                               COURT OF APPEALS OF VIRGINIA


Present: Judges Elder, Beales and Senior Judge Annunziata


MILLER & LONG, INC. AND
 HARTFORD CASUALTY INSURANCE COMPANY/
 SPECIALTY RISK SERVICES
                                                                      MEMORANDUM OPINION *
v.     Record No. 1132-11-2                                                PER CURIAM
                                                                         DECEMBER 6, 2011
LAMONT JAMES KNIGHT


              FROM THE VIRGINIA WORKERS’ COMPENSATION COMMISSION

                 (Claire C. Carr; Rachel A. Riordan; Kalbaugh Pfund & Messersmith,
                 on brief), for appellants. Appellants submitting on brief.

                 (Lynn A. Bradley; Tucker Griffin Barnes, P.C., on brief), for
                 appellee. Appellee submitting on brief.


       Miller & Long and its insurer, Hartford Casualty Insurance Company/Specialty Risk

Services, (hereinafter collectively employer) appeal a decision of the Workers’ Compensation

Commission finding that the left fibular fracture suffered by Lamont James Knight (claimant) on

December 25, 2009, was a compensable consequence of his work-related accident on October

22, 2009. We have reviewed the record and the commission’s opinion and find that there is

credible evidence to support the unanimous opinion of the commission. Accordingly, we affirm

the commission’s decision.

                                            I. Background

       We view the evidence on appeal in the light most favorable to “the prevailing party

before the commission.” Dunnavant v. Newman Tire Co., 51 Va. App. 252, 255, 656 S.E.2d

431, 433 (2008).

       *
           Pursuant to Code § 17.1-413, this opinion is not designated for publication.
       Claimant, a carpenter’s helper, fell on October 22, 2009, while carrying a

twenty-one-foot metal beam on his shoulder with his right arm. Claimant landed on his tailbone

and left side and immediately experienced pain in the upper part of his left hip and in his right

wrist. After reporting his injuries to the foreman and the superintendent, he sought emergency

treatment at the University of Virginia Hospital (UVA) on October 26, 2009. UVA diagnosed

claimant with left hip and right wrist contusions and placed him on “light duty and lifting”

through October 28, 2009.

       On October 29, 2009, claimant returned to UVA complaining of problems with his left

lower back, but no radiating pain. X-rays revealed no fractures in his lumbar spine, coccyx, or

right wrist. UVA placed claimant in a wrist splint and excused him from work for five days. On

November 2, 2009, claimant reported to UVA he was suffering from acute lower back pain, now

radiating into his upper back. Claimant stated he had experienced back pain for two weeks.

UVA prescribed Vicodin and restricted claimant from activities involving lifting, bending,

twisting, or standing. The restrictions extended through November 9, 2009.

       Beginning November 4, 2009, claimant received medical treatment from Dr. Evan B.

Heald, an internist at University Medical Associates Clinic (UMA). Claimant’s pain had

progressed to his left shoulder and neck, with occasional pain in his left wrist, and some pain

radiating into his lateral left thigh. He also experienced tiredness in his low back with no focal

weakness. Dr. Heald diagnosed claimant with “[l]ow back strain with some possible

referred/radicular symptoms into the left lateral thigh,” and released him for light-duty work until

November 9, 2009. In addition to the November 2 work restrictions, claimant was prohibited

from heavy sweeping or pushing.

       Five days later, claimant returned to UMA and saw Dr. Joel Schectman. At that time, he

complained of pain in his left side and intermittent numbness in the bottom of his foot.

                                              - 2-
Dr. Schectman, who found claimant suffered from low back pain and sciatica, prescribed

physical therapy, heat, and medication.

       UMA continued to treat claimant for lower back pain, as well as pain radiating into his

left leg and foot. On November 20, 2009, claimant reported to Dr. P. Preston Reynolds that his

left leg was “weak and unreliable.” He also reported an episode of incontinence.

       On December 2, 2009, Dr. A. Bobby Chhabra, an orthopedic surgeon at McCue Center

Outpatient Clinic, examined claimant. Dr. Chhabra recommended continuing his light-duty

restrictions and ordered an MRI of claimant’s right wrist and lumbar spine. On December 14,

2009, Dr. Gavin Slitt, an internist at UMA, wrote a letter excusing claimant from work for

several dates from October through December 2009. Dr. Slitt noted that claimant’s symptoms

were “most consistent with mechanical lower back injury.”

       Claimant underwent an independent medical examination (IME) on December 23, 2009.

