COURT OF APPEALS OF VIRGINIA 

Present: Judges Coleman, Elder and Senior Judge Cole 

Argued at Richmond, Virginia 

WILLIAMS INDUSTRIES, INC. AND 

 PACIFIC EMPLOYERS INSURANCE COMPANY 

 OPINION BY 

v. Record No. 0861-96-2 JUDGE MARVIN F. COLE 

 FEBRUARY 11, 1997 

TERRY LYNN WAGONER 

 FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION 

 Arthur T. Aylward (Midkiff & Hiner, P.C., on 

briefs), for appellants. 

 B. Mayes Marks, Jr. (B. Mayes Marks, Jr., 

P.C., on brief), for appellee. 

 Williams Industries, Inc. and Pacific Employers Insurance 

Company (collectively "employer") appeal the decision of the 

Workers' Compensation Commission ("commission") awarding 

temporary total disability benefits to Terry Lynn Wagoner 

("claimant"). Employer argues that the commission erred (1) in 

determining that claimant's work-related spinal injuries 

aggravated his idiopathic hip disease; (2) in applying the 

compensable consequences doctrine; and (3) in concluding that 

employer was responsible for all expenses related to claimant's 

hip disease. Because the commission did not err, we affirm its 

decision. 

Background

 Claimant, who worked as a draftsman for employer, suffered a 

back injury on April 11, 1991, in an accident accepted as 

compensable by employer. Claimant's injuries included herniated 
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discs at L4-5 and L5-S1, as well as degenerative joint disease 

and spinal stenosis. Claimant underwent various surgical 

procedures to treat his spinal injuries, which included bone 

grafts taken from his hips. A laminectomy and discectomy for the 

herniation at L4-5 was performed by Dr. Hallett H. Mathews, 

treating physician and orthopaedic surgeon, on May 9, 1991. Dr. 

Mathews reported that claimant's work-related injury continued. 

Fusion surgery was performed on April 1, 1993, for the spinal 

stenosis at L4-5 with intercondylar collapse at L5-S1, and for a 

lumbar instability syndrome. The employer accepted liability for 

these conditions and paid related benefits. Claimant last 

received compensation on October 6, 1993, before he returned to 

work. 

 In August 1994, claimant began reporting tenderness and pain 

in both hips. On August 3, 1994, Dr. Mathews found evidence of 

avascular necrosis ("AVN") in both of claimant's hips.1

 On 

October 17, 1994, Dr. Mathews commented that claimant "is having 

a lot of back aggravation because of his protected gait for both 

hips. He has [AVN] and we have made this diagnosis bilaterally." 

 On August 5, 1994, orthopaedic surgeon Dr. Douglas E. Jessup 

 1Dorland's Illustrated Medical Dictionary, 26th ed. (1985) 

defines necrosis as "the sum of the morphological changes 

indicative of cell death and caused by the progressive 

degradative action of enzymes . . . ." Dorland's further 

identifies osteonecrosis as "death, or necrosis, of bone," and 

avascular necrosis as such cell death "due to deficient blood 

supply." 

 Medical evidence in this case states that "AVN is due to a 

disruption of the blood flow within the femoral heads." 
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agreed that claimant had "idiopathic osteonecrosis [of] both 

femoral heads." Orthopaedic surgeon Dr. William A. Jiranek 

examined claimant on October 21, 1994, also diagnosed bilateral 

osteonecrosis, and recommended surgery, which was performed on 

December 14, 1994. 

 On December 21, 1994, Dr. Rebecca M. Bigoney opined that 

claimant's AVN "clearly appears to be related to the previous 

back injury." On February 13, 1995, Dr. Mathews noted complaints 

of back and left leg symptoms and reported that claimant "has had 

bilateral hip, [AVN] and coring by Dr. Jiranek and certainly his 

hips have been made worse by the lumbar spine surgery and the 

protection that he has had to do for his back and also the stairs 

and steps which have been part of his job requirements." On 

March 8 and March 15, 1995, Dr. Mathews again commented on the 

interrelationship between claimant's back and hip pain, stating 

that claimant's ongoing back condition "has certainly caused wear 

and tear in his hips which has propagated an ongoing condition of 

[AVN]. They are now feeding off of each other with 

symptomatology." 

