Title: Sisbro, Inc. v. Industrial Comm'n
Citation: N/A
Docket Number: 93729
State: Illinois
Issuer: Illinois Supreme Court
Date: May 22, 2003

Docket No. 93729-Agenda 8-March 2003.
SISBRO, INC., Appellee, v. The INDUSTRIAL COMMISSION  								
								et al. (George Rodriguez, Appellant).
Opinion filed May 22, 2003.
	CHIEF JUSTICE McMORROW delivered the opinion of the
court:
	Claimant, George Rodriguez (claimant), twisted his ankle as
he stepped out of a delivery truck and into a pothole while making
a delivery of dairy products for his employer, Sisbro, Inc. (Sisbro).
The Industrial Commission awarded claimant workers'
compensation benefits, finding that there was a causal relationship
between this work-related injury and the acute onset of a
degenerative condition in claimant's right foot-Charcot
osteoarthropathy. The circuit court confirmed the award.
	On appeal, the Appellate Court, Industrial Commission
Division, reversed the judgment of the circuit court, ruling that
claimant's condition was not compensable under the Worker's
Compensation Act because claimant's health had deteriorated to
such an extent that normal daily activity could have caused the
injury (the "normal daily activity exception") or because the
activity which caused the injury presented risks no greater than
those to which the general public is exposed. 327 Ill. App. 3d 868.
	We granted claimant's petition for leave to appeal (177 Ill. 2d
R. 315(a)), and now reverse the judgment of the appellate court
and affirm the judgment of the circuit court.

BACKGROUND
	Claimant filed an application for adjustment of claim seeking
disability benefits from his employer pursuant to the Workers'
Compensation Act (the Act). 820 ILCS 305/1 et seq. (West 2000).
Claimant alleged that an accidental injury arising out of and in the
course of his employment was causally related to the onset of a
degenerative condition in his right foot-Charcot
osteoarthropathy-which caused him to be disabled and unable to
work. Sisbro disputed the claim on three points: (1) whether the
accidental injury arose out of and in the course of employment, (2)
whether claimant's disabling condition was causally related to his
injury, and (3) the amount of claimant's annual earnings. On July
6, 1999, a hearing was held before an arbitrator to resolve the
disputed matters.
	At this hearing, the arbitrator learned that claimant was a 54-year-old male who had been afflicted with Type II (adult onset)
diabetes for the past six years. For the past 2½ years, claimant was
employed by Sisbro as a delivery truck driver. Claimant's job
required him to drive an 18-wheeler truck to St. Louis to pick up
dairy products and then deliver them to various grocery stores in
Illinois. Claimant also was required to load the truck at St. Louis
and off-load product from the truck at various grocery stores.
	Claimant testified before the arbitrator that, on March 26,
1998, after backing into the docking area of Peavly Dairy to pick
up a load of dairy products, he twisted his right ankle when he
stepped down out of the truck and into a pothole. Claimant
testified that, at the time of the incident, he felt pain and his right
ankle swelled slightly. The swelling and pain resolved within a
few days.
	Claimant testified that he visited a podiatrist, Dr. Reed, on
April 6, 1998, for preventative foot care in relation to his diabetes.
Although claimant had no pain or swelling in his ankle at that
time, he informed the doctor of the March 26 accident and was
advised to notify the doctor if his condition changed. Over the next
few weeks, claimant's ankle began to swell repeatedly and the
swelling would not resolve. Claimant saw Dr. Reed again on April
24, 1998, at which time X rays were taken and tests were
performed. Based on these tests, claimant was diagnosed with
Charcot osteoarthropathy and ordered to stay off his foot.
	Claimant supported his claim with the May 26, 1999,
evidence deposition of Dr. Brennan R. Reed, a podiatric
orthopedist and claimant's treating physician. In this deposition,
Dr. Reed testified that he began treating claimant in 1995, when
claimant suffered a broken toe. Since that time, Dr. Reed saw
claimant about every two to three months for preventative foot
care in conjunction with claimant's diabetes. Dr. Reed explained
that diabetes causes accelerated vascular disease and neuropathy
(nerve damage) and, accordingly, diabetics are susceptible to an
increased risk of injury to their lower extremities.
