                    COURT OF APPEALS OF VIRGINIA


Present: Judges Benton, Willis and Senior Judge Hodges
Argued at Richmond, Virginia


UNITED PARCEL SERVICE OF AMERICA AND
 LIBERTY MUTUAL FIRE INSURANCE COMPANY
                                            MEMORANDUM OPINION* BY
v.   Record No. 2488-01-2                JUDGE JERE M. H. WILLIS, JR.
                                                 MAY 14, 2002
DOUGLAS J. WHEELER, SR.


          FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

            John Chadwick Johnson (Christopher M. Kite;
            Catherine I. Henritze; Frith Anderson &
            Peake, P.C., on brief), for appellants.

            Gregory O. Harbison (Geoffrey R. McDonald &
            Associates, on brief), for appellee.


     United Parcel Service of America ("UPS") appeals a decision

of the Workers' Compensation Commission awarding Douglas J.

Wheeler, Sr. benefits for a total knee replacement resulting

from an aggravation of a pre-existing, compensable left knee

injury.   UPS contends that the commission's finding that Wheeler

established by a preponderance of the evidence that the knee

replacement is necessitated by his accident of July 1, 1998, is

unsupported by the evidence.    We affirm the commission's

decision.




     * Pursuant to Code § 17.1-413, this opinion is not
designated for publication.
                            I.    BACKGROUND

        On appeal, we must view the evidence in the light most

favorable to the party prevailing below.       Creedle Sales Co. v.

Edmonds, 24 Va. App. 24, 26, 480 S.E.2d 123, 124 (1997).

                             A.    INJURIES

        Douglas Wheeler has been employed by UPS as a package car

and truck driver for over thirty years, during the course of

which he has sustained several workplace accidents.      In July

1982, he injured his left knee and was treated by

Dr. Crickenberger for a torn medial meniscus.      On September 16,

1982, Dr. Crickenberger performed surgery on Wheeler's left

knee.    He released Wheeler to light duty on December 6, 1982.

        On April 25, 1983, Wheeler returned to Dr. Crickenberger.

He complained that he had experienced increased swelling in his

left knee over the previous four weeks, as a result of striking

his knee on a metal bar as he stood from a table.      On May 2,

1983, Dr. Crickenberger diagnosed traumatic fusion of the left

knee.    Wheeler returned to full duty that day.

        On August 30, 1983, Wheeler returned to Dr. Crickenberger

for a six-month check-up.    Dr. Crickenberger noted that "[i]n

view of the recurrent synovial thickening and effusion and the

fact that the taps are always bloody by history . . . I have

arranged a consultation with Dr. Pendleton for rheumatology."

        In September 1983, Dr. Crickenberger re-examined Wheeler.

He noted that Dr. Pendleton had found no arthritis.      However, he

                                  - 2 -
felt that further arthroscopic surgery was required and

scheduled Wheeler for surgery.    On October 5, 1983, Wheeler

underwent arthroscopic surgery with partial synectomy.      On

October 10, 1983, Dr. Crickenberger noted that Wheeler was "up

to walking a mile a day.    At surgery he was found to have

significant pigmented villondular synivitis [sic] . . . ."

        Between October 1983 and May 1986, Dr. Crickenberger

treated Wheeler conservatively.    His office notes repeatedly

diagnose Wheeler as suffering from pigmented villonodular

synovitis ("PVN") and report a regimen of prescription

medications.    Other than a five-week period following a

December 5, 1983 visit, it does not appear that any work

restrictions were placed on Wheeler.     On June 18, 1986, Wheeler

once again underwent arthroscopic surgery to address the PVN.

In his office note the following day, Dr. Crickenberger stated

that the PVN had progressed and "basically destroyed the medial

meniscus," requiring significant synovial resection.

        Wheeler was released to work on September 15, 1986.      He

continued to experience swelling and discomfort in the left

knee.    On July 1, 1998, his left knee buckled, causing him to

fall out of the cab of his truck.    He continued working for

several days, but on July 6, 1998, he sought medical treatment

from Dr. Powledge.    Because of Wheeler's long-standing treatment

history with Dr. Crickenberger, Dr. Powledge referred him to

Dr. Crickenberger.

                                 - 3 -
        Dr. Crickenberger examined Wheeler on July 21, 1998 and

referred him to Dr. McCue.      On August 17, 1998, Dr. McCue

recommended a synovectomy, which was performed on October 1,

1998.    During follow-up treatment, between December 1998 and May

1999, both Dr. Crickenberger and Dr. McCue noted that Wheeler

had persistent swelling/effusion of the left knee.      On June 28,

1999, Wheeler reported decrease in pain and exhibited a range of

motion of zero to ninety degrees.       He was released to work.

