Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            COLEEN J. RHEA,               :
 
                                          :
 
                 Claimant,                :      File Nos. 820183
 
                                          :                886121
 
            vs.                           :                872759
 
                                          :
 
            WILSON FOODS CORPORATION,     :    A R B I T R A T I O N
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                 Self-Insured,            :
 
                 Defendant.               :
 
            ___________________________________________________________
 
            
 
                 Colleen Rhea (claimant) filed three petitions for 
 
            arbitration as a result of injuries to claimant's hand and 
 
            shoulder.  The petitions were filed on the following dates:  
 
            File Number 886121, April 27, 1989, File Number 820183, 
 
            December 31, 1987 and File Number 872759 on April 27, 1989.  
 
            The alleged injury dates are as follows:  File Number 
 
            886121, November 11, 1987, File Number 820183, March 27, 
 
            1986, and File Number 872759, February 26, 1988.  Wilson 
 
            Foods, Inc. (Wilson) was identified as employer and is 
 
            self-insured for the purposes of workers' compensation 
 
            liability.  On April 30, 1991, these matters came on for 
 
            hearing in Storm Lake, Iowa.  The parties appeared as 
 
            follows:  the claimant in person and by his counsel Harry 
 
            Smith of Sioux City, Iowa and Wilson by its counsel David 
 
            Sayre of Cherokee, Iowa.  
 
            
 
                 The record in this proceeding consisted of the 
 
            following:
 
            
 
                 1.  The live testimony of the claimant and Dr. Keith 
 
            Garner.  
 
            
 
                 2.  Joint exhibits 1-6 and 8-25.
 
            
 
                 3.  Defendants' exhibit A.
 
            
 
                               preliminary matters
 
            
 
                 At the conclusion of the hearing, the undersigned asked 
 
            counsel for both parties for an assessment of the industrial 
 
            value to be assigned for the injuries suffered by the 
 
            claimant in this dispute.  There was discussion of an award 
 
            of a permanent total disability benefit for the claimant.  
 
            At that juncture, an objection was noted for the record that 
 
            a question of permanent total disability had not been 
 
            identified as an issue prior to the time of the hearing.  
 
            The objection was overruled.  The undersigned is free to 
 
            decide the extent of claimant's industrial disability from 0 
 
            to 100 percent depending on the evidence adduced at the time 
 
            of the hearing.  As long as claimant identified industrial 
 
            disability as an issue, the range of the award is not 
 
            limited.  Consequently, the ruling on the objection is 
 
            reaffirmed and overruled.
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            
 
                 In claimant's brief there was a reference to medical 
 
            records from Dr. Mike O'Neil, identified as Exhibit 3.  No 
 
            such exhibit was offered at the time of the hearing.  
 
            Exhibit 3 in this record is a document from Dr. Dennis Nitz 
 
            regarding an EMG study.  Additionally, there was mention 
 
            made in the brief of two agreements for settlement that were 
 
            made in connection with the injuries identified herein.  A 
 
            review of the file indicates that no such agreements have 
 
            been made part of these files. 
 
            
 
                                   stipulations
 
            
 
                 In connection with all three injuries the parties 
 
            stipulated to the following matters at the time of the 
 
            hearing:
 
            
 
                 a.  An employer-employee relationship existed between 
 
            claimant and employer at the time of the alleged injury.
 
            
 
                 b.  The type of permanent disability, if the injury is 
 
            found to be a cause of permanent disability, is industrial 
 
            disability to the body as a whole.
 
            
 
                 c.  The rate of compensation, in the event of an award, 
 
            is as follows:
 
            
 
                    File Number          Rate           Gross Wage
 
                      872759            $246.12          $375.00
 
                      886121            $246.12          $375.00
 
                      820183            $236.90          $369.00
 
            
 
                 At the time of all of these injuries, claimant was 
 
            married and had two children.  She is entitled to four 
 
            exemptions.
 
            
 
                 d.  The entitlement to medical benefits is not in 
 
            dispute.
 
            
 
                 e.  Wilson makes no claim for employee nonoccupational 
 
            group health plan benefits paid prior to hearing.
 
            
 
                 f.  On File Number 820183, Wilson has paid 28.5 weeks 
 
            of compensation at the rate of $236.90 per week prior to the 
 
            hearing and is entitled to a credit for that amount.  
 
            Additionally, Wilson has 25 weeks of compensation for File 
 
            Numbers 886121 or 872759 at the rate of $246.12 per week 
 
            prior to the hearing and is entitled to a credit for that 
 
            amount.  
 
            
 
                 g.  The parties have agreed on the amount of the costs 
 
            to be taxed in this matter.
 
            
 
                 In connection with the injury suffered on March 27, 
 
            1986 the  parties stipulated to the following matters at the 
 
            time of the hearing:
 
            
 
                 a.  The claimant sustained an injury on March 27, 1986, 
 
            which arose out of and in the course of employment.
 
            
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
                 b.  The injury caused a permanent disability.
 
            
 
                 c.  The type of permanent disability, if the injury is 
 
            found to be a cause of permanent disability, is a scheduled 
 
            member disability to the hand.
 
            
 
                 d.  The commencement date for permanent partial 
 
            disability, is July 27, 1986.
 
            
 
                 In connection with the injury suffered on November 11, 
 
            1987 the parties stipulated to the following matters at the 
 
            time of the hearing:
 
            
 
                 a.  The claimant sustained an injury on November 11, 
 
            1987, which arose out of and in the course of employment.
 
            
 
                 b.  The injury caused a permanent disability.
 
