The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel review was held on March 4, 1999, at the request of the claimant.

Issue

Whether or not the claimant is entitled to payment of wage loss benefits and medical treatment beyond March 11, 1997; and

Whether or not a Medical Review Panel should be convened.

Decision

That the claimant is entitled to payment of wage loss benefits and medical treatment beyond March 11, 1997; and

That a Medical Review Panel should not be convened.

Background

On September 7, 1995, the claimant slipped off a ladder twisting his left knee while employed as a sheet metal worker. Following examination by the attending physician on September 12, 1995, the claimant was diagnosed with a left knee effusion and a medial lateral ligament sprain. The physician also noted that the claimant had a pre-existing condition, namely varicose veins. The claim was accepted by the Workers Compensation Board (WCB) and benefits commenced.

In January 1996, an orthopaedic specialist stated that the claimant's leg problems were multifactorial in nature, with chronic venous disease, internal derangement of the knee and a soft tissue injury about the left ankle.

On February 3, 1996, the claimant underwent an MRI examination of the left knee. The findings revealed an oblique tear involving the posterior horn and body of the medial meniscus with no associated displaced fragment. The lateral meniscus was intact, there was joint effusion and popliteal cyst, cruciate and collateral ligaments were intact and varicose veins were noted. On May 17, 1996, the claimant underwent a partial medial meniscectomy that was accepted as a WCB responsibility.

In a follow-up report dated May 23, 1996, the treating surgeon noted that the claimant was healing well after the arthroscopy procedure. The claimant had continued posteromedial pain and it seemed that it was an exacerbation of his varicose veins. An above the knee stocking was ordered.

In a letter dated August 8, 1996, a vascular surgeon stated that the claimant had two obvious conditions. One was vein disease and the other a knee trauma. The surgeon said it was really difficult to assign symptoms simply to one or the other. He believed, however, that most of the symptoms were related to the knee injury and that the venous changes were secondary. The surgeon said it was appropriate to concentrate on rehabilitation of the knee joint with relatively minor supportive care for the venous disease. He did not recommend any further investigation or operative treatment with respect to the vein disease.

In a memo dated September 10, 1996, a WCB medical advisor provided the opinion that the claimant's vein problem was not related to the compensable injury or to surgery, given that there was no evidence of DVT (deep vein thrombosis). Imposed restrictions were to avoid crouching, squatting and climbing and to wear a compression stocking. In October 1996, the treating physician requested that the claimant undergo a functional ability evaluation. The claimant also attended physiotherapy sessions for range of motion and quadriceps exercise.

On November 21, 1996, the treating orthopaedic surgeon wrote to the attending physician stating that the claimant's knee condition was stable and had plateaued although not resolved. He felt that surgery directed towards the venous disease would now be reasonable. If there were not to be a procedure on his veins, then he would review him regarding a repeat arthroscopy. In the meantime, the orthopaedic surgeon felt the claimant should stay off ladders as a sheet metal installer and switch to lighter or sedentary work.

A WCB medical advisor examined the claimant in December 1996. The medical advisor's examination findings suggested that the claimant still had pain and effusion as a result of the compensable injury. Heat and varicosities on the medial side of the knee were noted and a further consult was recommended.

On February 6, 1997, the treating orthopaedic surgeon reported his examination findings of the claimant. He stated that the claimant had widespread complaints since his accident, which included visual disturbance in the right eye, ongoing left ankle complaints, symptoms referable to his knee and varicose veins. The knee showed no evidence of infection and that there may be a small effusion. Range of motion was well maintained and the ligaments were stable. The surgeon indicated that some of the claimant's posteromedial knee pain might be related to his medial meniscal tear, which was surgically treated in May 1996.

In a decision dated March 5, 1997, the WCB advised the claimant that wage loss compensation would be paid to March 11, 1997, inclusive and final. This decision was reached after consulting with a WCB medical advisor on March 3, 1997. The decision acknowledged that the claimant sustained a left knee injury on September 7, 1995 and that he had surgery performed in May 1996. It was noted that the claimant had a pre-existing condition but that it had not been enhanced or aggravated by the compensable injury. After review of all file correspondence and the comments made by a WCB medical advisor, it was the opinion of claims services that the claimant had essentially recovered from the compensable injury. On March 13, 1997, the claimant appealed this decision to Review Office.

In a letter addressed to the family physician dated March 20, 1997, a vascular surgeon reported that it would be appropriate to remove some of the varicosities medial to the left knee. Arrangements were being made for excision of the varicosities under local anaesthetic on June 4, 1997.

At the request of Review Office, a WCB orthopaedic specialist reviewed the case on April 10, 1997. He believed that the claimant's ongoing problems were related to his varicose veins and they were not as a result of the September 7, 1995 compensable injury. There was well recorded evidence of pre-existing bilateral (1987) varicose vein problems with previous stripping/ligation. The use of injections, support hose and the development of stasis dermatitis confirmed the pre-existing nature of the claimant's problems. Insofar as the knee joint itself was concerned, the orthopaedic specialist stated that the claimant may be developing early osteoarthritis as a result of his previous meniscectomy.