 On March 13, 1995, claimant filed a change in condition 

application, requesting temporary total disability benefits for 

the period from December 14, 1994 to January 3, 1995, payment of 

all bills related to the hip surgery, and permanent partial 

disability benefits. The deputy commissioner found that while 

not actually causing claimant's AVN, treatment for claimant's 
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work-related spinal injuries aggravated the AVN. The deputy 

commissioner awarded claimant temporary total disability benefits 

and surgery costs. 

 The full commission affirmed the deputy commissioner's 

opinion, finding that the record proved that claimant's AVN was 

both aggravated by and aggravated claimant's back injuries. The 

commission found employer liable for claimant's AVN condition, 

even if the condition was idiopathic in etiology. 

Analysis

 On appeal, we review the evidence in the light most 

favorable to the party prevailing below. R.G. Moore Bldg. Corp. 

v. Mullins, 10 Va. App. 211, 212, 390 S.E.2d 788, 788 (1990). 

Factual findings by the commission that are supported by credible 

evidence are conclusive and binding upon this Court. Code 

§ 65.2-706; Manassas Ice & Fuel Co. v. Farrar, 13 Va. App. 227, 

229, 409 S.E.2d 824, 826 (1991). 

 The commission found, and claimant concedes, that no 

evidence proved that his original back injury caused the AVN in 

his hips. Claimant argues, however, that his AVN preexisted his 

back injury and was aggravated by the back injury. Employer 

argues that claimant's AVN arose after claimant's back injury and 

became debilitating independent of the back injury. 

 The doctrine of compensable consequences is well established 

and has been in existence for many years. We have stated the 

basic principle: 

 When the primary injury is shown to have 
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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 

independent intervening cause attributable to 

claimant's own intentional conduct. 

Morris v. Badger Powhatan/Figgie, Int'l., Inc., 3 Va. App. 276, 

283, 348 S.E.2d 876, 879 (1986) (quoting A. Larson, The Law of 

Workmen's Compensation, §§ 13 and 81.30). 

 Larson further explains that: 

 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 concepts 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 

upon the concepts of "direct and natural 

results," and the claimant's own conduct as 

an independent intervening cause. 

Id. at § 13.11. 

 In Burlington Mills Corp. v. Hagood, 177 Va. 204, 13 S.E.2d 

291 (1941), claimant was working at a machine, about fifteen feet 

from an electric motor which was being repaired. A loose wire in 

the motor caused a short circuit, which produced an electric 

flash and a sound resembling that of a shotgun. Claimant saw the 

flash and fell backwards when she was rescued by a co-employee. 
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First aid was administered and she was sent home. She testified 

that she was in good health prior to this incident. She returned 

to work the following day. While at work about a month later, 

claimant looked up and suddenly saw the employee who had caught 

her when she fell. She fainted and fell and at the time of the 

hearing had not returned to work. The medical evidence of both 

parties conclusively established that the cause of the disability 

was traumatic neurosis. The commission traced this to the 

original accident and awarded compensation for the neurosis. The 

Supreme Court said: 

 The doctors thus, in effect, stated that 

traumatic neurosis was traceable to the shock 

or disturbing effect on the nerves of the 

patient, and that in turn, the irritation of 

the nerves caused functional disorders, and, 

that whether the disability resulted from 

nervous reaction or from auto-suggestion set 

in motion by memory of the accident, the 

result was the same to the injured person. 

Id. at 209, 13 S.E.2d at 293. 

 The Supreme Court pointed out in Burlington Mills Corp. that 

the claimant's disability was occasioned by an injury which "may 

be fairly traced" to a risk which arose out of and in the course 

of her employment. There was a direct causal relation between 

the electric flash and the irritated condition of her nervous 

system. Id. at 210, 13 S.E.2d at 293; see also E.C. Womack, Inc. 

v. Ellis, 209 Va. 588, 592-93, 166 S.E.2d 265, 268-69 (1969) 

(holding that psychiatric symptoms resulting in disability from 

work flowed from injuries received in primary accident and were 
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compensable); Imperial Trash Service v. Dotson, 18 Va. App. 600, 

606-07, 445 S.E.2d 716, 720 (1994) (citation omitted) (stating 

general rule "'When 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 independent intervening cause 

attributable to claimant's own intentional conduct.'"). 