        On September 20, 1999, Dr. Crickenberger again saw Wheeler

and noted continued diffuse swelling.      He also noted that the

knee had good range of motion and was stable.      On the same day,

Dr. McCue noted in a letter to Dr. Crickenberger that Wheeler

"may well be ready for a knee replacement."      On June 22, 2000,

Dr. Crickenberger advised Wheeler to undergo the surgery.       In

his notes he addressed the relationship between Wheeler's PVN

and the March 1982 accident.

             Certainly the patient had the injury to his
             knee approximately 3/82. No problem prior
             to that. Whether or not the PVN was there
             at the time of the injury there is no way of
             knowing, but that if it were there certainly
             you can argue that the injury aggravated an
             underlying problem. On the other hand,
             certainly people get PVN and it progresses
             without trauma. Patient is advised that it
             is difficult to look in crystal ball [sic]
             and make a definite decision in reference to
             this matter with the information available.

              *      *      *       *       *      *      *

             Patient was advised that the trauma did not
             cause the PVN but he has a fairly sound

                                  - 4 -
          argument that the trauma and activities at
          work have contributed to the underlying
          problem.

           *        *        *      *      *        *      *

          I would encourage him to resolve this
          problem ASAP and proceed with surgery as
          outlined by Dr. McCue.

Wheeler elected to undergo the surgery.        However, UPS denied

authorization, and the surgery was postponed pending the

resolution of this issue.

               B.       EVIDENCE RELATING TO CAUSATION

     On April 28, 1999, Dr. Crickenberger responded to an

inquiry regarding the causal relationship between the July 1,

1998 accident and the PVN as follows:

          Is the left knee pigmented villondular
          synovitis causality [sic] related to the
          slip and fall of 07-01-98 within reasonable
          medical certainty? Yes -- injury aggravated
          underlying synovitis.

          Is the industrial accident of the left knee
          on 07-01-98 the major consequentially [sic]
          cause of the villondular synovitis? Yes
          -- synovitis pre existing injury was the
          major aggravating cause.

     In a letter to Wheeler's then attorney, dated August 15,

2000, Dr. Crickenberger wrote, "I addressed the problem of

having no problems of his knee prior to his initial injury in

3/82 and that certainly the injury could aggravate the

underlying condition of PVN."

     On September 19, 2000, Dr. McCue responded to a medical

questionnaire and answered the following:


                                  - 5 -
            Do you believe within a reasonable degree of
            medical probability that the injury which
            Mr. Wheeler suffered to his left knee on
            July 1, 1998 aggravated the pigmented
            villondular [sic] synovitis? The injury
            that Mr. Wheeler suffered on 7-1-98
            certainly aggravated the pigmented
            villonodular synovitis, but no-one is
            exactly sure what the originating cause of
            the [PVN] cause [sic] itself.

            Do you believe that Mr. Wheeler would need a
            total knee replacement even if he did not
            suffer from pigmented villondular [sic]
            synovitis? I do believe he needs a total
            knee replacement.

     On January 2, 2001, Dr. Crickenberger was deposed.

He testified on direct examination that the extent of Wheeler's

PVN is significant and that this condition will naturally

progress.   He testified that the PVN could progress to the

extent of requiring a total knee replacement.   More

specifically, with respect to Wheeler, he could not state how

much of Wheeler's symptomatic progression was due to his

injuries and how much was due to the natural course of

progression of his PVN.

     When asked if he could state that, absent the July 1998

accident, Wheeler would not need a total knee replacement, he

answered that he "could not state that to a medical certainty."

Dr. Crickenberger attributed the thickened synovial lining in

Wheeler's knee to "both the PVN and the injury."    He elaborated

on his opinion regarding the causal relationship:




                                - 6 -
           Q: So his trauma or whatever trauma he had
           sustained as a result of the fall in July of
           1998 had subsided?

           A: I don't think you can separate the two
           completely. Certainly the trauma -- if I
           can elaborate. Certainly the PVN, or
           pigmented villus synovitis wasn't caused by
           the trauma. For sure it was there. Had
           documentation that it was there.

           For sure the trauma exacerbates the
           underlying condition and, of course, the
           underlying condition is an ongoing
           condition.

           Q:   It continues to degenerate?

           A: Right, and how much worse it made it,
           what rate it made things more rapid, I can't
           tell you. I tell you with the positive
           finding we had, tends to make you think
           there probably was significant injury.

            *       *      *      *      *     *      *

           From that point on it's like taking a person
           with arthritis and hitting them in the knee
           with a hammer. The hammer didn't cause the
           arthritis, but the condition flares up and
           goes on.

     On April 25, 2000, at the request of UPS, Dr. Powledge

conducted a medical evaluation and records review of Wheeler.

