An unpublished opinion of the North Carolina Court of Appeals does not constitute controlling legal authority. 

Citation is disfavored, but may be permitted in accordance with the provisions of Rule 30(e)(3) of the North Carolina 

Rules of Appellate Procedure.

NO. COA14-821

NORTH CAROLINA COURT OF APPEALS

Filed: 17 March 2015

JAMES WILLIAMS,

Employee,

 Plaintiff

v. The North Carolina Industrial 

Commission

I.C. No. X68962

BEST CARTAGE, INC.,

Employer,

and 

NATIONAL INTERSTATE INSURANCE CO., 

Carrier,

Defendants.

Appeal by defendants from Opinion and Award entered 27 May 

2014 by the North Carolina Industrial Commission. Heard in the 

Court of Appeals 3 December 2014.

The Deuterman Law Group, by Jeffrey P. Lewis, for plaintiff.

Teague, Campbell, Dennis & Gorham, L.L.P., by Ben S. Greenberg 

and William A. Bulfer, for defendants.

DAVIS, Judge.
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Best Cartage, Inc. (“Best Cartage”) and National Interstate 

Insurance Co. (collectively “Defendants”) appeal from the Opinion 

and Award of the North Carolina Industrial Commission (“the 

Commission”) awarding James Williams (“Plaintiff”) workers’ 

compensation benefits with respect to his left knee injury. On

appeal, Defendants contend that the Commission erred in (1) failing 

to specifically determine the reason for Plaintiff’s fall; and (2) 

concluding that Plaintiff’s left knee injury was causally related 

to his work-related accident and, therefore, compensable. After 

careful review, we affirm the Commission’s Opinion and Award.

Factual Background

Plaintiff was employed as a long-haul semi-truck driver for

Best Cartage. At approximately 6:00 a.m. on 4 October 2011, 

Plaintiff parked his truck on an unpaved portion of the parking 

lot of a Huddle House restaurant in Bishopville, South Carolina, 

intending to have breakfast there. As he opened the driver’s side 

door and began to exit the cab, Plaintiff’s left foot “unexpectedly 

landed in a hole or on some loose gravel,” and his left knee 

twisted. Plaintiff then fell to his right toward the truck and 

also twisted his right knee. He felt immediate pain in both knees 

with the pain in his left knee being more acute. Later that day,

Plaintiff returned to Best Cartage’s base office in Kernersville, 

North Carolina and reported the incident.
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On the following day, Best Cartage sent Plaintiff to PrimeCare 

in Kernersville for a medical examination. At PrimeCare, Plaintiff 

was treated by Dr. Camille Andy (“Dr. Andy”) who diagnosed him

with a “left medial knee sprain and degenerative joint disease, 

and right knee pain.”

On 17 October 2011, Plaintiff filed a Form 18 “Notice of 

Accident to Employer and Claim of Employee.” On 26 October 2011, 

Defendants responded by submitting a Form 61 “Denial of Workers’ 

Compensation Claim.” On 31 October 2011, Plaintiff moved to have 

his claim assigned for hearing.

On 14 December 2011, Plaintiff saw Dr. Scott Dean (“Dr. 

Dean”), an orthopedist, regarding his left knee pain. Dr. Dean 

recommended that Plaintiff undergo a total knee replacement of the

left knee. Dr. Dean performed left total knee replacement surgery 

on Plaintiff on 13 March 2012. During his deposition, Dr. Dean 

testified to a reasonable degree of medical certainty that 

Plaintiff’s left knee injury was causally related to his 4 October 

2011 accident.

The matter was heard before Deputy Commissioner Robert J. 

Harris on 12 March 2013. Deputy Commissioner Harris filed an 

opinion and award on 28 August 2013, finding that Plaintiff’s left 

knee injury was causally related to the 4 October 2011 incident.

He determined that Plaintiff was therefore entitled to all medical 

expenses incurred, or to be incurred, as a result of the injury.
-4-

Defendants appealed to the Full Commission. On 27 May 2014, 

the Commission issued an Opinion and Award affirming Deputy 

Commissioner Harris’s opinion and award and concluding, in 

pertinent part, as follows:

Plaintiff sustained a compensable injury by 

accident to his left knee arising out of and 

in the course of his employment with 

defendant-employer upon the occurrence of the 

4 October 2011 incident, which injury caused 

a compensable exacerbation of plaintiff’s preexisting left knee arthritis condition.

