1

Filed 12/26/13 Certified for publication 1/15/14 (order attached)

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

THIRD APPELLATE DISTRICT

----

CITY OF SACRAMENTO

Petitioner,

v.

WORKERS’ COMPENSATION APPEALS BOARD 

and ARTHUR CANNON,

Respondents.

C072944

(Super. Ct. No. ADJ7238353)

In this workers’ compensation case, an agreed medical examiner determined that 

respondent Arthur Cannon’s left foot condition -- plantar fasciitis -- was equivalent to a 

limp with arthritis, which resulted in a 7 percent whole person impairment for purposes 

of determining permanent disability. On review, Cannon’s self-insured employer, the 

City of Sacramento (the city) contends a rating of impairment by analogy to a different 

condition is impermissible when (as here) no objective abnormalities are found and the 

rating is based solely on subjective complaints of pain. The city also contends that a 

“rating by analogy” is permissible only in complex or extraordinary cases, and plantar 

fasciitis is neither. 

Finding no merit in the city’s arguments, we affirm.
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FACTUAL AND PROCEDURAL BACKGROUND

In October 2008, Cannon injured his left foot and heel while working as a police 

officer for the city. He was diagnosed with plantar fasciitis and provided with physical 

therapy, cortisone injections, and an orthotic device. His primary treating physician 

found him permanent and stationary in January 2010, with no impairment of his activities 

of daily living and capable of performing his usual occupation.

In October 2010, an agreed medical examiner, Dr. William Ramsey, agreed 

Cannon was permanent and stationary and that there was no impairment but 

recommended that he be precluded from such things as prolonged running. 

In February 2011, at the request of Cannon’s attorney, Dr. Ramsey issued a 

supplemental report “to comment regarding [Cannon]’s impairment status using 

Almaraz/Guzman-II issues.”1 Dr. Ramsey explained that at the time of his original report 

in October 2010, he was “unable to offer any impairment from a strict interpretation of 

the AMA Guides, 5th Edition”

2 because “other than some tenderness, no objective 

abnormalities were identifiable.” Now, however, Dr. Ramsey determined that it was 

acceptable to characterize Cannon’s residual condition “using a gait derangement 

abnormality” “by analogy, using Almaraz/Guzman-II as a basis.” Noting that Cannon’s 

problem was “relatively mild,” with “the left heel causing weightbearing problems” and 

the likelihood that the condition “would . . . be aggravated appreciably by running 

activity on other than a short-term basis,” Dr. Ramsey recommended characterizing 

 

1 As we will explain, Almaraz/Guzman refers to the decision of the Workers’ 

Compensation Appeals Board (the board) in Almaraz v. Environmental Recovery 

Services/Guzman v. Milpitas Unified School Dist. (2009) 74 Cal.Comp.Cases 1084.

2 AMA Guides refers to the American Medical Association (AMA) Guides to the 

Evaluation of Permanent Impairment (5th Edition), discussed more fully below.
3

Cannon by reference to “Table 17-5, page 529,” as having “a limp, despite the absence of 

any arthritic changes about adjacent joints, equivalent to 7% whole person impairment.” 

In June 2011, at the request of the city’s attorney, Dr. Ramsey issued a second 

supplemental report “to further discuss the basis for [his] recommending some 

impairment due to [Cannon]’s residual heel complaints.” In this report, Dr. Ramsey 

noted that “heel pain, or for that matter, other aspects of pain that do not have any 

accompanying objective measurement abnormalities, do not rate anything in the AMA 

Guides, whether or not these problems interfere with one’s activities. Thus, a strict 

interpretation of the Guides does not always appropriately characterize an injured 

worker’s problems.” Dr. Ramsey explained because Cannon’s heel pain “interferes with 

weightbearing activities, particularly running,” he “thought that by analogy, it would be 

similar to an individual with a limp and arthritis, resulting in the 7% impairment 

recommended.” 

The case was tried in October 2011. In a trial brief, the city argued that a rating by 

analogy under Almaraz/Guzman would be proper only if the case could be characterized 

as “complex or extraordinary,” which Cannon’s injury could not be. The workers’ 

compensation judge (judge) agreed, finding that Cannon had no permanent disability 

because his medical condition was not complex or extraordinary and therefore did not 

warrant departure from a strict application of the AMA Guides. 

