The Appeal CommissionThe Workers Compensation Act of Manitoba

On March 2, 1979, while employed as a labourer, the worker was knocked unconscious by a log that struck him on the left side of his head. He suffered severe bruising to his left cheek and temple and was hospitalized for 2 days. Following the accident the worker complained of intermittent headaches; persistent ringing and decreased hearing in his left ear and vertigo and ataxia on rapid head movements. Testing revealed that as a result of the accident the worker suffered a left-sided vestibular[1] and cerebellar[2] deficit and an aggravation of a hearing deficit and increase in tinnitus.

In November 1980 a Medical Review Panel (MRP) reviewed the relationship between the initial accident and the thumb amputation. The notes of the MRP indicate that the worker complained of ringing in his ears which worsened since the initial accident with a constant high pitched noise in his left ear. The ringing was more noticeable when the worker was tense. The worker also complained of dizziness when getting up from a bent position; when moving his head from side to side, such as when driving that requires him to look at the driving panel and make repeated eye movements from side to side; and a feeling of things going around to the left. He was also taking medication to adjust changes in his mood.

The MRP commented on the worker’s slowed reflexes and lack of psychological well-being as a result of the initial accident and concluded that the loss of the right thumb was directly related to the disability occasioned by the March 2, 1979 accident. The MRP’s findings became the basis for the WCB’s acceptance of the worker’s right thumb amputation. The worker was given a permanent partial disability award for vestibular and cerebellar dysfunction, aggravation of a hearing deficit and increase in tinnitus.

The worker was subsequently employed for many years as a long haul truck driver often driving 48 hour trips between Winnipeg and Vancouver. In 2002, the worker contacted the WCB for complaints of increased hearing loss and ringing in his left ear attributed to noise exposure while employed as a labourer in the 1970’s and 1980’s. A permanent impairment award was made for his hearing loss condition.

In a medical report dated March 4, 2003, the worker’s physician noted that the worker had complex surgery to his right hand including a number of tendon transfers and that the worker complains that his hand becomes painful, stiff and swollen that worsens when driving. The worker also complained of pain radiating up his right arm, shoulder and neck. The physician diagnosed the worker as suffering from neuropraxia/tendonitis in his right hand and possible nerve entrapment from the cervical spine.

On December 1, 2003 the worker advised the WCB that, on the advice of his physician, he had to reduce his hours of truck driving due to swelling in his right hand and that he also was having difficulties with dizziness especially while driving in the mountains. The worker indicated that reducing his driving helped these problems.

The medical information on file also includes the following:

• A report dated December 15, 2003 from the worker’s neurologist in which the neurologist refers to the worker’s symptoms of weakness in the right hand; numbness in the fingers; significant pain up in his neck and shoulders that increases when driving long distances; and vertigo and unsteadiness when traveling through the mountains. The neurologist notes that the worker cut down on his driving by 50% and felt somewhat better. The neurologist was of the opinion that all of the worker’s ongoing symptoms are related to the two accidents and that the worker’s vertigo was secondary to his initial accident. The neurologist also stated that the worker can still drive heavy vehicles but not at the same frequency as before. He indicated that nerve conduction studies and an MRI would be performed.

• A report dated December 17, 2003 from the worker’s physician noting that the worker complains of intermittent vertigo mainly precipitated by long road trips especially at increased altitude. The report indicates that the worker is on the road for many hours at a time and as he gets tired his dizziness and arm pain increases. The physician referred to the 1979 testing indicating that the worker had vestibular and cerebellar problems related to that accident. The physician concluded that the worker has on-going inner ear/cerebellar problems. He restricted the worker to 3 trips per month rather than his usual 6 and the worker reported immediate improvement in his symptoms. The physician diagnosed the worker with the following conditions:

1. Tinnitus secondary to the head injury of 1979;
2. Intermittent vertigo secondary to the 1979 accident;
3. Neurosensory hearing loss on the left side;
4. Neuropraxia of right arm and neck plus hand deformity from extensive plastic surgery tendon transfers of the right hand.

• An MRI of the worker’s brain was considered normal and a nerve conduction study report dated March 12, 2004 indicated no definite evidence of carpal tunnel syndrome (CTS).

• A WCB physician reviewed the file in February 2004 and noted that the worker’s vestibular problems were related to the original compensable injury of March 2, 1979. The WCB consultant requested that vestibular testing be conducted to determine if the worker should have reduced the amount of truck driving. He answered “no” to the question of whether the worker’s right hand/arm problems were directly related to the thumb amputation. No reasons for this conclusion were provided.

