The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on August 4, 2005, at the request of a worker advisor, acting on behalf of the worker. The Panel discussed this appeal on the same day.

Issue

Whether or not responsibility should be accepted for the worker's right knee complaints beyond April 13, 2004.

Decision

That responsibility should not be accepted for the worker's right knee complaints beyond April 13, 2004.

Decision: Unanimous

Background

On January 29, 2003, the worker filed a claim with the Workers Compensation Board (WCB) for a right knee injury that occurred in the workplace on January 21, 2003. The worker's description of injury was as follows: "I was giving a guy a shower. I got him out and dried him off. I went to put the towel over the shower, and I turned to grab a container that was on the counter and my feet went from under me and I fell on the ramp and landed on my back side. I guess when I turned I pulled a muscle in my knee."

A Doctor's First Report revealed that the worker was examined on January 22, 2003 for pain and decreased range of motion of his right knee. The diagnosis rendered was a right knee possible cartilage contusion. The physician noted that the worker had a history of previous right knee problems. The physician also commented that the worker had returned to his full regular duties as of January 25, 2003.

In a follow-up report dated February 6, 2003, the attending physician reported that the worker was presently doing fine and was able to hop on one knee without a problem. The worker could heel and toe walk as well.

On March 4, 2003, the treating physician reported that the worker had persisting right knee pain which had been getting worse over the past 3-4 days with more pain along the medial aspect.

The worker was subsequently examined by an orthopaedic specialist who arranged for the worker to undergo an MRI examination of his right knee on May 22, 2003.

In a June 9, 2003 report, the orthopaedic specialist noted that the MRI findings revealed a complete disruption of a previous right ACL graft as well as a bone bruise of the right tibial plateau. It also confirmed medial compartment degenerative changes. Treatment suggestions included a trial of bracing and physiotherapy. If this type of treatment failed, the specialist was of the opinion that the worker may be a candidate for revision ACL reconstruction.

On September 12, 2003, a second orthopaedic surgeon, specializing in knee, shoulder and sports injuries, made the following comments after his examination of the worker:

"This gentleman is not a candidate for ACL reconstruction, as I don't think it will give him any increased stability because of his severe OA. I think he would be a candidate for TKR [total knee replacement] based on his increased symptomatology. The reality is that this gentleman has a chronic ACL insufficient knee, which was reconstructed but most likely wasn't functioning for quite some time. I don't think that Osteotomy would give him significant relief."

In an October 7, 2003 report, a third orthopaedic surgeon agreed that the worker was a candidate for a total knee arthroplasty. He referred the worker to a fourth orthopaedic surgeon for an assessment to consider the possibilities of a TKR. On October 7, 2003, the fourth orthopaedic surgeon agreed that the worker was a candidate for a TKR.

On January 29, 2004, a WCB case manager asked a WCB medical advisor to review the file and to comment on the current diagnosis, its relationship to the compensable injury and whether surgery should be authorized by the WCB. In a response dated February 5, 2004, a WCB orthopaedic consultant stated, in part, "I have difficulty believing that the twisting injury described and his rapid recovery was responsible for tearing of the anterior cruciate reconstruction…the proposed surgery is for painful degenerative osteoarthritis of the right knee joint. WCB responsibility for this surgery would only be considered if there had been an aggravation of the pre-existing condition to such a degree that it was now an enhancement."

In a decision dated April 7, 2004, the WCB case manager informed the worker that wage loss benefits would be paid to April 13, 2004 inclusive and final. It was the case manager's opinion that the worker's current difficulties were related to degenerative osteoarthritis of the right knee joint which was not aggravated or enhanced by the compensable injury. It was felt that the worker had recovered from the effects of his compensable accident and any ongoing difficulties were unrelated to the compensable injury.

On April 16, 2004, the first treating orthopaedic specialist wrote to the WCB and outlined his opinion that the worker's condition had been enhanced by his compensable injury.

On April 22, 2004, the treating physician stated that the worker's knee was presently painful and unstable and that prior to his injury, his knee was not unstable or painful as he had no problems with it.

In a submission dated September 22, 2004, a worker advisor contended that the worker's ongoing knee difficulties were compensable based on a report from the second treating orthopaedic surgeon dated August 5, 2004 and in conjunction with WCB policy 44.10.20.10, Pre-existing Conditions.

On December 23, 2004, a WCB orthopaedic consultant reviewed the file information and advised primary adjudication that his opinion remained unchanged from his previous review of the file. The consultant outlined his opinion that the compensable injury did not cause a tear of the ACL nor did it enhance a pre-existing condition.

On February 15, 2005, the WCB case manager determined that no change would be made to the decision of April 7, 2004. On February 17, 2005, a worker advisor appealed this decision to Review Office.

In a decision dated April 8, 2005, Review Office confirmed that there was no responsibility beyond April 13, 2004. Review Office based its decision on the mechanism of the injury and the medical information on file. It was Review Office's opinion that the compensable injury resulted in a strain/sprain of the knee which did not enhance the worker's pre-existing conditions. On May 27, 2005, the worker advisor appealed Review Office's decision and a hearing was arranged.

Reasons

As the background notes indicate, the worker sustained a strain/sprain to his right knee at the time of his compensable accident on January 21, 2003. The preponderance of evidence also confirms that the worker has had longstanding osteoarthritis of the right knee.

On March 24, 2003, the worker was examined by an orthopaedic surgeon, who reported the following comments and observations:

"Radiographs of the right knee were reviewed. This shows evidence of a previous anterior cruciate ligament reconstruction with tunnel in the tibia. There is also significant medial joint line osteoarthritis as well as patellofemoral osteoarthritis. Due to a combination of Mr. [the worker's] previous surgery, his apprehension and somewhat atypical pattern of tenderness, I am unclear as to what injury, if any, he has sustained as a result of his work place injury. I have submitted a request for an MRI examination of the right knee to ascertain if there is any intraarticular pathology present."

An MRI of the right knee taken on May 22, 2003 revealed: "Torn ACL reconstruction. Extensive degenerative changes seen about the medial femoral tibial compartment." The treating orthopaedic surgeon discussed the results of the MRI with the worker, who requested a referral to a second orthopaedic specialist in order to discuss his case further.

We note with interest certain comments recorded by the second orthopaedic specialist in his letter of August 5, 2004 to the worker's worker advisor.

"It is impossible to be precise about when his ACL reconstruction tore, however based on the objective signs of carnosity in his knee, i.e. severe osteo-arthritis, it is most likely that the graft was disrupted some time before this event.

The osteo-arthritis present in this gentleman's knee is longstanding in nature and did not occur at the time of the accident, as this takes many years to develop. Based on the patient's history, he did not have symptoms up to the accident, however that does not exclude the reality that he had significant degenerative changes in his knee, which had been developing over many years.

On balance of probabilities at some point in time, this gentleman would most likely have had the emergence of symptoms with or without this workplace injury, as degenerative changes had been accumulating over many years. It is likely that he would still have required total knee replacement at some time in the future."

After having thoroughly considered all of the evidence, we find that the worker's continuing right knee difficulties are not, on a balance of probabilities, causally related to his compensable injury, but rather, are associated with his pre-existing longstanding degenerative knee condition. We further find that responsibility should not be accepted for the worker's right knee complaints beyond April 13, 2004.

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 19th day of September, 2005