Baltimore County v. Michael Quinlan, No. 319, Sept. Term 2017
Opinion by Leahy, J.

Workers’ Compensation Act > Occupational Diseases > Burden of Proof
A covered employee claiming that a degenerative disorder is compensable as an occupational
disease carries the burden, under Maryland Code (1991, 2016 Repl. Vol.), Labor & Employment
Article (“LE”), § 9-502(d)(1), of proving that the risk factors of the disease (1) adhere in the nature
of the employee’s employment and (2) caused the employee to become disabled.
Circuit Court for Baltimore County
Case No. 03-C-16-004811


                                                  REPORTED

                                     IN THE COURT OF SPECIAL APPEALS

                                               OF MARYLAND

                                                      No. 319

                                             September Term, 2017



                                            BALTIMORE COUNTY

                                                        v.

                                             MICHAEL QUINLAN



                                        Leahy,
                                        Reed,
                                        Shaw Geter,

                                                      JJ.


                                              Opinion by Leahy, J.


                                        Filed: August 30, 2018




          2018-08-30
          14:24-04:00
       A jury in the Circuit Court for Baltimore County found that Mr. Michael Quinlan

(“Appellee”) suffered an occupational disease in the form of degenerative tears in the

medial and lateral menisci in his right knee arising out of and in the course of his

employment as a paramedic/firefighter for Baltimore County (“Appellant” or the

“County”). The County appeals that decision, presenting a single issue for our review:

“Whether right knee degenerative tears of the medial and lateral menisci and their

underlying cause, osteoarthritis, constitute[] an occupational disease as defined by the

Maryland’s Workers’ Compensation Act[.]”

       The Workers’ Compensation Act (the “Act”) provides that a covered employee may

recover for an occupational disease that “is due to the nature of an employment in which

hazards of the occupational disease exist and the covered employee was employed before

the date of disablement.” Maryland Code (1991, 2016 Repl. Vol.), Labor & Employment

Article (“LE”), § 9-502(d)(1)(i). Mr. Quinlan established through testimony presented at

trial that repetitive kneeling and squatting is (1) a regular part of a paramedic’s job and (2)

a risk factor for developing menisci tears and, in turn, osteoarthritis in the knees. We hold

that Mr. Quinlan presented sufficient evidence at trial establishing that the degenerative

menisci tears he suffered were an occupational disease for which he may recover under LE

§ 9-502(d)(1)(i).

                                     BACKGROUND

                    A. Mr. Quinlan’s Workers’ Compensation Claim

       Mr. Quinlan filed an employee’s claim with the Workers’ Compensation

Commission (“Commission”) on October 19, 2015, asserting that he developed meniscal
tears in his right knee due to his job duties as a paramedic/firefighter. The Commission

held a hearing on March 31, 2016, on the following issues regarding Mr. Quinlan’s claim:

       1. Did the employee sustain an occupational disease arising out of and in the course
          of employment?

       2. Temporary Total Disability

       3. Average Weekly Wage

       On April 5, 2016, the Commission found that Mr. Quinlan “did not sustain an

occupational disease of Right Knee degenerative tears arising out and in the course of

employment as alleged to have occurred on February 11, 2015,” and issued an order

disallowing Mr. Quinlan’s claim. The Commission noted that the second issue (temporary

total disability) was raised but not litigated and found Mr. Quinlan’s average weekly wage

to be $2,082.16. Later that month, on April 29, he filed a petition in the Circuit Court for

Baltimore County for review of the Commission’s decision and requested a jury trial.

                                B. Trial in Circuit Court

       The circuit court held a jury trial on April 19-20, 2017. Mr. Quinlan testified first.

At the time of trial, he was 51 years old, 5’9” tall, and weighed between 230-240 lbs. He

explained that he has worked for the Baltimore County Fire Department as a paramedic

since September 1994. The job requires him to work four days on followed by four days

off; the first two days on are ten-hour shifts and the second two are fourteen-hour shifts.

Over those four days, he responds to about 26 to 30 calls that last an average of 60-90

minutes each. According to Mr. Quinlan, calls for paramedics range from “anything from

patient assist, meaning like just helping somebody off the floor, to cardiac arrest to rescues



                                              2
to chest pain[.]” Because many of the calls are in response to people who are in a

heightened state of anxiety or pain and the patients may be on the floor, a couch, or a bed,

and may be unconscious, Mr. Quinlan has to “kneel down to their level while [] talking to

them instead of hovering over top of them.” When he kneels, he’ll often do so on his right

knee. In some situations, for example, if a patient is in cardiac arrest, he will “be on the

floor for a little while, either doing compressions, airway managements,” or “doing an I.V.”

While working, he also has to carry patients and equipment up and down steps.

       Aside from work, Mr. Quinlan testified that he golfs recreationally, lifts upper body

weights, and occasionally rides a bike or goes sailing with friends. The County established

on cross-examination that he has also posed for a picture squatting next to a dog and that

he sometimes carries groceries or a laundry basket up the 10-20 stairs at his house.