Defendants filed a timely notice of appeal to this Court.

Analysis

Our review of an opinion and award by the Commission is 

“limited to consideration of whether competent evidence supports 

the Commission’s findings of fact and whether the findings support 

the Commission’s conclusions of law.” Richardson v. Maxim 

Healthcare/Allegis Grp., 362 N.C. 657, 660, 669 S.E.2d 582, 584 

(2008). The Commission’s findings of fact are conclusive on appeal 

if supported by competent evidence even if there is evidence to 

support contrary findings. Avery v. Phelps Chevrolet, 176 N.C.

App. 347, 353, 626 S.E.2d 690, 694 (2006). On appeal, this Court 

will not “weigh the evidence and decide the issue on the basis of 

its weight. The court’s duty goes no further than to determine 

whether the record contains any evidence tending to support the 

finding.” Smith v. Champion Int’l, 134 N.C. App. 180, 182, 517 
-5-

S.E.2d 164, 166 (1999) (citation and internal quotation marks 

omitted).

I. Nature of Accident

In their first argument on appeal, Defendants challenge the 

Commission’s finding of fact 11, which states as follows:

Plaintiff did acknowledge that, as a truck 

driver he would have to expect to step down 

onto different surfaces, such as pavement, 

sand or gravel, when getting out of his truck. 

Plaintiff also acknowledged that he was not 

sure exactly what his left foot had stepped on 

or in when this incident occurred. However, 

the Commission finds that the incident was an 

unexpected departure from plaintiff’s usual 

work routine and/or was an unexplained fall. 

The Commission finds that the circumstances of 

plaintiff’s injury on 4 October 2011 

constituted an interruption of his normal work 

routine and the introduction thereby of 

unusual circumstances likely to result in 

unusual results and/or was an unexplained 

fall. As such, on 4 October 2011, plaintiff 

sustained an injury by accident arising out of 

and in the course of his employment with 

defendant-employer.

(Emphasis added.)

Defendants take issue with the Commission’s use of the term 

“and/or,” asserting that the Commission “has not made specific 

findings as to the crucial facts that are required for a 

determination of whether Plaintiff is entitled to Compensation.”

They further contend that the Commission’s “refusal to make a 

specific determination with regard to this crucial fact falls short 

of its judicial obligations and warrants reversal or, in the 
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alternative, remand for a determination as to whether Plaintiff’s 

alleged injury constituted an interruption of his normal work 

routine due to what he stepped down on or an unexplained fall.”

It is well established that “[u]nder the Workers’

Compensation Act, an injury is compensable if the claimant proves 

three elements: (1) that the injury was caused by an accident; 

(2) that the injury was sustained in the course of the employment; 

and (3) that the injury arose out of the employment.” Philbeck v. 

Univ. of Michigan, __ N.C. App. __, __, 761 S.E.2d 668, 671 (2014)

(citation and internal quotation marks omitted).

As an initial matter, we take this opportunity to note our 

disapproval of the Commission’s use of the term “and/or.” See

Gibson v. Cent. Mfrs. Mut. Ins. Co., 232 N.C. 712, 717, 62 S.E.2d 

320, 323 (1950) (“[T]he Court has inferentially condemned the use 

of the term ‘and/or’ in statutes, and in verdicts in judicial 

proceedings. Moreover, the annotators of reported cases, and the 

text writers indicate that much has been written in condemnation 

of the term ‘and/or.’ It is declared, in effect, that the courts 

generally hold that the term ‘and/or’ has no place in judicial 

proceedings, pleadings, verdict or judgment.” (citation omitted)); 

Gordon v. State Farm Mut. Auto. Ins. Co., 6 N.C. App. 185, 188, 

169 S.E.2d 514, 516 (1969) (“We do not look with favor upon the 

ambiguous and uncertain term ‘and/or.’” (citation and internal 

quotation marks omitted)).
-7-

Here, the Commission’s use of the term “and/or” compels us to 

read the provisions of finding of fact 11 containing this term in 

both the conjunctive and the disjunctive. See State ex rel. N.C. 

