Medical causation
Section 287.020.3(1) RSMo sets forth the relevant test for medical causation, and provides, in relevant part, as follows:
An injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability. "The prevailing factor" is defined to be the primary factor, in relation to any other factor, causing both the resulting medical condition and disability.
Employee advances the expert medical opinion of Dr. P. Brent Koprivica, who believes that the accident of July 3, 2008, was the prevailing factor causing employee to suffer internal derangement of the right knee, but that employee does not suffer from complex regional pain syndrome. Dr. Koprivica rated a 30\% permanent partial disability of the right knee for employee's physical impairments resulting from the work injury.
In addition, Dr. Koprivica determined that, separate from the physical impairments attributable to the work injury, employee has developed probable chronic pain syndrome with an underlying major depressive disorder. Dr. Koprivica indicated that he would defer to a mental health expert with regard to validating such diagnoses, but noted that he would add to his permanent partial disability rating any additional disability referable to the psychological/psychiatric effects of the work injury.
With regard to the issue of the psychological effects of the work injury, employee advances the expert opinion of Dr. Allan Schmidt, a PhD psychologist, who believes the work injury is the prevailing factor causing employee to suffer depression and a pain disorder, which he rates at 20 % permanent partial disability of the body as a whole.
Employer and the Second Injury Fund do not advance any contrary expert psychological/psychiatric opinion evidence. Although we share the administrative law judge's concern that Dr. Schmidt's opinions may be entitled to less weight given his choice to rely upon Dr. Koprivica's report for employee's medical treatment history rather than to personally review employee's medical records, we are not convinced that his opinions are, in the absence of any contrary expert opinion evidence, entirely "weightless." After careful consideration, we credit the causation opinions from both Dr. Koprivica and Dr. Schmidt. We find that the accident of July 3, 2008, was the prevailing factor causing employee to suffer: (1) internal derangement of the right knee with associated permanent partial disability of the right knee referable to her physical impairment; and (2) depression and a pain disorder with associated permanent partial disability of the body as a whole referable to the psychological effects of the work injury.
Injury No. 08-064252
Employee: Deirdre Francis
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**Nature and extent of disability**
In her brief, employee makes clear that she does not argue that the Second Injury Fund is liable for permanent total disability benefits; rather, she asks us to find that her work injury of July 3, 2008, considered alone and in isolation, caused her to suffer permanent total disability.
The test for permanent total disability is whether the worker is able to compete in the open labor market. The critical question is whether, in the ordinary course of business, any employer reasonably would be expected to hire the injured worker, given his present physical condition.
*Molder v. Mo. State Treasurer*, 342 S.W.3d 406, 411 (Mo. App. 2011).
We are not persuaded by employee's claim for permanent total disability benefits from the employer. Dr. Koprivica did not opine that employee is permanently and totally disabled as a result of the work injury, and additional factors, such as employee's return to work as a substitute teacher for approximately two years following her release from treatment for the work injury,[^1] the unclear contribution of the effects of the motor vehicle accident of May 2012 upon her overall condition,[^2] and her receipt of unemployment compensation benefits after quitting work as of May 2012, all cast doubt upon the proposition that the last injury caused any total disability that employee may now suffer.
On the other hand, we do find somewhat inadequate the administrative law judge's finding of 20% permanent partial disability of the right knee. We note that although the authorized treating physician, Dr. Key, recommended surgical intervention for employee's right knee as early as November 24, 2008, employee did not receive this treatment for over eight months, owing in part to employer's reluctance to authorize the procedure. Dr. Snyder finally performed surgery on August 12, 2009, over a year after the injury to employee's knee occurred, but employee did not experience any significant improvement in her symptoms.
We note also that the treating rehabilitation/pain management physician, Dr. Joseph Galate, imposed severe restrictions upon employee's functioning as a result of the work injury. Specifically, Dr. Galate determined as of January 26, 2010, that employee should perform only sedentary duties; refrain from any repetitive bending or twisting; and not lift over 10 pounds. When Dr. Galate released employee from his care as of March 3, 2010, he indicated that there had not been any change or progress in employee's condition. In his final note of April 16, 2010, Dr. Galate stated he would not impose any permanent restrictions, but he did not provide any explanation for removing the prior restrictions, other than to suggest that employee had "returned to work at Full Duty" as of March 3, 2010. *Transcript*, page 229. But this suggestion is belied by Dr. Galate's own note of
[^1]: Employee testified that working as a substitute teacher required her to be very active and on her feet 90% of the time.
[^2]: Dr. Koprivica did not address the effects of the May 2012 accident, as he evaluated employee in February 2012.