            
 
                 c.  The type of permanent disability, if the injury is 
 
            found to be a cause of permanent disability, is industrial 
 
            disability to the body as a whole.
 
            
 
                 In connection with the injury suffered on February 26, 
 
            1988, the parties stipulated to the following matters at the 
 
            time of the hearing:
 
            
 
                 a.  An employer-employee relationship existed between 
 
            claimant and employer at the time of the alleged injury.
 
            
 
                 b.  The type of permanent disability, if the injury is 
 
            found to be a cause of permanent disability, is industrial 
 
            disability to the body as a whole.
 
            
 
                                      Issues
 
            
 
                 The issues for resolution for all three injury dates 
 
            are as follows:
 
            
 
                 1.  Whether claimant sustained an injury on February 
 
            26, 1988 which arose out of and in the course of her 
 
            employment with Wilson.
 
            
 
                 2.  Whether a causal relationship exists between 
 
            claimant's claimed injuries and the claimed disability and 
 
            the nature and extent of any entitlement to benefits, if 
 
            any.
 
            
 
                                findings of facts
 
            
 
                 1.  At the time of the hearing, claimant was 33.  At 
 
            the time of claimant's first injury to her hand, she had 
 
            just turned 28 years old.  At the time of the second injury, 
 
            on November 11, 1987, claimant was 29 years old.  At the 
 
            time of the alleged third injury, claimant was a day short 
 
            of being 30 years old.
 
            
 
                 2.  Claimant is a high school graduate and has attended 
 
            Iowa Lakes Community College.  She attended that institution 
 
            for three quarters focusing in the areas of clerical, 
 
            accounting, and office machines.  This is the only post high 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            school education claimant has had.  Claimant left school and 
 
            entered the work force, initially at Hilltop Nursing Home as 
 
            kitchen help.  Claimant was paid minimum wage.  Thereafter, 
 
            claimant worked at a series of jobs for minimum wage.  
 
            Claimant performed retail sales work, restaurant help work 
 
            and office work.  Claimant began working for Wilson in 1983.  
 
            Claimant worked on the kill floor and in the packaging 
 
            department.  Claimant has also worked in the wiener room, 
 
            the pump and press room, and the conversion room.  
 
            Claimant's most recent positions included boning hams, and 
 
            using a stylexer to shave fat off of hams.
 
            
 
                 3.  Prior to the time that claimant was employed by 
 
            Wilson, she was in good health and had no complaints of 
 
            difficulties with her hand or shoulder.
 
            
 
                 4.  Beginning in 1985, claimant developed work related 
 
            injuries.  She was diagnosed as having trigger finger in her 
 
            right hand.  She had a trigger finger release and was 
 
            assigned a four percent functional impairment rating to the 
 
            right hand due to the trigger finger surgery.  This rating 
 
            was given in September of 1985 by the orthopedic surgeon who 
 
            performed the surgery, Oscar M. Jardon, M.D.
 
            
 
                 5.  Beginning in 1986, claimant began to experience 
 
            carpal tunnel syndrome symptoms in her right hand.  In March 
 
            of 1986, her hand became too numb to work.  Claimant was 
 
            taken off work on March 27, 1986.  On April 23, 1986, Dr. 
 
            Jardon performed a carpal tunnel release for claimant.  
 
            During the course of the surgery, Dr. Jardon discovered that 
 
            claimant had a rupture of the flexor digitorum profundus to 
 
            the fifth finger.  As a result of that discovery, Dr. Jardon 
 
            increased claimant's functional impairment rating.  On June 
 
            30, 1986, claimant was awarded a rating of fifteen percent 
 
            (15%) of the hand.  Dr. Jardon reaffirmed his fifteen 
 
            percent (15%) rating on July 31, 1986.  Claimant was 
 
            returned to work shortly after the rating was given.  
 
            Thereafter, claimant continued to complain of right wrist 
 
            pain beginning in September of 1986 and intermittently 
 
            thereafter.  EMG studies were performed on September 22, 
 
            1987.  These studies
 
            
 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            showed that there was no evidence of carpal tunnel in the 
 
            right hand at that time.  Claimant was not off work during 
 
            this time period.
 
            
 
                 6.  On November 11, 1987, claimant slipped on some fat 
 
            and fell off a stand, landing on her right shoulder and left 
 
            forearm.  After the fall, there was an onset of pain in the 
 
            right shoulder area.  Claimant returned to work the next day 
 
            and had no further pain complaints in her right shoulder 
 
            until January 1988.
 
            
 
                 7.  After claimant complained of pain in her shoulder 
 
            in January, Dr. Garner, Wilson's company physician, referred 
 
            claimant to Dr. Jardon.  Dr. Jardon saw claimant on January 
 
            13, 1988 and noted that claimant's carpal tunnel syndrome 
 
            had not reappeared but that claimant's shoulder showed 
 
            evidence of mild inflammation.  Dr. Garner ordered x-ray 
 
            studies of claimant's right shoulder on February 26, 1988  
 
            The x-ray study revealed a soft tissue swelling over the 
 
            acromioclavicular joint.  Additionally, the 
 
            acromioclavicular joint appeared to be slightly widened, 
 
            suggestive of a first degree tear in the rotator cuff.  
 
            However, no follow-up studies were performed to confirm a 
 
            possible tear of the rotator cuff.  The x-ray did not show a 
 
            soft tissue injury.  Claimant was not taken off work at the 
 
            time the x-ray was performed.  Claimant was receiving 
 
            physical therapy three times a week.  
 
            
 
                 8.  Claimant continued to complain of right shoulder 
 
            pain.  On March 30, 1988, claimant was taken off work for 
 
            three weeks and a diagnosis of tendinitis was made by the 
 
            company nurse.
 
