               IN THE COMMONWEALTH COURT OF PENNSYLVANIA


Cathy Nigro,                             :
                   Petitioner            :
                                         :   No. 1802 C.D. 2017
            v.                           :
                                         :   Submitted: March 16, 2018
Workers’ Compensation Appeal             :
Board (Aetna Inc.),                      :
                   Respondent            :


BEFORE:     HONORABLE RENÉE COHN JUBELIRER, Judge
            HONORABLE PATRICIA A. McCULLOUGH, Judge
            HONORABLE JAMES GARDNER COLINS, Senior Judge


OPINION NOT REPORTED

MEMORANDUM OPINION
BY JUDGE McCULLOUGH                                            FILED: May 22, 2018


            Cathy Nigro (Claimant) petitions for review of the November 8, 2017
order of the Workers’ Compensation Appeal Board (Board) affirming the decision of
the Workers’ Compensation Judge (WCJ) denying Claimant’s claim petition.


                           Facts and Procedural History
            Claimant was employed by Aetna, Inc. (Employer) in various capacities
since 1990, and last served as a senior claims benefits specialist for Employer. On
December 2, 2013, Claimant filed a claim petition alleging that she sustained an injury
to her left hand, arm, and fingers on April 30, 2012, as a result of cumulative trauma
from typing in the course and scope of her employment with Employer. Claimant
sought total disability benefits as of May 17, 2012, the date she stopped working for
Employer. Employer filed an answer denying the material allegations of Claimant’s
petition. Employer later filed an amended answer raising an affirmative defense that
Claimant’s petition was barred by the 3-year statute of limitations set forth in section
315 of the Pennsylvania Workers’ Compensation Act (Act).1 The case was assigned
to the WCJ and proceeded with hearings. (Findings of Fact Nos. 2-3.)
                At these hearings, Claimant testified that she worked for Employer since
1990, and her last position as a senior claims benefits specialist involved reprocessing
insurance claims by typing targets.                 Claimant stated that she typically typed
continuously during an 8-hour shift, except during breaks. Claimant noted that while
typing on April 30, 2012, her left hand turned deep blue and she started having pain
and muscle spasms in that hand. Claimant indicated that she worked from home and
was in contact with her supervisor, Michael Abrams, once or twice per week. Claimant
said that she reported to Abrams that she was having difficulty working because of the
problems with her left hand and eventually stopped working as of May 16, 2012. At
that time, Claimant also reported her symptoms as a work-related injury to the
appropriate unit of Employer. (Finding of Fact No. 5(a)-(b).)
                Claimant sought treatment from her primary care physician, a vascular
surgeon, and a neurologist before coming under the care of Anna Mathew, M.D., a
physiatrist. As of the date of her testimony, January 15, 2014, Claimant stated that she

       1
          Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §602. Section 315 of the Act provides,
in pertinent part,

                In cases of personal injury all claims for compensation shall be forever
                barred, unless, within three years after the injury, the parties shall have
                agreed upon the compensation payable under this article; or unless
                within three years after the injury, one of the parties shall have filed a
                petition as provided in article four hereof.