Cannon petitioned for reconsideration, arguing that a case does not have to be 

complex or extraordinary to be rated by analogy under Almaraz/Guzman. The board 

granted reconsideration and, agreeing with Cannon, rescinded the judge’s findings and 

award and returned the matter to him for a new permanent disability rating based on 

Dr. Ramsey’s findings. With one member dissenting, the board explained that “the 

language cited by the [judge] to limit a rating by analogy only to cases with ‘complex or 

extraordinary’ medication conditions does not support his interpretation. Rather than 

further restrict a physician’s expertise, this language should be read to reflect the ability 
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of a physician to rate an impairment by analogy, within the four corners of the Guides, 

where a strict application of the Guides does not accurately reflect the impairment being 

assessed.” The board noted that Cannon’s “condition, plantar fasciitis, does not have a 

standard rating, with no specifically applicable ‘chapter, table or method’ provided in the 

AMA Guides, and thus can only be rated by analogy to other impairments, and/or by 

analysis of the injury’s impact on activities of daily living.” The board concluded that 

Dr. Ramsey had “provided by analogy an accurate assessment of [Cannon]’s medical 

condition that meets the requirements of Almaraz/Guzman, for a condition that is not 

covered by the AMA Guides.” 

The city subsequently sought a writ of review, which we issued.

DISCUSSION

On review, the city contends it is improper to rate an applicant’s condition by 

analogy under Almaraz/Guzman where there are no objective findings and the rating is 

based solely upon subjective complaints and speculation. The city further argues that 

under the Sixth District’s decision in Milpitas Unified School Dist. v. Workers’ Comp. 

Appeals Bd. (2010) 187 Cal.App.4th 808 (Milpitas Unified),“a variation from the strict 

application of the [AMA Guides’] whole person impairment analysis must apply only to 

those cases that are complex or extraordinary.” We disagree on both points.

I

Statutory Background

We draw the necessary statutory background, at some length, from Milpitas 

Unified:
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“1. [Labor Code] Section 4660[3]

“The workers’ compensation system in California underwent comprehensive 

reform in 2004 with the passage of Senate Bill No. 899. . . . The revised provisions 

substantially affected the assessment of an injured worker’s permanent disability. A 

schedule for assessing permanent disability had been required since 1937, and it was 

always expressly intended to manifest ‘prima facie evidence of the percentage of 

permanent disability to be attributed to each injury covered by the schedule.’ . . . 

[H]owever, no guidance was provided for the formulation of the schedule until the 2004 

amendment. In accordance with the revision, the administrative director is now required 

to develop and regularly amend the rating schedule based on specified data from 

empirical studies. The schedule ‘shall promote consistency, uniformity, and objectivity.’

[Citation.] As so directed, the administrative director published a new PDRS [permanent 

disability rating schedule] effective January 1, 2005, which incorporated the fifth edition 

of the [AMA] Guides in its entirety. [Citation.]

“2. Impairment and Disability

“The statutory revision most significant for the resolution of [this] case is the new 

condition that the determination of ‘the “nature of the physical injury or disfigurement” 

shall incorporate the descriptions and measurements of physical impairments and the 

corresponding percentages of impairments published in the [AMA Guides].’ (§ 4660, 

subd. (b)(1).)

“First published in 1971 to provide ‘a standardized, objective approach to 

evaluating medical impairments’ [citation], the AMA Guides sets forth measurement 

criteria that certified rating physicians and chiropractors can use to ascertain and rate the 

medical impairment suffered by injured workers. [Citation.] ‘Impairment’ is defined in 

 

3 All further section references are to the Labor Code.
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the Guides as ‘a loss, loss of use, or derangement of any body part, organ system or organ 

function.’ [Citation.] The impairment ratings provided in the Guides ‘were designed to 

reflect functional limitations and not disability.’ [Citation.] They ‘reflect the severity of 

the medical condition and the degree to which the impairment decreases an individual’s 

ability to perform common activities of daily living (ADL), excluding work.’ [Citation.]

“A permanent disability, on the other hand, ‘ “ ‘causes impairment of earning 

capacity, impairment of the normal use of a member, or a competitive handicap in the 

open labor market.’ ” ’ [Citation.] ‘A disability is considered permanent when the 

employee has reached maximal medical improvement, meaning his or her condition is 

well stabilized, and unlikely to change substantially in the next year with or without 

medical treatment.’ [Citation.] Permanent disability is expressed as a percentage: 

Anything less than 100 percent (total disability) entitles the injured worker to a 

prescribed number of weeks of indemnity payments in accordance with that percentage. 

[Citation.] ‘Thus, permanent disability payments are intended to compensate workers for 

both physical loss and the loss of some or all of their future earning capacity.’ [Citation.]