       In 2005, Mr. Quinlan hurt his right knee on the job while assisting a patient down a

set of stairs; he saw a doctor a few times for the pain at the suggestion of an officer at work.

Then, around 2014, Mr. Quinlan saw a doctor again for more problems associated with his

right knee. He testified that after a shift, he was experiencing pain and “thought it was

something that might just go away on its own” but the next day he noticed clicking when

he walked. When he tried to pop his knee to alleviate the pain, “it just hurt more.”

Although he felt knee soreness and stiffness throughout his career, he indicated that this

time felt more severe and consistent, and that the clicking was a new development. His

personal physician told him to get an MRI and referred him to an orthopedic surgeon. In

February 2015, Mr. Quinlan underwent a partial meniscectomy on his right knee. After

surgery, he returned to work.


                                               3
                               1. Dr. Cochran’s Testimony

       Following Mr. Quinlan’s own testimony, he presented a video deposition of Dr.

Barbara Cochran, who specializes in internal medicine, occupational medicine, psychiatry,

and pulmonary medicine.        Dr. Cochran testified that she evaluated Mr. Quinlan to

determine whether his right knee issue was related to his occupation as a paramedic. She

explained that her evaluation procedure includes reviewing a patient’s medical records and

any medications he or she may be on, speaking to the patient, and looking at the patient’s

occupational history and job functions. She then reviews peer-reviewed medical literature

to incorporate into her report. Dr. Cochran said that understanding the patient’s job

functions, shift work, and whether he or she takes breaks is vital to forming a reliable

opinion relating to osteoarthritis.

       Dr. Cochran highlighted the functions of EMT/paramedic work that require

paramedics like Mr. Quinlan to transport heavy patients, get them on stretchers or into the

ambulance, and bend down to take vital signs, talk to, or triage patients. Regarding lifting

patients onto stretchers, she stated, “they’re low to the ground. So you’re in [a] squatting

position, which puts a great deal of stress on the knee, because you know you’re going to

lift with your knees, you don’t lift with your back.”

       Mr. Quinlan had tears in his medial and lateral menisci when surgery was performed

on his right knee. Dr. Cochran explained that tears of the menisci are “part of the

continuum of osteoarthritis.” She stated that “any type of motion or repetitive trauma” will

cause “inflammation [of the] synovium, which is the covering over the bone[,] and then

that progresses and so then you can get abnormal bone formation or you can get, again,


                                             4
changes in the meniscus.”

       As for risk factors, Dr. Cochran opined that age played a role in Mr. Quinlan’s

osteoarthritis in the sense that

       as you age you have that many more moments . . . where you can [] injure
       your knee[.] . . . [I]t’s a risk factor in terms of how many times you were
       walking or how many times you were kneeling or bending. But his particular
       case, he developed this at a much earlier age than one would expect to see it.

Gender was not a risk factor for him because osteoarthritis occurs more frequently in

women and Mr. Quinlan was diagnosed in only one of his knees, and no genetic factors

have yet been identified as risk factors. Joint injuries were another risk factor, according

to Dr. Cochran, but Mr. Quinlan did not appear to have any. Having reviewed Mr.

Quinlan’s medical records from 2005, Dr. Cochran testified that Mr. Quinlan’s injury back

then was not the type of joint injury contemplated as a potential risk factor: “He had a

totally normal examination of his knee, there wasn’t any infusion, there wasn’t any

swelling, there wasn’t any laxity, there’s nothing there that indicated he had any significant

injury to his knee.”

       Dr. Cochran explained that overuse or repetitive trauma is another risk factor. She

then outlined the stress that squatting can put on the knees and observed that “as you come

up and unbend you’re exerting tremendous forces downward on the structures and they’re

going to again protect the ligaments and protect the joint integrity, but they’re going to put

pressure on the meniscus.” She continued:

       When you do repetitive motions, . . . what happens is that you have an
       inflammation and it doesn’t have to be big inflammation, it can be a small
       inflammation. But what happens is you get, the body will repair itself as long
       as there is enough time for the reparative molecules, which are called . . .


                                              5
       cytokines, but there’s pro-inflammatory and they’re healing and there’s a
       number of different structures, or things that do that but, again, when you do
       this on a repetitive basis, the body does not have time to compensate and
       repair. So, you have inflammation, partial healing, inflammation, so it builds
       up.

       She then discussed one study that showed “repetitive kneeling and repetitive

squatting” can “markedly increase[] risk” for osteoarthritis, which “is a cumulative injury,”

and another study that showed fire fighters have a “significant” relative risk of

osteoarthritis. Specific to Mr. Quinlan, Dr. Cochran opined that, based on two different

types of causation analysis, including a six-step occupational-practice guideline

documented in the American College of Occupational and Environmental Medicine, Mr.

Quinlan’s “essential job functions, which include considerable repetitive kneeling,

bending, stress on the knee, [are] the cause of his knee osteoarthritis.” She testified that

the medical literature she reviewed supported her conclusion.