            
 
                 9.  On April 20, 1988, claimant was referred to Mark 
 
            Wheeler, M.D., an orthopedist for further examination of her 
 
            shoulder.  Upon examination, Dr. Wheeler determined that 
 
            there had been an insidious onset of pain with no 
 
            precipitating trauma or event.  Dr. Wheeler in his history 
 
            indicated that claimant regularly uses a Whizard knife in 
 
            her work.  Dr. Wheeler found that claimant had tendinitis in 
 
            her right shoulder.  As a result of the tendinitis, Dr. 
 
            Wheeler took claimant off work for three weeks.  Claimant 
 
            did not advise Dr. Wheeler that she had fallen on November 
 
            11, 1987.
 
            
 
                 10. When Dr. Wheeler saw claimant again on July 7, 
 
            1988, he indicated that claimant's work had aggravated the 
 
            symptoms of tendinitis in her right shoulder, but that she 
 
            was working.  Claimant was released to return to work after 
 
            this examination.  Claimant was returned to work without 
 
            restriction on July 21, 1988.
 
            
 
                 11. On October 20, 1988, claimant continued to complain 
 
            of shoulder pain and that she was ready to quit work.  She 
 
            returned to see Dr. Wheeler for a rating of her shoulder.  
 
            Dr. Wheeler found that claimant had a ten percent functional 
 
            impairment of her shoulder.  However, Dr. Wheeler did not 
 
            impose any restrictions at the time he gave this rating to 
 
            claimant.  The rating was based on her limitations of 
 
            external and internal rotation and her limitation of ten 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            degrees of full abduction and flexion.  Claimant's ten 
 
            percent functional impairment rating was attributed to the 
 
            loss of motion that she had in the joint.  Dr. Wheeler gave 
 
            claimant a release for full duty on October 20, 1988. 
 
            
 
                 12. On January 20, 1989, claimant voluntarily quit her 
 
            employment with Wilson to accept a new position.  Claimant 
 
            was under the impression from conversations that she had 
 
            with her medical providers that she should leave the packing 
 
            industry as a worker.  However, there is no documentary 
 
            evidence that would support this conclusion.  Further, there 
 
            was no recommendation by any of claimant's doctors in any 
 
            written form that indicates they advised her to stop working 
 
            at Wilson as a result of her injuries at the time she left 
 
            Wilson.
 
            
 
                 13. On May 11, 1989, Pat Luse, D.C., evaluated claimant 
 
            for the purposes of assigning an industrial disability 
 
            rating.  Dr. Luse identified two injuries that claimant had 
 
            suffered, one on February 26, 1988 and another on November 
 
            11, 1987.  Apparently, Dr. Luse was unaware that claimant 
 
            had suffered an injury with carpal tunnel syndrome claimed 
 
            to have occurred on March 27, 1986.  Dr. Luse did note that 
 
            claimant had a carpal tunnel release on the right hand 
 
            however.  It is unclear from Dr. Luse's report the total 
 
            loss he assigned to claimant's hand for the carpal tunnel 
 
            release.  He did not separately identify this condition as 
 
            an injury.(1)  The balance of the report discussed claimant's 
 
            shoulder.  Dr. Luse did not separately rate claimant's 
 
            shoulder.  Dr. Luse rated separate parts of claimant's loss 
 
            and then combined the values.  Dr. Luse indicated that he 
 
            used the AMA Guides to the Evaluation of Permanent 
 
            Impairment, third edition, but he did not indicate that he 
 
            used the combined value table for assessing the loss.  He 
 
            summarily concluded that claimant had a functional 
 
            impairment rating of 20%.  The worksheet referenced in his 
 
            report was not part of the exhibit that was submitted at the 
 
            time of trial.
 
            
 
                 14. In November of 1989, claimant began to work at 
 
            Countryside Nursing Home.  After she had been working at the 
 
            nursing home, claimant's shoulder flared up again.  Claimant 
 
            testified that her pain was worse at Countryside and that 
 
            she was having more problems.  Claimant quit her work at 
 
            Countryside Nursing Home in March of 1990.  She indicated to 
 
            (1).  From Dr. Luse's report, it is unclear exactly what 
 
            disability of functional impairment rating he assigned to 
 
            claimant's hand.  There were three parts to the rating, a 
 
            nine percent rating to the upper extremity for a motor 
 
            impairment loss, a ten percent rating for loss of function 
 
            due to sensory deficit and a ten percent loss assigned to 
 
            the ruptured flexor digitorum profundus tendon.  However, 
 
            Dr. Luse did not combine these values to reach an impairment 
 
            rating for claimant's hand.  Since Dr. Jardon performed the 
 
            surgery and had an opportunity to see the claimant before 
 
            and after the surgery, Dr. Jardon's rating of 15 percent to 
 
            the hand will be adopted as the rating for the functional 
 
            impairment loss for claimant's hand.
 
            
 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            her medical providers that she was in too much pain to 
 
            continue working.  On April 3, 1990, Dr. Wheeler sent a 
 
            report to the Iowa Disability Determination Service Bureau 
 
            regarding claimant's shoulder condition.  He indicated that 
 
            claimant had chronic recurring tendinitis in her right 
 
            shoulder.  Dr. Wheeler gave her a lifting and carrying 
 
            restriction of no greater than 20 pounds and a restriction 
 
            of no work above shoulder level.  He further indicated that 
 
            her standing was unlimited as well as walking and sitting.  
 
