Decision #30/08 - Type: Workers Compensation
Preamble
In November 2004, the worker filed a claim with the Workers Compensation Board (WCB) for groin pain that he related to an incident at work on November 10, 2004. The claim was accepted by the WCB and the worker was paid wage loss benefits and medical aid benefits to April 25, 2007 when it was determined by primary adjudication and Review Office that the worker’s ongoing difficulties with his groin, low back, hip and hands were no longer related to the compensable injury of November 10, 2004. The worker disagreed and filed an appeal with the Appeal Commission. A hearing was held on January 17, 2008.Issue
Whether or not the worker is entitled to wage loss benefits and services beyond April 25, 2007.Decision
That the worker is not entitled to wage loss benefits and services beyond April 25, 2007.Decision: Unanimous
Background
On November 10, 2004, the worker reported that he was walking across three pipes while carrying 14 feet of stringer weighing 150 pounds. When he tried to position his left leg over the pipes, he felt something let go in his groin area. The worker was later diagnosed with an inguinal muscle strain by a general surgeon and a CT scan was ordered to ensure that a small hernia was not present. The WCB accepted the claim and benefits were paid to the worker commencing November 16, 2004.
Over the next few weeks, the worker complained of ongoing discomfort in his left groin and hip region. He was seen by a neurologist on January 26, 2005 and it was his impression that the worker sustained an iliopsoas muscle strain with little to suggest neurologic involvement. The worker was assessed by an orthopaedic specialist on January 31, 2005 who could not identify a specific diagnosis for the worker’s symptoms. X-ray examination of the pelvis and left hip showed no evidence of any hip abnormalities. A CT scan of the abdomen on February 14, 2005 revealed no abnormalities. The worker was also seen by a physiotherapist on March 11, 2005 and was diagnosed with possible hip sprain/subluxation and possible femoral neuropathy.
On March 21, 2005, the worker was assessed by a WCB medical advisor who reported that the worker demonstrated some diffuse moderately severe left anterior groin pains with left leg weight bearing. He also found some evidence of abnormal pain behavior and inconsistent findings complicating the examination. He recommended that the worker proceed with physiotherapy to increase mobility of the left hip and muscle power in the left lower extremity. On April 22, 2005, the treating physiotherapist advised the WCB that the worker was improving objectively but subjectively he reported no improvement.
The worker was then assessed by a sports medicine specialist on July 18, 2005. He said the worker demonstrated a significant amount of pain behavior and focus which made it difficult for him to adequately determine the exact cause of his discomfort. The specialist arranged for a bone scan to determine if the worker had an occult injury to the left hip. In the interim, the worker was prescribed a groin support strap brace.
A bone scan taken on July 29, 2005 revealed no evidence of a hip fracture. A CT of the pelvis taken August 17, 2005 suggested findings of early sacroiliitis suspected on the left.
On August 22, 2005, the worker was seen by a physical medicine and rehabilitation specialist (a physiatrist) for complaints of left hip pain and pain down to the left knee for the past year. The physiatrist’s impression of the worker’s condition was sacroiliac and inguinal ligament strain. She indicated that she could not do anything for this condition.
On September 21, 2005, a WCB medical advisor told a WCB adjudicator that the sacroiliitis indicated on the CT scan of August 17, 2005 was a pre-existing condition and may be the cause of the worker’s ongoing pain complaints.
The worker underwent a CT scan of his lower back on January 5, 2006. No significant abnormalities were noted.
The case was reviewed by a WCB medical advisor at the request of the case manager. On February 28, 2006, the medical advisor indicated that the current diagnosis was non-specific left groin and leg pain. He found no abnormalities that would support any ongoing disability from work nor identify a diagnosis that would be related to the workplace injury of November 10, 2004.
On March 6, 2006, a WCB case manager determined that the medical information did not establish a cause and effect relationship between the November 10, 2004 accident and the worker’s current difficulties. The worker was advised that this decision was based on subsection 4(1) and 39(2) of The Workers Compensation Act (the Act) and that wage loss benefits would be paid to March 13, 2006 inclusive and final.