	Dr. Reed testified that he examined claimant's feet on April
6, 1998, as part of a regularly scheduled preventative care visit. At
that time, claimant mentioned that he had twisted his ankle a few
days earlier and had experienced some pain and swelling in his
ankle and foot. Dr. Reed observed no evidence of pathology at the
time of this exam and, consequently, took no action. On April 24,
1998, however, claimant contacted Dr. Reed's office complaining
of pain and swelling in his right ankle and foot. Dr. Reed saw
claimant that same day and the exam revealed that claimant "had
gross swelling, which is edema, and heat or erythema of the right
foot, entire ankle, dorsal foot and his digits as well. The foot was
also ruborous, which means red in coloration, and there was mild
pain to deep palpation of the dorsal mid-foot over what we call the
Lis Francs." X rays of claimant's foot showed "marked chronic
degenerative changes involving the ankle." Based on these X rays,
Dr. Reed diagnosed claimant's condition to be "acute onset of
diabetic Charcot osteoarthropathy." Dr. Reed defined Charcot as
a condition associated with the destruction of the bone and tissue
of the joint caused by an underlying neurological involvement,
often related to diabetes. The recommended treatment for Charcot
is to keep the joint rested to give the joint an opportunity to heal
and to avoid any further injury or destruction. For this reason,
claimant's leg was placed in a cast for support and claimant was
advised to keep the leg elevated and to avoid placing any weight
on the leg. Accordingly, claimant was unable to work.
	When asked about what might have caused Charcot to
develop in claimant's right ankle, Dr. Reed explained that Charcot
is typically initiated by some type of trauma. Dr. Reed admitted
that, in some instances, the trauma may be minor. The mere act of
stepping off a curb, walking on uneven ground, or wearing
uncomfortable shoes may trigger Charcot. In the present case,
however, it was Dr. Reed's opinion, based on a reasonable degree
of medical certainty, that the trauma which initiated the onset of
Charcot in claimant's right ankle was the work-related accident on
March 26, 1998, when claimant twisted his ankle stepping down
from his truck. Dr. Reed testified that, in his opinion, claimant had
the underlying neuropathy, but had not developed Charcot in his
right ankle prior to March 26, 1998. The accident, he said,
triggered the acute onset of Charcot osteoarthropathy.
	 Sisbro offered an opposing expert opinion through the
evidence deposition of Dr. John Gragnani, a physician who is
board certified in occupational and environmental medicine and
specializes in physical medicine and rehabilitation. At the request
of Sisbro, Dr. Gragnani examined claimant once on July 6, 1998.
Based on this single examination and a review of claimant's
medical records, Dr. Gragnani offered the opinion that the Charcot
condition in claimant's right ankle was a "much more long-standing condition" which preexisted March 26, 1998. In his view,
the Charcot joint developed slowly over time as a result of
claimant's poorly controlled diabetes, the related neuropathy, and
"microtraumas" to the feet caused by everyday living.
	After considering all of the evidence, the arbitrator issued a
written memorandum of decision on September 17, 1999. The
arbitrator ruled that claimant's act of twisting his ankle was an
accident which arose out of and in the course of his employment
with Sisbro. Further, the arbitrator held:
		"Based on [the claimant's] uncontradicted testimony
regarding the onset of his condition, and the more credible
opinions of Dr. Reed, the Arbitrator finds that [the
claimant's] condition of ill-being, being Charcot
osteoarthropathy, is causally related to his injury."
	The arbitrator ruled that claimant had been temporarily and
totally disabled for a period of 62 and 3/7 weeks and found
claimant eligible to receive compensation for this period. The
arbitrator also awarded claimant the further sum of $983.65 in
medical expenses and ruled that the current award of temporary
total disability compensation would not be a bar to any further
hearings for additional amounts of temporary total disability
compensation or for compensation for permanent disability.
	Sisbro filed a petition for review with the Industrial
Commission pursuant to section 19(b) of the Act. 820 ILCS
305/19(b) (West 2000). Upon review, the Industrial Commission
affirmed and adopted the decision of the arbitrator in a written
order dated March 16, 2000. In addition, the Commission
remanded the matter to the arbitrator "for further proceedings for
a determination of a further amount of temporary total
compensation or of compensation for permanent disability, if any,
pursuant to Thomas v. Industrial Comm'n, 78 Ill. 2d 327 (1980)."
