Crew v. First Source Furniture Group

IN THE SUPREME COURT OF TENNESSEE
AT JACKSON
April 1, 2008 Session

LACAY CREW V. FIRST SOURCE FURNITURE GROUP d/b/a
ANDERSON HICKEY COMPANY

Appeal by permission from the
Supreme Court Special Workers’ Compensation Appeals Panel
Lauderdale County Chancery Court
No. 12958-38-69 Dewey Whitenton, Chancellor

No. W2006-00713-SC-WCM-WC - Filed June 24, 2008

In 2004, the plaintiff, Lacay Crew, filed a workers’ compensation claim alleging injuries to her left
and right hands, wrists, and arms, while in the course and scope of her employment. In response,
the defendant, First Source Furniture Group, d/b/a Anderson Hickey Company, denied the claim on
issues of causation. The trial court found that Crew sustained a compensable, gradual injury to both
upper extremities and awarded a permanent partial vocational disability of 25% to each upper
extremity equating to a judgment award of $25,479.00. Discretionary costs in the amount of $150.00
were awarded for reimbursement to Crew for a doctor’s completion of a Tennessee Department of
Labor Form C-32 on Crew’s behalf. The Special Workers’ Compensation Appeals Panel found that
there was insufficient evidence of causation and dismissed the case. We affirm the decision of the
Appeals Panel.

Tenn. Code Ann. § 50-6-225(e); Findings of Fact and Conclusions of Law of the Special
Workers’ Compensation Appeals Panel Affirmed.

GARY R. WADE, J., delivered the opinion of the court, in which WILLIAM M. BARKER, C.J., and
CORNELIA A. CLARK, and WILLIAM C. KOCH , JR., JJ., joined. JANICE M. HOLDER , J., not
participating.

S. Newton Anderson and Gayle B. Lakey, Memphis, Tennessee, for the appellant, First Source
Furniture Group d/b/a Anderson Hickey Company.

Steven C. Grubb, Memphis, Tennessee, for the appellee, Lacay Crew.

OPINION
I. Facts
 Lacay Crew (“Crew”), who was 39 years of age at the time of trial, is a high school graduate.
She attended college for a time, studying voice range and music. Her work career began with
packing automobile parts at Tennessee Electroplating for approximately six months and putting parts
on the line for motors for fans at Magnetek Universal Electric. She began working for First Source
Furniture Group, d/b/a Anderson Hickey Company (“Anderson Hickey”) in 1991, where she
operated a break press. Her job required that she bend parts that would later be used to assemble
desks. In 1995, she left Anderson Hickey and became a substitute teacher. In 1999, when she
returned to Anderson Hickey, she was initially assigned to the welding department, where she
assembled filing cabinets and later began to assemble desks on the line.1 She worked there
continuously until January 28, 2002, when she was permanently laid off. Anderson Hickey’s plant
closed two months later.

In October 2001, during the time in which she was working in desk assembly, Crew used a
rubber hammer weighing approximately five pounds to bend drawers in order to assure a proper fit.
When a desk on the moving assembly line lacked all of the necessary parts, Crew, with the help of
others, would lift as much as 200-300 pounds of weight. Her work was varied and included welding
and working on the hang line lifting files. On her own, she could lift approximately 30 to 40 pounds.

On October 13, 2001, Crew noticed that her wrist was swollen. Ten days later, the swelling
was worse. She reported her condition to her supervisor because she could not remove her ring from
her finger. Anderson Hickey referred her to a Dr. Robbins.

Before being treated by Dr. Robbins, Crew completed a workers’ compensation
questionnaire. She reported that she lifted items from the floor to the “peds,” helped to fit drawers
on a desk line “in an upward [and] downward motion all day,” and “notice[d] tingling in [her]
fingers and also swelling of the fingers [and] wrist.” During the course of treatment on her left wrist,
Crew began to experience pain in her right wrist as well. Dr. Robbins, who last saw Crew in
December of 2001, authorized her return to work with a ten pound lifting restriction. Ultimately, he
referred her to a Dr. Carl Huff, an orthopedic surgeon.

On December 21, 2001, Crew had her first appointment with Dr. Huff. She complained at
that time of numbness in her left hand and a gradual onset of symptoms occurring in the previous
two months associated with repetitious use of her hand at work. She also reported that she had been
wearing a brace and using medications. Dr. Huff found that Crew had nearly a full range of motion

1
Crew testified on direct examination that she cam e back to Anderson Hickey in 1999 in the welding
department and that she did that “[u]p to 2002” for “about a year and a half.” She also stated that she went back in
“about ‘97, ‘98” in “desk assembly.”

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but tested positive on both a Phalen’s test2 and Tinel’s sign.3 He also noted that she displayed a
slight weakness of pinch and had decreased sensation in her thumb and fingers. Dr. Huff
acknowledged that the validity of these results depends upon subjective responses from a patient to
questions relative to sensation. Radiographs of Crew’s left wrist were negative. Dr. Huff ordered
an electromyogram (“EMG”), which measures the speed of the transmission of an electrical impulse
along the path of the nerve, to determine whether Crew was suffering from carpal tunnel syndrome.
He deemed the EMG as particularly reliable because it “doesn’t require patient response.” Dr. Huff
returned Crew to work with a five-pound lifting limit, a repetitive work restriction, and a wrist
immobilizer.