            Additionally, claimant was not limited in terms of stooping, 
 
            climbing, kneeling or crawling.  Claimant's manual dexterity 
 
            was adequate and her hearing, speaking and traveling 
 
            abilities were not restriction in a work environment.
 
            
 
                 15. On April 17, 1990, Dr. Garner, directed a letter to 
 
            the Social Security Administration in support of claimant's 
 
            application for Social Security disability income.  Dr. 
 
            Garner indicated that claimant had a history of trigger 
 
            finger, right carpal tunnel syndrome, and a probable right 
 
            rotator cuff tear.(2)    Dr. Garner indicated that claimant 
 
            had continuing complaints of pain in her right shoulder.  He 
 
            found on the date of his examination, no evidence of 
 
            swelling, redness or instability.  Additionally, he found no 
 
            evidence of nerve root compression.  He found that her range 
 
            of motion was fairly normal and that she had some 
 
            crepitation with rotation of the shoulder.  In terms of 
 
            claimant's restrictions, Dr. Garner concluded that claimant 
 
            could not lift or carry more than 10 pounds.  He felt that 
 
            she could walk, stand, move about and sit without 
 
            restrictions.  Additionally, claimant was capable of 
 
            stooping, climbing and crawling.  Claimant can handle 
 
            objects, see and hear, however, Dr. Garner did note that 
 
            claimant would have great difficulty doing any type of 
 
            manual labor with her right shoulder.  Dr. Garner concluded 
 
            that claimant has tried to do manual labor with her right 
 
            arm and this has not worked out.  He recommended that she 
 
            not do this type of work in the future.
 
            
 
                 16. In June of 1990, claimant participated in a 
 
            demolition derby at the Cherokee fairgrounds.  During the 
 
            course of a demolition derby, claimant attempts to run into 
 
            other automobiles being driven in a large track infield type 
 
            area.  Additionally, claimant attempts to avoid being hit.  
 
            In the demolition derby that claimant participated in, if a 
 
            participant was struck three times then the car and driver 
 
            were disqualified.  Claimant participated in this activity 
 
            though she was not in the competition very long.  
 
            
 
                 17. As of the date of the hearing, claimant had had no 
 
            further medical care for her shoulder.  Additionally, at the 
 
            time of the hearing, claimant indicated that she could not 
 
            (2).  Dr. Garner qualified this part of his letter at the 
 
            time of hearing, when he indicated that there had been no 
 
            firm diagnosis of a rotator cuff tear.  He orally amended 
 
            his letter to indicate that claimant had a possible rotator 
 
            cuff tear.  He did indicate that the muscle on top of 
 
            claimant's shoulder was involved in claimant's ongoing pain 
 
            complaints.
 
            
 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            mow the lawn, she could not vacuum and she could not play 
 
            recreational softball.  Additionally, claimant could not 
 
            ride a motorcycle or drive a car with a clutch.  She 
 
            indicated that her activities regarding grocery shopping and 
 
            playing with her children had been limited.  
 
            
 
                                CONCLUSIONS OF LAW
 
            
 
                 I.  March 27, 1986 Injury
 
            
 
                 The only issue for resolution regarding this injury is 
 
            the extent of permanent partial disability claimant is 
 
            entitled to as a result of the carpal tunnel injury to her 
 
            hand.  Claimant contends that she is entitled to a benefit 
 
            in excess of 15%.  Wilson asserts that claimant has been 
 
            paid all that she is entitled to receive.
 
            
 
                 Permanent partial disabilities are classified as either 
 
            scheduled or unscheduled.  A specific scheduled disability 
 
            is evaluated by the functional method; the industrial method 
 
            is used to evaluate an unscheduled disability.  Martin v. 
 
            Skelly Oil Co., 252 Iowa 128, 133, 106 N.W.2d 95, 98 (1960); 
 
            Graves v. Eagle Iron Works, 331 N.W.2d 116 (Iowa 1983); 
 
            Simbro v. DeLong's Sportswear, 332 N.W.2d 886, 887 (Iowa 
 
            1983).  The right of a worker to receive compensation for 
 
            injuries sustained which arose out of and in the course of 
 
            employment is statutory. The statute conferring this right 
 
            can also fix the amount of compensation to be paid for 
 
            different, specific injuries.  Barton v. Nevada Poultry Co., 
 
            110 N.W.2d 660, 663 (Iowa 1961);  Soukup v. Shores Co., 268 
 
            N.W. 598, 601 (Iowa 1936).  Where there is an injury to a 
 
            specific part of claimant's body, such loss shall be 
 
            compensable only to the extent provided by the statute.  
 
            Thus by legislative edict, where the result of an injury 
 
            causes the loss of a foot, or eye etc, such loss, together 
 
            with its ensuing natural results upon the body, is declared 
 
            to be a permanent partial disability and entitled only to 
 
            the prescribed compensation.  Barton, 110 N.W.2d at 663.  
 
            
 
                 Expert medical evidence forms the basis for evaluating 
 
            a claimant's functional impairment.  This evidence must be 
 
            considered with all other evidence introduced bearing on the 
 
            causal connection.  Burt v. John Deere Waterloo Tractor 
 
            Works, 73 N.W.2d 732, 738 (Iowa 1955).  Moreover, the expert 
 
            opinion may be accepted or rejected, in whole or in part, by 
 
            the trier of fact.  Sondag v. Ferris Hardware, 220 N.W.2d 
 
            903, 907 (Iowa 1974).  Finally, 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 material circumstances.  Bodish v. Fischer, Inc., 
 
            133 N.W.2d 867, 870 (Iowa 1965); Musselman v. Central 
 
            Telephone Co., 154 N.W.2d 128, 133 (Iowa 1967).  The Supreme 
 
            Court has also observed that greater deference is ordinarily 
 
            accorded expert testimony where the opinion necessarily 
 
            rests on medical expertise.  Sondag, 220 N.W.2d at 907.  
 
