The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on November 18, 1999, at the request of legal counsel, acting on behalf of the claimant. The Panel discussed this appeal on November 18, 1999.

Issue

Whether or not the claimant's symptoms are causally related to her 1989 compensable injury or to a subsequent accident arising out of and in the course of her employment; and

Whether or not the claimant is entitled to further benefits and services beyond June 1992.

Decision

The claimant's symptoms are not causally related to her 1989 compensable injury or to a subsequent accident arising out of and in the course of her employment; and

The claimant is not entitled to further benefits and services beyond June 1992.

Background

In August 1989 the claimant submitted a claim for compensation benefits in relation to numbness and pain in both wrists which she related to bagging chickens and turkeys. The claimant was subsequently diagnosed with bilateral carpal tunnel syndrome and underwent carpal tunnel releases to both wrists.

In a progress report, dated July 10, 1990, the attending physician reported that the claimant returned to work on June 25, 1990. The physicians stated "Hands are better, not as painful but still swelling of the right fourth metacarpal phalangeal joint and painful left thumb metacarpal phalangeal joint. Managing with discomfort." Temporary total disability benefits were paid between November 6, 1989 to June 22, 1990 inclusive and final.

On July 3, 1992, the claimant submitted a further claim for compensation benefits in relation to right hand, shoulder and knee pain, which occurred on June 15, 1992. The employer's report of injury indicated that the claimant reported to her supervisor that her hands, shoulder and left knee were hurting and that she felt it was due to arthritis and possibly cysts in her joints.

In a sworn statement, dated July 20, 1992, the claimant clarified that she was presently off work for problems related to both hands and for an aching right shoulder. She felt these problems were due to the work duties she performed on June 15th and 16th, 1992.

When she returned to work in June 1990, the claimant stated that her hands were okay. Between Christmas 1990 and March 1991, the claimant was laid off work due to a shortage of work. She had no further problems again until she injured her left middle finger at work on August 12, 1991. Her whole left hand was swollen and she was off work for 2-3 weeks. Between January 10, 1992 and June 12, 1992, the claimant was again laid off due to a shortage of work and received unemployment insurance benefits during this time.

On June 12, 1992, the claimant stated that she worked in "cut up" all day and had no problems of any kind with her hands or shoulder. Her left knee was sore but she did not know why. On June 15, 1992, both hands started to swell and burn. There was no accident or injury to account for these difficulties. At lunchtime she went to see a doctor and he told her not to work for 2 weeks. The claimant indicated that she continued working because she needed the money. When she started work on the morning of June 16, 1992, the claimant said she could barely open and close her hands. As the day went on her hands got worse and she noticed soreness in her right shoulder. She felt this had occurred because the work she was doing was too hard. On June 22, 1992, her attending physician advised her to submit a claim, as her condition may be work related.

Medical information indicates that the claimant was seen by a physician on June 15 and June 17, 1992. The diagnosis was long standing arthritis in both hands and shoulder. No accident history or relationship to employment was mentioned. It was also noted that the claimant was seen for similar complaints on June 1, 1992 (arthritic problems).

A doctor's first report, dated June 22, 1992, indicated the worker's history of injury was excessive repetitive work causing pain in the right hand/shoulder. The treating physician diagnosed tenosynovisitis right shoulder, both hands and left knee. Follow up reports were also received, dated July 2, 1992 and August 17, 1992.

On September 1, 1992, Claims Services of the Workers Compensation Board (WCB) determined that the claim for compensation was not acceptable. It was the opinion of Claims Services that the evidence did not establish a relationship between the claimant's right/left hand and right shoulder difficulties and an accident arising out of and in the course of her employment.

A worker advisor prepared a submission on behalf of the claimant, dated June 21, 1994. The worker advisor contended that a relationship between the claimant's injuries and the nature of her work could be established on a balance of probabilities. In support of her position, new medical information, dated February 27, 1994 was submitted in which the physician opined that a portion of the claimant's difficulties were related to an incompletely released carpal tunnel. He also ruled out arthritis as a diagnosis. A February 22, 1994, report from the treating physician advised that while the claimant's symptoms were consistent with arthritis, they were equally consistent with tenosynovitis. The doctor stated that the claimant's shoulder difficulties were consistent with shoulder impingement syndrome related to her duties of eviscerating and pulling crops.

In view of the above information, primary adjudication requested additional medical information together with another statement from the claimant. On July 12, 1994, the claimant indicated that during the times she was laid off work, her wrists and hands were always sore and that they became progressively worse after returning to work. The claimant felt that her symptoms were related to her carpal tunnel injuries and that she had returned to work too early after the operations. There were no new accidents, which caused her difficulties.

On August 29, 1994, a report from the Hand Clinic indicated, in part, the following: "the general appearance of the right hand leads us to believe that she might be experiencing a third stage post traumatic sympathetic dystrophy as an outcome of her carpal tunnel release." A referral to the Pain Clinic was then made for a trial of quanethidine blocks.