On April 11, 1997, Review Office confirmed that no responsibility would be accepted for wage loss benefits and medical treatment beyond March 11, 1997. Review Office indicated that the claimant had a phlebitis/varicose vein problem in both legs that pre-existed the September 7, 1995, accident. This condition clearly was not caused by the accident as noted by the early reporting of these conditions and the past treatment of these conditions. Review Office believed the claimant had achieved recovery from the effects of his accident and that his ongoing difficulties were unrelated to the effects of the accident. This conclusion included the eye difficulties, the varicose vein problem and the requirement for a brain scan.

A worker advisor wrote to the Review Office on December 21, 1998, requesting reconsideration of the April 11, 1997 decision. It was the worker advisor's position that the claimant had not returned to his pre-accident status following his compensable injury and that the compensable injury caused his varicose vein condition to become enhanced. In support, the worker advisor submitted additional medical information for review. The worker advisor also requested the convening of a Medical Review Panel (MRP) in accordance with Section 67(4) of the Workers Compensation Act (the Act) if Review Office did not rescind its earlier decision.

On February 5, 1999, Review Office determined the following:

• that the new and additional evidence submitted did not warrant any change to the previous decisions, namely that the claimant's work related accident of September 1995 did not significantly enhance or worsen his pre-existing varicose vein problem. It was also confirmed that the claimant was not entitled to wage loss benefits beyond March 11, 1997.
• that the case would be referred back to claims services to make the appropriate arrangements for the claimant's left knee to be examined for the purpose of determining whether there was any residual impairment associated with the claimant's work related accident in September 1995 and/or surgery to the left knee.
• the convening of a MRP was not warranted, as Review Office did not believe there was reason to request the opinion of a medical panel under the provisions of section 67(4) of the Act.

The claimant was interviewed by an impairment awards medical advisor on April 22, 1999. However, an examination of the claimant's knee condition did not take place. "...We discussed not proceeding with the examination at this point but rather that, he would pursue further the appeal process as to whether his venous insufficiency would be accepted as related to his compensable injury, with me indicating that the examination would have a change in emphasis if the latter were accepted."

In May 1999, the worker advisor submitted two additional medical reports for Review Office to consider. On June 9, 1999, Review Office stated that the new information did not change its former decisions. In January 2000, the worker advisor appealed the decisions made by Review Office on April 11, 1997, February 5, 1999 and June 9, 1999. An Appeal Panel hearing was then arranged.

Reasons

At the hearing, the claimant described in detail the mechanism of his injury:

"I had a ladder against the wall in a basement. I locked my knee, my leg and my knee into the rungs of the ladder with my ankle down here and my knee locked into this rung and my ankle locked into that rung. I was holding a piece of ductwork when one of the other helpers had pushed it from behind. The ladder tipped and it flipped me over and then it crushed my leg back underneath the ladder, and I was laid out on the floor at the back of the footing."

Q. So was it your calf or your thigh that was crushed or both?
A. It was a combination of both...

Five days following the accident, the claimant attended his treating physician and presented with ankle and knee swelling together with visible phlebitis swelling back of the knee. The evidence further confirms that the claimant continued to experience this left leg and ankle swelling and that he wore a long leg anti-embolic stocking. The claimant testified that with the exception of a removal of a varicose vein in his calf in 1987, he never experienced any problems with his left leg and ankle prior to his compensable injury. In fact, less than a month after his 1987 surgery, the claimant returned to his regular job duties and continued to work without any problems for the next eight years.

Q. And did you have any trouble with that leg again following that 1987 surgery?
A. Nothing, no.

Q. Did you miss any time from work between 1987 and 1995?
A. No.

Q. Did you ever have to go back to the doctor between 1987 and this accident, this leg accident?
A. No, not for that leg. I may have seen a doctor for - - in fact, I did see a doctor because a piece of steel in one of my arms. He just pulled it out. But not - - if we're sticking strictly with the left leg, no, nothing.

The accident employer also confirmed that the claimant prior to the accident did not miss any time from work while in his employ due to left leg problems.

Eventually, the treating physician referred the claimant to a vascular surgeon for an opinion. He examined the claimant on February 12th, 1998 and reported as follows:

"In my opinion the veins we are seeing now are secondary varicose veins, the swelling is secondary to deep venous insufficiency. I would venture a guess that following his injury he sustained deep vein thrombosis involving the deep veins in the left leg and what we are seeing now is a manifestation of deep venous insufficiency, i.e. persistent swelling of the leg, stasis changes as well as secondary varicose veins."

A second vascular surgeon examined the claimant on March 16th, 1998. He provided the following report to the treating physician:

"I initiated a bilateral nuclear medicine venogram that was performed on March 18, and confirmed patency of the venous system. This finding will support the presence of severe left sapheno-femoral incompetence associated with primary varicosity of the long saphenous distribution. Based on the above finding, he will be a candidate for left sapheno-femoral disconnection under local anesthesia."

We find, based on the weight of evidence that the claimant on a balance of probabilities incurred a deep vein thrombosis at the time of his compensable injury and it is this in conjunction with his varicose veins which is causing his ongoing left leg difficulties. Accordingly, the claimant is entitled to payment of wage loss benefits and medical treatment beyond March 11th, 1997.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
R. Frisken, Commissioner

Recording Secretary, B. Miller

R. W. MacNeil - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 12th day of April, 2000