Case Title: LOIS JUDD V. STATE OF WYOMING ex rel. WYOMING WORKERS SAFETY AND COMPENSATION DIVISION

Citation: 

Docket Number: S-09-0095

State: wyoming

Court: Wyoming Supreme Court

Date: 2010-06-25T00:00:00Z

Document:
LOIS JUDD V. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2010 WY 85Case Number: S-09-0095Decided: 06/25/2010NOTICE:  This opinion is subject to formal revision before publication in Pacific Reporter Third.  Readers are requested to notify the Clerk of the Supreme Court, Supreme Court Building, Cheyenne, Wyoming 82002, of any typographical or other formal errors so that correction may be made before final publication in the permanent volume.
APRIL 
TERM, A.D. 2010

 
 
LOIS 
JUDD,Appellant(Petitioner),v.STATE OF WYOMING ex 
rel. WYOMING WORKERS' SAFETY AND COMPENSATION 
DIVISION,Appellee(Respondent).

 
 
Appeal 
from the District Court of Converse County

The 
Honorable John C. Brooks, Judge

 
 

Representing 
Appellant:

Nancy 
L. Williams, Attorney at Law, Douglas, Wyoming

 
 

Representing 
Appellee:

Bruce 
A. Salzburg, Wyoming Attorney General; John W. Renneisen, Deputy Attorney 
General; James Michael Causey, Senior Assistant Attorney 
General

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, BURKE, JJ.

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Lois Judd 
suffered an injury to her right knee while at work. The Workers' Compensation 
Division (Division) found the injury to be compensable and awarded 
benefits.  Judd's knee continued to 
cause her pain and approximately six months later she sought preauthorization 
from the Division for knee replacement surgery on her right knee. The Division 
determined that Judd's current knee problems related solely to preexisting 
degenerative arthritis and denied further benefits. The Division's denial was 
upheld by the Medical Commission and affirmed by the district court. We 
reverse.

 
 
ISSUES

 
 
[¶2]      Judd presents 
these issues on appeal:

 
 
A. 
Did the Medical Commission have jurisdiction to hear this case?  

 
 
B. 
Was the decision by the Medical Commission Hearing Panel arbitrary, capricious, 
or an abuse of discretion, or otherwise not in accordance with the 
law?

 
 
C. 
Was the Findings of Fact, Conclusions of Law and Order of Medical Commission 
Hearing Panel denying benefits for total right knee replacement supported by 
substantial evidence?  

 
 
FACTS

 
 
[¶3]      Lois Judd began 
working as an aide for North Platte Physical Therapy of Douglas, Wyoming, on 
August 19, 2006.  As an aide, Judd's 
responsibilities included direct patient care, transfer of patients, 
administration of exercises at the instruction of the therapist, and general 
maintenance of the therapy department. On November 8, 2006, while working, Judd 
tripped, fell to the floor and injured her right knee.  She immediately experienced pain, 
swelling and decreased range of motion in her right knee.  Dr. Mark Murphy, who would become Judd's 
treating physician, was in the vicinity and looked at Judd's knee.  Dr. Murphy instructed that heat be 
applied to the knee, that Judd make an appointment for an examination, and that 
she stay off the knee until her appointment.  

 
 
[¶4]      On November 9, 
2006, the day following her work injury, Judd had an x-ray taken of her right 
knee.  The x-ray showed severe 
arthritic disease in the patellofemoral compartment and an old injury to the 
medial collateral ligament.  

 
 
[¶5]      On November 22, 
2006, Judd saw Dr. Murphy for a formal examination.  During that examination, Judd reported 
that she had continuing pain and swelling, that she had been doing physical 
therapy since the injury and that she was still using crutches.  Judd also reported that prior to her 
November 8, 2006, fall, she had experienced some aching in her right knee with 
changes in the weather.  On that 
same date, Judd had an MRI taken of her right knee.  The MRI showed:

 
 
1)         
Considerable degenerative disease of the medial compartment with loss of 
areas of the femoral and tibial cartilage, increased bone density/sclerosis of 
the articulating surface with some irregularity, marginal osteophyte formation, 
and increased T2 signal/edema in the anterior portion of the medial tibial 
plateau and adjacent femoral condyle.

 
 
2)         
Irregularities and increased signal in the menisci, particularly the 
medial, consistent with degenerative change.  A definite surface communicating tear is 
not clearly seen on both views, but it appears to be present in the posterior 
horn of the medial meniscus.

 
 
3)         
Small approximately 1cm popliteal cyst.

 
 
4)         
Mild degenerative changes of the lateral and patellofemoral 
articulations.  

 
 
[¶6]      Judd saw Dr. 
Murphy again on November 29, 2006, and underwent arthroscopic surgery on her 
right knee on November 30, 2006.  
Dr. Murphy's Operative Report reported the following postoperative 
diagnoses:

 
 
1.   Right knee medial meniscus tear, 
extensive.

 
 
2.   Extensive grade IV chondromalacia 
patellofemoral joint.

 
 
3. 
Extensive grade III and IV chondromalacia medial 
compartment.

 
 
4.   Medial hypertrophic parapatellar 
plica.  

 
 
Dr. 
Murphy's deposition was taken, and he explained the postoperative 
diagnoses.  Dr. Murphy described the 
degenerative changes in Judd's right knee as longstanding, and he testified that 
the medial meniscus tear likely predated Judd's November 8, 2006, fall.  He further 
testified:

 
 
Despite 
the pretty impressive technical and diagnostic abilities of the MRI, direct 
vision is clearly  gives me a better picture of what's going 
on.

 
 
There 
was a plica, which is a scarred fold in the joint lining.

 
 
There 
was grade four chondromalacia on the under surface of the patella and in the 
groove that the patella or kneecap tracks.  
And grade four is down to raw, exposed bone.

 
 
And 
there was grade three of four chondromalacia of the medial femoral condyle  the 
inside of her knee  as well as a medial meniscus tear.  

 
 
I 
expected to see changes in the cartilage from the changes on her x-ray; I 
expected the medial meniscus tear.  
But I  it  but the true extent of damage to the cartilage was really 
brought home by the direct vision of the cartilage surfaces.  

 
 
[¶7]      The Division paid 
for the arthroscopic surgery on Judd's right knee, and Judd applied for and 
received temporary total disability benefits for the expected recovery period 
following that surgery.  On December 
13, 2006, Judd saw Dr. Murphy and reported that she thought her right knee was 
improving, but on January 3, 2007, in another follow-up visit, Judd reported 
frustration with her inability to put weight on her right knee.  During the January appointment, Dr. 
Murphy discussed with Judd the option of total knee replacement for the right 
knee.  On February 7, 2007, an x-ray 
of Judd's right knee was taken in conjunction with the discussion of a total 
knee replacement.  The x-ray showed 
diffuse osteoporosis and no acute fracture or dislocation.  