On October 3, 1994, the treating physician outlined his examination findings of the claimant from July 10, 1990, through to September 22, 1994. In his opinion, the claimant's condition in both her hands, wrists and right shoulder was due to the repetitive nature of her work at the processing plant.

A report from the Pain Clinic, dated December 13, 1994, indicated that the claimant had a bone scan which demonstrated minor arthritic changes in her hands but otherwise no suggestion of reflex sympathetic dystrophy. She continued to demonstrate cold hands bilaterally and was agreeable to a trial of guanethidine blocks. After undergoing this trial the claimant did not experience any significant improvement in her symptoms. She continued to describe burning and at times numbness radiating from her wrist into her fingers. The most recent nerve conduction studies seemed to demonstrate continued impairment of the median nerves bilaterally. She may require further revision to alleviate this problem.

On February 1, 1995, a WCB medical advisor reviewed the case and was of the view that the claimant's difficulties were not due to either CTS or to the work she performed in June 1992. The medical advisor was certain that the claimant's difficulties were due to arthritis. On February 7, 1995, Claims Services wrote to the claimant indicating that no change would be made to its earlier decision.

Subsequent medical reports showed that the claimant sought treatment from a hand specialist on February 13, 1995, for recurrence of her right carpal tunnel syndrome. On June 2, 1995, the claimant underwent surgery, i.e. compression median nerve right hand and division palmar cutaneous nerve neuroma. In a follow up report, dated November 29, 1995, the hand specialist stated that recent nerve conduction studies showed no abnormality in either median nerve. The claimant was still complaining of significant pain in both her hands with some loss of dexterity. The specialist felt that this was mainly articular in nature and was a manifestation of early osteoarthritis.

On January 5, 1996, the case was reviewed by a WCB medical advisor who stated the following:

"In my Nov. comment I indicated there might be a relationship to the initial surgery if sympathetic dystrophy were a factor. On further review of file it is apparent that CTS was never the dominant cause of her symptoms and that she has had from the outset regional myofascial pain or brachio radialis syndrome. I think the problems may relate to overuse. I don't feel she has recovered because I don't think she has yet been treated for her primary condition. After this length of time an element of chronic pain behavior may also be a significant barrier to recovery."

On February 9, 1996, the claimant was advised that the WCB had established a relationship between the initial compensable injury and the June 2, 1995, surgery. As a result, the claimant was provided with six weeks of time loss benefits from June 2, 1995 to July 13, 1995 inclusive. Any further time loss was not considered to be due to the compensable injury and was not a WCB responsibility.

In a memo, dated June 5, 1996, the WCB medical advisor clarified his earlier comments of January 5, 1996, with regard to the regional myofascial pain or brachioradialis syndrome secondary to overuse, as the likely primary pathology. The medical advisor stated, "Other possible causes were fibromyalgia and as stated in the memo, abnormal pain behavior would have to be considered also after this length of time. In my second last paragraph, there is need for clarification regarding the status of recovery, in that, I admit she may have ongoing symptoms from any of the above diagnoses I have mentioned, but given the fact that no new injury has been reported, and given the fact that the original compensable injury was in 1989, there is no way that the current symptoms can be related to the 1989 compensable injury as any of the conditions mentioned such as myofascial pain or overuse syndrome would have spontaneously resolved in this time interval, particularly with lack of use in the interim."

In a letter, dated June 26, 1996, primary adjudication advised the claimant that the last medical report on file from the hand specialist indicated her present ongoing hand symptoms were mainly related in nature to the manifestation of early osteoarthritis. The WCB would not be accepting further responsibility for her hand condition in relation to the bilateral carpal tunnel syndrome which was incurred in November 1989 as medical information on file indicates that the work related component of the carpal tunnel syndrome had resolved. It was the opinion of primary adjudication, that although the claimant may have ongoing symptoms, there had been no report of any new injury incurred at work and given the fact that the original compensable injury was for bilateral carpal tunnel syndrome in 1989, it was unlikely that the current symptoms can be related to the 1989 compensable injury.

On April 30, 1998, a physical medicine and rehabilitation specialist agreed that the claimant had a mild thoracic outlet syndrome due to her neck and shoulder girdle posture. There was forearm myofascial pain and there continued to be chronic weakness in the hands with probably a chronic synovitis of the right wrist. On June 4, 1998, the specialist indicated that it was highly probable that the claimant's present problems can be attributed to the repetitive manual activity, which she had to discharge in a poultry-processing plant. In a follow up report, dated August 4, 1998, the specialist stated that physiotherapy did not produce much in the way of benefit and clinically the claimant had been left with quite generalized secondary myofascial pain or hand intrinsic muscle and shoulder girdle muscle pain. There was still a suggestion of a right wrist synovitis with localized tenderness and thickening.

