COURT OF APPEALS OF VIRGINIA 

Present: Chief Judge Fitzpatrick, Judges Coleman and Elder 

Argued at Salem, Virginia 

ALLEN & ROCKS, INC. AND 

 NORTH RIVER INSURANCE COMPANY 

 OPINION BY 

v. Record No. 0768-98-3 CHIEF JUDGE JOHANNA L. FITZPATRICK 

 DECEMBER 22, 1998 

PERRY LEE BRIGGS 

 FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION 

 S. Vernon Priddy, III (Collin J. Hite; Sands, 

Anderson, Marks & Miller, on brief), for 

appellants. 

 Gary Lumsden (Rhonda L. Overstreet; Lumsden, 

Overstreet & Hansen, on brief), for appellee. 

 Allen & Rocks, Inc. and its insurer (collectively referred 

to as "employer") contend the Workers' Compensation Commission 

("commission") erred (1) in finding that Perry Lee Briggs' 

("claimant") injury to his left knee was a compensable 

consequence of his work-related back injury; (2) in refusing to 

remove Dr. Murray Joiner as claimant's treating physician; and 

(3) in awarding attorney's fees. For the following reasons, we 

affirm in part and reverse in part. 

I. BACKGROUND

 On April 24, 1980, claimant, a porter, suffered a 

compensable injury to his lower back when he slipped on stairs in 

the course of his employment. His claim was accepted by employer 

and several awards for compensation benefits and lifetime medical 

benefits have been entered. 
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 The evidence established that claimant came under the care 

of Dr. Murray Joiner, a physiatrist, on November 9, 1994. 

Following an initial evaluation of claimant, Dr. Joiner noted a 

history of two lumbar laminectomies, a spinal fusion, and a right 

meniscus repair surgery. On that occasion, claimant reported 

"bilateral low back pain which is constant and sharp in quality," 

with radiation into his right lower extremity. Dr. Joiner 

initially diagnosed claimant's condition as "failed back 

syndrome," and he recommended injections and physical therapy. 

 Over the next year, claimant followed this treatment plan of 

physical therapy and injections. On February 27, 1996, claimant 

returned to Dr. Joiner with severe pain in his lower left leg. 

Dr. Joiner opined that the left knee pain was "[secondary] to 

chronic gait deviations," caused by claimant's failed back 

syndrome. Claimant was referred for additional physical therapy 

to treat his back and left knee pain. On at least seven 

occasions in 1996, Dr. Joiner assessed claimant's condition as 

left knee pain secondary to chronic back pain. In 1997, Dr. Sam 

Samarsinghe, a pain management specialist, treated claimant for 

"increased back discomfort with bilateral leg radiation." 

 When employer's insurance carrier initially denied medical 

coverage for claimant's knee condition, Dr. Joiner wrote the 

company several letters. On March 5, 1996, Dr. Joiner requested 

Jean Ellison, a claims examiner, to reconsider the denial of 

medical treatment. Dr. Joiner repeated his diagnosis that 
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claimant suffered from knee pain secondary to chronic gait 

deviations with failed back syndrome. He concluded, "Mr. Briggs 

would not suffer his current knee pathology if he did not have 

the gait deviations which are directly related to his failed back 

syndrome." A similar letter was written on January 6, 1997, 

requesting that the insurer approve medical expenses for a knee 

brace and physical therapy for claimant's back injury and 

bilateral knee problems. The insurer continued to deny the claim 

asserting that the medical care did not "appear" to relate to the 

original workers' compensation claim. 

 At employer's request, claimant underwent an independent 

medical evaluation by Dr. Daniel L. Hodges on November 11, 1996.1

 In his report, Dr. Hodges reviewed claimant's medical history 

and noted his complaints of pain radiating into both lower 

extremities. Dr. Hodges concluded that claimant suffered from 

"failed back syndrome" and a "[history] of right knee surgery 

with secondary mechanical pain due to his antalgic gait from his 

low back." 