“ ‘In determining the percentages of permanent disability, account shall be taken 

of the nature of the physical injury or disfigurement, the occupation of the injured 

employee, and his or her age at the time of the injury, consideration being given to an 

employee’s diminished future earning capacity.’ (§ 4660, subd. (a).) The ‘nature of the 

physical injury’ refers to impairment, which is expressed as a percentage reflecting the 

‘severity of the medical condition and the degree to which the impairment decreases an 

individual’s ability to perform common activities of daily living (ADL), excluding work.’

[Citation.] In each case impairment ratings are combined and converted to a [whole 

person impairment] (WPI) rating, which reflects the impact of the injury on the ‘overall 

ability to perform activities of daily living, excluding work.’ [Citation.] The WPI is then 

adjusted for diminished future earning capacity . . . the employee’s occupation 

classification at the time of the injury, and age. Of these four components, it is the 
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‘nature of the injury,’ expressed in terms of impairment, that is the source of the 

controversy in this case.” (Milpitas Unified, supra, 187 Cal.App.4th at pp. 818-820, fns.

omitted.)

II

Almaraz/Guzman

In Almaraz/Guzman, the board concluded that “the WPI component of any 

scheduled permanent disability rating must be based on the AMA Guides, i.e., the WPI 

component cannot be predicated on the opinion of a physician who has gone outside the 

four corners of the Guides to make an impairment determination.” (Almaraz/Guzman, 

supra, 74 Cal.Comp.Cases at p. 1101.) The board then went on to explain as follows:

“Nevertheless, although the WPI component of a scheduled rating must be 

founded on the AMA Guides (except in the case of psychiatric impairments), a physician 

is not inescapably locked into any specific paradigm for evaluating WPI under the 

Guides. Section 4660(b)(1) provides that the WPI component of a scheduled rating is to 

be rooted in ‘the descriptions and measurements of physical impairments and the 

corresponding percentages of impairments published in the [AMA Guides].’ Therefore, 

section 4660(b)(1) does not mandate that the impairment for any particular condition 

must be assessed in any particular way under the Guides. Moreover, while the AMA 

Guides often sets forth an analytical framework and methods for a physician in assessing 

WPI, the Guides does not relegate a physician to the role of taking a few objective 

measurements and then mechanically and uncritically assigning a WPI that is based on a 

rigid and standardized protocol and that is devoid of any clinical judgment. Instead, the 

AMA Guides expressly contemplates that a physician will use his or her judgment, 

experience, training, and skill in assessing WPI.

“Specifically, the AMA Guides provides: ‘The physician’s role in performing an 

impairment evaluation is to provide an independent, unbiased assessment of the 

individual’s medical condition, including its effect on function, and identify abilities and 
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limitations to performing activities of daily living. . . . Performing an impairment 

evaluation requires considerable medical expertise and judgment.’ [Citation.] Similarly, 

the Guides states: ‘The physician must use the entire range of clinical skill and judgment 

when assessing whether or not the measurements or tests results are plausible and 

consistent with the impairment being evaluated. If, in spite of an observation or test 

result, the medical evidence appears insufficient to verify that an impairment of a certain 

magnitude exists, the physician may modify the impairment rating accordingly and then 

describe and explain the reason for the modification in writing.’ [Citation.] Further, the 

Guides recites: ‘In situations where impairment ratings are not provided, the Guides

suggests that physicians use clinical judgment, comparing measurable impairment 

resulting from the unlisted condition to measureable impairment resulting from similar 

conditions with similar impairment of function in performing activities of daily living. 

[¶] The physician’s judgment, based upon experience, training, skill, thoroughness in 

clinical evaluation, and ability to apply the Guides criteria as intended, will enable an 

appropriate and reproducible assessment to be made of clinical impairment.’ [Citation.]

“Therefore, based upon the physician’s judgment, experience, training, and skill 

each reporting physician (treater or medical-legal evaluator) should give an expert 

opinion on the injured employee’s WPI using the chapter, table, or method of assessing 

impairment of the AMA Guides that most accurately reflects the injured employee’s 

impairment. [Citation.] This does not mean, of course, that a physician may arbitrarily 

assess an injured employee’s impairment. As stated by the AMA Guides, ‘[a] clear, 

accurate, and complete report is essential to support a rating of permanent impairment’ 

and the report should ‘explain’ its impairment conclusions. [Citation.] In other words, a 

physician’s WPI opinion must constitute substantial evidence upon which the [board]

may properly rely, including setting forth the reasoning behind the assessment. 

