The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on May 30, 2001, at the request of a union representative, acting on behalf of the claimant. The Panel discussed this appeal on May 30, 2001.

Issue

Whether or not the claimant's left cubital tunnel syndrome and bilateral carpal tunnel syndrome is related to her compensable accident of August 18, 1997; and

Whether or not the claimant is entitled to further benefits in relation to her August 18, 1997 compensable accident.

Decision

That the claimant's left cubital tunnel syndrome is related to her compensable accident of August 18, 1997; and

That the claimant's bilateral carpal tunnel syndrome is not related to the compensable accident of August 18, 1997; and

That the claimant is entitled to further benefits in relation to her August 18, 1997 compensable accident.

Background

On August 18, 1997, the claimant was assisting a healthcare aide who was helping a resident (weighing approximately 325 lbs.) put on his sweat pants and then into a wheelchair. While standing the resident's left knee buckled and he started to fall. To prevent the resident from falling, the claimant used both hands and grabbed the waist band of his pants and maneuvered him into the wheelchair. The claimant indicated that she was told afterwards by the healthcare aid that she (the claimant) took all of the resident's weight herself. Shortly thereafter the claimant began to experience stiffness, tightness and pain in her head/neck, shoulders, arms, and entire back including the buttocks.

The claimant also indicated that her left arm pain increased and she was experiencing pins and needles and numbness in her hand and 4th and 5th fingers, plus her entire left arm and shoulder were painful. The claimant indicated that from the time of the injury until she sought medical treatment from the attending physician on September 15, 1997, she was treating herself with over the counter muscle relaxants, analgesics and anti-inflammatory medications. Medical reports on file showed that the claimant was treated for epicondylitis, myofascial pain of her neck and shoulders and thoracic outlet syndrome.

In March 1998, a WCB physical medicine and rehabilitation specialist assessed the claimant. The examination findings and opinion put forth by the specialist suggested some muscle origin symptomatology. He was unable to identify any area of regional myofascial pain syndrome activity in the shoulder girdle area. There was some myofascial pain syndrome activity of the forearm. It was suspected that this was secondary to the prior lateral epicondylitis involvement. Clinical examination did not reveal evidence of any lateral epicondylitis on either side, with no tenderness on palpating over the lateral epicondyles. The specialist was unable to detect any evidence for any neurogenic or vascular thoracic outlet syndrome. There was a clinical suggestion and historical evidence suggesting a possible bilateral mild carpal tunnel syndrome present. He wondered about some ulnar nerve involvement to the posterior elbow areas bilaterally. "This on the left may be the cause, of her subjective symptomatology into the 4th and 5th fingers. Both of these would be unrelated to her most recent injury. In any case, carpal tunnel syndrome is likely a pre-existing structural condition. As well, she has become symptomatic with numbness in her right upper extremity in the hand only recently while off of her work demands since August."

The WCB specialist recommended a graduated return to work program beginning with 4 hours and increased by 1 hour every 2 weeks. He also suggested that a screening nerve conduction study, of both the median and ulnar nerves, be carried out. In subsequent correspondence to file dated March 25, 1998, the WCB specialist commented that the nerve conduction studies was not WCB responsibility and that the tests should be arranged by the attending physician. Effective June 6, 1998, the claimant was back to full duties and wage loss benefits were paid to June 5, 1998, inclusive and final.

On July 29, 1998, the claimant underwent nerve conduction studies (NCS) and the findings suggested minimal bilateral carpal tunnel syndrome and mild left focal ulnar neuropathy (level of the ulnar groove).

On November 2, 1998, Claims Services wrote to the claimant to advise that the NCS were reviewed by a WCB medical advisor. It was the medical advisor's opinion that the NSC did not specifically test for thoracic outlet syndrome and was not conclusive for the diagnosis of thoracic outlet syndrome. The analysis indicating mild focal ulnar neuropathy at the level of the ulnar groove was not resultant of the compensable injury which the claimant sustained on August 18, 1997 as the mechanism of injury described did not include a direct trauma to that area. The claimant was advised that the WCB would not accept responsibility for the costs associated with the NSC or any future costs related to these symptoms.

