Decision #11/99 - Type: Workers Compensation
An Appeal Panel hearing was held on June 10, 1998, following receipt of an appeal from the claimant. The Panel met on several occasions to discuss the case the last meeting being December 8, 1998.
Whether the claimant’s left knee complaints subsequent to November 1995 are related to his October 1994 compensable accident.
That the claimant’s left knee complaints subsequent to November 1995 are related to his October 1994 compensable accident.
A complete background concerning the details of this case can be found in Appeal Panel Decision No. 16/98 dated January 21, 1998, and will not be repeated in its entirety.
Briefly, the claimant sustained a compensable left knee injury on October 12, 1994, during the course of his employment as a utility worker. The initial diagnosis was described as a strained left knee and possible cruciate ligament tear. The claimant subsequently returned to an alternate work program but continued to experience ongoing knee difficulties. In May 1996, an orthopaedic surgeon diagnosed the claimant’s condition as being “patellofemoral syndrome.”
On September 10, 1996, primary adjudication advised the claimant that no further responsibility would be accepted for his knee condition beyond November 1995 and that there was no need for work restrictions with respect to the compensable injury. In the opinion of primary adjudication, the weight of medical evidence did not support a causal relationship between the claimant’s ongoing complaints and the compensable injury.
In March 1997, the case was considered by the Review Office at the request of the claimant’s union representative. After consulting with a WCB orthopaedic specialist, the Review Office found that there was no need to convene a Medical Review Panel (MRP) under section 67(4) of the Workers Compensation Act (the Act) and that the claimant’s left knee complaints subsequent to November 1995, were not related to his October 1994 compensable accident.
In accordance with an appeal form submitted by the claimant’s union representative, the case was again considered by Review Office on December 12, 1997. Based on submitted medical information, the Review Office granted the union representative’s request for an MRP. This decision was appealed by the employer’s representative which led to an Appeal Panel review on January 16, 1998. In its decision of January 21, 1998, the Appeal Panel concluded that there was a difference of medical opinion sufficient to require the convening of an MRP under Section 67(4) of the Act. On February 17, 1998, an MRP was convened and all interested parties were provided with the report.
The Review Office confirmed in its decision, dated April 24, 1998, that the claimant’s left knee complaints subsequent to November 1995 were not related to his October 1994 compensable accident. The Review Office made reference to the following question that was posed to the MRP:
"What is the relationship between the current diagnosis and the claimant's compensable accident? Please provide rationale for your answer."
The MRP’s response was as follows:
"The relationship is based on the history of pain which developed after the injury and continues to the present. There are no objective signs which relate to the compensable injury. This chronic pain, knee, is known as Patellofemoral Syndrome."
Based on the MRP’s response to the above, the Review Office interpreted the MRP’s comments to mean that there was no physical evidence to establish a relationship between the claimant’s compensable accident and his ongoing knee complaints. The Review Office was unable to conclude that the claimant’s continuing knee complaints were related to his October 1994 compensable accident.
On June 10, 1998, an Appeal Panel hearing was held at the request of the claimant’s union representative who appealed the Review Office’s decision of April 24, 1998. Following the hearing and discussion of the case, the Appeal Panel requested the claimant to be examined by an independent orthopaedic specialist. The examination took place on July 8, 1998, and all interested parties were later provided with a copy of the results.
The Appeal Panel met to discuss the case on August 28, 1998. Following its discussion, the Panel requested further clarification from the MRP which first met on February 17, 1998. The MRP was specifically asked to clarify its responses to questions 3 & 5 in light of the findings documented by the independent specialist who examined the claimant on July 8, 1998. On October 21, 1998, the MRP responded to the Panel’s request and a copy of same was provided to all interested parties for comment.
On December 8, 1998, the Appeal Panel met to render its final decision after taking into consideration final arguments that were presented by the union and employer representatives.
