BEFORE THE IOWA INDUSTRIAL COMMISSIONER ORLA JANE SMITH, Claimant, File Nos. 773001 vs. 853642 FLEETGUARD, INC., A R B I T R A T I 0 N Employer, D E C I S I 0 N and F I L E D LIBERTY MUTUAL INSURANCE COMPANY, JUN 07 1989 Insurance Carrier, INDUSTRIAL SERVICES Defendants. STATEMENT OF THE CASE This is a proceeding in arbitration brought by claimant Orla Jane Smith against defendant employer Fleetguard, Inc., and defendant insurance carrier Liberty Mutual Insurance Company to recover benefits under the Iowa Workers' Compensation Act as the result of injuries sustained on August 21, 1984 (773001: right leg) and January 28, 1987 (853642: back). This matter came on for hearing before the undersigned in Fort Dodge, Iowa, on August 23, 1988, and was deemed fully submitted at the close of hearing. The record in this proceeding consists of claimant's exhibits 1 through 40, defendants' exhibits 1 through 62, both inclusive, and the testimony of claimant, Arlo Smith and Dolores Hayworth. It should be pointed out that a large number of the exhibits were duplicates, although the hearing assignment order specified that every reasonable effort should be made to avoid duplication. ISSUES Pursuant to the prehearing report submitted by the parties and approved at hearing, the following issues have been stipulated in file number 773001: That an employment relationship existed at the time of the injury; that claimant sustained an injury on August 21, 1984, arising out of and in the course of that employment; that the injury caused both temporary and permanent disability; that claimant is entitled to compensation for healing period from August 20, 1984 through October 9, 1986; that claimant is entitled to compensation for 66 weeks of permanent partial disability based upon a 30% loss of the use of the right leg, which is a scheduled member disability; that the commencement date for permanent partial disability is in October, 1986; that the appropriate rate of weekly benefits is $185.88; that affirmative defenses are waived; that all requested medical benefits have been or will be paid by defendants (except as to 1988 expenses); that defendants are entitled to credit under Iowa Code section 85.38(2) of $2,044.00 from February 29, 1988 through June 8, 1988; that defendants are entitled to credit for benefits voluntarily paid at the stipulated rate from September 3, 1985 through October 21, 1986 as healing period benefits (except for claimant's temporary partial disability from June 11, 1986 through July 14, 1986) and for 66 weeks of permanent partial disability voluntarily paid. Presented for determination are issues as to whether claimant is entitled to medical expenses and temporary total disability resulting from a fall sustained in 1988 and whether the same is attributable to claimant's 1984 injury. Defendants have taken the position that the 1988 fall is not properly at issue with respect to claimant's 1984 injury; ruling was reserved. Defendants' objection is at this time overruled. The 1988 fall is properly at issue. Pursuant to the prehearing report submitted by the parties and approved at hearing with respect to file number 853642, the following issues have been stipulated: The existence of an employment relationship at the time of the alleged injury; that if the injury is found to be a cause of permanent disability, it is an industrial disability to the body as a whole; that the appropriate rate of weekly benefits is $193.82; that affirmative defenses are waived; that the provider of medical services, supplies and treatment would testify that the treatment was reasonable and necessary, that the fees were reasonable, and defendants are not offering contrary evidence; that the expenses were authorized by defendants. Issues presented for determination in case number 853642 include: Whether claimant sustained an injury on January 28, 1987, arising out of and in the course of her employment; whether the alleged injury caused temporary or permanent disability; the extent of claimant's entitlement to healing period or temporary total disability benefits; the extent of claimant's entitlement to compensation for permanent disability; claimant's entitlement to medical benefits; whether claimant is entitled to benefits pursuant to the odd-lot theory of permanent disability; whether penalty benefits should be awarded under Iowa Code section 86.13. REVIEW OF THE EVIDENCE Claimant testified that she was 47 years old at the time of hearing and that she is a high school graduate with no further education beyond various on-the-job training. Her work history includes a stint from June, 1960 to June, 1961 with a bank as a clerical employee who acted as a head poster, file clerk and operated business machines. She worked for approximately six months as a receptionist/clerk with Valley Clinic, which duties included answering the telephone, operating a postal machine and some bookkeeping. She worked for approximately one year with Sheller-Globe as an office employee, operating business machines, typing, filing and answering the telephone. Claimant was then out of the labor market for approximately ten years while she raised her family. She next accepted a position with Breck Company in which she acted as inspector, box maker, bottle feeder and packer. Claimant held this position for approximately one year. Thereafter, she worked on two occasions with the Sheaffer Pen Company working in the mail room and in plastic fabrication. She took a position for only a few months putting decals on semi-tractor trucks, worked for approximately one year in a soldering job with E. J. Johnson, and then worked fewer than six months as a telephone solicitor for a sales business. Claimant began her work with Fleetguard,in September, 1983, and this has been her only employment since that date. Claimant testified to an extensive medical history, particularly as regards her right knee. She was involved in an automobile accident in 1966 and suffered neck injuries, still having some problems secondary to that. She injured her right knee in a fall at home on January 6, 1977, undergoing her first knee surgery on March 15, 1977. Claimant fell while employed with a different business in February, 1979, and underwent her second right knee surgery on September 27, 1979. Thereafter, claimant underwent a patellectomy on May 27, 1980. In 1980, claimant moved to Garner, Iowa, and has since been under the care of Sterling Laaveg, M.D. Previous surgery was undertaken through the office of Koert R. Smith, M.D., in Burlington, Iowa. After another fall in 1980, claimant underwent a fourth surgical procedure to the right knee, arthroscopy on January 12, 1981. Claimant described her stipulated work injury of August 21, 1984, as occurring when a fork lift struck a line, which struck a basket that hit claimant in the right knee. After various treatments with physical therapy, casts, and the like, claimant underwent surgery on March 12, 1985, described as right knee arthroscopic excision of adhesions; arthroscopic excision of suprapatellar plica and lateral retinacular release. Claimant then remained off work until her sixth surgery, which was undertaken on September 10, 1985, in hopes of relieving her persistent pain. This operation involved fusing the right knee with external fixation, which of course resulted in claimant being permanently unable to bend the right knee. The external fixation was removed on November 21, 1985, the seventh surgical procedure to the right knee. Claimant attempted to return to work on a part-time basis on June 16, 1986, but was then taken off work by Dr. Laaveg on June 20. In a letter to a claims adjustor, Dr.Laaveg opined on October 9, 1986, that claimant had reached maximum healing of the right knee, that her final impairment rating for the lower extremity was 60% based on dysesthetic, paresthetic sensory changes, pain pattern in and around the knee, and the fusion. Dr. Laaveg also imposed work restrictions: Claimant should not be in a job in which she had to stand for over two hours at any one time, should not have to lift off the floor or carry over 25 pounds, and should avoid having to do frequent bending or twisting since this would put undue stress on the opposite knee. Dr. Laaveg further stated that these restrictions effectively eliminated claimant from any mechanical work. Claimant testified that she worked on a part-time basis after returned to work on January 12, 1987. She began working a full-time job on January 19, 1987, suffered pain to the back and left leg and was taken off work by Dr. Laaveg, and then returned on a half-day basis January 26, 1987. She worked four hours on Monday, Tuesday and Wednesday, (January 28, 1987), but suffered a great deal of pain from stooping and climbing. She