Three weeks later, Dr. Huff conducted a second examination. In the meantime, the EMG
report indicated no carpal tunnel syndrome to the left upper extremity. On physical examination,
however, Dr. Huff found “marked tenderness over the first dorsal extensor compartment at the
wrist,” “increased pain” in the same area, a diminished strength of pinch, and a negative Phalen’s
test and Tinel’s sign over the median nerve. Crew’s range of motion remained full. Dr. Huff
diagnosed de Quervain’s tendonitis4 of the left wrist and ordered a cortisone shot, medications for
pain, an immobilizer, and further testing. Because Crew was still complaining of some numbness
in her left hand, Dr. Huff ordered lab testing for arthritic and rheumatological issues. He again
returned her to work with the five-pound lifting restriction and repetitive work restriction.

When Crew returned to Dr. Huff on January 24, 2002, for a third visit, she reported that her
grip and pinch had “definitely improved.” Her examination showed minimal tenderness, her pinch
and grip strength were near normal, and she had no loss of sensation. Dr. Huff prescribed an anti-
inflammatory medication and returned her to work without restrictions.

One week later, Crew returned to see Dr. Huff complaining of pain in her left shoulder and
right wrist and generalized pain in her joints. By then, Dr. Huff had the lab results for rheumatology,
which indicated that Crew had lupus, an inflammatory arthritic condition. He noted pain and
swelling in multiple parts of her body and stated that it was “possible” that her return to work at full
duty had aggravated her condition. It was also his opinion that Crew would be permanently unable
to resume repetitious work. Dr. Huff advised her to seek follow up care for her lupus from her
primary care physician.

2
Dr. Huff described the Phalen’s test as “a compression test of the median nerve where the wrist is flexed for
60 seconds, and then they get a tingling in the distribution of the median nerve.”
3
Dr. Huff described the Tinel’s sign as a “tap over the nerve” that results in a “radiating paresthesia in the
distribution of the nerve.”
4
Dr. Huff described de Quervain’s tendonitis as a “stenosing tenosynovitis of the extensor tendons to the
thumb, actually the abductor pollicis longus and extensor pollicis brevis . . . . [a]s they course through the first dorsal
extensor compartment, they get tightness and pressure and this causes pain when these tendons glide with movement.”
It is also known, among other things, as De Quervain’s tenosynovitis and De Quervain’s Syndrome. Tendonitis can
also be spelled “tendinitis.”

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 In December of 2002, Crew again saw Dr. Huff on a follow-up basis, complaining of
numbness in the left hand and, for the first time, in the right hand. She also displayed triggering of
her left middle finger, tenderness over the de Quervain’s tendons of the left wrist, decreased
sensation in her fingers, and a slight weakness of pinch in both hands. She reported a tingling
paresthesia with the Phalen’s test in both wrists. Dr. Huff ordered EMGs to both the left and right
upper extremities, but released Crew to full duty with no restrictions.

On January 24, 2003, Dr. Huff determined that the EMG was negative as to both extremities
“with no indication of carpal tunnel syndrome or other peripheral nerve entrapment.” He found no
specific pathological condition, a full range of motion, and normal pinch and grip strength, sensation,
and circulation. He placed no restrictions and gave a full duty release. It was his opinion, based on
a reasonable degree of medical certainty and any guidelines for impairment, that Crew had sustained
“[n]o impairment.” It was his further opinion that if she had left employment with Anderson Hickey
and begun other work as a box assembler for nine months, that “the new job would have caused the
carpal tunnel since her EMG, when I did it last was normal.” Dr. Huff concluded that any disability
to Crew’s upper left extremity was the result of something “after she left my office.”

On August 22, 2002, some eight months after being laid off by Anderson Hickey and when
under the treatment of Dr. Huff, Crew visited Dr. John Janovich, an orthopedic surgeon.5 Crew
testified that she saw Dr. Janovich based on a referral from her sister. On that date she told him of
the problems she was having with her hands, wrists, and arms. Dr. Janovich conducted some tests,
but rendered no other treatment at that time.

After her employment ended at Anderson Hickey, Crew worked briefly at a Slim Fast plant,
where she picked up and stacked cans eight hours a day, five days a week with some overtime.
Beginning January 2003, she was employed for eight months by Paslode, making boxes and placing
nails on a conveyor belt. On September 3, 2003, near the end of her employment at Paslode, Crew
sought medical treatment for the first time since having last seen Dr. Huff. Dr. David West, an
orthopedic surgeon, heard Crew’s complaint about left and right wrist pain with some shoulder pain.6
He noted a history of pain for approximately two years with negative EMGs on both upper
extremities. Because of continuing symptoms and the passage of time, Dr. West conducted another
EMG, which this time was positive for moderate carpal tunnel on the right wrist. Three weeks later,
Dr. West performed right carpal release surgery on Crew’s right wrist.7 He later concluded that
Crew had healed well and discharged her on November 18, 2003.