	Sisbro sought review of the Industrial Commission's decision
in the circuit court of Adams County. In a hearing before Judge
Dennis K. Cashman, counsel for Sisbro argued:
		"This case, I believe, is a classic example of a case where
the [claimant's] injury did not arise out of employment. I
believe it should be analyzed under the cases I have set
out to you in my brief, principally that of the Hansel &amp;
Gretel case [215 Ill. App. 3d 284 (1991)]."
	Later on in his argument, Sisbro's counsel restated his
position:
		"You can decide whether the decision the Commission
made was against the manifest weight of the evidence
once you look at the evidence in this case, but,
nevertheless, even if you decide the stepping in the hole
was the inciting trauma, if there has to be a trauma to start
this condition, it's still not compensable as an accident
because he was at no greater risk to-by the pothole or
hole stepped in, by driving a truck. The risk he had was a
risk peculiar to him because of his diabetic condition,
which was, again, to use my words, so out of control that
anything could have incited the disease."
	The circuit court, after hearing counsel's argument, held that,
"the question is whether [the injury] truly falls within the category
of a work-related injury." The circuit court then ruled that the
Industrial Commission's resolution of this factual issue was not
against the manifest weight of the evidence and confirmed the
Commission's decision.
	Once again, Sisbro appealed. The Appellate Court, Industrial
Commission Division, heard the appeal. In a split decision, a
majority of the court reversed the decision of the Industrial
Commission, finding that "[a]n employee whose preexisting
condition was aggravated by an accident at work is not entitled to
[worker's compensation] benefits 'where [his] health has so
deteriorated that any normal, daily activity could have caused the
injury, or where the activity engaged in presents risks no greater
than that to which the general public is exposed.' " (Emphasis in
original.) 327 Ill. App. 3d at 874, quoting General Refractories v.
Industrial Comm'n, 255 Ill. App. 3d 925, 931 (1994).
	The majority further held:
			"The arbitrator found that claimant's accident of March
1998 caused his Charcot but did not consider whether
claimant nonetheless should be barred from compensation
in light of uncontradicted testimony that normal daily
activity was sufficient to cause Charcot in claimant. Nor
did the Commission, in reviewing the findings of the
arbitrator, consider either of the two exceptions to the rule
permitting compensation for work-related aggravation of
a preexisting condition. Because we determine that this
case falls into one of those exceptions, we hold that the
Commission's award of compensation was against the
manifest weight of the evidence." 327 Ill. App. 3d at 879.
	We granted claimant's petition for leave to appeal. 177 Ill. 2d
R. 315(a). The Illinois AFL-CIO and the Illinois Trial Lawyers
Association have filed briefs amicus curiae in support of claimant,
George Rodriguez.

ANALYSIS
	In the case at bar, claimant argues that the appellate court
erred in reversing the Industrial Commission's award of benefits.
Claimant contends that the appellate court failed to accord the
appropriate deference to the factual findings of the Industrial
Commission and, in addition, applied an overly broad
interpretation of the "normal daily activity" limitation on recovery
in preexisting condition cases. We agree.
	To obtain compensation under the Act, a claimant bears the
burden of showing, by a preponderance of the evidence, that he
has suffered a disabling injury which arose out of and in the course
of his employment. Baggett v. Industrial Comm'n, 201 Ill. 2d 187
(2002); Paganelis v. Industrial Comm'n, 132 Ill. 2d 468, 480
(1989); Horath v. Industrial Comm'n, 96 Ill. 2d 349, 356 (1983);
Jones v. Industrial Comm'n, 93 Ill. 2d 524, 526 (1983); Rogers v.
Industrial Comm'n, 83 Ill. 2d 221, 223 (1980). "In the course of
employment" refers to the time, place and circumstances
surrounding the injury. Lee v. Industrial Comm'n, 167 Ill. 2d 77,
81 (1995); Scheffler Greenhouses, Inc. v. Industrial Comm'n, 66 Ill. 2d 361, 366 (1977). That is to say, for an injury to be
compensable, it generally must occur within the time and space
boundaries of the employment. 1 A. Larson, Worker's
Compensation Law §12.01 (2002). It is not enough, however, to
simply show that an injury occurred during work hours or at the
place of employment. The injury must also "arise out of" the
employment. Parro v. Industrial Comm'n, 167 Ill. 2d 385, 393
(1995) (the occurrence of an accident at the claimant's workplace
does not automatically establish that the injury arose out of the
person's employment); Caterpillar Tractor Co. v. Industrial
Comm'n, 129 Ill. 2d 52, 62 (1989).
