Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
            _____
 
                                          :
 
            BRENDA SMITH,                 :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 824666
 
            WINNEBAGO INDUSTRIES,         :
 
                                          :        A P P E A L
 
                 Employer,                :
 
                                          :      D E C I S I O N
 
            and                           :
 
                                          :
 
            SENTRY INSURANCE,             :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            _____
 
            
 
                 The record, including the transcript of the hearing 
 
            before the deputy and all exhibits admitted into the record, 
 
            has been reviewed de novo on appeal.
 
            
 
                                      issues
 
            
 
                 Defendants state the following issues on appeal:  
 
            Whether claimant's left elbow conditions are causally 
 
            related to the injury in 1986.  Whether claimant has a 
 
            permanent disability as a result of the left elbow condition 
 
            following surgery by Dr. Eversmann.
 
            
 
                                 findings of fact
 
            
 
                 The findings of fact contained in the proposed agency 
 
            decision filed April 2, 1991 are adopted as set forth below.  
 
            Segments designated by asterisks (*****) indicate portions 
 
            of the language from the proposed agency decision that have 
 
            been intentionally deleted and do not form a part of this 
 
            final agency decision.  Segments designated by brackets ([ 
 
            ]) indicate language that is in addition to the language of 
 
            the proposed agency decision.
 
            
 
                 Claimant is a 32-year-old who began working for the 
 
            defendant employer on October 19, 1984.  Her prior work 
 
            history was mainly working part-time in seasonal jobs and in 
 
            grocery stores as a clerk stocking shelves, etc.  Claimant's 
 
            work with
 
            
 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            the defendant employer involved patching and painting.  She 
 
            described this as receiving fiberglass and checking it for 
 
            air holes, sanding it and painting it.  She used various 
 
            tools with which she had to apply pressure to break out the 
 
            air bubbles.  She indicated there is no bending or reaching, 
 
            but the job required moving and lifting small-to-large parts 
 
            off the assembly line and setting them on the floor as 
 
            needed.  She would then carry them to her work place.
 
            
 
                 Several months prior to April 1986, claimant was 
 
            experiencing pain, numbness and tingling in her forearm.  
 
            She told the foreman.  He tried to find jobs for claimant 
 
            that would not bother her.  Claimant said she started to use 
 
            her left hand more to compensate for her right.  Claimant 
 
            first saw Dr. David Dennis on April 3, 1986 and then 
 
            switched to T. C. Mead, M.D., who put her in a brace and 
 
            returned her to work.  Claimant returned to an office job 
 
            rather than to the floor.  Claimant testified she returned 
 
            to her floor job in January 1987.  She indicated Dr. Mead 
 
            told her not to return to her job at Winnebago.  Claimant 
 
            related her continued problems, medical treatment and 
 
            surgeries with Ronald Bergman, D.O.
 
            
 
                 Claimant said that around Christmas 1988, during a 
 
            school semester break, she tried to call Dr. Bergman again 
 
            to set up an appointment.  The doctor's office called her to 
 
            see if she had insurance company approval.  Claimant 
 
            responded she did not know that she needed approval.  
 
            Claimant then called the insurance company and told them 
 
            that she needed an appointment.  She related that the 
 
            insurance company told her it must be a new injury, that she 
 
            had already been paid her permanent partial disability for 
 
            her April 3, 1986 injury and that there would be no further 
 
            responsibility.  Subsequent thereto, claimant went for 
 
            further evaluation with Ronald Bergman, D.O., under her 
 
            husband's medical insurance.  She indicated Dr. Bergman did 
 
            grip strength and sensitivity tests and the three visits 
 
            were less than 30 minutes.  Claimant was not getting 
 
            satisfaction and therefore went to William W. Eversmann, 
 
            Jr., M.D., an orthopaedic surgeon, who specialized in hand 
 
            surgery.  Claimant communicated she was there three times 
 
            and each session lasted one hour.  Dr. Eversmann did a 
 
            cubital release on the left elbow which claimant said 
 
            eliminated her numbness and tingling and her awaking at 
 
            night due to her pain.  Claimant related she still has right 
 
            elbow problems even after Dr. Eversmann did surgery on her 
 
            left elbow.  She indicated that she still drops things and 
 
            it appears a nerve "pops" over her crazy bone causing shock 
 
            and numbness in her right elbow.
 
            
 
                 Claimant said she has present restrictions in her arms 
 
            and hands which will be discussed later.  Claimant is now 
 
            working in a convenience store-gas station as a clerk and 
 
            runs a cash register.  She indicated she does not mop, but 
 
            she fills the cooler and stocks the shelves.  Claimant 
 
            communicated that the job requires repetitive work with both 
 
            hands.  Claimant is also still going to school taking a 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            business management course hoping to obtain an associate 
 
            arts degree.  Claimant said she has one and one-half years 
 
            to go under her four-year program at Buena Vista College.  
 
            Claimant indicated that her work at the convenience store 
 
            aggravates her arms and hands.  She indicated she has broken 
 
            many bottles of pop due to dropping the bottles.  She 
 
            acknowledged that due to her problems and not getting the 
 
            treatment she felt she was entitled to, she contacted her 
 
            attorney in the spring of 1989.  Her attorney eventually set 
 
            up the appointment with Dr. Eversmann for an evaluation, but 
 
            not treatment.  After the evaluation, which took several 
 
            visits, she eventually had the surgery performed by Dr. 
 
            Eversmann.  Claimant emphasized her health was good prior to 
 
            her April 3, 1986 injury and that the only injury she had 
 
            previously was a sprained right wrist due to a fall in 
 
            January of 1985.  This healed and there is no residual 
 
            injury or problem from that injury.
 
            
 
                 Dr. Eversmann testified through his deposition on 
 
            February 25, 1991.  He communicated that, when people come 
 
            daily for independent medical evaluations at his medical 
 
            clinic, he and one other doctor usually get the cases 
 
            involving the hand.  He communicated that he does 
 
            approximately one to two hand surgeries per week.  Dr. 
 
            Eversmann first came into contact with the claimant on March 
 
            28, 1989.  The doctor related the history he took from the 
 
            claimant which included the fact that Dr. Mead performed a 
 
            left carpal tunnel release in June of 1987, and Dr. Bergman 
 
            performed a right carpal tunnel release in November of 1987, 
 
            a March 1988 left carpal tunnel and ulnar nerve release, and 
 
            right cubital tunnel operation in April of 1988.  After the 
 
            doctor's evaluation, he concluded that claimant had an 
 
            active and probably progressive cubital tunnel syndrome at 
 
            the left elbow.  Claimant had not had her left elbow 
 
            previously operated on.  He communicated her left wrist was 
 
            stable at the time and did not need any further surgical 
 
            intervention.  He also indicated the right elbow at that 
 
            time, May 3, 1989, was not terribly symptomatic, but he 
 
            thought that the ulnar nerve at the right elbow would 
 
            require an operation to prevent the subluxation of the nerve 
 
            or to prevent injury or subluxation across the elbow at the 
 
            medial epicondyle (Dr. Eversmann deposition exhibit 2, page 
 
            9).  On June 5, 1989, the doctor performed surgery involving 
 
            decompression of the ulnar nerve and performed a medial 
 
            epicondylectomy in order to correct claimant's problem with 
 
            her ulnar nerve at the left elbow.  The doctor concluded 
 
            that claimant's healing period from the operation he 
 
            performed on June 5, 1989 began on that date up to August 
 
            15, 1989.  The doctor also said there was a causal 
 
            relationship which was very clear and concise that the 
 
            claimant had a cumulative trauma or
 
            
 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            repetitive motion disorder manifested by cubital tunnel 
 
            syndrome directly related to her work and probably dating 
 
            back to January and February 1987 (Dr. Eversmann deposition, 
 
            pages 14 and 15).  The doctor testified to the various 
 
            comprehensive tests and comprehensive series of medical 
 
            evaluations he performed on the claimant.  He indicated 
 
            these studies would normally be classified as a functional 
 
            capacity assessment (Dr. Eversmann deposition, page 16; 
 
            deposition exhibit 1).  Dr. Eversmann said:
 
            
 
                 A.  . . . although she is normal when one does a 
 
                 functional capacity assessment within the confines 
 
                 of the AMA Guides, there also can be no question 
 
                 that a person who has had multiple operations for 
 
                 multiple cumulative trauma disorders is at a 
 
                 tremendous risk and should not be referred back to 
 
                 certain types of employment.  So that although it 
 
                 is important to realize that there is no finite 
 
                 impairment that I can isolate by the usual guides, 
 
                 there also is a very specific and strong 
 
                 recommendation that she should not engage in 
 
                 activities that require certain motions of 
 
                 repetitive nature in the course of seeking 
 
                 additional employment.
 
            
 
            (Dr. Eversmann deposition, page 17, lines 3 through 16)
 
            
 
                 The doctor also indicated that claimant should not:
 
            
 
                 A.  . . . she should not engage in any repetitive 
 
                 motion activities on a continuing basis which 
 
                 require flexion and extension of the elbow 
 
                 repetitively, particularly forceful extension of 
 
                 the elbow, not so much concerned about forceful 
 
                 flexion of the elbow at this point, and she should 
 
                 not engage in activity that requires repetitive 
 
                 motions with wrist flexion, that is, using the 
 
                 hand and forearm with the wrist bent in a downward 
 
                 position.  This too would be most dangerous having 
 
                 had the multiple surgeries that she has had for 
 
                 these types of problems which are caused by these 
 
                 types of motions.
 