 Claimant filed a claim seeking to hold employer responsible 

for medical treatment to his left knee as a compensable 

 1While there was some dispute as to whether the November 11, 

1996 medical report of Dr. Hodges was made part of the record 

before the deputy commissioner, the full commission considered 

the report in rendering its opinion. As noted by the commission, 

Dr. Hodges' opinion was not contradictory to the opinion of Dr. 

Joiner and, therefore, any error in the deputy commissioner's 

failing to keep the record open was harmless. Furthermore, this 

procedural issue was not raised on appeal and is not before us. 
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consequence of his back injury. Thereafter, employer filed an 

application requesting a change in treating physicians. On March 

28, 1997, claimant filed a supplemental claim requesting 

attorney's fees because employer denied necessary medical 

treatment without reasonable grounds. 

 The parties agreed to submit the issues for a hearing on the 

record. The commission found that claimant's injury to his left 

knee was a compensable consequence of his work-related back 

injury. The commission denied employer's application to remove 

Dr. Joiner as claimant's treating physician and awarded claimant 

his requested attorney's fees. 

II. COMPENSABLE CONSEQUENCES AND CUMULATIVE TRAUMA

 Employer argues that the commission erred in awarding 

benefits to claimant because his left knee condition was a result 

of cumulative trauma injury not covered by the Act. According to 

employer, claimant's knee pain constituted a new cumulative 

trauma injury because it was caused by an ongoing disturbance in 

his gait. Employer contends that as a matter of law the doctrine 

of compensable consequences does not apply when there is a 

gradually incurred injury. This argument presents an issue of 

first impression for this Court. 

 The full commission found that claimant's knee pain was 

caused by his gait deviations, which was a direct result of the 

compensable work injury to his back. Accordingly, the commission 

held it was a "compensable consequence" of the original injury. 
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The doctrine of compensable consequences arose from a line of 

Supreme Court cases discussing chain of causation principles. In 

Justice v. Panther Coal Co., 173 Va. 1, 2 S.E.2d 333 (1939), the 

claimant fractured his pelvis in the course of his employment. 

While in the hospital for treatment of the compensable injury, 

the claimant died from acute lobar pneumonia. See id. at 3, 2 

S.E.2d at 334. Reversing the commission's denial of benefits, 

the Court wrote: 

 Decedent was hale and hearty for several 

years immediately preceding the accident. He 

was never sick during this period. After the 

accident, exposure and operation, he was 

confined to the hospital where we presume all 

proper precautions were taken to prevent the 

onslaught of pneumonia from any source. 

Notwithstanding these precautions, pneumonia 

developed in an otherwise apparently vigorous 

and healthy man within five days from the 

date of the accident and within three days 

from the date ether was administered, 

resulting in death some five days later. In 

the absence of positive affirmative evidence, 

tending to establish a break in the chain of 

causation, the inevitable conclusion from the 

evidence is that the death of the decedent 

resulted "naturally and unavoidably from the 

accident." 

Id. at 7, 2 S.E.2d at 336 (emphasis added). 

 In Leonard v. Arnold, 218 Va. 210, 237 S.E.2d 97 (1977), the 

Court adopted the term "compensable consequences" and provided 

the following rule: "When a primary injury under the Workmen's 

Compensation Act is shown to have arisen out of the course of 

employment, every natural consequence that flows from the injury 

is compensable if it is a direct and natural result of a primary 
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injury. . . . This doctrine extends the canopy of the Workmen's 

Compensation Act to the resulting injury. This is so because the 

second injury is treated as if it occurred in the course of and 

arising out of the employee's employment." Id. at 214, 237 

S.E.2d at 99-100. See also Immer & Co. v. Brosnahan, 207 Va. 

720, 727-28, 152 S.E.2d 254, 258-59 (1967) (applying chain of 

causation rule and awarding compensation benefits for the 

claimant's injuries sustained in an automobile accident while en 

route to a medical provider for treatment of original 

work-related injury). 

 More recently, we addressed the doctrine of compensable 

consequences in Amoco Foam Products Co. v. Johnson, 26 Va. App. 

