July 17, 2001

No. 2--00--1331WC

IN THE APPELLATE COURT OF ILLINOIS

SECOND JUDICIAL DISTRICT

Industrial Commission Division

The claimant, Debbie Oblak, filed an application foradjustment of claim under the Workers' Compensation Act (Act) (820ILCS 305/1 et seq. (West 1992)), seeking benefits for injuries shesustained on August 11, 1992, while working as a nurse in theemploy of Elmhurst Memorial Hospital (Elmhurst). The IndustrialCommission (Commission) ordered Elmhurst to pay the claimant $228per week for 156.66 weeks for 66 2/3% permanent partial disability(PPD) to her right arm, $253.33 per week for 90 4/7 weeks fortemporary total disability (TTD), and $40,419.36 in medicalexpenses. The circuit court of DuPage County confirmed theCommission's decision. On appeal, Elmhurst contends only that theportion of the Commission's decision ordering it to pay $40,419.36in medical expenses is against the manifest weight of the evidence.

On August 11, 1992, the claimant sustained an injury to herright hand and arm while working as a nurse for Elmhurst. According to the claimant, she immediately began to experience painin her right hand and wrist. The claimant sought medical attentionat Elmhurst's emergency room on August 13, 1992. At that time, shewas diagnosed as suffering from a sprained right wrist. Theemergency room physician prescribed a splint and instructed her toseek follow-up treatment from her own physician.

In the five months that followed, the claimant came under thecare of seven physicians, four of whom were recommended byElmhurst, and was treated with therapy and anti-inflammatorymedications. Dr. Frank Lagattuta diagnosed the claimant withtenosynovitis of the carpal bone and was of the impression that shesustained an ulnar lesion. Dr. Denes Martonffy arrived at adifferential diagnosis of muscular/tendon avulsion of the distalaspect of the upper right extremity and possible soft tissue traumato the right ulnar nerve at wrist level. During that same periodof time, the claimant had an arthrogram, an MRI, and an EMG, noneof which revealed any abnormalities. She continued, though, tocomplain of a burning-type sensation in her right wrist andforearm.

On January 15, 1993, the claimant came under the care of Dr.Kenneth Schiffman. He recorded that the claimant complained of aburning-type pain which seemed to start at the volar ulnar aspectof the forearm with radiation of the pain up the forearm and to thevolar aspect of the wrist. He also noted that she complained ofoccasional numbness and tingling in her fingers. On examination ofthe claimant's right upper extremity, Dr. Schiffman noted aswelling or prominence at the distal volar ulnar forearm, slightlytender to palpation. His impression at that time was that theclaimant injured the flexor superficialis to the small finger andmay have disrupted the muscle at the myotendinous junction. Dr.Schiffman recommended occupational therapy with a hand therapist.

The claimant next saw Dr. Schiffman on February 11, 1993. Hisnote of that visit reflects that the claimant still complained ofa burning-type pain along the volar ulnar aspect of the wrist andalso some pain along the dorsal aspect of the wrist in the regionof the distal radial ulnar joint. Dr. Schiffman still was of theimpression that the claimant had a possible flexor myotendinoustear. Because the claimant received no relief from therapy and allattempts at conservative treatment had failed, Dr. Schiffmanrecommended surgery.

On February 24, 1993, Dr. Schiffman performed exploratorysurgery on the claimant's right forearm flexor compartment. Themyotendinous junction was found to be intact and minimal flexoradhesion was noted.

The claimant continued to treat with Dr. Schiffmanpostoperatively. His notes state that the claimant continued tocomplain of pain to the distal aspect of the right distal radialjoint as well as at the distal end of the right ulna. Dr.Schiffman recommended a CT scan.

On April 6, 1993, the claimant again saw Dr. Schiffman. HerCT scan showed no signs of subluxation of the distal radioulnarjoint. However, the claimant continued to complain of pain to theulnar aspect of the wrist. Because of the claimant's ongoing pain,Dr. Schiffman recommended that she undergo an arthroscopicexamination with a possible triangular fibrocartilage complexdebridement and a possible ulnar shortening osteotomy.