       On cross-examination, the County elicited from Dr. Cochran that she never

observed Mr. Quinlan physically and only spoke to him on the phone for around 30

minutes. She also testified that weight was a risk factor for osteoarthritis and would be a

factor independent of Mr. Quinlan’s employment. One study showed that patients over

197 pounds are more likely to suffer from osteoarthritis. Aside from weight posing a risk,

Dr. Cochran did not consider Mr. Quinlan’s weightlifting to factor in because he lifts

weights with mostly upper extremities and not his legs. Dr. Cochran also testified that she

would not be surprised to learn that Mr. Quinlan experienced some soreness in his left knee

because “he has an anatomically altered right knee, so that’s going to create more stress on

the contralateral knee.”


                                             6
        The County then spent a large part of its cross-examination parsing the findings of

the studies on which Dr. Cochran relied.          For instance, the County challenged the

Framington Heart Study, contending that the sample size of male subjects was too small to

sufficiently demonstrate a link between a person’s occupation and being symptomatic for

osteoarthritis. Dr. Cochran responded by explaining that she did not think the study’s

sample size impacted what the study was trying to show with respect to the physical

demands of knee bending. Another study noted that meniscal damage and osteoarthritis

occur frequently in the general population. In response to the County’s questioning, Dr.

Cochran clarified that job stress is not the only cause of osteoarthritis in the knee.

        On re-direct, Dr. Cochran clarified that the small sample size of the Framington

study

        ha[d] nothing to do with the causation analysis or what occupational risk
        factors there are that put stress in the knee that leads to the development of
        chronic inflammation that exceeds the reparative capacity of the body
        leading to the degradation of the knee structure, starting with synovium,
        extending to the [] menisci, extending to the bones, I mean, again, along a
        continuum.

Additionally, she testified that none of the non-occupational risk factors or studies explain

why Mr. Quinlan would have osteoarthritis in only his right knee if it was not caused by

his work. Finally, she testified that having reviewed the report of the County’s expert, Dr.

Richard Hinton, she “did not see any causation analysis at all.”

                                2. Dr. Hinton’s Testimony

        Trial resumed on April 20 with the video deposition of Dr. Hinton, an orthopedic

surgeon who was qualified as an expert to testify on behalf of the County. Dr. Hinton



                                              7
performed an independent medical exam on Mr. Quinlan on December 18, 2015. During

that exam he observed that Mr. Quinlan “walked with a reciprocal gait without an obvious

limp[,]” and “had a mild varus alignment or a mild bowing to both legs bilaterally.” This

bowing, he explained, could be the cause or the result of an injury to the knee. Dr. Hinton

recalled that Mr. Quinlan’s ranges of motion with his knee and hip were within the normal

limits, but he did “have reproducible tenderness to palpation or pushing in the medial side

of his knee on both the left and right knee.” Dr. Hinton found him to have “had a gradual

onset of medial knee pain.” Mr. Quinlan’s MRI, clinical exams, x-rays, and Dr. Hinton’s

exam were all “consistent with previous partial meniscectomy, lateral meniscectomy, early

arthritis in the medial side of the knee and some mild arthritis behind the knee cap[.]”

Although Mr. Quinlan had improved after his surgery, his medial knee pain had increased

over the few months leading up to his exam, which Dr. Hinton found to be “most consistent

with early arthritis in the medial compartment.”

       When asked to define Mr. Quinlan’s condition, Dr. Hinton explained:

       [A]t the time of his [exam], I thought his primary complaints were related to
       arthritis on the inside of his knees and he had a history of a meniscus tear and
       meniscectomy, which is a risk factor for that. I thought his symptoms were
       most consistent when I saw him with arthritic complaints.

Dr. Hinton then responded as follows when the County asked whether Mr. Quinlan’s work

as an EMT paramedic caused his injury:

       I was asked whether I thought . . . his work was a primary or direct cause of
       his meniscus issues, which I think contributed to his arthritis. He didn’t give
       me a history of specific injury or specific incidents or cumulative
       symptomatic episodes on the job. So, I cannot relate the meniscus tears
       directly to his duties as a firefighter and EMT. Certainly, there is literature
       that suggests that people who are in firefighter/EMT positions have higher


                                              8
       rates of both meniscus tears and of arthritis, as do people in many physically
       demanding job descriptions. I would say that there is a debate about why
       that is and I think there’s literature to support different ways of approaching
       that literature. My view of looking at it is that physically demanding workers
       . . . have higher rates of injury and those injuries are recognizable, they are
       cumulative in nature but they’re recognizable reportable injuries that then put
       them at risk for problems over the long term. I’m not convinced that
       asymptomatic use in this situation leads to a definable process later in life.

The County then asked more directly whether Mr. Quinlan’s job caused his injury and Dr.

Hinton responded, “I do not think it is the primary cause of his problem or definably the

primary cause of his problem, given mostly his history.” Dr. Hinton also explained that

Mr. Quinlan’s weight was between overweight and obese and that, as well as his age, were

risk factors for arthritis and menisci tears.