 
 
[¶8]      On February 13, 
2007, Judd, through Dr. Murphy's office, submitted an application for 
preauthorization of a total knee replacement surgery on her right knee.  The Division responded that it could not 
provide the requested authorization without additional information concerning 
the relationship between Judd's work injury and the need for the proposed 
surgery.  On April 17, 2007, the 
Division sent Judd to Dr. Paul Ruttle, an orthopedic surgeon, for an independent 
medical evaluation.  Dr. Ruttle 
concluded that Rudd's need for total knee replacement surgery on her right knee 
was not related to her November 2006 work injury:

 
 
The 
patient's current problems appear unrelated to original work exposure.  It is clear that this patient has 
significant pre-existing osteoarthrosis in right knee.  A grade IV chondromalacia at 
patellofemoral joint and medial compartment simply did not develop as the result 
of a fall while working on November 8, 2006.  Indeed, the patient was symptomatic 
relative to knee, noting aching pain in knee accompanying weather changes prior 
to operation.  It is also of note 
that the patient has undergone a total knee arthroplasty in the past on 
left.  Approximately 30% of patients 
who require total knee arthroplasty on one side will develop significant 
degenerative changes on the contralateral side.

 
 
Further 
complicating the patient's case is the fact that she is 5'2" and weighs 190 
pounds.  This results in a body mass 
index of 35 which is considered obese.  
Work in the orthopedic and rheumatologic literature in the United States 
and Europe suggests a strong association between obesity and the development of 
osteoarthrosis in the knee. 

 
 
Relative 
to specific questions, What was the extent of the injury sustained in work 
injury November 8, 2006?  The 
patient appears to have rendered underlying meniscal pathology symptomatic in 
the face of severe pre-existing degenerative osteoarthrosis in 
knee.

 
 
In 
your medical opinion, what disability time frame would you anticipate was 
related to this injury?  
Approximately two months.  
This two month period would allow time in the knee that was not affected 
by significant pre-existing osteoarthrosis to heal.

 
 
Are 
there more probable causes for misjudged severe arthritic disease and 
degenerative disease than the incident November 8, 2006?  Yes.  The rationale for this has been outlined 
above.  As noted, the patient's 
problems were clearly pre-existing and related in combination to a genetic 
predisposition to osteoarthrosis in the knee and underlying 
obesity.

 
 
In 
all medical probability, is the need for total knee replacement a direct result 
of the November 8, 2006 injury?  No. 
The rationale of this has been outlined above.

 
 
Would 
Ms. Judd's severe arthritic disease and degenerative disease, in your opinion, 
be primarily due to aging and normal activities of daily living?  Yes.  Concurrent with genetic predisposition 
as presented by pathology that was treated with total knee on left and 
obesity.  

 
 
[¶9]      On May 4, 2007, 
the Division issued a final determination letter denying coverage for the 
proposed total knee replacement surgery on the right knee based on its 
conclusion that the need for the surgery was due to Judd's preexisting 
condition. By separate letter, the Division also informed Judd on May 4, 2007, 
that based on Dr. Ruttle's evaluation, Judd had reached maximum medical 
improvement with a one percent permanent partial impairment rating and the 
Division would no longer be paying her temporary total disability benefits.  

 
 
[¶10]   On May 16, 2007, Judd submitted a 
written objection to the denial of her surgery preauthorization and requested a 
hearing on that issue.  Judd also 
submitted a response to the permanent partial impairment rating.  In her response, Judd objected to the 
rating and requested a second opinion.  
Judd stated as the basis for her objection, "I was not obese as stated 
when the accident occurred.  I was 
working fine, standing on my feet, and now I can barely walk w/out severe 
pain."  

  

[¶11]   The Division referred the issue of 
Judd's surgery request to the Office of Administrative Hearings (OAH) for 
hearing and referred the issue of Judd's permanent partial impairment rating to 
Dr. Anne MacGuire, a rheumatologist, for a second opinion.  The OAH determined it lacked 
jurisdiction over Judd's case because of the nature of the issue and on June 12, 
2007, returned the case to the Division for referral to the Medical 
Commission.  On June 15, 2007, the 
Division referred Judd's request for hearing on the surgery preauthorization 
request to the Medical Commission.  

  

[¶12]   On June 25, 2007, Judd was examined 
by Dr. MacGuire for a second opinion on her permanent partial impairment 
rating.  Dr. MacGuire 
concluded:

 
 
Reviewing 
the entire case of the injury, the claimant twisted her knee and injured her 
right medial meniscus.  She 
qualifies for a 1% impairment of the right knee secondary to this injury.  All other issues, specifically the 
extensive degenerative arthritis of the right knee were very clearly 
pre-existing. 

 

Addressing 
the questions put to me by the Division:

 
 
1.  What was the extent of the injuries 
sustained from the work incident on 11-8-06?

 
 
Answer:

The 
claimant suffered a torn right medial meniscus on 11-8-06.  This injury did not cause the extensive 
pre-existing degenerative arthritis of her right knee.

 
 
2.  In your medical opinion, what timeframe 
of disability, would you anticipate related to this 
injury?

 
 
Answer:

It 
would be my impression that the claimant should have been recovered from the 
torn medial meniscus within 6-8 weeks.

 
 
3.  Are there more probable causes for Ms. 
Judd[s] severe arthritic disease and degenerative disease than the incident on 
11-8-06?

 
 
Answer:

The 
claimant has a previous history of significant obesity.  At 5'2" tall with weighing close to 250 
pounds, she has had extensive and excessive weight bearing on her knees.  The left knee has already been replaced 
secondary to severe end-stage degenerative arthritis.  Dr. Murphy's arthroscopic evaluation, 
shortly after the injury documented basically bone on bone in an end stage right 
knee.  The current literature 
reflects that women have more degenerative arthritis of their knees than men in 
general, usually secondary to excessive weight gain and decreased activity and 
decreased muscle strength in both lower extremities.  Much of the current osteoarthritis at 
this time is felt to be genetically determined.  This claimant had pre-existing left knee 
arthroplasty secondary to end-stage degenerative arthritis.  At the time of this injury, she also had 
end-stage degenerative arthritis of the right knee.  It is expected that the claimant would 
have needed a right total knee fairly quickly, whether or not she had sustained 
this minor injury.