5
None of Dr. Janovich’s medical records provided include the August 2002 visit.
6
Nothing in the record indicates that Crew sought any medical care for her bilateral upper extremity complaints
from the time she left Dr. Huff’s care on January 24, 2003 and her visit with Dr. W est on September 3, 2003.

7
Dr. West testified by deposition that the surgery was on January 24, 2003, but his medical notes indicate the
date of procedure as September 24, 2003. In another part of his testim ony, he stated that he provided treatment in
September 2003.

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 Dr. West completed a Tennessee Department of Labor C-32 Form and opined that Crew
sustained a 2% permanent physical impairment to a scheduled member. He determined that her
impairment more probably than not arose out of her employment. By deposition, Dr. West
acknowledged that he was aware that Crew’s employment with Anderson Hickey was terminated
in January of 2002, and was further aware that she worked at Paslode from January to September
2003. Dr. West, who was unable to determine to a reasonable degree of medical certainty which
employer, Anderson Hickey or Paslode, was responsible for Crew’s right carpal tunnel condition,
observed as follows:

The only true fact . . . is that you had a physician that examined her during the time
she worked for Anderson Hickey, who did a detailed EMG nerve conduction study
that revealed that she did not have carpal tunnel, by EMG. Whether she had
numbness and pain and disability to her hand, I didn’t examine her during that time,
so I can’t say. But the EMG was positive from the time that she left Anderson
Hickey until when I saw her. That is the only true statement I know. And so you
could assume that the patient developed carpal tunnel during that period, because the
previous EMG was normal.

Upon being questioned as to the injury to Crew’s right wrist, Dr. West said, “I think the fact is . . .
that the patient developed a positive EMG within nine months of the normal one. So by assumption,
that would mean that the second employer would have been at least the aggravating cause, if not the
cause.” He also stated that the repetitive type of work described as being Crew’s duties at Paslode
was the type of work that can commonly result in carpal tunnel syndrome, and that based on such
a job description, it was likely that there was a progression and aggravation of Crew’s right wrist
injury. Although Crew was “having problems in terms of what she described” prior to seeing him
and while employed at Anderson Hickey, Dr. West explained it did not “necessarily mean she had
carpal tunnel.”

In April of 2004, Crew returned to Dr. Janovich with a claim of left carpal tunnel syndrome.
She saw him through November 10, 2004. Dr. Janovich completed a C-32 Form in support of her
claim. He determined that Crew had pain and numbness in both upper extremities with tingling in
the fingers and pain. He noted a positive Tinel’s and Phalen’s tests on both hands. He diagnosed
bilateral carpal tunnel syndrome, bilateral cubital tunnel syndrome, chronic radial epicondylitis on
the left, and tendonitis on the left and trigger finger. On April 19, 2004, Dr. Janovich performed an
EMG on Crew. There was a positive result. Two months later he found the same positive Tinel’s
and Phalen’s tests and carpal tunnel syndrome. On June 29, 2004, Dr. Janovich performed a left
carpal tunnel release as well as a trigger finger release of the third and fourth digits on the left hand.
After the surgery, Crew’s symptoms continued, including a positive Tinel’s over the ulnar nerve at
her visit with Dr. Janovich in October of 2004. Crew was released from Dr. Janovich’s care weeks
later with a 5% permanent partial disability rating to her upper left extremity, with numbness of the
ring finger on the left. Like Dr. West, Dr. Janovich checked the space in the C-32 Form affirming
that “this injury more probably than not [arose] out of the [Plaintiff’s] employment.” Dr. Janovich
offered no further proof as to causation.

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 At trial, Crew testified that when she began her job at Paslode, she was having the same
problems with her wrists, hands, and arms that she previously had since October 2001, when she
worked at Anderson Hickey. At one point, she stated that the swelling and numbness had stayed “the
same way it was” when she first started having problems, and at another point, she testified that the
condition “[g]ot worse” while working at Paslode. She explained that she stopped working at
Paslode because of her hands, her last surgery, bad health, and “uncontrollable blood pressure.”

Crew’s husband, Donnie Crew, confirmed that she started having some problems with her
hands and wrists while working for Anderson Hickey. He recalled that Crew had first complained
about her left hand and then later complained about her right hand. He also recalled massaging her
hands and when she returned from work because of swelling. Sandra McElrath, Crew’s sister,
testified that she saw swelling in her hands during the period she worked for Anderson Hickey and
recommended that she see a doctor. McElrath testified that Crew wore a brace on her arm during
that time, held her hands in a “certain position,” and complained of numbness and tingling in her
hands and wrists. Angela Currie, who also worked at Paslode, described Crew’s job as building
boxes, closing them, and having to “constantly” do it “all day long.” When questioned about any
changes in Crew’s condition, Currie testified that during Crew’s time at Paslode, she noticed that
“it was getting worse on her,” and that Crew had difficulty opening a door and holding anything
without dropping it. She also testified that since Crew left the job at Paslode, her hands, fingers, and
wrists were still swollen the same as when she was at Paslode.