            
 
            (Dr. Eversmann deposition, page 17, line 20 through page 18, 
 
            line 7)
 
            
 
                 Dr. Eversmann said that these restrictions are 
 
            applicable to both of claimant's upper extremities.  The 
 
            doctor also causally connected these restrictions to her 
 
            injury, including the injuries for which Dr. Bergman had 
 
            treated claimant in Des Moines and for which Dr. Eversmann 
 
            has treated claimant in Cedar Rapids (Dr. Eversmann 
 
            deposition, page 18).  The doctor considered these 
 
            restrictions permanent at the time of his deposition which 
 
            was taken approximately two weeks before the hearing.
 
            
 
                 Dr. Eversmann thought claimant had a very satisfactory 
 
            result from her treatment from him and he noted that she has 
 
            regained strength in her arm to at least an average degree 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            for her size and sex.  She also now has full range of motion 
 
            of her elbow (Dr. Eversmann deposition, page 27).
 
            
 
                 Dr. Bergman, who is a plastic and reconstruction 
 
            surgeon, testified through his deposition on March 5, 1991.  
 
            He recalled the various surgeries he performed on the 
 
            claimant, namely November 20, 1987 (right carpal tunnel 
 
            release), March 7, 1988 (left carpal tunnel and left ulnar 
 
            nerve release), and April 29, 1988 (right cubital tunnel).  
 
            The doctor indicated that, inasmuch as he had performed a 
 
            cubital tunnel surgery on the right side in April of 1988, 
 
            he would have examined the claimant to see if there were any 
 
            other cubital tunnel problems.  The doctor opined that, at 
 
            the time of claimant's right cubital tunnel injury, claimant 
 
            did not have a left side cubital tunnel syndrome.  He felt 
 
            that the tests he gave at the time would have revealed a 
 
            bilateral problem if claimant had one.  He also indicated 
 
            that, as of June 13, 1988, he imposed no restrictions on the 
 
            claimant.  The doctor opined that he made an impairment 
 
            rating at that time with the assistance of an office 
 
            technician and he opined that claimant's impairment would be 
 
            one percent of the right hand based on decreased grip and 
 
            one percent of the left hand based on decreased grip.  Dr. 
 
            Bergman acknowledged that claimant went to Dr. Eversmann, an 
 
            orthopaedic surgeon, on March 28, 1989 and that Dr. 
 
            Eversmann performed a left cubital release in June of 1989.  
 
            The doctor highly doubted claimant had developed a condition 
 
            that Dr. Eversmann diagnosed in June of 1988 that would have 
 
            resulted from an injury claimed by her on April 3, 1986.  
 
            Dr. Bergman was then asked whether the examination of 
 
            Kenneth B. Washburn, M.D., on October 14, 1987 in which he 
 
            found there was no evidence of carpal tunnel syndrome on the 
 
            right and apparently never found any evidence of a cubital 
 
            tunnel syndrome would fortify his opinion that at the time 
 
            of his examination of claimant there was no cubital tunnel 
 
            syndrome likely as a result of that injury.  Again, Dr. 
 
            Bergman said he highly doubted it.  Dr. Bergman's answer is 
 
            of interest since Dr. Washburn saw no evidence of a right 
 
            carpal tunnel situation on that October 14, 1987 examination 
 
            and yet on November 20, 1987, claimant did in fact have a 
 
            right carpal tunnel release performed by Dr. Bergman.  
 
            Claimant also within five months thereafter had a left 
 
            carpal tunnel release and a left ulnar nerve release and 
 
            within six months a right cubital tunnel operation, all 
 
            performed by Dr. Bergman.  It would appear that Dr. Washburn 
 
            saw none of those either and yet the fact is there was 
 
            surgery.  *****
 
            
 
                 *****
 
            
 
                 Joint exhibit B5, page 2, reflects that, on June 10, 
 
            1987, T. C. Mead, M.D., performed a left carpal tunnel 
 
            release.  On that same report he had diagnosed a bilateral 
 
            carpal tunnel syndrome, left worse than the right.  The 
 
            right carpal tunnel was done on November 20, 1987 by Dr. 
 
            Bergman, approximately 17 months later.  Joint exhibit B5, 
 
            page 12, shows October 14, 1987 notes of Dr. Washburn in 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            which at that time his impression was that there was no 
 
            definite evidence of carpal tunnel syndrome on the right by 
 
            nerve conduction testing on this date.  He did, however, 
 
            indicate that positive Tinel's over the median nerve at the 
 
            wrist bilaterally are puzzling.  "A very mild carpal tunnel 
 
            syndrome cannot be entirely ruled out.  I would certainly 
 
            hesitate to do any surgery on either hand at this particular 
 
            point."  (Exhibit B5, page 12)   There was reference to this 
 
            comment of Dr. Washburn when Dr. Bergman's attention was 
 
            called to the same note, although it appears Dr. Bergman was 
 
            using Dr. Washburn's reference that there was no evidence of 
 
            carpal tunnel.  Yet, in reading Dr. Washburn's note, he 
 
            indicates there is no evidence and yet goes on to say that 
 
            things are not only puzzling medically but he would not rule 
 
            out a mild carpal tunnel syndrome entirely.  *****
 
            
 
                                conclusions of law
 
            
 
                 The conclusions of law contained in the proposed agency 
 
            decision filed April 2, 1991 are adopted as set forth below.  
 
            Segments designated by asterisks (*****) indicate portions 
 
            of the language from the proposed agency decision that have 
 
            been intentionally deleted and do not form a part of this 
 
            final agency decision.  Segments designated by brackets ([ 
 
            ]) indicate language that is in addition to the language of 
 
            the proposed agency decision.
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of April 3, 
 
            1986 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 
 
            Hosp., 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. Cent. Tel. Co., 261 
 
            Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 Iowa Code section 85.34(2)(s) states:
 
            
 
                    The loss of both arms, or both hands, or both 
 
                 feet, or both legs, or both eyes, or any two 
 
                 thereof, caused by a single accident, shall equal 
 
                 five hundred weeks and shall be compensated as 
 
                 such, however, if said employee is permanently and 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
                 totally disabled the employee may be entitled to 
 
                 benefits under subsection 3.
 
            
 
                 Iowa Code section 85.27 provides, in part:
 
            
 
                    For purposes of this section, the employer is 
 
                 obliged to furnish reasonable services and 
 
                 supplies to treat an injured employee, and has the 
 
                 right to choose the care.  The treatment must be 
 
                 offered promptly and be reasonably suited to treat 
 
                 the injury without undue inconvenience to the 
 
                 employee.  If the employee has reason to be 
 
                 dissatisfied with the care offered, the employee 
 
                 should communicate the basis of such 
 
                 dissatisfaction to the employer, in writing if 
 
                 requested, following which the employer and the 
 
                 employee may agree to alternate care reasonably 
 
                 suited to treat the injury.  If the employer and 
 
                 employee cannot agree on such alternate care, the 
 
                 commissioner may, upon application and reasonable 
 
                 proofs of the necessity therefor, allow and order 
 
                 other care.  In an emergency, the employee may 
 
                 choose the employee's care at the employer's 
 
                 expense, provided the employer or the employer's 
 
                 agent cannot be reached immediately.
 
            
 
                 It was held that workers' compensation benefits for 
 
            permanent partial disability of two members caused by a 
 
            single accident is a scheduled benefit under Iowa Code 
 
            section 85.34(2)(s).  Simbro v. Delong's Sportswear, 332 
 
            N.W.2d 886 (Iowa 1983).  The degree of impairment caused by 
 
            a partial loss must be computed on the basis of functional, 
 
            rather than industrial, disability.
 
            
 
                 *****
 
            
 
                 [The first issue to be resolved is whether claimant's 
 
            left elbow conditions are causally related to her employment 
 
            with defendant employer.  Claimant was seen by Dr. Bergman 
 
            who eventually did surgeries for right carpal tunnel release 
 
            (November 20, 1987), left carpal tunnel release (March 7, 
 
            1988), and right cubital tunnel release (April 29, 1988).  
 
            It was Dr. Bergman's opinion that at the time of the right 
 
            cubital tunnel release claimant did not have a left side 
 
            cubital tunnel syndrome.  However, Dr. Eversmann who treated 
 
            claimant later was of the opinion that there was a causal 
 
            connection between claimant's work and the left cubital 
 
            tunnel syndrome.  Dr. Eversmann's opinion on causal 
 
            connection will be given greater weight.  He was also 
 
            claimant's treating physician.  He treated claimant more 
 
            recently than Dr. Bergman.  He also adequately explained the 
 
            difference of opinions between himself and Dr. Bergman by 
 
            pointing out that claimant had a right cubital tunnel 
 
            release due to repetitive type work and that claimant was 
 
            continuing to have problems with the left upper extremity 
 
            when she completed treatment with Dr. Bergman.  Claimant has 
 
            proved that her left cubital tunnel syndrome was caused by 
 
            her work with defendant employer.]
 
            
 
                 Claimant incurred a healing period beginning June 5, 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            1989 to and including August 15, 1989, amounting to 10.286 
 
            weeks as a result of her last surgery, all of which resulted 
 
            from claimant's April 3, 1986 work injury.
 
            
 
                 *****
 
            
 
                 [The next issue to be resolved is the extent of 
 
            claimant's disability if any caused by her left cubital 
 
            tunnel syndrome.  The parties apparently agree and the 
 
            defendants have paid weekly benefits for the right and left 
 
            carpal tunnel syndrome and the right cubital tunnel 
 
            syndrome.
 
