Title: Middlemass v. State ex rel. Wyo. Workers' Safety & Comp. Div.

State: wyoming

Issuer: Wyoming Supreme Court

Document:

CAROL J. MIDDLEMASS v. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2011 WY 118Case Number: S-10-11-0007Decided: 08/11/2011NOTICE: 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 correction may be made before final publication in the permanent volume.
APRIL 
TERM, A.D. 2011

 
 

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

 
 
 
 

Appeal 
from the District Court of Park County

The 
Honorable Steven R. Cranfill, Judge

 
 
Representing 
Appellant:

Matthew 
D. Winslow of Keegan & Winslow, P.C., Cody, Wyoming.

 
 
Representing 
Appellee:

Gregory 
A. Phillips, Wyoming Attorney General; John W. Renneisen, Deputy Attorney 
General; James Michael Causey, Senior Assistant Attorney General; Kelly 
Roseberry, Assistant Attorney General.  

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

 
 
KITE, 
Chief Justice.           

 
 
[¶1]      Carol J. 
Middlemass appeals from the district court's affirmance of the Office of 
Administrative Hearings (OAH) decision upholding the Wyoming Workers' Safety and 
Compensation Division's (Division) denial of her request for worker's 
compensation benefits for an injury to her shoulder.  She claims the OAH's determination that 
she failed to meet her burden of proving the injury resulted from her work 
activities is not supported by substantial evidence and the OAH erred by ruling 
that medical evidence was necessary to establish the cause of her shoulder 
injury.  

 
 
[¶2]      We affirm.  

 
 
 
 
ISSUES

 
 
[¶3]      Although Ms. 
Middlemass articulates the issues differently, the issues we must decide 
are:

 
 
            
1.         
Is there substantial evidence to support the hearing examiner's 
conclusion that Ms. Middlemass did not meet her burden of proving that her 
shoulder injury was caused by her work activities?

 
 
            
2.         
Did the OAH correctly conclude that expert medical evidence was necessary 
to establish causation?

 
 
 
 
FACTS

 
 
[¶4]      Ms. 
Middlemass was involved in a serious car accident in 1987.  She suffered many injuries, including a 
broken right shoulder.  Ms. 
Middlemass spent two to three months in the hospital and then underwent several 
months of physical therapy.  She 
recovered and was able to use her shoulder normally.  

 
 
[¶5]      Ms. Middlemass 
was a packer for Y-Tex Corporation in Cody, Wyoming.  Her job was to retrieve newly molded 
livestock ear tags from a conveyor belt, place insecticide tabs in the ear tags, 
fill plastic bags with twenty ear tags, seal the bags and place the bags in a 
box for shipping.  She sat on a 
swiveling chair and the work area was set up in a semi-circle around her.  Ms. Middlemass stated that on February 
12, 2009, she injured her right shoulder when she reached for some tags.  She continued to work until shortly 
before her shift ended, but stated that she was in significant pain.  The next day she was unable to work 
because of the pain.  Ms. Middlemass 
was examined at an urgent care center and referred to orthopedist, Jimmie Biles, 
M.D.    

 
 
[¶6]      At Dr. Biles' 
office, Ms. Middlemass was seen by Mary Phillips, an orthopedic specialty nurse 
practitioner.  Ms. Middlemass 
underwent an MRI which showed three areas of pathologya complete tear of the 
supraspinatus at the top part of the rotator cuff; a partial tear of the 
infraspinatus at the back part of the rotator cuff; and a tear of the labrum, 
the cartilage inside the shoulder joint around the socket.    

 
 
[¶7]      Ms. Middlemass 
filed an injury report and applied for worker's compensation benefits, but the 
Division denied her claim due to her preexisting condition from the 1987 
automobile accident.  Ms. Middlemass 
objected and the Division referred the matter to the OAH for a contested case 
hearing.  At the hearing, Ms. 
Middlemass, her employer, and the Division presented evidence, including the 
deposition testimony of Dr. Biles.  
Ms. Middlemass conceded that the supraspinatus and labrum tears were 
attributable to her preexisting condition and focused on obtaining worker's 
compensation coverage for the infraspinatus tear.    