The trial court found that Crew sustained a compensable gradual injury to her arms and wrists
while employed with Anderson Hickey. The court considered the credible lay and medical testimony
and awarded permanent partial disability to the right and left arm of 25%. It further found that the
anatomical impairment was 5% to the left upper extremity, based on the opinion of Dr. Janovich,
and 2% to the right upper extremity, as rendered by Dr. West. The trial court also awarded
discretionary costs of $150 as reimbursement for the cost of completion of the Tennessee
Department of Labor C-32 Form by Dr. David West.

The Workers’ Compensation Panel reversed, finding that Crew had failed to establish
causation through her employment with Anderson Hickey. The panel specifically found that both
EMGs conducted by Dr. Huff showed no evidence of carpal tunnel syndrome in Crew’s left or right
wrists, and that her work at Paslode involved “the very types of repetitive motions that . . . could
cause carpal tunnel syndrome.”

II. Standard of Review
In Tennessee workers’ compensation cases, this Court reviews the trial court’s findings of
fact de novo, accompanied by a presumption of correctness of the finding, unless the evidence
preponderates otherwise. Tenn. Code Ann. § 50-6-225(e)(2) (2005 & Supp. 2007); Wilhelm v.
Krogers, 235 S.W.3d 122, 126 (Tenn. 2007). “This standard of review requires us to examine, in
depth, a trial court’s factual findings and conclusions.” Galloway v. Memphis Drum Serv., 822
S.W.2d 584, 586 (Tenn. 1991) (citing Orman v. Williams Sonoma, Inc., 803 S.W.2d 672, 675 (Tenn.
1991)). We give considerable deference in reviewing the trial court’s findings of credibility and

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assessment of the weight to be given to that testimony, when the trial court has heard in-court
testimony. Whirlpool Corp. v. Nakhoneinh, 69 S.W.3d 164, 167 (Tenn. 2002). On questions of law,
our standard of review is de novo with no presumption of correctness. Wilhelm, 235 S.W.3d at 126
(citing Perrin v. Gaylord Entm’t Co., 120 S.W.3d 823, 826 (Tenn. 2003)). The extent of vocational
disability is a question of fact to be decided by the trial judge. Johnson v. Lojac Materials, 100
S.W.3d 201, 202 (Tenn. 2001). Although workers’ compensation law must be construed liberally
in favor of an injured employee, it is the employee’s burden to prove causation by a preponderance
of the evidence. See Thomas v. Aetna Life & Cas. Co., 812 S.W.2d 278, 283 (Tenn. 1991).

III. Analysis
Anderson Hickey first contends that the trial court erred in awarding Crew a 25% permanent
partial disability to each arm. To support its argument, Anderson Hickey submits that (1) the trial
court’s finding that Crew’s injuries to both upper extremities and the extent of the related
impairment was caused by her employment with Anderson Hickey is not supported by the evidence;
and (2) the trial court erred by failing to apply the “last injurious injury” rule in this case, which
would preclude recovery from Anderson Hickey for any disability claims.

A. Causation
Tennessee Code Annotated section 50-6-241 (2005) dictates that an employee who sustains
a permanent partial disability as a result of a workplace injury is entitled to receive permanent partial
disability benefits. The claimant in a workers’ compensation suit has the burden of proving every
element of his or her case by a preponderance of the evidence. Elmore v. Travelers Ins. Co., 824
S.W.2d 541, 543 (Tenn. 1992). To be compensable under workers’ compensation law, an injury
must “aris[e] out of and in the course of employment.” See Tenn. Code Ann. § 50-6-102(13) (2005);
Thornton v. RCA Serv. Co., 221 S.W.2d 954, 955 (Tenn. 1949). The phrase “arising out of” refers
to the cause or origin of the injury and the phrase “in the course of” refers to the time, place, and
circumstances of the injury. Hill v. Eagle Bend Mfg, Inc., 942 S.W.2d 483, 487 (Tenn. 1997). If
it is apparent to the rational mind, after considering all of the circumstances that there is a causal
connection between the conditions under which the work is required to be performed and the
resulting injury, then such accidental injury “‘arises out of one’s employment.’” Wilhelm, 235
S.W.3d at 127 (quoting Fink v. Caudle, 856 S.W.2d 952, 958 (Tenn. Workers’ Comp. Panel 1993)).