 Assuming that claimant's AVN preexisted his back injury, the 

law supports the commission's decision that employer was liable 

for the costs associated with claimant's AVN. It is well 

established that the employer takes the employee as the employer 

finds the employee, even where the employee suffers some physical 

infirmity. Kemp v. Tidewater Kiewit, 7 Va. App. 360, 363, 373 

S.E.2d 725, 726 (1988). "A finding that a pre-existing condition 

'was accelerated or aggravated' by an injury sustained in an 

industrial accident establishes a causal connection between the 

injury and disability[,] and the 'disability resulting therefrom 

is compensable under the Workers' Compensation Act.'" Southern 

Iron Works, Inc. v. Wallace, 16 Va. App. 131, 134, 428 S.E.2d 32, 

34 (1993) (quoting Olsten of Richmond v. Leftwich, 230 Va. 317, 

320, 336 S.E.2d 893, 895 (1985)). As we will discuss below, 

sufficient evidence proved that claimant's back injury 

accelerated and aggravated his AVN. Therefore, the commission 

did not err in ruling that employer was liable if claimant's AVN 

preexisted his back injury. 
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 Assuming that claimant's AVN did not preexist his back 

injury, but instead arose after his back injury, the commission 

also did not err in ruling that employer was nevertheless liable 

for the costs associated with claimant's AVN. The commission 

found that the claimant's back injury was aggravated by his AVN 

because he had to alter his gait pattern and body mechanics to 

accommodate the AVN pain. Moreover, it found to the extent his 

back was dysfunctional, the partial loss of use inhibits such 

accommodation with respect to the AVN, aggravating that 

condition. Additionally, the commission found that because the 

AVN had to be treated in order to reduce the effects on the work 

injury, the employer is responsible for the costs of such 

treatment. We have reviewed the medical record and we find 

credible evidence to support the commission's findings. 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. See Leonard v. Arnold, 218 

Va. 210, 214, 237 S.E.2d 97, 100 (1977); Bartholow Drywall Co., 

Inc. v. Hill, 12 Va. App. 790, 794, 407 S.E.2d 1, 3 (1991). 

 Here, the commission did not err in determining that the 

evidence proved the requisite "causal connection" between 

claimant's AVN and his back injury. The most competent medical 

evidence supporting the commission's conclusion includes the 

February 13, 1995 note from Dr. Mathews, which reported that 
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claimant "has had bilateral hip, [AVN] and coring by Dr. Jiranek 

and certainly his hips have been made worse by the lumbar spine 

surgery and the protection that he has had to do for his back and 

also the stairs and steps which have been part of his job 

requirements." (Emphasis added.) On March 8 and March 15, 1995, 

Dr. Mathews again commented on the interrelationship between 

claimant's back and hip pain, stating that claimant's ongoing 

spine condition "has certainly caused wear and tear in his hips 

which has propagated an ongoing condition of [AVN]." Lastly, Dr. 

Bigoney opined that claimant's AVN "clearly appears to be related 

to the previous back injury." 

 This evidence supports the commission's finding that 

claimant's increasingly debilitating AVN was a natural 

consequence that flowed from and was a direct result of his back 

injury. Accordingly, claimant met his burden of proving that his 

AVN was a compensable consequence of his back injury. 

 Finally, we agree with the commission's determination that 

employer should pay all costs related to claimant's treatment for 

his AVN. The commission stated: 

 [B]ecause the [AVN] must be treated to reduce 

the symptomatology and its effects on the 

direct work injury, such treatment is 

effectively treatment of the direct work 

injury, and the employer must be responsible 

for the costs of such treatment on these 

grounds also. . . . [I]t is clear that the 

claimant's [AVN] is both aggravated by and 

aggravates the claimant's work injury, so the 

employer is liable for that condition also, 

even if it was idiopathic in etiology. 
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The commission did not err, therefore, in holding the employer 

responsible for all the expenses. 

 For these reasons, we affirm the commission's decision. 

 Affirmed.