 
 
[¶8]      The hearing 
examiner issued a decision upholding the Division's denial of Ms. Middlemass' 
claim.  He concluded that she had 
failed to meet her burden of proving that the infraspinatus tear was caused by 
her work activities.  In particular, 
he stated that, because of her preexisting right shoulder condition, causation 
needed to be established by medical evidence and Dr. Biles was equivocal in his 
testimony about the cause of the infraspinatus tear and had incorrect 
information about the circumstances of her February 2009 injury.      

 
 
[¶9]      Ms. Middlemass 
filed a petition for review with the district court, which affirmed the OAH 
decision.  She then appealed to this 
Court.    

 
 
 
 
STANDARD 
OF REVIEW

 
 
[¶10]   When an appeal is taken from a 
district court's review of an administrative agency's decision, we consider the 
case as if it had come directly from the administrative agency without giving 
any deference to the district court's decision. Dutcher v. State ex rel. Wyo. Workers' 
Safety & Comp. Div., 2010 WY 10, ¶ 9, 223 P.3d 559, 561 (Wyo. 2010); 
Dale v. S & S Builders, LLC, 2008 WY 84, ¶ 8, 188 P.3d 554, 557 (Wyo. 
2008). Our review is governed by Wyo. Stat. Ann. § 16-3-114(c) (LexisNexis 
2011):

 
 
(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:

(i) 
Compel agency action unlawfully withheld or unreasonably delayed; 
and

(ii) 
Hold unlawful and set 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.

            

[¶11]   In accordance with § 16-3-114(c), 
we review the agency's findings of fact by applying the substantial evidence 
standard.  Dale, ¶ 22, 188 P.3d  at 561. 
 Substantial evidence means "such relevant evidence 
as a reasonable mind might accept as adequate to support a conclusion."  Bush v. State ex rel. Wyo. Workers' 
Comp. Div., 2005 WY 120, ¶ 5, 120 P.3d 176, 179 (Wyo. 2005) (citation 
omitted).  See also, Kenyon v. State ex rel. Wyo. Workers' Safety 
& Comp. Div., 2011 WY 14, ¶ 11, 247 P.3d 845, 849 (Wyo. 2011).  "Findings of fact are supported by substantial evidence if, from the evidence 
preserved in the record, we can discern a rational premise for those 
findings."  Kenyon, ¶ 11, 247 P.3d  at 849, quoting 
Bush, ¶ 5, 120 P.3d  at 179.     

 
 
[¶12]   Reviewing an agency's determination 
that the claimant did not satisfy her burden of proof, we apply the following 
standard:

 
 
If 
the hearing examiner determines that the burdened party failed to meet his 
burden of proof, we will decide whether there is substantial evidence to support 
the agency's decision to reject the evidence offered by the burdened party by 
considering whether that conclusion was contrary to the overwhelming weight of 
the evidence in the record as a whole.  
If, in the course of its decision making process, the agency disregards 
certain evidence and explains its reasons for doing so based upon determinations 
of credibility or other factors contained in the record, its decision will be 
sustainable under the substantial evidence test. Importantly, our review of any 
particular decision turns not on whether we agree with the outcome, but on 
whether the agency could reasonably conclude as it did, based on all the 
evidence before it.

 

Dale, 
¶ 
22, 188 P.3d  at 561 (citations omitted).  

 
 

[¶13]   "We review an agency's conclusions 
of law de novo, and will affirm only if the 
agency's conclusions are in accordance with the law.'"  Kenyon, ¶ 13, 247 P.3d  at 849, quoting 
Moss v. State ex rel. Wyo. Workers' Comp. 
Div., 2010 WY 66, ¶ 11, 232 P.3d 1, 4 (Wyo. 2010);  Dale, ¶ 26, 188 P.3d  at 
561-62.