77 P.S. §602.

                                                    2
continued to have discoloration and pain in her left hand. Claimant acknowledged that
she had previous problems with that hand dating back to 2003, at which time she
underwent carpal tunnel and cubital tunnel surgery, but noted that she returned to full
duty work in 2006. Claimant also acknowledged that she underwent left tennis elbow
surgery in 2011, but stated that she had returned to her regular position shortly
thereafter. (Finding of Fact No. 5(c)-(d).)
             On cross-examination, Claimant admitted that she received short-term and
long-term disability benefits through Employer after she stopped working in May 2012.
Claimant also stated that she did not receive any workers’ compensation benefits
related to her prior carpal tunnel, cubital tunnel, or left tennis elbow surgeries. As of
the January 2014 hearing, Claimant acknowledged that she had only seen Dr. Mathew
on one occasion in November 2013 and had not received any medical treatment for her
claimed left hand work injury. Claimant also acknowledged that her left hand was not
discolored at the hearing but explained that the discoloration varies from time to time.
Claimant denied having any complaints or symptoms in her left hand since the last
surgery, up until April 30, 2012, when the symptoms started all at once. Claimant
noted that Dr. Mathew had recommended therapy but had not yet scheduled the same
due to an unrelated medical condition. Finally, Claimant indicated her belief that she
was entirely unable to work and denied that she could perform even a sedentary
position without the use of her left hand. (Finding of Fact No. 5(e)-(j).)
             Claimant presented the deposition testimony of Dr. Mathew, who is
board-certified in internal medicine and occupational and environmental medicine, in
support of her claim petition. Dr. Mathew began by stating that she does not perform
surgery and mainly focuses her practice on rehabilitation and non-surgical treatment.
Dr. Mathew testified that she first evaluated Claimant on November 18, 2013, for
complaints of pain, spasm, and discoloration in Claimant’s left hand. She noted that

                                              3
an EMG performed in June of 2013 indicated residual effects from prior carpal tunnel
surgery and mild, bilateral carpal tunnel syndrome. She also noted that Claimant had
been referred to a pain clinic but was not willing to take the prescribed narcotic
medications. She was aware of Claimant’s prior surgeries and ultimately diagnosed
Claimant with chronic left arm pain, secondary to cumulative trauma disease with a
history of cubital tunnel syndrome, carpal tunnel syndrome, and lateral epicondylitis.
She prescribed medication and recommended therapy as a means to alleviate
Claimant’s problems. (Finding of Fact No. 6(a).)
              Dr. Mathew’s deposition occurred on May 15, 2014, and she testified that
she last saw Claimant on May 6, 2014, at which time Claimant had just begun hand
therapy. She noted that Claimant continued to complain of the same left hand
symptoms reported at the initial evaluation, as well as new pain in the right arm. She
went on to explain that individuals who perform a lot of typing can have cumulative
trauma disease, which she described as a soft tissue injury that is commonly the result
of micro-trauma secondary to repetitive or stressful movement. She believed that
Claimant’s prior and current problems could all fall under the heading of cumulative
trauma disease. She stated that typing and repetitive use of the fingers, along with the
force exerted and abnormal posture, could be factors leading to cumulative trauma
disease, but admitted that it was difficult to determine the exact cause without visiting
Claimant’s job site.2 Finally, Dr. Mathew opined that Claimant is totally disabled as a
result of her work-related condition. (Finding of Fact No. 6(b)-(e).)
              On cross-examination, Dr. Mathew agreed that she had not evaluated
Claimant until 18 months after Claimant stopped working. However, she maintained
her position that Claimant’s ongoing subjective complaints were related to her typing

       2
        On cross-examination, Dr. Mathew admitted that she had not visited Claimant’s work site.
(Reproduced Record (R.R.) at 90a.)

                                               4
activities for Employer even though Claimant had not worked for two years. She
disagreed with the opinion of Employer’s medical expert that Claimant’s work
activities were not the cause of her subjective complaints. She described cumulative
trauma disease as a real syndrome and indicated her belief that she is more familiar
with this condition than Employer’s medical expert. She did acknowledge that an
arterial Doppler study and a 3-phase bone scan of Claimant’s left arm taken in 2012
were normal. She also acknowledged that she never noticed Claimant’s left hand being
blue during any examination. While she was aware that Claimant suffered from
depression, anxiety, and post-traumatic stress disorder, Dr. Mathew could not opine
whether these mental issues prevented Claimant from working.               Finally, she
acknowledged that notes from Claimant’s April 27, 2012 visit to her primary care
physician reference Claimant’s left hand turning blue, but do not mention pain, and
that notes from a September 27, 2012 visit reflect a normal examination with the
exception of some left shoulder pain. (Finding of Fact No. 6(f)-(k).)
             Employer presented the deposition testimony of Robert Goitz, M.D., a
board-certified orthopedic surgeon with an added qualification for hand surgery, in
opposition to Claimant’s petition. Dr. Goitz stated that he focuses his practice on
treating patients for all conditions of the hand, wrist, and arm. He examined Claimant
on February 24, 2014, at which time Claimant complained of discoloration of her left
hand and pain radiating from her left hand to her shoulder, as well as weakness, spasms,
and cramping in her left hand. Claimant described her position with Employer as
involving continuous typing activities and informed Dr. Goitz that the symptoms had
not changed since she stopped working. Dr. Goitz reviewed Claimant’s medical
records, which detailed her previous carpal tunnel, cubital tunnel, and left tennis elbow
surgeries. (Finding of Fact No. 7(a)-(b).)