• The worker was examined and tested by a specialist in otolaryngology (“ENT specialist”). In his first report dated March 29, 2004, before vestibular testing was performed, the ENT specialist states that “although I think this is a non-specific dizziness, I do not think there is any reason presently to restrict his driving”. Results from vestibular testing included a posturography report that showed markedly abnormal performance “indicating organic vestibular dysfunction”. After reviewing the test results, the ENT specialist states in a report dated June 28, 2004: “[The worker] has some abnormal posturography however suggesting a vestibular problem. He says that the caloric test was similar to his own dizziness, which is interesting. He said it is worse in the mountains. He wonders if he should drive. I think there is some question about how well he will do driving. I think it is safe for him to do so. He does have a real problem and this may become worse at times.”

• In a report dated July 21, 2004, the worker’s physician responds to the case manager’s request to clarify his rationale for reducing the number of driving trips. The physician notes the lack of clarity in the opinion of the ENT specialist, who suggests the worker is safe to drive and at the same time questions how well the worker will do driving and states the problem can worsen at times. The physician indicates that, based on his assessment of the character of the worker and the improvement in the symptoms with reduced hours, the worker needs to rest between trips at this time and recommends that the worker reduce his driving with a review in December 2004.

• In a subsequent letter to the WCB dated August 11, 2004 the worker’s neurologist states: “I believe on the basis of [the worker’s] clinical picture that he would benefit from a reduced workload by 50% and continue massage therapy to relieve the swelling and pain in his affected right hand and arm.”

• The worker was called in for an examination by a WCB physical medicine and rehabilitation consultant (“WCB physiatrist”) on February 1, 2005. The WCB physiatrist noted that the worker’s primary symptoms were dizziness when driving, which improved with a decrease in work time; persistent tinnitus and an aching in his right arm radiating to the shoulder. The WCB physiatrist also noted other symptoms such as pain in the head, neck, both upper extremities, upper, mid and lower back, aching in joints of hands and feet, stiffness and fatigue, difficulty sleeping and occasional depression. He noted that “there was no pathoanatomical diagnosis identified on the current examination to explain his symptoms”. The physiatrist recommended metabolic and rheumatologic screening; review by a cardiologist prior to starting aerobic exercise and consideration for a sleep study. Pending these investigations, the physiatrist stated that “[i]t appears appropriate to currently maintain the claimant at half time duties”.

• In a report dated March 10, 2005, the worker’s chiropractor notes that the worker continues to suffer from dizziness and restrictions in range of motion in his neck and right shoulder and that these symptoms appear to be the result of a compensation for the right arm, causing tension to build up throughout the shoulder blade and right neck. A request for continued monthly treatments to the worker’s neck and shoulders is accepted by the WCB for a 12 month period.

• The worker was assessed by an occupational therapist from the Driver Assessment and Management Program. In a report dated April 19, 2005, the therapist notes that the worker can manipulate the gearshift and control the steering wheel using modified techniques to compensate for thumb loss and that the worker has developed chronic right upper quadrant strain due to these modified techniques that worsens with driving. The therapist notes that the worker has had to reduce his work to halftime to control right elbow, shoulder and neck pain. The therapist also notes that the worker’s awkward reach to the gear shift may be contributing to neck, shoulder and forearm irritation.

On April 21, 2005, the WCB case manager asked the WCB physiatrist to clarify his February 2005 report and advise whether there was a continuing cause and effect relationship between the worker’s problems and the compensable injury. The WCB physiatrist advised that he could not rule out some relationship but that it was difficult to relate all of the problems to that injury.

The case manager also asked whether the worker’s vestibular problems were related to the original head injury. The WCB physiatrist advised that the file suggests they are related as the ENT specialist noted that there was an organic vestibular problem.

The case manager asked the WCB physiatrist whether there was a need for the worker to reduce his work time. The physiatrist was not sure and indicated that a review by the WCB ENT specialist was required.

In a report dated May 17, 2005, the worker’s physiotherapist, who assessed the worker over 14 visits, noted that the worker presented with complaints of feeling dizzy, off balance, light-headed and disoriented, with headaches, vertigo and arm pain greater in the right arm and neck pain. The physiotherapist stated that the worker’s right thumb amputation “was problematic because now his entire right arm and upper quadrant were very sore and easily fatigued.” She concluded that “[b]ecause of his non-specific vestibular findings and on-going upper quadrant pain, my physiotherapy diagnosis would be some combination of cervical vertigo related to right upper quadrant pain and overuse with decompensation secondary to the aging process, complicated by an old H.I. [head injury] dating back to 1979.”