Dr. Howard G. Stern, who examined claimant, concluded his left lower back pain was causally

related to the October 22, 2009 accident and recommended light-duty restrictions.

       Two days after his IME, claimant fell after twisting his left ankle as he walked to his

mailbox. When claimant sought medical treatment on December 28, 2009, he reported he fell

after his “back [and] leg gave out.” An x-ray revealed a fracture in claimant’s left distal fibula.

       Dr. Adam Shimer, an orthopedic surgeon who treated claimant on January 4, 2010,

observed that he had suffered “persistent subjective weakness of his left leg” for the past two and

a half months, and continued to complain of low back pain and left leg pain and weakness.

Dr. Shimer noted claimant reported that the weakness in his left leg had caused him to fall and

fracture his ankle.

       On January 16, 2010, claimant underwent an MRI of his lumbar spine. The MRI

revealed no “fracture, malalignment, or soft tissue injury” and showed mild, multilevel

                                              - 3-
degenerative changes and stenosis. While Dr. Shimer saw no “compressive or traumatic lesions

that could account for his left leg weakness,” he recommended aggressive physical therapy for

claimant, and noted that, if claimant’s symptoms persisted, an EMG/nerve conduction study

should be considered.

       Based on the MRI results, Dr. Stern prepared an addendum to his IME in June 2010,

opining that no causal relationship existed between claimant’s October work accident and his fall

in December. Dr. Stern found that claimant had not suffered any structural lumbar spine injury

in his work accident and that his back injury had fully resolved without any permanency.

       Dr. Andrew Wolf, a UMA physician who oversaw claimant’s treatment beginning

November 4, 2009, disagreed with Dr. Stern’s assessment. In a letter dated July 14, 2010,

Dr. Wolf observed that

              it is certainly plausible that sudden back pain and spasm – as
              [claimant] related occurred – could cause [him] to be unbalanced
              and feel as though his leg gave out. His history given to the
              resident physician on 12/28/09 was that he “fell on Friday after his
              back and leg gave out” so the early medical documentation is
              consistent with this. If the back pain caused the 12/25/09 fall, the
              fibula fracture is indeed related the October 2009 work accident.
              All treatment necessitated by the fracture and work disability from
              it would also be related to the October 2009 work accident.

                  . . . I would like to emphasize that MANY people have severe
              low back pain without demonstrated findings on an MRI-the MRI
              will rarely if ever show findings of severe lumbosacral strain,
              which is what I believe is causing the predominant symptoms in
              Mr. Knight’s case. Mr. Knight clearly has suffered and continues
              to suffer low back pain that began close in time to his October,
              2009 fall (beginning later in the day and getting progressively
              worse over the ensuing day or two, which is what one would
              expect with severe lumbosacral strain, as opposed to disc
              herniation, which generally causes maximum pain immediately
              upon injury). . . . Mr. Knight’s pain complaints and his history of
              onset and worsening are completely consistent with the
              unremarkable MRI findings.

                             *     *     *      *     *     *     *


                                             - 4-
               Regarding Mr. Knight’s occupational status, I continue to hold to
               the opinion . . . [that] [t]o a reasonable degree of medical
               probability, the work disability and work restrictions issued
               throughout Mr. Knight’s treatment at UMA 1 are the result of the
               October 2009 work accident.

       Dr. Wolf “strongly recommended” physical therapy for claimant, and if that proved

unsuccessful, an EMG/nerve conduction study due to the risk of “impingement . . . not fully

evident on the MRI.” Dr. Wolf observed that impingement was consistent with the finding of

mild L5-S1 foraminal stenosis on the MRI and claimant’s response to neuropathic medications.

       At the compensation hearing, claimant denied having ever missed time from work prior

to October 22, 2009, as the result of problems with his lower back, right wrist, left hip, or left

leg. Claimant testified that, following the October accident, he experienced pain in his right

wrist and his “hip area all the way around to [his] . . . center back.” In addition, he had pain

“running” down his left leg, and he noted, “at times . . . my back . . . and my left leg would feel

flimsy, weak and . . . give out to where I had to sit down.” Claimant explained that, on the day

of his December accident, his leg and back felt “flimsy” and “gave out” as he stepped off the

curb outside his apartment.

                                            II. Analysis

       Employer argues the commission erred in finding that claimant’s fibular fracture and fall

on December 25, 2009, was a compensable consequence of his October 22, 2009 work accident.

