The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on May 28, 2001, at the request of the claimant. The Panel discussed this appeal on May 28, 2001.

Issue

Whether or not the worker is entitled to wage loss benefits beyond February 10, 2000.

Decision

The worker is not entitled to wage loss benefits beyond February 10, 2000.

Background

In January 1998, the claimant submitted an application for compensation benefits indicating that his carpal tunnel syndrome was caused from his employment activities of installing doors and windows. The claimant stated that he had to hang on tight with both hands to doors and/or window frames/glass panels when lifting and installing them.

On January 16, 1998, the attending physician noted that the claimant experienced a gradual onset of tingling and weakness of both hands. Objective findings revealed tenderness in both wrists and flexion pain. Tinel's testing was positive on the right and negative on the left with a negative Phalen's test bilaterally. Grip strength was +4 bilaterally with no muscle wasting. The diagnosis rendered was carpal tunnel syndrome.

On January 26, 1998, the claimant underwent nerve conduction studies. The results revealed no evidence of carpal tunnel syndrome on either side.

In a memo dated February 25, 1998, a Workers Compensation Board (WCB) medical advisor documented that he discussed the case with the attending physician who felt that the claimant had tendonitis of the flexor tendon of the wrist causing irritation to the median nerve. He stated that the numbness had resolved but the claimant continued to have weakness. It was suggested that with physiotherapy treatments the claimant should be able to return to work in 3-4 week's time. The medical advisor commented that the claimant's work activities could cause tendonitis of the wrist.

Between March and June 1998, the claimant was seen by the attending physician with complaints of pain and stiffness in both hands and forearms and tenderness in the medial epicondyle.

In July 1998, a WCB medical advisor examined the claimant to assess his current capabilities. The medical advisor concluded that the only diagnosis to make at this point was mild medial epicondylitis. Recommendations were made for the claimant to return to work at modified duties and to undergo therapy directed towards his elbow, wrist and fingers.

On October 29, 1998, an orthopaedic specialist assessed the claimant's right arm condition. He thought that the claimant simply had a medial epicondylitis with common flexor origin tendonitis and further physiotherapy was arranged.

On April 7, 1999, the attending physician noted objective findings of tenderness in the forearm muscles and tenderness in the medial epicondyle. A referral was made for the claimant to see a physiatrist.

A WCB physical medicine and rehabilitation consultant assessed the claimant on June 15, 1999. The consultant stated in part that based on the current clinical examination and interview there was report of no change in symptomatology, now approximately 1 years off regular work duties. The primary current complaints included prominent stiffness present throughout the day in both hands, worse at night, and a sensation of swelling in the hands and wrists. There was tightness present in the forearms, more on the right than the left, and intermittent paresthesiae into the third to fifth fingers on the right hand. There were no objective findings on examination. There was no neurological impairment or evidence of any cervical root irritation or compression and there was no evidence suggesting significant ulnar involvement. There did not appear to be any active myofascial pain syndrome involvement or any active medial or lateral epicondylitis. He stated that the prior epicondylitis suggested on file likely had resolved. Clinical examination did not suggest any active inflammatory arthritis present. The consultant indicated, "If work related factors were important in etiology, the expectation would be that resolution or significant improvement would have been expected being off the job work demands for now 1 years, rather than no improvement in symptomatology over the last 1 year period despite being off the job physical demands."

On September 7, 1999, the claimant underwent nerve conduction studies which revealed mild to moderate slowing in the right ulnar nerve across the elbow with denervation in the right FDP (ulnar) consistent with ulnar neuropathy. There was no evidence of a radial neuropathy.

In a report dated January 6, 2000, a physical medicine and rehabilitation consultant indicated that the claimant's arm symptoms seemed to be slowly improving and there seemed to be marked improvement for a few days post-acupuncture treatments. The claimant's right arm strength was almost full but was inhibited slightly by myofascial discomforts. Active trigger points were found in the right forearm, the brachio-radialis, the wrist and finger extensors and in the biceps and brachio-radialis muscle. The consultant indicted that the claimant should be involved in a more physically demanding exercise program.

On February 3, 2000, the WCB advised the claimant that his case had been reviewed by a WCB medical advisor who was of the opinion that his ongoing symptoms appeared unrelated to the stated injuries of January 12, 1998. It was determined that the claimant had recovered from the effects of his compensable injury and any problems he was currently experiencing were now due to a non-compensable pre-existing condition. The claimant was advised that wage loss benefits would be paid to February 10, 2000 inclusive and final.

In a letter dated April 3, 2000, a worker advisor submitted additional medical information from the attending physician dated March 29, 2000 in which he indicated that the claimant had right sided ulnar neuropathy which was directly related to his workplace duties. On May 11, 2000, a WCB physical medicine and rehabilitation consultant reviewed the file and stated, in part, the following:

"On file review, the current mild to moderate right ulnar neuropathy, on a balance of medical probabilities, appears to be acquired and has been acquired while off work and off work duties and physical demands. It is, on a balance of medical probabilities, not related to the initial work injury of January 12, 1998 nor related to the employment prior to January 12, 1998."

On May 18, 2000, the claimant was apprised of the consultant's comments and was advised that no change would be made to the decision of February 3, 2000.