“We have held in numerous cases that expert medical testimony is required to establish the
permanency of an injury except where the permanent disability is obvious to a layman, such as an
amputated leg.” Henley v. Roadway Exp., 699 S.W.2d 150, 155 (Tenn. 1985). While causation
must be proven through medical evidence, “absolute certainty . . . is not required.” Fitzgerald v.
BTR Sealing Sys., 205 S.W.3d 400, 404 (Tenn. 2006). Benefits may be awarded, therefore, where
medical evidence shows that the employment “‘could or might have been the cause’” when there is
also lay testimony from which causation may be inferred. Id. at 404 (quoting Clark v. Nashville
Mach. Elevator Co., 129 S.W.3d 42, 47 (Tenn. 2004)). “If medical testimony is presented by
deposition, this Court may make an ‘independent assessment of the medical proof to determine
where the preponderance of the evidence lies.’” Wilhelm, 235 S.W.3d at 127 (quoting Conner Bros.
Excavating Co. v. Long, 98 S.W.3d 656, 660 (Tenn. 2003)). “Any reasonable doubt as to whether

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the worker’s injuries arose out of his employment must be construed in the worker’s favor.”
Wilhelm, 235 S.W.3d at 127.

The trial court considered the deposition testimony of Drs. West and Huff, as well as the C-
32 Forms that were completed by Drs. West and Janovich. It further heard testimony from Crew,
her husband, sister, and long-time friend and found that Crew “sustained a compensable, gradual
injury to both upper extremities arising out of and within the course and scope of her employment.”

The Panel disagreed with the trial court’s findings specifically as to causation:

Our independent review of the record in this case shows that the plaintiff was not
suffering from carpal tunnel syndrome in her left wrist as of January 7, 2002, when
an EMG conducted by Dr. Huff showed no evidence of carpal tunnel syndrome.
The EMG was performed less than one month prior to plaintiff’s lay-off from her
employment with Anderson Hickey. In addition, a second EMG conducted by Dr.
Huff on January 14, 2003, showed no evidence of carpal tunnel syndrome in the
plaintiff’s left or right wrists. Only nine months later did the plaintiff have a
positive EMG for carpal tunnel syndrome. This occurred after plaintiff had
obtained employment through Paslode, at which her job duties were the very types
of repetitive motions that, according to the medical proof in this case, could cause
carpal tunnel syndrome. The generic statement checked by Dr. Janovich in the C-
32 form is not sufficient to support a finding that the plaintiff sustained a
compensable workers compensation injury with the defendant. Moreover, the
plaintiff’s complaints of swelling in her left and right wrists prior to the positive
EMG through Dr. West’s office have an independent medical explanation–her
diagnosis of inflammatory arthritis or lupus.

Prior case law is helpful to our determination of whether the injury qualifies as “arising out
of” and “in the course of” Crew’s employment. This Court in Glisson v. Mohon International, Inc.
considered whether an injury arose out of the employment. 185 S.W.3d 348, 354 (Tenn. 2006). We
reasoned that “except in the most obvious cases, causation must be established through medical
evidence.” Id. (citing Orman, 803 S.W.2d at 676). We also emphasized the importance of the C-32
Form in support of a medical report in workers’ compensation cases. Id. at 354 n.3. We stated that
“[a]lthough causation cannot be based upon speculative or conjectural proof, absolute medical
certainty is not required, and reasonable doubt must be resolved in favor of the employee.” Id. (citing
Long v. Tri-Con Indus., 996 S.W.2d 173, 177 (Tenn.1999)). Accordingly, if an employee presents
medical evidence showing that the employment could or might have been the cause of his or her
injury when lay testimony reasonably suggests causation, it is appropriate to award benefits. Id.

Relevant workers’ compensation statutes direct that

(1) [a]ny party may introduce direct testimony from a physician
through a written medical report on a form established by the

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 commissioner of labor and workforce development ...[and] (2) [t]he
written medical report of a treating or examining physician shall be
admissible at any stage of a workers’ compensation claim in lieu of
a deposition upon oral examination.

Tenn. Code Ann. § 50-6-235(c)(1)-(2) (2005). In consequence, parties may use a medical report,
commonly referred to as a C-32 Form, in lieu of depositions as evidence at trial.

Upon our review of this record, we are persuaded that the Panel properly concluded that the
evidence preponderates against the trial court’s finding that carpal tunnel syndrome arose out of
Crew’s employment with Anderson Hickey. While she complained of pain and sought treatment for
her left extremity, there is no medical evidence showing that Crew was suffering from carpal tunnel
syndrome in her left wrist as of January 7, 2002–the time at which the EMG conducted by Dr. Huff
was negative for carpal tunnel and less than one month before Crew’s lay-off from her employment.
Moreover, another EMG conducted one year later showed no carpal tunnel syndrome in Crew’s left
or right wrists. We have explained that it is “reasonable that the physicians having greater contact
with [a] Plaintiff would have the advantage and opportunity to provide a more in-depth opinion, if
not a more accurate one” of any resulting impairment or disability. Orman, 803 S.W.2d at 677.
Pursuant to our previous reasoning, Dr. Huff–the treating doctor nearest to the time of employment
with Anderson Hickey–is in the best position to provide a medical opinion as to the injuries at issue.
It was his opinion, as stated, that as of his last treatment, she did not have any type of injury
qualifying as a permanent impairment. The results of the EMG first in January of 2002, as to the left
upper extremity, and that performed in January of 2003, as to the left and right upper extremities
support his conclusion.