 
 
 
 
DISCUSSION

 
 

[¶14]   A worker's compensation claimant has the burden 
of proving all of the essential elements of her claim by a preponderance of the 
evidence.  State ex rel. Wyo. Workers' Safety & 
Comp. Div. v. Slaymaker, 2007 WY 65, ¶ 13, 156 P.3d 977, 981 (Wyo. 2007); 
Sanchez v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2006 WY 
64, ¶ 7, 134 P.3d 1255, 1257 (Wyo. 2006).  "This burden includes establishing the 
cause of the condition for which compensation is claimed and proving that the 
injury arose out of and in the course of employment."  Hanks v. City of Casper, 2001 WY 
4, ¶ 6, 16 P.3d 710, 711 (Wyo. 2001).  
See also, State ex rel. Wyo. Workers' Comp. Div. v. Espinoza, 924 P.2d 979, 981 (Wyo. 1996).  
Preexisting 
conditions are excluded from the definition of compensable injury.  Wyo. Stat. Ann. § 27-14-102(a)(xi)(F) 
(LexisNexis 2011).  

 
 
[¶15]   Nevertheless, an employee who has a pre-existing condition may still 
recover if her "employment aggravated, accelerated, or combined with the disease 
or infirmity to produce the death or disability for which compensation is 
sought."  Dutcher, ¶ 14, 223 P.3d  at 562, quoting 
Lindbloom v. Teton Int'l, 684 P.2d 1388, 1389 (Wyo. 1984).  "To prove 
aggravation of a preexisting 
condition, a claimant must demonstrate by a preponderance of the evidence that 
the work contributed to a material degree to the aggravation of the condition.'" 
 Dutcher, ¶ 15, 223 P.3d  at 562, citing 
Slaymaker, ¶ 14, 156 P.3d  at 981-82.  

 
 
[¶16]   The OAH reached the following 
conclusions regarding the evidence of the cause of Ms. Middlemass' shoulder 
injury:

 
 
            
19.       
As Claimant concedes, she has had for a substantial period of time a 
rotator cuff injury consisting of a full thickness tear of the supraspinatus 
muscle-tendon and a long standing cartilage abnormality inside the shoulder 
joint itself, all quite obviously stemming from the 1987 motor vehicle 
accident.  The question becomes 
whether the partial tear of the infraspinatus can be said to have been caused by 
Claimant's work activities on February 12, 2009.

 
 
            
20.       
Contrary to Claimant's assertion, this is not a case where credible 
testimony by the Claimant that she did not have pain prior to the work effort at 
a particular time and then subsequently became painful is adequate to 
demonstrate a work injury.  Because 
of the preexisting condition affecting the other part of the rotator cuff, the 
Office concludes that medical proof is necessary to demonstrate 
work-relatedness.

 
 
            
21.       
The need for convincing medical proof is problematic for Claimant because 
it appears Dr. Biles' understanding of the mechanism of injury was an activity 
that Claimant did not undertake at work, namely reaching overhead and 
outward.  He did not have an 
accurate history.

 
 
            
22.       
Additionally, Dr. Biles' testimony was equivocal, indicating that he 
couldn't really give an opinion as to whether the partial tear of the 
infraspinatus occurred at the time of the "accident" (which, again, he 
misunderstood) or whether it was progression of the supraspinatus tear.  When he states that it is possible that 
this partial tear was worsened by Claimant's activity, again, he had a 
misunderstanding of the work activity.  
As noted by the Division, Claimant's activities were much more strenuous 
and vigorous outside of work than at work.  
Accordingly, the Office does not find Dr. Biles' testimony persuasive 
medical proof of the existence of a work injury. 

 
 
23.       There was a 
failure of proof that Claimant's employment aggravated, accelerated or combined 
with the pre-existing rotator cuff disease process.

