COURT OF APPEALS OF VIRGINIA 

Present: Judges Fitzpatrick, Overton and Senior Judge Duff 

Argued at Alexandria, Virginia 

FAIRFAX COUNTY SCHOOL BOARD 

 MEMORANDUM OPINION* BY 

v. Record No. 2771-96-4 JUDGE JOHANNA L. FITZPATRICK 

 JUNE 17, 1997 

LISA M. LEWIS PUEBLA 

 FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION 

 Michael N. Salveson (Hunton & Williams, on 

briefs), for appellant. 

 Thomas W. Ullrich for appellee. 

 On appeal from the decision of the Virginia Workers' 

Compensation Commission awarding Lisa Puebla (claimant) benefits, 

Fairfax County School Board (employer) contends that the 

commission erred in (1) imposing an improper burden of proof on 

employer and (2) finding that claimant's medical problems are 

causally related to her industrial accident. For the following 

reasons, we reverse the decision of the commission.1

 

 BACKGROUND 

 On October 26, 1993, claimant suffered minor injuries when 

the school bus in which she was riding as an attendant stopped 

suddenly and caused her to fall. She suffered a contusion to the 

head, dizziness, contusions to both knees, and a cervical strain. 

 

 *Pursuant to Code § 17-116.010 this opinion is not 

designated for publication. 

 1Because we reverse on the causation issue, we do not 

address the burden of proof issue for purposes of this appeal. 
 2 

 The commission found this injury to be compensable, and awarded 

her benefits. 

 Following her accident, claimant received treatment from 

several physicians. Dr. Kerry Lewis (Dr. Lewis) treated claimant 

for her cervical injury. His notes following claimant's first 

visit on November 1, 1993 reflect the following impressions: 

 Exam of skull reveals slight tenderness in 

the right temporal area. There is no 

significant soft tissue swelling . . . . 

Neck-supple w/ good ROM. . . . Chest wall 

reveals tenderness along the left anterior 

ribcage . . . . Abd-massively obese, 

nontender, no organomegaly. . . . Exam of 

left knee reveals tenderness . . . . There is 

good ROM w/o instability. 

 On March 11, 1994, Dr. Lewis concluded that he "[w]ould feel 

at this point that [claimant] has no physical limitations based 

on her prior neck injury . . . . I feel there are no physical 

limitations related to her neck injury currently." He reiterated 

this conclusion in correspondence dated April 12, 1995 to Linda 

Glassco, claims specialist: "[A]t that time that [claimant] 

exhibited no significant physical limitation based on her prior 

neck injury. I felt [] [claimant] was fully capable of doing 

secretarial work which required tasks such as filing or sitting 

at a desk. I have not had contact with her or spoken to her 

since that last visit." Finally, Dr. Lewis stated as follows: 

 I believe [claimant] did suffer a cervical, 

thoracic and lumbar strain as a result of her 

accident on 10/26/93. It appears that [she] 

has, in general, recovered from her cervical 

and lumbar strain. There is no objective 

evidence of current injury. . . . I feel that 

[claimant] is capable of performing sedentary 
 3 

tasks such as secretarial work. I do not 

feel she is capable of further work as a 

school bus attendant. I feel the inherent 

instability of moving about on a traveling 

bus is not in her best interest and leaves 

her open to further falls and possible 

additional injury. 

(Emphasis added.) 

 Claimant's orthopedic surgeon, Dr. Rubin D. Cabrera (Dr. 

Cabrera), examined her and on November 5, 1993, he noted that she 

was overweight, and at the time of her accident weighed "about 

312 lbs." He diagnosed claimant with "contusion of head. 

Dizziness. Contusion of both knees with more pain on the left 

than before. Obesity -- thyroid problem." On February 4, 1994, 

Dr. Cabrera found that "[e]xamination of the knee revealed that 

examination is still difficult because of the thickness of the 

subcutaneous fat in this patient. There is a normal ROM. There 

is diffuse tenderness. Patient is walking, using a cane." Dr. 

Samuel R. Sawmiller examined claimant on February 8, 1994, for a 

second opinion regarding her knees. He concluded as follows: 

 This patient has pre-existing arthritis 

in her knee, primarily patella femoral, 

secondary to her weight. She has obviously 

sprained the left knee and this has set off a 

vicious cycle of pain, synovitis, aggravated 

by the weight which has caused her to do most 

of the work with the right knee that has now 

made the right knee sore. 