       On cross-examination, Dr. Hinton agreed that the medical literature showed that, as

a population, people in more physically demanding jobs and people who do more squatting

and kneeling—such as firefighters, farmers, warehouse workers, or EMTs—have a greater

risk for osteoarthritis and problems in their knees. In Dr. Hinton’s opinion, however, the

medical research did not yet explain why that portion of the population was more at risk,

but he speculated that it could be linked to more “definable injuries, . . . less access to

health care, . . . they smoke more, . . . [or] they’re overweight, we don’t know.” Dr. Hinton

did acknowledge that the CDC considered occupations involving repetitive knee bending

and squatting to be a risk factor for osteoarthritis, along with “age, genetics, weight,

injuries, [and] infections[.]”

       Dr. Hinton then stated that he would consider Mr. Quinlan’s 2005 on-the-job injury

one instance that could be considered a relevant symptom for cumulative trauma, which



                                                9
sparked the following exchange:

      [MR. QUINLAN’S COUNSEL]: Okay and so in, in the sense that he had
      other episodes of[] tripping or, you know, banging his knee or, you know,
      lifting a heavy patient and saying oh, I have pain, those would be things that
      would sway you to the conclusion in part, at least, or move you closer to the
      conclusion that his occupation did have a primary role in the, in the
      development of his osteoarthritis, right?

      DR. HINTON: The fact that he had an episode, it was definable and required
      treatment, makes me, I have to bring into the equation that injury on the job
      as potentially a risk factor for some of his knee complaints.

                                      * * *

      DR. HINTON: And again, it’s one episode but it is [one] more episode
      than I had when I did my [exam] on him.

                                      * * *

      DR. HINTON: So, it, it does [sic] into the equation a little bit more than it
      did when I saw him for my [exam]. I think he also has, again, other risk
      factors that are just as significant as that, but I didn’t have that when I did
      my–

      [MR. QUINLAN’S COUNSEL]: Okay. So, [] that episode, if I understand
      you correctly, moves you closer to supporting the, the idea that the
      occupation had a more than indirect role in [the] development of his knee
      osteoarthritis, correct, if I understand you correctly?

                                      * * *

      DR. HINTON: . . . [I]t’s important, the fact is he had an occupational
      injury that I think could contribute to long term knee problems.

      [MR. QUINLAN’S COUNSEL]: All right.

      DR. HINTON: I’m not convinced that his occupation as an
      EMT/firefighter is any more injurious or risky for his knee th[a]n a
      bunch of other jobs out there. But he did have an on the job injury,
      which I have to put into the equation.

(Emphasis added). Dr. Hinton then testified that he believed weight was the biggest risk


                                            10
factor, followed by age, and “a history of definable injury on the job is next[,]” followed

by body alignment and gender. Although he would not consider an occupational injury as

the primary cause, he described it as a “potential cause” or “arguable cause.”

                                      3. The Verdict

       The jury returned a verdict finding that Mr. Quinlan “sustain[ed] an occupational

disease of right knee degenerative tears of the medial and lateral menisci of the right knee,

arising out of and in the course of his employment.” Four days later, on April 24, 2017,

the court, Judge Ruth Jakubowski, entered an order vacating the Commission’s order and

remanding the case for entry of an order consistent with the jury’s verdict.

       The County noted its timely appeal to this Court on April 28, 2017.

                                      DISCUSSION

                                            I.

       The County argues on appeal that “[t]here is absolutely no evidence that right knee

degenerative tears of the medial and lateral menisci is an occupational disease.” It asserts

that to be compensable, “the disease must be an inherent risk of employment.” According

to the County, the testimony of Doctors Hinton and Cochran make clear that osteoarthritis

and degenerative knee tears are “not [] disease[s] inherent in Mr. Quinlan’s employment[.]”

The County asserts: “Osteoarthritis is not a disease caused by employment, but is rather a

disease of life. . . . [T]he mere happening of pain or discomfort while at work does not

render these conditions work related, caused by work, or is [sic] an occupational disease.”

The County also challenges Dr. Cochran’s reliance on the Framington Heart Study, “in

which the authors agree they do not have enough subjects to reach a definitive opinion


                                             11
regarding the relationship between occupational stress and O/E/degenerative meniscus

tears.” Finally, after reiterating that Mr. Quinlan is overweight and lives in a house with

stairs, the County asserts: “A disease cannot be occupational if it [is] wide spread in the

population and is not inherent to the occupation.”

       In response, Mr. Quinlan contends that “the proper analysis is not whether a disease

is labeled occupational or not, . . . but rather whether the basic job responsibilities exposed

an individual to conditions that could lead to the disease.” He asserts that he “provided the

jury with more than enough evidence for them to find that his responsibilities as a

paramedic led to his occupational disease of right knee degenerative tears.” In addition to

his own testimony about his job requirements and the aches and pains he felt regularly, Mr.