On April 7, 2006, a worker advisor appealed the above decision to Review Office. It was his contention that the worker continued to suffer from the effects of his compensable injury even though a confirmable diagnosis had not been established. He said there was no evidence on file to support that the worker’s disability was related to a pre-existing condition. He suggested that further investigations are required of the hips and sacroiliac areas to determine a diagnosis.
A left hip x-ray taken April 27, 2006 revealed no abnormality about the sacroiliac joint.
In a May 3, 2006 decision, Review Office determined that the worker was entitled to wage loss benefits and coverage for treatment after March 13, 2006. Review Office’s decision was based on several factors, i.e. the worker’s complaints and presentation had been consistent since the workplace injury; the worker remained under medical investigation; an MRI examination had not yet been carried out as was suggested by at least two specialists.
On May 10, 2006, an MRI of the left groin revealed mild atrophy of the left gluteal muscles.
The worker was evaluated by a neurologist on July 24, 2006. His report outlined patient information as provided by the worker and his examination findings. He concluded that there was no neuromuscular basis for the worker’s complaints.
A second physiatrist reported that he saw the worker in follow up on August 30, 2006. The worker complained of low back pain that radiated into the left buttock and walked with an antalgic gait wearing a brace. He stated that he reviewed a prior CT scan and there was some sclerosis and early erosions in the left SI joint. He stated the radiologist questioned seronegative spondyloarthropathy and this was possibly the cause of the worker’s pain.
On October 19, 2006, an x-ray of the lumbar spine showed a lumbar scoliosis convex to the right. There was some narrowing of the L4-L5 disc space and no other abnormality was seen.
On October 23, 2006, the second physiatrist indicated that the worker had muscular pain secondary to anxiety. “There obviously is tremendous psychological overlay.” He noted that the worker walked in with a broken right cane and claimed that his left hand was swollen because he used the cane.
The worker was interviewed at the WCB’s Pain Management Unit (PMU) on January 4, 2007. At a subsequent meeting held on March 2, 2007, the PMU opined that the worker’s presentation did not meet the criteria for a diagnosis of chronic pain syndrome. It was also of the view that any psychological factors involved in the worker’s pain levels and limited function were related to pre-existing congenital/developmental personality factors rather than the compensable injury, given the lack of pathoanatomical basis for his complaints.
The worker sought treatment from a chiropractor on January 16, 2007 with complaints of persistent/severe left more than right lumbopelvic and groin pain. The diagnosis was possible mechanical/myofascial lumbopelvic pain. He noted the worker had difficulty with walking and sitting due to the pain. Chiropractic treatment was authorized by the WCB up until March 6, 2007.
On March 28, 2007, the worker was advised by primary adjudication that he would receive wage loss benefits up until April 25, 2007 as it was determined that the medical information as well as surveillance information of his activities between February 2006 and February 2007 did not establish a cause and effect relationship between his accident of November 10, 2004 and his current difficulties with his groin, lower back, hip and hands. The worker disagreed with the decision and appealed to Review Office. He stated that his injury prevented him from returning to his pre-accident employment as a carpenter.
On May 9, 2007 Review Office determined that the worker was not entitled to wage loss benefits and services beyond April 25, 2007. Review Office noted that medical investigations failed to identify any pathoanatomical diagnosis to account for the worker’s ongoing physical complaints in relation to his compensable accident. As well, a review of possible psychological factors contributing to the worker’s ongoing presentation of pain and disability failed to link these problems to the at work injury. Given the lack of any substantive medical evidence which would relate the worker’s continuing complaints to the injuries sustained on November 10, 2004, Review Office was unable to accept the worker’s appeal. Review Office’s decision was appealed by the worker’s advocate and a hearing was arranged.
Reasons
Applicable Legislation
The Appeal Commission and its panels are bound by the Act, regulations and policies of the Board of Directors.