In support of this argument, employer maintains claimant’s testimony that he fell because his

back “gave out” is not credible. It also contends that Dr. Wolf failed to give an opinion within a

reasonable degree of medical certainty that appellant’s back injury caused his December fall.



       1
         Following his December fall, UMA health care providers continued to treat claimant
and excuse him from work. On March 18, 2010, Dr. Amy Althoff wrote a letter restricting him
from returning to work until “he has received physical therapy treatment which is medically
indicated of [sic] his back and leg pain.”
                                             - 5-
       To receive an award of medical benefits under Code § 65.2-603(A)(1), the evidence must

“support a finding of causal relation between the accidental injury and the [medical] treatment.”

Watkins v. Halco Eng’g, Inc., 225 Va. 97, 101, 300 S.E.2d 761, 763 (1983). The claimant bears

the burden of proving this causal relation by a preponderance of the evidence. Hoffman v.

Carter, 50 Va. App. 199, 214, 648 S.E.2d 318, 326 (2007). In other words, “for the disability

[and its attendant medical treatments] to be compensable, it must be more probable than not that

[the accident] was caused by the work-related factor.” Duffy v. Commonwealth ex rel. Dep’t of

State Police, 22 Va. App. 245, 251, 468 S.E.2d 702, 705 (1996).

               Where such a causal link exists, “the doctrine of compensable
               consequences extends the coverage of the Workers’ Compensation
               Act to the subsequent injury because the subsequent injury is
               treated as if it occurred in the course of and arising out of the
               employee’s employment.”

Berglund Chevrolet, Inc. v. Landrum, 43 Va. App. 742, 751, 601 S.E.2d 693, 697 (2004)

(quoting Bartholow Drywall Co. v. Hill, 12 Va. App. 790, 794, 407 S.E.2d 1, 3 (1991)) (citation

omitted).

       The commission’s determination of causation is a finding of fact. See Henrico Cnty Sch.

Bd. v. Etter, 36 Va. App. 437, 443, 552 S.E.2d 372, 375 (2001); Marcus v. Arlington Cnty Bd. of

Supers., 15 Va. App. 544, 551, 425 S.E.2d 525, 530 (1993). “The commission’s factual

findings . . . are conclusive and binding on this Court if supported by credible evidence.” R.G.

Moore Bldg. Corp. v. Mullins, 10 Va. App. 211, 213, 390 S.E.2d 788, 789 (1990). “The fact that

there is contrary evidence in the record is of no consequence if there is credible evidence to

support the commission’s finding.” Wagner Enters, Inc. v. Brooks, 12 Va. App. 890, 894, 407

S.E.2d 32, 35 (1991) (citing Ingersoll-Rand Co. v. Musick, 7 Va. App. 684, 688, 376 S.E.2d 814,

817 (1989)).




                                              - 6-
       “Causation of a medical condition may be proved by either direct or circumstantial

evidence, including medical evidence or ‘the testimony of a claimant.’” Farmington Country

Club v. Marshall, 47 Va. App. 15, 26, 622 S.E.2d 233, 239 (2005) (quoting Dollar Gen. Store v.

Cridlin, 22 Va. App. 171, 176, 468 S.E.2d 152, 154 (1996)). “‘Medical evidence is not

necessarily conclusive, but is subject to the commission’s consideration and weighing,’” Cridlin,

22 Va. App. at 176, 468 S.E.2d at 154 (quoting Hungerford Mech. Corp. v. Hobson, 11 Va. App.

675, 677, 401 S.E.2d 213, 215 (1991) (addressing evidence used to establish percentage of

incapacity suffered by employee)), and the commission may consider a claimant’s testimony in

its determination of causation, id. (citing Morris v. Badger Powhatan/Figgie Int’l, Inc., 3

Va. App. 276, 281, 348 S.E.2d 876, 878 (1986)). To this end, this Court has held,

               “To appraise the true degree of indispensability which should be
               accorded medical testimony, it is first necessary to dispel the
               misconception that valid awards can stand only if accompanied by
               a definite medical diagnosis. True, in many instances it may be
               impossible to form a judgment on the relation of the employment
               to the injury, or relation of the injury to the disability, without
               analyzing in medical terms what the injury or disease is. But this is
               not invariably so. In appropriate circumstances, awards may be
               made when medical evidence on these matters is inconclusive,
               indecisive, fragmentary, inconsistent, or even nonexistent.”

Id. at 177, 468 S.E.2d at 154-55 (quoting 2B Arthur Larson, The Law of Workmen’s

Compensation § 79.51(a) (1995)).