at that time was working as an inspector, but had been given an additional department to check, which involved additional walking. She also was required to use a testing device that she referred to as the "thing," that required essentially all of her strength to operate, exacerbating the symptoms. In the evening of January 28, 1987, claimant's entire leg went numb (for the first time ever) following which she undertook diagnostic tests resulting in surgery for a herniated intervertebral disc L5-S1 on the right with marked S1 radicular malfunction from compression neuropathy on February 4, 1987. Claimant was released to return to work effective January 29, 1988, but defendant temporarily had no position available for her at that time. She was scheduled to return to work on February 29, 1988, but suffered a fall down stairs at home on February 18, 1988, which involved a fractured ankle. Claimant described her fall as occurring while she was walking down stairs with nothing previously wrong. She stepped and suffered pain to the ankle, hearing an audible "crack," following which she blacked out and awakened at the bottom of the stairs. Claimant denied tripping, and testified on cross-examination to her belief that the ankle fracture was the cause of her fall. Claimant returned to work on a part-time basis on June 9, 1988 in her previous job as inspector. She last worked in mid-July, 1988, being taken off work by her physician due to pelvic and back problems. She testified that at time of hearing, her physician and employer were negotiating a return to work at an appropriate position. In a meeting of July 30, 1988 with claimant, her employer and Dr. Laaveg, it was decided that claimant would undergo continuing physical therapy and a work hardening program. Claimant's last physical therapy session may have been the day before hearing, as she anticipated finishing physical therapy later that week. Claimant was unsure whether she could return to her previous position as inspector, because the position did require substantial stooping and climbing and physical strength (to check welds with the "thing," an arbor press). Claimant believes that the stooping and climbing is injurious to her hip. She indicated that Dr. Laaveg would make the determination as to whether she could return to that position. Claimant forthrightly testified that she believes she is capable of performing office type work, or at least is willing to attempt such work. Claimant's current complaints are of pain in the back, pelvis, right hip, and buttocks down the right leg. This affects her approximately three-fourths of the time. She is unable to walk as much as two miles (although this is also in part due to the fractured ankle). Of course, the right knee is still fused and cannot be bent. Claimant indicated that since the back injury of January, 1987, she has had to further limit her activities due to an inability to sit for long periods. An examination of claimant's medical history shows that she has long been subject to falls. Dr. Laaveg's notes of November 6, 1980 (claimant's exhibit 5, page 3) reflect that claimant has complained of her knee giving out on occasion and on one occasion she almost fell down the basement stairs except for catching herself at the railing. Dr. Laaveg's note of August 23, 1983 shows claimant complaining that her knee "wants to give away at times." Dr. Laaveg's note of November 26, 1984, reflects that "the patient recently fell when her knee gave out on her, inspite of being in the knee immobilizer." As noted, claimant first hurt her knee in a fall at home in January, 1977, and fell at work in February, 1979. Claimant also fell in a parking lot owned by another employer on June 23, 1983. Dr. Laaveg's notes of February 19, 1988, shortly after her ankle fracture, reflect a history of: This woman with previous major back surgery and a fusion of the right knee tripped going down 4 steps in her home twisting her ankle. Dr. Laaveg testified by deposition taken June 17, 1988. With respect to the 1988 fall at home, he stated: Q. In February of 1988 this incident occurred at home where she tripped, I believe, and injured her is it right ankle or left ankle? A. Right. Q. I think there was something in the notes about left, so that would be incorrect, it would be the right ankle, would it not? A. Right ankle is the one that she injured. Q. All right. Now I guess what I need to know if I can is although this incident occurred at home in February of 1988, and although you had indicated approximately two weeks or so prior that she had reached maximum recuperation with respect to her back condition, did the fact that she had a substantially impaired right lower extremity and the impact that that had on her gait and her walking, did that significantly contribute in your opinion to the incident that occurred at home in mid-February of 1988? MR. TREVINO; Excuse me before you answer. I'm going to object to that question for the reason that there isn't any proper foundation as to the precise manner in which the fall at home occurred on February 19th, 1988. And without such information and foundation it becomes speculative on the part of Dr. Laaveg to express a causal connection between the two. Q. First of all, preparatory to answering my question, do your records reflect, in fact, how the fall occurred? A. The patient, according to Dr. Fisher's note of 2-19-88 tripped going down four steps in her home twisting her ankle on the day prior to Dr. Fisher's examination. Q. With that history in mind, are you able to answer the question that I asked? A. There's no doubt that when somebody has a knee fusion in specific that you do not move in the normal way, the way a person normally would to go up and down stairs and it's far more difficult to go up and down stairs with a fused knee than it is without one and probably the most difficult part of having a fused knee and certainly would contribute to anybody's falling who has a fused knee going up and down stairs. Specifically relating to her back, we have no history that states she had sudden pain in her back or sudden feelings of giving, so I have no reason to believe that her back contributed at all to the fall. In actual fact, I have not discussed with her whether she felt that the fused knee contributed or not, but I would suspect it probably did. (Claimant's exhibit 35, page 71, line 11 through page 73, line 13) Further in the deposition, Dr. Laaveg testified: Q. To the extent that you've indicated her fused knee may have contributed to the fall she had when she broke her ankle in February falling down some steps, wouldn't one expect if, indeed, the fused knee was a major contributing factor or contributing factor to some extent in that fall that she would fall every time she went down some steps or up some steps? A. Not necessarily, really. I mean you and I don't fall every time we go up and down stairs, but we do occasionally fall going up or downstairs because we miss a step. She has a greater risk because of her fused knee of falling going up and down steps than if she did not have it. Q. But you don't know the specific circumstances of that fall? A. No. The record states she fell four steps. (Claimant's exhibit 35, page 85, line 20 through page 86, line 11) Claimant had a history of some back pains preexisting her alleged work injury. Dr. Laaveg's notes of December 3, 1984 indicate that claimant had called complaining of "terrible back pain" with radiation into the right leg to the foot, although denying numbness. Claimant also continued to complain of knee pain. Claimant testified that by radiation her history was that of relating to the leg cast only. Dr. Laaveg's note of December 17, 1984 refers to claimant's "significant" back pain as improved, although claimant was still somewhat tender in the low back area, having no neurologic symptoms. The notes of Lyle Fuller, M.D., of October 26, 1983 indicate that claimant was "having a great deal of pain in her right lower back area. Does alot [sic] of lifting at work." Claimant does not recall reporting this pain to Dr. Fuller, and further testified that the pain went away and that she had no history of back pain prior to October, 1983. Claimant also complained to Dr. Fuller of pain in the left sciatic notch, although claimant does not recall that complaint and further testified that this pain had also gone away. Claimant also does not recall telling Dr. Laaveg in June, 1986, that she had suffered intermittent numbness of the right leg. Dr. Laaveg's office notes of January 23, 1987 state: Orla Jane comes today for evaluation of back pain. The patient, a week ago, went to work 4 hours a day. On Monday she worked 8 hours a day. She has to do quite a bit of walking. She's had some aching