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IMPORTANT NOTICE
NOT TO BE PUBLISHED OPINION

THIS OPINION IS DESIGNATED"NOTTOBE PUBLISHED." PURSUANTTOTHERULES OFCIVIL PROCEDURE PROMULGATED BYTHE SUPREME COURT, CR76.28(4)(C), THIS OPINION IS NOTTO BE PUBLISHED ANDSHALL NOTBE CITED ORUSEDAS BINDING PRECEDENTIN ANY OTHER CASEIN ANY COURT OF THIS STATE; HOWEVER, UNPUBLISHED KENTUCKYAPPELLATE DECISIONS, RENDEREDAFTERJANUARY 1, 2003, MAYBE CITED FOR CONSIDERATION BYTHE COURTIFTHERE IS NOPUBLISHED OPINION THATWOULDADEQUATELYADDRESS THEISSUE BEFORETHE COURT. OPINIONS CITED FORCONSIDERATION BY THE COURTSHALL BE SET OUTAS AN UNPUBLISHED DECISION IN THEFILED DOCUMENTAND A COPYOFTHE ENTIRE DECISION SHALL BE TENDEREDALONGWITHTHE DOCUMENTTO THECOURTANDALLPARTIES TOTHE ACTION.
RENDERED: MARCH24, 2011 NOTTO BE PUBLISHED
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2010-SC-000203-WC
BETTS USA, INC. APPELLANT
ON APPEAL FROM COURTOFAPPEALS
CASE NOS. 2009-CA-001474-WC AND 2009-CA-001640-WC
WORKERS'COMPENSATION BOARD NO. 07-98477

DEBBIE MURSKI;
HONORABLEJOSEPH W. JUSTICE,
ADMINISTRATIVE LAWJUDGE; AND
WORKERS' COMPENSATION BOARD APPELLEES

AND 2010-SC-000221-WC

DEBBIE MURSKI CROSS-APPELLANT

ON APPEAL FROM COURTOF APPEALS
V. CASE NOS. 2009-CA-001474-WC AND 2009-CA-001640-WC WORKERS' COMPENSATION BOARDNO. 07-98477
BETTSUSA, INC.;
HONORABLEJOSEPH W. JUSTICE,
ADMINISTRATIVE LAWJUDGE; AND
WORKERS' COMPENSATION BOARD CROSS-APPELLEES

MEMORANDUM OPINIONOF THE COURT
AFFIRMING
The Workers' Compensation Board reversed anAdministrative Law Judge's (ALJ's) finding that the claimant did not sustain a work-related left knee injury and remanded for the entry of an award of medical benefits. The Board affirmed insofar as the ALJ failed to award permanent income benefits. The Courtof Appeals affirmed.
Appealing, the employer asserts that the Board erred by substituting its judgment and finding that the claimant sustained awork-related injury that entitled her to the disputed medical benefits. The claimant asserts in a cross appeal that the Board erred by failing to order the ALJ to determine on remand whether she has reached maximum medical improvement (MMI) and, if she has, to address her permanent impairment rating.
We affirm. The evidence compelled findings that the claimant sustained awork-related left knee injury; that it was more than a temporary sprain or strain; and that it caused her pre-existing dormant degenerative condition to become symptomaticand culminate in surgery. Thus, the surgery and other reasonable and necessary medical treatmentwere compensable. The ALJ determined reasonably that the claimant was not entitled to permanent income benefits.
The claimant worked for the defendant-employer as an injection mold
technician. She spent mostof the day on her feet, overseeing machines that
manufactured toothpaste tubes. She evaluated production quality, assisted in
packaging the finished product, and lifted boxes that weighed from fifteen to
thirty pounds boxes throughout the day. She also spentabout two hours per . day on paperwork.
The claimant volunteered to perform maintenance work on all fourteen
presses during the 2007 Christmas shutdown. Her duties throughout the
shutdown period required extensive kneeling, crawling, and crouching as well
as raising and lowering her body in order to clean the machines. She testified
that her left knee began to feel sore and that she heard a loud "pop" and
experienced pain in her left kneecapwhile getting up from a kneeling position
onJanuary 8, 2007. She informed her supervisor immediately and was sent to
St. Elizabeth Business Health Center.
The claimant testified that she had never been treated for left knee
problems before January 8, 2007 except for aviral infection about six years
earlier. Records from St. Elizabeth Business Health Center indicate that she
sought treatment on January 8, 2007 for intermittent pain in her left knee that
she rated at 3 on a scale of 10. She reported a gradual increase in left knee
pain while crawling and squatting at work, which grew worse when she walked
or bent the knee. She stated that the knee made a"crunchy" noise when she
walked. Dr. Kunkler conducted a physical examination that revealed signs of
mild tenderness in the anteriorknee, more on the medial aspect, but no
bruising, abrasions, swelling, or effusion. He noted that the knee was stable
and that extension was normal but flexion was 60 degrees. Dr. Kunkler
diagnosed a work-related knee strain for which he prescribed pain medication
and recommended that she use a knee brace and work on range of motion as
her symptoms improved. He attributed the claimant's complaints to her work activities and assigned restrictions.
Notes from a follow-up exam on January 15, 2007 indicated signs of tenderness but no swelling in the pre-patellar bursa, signs of tenderness in the patellar tendon, and limited range of motion. Flexion was 100 degrees. The diagnosis remained a knee strain.
The claimant remained off work from January9, 2007 through January 22, 2007, during which time the employer paid voluntary temporary total disability (TTD) benefits. She returned to Dr. Kunkler on February 21, 2007, at which time he noted signs of mild tenderness in the left anterior knee. Range of motion and gait were normal, and the knee was stable. He diagnosed a knee strain with persistent pain and possible PFS (patellofemoral syndrome) and noted her wish to continue performing regular duty work.
Dr. Larkin began treating the claimant in March 2007 on referral from Dr. Kunkler. His treatment notes indicate that she complained of experiencing pain and catching in the left knee since January 8, 2007 but was unsure what caused it. Physical examination of the left knee revealed signs of focal tenderness medially as well as a positive McMurray's, Apley's, and flexion compression medially, none of whichwere present in the right knee. Dr. Larkin thought initially that she had torn the medial meniscus and ordered an MRI. The radiologist's report noted a history of trauma with medial pain and reported findings that included alateral femoral condyle bone bruise, patellofemoral degenerative changes, and a lateral subluxation of the patella.
Dr. Larkin's notes from March 21, 2007 indicate that the claimant

