Decision #70/09 - Type: Workers Compensation

Preamble

The worker sustained a compensable injury to his right wrist on February 14, 2004. The issue presently being appealed by the worker relates to a decision made by Review Office on January 23, 2009 which determined that his right shoulder and arm pain was not the result of his compensable wrist injury of February 14, 2004. An appeal was filed with the Appeal Commission through the Worker Advisor Office and a hearing was held on May 21, 2009 to consider the matter.

Issue

Whether or not a relationship exists between the worker’s right shoulder/arm pain and the compensable injury of February 14, 2004.

Decision

That a relationship does not exist between the worker’s right shoulder/arm pain and the compensable injury of February 14, 2004.

Decision: Unanimous

Background

On February 14, 2004, the worker was chipping ice off a sidewalk with a long handled chipper for over two hours when his right hand started to get tired. When he awoke the next morning, his thumb and wrist were swollen and the pain ran all the way to his elbow.

Initial medical reports diagnosed the worker’s condition as a traumatic neuropraxia of the right wrist. When seen by a neurologist on April 22, 2004, it was his view that the worker’s symptoms were related to musculoskeletal pathology rather than a nerve entrapment syndrome or nerve injury. When seen by a sports medicine specialist on June 2, 2004, he reported that x-rays of the wrist and hand along with a nerve conduction study were considered to be normal. In the specialist’s opinion, the worker was recovering from a carpal strain.

Subsequent file records showed that the worker’s wrist pain continued despite physiotherapy, medication and cortisone treatment. This led to further testing and consultations by several specialists. An MRI of the right wrist taken October 17, 2004 revealed minimal chondromalacia involving the lunate. A right wrist arthroscopy done on April 22, 2005, showed no significant abnormalities and no evidence of a ligamentous tear.

Following a June 10, 2005 WCB call in examination, the medical advisor outlined the opinion that the worker had an RSD [reflex sympathetic dystrophy syndrome] type condition given his description of symptoms and clinical findings. The medical advisor indicated that this could be related to the initial injury and would explain why things had not improved with appropriate treatment.

On June 16, 2005, a physiotherapist reported that the worker’s subjective complaints were pain in the upper back/neck and right shoulder girdle along with tingling into the right upper extremity, headaches and decreased function of the right upper extremity. The therapist’s diagnosis was a shoulder strain.

A bone scan taken on July 13, 2005 showed the following findings: “The reduced flow to the right arm is very non-specific and can be seen with disuse. There are no scintigraphic findings suggestive of reflex sympathetic dystrophy.”

On September 1, 2005, the accident employer indicated that they were no longer able to accommodate the worker with appropriate duties. The worker’s file was forwarded to a vocational rehabilitation consultant to consider employment opportunities for the worker.

On September 8, 2005, the physiotherapist reported subjective complaints of pain in the right upper back/neck, right shoulder, right wrist and hand. The therapist opined that the cervical and right shoulder signs and symptoms were easily aggravated due to overcompensating from his right wrist.

On October 25, 2005, the treating physician reported that the worker sustained a new strain injury after he grabbed his dog with his right hand and experienced an acute pain in his wrist and 5th finger with swelling and bruising of the hand.

In late October 2005, the director of a pain clinic reported “There does not seem to be a significant neuropathic or sympathetic component to his pain and therefore further goals for management should include improving his pain control so that hopefully he had (sic) gradually improve his function…I will be recommending a trial of sustained release opioid, which hopefully can improve his pain control...I also understand that he is in the process of beginning a retraining program, which may involve computers and hopefully this will result in less stress overall on his wrist and arms, allowing him to be more productive for the future.”

On February 7, 2006, a rheumatologist reported that the worker’s presentation was unlikely related to reflex sympathetic dystrophy.

On February 10, 2006, the treating physician reported that the worker’s shoulder was better and did not lock up. On April 15, 2006, the physician reported that the worker feels pain into his right shoulder and into the pectorals with weather changes.

In a May 23, 2006 report, a physical medicine and rehabilitation specialist [physiatrist] outlined his examination findings as follows: “…there was tenderness in the mid carpal region. He also had mild allodynia affecting the right hand. He may have sympathetic overactivity in the right upper extremity. There was also a number of trigger points in muscles around the shoulder area and as well as spinal segmental sensitivity at C3 and T2. The increased input from these nociceptors can alter the sympathetic tone considerably.”

On May 23, 2006, the worker had x-rays of the cervical spine with oblique views which showed moderate disc narrowing at C6-7 with associated spurring. The facet joints appeared normal.