Quinlan points to Dr. Cochran’s testimony about the stresses his job responsibilities placed

on his right knee and Dr. Hinton’s acknowledgment that his job could have played a role

in his degenerative tears. Mr. Quinlan then argues that his occupational responsibilities

need only contribute in part to his diagnosis. He says he does not, nor has he ever

“dispute[d] that there were potentially other causes in addition to his work that could have

led to the diagnosis because by law there can be more than one cause for the degenerative

tears as long as his work as a paramedic contributed in part, which there is ample evidence

that it did.”

       A claimant appealing the Commission’s denial of a claim retains the burden of proof

before the circuit court. Keystone Masonry Corp. v. Hernandez, 156 Md. App. 496, 505

(2004) (citations omitted). On an appeal of a jury verdict to this Court, we treat the jury’s

decision as conclusive on all issues of fact. Id. at 506 (citation omitted). We will not


                                              12
reweigh the evidence; we must determine simply whether the evidence presented at trial

was legally sufficient to support the jury’s decision. Id. Any issues of law, we review de

novo. See Reger v. Wash. Cty. Bd. of Ed., 455 Md. 68, 95 (2017).

       Under the Maryland Workers’ Compensation Act, an occupational disease is “a

disease contracted by a covered employee: (1) as the result of and in the course of

employment; and (2) that causes the covered employee to become temporarily or

permanently, partially or totally incapacitated.” LE § 9-101(g). As far back as 1939, the

Court of Appeals has described an occupational disease as “some ailment, disorder, or

illness which is the expectable result of working under conditions naturally inherent in the

employment and inseparable therefrom, and is ordinarily slow and insidious in its

approach.” Foble v. Knefely, 176 Md. 474, 486 (1939) (citations omitted). For an illness

to be compensable as an occupational disease, it must also satisfy the limitations of LE §

9-502, which provides in relevant part:

       (d) Limitation on liability. – An employer and insurer are liable to provide
       compensation under subsection (c) of this subsection only if:
           (1) the occupational disease that caused the death or disability:
               (i) is due to the nature of an employment in which hazards of the
               occupational disease exist and the covered employee was
               employed before the date of disablement; or
               (ii) has manifestations that are consistent with those known to result
               from exposure to a biological, chemical, or physical agent that is
               attributable to the type of employment in which the covered employee
               was employed before the date of disablement; and
           (2) on the weight of the evidence, it reasonably may be concluded that
           the occupational disease was incurred as a result of the employment of
           the covered employee.

(Emphasis added).

       A trio of decisions from the mid-to-late-‘90s addressing mental illness are


                                            13
instructive in defining the contours of what qualifies as an occupational disease within the

meaning of the Act. The first of these cases is Davis v. Dynacorp, 336 Md. 226 (1994).

Davis was a computer operator who claimed to have suffered an occupational disease based

on “‘continual harassment’ by both management and fellow employees at Dynacorp[,]”

including bullying, racial abuse, phone calls at home, the defacement of his vehicle, and

coworkers following him outside of work. Id. at 228. “As a result of these and other

similar incidents, Davis alleged that he experienced restlessness, sleeping problems,

headaches, and developed post-traumatic stress syndrome, which prevented him from

returning to work.” Id. The Commission disallowed his claim and the circuit court

affirmed. Id. at 229-30.

       While the appeal was pending before this Court, the Court of Appeals granted

certiorari to consider, inter alia, whether LE § 9-502(d)(1) “requires the employer to

provide occupational disease compensation for ‘job harassment which causes mental

injury.’” Id. at 230. The Court of Appeals observed that “[i]n the instant case, there simply

is not the requisite relationship between the nature of Davis’s work and the ‘disease’ that

he allegedly sustained.” Id. at 238. Although the Court was “not willing to rule out the

possibility that some gradually resulting, purely mental diseases could be compensable

occupational diseases or that there may be circumstances where work-induced stress may

result in a compensable occupational disease[,]” it rejected Davis’s claim. Id. at 238-39.

The Court held “that the mental disease resulting from the harassment encountered by

Davis was not due to the nature of his employment.” Id.

       Three years later, the Court of Appeals revisited the issue in Means v. Baltimore


                                             14
County, 344 Md. 661 (1997). The Court in Means held that post-traumatic stress (“PTSD”)

could, in fact, be compensable as an occupational disease. Id. at 662. Means was a

paramedic who alleged that “‘working a medic unit’” with the County caused her PTSD.

Id. Specifically, Means alleged that her work at two gruesome motor vehicle accidents

caused her PTSD—one in which five teenagers died and one in which a motorcyclist

crashed without wearing a helmet. Id. at 662-63. The Commission found that Means had

not suffered an occupational disease; she appealed, and the circuit court granted summary

judgment in favor of the County on the ground that “PTSD may not form the basis as an

occupational disease claim” as a matter of law, despite Means’ proffer that a therapist

would testify that her employment as a paramedic caused her PTSD. Id. at 664. Again,

the Court of Appeals granted certiorari before this Court considered the claimant’s appeal.

Id.

