The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on March 1, 2001, at the request of the claimant. The Panel discussed this appeal on several occasions, the last one being June 7, 2001.

Issue

Whether or not the claimant is entitled to payment of wage loss benefits beyond August 4, 2000; and

Whether or not responsibility should be accepted for the claimant's secondary accident of March 3, 2000.

Decision

That the claimant is not entitled to payment of wage loss benefits beyond August 4, 2000; and

That responsibility should not be accepted for the claimant’s secondary accident of March 3, 2000.

Background

While employed as a labourer on April 26, 1999, the claimant was pulling doors across a floor when she incurred pain in both knees. The claimant described the incident as follows: "pulling doors on the floor & while pulling doors they banged on my knees on a continuous basis causing my knees pain. Also lifting doors using my knees." Medical information received in this matter are summarized as follows:

• X-rays of both knees dated April 16, 1999 demonstrated no joint effusion on either side. The joint spaces were well maintained. No other significant bone or joint abnormality was seen.
• A Doctor's First Report dated June 22, 1999 (date of first treatment was May 1, 1999) diagnosed the claimant with soft tissue injury and possible internal injury. The claimant was referred to an orthopaedic specialist for treatment.
• On June 15, 1999, an orthopaedic surgeon assessed the claimant with "bilateral patellofemoral pain". Physiotherapy, anti-inflammatories and a neoprene cutout brace were prescribed for the claimant.
• In a memo of July 27, 1999, a Workers Compensation Board (WCB) medical advisor commented that patellofemoral syndrome was a common condition especially in young females.
• On August 13, 1999, a WCB physiotherapy consultant assessed the claimant's status. Following examination, the physiotherapy consultant commented that the claimant's current presentation was not consistent with patellofemoral syndrome. Her complaints of limited standing and walking tolerance were not consistent with this syndrome. There was inconsistency also noted in her inability to heel or toe walk. The physiotherapy consultant also indicated in his examination notes that it was difficult to understand why the claimant continued to experience ongoing problems when she had been away from the aggravating situation for almost 4 months and was on an appropriate therapy program. He recommended that the case manager review the case with a WCB medical advisor who should then contact the treating physician. A return to work plan should be initiated at that time.
• In a follow-up report dated September 21, 1999, the orthopaedic surgeon indicated that the claimant's bilateral patellofemoral pain was 50% improved. He thought that the claimant should try returning to work in October and gradually to increase her hours.
• On January 13, 2000, x-rays were taken of both knees. The impression read, "Slight reactive degenerative changes are present in both knees. There has been no significant change from April of 1999."
• On February 16, 2000, the claimant was assessed by a WCB medical advisor with respect to ongoing difficulties that she was experiencing with her knees. The medical advisor stated in part, "The relationship to her reported compensable injury can be made as patellofemoral itself can take a good deal of time to settle. There are also factors relating to her weight and biomechanical factors involving her feet, which more than likely have an impact on her recovery."
• The claimant was assessed by a second orthopaedic surgeon on February 24, 2000. The specialist felt that the claimant may have a tear of the medial meniscus and he arranged for an MRI to be carried out.
• A Chiropractor's First Report dated March 20, 2000, noted the following worker's history of injury, "She stated she had been pulling doors on the floor which continuously banged on her knees and lifted doors with knees. She got weaker and fell downstairs 3x end of February/March 2000." The chiropractor's diagnosis was chronic T/F joint instability bilaterally.
• On April 10, 2000, the treating physician noted that the claimant was seen on March 7, 2000 for a secondary accident that occurred on March 3, 2000. The physician stated that the history given by the claimant was that she was coming down stairs at home when her knees gave out. She rolled over the stairs hurting her head, neck and upper back. The claimant was diagnosed with a soft tissue injury in the occipital area, sprained neck and trapezius muscles. The physician stated that due to the claimant's bilateral knee problems she was advised to be off work until further notice.
• The results of the left knee MRI findings taken April 8, 2000, revealed that the anterior and posterior cruciate, medial and lateral collateral ligaments were intact. Both menisci demonstrated normal morphology and signal intensity with no evidence for a tear.
• On June 17, 2000, a WCB medical advisor reviewed the case at the request of primary adjudication. In response to questions posed by primary adjudication, the medical advisor was of the opinion that the claimant's chronic knee pain was unlikely related to her work injury and that she had recovered from any effects of her compensable injury. With respect to the claimant's neck and back problems subsequent to her fall in March 2000, the medical advisor concluded that the neck and back difficulties were not related to the knee injury.

On July 28, 2000, primary adjudication advised the claimant that the weight of evidence did not support a continued cause and effect relationship between the compensable injury and her ongoing knee symptoms. Based on Section 39(2) of the Workers Compensation Act (the Act), wage loss benefits would be paid to August 4, 2000 inclusive and final. It was also determined by primary adjudication that the predominant cause of the claimant's secondary accident of March 3, 2000 was not due to her compensable knee injury and that no responsibility would be accepted for her neck and back difficulties. In September 2000, the claimant appealed this decision to Review Office.

