The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on August 16, 1999, at the request of a worker advisor, acting on behalf of the claimant. The Panel discussed this appeal on August 16, 1999 and October 20, 1999.

Issue

Whether or not the claimant's symptoms and functional restrictions beyond December 26, 1998 are related to her compensable injury of June 18, 1997; and

Whether or not the claimant is entitled to further wage loss after December 26, 1998.

Decision

That the claimant's symptoms and functional restrictions beyond December 26, 1998 are not related to her compensation injury of June 18, 1997; and

That the claimant is not entitled to wage loss benefits after December 26, 1998.

Background

While performing the duties of a nurse's aide on June 18, 1997, the claimant was transferring a resident from chair to bed when she felt a pull and sharp pain in her right shoulder. After the incident, the claimant kept working until July 4, 1997, but then discontinued due to pain. On July 10, 1997, the attending physician diagnosed post-traumatic bursitis and the claimant was referred to physiotherapy.

On August 22, 1997, the claimant was examined by a Workers Compensation Board (WCB) physiotherapy consultant who was of the opinion that physiotherapy treatment should focus on the scapular musculature as opposed to the glenohumeral joint. It was further recommended that a WCB medical advisor review the case in 2-3 weeks time concerning a graduated return to work program. In October 1997, the claimant commenced a graduated return to work program with the accident employer.

The claimant was assessed by an orthopaedic specialist on October 30, 1997. The specialist reported that the claimant's presentation suggested a shoulder strain with continued pain arising from the periscapular muscles, subdeltoid bursa and rotator cuff, with internal derangement. The specialist suggested that the claimant remain on restricted duties and to consider a subacromial injection if there was no resolution within six weeks.

On November 18, 1997, a consultant specializing in pain and stress management diagnosed the claimant with sleep disturbance and myofascial pain of the supraspinatus, infraspinatus and upper trapezius.

On January 6, 1998, nerve conduction studies confirmed a right focal ulnar neuropathy at the elbow in the cubital tunnel.

The claimant was examined by a WCB medical advisor on March 4, 1998. Following the examination, it was suggested that the claimant be referred to a physical medicine specialist to treat the areas of myofascial pain.

In a report dated March 26, 1998, the physical medicine specialist reported muscular tenderness in the right trapezius, right infraspinatus and right levator scapular muscles. He was unable to identify any definitive regional myofascial pain syndrome activity however he felt that prior acupuncture treatment may have treated some of this. The claimant also demonstrated paraesthesia in her hands which was likely due to the focal ulnar neuropathy at the level of the cubital tunnel. According to the specialist, if this were the case it would be unrelated to the compensable injury. Also, if the condition did not improve the claimant would require referral for surgical opinion on the release or transposition of the ulnar nerve. The physician suggested a trial of some directed needling treatment to the musculature of the right scapular girdle.

On May 20, 1998, a WCB medical advisor reviewed the case. It was his medical opinion that there was a cause and effect relationship between the cubital tunnel syndrome and the compensable injury.

On July 22, 1998, a WCB medical advisor determined that the current diagnosis was ulnar neuropathy, partially treated myofascial pain and general deconditioning. There was an ongoing cause and effect relationship between the diagnosis and the compensable injury.

In a follow up report dated August 28, 1998, the physical medicine specialist stated that he was uncertain as to the exact cause of reported tenderness on palpation over the scapular girdles soft tissues on the right. There was no evidence of any myofascial pain syndrome activity. The current trial of trigger point needling treatment had not produced any reported benefit. He felt there was no indication for further needling treatment in the musculature.

Following a review of file documentation, a WCB medical advisor stated in a memo dated October 13, 1998, that the claimant had no definitive clinical findings to correspond with her complaints. It was felt that the claimant should progress to full time duties.

On December 1, 1998, the claimant was advised by Claims Services that by December 27, 1998, she would be returning to full time regular duties and that benefits would be payable to December 26, 1998 inclusive and final.

On December 14, 1998, a union representative appealed this decision stating that the claimant was not fit to resume full duties and that she continued to suffer from pain and discomfort.

On December 16, 1998, the claimant was assessed by a second treating physical medicine and rehabilitation specialist. Her impression was that the claimant had some myofascial pain syndrome of her upper back muscles and her right shoulder girdle muscle. It was felt that trigger point injections at the present time would not help and that the treatment should now be directed at a work hardening program for the claimant.

In a decision dated February 12, 1999, the Review Office determined that:

• the current evidence did not show that the claimant’s ongoing loss of earning capacity after December 26, 1998, was reasonably due to the work related accident she suffered in June 1997;

• there was no ongoing effect of the claimant’s work related accident for which further healthcare treatment after December 26^th was reasonably necessary or advisable; and

• that the claimant was not entitled to further benefits after December 26, 1998.