The WCB case manager wrote to the worker’s ENT specialist asking whether his findings support the need for the worker to be removed from his driving duties. The ENT specialist responded in a report dated May 27, 2005 by stating “[p]lease refer to my letter of June 28^th, which suggests driving would be allowed.”

The WCB case manager reviewed the file with the WCB ENT specialist to determine whether the worker’s vestibular problems were related to the original injury and whether the reduction in driving due to the vestibular problems was related to that injury.

In a memorandum to the file dated July 12, 2005, the WCB case manager notes that the WCB ENT specialist reviewed the file and stated that he was unable to provide an opinion on the worker’s reduced driving as it appeared to be due to right elbow, shoulder and neck pain and not a vestibular condition, and therefore the matter should be referred to the general medical advisor.

According to the file notes, the WCB ENT specialist was not pleased with the conflicting opinions with regards to the worker’s driving capabilities, and the WCB ENT specialist advised that he was unable to provide an opinion on the vestibular condition “as the information on file is conflicting and does not appear to make sense”. The file notes indicate that the WCB ENT specialist stated that if the worker is only able to drive 50% of the time due to dizziness, he shouldn’t be able to drive at all. The notes end with a recommendation that the motor vehicle branch be notified and if the worker cannot drive due to dizziness, the file should be reviewed to determine whether this is related to the compensable injury.

A WCB medical advisor reviewed the file in September 2005 to address whether the worker’s dizziness and right arm/shoulder discomfort necessitated a reduction in driving. Regarding the right arm symptoms the WCB advisor referred to the call in notes of the WCB physiatrist that stated there was no pathoanatomical diagnosis to explain the worker’s symptoms and that the worker reported diffuse pain symptoms above and below the waist, fatigue and sleep disturbance. The advisor concluded that these symptoms reflected a non-specific pain syndrome unrelated to the 1979 accident.

With respect to symptoms of dizziness, the WCB medical advisor interpreted the reports from the worker’s ENT specialist as indicating that the worker was fit to drive and refers to the WCB ENT specialist’s comments that if the worker was fit to drive halftime, he was equally fit to drive fulltime. The WCB advisor concluded that the information does not indicate a medical condition in relation to the March 2, 1979 injury for which a restriction on the duration of driving or on driving at higher altitudes would be considered medically required.

By letter dated October 11, 2005 the WCB case manager notified the worker that the WCB would not cover wage loss associated with a reduction in driving frequency. Costs for ongoing chiropractic treatments related to the worker’s right thumb amputation, medical aid costs and further investigation into the worker’s vestibular problems would be covered.

A detailed report dated November 15, 2005 was provided by the worker’s physician reviewing the worker’s 24 year medical history since the 1979 accident. The physician concludes that the worker has had continuing vestibular and cerebellar problems with symptoms of vertigo, dizziness and tinnitus that remain unresolved. The physician also notifies the WCB that as a result of safety concerns due to possible dizzy spells when driving in mountains, he has declared the worker unfit to drive heavy vehicles and cancelled his Class I driving license (semi-trailer trucks). The worker was approved for Class III (trucks with more than two axles).

On January 31, 2006 a WCB medical advisor reviewed the file and stated:

“That the dizziness and vertigo are related to the compensable injury of 1979 is not in dispute. If these symptoms, (now combined with the effects of time and aging, as suggested by the family physician) are felt to render him unsafe to drive a vehicle at times, then he should not have a driver’s license of any class and would be unable to carry on with his previous occupation as a truck driver. In this case his loss of ability to drive would then be at least in part related to the 1979 injury.”

The WCB medical advisor goes on to conclude that the worker’s dizziness is related to the original injury, but that a medical necessity to drive halftime has not been established as “one is either fit to drive or not.”

The WCB medical advisor also relies on the WCB physiatrist’s examination in February 2005 in concluding that although the loss of the right thumb is related to the original injury, the worker’s current symptoms involving the right and left arms, neck and head were not related to the right thumb amputation.

The worker’s neurologist provides another report dated April 3, 2006, in which he advises the WCB that he believes that the swelling, numbness and weakness in the worker’s right hand are related to the tendon transfers as well as the thumb amputation.