            
 
                 In this instance, the only evidence of an increased 
 
            impairment for claimant's hand is from the report of Dr. 
 
            Luse.  Dr. Luse did not correlate his findings to claimant's 
 
            hand.  He assigned his rating to claimant's upper extremity.  
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            In connection with the rating, Dr. Luse did not combine the 
 
            values to arrive at a functional impairment for claimant's 
 
            hand.  Dr. Luse did not recognize claimant's hand injury as 
 
            a separate injury for the purpose of the evaluation he did 
 
            in May of 1989.  Finally, Dr. Luse did not have an 
 
            opportunity to follow claimant's course of treatment and 
 
            perform the surgery and post operative care.  He only saw 
 
            claimant once.  Consequently, Dr. Luse's opinion can be 
 
            accorded little weight in connection with the loss to 
 
            claimant's hand.  The functional impairment rating of 15% 
 
            given by Dr. Jardon on July 30, 1986 and reaffirmed by him 
 
            will be adopted as the rating for claimant's hand.  
 
            Consequently, claimant will take nothing further on the 
 
            claim for her hand as that claim was fully paid by Wilson 
 
            prior to the hearing on this matter.
 
            
 
                 II.  November 11, 1987 injury 
 
            
 
                 The threshold issue to resolve with this injury and the 
 
            injury of February 26, 1988 is to determine whether there 
 
            were two separate injuries or one injury and an aggravation 
 
            that led to a diagnosis of chronic tendinitis in March of 
 
            1988.  
 
            
 
                 Wilson does not dispute that claimant fell on November 
 
            11, 1987 while she was at work.  However, Wilson does 
 
            dispute that claimant suffered another injury on February 
 
            26, 1988.  Claimant urges that she suffered two injuries 
 
            that have contributed to her permanent partial disability 
 
            that should be compensated industrially.  The evidence 
 
            supports claimant's contention that she was injured on 
 
            November 11, 1987.  However, it does not support a 
 
            conclusion that claimant suffered any permanent disability 
 
            from her fall.
 
            Claimant has the burden of proving by a preponderance of the 
 
            evidence that the injury of November 11, 1987, is causally 
 
            related to the disability on which she now bases her claim.  
 
            Bodish, 133 N.W.2d at 868;  Lindahl, 18 N.W.2d at 613-14.  
 
            A possibility is insufficient; a probability is necessary.  
 
            Burt, 73 N.W.2d at 738.  The question of causal connection 
 
            is essentially within the domain of expert testimony.  
 
            Bradshaw, 101 N.W.2d at 171.
 
            
 
                 Expert medical evidence must be considered with all 
 
            other evidence introduced bearing on the causal connection.  
 
            Burt, 73 N.W.2d at 738.  The opinion of the experts need 
 
            not be couched in definite, positive or unequivocal 
 
            language.  Sondag, 220 N.W.2d at 907.  Moreover, the expert 
 
            opinion may be accepted or rejected, in whole or in part, by 
 
            the trier of fact.  Sondag, 220 N.W.2d at 907.  Finally, 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 material circumstances.  
 
            Bodish, 133 N.W.2d at 870; Musselman, 154 N.W.2d at 133.  
 
            The Supreme Court has also observed that greater deference 
 
            is ordinarily accorded expert testimony where the opinion 
 
            necessarily rests on medical expertise.  Sondag, 220 N.W.2d 
 
            at 907.
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            
 
                 The evidence shows that claimant fell and was off work 
 
            the night she fell.  She returned to work the next day.  
 
            Claimant had no further complaints relating to her shoulder 
 
            until January 4 1988.  The fall in November of 1987 did not 
 
            have any affect on the claimant's ability to work.  She went 
 
            home the night of the fall and returned to work the next 
 
            day.  Claimant lost no time at work as a result of the fall 
 
            on November 11, 1987.  Claimant did not recount any 
 
            traumatic event for Dr. Jardon on January 13, 1988 that 
 
            would have led him to conclude that she suffered permanent 
 
            damage to her shoulder at the time of her fall.  Moreover, 
 
            claimant did not think her fall was important enough to 
 
            mention to Dr. Wheeler, when she was examined in April 
 
            regarding pain in her shoulder.  Even Dr. Luse did not 
 
            differentiate between the injury on November 11, 1987 and 
 
            the injury suffered in February.  The greater weight of the 
 
            evidence supports the conclusion that claimant did not 
 
            suffer any disability as a result of her fall on November 
 
            11, 1987.  Consequently, claimant will take nothing for this 
 
            injury.
 
            
 
                 III.  February 26, 1988 Injury
 
            
 
                 Regarding the February 26, 1988 injury, claimant has 
 
            the burden of proving by a preponderance of the evidence 
 
            that she received an injury on February 26, 1988 which arose 
 
            out of and in the course of her employment. McDowell v. Town 
 
            of Clarksville, 241 N.W.2d 904, 908 (Iowa 1976); Musselman, 
 
            154 N.W.2d at 130.  The words "arising out of" have been 
 
            interpreted to refer to the cause and origin of the injury.  
 
            McClure v. Union County, 188 N.W.2d 283, 287 (Iowa 1971);  
 
            Crowe v. DeSoto Consolidated School District, 68 N.W.2d 63, 
 
            65 (Iowa 1955).  The words "in the course of" refer to the 
 
            time, place and circumstances of the injury.  McClure, 188 
 
            N.W.2d at 287; Crowe, 68 N.W.2d at 65.  A determination that 
 
            an injury "arises out of" the employment contemplates a 
 
            causal connection between the conditions under which the 
 
            work was performed and the resulting injury; i.e., the 
 
            injury followed as a natural incident of the work.  
 