discomfort in her knee that's unchanged from previously. Her back has been bothering her, especially on the left side radiating to the left buttocks. She denies any neurological symptoms. It became severe enough that she was unable to go to work on Monday. Exam of the patient reveals that she is tender at the lumbosacral area and over the left posterior iliac crest. Straight leg raises are negative. Knee jerk is absen due to effusion over +2, ankle jerk +2/+2. She can toe walk and heel walk. Her neurosensory exam is intact. I think the patient is causing irritation of her back due to slight overuse while walking with her effused knee, especially since she's not used to being up this length of time. She'll go down to total bed rest this week, except for bathroom or eating. I started her on FELDENE as an anti-inflammatory drug. She was warned against GI toxicity. She was given samples, 20 mg, 30 tablets, 2 refills. She'll go back to using her corset. She was fitted with a Warm-n-Form corset today, and she'll use it when she's up and walking and when she's beginning to work. On Monday she can return to work at a four hour day. I talked to her supervisor who was with her in the office today. We will have her go to a slightly different job, and the second week she can begin at 6 1/2 hours a day, and then go to an 8 hour day as tolerated. This does not require any lifting. It falls within the guidelines of her previous restrictions. (Claimant's exhibit 5, page 20) Claimant testified that she advised Dr. Laaveg of pains on her left side on January 23, 1987, and that the pain shifted to her right side later. She further indicated that when she returned to work from January 26-28, 1987. Claimant had been off work from January 20-23, 1987, because of feeling weak and faint. She cannot now "pinpoint" the spot where she hurt her back in this incident. Claimant testified that she worked in department 6, a different department, on her last three days. Claimant recalls nothing unusual by way of a precipitating event on January 28. She worked four hours per day on those three days. Claimant conceded that her testimony at her deposition was that she noticed that pain came on her while working a testing machine. Claimant testified that her leg felt "asleep" on January 29, 1987. She differentiated this sensation from the following Monday, February 2, 1987, when her leg felt numb, such that it could not be felt at all. Claimant had stayed in bed the entire weekend from the prior Thursday before February 2, 1987. Dr. Laaveg's letter to a claims adjustor employed by defendant insurance carrier on January 27, 1987, indicated that claimant had returned that day with increased aching in her back. He specified that claimant had moved from a four-hour day to an eight-hour day on Monday (January 26, 1987 was a Monday) and that she had begun having increasing discomfort. Dr. Laaveg stated that he believed it was due to an overuse syndrome as claimant had just been getting up and doing regular work. Dr. Laaveg wrote a "To Whom It May Concern" letter on January 29, 1987, indicating that claimant was having significant pain in her back with numbness in the right leg and advised that claimant stay at bedrest until returning to work on February 2, 1987. R. McCoy, M.D., an associate of Dr. Laaveg, saw claimant on February 2, 1987 with complaints of pain down the right lower extremity. He caused a myelogram and x-rays to be taken showing herniated nucleus pulposis at L5-S1 on the right. Dr. McCoy then performed surgery on February 4, 1987. Dr. McCoy noted that claimant was unable to rise to her tiptoes on the right side and that she had been capable of walking on tiptoes when she saw Dr. Laaveg; his notes mused that this might represent neurologic deficit coining on in the last week and one-half. Dr. Laaveg carried on a correspondence during 1987 with Gary and William Walljasper, Liberty Mutual claims adjusters. On March 6, he reported: Orla J. Smith has returned after her lumbosacral dis [sic] surgery for a workmans' [sic] compensation injury. She was seen by my partner, Dr.McCoy, in by (sic] absence for a work injury in which she bent over and had sudden pain in her back with increasing pain in the right buttock and down the right leg. A myelogram confirmed that she had a ruptured disc. Dr. McCoy did surgery on 2/4/87, with removal of a herniated L5-S1 disc on the right with removal of 4 free fragments and exploration at the L4-5 interspace as well. (Claimant's exhibit 32, page 1) On June 3, 1987, he wrote: Orla J. Smith has asked that I clarify for you again what I stated in my March 6 letter. On 1-23-87 after the patient had been at work approximately one week I saw the patient with her complaining of significant increased back ache as she had been walking and doing the minor twisting and bending required in her supervisory job at work. There was no specific episode. She was having pain radiating into the left side and into the left buttock. The pain became severe enough at that time that she had not been able to go to work for one day that week. Her neurological exam was completely intact and we treated her conservatively. She returned to work and on 1-29-87 I received a phone call that her entire right leg had been numb. I asked her to go to bed rest over the weekend to see how her symptoms would respond and they did not. On 2-2-87 the patient was seen by Dr. McCoy, my partner. At that time she had definite neurological deficit and she was unable to walk on her tip toes on her right side. She was admitted to the hospital where a myelogram showed a herniated right L5 S1 disc. Therefore, on 2-4-87 the patient underwent a right L5 S1 disc excision with exploration of the L4-5 interspace with the removal of four free fragments of disc material that were in the spinal canal. The patient has been slow in her recovery period postoperatively. She is hampered somewhat by the fact that she has a fusion of the right knee. She is responding to conservative measures at this time. Our history would indicate that this is definitely a work related condition. The patient began having increasing back pain with her return to work, her standing and her walking. She developed sciatica while at work and eventually weakness. This directly lead [sic] to her surgical exploration. It is my opinion that this is definitely work related. (Claimant's exhibit 32, page 4) Dr. Laaveg wrote again on September 9, 1987: The patient tells me there is hesitation again on the part of the Workman's Compensation company that this is a work related problem and a separate incident from her knee problem. Please review my previous letters to your company. I have also talked by phone to both Walljasper brothers who have handled Mrs. 0. J. Smith's claim. I have expressed explicitly to both of them that this is a separate incident which I believe is work related and as such should be covered under Workman's Compensation. If for some reason your company needs further clarification on this issue, I would be happy to respond. (Claimant's exhibit 32, page 8) Finally, Dr. Laaveg wrote again on September 22, 1987: I have reviewed the tape of the light duty position at Fleetguard that reportedly is the light duty position that Orla [sic] Jane Smith was working at at the time of her injury. The tape is of an elderly woman who is standing at what appears to be a light duty position. She works at different stations, sometimes flexing forward approximately 25-30 [degrees] but other times flexing forward to 45 (degrees]. She is not lifting anything heavy, she is not doing a great deal of bending or twisting. She is wearing a cranberry pair of pants with a blue top and has gray hair. The job appears to be light duty. It is unclear by the film if this video truly represents the entire job description. However, even a light duty job such as this can cause a significant back injury. Office workers bending over to pickup [sic] a paper clip on the floor or stretching slightly to file something in the back of a cabinet can all twist enough to put significant force through their back such that they can rupture a disc or herniate a disc. Orla Jane Smith had had back pain intermittently prior to the work incident. She however, had not had significant sciatica. The sciatica comes with extrusion of a disc fragment. At the time of surgery, several free disc fragments were seen by my partner, Dr. Robert McCoy. In fact there were four free fragments, indicating a ruptured disc. Even the light duty job seen in the video tape, reportedly the one that Mrs. Orla Jane Smith was working at, could put enough force through the patient's back that she could herniate a disc. The patient's right knee fusion is not directly related to the patient's back problem. The back