Title: EUGENE M. LANGBERG V. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

State: wyoming

Issuer: Wyoming Supreme Court

Document:

EUGENE M. LANGBERG V. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2009 WY 39203 P.3d 1098Case Number: S-08-0001Decided: 03/18/2009
OCTOBER 
TERM, A.D. 2008

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

 
 
Appeal 
from the District Court of Laramie County

The 
Honorable Nicholas G. Kalokathis, Judge

 
 

Representing 
Appellant:

Thomas 
L. Lee, Attorney at Law, Cheyenne, Wyoming 

 
 

Representing 
Appellee:

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

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

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Eugene Langberg 
suffered two separate injuries to his left wrist while on the job.  Ultimately, he underwent surgery on his 
wrist.  The Workers' Compensation 
Division (the Division) covered the initial treatment for the injuries but 
denied coverage for the surgery.  
The Division found the surgery to be necessitated by a preexisting 
condition that was not materially aggravated by his job injuries.  The district court upheld the Division's 
final determination.  We 
reverse.

 
 
ISSUES

 
 
[¶2]      Langberg presents 
two issues:

 
 

1.            
Did 
the Hearing Examiner correctly find that [Langberg's] condition was a 
preexisting condition?

 
 
2.         
If so, did the Hearing Examiner correctly find that the work place 
incidents did not materially aggravate [Langberg's] preexisting condition?

 
 
FACTS1

[¶3]      In June 2005, 
Langberg was employed with the City of Cheyenne, Parks and Recreation 
Division.  On June 27, he injured 
his left wrist moving a metal picnic table with attached benches weighing over 
two hundred pounds.  Langberg 
testified he heard and felt a pop and immediate pain in the ulnar side of his 
left wrist.  Langberg also suffered 
tingling along the lateral aspect of the fifth finger.  Langberg reported the injury to his 
supervisor, who told him to complete an injury report and seek medical 
attention.  An x-ray revealed no 
abnormalities.  Langberg was 
diagnosed with a wrist sprain and given a wrist splint.  The Division determined the injury to be 
compensable.

 
 
[¶4]      In October 2005, 
while still working for the Parks and Recreation Division, Langberg again 
injured his left wrist in the exact same location while shoveling snow.  The pain from this injury was far more 
intense than the June injury.  
Langberg notified his supervisor.  
The supervisor told Langberg to seek immediate medical attention.2  

 
 
[¶5]      At this stage 
Langberg was diagnosed as suffering from carpal tunnel syndrome in his left 
wrist.  Langberg underwent physical 
therapy for the condition, but the pain did not resolve.  Langberg was referred to Dr. Judson Cook 
for further evaluation.  Dr. Cook 
ordered an MRI and a nerve conduction study on the left wrist.  The nerve conduction study was 
normal.  The MRI showed findings 
"worrisome for Kienbock's disease with cystic degeneration and early 
fragmentation and collapse along the radial side of the lunate at the 
scapholunate articulation."3  Dr. Cook referred Langberg to an 
orthopedic specialist, Dr. Jean Basta, for consultation.

 
 
[¶6]      Langberg saw Dr. 
Basta on October 31, 2005.  Dr. 
Basta definitively ruled out carpal tunnel syndrome.  Dr. Basta took new x-rays of the 
wrist.  According to Dr. Basta's 
notes, the new "x-rays show a little bit of cyst in the lunate.  It looks like a little bit of Kienbock 
disease.  His MRI shows the same 
thing."  Because of the suspected 
Kienbock's, Dr. Basta put a wrist cast on Langberg's left wrist to immobilize 
it.  

