The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An appeal panel hearing was held on July 26, 2005, at the request of a worker advisor, acting on behalf of the worker. The panel discussed this appeal on July 26, 2005 and again on February 20, 2006.

Issue

Whether or not responsibility should be accepted for the conditions of left carpal tunnel syndrome and left ulnar neuropathy as being related to the compensable left shoulder injury; and

Whether or not the worker is entitled to payment of wage loss beyond July 25, 2004.

Decision

That responsibility should not be accepted for the conditions of left carpal tunnel syndrome and left ulnar neuropathy as being related to the compensable left shoulder injury; and

That the worker is not entitled to payment of wage loss beyond July 25, 2004.

Decision: Unanimous

Background

In October 2002, the worker submitted a claim to the Workers Compensation Board (WCB) for left shoulder pain which began to develop around June or July 2002 during the course of his employment as a heavy duty mechanic. Following a review of initial medical reports along with information that was obtained from the employer regarding the late reporting of the accident, the WCB accepted responsibility for the worker's left shoulder difficulties and wage loss benefits were paid to the worker commencing December 12, 2002.

A review of medical information since the inception of the claim revealed the following:

• November 1, 2002 - an orthopaedic specialist noted that the worker complained of clicking in his left shoulder and numbness in the left third, fourth and fifth fingers intermittently. The diagnosis rendered was bursitis of the left shoulder.
  
  
• December 5, 2002 - the family physician reported that the worker was first assessed on June 11, 2002 and complained of pain in his left shoulder after pulling on a wrench at work. The initial diagnosis was tendonitis of the left shoulder. X-rays of the left shoulder taken June 11, 2002 and November 4, 2002 were unremarkable. The physician noted that the worker had a similar injury to his left shoulder on March 19, 2000 when he fell at home.
  
  
• March 18, 2003 - following an examination at the WCB's offices, a WCB medical advisor reported that the worker complained of ongoing left shoulder pain going down to his upper arm and tingling into his middle, ring and little finger with any sustained or repeated movement. The medical advisor outlined his opinion that the worker's symptoms and clinical findings were consistent with a rotator cuff injury and possibly a bicipital tendon injury or a labral tear. An MRI was suggested to clarify the diagnosis.
  
  
• May 23, 2003 - an MRI examination revealed multiple cysts within the glenoid and a type 1 acromion with mild AC arthritis. The MRI was negative for a rotator cuff tear or cuff atrophy and a labral tear was not detected.
  
  
• June 6, 2003 - an orthopaedic specialist reported that the worker complained of pain from the left shoulder radiating into the left arm and left elbow. He complained of intermittent numbness and weakness of the left third, fourth and fifth fingers and that his left finger shook when holding his left elbow and forearm in extension. The diagnosis rendered was recurrent bursitis of the left shoulder and ongoing degenerative changes in the shoulder.
  
  
• June 18, 2003 - a WCB medical advisor outlined her opinion that the current diagnosis was ongoing impingement secondary to rotator cuff tendonitis and that the impingement and tendonitis were both related to the compensable injury.
  
  
• September 18, 2003 - a physical medicine and rehabilitation specialist stated that the worker was seen regarding ongoing difficulties with his left shoulder and discomfort that seemed to radiate to the left anterior arm and little finger of the left hand. The specialist reported that the worker's arm was caught in a transmission of a truck while lying on his back and that this pulled his arm hard in a backwards way. The specialist noted that the worst area was in the left superior/posterior shoulder region just at the upper part of the scapula and that it spread to the anterior shoulder and down the arm. It was concluded that the worker had a lot of myofascial symptomatology.
  
  
• December 4, 2003 - the physical medicine and rehabilitation specialist reported that the worker's symptomatology on the inside of his left arm and elbow region had significantly improved with injection treatments. The worker, however, still complained of some significant discomfort when he raised his arm up into the 90 degrees of abduction position along with numbness and deadness sensation along the inside border of his hand extending into the ring and little fingers.
  
  
• January 22, 2004 - a WCB medical advisor examined the worker and stated, in part, that the worker continued to complain of symptoms from his left shoulder going down his left arm and hand since the June 2002 work related injury.
  
  
• January 29, 2004 - nerve conduction studies revealed the following findings "…the left upper extremity does not show any evidence of neurogenic thoracic outlet syndrome. It does, however, indicate moderately severe carpal tunnel syndrome as well as moderately severe focal ulnar neuropathy at the level of the ulnar groove. There is no evidence of Guyan's canal syndrome neither is there evidence of a plexopathy or more proximal lesion."
  
  
• March 24, 2004 - a specialist noted that the worker complained of left hand numbness that started in June of 2000 and recent right hand symptoms. He noted numbness and tingling affecting the middle, ring and little finger. The diagnosis rendered was left carpal tunnel syndrome and ulnar nerve neuropathy at the left elbow. Decompression surgery of both the ulnar nerve and the median nerve was suggested.
  
  
• April 5, 2004 - family physician reports subjective complaints of left shoulder pain with numbness in the right arm more than the left arm.
  
  
• April 27, 2004 - a WCB medical advisor reviewed the file information and stated that the current diagnosis related to the compensable injury was myofascial pain of the left shoulder. The following diagnoses were not related to the compensable injury: AC arthrosis, left carpal tunnel syndrome, left ulnar neuropathy and facet osteoarthritis of the cervical spine.
  
  
• May 4, 2004 - a WCB medical advisor outlined her opinion that the worker may benefit from a six week work hardening program.

On May 4, 2004, a WCB case manager advised the worker that the WCB was only accepting responsibility for the myofascial pain in his left shoulder. The WCB was not accepting responsibility for the diagnoses of AC arthrosis, left carpal tunnel syndrome, left ulnar neuropathy or facet osteoarthritis of the cervical spine as being related to his compensable injury.

