Court Opinion

ID: 6329061
Source: CourtListenerOpinion
Date Created: 2022-04-01 14:03:38.461171+00
Date Added: 2024-06-11T09:22:47.351698
License: Public Domain

IN THE SUPREME COURT OF IOWA

                                  No. 21–0777

               Submitted February 23, 2022—Filed April 1, 2022

ROSA CHAVEZ,

      Appellant,

vs.

MS TECHNOLOGY LLC and WESTFIELD INSURANCE COMPANY,

      Appellees.

      Appeal from the Iowa District Court for Polk County, Sarah Crane, Judge.

      A workers’ compensation claimant challenges the commissioner’s

treatment of her rotator cuff injury as a scheduled shoulder injury rather than

an unscheduled whole body injury under Iowa Code section 85.34(2).

AFFIRMED.

      Christensen, C.J., delivered the opinion of the court, in which all

participating justices joined. Mansfield and McDermott, JJ., took no part in the

consideration or decision of the case.

      Erin M. Tucker (argued) of Tucker Law Office, Des Moines, for appellant.
                                      2

      Lori N. Scardina Utsinger (argued) of Betty, Neuman & McMahon, P.L.C.,

Davenport, for appellee.

      Jay M. Smith of Smith & McElwain Law Office, Sioux City, for amicus

curiae Iowa Federation of Labor, AFL-CIO.

      Andrew W. Bribriesco, Bettendorf, for amicus curiae League of United

Latin American Citizens of Iowa.

      Jason D. Neifert of Neifert, Byrne & Ozga, P.C., West Des Moines, for

amicus curiae Workers’ Compensation Core Group of the Iowa Association for

Justice.
                                         3

CHRISTENSEN, Chief Justice.

      This case presents our first opportunity to interpret the legislature’s 2017

amendment to Iowa Code section 85.34(2), which added “shoulder” to the list of

scheduled member injuries for determining the award amount for permanent

partial disability in a workers’ compensation proceeding. See Iowa Code

§ 85.34(2)(n) (2018). In the course of her employment, the claimant sustained a

“full thickness rotator cuff tear that has retracted to the level of the glenoid,

severe AC arthrosis, tendonitis and tearing of the biceps tendon.” She sought

permanent partial disability benefits for this injury, arguing her rotator cuff

injury qualified as an unscheduled injury to the body as a whole, thereby

entitling her to industrial disability benefits, instead of a scheduled injury to the

shoulder.

      The workers’ compensation commissioner disagreed, concluding the

claimant’s rotator cuff injury was a scheduled shoulder injury under Iowa Code

section 85.34(2)(n), and the district court affirmed on judicial review. We retained

the claimant’s appeal. For the reasons explained below, we affirm the district

court decision that claimant’s rotator cuff injury is a scheduled shoulder injury

under section 85.34(2)(n). We also affirm the district court decision that

substantial evidence supports the commissioner’s finding that Chavez failed to

prove her biceps tear resulted in a permanent disability to her arm under section

85.34(2)(m).
                                          4

      I. Background Facts and Proceedings.

      On February 5, 2018, Rosa Chavez sustained a work injury in the course

of her employment as a lab technician at MS Technology, LLC. Chavez performed

a variety of tasks in this position, including mopping. At the time of her injury,

Chavez was wringing out a mop by pushing it down in a mop bucket when she

heard a pop and felt immediate pain in her right shoulder. She sought treatment

for the pain on February 8, and her medical provider referred her to Dr. Todd

Peterson, an orthopedic surgeon, for further evaluation.

      Dr. Peterson evaluated Chavez on April 12, and Chavez reported

experiencing pain on both the anterior and posterior aspect of her right shoulder

and pain radiating down her right arm. Dr. Peterson ordered an MRI, which

revealed “a large full thickness tear of the rotator cuff with retraction to around

the level of the glenoid,” “[s]evere AC arthrosis,” “[b]iceps tendonitis and tearing,”