 
 
[¶7]      In early 
December, Langberg sought treatment from Dr. Mark Durbin, an orthopedic surgeon 
specializing in hand and upper extremity surgery. Dr. Durbin definitively 
diagnosed Langberg as suffering from Kienbock's disease.  Dr. Durbin operated on Langberg's left 
wrist shortly after the first visit.  
Through deposition, Dr. Durbin testified he conducted the surgery 
"[b]ecause on the MRI it showed that the cyst had some collapse to it, and that 
he was developing avascular necrosis to the lunate."  Dr. Durbin testified the most 
significant finding of the surgery was his identification "that the bone had 
minimal vascularity to it, and bone becomes very hard when it loses its vascular 
supply, so the bone was dying."  
This is consistent with Kienbock's.  
Ultimately, Dr. Durbin opined that the work injury(ies) materially 
exacerbated the disease.  

 
 
[¶8]      Meanwhile, on 
November 14, 2005, the Division issued a final determination denying benefits 
for treatment of medical symptoms relating to Kienbock's disease.  Langberg objected to the denial and 
timely requested a hearing.  The 
matter was referred to the Office of Administrative Hearings (OAH).  The OAH granted Langberg medical 
benefits for all treatments up until surgery, considering those treatments 
diagnostic.  Medical benefits for 
the surgery, which the OAH considered solely related to Kienbock's, as well as 
any further expenses related to Kienbock's disease, were denied.   

 
 
[¶9]      Specifically, the 
OAH determined there was insufficient evidence to prove the work injuries caused 
Langberg's Kienbock's disease.  
Rather, the OAH determined the Kienbock's disease was a preexisting 
condition.  Langberg thus was 
required to prove his two work injuries materially aggravated his Kienbock's 
disease.  The OAH determined 
Langberg had not met his burden.

 
 
DISCUSSION

 
 
[¶10]   As is well known, we are 
statutorily constrained in our review of contested case hearings to determining 
if the agency's decision is supported by substantial evidence, is arbitrary and 
capricious, or is otherwise not in accordance with law.  Wyo. Stat. Ann. § 16-3-114(c)(ii)(A) and 
(c)(ii)(E) (LexisNexis 2007).  We 
defer to an agency's findings of fact if supported by substantial evidence upon 
the record as a whole.  We review 
questions of law de novo.  We are 
not at liberty to substitute our judgment for that of the agency if the agency 
decision is reasonable under the circumstances.  Dale v. S&S Builders, LLC, 2008 WY 
84 ¶¶ 21-26, 188 P.3d 554, 561-62 (Wyo. 2008).  It is the claimant's burden to prove all 
elements of the claim.  If the OAH 
determines the claimant did not meet his or her burden of proof, we review the 
finding to determine "whether that conclusion was contrary to the overwhelming 
weight of the evidence in the record as a whole."  Id. at ¶ 22; see also Horn-Dalton v. State ex rel. 
Wyoming Workers' Safety and Comp. Div., 2009 WY 14, ¶ 7, 200 P.3d 810, 813 
(Wyo. 2009). 

 
 
Causation 
of Kienbock's disease 

 
 
[¶11]   Langberg argues the evidence is 
sufficient to prove the cause of his Kienbock's disease was a single traumatic 
injury.  He primarily relies on the 
fact that the x-rays taken after the first injury in June did not show any 
abnormalities.  The x-rays taken by 
Dr. Basta at the end of October revealed a "little bit of cyst in the 
lunate."  When combined with 
Langberg's testimony that he had no prior problems with his wrist, Langberg 
argues this circumstantial evidence irrefutably points to the work injury(ies) 
being the trigger for the onset of his Kienbock's disease.  

 
 
[¶12]   We agree with Langberg's general 
theory that it is possible for proof of lack of medical problems before a work 
injury and change immediately following the injury to establish the medical 
impairment was caused by the work injury.  
See, e.g., McIntosh v. State ex rel. Wyoming Medical 
Comm'n, 2007 WY 108, 162 P.3d 483 (Wyo. 2007); Murray v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 993 P.2d 327, 332 (Wyo. 1999).  All cases, however, are decided on their 
own facts and circumstances, with all facts being taken into account.  In this case, Langberg's hypothesis is 
refuted by his own treating physician, Dr. Durbin.

