The Appeal CommissionThe Workers Compensation Act of Manitoba

Background

The worker has been employed with the accident employer for over 25 years. Though her duties have varied over the years, the main job duties which are pertinent to this appeal are those of a meat cutter. A meat cutter’s job consists in grabbing bunches of sausages with both hands, straightening them by rolling them backwards and forwards with open flat palms and finger tips slightly curled then hitting them against the sides of a bin and feeding them through a cutter. The cut sausages fall into another bin which the worker lifts and transports to another area.

In 2000 she was working at bunching sausages when she felt something pull in her right arm. She was diagnosed with right epicondylitis and her claim for compensation was accepted by the WCB. The worker returned to her regular duties approximately 7 weeks later. However, the worker says that her right arm pain never went away.

Then on October 1, 2002, the worker was working at her regular duties cutting and bunching sausages when she suffered an injury to her right hand. She filed a claim for this injury as well as a non-specific claim for her continuing upper extremity condition.

The worker saw her family physician on October 7, 2002 who diagnosed the worker with bilateral lateral epicondylitis. The family physician’s first report notes subjective complaints of pain and stiffness in both thumbs radiating to her elbows and shoulders. Clinical examination revealed tenderness in the metacarpal joints of both thumbs, the lateral epicondyles and deltoid muscles. The family physician noted that the worker had the same symptoms in her 2000 claim. A subsequent report states that the worker’s symptoms were caused by a repetitive stress injury to her arms, elbows and wrists.

As the worker’s symptoms did not subside she was referred to physiotherapy and an orthopaedic specialist. The orthopaedic specialist thought that the worker suffered a muscle strain. On examination he found good range of motion in the neck, no tenderness in the shoulder or elbow, good movement in the elbow but some tenderness over the right and left radial styloid.

The worker continued with physiotherapy but her symptoms still did not subside and she remained off work.

On March 5, 2003 she was examined by a WCB medical advisor, who offered the following opinion:

“…She appears to have had a probable tendonitis in the extensor tendons to the left thumb, at the radial wrist and over the dorsum of the left hand as well as bilateral lateral epicondylitis and more recently a right medial epicondylitis. Her left upper extremity symptoms have largely settled and provocative testing for left lateral epicondylitis, left medial epicondylitis and left de Quervain’s tenosynovitis are considered negative today. Provocative testing for right medial epicondylitis is negative and mildly positive for right lateral epicondylitis (only with the elbow fully extended). There was no abnormal pain behaviour displayed. Today’s clinical examination correlates well with her clinical history and she has made a good functional recovery. It appears that her main area of difficulty now is the right lateral epicondyle region. These symptoms have also improved over time. There was no clinical evidence of carpal or cubital tunnel syndrome.”

The medical advisor outlined restrictions for the worker’s right extremity for a two month period before beginning a graduated return to work. A workplace assessment was done and the worker was referred to a sports medicine specialist for a possible corticosteroid injection.

The worker saw the sports medicine specialist on September 4, 2003. His reporting letter to the family physician of same date states that the worker did not display any lateral epicondylitis symptoms. Rather, he found extensor tendonitis of the right wrist as well as right rotator cuff tendonitis. A cortisone injection was recommended.

The case was discussed between a WCB case manager and WCB medical advisor on October 6, 2003. The WCB medical advisor thought that the worker’s compensable injury of epicondylitis had resolved and the recent findings of the sports medicine specialist could not be linked to the compensable injury as there had been no previous findings of these symptoms by either himself or the worker’s orthopaedic specialist in 2002.

The sports medicine specialist did not agree with this position. On October 28, 2003 he wrote to the WCB:

“I am of the opinion that this patient’s forearm (extensor) and APL pain is a direct consequence of her work place repetitive activity. Activities of daily living would aggravate these symptoms.

As you are aware, extensor tendonitis manifests with forearm pain and can be a continuum of lateral epicondylitis. Therefore, I am unclear as to the conclusions made regarding recovery from the compensable injury. I would recommend changes in the patient’s employment as I might anticipate exacerbation of symptoms upon return to the repetitive nature of her work.”