       “‘As the factfinder, the commission is charged with the responsibility of resolving

questions . . . of controverted facts,’” including questions of witness credibility. United Airlines,

Inc. v. Hayes, 58 Va. App. 220, 238, 708 S.E.2d 418, 426-27 (2011) (quoting Metro. Wash.

Airports Auth. v. Lusby, 41 Va. App. 300, 312, 585 S.E.2d 318, 323 (2003)).

       In support of its argument that claimant’s testimony regarding the cause of his December

fall is not credible, employer notes that claimant told Dr. Francisco Caycedo on January 6, 2010,

that he injured his ankle because he “slipped while walking . . . .” However, the commission
                                              - 7-
reviewed claimant’s medical records and found that his history of reported pain in his back and

left leg, as well as weakness in his left leg, corroborated his testimony that his back “gave out”

on December 25, 2009, resulting in his fall. It noted that, beginning in early November 2009,

claimant had reported pain radiating from his back to his left leg and foot, as well as “left-sided

pain with intermittent foot numbness.” On November 9, 2009, he was diagnosed with sciatica,

and on November 20, 2009, claimant reported to Dr. Reynolds his left leg was “weak and

unreliable” and that he had experienced an episode of incontinence. Consistent with his reports

of weakness in his leg and numbness in his foot, claimant told Dr. Preston on December 28,

2009, he had fallen three days earlier after his back and leg “gave out.” Dr. Slitt, who

documented that claimant’s back “gave out,” found claimant’s explanation “consistent with a fall

and fracture.” Dr. Shimer noted claimant had a history of left leg numbness “which led his left

leg to collapse and resulted in injury to his left ankle.”

        Claimant’s account was further corroborated by Dr. Wolf’s July 14, 2010 letter stating

that the progression and nature of his complaints to his health care providers, as well as the lack

of MRI findings, were consistent with a severe lumbosacral strain. Dr. Wolf found it plausible

that claimant’s back pain and spasm caused him to feel as if his back gave out. Dr. Wolf went on

to opine, to a reasonable degree of medical probability, “that the work disability and work

restrictions issued throughout Mr. Knight’s treatment at UMA are the result of the October 2009

work accident.”

        Employer points out that claimant testified he had “problems” with his right ankle prior

to the accident on October 22, 2009, as well as “instability and problems with [his] gait.” It

argues that, at the time of Dr. Wolf’s letter, Dr. Wolf was “apparently not aware of” this

pre-existing gait problem, thereby diminishing the weight of his causation opinion. Employer

also attacks the credibility of Dr. Wolf’s opinion letter because it fails to address Dr. Wolf’s

                                                - 8-
January 13, 2010 notation that claimant reported he “fell . . . in the snow” in December 2009.

However, employer points to nothing in the record indicating Dr. Wolf was unaware of

claimant’s pre-existing right ankle problem or that claimant told Dr. Wolf his fall resulted from

slippery winter conditions rather than his back “giving out.” Cf. Sneed v. Morengo, Inc., 19

Va. App. 199, 205, 450 S.E.2d 167, 171 (1994) (no error in discounting medical opinion where

claimant expressly acknowledged never having revealed his complete medical history). See also

Amelia Sand Co. v. Ellyson, 43 Va. App. 406, 412, 598 S.E.2d 750, 753 (2004) (expert opinion

still credible despite lack of access to claimant’s entire medical history where record failed to

show claimant lied to health care provider or that expert had changed his original opinion).

       As there is credible evidence in the record to support the commission’s finding of

causation, we do not disturb the commission’s finding on review. See City of Norfolk v. Lillard,

15 Va. App. 424, 430, 424 S.E.2d 243, 246 (1992). Furthermore, because we conclude the

commission did not err in finding that the fibular fracture on December 25, 2009, was a

compensable consequence of the October 22, 2009 work accident, we need not address

employer’s argument 2 that the commission erred in finding claimant was entitled to

compensation benefits and was disabled as alleged.

                                                                                           Affirmed.




       2
           Employer argues that

                if this Court finds that the December 25, 2009 incident was not a
                compensable consequence of the initial October 22, 2009 work
                accident, the resulting disability from the fibular fracture is
                therefore unrelated to the work accident of October 22, 2009. As
                such, the alleged period of disability should be barred as the
                evidence reflects the claimant unjustifiably refused selective
                employment and abandoned his job with the employer.

                                              - 9-