“mild supraspinatus atrophy,” and “acromial spurring.” Her primary injury was

a rotator cuff tear. Consequently, Dr. Peterson recommended Chavez undergo

“shoulder arthroscopy with rotator cuff repair, biceps tenotomy, subacromial

decompression, and distal claviculectomy.” He also modified Chavez’s work

restrictions to include no overhead work or lifting over ten pounds. Chavez

underwent the following procedures on July 11: “[r]ight shoulder arthroscopy

with arthroscopic repair of the rotator cuff tendon of the supraspinatus,

infraspinatus, and subscapularis tendons; extensive debridement of the labrum,

biceps tendon, and subacromial space with biceps tenotomy, subacromial

depression.”
                                         5

      On November 8, Dr. Peterson placed Chavez on maximum medical

improvement, allowing her to continue working with no restrictions. He also

concluded Chavez had a six percent partial permanent impairment to her right

upper extremity. Chavez obtained an independent medical evaluation from

Dr. Sunil Bansal on May 13, 2019. Dr. Bansal opined that Chavez “incurred an

acute injury of her right shoulder” that “result[ed] in an acute injury to the

labrum,    rotator   cuff   and   attached   muscles.”   Dr. Bansal   agreed   with

Dr. Peterson’s identification of November 8, 2018, as the date of maximum

medical improvement and placed Chavez at a ten percent upper extremity

impairment, which he stated is equal to a six percent impairment of the body as

a whole.

      Chavez filed a petition for arbitration before the Workers’ Compensation

Commission on September 28, 2018, seeking workers’ compensation benefits for

injuries to her “right shoulder, neck and right upper extremity.” The case went

to hearing on October 1, 2019, where the parties primarily disputed whether

Chavez’s injury resulted in an unscheduled industrial disability or a scheduled

member injury to her shoulder in light of 2017 amendments to the Iowa Code

that identify the “shoulder” as a scheduled member for workers’ compensation

purposes. At the time of the hearing, Chavez continued to work for

MS Technology, LLC, without restrictions and had received a raise since her

injury.

      The deputy commissioner issued her arbitration decision on February 5,

2020, concluding Chavez incurred an unscheduled injury to the body as a whole.
                                       6

Nevertheless, the deputy commissioner limited Chavez’s recovery to a functional

impairment rating because Chavez had returned to work for the same or greater

pay. MS Technology, LLC, and its insurance carrier, Westfield Insurance

Company, (hereinafter Appellees) appealed, and Chavez cross-appealed to the

commissioner. On September 30, the commissioner issued a decision concluding

Chavez’s injury was compensable as a scheduled shoulder injury rather than an

unscheduled whole body injury and applied Dr. Bansal’s ten percent extremity

impairment rating. Chavez petitioned for judicial review, and the district court

issued a decision affirming the commissioner’s appeal decision that Chavez’s

injury was compensable as a scheduled shoulder injury on April 29, 2021.

Chavez filed a timely appeal, which we retained.

      II. Standard of Review.

      The standards set forth in Iowa Code chapter 17A guide “our judicial

review of agency decision-making to determine whether our conclusion is the

same as the district court.” Brewer-Strong v. HNI Corp., 913 N.W.2d 235, 242

(Iowa 2018). Further, “we review the commissioner’s interpretation of Iowa Code

chapter 85 for correction of errors at law instead of deferring to the agency’s

interpretation” because the legislature has not clearly vested the commissioner

with authority to interpret that chapter. Id. Nevertheless, “[w]e accept the

commissioner’s factual findings when supported by substantial evidence.”

Gumm v. Easter Seal Soc. of Iowa, Inc., 943 N.W.2d 23, 28 (Iowa 2020) (quoting

Bluml v. Dee Jay’s Inc., 920 N.W.2d 82, 84 (Iowa 2018)).
                                        7

      III. Analysis.

      Chavez argues the district court erred by finding her injury was a

scheduled member injury to her shoulder rather than an unscheduled whole

body injury under Iowa Code section 85.34(2). She also maintains that she is

entitled to an industrial disability analysis if her injury is an unscheduled whole

body injury. Alternatively, if we conclude that Chavez’s injury constitutes a

scheduled shoulder injury, Chavez claims she is entitled to an industrial

disability analysis because she incurred simultaneous injuries to her shoulder

and arm. We address these claims in turn as necessary.

      A. Defining Shoulder Injuries Under Chapter 85. The dispositive issue

in this case is the definition of “shoulder” under Iowa Code section 85.34(2)(n).