            
 
                 Dr. Bergman gave claimant functional impairment ratings 
 
            of one percent to each hand and imposed no restrictions on 
 
            claimant as of June 13, 1988.  June 13, 1988 was after the 
 
            surgeries he performed for right and left carpal tunnel 
 
            release and right cubital tunnel release but before Dr. 
 
            Eversmann's surgery for left cubital tunnel release on June 
 
            5, 1989.  Dr. Eversmann has not given a functional 
 
            impairment rating but has indicated the following 
 
            restrictions:]
 
            
 
                 . . . she should not engage in any repetitive 
 
                 motion activities on a continuing basis which 
 
                 require flexion and extension of the elbow 
 
                 repetitively, particularly forceful extension of 
 
                 the elbow, . . . and she should not engage in 
 
                 activity that requires repetitive motions with 
 
                 wrist flexion, that is, using the hand and forearm 
 
                 with the wrist bent in a downward position.
 
            
 
                 *****
 
            
 
                 [It is impossible to tell how much of Dr. Eversmann's 
 
            restrictions relate to the left cubital tunnel syndrome and 
 
            how much relate to the other problems claimant has had to 
 
            her right and left hands and arms.  It was Dr. Eversmann's 
 
            opinion that claimant had excellent result from the surgery 
 
            he performed for the left cubital tunnel syndrome.  It would 
 
            appear that it was Dr. Bergman's opinion that the right 
 
            cubital tunnel syndrome did not increase the functional 
 
            impairment rating.  He rated claimant's functional 
 
            impairment to each hand as being equal after surgery was 
 
            performed for the right cubital tunnel release.  Claimant 
 
            has the burden of proving entitlement to benefits and the 
 
            extent of her disability.  Claimant has not proved that her 
 
            left cubital tunnel syndrome and resulting surgery resulted 
 
            in any increased disability.
 
            
 
                 It appears that defendants have paid weekly disability 
 
            benefits based upon the impairment ratings of Dr. Bergman.  
 
            Claimant has not proved entitlement to additional benefits 
 
            for the left cubital tunnel syndrome.]
 
            
 
                 WHEREFORE, the decision of the deputy is affirmed in 
 
            part and reversed in part.
 
            
 
                                      order
 
            
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That defendants shall pay unto claimant healing period 
 
            benefits at the rate of one hundred forty and 50/100 dollars 
 
            ($140.50) per week for the period beginning June 5, 1989 up 
 
            to and including August 15, 1989, which amounts to ten point 
 
            two eight six (10.286) weeks.
 
            
 
                 That defendants shall pay the accrued weekly benefits 
 
            in a lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendants shall pay the claimant's bills as 
 
            represented by an exhibit in the amount of two thousand six 
 
            hundred forty-nine and 47/100 dollars ($2,649.47) plus 
 
            reimbursing claimant for two hundred twenty-three and 00/100 
 
            dollars ($223.00) worth of mileage.  The parties have 
 
            stipulated that all other medical bills and mileage have 
 
            been or will be paid.
 
            
 
                 That defendants shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 That defendants shall pay the costs of this matter 
 
            including transcription of the hearing and shall reimburse 
 
            claimant for the filing fee if previously paid by claimant.
 
            
 
                 That defendants shall file an activity report upon 
 
            payment of this award as required by this agency pursuant to 
 
            rule 343 IAC 3.1.
 
            
 
                 Signed and filed this ____ day of December, 1992.
 
            
 
            
 
            
 
            
 
                                          
 
            ________________________________
 
                                                   BYRON K. ORTON
 
                                              INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. Arthur C. Hedberg Jr.
 
            Attorney at Law
 
            840 Fifth Avenue
 
            Des Moines, Iowa 50309
 
            
 
            Mr. Harry W. Dahl
 
            Attorney at Law
 
            974 73rd St., Ste 16
 
            Des Moines, Iowa 50312
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                          5-1108; 5-1402.30;
 
                                          5-1402.40; 5-1803
 
                                          Filed December 21, 1992
 
                                          BYRON K. ORTON
 
                                          BJO
 
            
 
                           before the iowa industrial 
 
                                   commissioner
 
            ____________________________________________________________
 
            _____
 
                                          :
 
            BRENDA SMITH,                 :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 824666
 
            WINNEBAGO INDUSTRIES,         :
 
                                          :        A P P E A L
 
                 Employer,                :
 
                                          :      D E C I S I O N
 
            and                           :
 
                                          :
 
            SENTRY INSURANCE,             :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            _____
 
            
 
            
 
            5-1108; 5-1402.30
 
            Opinion of the more recent treating physician was accepted.  
 
            It was this physician's opinion that there was a causal 
 
            connection between claimant's work and her left cubital 
 
            tunnel syndrome.
 
            
 
            5-1402.40; 5-1803
 
            Claimant did not meet her burden of proving entitlement for 
 
            additional benefits due for her left cubital tunnel 
 
            syndrome.  The treating physician gave no impairment rating 
 
            for the left cubital tunnel syndrome.  He also did not 
 
            distinguish restrictions for the left cubital tunnel 
 
            syndrome from restrictions for right and left carpal tunnel 
 
            syndrome and right cubital tunnel syndrome.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            BRENDA SMITH,                 :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :         File No. 824666
 
            WINNEBAGO INDUSTRIES,         :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            SENTRY INSURANCE,             :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            
 
                              statement of the case
 
            
 
                 This case came on for hearing on March 12, 1991 at 
 
            Mason City, Iowa.  This is a proceeding in arbitration 
 
            wherein claimant seeks compensation for permanent partial 
 
            disability benefits as a result of bilateral upper 
 
            extremities injuries.
 
            
 
                 The record in the proceeding consists of the testimony 
 
            of the claimant, joint exhibits A, B, C, D and E and 
 
            claimant's exhibit 1.
 
            
 
                                      issues
 
            
 
                 The issues for resolution are:
 
            
 
                 1.  Whether claimant's alleged permanent partial 
 
            disability to her upper extremities is causally connected to 
 
            her April 3, 1986 injury;
 
            
 
                 2.  The nature and extent of claimant's permanent 
 
            partial disability to her bilateral upper extremities; and,
 
            
 
                 3.  Whether claimant is entitled to section 85.27 
 
            medical benefits with the issues therein being causal 
 
            connection and authorization as to $2,649.47 in medical 
 
            bills and $223.00 of mileage in relation to those medical 
 
            bills and treatment.
 
            
 
                                 findings of fact
 
            
 
                 The undersigned deputy, having heard the testimony and 
 
            considered all the evidence, finds that:
 
            
 
                 Claimant is a 32-year-old who began working for the 
 
            defendant employer on October 19, 1984.  Her prior work 
 
            history was mainly working part-time in seasonal jobs and in 
 
            grocery stores as a clerk stocking shelves, etc.  Claimant's 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            work with the defendant employer involved patching and 
 
            painting.  She described this as receiving fiberglass and 
 
            checking it for air holes, sanding it and painting it.  She 
 
            used various tools with which she had to apply pressure to 
 
            break out the air bubbles.  She indicated there is no 
 
            bending or reaching, but the job required moving and lifting 
 
            small-to-large parts off the assembly line and setting them 
 
            on the floor as needed.  She would then carry them to her 
 
            work place.
 
            Several months prior to April 1986, claimant was 
 
            experiencing pain, numbness and tingling in her forearm.  
 
            She told the foreman.  He tried to find jobs for claimant 
 
            that would not bother her.  Claimant said she started to use 
 
            her left hand more to compensate for her right.  Claimant 
 
            first saw Dr. David Dennis on April 3, 1986 and then 
 
            switched to T. C. Mead, M.D., who put her in a brace and 
 
            returned her to work.  Claimant returned to an office job 
 
            rather than to the floor.  Claimant testified she returned 
 
            to her floor job in January 1987.  She indicated Dr. Mead 
 
            told her not to return to her job at Winnebago.  Claimant 
 
            related her continued problems, medical treatment and 
 
            surgeries with Ronald Bergman, D.O.
 
            Claimant said that around Christmas 1988, during a school 
 
            semester break, she tried to call Dr. Bergman again to set 
 
            up an appointment.  The doctor's office called her to see if 
 
            she had insurance company approval.  Claimant responded she 
 
            did not know that she needed approval.  Claimant then called 
 
            the insurance company and told them that she needed an 
 
            appointment.  She related that the insurance company told 
 
            her it must be a new injury, that she had already been paid 
 
            her permanent partial disability for her April 3, 1986 
 
            injury and that there would be no further responsibility.  
 
            Subsequent thereto, claimant went for further evaluation 
 
            with Ronald Bergman, D.O., under her husband's medical 
 
            insurance.  She indicated Dr. Bergman did grip strength and 
 
            sensitivity tests and the three visits were less than 30 
 
            minutes.  Claimant was not getting satisfaction and 
 
            therefore went to William W. Eversmann, Jr., M.D., an 
 
            orthopaedic surgeon, who specialized in hand surgery.  
 
            Claimant communicated she was there three times and each 
 
            session lasted one hour.  Dr. Eversmann did a cubital 
 
            release on the left elbow which claimant said eliminated her 
 
            numbness and tingling and her awaking at night due to her 
 
            pain.  Claimant related she still has right elbow problems 
 
            even after Dr. Eversmann did surgery on her left elbow.  She 
 
            indicated that she still drops things and it appears a nerve 
 
            "pops" over her crazy bone causing shock and numbness in her 
 
            right elbow.
 