Utils. Comm’n v. McKinnon, 254 N.C. 1, 13, 118 S.E.2d 134, 143 

(1961) (explaining that the “oft condemned and ambiguous term 

‘and/or’ . . . contains both the conjunctive ‘and’ and the 

disjunctive ‘or.’”). Therefore, under this construction, we read 

finding of fact 11 as a determination by the Commission that

Plaintiff’s injury was the result of (1) an unexpected departure 

from Plaintiff’s usual work routine; (2) an unexplained fall; or

(3) both an unexpected departure from Plaintiff’s usual work 

routine and an unexplained fall. See Local Div. 589, Amalgamated 

Transit Union, AFL-CIO, CLC v. Com. of Mass., 666 F.2d 618, 627 

(1st Cir. 1981) (“[T]he words ‘and/or’ commonly mean ‘the one or 

the other or both.’”), cert. denied, 457 U.S. 1117, 73 L.Ed.2d 

1329 (1982).

Significantly, Defendants do not argue that there is no 

competent evidence in the record to support either of these two 

theories of compensability. Rather, they simply argue that the 

Commission was required to identify a single cause of Plaintiff’s 

injury and make a finding to that effect in its Opinion and Award. 

However, Defendants have failed to cite any caselaw specifically 

supporting their argument that the Commission’s failure to do so 

requires a remand. As such, while we agree that the far better 
-8-

practice would have been for the Commission to make a finding as 

to one specific cause of Plaintiff’s injury, we cannot hold that 

its failure to do so on these facts constituted reversible error 

unless one or both of the two theories identified by the Commission 

are insufficient to establish compensability under the Act. 

Therefore, we must address each of the two theories set out in 

finding of fact 11.

It is well settled that an unexpected departure from an 

employee’s normal work routine arising out of and in the course 

and scope of his employment resulting in injury represents one 

theory of compensability under the Act.

The terms “accident” and “injury” are separate 

and distinct concepts, and there must be an 

“accident” that produces the complained-of 

“injury” in order for the injury to be 

compensable. An “accident” is an “unlooked 

for event” and implies a result produced by a 

“fortuitous cause.” If an employee is injured 

while carrying on the employee’s usual tasks 

in the usual way the injury does not arise by 

accident. In contrast, when an interruption 

of the employee’s normal work routine occurs, 

introducing unusual conditions likely to 

result in unexpected consequences, an 

accidental cause will be inferred. The 

“essence” of an accident is its “unusualness 

and unexpectedness.”

Thus, in order to be a compensable “injury by 

accident,” the injury must involve more than

the employee’s performance of his or her usual 

and customary duties in the usual way.
-9-

Gray v. RDU Airport Auth., 203 N.C. App. 521, 525-26, 692 S.E.2d 

170, 174 (2010) (internal citations, quotation marks, brackets, 

and ellipses omitted).

However, this Court has held that if an employee’s injury is 

caused by a fall occurring during the course and scope of his 

employment “[i]t is not essential that there be evidence of any 

unusual or untoward condition or occurrence causing [the] fall 

which produces injury. The fall itself is the unusual, unforeseen 

occurrence which is the accident. A fall is usually regarded as 

an accident. . . . [A]n injury that is the result of a fall, which 

itself stems from an event that results from both the employee’s 

normal work routine and normal conditions, may still constitute an 

‘accident.’” Hedges v. Wake Cty. Pub. Sch. Sys., 206 N.C. App. 

732, 735, 699 S.E.2d 124, 126 (2010) (emphasis added), disc. review 

denied, 365 N.C. 77, 705 S.E.2d 746 (2011).

In addition, a second but related theory of compensability 

under the Act is that of the unexplained fall.

In a workers’ compensation case, if the cause 

or origin of a fall is unknown or undisclosed 

by the evidence, we apply case law unique to 

unexplained fall cases. When a fall is 

unexplained, and the Commission has made no 

finding that any force or condition 

independent of the employment caused the fall, 

then an inference arises that the fall arose 

out of the employment. This inference is 

permitted because when the cause of the fall 

is unexplained such that there is no finding 

that any force or condition independent of the 

employment caused or contributed to the 
-10-

accident, the only active force involved is 

the employee’s exertions in the performance of 

his duties.