 
 
4.  In all medical probability, is the need 
for a right total knee replacement a direct result of the 11-8-06 
injury?

 
 
Answer:

In 
all medical probability of the need for the right total knee replacement would 
have occurred within a very short period of time because of the extensive 
degenerative changes of the claimant's knee.  The injury did not cause the need for 
replacement.  The claimant was 
basically doomed to have a right totally arthroplasty because of pre-existing 
progressive end-stage degenerative arthritis caused by a multifactorial issues 
specifically significant obesity, smoking, decreased muscle strength, genetics, 
activity and poor fitness levels.

 
 
5.  Would Ms. Judd[s] severe arthritic 
disease and degenerative disease in your opinion be primarily due to aging and 
normal activities of day-to-day living?

 
 
Answer:

The 
literature is very clear that Mrs. Judd's severe arthritic disease and 
degenerative disease in the right and left knees is secondary to multifactorial 
issues, specifically poor conditioning, poor fitness, genetics, obesity and 
generalized lack of fitness.  These 
are specifically due to aging and the activities of day-to-day living.  

 
 
[¶13]   On August 7, 2007, before the 
Medical Commission heard and ruled on Judd's request for preauthorization of her 
total knee replacement surgery, Judd proceeded with the surgery.  In his Operative Report, Dr. Murphy, who 
performed the total knee replacement, listed Judd's preoperative and 
postoperative diagnoses as right knee osteoarthritis. 

 

[¶14]   The Medical Commission held its 
hearing on the disputed issue of worker's compensation coverage for Judd's right 
knee total knee replacement surgery on February 27, 2008.  In addition to the medical records and 
the independent medical evaluations of Drs. Ruttle and MacGuire, the parties 
submitted to the Medical Commission the depositions of Dr. Ruttle, Dr. Murphy 
and Charles Mangus, Judd's supervisor and physical therapist.  Judd testified in person during the 
hearing before the Commission. 

 
 
[¶15]   In his deposition testimony, Dr. 
Ruttle reiterated his opinion that Judd's need for total knee replacement 
surgery was not related to her workplace fall.  He also testified that he had reviewed 
additional records regarding Judd's medical history and that those records 
reinforced his opinion.  In 
particular, Dr. Ruttle reviewed records from treatment Judd received in 
1996.  The 1996 records showed that 
Judd was experiencing pain in both knees, had first reported knee pain fifteen 
years earlier, and had undergone a total knee replacement on her left knee in 
1996.  The records further showed 
that Judd was diagnosed with early degenerative arthritis in her right knee in 
1996 and had undergone an arthroscopic procedure on her right knee in 1986.  Specifically regarding the 1996 
treatment records, Dr. Ruttle testified:

 
 
A. 
 . . . .  I'll read you that line again.  The patient stated that she had 
initially noted pain in her knees  plural  approximately fifteen years 
ago.

 
 
So 
she had been having knee pain for a long time.  

 
 
[¶16]   Dr. Ruttle testified that he agreed 
with Dr. MacGuire's independent medical evaluation and explained the basis for 
his opinion that Judd's right knee total replacement surgery was unrelated to 
her fall at work:

 
 
A.        Well, as 
previously outlined, this patient had significant pre-existing degenerative 
osteoarthrosis in the right knee, that had in the past affected the same process 
that affected the left.

 
 
She 
had had a prior history of arthroscopy in the right knee  which she didn't fess 
up to, by the way, with me.  

 
 
She 
had ongoing complaints of right knee pain documented as far back as 
1996.

 
 
Sustained 
a minor fall which at most, if you want to look at the MR, resulted in a bone 
bruise on the tibia and femur.  That 
did not result in the need for a total knee arthroplasty.  That pathology was there the day that 
patient hit the ground.  And that's 
what resulted in the need for the total knee.  

 
 
[¶17]   On cross examination, Dr. Ruttle 
explained his position further with respect to his conclusions on causation and 
if and when Judd would have eventually required surgery had she not sustained 
her work injury.

 
 
A.        So I'm not sure 
exactly what she injured.

 
 
Again, 
I'm trying to be as concise as I can in the answer.  But it appears to me that even Dr. 
Murphy acknowledged that the  that the meniscus was torn and had  and, in his 
opinion, represented an acute  or excuse me, didn't represent an acute injury, 
but appeared to represent more of a chronic pathology.

 
 
So 
I'm not a hundred percent sure what was being treated there. 

 
 
Q.        But according to 
all these records that Doug has provided to you, and when you saw her 

 
 
A.        
Uh-huh.

 
 
Q.         even though she 
was feeling some pain with weather, isn't it a fact that she essentially was 
working full-time and not in extreme pain prior to this 
fall?

 
 
A.        That is 
correct.

 
 
Q.        And so again, 
would that fall have aggravated that pre-existing condition, to the point where 
she was not able to work and not able to function?

 
 
A.        I don't think 
so.

 
 
Q. 
       Well, 
how would you evaluate then the fact that she was working and essentially 
pain-free before and then fell and then was not pain-free after that and 
consistently could not work up until the total knee 
replacement?

 
 
A.        Well, sure.  But  you know, she's got this 
pre-existing pathology in there, and then she fell.  And then only objective  additional 
objective finding that you could really find that wasn't based on a chronic 
change was this bone bruise.  So 
maybe there was a bone bruise in there, but that bone bruise sure didn't require 
total knee replacement.

 
 
The 
patient had  again, you know, not to beat the  the horse to death.  But she clearly had pre-existing 
pathology in that knee that was similar to the other side.

 
 
So 
what happened there, I don't know.

 
 
But 
was this total knee required on the basis of this injury?  Of course not.  It was all pre-existing, very 
significant degenerative changes for which it was noted the patient was mildly 
symptomatic. She had pain with weather changes and had had symptoms it sounds 
like going back to 1996.

 
 
So 
I can't come to any other conclusion.

 
 
Q.        That there is a 
pre-existing condition, prior to the fall.

 
 
A.        Yeah.  And that it was symptomatic.  And I'm not sure that this injury 
rendered all that pathology symptomatic.  
I don't know.

 
 
Q.        You can't testify 
to that, then.

 
 
A.        
No.

 
 
Q.        You had indicated 
that she would need a total knee replacement on the right leg at some point; is 
that correct?

 
 
A.        That is 
correct.

 
 
Q.        Can you tell us 
when she would have needed that?

 
 
A. 
       
Probably not.  

 
 
[¶18]   Judd presented the deposition 
testimony of her treating physician, Dr. Murphy.  Dr. Murphy testified that he agreed with 
Drs. Ruttle and MacGuire that Judd's right knee degenerative osteoarthritis was 
longstanding and preexisting, but disagreed that the condition was not 
materially aggravated by Judd's work injury.  

 
 
Q.        According to Dr. 
Ruttle  in his report, he felt that the patient's current problems appear 
unrelated to the original work injury.