incident is a separate incident and should be considered a separate Workman's Compensation claim. Having a knee fusion does change slightly how a person bends and twists through the lumbosacral spine during activity. However, it does not automatically predispose the patient to back injury and it does not change the fact that this, by history, is a separate incident. I cannot be more explicit. once again, after reviewing this tape of a light duty position, it is my opinion that Mrs. Orla Jane Smith's back problem is a separate Workman's Compensation incident. (Claimant's exhibit 32, pages 9-10) Claimant was seen for evaluation by David J. Boarini, M.D. He wrote William Walljasper of Liberty Mutual on November 16, 1987: Upon examinations, the patient has an abnormal gait due to her fused right knee. The range of motion in the back is normal. Her back incision is nicely healed. Straight leg raising is negative bilaterally. There was some break away weakness in both legs but I could not detect any significant abnormality. The patient complained about decreased sensation over the lateral right foot and calf in a rather vague and inconsistent manner, certainly not radicular. Ankle reflexes were absent bilaterally while the knee reflex was absent on the right and normal on the left. Plantar reflexes are downgoing bilaterally. I've not reviewed the video tape which you sent me because of the patient's quite adamant denial that this is the work which she was actually doing when her current problem began. I would say that historically, despite the relatively light activity the patient was involved in in January of 1987, it does appear to have aggravated her symptoms and been the immediate cause of her subsequent surgery. I would also say that the patient has a history of chronic pain without significant underlying causes being identified. I think presently she has two difficulties. The first is her knee pain and any disability and restrictions which that requires. The second is chronic myofascial back pain, status post laminectomy. I don't think she has a significant neurological deficit nor can I find any objective evidence of a persistent radiculopathy. I think because of her back, she is entitled to a 5-6% permanent partial impairment, being status post laminectomy. I would put her on no specific work restrictions related to that, but I would have no disagreement with any restrictions which her orthopedic surgeons feel her previous knee surgery requires. (Claimant's exhibit 33) Dr. Laaveg then wrote Liberty Mutual on January 29, 1988: Orla Jane Smith has reached maximum healing concerning her back injury and subsequent surgery. The patient continues to have low back pain radiating into the right leg. She intermittently has numbness in her right leg. There is no weakness and neurologically she is intact. She has, at this time, a significant right trochanteric bursitis which we injected today. The patient has forward flexion of her back to 45-50 [degrees]. She is tender at L4-5 and L5 S1 and over her right and left iliac crests. The patient has reached maximum healing concerning her back. A final physical impairment has been given of 20%. One-fourth or 5% of this impairment is due to her previous condition and three-fourths or 15% is due to her injury, subsequent surgery and related to her present condition. A final work restriction has been given as follows: The patient should not be in a job in which she would lift over 10 pounds off the floor or carry over 15-20 pounds. She should avoid any repetitious bending or twisting. She should not sit or stand for longer than 30-60 minutes at any one time without being able to change her positions. (Claimant's exhibit 34, page 2) In his deposition, Dr. Laaveg testified to restrictions imposed in connection with claimant's right knee: That claimant should not stand for over two hours at any one time, should not lift off the floor or carry over 25 pounds, and should avoid frequent bending or twisting. After claimant's back injury and return to work release, claimant's restrictions were against lifting over 10 pounds off the floor, carrying over 15-20 pounds, and avoidance of repetitious bending and twisting. Dr. Laaveg further testified that claimant's final physical impairment rating was 60% of the lower extremity, which he indicated was a final "whole person" physical impairment of 24% pursuant to American Medical Association guidelines; one-half of that 60% was attributable to the preexisting condition. A review of the American Medical Association's Guides to the Evaluation of Permanent Impairment reflects that this equivalency is accurate. When asked as to causation, Dr. Laaveg testified: Q. Where does the herniation, the actual herniation come from then? I mean you described how it takes place, but what causes it? A. Well, that's a more difficult issue to talk to, because it can happen as simply as reaching over to pick up a Kleenex off the floor or sometimes it's very obvious, you have somebody weighing 200 pounds and he twists and turns and now he's got terrible sciatica. It can come from repetitious activity and it gradually bulges and squeezes out, it can come from lying in one position too long. We have common laborers who lift a hundred pounds all day and they come home and they are feeling fine and their wife asks them to reach the tea cup on the first shelf up and bam, they have bad sciatica. The amount of force in terms of twisting and turning is variable and a lot of it has to do with the position of the back at that particular time. Q. So you really can't attribute the herniation to any specific episode? A. No. According to our history and according to what I remember when Mrs. Smith was talking to us about this, I do not recall that she gave a specific episode. She as she went back to work and was standing and doing the minor bending and twisting at her job or inspecting required at that time began having increasing pain and discomfort down her leg that she had not experienced before to speak of. Q. Why would that -- she was doing light duty work at that time? A. Yes. Q. Why would that have been any different than her doing the vacuuming or washing dishes at home? A. It potentially would not have been, except her symptoms came on at that time. The other difference is she is now standing from four to six to eight hours a day as opposed to being at home where she can sit down more frequently. It could just as well have happened at home, but it didn't according to our history. Q. In other words, you don't have a history of anything else, of any specific episode at home? A. No. Q. Or at play? A. No, I don't. Q. And your history is that she was standing for substantial periods at work? A. Well, she was working a length of time in the day and I assume that they were following the guidelines that she was not standing any longer than two hours at any one time. I have no reason to believe that Fleetguard is not having the patient in a job as described. Q. I guess what I'm wondering is what's any different that she was doing at work that she physically would be doing at home? A. Well, she was standing more of the time, she was moving about, she was on her feet much longer than she was at home and she was doing some bending and twisting associated with her work as a light-duty job. Q. But we do bending and twisting when we go to wash the dishes or put things away or pick up the vacuum cleaner or move a lamp. A. Yes, that's right. Q. Right? A. Correct. Q. Is that the same type of activity that she would have been doing at work? A. Some of it would have been, I'm sure. But now she's doing it on a regular basis, where in the past she had not been doing it on a regular basis. Q. She had not been doing what on a regular basis? A. Okay, let me be more clear. She had been doing some of her own housework, not all of it perhaps. It's true that when we're at home you're bending and twisting and doing things. There really is no difference between bending and twisting at home or the length of time. I'm not telling you that this could not have happened at home; in fact, I just told you it often does. All I have is the patient's history that when she returned to work with increased activity of being at work, with increasing hours she began having more buttock pain, more leg pain. Q. And it is to that then that you attribute the herniation which was subsequently triggered? A. That's right. (Claimant's exhibit 35, page 24, line 13 through page 28, line 3) Dr. Laaveg also testified that the fact of claimant's knee fusion tended to put greater load through the spine because of awkward movements, but was unable to conclude that the knee was a contributing factor of a significant amount to claimant's disc herniation. With respect to