                                             5
             Dr. Goitz also reviewed a bone scan conducted on August 9, 2012, which
was normal, and various electrodiagnostic studies, the last of which, dated December
24, 2013, revealed mild, bilateral carpal tunnel syndrome. However, he testified that
such a result would be expected given Claimant’s prior surgeries. He did not relate
Claimant’s condition to her work activities for Employer due to the passage of almost
two years between his examination and when Claimant last worked and because a
causal relation between typing and carpal tunnel syndrome has never been established
medically. Upon examination, Dr. Goitz observed no visual abnormality of Claimant’s
left hand and full range of motion and no swelling of any area of Claimant’s left upper
extremity. Upon further examination, Dr. Goitz stated that Claimant had normal
sensation of each fingertip of both hands. Dr. Goitz indicated that the only clinical
abnormality related to a pinch strength test, which was indicative of an ulnar nerve
problem and inconsistent with the results of the electrodiagnostic studies.          He
questioned whether Claimant was giving effort during this test. He also questioned
whether Claimant was giving effort during a grip strength test, noting a high
discrepancy in the results on each side. In fact, Dr. Goitz performed this test three
times on each hand and the results varied to such an extent that he found that Claimant
was not giving a sufficient and consistent effort on each side. Essentially, he described
the examination of Claimant’s left hand as normal. (Finding of Fact No. 7(c)-(d).)
             Dr. Goitz testified that there was no medical explanation for Claimant’s
subjective complaints. He reiterated his belief that Claimant’s work activities were not
the cause of her complaints, especially because Claimant stopped working two years
before his examination, the symptoms did not change, and there were no studies to
support a relationship between repetitive typing and carpal tunnel or cubital tunnel
syndrome. He disagreed with Dr. Mathew’s opinion on causation, stating that only one
of Claimant’s arms was subjectively symptomatic. He opined that Claimant had fully

                                           6
recovered from any left hand symptoms she may have sustained and could return to her
full-time position without any restrictions. He also reiterated his belief that Claimant
was magnifying her symptoms during his examination. (Finding of Fact No. 7(e)-(g).)
              On cross-examination, Dr. Goitz stated that carpal tunnel and cubital
tunnel syndrome are not caused by low impact, low stress activities, but instead are
associated with high stress, highly repetitive activities such as moving heavy motors
on an assembly line. He acknowledged that some patients have complained that office
work, such as typing, exacerbated carpal and cubital tunnel conditions. Dr. Goitz
opined that, because Claimant continued to have the same complaints, unresolved two
years after she stopped working/typing, he would not diagnose her with cumulative
trauma disease. (Finding of Fact No. 7(h)-(i).)
              By decision and order circulated July 22, 2016, the WCJ denied
Claimant’s claim petition, concluding that she failed to meet her burden of establishing
that she sustained a work injury on April 30, 2012.3 In reaching this conclusion, the
WCJ rejected the testimony of Claimant as not persuasive, citing the lack of any
notation of discoloration of her left hand by Dr. Mathew or Dr. Goitz; the lack of any
complaints of left hand pain in the treatment notes of Claimant’s primary care physician
for visits on April 27 and September 27, 2012; and the symptom magnification as noted
by Dr. Goitz. Regarding the medical testimony, the WCJ accepted the testimony of
Dr. Goitz as more persuasive than that of Dr. Mathew, explaining that Dr. Goitz was
better qualified as an orthopedic surgeon with an added qualification for hand surgery,
and his opinion was more logical and thoughtful. The WCJ also noted that Dr. Mathew
provided no testimony regarding any physical examination of Claimant’s left hand. In

       3
         Alternatively, the WCJ concluded that Claimant failed to provide timely notice within 120
days of her work injury as required by section 311 of the Act, 77 P.S. §631, as Claimant knew or
should have known of the existence of her claimed work-related left hand condition in 2003 and its
possible relationship to her employment.