 
 
[¶17]   Ms. Middlemass claims the hearing 
examiner's conclusion that she did not meet her burden of proving the 
infraspinatus tear was work related is not supported by substantial 
evidence.  She also asserts the 
hearing examiner erred by requiring medical expert testimony to establish that 
her injury was work related.  

 
 
[¶18]   Starting with the substantial 
evidence issue, the hearing evidence included Ms. Middlemass' medical records 
from Dr. Biles' office, and testimony by Ms. Middlemass, three of her friends, 
her supervisor at Y-Tex, and Dr. Biles (by deposition).  Ms. Middlemass testified that she had 
injured her right shoulder in the 1987 car accident, but after undergoing 
physical therapy she had no limitations and did not experience pain.  The only residual effect from the 
accident was a feeling of stiffness in very cold weather.  She testified that, before the February 
2009 incident, she did not have any pain in her shoulder and could do almost 
anything, including staging gunfights with a performance group, doing work 
around her house, playing guitar, and assisting her disabled husband.   

 
 
[¶19]   Ms. Middlemass stated that on 
February 12, 2009, she was working at the conveyor belt, and ". . . behind me 
there was a box.  I'm doing this 
with my left hand, from left to right.  
But when I was doing it, I was just putting the bag in the box, and I 
reached over to grab the tag when I felt the pop that afternoon."  She further described the incident 
as:  "I was just reaching back, and 
when I reached back and I reached over to grab [the tags] off the conveyor belt, 
I felt this pop.  I hurt pretty 
good."  She testified that, after 
the incident, she was limited in what she could do with her right arm and had to 
give up many activities.  Three of 
Ms. Middlemass' friends testified at the hearing.  In general, they confirmed her active 
lifestyle before the incident and her limitations and pain after the 
incident.    

 
 
[¶20]   Dr. Biles' deposition was admitted 
at the OAH hearing.  He testified 
that he had diagnosed three different areas of pathology in Ms. Middlemass' 
shoulder: 1) a complete tear of the top part of the rotator cuff 
(supraspinatus); 2) a partial tear of the back part of the rotator cuff 
(infraspinatus); and 3) torn cartilage inside the shoulder joint involving the 
cartilage lip around the socket (labrum).    

 
 
[¶21]   Dr. Biles stated that x-rays and a 
MRI of Ms. Middlemass' shoulder showed a previous fracture of the humeral head 
and atrophy of the supraspinatus muscle.  
He explained that the earlier fracture had healed in such a way as to 
cause the head to rub on the acromion,2 
"and that indirectly certainly could cause a tear of the rotator cuff," which 
could result in the atrophy of the supraspinatus muscle.  Dr. Biles testified that the atrophy of 
the muscle and tear of the supraspinatus tendon definitely occurred before the 
February 2009 work incident.  He 
also testified that the labrum tear was "more likely to have occurred from the 
motor vehicle accident than just moving her arm overhead."  

 
 
[¶22]   Dr. Biles was questioned about the 
timing of the infraspinatus tear on the back part of the rotator cuff and 
stated, "I don't know, honestly.  I 
can't tell you whether [the infraspinatus tear] occurred at the time of the 
accident or whether that's progression of the supraspinatus tear."  The questioning continued: 

 
 
            
Q.        So 
it's possible that on February 12 of 09 that reaching behind caused this second 
pathology, the partial tear of the back part of the rotator 
cuff?

            
A.        Yes, 
it's possible.

            
Q.        Is it 
likely?

            
A.        I 
really don't know.  I can't give you 
a probability of when that partial tear occurred.

 
 
* 
* * 

 
 
            
Q.        
[W]e've established that we are not going to be able to establish one way 
or another whether it's more probable than not that the partial tear of the back 
part of the rotator cuff preexisted February 12, 09, 
correct?

            
A.        
Correct.  I can't tell you, 
based on the MRI, whether that partial tear occurred a long time ago or 
recently.