The worker did attempt a graduated return to work in 2003 which resulted in a worsening of pain in her forearm extensors. It was at this point that her family physician took her off work. The WCB accepted the worker’s injury as a recurrence of her compensable injury. However, as the relationship of her right thumb/tendon complaints to the workplace still remained unclear the worker was referred to a WCB sports medicine consultant and a “Hand Grip Evaluation” was conducted on December 22, 2003.

The “Hand Grip Evaluation” revealed that the worker did not give a full voluntary effort and the WCB sports medicine consultant could not find a specific diagnosis for the worker’s right arm symptoms. He also found little measurable impairment of function. Given the worker’s history however, he recommended preventive restrictions of limited repetitive and firmly resisted grasping with the right hand, with re-evaluation in one year.

The worker remained off work and was referred to an occupational health physician in January 2004. A medical report dated January 8, 2004 summarizes this physician’s findings and his opinion that the worker suffered from myofascial pain caused from longstanding repetitive overuse.

The case was once again reviewed by the WCB’s sports medicine consultant on May 14, 2004 with particular attention to the occupational health physician’s January 2004 report. The WCB sports medicine consultant maintained his position that the worker had recovered from the effects of her compensable condition. He dismissed the diagnosis of myofascial pain as an explanation for the worker’s symptoms:

“Myofascial pain, as referred to in the January 8, 2004 report, is a descriptive label rather than a pathology based diagnosis. The use of this label to account for chronic non-specific pain and tenderness remains controversial. Factors contributing to same include the i) the un-established validity of the myofascial trigger points, ii) the poor inter-rater reliability of the palpation findings upon which the diagnosis is dependant, iii) the lack of objective criteria distinguishing active (symptomatic) trigger points from latent (asymptomatic) ones, iv) the ubiquitous and/or variable nature of the reported palpation findings in the general population and v) the ability to reach valid diagnostic/functional conclusions based on a subjective response to palpation. Having said the above, physical findings suggestive of a myofascial pain syndrome were searched for but not detected at the December 22, 2003 assessment.”

In reply, the occupational health physician wrote a report dated December 2, 2004. He added that the worker’s difficulties were related to her work activities and that she was not able to return to her regular employment.

Evidence at the Hearing

The Occupational Health Physician

The occupational health physician diagnosed the worker with myofascial pain which he thought was related to the worker’s repetitive job duties. He testified that when he examined the worker in January 2004 he found that the long and lateral head of the triceps muscles were very tender. He explained that this is not a common finding in the general public; it is found in people who apply downward pressure through the arm onto a surface. This action is consistent with the worker’s job duties. When probed, these muscles referred pain down the arm and into the hand. Though he did not find any active myofascial trigger points he did find tenderness and taut bands.

The Family Physician

The family physician testified that she has cared for the worker since about 1990. In around 1996 the worker began complaining of upper limb complaints which she thought were due to the repetitive nature of her job duties. She added that the October 2002 injury was really just a continuation of the worker’s ongoing repetitive stress injury.

Independent Medical Examination

Following the hearing, the panel arranged an independent medical examination in attempt to determine the diagnosis of the worker’s ongoing right arm complaints.

The independent medical examiner, a physical medicine and rehabilitation specialist, examined the worker on August 9, 2006. His findings and conclusions are contained in a report dated August 18, 2006. Of note, the independent medical examiner opined:

“An anatomic diagnosis has not been deduced. Currently there are complaints of right upper limb symptoms with a pulling sensation with any repetitive motion. This is associated with pinch-roll tenderness over the skin and subcutaneous tissue only at the posterior right arm, proximal radial forearm, extensors and bilaterally over the distal radial styloid. While these findings are in the distribution of her pain complaint, they do not indicate a specific anatomic diagnosis.

There is currently no clinical evidence of tendinopathy, arthropathy or epicondylopathy to correlate with her clinical symptoms or clinical findings. There is no evidence of trigger points, increased muscle tone or referred pain to suspect a diagnosis of myofascial pain. There is no evidence of a neurologic or rheumatic condition to account for her symptoms.”