 
 
In 
your medical opinion, could you give us your 

 
 
A.        Well, I  I think 
what he's referring to is the fact that she had preexisting arthritis in the 
knee joint that would not have appeared on x-ray in the short period of time 
before her injury and when she saw me.  

 
 
So 
there were underlying  which were minimally symptomatic to her; a little 
achiness and soreness, by her history, when the weather 
changed.

 
 
And 
so I think what he is trying to say is, Murphy is doing a total knee replacement 
because she has degenerative arthritis, and her work injury did not cause the 
degenerative arthritis.

 
 
And 
I  strictly speaking, I think that is true.  She had arthritis before the work 
injury.  However, her experience of 
it and symptomatically and functionally she was working, she was going along 
with her life and functioning at a high level, and she fell on it and  and then 
she had symptoms.  Whether this was 
the straw that broke the camel's back and the previous 400 million straws did 
not break the camel's back, and this was the one that did, is an issue of 
apportionment.  But clearly she had 
significant problems afterwards.

 
 
The 
findings on x-ray, MRI, and even arthroscopy may have represented chronic 
degenerative changes of the knee.  
However, her level of function prior to this was excellent, without  as 
far as I know  any visits to doctors about knee 
arthritis.

 
 
And 
I'm not sure what the specific pathology in her knee was that was  that was 
aggravated or caused by the fall.  
But clearly she had significant symptoms after 
that.

 
 
Q.        So in your 
medical opinion, with some degree of medical probability, would you then say 
that the fall materially aggravated the degenerative condition in her right 
knee?

 
 
A.        I would say that, 
based on her symptoms.  And, unless 
you're willing to discount the entire history given by her, I think you have to 
accept that there was some material aggravation of her condition caused by the 
fall.

 
 
Now, 
having seen the inside of her knee, I can't point to you which finding in that 
knee was materially aggravated by the fall.  And for all I know, the interior of that 
knee may have looked exactly the same the day before the fall.  I don't know.

 
 
But 
certainly symptomatically  and her ability to use the knee  was materially 
aggravated by the fall.

 
 
Q.        And are you 
basing your opinion then on the history that you have and the experience and 
knowledge you have of this patient?

 
 
A.        
Yes.

 
 
Q.        And that would be 
based on that fact that she working a full-time job and had had no previous 
symptoms?

 
 
A.        Had minimal 
previous symptoms.  

 
 
[¶19]   In his deposition testimony, Dr. 
Murphy also addressed the issue of the inevitability and timing of Judd's total 
knee replacement surgery.  He 
testified:

 
 
Q.        Without the fall, 
if you would have seen Lois Judd's x-rays, MRI of the knee, and she was at work 
and functional, as she was prior to the fall, would you have told her she needed 
a total knee replacement?

 
 
A. 
       No.  I  I do that based on symptoms of 
pain.  I do total knee replacements 
for symptoms of pain and decreased function.

 
 
Q.        And is there any 
way that you would have known if and when there would have been a need for a 
total knee replacement?

 
 
A.        Without her 
telling me?  
No.

 
 
Q.        Without the 
symptoms of pain and inability to use the knee?

 
 
A.        That's 
correct.  Without those symptoms, we 
would not be having the discussion.

 
 
Q.        Okay.  So in your medical opinion, with some 
degree of medical probability, did the fall accelerate her need for a total knee 
replacement?

 
 
A.        I think that's 
probably fair, to say that.  
Yes.

 
 
Again, 
I think it was a material aggravation of a condition that, objectively looking 
at it, would certainly have, with the right clinical scenario, been suitable for 
a knee replacement.  Even before the 
injury.

 
 
However, 
I don't do joint replacements  I don't think anybody does do joint replacements 
 on joints just because they are arthritic.  They have to be highly symptomatic and 
function limiting.

 
 
Q.        In your medical 
opinion, with some degree of medical probability, was what brought Ms. Judd's 
knee to a symptomatic condition the fall?

 
 
A.        Yes.  

 
 
[¶20]   Dr. Murphy gave the foregoing 
testimony before having reviewed the records of Judd's 1996 treatment for knee 
pain in both knees.  A second 
deposition of Dr. Murphy was taken after he had an opportunity to review the 
1996 records.  After reviewing the 
1996 records, Dr. Murphy testified that those records did not change his 
opinion.  

  

Q.        Before we move on 
to Dr. Ruttle's deposition, I guess my question to you, Dr. Murphy, is in 
reviewing these old records, has it changed your opinion  let me look for 
sure.  When we took your deposition, 
you were indicating that you felt that the right knee was materially aggravated 
by the fall at work.  After you 
reviewed these records and have this additional information, has it changed your 
opinion regarding how this fall, work fall, has impacted Lois' right 
knee?

 
 
A.        I think my 
opinion was based on the history given to me by the patient regarding her 
symptoms.  Clearly, the records from 
Dr. McCarthy detail a significant arthritic condition preexisting in her right 
knee.  And, indeed, she had  he 
describes a surgery ten years prior to that, which would be 1986, so this is a 
condition that has given her some level of symptoms and problem also as far back 
as 20 years ago.

 
 
However, 
she was working full-time, had no significant complaints  at least I have not 
seen evidence that she had sought medical care  and she hadn't seen me for any 
problems in her right knee prior to the injury.  So I would stand by the fact that there 
was at least significant symptomatic material aggravation in her right knee, 
which I may not be able to, by any means, point a finger to in terms of her 
independent, underlying degenerative changes, and I may not be able to cull out 
what was acute and what was chronic.

 
 
However, 
by history, she was able to work full-time.  While it is possible she may have had 
symptoms, they were not symptoms that had ever brought her to my attention for 
her right knee problems prior to the injury.

 
 
Q.        And in looking at 
your previous deposition, you  not only that, but your records, medical 
records, after looking at the knee and doing the surgeries, you were aware that 
there was degeneration in the knee?

 
 
A.        
Absolutely.

 
 
Q.        And so your 
opinion was not based totally on the fact that it was a pristine knee.  You were fully aware that there has been 
some degeneration?

 
 
A.        Fully aware both 
from her X-rays, her knee arthroscopy, and findings on open arthrotomy that she 
had a preexisting degenerative condition.

 
 
Q.        As far as the 
history and any of the records we provided you, has there been anything 
additional or anything that would change your opinion of the fact that she was 
able to work and continued to be fully functional between the 96 surgeries or 
the 96 medical records and up to the point of the fall?

 
 
A.        I would accept 
that as a point of history.  I 
cannot personally witness that, but certainly I could witness she was working in 
a very demanding environment, North Platte Physical Therapy, prior to the 
injury.