            
 
                 Claimant said she has present restrictions in her arms 
 
            and hands which will be discussed later.  Claimant is now 
 
            working in a convenience store-gas station as a clerk and 
 
            runs a cash register.  She indicated she does not mop, but 
 
            she fills the cooler and stocks the shelves.  Claimant 
 
            communicated that the job requires repetitive work with both 
 
            hands.  Claimant is also still going to school taking a 
 
            business management course hoping to obtain an associate 
 
            arts degree.  Claimant said she has one and one-half years 
 
            to go under her four-year program at Buena Vista College.  
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            Claimant indicated that her work at the convenience store 
 
            aggravates her arms and hands.  She indicated she has broken 
 
            many bottles of pop due to dropping the bottles.  She 
 
            acknowledged that due to her problems and not getting the 
 
            treatment she felt she was entitled to, she contacted her 
 
            attorney in the spring of 1989.  Her attorney eventually set 
 
            up the appointment with Dr. Eversmann for an evaluation, but 
 
            not treatment.  After the evaluation, which took several 
 
            visits, she eventually had the surgery performed by Dr. 
 
            Eversmann.  Claimant emphasized her health was good prior to 
 
            her April 3, 1986 injury and that the only injury she had 
 
            previously was a sprained right wrist due to a fall in 
 
            January of 1985.  This healed and there is no residual 
 
            injury or problem from that injury.
 
            
 
                 Dr. Eversmann testified through his deposition on 
 
            February 25, 1991.  He communicated that, when people come 
 
            daily for independent medical evaluations at his medical 
 
            clinic, he and one other doctor usually get the cases 
 
            involving the hand.  He communicated that he does 
 
            approximately one to two hand surgeries per week.  Dr. 
 
            Eversmann first came into contact with the claimant on March 
 
            28, 1989.  The doctor related the history he took from the 
 
            claimant which included the fact that Dr. Mead performed a 
 
            left carpal tunnel release in June of 1987, and Dr. Bergman 
 
            performed a right carpal tunnel release in November of 1987, 
 
            a March 1988 left carpal tunnel and ulnar nerve release, and 
 
            right cubital tunnel operation in April of 1988.  After the 
 
            doctor's evaluation, he concluded that claimant had an 
 
            active and probably progressive cubital tunnel syndrome at 
 
            the left elbow.  Claimant had not had her left elbow 
 
            previously operated on.  He communicated her left wrist was 
 
            stable at the time and did not need any further surgical 
 
            intervention.  He also indicated the right elbow at that 
 
            time, May 3, 1989, was not terribly symptomatic, but he 
 
            thought that the ulnar nerve at the right elbow would 
 
            require an operation to prevent the subluxation of the nerve 
 
            or to prevent injury or subluxation across the elbow at the 
 
            medial epicondyle (Dr. Eversmann deposition exhibit 2, page 
 
            9).  On June 5, 1989, the doctor performed surgery involving 
 
            decompression of the ulnar nerve and performed a medial 
 
            epicondylectomy in order to correct claimant's problem with 
 
            her ulnar nerve at the left elbow.  The doctor concluded 
 
            that claimant's healing period from the operation he 
 
            performed on June 5, 1989 began on that date up to August 
 
            15, 1989.  The doctor also said there was a causal 
 
            relationship which was very clear and concise that the 
 
            claimant had a cumulative trauma or repetitive motion 
 
            disorder manifested by cubital tunnel syndrome directly 
 
            related to her work and probably dating back to January and 
 
            February 1987 (Dr. Eversmann deposition, pages 14 and 15).  
 
            The doctor testified to the various comprehensive tests and 
 
            comprehensive series of medical evaluations he performed on 
 
            the claimant.  He indicated these studies would normally be 
 
            classified as a functional capacity assessment (Dr. 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            Eversmann deposition, page 16; deposition exhibit 1).  Dr. 
 
            Eversmann said:
 
            
 
                 A.  . . . although she is normal when one does a 
 
                 functional capacity assessment within the confines 
 
                 of the AMA Guides, there also can be no question 
 
                 that a person who has had multiple operations for 
 
                 multiple cumulative trauma disorders is at a 
 
                 tremendous risk and should not be referred back to 
 
                 certain types of employment.  So that although it 
 
                 is important to realize that there is no finite 
 
                 impairment that I can isolate by the usual guides, 
 
                 there also is a very specific and strong 
 
                 recommendation that she should not engage in 
 
                 activities that require certain motions of 
 
                 repetitive nature in the course of seeking 
 
                 additional employment.
 
            
 
            (Dr. Eversmann deposition, page 17, lines 3 through 16)
 
            
 
                 The doctor also indicated that claimant should not:
 
            
 
                 A.  . . . she should not engage in any repetitive 
 
                 motion activities on a continuing basis which 
 
                 require flexion and extension of the elbow 
 
                 repetitively, particularly forceful extension of 
 
                 the elbow, not so much concerned about forceful 
 
                 flexion of the elbow at this point, and she should 
 
                 not engage in activity that requires repetitive 
 
                 motions with wrist flexion, that is, using the 
 
                 hand and forearm with the wrist bent in a downward 
 
                 position.  This too would be most dangerous having 
 
                 had the multiple surgeries that she has had for 
 
                 these types of problems which are caused by these 
 
                 types of motions.
 
            
 
            (Dr. Eversmann deposition, page 17, line 20 through page 18, 
 
            line 7)
 
            
 
                 Dr. Eversmann said that these restrictions are 
 
            applicable to both of claimant's upper extremities.  The 
 
            doctor also causally connected these restrictions to her 
 
            injury, including the injuries for which Dr. Bergman had 
 
            treated claimant in Des Moines and for which Dr. Eversmann 
 
            has treated claimant in Cedar Rapids (Dr. Eversmann 
 
            deposition, page 18).  The doctor considered these 
 
            restrictions permanent at the time of his deposition which 
 
            was taken approximately two weeks before the hearing.
 
            
 
                 Dr. Eversmann thought claimant had a very satisfactory 
 
            result from her treatment from him and he noted that she has 
 
            regained strength in her arm to at least an average degree 
 
            for her size and sex.  She also now has full range of motion 
 
            of her elbow (Dr. Eversmann deposition, page 27).
 
            
 
                 Dr. Bergman, who is a plastic and reconstruction 
 
            surgeon, testified through his deposition on March 5, 1991.  
 
            He recalled the various surgeries he performed on the 
 
            claimant, namely November 20, 1987 (right carpal tunnel 
 
            release), March 7, 1988 (left carpal tunnel and left ulnar 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            nerve release), and April 29, 1988 (right cubital tunnel).  
 
            The doctor indicated that, inasmuch as he had performed a 
 
            cubital tunnel surgery on the right side in April of 1988, 
 
            he would have examined the claimant to see if there were any 
 
            other cubital tunnel problems.  The doctor opined that, at 
 
            the time of claimant's right cubital tunnel injury, claimant 
 
            did not have a left side cubital tunnel syndrome.  He felt 
 
            that the tests he gave at the time would have revealed a 
 
            bilateral problem if claimant had one.  He also indicated 
 
            that, as of June 13, 1988, he imposed no restrictions on the 
 
            claimant.  The doctor opined that he made an impairment 
 
            rating at that time with the assistance of an office 
 
            technician and he opined that claimant's impairment would be 
 
            one percent of the right hand based on decreased grip and 
 
            one percent of the left hand based on decreased grip.  Dr. 
 
            Bergman acknowledged that claimant went to Dr. Eversmann, an 
 
            orthopaedic surgeon, on March 28, 1989 and that Dr. 
 
            Eversmann performed a left cubital release in June of 1989.  
 
            The doctor highly doubted claimant had developed a condition 
 
            that Dr. Eversmann diagnosed in June of 1988 that would have 
 
            resulted from an injury claimed by her on April 3, 1986.  
 
            Dr. Bergman was then asked whether the examination of 
 
            Kenneth B. Washburn, M.D., on October 14, 1987 in which he 
 
            found there was no evidence of carpal tunnel syndrome on the 
 
            right and apparently never found any evidence of a cubital 
 
            tunnel syndrome would fortify his opinion that at the time 
 
            of his examination of claimant there was no cubital tunnel 
 
            syndrome likely as a result of that injury.  Again, Dr. 
 
            Bergman said he highly doubted it.  Dr. Bergman's answer is 
 
            of interest since Dr. Washburn saw no evidence of a right 
 
            carpal tunnel situation on that October 14, 1987 examination 
 
            and yet on November 20, 1987, claimant did in fact have a 
 
            right carpal tunnel release performed by Dr. Bergman.  
 
            Claimant also within five months thereafter had a left 
 
            carpal tunnel release and a left ulnar nerve release and 
 
            within six months a right cubital tunnel operation, all 
 
            performed by Dr. Bergman.  It would appear that Dr. Washburn 
 
            saw none of those either and yet the fact is there was 
 
            surgery.  The undersigned realizes that there are some 
 
            doctors who readily pull out the surgical knife prematurely, 
 
            but the undersigned also believes that there had to have 
 
            been some indication of those things present and evident at 
 
            least at the time Dr. Washburn performed his examination.  
 
            Agency experience has shown time and time again that two 
 
            doctors can examine the same part of the body and yet draw 
 
            varied conclusions, with their opinions conforming to the 
 
            position of the party employing the particular doctor who is 
 
            doing the evaluation.  We may have that situation in the 
 
            case at bar.
 