[Citation.]
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“A physician’s WPI opinion that is not based on the AMA Guides does not 

constitute substantial evidence because it is inconsistent with the mandate of section 

4660(b)(1).” (Almaraz/Guzman, supra, 74 Cal.Comp.Cases at pp. 1103-1104, fn.

omitted.)

III

Milpitas Unified

In Milpitas Unified, the Sixth District reviewed the board’s decision in 

Almaraz/Guzman upon petition by Guzman’s employer. (Milpitas Unified, supra, 187 

Cal.App.4th at p. 812.) The court framed the “primary issue” as “whether section 4660, 

following the 2004 revisions, permits deviation from a strict application of the 

descriptions, measurements, and percentages contained in the Guides for purposes of 

determining the impairment resulting from an employee’s workplace injury.” (Id. at p. 

820.) In addressing that issue, the court “agree[d] with the District that the Guides must 

be applied ‘as intended’ and ‘as written,’ ” but the court took “a broader view of both [the 

AMA Guides’] text and the statutory mandate.” (Id. at p. 822.) The court explained as 

follows:

“Section 4660, subdivision (b)(1), recognizes the variety and unpredictability of 

medical situations by requiring incorporation of the descriptions, measurements, and 

corresponding percentages in the Guides for each impairment, not their mechanical 

application without regard to how accurately and completely they reflect the actual 

impairment sustained by the patient. To ‘incorporate’ is to ‘unite with or introduce into 

something already existent . . . ,’ to ‘take in or include as a part or parts . . . ,’ or to ‘unite 

or combine so as to form one body.’ [Citation.] Section 4660, subdivision (b)(1), thus 

requires the physician to include the descriptions, measurements, and percentages in the 

applicable chapter of the Guides as part of the basis for determining impairment.

“We cannot expand the statutory mandate by changing the word ‘incorporate’ to 

‘apply exclusively.’ Nor can we read into the statute a conclusive presumption that the 
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descriptions, measurements, and percentages set forth in each chapter are invariably 

accurate when applied to a particular case. By using the word ‘incorporation,’ the 

Legislature recognized that not every injury can be accurately described by the 

classifications designated for the particular body part involved. Had the Legislature 

wished to require every complex situation to be forced into preset measurement criteria, it 

would have used different terminology to compel strict adherence to those criteria for 

every condition. A narrower interpretation would be inconsistent with the clear provision 

that the Schedule—which itself incorporates the Guides [citation]—is rebuttable (§ 4660, 

subd. (c)), and it would not comport with the legislative directive to construe the workers’

compensation statutes liberally ‘with the purpose of extending their benefits for the 

protection of persons injured in the course of their employment. . . .’ ” (Milpitas Unified, 

supra, 187 Cal.App.4th at p. 822.)

The court later added as follows: “The Guides itself recognizes that it cannot 

anticipate and describe every impairment that may be experienced by injured employees. 

The authors repeatedly caution that notwithstanding its ‘framework for evaluating new or 

complex conditions,’ the ‘range, evolution, and discovery of new medical conditions’ 

preclude ratings for every possible impairment. [Citation.] The Guides ratings do 

provide a standardized basis for reporting the degree of impairment, but those are 

‘consensus-derived estimates,’ and some of the given percentages are supported by only 

limited research data. [Citation.] The Guides also cannot rate syndromes that are ‘poorly 

understood and are manifested only by subjective symptoms.’ [Citation.] [¶] To 

accommodate those complex or extraordinary cases, the Guides calls for the physician’s 

exercise of clinical judgment to assess the impairment most accurately. Indeed, 

throughout the Guides the authors emphasize the necessity of ‘considerable medical 

expertise and judgment,’ as well as an understanding of the physical demands placed on 

the particular patient.” (Milpitas Unified, supra, 187 Cal.App.4th at p. 823.)
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IV

The City’s Arguments

The city first argues that the legislative intent behind Senate Bill No. 899 in 2004 

was “to promote consistency and uniformity based upon objective findings” and here 

“there is consistency in the objective findings and that is there are no objective findings.” 

The thrust of the city’s argument is that a rating by analogy under Almaraz/Guzman is not 

permissible where (as here) no objective abnormalities are found and the rating is based 

solely on subjective complaints of pain.