The worker was referred to a plastic surgeon for assessment of possible surgery to his right thumb to improve his grip and hand function. In a report dated August 28, 2006, the surgeon provides his assessment of the worker’s right hand and arm. The surgeon notes that the worker has numbness and tingling in his fingers and on examination showed a positive Tinel sign and Phalen’s test. The surgeon was of the opinion that the worker has carpel tunnel syndrome (CTS) that is indirectly related to the accident as the worker has had to modify the use of his hand due to the amputation of the thumb.

The surgeon also notes in his report that the worker has pain at the lateral aspect of his right elbow. The surgeon was of the opinion that the worker has right lateral epicondylitis that is likely a result of accommodating the loss of his right thumb. Surgery to release a tight band of tissue in the hand was recommended and consideration of CTS decompression following review of nerve conduction studies.

In a letter dated October 13, 2006, a worker advisor asked the WCB to reconsider its denial of wage loss benefits on the basis that the new medical information indicated that the worker’s right hand and elbow condition are related to the 1979 compensable injury and these conditions are affecting his ability to work as a truck driver.

The file was again reviewed by the WCB medical advisor on November 29, 2006. The WCB advisor stated that when CTS is work related, duties involving forceful repetitive wrist movements and twisting, gripping, pulling, pinch pressure are typically implicated and it was unlikely that the worker’s driving duties involving the right hand, which would be used for holding the steering wheel and shifting gears, would promote CTS. The medical advisor was also doubtful that the worker’s duties involved repetitive and forceful wrist movements typically implicated in the development of right lateral epicondylitis.

The worker was notified by letter dated November 29, 2006 that the WCB’s decision denying benefits for a reduction of driving hours due to vertigo and dizziness had not changed and no responsibility would be accepted by for his right CTS and right lateral epicondylitis. The worker advisor appealed both of these decisions.

On January 5, 2007, the Review Office upheld the WCB decisions denying wage loss benefits for a reduction in driving and denying acceptance of responsibility for the worker’s right CTS and epicondylitis, relying significantly on the opinions expressed on file by the WCB medical advisors.

On June 20, 2007, the worker advisor submitted a report from the plastic surgeon dated April 30, 2007 indicating that the worker had undergone a right carpal tunnel decompression and an operation to the web space contracture of the thumb and excision of a ganglion from his right palm. The surgeon noted that the carpal tunnel release improved the worker’s pain in his palm and the numbness in his fingers. He also noted that there was tenderness on the palmar aspect of the 3^rd metacarpal joint with any form of lifting or gripping and that due to excessive wear and tear on this region as a result of the thumb amputation, the worker very likely has some degenerative changes in the joint causing chronic inflammation and thickening around the joint.

The worker advisor requested reconsideration of the Review Office decision. On June 28, 2007, the Review Office held that the surgeon’s report did not provide any new medical evidence regarding the relationship between the diagnoses of CTS and epicondylitis and the worker’s right thumb amputation.

On July 10, 2007, the worker advisor appealed the Review Office decisions and a hearing was held before the appeal panel on October 9, 2007. At the hearing the worker, who was represented by a worker advisor, provided evidence. An employer representative was also present.

At the hearing, the worker described how his symptoms of vertigo and arm pain affected his ability to drive long distances and in the mountains. He explained that when he drove in the mountains there was a change in the pitch of the tinnitus that was very annoying. He explained that his vertigo would often occur when he was in the mountains, making it difficult for him to focus. Sometimes when he was stopped at a light he felt as if he was still moving. Sometimes he lost the ability to focus and felt he was not in control. He testified that he had to modify his grip by using the base of his third finger to shift gears and that he uses this area at the base of his right finger to do all of his right handed gear shifting. He testified that shifting in the mountain passes involved extensive gear shifting and increased tension, particularly in bad weather. He explained that as he used his right hand driving swelling, aching and pain would develop in his right hand and arm. He also testified that the modification to the gear shift suggested by the occupational therapist did not provide a significant advantage.

The worker testified that currently he holds a class III driving license and he has been able to work recently driving an automatic truck that does not require shifting. He explained that he still has arm pain but he is only driving 8 or 9 hours as compared to his previous long-distance driving of 48 hour trips and so he is able to rest or exercise his arm to feel better.

