The Appeal CommissionThe Workers Compensation Act of Manitoba

Introduction

This appeal deals with the relationship between the worker’s right upper extremity symptoms after March 2005 and her January 26, 2002 compensable injury. It is complicated by what appears to have been a misdiagnosis of a pre-existing condition and a lack of information on the worker’s upper extremity symptoms and treatment after her compensable injury.

Background

The worker suffers from a pre-existing condition called Turner’s Mosaic Syndrome for which she is followed by an endocrinologist. Turner’s Mosaic Syndrome is a chromosomal deficiency. It does not affect joints or ligaments.

The January 26, 2002 Workplace Accident

The worker worked as a filing clerk. On January 26, 2002 the worker suffered a compensable injury to her right elbow that was diagnosed as lateral epicondylitis.

An emergency facility report dated February 18, 2002 noted the cause of the worker’s right elbow complaint to be “hit elbow on shelf”. The physician noted “fell” on right elbow three weeks ago. On examination there was no effusion but tenderness over the right lateral and medial epicondyle and pain on resisted wrist extension.

She was referred for physiotherapy. The physiotherapist’s chart notes indicate that the worker had four treatments from March 4, 2002 to April 2, 2002. The April 2, 2002 note indicates that the worker’s pain had resolved and her strength increased. She was discharged from physiotherapy at that time but educated on exercises and the use of a brace for three months. A subsequent entry dated November 18, 2003 noted that the worker had returned complaining of a re-aggravation and was provided treatment on that date.

The Alleged Recurrence

The WCB did not hear anything further from the worker until May 2005 when she claimed that she had had a recurrence of her January 2002 accident. She stated that since her January 2002 accident her symptoms had never abated and in fact was now spreading into her shoulder and neck area. She had continued to attend physiotherapy sessions in the facility where she worked, on an as needed basis. A facsimile provided to Review Office notes several treatments provided in 2004 and 2005. At the hearing, the worker added that in addition to these recorded dates, she would also go to the physiotherapy department in her workplace on an informal basis for ultrasound and ice packs. These informal visits did not appear on the facsimile. She added that since her January 2002 workplace accident she continued to work at her regular duties with the exception of filing as this duty seemed to aggravate her condition. She continued to the date of the hearing to be accommodated by her employer in this regard.

Several medical reports document the worker’s treatment in 2005.

The worker saw a physiotherapist in 2005. At the hearing she testified that this physiotherapist was new to her workplace and she had never seen her before. A July 8, 2005 report from the physiotherapist records the worker’s visit to her in March 2005. It notes that the worker’s arm started swelling after a long drive from Saskatchewan. Eight treatments were provided as of the date of the report. However, it also notes that physiotherapist’s opinion that the worker’s returning tendonitis was linked to “Klippel Feil Syndrome” and postural syndrome right shoulder and arm.

The worker testified that this was the first time she had ever heard the term “Klippel Feil Syndrome”. As stated earlier, the worker had been diagnosed with and followed for Turner’s Mosaic Syndrome. It was this diagnosis of Klippel Feil Syndrome that appears to have muddied the medical treatments and opinions on the worker’s condition.

The worker was also referred to an orthopaedic specialist in April 2005. His July 12, 2005 report notes:

“This lady has a complicated musculoskeletal history with a diagnosis of Klippel-Feil Syndrome, confirmed previously and characterized by a complete fusion of her cervical spine from top to bottom, as well as multiple partial fusions and some thoracic spine changes. Her current right upper extremity problem relates back to a work-related injury in 2002. She was reaching up overhead with her right arm, pulling down forceably (sic) and struck very heavily the back and tip of her left (sic) elbow and has ongoing since that time an upper extremity syndrome with pain around the elbow, arm and shoulder…She has a mildly painfully restricted right shoulder with pain on palpating and stressing the AC joint as well as some positive impingement signs but no gross rotator cuff weakness…She likely has acquired some rotator cuff chronic attrition, as well as AC joint arthritis. This may have been hastened along by her work injuries, as well as her Klippel-Feil, which may affect also her scapulothoracic and scapulohumeral mechanics.”

A further report from the orthopaedic specialist dated August 23, 2005 indicates that the worker’s right shoulder x-ray showed minor degenerative changes of the acromioclavicular joint with a very good glenohumeral joint. He said the explanation for the shoulder was likely some early degenerative change of the acromioclavicular joint related to an earlier work injury as well as the underlying anatomy and position of the scapula. The worker also had persistent upper extremity problems consistent with a lateral epicondylitis likely traumatic in nature dating back to an injury now three years ago.