On October 3, 2006, a WCB medical advisor outlined her opinion that the worker’s current treatment related to needling of the shoulder and neck was not related to his compensable right wrist injury. The medical advisor indicated that the worker was likely at MMI (maximum medical improvement) for the wrist and that no further treatment was likely to bring about significant benefit. The medical advisor commented that the previously outlined right wrist restrictions were considered permanent.

On October 5, 2006, a WCB case manager advised the worker that any costs related to needling treatment associated with his neck and shoulder was not a WCB responsibility. The worker contended that his shoulder/neck problems are associated with his hand/wrist problems and that they were all connected.

On October 17, 2006, the treating physician reported that the worker continues to need treatment for his shoulder and arm which tightened up due to abnormal mechanics at the right wrist.

In a decision dated November 14, 2006, it was confirmed to the worker that no responsibility would be accepted for his neck symptoms as being related to his right wrist claim and that he would not be covered for time loss on September 25, 26 and 28, 2006. The case manager made reference to a letter received from a treating physiatrist dated October 20, 2006 which indicated that the worker presented on August 20, 2006 with spinal sensitivity at C2 and at C5 which was diagnosed as myofascial pain. She indicated that the report was reviewed by a WCB medical advisor on November 9, 2006 and it was concluded that the diagnosis of myofascial pain was not related to the compensable diagnosis of a right wrist chronic regional pain syndrome.

In a letter dated January 7, 2007, the treating physician stated, “This letter is to certify that [worker] suffers from chronic R wrist pain since a work related injury on 14.02.05. There has as yet been no formal diagnosis made. The chronic pain in his R wrist causes him to have abnormal mechanics at the R shoulder which contributes to muscle tension in his neck and secondary headaches.”

On January 25, 2007, the worker appealed the November 14, 2006 decision to Review Office. He indicated that his arm, shoulder and neck pain all relate to his wrist injury and that he had no pre-existing pain prior to his February 14, 2004 injury.

On March 22, 2007, Review Office made the following decisions:

  1. That the worker’s myofascial pain was not related to his compensable injury and that responsibility should not be accepted for the worker’s neck symptoms. In reaching its decision, Review Office noted that the first mention of neck, shoulder and headache symptoms came about 16 months after the compensable injury which failed to establish a temporal relationship between the reported upper back/neck/shoulder problems and the compensable injury. Review Office indicated that the worker attributed his back, neck and shoulder problems to overuse and compensating for altered wrist functions but if this were the case, the worker’s symptoms should have abated as he was no longer working as of September 2005. Review Office noted that the treating physiatrist did not specify a relationship between the compensable wrist injury and the findings in the upper back, neck and right shoulder.

  1. That wage loss should not be paid for September 25, 26, or 28, 2006. Review Office indicated that this time loss was associated with migraines and medical treatment connected with myofascial pain/neck symptoms which was considered to be unrelated to his compensable injury.

In May 2007, a worker advisor asked Review Office to reconsider its decision of March 22, 2007 based on a report from the treating physiatrist dated April 20, 2007 which outlined the opinion that the symptoms affecting the worker’s neck and shoulder were related to the effects of his compensable injury.

In his report of April 20, 2007, the physiatrist stated:

“…The original right wrist condition did heal but without the elimination of the pain. There is a strong probability that the ongoing pain input from the wrist into the nervous system has created plastic changes within the spinal cord and supraspinal centers allowing for central sensitization. His wrist sensitivity allows heightened nociceptive transmission (peripheral sensitization) and this heightened input has created central sensitivity. Physical examination has identified the presence of a number of sensitized spinal segments including a C5 and C6 that fit with the pattern of heightened pain sensitivity found in the right upper extremity. The pain arising in his neck and right forequarter needs to be reviewed as part of the work-related injury.”

On July 17, 2007, a WCB physiatry consultant outlined the following opinion:

“The file evidence does not provide support for any plausible physical diagnosis as present from the original injury of Feb-14, 2004 (initial right hand/wrist tiredness), now three and one half years remote…In addition there is no plausible physical basis present on the file for any related restrictions…”.

On July 20, 2007, Review Office indicated that based on the totality of information, it was unable to establish a relationship between the compensable injury and the worker’s neck and shoulder symptoms.

On April 30, 2008, Review Office considered a 19 page narrative report from the treating physiatrist dated November 15, 2007. Review Office noted that before a diagnosis of myofascial pain can be accepted, the evidence must establish that the worker suffered an injury to a muscle in the region where the myofascial pain was present. Review Office found no evidence of an injury to the worker’s neck, right shoulder or forequarter area. Review Office noted that the physiatrist expressed the opinion that “…(worker) experienced a strain/sprain of his right wrist November 24, 2004 (sic) as a result of repetitive and forceful activity he was involved in. He has gone on to develop peripheral and central nervous system sensitivity that has created the pain in his forequarter.” Review Office indicated that it was unable to establish from the evidence that the worker continued to suffer from the effects of the soft tissue injury occurring to the worker’s right wrist on February 14, 2004.