Philbeck, __ N.C. App. at __, 761 S.E.2d at 672 (internal 

citations, quotation marks, brackets, and ellipses omitted).

Thus, while finding of fact 11 is hardly a model of clarity, 

the Commission determined that the evidence supported one or both 

of two recognized theories of compensability. Therefore, we 

conclude that remand is not necessary.

II. Causal Relationship

Defendants next contend that insufficient evidence was 

introduced to support the Commission’s determination that 

Plaintiff’s left knee injury was causally related to his 4 October 

2011 accident. Defendants contend that Dr. Dean’s opinion on 

causation was (1) impermissibly speculative; and (2) based upon 

the logical fallacy of post hoc, ergo propter hoc. We address 

each of these arguments in turn.

A. Causation Testimony of Dr. Dean

When the Commission relies on expert medical testimony, the 

expert’s testimony “must be such as to take the case out of the 

realm of conjecture and remote possibility” in order to constitute 

competent evidence of a causal relationship between the workrelated accident and the injury. Rogers v. Lowe’s Home 

Improvement, 169 N.C. App. 759, 765, 612 S.E.2d 143, 147 (2005) 

(citation and internal quotation marks omitted). A medical expert
-11-

[s]tating an accident “could or might” have 

caused an injury, or “possibly” caused it is 

not generally enough alone to prove medical 

causation; however, supplementing that 

opinion with statements that something “more 

than likely” caused an injury or that the 

witness is satisfied to a “reasonable degree 

of medical certainty” has been considered 

sufficient.

Carr v. Dep’t of Health & Human Servs., 218 N.C. App. 151, 155, 

720 S.E.2d 869, 873 (2012).

Defendants contend that no competent evidence existed to 

support the Commission’s findings of fact 5, 21, 25, and 26. These 

findings state as follows:

5. Long before the 4 October 2011 incident 

that is the basis of this claim, plaintiff had 

bilateral degenerative joint disease in both 

of his knees. His bilateral knee condition 

had been diagnosed as end-stage, bone-on-bone 

osteoarthritis. Plaintiff had undergone a 

right-sided total knee replacement in about 

2004. However, since starting with defendantemployer in 2007, he had been able to do his 

job without difficulty.

21. As Dr. Dean confirmed in his testimony, he 

believed that the 4 October 2011 incident 

exacerbated plaintiff’s pre-existing left 

knee arthritis condition. As Dr. Dean 

testified, the 4 October 2011 incident was the 

straw that broke the camel’s back for 

plaintiff’s left knee condition and sent it on 

a downward spiral to the total knee 

replacement. Dr. Dean provided this causation 

opinion taking into account plaintiff’s 

history, plaintiff’s prior complaints in 2009 

of left knee pain, his own objective findings, 

and his experience gained through 20 years of 

practice in sports medicine. As Dr. Dean 

noted, he had seen minimal trauma cause this 

scenario before.
-12-

25. The medical treatment that plaintiff has 

received for his left knee condition since 4 

October 2011 has been reasonably required to 

effect a cure, provide relief, and/or lessen 

the period of plaintiff’s disability.

26. Further medical treatment for plaintiff’s 

left knee condition is reasonably required to 

effect a cure and/or provide relief for his 

left knee condition.

Defendants further challenge the Commission’s conclusions of 

law 1, 3, and 4:

1. Plaintiff sustained a compensable injury by 

accident to his left knee arising out of and 

in the course of his employment with 

defendant-employer upon the occurrence of the 

4 October 2011 incident, which injury caused 

a compensable exacerbation of plaintiff’s 

preexisting left knee arthritis condition. 

N.C. Gen. Stat. § 97-2(6); Hedges v. Wake 

Cnty. Pub. Sch. Sys., 206 N.C. App. 732, 699 

S.E.2d 124 (2010), disc. rev. denied, __ N.C. 

__, 705 S.E.2d 746 (2011).

3. Plaintiff is entitled to have defendants 

pay for the medical treatment that he has 

received for his compensable left knee 

condition since 4 October 2011, including, but 

not limited to, the diagnostic testing and 

imaging, injections, prescriptions, surgery, 

hospitalization, physical therapy and mileage 

that plaintiff underwent or incurred while 

under the care of Dr. G. Scott Dean. N.C. 