                                                7
addition, the WCJ described Dr. Mathew’s opinion on causation as equivocal, as she
testified that Claimant’s work activities “could be factors leading to Claimant having
cumulative trauma disease, stating that it was difficult to determine the exact cause of
the disease,” and that “Claimant’s work activities could result” in her condition.
(Finding of Fact No. 13.) Claimant appealed to the Board, but the Board affirmed.


                                          Discussion
              On appeal to this Court,4 Claimant argues that the Board erred in affirming
the WCJ’s decision denying her claim petition. More specifically, Claimant argues
that she presented sufficient evidence to meet her burden of establishing that she
sustained an injury in the nature of cumulative trauma disease as result of her work for
Employer. We disagree.
              The law is well settled that the WCJ, as the fact-finder, has complete
authority over questions of witness credibility and evidentiary weight.                  Verizon
Pennsylvania, Inc. v. Workers’ Compensation Appeal Board (Mills), 116 A.3d 1157,
1162 (Pa. Cmwlth. 2015). For purposes of this Court’s review, it is irrelevant whether
evidence exists to support contrary findings; rather, if substantial, competent evidence
exists to support the WCJ’s necessary findings, those findings will not be disturbed on
appeal. Id. “Substantial evidence is such relevant evidence which a reasonable mind
might accept as adequate to support a finding.”                    Berardelli v. Workmen’s
Compensation Appeal Board (Bureau of Personnel State Workmen’s Insurance Fund),
578 A.2d 1016, 1018 (Pa. Cmwlth. 1990). Accordingly, the WCJ has exclusive

       4
         Our scope of review is limited to determining whether findings of fact are supported by
substantial evidence, whether an error of law has been committed, or whether constitutional rights
have been violated. Section 704 of the Administrative Agency Law, 2 Pa.C.S. §704; Meadow Lakes
Apartments v. Workers’ Compensation Appeal Board (Spencer), 894 A.2d 214, 216 n.3 (Pa. Cmwlth.
2006).

                                                8
province over credibility and weight determinations and may accept or reject the
testimony of any witness, in whole or in part. Verizon Pennsylvania, Inc., 116 A.3d at
1162. We may overturn a credibility determination “only if it is arbitrary or capricious
or so fundamentally dependent on a misapprehension of facts, or so otherwise flawed,
as to render it irrational.” Casne v. Workers’ Compensation Appeal Board (STAT
Couriers, Inc.), 962 A.2d 14, 19 (Pa. Cmwlth. 2008).
             In the present case, the WCJ rejected the testimony of Claimant and her
medical expert, Dr. Mathew, as neither credible nor persuasive. Additionally, the WCJ
accepted the testimony of Employer’s medical expert, Dr. Goitz, as credible and more
persuasive than that of Dr. Mathew. The credible testimony of Dr. Goitz supports the
WCJ’s findings and conclusions in this case. The WCJ provided ample explanation
for the reasoning underlying her credibility determinations. Claimant’s brief on appeal
consists almost entirely of a challenge to the WCJ’s credibility determinations and the
weight the WCJ assigned to the evidence presented by the parties. However, as noted
above, such determinations are within the exclusive province of the WCJ and will not
be disturbed on appeal. Verizon Pennsylvania, Inc.
             Moreover, Claimant argues that Dr. Mathew was more experienced with
cases of occupational disease and, in particular, cumulative trauma disease, than Dr.
Goitz, who worked as a surgeon. However, Claimant raised this issue before the WCJ
and it goes to the weight of the evidence to be assigned to the respective medical
testimony herein, which the WCJ ultimately decided in Employer’s favor. Claimant
has not presented any basis upon which this Court could conclude that the testimony
of Dr. Goitz was “arbitrary or capricious or so fundamentally dependent on a
misapprehension of facts, or so otherwise flawed, as to render it irrational.” Casne,
962 A.2d at 19. To the contrary, in his testimony, Dr. Goitz provided a thorough review
of his examination of Claimant, which included a normal bone scan in 2012, expected

