The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An appeal panel hearing was held on May 4, 2006, at the request of a worker advisor, acting on behalf of the worker. The worker appeared and provided evidence. She was represented by a worker advisor. A representative of the accident employer also attended and presented its submission.

Issue

Whether or not responsibility should be accepted for the arthroscopic surgery and the subsequent time loss from work.

Decision

That responsibility should not be accepted for the arthroscopic surgery and the subsequent time loss from work.

Decision: Unanimous

Background

Reasons

Claim History
On October 6, 2002, the worker injured her left lower leg at work when she caught her right leg in the ring of her laboratory chair, and hopped three steps on her left leg. Her claim was accepted by the Workers Compensation Board (hereafter the "WCB") for a calf muscle strain.

The worker continued to have left leg symptoms and on October 12, 2004, she underwent a left knee arthroscopy, which revealed Grade 2 and Grade 3 chondromalacia. The WCB refused to accept responsibility for the arthroscopy on the grounds that it was not related to the worker's compensable injury. Review Office maintained this decision on April 5, 2005.

The worker appeals this decision. It is her position that the compensable injury aggravated her pre-existing degenerative chondromalacia and necessitated the arthroscopy.

Background
On October 6, 2002, the worker was sitting on her laboratory chair working when the telephone rang. As she got up from her chair to answer the phone, her right foot got caught in the ring at the base of the chair. She lost her balance and hopped three steps in an awkward fashion until she reached a counter where she could catch her balance.

The worker finished her shift. Her left leg was sore but she thought it would get better with time. When it did not, she went to her family doctor on October 23, 2002 who diagnosed her with leg-calf muscle strain.

A duplex exam of the deep venous system of the left leg did not reveal any blood clotting and an x-ray of the left knee did not reveal any significant abnormality other than evidence of an old wound to her distal femur.

The worker also underwent a course of physiotherapy which allowed her to gain more movement. However, her left leg complaints continued.

She was referred to an orthopaedic specialist on February 13, 2003 who diagnosed her with a left medial meniscal tear with some calf muscle strain. A left knee arthroscopy or an MRI was suggested to provide a definite diagnosis.

An April 7, 2003 MRI revealed the following:

"The medial and lateral menisci appear unremarkable. The anterior and posterior crutiate (sic) ligaments appear unremarkable. The medial and lateral collateral ligaments appear unremarkable. The patellofemoral cartilage and extensor mechanism appear unremarkable."

On May 8, 2003, the orthopaedic specialist noted that the worker's reported pain was better overall. She had full range of motion with no effusion. He thought that she most likely sustained a muscle strain that was getting better with time.

On November 6, 2003, the worker returned to the orthopaedic specialist stating that her knee never got back to "normal". She also had a fall a week before which made her knee a little worse. Her main complaint at that time was of pain that she felt diffusely in the knee. She could not kneel, crouch or garden and had lost range of motion and flexion. He thought her knee symptoms were patellofemoral in nature but nonetheless ordered a bone scan and further physiotherapy treatments.

The bone scan was done on November 17, 2003. It suggested a synovial inflammatory process present in the left knee. A bony reaction was also identified corresponding to the known enchondroma.

When next seen on August 16, 2004, a repeat x-ray of the left knee was done which did not show any degenerative changes in the weight bearing part of the joint; it did however reveal mild spurring at the superior pole of the patella. On examination, the orthopaedic specialist now found moderate patellofemoral crepitus. He diagnosed her with left knee chondromalacia of the patella without significant mechanical symptoms. An arthroscopy was carried out on October 12, 2004 which revealed Grade 3 chondromalacia of the medial femoral condyle and Grade 2 chondromalacia of the medial tibial plateau and patella.

Worker's Position
The worker takes the position that responsibility should be accepted for the October 12, 2004 arthroscopic surgery because the workplace accident enhanced her degenerative knee condition. She relies on her pre-accident level of functioning, her post-accident need for surgery, and her orthopaedic specialist's reports of October 19, 2004 and June 21, 2005 which state respectively:

"…prior to her work-related injury…she did have some discomfort in her knee with gardening for long hours but that it was significantly worsened when she had an injury at work where she loaded her left knee with three jumps as she was trying to avoid a fall. The type of changes that were seen on arthroscopy, are generally degenerative in nature but I think her condition based on her subjective history, was exacerbated by her work related injury."

"In my opinion, she did have pre-existing complaints of early osteoarthritis in the left knee but her work related injury where she loaded her left knee with three awkward jumps while trying to avoid a fall by history did significant [sic] exacerbate the symptoms that she was having. She has found that the arthroscopy has helped her knee get back to the level of her pre-existing condition."

Employer's Position
The employer asks that the appeal panel uphold the Review Office decision. It takes the position that the worker only suffered a soft tissue strain to her calf and knee on October 6, 2002 and that there is no evidence to link this workplace accident to the degenerative condition in the worker's knee.

Analysis
The worker says that her degenerative knee condition was enhanced by the workplace accident because her level of functioning decreased after the accident to the point that she required surgery. She says that the WCB should therefore accept responsibility for the arthroscopic surgery and subsequent time loss from work.

We do not accept this proposition.

The worker's compensable injury was a left calf strain. The file indicates that as of May 8, 2003 her symptoms related to her strain were resolving. At that time she had full range of motion and no effusion, showing that her condition was near to her pre-accident level.

The worker's degenerative knee condition pre-existed the workplace accident. The worker testified at the hearing that the degenerative knee condition manifested itself when kneeling and gardening. On those occasions she experienced some soreness in the knee. The diagnosis of a pre-existing degenerative knee was confirmed by the worker's treating orthopaedic specialist.

The worker's orthopaedic specialist appears to say that the worker's degenerative knee condition and symptoms were "exacerbated" by the workplace accident. "Exacerbation" implies a temporary flare-up. It does not imply a permanent enhancement, nor does the orthopaedic specialist suggest that this is the case. Further, he does not say that the workplace accident made surgery necessary.

In reviewing and weighing the evidence, we cannot find sufficient evidence that would show, on a balance of probabilities, that the workplace accident played any role in the worker's pre-existing degenerative condition. We accept the WCB medical advisor's December 8, 2004 opinion that the worker's surgery cannot be related to her compensable injury:

"Extreme chondromalacia demonstrated as expected with no additional findings which could be considered to have a causal relationship to the [compensable injury]…"

Chondromalacia is a degenerative condition. It progresses with time. The fact that the worker's degenerative knee condition worsened after the workplace accident does not mean that it was enhanced by the workplace accident. In our opinion, the October 12, 2004 arthroscopy which revealed Grade 2 and Grade 3 degenerative changes to the worker's knee is indicative of a longstanding progressive process which started prior to the October 6, 2002 workplace accident.

We therefore find that responsibility should not be accepted for the arthroscopic surgery and subsequent time loss from work.

Accordingly, the worker's appeal is denied.

Panel Members

L. Martin, Presiding Officer
R. Koslowsky, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

L. Martin - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 13th day of June, 2006