JEFFREY HALL, Employee/Respondent, v. MEDINA GOLF & COUNTRY CLUB and LIBERTY MUT. INS., admin’d by HELMSMAN MGMT. SERVS., Employer-Insurer/Appellants, and ALLINA MED. CLINIC and INTERVENTIONAL SPINE AND PAIN PHYSICIANS, Intervenors.

The employer and insurer appeal the compensation judge’s award of payment for medical care from and after February 1, 2023.  We affirm.

The employee, Jeffrey Hall, began working as an equipment manager for the employer, Medina Golf & Country Club,^[1] in March 2015.  His duties included maintaining all power equipment at the golf course.  It was a “very physical” job requiring lifting, carrying, pushing, and pulling over 100 pounds.  (T. 28.)  He had no difficulties performing his job duties.

On May 9, 2022, the employee sustained a work-related injury to his low back while bending over to hook a strap to a mower axle.  He felt immediate pain and was seen that day at a HealthPartners Clinic.  He had difficulty standing, walked with a limp, and was diagnosed as having right sacroiliac pain with radicular symptoms and suspected nerve impingement.  The employee was off work for approximately four days before returning to light-duty work where he sat at a desk and instructed other employees how to maintain the equipment.

From May 10 through June 9, 2022, the employee received chiropractic care from Dr. Brian Opp.  At Dr. Opp’s request, on May 24, 2022, the employee underwent an MRI scan which showed a large disc herniation at L3-4 compressing the L4 nerve root, stenosis, and a possible concurrent hematoma at the same level.  There was also a disc bulge and edema at L4-5 with spondylolisthesis of L4 on L5, and a disc bulge at L5-S1.  Upon review of the MRI scan results, Dr. Opp referred the employee to Twin Cities Spine Center.

On June 10, 2022, the employee began care at Twin Cities Spine Center.  His first appointment was with a certified physician assistant (PAC), Brandon Byars.  The employee told PAC Byars that he was having significant issues with his right quadriceps, including falling and difficulty walking despite using a walker and crutches.  The employee was observed walking with a limp and he demonstrated significant weakness of his right quadriceps, an inability to extend the right leg against gravity, and decreased sensation in the right leg along the L4 dermatomal pattern.  The employee had symptoms of significant pain in his low back, pain radiating into his right leg, and numbness in the leg.  PAC Byars and Dr. Eiman Shafa reviewed the MRI scan, which showed compression of the L4 nerve root consistent with the quadriceps weakness.  Based on the scan and the employee’s other symptoms including pain, Dr. Shafa and PAC Byars stated that the only medical option was a surgical decompression and laminectomy at L3-5.  The employee was given work limitations of no bending, twisting, pushing, or lifting more than five pounds.

On August 1, 2022, the employee underwent the recommended surgery performed by Dr. Shafa.  The procedure was a minimally invasive hemilaminectomy with right subarticular decompression at L3-4 and L4-5, as well as microdiscectomy of a large, migrated disc extrusion at L3-4.  Post-surgery, Dr. Shafa ordered the employee to use a cane for walking and restricted the employee from working.  The employee was hospitalized from August 4 through August 10, 2022, at Abbott Northwestern Hospital.  He reported that he had unbearable pain after his low back surgery, uncontrolled by any medication, and that he had been unable to walk since August 1.  His fall risk was assessed as high.  An MRI scan was performed during this hospital stay, revealing recent post-surgical changes at L3-4, a post-operative hematoma at L3-5 contributing to spinal stenosis at L3-4, a recurrent disc fragment that had migrated at L3-4 displacing and possibly impinging the L4 nerve roots, multilevel spondylosis with degenerative grade 1 anterolisthesis of L4 on L5, moderate to severe right and moderate left neural foraminal stenosis at L5-S1, moderate canal stenosis at L4-5, and mild canal stenosis at L5-S1.

On September 9, 2022, Dr. Shafa examined the employee.  At that time, the employee was walking without any assistance and was eager to start therapy and return to work, although he was concerned given that his work was labor intensive.  Dr. Shafa noted the employee had ongoing right quadriceps weakness but was improving.  He ordered post-operative physical therapy twice a week for six weeks to focus on the right quadriceps weakness and continued the employee’s off-work restriction.  The employee reported that his symptoms continued after the surgery but were less severe.  His therapy began on September 14, 2022, at St. Francis Physical Therapy.