 
 
[¶23]   When questioned about the mechanism 
of Ms. Middlemass' injury, Dr. Biles testified:

 
 
            
Q.        Does 
turning and reaching the arm without any weight on it or anything like that, is 
that a normal cause of a tear to the cartilage or a rotator cuff 
tear?

            
A.        
Nope.  

            
* * *

            
Q.        And 
what, in your opinion, then, led to that result in this particular 
patient?

            
A.        I 
mean, she had  it's my understanding that she had  did she have a box in her 
arm or she was just putting something in a box?

            
Q.        Well, 
the history I was given  and I believe that's consistent with the history 
that's written on your NP's note  is that she was putting something in a 
box.

            
A.        So I 
mean, without lifting the box or having a load in her arm and turning her arm, 
it would be difficult to have these  all these injuries occur from 
that.

            

The 
doctor also stated:

 
 
            
Q.        I 
think you have been -- I think you had testified that it would be difficult to 
have all of these injuries occur from the turning.  I think we touched on this; I just want 
to be clear.

            
Assuming that the supraspinatus tear on the top and the labrum tear were 
preexisting, would the injury, as  or the mechanism of [the] injury, as 
described in her history, be consistent with the infraspinatus partial 
tear?

            
A.        
Yes.  It's possible she could 
have partially torn that part of the rotator cuff just from reaching overhead, 
reaching as she did.  

 
 
[¶24]   Ms. Middlemass' attorney questioned 
Dr. Biles about the use of a patient's history in forming a 
diagnosis:

 
 
            
Q.        . . . 
There was some discussion about opinions based on a self-reported history.  In your practice as an orthopedic 
surgeon, is a self-reported history from a patient something that you would 
generally rely upon in forming opinions?

            
A.        
Yes.

            
* * * 

            
Q.        In a 
case where there is a report of no pain prior to hearing a pop and then pain 
subsequent to that, is that something that you would generally rely on in 
forming a diagnosis?

            
A.        
Yes.

 
 
With 
regard to the cause of the infraspinatus tear, Dr. Biles 
testified:

 
 
            
Q.        And 
in performing a diagnosis on Carol Middlemass, can you say that it is  based 
upon the history and everything else in the chart, that it is likely or probable 
that this was the result of a workplace injury? 

            
A.        Are 
you referring to the infraspinatus  

            
Q.        
Yes.

            
A.        
--portion?

            
That actually is conceivable because rotator cuff tears of the 
suprapinatus frequently, usually propagate.  Over time, they tend to either extend 
into the infraspinatus or extend towards the front part of the rotator cuff, 
which is called the subscapularis.  
And it doesn't take as much trauma to extend a tear into the 
infraspinatus or the subscapularis if the supraspinatus is already torn.  

 
 
[¶25]   Dr. Biles continued by testifying 
about the symptoms associated with each of the pathologies present in Ms. 
Middlemass' shoulder.  He stated 
that with suprapinatus tears, people usually feel pain at the time of the 
injury, but the pain may then dissipate.  
He stated that there is "a 15- or 20-percent incidence of people having 
tears of the supraspinatus that never reported any pain.  So, it's conceivable that she could have 
good shoulder function with an isolated tear of the supraspinatus."  According to Dr. Biles, a labrum tear 
causes the following symptoms:  "It 
usually causes mechanical catching, clunking, popping-type symptoms when the arm 
is moved.  There's frequently not 
horrible pain, but, rather, mechanical symptoms of something getting caught or 
popping in the shoulder."  Dr. Biles 
was then questioned about symptoms of an infraspinatus tear and how that related 
to Ms. Middlemass' situation:

 
 
            
Q.        Now, 
with regard to the infraspinatus tear that we see in [Ms. Middlemass'] charts, 
what sort of symptoms would you expect to see with that?

            
A.        The 
shoulder would be more painful. . . . [I]f it's a partial tear, they would still 
be able to move their arm, but it would be more painful.