Gen. Stat. §§ 97-2(19) and 97-25.

4. Plaintiff is entitled to have Dr. G. Scott 

Dean designated as his treating physician in 

this claim and to have defendants authorize

and pay for the treatment that Dr. Dean 

recommends for plaintiff’s compensable left 

knee condition, including, but not limited to, 

diagnostic testing and imaging, physical 

therapy, pain management, prescriptions, 
-13-

referrals and mileage. Id.

Defendants challenge the portion of finding of fact 5 stating 

that “since starting with defendant-employer in 2007, he had been 

able to do his job without difficulty,” arguing that “[t]here is 

no evidence of record suggesting that Plaintiff had been able to 

do his job without difficulty since 2007.” However, they do not 

challenge findings of fact 4, 12, and 19. Finding of fact 4 

establishes that “Plaintiff started [work] with defendant-employer 

as a long-haul semi-truck driver in 2007.” Finding of fact 12 

states, in pertinent part, that one day after the accident, “Dr. 

Andy diagnosed [Plaintiff with] a left medial knee sprain and 

degenerative joint disease, and right knee pain. . . . [S]he wrote 

that plaintiff could return to sedentary work, with no lifting 

over five pounds, minimal walking and frequent position changes.”

Finding of fact 19 states that approximately nine to ten weeks 

later, “Dr. Dean restricted plaintiff to primarily sedentary-type 

activity.”

Thus, Defendants do not dispute the fact that Plaintiff was 

hired in 2007 and had been working as a truck driver from that 

date until the 4 October 2011 injury. No evidence was presented 

that he was not able to do his job as a truck driver prior to 4 

October 2011. Findings of fact 12 and 19 do establish, however,

that beginning the day after his injury, Plaintiff was restricted

by Dr. Andy from performing his normal duties as a truck driver
-14-

and again by Dr. Dean several weeks later. While Defendants point 

to the deposition testimony of Dr. Donna Gates for the purpose of 

showing that Plaintiff had complained of left knee pain on 25 

November 2009 during a “wellness visit and a recheck of his chronic 

medical problems,” this evidence does not suggest that Plaintiff 

was unable to perform his job duties prior to the 4 October 2011 

accident.

Therefore, while it is clear that Plaintiff had degenerative 

joint disease in his left knee prior to the 4 October 2011 injury, 

competent evidence exists in the record that the 4 October 2011 

incident aggravated his left knee condition, materially 

restricting his ability to work. We have consistently held that

[a] work-related injury need not be the sole 

causative force to render an injury 

compensable. When a pre-existing, nondisabling, non-job-related condition is 

aggravated or accelerated by an accidental 

injury arising out of and in the course of 

employment so that disability results, then 

the employer must compensate the employee for 

the entire resulting disability. This 

“aggravation rule” does not bar recovery if 

there is evidence of a causal connection 

between a claimant’s current disability and a 

prior condition. It also does not require 

that claimant suffer from new or different 

symptoms from those of which he previously 

complained; rather, the claimant must only 

demonstrate that his work-related injury 

contributed in some reasonable degree to the 

disability.
-15-

Brafford v. Brafford’s Const. Co., 125 N.C. App. 643, 646-47, 482 

S.E.2d 34, 37 (1997) (internal citations, quotation marks, and 

ellipses omitted).

Finding of fact 21 is supported by the testimony given by Dr. 

Dean during his deposition. Indeed, finding of fact 21 largely

tracks the following statements made by Dr. Dean:

A. Again, it just — and I think I put this in 

the note that it’s kind of like the fall, sort 

of, didn’t necessarily cause the arthritis, 

but it sent him on the — it was the straw that 

broke the camel’s back. It sent him on the 

spiraling path downward, you know, as far as 

the — I have just seen that — I have seen that 

pattern before.

. . . .

Q. So the decision that that’s the straw that 

breaks the camel’s back, is because he’s 

telling you that’s when it started getting 

worse?

A. Yes.

. . . .

Q. . . . If he had gotten out of the truck . 

. . and fell, would that still, kind of, start 

this downward spiral.

A. I have seen minimal trauma like that cause 

this scenario. I have seen that pattern 

before, yes.

