The Appeal CommissionThe Workers Compensation Act of Manitoba

This appeal deals with the causal relationship between the worker’s left foot and ankle complaints after February 24, 2005 and her workplace injury. Its determination hinges on the medical evidence and the worker’s self-reporting.

Background

On July 5, 2004 the worker injured her left foot at work. The exact circumstances of the accident are not clear. They do not however have much bearing on this decision. Suffice it to say that an obese customer stepped on the worker’s left foot and ankle. Despite her injury, the worker continued to work the next day.

The medical evidence on file suggests a relatively minor injury. For example, a July 7, 2004 hospital emergency report records minimal swelling and no bruising. She was diagnosed with a contusion of the left foot and sent home in good condition with crutches. An x-ray taken the same day revealed no bone or joint abnormality. The worker’s family physician later added a diagnosis of a sprain and a slab cast was recommended.

By July 20, 2004 the worker’s family physician noted an absence of swelling, bruising or tenderness. He did however note a psychological overlay with complaints of inability to weight-bear. He advised the worker to discard her slab cast and weight-bear.

The worker returned to work on August 1, 2004 at modified duties but only lasted a few hours. Shortly thereafter, the worker’s physical presentation appears to have changed. On August 4, 2004 she saw a doctor who noted decreased range of motion with pain on passive movement, erythema and swelling of the left foot.

She was referred to an orthopaedic specialist on August 12, 2004. The orthopaedic specialist noted that the worker’s left lower leg and foot were dusky bluish in colour with the skin being quite cool to touch; there was diffuse mild swelling about the foot and ankle and light touch hypersensitivity throughout the entire left foot and ankle with deeper palpation producing significant pain throughout, decreased pulse and mild stiffness of the ankle. The specialist questioned whether the worker might have a complex regional pain syndrome (“CRPS”). A walking foot cast was prescribed. Further tests were ordered along with a referral to a pain clinic and physiotherapy.

The physiotherapist expressed some concerns about the worker’s subjective pain complaints which are outlined in a September 9, 2004 WCB memorandum to file. The physiotherapist thought that the worker was highly exaggerating her pain and symptoms and was still not weight-bearing; this was causing her to lose muscle. The physiotherapist’s reports also indicate that the worker was refusing to do even gentle exercises with her foot.

On September 10, 2004, the results of a bone scan provided insight into some of the worker’s symptoms. It revealed that the worker’s reduced blood flow and delayed tracer uptake in the left lower leg, foot and ankle were consistent with marked disuse of the left leg and that there was no scintigraphic evidence of CRPS.

The worker’s WCB file was reviewed by a WCB medical advisor on September 23, 2004. The WCB medical advisor had difficulty relating the worker’s symptoms to her compensable injury and suspected abnormal pain behaviour. An independent medical examination (“IME”) was therefore arranged with a sports medicine specialist.

The orthopaedic specialist saw the worker on September 30, 2004. On the basis of her presentation and the bone scan, he told the worker to discontinue use of her crutches and concentrate on physiotherapy and rehabilitation.

The sports medicine specialist who performed the IME on November 19, 2004 agreed with the orthopaedic specialist. His diagnosis was a left foot contusion on July 5, 2004 and currently non-specific foot and ankle pain with evidence of incomplete rehabilitation and disuse changes. He did however think that there was a cause and effect relationship between the worker’s current symptoms and her compensable injury given the ongoing complaints.

A WCB physical medicine and rehabilitation specialist consultant was also asked to review the worker’s file. A February 16, 2005 report by this specialist indicates that he thought that a prior injury to the worker’s left foot and ankle might be the cause for her ongoing complaints. He also thought that the worker likely did not have the motivation or commitment to reverse the disuse. Even with further therapy, he felt the worker was unlikely to be compliant with progress to a home program.

A second bone scan done on February 21, 2005 confirmed the early bone scan and noted slight reduction in blood flow likely related to disuse or altered weight-bearing.

Then in April 2006 the worker was referred to a neurologist. The neurologist thought that the worker’s clinical features were in keeping with CRPS type II though he clarified that the mechanism of this complex syndrome was not well known. A similar diagnosis of CRPS type I was later made by an anaesthesia fellow at a pain clinic who saw the worker in October 2006.

Following the hearing, the anaesthesia fellow at the pain clinic was questioned by the panel about the rationale for her diagnosis and its causal relationship to the workplace accident of July 5, 2004. On January 3, 2007 she explained that the etiology of CRPS is uncertain. She believed that the worker did suffer from CRPS type I and that this syndrome was caused by her workplace accident. This diagnosis was made on the basis of several criteria, including the presence of an initiating noxious event or cause of immobilization, continuing pain, allodynia or hyperalgesia in which the pain is disproportionate to any known inciting event, evidence at some time of edema, changes in skin blood flow or abnormal sudomotor activity in the region of pain, and an exclusion of other conditions that would otherwise account for the degree of pain and dysfunction. The specialist discounted the bone scan results as a diagnostic test for CRPS and added that signs of disuse can occur with the presence of CRPS. She also commented that the orthopaedic specialist did not specifically exclude a diagnosis of CRPS.

Worker’s Evidence at the Hearing

The worker provided testimony at the hearing about the onset of her symptoms and their progression over time. She explained that prior to her workplace injury she did not have any impairment. On July 5, 2004 a customer stomped on her foot. When he saw how much it hurt he did it again. Her left foot and ankle hurt and turned colour instantly. When questioned further about this by the panel, the worker added that her foot instantly swelled and turned purple, blue, red, as well as a “bunch of different colours”.

The worker also testified that she had only seen the anaesthesia fellow once and had only had a physical examination of her foot. The worker also provided the anaesthesia fellow with a description of her workplace accident. No medical reports or tests of other medical practioners were provided to the anaesthesia fellow.

Worker’s position

The worker says that her ongoing symptoms are caused by the workplace accident and that she should therefore receive wage loss and medical aid benefits after February 24, 2005.

Analysis

To accept the worker’s appeal we must find on a balance of probabilities that the worker’s ongoing complaints are causally related to her July 5, 2004 workplace accident. We are unable to make that finding.

To date, the worker has been diagnosed with two different conditions: a contusion/sprain and CRPS type I. While we accept the first diagnosis, we do not accept the latter or that it is causally related to the workplace accident.

Despite the worker’s current evidence about her workplace injury, the medical reports at that time all indicate that the worker’s injury was not serious. In particular, there was minimal to no swelling or bruising of her left foot until one month after the workplace accident. This contrasts significantly with the worker’s evidence at the hearing that her foot swelled and turned colour instantly at the time of the incident. This history is not supported by the medical evidence on the file. Further, the diagnosis of CRPS was examined and dismissed by several medical practioners. This dismissal was confirmed by the September 2004 bone scan which stated that there was no radiologic evidence of CRPS; rather it indicated disuse. This diagnosis of disuse is consistent with the worker’s attitude toward her injury. Indeed, the medical reports at the time all indicate that the worker was failing to weight-bear despite medical advice to the contrary. Further, though the worker has consistently reported pain in her left foot, we find that there is insufficient evidence to link these pain complaints to her workplace accident.