At the request of Elmhurst, Dr. Charles Carroll examined theclaimant on May 5, 1993. He recorded the claimant's complaints ofpain and burning over the ulnar aspect of her right wrist,tenderness over the distal ulna and triangular fibrocartilagecomplex region, and numbness and pain radiating from her elbow. Dr. Carroll was of the impression that the claimant exhibitedevidence of ulnocarpal impingement of her right wrist and a mildulnar neuritis at the elbow. According to his notes, the ulnarneuritis was responsible for the pain in her forearm, and theulnocarpal impingement and a possible triangular fibrocartilagecomplex tear were responsible for her distal ulnar pain. Dr.Carroll wrote that the claimant's options were either to do nothingor to undergo arthroscopy of the wrist and a probable shorteningwith extra-articular compression plating. He specifically relatedthe claimant's condition to her work-related injury.

On June 3, 1993, Dr. Carroll performed an arthroscopy of theclaimant's right wrist with debridement of a triangularfibrocartilage complex tear and an ulnar shortening with theapplication of a plate. His postoperative diagnosis was atriangular fibrocartilage complex tear with ulnocarpal impingement.

Following surgery, the claimant remained under the care of Dr.Carroll. On July 14, 1993, he noted that the claimant wasundergoing therapy and making "slow but steady gains." On November23, 1993, Dr. Carroll reported that, although the surgeryalleviated the claimant's pain traceable to the triangularfibrocartilage complex and distal ulna, she continued to experiencea burning sensation to the medial elbow with numbness in the smallfinger. According to Dr. Carroll, the remaining problem wasseparate from the ulnocarpal impingement. He noted that theclaimant wished to undergo further treatment including an ulnarnerve transportation to alleviate her remaining pain. However, Dr.Carroll recommended that she first see a pain management consultantand suggested Dr. Ron Pawl. Dr. Carroll released the claimant toreturn to work on that date, but restricted her activities, statingthat she was not to use her injured hand.

On January 24, 1994, the claimant was examined by Dr. David J.Capobianco at the Mayo Clinic. Dr. Capobianco's notes of thatvisit state that he held the impression that the claimant had righthand and arm pain and dysethesias and that he wished to rule outulnar neuropathy and test her for sympathetically maintained painsyndrome. He referred the claimant to Dr. Stephen D. Trigg, anorthopedic surgeon in Mayo's department of orthopedic surgery, forfurther examination.

On February 1, 1994, Dr. Trigg examined the claimant todetermine if her persistent hand and wrist pain was due to a reflexsympathetic dystrophy problem. Dr. Trigg concluded that theclaimant's pain was due to: the triangular fibrocartilage complextear and subsequent ulnar recession; a possible subclinical or mildcubital tunnel syndrome, that is, an irritability or compression onthe ulnar nerve at the elbow, which is one of the various ulnarneuropathies; and a sympathetically maintained pain syndrome. Dr.Trigg referred the claimant to Dr. Timothy Lamer, an anesthesiologist specializing in pain management, practicing at Mayo'spain clinic. The purpose of the referral was to try a stellateganglion blockade to temporarily interrupt the claimant'ssympathetic nervous system. According to Dr. Trigg, the procedureis both diagnostic and therapeutic.

On February 11, 1994, the claimant was examined by Dr. Lamer. After examining the claimant, he arrived at a differentialdiagnosis of ulnar neuralgia versus reflex sympathetic dystrophy. Specifically, Dr. Lamer testified that he was of the impressionthat the claimant had right ulnar neuropathy exacerbatingpostoperative pain on the volar aspect of the arm. Dr. Lamer alsotestified that, in his opinion, the condition he diagnosed wascausally related to the claimant's injury at work. Dr. Lamerinjected the claimant's right ulnar nerve with a local anestheticand an anti-inflammatory solution which resulted in complete relieffrom pain for the duration of the anesthetic followed by a gradualreturn of the claimant's symptoms over a four-day period.

Dr. Lamer and his associate, Dr. Shields, continued to treatthe claimant with injections from February 1994 through September1994. During that period, the claimant was given in excess of teninjections to her right ulnar nerve and forearm. Although theinjections gave the claimant temporary relief, her pain persisted. Dr. Lamer testified that, in late September or early October, hecame to the conclusion that the plate in the claimant's arm mightbe the cause of part of her continuing pain and that it should,therefore, be removed.

On November 8, 1994, Dr. Trigg removed the plate in theclaimant's arm and performed an arthroscopy on her right wrist. During the procedure, Dr. Trigg removed a new triangularfibrocartilage complex tear. Following the procedure, Dr. Triggprescribed a course of physical therapy.

