                       COURT OF APPEALS OF VIRGINIA


Present: Chief Judge Fitzpatrick, * Judges Baker and Annunziata
Argued at Alexandria, Virginia


AMOCO FOAM PRODUCTS COMPANY
                                              OPINION BY
v.   Record No. 0324-97-4         CHIEF JUDGE JOHANNA L. FITZPATRICK
                                           DECEMBER 30, 1997
ESSIE L. JOHNSON


            FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

               Benjamin J. Trichilo (Trichilo, Bancroft,
               McGavin, Horvath & Judkins, P.C., on briefs),
               for appellant.
               Nikolas E. Parthemos (Prosser, Parthemos &
               Bryant, P.C., on brief), for appellee.



        Amoco Foam Products Company (employer) argues on appeal that

the Workers' Compensation Commission erred as a matter of law in

awarding benefits for an injury caused by a compensable

consequence.      We disagree, and we affirm the commission.

                                    I.

        On July 14, 1992, Essie L. Johnson (claimant) sustained a

compensable left ankle injury which required a lengthy course of

treatment, including surgery by Dr. John H. Zoller on June 7,

1994.       Claimant received temporary total disability benefits from

June 7 through August 25, 1994 and temporary partial disability

benefits beginning August 26 through October 19, 1994 as a result

of her ankle injury. 1
        *
      On November 19, 1997, Judge Fitzpatrick succeeded Chief
Judge Moon as chief judge.
        1
      After claimant achieved maximum medical improvement, the
parties stipulated to a 7% loss of function to the left foot.
        On August 20, 1994, while recovering from the surgery,

claimant's left ankle gave way and she fell, damaging her right

knee.    Dr. Zoller diagnosed her injury as internal derangement of

the right knee, and he performed an arthroscopy on November 22,

1994.    The deputy commissioner awarded claimant benefits for her

knee injury, finding that "employer is responsible for this right

knee injury as a compensable consequence of the original injury."

 The full commission affirmed the deputy's decision and found

that claimant's "testimony is sufficient to establish the link

between her serious ankle injury and her fall onto her knee."

This finding was not challenged.
        On November 12, 1995, claimant again fell and filed a claim

seeking compensation for an additional injury to her right knee.

 Dr. Zoller, in an April 9, 1996 letter, expressed his view:
          I tend to think that this was largely due to
          the injury of August 1994. She was having
          pain at the time of November 1995 following
          the injury of August 1994 and her knee
          "buckled" on her. I tend to think that her
          continued pain is what actually caused her to
          buckle, and that this is all causily [sic]
          related to the August 1994 injury.


        Dr. Joseph D. Linehan examined claimant at employer's

request.    He opined that claimant suffered a "degenerative

process in the right knee" and "the right knee problem is in no

way related to the sprained left ankle and its subsequent

surgery."    In a May 8, 1996 letter, Dr. Linehan wrote that "the

Claimant received permanent partial disability compensation
accordingly.



                                   2
fall of November 13, 1995 is not related to the left ankle injury

of July 14, 1992."

     Upon review of the evidence, the deputy commissioner gave

"great weight" to Dr. Zoller's opinion that the November 1995

fall "was caused by pain in the knee resulting from the August,

1994 accident which caused the claimant to feel that it buckled

under her."   The deputy commissioner found the November 1995 knee

injury was a compensable consequence of the August 1994 knee

injury and thus a compensable consequence of the original ankle

injury.
     The full commission affirmed, making the following specific

findings and conclusions:
          The knee injury originally sustained on
          August 20, 1994, is treated as if it occurred
          in the course of and arising out of the
          claimant's employment. Moreover, the
          doctrine of compensable consequences is
          applicable both to an aggravation of a prior
          compensable injury and a new injury.
          Therefore, the claimant is entitled to
          benefits for disability related to her
          compensable knee injury.

          Dr. Zoller, the claimant's treating
          physician, relates the November 12, 1995,
          fall to the August 20, 1994, injury. We find
          his opinion persuasive . . . . Dr. Linehan's
          report, which focuses on an irrelevant issue,
          was properly discounted by the Deputy
          Commissioner.


                                II.