Q. So if it was a fall, regardless of — I mean, 

he — there was a gravel parking lot, and he 

misstepped [sic], or if there was a hole, or 

what actually caused the trigger of the fall, 

wouldn’t really — would it impact your 

decision?
-16-

A. My decision?

Q. Or your opinion?

A. About what really caused it?

Q. Yes, sir.

A. I mean, the mechanism of injury, you 

consider how much energy went into the fall,

was it a fall from a height, was it just a 

stumble, was it a big impact? Some of that 

does, sort of, factor into does this all make 

sense with the pattern that I have seen before 

with, like, hundreds of other patients? So it 

does, kind of, factor into it. And I think 

that in his knee, with end stage bone on bone 

arthritis, it would not take very much at all 

to, kind of, tip him over the edge.

Findings of fact 25 and 26 are also supported by the testimony

of Dr. Dean.

Q. Dr. Dean, you first saw [Plaintiff] for 

left knee pain on December 14th, 2011, is that 

correct?

A. (The witness reviews notes.) Yes.

. . . .

Q. The next time [Plaintiff] saw you was 

January 6th of 2012?

A. (The witness reviews notes.) Yes.

Q. Excuse me. What complaints did [Plaintiff]

have when you saw him on January 6th?

A. (The witness reviews notes.) On January 

6th, he had reasonable relief from the left 

knee injection performed in December of 2011, 

but it was starting to wear off.

. . . .
-17-

Q. . . . What recommendations for treatment 

did you make regarding [Plaintiff’s] left knee 

at that time?

A. On the 6th, I thought his left knee was 

improved with an injection. He did have 

pretty severe arthritis. I thought he might 

need a knee replacement in the future. I 

refilled his Vicodin, which is a pain 

medicine, and I was going to see him back in 

six months.

. . . .

Q. And what was your plan at that appointment 

for treating [Plaintiff]?

A. Left knee replacement.

Q. And in fact, you performed a left knee 

replacement on March 13th, 2012, is that 

correct?

A. Yes.

. . . .

Q. Dr. Dean, approximately how many knee 

replacements do you do in a given year? A 

ballpark estimate is fine.

A. Probably 50 to 100.

Q. And in your experience, does a total knee 

replacement last the lifetime of the 

recipient?

A. No.

Q. How long does it typically last?

A. Depending on the age and activity level and 

weight of the patient, maybe 10 year [sic].

Q. And when a total knee replacement wears 

out, what’s the recommended method for 

treating that?
-18-

A. Typically, it has to be revised, based on 

the reason that it has worn out.

Dr. Dean’s testimony also supports findings of fact 25 and 26

in that it details the history of his treatment of Plaintiff’s 

knee and Dr. Dean’s accompanying diagnoses and medical 

recommendations. Furthermore, Dr. Dean’s testimony that 

Plaintiff’s left knee replacement was not a permanent solution and 

that his left knee issues would in all likelihood need to be 

addressed again in approximately 10 years supports finding of fact 

26 by showing that further future medical treatment for Plaintiff’s 

left knee condition will be necessary.

Defendants next argue that Dr. Dean’s stated opinions

concerning Plaintiff’s left knee injury were based solely upon 

speculation and conjecture. In making this argument, Defendants 

point to the following exchange in his deposition:

Q. Dr. Dean, I would like to ask that you 

consider the following assumption. Assuming 

that prior to October 4th, 2011 [Plaintiff] 

was asymptomatic with regards to his left 

knee, and that on October 4th, 2011 

[Plaintiff] stepped into a hole climbing out 

of the cab of his semi truck causing him to 

fall, and thereafter he had swelling, pain, 

and grinding — reports of a grinding sensation 

and a feeling of instability in his left knee. 

Assuming those facts, in your opinion, to a 

reasonable degree of medical certainty, did 

the event of October 4th, 2011 aggravate or 

accelerate the condition in [Plaintiff’s] left 

knee for which you operated on him on March 

13th, 2012?
-19-

[Defendants’ counsel]: Objection. You 

can go ahead.

A. Yes. And I think that was stated in the 

chart.