267, 494 S.E.2d 169 (1997). 

 In Virginia, the doctrine of compensable 

consequences "is well established and has 

been in existence for many years." Williams 

Indus., Inc. v. Wagoner, 24 Va. App. 181, 

186, 480 S.E.2d 788, 790 (1997). 

 This doctrine, also known as the chain of 

causation rule, provides that "where the 

chain of causation from the original 

industrial injury to the condition for which 

compensation is sought is direct, and not 

interrupted by any intervening cause 

attributable to the employee's own 

intentional conduct, then the subsequent 

condition should be compensable." 

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

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

Penkalski, 21 Va. App. 427, 432, 464 S.E.2d 554, 556 

(1995)) (emphasis added). 

 [W]hen the question is whether compensability 

should be extended to a subsequent injury or 

aggravation related in some way to the 

primary injury, the rules that come into play 
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are essentially based upon the concepts of 

direct and natural results, and the 

claimant's own conduct as an independent 

intervening cause. 

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

at 790 (citation omitted) (emphasis added). "The 

simplest application of this principle is the rule that 

all the medical consequences and sequelae that flow 

from the primary injury are compensable." American 

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

S.E.2d 511, 513 (1993) (citation omitted) (emphasis 

added). 

Id. at 273-74, 494 S.E.2d at 172-73. 

 While we have long accepted the doctrine of compensable 

consequences, employer urges us to adopt a narrow application of 

the rule when there exists a consequence that is not attributable 

to a sudden identifiable accident, but is instead gradually 

incurred. Here, employer contends it is irrelevant whether 

claimant's knee condition was a compensable consequence of his 

original back injury because under our Supreme Court's decision 

in The Stenrich Group v. Jemmott, 251 Va. 186, 467 S.E.2d 795 

(1996), an employee may not recover for cumulative trauma 

injuries, "however labeled or however defined." Id. at 199, 467 

S.E.2d at 802. Employer argues that the Stenrich rule bars 

recovery because claimant's knee condition, even if a consequence 

of his original injury, was the result of cumulative trauma 

triggered by a gait problem developed over a period of time. We 

disagree. 

 In Stenrich, the Court held as a matter of law that 

repetitive motion injuries such as "carpal tunnel syndrome" and 
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"tenosynovitis" are not compensable under the Act. Id. at 

189-91, 199, 467 S.E.2d at 797-98, 802. In determining that 

these injuries did not constitute occupational diseases, the 

Court made it clear that an "injury of gradual growth, . . . 

caused by the cumulative effect of many acts done or many 

exposures to conditions prevalent in the work, no one of which 

can be identified as the cause of the harm, is definitely 

excluded from compensation." Id. at 192-93, 467 S.E.2d 798-99 

(citing Aistrop v. Blue Diamond Coal Co., 181 Va. 287, 293, 24 

S.E.2d 546, 548 (1943) (internal quotations omitted)). Stenrich

sets the parameters for the initial coverage determination of a 

primary injury. 

 The Court in Stenrich did not consider whether the rule 

applies to "chain of causation" or "compensable consequence" 

injuries. The difference between a primary injury and an injury 

that is a compensable consequence of the primary injury is 

significant. Professor Larson explains: 

 A distinction must be observed between 

causation rules affecting the primary injury 

. . . and causation rules that determine how 

far the range of compensable consequences is 

carried, once the primary injury is causally 

connected with the employment. As to the 

primary injury, it has been shown that the 

"arising" test is a unique one quite 

unrelated to common-law principles of legal 

cause, and . . . the employee's own 

contributory negligence is ordinarily not an 

intervening cause preventing initial 

compensability. But when the question is 

whether compensability should be extended to 

a subsequent injury or aggravation related in 

some way to the primary injury, the rules 

that come into play are essentially based 
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upon the concept of "direct and natural 

results," and of claimant's own conduct as an 

independent intervening cause. 