After her surgery, the claimant continued to see Dr. Lamer forinjection therapy. According to Dr. Lamer, the claimant's symptomsafter her surgery were the same as they were preoperatively. Hispostoperative diagnosis was reflex sympathetic dystrophy, which heconsidered a new diagnosis and secondary to his original diagnosis.

When the claimant saw Dr. Trigg on February 8, 1995, shereported that she was not improving with therapy. The claimant didstate, however, that she was responding to the injection therapyadministered by Dr. Lamer. As of that visit, Dr. Trigg was of theopinion that the claimant's ongoing pain was the result of reflexsympathetic dystrophy and there was nothing further from a surgicalor therapeutic perspective that he could do for her.

When Dr. Lamer gave his deposition on April 21, 1995, hetestified that the claimant's reflex sympathetic dystrophy had"quieted down" and that she was "back to [her] original problem",ulnar neuralgia. Although he was of the opinion that the claimanthad reached maximum medical improvement as of that date, she hadnot been discharged from care. According to Dr. Lamer, theclaimant has a "chronic medical condition that she will have forthe foreseeable future." The claimant continued to be on medication and Dr. Lamer testified that she "will require periodicsurveillance and follow-up." He stated: "She will get in asituation where her pain will get bad and she will need additionalattention." He explained that "every time she stretches thatnerve, its going to become inflamed, and the pain is going to flareup".

At the request of Elmhurst, the claimant was examined by Dr.Michael Vender, a hand surgeon, on May 12, 1995. Dr. Venderexamined the claimant but did not review the deposition testimonyof either Dr. Lamer or Dr. Trigg or the records from the MayoClinic. He admitted that he was not aware that any diagnosis otherthan reflex sympathetic dystrophy was ever rendered in theclaimant's case. Nonetheless, the report of his examinationcontains his opinions that: the claimant appears to have reachedmaximum medical improvement as she had not responded to treatment,including pain management; further medical intervention would notprovide any significant change in symptomatology; and the claimantis able to perform the job activities of a nurse. Although Dr.Vender opined that the claimant's right hand was functional, headmitted that he could not say that the claimant did not experiencepain and stated that the question of why she has undergone severalsurgical procedures without improvement is beyond a discussion ofhand surgery and hand pathology.

Also on May 12, 1995, Dr. Ronald Pawl examined the claimant,again at Elmhurst's request. Dr. Pawl testified that, as of thatdate, he was of the opinion that "outside of the residuals of hersurgical intervention, [the claimant] did not have any medicaldisorder." He stated that he found no evidence that the claimantsuffered from reflex sympathetic dystrophy. Dr. Pawl admitted,however, that he did not review: any records of the claimant'smedical care after December 1992; the Mayo Clinic's records; therecords of Drs. Carroll, Lamer, and Trigg; or the depositiontestimony of Drs. Lamer and Trigg.

When the claimant testified at the arbitration hearing on June17, 1998, she stated that she was still experiencing pain in herarm with a great concentration in the area of her wrist. Shestated that the pain is eliminated temporarily when Dr. Lamer givesher an injection, but any repetitive use of the arm triggers areturn of the pain. She also testified that she takes oral painmedication on a daily basis.

The records of the Mayo Clinic reflect that, after he gave hisdeposition on April 21, 1995, Dr. Lamer continued to treat theclaimant's recurrent neuropathic right arm pain with"seriel/monthly axillary local anesthetic nerve blocks." Inexcess of 27 such injections were administered from April 21, 1995,through May 7, 1998. Dr. Lamer's notes state that each injectiongave the claimant approximately three weeks of relief from herpain, followed by "recurrent dysethesias and vasomotor symptoms."

Following a hearing, the arbitrator issued a decision, findingthat the claimant sustained an accidental injury on August 11,1992, which arose out of and in the course of her employment byElmhurst and that her condition of ill-being is causally related tothe injury she sustained on that date. The arbitrator specificallyfound the testimony of Dr. Lamer to be more credible than thetestimony of Drs. Vender and Pawl. The arbitrator awarded theclaimant the sum of $228 per week for 156.66 weeks for 66 2/3% PPDto her right arm, and $253.33 per week for 90 4/7 weeks for TTD. In addition, the arbitrator ordered Elmhurst to pay the further sumof $2,293.50, plus whatever amount the claimant owed to Mayo Clinicfor treatment rendered on or before April 21, 1995, for medicalservices. In so doing, the arbitrator specifically found thatElmhurst was not liable for the cost of the claimant's medical carerendered after April 21, 1995, the date upon which her treatingphysician determined that she had reached maximum medicalimprovement.