On October 28, 2022, PAC Byars examined the employee and noted continued significant weakness of the right quadriceps with ongoing falling.  Despite the employee’s regular attendance at physical therapy, he had ongoing weakness and remained unable to extend his right leg against gravity.  PAC Byars ordered a new MRI scan, prescribed a TENS unit, and continued the employee’s off-work restriction.  An MRI scan of November 28, 2022, showed post-operative changes at L3-4 with no recurrent herniations or nerve compression and stable stenosis, disc bulging at L4-5 with mild stenosis contacting the right L5 nerve root, and moderate stenosis at L5-S1 with L5 ganglionic encroachment/impingement.

On December 16, 2022, the employee returned to see PAC Byars.  He continued to have ongoing quadriceps weakness and still needed a cane to walk.  He walked with a limp, could not extend the right leg against gravity, and was showing signs of atrophy of the right leg.  PAC Byars noted the recent MRI scan showed a good surgical result and there was no significant compression of the L5 nerve root.  He wrote:

The employee was examined by Dr. Dustin Ward of iSpine on January 18, 2023.  Dr. Ward noted reduced right leg strength upon knee extension.  He recommended the employee begin taking gabapentin to address low back and right leg pain and ordered a transforaminal epidural steroid injection.  Depending on relief from the injection, he would consider other treatment including a spinal cord stimulator, medial branch block, and radiofrequency ablation.  He also referred the employee to specialized physical therapy, a MedEx program, at iSpine.

On February 17, 2023, the employee had a follow-up appointment at iSpine with PAC Elliott Wise.  The employee reported some improvement from the gabapentin and that he was continuing physical therapy at St. Francis until the MedEx program was approved.  He continued to demonstrate the same weakness in the right quadriceps.  The employee underwent a transforaminal epidural steroid injection on the right at L3-4 in late February 2023.

The employee was next seen at iSpine on March 13, 2023, by Dr. William Ahlenius.  The employee reported that the injection worsened his symptoms and decreased his walking tolerance.  Dr. Ahlenius noted the same symptoms of reduced sensation of the right leg and right leg weakness as previously reported and noted atrophy of the right leg.  He agreed that the employee was a good candidate for rehabilitation MedEx therapies at iSpine and referred the employee to begin such therapy twice a week for eight weeks, noting that given the employee’s muscle weakness and atrophy, a longer course of therapy was anticipated.  He specifically ordered physical therapy to focus on myofascial tenderness points, joint restrictions, functional strength, range of motion, muscle endurance, balance, and gait, as well as occupational therapy to focus on ergonomics and body mechanics, pacing, energy conservation, and performance of activities of daily living.  He recommended the employee also work on home exercises to maintain improvement.

The employee returned to iSpine for a follow-up appointment with PAC Wise on March 31, 2023.  The employee noted worsening symptoms and no relief following the transforaminal epidural steroid injection.  He told PAC Wise that he was continuing physical therapy at St. Francis while waiting for approval to begin MedEx therapy as ordered by Dr. Ahlenius.

After examining the employee on March 13, 2023, at the request of the employer and insurer, Dr. Jeffrey Dick issued a report on April 19, 2023.  During the examination, Dr. Dick noted grade 0/5 strength in the right quadriceps and hip flexors, and decreased sensation in the right leg.  He diagnosed the employee as status post-discectomy on the right at L3-4, degenerative spondylolisthesis at L4-5, and inconsistent weakness in the right leg.  Dr. Dick opined that although the employee had pre-existing degenerative changes in his low back, the work injury was a substantial cause of the employee’s L3-4 disc herniation.  He also opined that the medical care the employee received for his low back after the work injury was reasonable, necessary, and casually related to the work injury up until the employee had reached maximum medical improvement (MMI) as of February 1, 2023, six months following the L4-5 decompressive surgery.  After that date, Dr. Dick opined that no medical care was “necessary to prevent further deterioration of [the employee’s] low back condition that would be attributable” to the work injury.  (Ex. 3.)  He assigned work restrictions of avoiding climbing ladders or scaffolding, or any other work that would require balancing, and rated the employee at 14 percent permanent partial disability under Minn. R. 5223.0390, subp. 4D, 4D(1), and 4D(2).