	The "arising out of" component is primarily concerned with
causal connection. To satisfy this requirement it must be shown
that the injury had its origin in some risk connected with, or
incidental to, the employment so as to create a causal connection
between the employment and the accidental injury. Caterpillar
Tractor Co. v. Industrial Comm'n, 129 Ill. 2d 52, 58 (1989).
Stated otherwise, "an injury arises out of one's employment if, at
the time of the occurrence, the employee was performing acts he
was instructed to perform by his employer, acts which he had a
common law or statutory duty to perform, or acts which the
employee might reasonably be expected to perform incident to his
assigned duties. [Citations.] A risk is incidental to the employment
where it belongs to or is connected with what an employee has to
do in fulfilling his duties." Caterpillar Tractor Co. v. Industrial
Comm'n, 129 Ill. 2d  at 58.
	In the case at bar, the Commission found that claimant's act
of twisting his ankle as he stepped down from the 18-wheeler
delivery truck was an accidental injury which arose out of and in
the course of his employment. Sisbro does not seriously dispute
this finding. Rather, Sisbro argues that this accidental injury was
not causally-related to claimant's disabling condition, Charcot
osteoarthropathy. Sisbro argues that the overwhelming weight of
the evidence shows that claimant's condition (Charcot) was the
result of a preexisting condition (diabetes) and that his preexisting
condition (diabetes) was so "out of control" that it could have been
aggravated by normal activities of life. Moreover, Sisbro contends
that the appellate court correctly overturned the Commission's
decision as against the manifest weight of the evidence because
the Commission failed to consider whether the "normal daily
activity exception" to compensability applied under the facts of
this case.

A. Causal Connection in Preexisting Condition Cases
	It has long been recognized that, in preexisting condition
cases, recovery will depend on the employee's ability to show that
a work-related accidental injury aggravated or accelerated the
preexisting disease such that the employee's current condition of
ill-being can be said to have been causally-connected to the work-related injury and not simply the result of a normal degenerative
process of the preexisting condition. Caterpillar Tractor Co. v.
Industrial Comm'n, 92 Ill. 2d 30, 36-37 (1982); Caradco Window
&amp; Door v. Industrial Comm'n, 86 Ill. 2d 92, 99 (1981); Azzarelli
Construction Co. v. Industrial Comm'n, 84 Ill. 2d 262, 266 (1981);
Fittro v. Industrial Comm'n, 377 Ill. 532, 537 (1941).
	It is axiomatic that employers take their employees as they
find them. Baggett, 201 Ill. 2d  at 199. "When workers' physical
structures, diseased or not, give way under the stress of their usual
tasks, the law views it as an accident arising out of and in the
course of employment." General Electric Co. v. Industrial
Comm'n, 89 Ill. 2d 432, 434 (1982). Thus, even though an
employee has a preexisting condition which may make him more
vulnerable to injury, recovery for an accidental injury will not be
denied as long as it can be shown that the employment was also a
causative factor. Caterpillar Tractor Co. v. Industrial Comm'n, 92 Ill. 2d  at 36; Williams v. Industrial Comm'n, 85 Ill. 2d 117, 122
(1981); County of Cook v. Industrial Comm'n, 69 Ill. 2d 10, 18
(1977); Town of Cicero v. Industrial Comm'n, 404 Ill. 487 ( 1949)
(It is a well-settled rule that where an employee, in the
performance of his duties and as a result thereof, is suddenly
disabled, an accidental injury is sustained even though the result
would not have obtained had the employee been in normal health).
Accidental injury need not be the sole causative factor, nor even
the primary causative factor, as long as it was a causative factor in
the resulting condition of ill-being. Rock Road Construction Co.
v. Industrial Comm'n, 37 Ill. 2d 123, 127 (1967).