It was nine months after the second EMG when Crew first tested positive for carpal tunnel
syndrome in her right hand. This followed her eight-month period of employment at Paslode, where
she repeatedly stacked cans, an activity identified as a possible cause of carpal tunnel syndrome,
according to medical testimony. Dr. West, who began treating Crew more than a year and a half
after her employment with Anderson Hickey had ended, provided a C-32 Form which indicated that
Crew’s right carpal tunnel syndrome were caused by her “employment,” without specifically
identifying which employer. In his deposition, Dr. West acknowledged that he could not causally
relate Crew’s impairment of her right upper extremities to her work with Anderson Hickey. In fact,
he conceded it was more likely that the progression of her right arm injuries were caused by her
subsequent employment at Paslode.

Similarly, any medical evidence from Dr. Janovich linking injury causation with employment
came more than two years after Crew was laid off at Anderson Hickey. By checking a box on the
form, Dr. Janovich stated that Crew’s left upper extremity injuries were caused by her
“employment.” Neither Anderson Hickey nor Paslode was identified as the employer. Absent any
reference to causation through the employment by Anderson Hickey, Dr. Janovich’s medical records
do not meet the requisite burden of proof.

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 Although Crew testified, without contradiction, that she had complained of swelling in her
left and right wrists prior to the positive results of the EMG administered through Dr. West’s office,
those symptoms could have been attributed to the lupus diagnosis. In fact, Dr. Huff attributed
Crew’s complaints to her arthritic condition. Further, Crew conceded that her condition in both
hands became “worse” while working at Paslode. That, in addition to her positive left upper
extremity EMG study of September 2003–approximately one year and nine months after her
employment with Anderson Hickey and towards the end of her eight month employment with
Paslode–lends support to Dr. West’s assessment. Although Crew may have had “problems in terms
of what she described [while working for Anderson Hickey], it doesn’t necessarily mean she had
carpal tunnel,” he said. “I think the fact is . . . that the patient developed a positive EMG within nine
months of the normal one. So by assumption, that would mean that the second employer would have
been at least the aggravating cause, if not the cause.”

The medical records fail to link Crew’s carpal tunnel syndrome to any work associated with
Anderson Hickey. There is an insufficient basis to conclude that her carpal tunnel syndrome “arose
out of and in the course and scope of her employment” with Anderson Hickey. In summary, the
medical evidence available is that Crew sustained no impairment while working for Anderson
Hickey, as shown by Dr. Huff’s findings of normal EMG studies conducted in January 2002 and
January 2003–during the time of Crew’s employment with Anderson Hickey and one year thereafter.
Causation must be proven through medical evidence, except when obvious. See Glisson, 185
S.W.3d at 354; Fitzgerald, 205 S.W.3d at 404; Henley, 699 S.W.2d at 155. It is only after the
medical evidence establishes that duties from a specific employer may have been the cause that lay
testimony becomes considered as to causation. Glisson, 185 S.W.3d at 354.

Indeed, lay testimony confirmed that Crew suffered from swelling, pain, numbness, and
tingling in her hands and wrists while working for Anderson Hickey. Crew testified on her own
behalf, without contradiction, that she had complained of problems to Drs. Robbins and Huff and
that almost two years later, when she saw Dr. West, her complaints had not changed. The lay
testimony, however, without the support of medical evidence, is insufficient to establish a causal
relationship between the employee’s work activities with Anderson Hickey. See Glisson, 185
S.W.3d at 354; Fitzgerald, 205 S.W.3d at 404; Henley, 699 S.W.2d at 155.

B. Last Injurious Injury Rule
Had Crew met her burden of establishing a causal connection of her carpal tunnel syndrome
to her work at Anderson Hickey, our analysis could have required a consideration of whether
employer Anderson Hickey should be held liable in light of the “last injurious injury” rule. The last
injurious injury rule requires an employer to “take an employee as he finds him.” Baxter v. Smith,
364 S.W.2d 936, 942 (Tenn. 1962). The rule provides that “in determining which of two successive
insurers is liable in a workers’ compensation case, the insurer at the time of the employee’s last
injurious exposure is liable for the injury.” Bldg. Materials Corp. v. Britt, 211 S.W.3d 706, 713

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(Tenn. 2007).8 It is neither the last employment nor the last exposure to the hazards of the disease
which impose liability on an employer; rather, it is the last such exposure that is injurious to the
employee. Morell v. ASARCO, Inc., 611 S.W.2d 830 (Tenn. 1981). Thus, in order for the rule to
apply, there must be some showing that the employee’s condition worsened due to the working
conditions at the second employer, either by advancement or aggravation of the injury. See
Mahoney v. NationsBank of Tennessee, N.A., 158 S.W.3d 340, 346 (Tenn. 2005) (emphasis added)
overruled on other grounds, Britt, 211 S.W.3d at 713. Conversely, liability will not attach to an
injured employee’s last successive employer if the employee’s symptoms experienced while at the
first employer merely persist. Barker v. Home-Crest Corp., 805 S.W.2d 373, 373-74 (Tenn. 1991).
An aggravation or exacerbation of the employee’s injury must occur at the second employer. Id. at
375.