Under section 85.34, the classification of a workers’ compensation claimant’s

injury as either scheduled or unscheduled determines the extent of the

claimant’s entitlement to permanent partial disability benefits. Floyd v. Quaker

Oats, 646 N.W.2d 105, 109 (Iowa 2002). Paragraphs (a) through (u) of section

85.34 govern permanent partial disability payments for injuries to specific

members of the body and provide a schedule of benefits for injuries to those

specific members. Second Inj. Fund of Iowa v. Nelson, 544 N.W.2d 258, 269 (Iowa

1995); see also Iowa Code § 85.34(2)(a)–(u). Disabilities resulting from injuries

other than those listed in paragraphs (a) through (u) of section 85.34 are

considered unscheduled injuries that allow for benefits based on the injury to

the body as a whole and are evaluated according to the industrial method.

Second Inj. Fund of Iowa, 544 N.W.2d at 269; see also Iowa Code § 85.34(2)(v).
                                        8

      If an injury is classified as a scheduled member injury to her shoulder

under Iowa Code section 85.34(2)(n), the claimant is eligible for a percentage of

400 weeks of pay based on the impairment rating of the injury. In contrast, if an

injury is classified as an unscheduled whole body injury under section

85.34(2)(v), the claimant is eligible for payment for the functional impairment

resulting from the injury on a 500-week schedule and additional compensation

if the claimant did not return to work earning the same or greater wages as before

the injury. Thus, claimants typically receive greater compensation for

unscheduled whole body injuries than they would for scheduled member

injuries. In 2017, the legislature amended section 85.34(2) to add “shoulder” to

the list of scheduled injuries and set the benefits schedule for “the loss of a

shoulder” to “weekly compensation during four hundred weeks,” but it did not

define “shoulder.” 2017 Iowa Acts ch. 23, § 7 (codified at Iowa Code § 85.34(2)(n)

(2018)).

      The parties now dispute whether Chavez’s rotator cuff injury constitutes a

scheduled member injury to her shoulder under section 85.34(2)(n) or an

unscheduled whole body injury under section 85.34(2)(v). Chavez contends

“shoulder,” under section 85.34(2)(n), is narrowly defined to only include injuries

located within the glenohumeral (shoulder) joint, which is “a ball-and-socket

synovial joint between the head of the humerus and the glenoid cavity of the

scapula.” Glenohumeral joint, Stedmans Medical Dictionary 463600, Westlaw

(database updated Nov. 2014). Under this definition, damage to the proximal

side of the joint is considered an unscheduled whole body injury, damage to the
                                        9

distal side of the joint is considered a scheduled arm injury, and damage within

the glenohumeral joint is considered a scheduled shoulder injury. Appellees ask

us to affirm the commissioner and district court rulings, which defined

“shoulder,” under section 85.34(2)(n), more broadly to include Chavez’s injury

by defining “shoulder” as the shoulder structure, including injuries to the

tendons, ligaments, muscles, and articular surfaces connected to the

glenohumeral joint.

      Before we engage in any statutory construction, we must determine

whether the statutory language is ambiguous. Holstein Elec. v. Breyfogle, 756

N.W.2d 812, 815 (Iowa 2008). A statute is ambiguous when reasonable persons

could disagree as to its meaning. Ramirez-Trujillo v. Quality Egg, L.L.C., 878

N.W.2d 759, 770 (Iowa 2016). Here, Iowa Code section 85.34(2)(n) is ambiguous

because reasonable persons can—and do—disagree on the statutory meaning of

“shoulder,” as the deputy commissioner applied Chavez’s proffered definition

while the commissioner and district court applied Appellees’ proffered definition.

See 43 Am. Jur. Proof of Facts 3d 201, § 2 (1997) (“The ‘shoulder’ therefore may

be defined in at least three different ways.”). Consequently, we rely on our rules

of statutory construction to guide our interpretation of “shoulder” under section

85.34(2)(n). See Brewer-Strong, 913 N.W.2d at 251.

      Our goal in interpreting the statutory provisions contained in chapter 85

of the Iowa Code “is to determine and effectuate the legislature’s intent.” Id. at

249 (quoting Ramirez-Trujillo, 878 N.W.2d at 770). We do so “by looking at the

legislature’s language rather than speculating about what the legislature might
                                          10

have said.” Id. Further, “[w]e assess the statute in its entirety rather than isolated

words or phrases to ensure our interpretation is harmonious with the statute as

a whole.” Id. (quoting Ramirez-Trujillo, 878 N.W.2d at 770). “[L]egislative intent

is expressed by omission as well as by inclusion . . . .” In re Guardianship of

Radda, 955 N.W.2d 203, 209 (Iowa 2021) (alteration in original) (quoting Marcus

v. Young, 538 N.W.2d 285, 289 (Iowa 1995)). Thus, when the legislature includes

certain language in one section of a statute but omits it in another section of the

same statute, we generally presume the omission is intentional. Id.