In late May 2008, the worker advisor requested a Medical Review Panel (“MRP”) to address the difference of medical opinion expressed between the WCB’s physiatry consultant and the worker’s treating specialist. A MRP was granted and was held on November 28, 2008.

By report dated January 5, 2009, the MRP outlined its conclusions. With respect to diagnosis the MRP stated:

“The current condition affecting the neck and right shoulder is chronic diffuse pain complex. This conclusion is supported primarily by the description provided by the worker. More specific diagnoses were considered by the panel but no consensus could be reached.

The condition affecting the right wrist is lunate dysfunction with hypermobility without evidence of ligamentous tear on imaging to date. This conclusion is supported by MRI findings of early degenerative changes (sub-chondral cyst) and clinical exam revealing focal pain and tenderness at this level moreso than elsewhere.”

With respect to the question of whether a relationship existed between the current conditions and the injury sustained in February 2004, the MRP opined:

“There is a definite relationship between the worker’s current condition of wrist pain and the injury sustained on February 14, 2004. The injury occurred as a result of the repetitive trauma resulting from the ice chipper handle being repetitively hammered against the base of the wrist with impaction and potential subluxation of the lunate bone. This caused lunate dysfunction which has been ongoing to this day and which results in pain. This entity does not respond well to any available treatments.

It is very difficult to assign a definite relationship between the right shoulder/arm pain and the workplace injury particularly as the worker did not develop the pain until several months after the injury.”

On January 23, 2009, Review Office determined that there was a relationship between the compensable injury and the worker’s right wrist symptoms. It also determined that a relationship between the compensable injury and the worker’s right shoulder/arm pain could not be established. With regard to the second decision, Review Office concurred with the MRP’s opinion that it was very difficult to assign a definite relationship between the right shoulder/arm pain and the workplace injury as the worker did not develop the pain until several months after the injury. On February 5, 2009, the worker advisor appealed Review Office’s decision to the Appeal Commission and a hearing was arranged.

Reasons

Applicable Legislation:

The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations, and policies made by the WCB Board of Directors.

WCB Policy 44.10.80.40, Further Injuries Subsequent to a Compensable Injury (the “Further Injuries Policy”) applies to circumstances where a worker suffers a separate injury which is not a recurrence of the original compensable injury, but where there may be a causal relationship between the further injury and the original compensable injury. The Policy provides:

A further injury occurring subsequent to a compensable injury is compensable:

(i) where the cause of the further injury is predominantly attributable to the compensable injury; or

(ii) where the further injury arises out of a situation over which the WCB exercises direct specific control; or

(iii) where the further injury arises out of the delivery of treatment for the original compensable injury.

A further injury which occurs as a result of actions (for example, medical treatment) known by the worker not to be acceptable to the WCB is not compensable.

The Worker’s Position:

The worker was assisted by a worker advisor at the hearing. It was submitted that the Further Injuries Policy was applicable to the worker’s situation and that there was a relationship between the compensable right wrist injury and the subsequent problems he developed in the upper arm, shoulder and neck. It was argued that the symptoms didn’t just appear suddenly in June 2005, rather they were noticed by the worker soon after the compensable right wrist injury, but he did not pay much attention to them. There was a reasonable explanation for the delay in the progression of his symptoms. Initially, the secondary symptoms were controlled with acupuncture and physiotherapy treatments, but once those treatments stopped, the symptoms grew progressively worse in a relatively short space of time. It was noted that the worker’s treating physician and physiatrist both provided medical support that his secondary symptoms were related and predominately attributable to the compensable injury.

Analysis:

The issue before the panel is whether or not the worker’s right shoulder/arm/neck pain is related to the compensable right wrist injury of February 14, 2004. For ease of reference, the worker’s right shoulder/neck/arm pain will be referred to as his “right upper quadrant” condition. In order to decide the issue, the panel must choose between two sets of medical opinion.

On the one hand, the worker relies on medical reports from his family physician and the treating physiatrist who are of the opinion that the right upper quadrant condition is related to his compensable injury. The treating physiatrist, in particular, provided two very extensive medical reports in which he opined that: “The ongoing pain and functional limitation that he experiences affecting his neck, shoulder and right upper extremity are directly related to the work incident of February 14, 2004” and that “as a result of the pain that originated after this incident, [the worker] has developed peripheral and central nervous system sensitivity that have created ceroplastic changes within his nervous system that have allowed the spread of the pain to the forearm, elbow, arm, shoulder and neck.”