Both the claimant and Elmhurst sought a review of thearbitrator's decision. The Commission issued a decision, with onecommissioner dissenting, in which it determined that the arbitratorerred in finding that the care rendered to the claimant after April21, 1995, was not compensable. The Commission found that the carerendered by Dr. Lamer was reasonable and necessary as it providedrelief from an ongoing condition. As a consequence, the Commissionawarded the claimant $38,125.86 for medical expenses incurred atMayo Clinic in addition to the $2,293.50 awarded by the arbitratorand ordered Elmhurst to pay the claimant the sum of $40,419.36 formedical expenses. In all other respects, the Commission affirmedand adopted the decision of the arbitrator.

On appeal from the circuit court's order confirming theCommission's decision, Elmhurst argues that the decision to awardthe claimant the sum of $40,419.36 for medical expenses is againstthe manifest weight of the evidence. Specifically, it contendsthat the there is no evidence that the treatments rendered to theclaimant after April 21, 1995, at the total cost of $38,125.86,were either reasonable or medically necessary. We disagree.

Under the provisions of section 8(a) of the Act, an employeris required to pay for all necessary medical, surgical, andhospital services that are reasonably required to cure or relievethe effects of an accidental injury sustained by an employee andarising out of and in the course of her employment. 820 ILCS305/8(a) (West 1998). An employer's liability under this sectionof the Act is continuous so long as the medical services arerequired to relieve the injured employee from the effects of theinjury. Efengee Electrical Supply Co. v. Industrial Comm'n, 36Ill. 2d 450, 453, 223 N.E.2d 135 (1967). However, the employee isonly entitled to recover for those medical expenses which arereasonable and causally related to her industrial accident. Zarley v. Industrial Comm'n, 84 Ill. 2d 380, 389, 418 N.E.2d 717(1981). The question of whether medical treatment is causallyrelated to a compensable injury is one of fact to be determined bythe Commission, and its finding on the issue will not be reversedon review unless contrary to the manifest weight of the evidence. Zarley, 84 Ill. 2d at 389-90.

For a finding of fact to be contrary to the manifest weight ofthe evidence, an opposite conclusion must be clearly apparent. Caterpillar, Inc. v. Industrial Comm'n, 228 Ill. App. 3d 288, 291,591 N.E.2d 894 (1992). The Commission's determination on aquestion of fact is against the manifest weight of the evidenceonly when no rational trier of fact could have agreed. Dolce v.Industrial Comm'n, 286 Ill. App. 3d 117, 120, 675 N.E.2d 175(1996). The appropriate test is whether there is sufficientevidence in the record to support the Commission's determination. Benson v. Industrial Comm'n, 91 Ill. 2d 445, 450, 440 N.E.2d 90(1982).

In this case, Dr. Lamer testified that the claimant suffersfrom ulnar neuralgia which, in his opinion, is causally related toher injury on August 11, 1992. Although Dr. Lamer testified thatthe claimant had reached maximum medical improvement by April 21,1995, that is to say, she had recovered as far as the permanentcharacter of her injury would permit (see Mobil Oil Corp v.Industrial Comm'n, 309 Ill. App. 3d 616, 626, 722 N.E.2d 703(1999)), he found her condition to be chronic. The injectiontherapy administered to the claimant after April 21, 1995, didnothing to cure her condition, but the record certainly supportsthe conclusion that the injections helped to "relieve the effects"of her injury, namely, the chronic pain she suffers. As such, theexpenses which the claimant incurred for the injections shereceived after April 21, 1995, are recoverable under section 8(a)of the Act (820 ILCS 305/8(a) (West 1998)). We find, therefore,that the Commission's decision is not against the manifest weightof the evidence.

For the foregoing reasons, we affirm the circuit court's orderconfirming the Commission's decision.

Affirmed.

McCULLOUGH, P.J., and O'MALLEY, HOLDRIDGE, and RARICK, JJ.,concur.