      We also “look for ‘an interpretation that is reasonable, best achieves the

statute’s purpose, and avoids absurd results.’ ” Holstein Elec., 756 N.W.2d at

815 (quoting State v. Bower, 725 N.W.2d 435, 442 (Iowa 2006)). While Chavez

“is correct that we interpret workers’ compensation statutes in favor of the

worker, we still must interpret the provisions within the workers’ compensation

statutory scheme ‘to ensure our interpretation is harmonious with the statute

as a whole.’ ” Id. at 253 (quoting Ramirez-Trujillo, 878 N.W.2d at 770). These

rules of statutory construction guide our conclusion that “shoulder” under

section 85.34(2)(n) must be defined in the functional sense to include the

glenohumeral joint as well as all of the muscles, tendons, and ligaments that are

essential for the shoulder to function.

      Chavez’s treating physician, Dr. Peterson, diagnosed her injury as a “full

thickness rotator cuff tear that has retracted to the level of the glenoid, severe

AC arthrosis, tendonitis and tearing of the biceps tendon.” On appeal, Chavez

concedes that “injuries like labral tears, glenoid tears, bicep tears and
                                        11

glenohumeral joint instability” would be considered “shoulder” injuries under

her proposed definition because they are injuries located within the

glenohumeral joint. Her challenge is to the commissioner and district court

rulings that her rotator cuff injury is a “shoulder” injury under section

85.34(2)(n), which she maintains is incorrect “because every rotator cuff muscle

attaches proximally-to the glenohumeral joint.”

      A rotator cuff is “the anterior, superior, and posterior aspects of the

capsule of the shoulder joint reinforced by the tendons of insertion of the

supraspinatus, infraspinatus, teres minor, and subscapularis (SITS) muscles.”

Rotator cuff of shoulder, Stedmans Medical Dictionary 217890, Westlaw

(database updated Nov. 2014). The rotator cuff muscles “stabilize the

glenohumeral joint.” Id.; see also 43 Am. Jur. Proof of Facts 3d 201, § 4. “When

the complex of muscles and tendons which produce the joint’s stability are

damaged or not functioning correctly, conditions known as the ‘unstable

shoulder syndrome’, ‘rotator cuff disorder’, or ‘recurrent shoulder dislocations’

occur.” 43 Am. Jur. Proof of Facts 3d 201, § 3.

      Viewing section 85.34(2) in its entirety, it is apparent that the legislature

did not intend to limit the definition of “shoulder” solely to the glenohumeral

joint. Notably, the legislature refers to the joints of certain body parts in other

subsections, including the “shoulder joint,” yet it chose not to include the term

“joint” when adding “shoulder” to the list of scheduled injuries. See In re

Guardianship of Radda, 955 N.W.2d at 209. Compare Iowa Code § 85.34(2)(n),

with id. § 85.34(2)(m). If the legislature only wanted to encompass the
                                        12

glenohumeral joint under section 85.34(2)(n), it could have expressly stated so

as it did when referring to joints in other subsections. Yet, it chose to list “the

loss of a shoulder” as a scheduled injury under section 85.34(2)(n) instead.

      Moreover, we have previously explained that the “loss” referenced in

section 85.34(2) includes the “loss of the use of a scheduled member.” Floyd, 646

N.W.2d at 109. In other words, the loss of function. “The functional shoulder is

. . . not confined to the single anatomical joint known as the ‘shoulder’ or gleno-

humeral joint, but is a system which in its entirety has the largest range of

motion of any joint in the human body.” 43 Am. Jur. Proof of Facts 3d 201, § 4.

Simply put, the shoulder cannot function to its fullest extent without the

muscles that comprise the rotator cuff.