Dr. Laaveg's notes concerning the 1984 complaint of pain, he testified: Q. Now you made that impairment determination I trust with full knowledge of the fact that indeed, at least as reflected to some extent by your notes, you had periodically seen her with some back complaints on an intermittent basis in the past? A. Yes. Q. For example, in reviewing your notes, it appears to me that in December of 1984 she had related at least as you have reflected, quote, terrible back pain, end of quote, with some right leg complaints and right foot complaints? A. Uh-huh. Q. And that apparently was improved, at least according to your notes, on December 17th of 1984? A. I remember having that problem. Q. In any event, do you think that she extruded or ruptured or herniated her disc back in December of 1984 and was able to get along in spite of that with a ruptured or herniated disc resulting in four free fragments from that time? A. No. Q. And also you may not have these notes, but Dr. Fuller in his records that we have been provided indicates that as far back as October 28th of 1983 she was having some complaints of pain in her right lower back area. And the next time he sees her on October 28th of 1983 he says her back is improved and I don't see any more back complaints then until January of 1986. Do you have an opinion as to whether or not she had a ruptured or herniated or extruded disc back in October of 1983? A. She was not having significant enough symptoms or significant enough sciatica to think that she would have had any ruptured disc at that time. Q. I ask you to assume also that Dr. Fuller's notes reflect that in January of 1986 she had he says lower bad, b-a-d, period, pain, that may be lower back pain, I assume, on the left, and that she was tender in the left sciatic notch. Now would the sciatic notch indicate some back pain? A. It often is tender if patients are having back pain, mainly because your gluteus maximus is tender. And many times the sciatic nerve may be tender to put pressure on, which is where it comes out. Q. Now I have attempted to recount what I see as back pain history from your notes and from Dr. Fuller's notes for the period prior to January of 1987. Is there anything from my recounting of that record which would cause you to change your opinion that her impairment is approximately 15 percent related to what occurred in January of 1987 and five percent for the period prior to that time? A. No. (Claimant's exhibit 35, page 68, line 7 through page 70, line 11) Dr. Laaveg was also questioned concerning claimant's fall at home in 1988. He suspected that claimant's fused knee may have contributed to the fall, but the opinion was clearly based on Dr. Fischer's note of February 19, 1988, to the effect that claimant "tripped going down four steps in her home twisting her ankle." No additional limitations were placed on claimant by Dr. Laaveg or his associates by virtue of the right ankle fracture. Dr. Laaveg also testified concerning the opinions expressed by Dr. Boarini: Q. Now Dr. Boarini indicates that there is no evidence of persistent radiculopathy and I see from your records that you have indicated at least on some occasions since the surgery that she continues to have back to right leg pain with numbness on at least an intermittent basis. Is that accurate? A. That's accurate. Now we're getting to subtle differences between the difference between what is considered a radiculitis or inflammation in the nerve roots so they have pain in a dermatome distribution or numbness in that distribution and what people call radiculopathy. All of us agree that a radiculopathy means weakness. Many of us will not use that term radiculopathy if it is some numbness in that distribution or an ankle jerk or a knee jerk that is less. So you are getting into some subtleties here, but I don't think we are disagreeing in terms of our findings. Q. I think what I'm hearing you say is you can agree with Dr. Boarini that she has no persistent radiculopathy, but that does not mean she does not have intermittent back pain to the leg with numbness, is that essentially what you are saying? A. I agree. The patient is still having symptoms of pain in her back and pain into her leg. (Claimant's exhibit 35, page 77, line 7 through page 78, line 6) Claimant's deposition was taken on February 11, 1988. When asked about the work incident, she testified: Q. As I understand what you're saying, when you came back to work in January of '87 -- A. Yes. Q. -- you really can't pinpoint any specific incident that caused the back pain; it just started coming on? A. Yeah. I was having trouble, and eventually as I worked it got worse. Well, then they took me out of five and fifteen and put me in four because it was a smaller area. I wouldn't have so far to walk. And it wasn't as bad, but I had one -- one test I had to do, and I don't know what it's called, it's got a big lever and you have to pull it down and it tests to see how tight the things are, and it takes a lot of power, and that's when I think that it hit everything. I mean, that's when I really -- final -- Q. Did something occur while you were doing that that caused you pain? A. I had a terrible pain. It was in my hip. And then when I went home, then my leg went all completely numb on that Wednesday night. I remember that. Cuz it really scared me cuz -- (Defendants' exhibit 62, page 25, line 22 through page 26, line 18) When asked as to her restrictions, claimant testified: Q. Okay. I just have a couple of questions about that. He says a final work restriction has been given as follows: the patient should not be in a job in which she would lift over ten pounds off the floor or carry over fifteen to twenty pounds. Okay? A. Uh-huh. Q. Do you have any -- do you feel you'd be able to do that? A. Well, I asked Doctor Laaveg what that meant. I mean that didn't mean a whole lot to me, givin' me those restrictions. I says what is there for me to do? And he said office work. That's what he said that I could do. (Defendants' exhibit 62, page 33, lines 6-18) Claimant also testified as to the possibility of returning to office work: Q. Have you worked in an office before? A. Yes. Q. What kind of secretarial skills do you have? A. I've been a file clerk. I've been a bookkeeper. I've been a receptionist. A little bit of everything. Q. Can you type? A. Yes. Q. Have you had any reason to use any of those skills in the last year or two? A. No, I haven't. I have typed at home, but I haven't -- You know, just for my own benefit. I go type once in a while just to -- like type a letter for ourselves, you know, but I don't -- Q. Would you be willing to return to a job at Fleetguard that allowed you to do the type of work that you just described? A. Oh, yes. (Defendants' exhibit 62, page 36, line 25 through page 37, line 18) Arlo Smith testified that he is claimant's husband and that they have been married for some 29 years. He testified that, prior to claimant's back injury, she could go to games and dance, whereas now she is unable to sit or stoop. He agreed that the last few days claimant worked, she complained of her back and that when she returned on January 28, 1987, she turned off the car engine but was unable to immediately come in because of her complaints of back pain. On cross-examination, Mr. Smith testified that he does not recall total and sudden numbness coming on claimant on February 2, 1987, but that he felt the problem became progressively worse during the preceding long weekend, in which claimant did stay in bed pursuant to Dr. Laaveg's order. Dolores Hayworth testified that she has been a friend of claimant's for four years and that claimant was active in school activities before the claimed work injury. She agreed that claimant no longer participates in attending games, going on picnics or walks, and also specified that claimant stayed in bed on the Sunday before February 2, 1987, so that she did not have her usual Sunday morning coffee with Ms. Hayworth. APPLICABLE LAW AND ANALYSIS In file number 773001, the only issues presented relate to claimant's fall down stairs before returning to work on February 19, 1988. The undersigned will not reach the legal issue of whether disability caused by a nonwork injury is compensable if the nonwork injury is caused in part by a previous compensated injury. That is so because claimant has not established that her 1988 fall was caused by her right leg injury of August 22, 1984. As has been seen, Dr. Laaveg testified to his suspicion that the fused knee probably contributed to the fall. However, it is also clear that Dr. Laaveg's opinion on that matter was based upon Dr. Fisher's note of February 19, 1988, reflecting that claimant "tripped going down 4 steps in her home twisting her ankle." Based on claimant's credible testimony, this history is inaccurate. Claimant testified that she did not trip and that she heard an audible "crack" when she stepped down; she testified to her belief that the fractured ankle itself caused the fall. Given that the victim of this accident herself believes that the fracture caused the fall rather than the other way around, and given that this belief is clearly consistent with the observable evidence (the "crack"), it is held that the fracture to claimant's ankle caused her to fall and suffer additional disability. There is no evidence in the record whatsoever suggesting that claimant's previous right knee injuries caused her ankle to be more subject to fracture. Since the injury was caused by the fracture rather than by tripping, it cannot be said that any causal connection has been established between the 1984 knee injury and claimant's 1988 fall. Claimant has been fully compensated for the 1984 injury. In file number 853642, the parties dispute whether claimant sustained a back injury on January 28, 1987. An employee is entitled to compensation for any and all personal injuries which arise out of and in the course of the employment. Section 85.3(1). The injury must both arise out of and be in the course of the employment. Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 402, 68 N.W.2d 63 (1955) and cases cited at pp. 405-406 of the Iowa Report. See also Sister Mary Benedict v. St. Mary's Corp., 255 Iowa 847, 124 N.W.2d 548 (1963) and Hansen v. State of Iowa, 249 Iowa 1147, 91 N.W.2d 555 (1958). The words "out of" refer to the cause or source of the injury. Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 402, 68 N.W.2d 63 (1955). The words "in the course of" refer to the time and place and circumstances of the injury. McClure v. Union et al. Counties, 188 N.W.2d 283 (Iowa 1971); Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 402, 68 N.W.2d 63 (1955). The supreme court of Iowa in Almquist v. Shenandoah Nurseries, 218 Iowa 724, 254 N.W. 35 (1934) at 731-32, discussed the definition of personal injury in workers' compensation cases as follows: While a personal injury does not include an occupational disease under the Workmen's Compensation Act, yet an injury to the health may be a personal injury [Citations omitted.] Likewise a personal injury includes a disease resulting from an injury....The result of changes in the human body incident to the general processes of nature do not amount to a personal injury. This must follow, even though such natural change may come about because the life has been devoted to labor and hard work. Such result of those natural changes does not constitute a personal injury even though the same brings about impairment of health or the total or partial incapacity of the functions of the human body. ..... A personal injury, contemplated by the Workmen's Compensation Law, obviously means an injury to the body, the impairment of health, or a disease, not excluded by the act, which comes about, not through the natural building up and tearing down of the human body, but because of a traumatic or other hurt or damage to the health or body of an employee. [Citations omitted.] The injury to the human body here contemplated must be something, whether an accident or not, that acts extraneously to the natural processes of nature and thereby impairs the health, overcomes, injures, interrupts, or destroys some function of the body, or otherwise damages or injures a part or all of the body. The claimant has the burden of proving by a preponderance of the evidence that the injury on or about January 28, 1987 is causally related to the disability on which she now bases her claim. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Lindahl v. L.O. Boggs,.236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is insufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). However, expert medical evidence must be considered with all other evidence introduced bearing on the causal connection. Burt, 247 Iowa 691, 73 N.W.2d 732. The opinion of experts need not be couched in definite, positive or unequivocal language. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). However, the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Id. at 907. Further, the weight to be given to such an opinion is for the finder of fact, and that may be affected by the completeness of the premise given the expert and other surrounding circumstances. Bodish, 257 Iowa 516, 133 N.W.2d 867. See also Musselman v. Central Telephone Co., 261 Iowa 352, 154 N.W.2d 128 (1967). While a claimant is not entitled to compensation for the results of a preexisting injury or disease, the mere existence at the time of a subsequent injury is not a defense. Rose v. John Deere Ottumwa Works, 247 Iowa 900, 908, 76 N.W.2nd 756 (1956). If the claimant had a preexisting condition or disability that is aggravated, accelerated, worsened or lighted up so that it results in disability, claimant is entitled to recover. Nicks v Davenport Produce Co., 254 Iowa 130, 115 N.W.2d 812 (1962). When an aggravation occurs in the performance of an employer's work and a causal connection is established, claimant may recover to the extent of the impairment. Ziegler v. United States Gypsum Co., 252 Iowa 613, 620, 106 N.W.2d 591 (1960). An employer takes an employee subject to any active or dormant health impairments, and a work connected injury which more than slightly aggravates the condition is considered to be a personal injury. Ziegler v. United States Gypsum Co., 252 Iowa 613, 620, 106 N.W.2d 591 (1960), and cases cited. Claimant has herself testified inconsistently as to whether there was a specific work incident giving rise to this injury. At hearing, she indicated that pain developed at night when she went on full days working as an inspector in two departments. The question of causation is essentially within the domain of expert testimony. Dr. Laaveg has made entirely clear that he believes this was "definitely a work related condition." Dr. Boarini saw claimant for evaluation and agreed that claimant's "relatively light activity" of January, 1987 appeared to have aggravated her symptoms and been the immediate cause of her subsequent surgery. While claimant might well have developed similar problems working at home, the fact remains that she had just returned to work, and then on a full-day basis when her back problems erupted. While claimant had complained of pain in the past, Dr. Laaveg has also opined that she could not have continued working since 1986 had she suffered the ruptured disc at the time of the "terrible" back pain she complained of then. There is no evidence, expert or otherwise, indicating that this at least aggravation or "lighting up" of claimant's condition was caused away from the job. It is held that claimant has met her burden of proof in establishing that the cumulative injury of January 28, 1987 to her back arose out of and in the course of her employment, and that the injury caused healing period and permanent disability. Dr. Laaveg's letter of January 29, 1988 indicated that claimant had then reached maximum healing for her back. This operated to end the healing period. Functional impairment is an element to be considered in determining industrial disability which is the reduction of earning capacity, but consideration must also be given to the injured employee's age, education, qualifications, experience and inability to engage in employment for which he is fitted. Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W.2d 660 (1961). A finding of impairment to the body as a whole found by a medical evaluator does not equate to industrial disability. This is so as impairment and disability are not synonymous. Degree of industrial disability can in fact be much different than the degree of impairment because in the first instance reference is to loss of earning capacity and in the latter to anatomical or functional abnormality or loss. Although loss of function is to be considered and disability can rarely be found without it, it is not so that a degree of industrial disability is proportionally related to a degree of impairment of bodily function. Factors to be considered in determining industrial disability include the employee's medical condition prior to the injury, immediately after the injury, and presently; the situs of the injury, its severity and the length of healing period; the work experience of the employee prior to the injury, after the injury and potential for rehabilitation; the employee's qualifications intellectually, emotionally and physically; earnings prior and subsequent to the injury; age; education; motivation; functional impairment as a result of the injury; and inability because of the injury to engage in employment for which the employee is fitted. Loss of earnings caused by a job transfer for reasons related to the injury is also relevant. These are matters which the finder of fact considers collectively in arriving at the determination of the degree of industrial disability. There are no weighting guidelines that indicate how each of the factors are to be considered. There are no guidelines which give, for example, age a weighted value of ten percent of the total value, education a value of fifteen percent of total, motivation - five percent; work experience - thirty percent, etc. Neither does a rating of functional impairment directly correlate to a degree of industrial disability to the body as a whole. In other words, there are no formulae which can be applied and then added up to determine the degree of industrial disability. It therefore becomes necessary for the deputy or commissioner to draw upon prior experience, general and specialized knowledge to make the finding with regard to degree of industrial disability. See Peterson v. Truck Haven Cafe, Inc., (Appeal Decision, February 28, 1985); Christensen v. Hagen, Inc., (Appeal Decision, March 26, 1985). Claimant is 47 years old, a time when she might normally be expected to be in her peak earning years. While it is not impossible for her to be retrained at this age, extensive retraining would not appear especially feasible. Claimant's final work restrictions include not lifting over 10 pounds off the floor or carrying over 15-20 pounds, avoidance of repetitious bending or twisting and not sitting or standing for longer than 30-60 minutes at any one time without being able to change positions. Dr. Laaveg also instructed claimant that she would essentially be limited to office-type work. While Dr. Boarini did not specify restrictions himself, he did find that claimant had suffered a 5-6 percent permanent partial impairment relative her back injury. Dr. Laaveg found that claimant had a permanent physical impairment of 20 percent based on her back problems. Claimant has raised the issue of whether she should be entitled to permanent total disability under the odd-lot theory. See Guyton v. Irving Jensen Co., 373 N.W.2d 101 (Iowa 1985). That case held that a worker is an odd-lot employee when injury makes her incapable of work in any well-known branch of employment; when the only services she can perform are so limited in quality, dependability or quantity that a reasonably stable market for those services does not exist. Claimant bears the burden of establishing a prima facie case by showing that she is not employable in the competitive labor market. Id. Claimant testified forthrightly that she believes she is capable of returning to office work. While her experience in that area is from some years ago, it is nonetheless true that she does have some experience in the clerical field. Along with telephone solicitation, claimant has worked as a receptionist/clerk, answered the telephone, operated a postal machine, performed bookkeeping, operated business machines, typed, and filed. It is held that claimant has not established that the odd-lot theory applies to her. One factor tending to mitigate defendants' liability is that they have attempted to bring claimant back to work, although she proved unable to return because.of her subsequent fall in 1988. Perhaps the most significant limitation placed on claimant is that she is not to remain in one position for more than 30-60 minutes without being able to move about. Claimant appears to be foreclosed from a great deal of production work because of her restrictions against lifting, bending and twisting on a repetitive basis, and may also find herself foreclosed from many clerical positions by reason of this limitation. While, for example, claimant might be able to work as a cashier or salesperson, it is unreasonable to believe that she would be a competitive candidate for a position in word processing or data entry. Based upon the evidence in general and these factors in particular, the undersigned concludes that claimant currently has sustained an industrial disability of 60 percent by reason of her back condition, measured when her healing period ended and before her unfortunate fall at home. Of course, claimant also had preexisting industrial disability. Even before her back injury, she had been restricted against standing for over two hours at any one time, frequent bending or twisting and lifting or carrying over 25 pounds. While a scheduled member injury is to be compensated per the schedule, it is also clear that scheduled member injuries may also cause restrictions or limitations that might properly be considered indices of industrial disability. The back injury did not cause the previous industrial disability, and claimant should not be compensated for preexisting disability. It is appropriate to deduct from claimant's total industrial disability the amount of industrial disability that preexisted the injury. Bearce v. FMC Corp., file number 782809 (App. Decn., March 17, 1989); Brittian v. Fisher Controls, file number 1669180 (App. Decn., February 28, 1989). The restrictions placed upon claimant as the result of her back injury are similar to the preexisting restrictions in some respects, but are substantially more onerous by reason of the restriction against remaining in one place for more than 30-60 minutes without the opportunity of changing position. It is held that claimant's preexisting industrial disability was 25 percent, therefore claimant shall be awarded 35 percent industrial disability. It might be argued that as claimant's knee injury was a scheduled member disability, any credit to defendants should be on the basis of a scheduled member, even though industrial disability was caused by that injury. The evidence in this case shows that claimant had a 60 percent impairment of her right leg, of which half was attributable to the injury in file number 773001. Pursuant to Iowa Code section 85.34(2)(o), the loss of a leg is compensated on the basis of 220 weeks. Sixty percent of 220 weeks is 132 weeks. Calculated industrially, the credit is 125 weeks. While the result is very close with respect to these two approaches, the undersigned believes he is bound by decisions of the industrial commissioner to the effect that preexisting condition is to be evaluated industrially. To a small degree, that works in claimant's favor in this instance. The next issue to be considered is the question of claimant's entitlement to medical benefits under Iowa Code section 85.27. These are set forth in claimant's exhibit 36. The parties have stipulated that all requested benefits relating to the 1984 injury have been paid, except for expenses relative to claimant's 1988 fall. Because that has been found to be not work connected, further medical benefits shall not be awarded in file number 773001. In file number 853642, the Mercy Hospital bill shall be paid by defendants in the sum of $5,832.24; Internal Medicine in the sum of $14.00; Radiologists of Mason City in the sum of $356.00; Ntron in the sum of $42.75; Surgical Associates in the sum of $2,156.00. These expenses appear to be caused by claimant's back injury. The final issue to be determined is whether penalty benefits should be awarded under Iowa Code section 86.13. Defendants have at all times denied liability based on claimant's back injury. Dr. Laaveg expressed his clear opinion to defendant Liberty Mutual on June 3, 1987, that claimant had suffered a work-related injury. His letter of September 9, 1987 reiterated that point and noted that he had also talked by phone to both Walljasper brothers who had handled the claim. In his letter of September 22, 1987, Dr. Laaveg stated that he could not be more explicit in making clear that the claim was a work injury. Dr. Boarini, who saw claimant for evaluation, wrote to Liberty Mutual on November 16, 1987, further indicating that the back injury was work related. There is no indication that any physician has at any time advised defendants that claimant's injury was not work related. Generally speaking, penalties are not imposed where there are legitimate disputes on causation or extent of impairment. Just v. Hygrade Food Products Corporation, IV Iowa Industrial Commissioner Report, 190 (App. Decn., January 30, 1984). It has been held that a legitimate dispute over causation would appear to exist only when there are differing medical opinions as to causation. Conrad v. Matt Parrott & Sons, file number 827150 (Arb. Decn., March 28, 1988; Affirmed October 28, 1988). The issue of causation is essentially within the domain of expert testimony. Both of the experts who have expressed an opinion indicated to defendants that the injury was work related. Defendants' actions