Chairperson MacNeil and Commissioner Monk
The claimant sustained his compensable injury on November 10th, 1994, when he accidentally stepped into a hole and bent his knee backwards. Initially it was thought that the claimant had suffered a soft tissue strain to his knee. This diagnosis, however, was later amended to include patellofemoral syndrome by the treating physician. The claimant testified that his left knee symptoms persisted between October 1994 and the spring of 1996 as he continued to perform his regular duties. He stated his pain progressed to the point where he would wind-up limping at the end of each work day.
A WCB medical advisor examined the claimant on August 14th,1996, and concluded that as a result of the compensable event the claimant may have acutely irritated the patellofemoral articulation. In his opinion, “If Mr. [the claimant’s] work between October 1994 and spring (sic) 1996 involved repetitive squatting, repetitive climbing up or down ladders or stairs and / or significant walking in elements like deep snow, then it is probable that his workplace duties have contributed to the patellofemoral symptoms to date.” The medical advisor also went on to state in a memo to file, dated September 9, 1996, that the claimant’s duties over time were likely of more relevance to his current symptoms than the compensable injury of October 1994.
Ultimately the claimant, after discussion with his treating orthopedic surgeon, agreed to undergo arthroscopic lateral release for his patellofemoral problem even though, according to the surgeon, such a procedure may have an unpredictable outcome and was considered to be a treatment of last resort. The orthopedic specialist provided a report to the claimant’s union representative, dated November 1st, 1996, to which we attached considerable weight. He reported in part:
"...I concur with the WCB medical consultant that the patient had patellofemoral syndrome. I also agree with him that the bending the knee backward is not the usual mechanism causing patellofemoral problems. Patellofemoral syndrome is quite common in the general population. It does not have to be bilateral. There are many anatomic variables and also activity factors that might cause patellofemoral syndrome. It is quite possible that Mr. [the claimant] has pre-existing patellofemoral syndrome. The injury in October 1994 might have either caused acute aggravation of the patellofemoral syndrome, to make it clinically apparent, or to cause a simple strain to the knee."
At the request of the Review Office, a Medical Review Panel (MRP) was convened on February 17th, 1998. Following its examination, the Panel concluded that the claimant’s current diagnosis was “Patellofemoral Pain”. “This chronic pain, knee, is known as Patellofemoral Syndrome.” The Panel was asked to comment on the relationship between the current diagnosis and the claimant’s compensable accident. In response the Panel stated, “The relationship is based on the history of pain which developed after the injury and continues to the present. There are no objective findings which relate to the compensable injury.”
The foregoing response prompted the Appeal Panel to have the claimant examined by an independent Orthopedic specialist. In his report of July 20th,1998, the specialist acknowledged that the claimant’s current diagnosis was patellofemoral pain syndrome, however, in his opinion, on a balance of probabilities, this condition was not a sequela of the compensable injury.
The WCB’s Board of Directors amended their policy dealing with MRP’s by allowing the Board to request clarification of an MRP opinion within one year of the date of such report. This amendment was made effective March 30th, 1998. Pursuant to this policy amendment and in light of the independent orthopedic specialist’s conclusions, we requested the MRP to clarify what the relationship was between the claimant’s current diagnosis and his compensable accident. The MRP Panelists substituted their previous answer with the following: “After a knee injury it is not uncommon for patients to develop Patellofemoral Syndrome which in some cases becomes permanent. Based on the history of pain which developed after the injury and continues to the present, the Panellists (sic) agree that there is a relationship between the claimant’s compensable accident and his Patellofemoral Syndrome.”
We find, based on the weight of evidence, that the claimant’s left knee complaints subsequent to November 1995 are, on a balance of probabilities, related to his October 1994 compensable accident. The claimant’s appeal is, therefore, hereby allowed.
R.W. MacNeil, Presiding Officer
A. Finkel, Commissioner
C. Monk, Commissioner
Recording Secretary, B. Miller
R. W. MacNeil - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 15th day of January, 1999
Commissioner Finkel’s dissent
The issue in this appeal is whether the claimant’s left knee complaints subsequent to November 1995 are related to his October 1994 compensable accident.