      Defining “shoulder” in the functional sense under section 85.34(2)(n) best

achieves the statute’s purpose. Likewise, this functional definition aligns with

the American Medical Association’s Guides to the Evaluation of Permanent

Impairment, Fifth Edition, (AMA Guides) which is the guide “for determining the

extent of loss or percentage of impairment for permanent partial disabilities”

under section 85.34(2) in Iowa. Iowa Admin. Code r. 876—2.4. The AMA Guides

examine the shoulder’s active range of motion to evaluate impairment,

measuring functions like flexion, extension, internal and external rotation,

abduction, and adduction. See Cunningham v. Quad/Graphics, Inc., 522 S.W.3d

204, 205–07 (Ky. Ct. App. 2017) (explaining the evaluation process set forth in

the AMA Guides to assess shoulder impairment). Consequently, it is impossible

to evaluate shoulder impairment without some evaluation of the muscles,
                                              13

tendons, etc. that make the shoulder function. Chavez’s own medical records

support this conclusion, as the record is replete with references to Chavez’s

injury as a “shoulder” issue.

       For example, when Chavez first sought medical attention for the pain she

was experiencing from the mop incident, the medical notes documented,

“[Chavez] returns to office with continued complaints regarding her right

shoulder. She states that she feels like she injured her shoulder once again over

the weekend.”1 (Emphasis added.) When she subsequently met with the

orthopedic surgeon, she “present[ed] with complaints of right shoulder pain that

started on 2/5/18 while mopping at work.” (Emphasis added.) She obtained a

“Right Shoulder MRI” that led to the diagnosis of her “full thickness rotator cuff

tear that has retracted to the level of the glenoid, severe AC arthrosis, tendonitis

and tearing of the biceps tendon.” (Emphasis added.) The surgical procedure she

received was “[r]ight shoulder arthroscopy with arthroscopic repair of the rotator

cuff tendon of the supraspinatus, infraspinatus, and subscapularis tendons;

extensive debridement of the labrum, biceps tendon, and subacromial space with

biceps tenotomy, subacromial depression.” (Emphasis added.)

       Moreover, Dr. Bansal, who conducted Chavez’s independent medical

evaluation, described Chavez’s injury as “an acute on chronic injury of her right

shoulder.” (Emphasis added.) He explained,

       The shoulder is a ball and socket joint. However, the socket is very
       shallow, making it quite susceptible to injury. The shoulder itself

       1Chavez sought medical treatment for shoulder pain a few weeks before the injury at issue

due to a slip and fall on ice.
                                       14

      has a relatively immobile scapula and clavicle and a mobile humeral
      head interface at the shoulder joint. Consequently, the humeral
      head may move suddenly in relation to the rest of the shoulder joint,
      especially from the forceful wringing of the mop, requiring her
      shoulder to be in an abducted and rotated position, resulting in an
      acute injury to the labrum, rotator cuff, and attached muscles.

(Emphasis added.) In summary, Chavez’s medical records show that the

physicians who treated or assessed Chavez’s injury considered it to be a shoulder

injury.

      Chavez cites prior Iowa caselaw that looked to “the proximal point of the

joint to classify an injury under the workers’ compensation statutes” to treat

“shoulder” injuries as unscheduled whole body injuries, but that caselaw

developed before the legislature amended the statutory scheme to add shoulder

injuries to the list of scheduled member injuries under section 85.34(2). Holstein

Elec., 756 N.W.2d at 816; see Lauhoff Grain Co. v. McIntosh, 395 N.W.2d 834,

839–40 (Iowa 1986) (en banc); Second Inj. Fund, 544 N.W.2d at 269–70. Those

cases only discussed the dividing line between the arm and the body as a whole

because “shoulder” was not a scheduled injury at the time. See, e.g., Alm v.

Morris Barick Cattle Co., 38 N.W.2d 161, 163 (Iowa 1949). It was inconsequential

whether the injury was technically to the shoulder—all that mattered was

whether the injury was to the scheduled member arm or extended beyond it.

“Our rules of statutory construction hold that when the legislature amends a

statute, a presumption exists that the legislature intended to change the law.”

Colwell v. Iowa Dep’t of Hum. Servs., 923 N.W.2d 225, 235 (Iowa 2019). Thus,

the pre-2017 amendment caselaw that Chavez cites is unpersuasive.
                                         15

      Finally, Chavez’s remaining arguments for defining the “shoulder” only to

include the glenohumeral joint because it favors workers and reduces the need

for litigation determining whether a claimant’s injury is a “shoulder” under

section 85.34(2)(n) largely boil down to policy considerations that are best left for

the legislature to consider. More litigation may be needed in the short term to

develop the exact parameters of a scheduled shoulder injury under section

85.34(2)(n), but that does not warrant ignoring our rules of statutory

construction to interpret “shoulder” to be limited to the “shoulder joint.” In any

event, Chavez acknowledged during oral argument that treating injuries like hers

as whole body injuries would still require litigation in almost every case to

determine the disability rating for compensation purposes. This negates her

claim that her proffered definition is preferable because it favors the worker by

reducing the need for litigation.