            
 
                 On cross-examination, Dr. Bergman indicated that he 
 
            used the AMA Guides to the Evaluation of Permanent 
 
            Impairment and it appears that contrary to what is referred 
 
            to in the third edition of the AMA guides, the doctor does 
 
            not distinguish between impairment and disability.  The 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            doctor, on redirect examination, emphasized that he and 
 
            others on his staff do not follow the AMA guides slavishly 
 
            (Dr. Bergman deposition, page 21).  Dr. Bergman agreed that 
 
            the ability or lack of ability of claimant to do repetitive 
 
            motion is not evaluated in any rating considered by the AMA 
 
            guides.  He also agreed that the guides do not measure the 
 
            fact that one should avoid motion activities on a continuing 
 
            basis that require flexion and extension of the elbow.  Dr. 
 
            Bergman acknowledged that it is possible that, since 
 
            claimant had multiple surgeries, these problems and 
 
            complaints may be caused by the surgeries that were 
 
            performed.
 
            
 
                 Joint exhibit B5, page 2, reflects that, on June 10, 
 
            1987, T. C. Mead, M.D., performed a left carpal tunnel 
 
            release.  On that same report he had diagnosed a bilateral 
 
            carpal tunnel syndrome, left worse than the right.  The 
 
            right carpal tunnel was done on November 20, 1987 by Dr. 
 
            Bergman, approximately 17 months later.  Joint exhibit B5, 
 
            page 12, shows October 14, 1987 notes of Dr. Washburn in 
 
            which at that time his impression was that there was no 
 
            definite evidence of carpal tunnel syndrome on the right by 
 
            nerve conduction testing on this date.  He did, however, 
 
            indicate that positive Tinel's over the median nerve at the 
 
            wrist bilaterally are puzzling.  "A very mild carpal tunnel 
 
            syndrome cannot be entirely ruled out.  I would certainly 
 
            hesitate to do any surgery on either hand at this particular 
 
            point."  (Exhibit B5, page 12)   There was reference to this 
 
            comment of Dr. Washburn when Dr. Bergman's attention was 
 
            called to the same note, although it appears Dr. Bergman was 
 
            using Dr. Washburn's reference that there was no evidence of 
 
            carpal tunnel.  Yet, in reading Dr. Washburn's note, he 
 
            indicates there is no evidence and yet goes on to say that 
 
            things are not only puzzling medically but he would not rule 
 
            out a mild carpal tunnel syndrome entirely.  This is a good 
 
            example of the confusion in medical history and medical 
 
            inability to pinpoint certain repetitive or cumulative 
 
            injuries and the lack of success of certain tests to be 
 
            determinative at certain times apparently depending upon the 
 
            doctor involved and who may give them.  This is further 
 
            evidence of the problems that the industrial commissioner 
 
            often has in trying to rule on these cases and the confusion 
 
            among the members of the workers' compensation bar as to 
 
            determine cumulative injuries and the cumulative injury date 
 
            and determination of symptoms involved and whether there may 
 
            be in fact more than one cumulative injury.  It is obvious 
 
            to the undersigned that claimant's problems were basically 
 
            occurring or at least in an inchoate status in that claimant 
 
            was having problems, even though the doctors themselves may 
 
            have varying opinions as to what their tests may or may not 
 
            have shown.
 
            
 
                 It appears the crux of the argument between the parties 
 
            is whether on a scheduled injury the payment of benefits 
 
            would be based on the percent of impairment which in this 
 
            case from the defendants' standpoint would be a maximum of 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            one percent of the right hand and one percent of the left 
 
            hand.  Claimant contends that this rating by the doctor was 
 
            based on the AMA guides and that the undersigned can look 
 
            beyond the guides and look at factors that the AMA guides 
 
            obviously do not consider or make reference to the fact that 
 
            they are only guides and not the last word.  It is obvious 
 
            that the AMA guides are only guides and are not the last 
 
            word.  This is further seen by the fact that there are 
 
            constant changes going on in the AMA guides and the third 
 
            edition has not been out that long and they are already 
 
            working on a fourth edition.  This case is a good example of 
 
            how doctors look at scheduled members and what they see or 
 
            do not see and how it compares to what another doctor may 
 
            see as to a certain medical condition.  The undersigned 
 
            realizes that the workers' compensation bar would like to 
 
            have very definitive guidelines and be able to rely upon the 
 
            fact that if a doctor arrives under the AMA guides to a 
 
            percent of impairment, that that figure can be used in 
 
            multiplying the number of weeks as to the respective 
 
            schedule.  The undersigned realizes that would be ideal, but 
 
            it would also help if we could have some consistency within 
 
            the medical profession when a doctor looks at the same 
 
            scheduled member and supposedly has the same facts and comes 
 
            up with different conclusions, impairment, criteria, 
 
            analysis or diagnosis.  Many of the same individuals who 
 
            desire to have the percent of impairment be the decisive 
 
            factor in figuring the weeks of permanent partial disability 
 
            as to scheduled injuries, also use the percent figure in 
 
            figuring industrial disability.  Clearly, the two scenarios 
 
            are entirely different.
 
            
 
                 The claimant has had multiple surgeries to her 
 
            scheduled members.  Each surgery takes its toll.  Each time 
 
            a person cuts into one's body, there is a certain amount of 
 
            scar tissue and residue.  It is not known as to the reasons 
 
            for lack of success on the earlier surgeries or whether we 
 
            have a situation in which surgery was done sooner than it 
 
            should have been.  The fact is the claimant has had multiple 
 
            surgeries.  Claimant has permanent restrictions, namely that 
 
            "she should not engage in any repetitive motion activities 
 
            on a continuing basis which require flexion and extension of 
 
            the elbow repetitively, particularly forceful extension of 
 
            the elbow, . . . and she should not engage in activity that 
 
            requires repetitive motions with wrist flexion, that is, 
 
            using the hand and forearm with the wrist bent in a downward 
 
            position."
 
            
 
                 It is obvious that these permanent restrictions are a 
 
            result of claimant having the multiple surgeries to her left 
 
            and right upper extremities.  The AMA guides are just what 
 
            they are called--guides.  The undersigned can rely upon his 
 
            agency expertise to determine the ultimate fact as to how 
 
            much the disability should relate to the affected members in 
 
            this particular case.  Permanent restrictions that the 
 
            claimant has are much more severe as is obvious in this case 
 
            than the fact of whether there is any impairment as provided 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            under the limited use of the AMA guides and the provisions 
 
            therein.
 
            
 
                 The parties stipulated that, if the injury is found to 
 
            cause permanent disability, it is a scheduled member 
 
            disability to the bilateral upper extremities and they 
 
            stipulated that the injury was April 3, 1986.  It would 
 
            therefore appear that the provisions of section 85.34(2)(s) 
 
            would be applicable herein if liability and permanency are 
 
            found.  The undersigned finds that the permanent 
 
            restrictions placed on the claimant are substantial in view 
 
            of the nature of the work claimant was doing and has done 
 
            during her life and which it is obvious she is unable to do 
 
            to the same extent at this time with these permanent 
 
            restrictions.
 
            
 
                 Under Simbro v. Delong's Sportswear, 332 N.W.2d 886 
 
            (Iowa 1983), and as it applies to 85.34(2)(s), you would 
 
            take the two values on the combined values chart with 
 
            respect to the impairments of each scheduled member 
 
            converted to the body as a whole to reach a combined percent 
 
            of the body as a whole.  In the case at bar, the impairments 
 
            by the doctors under the AMA guides would amount to not more 
 
            than one percent of each scheduled member which would 
 
            combine to not more than two percent of the body as a whole.  
 
            Exhibit B1, pages 6 and 7, shows Dr. Eversmann's concern 
 
            about the use of the guides, particularly as a sole 
 
            criteria.  It is clear that, because of claimant's 
 
            restrictions, he indicates it would seem logical to be able 
 
            to rate some impairment, but emphasizes that such a rating 
 
            at that time is not possible using the current Guides to the 
 
            Evaluation of Permanent Impairment.  He refers to the fact 
 
            that there is apparently a fourth revision in the making 
 
            which he says may address this problem that currently exists 
 
            in the AMA guides.  The undersigned is fully aware of this 
 
            problem and agency experience has seen this problem, 
 
            particularly when there is little or no impairment rating, 
 
            but there are severe restrictions as in the case at bar.  
 
            The undersigned finds that, considering claimant's 
 
            restrictions and taking into consideration the agency 
 
            expertise, that the claimant in fact has a 20 percent 
 
            impairment each to her right and left upper extremities due 
 
            to her restrictions and multiple surgeries (12 percent body 
 
            as a whole impairment for each upper extremity).  Twelve 
 
            percent plus twelve percent converts to a 23 percent 
 
            combined impairment to the body as a whole.  The undersigned 
 
            finds that claimant has a 23 percent permanent partial 
 
            disability as a result of her bilateral upper extremities 
 
            work-related injury on April 3, 1986.
 
            
 
                 The undersigned further finds that claimant is entitled 
 
            to healing period benefits for the time off beginning June 
 
            5, 1989 up to and including August 15, 1989 at which time 
 
            claimant had another surgery.  The parties had agreed that 
 
            claimant was off during this period of time and indicated 
 
            that was 10 weeks.  In fact, the span is 10 weeks, 2 days.
 