This appeal deals with the payment of benefits for an accepted accident. Subsections 39(1) and 39(2) of the Act, provide that wage loss benefits are payable where an injury results in a loss of earning capacity and are paid until such a time as the loss of earning capacity ends.
Worker’s Position and Evidence at Hearing
The worker attended the hearing with a representative who made a submission on his behalf. The worker answered questions asked by his representative and the panel.
The worker’s stepmother was called as a witness. She advised the panel that prior to the injury, the worker was active in sports and was a good athlete. She stated that before the injury he had a job and now is unable to do anything, can’t get mobile in the morning, walks with a cane and can’t work. She also advised that before the injury he lived independently and now lives at her home and occasionally stays with his brother.
The worker described the accident that caused his injury. In answer to a question from his representative, he explained his view on what is happening to his body. The worker advised that when he fell, his leg came-up and he felt the actual hyper-extension of the tailbone on his left side. He said it feels like his hip on his left side is locked forward and his tailbone is applying pressure resulting in his leg being numb. He said he cannot carry weight or shift weight.
The worker advised that he is being referred to the pain management centre at a large hospital. He does not know when he will receive his first appointment. He noted that his last treatment was from a chiropractor but that WCB did not extend the treatment. The chiropractor had recommended physiotherapy but WCB did not approve physiotherapy. He advised that he is not currently using prescription medications.
The worker described his daily activities. He indicated that he has to use a cane to get around. He acknowledged that he is pretty much housebound. The worker advised that he has not looked for work.
The worker’s representative noted that the medical evidence is inconclusive but that a WCB medical advisor indicated there is a temporal relationship between the injury and symptoms.
Regarding the video surveillance on the file, the representative submitted that it did not demonstrate anything other than the worker is using his cane and limping.
The worker’s representative submitted that the panel must determine whether it is likely that the worker decided to deliberately change his lifestyle or more likely that there is a medical problem that requires further medical investigation.
Analysis
The issue before the panel was whether the worker is entitled to wage loss benefits and services beyond April 25, 2007. For the appeal to be successful, the panel must find that the worker’s symptoms and loss of earning capacity beyond this date are caused by his workplace injury. The panel was not able to make this finding.
The panel finds on a balance of probabilities that the worker’s ongoing symptoms and his reported inability to work are not related to the worker’s November 10, 2004 compensable injury and accordingly the worker is not entitled to wage loss benefits or services beyond April 25, 2007. In arriving at this decision the panel has considered the description of the worker’s workplace accident, his ongoing symptoms, and the reports of the numerous medical specialists who have examined the worker, including:
- two physiatrists
- two neurologists
- an orthopedic surgeon
- a sports medicine specialist
- the WCB pain management unit consisting of a physician and psychologist
These specialists have been unable to find a pathoanatomical diagnosis or any reasonable medical explanation for the worker’s ongoing condition in relation to his workplace injury. In addition many diagnostic tests have been performed but have not resulted in a diagnosis which relates the ongoing symptoms to the workplace injury. The tests included x-rays of the pelvis and left hip, an MRI of the left groin area, CT scan of abdomen, CT scan of pelvis area, CT scan of lumbosacral spine, bone scan and blood tests.
At the hearing, the worker’s representative referred to the opinion of a WCB medical advisor who noted there is a temporal relationship between the worker’s pain presentation and his workplace injury. The panel does not find that this comment is sufficient, on a balance of probabilities, to conclude there is a cause and effect relationship between the injury and the ongoing symptoms. The panel also notes that this physician found there is no pathoanatomical diagnosis for the worker’s presentation, despite multiple physical examinations/assessments.
After a review of all the medical evidence, the panel finds that the preponderance of medical evidence does not support a causal relationship between the worker’s symptoms as of and beyond April 25, 2007, and his 2004 compensable injury.
The worker’s appeal is declined.
Panel Members
A. Scramstad, Presiding OfficerA. Finkel, Commissioner
M. Day, Commissioner
Recording Secretary, B. Kosc
A. Scramstad - Presiding Officer
Signed at Winnipeg this 20th day of February, 2008