	Whether a claimant's disability is attributable solely to a
degenerative process of the preexisting condition or to an
aggravation or acceleration of a preexisting condition because of
an accident is a factual determination to be decided by the
Industrial Commission. Roberts v. Industrial Comm'n, 93 Ill. 2d 532, 538 (1983); Caterpillar Tractor Co. v. Industrial Comm'n, 92
Ill. 2d at 36-37; Caradco Window &amp; Door v. Industrial Comm'n,
86 Ill. 2d 92, 99 (1981). Further, a reviewing court must not
disregard or reject permissible inferences drawn by the
Commission merely because other inferences might be drawn, nor
should a court substitute its judgment for that of the Commission
unless the Commission's findings are against the manifest weight
of the evidence. Parro v. Industrial Comm'n, 167 Ill. 2d 385, 396
(1995); Castaneda v. Industrial Comm'n, 97 Ill. 2d 338, 341
(1983). "[T]o the extent that the medical testimony might be
construed as conflicting, it is well established that resolution of
such conflicts falls within the province of the Commission, and its
findings will not be reversed unless contrary to the manifest
weight of the evidence." Caterpillar Tractor Co. v. Industrial
Comm'n, 92 Ill. 2d  at 37.
	In the case at bar, Sisbro's main argument before the arbitrator
was that there was no causal connection between claimant's work-related injury (the twisted ankle) and his condition of ill-being
(Charcot). Sisbro's position, as set forth by its medical expert, Dr.
Gragnani, was that claimant's Charcot osteoarthropathy was the
result of the normal degenerative process of his preexisting
diabetic condition and the associated neuropathy. Sisbro
contended that claimant's diabetic condition was so "out of
control" that Charcot osteoarthropathy developed as a result of
normal activities of life and not as a result of the work-related
accident. Sisbro still maintains this to be true.
	As noted above, the arbitrator rejected Sisbro's argument,
finding more credible the opinion of claimant's expert that
claimant's Charcot osteoarthropathy was triggered when he
twisted his ankle. The Commission adopted the decision of the
arbitrator. The record clearly supports this determination.
	The testimony of Dr. Reed, claimant's treating physician,
established that claimant was asymptomatic for Charcot
osteoarthropathy prior to March 26, 1998. Shortly after twisting
his right ankle, however, claimant developed Charcot in his right
ankle. Further, Dr. Reed, who has experience in treating diabetic
foot problems, testified that Charcot is typically triggered by some
trauma. Although the triggering trauma can, in some instances, be
very minor, Dr. Reed testified that he believed, to a reasonable
degree of medical certainty, that the onset of Charcot in claimant's
right ankle was initiated as a direct result of the work-related
incident on March 26, 1998, when claimant twisted his ankle. It is
true that Sisbro presented conflicting expert testimony, but it was
within the province of the Commission to judge the credibility of
the witnesses, to draw reasonable inferences from their testimony,
and to resolve any conflict in claimant's favor. See Parro v.
Industrial Comm'n, 167 Ill. 2d  at 396.
	We cannot say that the Commission's determination of a
causal relationship between claimant's work-related injury and his
condition of ill-being is against the manifest weight of the
evidence. There is support in the record for the Commission's
finding that the work-related accidental injury aggravated or
accelerated claimant's preexisting condition. Thus, compensation
was properly awarded to claimant.
	Ordinarily, our review would end at this juncture since our
scope of review is limited to deciding whether the Commission's
award of compensation is against the manifest weight of the
evidence. However, Sisbro argues, and the appellate court held
below, that "despite the existence of a causal connection between
the accident in March 1998 and claimant's Charcot, claimant is
not entitled to compensation because Drs. Reed and Gragnani
agreed that even minor trauma can cause the onset of Charcot
arthropathy in claimant." 327 Ill. App. 3d at 872.

B. The "Normal Daily Activity Exception"
	In County of Cook v. Industrial Comm'n, 69 Ill. 2d 10, 17
(1977), we said that, "[t]o come within the [workers'
compensation] statute the employee need only prove that some act
or phase of the employment was a causative factor of the resulting
injury." We also noted, however, that:
		"The sole limitation to the above general rule is that
where it is shown the employee's health has so
deteriorated that any normal daily activity is an
overexertion, or where it is shown that the activity
engaged in presented risks no greater than those to which
the general public is exposed, compensation will be
denied." County of Cook, 69 Ill. 2d  at 18.