The employee underwent another MRI scan of his low back on May 10, 2023.  The scan showed chronic foraminal stenosis on the right at L3-4, bilaterally at L5-S1, with encroachment at the exiting nerve roots, a disc herniation at L4-5 without stenosis, mild stenosis at L5-S1, and multilevel degenerative changes.  Dr. Shafa sent the employee a follow-up letter on May 15, 2023, stating that while there was no recurrence of any large herniation or severe stenosis, there was ongoing wear and tear that might be contributing to his symptoms.

On May 15, 2023, the employee again saw Dr. Ahlenius at iSpine.  The employee reported ongoing difficulty in receiving approval for a knee brace that was ordered.  In addition to the usual low back and right leg pain, and right leg weakness, the employee was now having new pain into his left leg.  Dr. Ahlenius reviewed the MRI scan and opined that given there was a new, small disc herniation at L4-5 and that the employee was having new pain in his left leg, a referral to a surgeon was appropriate.  He also suggested an EMG of both legs to clarify whether the employee had active denervation within the leg.  He again suggested starting the specialized MedEx physical and occupational therapies that he had been recommending.  He continued the employee’s off-work restriction.

The employee returned to PAC Byars on May 26, 2023, with symptoms of ongoing right quadriceps weakness and significant right leg atrophy.  The employee indicated that his leg braces were not providing stability and that he continued to walk with a cane.  X-rays showed mild anterolisthesis of L3 on L4.  Because of the significant loss of muscle mass, PAC Byars ordered a custom fitted drop-lock knee brace.  He believed the odds of the employee gaining strength to be “quite poor” and that therapy did not seem likely to improve his leg strength.  (Ex. 4.)  He nevertheless agreed the employee could try the iSpine therapy to try to strengthen the right leg.

On June 5, 2023, the employee began the MedEx program, which involved physical and occupational therapy, at iSpine.

On June 7, 2023, the employer and insurer’s attorney notified the employee’s QRC that the employer could not accommodate the employee’s restrictions as set out by Dr. Dick and that the employee’s position with the employer had been eliminated effective January 24, 2023.  The attorney asked the QRC to amend the rehabilitation plan to include returning the employee to work with a different employer and to request the employee’s doctor, Dr. Ahlenius, to release the employee for modified work.  On June 12, 2023, Dr. Ahlenius placed work restrictions on the employee as follows: “Due to severe weakness and instability of the right lower extremity, awaiting bracing to stabilize right knee, along with ongoing back pain, he continues to need work restrictions.  At this time he would be able to work at a sedentary job if the work station allowed changing positions sitting to and from standing [and] [m]ust use cane for ambulation.”  (Ex. I.)

Dr. Daniel Hanson examined the employee on May 23, 2023, at the request of his attorney.  In his report dated June 21, 2023, Dr. Hanson indicated that he observed decreased strength in the right hip flexor and quadriceps, an absent patellar reflex on the right, and atrophy in the right quadriceps/gastrocsoleus/tibialis.  He also noted decreased sensation in the right leg consistent with the L4 and L5 dermatomal pattern and that the employee was unable to perform tandem gait due to right leg weakness and numbness.  He diagnosed the employee as having a chronic right L4 and L5 nerve injury as demonstrated by muscle atrophy, paresthesias, loss of patellar reflex, limp, and loss of balance, all caused by the work injury.  He opined that the medical care, including the care the employee received from iSpine, has been reasonable, necessary, and causally related to the work injury as that care was reasonably treating the neurological sequalae of his injury.  He also opined that the employee was not at MMI and that a spinal cord stimulator might be used on a trial basis.  If a stimulator was not to be attempted, then the employee was at MMI in Dr. Hanson’s opinion.  Finally, Dr. Hanson placed work restrictions on the employee of no frequent lifting, no lifting more than 40 pounds at any one time, as long as his right leg was not involved in the lifting process, no working at heights, and sitting/standing/walking for ten minutes before needing to change to a different position.  He also opined that the employee’s symptoms would likely result in him being unable to work at least one day in a five-day work week.