            Musselman, 154 N.W.2d at 130; Reddick v. Grand Union Tea 
 
            Co., 296 N.W. 800, 804 (Iowa 1941).
 
            
 
                 The Supreme Court has defined a personal injury for the 
 
            purposes of workers' compensation cases.  Almquist v. 
 
            Shenandoah Nurseries, 254 N.W. 35, 38 (Iowa 1934).  In this 
 
            case the Court found that a personal injury, is an injury to 
 
            the body, the impairment of health, or a disease, not 
 
            excluded by the Workers Compensation 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.  The injury to 
 
            the human body 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 Almquist Court further observed that while a 
 

 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            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.  A personal injury includes 
 
            a disease resulting from an injury.  However, the result of 
 
            changes in the human body incident to the general processes 
 
            of nature do not amount to a personal injury.  This is true, 
 
            even though natural change may come about because the life 
 
            has been devoted to labor and hard work.  Results of those 
 
            natural changes do 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 cumulative injury may occur over a period of time.  
 
            The injury in such cases occurs when, because of pain or 
 
            physical disability, the claimant is compelled to leave 
 
            work.  McKeever Custom Cabinets v. Smith, 379 N.W.2d 368, 
 
            374 (Iowa 1985).  Moreover, claimant's last employer becomes 
 
            liable for the cumulative injury, even if the incidents that 
 
            lead to the ultimate injury do not occur while a claimant is 
 
            employed with the last employer.  McKeever, 379 N.W.2d at 
 
            376; See also, Doerfer Division of CCA v. Nicol, 359 N.W.2d 
 
            428, 434-35 (Iowa 1984).
 
            After claimant complained of pain in her right shoulder she 
 
            was seen on January 13, 1988 by Dr. Jardon.  At the time she 
 
            was examined by Dr. Jardon, he noted mild inflammation in 
 
            her shoulder.  When the pain did not resolve, claimant was 
 
            referred to Dr. Wheeler who found that claimant had an 
 
            insidious onset of pain in her right shoulder.  Claimant was 
 
            compelled to leave work on March 30, 1988 as a result of the 
 
            tendinitis diagnosis.  Dr. Wheeler's notes indicated that 
 
            the source of claimant's tendinitis was unknown.  However, 
 
            he did conclude that claimant's tendinitis was aggravated by 
 
            her work.  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, 76 N.W.2d 756, 
 
            760-61 (Iowa 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. Gosek v. Garmer and Stiles 
 
            Co., 158 N.W.2d 731, 737 (Iowa 1968);  Barz v. Oler, 133 
 
            N.W.2d 704, 707 (Iowa 1965); Olson v. Goodyear Service 
 
            Stores, 125 N.W.2d 251, 256 (Iowa 1963); Nicks v. Davenport 
 
            Produce Co., 115 N.W.2d 812, 815 (Iowa 1962);  Yeager v. 
 
            Firestone Tire & Rubber Co., 112 N.W.2d 299, 302 (Iowa 
 
            1961); Ziegler v. United States Gypsum Co., 106 N.W.2d 591, 
 
            595 (Iowa 1960); Almquist, 254 N.W. at 38.
 
            
 
                 As a result of these conclusions by Dr. Wheeler, it is 
 
            clear that claimant suffered an aggravation of a preexisting 
 
            condition that caused her to leave work on March 30, 1988.  
 
            Consequently, there is sufficient evidence in the record to 
 
            conclude that claimant suffered an injury on March 30, 1988 
 
            to her shoulder.(3)
 
            
 
                 Once claimant has demonstrated that she suffered an 
 
            injury arising out of and in the course of her employment, 
 
            claimant must also prove by a preponderance of the evidence 
 
            that the injury of March 30, 1988 is causally related to the 
 
            (3).  This injury date is selected based on the holding in 
 
            McKeever Custom Cabinets v. Smith, 379 N.W.2d at 368, 374 
 
            (Iowa 1985) which requires a claimant to select an injury 
 
            date in a cumulative trauma case as the date that claimant 
 
            was compelled to leave work.
 
            
 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            disability on which she now bases her claim.  The authority 
 
            cited earlier in connection with the November 11, 1987 
 
            injury is equally applicable to this injury.  See p. 10.
 
            
 
                 The March 30, 1988 injury caused Dr. Wheeler to 
 
            conclude that claimant was suffering from chronic recurring 
 
            tendinitis.  Claimant has suffered a 10% permanent 
 
            functional impairment to her right upper extremity.  It is 
 
            clear that claimant's injury extends into the body as a 
 
            whole and is not limited to her right arm.  An injury to the 
 
            muscle group surrounding claimant's shoulder and on top of 
 
            her shoulder extends beyond her arm and into the body as a 
 
            whole.  Alm v. Morris Barrick Cattle Co., 38 N.W.2d 161, 163 
 
            (Iowa 1949).
 