       After distinguishing the occupation of a paramedic from that of a computer operator,

the Court of Appeals held that “PTSD may be compensable as an occupational disease

under the Workers’ Compensation Act if the claimant can present sufficient evidence to

meet the statutory requirements.” Id. at 670. The Court reasoned: “Unlike the computer

operator in Davis who divided his time between programming computers and reading

manuals, Means’s employment as a paramedic exposed her to events that could potentially

cause PTSD.” Id. at 671. Grappling with the difficulty of proof, the Court likened the

standard of proof to that of a physical injury and opined that PTSD could still be

compensable so long as the claimant proves the statutory requirements. Id. at 673.

Specifically, the Court observed that “[w]orkers who suffer back pain or soft tissue injury


                                            15
as a result of accidents or diseases arising in the course of employment are not denied

compensation due to the difficulty of verification.” Id. (internal quotation marks omitted).

The Court concluded by ruling that, on remand, Means “must prove that the mental illness

she suffers is due to the nature of a paramedic’s job and that employment as a paramedic

entails the hazard of developing PTSD.” Id. at 674-75 (citing LE § 9-502(d)(1)(i)).

       In the final case of this trilogy on mental illness as an occupational disease, the Court

of Appeals considered whether an extremely overworked transportation assistant could

recover for mental illness caused by work-induced stress. King v. Bd. of Ed. of Prince

George’s Cty., 354 Md. 369 (1999). While working as a transportation assistant, King

became responsible for the job duties of three separate positions: “transportation

technician, transportation assistant, and transportation management analyst.” Id. at 371.

King filed a claim with the Commission, alleging that she suffered from an occupational

disease in the form of a nervous breakdown due to working three jobs at one time. Id. at

372. The Commission disallowed her claim, the circuit court granted summary judgment

in the county’s favor, and this Court affirmed. Id. at 372-74.

       After granting certiorari, the Court of Appeals also affirmed. Id. at 382. The Court

explained that “[e]very occupational disease claim, whether mental or physical, must

satisfy the statutory standard of [LE] § 9-502(d)(1)(i), i.e., the alleged disease must be ‘due

to the nature of an employment in which hazards of the occupational disease exist.’” Id. at

381. Because King’s evidence “indicate[d] that she was an overworked employee in a

mismanaged position” and not that her illness was “somehow inherent in the nature of the

position of transportation assistant[,]” the Court held that King could not satisfy the


                                              16
requirements of LE § 9-502(d)(1)(i). Id. Nor did King present evidence that her illness

would occur any more frequently in her occupation than “in any other occupation in which

employees were overworked and/or mismanaged.” Id. The Court ruled that the term

“‘[e]mployment’ in the context of [LE] § 9-502(d)(1)(i) does not mean the specific job in

which the person is working; it means the profession or general occupation in which the

person is engaged.” Id. at 381-82 (citations omitted).

       In 2009, this Court decided an appeal involving facts very similar to those presented

in the underlying case. In Black & Decker Corp. v. Humbert, Black & Decker employed

Humbert as a licensed electrician and occasionally required him to work as a vehicle

mechanic, plumber, and carpenter, and operate a front-end loader to remove snow. 189

Md. App. 171, 174-76 (2009). Humbert’s employment required him to stand on a ladder

and reach up to the ceiling to replace lights, take down and put up ceilings, and replace and

install wires. Id. at 175. While performing mechanic work, he frequently had to lie on his

back under vehicles to reach his arm up into the engine compartment. Id. at 176. While

removing snow, he used his arm to push and pull the levers on a front-end loader. Id. After

a decade on the job and 25 total years as an electrician, Humbert sought medical attention

for fatigue and soreness in his right shoulder. Id. His doctor first diagnosed him with

“‘moderate tendonitis in the lateral supraspinatus tendon’” and eventually “discovered that

his problem was ‘possibly work related.’” Id. at 176-77. Diagnostic studies revealed that

a bone spur in Humber’s right shoulder contributed to the development of shoulder

impingement syndrome, also known as tendonitis. Id. at 177. His doctor testified that the

syndrome had two causes: “1) activities such as continuous reaching overhead that results


                                             17
in inflammation and 2) the presence of a spur.” Id. His doctor further explained that the

mere presence of a spur, however, “which is often a congenital condition, does not mean

that a person will develop impingement syndrome. But with the spur present, people often

develop impingement syndrome by years of repetitive activities such as reaching

overhead.” Id. His doctor testified further that Humbert’s job seemed to be “‘the type of

occupation that would . . . cause these problems to develop.’” Id. He reiterated, though,

that the job alone—absent the bone spur—would not have caused Humbert’s injury. Id. at

177-78.

       The Commission disallowed Humbert’s claim for benefits for an occupational

disease and he appealed to the circuit court. Id. at 174. After the circuit court denied Black

& Decker’s motion for judgment as a matter of law, a jury found that Humbert had suffered

an occupational disease. Id. at 175. Black & Decker appealed to this Court, asserting in

large part that the cause of Humbert’s injury was aggravation of a bone spur, which was

not occupational in character. Id. at 179. In affirming the circuit court’s judgment, we

distinguished the Court of Appeals’ decision in Blake v. Bethlehem Steel Co., 225 Md. 196

(1961), and relied on this Court’s decision in Allied-Signal, Inc. v. Bobbitt, 96 Md. App.