On August 21, 2006, all parties were provided with a copy of the independent medical examiner’s report and were asked to provide comments. Counsel for the worker submitted a response to the independent medical examiner’s report by the worker’s family physician. This response, dated September 6, 2006, deals mainly with the worker’s right arm symptoms prior to her October 2002 injury and the family physician’s position that the worker’s condition is caused by repetitive strain from her work duties. Of particular note is the last paragraph of this report that states: “I feel at the moment [the worker] might have recovered from her injury of 2002, however, if she goes back to the same job doing repetitive work, she will not last for more than a few weeks.”

In submitting this report to the panel, counsel for the worker requested that it be forwarded to the independent medical examiner for review. Counsel for the worker asked that the examiner reconsider his conclusions regarding the worker’s ongoing difficulties and the relationship to her job duties. This was not done as the panel was concerned mainly with the clinical findings of the examiner, not his conclusions on the causal relationship. The issue of whether the worker’s right arm complaints are related to her job duties is, in our view, an adjudicative issue for this panel to decide based on all of the evidence before us.

Worker’s Position

The worker says that she should be entitled to benefits beyond June 24, 2004 as she continues to suffer from right arm complaints which have been caused by many years of repetitive job duties and which prevent her from returning to her regular work.

Employer’s Position

The employer says that the worker should not be entitled to benefits beyond June 24, 2004 as the medical evidence demonstrates that she had recovered from her compensable injury by that date.

Analysis

To accept the worker’s appeal we must find that the worker had not recovered from the effects of her compensable injury as of June 24, 2004, either from a specific workplace accident on October 1, 2002, or from a long term non-specific injury arising out of the worker’s job duties. We are unable to make that finding.

As stated previously, the worker’s claim was accepted by the WCB for bilateral medial and lateral epicondylitis. This was the diagnosis that was initially made by the worker’s treating physician and confirmed by a WCB medical advisor after a call in examination. All symptoms of epicondylitis resolved by at least December 2003. In fact, it does not appear to be disputed by the worker or her treating physicians that this is the case.

What is in dispute is the worker’s other right arm complaint which has been variably termed repetitive stress injury, tendonitis, myofascial pain and non-specific pain complaints.

The worker and her treating physician both testified that the worker’s right arm complaints began in about 1996 and amplified in the late 1990s. Despite these complaints the worker continued to work and incurred three more injuries – one in 2000, one in 2002, and one in 2003 during a graduated return to work. The occupational health physician agrees that the worker’s job duties have caused these right arm complaints. He says that the repetitive nature of the worker’s job duties have resulted in myofascial pain.

In light of this position and the differing medical opinions on file about the diagnosis for the worker’s right arm complaint, we chose to send the worker to an independent medical examiner. The answer, quoted above, was categorical – there is no anatomic diagnosis. Myofascial pain was specifically examined for and not found. This was also the conclusion of the WCB sports medicine consultant in December 2003. That is not to say that these doctors did not find tenderness in the right arm. They did. Put simply, they disagree that this tenderness is accounted for by myofascial pain or by any other patho-anatomical cause.

In weighing the medical evidence, we accept the independent medical examiner’s and the WCB sports medicine consultant’s opinions that the worker’s tenderness cannot be accounted for by an anatomic diagnosis and more specifically cannot be accounted for by myofascial pain. Indeed, the occupational health physician conceded that he did not find any myofascial trigger points on examination. Further, the worker testified that she continues to be symptomatic despite having been away from the workforce since the fall of 2003.

Our decision to place greater weight on the opinion of the independent medical examiner arises from his specific area of expertise, physical medicine and rehabilitation, which specializes in soft tissue and muscular conditions as compared to the occupational health physician who described his medical education as a general practitioner with a keen interest in occupational health and some hands-on training by a physiatrist. We also note that the findings of the independent medical examiner in 2006 correlate strongly with the findings of the WCB sports medicine specialist in December 2003, much closer to the last date that the worker had worked, and to the date of termination of benefits. Based on the similarity of findings, the panel finds that the current independent medical examiner’s findings provide an accurate measure of the worker’s condition at the time her benefits were terminated on June 24, 2004.