 
 
Q.        Okay, I want to 
talk to you a little bit about Dr. Ruttle's deposition.  He certainly has a different 
opinion.  He feels that the fall is 
 was not the reason for  excuse me, that the fall did not cause the problem, 
and that the subsequent surgery was not as a result of the fall.  Have you had a chance to review his 
deposition, Dr. Murphy?

 
 
A.        I 
have.

 
 
Q.        And in some of 
the questions that were asked Dr. Ruttle that he identifies as important, I 
think you've already discussed, but I want to talk to you about his belief that 
she was at the endstage degenerative condition at the time of the fall.  How would you evaluate her 
knee?

 
 
A.        I would certainly 
say that she had significant and severe degenerative joint disease in her knee, 
which predated the fall.  And the 
presence of that degenerative joint disease, certainly made her more susceptible 
to even a relatively minor injury, pushing her over the edge.  But I would not contest that she had 
serious and severe underlying degenerative joint disease in her knee. 

 

However, 
by history and by my own experience, she worked  was able to go to work 
full-time in a relatively physically demanding environment as a physical therapy 
aid[e] at a very busy physical therapy office.  

 
 
[¶21]   In his second deposition, Dr. 
Murphy also testified again concerning the inevitability and timing of Judd's 
total knee replacement surgery and contrasted his views with those of Drs. 
Ruttle and MacGuire.

 
 
A.        I would not argue 
with the contentions of either Dr. M[a]cGuire or Dr. Ruttle that this fall did 
not cause the arthritis.  I agree 
with that.  The arthritis was 
preexisting for the whole host of reasons and well delineated in that article, 
and described by both Dr. Ruttle and Dr. M[a]cGuire.  And I would make no contention that her 
arthritis was caused by the fall.

 
 
However, 
I do total knee replacements for symptomatic  for symptoms of knee pain.  Most of the time, those symptoms are 
caused by severe degenerative arthritis, sometimes posttraumatic arthritis, 
sometimes rheumatoid arthritis, sometimes mild or moderate arthritis with severe 
pain.  The reason to do a knee 
replacement is to relieve pain.  
While I can't ontologically recreate the reasons why she had pain in her 
knee after that fall, she clearly had  by history and by her report  an 
inability to continue the level of activity that she had prior to the fall.  Whether the fall was the straw that 
broke the camel's back after truck loads of straws were loaded on the camel's 
back and one additional straw broke the camel's back, that is a matter for the 
division and the hearing officer to decide.  

 
 
In 
my view, I have to call them as I see them and play the hand I'm dealt, and the 
hand I was dealt was a woman who had difficulty walking on her knee after a fall 
at work with preexisting degenerative arthritis that had previously allowed her 
to fully function.

 
 
* 
* * * 

 
 
Q.        The other thing 
that I think has come up and  with Dr. M[a]cGuire and Dr. Ruttle is the fact 
that Dr. M[a]cGuire clearly states that she believes there would have been a 
knee replacement very shortly regardless of the fall, and Dr. Ruttle follows 
along with that.  And I believe we 
discussed this in your previous deposition, and I asked you to tell me your time 
line on that.  Can you give me a 
time line?

 
 
A.        I'm very sure I 
did not commit to that.  As I am 
amazed at the difference in individual people in how much arthritis they 
tolerate.  And how  how many times 
I have seen patients with absolute polished bone-on-bone, which must have been 
there for years and years and years, and they come in and tell me  tell me it 
started to get a little sore last month, and now they were having trouble 
walking.  So I'm very reluctant to 
commit to condemning people to a knee replacement based on the appearance of 
X-rays.

 
 
Q.        In your opinion 
you're unable to predict when she would have been  

 
 
A.        I think it's a 
reasonable prediction to say it is likely in someone who has bone-on-bone 
cartilage wearing their knee, that they will at some point need a knee 
replacement.  I think it's very 
difficult without careful history or knowing the patient to predict when that is 
going to be.

 
 
[¶22]   The testimony of Judd and Charles 
Mangus, her supervisor, was in keeping with Dr. Murphy's understanding of Judd's 
symptoms and functioning before her fall.  
Mr. Mangus testified that Judd was performing all duties of a physical 
therapy aide, without restriction, before her fall.  Judd likewise testified that before 
moving to Wyoming a month before she began working in her present position as a 
physical therapy aide, she had worked seventeen years for a WalMart in Texas 
performing cashier and stocking duties.  
Judd testified that before her recent fall, the only time she had taken 
off from work for knee problems was in 1996 when she underwent her left knee 
total knee replacement surgery.  
Judd further testified that before her fall she was working forty hours 
per week, "doing fine," and that her right knee "ached a little bit when it was 
cold." 

 
 
[¶23]   Following the hearing, the Medical 
Commission issued its Findings of Fact, Conclusions of Law, and Order of Medical 
Commission Hearing Panel.  The 
Medical Commission denied benefits for Judd's right knee total knee replacement 
surgery.  In so ordering, the 
Medical Commission made the following findings:

 
 
9.  . . . . This Panel notes, however, that 
Dr. Murphy was given an incomplete and inaccurate medical history from Ms. Judd 
regarding her prior right knee pathology.  
Dr. Murphy also agreed that he had never seen the medical records from 
Ms. Judd's prior left total knee replacement or other procedures. . . . Dr. 
Murphy also conceded that, even without the fall, with the pathology in Ms. 
Judd's knee, he would, ". . . start to probably think about a knee 
replacement."  . . . 
.

 
 
 * * * * 

 
 
In 
addition, this Panel finds that Dr. Murphy's opinion is against the greater 
weight of the medical evidence and unduly minimizes the level of preexisting 
pathology in Ms. Judd's right knee and we find that the fall did not amount to a material or substantial 
aggravation of her preexisting condition.  
Ms. Judd had a significant 
preexisting condition that was highly likely to require a total knee replacement 
procedure without the contribution of the fall.  We also note that the Division fully 
compensated Ms. Judd for the acute injury that likely occurred to her meniscus 
as a result of the fall and offered her a physical impairment award for that 
aspect of her injury.  Ms. Judd had 
been on the job for approximately three months, and we also find that the fall 
was a relatively minimal incident and we agree with Dr. Murphy when he confirmed 
in his deposition that a fall is generally not a triggering mechanism for a 
total joint replacement. . . .

