The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on October 22, 1998, at the request of the claimant. The Panel discussed this appeal on October 22, 1998, and December 22, 1998.

Issue

Whether the claimant is entitled to further benefits after June 22, 1998.

Decision

That the claimant is entitled to further benefits after June 22, 1998.

Background

While employed as a home maker on March 8, 1996, the claimant slipped on a wet laundry room floor after the floor had been washed. The diagnosis reported by the attending physician was a contusion to the left thigh and knee. The claim was accepted as a Workers Compensation Board (WCB) responsibility and benefits were paid accordingly.

Continuing progress reports received from the attending physician revealed that the claimant was sent for physiotherapy treatments relating to the left hip and thigh. X-rays of the left hip and knee taken on March 11, 1996, showed no bone or joint abnormality.

On August 9, 1996, the claimant was examined by a specialist who outlined a history of left hip and lateral type pain with radiation into the groin since the fall at work on March 8, 1996. Following examination, the specialist's impression was that the claimant had mild left leg radiculitis and left hip soft tissue pain syndrome. In a further report dated August 27, 1996, the specialist's impression was mechanical and myofascial pain syndrome affecting the paraspinal and glutei muscles on the left side. It was also noted that a CT scan of the lumbar spine, dated August 9, 1996, was considered normal.

The claimant underwent a diagnostic arthroscopy of the left knee on November 25, 1996. The preoperative diagnosis was "small area grade III chondromalacia. Lateral tibial plateau."

Following consultation with a WCB medical advisor in early January 1997, the adjudicator advised the claimant that her continuing care was no longer related to the March 8, 1996, compensable injury. As a result responsibility for any treatment beyond January 3, 1997, would not be accepted. This decision was later appealed by the claimant to the Review Office.

Subsequent file documentation contained a Doctor's First Report, dated April 11, 1997. The physician diagnosed the claimant's condition as a left trochanteric bursitis.

The claimant was examined at the WCB offices on July 30, 1997. The medical advisor confirmed from his examination findings that the claimant had a trochanteric bursitis. The medical advisor concluded was that the management of the claimant's compensable injury appeared to be satisfactory up to and inclusive of the date of her operative procedure. The medical advisor further indicated that the claimant should undergo aggressive physiotherapy directed towards her knee. Also the treating physician should then attend to the trochanteric bursa at the same time as her knee condition was being advanced. There appeared to be a lack of management in the claimant's status which could not be attributed to the claimant herself. It was felt that because of the delayed recovery, the claimant was beginning to show signs of pain focus and nonorganic physical signs. The medical advisor concluded that the claimant should be fit for a return to her employment within the next 3 to 4 weeks at full duties following the aggressive knee exercise program and treatment of her bursitis.

In a decision dated August 29, 1997, the Review Office accepted responsibility for the worker's treatment and time loss beyond January 31, 1997, and suggested that arrangements for a physiotherapy program be arranged.

The claimant underwent physiotherapy treatments in October and November 1997. Further investigations included a December 1997 bone scan which proved to be normal and a CT of the lumbar spine which also was considered normal.

The case was reviewed by a WCB medical advisor on May 27, 1998. The medical advisor commented there was no cause and effect relationship with the claimant's current symptoms. In the medical advisor's opinion, the claimant had recovered from the effects of the compensable injury. On June 15, 1998, the claimant was notified that wage loss compensation would be paid to June 22, 1998, inclusive and final.

On July 24, 1998, the case was considered by the Review Office upon receipt of the claimant's appeal. The Review Office confirmed that the claimant was no longer entitled to benefits after June 22, 1998, as the "predominant evidence does not support a conclusion that her ongoing symptoms/disablement after this date has been due to her work-related accident in March 1996."

An Appeal Panel hearing was held on October 22, 1998, at the request of the claimant. After the hearing and discussion of the case, the Panel requested additional medical information before discussing the case further. On December 4, 1998, the claimant was provided with three medical reports, two dated November 5, 1998, and the other, November 25, 1998, that were requested and received by the Appeal Commission. On December 22, 1998, the Panel met to render its final decision.

Reasons

As the background notes indicate, the claimant's benefits were terminated by Claims Services on June 22nd, 1998. The treating physician, however, informed the WCB in his progress report dated, May 29th, 1998, that the claimant was being referred to a Physiatrist for consultation on June 26th, 1998. Prior to the receipt and review of any report from the Physiatrist, the adjudicator in charge of the file concluded, based on the evidence available at the time, that the claimant had essentially recovered from the effects of her compensable injury.

The claimant was in fact seen by the Physiatrist on June 23rd, 1998, at which time his clinical assessment was that the claimant had chronic left tensor fascia lata strain and left L5-S1 facette joint strain with possibly degenerative changes. He also concluded that the claimant did not clinically have any peripheral nerve injury or compression or lumbosacral nerve root compression. With respect to treatment, the claimant underwent local injection into the four trigger points of the tensor fascia lata and "she was instructed to do daily back flexion exercises and stretching exercises of the left hip girdle muscles and tensor fascia lata to improve the movements and resolve the contractures and the trigger points of the affected muscles. I further discussed with her the proper ergonomics of work and activities of daily living with the aim to reduce significant mechanical stresses on her spine and hip joint." The claimant was seen on further follow-up appointments on July 17th, 1998, July 31st, 1998, and October 30th, 1998.

In addition to being examined by the Physiatrist after the termination of benefits, the claimant was also seen by a Neurologist as well as an Orthopaedic Surgeon. Both of these physicians recommended the claimant continue with the conservative measures under the care of the Physiatrist.

Prior to finalizing our decision, we requested that an updated report be obtained from the treating Physiatrist. We noted with extreme interest the following commentary contained in his report of November 25th, 1998:

"In summary Miss [the claimant] suffered soft tissue injury resulting from her fall. She may have possibly suffered lumbosacral facette joint injury and strain. She did not suffer any disc herniation or radiculopathy or peripheral nerve injury. On her visit to my Clinic on June 23rd, 1998, she presented with active trigger points of the left tensor fascia lata and had good pain relief for short periods after she received local injection with Xylocaine and Depo-Medrol of the trigger points. She further received trigger point injections of the left quadriceps and the tensor fascia lata on the 10th of July which gave her good relief for one week. She has developed chronic soft tissue pain syndrome and there has been no evidence of any significant bony disc or nerve injuries. I will not recommend any further investigations and she should be seen by the occasional rehab counsellor and should be encouraged to return to gainful employment. The best approach in her case will be graduated return to work and as her endurance and functional level improves, gradually the working hours can be increased to 8 hours per day." (emphasis ours)

The weight of evidence confirms, on a balance of probabilities, that the claimant had not fully recovered from the effects of her compensable injury when her benefits were discontinued on June 22nd, 1998. We therefore find that the claimant is entitled to further benefits after this date. In addition, we suggest that an aggressive time limited return to work program, as proposed by her treating Physiatrist, be initiated. Such a program, in our view, should begin as soon as possible.

The suggested return to work program is discretionary and implies, of course, that there shall be complete participation and involvement on the part of the claimant in her working towards a return to gainful employment.

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 19th day of February, 1999