      Ultimately, “[d]octors have been drawing these lines for years, deciding

whether an injury is a whole body injury or a scheduled injury under the Act,”

and “[t]here is no reason doctors cannot continue to do so under this new

amendment.” Injured Workers of Kan. v. Franklin, 942 P.2d 591, 608 (Kan. 1997)

(rejecting challenges to an amendment that added shoulders to the list of

scheduled injuries for workers’ compensation purposes). For these reasons,

“shoulder” is not limited to the glenohumeral joint. Chavez does not alternatively

argue that her particular injury should be considered anything other than an

unscheduled whole body injury, such as an arm. As we described above, it is

clear from Chavez’s medical records that her rotator cuff injury is a “shoulder”
                                        16

injury. Therefore, we affirm the commissioner and district court rulings that

Chavez suffered a scheduled injury to her shoulder under section 85.34(2)(n).

      B. Whether Chavez is Entitled to Industrial Disability Benefits. Chavez

maintains that should we conclude her shoulder injury is a scheduled injury,

she is entitled to industrial disability benefits because she injured two scheduled

members: her right shoulder and right arm. Section 85.34(2)(t) provides:

      The loss of both arms, or both hands, or both feet, or both legs, or
      both eyes, or any two thereof, caused by a single accident, shall
      equal five hundred weeks and shall be compensated as such;
      however, if said employee is permanently and totally disabled the
      employee may be entitled to benefits under subsection 3.

Iowa Code § 85.34(2)(t). Chavez acknowledges this section does not apply

because it does not mention shoulder injuries, so she argues instead that an

injury to her right arm and right shoulder falls under the catch-all provision in

section 85.34(2)(v). The relevant language in this section provides:

      In all cases of permanent partial disability other than those
      described or referred to in paragraphs “a” through “u”, the
      compensation shall be paid during the number of weeks in relation
      to five hundred weeks as the reduction in the employee’s earning
      capacity caused by the disability bears in relation to the earning
      capacity that the employee possessed when the injury occurred.

Id. § 85.34(2)(v).

      We need not address this statutory interpretation argument because

substantial evidence supports the commissioner’s finding that Chavez “failed to

carry her burden to prove her biceps tear results in any permanent disability to

her arm.” See Gumm, 943 N.W.2d at 28 (“[W]e accept the commissioner’s factual

findings when supported by substantial evidence.” (alteration in original)

(quoting Bluml, 920 N.W.2d at 84)). As the injured employee, Chavez had the
                                          17

burden to prove by a preponderance of the evidence that she sustained a

permanent partial disability to her arm under section 85.34(2)(m). See Xenia

Rural Water Dist. v. Vegors, 786 N.W.2d 250, 254 (Iowa 2010). Dr. Peterson

diagnosed Chavez with “[b]iceps tendonitis and tearing,” and Chavez underwent

a biceps tenotomy as part of her surgery. However, nothing in the record

indicates Chavez suffered a permanent impairment to her right arm apart from

the shoulder injury.

         As the district court aptly summarized in affirming the commissioner’s

determination that Chavez did not prove a permanent partial disability to her

arm under section 85.34(2)(m),

         Chavez did not present a separate permanent impairment rating for
         her arm from either Dr. Peterson or her expert Dr. Bansal.
         Dr. Bansal’s report is expressly limited to Chavez’s right shoulder:
         “This examination should focus on her right shoulder.” Dr. Bansal’s
         physical examination noted a 40% loss of abduction and 20% flexion
         strength loss in Chavez’s right shoulder as compared to the left
         shoulder. The only assessment that seems to reference the arms is
         “upper extremity reflexes,” which notes the same result for right and
         left of +2.

(Citations     omitted.)   Accordingly,   substantial    evidence   supports     the

commissioner’s finding that Chavez failed to meet her burden to prove her biceps

tear resulted in a permanent disability to her arm under section 85.34(2)(m).

         IV. Conclusion.

         For the aforementioned reasons, we affirm the judgment of the district

court.

         AFFIRMED.
                                     18

        All justices concur except Mansfield and McDermott, JJ., who take no

part.