 The basic rule is that a subsequent 

injury, whether an aggravation of the 

original injury or a new and distinct injury, 

is compensable if it is the direct and 

natural result of a compensable primary 

injury. 

 The simplest application of this 

principle is the rule that all medical 

consequences and sequelae that flow from the 

primary injury are compensable. 

* * * * * * * 

 The first group, about which there is no 

legal controversy, comprises the cases in 

which an initial medical condition itself 

progresses into complications more serious 

than the original injury; the added 

complications are of course 

compensable. . . . [O]nce the work-connected 

character of any injury, such as a back 

injury, has been established, the subsequent 

progression of that condition remains 

compensable so long as the worsening is not 

shown to have been produced by an independent 

nonindustrial cause.

A. Larson, The Law of Workmen's Compensation § 13.11, 13.11(a) 

(emphasis added). 

 In the instant case, claimant had already proven a 

compensable injury by accident to his back. Therefore, any 

subsequent injury to his knee that is the direct and natural 

result of the primary back injury is also compensable under the 

chain of causation rule. See Food Distribs., 24 Va. App. at 697, 

485 S.E.2d at 158; Leadbetter, 21 Va. App. at 432, 464 S.E.2d at 

556-57; Imperial Trash Serv. v. Dotson, 18 Va. App. 600, 606-07, 

445 S.E.2d 716, 720 (1994) (stating the general rule that "[w]hen 
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the primary injury is shown to have arisen out of and in the 

course of employment, every natural consequence that flows from 

the injury likewise arises out of the employment, unless it is 

the result of an intervening cause attributable to claimant's own 

intentional conduct"). 

 The fact that the compensable consequence does not meet the 

requirements of a primary "injury by accident" is of no moment. 

The opinions of both Dr. Joiner and Dr. Hodges established that 

claimant suffered knee pain secondary to and as a consequence of 

his failed back syndrome. Accordingly, we hold the commission 

did not err in refusing to apply Stenrich and affirm the finding 

of the commission. 

 III. FINDING OF CAUSATION

 Employer next argues that no credible evidence supports the 

commission's finding that claimant's knee condition is a 

compensable consequence of his back injury. We disagree. "The 

issue in cases involving the range of compensable consequences 

flowing from the primary injury is essentially one of whether the 

medical evidence proves a causal connection between the primary 

injury and the subsequent occurrence." Williams Indus., Inc., 24 

Va. App. at 188, 480 S.E.2d at 791 (citing Leonard, 218 Va. at 

214, 237 S.E.2d at 100; Bartholow Drywall Co. v. Hill, 12 Va. 

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

 On appeal, we view the evidence in the light most favorable 

to the claimant, who prevailed before the commission. See Amoco 
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Foam Products, 26 Va. App. at 272, 494 S.E.2d at 172. "A 

question raised by conflicting medical opinion is a question of 

fact." WLR Foods v. Cardosa, 26 Va. App. 220, 230, 494 S.E.2d 

147, 152 (1997). "'Decisions of the commission as to questions 

of fact, if supported by credible evidence, are conclusive and 

binding on this Court.'" Id. (quoting Manassas Ice & Fuel Co. v. 

Farrar, 13 Va. App. 227, 229, 409 S.E.2d 824, 826 (1991)). "'The 

fact that there is contrary evidence in the record is of no 

consequence.'" Id. (quoting Wagner Enters., Inc. v. Brooks, 12 

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

 In the instant case, the commission gave great weight to the 

opinion of claimant's treating physician and found that his left 

knee pain was related to his 1980 back injury. See Amoco Foam 

Products, 26 Va. App. at 272, 494 S.E.2d at 172 (citing Fingles 

Co. v. Tatterson, 22 Va. App. 638, 641, 472 S.E.2d 646, 647 

(1996) (the opinion of a treating physician is entitled to great 

weight)). Here, Dr. Joiner opined on numerous occasions that 

claimant's knee problems were causally related to his back 

injury. On February 27, 1996, Dr. Joiner diagnosed claimant with 

"left knee pain [secondary] to chronic gait deviations" caused by 

his failed back syndrome.2

 Likewise, Dr. Samarsinghe, the pain 

 

 2On March 5, March 18, July 2, August 21, September 10, and 

September 25, 1996, Dr. Joiner again assessed claimant's 

condition as left knee pain secondary to chronic back pain. 