            
 
                 Although Dr. Eversmann was not initially an authorized 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            doctor and claimant went to him initially for an evaluation, 
 
            Dr. Eversmann's bill and those additional bills associated 
 
            therewith, including the hospital, anesthesia and pathology 
 
            bills, totalling $2,649.47, shall be paid by the defendants 
 
            as defendants had denied liability for said bills and for 
 
            further treatment and surgery based on the premise that the 
 
            June 5, 1989 surgery was the result of a new injury and not 
 
            the April 3, 1986 injury.  This June 5, 1989 surgery did 
 
            improve claimant and is causally connected to claimant's 
 
            April 3, 1986 injury.
 
            
 
                 Defendants are responsible for the $223.00 worth of 
 
            mileage reimbursement concerning the medical treatment and 
 
            services that resulted in the $2,649.47 bill.
 
            
 
                 Claimant's $2,649.47 bill, plus the $223.00 of mileage 
 
            reimbursement and claimant's 23 percent permanent partial 
 
            disability are causally connected to claimant's bilateral 
 
            upper extremities April 3, 1986 work injury.
 
            
 
                                conclusions of law
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of April 3, 
 
            1986 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 
 
            Hosp., 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. Cent. Tel. Co., 261 
 
            Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
     
 
            
 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            Iowa Code section 85.34(2)(s) states:
 
            
 
                 The loss of both arms, or both hands, or both 
 
                 feet, or both legs, or both eyes, or any two 
 
                 thereof, caused by a single accident, shall equal 
 
                 five hundred weeks and shall be compensated as 
 
                 such, however, if said employee is permanently and 
 
                 totally disabled the employee may be entitled to 
 
                 benefits under subsection 3.
 
            
 
                 Iowa Code section 85.27 provides, in part:
 
            
 
                    For purposes of this section, the employer is 
 
                 obliged to furnish reasonable services and 
 
                 supplies to treat an injured employee, and has the 
 
                 right to choose the care.  The treatment must be 
 
                 offered promptly and be reasonably suited to treat 
 
                 the injury without undue inconvenience to the 
 
                 employee.  If the employee has reason to be 
 
                 dissatisfied with the care offered, the employee 
 
                 should communicate the basis of such 
 
                 dissatisfaction to the employer, in writing if 
 
                 requested, following which the employer and the 
 
                 employee may agree to alternate care reasonably 
 
                 suited to treat the injury.  If the employer and 
 
                 employee cannot agree on such alternate care, the 
 
                 commissioner may, upon application and reasonable 
 
                 proofs of the necessity therefor, allow and order 
 
                 other care.  In an emergency, the employee may 
 
                 choose the employee's care at the employer's 
 
                 expense, provided the employer or the employer's 
 
                 agent cannot be reached immediately.
 
            
 
                 It was held that workers' compensation benefits for 
 
            permanent partial disability of two members caused by a 
 
            single accident is a scheduled benefit under Iowa Code 
 
            section 85.34(2)(s).  Simbro v. Delong's Sportswear, 332 
 
            N.W.2d 886 (Iowa 1983).  The degree of impairment caused by 
 
            a partial loss must be computed on the basis of functional, 
 
            rather than industrial, disability.
 
            
 
                 It is further concluded:
 
            
 
                 That claimant incurred a work-related bilateral upper 
 
            extremities injury on April 3, 1986 which caused claimant to 
 
            incur five surgeries:  a left carpal tunnel release, a right 
 
            carpal tunnel release, a left carpal tunnel and left ulnar 
 
            nerve release, a right cubital tunnel operation and a medial 
 
            epicondylectomy to correct claimant's ulnar nerve problem at 
 
            the left elbow.
 
            
 
                 That claimant incurred a healing period beginning June 
 
            5, 1989 to and including August 15, 1989, amounting to 
 
            10.286 weeks as a result of her last surgery, all of which 
 
            resulted from claimant's April 3, 1986 work injury.
 
            
 
                 That claimant incurred restrictions as a result of her 
 
            April 3, 1986 work injury indicating:
 
            . . . she should not engage in any repetitive motion 
 
            activities on a continuing basis which require flexion and 
 

 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            extension of the elbow repetitively, particularly forceful 
 
            extension of the elbow, . . . and she should not engage in 
 
            activity that requires repetitive motions with wrist 
 
            flexion, that is, using the hand and forearm with the wrist 
 
            bent in a downward position.
 
            That Dr. Eversmann's treatment was helpful to claimant and 
 
            claimant was entitled to this care as the defendants 
 
            basically denied further medical, claiming claimant incurred 
 
            a new injury and had already been paid all to which she was 
 
            entitled.
 
            That claimant has a 23 percent permanent partial disability 
 
            to her body as a whole under section 85.34(2)(s).
 
            
 
                                      order
 
            
 
                 IT IS THEREFORE ORDERED:
 
            
 
                 That defendants shall pay unto claimant healing period 
 
            benefits at the rate of one hundred forty and 50/100 dollars 
 
            ($140.50) per week for the period beginning June 5, 1989 up 
 
            to and including August 15, 1989, which amounts to ten point 
 
            two eight six (10.286) weeks.
 
            
 
                 That defendants shall pay unto claimant one hundred 
 
            fifteen (115) weeks of permanent partial disability benefits 
 
            at the rate of one hundred forty and 50/100 dollars 
 
            ($140.50) per week beginning August 16, 1989.
 
            
 
                 That defendants shall pay the accrued weekly benefits 
 
            in a lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendants shall pay the claimant's bills as 
 
            represented by an exhibit in the amount of two thousand six 
 
            hundred forty-nine and 47/100 dollars ($2,649.47) plus 
 
            reimbursing claimant for two hundred twenty-three and 00/100 
 
            dollars ($223.00) worth of mileage.  The parties have 
 
            stipulated that all other medical bills and mileage have 
 
            been or will be paid.
 
            
 
                 That defendants shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 That defendants shall pay the costs of this action 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendants shall file an activity report upon 
 
            payment of this award as required by this agency pursuant to 
 
            rule 343 IAC 3.1.
 
            Signed and filed this _____ day of _____________, 1991.
 
            
 
            
 
            
 
            
 
                                          ______________________________
 
                                          BERNARD J. O'MALLEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies to:
 
            
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            Mr. Arthur C. Hedberg Jr.
 
            Attorney at Law
 
            840 Fifth Avenue
 
            Des Moines, Iowa  50309
 
            
 
            Mr. Harry W. Dahl
 
            Attorney at Law
 
            974 73rd Street
 
            Suite 16
 
            Des Moines, Iowa  50312
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
                           1108; 1803; 5-2503
 
                           Filed April 2, 1991
 
                           BERNARD J. O'MALLEY
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            BRENDA SMITH,                 :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :         File No. 824666
 
            WINNEBAGO INDUSTRIES,         :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            SENTRY INSURANCE,             :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            
 
            1108
 
            Found claimant incurred a bilateral upper extremity injury 
 
            that caused claimant to incur five surgeries, namely, a left 
 
            carpal tunnel release, a right carpal tunnel release, a left 
 
            carpal tunnel and left ulnar nerve release, a right cubital 
 
            tunnel operation, and a medial epicondylectomy to correct 
 
            claimant's ulnar nerve problem at the left elbow.
 
            
 
            1108; 1803
 
            Although doctors did not opine more than one percent 
 
            permanent impairment to each hand, a very credible 
 
            orthopaedic hand specialist emphasized that the AMA guides 
 
            are only guides and are deficient in addressing the 
 
            restrictions, etc.  Due to restrictions placed on the 
 
            claimant that "she should not engage in any repetitive 
 
            motion activities on a continuing basis which require 
 
            flexion and extension of the elbow repetitively, 
 
            particularly forceful extension of the elbow, . . . and she 
 
            should not engage in activity that requires repetitive 
 
            motions with wrist flexion, that is, using the hand and 
 
            forearm with the wrist bent in a downward position," the 
 
            deputy found 20 percent permanent impairment to each upper 
 
            extremity and under Simbro v. Delong's Sportswear, 332 
 
            N.W.2d 886 (Iowa 1983) and Iowa Code section 85.34(2)(s) 
 
            found claimant had a combined 23 percent permanent partial 
 
            disability (20 percent of upper extremity equals 12 percent 
 
            body as a whole; on combined charts 12 percent plus 12 
 
            percent equals 23 percent impairment to the body as a whole) 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            and entitled to 500 x 23 = 115 weeks of permanent partial 
 
            disability, which was caused by claimant's April 3, 1986 
 
            work injury.
 
            
 
            5-2503
 
            Found claimant entitled to 85.27 medical benefits and 
 
            mileage causally connected to the medical.  Medical services 
 
            helped claimant.  Defendants basically had denied further 
 
            medical, claiming a new injury.
 
            
 
 
            
 
            
 
            
 
            
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
            BRENDA SMITH,    
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                             File No. 824666
 
            WINNEBAGO INDUSTRIES,      
 
                                               R E M A N D
 
                 Employer,    
 
                                              D E C I S I O N
 
            and         
 
                        
 
            SENTRY INSURANCE,     
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
            This case was remanded to the industrial commissioner by the 
 
            Iowa District Court for further proceedings.  The order of 
 
            remand states that "the Industrial Commissioner did not 
 
            fully address claimant's theory of recovery."  Specifically, 
 
            the district court order stated that the industrial 
 
            commissioner did not address claimant's theory of recovery 
 
            for disability to the right upper extremity, but instead 
 
            addressed only the extent of any disability resulting from 
 
            the left cubital tunnel surgery.
 
