The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on October 22, 2001, at the claimant's request. The Panel discussed this appeal on several occasions, the last one being August 13, 2002.

Issue

Whether or not the claimant has recovered from the effects of her right shoulder complaints as of February 15, 2001.

Decision

That the claimant has not recovered from the effects of her right shoulder complaints as of February 15, 2001.

Decision: Unanimous

Background

On September 13, 2000, the claimant experienced pain in her right shoulder which she attributed to her work duties as a window assembler. On September 18, 2000, the attending physician diagnosed the claimant with a "right shoulder/neck strain (overuse) and a referral was made for physiotherapy treatments. The Workers Compensation Board (WCB) accepted the claim and compensation benefits commenced on September 14, 2000.

Ongoing progress reports were received from the attending physician and from the treating physiotherapist. On November 27, 2000, the attending physician noted pain over the superior aspect of the shoulder, worse with abduction or carrying a heavy load. He noted that physiotherapy could no longer help with function. Range of motion in the shoulder was "good". The physician referred the claimant to a specialist for further assessment.

Following an examination on December 8, 2000, a WCB medical advisor diagnosed the claimant with a right rotator cuff tendonitis based on the mechanism of injury, symptoms course and current clinical findings. "With the support of physiotherapy, exercise and the passage of time '90% improvement' has been realized, with the claimant noting improvement in pain, strength and function with objective evidence of full return of right shoulder range of motion. Although provocative testing was negative (supraspinatus testing, impingement testing), the claimant remains quite tender over the subacromial area." The medical advisor felt that the claimant was not totally disabled and could return to her pre-accident status within 4 to 6 weeks.

In a January 22, 2001 report, an orthopaedic specialist noted that all of the claimant's symptoms appeared to be localized to the acromioclavicular joint. Arrangements were being made for a bone scan. The specialist commented that with full range of pain free movement, there was no contraindication to work activity.

On January 24, 2001, the claimant underwent a bone scan. The results were read as being normal.

In a written decision dated February 19, 2001, primary adjudication confirmed to the claimant that it was felt she had recovered from the effects of her September 13, 2000 work accident given the normal findings found by her doctor and the normal bone scan results. Wage loss benefits and related medical costs were to be paid up to and including February 14, 2001.

On May 8, 2001, the claimant contacted the WCB to advise that she was still suffering from pain in her right shoulder and neck and was of the view that the February 19, 2001 decision was inadequate and not properly adjudicated. The case was referred to Review Office who in turn requested additional medical information.

On June 29, 2001, Review Office considered the file evidence that included reports from a physiatrist dated June 7, 2001, April 29, 2001 and February 15, 2001 and obtained medical advice from a WCB orthopaedic consultant on June 26, 2001. Review Office ultimately concluded that as of February 15, 2001, the claimant had recovered from the effects of her September 13, 2000 shoulder injury and was deemed fit to return to work with no loss of earning capacity.

After reviewing all the medical information including the opinions of two orthopaedic specialists, Review Office was of the position that whatever symptoms the claimant was experiencing beyond February 14, 2001 were not related to the strain injury of September 13, 2000. Review Office found no medical evidence to show that the claimant was disabled from employment and thus there was no loss of earning capacity. On July 18, 2001, the claimant disagreed with Review Office's decision and the case was referred to the Appeal Commission.

On October 22, 2001, an oral hearing was held to determine whether or not the claimant had recovered from the effects of her right shoulder complaints as of February 15, 2001. Following the hearing and discussion of the case, the Panel requested updated information from the claimant's treating orthopaedic specialist and physiatrist. On November 19, 2001, all interested parties were provided with medical reports dated November 6 and 14, 2001 and were asked to provide comment.

At a meeting held on December 4, 2001, the Panel noted that the claimant was undergoing an MRI examination of her right shoulder in January 2002 and that she would be seen in follow-up by both the physiatrist and orthopaedic surgeon once the MRI results were available. The Panel decided to await the MRI results and the follow-up appointment before discussing the case any further. On February 14, 2002, all interested parties were provided with copies of medical reports that were received by the Panel dated December 28, 2001, January 17, 2002 and February 9, 2002 and were asked to provide comment.

On March 1 and 6, 2002, the Panel met again to discuss the case. Prior to rendering a final decision, the Panel requested that further information be obtained from an independent orthopaedic specialist with regard to the etiology of "shoulder S.L.A.P. lesions". On July 19, 2002, all parties were provided with a copy of the specialist's report dated June 17, 2002 and were asked to provide comment. On August 13, 2002, the Panel met to render its final decision with respect to the issue under appeal.

Reasons

The claimant in this case injured her right shoulder in a workplace accident on September 13, 2000 and received wage loss and medical aid benefits from the Workers Compensation Board. The WCB adjudicator and Review Office later found that the claimant had recovered from the effects of her workplace injury as of February 15, 2001, and her benefits were terminated as of that date. The claimant has appealed that decision to this Panel.

For the claimant to succeed in her appeal, this Panel would have to find, on a balance of probabilities, that she had not recovered from the injury as of February 15, 2001, and that she was still entitled to benefits as provided in The Workers Compensation Act (the Act). Based on the evidence provided in the file and at the hearing, and, in particular, the evidence acquired after the original hearing was held, we have determined that the claimant had not recovered from the effects of her workplace injury as of February 15, 2001.