157 (1993), rev’d on other grounds, 334 Md. 347 (1994).

       In Blake, a pipe-fitter claimed that his chronic bronchitis was an occupational

disease, alleging that his work at Bethlehem Steel and exposure to dust aggravated a

bronchial susceptibility he had prior to his employment. 225 Md. at 198. After the

Commission granted Blake a workers’ compensation award, the company appealed and the

circuit court “found as matter of law that there was no evidence legally sufficient to show


                                             18
an occupational disease or aggravation thereof.” Id. at 197. At trial, “[t]here was testimony

that the incidence of bronchial disorders was no higher among workers around open hearth

furnaces than among the general city populations.” Id. at 198-99. On appeal, the Court of

Appeals explained that, “since chronic bronchitis and its sequelae were not shown to be

characteristic of the industry, the claim is that disability from a cause not itself

compensable, was ‘aggravated . . . or contributed to by an occupational disease[.]’” Id. at

200. Blake argued “that an ordinary disease may become occupational where it is

aggravated by the occupational environment.” Id. The Court disagreed, holding that even

if the working conditions aggravated Blake’s non-occupational disease, the result was not

an occupational disease. Id. The Court reasoned that to support a claim, “there must be a

finding that, in part at least, the disability is due to an occupational disease, and the claim

can be allowed only for that part.” Id.

        This Court in Humbert distinguished “the situation in Blake, where the claimant

suffered from pre-existing chronic bronchitis prior to working for the defendant,” from

Humbert, who “never had shoulder impingement syndrome prior to working for appellant

and, but for the work-related activities (frequent necessity to reach overhead as part of his

employment as an electrician), the shoulder impingement syndrome would not have

developed—according to [his doctor’s testimony].” 189 Md. App. at 182. We found

Humbert’s illness to be more akin to that in Bobbitt, in which the claimant also suffered

from shoulder impingement syndrome. Id. at 182-83 (citing Bobbitt, 96 Md. App. at 161,

166).

        In Bobbitt, this Court noted “that under the Blake analysis the focus is not whether


                                              19
the pre-existing condition is occupational in character but whether the resulting condition

is due, in part at least, to the occupation.” 96 Md. App. at 167 (emphasis added). Although

there was evidence to support the company’s position that the syndrome was due to the

aggravation of a prior condition, this Court reasoned that “we must view the evidence in

the light most favorable to appellee.” Id. Looking to expert testimony at trial, this Court

highlighted testimony that “the shoulder impingement syndrome resulted from the

repetitive activities inherent in her work; ‘you cannot separate the condition from the

work[.]’” Id. We held that “[t]his testimony establishe[d] that even if the arthritis effected

the development of the shoulder condition, the condition was due in part to the

characteristics of appellee’s employment[,]” and thus raised a jury question. Id. at 167-68.

       Recounting the decision in Bobbitt, this Court in Humbert emphasized that “the

focus that the court should apply is to the issue of whether the resulting condition (shoulder

impingement syndrome) is due, in part, to the occupation.” 189 Md. App. at 184. We went

on to hold that expert testimony at trial made it clear that “Humbert’s shoulder

impingement syndrome resulted, in part, from the repetitive overhead activities inherent in

his work as an electrician.” Id. Even though Humbert had not presented expert testimony

on ergonomics or the frequency with which electricians suffer impingement syndrome, we

reasoned that the jury could have found Humbert’s testimony regarding his job duties

sufficient to establish the job duties typical of electricians. Id. at 186. “Humbert’s

testimony was that the job requirements of an electrician made it necessary to have repeated

overhead arm motions; moreover, Dr. Wittstadt testified that such motions, when coupled

with the pre-existing bone spur, were the cause for the impingement syndrome.” Id.


                                             20
Additionally, we explained:

       To be compensable, it is the risk factors, not the disease, that must inhere in
       the nature of the employment. Taking the evidence in the light most
       favorable to Humbert, one of the risk factors of being an electrician is
       developing impingement syndrome due to the necessity of reaching about
       one’s head repeatedly.

Id. at 187.

       Finally, we recounted the Court of Appeals’ trilogy of mental illness cases discussed

above and synthesized the following standard for applying LE § 9-502(d)(1)(i): “[T]he

Court must examine the duties of a claimant’s profession to determine if the hazard that

led to the disease exists in the nature of that employment.” Id. at 191. We concluded that

Humbert “met that threshold requirement by introducing evidence that showed: 1)

overhead reaching is a regular part of an electrician’s job, and 2) repeated overhead

reaching is a risk factor for developing shoulder impingement syndrome.” Id.