The employee filed a claim petition in June 2022.  By the time the matter came on for hearing on June 28, 2023, most of the issues had been resolved.  The issue before the compensation judge was whether medical care from and after February 1, 2023, was reasonable and necessary.^[2]  The employee testified that he continued to use a cane to walk due to his right leg weakness, which helped with balance, but he had fallen a number of times.  The employee testified that he felt the physical therapy helped strengthen his other muscles to compensate for his “dead” quadricep.  (T. 37.)  He also said that he had just started the iSpine MedEx program and that this therapy was “way different” from the physical therapy he received at St. Francis.  (T. 42.)  He found the MedEx program beneficial in relieving his symptoms and in gaining strength.  He agreed that the iSpine providers had discussed the possibilities of a spinal cord stimulator, medical branch blocks, and radiofrequency ablation, but that the first step was to attempt the MedEx program.  He also testified that gabapentin helped “[a] little bit” in easing his nerve pain.  (T. 43.)

The compensation judge found that the medical care after February 1, 2023, was reasonable and necessary and ordered the employer and insurer to pay for the care, including the intervention claims of iSpine and Metro Surgery Center.  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).  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).

On appeal, the employer and insurer argue that substantial evidence does not support the compensation judge’s finding that the employee’s medical treatment after February 1, 2023, including the therapy at iSpine, the gabapentin prescription, and the epidural steroid injection, was reasonable and necessary.  We are not persuaded.

An employer is liable for medical care that may be reasonably required to cure or relieve from the effects of the work injury.  Minn. Stat. § 176.135, subd. 1.  Whether medical care is reasonable and necessary to treat a work injury is a question of fact for the compensation judge.  See Hopp v. Grist Mill, 499 N.W.2d 812, 814-15, 48 W.C.D. 450, 452-53 (Minn. 1993).

The employer and insurer’s appeal is premised on two arguments.  One, they rely upon the opinion of Dr. Dick, that the employee has a permanent condition that will not benefit from any medical care, which they argue is more persuasive than that of Dr. Hanson or any of the treating providers.  Two, they argue that the employee’s ongoing failure to improve during physical therapy at St. Francis, his failure to gain benefit from gabapentin after the first few weeks, and the failure of the epidural steroid injection, indicate that the care provided after February 1, 2023, is not reasonable and necessary.  

A compensation judge’s choice between two adequately founded medical expert opinions is generally upheld unless the opinion lacks foundation.  Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); see also Mattick v. Hy-Vee Foods Stores, 898 N.W.2d 616, 621, 77 W.C.D. 617, 624 (Minn. 2017).  The compensation judge relied upon Dr. Hanson’s opinion that the treatment was reasonable and necessary and upon the records of the employee’s medical providers which explained why the recommended treatment was warranted and how the treatment was meant to improve the employee’s symptoms.  The compensation judge also found that Dr. Dick’s opinion was not persuasive.  Moreover, Dr. Dick did not opine that the employee’s medical care after February 1, 2023, was not reasonable and necessary, but that there was no medical care that would prevent further deterioration of the employee’s medical condition.  As the compensation judge noted in his memorandum, whether medical care will prevent further deterioration of an injured worker’s medical condition is not a factor in the legal determination of whether the care was reasonable and necessary under Minnesota workers’ compensation law.

In addition, there is evidence in the record that the treatment at issue has provided some benefit to the employee.  While the employee’s quadriceps strength did not improve during his physical therapy at St. Francis, he testified that he gained strength in other muscles that supported his leg during therapy.  More importantly, however, at the time of the hearing the employee had begun receiving physical and occupational therapy in a specialized MedEx program at iSpine.  The employee testified that this program was “way different” than the physical therapy at St. Francis.  (T. 42.)  Further, he had undergone only two to three weeks of such MedEx care prior to the hearing and testified he had already noted increased strength and lessened symptoms.  That the physical therapy at St. Francis seemingly had not provided any additional benefit to the employee is irrelevant to whether the MedEx program at iSpine is reasonable and necessary to relieve the employee’s ongoing symptoms and weakness.

Similarly, while the gabapentin provided minimal relief to the employee, he testified that the medication was helping “[a] little bit.”  (T. 43.)  Finally, the epidural steroid injection was recommended by Dr. Ward at iSpine to determine whether other treatment, including a spinal cord stimulator, medial branch block, and radiofrequency ablation, should be considered based on the amount of relief provided by the injection.  The lack of relief from the injection does not affect the reasonableness and necessity of the treatment in this situation.

Substantial evidence supports the compensation judge’s finding that the medical treatment provided to the employee after February 1, 2023, was reasonable and necessary, and we affirm the compensation judge’s award of medical benefits for that treatment.