He concluded that no objective medical evidence established that

Wheeler sustained an additional injury to his left knee as a

result of his July 1998 fall.   He stated his agreement with

Drs. Crickenberger and McCue that a total knee replacement was

needed.   However, he opined that the need for the knee

replacement was due to Wheeler's PVN and to the fact that the




                                - 7 -
condition had not responded to less drastic surgical

intervention or radiation treatments.

                        C.   PROCEDURAL HISTORY

     On July 1, 1998, Wheeler sustained a compensable injury to

his left knee.    Benefits were paid pursuant to an award dated

July 27, 1999, until he returned to work on June 24, 1999.           On

April 27, 2000, Wheeler filed a claim for benefits with the

Workers' Compensation Commission seeking authorization to

undergo a total knee replacement pursuant to Code § 65.2-603.

     Following an October 19, 2000 hearing, Deputy Commissioner

Costa ruled that Wheeler's fall in 1998, "aggravated his

preexisting pigmented villonodular synovitis (PVN) and made a

total knee replacement necessary."          UPS timely filed a notice of

appeal, and the full commission affirmed.         UPS appeals that

decision.

                              II.    ANALYSIS

     UPS contends that no credible evidence supports the

commission's finding that the July 1, 1998 injury aggravated

Wheeler's pre-existing condition and necessitated a total knee

replacement.   We disagree.    Wheeler's treating physicians,

Drs. Crickenberger and McCue, were clear in their diagnoses that

the July 1, 1998 injury aggravated his pre-existing PVN

condition.   An aggravation of a pre-existing condition is

compensable.     See Southern Iron Works, Inc. v. Wallace, 16

Va. App. 131, 428 S.E.2d 32 (1993).

                                    - 8 -
     On at least three occasions, Dr. Crickenberger stated that

the July 1998 injury aggravated Wheeler's underlying PVN.   On

April 28, 1999, he responded to a questionnaire regarding the

relationship between Wheeler's July, 1998, left knee injury and

the pre-existing PVN.

          1. Is the left knee pigmented villondular
          synovitis causality [sic] related to the
          slip and fall of 07-01-98 within reasonable
          medical certainty?

          Yes -- injury aggravated underlying
          synovitis.

          2. Is the industrial accident of the left
          knee on 07-01-98 the major consequentially
          [sic] cause of the villondular synovitis?

          Yes -- synovitis preexisting injury was the
          major aggravating cause.

On September 26, 2000, Dr. Crickenberger responded to a request

from Wheeler's attorney for clarification of answers provided in

the questionnaire.

          [A]nswering your two questions on the last
          page of your letter of 9/6/00.

          1. The diagnosis of nodular synovitis of
          left knee was first made clinically in 1982
          as a "synovitis" but the pathology diagnosis
          of nodular synovitis [reference to PVN
          synovitis] was made on the pathologic report
          of 8/5/83 [reference to left knee].

          2. I do believe with a reasonable degree of
          medical probability that the work accident
          on 7/1/98 aggravated the underlying PVN, but
          certainly did not cause the PVN synovitis.

Finally, in his January 2, 2001 deposition, Dr. Crickenberger

stated:


                              - 9 -
             Certainly the PVN, or pigmented villus
             synovitis wasn't caused by the trauma. For
             sure it was there. Had documentation that
             it was there.

             For sure the trauma exacerbates the
             underlying condition and, of course, the
             underlying condition is an ongoing
             condition.

              *      *      *      *      *      *      *

             From that point on it's like taking a person
             with arthritis and hitting them in the knee
             with a hammer. The hammer didn't cause the
             arthritis, but the condition flares up and
             goes on.

     Like Dr. Crickenberger, Dr. McCue was clear in his

diagnosis.    On September 19, 2000, he responded to a medical

questionnaire.

             [Q]: Do you believe within a reasonable
             degree of medical probability that the
             injury which Mr. Wheeler suffered to his
             left knee on July 1, 1998 aggravated the
             pigmented villondular [sic] synovitis?

             [A]: The injury that Mr. Wheeler suffered
             on 7-1-98 certainly aggravated the pigmented
             villonodular synovitis, but no-one is
             exactly sure what the originating cause of
             the [PVN] cause [sic] itself.

     Credible evidence in the record supports the commission's

finding that Wheeler's July 1, 1998 injury aggravated a

pre-existing compensable condition, necessitating a total left

knee replacement.    "Decisions of the commission as to questions

of fact, if supported by credible evidence, are conclusive and

binding on this Court."     Manassas Ice & Fuel Co., 13 Va. App.

227, 229, 409 S.E.2d 824, 826 (1991).    "The fact that contrary


                                - 10 -
evidence may be found in the record is of no consequence if

credible evidence supports the commission's finding."   Id.

     The decision of the commission is affirmed.

                                                        Affirmed.




                             - 11 -