Although Anderson Hickey presented the last injurious injury rule as a defense, the trial court
did not directly address the issue. By finding that Crew “sustained a compensable, gradual injury
to both upper extremities arising out of and within the course and scope of her employment,” the trial
court only implicitly considered the injury as a consequence of her employment at Anderson Hickey.

We are persuaded that witness testimony implicated the last injurious injury rule. Dr. Huff
referred to the “new job” causing Crew’s carpal tunnel. Dr. West identified a “second employer”
as “at least the aggravating cause, if not the cause.” Crew testified that her condition “[g]ot worse”
while working at Paslode, and Currie stated that Crew’s condition got “worse” during her tenure
there.

Whether Crew’s subsequent work at Paslode constituted the last such exposure to injury, see
Morell, 611 S.W.2d at 830, and whether her condition was aggravated by her employment there, see
Mahoney, 158 S.W.3d at 346, are significant questions. See Barker, 805 S.W.2d at 373-74. Crew
argues that “[h]er injury and problems were well documented long before she began [employment
with Paslode],” and that Anderson Hickey’s proof of any “new injury” was “sketchy at best.” In
support of her position, she posits that “Dr. West’s strongest statement is that [Crew’s] employment
at Paslode . . . could ‘possibly’ have aggravated the condition in her right wrist.” Further, she
contends that Townsend v. State, 826 S.W.2d 434 (Tenn. 1992) and Smith v. Smith’s Transfer Corp.,
735 S.W.2d 221 (Tenn. 1987) stand for the proposition that a mere increase in pain is not enough
to constitute an injury by accident.

Crew’s belief that Anderson Hickey had presented inadequate medical evidence of a “new
injury” is contrary to our case law. In Barker, 805 S.W.2d at 373, this Court considered which of
two insurance carriers was obligated to pay benefits for a carpal tunnel injury. We held that the
cause of an employee’s carpal tunnel injuries was constant, and as such, the employee suffered a new
injury each day. Id. at 376. Similarly, in Lawson v. Lear Seating Corp., 944 S.W.2d 340, 342 (Tenn.

8
See Joseph H. King, Jr., The Exclusiveness of an Employee’s Workers’ Compensation Remedy Against His
Employer, 55 Tenn. L.Rev. 405, 425-26 (1988) (discussing the im plications of the exclusive remedy rule and last
injurious exposure rule).

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1997), the issue we faced was when the statute of limitations should begin in cases involving gradual
injury, such as carpal tunnel syndrome. Under workers’ compensation law, gradually occurring
injuries, such as carpal tunnel syndrome, are compensable as “accidental” injuries, rather than
occupational. Id. at 341. Although in some instances carpal tunnel syndrome results from a
traumatic event, in most cases it is a repetitive stress injury where the symptoms appear and worsen
over time. Id. We characterized the injury as a “new trauma” to the claimant’s hands each day that
she worked. Id. at 343.

In our view, the last injurious injury rule precludes any liability assessment against Anderson
Hickey. Dr. West confirmed that Crew’s employment at Paslode could have aggravated the
condition in her right wrist. See Mahoney, 158 S.W.3d at 346 (Tenn. 2005). Dr. West described
the “progression” of her injury such that it ultimately “manifested itself enough to be a positive
EMG.” Crew and Currie noticed that her condition worsened during her employment at Paslode.
See id. Thus, both medical and lay testimony supports the premise that Crew’s condition advanced,
and was aggravated, during her time of employment at Paslode.

Although the Smith and Townsend cases hold that there is no injury by accident where work
aggravates a preexisting condition merely by increasing the pain, we find that general principle
inapplicable in this instance. Smith, 735 S.W.2d at 221; Townsend, 826 S.W.2d at 434. In Smith,
there was no medical evidence presented that the employee’s keyboarding duties as a typist
“produced any physical change or advanced the incidence” of a congenital condition, other than
increased pain. Smith, 735 S.W.2d at 224. This Court determined that the work “aggravated” her
condition, even if it was not the sole cause, but found that her “only problem was pain” and not a
compensable “accident.” Id. at 224-25. In Townsend, medical proof as to a knee injury unrelated
employment showed an “independently progressive” condition. Townsend, 826 S.W.2d at 437.
Citing Smith, we reiterated that “there is no injury by accident where work aggravates a pre-existing
condition merely by increasing the pain.” Id. at 436. We concluded that there is a compensable
injury only “if the severity of the condition is advanced, or if it results in a disabling condition other
than increased pain.” Id. at 436.