     Viewed in the light most favorable to the claimant, who

prevailed before the commission, see Fairfax County v. Espinola,

11 Va. App. 126, 129, 396 S.E.2d 856, 858 (1990), the record



                                 3
reflects conflicting medical testimony from Dr. Zoller and Dr.

Linehan regarding the relationship between claimant's 1995 knee

injury and her ankle injury.    It was Dr. Zoller's view that the

November 1995 fall and knee injury were causally related to the

August 1994 knee injury.   Dr. Linehan opined that claimant

suffered from a degenerative knee process and that the November

1995 knee injury was unrelated to the original ankle injury.

     "A question raised by conflicting medical opinion is a

question of fact."   Department of Corrections v. Powell, 2 Va.

App. 712, 714, 347 S.E.2d 532, 533 (1986).   "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. v. Farrar, 13 Va. App. 227, 229, 409 S.E.2d 824,

826 (1991).   "The fact that there is contrary evidence in the

record is of no consequence."    Wagner Enters., Inc. v. Brooks, 12

Va. App. 890, 894, 407 S.E.2d 32, 35 (1991) (citation omitted).

See also American Filtrona Co. v. Hanford, 16 Va. App. 159, 428

S.E.2d 511 (1993).   The commission gave greater weight to the

opinion of claimant's treating physician and found that her 1995

knee injury was related to her 1994 knee injury, an original

compensable consequence of the ankle injury.    See Fingles Co. v.

Tatterson, 22 Va. App. 638, 641, 472 S.E.2d 646, 647 (1996)

(citing Pilot Freight Carriers, Inc. v. Reeves, 1 Va. App. 435,

439, 339 S.E.2d 570, 572 (1986)) (the opinion of a treating

physician is entitled to great weight).   We therefore affirm the



                                  4
commission's finding of a causal relationship between claimant's

1995 and 1994 knee injuries. 2

     The determination that the 1994 knee injury was a

compensable consequence of claimant's ankle injury is res

judicata.   It is undisputed that claimant's original 1992 injury

was not the immediate cause of her 1995 injury.   Consequently,

the issue before us is whether as a matter of law the commission

may award benefits for an injury caused by a compensable

consequence, or, in other words, whether a claimant may recover

for a compensable consequence of a compensable consequence.
                                 III.

     This issue is one of first impression in the Commonwealth,

but has been addressed by a sister state.   In Roseburg Forest

Products v. Zimbelman, 900 P.2d 1089 (Or. Ct. App. 1995), the

Court of Appeals of Oregon considered the claim of an employee

who developed an emotional condition after suffering a

compensable injury.   The stress of his emotional condition led to

a fatal heart attack.   The court found that "a compensable

consequential condition is itself a compensable injury" and that

the claimant's recovery depended upon proof of causal

relationships between the first and second and the second and

third injuries.   Id. at 1091.   The court did not require proof
     2
      The commission did not specify whether claimant's 1995
injury was a new injury or an aggravation of her 1994 injury
because the doctrine of compensable consequences applies to both.
 See Bartholow Drywall Co. v. Hill, 12 Va. App. 790, 407 S.E.2d 1
(1991).




                                  5
that the original work-related injury was the immediate cause of

the heart attack.     Id.   "[I]f the emotional condition is a

compensable injury because it is a compensable consequence of the

[work-related injury], and if the heart attack was caused in

major part by the emotional condition, then the heart attack is

compensable."   Id.

     In Virginia, the doctrine of compensable consequences "is

well established and has been in existence for many years."
Williams Indus., Inc. v. Wagoner, 24 Va. App. 181, 186, 480

S.E.2d 788, 790 (1997).
          This doctrine, also known as the chain of
          causation rule, provides that "where the
          chain of causation from the original
          industrial injury to the condition for which
          compensation is sought is direct, and not
          interrupted by any intervening cause
          attributable to the employee's own
          intentional conduct, then the subsequent
          condition should be compensable."