 
 
* 
* * * 

 
 
11.       This Panel 
finds that Ms. Judd had an extremely significant preexisting medical condition 
in her right knee at the time of the work injury.  The medical records that were generated 
by Dr. McCarthy, who performed the left total knee replacement in 1996, clearly 
show that Ms. Judd had a prior surgical intervention on her right knee, and that 
fact was not shared with her present surgeon.  Although Ms. Judd claims loss of memory 
due to a January 2006 stroke, it is apparent that her memory was functioning 
adequately regarding other historical medical measures that had been taken.  This Panel also finds that Ms. Judd did 
not sustain a material or 
substantial aggravation of her preexisting condition as a result of the work 
injury on November 8, 2006.  The 
contribution of the significant preexisting condition to the total knee 
replacement was far more considerable than the relatively minor fall that 
occurred on that date.  In addition, 
it appears that the Division provided reasonable acute care and treatment, 
including the arthroscopic procedure that was originally provided by Dr. Murphy, 
and as a result has met its obligation regarding the work-related portion of Ms. 
Judd's injury.  We further find that 
Ms. Judd's significant preexisting condition would have inevitably led to the 
need for a right total knee replacement regardless of the work injury on 
November 8, 2006.  

 
 
(Emphasis 
in original.)

 
 
[¶24]   During the course of the 
proceedings before the Medical Commission, Judd objected to the Division's 
referral of the contested case to the Medical Commission.  Judd contends that in the absence of 
agreement by the parties, a referral to the Medical Commission was not 
authorized by statute, and the Medical Commission therefore had no jurisdiction 
to hear this matter.  The Medical 
Commission rejected Judd's jurisdictional argument, concluding that the issue in 
this matter was a medically contested issue properly referred to the Medical 
Commission pursuant to Wyo. Stat. Ann. § 27-14-616.  

 
 
DISCUSSION

 
 
Standard 
of Review

 
 
[¶25]   On appeal from a district court's 
review of an agency decision, we afford no deference to the district court's 
decision. Rather, we review the case as if it came directly from the 
agency.  Straube v. State ex rel. Wyo. Workers' 
Safety & Comp. Div., 2009 WY 66, ¶ 13, 208 P.3d 41, 46 (Wyo. 2009); Dale v. S & S Builders, LLC, 2008 WY 
84, ¶ 8, 188 P.3d 554, 557 (Wyo. 2008); McIntosh v. State ex rel. Wyo. Med. 
Comm'n, 2007 WY 108, ¶ 8, 162 P.3d 483, 487 (Wyo. 2007).  As in all administrative proceedings, 
the scope of our review is governed by the factors specified in Wyo. Stat. Ann. 
§ 16-3-114(c) (LexisNexis 2009), which provides in pertinent 
part:

 
 
(c) 
To the extent necessary to make a decision and when presented, the reviewing 
court shall decide all relevant questions of law, interpret constitutional and 
statutory provisions, and determine the meaning or applicability of the terms of 
an agency action. In making the following determinations, the court shall review 
the whole record or those parts of it cited by a party and due account shall be 
taken of the rule of prejudicial error. The reviewing court 
shall:

 
 
* 
* * *

 
 
(ii) 
Hold unlawful and set aside agency action, findings and conclusions found to 
be:

(A) 
Arbitrary, capricious, an abuse of discretion or otherwise not in accordance 
with law;

(B) 
Contrary to constitutional right, power, privilege or 
immunity;

(C) 
In excess of statutory jurisdiction, authority or limitations or lacking 
statutory right;

(D) 
Without observance of procedure required by law; or

(E) 
Unsupported by substantial evidence in a case reviewed on the record of an 
agency hearing provided by statute.

 
 

[¶26]   We explained the proper application 
of these standards in Dale, ¶¶ 20-26, 
188 P.3d  at 560-62.  In short, we 
defer to an agency's findings of fact if supported by substantial evidence.  Id., ¶ 22, 188 P.3d  at 561. We will not 
substitute our judgment for that of the agency if the agency's decision is 
reasonable under the circumstances.  
Id. We review an agency's 
finding that the burdened party failed to prove all the elements of his claim to 
determine "whether that conclusion was contrary to the overwhelming weight of 
the evidence in the record as a whole."  
Id.; see also Langberg v. State ex rel. Wyo. Workers' 
Safety & Comp. Div., 2009 WY 39, ¶ 10, 203 P.3d 1098, 1101 (Wyo. 2009); 
Horn-Dalton v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2009 
WY 14, ¶ 7, 200 P.3d 810, 813 (Wyo. 2009). 

 
 
[¶27]   Finally, we review an agency's 
conclusions of law de novo.  Straube, ¶ 14, 208 P.3d  at 47; Dale, ¶ 26, 188 P.3d  at 561.  In particular, the interpretation and 
application of statutes are questions of law which this Court reviews de novo.  Chavez v. State ex rel. Wyo. Workers' Safety 
and Comp. Div., 2009 WY 46, ¶ 11, 204 P.3d 967, 970 (Wyo. 2009).  Likewise, questions regarding 
jurisdiction are questions of law reviewed de novo.  Routh v. State ex rel. Wyo. Workers' Safety 
& Comp. Div., 952 P.2d 1108, 1114 (Wyo. 1998).

 
 
Jurisdiction

 
 
[¶28]   Judd contends that the Division 
improperly referred her case to the Medical Commission.  Specifically, Judd argues that because 
she did not request or agree to the referral of her case to the Medical 
Commission, pursuant to Wyo. Stat. Ann. § 27-14-616(e), the Medical Commission 
lacked jurisdiction to hear this contested case.  We disagree.

 
 
[¶29]   The option of the parties to agree, 
pursuant to Wyo. Stat. Ann. § 27-14-616(e), to have a contested case or issue 
referred to the Medical Commission is only one of the methods by which the 
Medical Commission may attain jurisdiction over a matter.  The Division itself has authority to 
directly refer medically contested matters to the Medical Commission for 
hearing.  Wyo. Stat. Ann. § 
27-14-616(b)(iv) (LexisNexis 2009).  
On appeal, Judd has not suggested that this case does not present a 
medically contested issue, and we therefore conclude that the Division properly 
referred this case to the Medical Commission after the OAH returned the case to 
it.

 
 
[¶30]   We also find unpersuasive Judd's 
suggestion that once she had undergone surgery without preauthorization, the 
issue was moot and the Medical Commission lost jurisdiction over the 
matter.  The statute authorizing the 
referral of a contested case to the Medical Commission provides that following 
referral to the Medical Commission, the hearing panel shall have jurisdiction to 
decide all issues relating to the employee's written notice of objection.  Wyo. Stat. Ann. § 27-14-616(b)(iv) 
(LexisNexis 2009).  Regardless of 
whether the issue was preauthorization of Judd's surgery or compensation to 
cover that surgery after the fact, the same medically contested issues arising 
from Judd's objection to the Division's denial of benefits remained to be 
resolved.  The Medical Commission 
properly retained jurisdiction over the contested case.