                                           9
results from electrodiagnostic studies conducted in 2013, what he perceived to be
symptom magnification by Claimant, and his opinion as to her condition, which he
believed was unrelated to her activities at work. Thus, the credibility determinations
of the WCJ must stand.
               Finally, Claimant appears to suggest in her brief that the causal connection
between Claimant’s injury and her disability in this matter was obvious, thereby
obviating the need for presentation of medical evidence establishing the same. Again,
we disagree.
               Claimant is correct that in cases where the connection between a work
injury and subsequent disability is obvious, a claimant need not present medical
evidence establishing this connection.        Northwest Medical Center v. Workers’
Compensation Appeal Board (Cornmesser), 880 A.2d 753, 755 (Pa. Cmwlth. 2005).
In Northwest Medical Center, we explained that “[a] causal connection is obvious
where an individual is doing an act that requires force or strain and pain is immediately
experienced at the point of force or strain.” Id. (citation omitted). In that case, the
claimant, a registered nurse, felt a pop in his back and immediately experienced pain
and stiffness while attempting to move a large patient, which he immediately
mentioned to a coworker. Within a week, the claimant was hospitalized and operated
on for a herniated disk.
               The present case is distinguishable. In this case, Claimant underwent
multiple surgeries in the past related to carpal tunnel syndrome and tennis elbow, and
Claimant admitted that she did not receive workers’ compensation benefits for time
missed as a result of these surgeries. In addition, while Claimant testified that she first
experienced problems with her left hand on April 30, 2012, she continued working for
an additional two weeks, until May 16, 2012. Claimant did not cease working as a
result of an easily identifiable event or immediate onset of pain. To the contrary,

                                             10
Claimant was alleging cumulative trauma disease, which by its very terms consists of
repeated trauma to an identified area. Further, the fact that the causal relationship was
not obvious is emphasized by the disagreement between the medical experts in this
case, Dr. Mathew and Dr. Goitz, regarding the very existence of a causal connection
between repetitive typing and carpal tunnel or cubital tunnel syndrome. Thus, we
cannot agree with Claimant to the extent that she argues that the causal connection
between her injury and disability in this matter was obvious.


                                      Conclusion
             The causal connection between Claimant’s purported work injury and
disability in this matter was not obvious, such that medical evidence was necessary to
establish the same. In that regard, the WCJ accepted the testimony of Dr. Goitz as
credible and more persuasive than that of Dr. Mathew, and this credible testimony
supports the WCJ’s findings and conclusions that Claimant failed to meet her burden
of establishing that she sustained a work injury on April 30, 2012. The WCJ’s
credibility determination is binding on this Court and will not be disturbed on appeal.
             Accordingly, the Board’s order is affirmed.




                                            ________________________________
                                            PATRICIA A. McCULLOUGH, Judge




                                           11
               IN THE COMMONWEALTH COURT OF PENNSYLVANIA


Cathy Nigro,                          :
                  Petitioner          :
                                      :    No. 1802 C.D. 2017
           v.                         :
                                      :
Workers’ Compensation Appeal          :
Board (Aetna Inc.),                   :
                   Respondent         :


                                  ORDER


           AND NOW, this 22nd day of May, 2018, the order of the Workers’
Compensation Appeal Board, dated November 8, 2017, is hereby affirmed.




                                          ________________________________
                                          PATRICIA A. McCULLOUGH, Judge
