Decision #88/09 - Type: Workers Compensation

Preamble

A hearing was held on July 21, 2009 to consider the matter.

Issue

Whether or not the worker is entitled to wage loss benefits beyond March 24, 2006; and

Whether or not the worker is entitled to medical aid benefits beyond May 16, 2006.

Decision

That the worker is not entitled to wage loss benefits beyond March 24, 2006; and

That the worker is not entitled to medical aid benefits beyond May 16, 2006.

Decision: Unanimous

Background

On September 22, 2005, the worker filed a claim with the WCB reporting that she was experiencing difficulties with her right elbow, arm and shoulder which she related to the use of a keyboard and workstation.

A report received from the treating physician dated August 22, 2005 indicated that the worker complained of work related acute on chronic symptoms of the right forearm, upper arm and shoulder. The diagnoses rendered were as follows:

· Acute right lateral epicondylitis

· Acute on chronic tendonitis/myositis

· Right forearm, upper arm, and shoulder muscular pains

· Right elbow pain radiating into the right forearm, upper arm and right shoulder.

A WCB medical advisor reviewed the file on November 21, 2005 at the request of initial adjudication. The medical advisor indicated the following:

“Repetitive flexion/extension wrist/forearm/elbow activities can be associated with the tendinitis or tendonopathy problems reported, however, the epicondylitis reported tends to be more associated with repetitive forceful activities, and not just those repetitive activities. Abnormal postures for prolonged periods of time can cause some muscle fatigue and irritability as well.”

The medical advisor further stated that he was not sure whether the diagnosis of epicondylitis was supported by the clinical findings reported by the attending physician.

On November 22, 2005, the claim for compensation was accepted based on the diagnosis of right forearm, upper arm and shoulder tendonitis and benefits were paid to the worker. File information also indicated that the worker started a graduated return to work program at four hours per day with restrictions to limit the use of her right upper extremity and shoulder.

On December 19, 2005, an MRI report of the right shoulder revealed a solidly united fracture of the surgical neck of the right humerus, with some residual deformity. There is one half shaft width of anterior displacement and mild varus angulation at the fracture site. No other bone or joint abnormality was seen.

On January 9, 2006, a massage therapist reported that the worker had shown tremendous improvement over the last three months. “Her muscles are much more relaxed and inner tension has been reduced by 75-80%, and most of the pain she was experiencing has been alleviated…[the worker] will have to continue treatments, though less frequently until all muscles return to normal function. The cartilage in the shoulder joint has started to regenerate but can take up to 10 months to return to normal. With the improvements I have seen to date, I feel confident that [the worker] will regain full use of her right shoulder and arm in due time.”

In a report dated January 11, 2006, the treating physician diagnosed the worker with “chronic strain of the right lateral, posterior shoulder muscles with secondary chronic tendonitis.”

Following a WCB call in examination on January 30, 2006, a WCB medical advisor made the following determinations:

· The worker had recovered from the initial diagnosis of right elbow tendinitis/right lateral epicondylitis.

· Massage treatment, twice per week administered between September 27 and mid December 2005 should be accepted as a WCB financial responsibility.

· Once the worker was educated and was familiar with home exercise, further physiotherapy attendance related to the right elbow/forearm would not be recommended or required.

· The worker should not be restricted from returning to her pre-accident duties in relation to her right elbow/forearm. A gradual re-introduction to typing along with an ergonomic work station, tennis elbow strap for repetitive forceful grasping would lessen the risk of flare-ups.

· The clinical presentation was not indicative of a probable rotator cuff tendonitis.

· The worker reported right shoulder girdle pain. The current physical findings of the right shoulder did not support the imposition of restrictions on the worker’s pre-accident duties.

On February 8, 2006, the above medical advisor spoke with the treating physician. The treating physician agreed that the worker had recovered from her right elbow/forearm condition and that her current right shoulder condition was not arising from a rotator cuff tendon lesion. He indicated that at the examination on February 6, 2006, the worker’s condition had shown considerable improvement. He agreed that the worker could gradually return to all of her pre-accident duties subsequent to an upcoming 3 week holiday.

In a report dated April 11, 2006, the treating physician indicated that he saw the worker on March 20, 2006. He noted that the worker had worked her way back up to six hours a day. The worker, however, noticed mild discomfort developing at the medial and lateral epicondyle as well as into the forearm and right shoulder. The worker had full range of movements of her right shoulder and elbow with no difficulties. The physician further advised that the worker was restricted to light duty work of no more than 2 pounds of lifting, pushing, pulling or carrying with her right arm for the next four weeks. He felt that this restriction was needed due to the fact the worker was developing recurring symptoms which could become more severe and disabling and appeared to relate to her previous compensable problems. A referral to a physical medicine specialist was arranged.