As noted in the background, the WCB originally accepted the worker's claim on the basis of a first diagnosis of "a right shoulder/neck strain (overuse)." Over time, a number of additional diagnoses were offered, including a right rotator cuff tendonitis, and later, symptoms that were localized to the claimant's acromioclavicular joint. A number of physicians noted continuing pain complaints with activity, but noted that the claimant had full range of motion of her shoulder and that a bone scan of the right shoulder was negative. A physiatrist noted impingement signs but an injection provided no relief to the claimant. Eventually, the Review Office referred this file for a review by the WCB's orthopaedic consultant who felt that a CT scan or MRI was not necessary, and stated:

"Based on the medical evidence on the file and the time that has passed, I believe that the decision that the claimant had recovered and was capable of full duties as of February 15, 2001 was reasonable. I do not identify any medical evidence to suggest that there was a continuing disability beyond February 14, 2001"

This opinion was incorporated into the decision of the Review Office which concluded that "it is felt that whatever symptoms the claimant was experiencing beyond February 14, 2001, were not related to the strain injury of September 13, 2000." [emphasis added]

Following the appeal hearing, the panel sought an updated medical report from the claimant's treating physiatrist, whom the claimant was scheduled to see. The physiatrist provided a report on January 17, 2002, in which he states:

"She underwent an MR arthrogram of the right shoulder at the St. Boniface Hospital on December 28, 2001. A superior labral tear extending into the anterior labrum was detected. The rotator cuff complex was intact. My impression is that this finding is the probable cause of her continued symptoms

In my opinion, [the claimant] is not currently capable of returning to her pre-accident employment, assembling windows. She describes right shoulder pain at rest with increased pain during activity. The findings on MRI are consistent with limitation of shoulder function.

[The claimant's] physical restrictions currently include limited abduction and overhead work. She should avoid heavy lifting with the right upper limb"

The claimant's treating orthopaedic surgeon came to a similar conclusion regarding work restrictions, stating that "physical restrictions are for no heavy use of the affected right shoulder, particularly pushing and pulling, lifting and overhead work. These restrictions may be lifted if she has successful surgery, or if she does spontaneously improve. This spontaneous improvement would be somewhat unexpected, in view of the findings and for her particular job needs."

The Panel reviewed the MRI findings of December 28, 2001 and noted the finding of a superior labral tear whose "appearance is consistent with a SLAP variant (type V)." The Panel felt it was necessary to determine the nature of this particular medical finding, and also to determine whether or not this diagnosis was a consequence of the workplace injury sustained by the claimant. This file was sent to an independent orthopaedic surgeon for review and comment. In his report to the Panel dated June 17, 2002 he notes that "SLAP lesions are not common but can be the source of significant disability to a patient. SLAP lesions are difficult to diagnose and usually require CT or MRI arthrograms or arthroscopy to achieve a diagnosis. SLAP lesions are frequently managed successfully with arthroscopic treatment."

The independent orthopaedic surgeon then offered the following comments, on which the Panel places particular weight:

[The claimant] had no prior symptomology in her right shoulder prior to her increased workload of the 13th of September 2000. Since that time, she has persistently complained of right shoulder pain that has probably worsened with the passage of time. A variety of examining physicians have stated different clinical findings and different diagnoses. A superior labral anterior/posterior lesion causing symptomology is frequently very hard to diagnose. Clinically therefore it is not surprising there is a mixed variety of recorded physical findings and especially diagnoses. However the MRI is quite definitive and does show a significant superior labral tear. The tear involves the superior labrum and extends into the anterior labrum which is described as being detached. It doesn't really state that the superior labrum and its biceps attachment is also detached.

It is my opinion that the pathology identified on MRI arthrogram taken at the St. Boniface Hospital 28th of December, 2001 is a result of [the claimant's] work activities. It is also the factor contributing to her ongoing pain and inability to improve her endurance or force loading of he shoulder. She would require surgical intervention arthroscopically depending on the findings at the time. She may require simple debridement of the labral tear and detachment. However if there is instability especially superiorly and related to the biceps attachment, re-anchoring would be required.

It is my opinion [the claimant] is unable to return to her window assembly occupation because of the labral tearing or SLAP lesions in her right shoulder. These are the result of her work-related injuries September 13, 2000."

As to the causal relationship between the claimant's SLAP injury and her work duties, the independent specialist notes that the claimant's job duties require consistent compressive loading of the shoulder in a variety of positions. However, the specialist states he was unclear as to the amount of overhead shoulder activity in the claimant's job. He noted that this type of injury appears to occur from chronic repetition in an overhead fashion including throwing and overhead work, all of which would involve the use of the outstretched arm.

The Panel reviewed the claimant's job duties as noted in the file, at the hearing, and in supplementary information provided by the claimant in a letter dated July 30, 2002. Based on this information and in particular the job duties associated with the overhead loading of spacer bar rolls, the Panel finds that the claimant's job duties did, on a balance of probabilities, cause the claimant to suffer a SLAP lesion within her right shoulder.

Based on the evidence, we find that the claimant's SLAP lesion is causally related to the original workplace injury in September 2000. We also note that her physiatrist and orthopaedic surgeon provided physical restrictions arising out of this diagnosis which would preclude the claimant from returning to her pre-accident job at the time her benefits were terminated on February 15, 2001.

The claimant's appeal is hereby allowed.

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 13th day of September, 2002