Prior to rendering a decision with respect to the claimant's appeal, Review Office sought the medical advice from a WCB orthopaedic consultant on September 26, 2000. The orthopaedic consultant was asked to comment on the diagnosis of the bilateral knee condition. The consultant responded that there was no definitive diagnosis or significant pathology demonstrated. He stated that the "giving away" of the claimant's knees were not related to the compensable injury and that there was no reason for the claimant not to be back at full time employment.

On September 29, 2000, Review Office determined that the claimant was not entitled to payment of wage loss benefits beyond August 4, 2000 and that no responsibility would be accepted for the claimed secondary accident of March 3, 2000. Review Office noted that the claim had been accepted for bilateral patellofemoral pain and that subsequent investigations had not revealed any other symptomatology that would be related to the described compensable injury. Given the available information, Review Office was satisfied that the claimant had recovered from the effects of her claimed injury to her knees.

Review Office referred to WCB policy 44.10.80.40.01 which involves the adjudication of subsequent injuries to a work injury. In accordance with the provisions of this policy, Review Office determined that the claimant's knee condition was not one, which would cause her knee to collapse or give way resulting in a fall such as the worker had on March 3, 2000. The resulting injuries from the fall were therefore not compensable in the opinion of Review Office. On November 21, 2000, the claimant appealed Review Office's decision and an oral hearing was arranged for April 3, 2001.

Following the Appeal Panel hearing on April 3, 2001, the Panel met to discuss the case and requested that additional information be obtained from two of the claimant's treating physicians. Responses received from the treating physicians dated April 23 and April 25, 2001 were provided to the claimant for comment. On June 7, 2001, the Panel met to render its final decision on the issues under appeal.

Reasons

Following her compensable injury in 1999, the claimant continued to experience ongoing bilateral knee pain more pronounced on the left than on the right. The claimant described the pain as usually being centred on her left kneecap. A second orthopaedic specialist examined the claimant on or about February 24th, 2000:

"On examination, I note that the patient can walk without a limp. The patient does have a good range of motion of her knee. The patient does have no effusion of her knee. Ligaments of her knees are stable. The patient does have a little discomfort pushing the patella against the femoral condyles. The patient does have some tenderness on the medial joint line of her left knee which is more pronounced than the medial joint line on her right knee. McMurray's test is negative. The patient may have a tear of the medial meniscus, however, at this time to investigate this patient further I think I will get an MRI that will help to determine if there is a significant tear of the medial meniscus."

An MRI performed on April 17th, 2000 recorded normal findings. In light of the foregoing together with other evidence on file, the WCB considered the claimant to have recovered from the effects of her compensable injury and therefore discontinued benefits in early August 2000.

A third orthopaedic specialist was consulted on January 18th, 2001. At this time, the claimant presented with "left knee pain, most of it localized underneath the knee cap and the attachment of the patellar tendon" and without any limp. In reaching our decision, we attached considerable significance to the clinical findings and opinion expressed by this physician.

"On observation, minor swelling noted, synovial type, at both knees. No gross effusion at least during this present visit. [S]he could walk tiptoes and heels without any difficulty. Range of movement of both knees is equal. On squatting, the patient complains of pain deep to the patella, particularly on the left side along with some tenderness at the patellar tendon attachment. Patellar grinding or excursion test is positive bilaterally. There is 1 cm. wasting noted at the left quadriceps. Left cruciate seems to be slightly tender but no gross laxity. McMurray's manoeuvre is obviously negative.

X-ray of both knees taken at my office on January 18 reviewed by me revealed sharpening or spurring of the intercondylar tubercle indicating early osteoarthritic change. Also some osteoarthritic change, minor type, at the patellofemoral compartment with osteophyte formation at the patellar margin.

The patient was rechecked at my office on January 22 when all these investigative findings were available in my chart and it was discussed with her. No doubt, on the basis of the symptomatology and investigative findings, the patient is suffering from osteoarthritis of the patellofemoral compartment, early phase. To my opinion, symptomatic treatment with non-steroidal anti-inflammatory drugs was advised to Dr. [the treating physician] which should be prescribed by him. Dr. [the treating physician] was also advised to arrange for the patient to undergo quadriceps building exercises by physiotherapy."

We find the medical evidence together with the described mechanism of injury do not support the claimant's contention that her continuing difficulties beyond August 4, 2000 are attributable to the original compensable injury. Accordingly, she is not entitled to the payment of wage loss benefits after this date. In addition, we further find that the claimant's secondary accident of March 3rd, 2000 is not related to her workplace activities or her initial compensable injury, as the medical evidence does not demonstrate any compensable medical condition of the claimant's knees that could cause the claimant's fall. Therefore responsibility should not be accepted for this event.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

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

Signed at Winnipeg this 28th day of June, 2001