Crew did not present facts to support any contention that her work at Paslode merely
increased the pain. Instead, she testified, without further explanation, that her condition worsened
while at Paslode. Her EMG’s, which were negative while employed at Anderson Hickey, were
positive after her employment at Paslode. Dr. West actually testified that Crew’s condition was
“aggravated” by her tenure there, the very kind of medical evidence implicating the last injurious
rule. Our previous holdings in Barker and Lawson support that determination. Because of her carpal
tunnel syndrome, Crew suffered a new accident resulting in injury each day. Anderson Hickey is,
therefore, not liable for Crew’s injuries under workers’ compensation law. See Hudgins v. U. S. Fid.
& Guar. Co., 479 S.W.2d 804 (Tenn. 1972) (finding that the first insurance carrier’s demonstration
that the employee was injuriously exposed to an occupational disease during the second employment
resulted in absolving the first employer and its carrier of liability relating to permanent partial
disability from the disease even though the second employer was not a party and its liability was not
adjudged).

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 C. Last Day Worked Rule
Inextricably linked to the last injurious injury rule is the last day worked rule. Although the
parties did not raise this potential issue, the trial court’s finding that Crew sustained a vocational
disability “arising out of her on the job injury of October 23, 2001” necessitates a review of the rule’s
application. Initially, gradually occurring injuries, such as carpal tunnel syndrome, are compensable
as “accidental” injuries, rather than occupational. Lawson, 944 S.W.2d at 341. Although in some
cases carpal tunnel syndrome results from a traumatic event, in most cases it is a repetitive stress
injury where the symptoms appear and worsen over time. Id. Because symptoms can be “episodic”
as job duties change, it is difficult, at best, to determine when the “accident resulting in the injury”
occurs. Id.

In Britt, 211 S.W.3d at 708, the sole issue was whether in a workers’ compensation action
the employee’s claim for benefits was time-barred by the statute of limitations. In 1997, Britt
reported back pain to his employer, and after some improvement in his condition, subsequently
reported that his back pain was becoming worse. Id. He sought permanent partial disability benefits
for the first time in 2002. Id. Although the trial court held that the employee’s claim was time-
barred by the statute of limitations–since Britt did not file within one year of his original back
injury–the Special Workers’ Compensation Appeals Panel found that the claim was not time-barred.
Id. Using the last-day-worked rule, this court affirmed that the statute of limitations set forth in
Tennessee Code Annotated section 50-6-203 does not begin to run until the employee is prevented
from working due to the employee’s injury. Id.; see Tenn. Code Ann. § 50-6-203(b)(2) (2005);
Lawson, 944 S.W.2d at 341; Barker, 805 S.W.2d at 376.

This line of reasoning instructs us that when an injury such as Crew’s is gradually occurring,
as with her carpal tunnel syndrome, the last day worked rule is used to help establish the date on
which the injury occurred. See Britt, 211 S.W.3d at 711; Lawson, 944 S.W.2d at 341-42; Barker,
805 S.W.2d at 375. Crew’s last day of work in which she was experiencing a new injury each day
was at Paslode, where she worked until approximately August or September of 2003.

D. Permanent Partial Disability Award
Anderson Hickey also argues that the evidence preponderates against the trial court’s award
of 25% permanent partial disability to each upper extremity. Because we have determined that an
award to Crew was inappropriate based on issues of causation and pursuant to the last injurious
injury rule, we need not address this issue.

E. Discretionary Costs - C-32 Form
Finally, Anderson Hickey argues that the trial court erred by awarding Crew discretionary
costs of $150 for reimbursement of charges she incurred for a doctor’s completion of a Tennessee
Department of Labor C-32 form. The contention is that Dr. West’s testimony did not relate Crew’s
injury to her employment with Anderson Hickey. Rule 54.04(1) of the Tennessee Rules of Civil
Procedure provides, in part, that “[c]osts . . . shall be allowed to the prevailing party unless the court
otherwise directs.” Adjudging costs is within the reasonable discretion of the trial court. Lock v.

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Nat’l Union Fire Ins. Co., 809 S.W.2d 483, 490 (Tenn. 1991). Furthermore, the trial judge may
apportion the costs between the litigants as is deemed equitable. Tenn. Code Ann. § 20-12-119
(1994). Accordingly, the judgment of the trial court will not be disturbed on appeal absent a
showing that the trial judge abused his discretion. Perdue v. Green Branch Mining Co., 837 S.W.2d
56 (Tenn. 1992); Lewis v. Bowers, 392 S.W.2d 819, 823 (Tenn.1965).

Crew is no longer the prevailing party. Moreover, the information gleaned from Dr. West’s
C-32 filing was adverse to Crew’s position. Thus the trial court erred by awarding discretionary costs
to Crew.

IV. Conclusion
Crew failed to meet her burden of establishing causation between her employment at
Anderson Hickey and her carpal tunnel syndrome. Further, the last injurious injury rule precludes
Anderson Hickey from being held liable for Crew’s claim. Pursuant to our holding, Crew is not
entitled to discretionary costs. We, therefore, affirm the decision of the Appeals Panel and remand
to the trial court for entry of an order dismissing the complaint. Costs are assessed to Crew.

______________________________
GARY R. WADE, JUSTICE

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