Review Office stated that the work related accident in June 1997 probably caused a soft tissue strain injury to the right shoulder region and did not contribute significantly to subsequent findings of ligamentous instability in both shoulders or of ulnar neuropathy at the right elbow. Review Office was satisfied there were no objective clinical findings to account for the claimant’s contention of persistent symptoms or of disablement from normal work activity subsequent to December 26, 1998. Review Office was of the view that the claimant’s ongoing symptoms were more likely than not associated with some other cause which was not attributable to the accident arising out of and in the course of employment. This included ligamentous laxity of her shoulders, ulnar neuropathy or general deconditioning - none of which would entitle her to benefits under the provisions of The Workers Compensation Act (the Act).

On May 6, 1999, a worker advisor requested the Review Office to reconsider its earlier decision based on a medical report from the second treating physical medicine and rehabilitation specialist dated April 13, 1999, in which she stated that the claimant’s current problem was related to the June 1997 work injury. On May 21, 1999, the Review Office confirmed that the latest information did not provide any new evidence which would change its earlier decision. On June 3, 1999, the worker advisor appealed the Review Office’s decision and an oral hearing was scheduled for August 16, 1999.

Following the hearing and discussion of the case, the Appeal Panel requested additional information prior to rendering its final decision. Specifically, the Panel requested further medical information from the treating neurologist along with the results of a MRI scan.

Reasons

The issue in this appeal is whether or not the claimant's symptoms and functional restrictions beyond December 26, 1998 are related to the compensable injury of June 18, 1997 and whether or not the claimant is entitled to wage loss benefits after December 26, 1998.

The relevant subsection of The Workers Compensation Act (the Act) in this appeal is subsection 39(2) which provides for the duration of wage loss benefits.

The claimant was injured in the course of her employment while transferring a patient from a chair to a bed at a long term care facility on June 18, 1997. The claim was accepted as a WCB responsibility and benefits were paid until December 26, 1998.

In this appeal we reviewed all the evidence on file, and given or received during the hearing process and find that the evidence, on a balance of probabilities, supports a finding that the claimant’s symptoms and functional restrictions beyond December 26, 1998 are not related to the compensable injury of June 18, 1997 and that the claimant is not entitled to the payment of wage loss benefits after December 26, 1998. In arriving at this conclusion we relied on the following evidence.

• the Employer’s Report of Injury dated June 30, 1997 also indicates injury to the right shoulder. The attending physician in the Doctor’s First Report dated July 10, 1997 diagnoses post-traumatic bursitis of the right shoulder;

• physiotherapy treatments were instigated in July, 1997 for treatment of right shoulder symptoms. In a pain diagram completed on August 22, 1997 for physiotherapy the claimant indicates that she has aching and burning pain in the right shoulder area;

• in a report dated August 20, 1997 based on a examination of the same day, the attending physician indicated that the claimant should be able to return to light duties;

• on August 22, 1997 the claimant was examined by the WCB physiotherapy consultant for recommendations with respect to further physiotherapy management. The physiotherapist indicated that further therapy was required and recommended an ongoing regime of stabilization and strengthening. On examination the consultant found that the glenohemural joint was essentially normal and noted increased laxity on stability testing which was present bilaterally. He further recommended that the file be reviewed in 2-3 weeks regarding any possible restrictions and a graduated return to work;

• a WCB medical advisor reviewed the file on September 24, 1997 and indicated that a graduated return to work would be appropriate with restrictions of limited lifting greater than 25 lbs. or repetative lifting for 4 weeks;

• in a report dated October 30, 1997 a treating orthopaedic consultant indicated that the claimant was still experiencing shoulder problems, that physiotherapy was still indicated and that the claimant needed to remain on restricted duties and be reassessed in six weeks if the symptoms were not resolved;

• the claimant was examined by an attending physician on November 10, 1997 at the Centre for Pain and Stress Management. The physician indicated that the claimant had sleep disturbance, myofascial pain of the right supraspinatus, infraspinatus and upper trapezius and the claimant might benefit from a short course of trigger point acupuncture. The acupuncture treatments were approved by the WCB;

• electrophysiologic testing carried out on January 6, 1998 revealed that the tests with respect to the long thoracic nerve and the auxillary nerve were normal and there was no evidence of carpal tunnel syndrome. The tests revealed that there was evidence of focal ulnar neuropathy at the elbow including the cubital tunnel;

• the claimant was referred to a physical medicine and rehabilitation specialist and examined on March 27, 1998. The specialist stated in part:

“ Firstly, based on the current clinical examination there was a restricted area of some muscular tenderness present in the right trapezius, right infraspinatous and right levator scapula muscles. I was unable to identify any definite active regional myofascial pain syndrome activity.

Neurologic examination was unremarkable except for the symptomology of parathesias in the hands. I did Tinel’s testing over the cubital tunnel bilaterally and she had symptoms of radiating parathesias when done on the right, this suggesting that the parathesias in her hands which are duplicated with Tinel’s testing are likely on the basis of the focal ulnar neuropathy detected with the electrophysiologic studies, this at the level at the cubital tunnel. Note: this would be, if present unrelated to her injury.”