	Sisbro interprets this "limitation" language to mean that there
exists a "normal daily activity exception" to the general rule
allowing compensation for work related injuries which aggravate
or accelerate a preexisting condition. Sisbro maintains that the
majority of the appellate court was correct when it held that "a
claimant is not entitled to compensation, regardless of whether his
condition of ill-being was caused by work-related aggravation of
a preexisting condition, if his physical condition has so
deteriorated that his condition of ill-being could have been
produced by normal daily activity." (Emphases added.) 327 Ill.
App. 3d at 873. Thus, it is Sisbro's position that, even if the
Commission was correct when it found a causal connection
between claimant's work-related injury and the onset of Charcot,
we must find the award of benefits to be against the manifest
weight of the evidence because the Commission "did not consider
whether claimant nonetheless should be barred from compensation
in light of uncontradicted testimony that normal daily activity was
sufficient to cause Charcot in claimant." 327 Ill. App. 3d at 879.
In other words, Sisbro contends that, even when a work-related
accidental injury is shown to be an actual causal factor in bringing
about an employee's disabling condition, recovery should be
denied if normal daily activity could have brought on claimant's
disabling condition. We disagree.
	In County of Cook, we cited National Malleable &amp; Steel
Castings Co. v. Industrial Comm'n, 32 Ill. 2d 184 (1965), and
Illinois Bell Telephone Co. v. Industrial Comm'n, 35 Ill. 2d 474
(1966), as the basis for our finding a "limitation" on the general
rule that compensation is available to a claimant as long as a work-related injury was a causative factor in the aggravation or
acceleration of a preexisting condition. Thus, we look to those
cases to interpret the meaning of the "limitation" language we
used in County of Cook.
	In National Malleable an employee died of a heart attack. The
employee's widow then filed a workers' compensation claim
alleging that the employee had sustained accidental injuries which
arose out of and in the course of his employment and that there
was a causal relationship between the alleged injuries and the
employee's subsequent heart attack and death. Evidence was
presented which established that although the employee reported
to work on the alleged day of the "accident," he had been sent
home before he began his shift because he did not feel well. After
leaving work, the employee went to a medical center, where he
saw a doctor and reported that he had been having chest pains over
the previous four-day period. The doctor prescribed some
medication. After filling the prescription, the employee returned
home and went to bed. He was found dead the next morning.
	A physician who was called as a medical expert in support of
the claim, gave the opinion that the employee showed definite
signs of heart disease over the four-day period prior to his death
and, as a result, any exertion such as walking up and down stairs,
driving to work, or going to the doctor's office, could have
precipitated his fatal heart attack. Since the employee had
performed these activities on the workday prior to his death, the
expert concluded that the employee's cause of death "was
'involved' with the decedent's final work episode." We rejected
this opinion and found no causal relationship between the
employee's fatal heart attack and his employment. Quoting a New
York case, Burris v. Lewis, 2 N.Y.2d 323, 326, 141 N.E.2d 424,
426 (1957), we said,
		" 'But where, as here, a heart has deteriorated so that any
exertion becomes an over-exertion, where the mere
circumstance that the employee was engaged in some kind
of physical labor is what impels the doctor to testify that
his work caused his death, we would have reached a
point, if this award were to be upheld, where all that is
necessary to sustain an award is that the employee shall
have died of heart disease.' " National Malleable &amp; Steel
Castings Co. v. Industrial Comm'n, 32 Ill. 2d  at 189.
	Similarly, in Illinois Bell Telephone Co. v. Industrial
Comm'n, 35 Ill. 2d 474 (1966), an employee died at home as a
result of a heart attack. The only connection between the
employee's heart attack and his employment was that, earlier on
the day of his fatal attack, the employee had walked four blocks to
deliver some papers and, upon returning to his office, felt ill and
took a nitroglycerin pill. Two doctors testified that there was a
causal connection between the employee's work activities and his
subsequent death, "basing their opinions on the fact that [the
employee] had a pre-existing heart condition and that walking
magnified the work effort."Illinois Bell Telephone, 35 Ill. 2d  at
476. However, we found the work connection too tenuous. Citing
to National Malleable we said:
		"The mere fact that he was at work on the day of his heart
attack and left early is not sufficient to establish a causal
relationship between his employment and his subsequent
death, nor is it enough, where one's heart has deteriorated
so that any exertion becomes an overexertion, to merely
show that he had engaged in some kind of physical
activity before suffering the attack." Illinois Bell
Telephone, 35 Ill. 2d  at 477.