 
 
[¶13]   Dr. Durbin testified at the hearing 
by means of deposition.  He 
testified that Langberg suffered from early stage Kienbock's disease.  He explained the cause of Kienbock's 
disease is unknown.  Dr. Durbin 
testified he is aware of some indication in medical literature that it might be 
caused by trauma, but he did not know of any proof supporting this theory.  On the contrary, many cases of 
Kienbock's disease are not caused by an identifiable trauma.  

 
 
[¶14]   As for Langberg's case in 
particular, Dr. Durbin found no significance in the fact that Langberg had no 
wrist problems prior to his work injuries.  
Dr. Durbin testified that, while the work injuries certainly precipitated 
Langberg's wrist pain, he could only speculate as to whether the injuries 
actually caused the onset of Kienbock's disease.  Ultimately, Dr. Durbin testified: "did 
the Kienbock's start from the original injury?  I can't necessarily say it did."    

 
 
[¶15]   Langberg argues this testimony is 
ambivalent as to whether a single traumatic event caused his Kienbock's 
disease.  He points out that, while 
Dr. Durbin testified he couldn't say the injury(ies) did cause the onset of the 
disease, he also testified he couldn't say the injury(ies) did not cause the 
onset of the disease.  Langberg 
argues this ambiguity negates any reliance on Dr. Durbin's testimony regarding 
causation.  Consequently, his theory 
that the work injuries are the causative factor is the only viable theory.  

 
 
[¶16]   The flaw in Langberg's reasoning is 
that Dr. Durbin, an expert in the field and intimately familiar with Langberg's 
medical condition, effectively testified that Langberg's theory is pure 
speculation.  Speculation does not 
rise to the level of proof needed to support a finding that his Kienbock's 
disease was a direct result of his work injury(ies).  Anastos v. General Chem. Soda Ash, 2005 
WY 122, ¶ 21, 120 P.3d 658, 666 (Wyo. 2005); Frazier v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 997 P.2d 487, 490 (Wyo. 2000).  In the face of the direct medical 
testimony from Langberg's own treating physician, we find the OAH's decision is 
not against the overwhelming weight of the evidence.  Consequently, we agree Langberg's 
Kienbock's disease was not caused by his work injury(ies) but rather was a 
preexisting condition.

 
 
Material 
aggravation of a preexisting condition

 
 
[¶17]   As a general rule, treatment for a 
condition preexisting the start of employment is not compensable.  Wyo. Stat. Ann. § 27-14-102(a)(xi)(F) 
(LexisNexis 2007).  A compensable 
claim might arise, however, "if the employment aggravated, accelerated, or 
combined with the disease or infirmity to produce the . . . disability for which 
compensation is sought.'  1 Larson's 
Workmen's Compensation Law, § 12.20, p. 3-276."  Lindbloom v. Teton International, 684 P.2d 1388, 1390 (Wyo. 1984); see also 
Ramos v. State ex rel. Wyoming Workers' Safety & Comp. Div., 2007 WY 85, 
¶ 17, 158 P.3d 670, 676 (Wyo. 2007);  
Boyce v. State ex rel. Wyoming 
Workers' Safety & Comp. Div., 2005 WY 9, ¶ 10, 105 P.3d 451, 455 (Wyo. 
2005).  It is Langberg's burden to 
prove, by a preponderance of the evidence, his work-related injuries materially 
aggravated, accelerated, or combined with his Kienbock's to necessitate the 
surgery for which he is seeking compensation.  State ex rel. Wyoming Workers' Safety & 
Comp. Div. v. Slaymaker, 2007 WY 65, ¶ 14, 156 P.3d 977, 982 (Wyo. 2007); Salas v. Gen. Chem., 2003 WY 79, ¶ 10, 
71 P.3d 708, 711 (Wyo. 2003); Lindbloom, 
684 P.2d  at 1389-90.  