            
Q.        If 
the evidence in this case shows that [Ms. Middlemass] was functioning without 
pain and without appreciable limitations prior to the injury but then ever since 
the injury has had consistent pain in the shoulder, would that be consistent 
with the partial tear of the infraspinatus having occurred as she reported in 
her medical history?

            
A.        
Yes.

            

[¶26]   Kenneth White was Ms. Middlemass' 
supervisor at Y-Tex and testified as to how the tag production process worked 
and what a packer, like Ms. Middlemass, did with the ear tags.  His description of a packer's work 
duties generally mirrored Ms. Middlemass' testimony.  Of particular importance to the issues 
on appeal, he testified the weight of a full bag of tags the packer would place 
in a shipping box was only 11.5 ounces and his description of a packer's duties 
did not include any overhead reaching.     

 
 
[¶27]   The hearing examiner held that Dr. 
Biles' testimony was insufficient to establish that Ms. Middlemass' work 
activities caused her infraspinatus injury.  We note that it makes no difference 
whether the infraspinatus tear was a new injury or an aggravation of Ms. 
Middlemass' preexisting condition; the issue for our determination remains the 
samewhether her work activities caused her current condition/injury.  Based upon our review of the record, we 
conclude the OAH decision was not against the overwhelming weight of the 
evidence and was, therefore, supported by substantial evidence.      

 
 
[¶28]   Dr. Biles was only able to state 
that it was "conceivable" or "possible" that Ms. Middlemass' infraspinatus tear 
was related to her work activities.  
Our precedent establishes that medical testimony stating the claimant's 
work "contributed to" the injury or the injury was "most likely" or "probably" 
the product of the workplace is sufficient to satisfy the requirements.  Boyce v. State ex rel. Wyo. Workers' Safety 
& Comp. Div., 2005 WY 9, ¶ 21, 105 P.3d 451, 458 (Wyo. 2005), citing 
Jim's Water Serv. v. Eayrs, 590 P.2d 1346, 1349 (Wyo. 1979) and Claim 
of Vondra, 448 P.2d 313 (Wyo. 1968).  
See also, Salas v. General 
Chemical, 2003 WY 79, ¶ 10, 71 P.3d 708, 711 (Wyo. 2003).  However, "opinions expressed by medical 
experts in terms of can,' could,' or possibly' are not sufficient to meet an 
employee's burden of proof." Boyce, ¶ 
22, 105 P.3d  at 458, citing Thornberg v. State ex rel. Wyo. Workers' Comp. Div., 913 P.2d 863 (Wyo. 
1996).  Dr. Biles' testimony that it 
was "conceivable" or "possible" that Ms. Middlemass' infraspinatus tear was 
caused by her work activities falls within the latter category of insufficient 
medical proof.  

 
 
[¶29]   The hearing examiner also 
discounted Dr. Biles' opinion because he did not have a correct understanding of 
Ms. Middlemass' work activities.  At 
one point, Dr. Biles indicated that he thought Ms. Middlemass was holding a box 
and putting something in it when she felt the pop.  At another point, he testified that he 
thought she was reaching overhead when she was injured.  Ms. Middlemass testified that she was 
reaching to grab the tags when she was injured.  She did not state that she was reaching 
overhead or holding a box or any significant weight at the time.  In fact, she testified that no overhead 
reaching was required to perform her work duties.  A hearing examiner is not bound by a 
medical expert's opinion when it is "unreasonable, not adequately supported by 
the facts upon which the opinion is based, or based upon an incomplete and inaccurate medical 
history provided by the 
claimant."  Watkins v. State ex 
rel. Wyo. Medical Comm'n, 2011 WY 49, ¶ 25, 250 P.3d 1082, 1091 (Wyo. 2011), 
quoting Taylor v. State ex rel. Wyo. Workers' Safety & Comp. Div., 
2005 WY 148, ¶ 15, 123 P.3d 143, 148 (Wyo. 2005).  See also, Torres v. State ex rel. Wyo. Workers' Safety 
& Comp. Div., 2011 WY 93, ¶ 24, 253 P.3d 175, 181 (Wyo. 2011).  