	Notably, in Rock Road Construction Co. v. Industrial
Comm'n, 37 Ill. 2d 123, 127 (1967), we distinguished National
Malleable and Illinois Bell. In Rock Road, the claimant was an
asphalt truck driver who, after making a pickup, died at the wheel
of the delivery truck Claimant's expert expressed the opinion that
the decedent's duties in connection with climbing upon the truck
and rolling the tarpaulin up and down on the day of his death were
sufficient to precipitate his fatal heart attack. Although the
employer provided three medical experts, they could not agree on
what had precipitated the claimant's heart attack.
	On review, we rejected the employer's contention that
claimant's condition had so deteriorated that any activity might
have precipitated the attack, stating:
		"[T]he normality of the activity involved for the victim of
a heart attack is not the controlling factor in these cases.
***
			It seems likely from this record that the ultimate result
of decedent's heart condition would have been death at
some indeterminate future date. It is, of course, possible
that this could have occurred in a situation wholly
unrelated to work or exertion. But neither of these
circumstances necessarily renders an award of
compensation against the manifest weight of the evidence
[citations] if it may be legitimately inferred from the
evidence before the commission that occupational activity
or exertion was in fact a causative factor in hastening
decedent's death." Rock Road Construction, 37 Ill. 2d  at
128.
	National Malleable and Illinois Bell do not stand for the
proposition that where a causal connection between work and
injury has been established, it can be negated simply because the
injury might also have occurred as a result of some "normal daily
activity." Rather, these cases demonstrate that whether "any
normal daily activity is an overexertion" or whether "the activity
engaged in presented risks no greater than those to which the
general public is exposed" are matters to be considered when
deciding whether a sufficient causal connection between the injury
and the employment has been established in the first instance. We
have never found a causal connection to exist between work and
injury and then, in a further analytical step, denied recovery based
on a "normal daily activity exception" or a "greater risk
exception."
	We note that, in the case at bar, the appellate court, in its
majority opinion, cites County of Cook v. Industrial Comm'n, 68 Ill. 2d 24 (1977), Greater Peoria Mass Transit District v.
Industrial Comm'n, 81 Ill. 2d 38 (1980), and Hansel &amp; Gretel Day
Care Center v. Industrial Comm'n, 215 Ill. App. 3d 284 (1991), as
standing for the proposition that "a claimant cannot receive
benefits where, due to his debilitated state, his condition of ill-being could have been caused by normal daily activities."
(Emphasis added.) 327 Ill. App. 3d at 874-75. We disagree.
	In County of Cook, an employee who, for more than 10 years,
suffered from hypertension which had, in the past, required
hospitalization, had a stroke as she pushed her chair back from her
desk at work, in preparation to go to lunch. The employee
presented no expert evidence to establish a causal link between her
stroke and her employment. The County's expert, on the other
hand, testified that there was no causal connection between the
employee's work duties and her stroke and subsequent disability.
In resolving the issue of causation, we said:
			"Every employee whose disease or preexisting
condition disables him while at work is not automatically
entitled to a recovery under the Workmen's
Compensation Act. In Carson-Payson Co. v. Industrial
Com. (1930), 340 Ill. 632, 639, this court said, quoting
from Lord Chancellor Loreburn's opinion in Hughes v.
Clover, Clayton &amp; Co. (1910), 102 L.T.R. 340, 342, aff'g
(1909) 2 K.B. 798,101 L.T.R. 475:
			' "*** In each case the arbitrator ought to consider
whether, in substance, as far as he can judge on such a
matter, the accident came from the disease alone, so
that, whatever the man had been doing, it would
probably have come all the same, or whether the
employment contributed to it. In other words, did he die
from the disease alone, or from the disease and
employment taken together, looking at it broadly." ' "
County of Cook, 68 Ill. 2d  at 31-32.