Food Distribs. v. Estate of Ball, 24 Va. App. 692, 697,

          485 S.E.2d 155, 158 (1997) (quoting
          Leadbetter, Inc. v. Penkalski, 21 Va. App.

          427, 432, 464 S.E.2d 554, 556 (1995))

          (emphasis added).     [W]hen the question is

          whether compensability should be extended to

          a subsequent injury or aggravation related in

          some way to the primary injury, the rules

          that come into play are essentially based

          upon the concepts of direct and natural




                                    6
           results, and the claimant's own conduct as an

           independent intervening cause.

Williams Indus., Inc., 24 Va. App. at 186, 480 S.E.2d at 790

(citation omitted) (emphasis added).   "The simplest application

of this principle is the rule that all the medical consequences

and sequelae that flow from the primary injury are compensable."

 American Filtrona Co. v. Hanford, 16 Va. App. 159, 163, 428

S.E.2d 511, 513 (1993) (citation omitted) (emphasis added).
     Employer contends that, because claimant failed to establish

an immediate causal relationship between the original ankle

injury and her 1995 knee injury, as a matter of law, we must

reverse the commission's award.   However, employer advocates a

more narrow view of causation than that contemplated by the

enumerated principles.   The phrases "chain of causation," "direct

and natural results," and "all the medical consequences and

sequelae" anticipate the possibility of more than just one event;

the doctrine of compensable consequences is not limited to merely

one immediate consequence of an industrial injury.

     Compensable consequences include injuries sustained not as

an immediate result of the original injury but as a result of

some intermediate event which was itself a result of the original

injury.   See Immer & Co. v. Brosnahan, 207 Va. 720, 152 S.E.2d

254 (1967) (injuries sustained in car accident while traveling to

treatment for original injury are compensable); Food Distribs.,

24 Va. App. at 699-700, 485 S.E.2d at 159 ("suicide is



                                  7
compensable if the [work-related] injury produces mental

derangement and the mental derangement produces suicide");

Imperial Trash Serv. v. Dotson, 18 Va. App. 600, 602, 445 S.E.2d

716, 718 (1994) (death was compensable where claimant "died as a

result of cardiac arrest caused by [work-related] heatstroke");

American Filtrona Co., 16 Va. App. at 164, 428 S.E.2d at 514

(employer responsible for costs of "hepatitis . . . found to have

resulted from a blood transfusion or any other medical treatment

necessitated by the original industrial injury").   See also Code

§ 65.2-605 (consequences of treatment provider malpractice are

compensable as part of the original injury).   We see no reason to

deviate from these principles when the intermediate event is a

compensable consequence.

     We find additional support in cases which treat the first

compensable consequence as if it were the primary injury.
          "When the primary injury is shown to have
          arisen out of and in the course of
          employment, every natural consequence that
          flows from the injury likewise arises out of
          the employment, unless it is the result of an
          independent intervening cause attributable to
          claimant's own intentional conduct."

Imperial Trash Serv., 18 Va. App. at 606-07, 445 S.E.2d at 720

(quoting Morris v. Badger Powhatan/Figgie Int'l, Inc., 3 Va. App.

276, 283, 348 S.E.2d 876, 879 (1986)).   "In other words, where a

causal connection between the initial compensable injury and the

subsequent injury is established . . . the subsequent injury is

treated as if it occurred in the course of and arising out of the




                                8
employee's employment."   Bartholow Drywall Co. v. Hill, 12 Va.

App. 790, 794, 407 S.E.2d 1, 3 (1991) (citations omitted).    This

reasoning underscores the causal connection between the primary

and consequential injuries.   An employer may be held responsible

for a later injury resulting from a compensable consequence if

the claimant establishes the requisite causal relationship

between the two events.

     In the instant case, the evidence established that

claimant's 1995 knee injury was causally related to her 1994 knee

injury which was causally related to her initial ankle injury.

This chain of causation is direct and natural, and there is no

evidence of any intervening cause attributable to claimant's

conduct.   Furthermore, claimant's 1994 compensable consequence

knee injury becomes a primary injury, and the injury it caused in

1995 is clearly a compensable consequence of it.   We hold that

claimant's November 1995 knee injury is a compensable consequence

of her 1994 knee injury and of her 1992 ankle injury.   For the

foregoing reasons, we affirm the commission.
                                                          Affirmed.




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