 There is little question that this 

patient had problems although asymptomatic 

prior to the injury and that these knees will 

never, ever be resolved to normal knees. 

 It is my feeling that this patient 

should probably not be back in a school bus 

at any time in the foreseeable future just 
 4 

because of the difficulty of dealing with a 

moving bus and getting in and out through the 

entryway. 

Additionally, he noted that "[t]he only constructive suggestion I 

have is weight loss but I see no reason to offer further 

injections or orthopaedic treatment of this knee" and that "[a]t 

the present time I don't see how this patient can work on a 

school bus. She will be employable at a sedentary type job where 

she does not have to stand or walk." 

 Dr. Thomas Fogarty, a psychiatrist, examined claimant on 

March 23, 1994, and determined that: 

 [T]his is a 27 year old woman who has a prior 

history of significant depression which had 

gone untreated. She is currently on a 

complicated regimen of medications, which she 

cannot take due to side effects. . . . It is 

very difficult to determine what is causing 

her headache at this time. It could very 

well be improved with alteration of her 

medicine or regimen. 

He later examined claimant upon her admission to the hospital on 

October 16, 1994 for seizures. He found that: 

 [T]he patient had significant illness 

behavior which was compounded by her 

psychosocial situation and family dynamics. 

Approximately three days prior to discharge, 

she developed a generalized shaking and at 

times unresponsive and invariable way [sic]. 

 She was seen in neurologic consultation as 

well as by the house physician, who agreed 

that the patient probably had pseudo 

seizures. As the behavior persisted, it 

appeared to be goal directed with secondary 

gain suggesting a conscious and willful 

aspect of her behavior consistent with 

malingering . . . . [I]t was felt that 

continued inpatient hospitalization would 

lead to further regression in her behavior 

. . . . It became clear that she did not want 
 5 

to return to her part time position. It was 

emphasized that she could not return to full 

time employment at this point as a bus aide, 

nor could she be expected to be fully 

compensated without working . . . . 

 . . . She was discharged with a 

diagnosis of cervical and lumbar myofascial 

pain, bilateral knee pain of unclear 

etiology, prescription medication abuse, 

somatoform pain disorder and atypical 

depression rule out conversion disorder 

versus malingering. 

 On December 8, 1995, more than two years after claimant's 

compensable injury, Dr. Cabrera saw claimant for yet another 

complaint. His notes reflect the following events: 

 [Claimant] says that on December 1, 1995, 

both of her knees locked up for about 6 

minutes. Since that day, they occasionally 

give out and she has constant pain. . . . 

* * * * * * * 

 Examination shows that she has good ROM of 

both knees. She has no crepitation and no 

instability of the collateral ligaments. I 

could not find any evidence of effusion. 

. . . 

 I had told [claimant] during the examination 

that I did not see any relationship between 

the accident and her present symptoms. I 

believe she needed investigations. 

(Emphasis added.) Finally, Dr. Cabrera examined claimant on 

January 18, 1996, and concluded that both knees were "normal." 

Dr. Cabrera further indicated that claimant's initial compensable 

knee sprain had healed, that the symptoms claimant complained of 

"are subjective symptoms, but they could have a pathological 

basis due to [claimant's] overweight," and that she could "return 
 6 

to a sedentary type of work from the orthopedic point of view and 

her knee problems." 

 On March 14, 1996, employer requested the commission to 

suspend or terminate claimant's benefits, on the grounds that her 

disability at the present time was unrelated to the industrial 

accident. Upon review, the deputy commissioner determined that 

claimant's benefits should be reinstated. The deputy 

commissioner found as follows: 

 A review of the evidence leads us to conclude 

that the employer has failed to establish 

that [claimant's] compensable injury no 

longer contributes to her disability. While 

it is clear from the medical records that the 

employee suffers from several medical 

problems, the records further show that as a 

result of her compensable injury, the 

employee has sustained knee problems 

complicated by a pre-existing condition. 

 The full commission agreed that the "employer's evidence 

fails to show she has recovered from other injuries of the 

accident" and found that, 

 the fact that the claimant's condition has 

generally healed does not show that the 

injury in question has resolved. Neither 

does the absence of objective evidence 

necessarily mean there is no actual injury 

 . . . . 