 
 
Material 
Aggravation of Preexisting Condition

 
 
[¶31]   The law governing a claimant's 
burden of proof for claims related to a preexisting condition is well 
established.  We summarized the 
applicable principles in Ramos v. State 
ex rel. Wyo. Workers' Safety & Comp. Div., 2007 WY 85, ¶¶ 17-18, 158 P.3d 670, 676-77 (Wyo. 2007):

 
 

In 
order to be eligible to receive worker's compensation benefits, a claimant must 
have sustained an "injury" as defined by Wyo. Stat. Ann. § 
27-14-102(a)(xi)(LexisNexis 2001). "Injury' means any harmful change in the 
human organism other than normal aging . . . arising out of and in the course of 
employment while at work. . . ." To demonstrate that an injury arose out of the 
course of employment, the claimant must establish a causal connection between 
the work-related incident and the injury.  
Hanks v. City of Casper, 2001 
WY 4, ¶ 6, 16 P.3d 710, 711 (Wyo. 2001). The claimant bears the burden of 
proving this causal connection by a preponderance of the evidence.  Clark v. State ex rel. Wyoming Workers' 
Safety and Compensation Div., 2001 WY 132, ¶ 19, 36 P.3d 1145, 1150 (Wyo. 
2001).  "A preponderance of the 
evidence' is defined as proof which leads the trier of fact to find that the 
existence of the contested fact is more probable than its non-existence.'"  Matter of Workers' Compensation Claim of 
Thornberg, 913 P.2d 863, 866 (Wyo. 1996) (quoting Scherling v. Kilgore, 599 P.2d 1352, 
1359 (Wyo. 1979)). 

 
 

Anastos 
v. General Chemical Soda Ash, 
2005 WY 122, ¶ 20, 120 P.3d 658, 665-66 (Wyo. 2005).

 
 

"Injury," 
as the term is defined in Wyo. Stat. Ann. § 27-14-102(a)(xi) (LexisNexis 2003) 
of the Wyoming Workers' Compensation Act, does not include any injury or 
condition preexisting at the time employment begins with the employer against 
whom a claim is made. However, "in Wyoming an employer takes the employee as he 
finds him." Lindbloom 
v. Teton International, 
684 P.2d 1388, 1389 (Wyo. 1984). If 
an employee suffers from a preexisting condition, that employee may still 
recover if his employment substantially or materially aggravates that condition. 
Id. 
In Lindbloom, 
we cited with approval the widely accepted treatise, Larson's Workmen's 
Compensation Law, for the proposition that:

 
 

Preexisting 
disease or infirmity of the employee does not disqualify a claim under the 
arising out of employment' requirement if the employment aggravated, 
accelerated, or combined with the disease or infirmity to produce the death or 
disability for which compensation is sought.

 
 

1 
Larson's Workmen's Compensation Law, § 12.20, p. 273-276. Larson goes on to 
say:

 
 

Since 
the rule of law stated at the beginning of this section is so widely accepted, 
in practice most of the problems in this area are medical rather than legal. * * 
* * It will be found then that denials of compensation in this category are 
almost entirely the result of holdings that the evidence did not support a 
finding that the employment contributed to the final result. Whether the 
employment aggravated, accelerated, or combined with the internal weakness or 
disease to produce the disability is a question of fact, not law, and a finding 
of fact on this point . . . based on any medical testimony . . . will not be 
disturbed on appeal.

 
 

Id., 
§ 12.20, p. 313-16.

 
 

Boyce 
v. State ex rel. Wyoming Workers' Safety & Comp. Div., 
2005 WY 9, ¶ 10, 105 P.3d 451, 454-55 (Wyo. 2005).

 
 

Expert 
opinion testimony ordinarily will be required to establish the link between the 
employee's work activity or injury and the preexisting disease or condition; the 
expert need not state with specificity that the work activities or injury 
materially or substantially aggravated, accelerated, or combined with the 
preexisting disease or condition to necessitate the medical treatment for which 
compensation is sought; and the expert need not apportion between the work 
activity or injury and the preexisting disease or condition; the relative 
contribution of the work activity or injury and the preexisting disease or 
condition is not weighed. Boyce, 
¶¶ 11, 16, 105 P.3d  at 455, 456.

 
 

Ramos, 
¶¶ 17-18, 158 P.3d at 676-77; see 
also Straube, ¶ 15, 208 P.3d at 
47-48; Montoya v. State ex rel. Wyo. 
Workers' Safety & Comp. Div., 2009 WY 32, ¶ 22, 203 P.3d 1083, 1089-90 
(Wyo. 2009).

 
 
[¶32]   At the outset of our discussion, it 
is helpful to point out what is truly in dispute in this matter and what is not. 
Neither Judd nor her treating physician disputes the preexisting degenerative 
arthritis in Judd's knee or the severity of that preexisting condition.  Likewise there is no dispute among the 
medical experts who examined and evaluated Judd as to the cause of her 
degenerative arthritis.  Neither 
Judd nor her treating physician suggests that her fall in the workplace caused 
her degenerative condition.  

 
 
[¶33]   Additionally, there is no dispute 
in the evidence that Judd's job as a physical therapy aide was physically 
demanding or that for the approximately three months before her work-related 
fall, Judd was working fulltime in that position without restriction.  Similarly, there is no dispute that in 
the approximately seventeen years before Judd began her job as a physical 
therapy aide, she worked for WalMart performing cashier and stocking duties and 
had taken time off for her knee condition only in 1996 when she underwent a 
total knee replacement on her left knee.  

 
 
[¶34]   Regarding the work accident itself, 
there is no dispute that on November 8, 2006, Judd tripped in the workplace, 
fell to the ground and experienced immediate pain and swelling in her right 
knee.  Finally, there is no dispute 
that prior to her workplace fall, Judd experienced only minor aching in her 
right knee with changes in the weather, and after the fall, she was in pain, 
could not put weight on the knee and did not regain function in the knee until 
the total knee replacement surgery was performed.1

 
 
[¶35]   The point on which the experts 
disagreed is whether Judd's fall in the workplace materially aggravated Judd's 
preexisting arthritis in her right knee.  
Again, it is important to point out that the experts did not disagree on 
the facts relating to this question, but instead only on the conclusions 
regarding causation to be drawn from those facts.   Judd's treating physician, Dr. 
Murphy, concluded that because Judd had only minor aching with cold weather 
before her fall and debilitating pain and loss of function after her fall, the 
fall had materially aggravated her degenerative arthritis.  The independent evaluators, Drs. Ruttle 
and MacGuire, did not dispute those basic facts, but they concluded that because 
the fall did not change the underlying knee pathology, that is physically alter 
the degenerative arthritis, and because Judd's total knee replacement surgery 
was inevitable, there was no material aggravation of the preexisting 
condition.  