Additionally, in his progress notes dated June 23, 1997, Dr. 

Joiner opined that claimant suffered from chronic bilateral knee 

pain secondary to failed back syndrome. 
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management specialist, treated claimant for "increased back 

discomfort with bilateral leg radiation." (Emphasis added). 

Claimant was ultimately referred to physical therapy for 

treatment of "[left] knee pain." 

 There was also additional evidence supporting the 

commission's findings in Dr. Joiner's correspondence to the 

insurer. On March 5, 1996, Dr. Joiner wrote, 

 Mr. Briggs presented back to my office . . . 

reporting that you had denied his physical 

therapy as ordered at his previous visit. 

 First of all, only a small portion of his 

physical therapy had to actually do with his 

knee. The majority of the treatment 

interventions were directed at his low back 

which I believe is indisputably compensable. 

 As it relates to his left knee pain, as you 

will note in my note of 2/27/96 my impression 

was that his "left knee pain, secondary to 

chronic gait deviations with #1 (#1 was 

failed back syndrome) increased with extended 

walking on school campus." Mr. Briggs would 

not suffer his current knee pathology if he 

did not have the gait deviations which are 

directly related to his failed back syndrome. 

(Emphasis added). In a similar letter dated January 6, 1997, Dr. 

Joiner also requested approval for medical expenses for 

claimant's "work related back and bilateral knee problems." 

 Finally, as noted by the full commission, employer presented 

no evidence contradicting Dr. Joiner's opinion that claimant's 

left knee condition was secondary to his back injury. Employer 

contends Dr. Hodges' independent medical examination constitutes 

credible evidence that claimant's current knee pain is not a 
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compensable consequence of his back injury. However, in his 

report, Dr. Hodges noted that claimant had "a pins and needles 

sensation radiating into both [lower extremities], as well as 

bilateral knee pain, right greater than left." (Emphasis added). 

 Even assuming that Dr. Hodges' opinion was limited to an 

assessment of right knee pain, this opinion does not contradict 

Dr. Joiner's assessment. When we examine the evidence in the 

light most favorable to claimant, the prevailing party below, we 

conclude that the commission's decision is supported by credible 

evidence. See Jenkins v. Ford Motor Co., 27 Va. App. 281, 289, 

498 S.E.2d 445, 449 (1998); New Leaf, Inc. v. Webb, 26 Va. App. 

460, 467, 495 S.E.2d 510, 514 (1998). 

IV. CHANGE IN TREATING PHYSICIAN

 Employer next argues that the commission erred in refusing 

to order a change in claimant's treating physician. "Medical 

management of the employee is not to be directed by the employer. 

 An employer can require an employee to select an attending 

physician from its panel of three, but only an attending 

physician or the [Workers' Compensation] Commission may require

an employee to see another physician." Schwab Constr. v. 

McCarter, 25 Va. App. 104, 109-10, 486 S.E.2d 562, 565 (1997) 

(quotations omitted); see also Jensen Press v. Ale, 1 Va. App. 

153, 158, 336 S.E.2d 522, 525 (1985) ("A long-held principle of 

the . . . Commission, founded on Code § 65.1-88 [now Code 

§ 65.2-603], is that medical management of the claimant is to be 
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directed by the treating physician, not by an employer's 

representative."). 

 The commission may order a change in the treating physician 

when the physician refuses to timely provide copies of the 

employee's medical reports to the employer upon request. See

Wiggins v. Fairfax Park Ltd. Partnership, 22 Va. App. 432, 442, 

470 S.E.2d 591, 596-97 (1996). The commission has previously set 

forth several grounds upon which it will order a change in an 

employee's treating physician: 

 inadequate treatment is being rendered; it 

appears that treatment is needed by a 

specialist in a particular field and is not 

being provided; no progress being made in 

improvement of the employee's health 

condition without any adequate explanation; 

conventional modalities of treatment are not 

being used; no plan of treatment for 

long-term disability cases; and failure to 

cooperate with discovery proceedings ordered 

by the Commission. 