 
 
[¶30]   Interestingly, the notes from Dr. 
Biles' office do not state that she reported she was injured while reaching 
overhead or holding a box:

 
 
On 
02/12/09 Carol Middlemass was at work.  
She works at Y-Te[x] doing conveyor work.  She states that she turned to place 
something in a box and heard a pop in the right shoulder.  The shoulder was painful.  She tried to work the next day but was 
unable [to] and states that it has been painful since.  She has tried to work off and on but has 
not been successful.  She was 
evaluated at Urgent Care on 02/19/09.  
. . . The patient states that she has pain with reaching out and with 
overhead reach.   She also has 
pain in the right shoulder when lying on it and when pushing buttons with the 
right hand.  

 
 
 
 
Dr. 
Biles' misunderstanding of Ms. Middlemass' work activities could have occurred 
because he had never actually seen Ms. Middlemass.  She testified that she had only been 
examined by Dr. Biles' nurse practitioner.  
Consequently, he was relying on his interpretation of the nurse 
practitioner's notes when making his diagnosis and giving his deposition 
testimony.  

 
 
[¶31]   Dr. Biles testified that "without 
lifting the box or having a load in her arm and turning her arm, it would be 
difficult to have these -- all these injuries occur from that."  Thus, Dr. Biles clearly did not believe 
that Ms. Middlemass could have torn her infraspinatus tendon by simply reaching 
for tags, as she described.  Under 
these circumstances, there was substantial evidence to support the hearing 
examiner's finding that Dr. Biles' testimony did not establish that her shoulder 
injury was work related.

 
 
[¶32]   Citing to Thornberg and Walmart Stores v. Clark, 969 P.2d 550 
(Wyo. 1998),3 Ms. Middlemass claims that 
medical evidence was unnecessary to establish the causation element of her 
claim.  She asserts that these cases 
allow causation to be established by the claimant's testimony alone, without the 
need for expert medical testimony.  Ms. Middlemass argues, therefore, that 
the uncontroverted evidence that her shoulder was fully functional and she did 
not have any pain before the work place incident and she was in constant pain 
and had very limited use of the shoulder after the incident was sufficient to 
establish causation.  

 
 
[¶33]   In Thornberg, 913 P.2d  at 867, we 
stated:  "Generally, when a single 
incident is alleged to have caused an injury, medical testimony is not required 
if it is not essential to establish a causal connection between the occurrence 
and the injury."  The decision also 
states, however, that "under certain circumstances, medical testimony may be 
essential to establish a causal connection."  Id.  
Mr. Thornberg injured his tailbone when the dump truck he was driving 
slammed down over a ridge of dirt.  
Several months later, he developed coccydynia which presented with 
symptoms of rectal discomfort and abscesses.  Id. at 865.  We held that, as a practical matter, 
medical testimony was indispensible in Mr. Thornberg's case because the medical 
condition complained of was not "immediately and directly or naturally and 
probably'" the result of the workplace incident.  Id. at 867, quoting Hansen v. Mr. D's Food Center, 827 P.2d 371, 373 (Wyo. 1992).   

 
 
[¶34]   As Thornberg confirms, there is a line of 
worker's compensation cases holding that medical expert testimony is not always 
required to establish causation.  See, e.g., Forni v. Pathfinder Mines, 834 P.2d 688, 
693 (Wyo. 1992); Hansen, 827 P.2d  at 
373; Gray v. State ex rel. Wyo. Workers' 
Safety & Comp. Div., 2008 WY 115, ¶ 17, 193 P.3d 246, 251-52 (Wyo. 
2008).  Nevertheless, Thornberg also recognizes that in many 
cases expert testimony will be required.  
In the case at bar, we have a claimant with a complex medical history and 
a complex diagnosis.  She had three 
distinct pathologies in her shoulder, two of which were clearly 
preexisting.  Ms. Middlemass 
maintains that her pain must have been caused by the infraspinatus tear because 
the other two conditions were not necessarily painful.  While Dr. Biles stated that a patient 
may have a supraspinatus tear or a labrum tear and not suffer any pain, he did 
not indicate that was the norm or always the case.  In fact, he stated that just fifteen to 
twenty percent of people with supraspinatus tears did not report any pain.  Moreover, this is not a case like those 
referenced in Thornberg where the 
injury was an immediate, direct or natural result of the workplace injury.  To the contrary, Dr. Biles indicated it 
was unlikely that the work activities engaged in by Ms. Middlemass would have 
led to her shoulder injury.  
Compare, Slaymaker, ¶ 17, 156 P.3d  at 983-84 (medical evidence linked the specific work activity being 
performed at the time of the injury and the injury).   