Defendants assert that this portion of his testimony was 

premised upon the following three assumptions: (1) that Plaintiff 

was asymptomatic prior to 4 October 2011; (2) that Plaintiff 

stepped into a hole when he exited his tractor trailer and fell as 

a result of doing so; and (3) that Plaintiff had swelling, pain, 

and a grinding sensation as a result of the fall. Defendants also 

contend that this testimony served as the sole basis for Dr. Dean’s 

opinion on causation and, therefore, if any of these assumptions 

are unsupported by competent evidence, then Dr. Dean’s testimony 

is insufficient to establish a causal connection between 

Plaintiff’s injury and the 4 October 2011 accident. We reject 

Defendants’ argument.

In finding of fact 7 (a finding Defendants have not 

challenged), the Commission determined that when Plaintiff’s “left 

foot hit the ground, it unexpectedly landed in a hole or on some 

loose gravel or sand, and plaintiff’s left knee twisted.” In 

addition, finding of fact 8 — also unchallenged by Defendants —

states that “Plaintiff felt immediate pain in both of his knees 

upon the occurrence of this incident.”

Even assuming the portion of the hypothetical question 

premised on Plaintiff having been asymptomatic prior to the 4 
-20-

October 2011 incident was not supported by competent evidence, we 

do not believe that this renders Dr. Dean’s ensuing testimony 

incompetent on the causation issue. It is well established that 

“[a] hypothetical question need only present sufficient facts to 

allow the witness to express an intelligent and safe opinion. It 

[is] not incumbent on the plaintiff to include in his hypothetical 

questions all the evidence bearing upon the fact to be proved; the 

defendants ha[ve] the right to present other phases of the evidence 

in counter-hypothetical questions.” Robinson v. J. P. Stevens & 

Co., 57 N.C. App. 619, 622-23, 292 S.E.2d 144, 146 (1982) (internal 

citations, quotation marks, and brackets omitted).

During his cross-examination of Dr. Dean, Defendants’ counsel 

did, in fact, pose a counter-hypothetical question:

Q. And then if there — so if there was 

evidence to the contrary, if for example, 

there was a prior exam that showed bone on 

bone or if there was a prior diagnosis of end 

stage arthritis with associated pain, then 

that would be evidence that the fall didn’t 

cause [Plaintiff’s injury]?

A. Again, it just — and I think I put this in 

the note that it’s kind of like the fall, sort 

of, didn’t necessarily cause the arthritis, 

but it sent him on the — it was the straw that 

broke the camel’s back. It sent him on the 

spiraling path downward, you know, as far as 

the — I have just seen that — I have seen that 

pattern before.

On redirect examination, Dr. Dean then testified as follows:

Q. You — when [Defendants’ counsel] was 

questioning you, we’ve talked about this, kind 
-21-

of, the downward spiral and the trigger event 

for — or to, kind of, start somebody on that 

spiral. And I think you — I don’t want to put 

words in your mouth, but I think you indicated 

that with the arthritis that [Plaintiff] had 

that it wouldn’t take much to, kind of, start 

him on that spiral downward. If he had gotten 

out of the truck — regardless of whether there 

was a hole that he stepped in or not, but he 

got out of the truck, lost his balance, and 

fell, would that still, kind of, start this 

downward spiral?

A. I have seen minimal trauma like that cause 

this scenario. I have seen that pattern 

before, yes.

We are satisfied that — taken as a whole — Dr. Dean’s opinion 

testimony was sufficient to establish causation. As such, the 

Commission was entitled to rely upon his testimony that Plaintiff’s 

left knee injury was causally related to his 4 October 2011 

accident.

B. Post Hoc, Ergo Propter Hoc

Defendants also argue that Dr. Dean based his opinion on the

post hoc, ergo propter hoc logical fallacy. We disagree.

The maxim “post hoc, ergo propter hoc,”

denotes the fallacy of confusing sequence with 

consequence, and assumes a false connection 

between causation and temporal sequence. As 

such, this Court has treated the maxim as 

inconclusive as to proximate cause. . . . In 

a case where the threshold question is the 

cause of a controversial medical condition, 

the maxim of “post hoc, ergo propter hoc,” is 

not competent evidence of causation.
-22-

Young v. Hickory Bus. Furn., 353 N.C. 227, 232, 538 S.E.2d 912, 

916 (2000) (internal citations, quotation marks, and ellipses 

omitted).