continued to complain of pain when ascending and descending stairs, kneeling, squatting, and bending. He noted that the majority of the pain was anteromedial and recorded findings of positive pain with flexion compression past 120 degrees; an equivocal Apley's; and diffuse, non-specific pain with McMurray's. He noted explaining to the claimant that she was "suffering from patellofemoral [osteoarthritis] directly related to her job."
The claimant missed workfrom March 14 until April 29, 2007, during which time her employer again paid TTD. Hercondition continued to deteriorate after she returned to work. Moreover, cortisone injections and other conservative treatment failed to relieve her symptoms.
Dr. Larkin's findings on March 14, 2007 included pain with patella compression and a positive flexion compression test but no true Apley's or McMurray's. They remained the same as ofJuly 30, 2007. Noting the duration of the claimant's symptoms and.the presence of"an underlying recurrent patella subluxation pattern," he recommended arthroscopic surgery.
On September 28, 2007 Dr. Larkin performed surgical procedures on the
left knee to address patellar chondromalacial as well as an extensor
mechanism malalignment. His post-operative notes indicate that arthroscopic
surgery revealed and he repaired a focal osteochondral defect of the lateral
facet that extended onto the medial facet, which he described as being a "full
TABER'S CYCLOPEDIC MEDICAL DICTIONARY 395 (19TH ED. 2001) defines chondromalacia as being a "[s]oftening ofthe articular cartilage, usually involving the patella.
thickness grade 3 change without exposed bone." In a separate procedure he realigned the left patella and reconstructed the extensor mechanism.
Although the claimant's symptoms improved initially after the surgery, they worsened over time and she did not return to work. In February 2008 Dr. Larkin noted her complaintthat her left knee pain had become nearly unbearable. Yet, the post-operative MRI"looked absolutely fantastic." He recommended that she see a neurologist for pain management.
Dr. Burger saw the claimant in March 2008 concerning complaints of sharp and throbbing pain that she rated at six outofa possible ten. He compared the pre-and post-surgical MRIs and conducted a physical examination, which indicated that motion was good with moderate patellofemoral clicking and that there was diffuse quadriceps atrophy. He recommended physical therapy and a repeat course of anti-inflammatory medication and possibly cortisone injections. If they failed, he suggested viscosupplementation for treatment of the underlying degenerative condition.
In April 2008 Dr. Larkin noted a significant amount of patellofemoral crepitus from forty to sixty degrees but an otherwise normal exam. He stated that they would try viscosupplementation injections and recommended aquatic therapy. A final note from June 2008 indicates that the injections failed to help and-that the remaining option waspain management.
Dr. Wunderevaluated theclaimant in June 2008. He opined that she had an acute onset of symptoms while kneeling at work, which substantially aggravated the pre-existing chondromalacia and lateral subluxation in her knee. He attributed her present symptoms to the injury at work, noting that her medical records described the incident and that imaging studies verified the presence of bone bruising, which would support the occurrence of"fairly significant trauma to the knee." He did not think that she had reached MMI unless treatmentwasdiscontinued, in which case she would be at MMIwith a permanent impairment rating of 7%.
Dr. Bender, an orthopedic surgeon, evaluated the claimant for the employer in May2008. He identified patellofemoral abnormalities in both knees. Although he noted that she appeared to have suffered a left knee sprain or strain onJanuary 8, 2007, he "[did] not believe the eventresulted in a harmful change in the humanorganism supported by objective medical findings." Noting that the chronic degenerative changes shown on the March 2007 MRI would have existed before the January 2007 incident at work, he opined that the incident did notnecessitate the surgery performed by Dr. Larkin and did not require further treatment. He considered the surgery and present medicaltreatmentto be appropriate medically but attributed the need for them to the claimant's pre-existing degenerative changes and body habitus. He stated that she could return to the work she performed before the January 2007 incident and required no additional treatment for its effects.
Dr. Bender was deposed in September 2008. When asked whether the surgical treatmentwasreasonable, necessary, and related to "the episode she described on January 8, 2007," he stated. that it was "appropriate to perform a diagnostic arthroscopy" but that the procedure performed to adjust the position of the claimant's patella addressed unrelated pre-existing conditions. Noting that she was deconditioned, about eighty pounds overweight, had bilateral patellofemoral disease, and significant valgus in both knees,2 he stated that the positioning of her patella resulted from her body habitus and not her work activities ofJanuary S, 2007. He could not say whether the pre

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