  

[¶35]   The other case Ms. Middlemass 
cites, Walmart, is a negligence case 
and does not directly involve worker's compensation law or benefits.  Walmart challenged the sufficiency of 
Mr. Clark's evidence establishing the causal connection between his fall in the 
store and his injuries on the basis that there was insufficient expert medical 
testimony to establish the connection.  
Reviewing the jury's verdict, we stated:

 
 
[T]he 
testimony of the plaintiff may be sufficient, without the use of experts to 
establish the element of causation between an accident and the plaintiff's 
injuries.  . . .  The jury may reasonably infer that an 
absence of pain prior to the accident, and the onset of pain afterwards, is 
evidence that the accident caused the pain.

 
 

Walmart, 
969 P.2d  at 551-52.   

 
 
[¶36]   Even putting aside the obvious 
procedural differences between civil negligence cases and worker's compensation 
cases, we do not find Walmart to be 
persuasive in this context.  There 
was no indication in Walmart that Mr. 
Clark had any preexisting condition or that there were any complicating factors 
like the two preexisting and non-compensable shoulder conditions in this 
case.  Walmart is so different from the case at 
bar, it cannot be considered to be relevant precedent.  

 
 
[¶37]   Under the circumstances presented 
here, the hearing examiner properly ruled expert medical testimony was required 
to establish that Ms. Middlemass' work activities caused the infraspinatus 
tear.  This is not a case where the 
injury was immediately and directly or naturally and probably the result of Ms. 
Middlemass' work activities.  Ms. 
Middlemass' history of an injury to her right shoulder in a severe automobile 
accident, coupled with the fact that two of the conditions she was suffering 
from at the time of the workplace incident clearly were not work-related, made 
expert medical testimony critical to establish causation.

 
 
[¶38]   Affirmed.  

            
 

 
 
FOOTNOTES

 
 

1Ms. Middlemass also claims the OAH erred by ruling that her injury was 
one which occurred over a substantial period of time and concluding that she had 
not met the heightened standard of proof under Wyo. Stat. Ann. § 27-14-603(a) 
(LexisNexis 2011) required for such injuries.  Our other rulings in this case make it 
unnecessary to review this alternative ground for denial; consequently, we will 
not discuss it.  

2The 
acromion is defined as 
"the outer end of the spine of the scapula  . . . protecting the glenoid cavity, 
forming the outer angle of the shoulder and articulating with the clavicle. 
 Also called acromial 
process."  Webster's Third New Int'l Dictionary 19 
(2002). 

 
 

3Ms. Middlemass also cites to two cases from other jurisdictions holding 
that, under certain circumstances, a medical expert's equivocal testimony 
coupled with the claimant's testimony about her condition can provide sufficient 
evidence to establish the causation element of a worker's compensation 
claim.  P & L Constr. Co., Inc. v. Lankford, 
559 S.W.2d 793, 794 (Tenn. 1978); Miller v. Penmac Personnel Serv., Inc., 
68 S.W.3d 574, 580 (Mo. Ct. App. 2002) (overruled on other grounds).  These cases are simply corroborative of 
Wyoming precedent and do not advance our inquiry.  Consequently, we do not need to 
separately analyze them.