* * * * * * * 

 The burden is on the employer, as the 

moving party in these proceedings, to prove 

that the medical evidence preponderates to 

establish that the claimant's disabling 

medical problems are unrelated to her work 

injury. We agree with the Deputy 

Commissioner that the employer failed to 

satisfy its burden of proof in this case, and 

the June 7, 1996 Opinion is AFFIRMED. 
 7 
 8 

 CAUSAL CONNECTION 

 Employer argues that no credible evidence supports the 

commission's finding that claimant's ongoing medical problems are 

causally related to the industrial accident. We agree. 

 In its application for review of claimant's award on the 

grounds of change in condition, the burden was upon employer, the 

party alleging such change, to prove its allegations by a 

preponderance of the evidence. See Great Atlantic & Pacific Tea 

Co. v. Bateman, 4 Va. App. 459, 464, 359 S.E.2d 98, 101 (1987). 

 The commission's finding with respect to the casual 

relationship between an accident and an injury is generally 

binding on appeal, if based on credible evidence. C.D.S. Constr. 

Services v. Petrock, 218 Va. 1064, 243 S.E.2d 236 (1978); 

Ingersoll-Rand Co. v. Musick, 7 Va. App. 684, 688, 376 S.E.2d 

814, 817 (1989). Additionally, if reasonable inferences may be 

drawn from credible evidence, they also will be upheld on appeal. 

See Tumlin v. Goodyear Tire & Rubber Co., 18 Va. App. 375, 378, 

444 S.E.2d 22, 23 (1994). Causation is established when it is 

apparent to the rational mind upon consideration of all the 

circumstances that a causal connection exists between the work 

conditions and the resulting injury. See, e.g., Bradshaw v. 

Aronovitch, 170 Va. 329, 335, 196 S.E. 684, 686 (1938); Marketing 

Profiles, Inc. v. Hill, 17 Va. App. 431, 434, 437 S.E.2d 727, 729 

(1993). 

 It is undisputed that, on October 26, 1993, claimant 
 9 

suffered minor injuries to her knees, head, and spine in a 

work-related accident. It is also undisputed that claimant 

suffers from obesity and ailments related to her weight 

condition. However, the record unequivocally establishes that 

all of claimant's treating physicians determined that any effects 

of claimant's industrial accident have long since dissipated. 

Under familiar principles, the opinions of treating physicians 

are entitled to great weight. See, e.g., Pilot Freight Carriers, 

Inc. v. Reeves, 1 Va. App. 435, 339 S.E.2d 570 (1986). Thus, we 

hold that there is no connection between the work-related 

injuries and claimant's current complaints. 

 Dr. Lewis' records indicate that, as of March 11, 1994, 

claimant had "no physical limitations related to her neck injury" 

that occurred on October 26, 1993, and that she had generally 

"recovered from her cervical and lumbar strain." Dr. Sawmiller's 

diagnosis of claimant as of February 1994 was that she had 

"pre-existing arthritis in her knee" and that "this patient had 

problems . . . prior to the injury." He also found that 

claimant's "knees will never, ever be resolved to normal knees." 

 Dr. Fogarty examined claimant for possible neurological 

problems, and found that "[i]t is very difficult to determine 

what is causing her headache" and that "[t]he patient had 

significant illness behavior . . . [that] appeared to be goal 

directed with secondary gain suggesting a conscious and willful 

aspect of her behavior consistent with malingering . . . ." He 
 10 

determined that claimant's ultimate diagnosis upon discharge was 

"cervical and lumbar myofascial pain, bilateral knee pain of 

unclear etiology, prescription medication abuse, somatoform pain 

disorder and atypical depression rule out conversion disorder 

versus malingering." Finally, Dr. Cabrera determined that 

claimant's December 1995 knee complaints "had no relationship" to 

her earlier work-related injury. He also found that claimant's 

initial compensable knee sprain had healed. 

 Accordingly, the evidence supports employer's allegation of 

change in condition. No credible evidence and no inferences 

therefrom support the commission's conclusion that claimant's 

current complaints are causally related to her October 26, 1993 

accident. Rather, the medical evidence confirms that claimant's 

obesity and related difficulties existed prior to her compensable 

injury and would "never, ever" be "resolved," regardless of the 

healing of her October 1993 injury. The evidence fails to 

establish that claimant's current problems are causally related 

to her 1993 accident. 

 The decision of the commission is reversed. 

 Reversed.