            Once a permanent injury has been found, if claimant has an 
 
            impairment to the body as a whole, an industrial disability 
 
            has been sustained.  Industrial disability was defined in 
 
            Diederich v. Tri-City Railway Co., 258 N.W.2d 899, 902 
 
            (Iowa 1935) as loss of earning capacity and not a mere 
 
            `functional disability' to be computed in the terms of 
 
            percentages of the total physical and mental ability of a 
 
            normal person.  The essence of an earning capacity inquiry 
 
            then, is not how much has the claimant been functionally 
 
            impaired, but whether that impairment, in combination with 
 
            the claimant's age, education, work experience, pre and post 
 
            injury wages, motivation and ability to get a job within her 
 
            restrictions, if any restrictions have been imposed, have 
 
            caused a loss of earning capacity.  Olson v. Goodyear 
 
            Service Stores, 125 N.W.2d 251, 257 (Iowa 1963); Diederich 
 
            v. Tri-City Railway Co., 258 N.W. 899, 902 (Iowa 1935);  
 
            Peterson v. Truck Haven Cafe, Inc., 1 Iowa Industrial Comm'r 
 
            Dec. No. 3, 654, 658 (1985); Christensen v. Hagen, Inc., 1 
 
            Iowa Industrial Comm'r Dec. No. 3, 529, 534-535 (1985). 
 
            There are no weighting guidelines that indicate how each of 
 
            the factors are to be considered.  There is no equation 
 
            which can be applied and then calculated to determine the 
 
            degree of industrial disability to the body as a whole.  It 
 
            therefore becomes necessary for the deputy or commissioner 
 
            to draw upon prior experience and general and specialized 
 
            knowledge to make a finding with regard to the degree of 
 
            industrial disability.  See, Peterson, 1 Iowa Industrial 
 
            Commissioner Decisions No. 3, at 658; Christening, 1 Iowa 
 
            Industrial Commissioner Decisions No. 3, at 535.
 
            
 
                 In this instance, the only limitation claimant had when 
 
            she was released to return to work at Wilson was a 10% 
 
            functional impairment to her right upper extremity.(4)  
 
            Claimant returned to work at her same job and at the same 
 
            rate of pay she had prior to the date of her injury.  
 
            Claimant's relative age also plays a role.  Where the 
 
            claimant is young, the industrial disability is not as 
 
            serious as it would be for an older employee. Mccoy v. 
 
            Donaldson Company, Inc., File nos. 752670, 805300, (Iowa 
 
            Ind. Comm'r App. 1989); Walton v. B & H Tank Corp., II Iowa 
 
            Industrial Commissioner Report 426, 429 (Arb. 1981); Becke 
 
            v. Turner-Busch, Inc., 34 Biennial Report Iowa Industrial 
 
            Commissioner 34, 36 (Appeal 1979).  Claimant was almost 30 
 
            at the time of her injury.  Claimant also has a high school 
 
            diploma and has some post high school education.  Claimant 
 
            returned to work without any restrictions in July of 1988.  
 
            (4).  Dr. Luse found significant impairment five months after 
 
            claimant left her employment with Wilson and that these 
 
            findings suggest that claimant's employment at Wilson is the 
 
            sole cause of her functional impairment.  However, Dr. 
 
            Luse's conclusions are not persuasive.  The evidence from 
 
            Dr. Wheeler, an orthopedic physician is more compelling.  
 
            Dr. Wheeler had a better opportunity to observe the claimant 
 
            as her treating physician.  He saw her on a number of 
 
            occasions and was in a better position to judge her 
 
            limitations after she had been at work and off work.  Dr. 
 
            Luse saw claimant only once, nearly 18 months after the 
 
            diagnosis was made.  Consequently, Dr. Luse's rating will be 
 
            given little weight and Dr. Wheeler's rating will be adopted 
 
            as the correct functional impairment for claimant's 
 
            shoulder.  
 
            
 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            Claimant's post injury employment and recreational 
 
            activities are also factored into this consideration.  When 
 
            considering the effects of multiple injuries on the earning 
 
            capacity of an injured worker, the case of Bearce v. FMC 
 
            Corporation, 465 N.W.2d 531 (Iowa 1991) is instructive.  The 
 
            court found that an employer should not be responsible for 
 
            an industrial disability the employer did not cause.  Where 
 
            claimant has suffered a prior injury but has returned to 
 
            work full time, earning full time wages without any physical 
 
            restrictions, does all the assigned work, seeks no medical 
 
            attention, loses no time from work due to the injury and 
 
            suffers no drop in pay, the claimant has not suffered an 
 
            industrial loss.  Bearce, 465 N.W.2d at 536-37.  
 
            Claimant voluntarily left her Wilson job in January 1989 to 
 
            accept new employment.  The job claimant was supposed to 
 
            take did not materialize.  However, claimant eventually went 
 
            to work for Countryside Nursing Home between November 1988 
 
            and March 1990.  Claimant testified that she had more pain 
 
            after this employment experience than when she was working 
 
            at Wilson.  Dr. Wheeler imposed lifting restrictions on her 
 
            after this employment experience as did Dr. Garner.  There 
 
            is no evidence that claimant had further problems with her 
 
            shoulder after she returned to work at Wilson in July and 
 
            after she was rated in October of 1988.  Claimant did not 
 
            seek any medical treatment for her shoulder during the time 
 
            between January 1989 and March or April 1990 except for an 
 
            evaluation for the purposes of worker's compensation 
 
            benefits in May of 1989.  These factors suggest that a 
 
            substantial portion of claimant's disability resulted from 
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            her sojourn at Countryside Nursing Home rather than with 
 
            Wilson.  Moreover, claimant's participation in the 
 
            demolition derby suggests that claimant's injury to her 
 
            shoulder is not as debilitating as she indicated.  
 
            Based upon the foregoing factors, all of the factors used to 
 
            determine industrial disability, and employing agency 
 
            expertise, it is determined that claimant sustained a 15% 
 
            industrial disability.
 