In examining the file in its entirety, it is apparent that the claimant’s knee complaints have been the subject of considerable medical examination and commentary. While there is a general agreement among medical practitioners that the claimant currently suffers from patellofemoral pain, the challenge has been to determine whether this pain is related to the workplace accident and the injuries sustained.
The submissions of the representatives of the employer and claimant at the hearing on this point focus on three areas:
· The clarity of diagnosis throughout the period in question, in particular, the absence of objective findings by examining physicians regarding the compensable injury, and thus the degree of severity to be attributed to the original injury;
· Whether the etiology of patellofemoral pain as experienced by the claimant is consistent with the mechanisms of the original compensable injury;
· The accuracy of the “history of pain” that is recited by the claimant and used as the basis of a number of medical opinions to establish causality.
I have reviewed the evidence on the file, and in my opinion, the weight of the evidence supports, on a balance of probabilities, the finding that the patellofemoral pain is not related to the compensable injury. This finding is based on the evidence regarding the severity of the original injury, the etiology of patellofemoral pain, and the accuracy of the history of pain or subjective complaints provided by the claimant to medical practitioners.
Regarding the severity of the original injury, I note the following evidence supports a finding that the original injury was not severe:
· A report by a WCB physician based on an examination held on June 9, 1996 states that “Mr. [claimant]’s physical capabilities are primarily dependent on his symptoms rather than on the measurable deficits of left knee function.”
· A report by a WCB physician based on an examination held on August 14, 1996 states that:
"Mr. [claimant]'s current left knee symptoms are patellofemoral in nature. There is no clinical or imaging evidence to suggest the presence of meniscal or ligamentous pathology. As a result of the compensable event, Mr. [claimant] may have suffered a left knee joint strain. To the extent he did, it has fully resolved. As a result of the compensable event. Mr. [claimant] may have acutely irritated the patellofemoral articulation. To the extend the latter occurred, one would have anticipated full resolution of patellofemoral symptomatology over a relatively short term, i.e. in terms of up to a few weeks."
· A memo by a WCB medical advisor dated March 5, 1997 notes that “Claimant had no pre-existing pathology on x-ray, MRI, or at arthroscopy. As well, there is no pathology of the patellofemoral joint noted during the arthroscopy to account for the ongoing patellofemoral pain. I do not think that one hyper-extension injury to the knee accounting for only a short 18 hour work alteration can account for the ongoing symptoms of patellofemoral pain. It might account for knee pain in the short term due to a mild knee strain but all other significant pathology has been ruled out with the investigations.”
· A report by the attending orthopaedic surgeon, dated November 1, 1996 which states, “I concur with the WCB medical consultant that bending the knee backward is not the usual mechanism causing patellofemoral problems. It is quite conceivable that Mr. [claimant] suffered only a sprain from the accident.”
· The Medical Review Panel report of February 17, 1998 notes the absence of objective medical findings in respect of the original knee strain.
Regarding the etiology of the onset of patellofemoral pain and whether it is a sequela of the original compensable injury, I note the following evidence:
· Additional comments by the claimant’s attending orthopaedic surgeon, in a report of November 1, 1996, that:
"Patellofemoral syndrome is quite common in the general population. It does not have to be bilateral. There are many anatomic variables and also activity factors that might cause patellofemoral syndrome, It is quite possible that Mr. [claimant] has pre-existing patellofemoral syndrome. The injury in October 1993 might have either caused acute aggravation of the patellofemoral syndrome to make it clinically apparent, or to cause a simple strain to the knee. However, the straining of the knee causes some degree of muscle atrophy from disuse. We know quadriceps muscle weakness can result in patellofemoral syndrome in some groups of individuals."
· A report by the claimant’s attending physician dated September 23, 1997 acknowledges the difficulty in linking the patellofemoral pain to the mechanism of injury, stating, “I have been treating him for ongoing knee problems since 1994 and have no other reasonable conclusion other than to state that while unusual as far as the mechanisms of injury, I do believe that his persistent ongoing knee problems are a direct result of his hyperextension injury.”
