of the September [sic] 15, 2020 work injury.”  (App. Brief at 27.)  The employee cites Dr. McCarty’s medical note to support her claim that the left shoulder condition continues to be related to the work injury.  Although Dr. McCarty indicated in a treatment note that the employee’s diagnosis is “arthritic acromioclavicular joint aggravated by work injury,” he does not provide his medical opinion as to causation, the reasonableness and necessity of treatment, the need for restrictions, nor does he mention any permanent partial disability as a result of the work incidents.  (Id. at 26-27; Ex. C.)  Further, Dr. McCarty did not mention what additional medical records he reviewed.^[2]  A failure to explain the mechanism of injury or the underlying reasons for a causation opinion may certainly go to the persuasiveness or weight that may be afforded that opinion.  Henchal v. Fed. Express Corp., No. WC07-212 (W.C.C.A. Jan. 30, 2008).

The employee has the ultimate burden to prove that a condition is related to a work injury for the condition to be compensable.  Salmon v. Wheelabrator Frye, 409 N.W.2d 495, 497, 40 W.C.D. 117, 122 (Minn. 1987); Schallock v. Battle Lake Good Samaritan Ctr., No. WC18-6228 (W.C.C.A. May 31, 2019).  Except for common afflictions, it is necessary to submit a medical opinion tying the current problems to a work-related injury.  Carroll v. Univ. of Minn., slip op. (W.C.C.A. May 4, 1999); Bender v. Dongo Tool Co., 509 N.W.2d 366, 367 49 W.C.D. 511, 513 (Minn. 1993).  In this case, the mention of a work injury by Dr. McCarty in office notes without any explanation or foundation, and the lack of an explanation as to the causal connection between the employee’s injuries and the work incidents, is not so compelling as to rebut the compensation judge’s choice of medical experts’ opinion.  Since Dr. Wojceihoski had the necessary foundation on which to base his medical opinion regarding the employee’s left shoulder, we affirm the compensation judge’s findings.

The compensation judge also found that the employee did not sustain any new injuries as a result of the July 11, 2022, incident, and that her other claimed injuries to her right shoulder, cervical spine, thoracic outlet syndrome, and bilateral elbows, are not causally related to any work injury.  In making these findings, the compensation judge also relied upon the opinions of Dr. Wojceihoski and Dr. Simonet. 

The employee was first suspected of having thoracic outlet syndrome by Dr. McCarty in April 2021.  Dr. Karimi confirmed the diagnosis following a left interscalene block.  In his treatment notes from February 27, 2023, Dr. Karimi stated that the employee had neurogenic thoracic outlet syndrome “directly related to the injury she suffered at work where she was trying to prevent the patient from falling.”  (Ex. I at 555-56.)  However, his treatment notes provided no explanation as to the causal connection between the mechanism of injury and the diagnosis nor did he mention what additional medical records, if any, he reviewed.  In contrast, the reports of both Dr. Wojciehoski and Dr. Simonet discussed the congenital nature of the condition as well as the unlikeliness of the mechanism of the work injury to cause thoracic outlet syndrome.  Dr. Simonet also reviewed the EMG results and all relevant medical records before rendering his opinion.  As the opinions of Drs. Wojciehoski and Simonet are not lacking in foundation, the judge’s reliance on those opinions was appropriate and, we affirm.

The employee was involved in a motor vehicle accident that caused injury to her neck in 1987 or 1988.  She claimed that the July 11, 2022, work incident also caused injury to her neck.  An MRI on August 26, 2022, showed multilevel spondylosis, moderate front back central stenosis, and other degenerative findings.  Dr. Hunt, who first saw the employee on October 7, 2022, stated in an office note, “she developed the symptoms after her injury on July 11, 2022, which I believe represent exacerbation of her underlying condition as a result of the injury she sustained at work.” (Ex. I.)  His office note does not provide any further explanation of his understanding of the mechanism of injury or the causal connection between the injury and her condition.  Also, it is unclear in the record what, if any, information Dr. Hunt had about her prior neck injury.  In contrast, Dr. Simonet’s report reflects that he had a complete history and an accurate understanding of the mechanism of the claimed injury.  Again, the compensation judge’s reliance on the opinions of Dr. Simonet was appropriate and, we affirm.^[3]

The employee argues that the judge erred by expanding the issues in his findings from the causal relation of the employee’s work injury and the reasonableness of medical treatment to a denial of primary liability.  Since the employer and insurer had previously paid for medical treatment related to the employee’s left shoulder after February 2021, even after obtaining the medical report of Dr. Wojciehoski, she argues that the compensation judge is equitably estopped from finding that medical treatment after that date is not causally related to the work injury.  We disagree.

With regard to the left shoulder, the stated issues included: 1) whether the employee sustained an injury on February 15, 2020; 2) whether the medical treatment had been reasonable, necessary, and causally related to the work injury; 3) whether the employee is in need of restrictions as a result of the work injury; and 4) whether she is entitled to payment of TPD benefits as a result of the work injury.  The compensation judge found that medical treatment to the left shoulder was related to the work injury through February 2021.  There is no finding that the injury was temporary, nor is there a finding that the employer and insurer are not primarily liable for the left shoulder injury.

The employee argues that she is prejudiced by this finding and that had the defense been raised, she would have “had her treating doctors provide opinions on temporary versus permanent aggravations.”  (App. Brief at 24.)  However, the record reflects that a notice to discontinue benefits was filed on January 3, 2023, over six months prior to the hearing at issue.  The notice sought to discontinue benefits based on the IME report of Dr. Simonet, which provided an opinion that her left shoulder condition was not work related.  The compensation judge’s findings did not expand the issues and did not unfairly prejudice the employee.  As substantial evidence supports the findings of the compensation judge, we affirm.