• the physical medicine and rehabilitation specialist further indicated in the same report that the claimant might benefit from some directed needling treatment and exercises for the musculature of the right scapular girdle and suggested that the claimant add some regular general fitness activity that uses the muscles in smooth movement such as swimming on a regular basis. He indicated:

“ I would expect that she should have resolution of any residual muscle involvement with treatment and that following this she should be able to return to her previous duties.”

• in a subsequent report dated August 28, 1998 based on an examination of the same day the physical medicine and rehabilitation specialist indicated that the claimant had completed a trial of trigger point needling and physiotherapy with no reported benefit. He states in part:

“ ... I am uncertain as to the exact cause of her reported tenderness on palpation over the scapular girdles soft tissue on the right. As in the prior examination there was no evidence of any active myofascial pain syndrome activity, or organic musculoskeletal problem to explain the symptoms. I would have expected that the muscular symptoms should have resolved to date prior to directed trigger point needling treatment and the activities to date. I am uncertain as to why there continues to be reported symptoms in the soft tissues and reported aggravation of same with heavier duties. However it would be reasonable to encourage work on flexibility, exercises, add some regular range of motion to general fitness activity and to continue on with her current work at light duties. The longer term goal would be to gradually progress up in her work physical demands, likely the number of hours and then to progress to her regular duties.”

• the claimant was seen by a second attending physical medicine and rehabilitation specialist on December 16, 1998 who documents the claimant’s history. With respect to the ulnar neuropathy at the elbow in the cubital tunnel the specialist indicates in part:

“ We did actually get a copy of the report from Dr. (neurologist) and they were at that time trying to rule out long thoracic nerve injury or auxillary nerve injury and the EMG and Nerve Conduction Study was negative for this and there was no evidence of any carpal tunnel syndrome though it showed a focal ulnar neuropathy at the elbow in the cubital tunnel which is probably more related to a pressure neuropathy from resting on the elbow.

Impression is that she does have some myofascial pain syndrome of her upper back muscles and her right shoulder girdle muscle. Since it has been 1 ½ years since the injury I do not think that trigger injections at the present time are going to help. In fact most of the focus now should be a work hardening program for her to return to her previous occupation.”

• in a subsequent report dated April 13, 1999 by the second attending physical medicine and rehabilitaiton specialist we note the following in part:

“ As far as current restrictions on her workplace activities, I particularly do not have any restrictions on her as long as she does the stretching as well as the strengthening on her own to improve the strength of her right shoulder which is mildly weak.

...Ideally she should have her work hardening program before she returns to regular duties. The other thing is to wait and see what the MRI Scan shows prior to her returning to her regular work.”

• benefits were terminated at the conclusion of a graduated return to work program December 26, 1998;

• following the hearing the panel requested a copy of the MRI report and an opinion from the treating neurologist. In a report dated September 17, 1999 the attending neurologist indicated that:

“ As the MRI examination has yielded a negative result, I have, as I intimated would be the case no basis for invoking any neuromuscular diagnosis for Ms. [the claimant’s ] symptoms for which indeed I do not have a neurologic explanation.”

Based on the evidence outlined, on a balance of probabilities, we find that the claimant has recovered from the effects of the compensable right shoulder injury. We are also of the view that the development of the ulnar neuropathy of the right elbow at the cubital tunnel on a balance of probability is not a sequela of the compensable injury for which this file was established.

In reaching our conclusion that the claimant has recovered from the effects of the compensable right shoulder injury, we place weight on the comments of the first physical medicine and rehabilitation specialist who based on his examination of March 27, 1998 expressed the opinion that the claimant should have resolution of any residual muscle involvement with treatment. We further note in the specialist’s subsequent report of August 28, 1998 that the specialist reports no evidence of any active myofascial pain or organic musculoskeletal problems to explain the claimant’s ongoing symptoms. We also note the second attending physical medicine and rehabilitation specialist expressed his opinion on April 13, 1999 indicating that the claimant did not have any restrictions to employment. We further note the normal results of the MRI testing carried out July 30, 1999.

In determining that the claimant’s elbow complaints are not causally related to the compensable shoulder injury we take note that the proximate evidence including early medical documentation and the Worker’s and Employer’s Reports of Injury reference only a right shoulder injury. We note the first mention of any problem involving a right elbow neuropathy did not become apparent until approximately six months post shoulder injury. We also note the first physical medicine and rehabilitation specialist’s report dated March 27, 1998 where the physician expresses the opinion that the right elbow neuropathy would be unrelated to the compensable shoulder injury.

In light of our findings that the claimant has recovered from the compensable injury of June 18, 1997 there would be no entitlement to further wage loss benefits after December 26, 1998. Therefore the claimant’s appeal on both issues is denied.

Panel Members

D.A. Vivian, Presiding Officer
E. Krosney, Commissioner
R. Frisken, Commissioner

Recording Secretary, B. Miller

D.A. Vivian - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 8th day of November, 1999