· A report by an independent orthopaedic surgeon, dated July 20, 1998, states, after an examination of the claimant:
"The patient does describe stepping into a hole and sustaining a hyperextension injury to his knee. It should be noted that with a direct blow to the front of the knee, such as hitting the boards playing hockey, directly with the front of the knee, or falling down hard onto the knee, could precipitate a traumatic chondromalacia patella. This patient, however, did not have any such mechanism of injury. What the patient had would appear to be a sprain of his knee. The patient did not seek medical attention until a few days later. The patient did not have any swelling of his knee."
The issue regarding “history of pain” centres on the Medical Review Panel’s reliance on same as the basis of its findings of causality. In particular, the Medical Review Panel of February 17, 1998 notes the absence of objective findings for the original knee strain, and state in Question 5 that the relationship between the current diagnosis and the claimant’s compensable accident “is based on the history of pain which developed after the injury and continues to the present. There are no objective findings which relate to the compensable injury. This chronic pain, knee is known as Patellofemoral Syndrome.” [emphasis mine]
This answer was subsequently clarified by the Medical Review Panel on October 21, 1998, as follows:
"After a knee injury it is not uncommon for patients to develop Patellofemoral Syndrome which in some cases become permanent. Based on the history of pain which developed after the injury and continues to the present, the Panellists agree that there is a relationship between the claimant's compensable accident and his Patellofemoral Syndrome." [emphasis mine]
Regarding this history of pain, I note the following evidence that supports a finding that the history of pain was not accurately reported by the claimant, and that this impacts on whether a causal relationship can be established between the claimant’s current complaints and the original workplace injury:
· The evidence indicates that the claimant had a hyperextension injury when he stepped into a hole in October 1994. He suffered no time loss from work, with the exception of 18 hours for physiotherapy. He continued on full duties from October 1994 to April 1996. The interview notes for the Medical Review Panel, however, record that the claimant had not returned to full duties since the date of the accident.
· The claimant’s testimony at the hearing and as reported in the interview notes in the Medical Review Panel report of February 17, 1998, is that his knee locked up on him up to 20 - 30 times per day and that he has fallen on occasion. However, countering these comments, I note the following:
- A report by an orthopaedic surgeon dated November 1, 1996 refers to his examination of the claimant on May 4, 1995, which states, "He stepped in a hole at work in October 1994 and felt abrupt pain to his left knee. There was never any significant swelling to his knee. He complained of tightness to his left knee. There was no history of locking or giving out. According to the patient, he did not miss any days of work." [emphasis mine]
- Subsequent to this visit, the claimant did not seek any medical treatment from May 29, 1995 to March 26, 1996.
- A report by an independent orthopaedic surgeon dated July 20, 1998 comments,
"...the patient subjectively does describe a lot of problems with his knee. The patient states that his knee will collapse on him. The patient states that he has fear of handling a chainsaw, since his knee might give out and he would fall, causing injury to himself and others. I should, however, note that a patient who would have as severe a problem with his knee, as this patient describes, would be expected to have more in the way of positive finding, such as muscle atrophy of the quadriceps. The patient has subjective complaints, but there is little to find objectively on examination, or arthroscopy, and on the MRI. [emphasis mine]
- The orthopaedic surgeon in his July 20, 1998 report concludes, "It is my opinion, on the balance of probabilities, that the patient's patellofemoral pain syndrome is not a sequel of his compensable injury. It is my opinion that the injury the patient sustained was a sprain of his knee. It is my opinion that the sprain of his knee has healed."
I place considerable weight on the findings of the independent orthopaedic surgeon regarding the accuracy of the claimant’s complaints, especially when viewed in light of the other inconsistencies noted. Given the Medical Review Panel’s reliance on these complaints as the basis of their findings of a causal relationship, I also place greater weight on the conclusions of the independent orthopaedic surgeon that the claimant’s patellofemoral pain syndrome is not a sequela of his compensable injury.
Having reviewed the evidence on file and the submissions made at the hearing, I find that the weight of evidence does not, on a balance of probabilities, support a causal relationship between the claimant’s current patellofemoral pain and the original compensable injury. As such, I would deny the claimant’s appeal.
A. Finkel, Commissioner