Following the hearing, the panel noted that nerve conduction studies and operative reports were not on file and requested diagnostic, consultation or other medical reports since 2006 from the worker’s plastic surgeon.

The medical information received from the surgeon included the following:

• A report dated August 28, 2006 from the worker’s plastic surgeon addressed to the referring physician. The report outlined the worker’s complaints of numbness in his index, ring and middle fingers of his right hand with pain radiating proximally up to the shoulder and neck as well as swelling and stiffness in the hand and pain on the lateral aspect of the elbow; and

• A report from the neurologist dated November 27, 2006. The report notes that the worker continues to experience vertigo and unsteadiness and his right hand has become progressively weaker with considerable pain in the neck and right arm diffusely. The neurologist reports that the nerve study shows evidence of mild to moderate right carpal tunnel syndrome;

The panel met on November 14, 2007 and rendered its decision allowing the worker’s appeal on both issues.

Analysis

In this case, the panel must determine whether, in accordance with subsections 4(1) and (2) of The Workers Compensation Act in force at the time of the worker’s 1979 compensable injuries, the worker’s current difficulties are related to those 1979 injuries and if so, whether the worker was disabled from working as a long-haul truck driver as a result.

The evidence before the panel indicates that the symptoms that the worker consistently complained of as affecting his ability to drive in 2003 were swelling and pain in his right hand and arm as well as dizziness when driving that worsened when driving long distances and in the mountains. These long distance trips between Winnipeg and Vancouver were part of the regular job duties that the worker performed when his symptoms started to increase in 2003.

The panel is of the opinion that, on a balance of probabilities, the medical evidence supports a conclusion that:

a) The worker’s dizziness when driving long distances and in the mountains was related to his previous 1979 compensable injury;

b) The worker’s right hand and arm problems were related to his right thumb amputation;

c) The worker’s dizziness and right hand and arm problems affected his ability to perform his duties as a long-haul truck driver, such that he was required to reduce his driving hours.

We have reached this conclusion for the following reasons.

The WCB medical staff ultimately concluded that there was no doubt that the worker’s dizziness was related to the 1979 compensable injury. However, one of the significant difficulties with the WCB medical review of this file is the manner in which they assessed the worker’s vestibular problems in order to determine if they were affecting the worker’s ability to perform his driving duties.

The file indicates that when the WCB specialists and advisors were asked to review the file and provide an opinion on the worker’s fitness to drive, they did not undertake a thorough analysis to determine whether the worker’s vestibular condition impaired his ability to perform all elements of his specific driving duties on the job. Instead, the WCB medical staff stated that if the worker was fit to drive 50% of the time, he was fit to drive 100% of the time. This statement became a primary factor leading to the denial of wage loss benefits. However, the flaw in this reasoning was that the opposite conclusion is also possible. If the worker was unfit to drive 50% of the time, he was unfit to drive 100% of the time, which would support an award of wage loss benefits. It also failed to deal with the unique driving issues faced by this particular worker with his particular routes.

The panel notes, from the evidence at the hearing that the worker’s problems with both dizziness and vertigo symptoms rose proportionately to the length of his long distance trips; his restrictions reducing him from 100% to 50% hours were not intended to be an absolute bar against driving, but rather, to deal with the “endurance” issues that led to an increase in his symptoms.

In this regard, the panel notes that the opinions of the worker’s physician and neurologist support this finding. The worker’s physician was of the opinion that the worker’s dizziness and right arm symptoms worsened with long hours of driving and in the mountains and that in order to alleviate these problems the worker needed to rest more and reduce his driving duties by 50%.

The neurologist was of the opinion that the worker’s right arm difficulties and dizziness were both related to the 1979 injuries and that the arm problems increased when the worker drove long distances. The neurologist also agreed that the worker should reduce his driving workload by 50%.

Also of significance was the testimony of the worker explaining how driving long distances and in the mountains caused him tension and fatigue and increased his symptoms of dizziness and arm pain.

The panel also finds that the opinion of the worker’s ENT specialist that suggests that it is safe for the worker to drive, but notes that he is unsure how well the worker will do driving, was based solely on consideration of the worker’s vestibular problems and leaves open the possibility that the worker might have to nevertheless decrease his driving. When this opinion is taken together with the physician and neurologist’s opinion that assessed the worker’s arm symptoms as well as his overall ability to perform the specific duties of long haul driving, the panel is of the view that the medical evidence supports a conclusion that the worker’s ability to drive long distances and in the mountains was impaired.