The city’s argument is not persuasive. There is nothing in the 2004 amendment to 

section 4660 that precludes a finding of impairment based on subjective complaints of 

pain where no objective abnormalities are found. If the 2004 amendment had required 

strict compliance with or the mechanical application of the AMA Guides in assessing 

impairment, then the city might have a valid point because, as Dr. Ramsey explained 

here, “aspects of pain that do not have any accompanying objective measurement 

abnormalities, do not rate anything in the AMA Guides, whether or not these problems 

interfere with one’s activities.” Thus, under a strict application of the AMA Guides, a 

condition that has no objective manifestation cannot be considered an impairment. As 

the Sixth District found in Milpitas Unified, however, if the Legislature had intended to 

require such an approach to the determination of permanent disability, “it would have 

used different terminology to compel strict adherence to th[e] criteria [in the AMA 

Guides] for every condition.” (Milpitas Unified, supra, 187 Cal.App.4th at p. 822.) 

Instead, the Legislature provided only that “the ‘nature of the physical injury or 

disfigurement’ shall incorporate the descriptions and measurements of physical 

impairments and the corresponding percentages of impairments.” (§ 4660, subd. (b)(1), 

italics added.) Here, Dr. Ramsey complied with this legislative directive by rating 

Cannon’s condition by analogy to the part of the AMA Guides dealing with a limp and 
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arthritis. The city’s argument that he was not allowed to do so because Cannon’s 

condition had no objective manifestation is without merit.

The city’s second argument is that under Milpitas Unified, a rating by analogy 

under Almaraz/Guzman is permissible only in complex or extraordinary cases. The city 

asserts, ipse dixit, that “[p]lantar [f]asciitis is neither complex nor extraordinary” and 

therefore a rating by analogy was improper here.

We agree with the board majority that this is an unwarranted interpretation of the 

Sixth District’s decision in Milpitas Unified. What the Sixth District said was this: “The 

Guides . . . cannot rate syndromes that are ‘poorly understood and are manifested only by 

subjective symptoms.’ [Citation.] [¶] To accommodate those complex or extraordinary 

cases, the Guides calls for the physician’s exercise of clinical judgment to assess the 

impairment most accurately.” (Milpitas Unified, supra, 187 Cal.App.4th at p. 823, italics 

added.) Thus, the Sixth District was using the term “complex or extraordinary cases” to 

describe “syndromes that are ‘poorly understood and are manifested only by subjective 

symptoms,’ ” which the AMA Guides do not, and cannot, rate.

It is undisputed that Cannon’s condition -- plantar fasciitis -- is manifested only by 

his subjective experience of pain. Thus, his condition appears to fall right into the 

category of cases the Sixth District was describing in Milpitas Unified, where the AMA 

Guides “calls for the physician’s exercise of clinical judgment to assess the impairment 

most accurately.” (Milpitas Unified, supra, 187 Cal.App.4th at p. 823.) Dr. Ramsey 

performed that assessment here and determined that Cannon’s plantar fasciitis resulted in 

a 7 percent whole person impairment equivalent to a limp with arthritis. The city has 

shown no error in that assessment and no error in the board’s decision based on that 

assessment.
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DISPOSITION

The board’s opinion and decision after reconsideration is affirmed. Respondents

shall recover their costs on review in this court. (Cal. Rules of Court, rule 8.493(a).)

 ROBIE , J.

We concur:

 RAYE , P. J.

 NICHOLSON , J.
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Filed 1/15/14

CERTIFIED FOR PUBLICATION

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

THIRD APPELLATE DISTRICT

----

CITY OF SACRAMENTO,

Petitioner,

v.

WORKERS’ COMPENSATION APPEALS BOARD 

and ARTHUR CANNON,

Respondents.

C072944

(Super. Ct. No. ADJ7238353)

ORDER CERTIFYING 

OPINION FOR 

PUBLICATION

THE COURT:

The opinion in the above-entitled matter filed December 26, 2013, was not 

certified for publication in the Official Reports. For good cause it appears now that the 

opinion should be published in the Official Reports and it is so ordered.

BY THE COURT:

 RAYE , P. J.

 NICHOLSON , J.

 ROBIE , J.
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EDITORIAL LISTING

APPEAL from a decision of the Workers’ Compensation Appeals Board. 

Affirmed.

 Laughlin, Falbo, Levy & Moresi and Sidney L. Lamb; Lenahan, Lee, Slater & Pearse 

and Gerald M. Lenahan for Petitioner.

 Mastagni, Holstedt, Amick, Miller & Johnsen; Jonathan W.A. Liff, Eric D. Ledger for 

Respondent Arthur Cannon.

 No appearance for Respondent, Workers’ Compensation Appeals Board.