Powers v. J. B. Constr. Co., 68 O.I.C. 208, 211 (1989) 

(construing Code § 65.1-88 (now Code § 65.2-603)). Additionally, 

when an employer seeks to change claimant's treating physician 

because the claimant has made little progress and no treatment 

plan has been derived, the employer must identify the alternative 

care that should be substituted and must demonstrate that the 

suggested care would be more appropriate and productive. See

Bennett v. Fairfax County Sch. Bd., 74 O.W.C. 1, 4 (1995). 

 The commission's construction of the Act is entitled to 

great weight on appeal. See Gray v. Graves Mountain Lodge, Inc., 
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26 Va. App. 350, 353, 494 S.E.2d 866, 868 (1998). In light of 

these well-settled principles, employer's application for a 

change in claimant's treating physician is without merit. None 

of the enumerated reasons for ordering a change in treating 

physician are found in this record. Moreover, the commission 

specifically found that "employer's request is primarily because 

of Dr. Joiner's `personal intervention as an advocate for the 

claimant.'" In its application seeking to remove Dr. Joiner as 

treating physician, employer alleged that 

 Dr. Joiner has departed from objective 

treatment of the claimant and has become 

biased and irrationally tainted, as shown by 

his letter to the carrier dated January 6, 

1997. . . . Further, the absence of 

improvement in the claimant's condition is 

without explanation, and Dr. Joiner's 

treatment is inadequate and without a 

distinguishable treatment plan. 

Employer offered no valid reason to question Dr. Joiner's 

treatment of claimant; rather, it simply suggested Dr. Hodges as 

a "viable alternative." In seeking a change in the claimant's 

treating physician, the employer must identify alternative care 

that would be more productive and Dr. Hodges' opinion that 

claimant had reached "[maximum medical improvement] with future 

treatments such as [physical therapy]" is not sufficient. Like 

the commission, "[w]e are unwilling to order a change in treating 

physicians simply because the employer objects to the tone of Dr. 

Joiner's letter to the claims examiner." The commission did not 

abuse its discretion in refusing to order a change in treating 
- 16 - 

physicians. 

V. AWARD OF ATTORNEY'S FEES

 The commission awarded $350 in attorney's fees against 

employer for unreasonably defending the claim. The commission 

has the authority to award attorney's fees against the employer 

if it determines that the employer defended the claim "without 

reasonable grounds." Code § 65.2-713(A). "If an employer 

refuses to pay a claim, reasonably believing that it is not 

compensable, and in the course of its investigation the grounds 

for refusal are not so contradicted as to be shown unfounded, 

then the subsequent defense is reasonable, even if it is later 

proven misplaced or in error." Volvo White Truck Corp. v. Hedge, 

1 Va. App. 195, 201, 336 S.E.2d 903, 907 (1985) (citing Norfolk 

Dep't of Fire v. Lassiter, 228 Va. 603, 605, 324 S.E.2d 656, 

657-58 (1985)). 

 In this case, employer had reasonable grounds to believe it 

had no responsibility to pay for claimant's medical treatment 

because we have never addressed the issue of whether a cumulative 

trauma injury incurred after the primary injury falls within the 

doctrine of compensable consequences. "Although we have rejected 

employer's argument, the merits of that argument are an 

appropriate consideration in our review of the attorney's fees." 

Lynchburg Foundry Co. v. Goad, 15 Va. App. 710, 716, 427 S.E.2d 

215, 219 (1993). Accordingly, we hold that the award of 

attorney's fees was an abuse of discretion. 
- 17 - 

 For the foregoing reasons, we affirm the decision of the 

commission on the merits but reverse its decision as to the award 

of attorney's fees. 

 Affirmed in part and reversed in part.