The panel is therefore of the opinion that, on a balance of probabilities the medical evidence supports a conclusion that the worker’s dizziness and right arm problems impaired his ability to drive long distances and to drive in the mountains.

With respect to the issue of whether the worker’s right hand/arm problems were related to the 1979 thumb amputation, the panel notes that the WCB medical advisor concluded that these symptoms were not related to the right thumb amputation by relying on the call in examination notes of the WCB physiatrist that referred to a wide range of pain and symptoms experienced by the worker in other areas of his body. The WCB medical advisor was of the view that the working diagnosis was non-specific pain disorder and included the worker’s right arm symptoms as part of this diagnosis.

The panel is of the view that the worker’s right hand and arm symptoms should be viewed separately from the other diffuse symptoms that the worker described when examined by the WCB physiatrist. The worker has consistently related his inability to drive primarily to his right arm problems and dizziness. A review of the WCB physiatrist’s report indicates that he did not rule out a relationship between the worker’s right arm problems and the 1979 injury. When the WCB case manager asked the WCB physiatrist “Do you feel based on your finding a cause/effect relationship continues to exist at this time and are causative of [the worker’s] numerous problems?”, the reply is noted as “I cannot rule out some relationship – but difficult to relay all of the problems”. Unfortunately, the WCB physiatrist was not asked to clarify which symptoms he felt were related or specifically, if the right arm/hand problems were related to the 1979 injury.

On reviewing all of the evidence, the panel places greater weight on the opinions of the worker’s neurologist, surgeon and physiotherapist, that the worker’s right hand arm problems were related to the 1979 thumb amputation and the associated surgeries and tendon transfers. The panel is of the opinion that the medical evidence supports a conclusion that the worker’s right arm problems were related to the 1979 thumb amputation.

Therefore, with respect to the first issue of whether or not the worker is entitled to wage loss benefits, the panel holds that both the worker’s dizziness and right arm problems were related to the 1979 compensable injuries and that these problems disabled the worker by impairing his ability to perform his long-haul truck driving duties requiring that he reduce his driving hours and ultimately stop long-haul driving completely. We therefore find that the worker is entitled to wage loss benefits.

With respect to the second issue of whether or not the WCB should accept responsibility for the worker’s right handed CTS and right elbow epicondylitis as sequelae of the worker’s right thumb amputation, the panel is of the opinion that on a balance of probabilities both of these conditions are related to the right thumb amputation and the subsequent surgeries and tendon transfers and the modifications in the use of his hand and arm that he has had to make in order to continue long-haul truck driving.

The worker’s neurologist indicated in his report of April 3, 2006 that the numbness, swelling and weakness in the worker’s hand were related to the tendon transfers and the thumb amputation. The surgeon indicated in his report dated August 28, 2006, following examination of the worker, that the worker has right handed CTS that is indirectly related to the accident “as [the worker] has had to modify the use of his hand due to the amputation of thumb” and that the worker has right lateral epicondylitis “likely a result of accommodating the loss of his right thumb.”

Nerve conduction studies were conducted and based on the results the neurologist indicates in his November 27, 2006 report that the worker has mild to moderate right CTS.

The panel notes that the WCB medical advisor’s opinion that the CTS was not related to the worker’s driving duties was made on November 7, 2007, prior to receipt of the nerve conduction studies and prior to the surgeon’s report indicating that the carpal tunnel release resulted in improvement of the worker’s condition.

The panel also notes the worker’s testimony regarding the significant overuse of the area at the base of his right third finger in order to accommodate for the loss of his right thumb. In our opinion the overuse in this hand area and the significant gear shifting required in long-haul driving together with the extensive tendon transfers that had occurred during surgery, would be factors supporting the development of CTS in the worker’s right hand.

It is also of significance that CTS and epicondylitis were only noted in the worker’s dominant right hand and arm, which is another factor in support of the conditions being related to the consequences of the right thumb amputation.

In this case, the panel places greater weight on the expertise of the surgeon and neurologist than that of the WCB medical advisor and concludes that on the balance of probabilities the worker’s right carpal tunnel syndrome and right epicondylitis are related to the consequences of the 1979 right thumb amputation.

The panel therefore holds that responsibility should be accepted by the WCB for the worker’s right carpal tunnel syndrome and right epicondylitis as a sequelae of the right thumb amputation. The worker’s appeal on both issues raised in this matter is allowed.