A WCB medical advisor stated on May 1, 2006 that the reported findings over the medial and lateral epicondyles would not constitute findings of epicondylitis. He noted that the worker did not perform repetitive, forceful grasping/pushing/pulling with her right arm at work and her work station had been redesigned. The worker would not be subjected to prolonged awkward right arm postures and keyboarding, mousing and answering telephones were not consistent with the development of acute tendonitis at the lateral or medial elbow. The medical advisor indicated that the worker’s current elbow complaints were not consistent with her job duties.

In a decision dated May 16, 2006, the worker was advised that the WCB was unable to relate the problems she was currently having to her workplace injuries or duties. The case manager noted that all parties were in agreement that her right elbow complaints had resolved when she was assessed at the WCB in January 2006. It was indicated that the physician’s April 11, 2006 report would not be representative of epicondylitis and her work duties currently were not considered to be repetitive nor forceful and there was no indication that she would have been subjected to prolonged, awkward right angle positioning with the right arm. These were all requirements of the development of acute tendonitis and were not consistent with her workplace duties.

On June 23, 2006, the worker saw a physical medicine specialist. He reported spending approximately one hour with the worker, mostly discussing whether her condition was work-related. Ultimately, he was not able to determine whether her medical condition was due to her work environment or not. He reported that the worker had symptoms and some signs that could be consistent with rotator cuff tendinopathy. Alternatively, the physical medicine specialist stated that the worker may have some intrinsic cuff disease consistent with that which can occur spontaneously in the fifth and sixth decades, which may be contributing to rotator cuff symptoms as well. At the time of the examination, it did not appear that the worker had evidence of a lateral epicondylopathy.

In September and October 2006, the worker provided the WCB with additional medical information for its consideration.

On November 14, 2006, the worker was advised that the new information had been reviewed in consultation with WCB medical consultants who felt that the noted problems and treatments remained unrelated to her August 10, 2005 compensable injury.

On June 26, 2007, a physiatrist outlined his view that the worker had significant problems with her right upper extremity and that it was highly probable that her problems were directly related to an improper work station. He noted that once the worker was given a better workstation in March 2006, she had a reduction in pain symptoms but they still remain easily aggravated and she had more pain at work than she did when she was away from work. He recommended that the work station be looked into and modified. It was indicated that the worker had some soft tissue pain around the shoulder and right forearm which may be amenable to myofascial trigger point needling.

A chiropractic report dated July 23, 2007 indicated that the worker suffered from chronic recurrent low back pain. He noted that he had treated the worker for bilateral strain of her pronator teres muscles since July 18, 2007. The worker also had previous right rotator cuff strain since 2005 which was exacerbated at the end of May 2007.

On September 27, 2007, the worker was assessed by a WCB physiatry consultant. In his opinion, there was no evidence of right elbow tendonitis or right lateral epicondylitis on the current examination. There were no significant objective physical findings. He concluded that there was no need for any restrictions related to the worker’s pre-accident duties and that the worker was capable of performing full time hours at work.

A worksite assessment was performed by a WCB rehabilitation specialist on October 1, 2007.

In a decision dated October 9, 2007, the worker was advised that the WCB was unable to accept responsibility for treatments any of her current problems as they were determined to be unrelated to the original injury and treatment. This decision was reached based on the findings of the WCB physiatry consultant dated September 27, 2007 and the findings at a previous WCB call in examination.

On April 14, 2008, it was reported by the worker’s treating physiatrist that the worker had not recovered as she had a chronic pain condition. It was reported that the worker had soft tissue pain affecting her neck, right shoulder and right upper extremity.

On June 12, 2008, the WCB’s physiatry consultant reviewed the April 14, 2008 medical report and stated the following:

  1. The apparent initial diagnosis with the claim initiation in 2005 was of an elbow tendonitis and lateral epicondylitis. The worker has some diffuse sensitivity present of both the upper and lower body that includes the right shoulder area. However there was no physical or pathoanatomical diagnosis identified for this. Also no physical contraindication was identified for the worker to increase her physical activities and to continue in her current sedentary clerical job duties without restrictions.

  1. No physical or pathoanatomic diagnosis has been identified for the diffuse sensitivity present of both the upper and lower body that includes the right shoulder.