Defendants’ argument on this issue is based on the following 

portion of Dr. Dean’s testimony:

Q: So basically, [the pain] wasn’t there on 

day one, he alleges to have the injury on day 

two, on day three he has pain. So because it 

wasn’t there before and is there now, that’s 

how you identify the injury as being the 

cause?

A: As, I think I called it, an exacerbating 

factor, yes.

However, Dr. Dean also testified as follows:

Q. And the, I guess, objective ability to view 

the joint and see if it’s bone on bone or if 

there is actual cushion there that could work?

A. Yeah. It’s really just based on his — what 

he tells me and then objectively what the knee 

is telling me. . . . 

. . . .

Q. And then if there — so if there was evidence 

to the contrary, if for example, there was a 

prior exam that showed bone on bone or if there 

was a prior diagnosis of end stage arthritis 

with associated pain, then that would be 

evidence that the fall didn’t cause it?

A. Again, it just — and I think I put this in 

the note that it’s kind of like the fall, sort 

of, didn’t necessarily cause the arthritis, 

but it sent him on the — it was the straw that 

broke the camel’s back. It sent him on the 

spiraling path downward, you know, as far as 

the — I have just seen that — I have seen that 

pattern before.
-23-

. . . .

Q. So the decision that that’s the straw that 

breaks the camel’s back, is because he’s 

telling you that’s when it started getting 

worse?

A. Yes.

. . . .

Q. . . . If he had gotten out of the truck . 

. . and fell, would that still, kind of, start 

this downward spiral.

A. I have seen minimal trauma like that cause 

this scenario. I have seen that pattern 

before, yes.

Q. So if it was a fall, regardless of — I mean, 

he — there was a gravel parking lot, and he 

misstepped [sic], or if there was a hole, or 

what actually caused the trigger of the fall, 

wouldn’t really — would it impact your 

decision?

A. My decision?

Q. Or your opinion?

A. About what really caused it?

Q. Yes, sir.

A. I mean, the mechanism of injury, you 

consider how much energy went into the fall, 

was it a fall from a height, was it just a 

stumble, was it a big impact? Some of that 

does, sort of, factor into does this all make 

sense with the pattern that I have seen before 

with, like, hundreds of other patients? So it 

does, kind of, factor into it. And I think 

that in his knee, with end stage bone on bone 

arthritis, it would not take very much at all 

to, kind of, tip him over the edge.
-24-

We are satisfied that Dr. Dean’s determination that a causal 

connection existed between the 4 October 2011 accident and 

Plaintiff’s left knee injury was based on more than post hoc, ergo 

propter hoc reasoning. We have held that where a medical expert 

relies upon something more than mere temporal sequence, a post 

hoc, ergo propter hoc issue does not exist. See Legette v. 

Scotland Mem’l Hosp., 181 N.C. App. 437, 456, 640 S.E.2d 744, 756 

(2007) (“[Doctor’s] opinion testimony was not based solely on the 

notion of post hoc ergo propter hoc. [Doctor] also testified that 

Plaintiff’s description of the accident was consistent with a 

trauma of the type that would be associated with the development 

of lymphedema in someone with Plaintiff’s medical history.”), 

appeal dismissed and disc. review denied, 362 N.C. 177, 658 S.E.2d 

273 (2008); see also Carr, 218 N.C. App. at 156, 720 S.E.2d at 874

(“[Doctor’s] opinion, however, was based on more than merely the 

sequence of events. In his deposition, [Doctor] stated that 

although ‘a lot of it is based on timing,’ his opinion was based 

on the mechanism of injury as well as the temporal relationship 

between the incident and symptoms.”).

In the present case, Dr. Dean relied on Plaintiff’s 

description of the accident and his objective diagnosis of the 

injury based upon his examination of “hundreds of other patients”

in reaching his opinion to a reasonable degree of medical certainty 

that Plaintiff’s left knee injury was causally related to his 4 
-25-

October 2011 accident. Therefore, we reject Defendants’ 

contention that Dr. Dean relied solely on post hoc, ergo propter 

hoc reasoning in his opinion regarding causation.

Conclusion

For the reasons stated above, the Commission’s Opinion and 

Award is affirmed.

AFFIRMED.

Judges ELMORE and STEPHENS concur.

Report per Rule 30(e).