            
 
            Claimant has a disability resulting from her right and left 
 
            carpal tunnel conditions, her right and left ulnar 
 
            conditions, and her right cubital tunnel condition.  
 
            Claimant's left cubital tunnel condition developed at a 
 
            point in time indicating it is not causally connected to her 
 
            work injury.  
 
            
 
            Claimant's ratings of impairment under the AMA Guides to the 
 
            Evaluation of Permanent Impairment are minimal.  However, 
 
            claimant's physical restrictions against doing repetitive 
 
            work indicate the actual loss of use is greater than the 
 
            impairment ratings alone indicate.  
 
            
 
            Claimant has a disability of 23 percent as a result of the 
 
            combination of her right and left carpal tunnel conditions, 
 
            her right and left ulnar conditions, and her right cubital 
 
            tunnel condition.  Defendants shall pay unto claimant one 
 
            hundred fifteen (115) weeks of permanent partial disability 
 
            benefits at the rate of one hundred forty and 50/100 dollars 
 
            ($140.50) per week beginning August 16, 1989.  All other 
 
            aspects of the order portion of the appeal decision filed 
 
            December 21, 1992 are incorporated herein.
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            Signed and filed this ____ day of June, 1994.
 
            
 
            
 
            
 
            
 
                                     ________________________________
 
                                            BYRON K. ORTON
 
                                       INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. Arthur C. Hedberg, Jr.
 
            Attorney at Law
 
            840 Fifth Avenue
 
            Des Moines, Iowa 50309
 
            
 
            Mr. Harry W. Dahl, III
 
            Attorney at Law
 
            974 73rd St., Suite 16
 
            Des Moines, Iowa  50312
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                            5-1803
 
                                            Filed June 29, 1994
 
                                            Byron K. Orton
 
            
 
                       BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
            BRENDA SMITH,    
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                               File No. 824666
 
            WINNEBAGO INDUSTRIES,      
 
                                                 R E M A N D
 
                 Employer,   
 
                                               D E C I S I O N
 
            and         
 
                        
 
            SENTRY INSURANCE,     
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
            
 
            
 
            5-1803
 
            On remand, held that claimant had a 23 percent permanent 
 
            partial impairment of her upper extremities under Iowa Code 
 
            section 85.24(2)(s).
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DEBRA A. (NYREEN) BELL,
 
         
 
              Claimant,
 
                                                     FILE NO. 824692
 
         vs.
 
                                                 A R B I T R A T I 0 N 
 
         JOHN MORRELL & CO.,
 
                                                     D E C I S I 0 N
 
              Employer,
 
         
 
         and                                            F I L E D
 
         
 
         NATIONAL UNION FIRE                           APR 21 1988
 
         INSURANCE COMPANY,
 
                                              IOWA INDUSTRIAL COMMISSIONER
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
                              STATEMENT OF THE CASE
 
         
 
              This is a proceeding in arbitration brought by Debra A. Bell 
 
         formerly known as Debra A. Nyreen, claimant, against John Morrell 
 
         & Company, employer (hereinafter referred to as Morrell), and 
 
         National Union Fire Insurance Company, insurance carrier, for 
 
         workers' compensation benefits as a result of an alleged injury 
 
         on April 3, 1986.  On February 11, 1988, a hearing was held on 
 
         claimant's petition and the matter was considered fully submitted 
 
         at the close of this hearing.
 
         
 
              The parties have submitted a prehearing report of contested 
 
         issues and stipulations which was approved and accepted as a part 
 
         of the record of this case at the time of hearing.  Oral 
 
         testimony was received during the hearing from claimant and the 
 
         following witnesses:  Sandra Jordan and Perry McCaskill.  The 
 
         exhibits received into the evidence at the hearing are listed in 
 
         the prehearing report.
 
         
 
                                      ISSUES
 
         
 
              The parties submitted the following issues for determination 
 
         in this proceeding:
 
         
 
                I.  Whether claimant received an injury arising out of and 
 
         in the course of her employment;
 
         
 
               II.  Whether there is a causal relationship between the 
 
         work injury and the claimed disability;
 
         
 
              III.  The extent of weekly disability benefits to which 
 
         claimant is entitled; and,
 
                                                
 
                                                         
 
         
 
               IV.  The extent of claimant's entitlement to medical 
 
         benefits under Iowa Code section 85.27.
 
         
 
                            SUMMARY OF THE EVIDENCE
 
         
 
              The following is a summary of the evidence presented in this 
 
         case.  For the sake of brevity, only the evidence most pertinent 
 
         to this decision is discussed.  Whether or not specially referred 
 
         to in this summary, all of the evidence received at the hearing 
 
         was reviewed and considered in arriving at this decision.  As 
 
         will be the case in any attempted summarization, conclusions 
 
         about what the evidence offered may show are inevitable.  Such 
 
         conclusions, if any, in the following summary should be 
 
         considered as preliminary findings of fact.
 
         
 
              Claimant contains that she received an injury in the form of 
 
         carpal tunnel syndrome to her right wrist during her third day of 
 
         employment at defendants' packing plant in April of 1986.  
 
         Claimant testified that prior to her alleged injury she was moved 
 
         to five different jobs in the plant, including such jobs as 
 
         grading bellies, wrapping butt, trimming fat, trimming knuckles 
 
         and boning picnic hams.  It was while performing the boning of 
 
         hams job that she claims to have injured her wrist.  Claimant was 
 
         terminated by defendants after approximately one week on the job.  
 
         Claimant testified that she was not told any reason for this 
 
         termination. Claimant's supervisor testified that her termination 
 
         was due to the fact that she could not keep up with the work and 
 
         that she was only a probationary employee.
 
         
 
              Claimant testified at hearing that on April 3, 1986, while 
 
         boning hams she tossed a boned ham onto an overhead conveyor belt 
 
         and in the process, the sleeve of her smock became caught in a 
 
         conveyor belt mechanism which tightened the sleeve around her 
 
         right wrist squeezing her hand between the conveyor belt and a 
 
         support bar.  While pulling to free her right hand from the 
 
         conveyor mechanism, she felt pain in her right arm and when she 
 
         finally was able to remove the hand from the mechanism, it began 
 
         to swell around the right wrist area according to claimant.  
 
         Sandra Jordan, a fellow employee, testified that she knows 
 
         claimant personally and worked with claimant in 1985 at a previous 
 
         packing plant called "Pakfab."  Jordan testified that although she 
 
         didn't see the entire sequence of events as she was working in a 
 
         different area, she was able to observe claimant from her work 
 
         station and that she saw claimant's hand "go up" and claimant 
 
         "taking ahold of her other arm."  Claimant testified that she 
 
         reported her wrist injury to her foreman immediately and that he 
 
         told her that she was only a probationary employee.  She claims 
 
         that the foreman told her that if she reported the injury she 
 
         would be fired.  The foreman denied such statements in his 
 
         testimony and stated that he first became aware of claimant's 
 
         claim of injury only after being contacted by defense counsel in 
 
         the fall of 1987.
 
         
 
              Claimant said that after the April 3, 1986 incident referred 
 
                                                
 
                                                         
 
         to above, the wrist swelling and shooting pains into the elbow 
 
         continued and she had never before experienced such problems.  
 
         She stated that her problems then became worse with a loss of 
 
         strength and an inability to hold objects.  Claimant did not 
 
         immediately seek medical treatment for this condition.  Claimant 
 
         was examined on May 20, 1986 by John J. Dougherty, M.D., upon 
 
         referral for examination by the Nebraska State Department of 
 
         Rehabilitation. According to Dr. Dougherty, claimant reported to 
 
         him that she had carpal tunnel surgery in 1982 for prior right 
 
         hand wrist problems and that "she didn't do well after surgery."  
 
         Dr. Dougherty reports that claimant told him that before she 
 
         began working for Morrell she had worked for a previous packing 
 
         plant called Pakfab and that she expressed problems with this job 
 
         in that she "couldn't do any lifting."  Claimant told Dr. 
 
         Dougherty that she was fired at Morrell because she couldn't do 
 
         the job.  She also told him that "they required lifting, but 
 
         because of the previous problem she did not see any doctor."  
 
         There was no mention of any injury in April, 1986, to Dr. 
 
         Dougherty in Dr. Dougherty's history.  Claimant explained in her 
 
         deposition that Dr. Dougherty's reports are inaccurate.
 
         
 
              Claimant then sought treatment from C. Robert Adams, M.D., a 
 
         neurologist, on July 18, 1986 for persistent pain and weakness of 
 
         the right arm.  She told Dr. Adams that she did reasonably well 
 
         until April of 1986, when she was throwing a piece of meat on a 
 
         table and "hit her hand on the table."  She stated that she has 
 
         numbness, tingling and weakness of the right hand since that 
 
         time. Dr. Adams felt that claimant may have carpal tunnel 
 
         syndrome.  In August, 1986, Dr. Adams performed an EMG test which 
 
         proved to be normal.  According to the medical records in the 
 
         latter part of 1986 and the early part of 1987, claimant received 
 
         pain medication for her wrist problems from a previous physician, 
 
         Jay Walston, M.D.  In June, 1987, claimant returned to Dr. Adams 
 
         who noted an increase in claimant's symptoms in the right wrist 
 
         and a second EMG test confirmed a worsening of a carpal tunnel 
 
         problem.  Dr. Adams now recommends surgery to alleviate some of 
 
         claimant's right wrist problems.
 