 
 
[¶18]   Langberg relies on two categories 
of evidence in support of his claim for benefits.  First, Langberg relies on the 
circumstances, including the fact that he had no history of left wrist problems 
before the work injuries.  Rather, 
his problems began after the injuries.  
The second category is the testimony of Dr. Durbin, most especially Dr. 
Durbin's testimony that Langberg's injuries materially exacerbated his 
Kienbock's.

 
 
[¶19]   The Division engages Langberg over 
the definition of "exacerbate."  
Langberg argues the term is synonymous with "aggravate."  The Division argues the two terms not 
only are not interchangeable, but in fact are mutually exclusive.  Unfortunately, nobody asked Dr. Durbin 
to define the word "exacerbate" as he was using it or compare it to the word 
"aggravate."  

 
 
[¶20]   The positions of both parties find 
support in reference books.  In the 
Online Merriam Webster Dictionary, "aggravate" and "exacerbate" share a common 
definition  to make more severe.  
Compare 
http://www.merriam-webster.com/dictionary/exacerbate with 
http://www.merriam-webster.com/dictionary/aggravate.  The same is true in the Online Merriam 
Webster Medical Dictionary.  Compare http://www.merriam-webster. 
com/medical/exacerbate with 
http://www.merriam-webster.com/medical/aggravate.  

 
 
[¶21]   The Division, for its part, insists 
the term "exacerbate" as used by Dr. Durbin under the facts of this case is 
consistent with the term as defined in the American Medical Association Guides 
to the Evaluation of Permanent Impairment (Guides).4  The Division argues that, in the Guides, 
"exacerbation" is defined as a short-term increase in severity of a preexisting 
medical impairment; this contrasts with "aggravation," which is defined as a 
permanent increase in severity of a preexisting medical impairment.  Under these definitions, a finding of 
one contraindicates a finding of the other.  Indeed, the Division points out the 
Guides expressly states that "[e]xacerbation does not equal aggravation."  

 
 
[¶22]   We initially note that, as 
suggested by its title, the Guides applies to the evaluation of permanent 
impairments.  Dr. Durbin was not 
engaged in rating a permanent impairment.  
Instead, he was Langberg's treating physician.  Consequently, the Guides's definitions 
do not automatically apply to this situation.  We still, however, must determine 
whether Dr. Durbin, on his own, used the word "exacerbate" as a unique, more 
limiting term than the term "aggravate."  

 
 
[¶23]   We find the question of whether Dr. 
Durbin used the term "exacerbation" in the same context as the Guides is 
determined by the language of the Guides itself.  We note the Division quotes only a 
portion of the applicable language in the Guides.  In full, the Guides 
read:

 
 
Exacerbation: 
Temporary worsening of a preexisting 
condition.  Following a transient 
increase in symptoms, signs, disability, and/or impairment, the person recovers 
to his or her baseline status, or what it would have been had the exacerbation 
never occurred.  Given a condition 
whose natural history is one of progressive worsening, following a prolonged but 
still temporary worsening, return to pre-exacerbation status would not be 
expected, despite the absence of permanent residuals from the new 
cause.

 
 
Robert 
D. Rondinelli, et al., AMA Guides to the 
Evaluation of Permanent Impairment 611 (6th ed. 2008) (emphasis in 
original).

 
 
Aggravation: 
Permanent worsening of a preexisting 
condition.  A physical, chemical, 
biological, or other factor results in an increase in symptoms, signs, and/or 
impairment that never returns to baseline, or what it would have been except for 
the aggravation (the level pre-determined by the natural history of the 
antecedent injury or illness). 

 
 

Id. 
at 609 (emphasis in original).  The 
Guides briefly discuss the differentiation between the terms in the body of the 
text:

 
 
Although 
there are circumstances in which an event was the sole or primary cause of a 
given effect, in many instances patients have preexisting pathology that may 
have contributed to their current clinical condition.  Aggravation is a circumstance or event 
that permanently worsens a preexisting or underlying condition.  The terms exacerbation, recurrence, or flare-up 
generally imply worsening of a condition temporarily, which subsequently returns 
to baseline.  Exacerbation does not 
equal aggravation.  