In a report dated November 23, 1998, a hand and wrist surgeon noted that the claimant had recently undergone nerve conduction studies which indicated mild compression of the ulnar nerve in the region of the cubital tunnel and mild bilateral carpal tunnel syndrome. The surgeon suggested an anterior transposition of the left ulnar nerve and surgical decompression of the carpal tunnel.

On December 15, 1998, a WCB medical advisor advised the surgeon that no financial responsibility would be accepted for the proposed procedure. The medical advisor indicated that when the claimant was examined at the WCB's offices in March 1998, it was the opinion of the specialist at that time that no causal relationship existed between the compensable injury and the mild neurologic symptoms present at the time of the claimant's examination.

On January 8, 1999, the claimant appealed the WCB's decision not to accept responsibility for the surgical procedure noted above. Prior to considering the appeal, Review Office sought the advice of a WCB orthopaedic specialist on February 22, 1999.

In a decision dated March 5, 1999, Review Office agreed that the claimant's work related accident of August 1997 did not likely contribute significantly to the cause of her recent nerve injuriesdiagnosed as left cubital tunnel syndrome and bilateral carpal tunnel syndrome. Review Office stated that the cause and effect relationship was not supported by the predominant medical evidence on file despite a historical connection to some extent. Benefits were not payable for the effects of these injuries under the provisions of the Act. Review Office also recommended that further investigation and adjudication should be undertaken to establish whether or not the claimant's occupation involved hazards which exposed her to increased risks for the development of cubital tunnel syndrome or carpal tunnel syndrome and whether the claimant had an entitlement to benefits. (Subsequent file information revealed that the WCB opened two files with respect to cubital and carpal tunnel conditions, however the WCB determined that they did not qualify as compensable accidents.)

In February 2001, the claimant's union representative appealed Review Office's decision and an oral hearing was convened.

Reasons

This is the case of a Licensed Practical Nurse who sustained a number of strain injuries, due to an incident, in August 1997, in the personal care home where she worked. She was assisting a resident, who weighed more than 300 pounds, to transfer from a tub chair to a wheel chair, when his legs buckled under him. The claimant grabbed the waist of his pants to prevent him from falling, suffering strain injuries to her neck, shoulders, arms, back and buttocks.

Most of these strain injuries healed in time. However, she developed bilateral carpal tunnel syndrome and left arm cubital tunnel syndrome.

Her strain injuries were accepted as a compensable result of the workplace accident, but the carpal and cubital tunnel syndromes were determined not to be causally linked to the accident.

She appealed to Review Office, which decided that the nerve injuries involving her left elbow and wrists were not a result of the August 1997 workplace accident. In this same decision, Review Office found that the carpal and cubital tunnel syndromes might be due to long-term repetitive stresses in her job and referred those matters for further investigation. That investigation led to two separate claims, which are not the subject of this appeal.

She has appealed the first part of the Review Office decision to this Commission: whether or not her left cubital tunnel syndrome and bilateral carpal tunnel syndrome are causally related to the August 1997 accident. A second issue under appeal - whether she is entitled to further benefits - will flow from the decision on the first.

For her appeal to succeed, the panel must determine that one or both of the carpal tunnel or cubital tunnel syndrome were caused by the incident in August 1997.

We have determined that the cubital tunnel syndrome was a result of this incident, but the carpal tunnel syndrome was not.

In coming to our decision, we carefully reviewed the claimant's file, as well as hearing testimony from her and her advocate at an oral hearing.

We noted that, over a number of months following the workplace accident, the claimant was given a number of diagnoses of her condition, including epicondylitis, a traction injury to her brachial plexus, myofascial pain to her neck and upper back muscles and thoracic outlet syndrome, with claviculo-costal syndrome. She did not respond particularly well to the treatment prescribed for these conditions.

It was not until she was sent for a nerve conduction study, at the recommendation of the WCB consultant who examined her at a call-in, that the cubital and carpal tunnel syndromes were diagnosed.

Initially, the claimant visited a chiropractor, who did note, among other things, that she was experiencing pain and reduced range of motion in her left wrist. On her first visit to a medical doctor - about a month after the accident - the doctor reported pain to her left lateral epicondyle. Two weeks later, she visited a physiotherapist, who, in her initial assessment, reported that the claimant was experiencing numbness and tingling in some of the fingers on her left hand. She further noted that the claimant experienced tenderness when the left ulnar nerve was palpated. The physiotherapist also wrote that she suspected a "traction injury on the lower brachial plexus" as being responsible for the claimant's neurological symptoms.