Contrary to this, the Medical Review Panel, in its report dated November 28, 2008, states that: “it is very difficult to assign a definite relationship between the right shoulder/arm pain and the workplace injury, particularly as the worker did not develop pain until several months after the injury.” The WCB’s physical medicine consultant also opined that the file material did not provide support for any plausible physical diagnosis as present from the original compensable injury of February 14, 2004.

After reviewing the file material and hearing the worker’s testimony, the panel accepts the opinion of the Medical Review Panel and therefore finds that the worker’s right upper quadrant condition is not related to his original compensable injury. In coming to this decision, we note the following:

  • At the hearing, the worker explained that he began to experience the secondary symptoms of pain and tightness in his upper arm and shoulder a couple of weeks after the compensable injury. He said that since the pain in his wrist was so severe, he never paid much attention to the other symptoms. He was attending physiotherapy at the time and received acupuncture treatment. This helped to keep the condition in check. After the WCB cut him off physiotherapy, however, his condition gradually worsened and the tightness became progressively worse. Finally, in June 2005, he experienced an episode where his whole right side “seized up” on him and he sought further treatment from his physiotherapist. It was submitted on behalf of the worker that there was never really a delay in onset of symptoms.
  • The difficulty with the worker’s explanation is that throughout the period from February 2004 to June 2005, the medical records do not reflect any reporting by the worker of any issues with his right upper quadrant. This is despite the fact that he was in regular, frequent contact with both his family physician and physiotherapist during this time. He had also consulted with numerous specialists regarding his wrist. None of the reports give any history of problems with the neck, shoulder or arm. The first mention of the upper quadrant condition was in the notes from the call-in examination by the WCB medical advisor on June 10, 2005 where she notes: “With increased activities, he will get tightness going all the up (sic) his arm to his neck.” The first significant complaint is recorded in the physiotherapist’s report of June 16, 2005 (relating to an attendance on June 10, 2005) where the subjective complaints describe: “pain in upper back/neck and R shoulder girdle region; tingling up to R upper extremity; headaches ++; decreased function using R upper extremity.”
  • The panel also notes that the forms completed by the physiotherapist requesting additional treatment in May and June 2004 reference treatment for the right wrist only. It does not indicate that the worker was receiving any treatment for the arm, shoulder or neck. When questioned at the hearing, the worker confirmed that the physiotherapist’s treatments were focused on the wrist, but that acupuncture treatments often involved needles which were inserted along the entire length of his arm, from the top of his shoulder down to his fingertips.
  • In the circumstances, the panel cannot find that there were right upper quadrant symptoms present from the outset, that were simply controlled by acupuncture and physiotherapy, then worsened as time progressed. It would appear from the medical reports that the right upper quadrant condition only developed some time after the original compensable injury, and we so find.
  • The report of the treating physiatrist appears to be based on the assumption that the right upper quadrant condition was present right from the outset. The report of April 2007 states: “This 42 year old gentleman has had ongoing pain in his right neck, shoulder, arm, forearm wrist and hand since February 14, 2004 … His condition has not changed considerably since the reports of his initial presentation.”
  • As noted by the worker advisor, the subsequent report of the treating physiatrist dated November 15, 2007 appears to amend the opinion to take into account the delay in onset of symptoms. Instead of relating the secondary symptoms to the original mechanism of injury, he acknowledges that the worker: “continually indicated to me that he developed pain in his right wrist on February 24 (sic) and over time, he has developed pain in the rest of his right upper extremity.” The treating physiatrist then attributes the development of the secondary symptoms to “peripheral and central nervous system sensitivity that has created the pain affecting his right forequarter … I feel he has fluctuation symptoms attributable to the sympathetic branch of the autonomic nervous system that are enhanced through physical and/or psychological activity.”
  • The panel notes that this opinion regarding etiology was not adopted by the MRP. We also note that the worker has described very wide ranging pain throughout his right upper quadrant which would seem inconsistent with the development of a segmental disorder, which would typically produce pain over a very defined area. Further, although the MRP noted diffuse soft tissue tenderness, it was noted that the worker did not have tender points consistent with ACR-defined fibromyalgia tender points, taut bands were not reliably discerned and no pain referral patterns on palpation were reliably elicited.

After a review of all the evidence, it is the panel’s decision that the opinion of the MRP is to be preferred over that of the treating physiatrist and the general practitioner. Although it was argued by the worker advisor that the standard applied by the MRP, namely that: “it is very difficult to assign a definite relationship”, was greater than is required by the Act, the panel is satisfied on a balance of probabilities that there is no relationship between the worker’s right shoulder/arm/neck pain and the compensable injury of February 14, 2004. The worker’s appeal is therefore dismissed.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 8th day of July, 2009

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