 
 

Id. 
at 25 (emphasis in original).  

 
 
[¶24]   Langberg's case certainly was not 
one of a temporary increase in severity.  
His condition was dormant prior to his injuries.  The injuries began the process of 
pain.  As the Guides recognize, 
returning to baseline is not expected in the case of a progressive degenerative 
disease.  Therefore, Dr. Durbin 
could not have been using the term "exacerbate" as defined by the Guides.  

 
 
[¶25]   Under the specific circumstances of 
this case, we find no ambiguity in Dr. Durbin's use of the term "exacerbate." 
Dr. Durbin used the word "exacerbate" consistently with its common dictionary 
definition  to increase in severity.  
Any finding to the contrary is against the overwhelming weight of the 
evidence.

 
 
[¶26]   Dr. Durbin's testimony is 
sufficient to establish a causal link between Langberg's work injuries and his 
surgery:

 
 
[T]he 
causal connection between an accident or condition at the workplace is satisfied 
if the medical expert testifies that it is more probable than not that the work 
contributed in a material fashion to the precipitation, aggravation or 
acceleration of the injury.   

 
 

Pino 
v. State ex rel. Wyo. Workers' Safety & Comp. Div., 
996 P.2d 679, 685 (Wyo. 2000); see also 
Salas, ¶ 10, 71 P.3d  at 712.  
Dr. Durbin's exact testimony is:

 
 
I 
can't tell you when the Kienbock's disease started, but I know that the pain 
started in that time when he felt something pop in his wrist.  So did the Kienbock's start from the 
original injury?  I can't 
necessarily say it did.  Did the 
original injury exacerbate the Kienbock's and cause pain?  More likely than not.  

 
 
Dr. 
Durbin considered this a material exacerbation. Dr. Durbin's direct testimony on 
the issue overwhelmingly establishes the requisite causal connection between 
Langberg's work-related injuries and his surgery.

 
 
CONCLUSION

 
 
[¶27]   Dr. Durbin testified Kienbock's 
disease is of unknown etiology.  
Therefore, he could only speculate as to the cause and time of onset of 
Langberg's Kienbock's disease.  No 
other evidence was introduced regarding the onset of the disease.  Consequently, we affirm the OAH's 
determination that Langberg's work-related injuries did not cause his Kienbock's 
disease.

 
 
[¶28]   We find, however, that Langberg's 
work-related injuries did materially aggravate his Kienbock's disease, leading 
directly to his need for surgery.  
Langberg's Kienbock's disease was dormant prior to his work-related 
injuries.  After his original 
injury, he heard and felt a pop in his left wrist and experienced pain.  After his second injury the pain in his 
left wrist increased in severity.  
These injuries signify acute trauma rather than simply a natural 
progression of the disease.  Dr. 
Durbin expressly testified the work-related injuries materially exacerbated his 
Kienbock's disease.  

 
 
[¶29]   Given this evidence, and upon 
review of the record as a whole, the evidence overwhelmingly supports a finding 
that Langberg's work-related injuries led to his need for surgery.  The OAH erred in determining 
otherwise.  The case is reversed and 
remanded for the award of appropriate benefits.

 
 
FOOTNOTES

 
 

1The 
hearing examiner expressly found Langberg's testimony credible.  Since he was the only witness at the 
hearing, and all medical evidence is consistent, there are no factual 
disputes.  

 
 

2The Division argued the second injury should not be considered because it 
was not properly reported.  The 
Division made this argument directly before the OAH, and the OAH found against 
the Division on the issue.  The 
Division did not appeal the decision.  
We therefore will consider both injuries.

 
 

3Kienbock's disease is a progressive, degenerative disease causing a loss 
of blood supply to the lunate bone, thus causing the bone to die (avascular 
necrosis).  

 
 

4The Guides 
consists of one volume.