On May 10, 2004, the case manager advised the worker that arrangements were being made for him to complete a six week work hardening program after which he would be deemed fit to return to his regular duties. The worker indicated that he would be unable to do either of these because of his hands. The case manager advised the worker that if he could not participate in the work hardening program because of his non-compensable hand difficulties, the WCB would pay him wage loss benefits only for the period of time that he would have been engaged in the work hardening program. After that period he would be deemed fit to return to his regular duties. In a decision dated June 15, 2004, the worker was advised that wage loss benefits would end on July 25, 2004.

On October 8, 2004, Review Office considered the case based on an appeal submission by the employer who was contesting the acceptance of the claim. Review Office ultimately determined that the worker's left shoulder injury occurred while working on a transmission and confirmed that the claim was acceptable.

In a submission to Review Office dated November 19, 2004, a worker advisor appealed the WCB's decisions of May 4 and June 15, 2004. The worker advisor outlined his opinion that there was medical and other evidence on file to support the position that the worker's left carpal tunnel syndrome and left ulnar neuropathy arose from the worker's compensable left shoulder injury. The worker advisor said there was only minimal resolution of the worker's ongoing shoulder problems between June 2002 to June 2004 and that it was highly unlikely that the worker would have been able to resume his full regular duties as a heavy equipment mechanic even if he had been able to participate in the work hardening program.

Prior to considering the worker advisor's appeal, Review Office sought the advice of a WCB orthopaedic consultant. The orthopaedic consultant advised Review Office that in his opinion, the evidence did not demonstrate any significant shoulder pathology and that the worker's left carpal tunnel syndrome and left ulnar neuropathy were unrelated to the reported accident.

On February 25, 2005, Review Office confirmed that the worker's left carpal tunnel syndrome and left ulnar neuropathy were not the result of the compensable accident and that he was not entitled to wage loss benefits beyond July 25, 2004. Review Office felt that the worker's left shoulder condition would have or should have resolved sufficiently following the work hardening program to have allowed him to return to his normal type of work. Review Office believed that the worker had been appropriately compensated for his wage loss from work with respect to his left shoulder injury.

On July 26, 2005, an appeal panel hearing took place at the worker advisor's request. At the conclusion of the hearing, the appeal panel decided to arrange for the worker to be assessed by an independent medical examiner with respect to his left shoulder status. On November 8, 2005, an orthopaedic specialist assessed the worker's left shoulder and his report dated December 7, 2005 was forwarded to the interested parties for comment. On February 20, 2006, the panel met further to discuss the case and considered a final submission from the worker advisor dated January 27, 2006.

Reasons

As the background notes indicate, the worker developed left shoulder pain on or about June or July 2002 while performing his work duties as a heavy duty mechanic. The attending physician diagnosed the worker's condition as being bursitis of the left shoulder. An x-ray of the affected shoulder demonstrated no significant bone or joint abnormality. Similarly, a CT scan undertaken on February 12, 2003 revealed no evidence of significant arthritic erosions, rotator cuff calcification and/or calcification of the subacromial bursa.

A WCB medical advisor examined the worker on March 18, 2003 and recorded that her clinical findings were consistent with a rotator cuff injury and quite possibly a bicipital tendon injury as well as maybe a labral tear. However, an MRI of the left shoulder conducted on May 23, 2003 confirmed as follows: "No rotator cuff tear or cuff atrophy is seen. No labral abnormality is detected." Mild AC (acromioclavicular) arthrosis, on the other hand, was detected.

Despite ongoing treatment, the worker continued to experience left shoulder difficulties. On January 29, 2004, he underwent nerve conduction studies and the treating neurologist reported the following findings: "This electrophysiologic study of the left upper extremity does not show any evidence of neurogenic thoracic outlet syndrome. It does, however, indicate moderately severe carpal tunnel syndrome as well as moderately severe focal ulnar neuropathy at the level of the ulnar groove." After an April 27, 2004 file review, a WCB medical advisor concluded that the diagnoses of AC arthrosis, left carpal tunnel syndrome, left ulnar neuropathy and facet osteoarthritis of the cervical spine were unrelated to the compensable injury.

The attending physician referred the worker to an orthopaedic surgeon for a consultation. Following his examination, the surgeon reported, in part, these findings: "Range of motion of his left shoulder is at 150/45/L5. He complains of difficulty raising his left shoulder fully. Passive range of motion is satisfactory. He also complains of a numbing sensation involving his left hand during range of motion to his left shoulder. The left shoulder is felt to be stable. His previous magnetic scan performed in May 2003 is reviewed. No significant pathology is identified." (Emphasis ours)

After having considered all of the evidence, we agree with the conclusions reached by the Review Office and the WCB orthopaedic consultant that the worker's left carpal tunnel syndrome and left ulnar neuropathy were not occasioned by the compensable injury and therefore responsibility should not be accepted for these conditions.

With respect to the worker's ongoing left shoulder pain difficulties, we decided to have him examined by an independent medical examiner prior to our determining whether or not these difficulties continued to be compensable. A thorough review of the independent medical examiner's report in conjunction with the rest of the evidence, led us to conclude that the worker's present shoulder condition is, on a balance of probabilities, no longer related to his work injury and/or activities in 2002.

We further find that the worker is not entitled to payment of wage loss beyond July 25, 2004. Accordingly, the worker's appeal is hereby dismissed.

Panel Members

R. W. MacNeil, Presiding Officer
J. MacKay, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

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

Signed at Winnipeg this 23rd day of March, 2006