Shortly after this, the claimant visited a physical medicine specialist who diagnosed myofascial pain in her neck muscles and "some elements of a thoracic outlet syndrome", to explain the numbness in the claimant's left hand, even though a common test used for that condition was negative. As a result of this diagnosis, treatment in the following weeks and months focused on the neck and upper back regions.

It wasn't until almost a year after the accident that she had a nerve conduction study (NCS) performed. This study found her to be suffering from minimal bilateral carpal tunnel syndrome and mild left focal ulnar neuropathy at the cubital tunnel.

Nonetheless, she had returned to work - through a graduated return to work program - in the spring of 1998.

Subsequent to the NCS, she was referred to a plastic surgeon who recommended surgery to deal with the left cubital tunnel syndrome, which was performed in January 1999. She has had a complete recovery from the symptoms of cubital tunnel syndrome and is able to function fully, as before the accident.

The specific issue the panel had to determine was whether or not cubital tunnel syndrome could be caused by a traumatic incident. The physical medicine consultant to the WCB, in his report on his examination of the claimant, gave the opinion that neither the carpal tunnel syndrome, nor the cubital tunnel syndrome would be related to her most recent injury. This opinion was, later, reinforced by a board orthopaedic consultant.

We note that the Review Officer responsible for this file was the first to draw a line from the accident to her left elbow and wrist problems. He queried whether the apparent severity of her original accident, followed by her ongoing symptoms, might not support a causal link between the accident and the injury.

This, coupled with the testimony of the claimant, led us to seek further information on this type of injury. We consulted the Attorney's Textbook of Medicine, Third Edition. From this we note "brachial plexus injuries resulting from high velocity traction to the arm result in stretching between the shoulder and the neck.". We note that both brachial plexus injuries and thoracic outlet syndromes both of which were provisional diagnoses on this claim for the outset - can result in neurological symptoms in the ulnar distributions in the arm, because of the passage of these nerves through these structures. This is consistent with the mechanism of injury in this case, that being an extreme forceful extension of her arm when the patient fell.

These provisional diagnoses are also consistent with the physiotherapist's observation of ulnar nerve denervation and with the provisional diagnosis of thoracic outlet syndrome, and with the claimant's evidence as to which fingers were causing her difficulties.

Although these diagnoses were ultimately ruled out, we note that the ulnar symptoms continued. We note that traction injuries (a forceful extension or tugging) can be the cause of the neck related syndromes noted above, and can also be the cause of a cubital tunnel syndrome.

In this case, we note that the claimant's injury arose after she caught the waistband of a falling patient, which resulted in a forced extension of her arm and a pulling sensation in her neck, back and left arm. Given the mechanism of the claimant's injury and given that her symptomatology emerged shortly after the accident and given the above analysis, we have concluded that the preponderance of evidence supports that the claimant's cubital tunnel syndrome is causally linked to her workplace accident of August 18, 1997.

In considering her carpal tunnel syndrome, we have come to a different conclusion. We note, from the medical file and from the claimant's testimony, that there were few, if any, symptoms of carpal tunnel syndrome. She didn't report any such complaints to any of the medical practitioners she was seeing. The board call-in specialist was the first to suggest the possibility of this diagnosis, which was confirmed by the NCS.

This specialist noted that, if it did exist, it would likely be due to a pre-existing structural condition. The claimant also indicated that she has not had any symptoms related to carpal tunnel syndrome, nor has she received any treatment for same. We also note that the mechanism of injury does not support the development of a bilateral CTS.

For this reason, we conclude that the claimant's bilateral carpal tunnel syndrome is not causally related to her workplace accident of August 18, 1997.

In respect of the second issue before us, given our decision above, we conclude that the claimant is entitled to further benefits, which would include, but are not restricted to, the cost of the surgery, costs associated with the tests to confirm the diagnosis and wage loss benefits during the recovery period.

Accordingly, the appeal is allowed, in part, as noted above.

Panel Members

T. Sargeant, Presiding Officer
A. Finkel, Commissioner
C. Monk, Commissioner

Recording Secretary, B. Miller

T. Sargeant - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 25th day of June, 2001