	We concluded that, even though the employee had suffered a
stroke while at work when getting up from her chair, the stroke did
not arise from her employment and, thus, there was no causal
connection between her employment and her condition of ill-being
resulting from the stroke. The Commission's determination to the
contrary was not supported by the evidence and, thus, was against
the manifest weight of the evidence. County of Cook, 68 Ill. 2d  at
34.
	In Greater Peoria, the employee was a bus driver who, after
completing her route, went to the driver's room to return bus
schedules and transfers. She accidentally dropped the papers on
the floor and, when bending over to retrieve them, lost her
balance. In trying to "catch herself," she may or may not have hit
her shoulder on something. After this incident, the employee's
shoulder pained her and she later determined that she had
dislocated her shoulder. Medical evidence established that the
employee's shoulder was a "time bomb" that might have
dislocated with any normal daily activity. We concluded that
although the dislocation occurred at work, it did not arise out of
the employment. We said:
		"Completely absent from the record is any evidence that
claimant's work (1) further deteriorated her shoulder, (2)
aggravated it, (3) precipitated its dislocation, or (4)
accelerated the occasion for its dislocation." Greater
Peoria, 81 Ill. 2d  at 43.
	Since the record indicated that the employee's preexisting
condition was the actual cause her condition of ill-being, we held
that the Commission's determination that the employee's injury
arose out of her employment was against the manifest weight of
the evidence. Greater Peoria, 81 Ill. 2d  at 43.
	Finally, in Hansel &amp; Gretel, the employee was a child-day-care worker. Medical evidence established that the employee had
a longstanding problem with her right knee. Over the past 10
years, the knee would often get stiff and "lock up." One day, while
at work, the employee's leg "locked up" after she had been sitting
at a low (children's) table. When the employee attempted to get up
from the chair she felt pain in her knee and, ultimately, had to
"hop" up with her right knee still "locked up." She later sought
medical treatment and, a month later, had surgery on her knee.
Surgery revealed that the employee had a meniscus tear in the
cartilage of her right knee. The surgeon testified that there was no
way to tell whether the tear had been present before the work
incident or for how long it might have existed. The surgeon
testified that it was possible that the "locking up" incident at work
could have exacerbated a preexisting tear, but it was also possible
that the tear had been the same both before and after the incident.
The appellate court, on review, concluded that it was against the
manifest weight of the evidence for the Commission to have found
that the incident at work aggravated the claimant's preexisting
condition. Hansel &amp; Gretel, 215 Ill. App. 3d at 294.
	In each of the three above-cited cases the reviewing court
found that the manifest weight of the evidence showed that the
employee's condition of ill-being was caused by the normal
degenerative process of the preexisting condition and not because
an accidental injury which arose out of the employment aggravated
or accelerated the preexisting condition. In contrast, the record in
the case at bar supports the Commission's finding that when
claimant twisted his ankle he was performing duties which were
related to his employment and that this injury was causally
connected to the onset of Charcot.

CONCLUSION
	When an employee with a preexisting condition is injured in
the course of his employment, serious questions are raised about
the genesis of the injury and the resulting disability. The
Commission must decide whether there was an accidental injury
which arose out of the employment, whether the accidental injury
aggravated or accelerated the preexisting condition or whether the
preexisting condition alone was the cause of the injury. Generally,
these will be factual questions to be resolved by the Commission.
However, the Commission's decision must be supported by the
record and not based on mere speculation or conjecture. If there is
an adequate basis for finding that an occupational activity
aggravated or accelerated a preexisting condition, and, thereby,
caused the disability, the Commission's award of compensation
must be confirmed.
	In the present case, the Commission found that claimant's
March 26, 1998, work-related accidental injury was causally
related to the claimant's Charcot. Based on our review of the
record, we find that it may be legitimately inferred from the
evidence before the Commission that occupational activity was, in
fact, a causative factor in hastening claimant's contraction of
Charcot. Accordingly, we reverse the judgment of the appellate
court and affirm the judgment of the circuit court.
Appellate court judgment reversed;
circuit court judgment affirmed.
	JUSTICE RARICK took no part in the consideration or
decision of this case.