 
 
[¶36]   The Medical Commission denied 
compensation for Judd's total knee replacement surgery, concluding it was 
inevitable and the "contribution of the significant preexisting condition to the 
total knee replacement was far more considerable than the relatively minor fall 
that occurred on that date."  By 
employing that rationale for denying Judd's claim, the Medical Commission 
misapplied the law regarding the compensability of injuries resulting from 
aggravation of a preexisting condition.  
First, the Commission committed a legal error when it relied upon the 
conclusions of Drs. Ruttle and MacGuire that no material aggravation of Judd's 
condition can be found because there was only an increase in symptoms and not a 
change in the underlying pathology of the preexisting condition.  Wyoming law does not require a change in 
the underlying pathology to find a material aggravation.  What it requires is that the work injury 
combine with the preexisting condition to create the present disability and need 
for treatment.  See Langberg, ¶ 28, 203 P.3d  at 1104 
(holding injury compensable where work injury did not cause Kienbock disease but 
rendered dormant condition symptomatic, creating need for surgery); Montoya, ¶¶ 23-25, 203 P.3d  at 1090 
(holding fall at work increased symptoms of preexisting traumatic brain injury 
and created compensable disability); Ramos, ¶ 26, 158 P.3d  at 679 (holding 
facial work injury did not create periodontal disease but combined with it to 
necessitate compensable dental treatment); Salas v. General Chemical, 2003 WY 79, 
¶¶ 19-22, 71 P.3d 708, 715-16 (Wyo. 2003) (holding knee surgery compensable 
where work injury aggravated pain of preexisting degenerative knee condition). 

 
 
[¶37]   This Court recently decided a case 
that presented facts similar to this case.  
See State ex rel. Wyo. Workers' Safety & 
Comp. Div. v. Slaymaker, 2007 WY 65, 156 P.3d 977 (Wyo. 2007).  In Slaymaker, the claimant suffered from a 
preexisting lower back condition, including bulging discs, annular tears and 
arthropathy, a degenerative condition.  
Id., ¶ 7, 156 P.3d  at 
980.  Following a work injury the 
claimant suffered when trying to move an all-terrain vehicle, the OAH awarded 
benefits for a torn muscle and ligament damage but denied treatment for the 
preexisting conditions.  Id.  We reversed, 
explaining:

 
 
Moreover, 
other evidence presented at the hearing established, without contradiction, that 
Mr. Slaymaker's physical condition deteriorated significantly following the 
accident. Prior to May 29, 2003, Mr. Slaymaker was suffering from lower back 
pain and had sought medical treatment for that condition. However, he was able 
to manage his pain sufficiently to continue working fifty hours per week at his 
physically demanding job. Following the ATV accident, he was in severe pain, 
could no longer work, and needed assistance getting out of his 
truck.

 
 

Slaymaker, 
¶ 23, 156 P.3d  at 985.

 
 
[¶38]   This case presents a nearly 
identical situation.  It is 
undisputed that Judd's condition changed dramatically after her work 
injury.  Before her fall, she was 
working forty hours per week without restriction.  After her fall, she was unable to put 
weight on her knee or work.  Drs. 
Ruttle and MacGuire mistakenly concluded that this change did not represent a 
material aggravation of Judd's preexisting condition, and the Medical Commission 
erred in relying on those opinions to deny benefits for the aggravation of 
Judd's preexisting condition.

 
 
[¶39]   The Commission likewise erred in 
relying on the conclusions of Drs. Ruttle and MacGuire that no material 
aggravation of Judd's condition can be found because surgery to treat Judd's 
preexisting condition was inevitable.  
We have rejected the inevitability of injury or surgery as a basis to 
deny compensation.  See Straube, ¶ 17, 208 P.3d  at 48 
(holding employer takes an employee as he finds him and it is not material that 
injury could have occurred at anytime); State ex rel. Wyo. Workers' Safety & 
Comp. Div. v. Roggenbuck, 938 P.2d 851, 853 (Wyo. 1997) (holding surgery to 
treat preexisting condition compensable where "work effort brought the need for 
surgery to a head and forced the surgery to be done at this time"). 

 
 
[¶40]   Finally, the Medical Commission 
erred in comparing the relative contributions of the work injury and the 
preexisting condition as a basis to deny compensability of Judd's present 
disability and need for surgery.  
The Commission's conclusion that the "contribution of the significant 
preexisting condition to the total knee replacement was far more considerable 
than the relatively minor fall that occurred on that date," is a clear statement 
of apportionment, and we have held that such apportionment is not permitted by 
Wyoming statute.  State ex rel. Wyo. Workers' Safety & 
Comp. Div. v. Faulkner, 2007 WY 31, ¶ 18, 152 P.3d 394, 399-400 (Wyo. 
2007).

 
 
CONCLUSION

 
 
[¶41]   The evidence is undisputed that 
despite Judd's preexisting degenerative condition, she was able to work fulltime 
without restriction before her work injury, and after her work injury, she 
suffered debilitating pain that prevented her from putting weight on her knee 
and from working.  The work injury 
brought Judd's need for surgery to a head, and the Medical Commission erred in 
denying benefits for the surgery.   
The case is reversed and remanded for the award of appropriate 
benefits.

 
 
FOOTNOTES

 
 

1The Medical Commission suggested in its findings that Judd's testimony 
should be given less weight because she did not disclose to her treating 
physician or the independent evaluators a 1986 arthroscopic procedure on her 
right knee, which she claims to have forgotten while at the same time 
remembering other details of her medical history.  We believe the Commission's focus on 
this omission was misguided.  First, 
the 1986 arthroscopic procedure was irrelevant to the medical picture.  With or without that procedure, Judd had 
severe bone-on-bone degenerative arthritis in her right knee, and it was that 
degenerative condition that was the basis for the opinions of the independent 
evaluators on whose judgment the Commission relied in reaching its 
decision.  Second, given the 
confused state of the 1996 medical records, with the word "right" repeatedly 
crossed out and replaced with the word "left," the records hardly represent 
definitive proof that Judd ever underwent an arthroscopic procedure on her right 
knee.  It is entirely possible that 
the reason Judd does not recall the procedure is that it never happened and the 
notation in the record is a typographical error.

 
 
That said, we do not substitute the Commission's credibility 
determinations with our own.  The 
weight the Commission chose to give Judd's testimony ultimately does not affect 
the outcome of this matter.  Dr. 
Ruttle, whose opinion the Medical Commission gave the greatest weight, 
acknowledged and accepted as accurate in forming his opinion, that Judd was able 
to work and had minimal aching with weather changes before her fall and 
debilitating pain and loss of function in her right knee after her fall.  Additionally, Judd's ability to work 
fulltime without restriction in a physically demanding job for approximately 
three months before her fall was confirmed by the testimony of her supervisor, 
Charles Mangus.