have caused claimant to go without income during her healing period and to resort to the necessity of retaining counsel to secure what was rightfully due her. Penalty benefits shall be assessed as to the healing period. The penalty shall be in the amount of 35 percent. This percentage is chosen essentially because of the belief of the undersigned that the maximum 50 percent penalty should more appropriately be imposed in extreme situations or under truly egregious facts. After all, there was no specific incident at work giving rise to this injury, so even though the expert testimony is unanimous, the failure to pay healing period benefits is not so extreme a lapse as might well be the case under different facts. No penalty benefits shall be awarded as to claimant's permanent partial disability. Because claimant already had serious industrial disability preexisting the work injury, it is certainly reasonable for defendants to question the degree to which industrial disability resulted from this injury. Liability here is not nearly so clear as is the case with healing period benefits. FINDINGS OF FACT THEREFORE, based on the evidence presented, the following ultimate facts are found: 1. At all times relevant, claimant was employed by defendant Fleetguard, Inc. 2. As stipulated, claimant suffered an injury arising out of and in the course of that employment to the right leg (773001) on August 21,.1984. 3. As stipulated, claimant has received all benefits to which she is entitled with respect to her right leg injury, except as to disability created by her fall at home in February, 1988. 4. Claimant's fall in 1988 was caused by.the fracture of her right ankle while descending stairs. 5. There is no evidence showing that the fracture of claimant's ankle was in any way caused by the injury to claimant's right leg (knee) sustained on August 21, 1984. 6. Following substantial time off work, claimant worked half days, then full days, from January 23 to January 28, 1987. 7. After working on January 28, 1987, claimant began suffering pain and her entire leg developed numbness, following which claimant underwent surgery for a herniated intervertebral disc at L5-S1 on the right with marked S1 radicular malfunction from compression neuropathy on February 4, 1987. 8. The medical evidence establishes that claimant's back injury was caused by her employment, which involved stooping, climbing, substantial walking and the use of a testing device known as an arbor press, which required all of claimant's strength to operate. 9. Claimant was totally disabled from work from January 29, 1987 until her release to return to work effective January 29, 1988. 10. Although advised by two physicians that claimant's injury was work related, defendants did not voluntarily pay temporary total disability or healing period benefits, and have not done so through the date of hearing. 11. As stipulated, claimant's rate of compensation in file number 853642 is $193.82 per week. 12. As stipulated, claimant's back injury is an injury to the body as a whole. 13. Claimant's work injury has caused her permanent disability and a diminution of her earning capacity. 14. Claimant has been given physical limitations by reason of her back injury that include not lifting over 10 pounds from the floor or carrying over 15-20 pounds, avoiding repetitious bending or twisting and avoiding sitting or standing for longer than 30-60 minutes at any one time without being able to change position. 15. Claimant's physician assigned her a 20 percent physical impairment, of which 15 percent was attributable to this back injury and 5 percent was preexisting. 16. Claimant had preexisting industrial disability including restrictions placed on her activity by reason of the 1984 knee injury, although the knee injury was compensated as a scheduled member disability and not industrially. 17. Claimant was a credible witness. 18. With respect to claimant's back injury, the following portions of medical bills are causally connected to the injury: Mercy Hospital $5,832.24 Internal- Medicine 14.00 Radiologists of Mason City 356.00 Ntron 42.75 Surgical Associates 2,156.00 CONCLUSIONS OF LAW WHEREFORE, based on the principles of law previously stated, the following conclusions of law are made: 1. Claimant has failed to establish that injuries resulting from her fall at home in 1988 are causally connected to the knee injury of 1984 (773001). 2. Claimant sustained an injury to her back arising out of and in the course of her employment on January 28, 1987 (853642). 3. Claimant's back injury was an injury to the body as a whole. 4. Claimant's back injury directly caused a healing period from January 29, 1987 through January 28, 1988 (52 weeks). 5. Claimant has established a permanent partial disability of 60 percent of the body as a whole with respect to her back condition; however, claimant had a preexisting permanent partial disability of 25 percent of the body as a whole with respect to her back for which defendants should be entitled to credit. Claimant shall be awarded permanent partial disability of 35 percent of the body as a whole. 6. Claimant is entitled to medical expenses under Iowa Code section 85.27 as set forth above. 7. Claimant is entitled to penalty benefits under Iowa Code section 86.13 in the amount of 35 percent of the healing period benefits, all of which were unreasonably delayed; she is not entitled to penalty benefits with respect to her permanent partial disability award. ORDER THEREFORE, IT IS ORDERED: Claimant shall take nothing from this proceeding with respect to file number 773001. Defendants are to pay to claimant fifty-two (52) weeks healing period benefits at the stipulated rate of one hundred ninety-three and 82/100 dollars ($193.82) per week, totalling ten thousand seventy-eight and 64/100 dollars ($10,078.64). Defendants are to pay unto claimant penalty benefits under Iowa Code section 86.13 in the sum of thirty-five percent (35%) of the fifty-two (52) weeks of healing period benefits unreasonably delayed or eighteen point two (18.2) weeks, totalling three thousand five hundred twenty-seven and 52/100 dollars ($3,527.52). Defendants are to pay one hundred seventy-five (175) weeks permanent partial disability benefits [thirty-five percent (35%) of the body as a whole, after deducting twenty-five percent (25%) prior disability from claimant's current sixty percent (60%) permanent partial disability of the body as a whole] at the stipulated rate of one hundred ninety-three and 82/100 dollars ($193.82) per week, totalling thirty-three thousand nine hundred eighteen and 50/100 dollars ($33,918.50). Defendants shall pay the following medical expenses: Mercy Hospital $5,832.24 Internal Medicine 14.00 Radiologists of Mason City 356.00 Ntron 42.75 Surgical Associates 2,156.00 The unpaid healing period benefits have all accrued and shall be paid in a lump sum together with statutory interest thereon pursuant to Iowa Code section 85.30. The commencement date of permanent partial disability is January 29, 1988; all unpaid benefits which have accrued as of the date of this decision shall be paid in a lump sum together with statutory interest thereon pursuant to Iowa Code section 85.30. The penalty benefits awarded herein shall be paid in a lump sum, but interest shall accrue only from the date of this decision. The costs of each action shall be assessed to defendants pursuant to Division of Industrial Services Rule 343-4.33. Defendants shall file claim activity reports in file number 853642 as requested by this agency pursuant to Division of Industrial Services Rule 343-3.1. Signed and filed this 7th day of January, 1989. DAVID RASEY DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. Robert S. Kinsey III Attorney at Law 214 North Adams P.O. Box 679 Mason City, Iowa 50401 Mr. Tito Trevino Attorney at Law 503 Snell Building P.O. Box 1680 Fort Dodge, Iowa 50501 1402.30, 51402.30, 51702 4000.2 Filed June 7, 1989 DAVID RASEY BEFORE THE IOWA INDUSTRIAL COMMISSIONER ORLA JANE SMITH, Claimant, File Nos. 773001 vs. 853642 FLEETGUARD, INC., A R B I T R A T I 0 N Employer, D E C I S I 0 N and LIBERTY MUTUAL INSURANCE COMPANY, Insurance Carrier, Defendants. File Number 773001 51402.30 Claimant failed to prove that 1988 fall from ankle fracture was causally related to 1984 knee injury. File Number 853642 1402.30 Evidence showed back injury arose out of and in the course of employment, causing disability. 51702 Claimant having 60% permanent partial disability was awarded 35% permanent partial disability after deducting 25% prior permanent partial disability. 4000.2 Claimant awarded 35% penalty benefits on unreasonably delayed healing period award, where two physicians advised defendants that injury was work related.