A September 12, 2005 report from the specialist noted that the worker had ongoing upper extremity pain since her 2002 work injury. It was his impression that she had cascaded problems starting with her work injury, which had been prolonged by the underlying abnormalities both in her shoulder and elbow, but also worsened somewhat by her stiffness related to Klippel-Feil. He recommended injections into the right lateral epicondyle and the right acromioclavicular joint subacromial space.

A November 22, 2005 report from the specialist clarified the diagnosis as a work-related injury in 2002 with ongoing right upper extremity with an underlying pre-existing Klippel-Feil syndrome. He recommended treatment for lateral epicondylitis including physiotherapy, medications, exercises, activity modifications and injections and possibly job modifications.

Two WCB medical advisors reviewed the worker’s WCB file and opined that there was no relationship between the worker’s right upper extremity problems and her January 2002 workplace accident. A November 30, 2005 medical notes sums up the rationale:

“…The [mechanism of injury] suggests she banged her [right] elbow on a desk twice in one day at work in Jan, 2002. I note the ER report of February 18, 2002 also documents a fall 3 weeks before – not work-related at which time she fell on her [right] elbow as well. The [physiotherapy] report from April 30, 2002 also reports the symptoms resolved with an [increase] in strength and no further [physiotherapy] report until Nov 18/03. I also note the significant pre-[existing] Klippel Feil Syndrome, [acromioclavicular] joint osteoarthritis. I also note the onset of elbow pain “1 week ago after driving…” noted in the [physiotherapist] March 31/05 report…”

On May 29, 2006, the orthopaedic specialist reported that the worker’s shoulder symptoms settled with a cortisone injection last year and the shoulder was not currently an active clinical problem. The right elbow pain was relieved for several months but the pain returned. An MRI of the right elbow showed a small to moderate joint effusion but there was no obvious other problem identified in the joint to explain the presence of that effusion. The primary problem was post-traumatic lateral epicondylitis. He thought that there may also be some secondary degree of synovitis around the radial neck which was contributing to the effusion.

In August 2006, the worker’s endocrinologist attempted to dispel the confusion about the worker’s pre-existing condition. She wrote a medical note indicating that the worker’s diagnosis “has been Turner’s Mosaic Syndrome with no effect on elbows or other joints”.

With this diagnosis in hand, the orthopaedic specialist revised his earlier opinions in a September 11, 2006 report.

“…I regret I am one of several who has apparently passed on a wrong diagnosis…the diagnosis regarding her right elbow is outlined in the enclosed May 29, 2006 clinical notes. It is not a pure lateral epicondylitis, but I think close enough to pursue the lateral epicondylectomy.

Epicondylitis may arise from specific injuries such as a direct contusion documented in 2002. It tends to be somewhat recurrent and chronic condition. She is probably more prone to chronicity and failure to resolve, related to her ongoing work … in combination with her congenital neck and shoulder abnormalities and somewhat restricted function. Therefore the work injury of 2002 can be the triggering incident and ongoing work aggravation in the presence of her Turner’s Mosaic Syndrome tend to keep in (sic) going. You are correct in assuming that elbow pain can radiate proximally and distally, although not usually specifically to the neck and shoulder. Shoulder pain, particularly that arising from the [acromioclavicular] joint, is more notable for referring proximally in the base of the neck and distally into the upper extremity. There is likely some overall association among her elbow complaints, her shoulder complaints, and her underlying Turner Mosaic Syndrome and her work…”

After reviewing these additional medical reports, the WCB medical advisor maintained his opinion:

“The newer more recent medical reports do not contain any new medical information. Previous opinion still stands – multiple significant musculoskeletal problems with previous resolution of [compensable injury].”

Analysis

On weighing the evidence, we find on a balance of probabilities that the worker has never recovered from her compensable injury and her right elbow symptoms continue to be related to that compensable injury. We do not however find that her shoulder and neck symptoms are causally related to this compensable injury.

In the case before us, the evidence is that the worker never fully recovered from her right lateral epicondylitis that she suffered in January 2002. Though a physiotherapist’s chart note did indicate that her pain had resolved and her strength increased, the evidence from the worker is that though her symptoms were better, she nonetheless continued to be symptomatic and did seek out treatment on an informal basis. There is also evidence that the worker did seek out help from her own family physician in 2003 for recurrence of her condition.