In a further submission dated August 17, 2000, the worker advisor made reference to a report from a hand and wrist plastic surgeon dated July 21, 2000. The surgeon stated that the ulnar nerve neuropathy was enhanced by the repetitive nature of the claimant's work duties as a door and window installer and that surgery was required. The worker advisor contended that based on the surgeon's comments, the claimant's benefits should be reinstated and that responsibility should be accepted for the claimant's upcoming surgery and recovery time.

On September 7, 2000, the worker advisor was informed that the recent medical information had been reviewed by a WCB medical advisor. "Based on this current information on the balance of medical probabilities, Mr. [the claimant's] wrist problems with regards to the ulnar nerve are not related directly or indirectly as hypothesized in the letter from his medical doctor dated July 12, 2000." The worker advisor's appeal was therefore denied.

On October 10, 2000, the claimant appealed the WCB's decisions of February 3, 2000, May 18, 2000 and September 7, 2000. The case was referred to Review Office for consideration.

In a decision dated January 19, 2001, Review Office determined that the claimant was not entitled to wage loss benefits beyond February 10, 2000. Review Office was of the opinion that "the onset of symptoms suggestive of ulnar nerve neuropathy almost nine months after the worker was last employed, cannot reasonably be found to be attributable to his work. As such, Review Office confirms that the worker is not entitled to wage loss benefits beyond what has already been paid." On March 5, 2001, the claimant appealed Review Office's decision and an oral hearing was convened.

Reasons

This is the case of a young worker who suffered an injury to both of his lower arms and wrists as a result of repetitive stresses in his workplace. He worked as a window and door installer, which involved using his arms in a lot of awkward positions - lifting windows (often over his head), holding them in place, installing them, removing other windows and doors and so on.

His claim was accepted as compensable by the board and he was paid wage loss benefits for twenty-five months, after which time his benefits were terminated, on the basis that he had recovered from the effects of his compensable injury. He appealed that ruling to the Review Office, which upheld the earlier decision. It is from that decision that he appeals to this commission.

The issue before the panel was whether or not he is entitled to benefits beyond February 10, 2000. For his appeal to be successful, the panel had to determine that he continued to suffer from the effects of his compensable injury beyond that date. More specifically, we had to determine that he had not recovered from the effects of tendonitis and medial epicondylitis; and/or that his ulnar neuropathy was a result of his workplace accident.

We determined that he had recovered from his compensable injuries and that the ulnar problems were not causally related to his work. In coming to our decision, we carefully reviewed the file, as well as hearing the testimony of the claimant at an oral hearing.

The claimant began to experience pain in his arms and hands in the fall of 1997, but continued to work until January 1998, when he was no longer able to work and filed a claim with the WCB.

The initial diagnosis, made by the claimant's family doctor, was of carpal tunnel syndrome (CTS) to both hands. However, when a nerve conduction study was performed a couple of weeks after the accident, there was no evidence of CTS. A month after the filing of the claim, his doctor and a board medical advisor settled on a diagnosis of tendonitis and the claim was accepted as work-related. A course of physiotherapy was prescribed by way of treatment.

Five and a half months later, another board doctor diagnosed mild medial epicondylitis. Physiotherapy continued.

Over the next year or so, his condition did not improve. Indeed, his symptomatology seemed to spread. In October of 1998, he presented with extreme pain in his right hand, his hand clenched into a fist, which he was unable to open.

In June of 1999, he was examined by a board consultant in Physical Medicine and Rehabilitation, who found no active myofascial pain, no active medial or lateral epicondylitis, no carpal tunnel syndrome and no evidence of significant ulnar involvement. He was of the opinion that any work-related epicondylitis would have resolved by this time, one-and-one-half years after ceasing to work.

He referred the claimant for a nerve conduction screening, which was done in September 1999. This test did show the claimant to have mild to moderate ulnar neuropathy, which was treated by decompression surgery in October 2000.

The panel was called upon to determine whether or not this ulnar neuropathy was causally related to his employment. In our considerations, we carefully reviewed the claimant's medical file.

We noted that the claimant's original symptoms, as well as those which followed in the weeks after he filed his claim, were not symptoms consistent with ulnar neuropathy. The nerve conduction study done in January 1998 did not show any ulnar problems. The first suggestion of such problems was made almost a year and a half after the claim, when the board medical consultant noted he could find no clinical evidence of such problems. The clinical diagnosis of ulnar neuropathy first came twenty months after the claim was filed and two years after he first started experiencing pains in his hands.

We have concluded that - on a balance of probabilities - the claimant's ulnar neuropathy was not causally related to his employment. In coming to this decision, we have given considerable weight to the opinion of the board consultant, noted above. In addition to the observations noted in the previous paragraph, this doctor wrote that, in addition to the nerve conduction study in 1998, the claimant was seen by a sports physician and an orthopaedic surgeon, with a lot of experience with ulnar neuropathy. It was the consultant's opinion that, if any ulnar problems had existed in this period, these doctors would not have missed them.

We are further of the opinion that the preponderance of evidence supports a conclusion that the claimant had recovered from his compensable injuries by February of 2000. In this consideration, we relied on the medical evidence that, by two years after filing his claim, these problems - tendonitis and medial epicondylitis - would have resolved. We note, in particular, that the board physical medicine consultant could find no sign of active epicondylitis in June of 1999 and concluded that this had resolved.

Given these findings, it follows that he is not entitled to wage loss benefits beyond February 10, 2000.

Accordingly, we uphold the decision of the Review Office and dismiss the appeal.

Panel Members

T. Sargeant, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

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

Signed at Winnipeg this 27th day of June, 2001