         
 
              Initially in her deposition taken by defendants in March, 
 
         1987, claimant denied any prior wrist or arm problems.  However, 
 
         she admitted upon further questioning about her prior surgery in 
 
         1982 that she suffered numbness and tingling of her fingers in 
 
         1982 while working for another meat packing plant, IBP.  These 
 
         problems led to surgery on her right wrist in March of 1982.  
 
         She, however, stated in her deposition that she had no problems 
 
         after July or August of 1982, contrary to what she told Dr. 
 
         Dougherty in May of 1986.  According to claimant's medical 
 
         records, claimant was treated in the latter part of 1981 and 
 
         during 1982 for DeQuervains syndrome of the right wrist which 
 
         eventually led to release surgery of the tendon sheath over the 
 
         thumb tendon. Claimant still had a visible scar from this surgery 
 
         which was performed by a Dr. Mumford (first name unknown).  
 
         According to Dr. Mumford's records, after claimant was released 
 
         from his care in 1982, claimant called him in June of 1984, 
 
         complaining that her right wrist "continues to shake since the 
 
                                                
 
                                                         
 
         surgery" and that she "can't hold job."
 
         
 
              Claimant also denied any prior wrist problems, surgery or 
 
         receipt of workers' compensation benefits for the 1982 injury in 
 
         her application for employment with Morrell in March of 1986. 
 
         Claimant responded negatively to inquiries in written and oral 
 
         form as to prior injuries or surgeries to the examining physician 
 
         Milton Grossman, M.D.  Claimant stated in her deposition that she 
 
         was advised to answer in that manner by Dr. Grossman because he 
 
         told her that her prior injury and surgery was not the business 
 
         of Morrell.  Dr. Grossman in correspondence to defendants' 
 
         attorneys, after being informed of claimant's statements in her 
 
         deposition, denies giving any such advice to claimant.  He states 
 
         that the patients fill out the inquiries before he even talks to 
 
         them.
 
         
 
              Claimant testified that she left IBP in 1982 during a strike 
 
         and moved to the State of Washington.  In the State of 
 
         Washington, claimant states that she performed meat packing and 
 
         bakery work. She said that she had no problems with this work.  
 
         In 1985, she returned to Iowa to care for her mother and worked 
 
         for three or four months at Pakfab performing meat cutting work.  
 
         Claimant stated in her deposition that she left Pakfab because 
 
         they reduced her weekly number of hours.  She however had no 
 
         explanation why she would leave a full time permanent job at 
 
 
 
                            
 
                                                         
 
         Pakfab to except only a one month temporary job to replace 
 
         striking workers at a bakery called Interbake.  In her employment 
 
         application to Morrell she said that she left Pakfab due to a 
 
         layoff.  According to Pakfab's records she was terminated due to 
 
         absenteeism.  Claimant said in the deposition that she only 
 
         missed a few days due to colds and flu.
 
         
 
              In his reports, Dr. Adams felt that there is a causal 
 
         connection between claimant's current carpal tunnel syndrome 
 
         problems and the events of April 3 related to him by claimant at 
 
         Morrell.  Dr. Dougherty, when confronted with the records in this 
 
         case, states as follows:
 
         
 
              She told me she got it caught in a belt.  That is what she 
 
              told Dr. Adams.  However, the first time she saw Dr. Adams, 
 
              she apparently told him she got hit in the hand and this is 
 
              what she told Dr. Walston.  Also, she had an EMG by Dr. 
 
              Adams on 8-8-86 which was normal.  At that time, when Dr. 
 
              Adams saw her first in July of 1986, she said she hit her 
 
              hand on a table.  On reviewing Dr. Mumford's old notes and 
 
              Dr. Butler's notes, you can see very readily that she has 
 
              had trouble before.  She really didn't have a carpal tunnel 
 
              release by Dr. Mumford, rather she had a release of 
 
              DeQuervains disease, which is totally different.  Probably 
 
              she never really had any flexor tendonitis.  It is rather 
 
              interesting also that she said she didn't do well after the 
 
              surgery for her carpal tunnel, which really wasn't a carpal 
 
              tunnel at all.  Then at another time, she said she had no 
 
              trouble after the surgery. According to your note, 
 
              apparently after Dr. Adams saw her in November of 1987, he 
 
              indicates that the nerve conduction studies and EMG revealed 
 
              worsening medial neuropathy at the carpal tunnel or carpal 
 
              tunnel syndrome on the right, from when the tests were done 
 
              on 8-8-86.  They called the 8-8-86 EMG normal, I believe, so 
 
              if there is anything, it would be worse.
 
         
 
              . . .
 
         
 
              On attempting to evaluate this whole thing, I would concur 
 
              that there is an awful lot of inconsistencies.  She may have 
 
              a carpal tunnel syndrome now, but I don't think this is 
 
              related to the incident of 4/3/86 ....
 
         
 
                           APPLICABLE LAW AND ANALYSIS
 
         
 
              I.  Claimant has the burden of proving by a preponderance of 
 
         the evidence that claimant received an injury which arose out of 
 
         and in the course of employment.  The words "out of" refer to the 
 
         cause or source of the injury.  The words "in the course of" 
 
         refer to the time and place and circumstances of the injury.  
 
         See Cedar Rapids Community Sch. v. Cady, 278 N.W.2d 298 (Iowa 
 
         1979); Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 402, 68 
 
         N.W.2d 63 (1955). An employer takes an employee subject to any 
 
         active of 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 
 
         therein.
 
         
 
              In the case sub judice, claimant has not demonstrated by the 
 
         greater weight of credible evidence that she suffered a work 
 
         injury to her right wrist at Morrell in April of 1986.  Dr. 
 
         Adams' views are not convincing.  The doctor did not sufficiently 
 
         explain his causal connection views when the records clearly show 
 
         a worsening of claimant's condition after she had left John 
 
         Morrell in April of 1986.  Also, Dr. Adams is relying upon the 
 
         histories provided to him by claimant and claimant is not found 
 
         to be credible.  The inconsistencies in claimant's various 
 
         stories and repeated attempts to deceive in her deposition cannot 
 
         be explained away by an understandable exaggeration as is 
 
         observed in many claimants who appear before this agency.  Also, 
 
         the clear views of Dr. Dougherty are the most convincing.  If 
 
         claimant does have carpal tunnel syndrome, it is not due to 
 
         anything that may have happened to her at Morrell.  The testimony 
 
         of claimant's acquaintance, Jordan, was not of much help to 
 
         claimant.  First, it appeared quite implausible that a busy 
 
         packinghouse worker would, without reason, simply look up at a 
 
         very convenient time observe the work injury.  However, assuming 
 
         that Jordan is credible and she is correct in her observations 
 
         she saw very little of the events and only observed the swelling 
 
         which could have began at any time.  Her testimony that claimant 
 
         had no problems at Pakfab appear quite inconsistent with prior 
 
         past medical records.
 
         
 
                              FINDINGS OF FACT
 
         
 
              1.  Claimant could not be found to be a credible witness.
 
         
 
              2.  In 1982, while working for a meat packing firm, claimant 
 
         injured her right wrist consisting of numbness, tingling and loss 
 
         of strength in her right hand and was diagnosed as suffering from 
 
         a DeQuervains release syndrome and a release surgery was 
 
         performed.  Claimant suffered shooting pains into her arm both 
 
         before and after this surgery.
 
         
 
              3.  Claimant has only worked intermittently since 1982 and 
 
         continues to suffer problems in her right wrist consisting of 
 
         pain, numbness, tingling and loss of strength.  She also 
 
         continues to have right arm shooting pain.
 
         
 
              It could not be found that any of the claimant's current 
 
         right wrist problems were due to her work at Morrell.
 
         
 
                           CONCLUSIONS OF LAW
 
         
 
              Claimant has not established entitlement to workers' 
 
         compensation benefits.
 
         
 
                               ORDER
 
         
 
                                                
 
                                                         
 
               1.  Claimant shall take nothing from these proceedings.
 
         
 
               2.  Due to her lack of credibility, claimant shall pay the
 
         cost of this action pursuant to Division of Industrial Services
 
         Rule 343-4.33.
 
         
 
         
 
              Signed and filed this 21st day of April, 1988.
 
         
 
         
 
                                           
 
         
 
         
 
                                            LARRY P. WALSHIRE
 
                                            DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Bryan J. Arneson
 
         Attorney at Law
 
         340 Insurance Centre
 
         507 - 7th St.
 
         Sioux City, Iowa  51101
 
         
 
         Mr. Thomas M. Plaza
 
         Attorney at Law
 
         200 Home Federal Bldg.
 
         P. 0. Box 3086
 
         Sioux City, Iowa 51102
 
 
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                                 1100
 
                                                 Filed April 21, 1988
 
                                                 LARRY P. WALSHIRE
 
         
 
                   BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DEBRA A. (NYREEN) BELL,
 
         
 
              Claimant,
 
                                                      FILE NO. 824692
 
         vs.
 
                                                   A R B I T R A T I 0 N
 
         JOHN MORRELL & CO.,
 
                                                       D E C I S I 0 N
 
              Employer,
 
         
 
         and
 
         
 
         NATIONAL UNION FIRE
 
         INSURANCE COMPANY,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
         1100
 
         
 
              Claimant failed to establish causal connection of her carpal 
 
         tunnel problems to her work at defendants' packing plant after 
 
         only three days on the job.  Claimant lacked credibility in 
 
         denying the extent of her prior problems which seem to stem from 
 
         a work injury while working for a previous employer several years 
 
         before the alleged work injury in this case.  All benefits were 
 
         denied.