In a memo, dated September 23, 1998, a WCB medical advisor expressed his opinion that the claimant's symptoms and progress did not seem to be related to any compensable injury on file. On November 24, 1998, primary adjudication advised the claimant that no change would be made to its previous decision.

On April 23, 1999, the claimant's solicitor contended that the claimant continued to suffer from her compensable injuries. "Whether or not her present symptoms are as a result of a reflex sympathetic dysfunction, the fact of the matter is, the cause or root of the problem is her compensable injuries." Enclosed with the appeal was a May 17, 1999, report from a physical medical and rehabilitation specialist.

In a decision, dated July 30, 1999, the Review Office determined that the claimant's injuries about June 1992 were not causally connected to an accident arising out of and in the course of employment which happened either in 1989 or more recently when the symptoms apparently worsened in June 1992. Benefits were not payable under the provision of the Act for any injuries the claimant may have had since June 1992.

Based on the weight of evidence, Review Office concluded the following:

• the diagnosis or probable etiology of the claimant's various symptoms subsequent to June 1992 was likely unknown;
• there was no clinical evidence of any residual effect reasonably or probably attributed to the work-related carpal tunnel injury she suffered in 1989; and
• several speculative medical diagnoses and medical opinions about causation had been influenced by the claimant's historical information which can be best described as consistently inconsistent;
• a chain of causation had not been established between the 1989 work related injury and the recent symptoms or disablement which began about June 1992;
• a work related cause of the claimant's problems beginning in June 1992 was not sufficient to satisfy a test of probability, noting the absence of a specific accident leading to the onset of symptoms. Review Office also noted the claimant's limited exposure to forceful repetitive activities at work for six months prior to June 1992 and for an extended period since June 1992.

On August 16, 1999, the claimant's solicitor appealed the Review Office's decision and an oral hearing was convened.

Reasons

The physicians at a local Hand Clinic reported to the referring physician on August 29th, 1994 as follows: "The symptoms of which she complains and the general appearance of the right hand leads us to believe that she might be experiencing a third stage post traumatic sympathetic dystrophy as an outcome of her carpal tunnel release." The claimant was then referred to the Pain Clinic for examination with respect to her reflex sympathetic dystrophy. On December 13th, 1994, the Director of the Pain Clinic advised the rehabilitation physicians that a bone scan demonstrated no suggestion of reflex sympathetic dystrophy.

We find that the carpal tunnel syndrome diagnosed in 1995 is not related to the claimant's bilateral carpal tunnel decompressions performed in February and April of 1990. The evidence strongly suggests that the claimant's subsequent development of carpal tunnel syndrome was related to something other than her former work duties. In particular, the evidence reveals that the claimant worked less than 10 days in 1992. Also of importance were the results of nerve conduction studies carried out on May 16th, 1994. In a letter to the claimant's solicitor, dated February 10th, 1995, the then treating physiatrist provided the following comments:

"The most recent nerve conduction studies are dated May 16, 1994. The interpretation of this report suggested, no evidence of ulnar neuropathy, on either side. There was mild residual left carpal tunnel syndrome. There was no evidence of carpal tunnel syndrome on the right."

When examined by the hand specialist in February of 1995, the claimant's main problems were in the right hand with "pain, stiffness and some pallor."

The claimant was once again examined by the second treating physiatrist on March 24th, 1998. The claimant's discomfort extended from her right wrist into the fingers and occasionally up the arm to the elbow and further to the shoulder. He also confirmed that "subsequent nerve conduction studies did not show any transmission impairment in the median nerve." In his opinion the physiatrist agreed with the hand surgeon that the claimant has "a mild thoracic outlet syndrome due to her neck and shoulder girdle posture." He recommended a course of physiotherapy for the claimant that involved working on her shoulders, posture, mobility, general strength and stretching out the muscles affected by myofascial pain.

We are of the view that the claimant's current physical difficulties are unrelated to her 1989 compensable injury. In this regard, we attached considerable weight to the WCB medical advisor's opinion, which is contained in a memorandum, dated September 23rd, 1998.

"I don't feel that the difficulties are likely related to either incident [i.e., the CTS or the work performed in 1992] per se. Even her own physicians, despite on some occasions (such as June 1998) describing her problems as 'likely attributable to repetitive activity at the poultry plant', indicated (June 3, 1998, April 30, 1998) that she has a mild thoracic outlet syndrome due to her neck and shoulder girdle posture. Mention was also made of a myofascial pain and synovitis. Neither of these circumstances would necessarily be related to any work activity no matter how repetitive or heavy. It also appears, although many results are not in the file, that there is a paucity of objective findings of any pathology at all."

We find, based on the weight of evidence, that the claimant's symptoms are not, on a balance of probabilities, causally related to her 1989 compensable injury or to a subsequent accident arising out of and in the course of her employment. Accordingly, the claimant would not be entitled to benefits and services beyond June 1992.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
R. Frisken, Commissioner

Recording Secretary, B. Miller

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

Signed at Winnipeg this 8th day of December, 1999