       Returning to the County’s appeal in this case, we believe that Mr. Quinlan presented

evidence sufficient to prove that his menisci tears are an occupational disease. According

to Mr. Quinlan’s trial testimony, being a paramedic required him to kneel for lengthy

periods of time, numerous times per week during his 24-year career with the County, and

that he tended to kneel on his right knee. His job also required him to carry heavy patients

down stairs and lift them onto stretchers. Prior to his knee surgery, Mr. Quinlan’s job

caused him to seek medical treatment for knee soreness on at least one prior occasion.

       In addition to testifying about his job duties and the soreness he felt routinely after

work, Mr. Quinlan presented expert testimony supporting his claim that he suffered an

occupational disease. Dr. Cochran testified that overuse or repetitive trauma were risk


                                             21
factors for Mr. Quinlan’s injury because the stress of squatting puts pressure on the menisci

and doing so on a repetitive basis causes inflammation to reoccur more quickly than the

body can repair itself. She also testified that at least one study showed that firefighters

have a “significant” risk of osteoarthritis relative to the rest of the population. Dr. Cochran

opined that Mr. Quinlan’s “essential job functions, which include considerable repetitive

kneeling, bending, stress on the knee, [are] the cause of his knee osteoarthritis.”

       Likewise, the County’s own expert, Dr. Hinton, acknowledged that medical

literature suggests that people in more physically demanding jobs, such as firefighters and

EMTs, suffer menisci tears and arthritis at a higher rate than the general population and

that the CDC considers “occupations involving repetitive knee bending and squatting” as

risk factors for osteoarthritis. Additionally, after being informed on re-cross-examination

that Mr. Quinlan suffered a prior work-related knee injury, Dr. Hinton changed his opinion

to conclude that an occupational injury was a “potential” or “arguable” cause of Mr.

Quinlan’s menisci tears and arthritis.

       The County suggests that osteoarthritis cannot be an occupational disease because

it is “a disease of life” and is “something that will happen to all of us.” Even if the County

had preserved this sweeping legal argument, see Maryland Rule 8-131(a) (“Ordinarily, the

appellate court will not decide any other issue unless it plainly appears by the record to

have been raised in or decided by the trial court[.]”), we would find it unconvincing. As

we stated in Humbert, “[t]o be compensable, it is the risk factors, not the disease, that must

inhere in the nature of the employment.” Id. at 187 (emphasis added). The Act does not

limit occupational diseases to rare diseases or those exclusive to a specific profession.


                                              22
Instead, the disease must be one “due to the nature of an employment in which hazards of

the occupational disease exist and the covered employee was employed before the date of

disablement[.]” LE § 9-502(d)(1)(i). As the Court of Appeals explained in Means,

“[w]orkers who suffer back pain or soft tissue injury as a result of accidents or diseases

arising in the course of employment are not denied compensation due to the difficulty of

verification.” 344 Md. at 673 (citation and quotation marks omitted).

       Looking to the risk factors relevant in this case, the County’s own expert testified

that people in occupations that require more squatting and kneeling—such as EMTs and

firefighters—are at a higher risk for osteoarthritis and knee problems. Similarly, Dr.

Cochran testified that people in Mr. Quinlan’s occupation suffer menisci tears and arthritis

at a higher rate than the general population. Cf. King, 354 Md. at 381 (noting that King

failed to present evidence showing that her illness would occur more frequently in her

occupation than “in any other occupation”). That other risk factors—such as Mr. Quinlan’s

weight—were present does not preclude the jury from concluding that Mr. Quinlan’s

occupation caused the degenerative tears in his menisci. See Hernandez, 156 Md. App. at

505-06. The evidence also showed that Mr. Quinlan did not have menisci tears or

osteoarthritis prior to working for the County. As this Court explained in Humbert, “the

focus that the court should apply is to the issue of whether the resulting condition . . . is

due, in part, to the occupation.” 189 Md. App. at 184 (emphasis added). Viewed in the

light most favorable to Mr. Quinlan, the evidence at trial established that, even if Mr.

Quinlan’s weight and age were contributing factors to the development of his knee

condition, “the condition was due in part to the characteristics of appellee’s


                                             23
employment[,]” and thus raised a jury question. See Bobbitt, 96 Md. App. at 167-68.

       In sum, Mr. Quinlan met the statutory requirements of LE § 9-502(d)(1) by

establishing at trial that the degenerative menisci tears were an occupational disease

through testimony that showed that repetitive kneeling and squatting is (1) a regular part

of a paramedic’s job and (2) a risk factor for developing menisci tears, which Dr. Cochran

explained are “part of the continuum of osteoarthritis.” See Humbert, 189 Md. App. at

191. This was sufficient evidence for the jury to determine that, “but for the work-related

activities[,]” his condition would not have developed. Id. at 182. We will not second guess

the jury’s fact finding on appeal. See Hernandez, 156 Md. App. at 506.

                                          JUDGMENT OF THE CIRCUIT COURT
                                          FOR BALTIMORE COUNTY AFFIRMED.
                                          COSTS TO BE PAID BY APPELLANT.




                                            24