            
 
                 The commencement date for the payment of benefits is 
 
            the date that claimant is released to return to work or the 
 
            treating physician makes a judgment that maximum recovery 
 
            has been achieved.  Peterson v. John Morrell & Co., File 
 
            Nos. 906408, 933308, Slip op. (Iowa Ind. Comm'r Arb. May 21, 
 
            1991).  When a permanent rating is given, it indicates that 
 
            the physician does not expect the claimant to improve and 
 
            this conclusion meets the criteria of Iowa Code section 
 
            85.34(1) and Thomas v. William Knudson & Sons, Inc., 349 
 
            N.W.2d 124, 126 (Iowa App. 1984) for ending a healing 
 
            period.
 
            
 
                 In this instance, claimant was released to return to 
 
            full duty on approximately July 21, 1988.  Dr. Wheeler 
 
            concluded that he had little to offer claimant at the time 
 
            of the July 7, 1988 examination.  She was fully released 
 
            from Dr. Wheeler's care on October 20. 1988.  Dr. Wheeler 
 
            rated claimant on October 20, 1988.  It is clear from the 
 
            medical evidence submitted that there was no change in 
 
            claimant's condition after the July 7, 1988 examination.  
 
            Consequently, claimant's healing period for her shoulder 
 
            ended on July 7, 1988 and permanency payments should be paid 
 
            from July 8, 1988.
 
            
 
                                      order
 
            
 
                 THEREFORE, it is ordered that:
 
            
 
                 1.  Claimant shall take no additional benefits for the 
 
            injury suffered to her right hand.  Wilson has paid claimant 
 
            28.5 weeks of compensation at the rate of $236.90 per week 
 
            prior to the date of the hearing.  No other amounts are owed 
 
            for this injury.
 
            
 
                 2.  Claimant shall take no benefits for the injury 
 
            suffered on November 11, 1987.
 
            3.  Wilson shall pay to claimant permanent partial 
 
            disability benefits in the amount of fifteen percent (15%) 
 
            with payment commencing on July 8, 1988 at the rate of 
 
            $246.12 per week.  As these benefits have accrued, they 
 
            shall be paid in a lump sum together with statutory interest 
 
            thereon pursuant to Iowa Code section 85.30 (1991).
 
            3.  Wilson is entitled to a credit of 25 weeks of 
 
            compensation for the injury to claimant's shoulder 
 
            identified in File Number 872759 at the rate of $246.12 per 
 
            week.
 
            4.  The costs of this action shall be assessed to Wilson 
 
            pursuant to rule 343 IAC 4.33.
 
            5.  Wilson shall file claim activity reports as required by 
 
            rule 343 IAC 3.1.
 
            
 

 
            
 
            Page  15
 
            
 
            
 
            
 
            
 
     
 
            
 
            
 
            Page  16
 
            
 
            
 
            
 
            
 
            Signed and filed this ____ day of October, 1991.
 
            
 
            
 
            
 
            
 
                                          
 
            ________________________________
 
                                          ELIZABETH A. NELSON
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr Harry H Smith
 
            Attorney at Law
 
            PO Box 1194
 
            Sioux City Iowa 51102
 
            
 
            Mr David L Sayre
 
            Attorney at Law
 
            223 Pine Street
 
            PO Box 535
 
            Cherokee Iowa 51012
 
            
 
 
         
 
 
 
 
 
 
 
 
 
 
 
                   5-1108.50; 5-1402.40;
 
                   5-1803; 5-1803.1
 
                   Filed October 24, 1991
 
                   ELIZABETH A. NELSON
 
         before the iowa industrial commissioner
 
         ____________________________________________________________
 
		                   :
 
         COLEEN J. RHEA,           :
 
		                   :      File Nos. 820183
 
              Claimant,	           :                886121
 
                   		   :                872759
 
		         vs.       :
 
                		   :    A R B I T R A T I O N
 
         WILSON FOODS CORPORATION, :
 
		                   :      D E C I S I O N
 
              Employer, 	   :
 
              Self-Insured,        :
 
              Defendant.           :
 
         ___________________________________________________________
 
         
 
         5-1108.50
 
         The medical evidence demonstrated that claimant suffered a 
 
         cummulative trauma injury that caused her to leave work after her 
 
         physician indicated she had chronic tendinitis in her shoulder.
 
         
 
         5-1402.40
 
         Claimant failed to show that she was entitled to a higher 
 
         disability benefit for her hand after carpal tunnel release.  The 
 
         opinion of the evaluating chiropractor was rejected in favor of 
 
         the opinion of the treating orthopedic surgeon who had a better 
 
         opportunity to evaluate claimant's loss.  In connection with the 
 
         injury in file number 886121, claimant did not show that a fall 
 
         five months before the diagnosis of chronic tendinitis resulted 
 
         in any disability to her shoulder.
 
         
 
         5-1803 - 5-1803.1
 
         Claimant, a 30-year-old high school graduate with three quarters 
 
         of post-high school education, who had worked at minimum wages 
 
         all her life until she worked at Wilson, was awarded a 15 percent 
 
         industrial disability for tendinitis in the shoulder.  Claimant 
 
         was released to return to work with a ten percent functional 
 
         impirment rating and no restrictions in July of 1988.  She worked 
 
         until she voluntarily quit her employment in January of 1989.  
 
         Claimant subsequently worked for a nursing home.  This activity 
 
         aggravated her shoulder.  After this employment, claimant's 
 
         primary treating physicians imposed lifting restrictions and work 
 
         restrictions.  This loss was not attributable to Wilson.  Bearce 
 
         v. FMC Corp., 465 N.W.2d 531 (Iowa 1991).