  1. No apparent causal relationship is present.

  1. No restrictions would be suggested.

  1. There was no initial claim incident, only some gradual onset symptoms of tendonitis/epicondylitis in 2005. On the current examination (about 3 years later) there was no evidence of the 2005 claim tendonitis/epicondylitis which appears to have resolved, and on a balance of probabilities these 2005 claim complaints have resolved.

On June 13, 2008, the worker was advised that the WCB remained of the opinion that the physical effects from the August 2005 injury had resolved. This was based on the view that no apparent causal relationship was evident between the August 2005 claim and current symptoms noted in the April 2007 report, and therefore the compensable restrictions were no longer applicable to her claim.

On August 6, 2008, the Worker Advisor Office requested reconsideration of the June 13, 2008 decision. It was the worker’s position that there was a causal relationship between her current condition of myofascial dysfunction and the August 2005 claim for right elbow tendonitis and lateral epicondylitis. In support of her position reference was made to the findings of an occupational health physician and the April 14, 2008 physiatrist’s opinion.

In September 2008, the worker advised Review Office that ergonomic changes were not made to her workstation and that she remained symptomatic.

On August 15, 2008, Review Office referred the file to a WCB medical advisor for clarification of his examination of the worker on January 30, 2006. He stated:

“Following review of the examination findings, the diagnosis remains non-specific pain about the right shoulder girdle musculature. No clinical evidence of rotator cuff tendinopathy or of a myofascial pain syndrome was discovered at examination…The clinical examination was not consistent with a myofascial pain syndrome.”

On November 13, 2008, the case was considered by Review Office. Review Office determined that the worker was not entitled to wage loss benefits beyond March 24, 2006 except for payment of wage loss benefits for attending the WCB examination on September 27, 2007 and that there was no entitlement to coverage of medical treatment beyond May 16, 2006. In reaching its decision, Review Office noted the following:

· the worker’s injuries were soft tissue in nature as there was no other evidence to suggest a more significant injury.

· the WCB call–in examination of January 30, 2006, during which it was indicated that the worker had recovered from the initial diagnosis of right elbow tendonitis/right lateral epicondylitis, that there was no indication of a probable rotator cuff tendinitis and that the worker would not require restrictions for her pre-accident duties.

· the September 8, 2008 WCB medical advisor’s assessment that the clinical exam was not consistent with myofascial pain syndrome and that the diagnosis remained non-specific pain about the right shoulder girdle musculature.

· the June 27, 2006 comments by the treating physiatrist that he was unable to determine whether the worker’s medical condition was due to her work environment or that the worker had evidence of a lateral epicondylopathy.

· the changes shown in the September 30, 2008 MRI were consistent with the worker’s age.

· the worker did not have findings related to a workplace accident during her initial MRI on December 19, 2005. Review Office felt that the new findings reported on the MRI of September 30, 2008 were consistent with degenerative changes, unrelated to employment activities.

· the September 27, 2007 comments by the WCB physiatry consultant there were was no evidence of a right elbow tendonitis or right lateral epicondylitis and it appeared to have resolved.

· despite modifications to the worker’s workstation, her symptoms continued resulting in her stopping work effective January 7, 2008.

· the evidence did not support the contention that the worker’s ongoing right sided symptoms were related to her employment, as her employment activities required bilateral use of her upper limbs.

On March 10, 2009, the worker 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 of the Board of Directors. Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB. Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such a time as the worker’s loss of earning capacity resulting from the accident ends.

The Worker’s Position

The worker was represented at the hearing by a worker advisor. The worker’s position was that her current diagnosis of chronic right shoulder tendonitis and myofascial pain dysfunction were related to the August 10, 2005 compensable injury and the ongoing ergonomic difficulties with her workstation. The onset of right sided symptoms occurred following a change in the workstation. The initial diagnosis was chronic tendonitis, myonitis of the upper arm and shoulder and elbow epicondylitis and tendonitis. The diagnosis of chronic tendonitis and myonitis of the upper arm and shoulder have remained consistent. It was also submitted that the worker developed a secondary condition of myofascial pain dysfunction which was attributable to the ongoing right arm and shoulder difficulties and the poor ergonomics of her workstation. Due to her ongoing difficulties, the worker was not able to perform her duties after December 14, 2007. It was submitted that her loss of earning capacity should be accepted because there was a direct relationship between the poor ergonomics and her compensable injury.

The Employer’s Position

Two representatives appeared on behalf of the employer. It was submitted that no further wage loss benefits were payable as any loss of earning capacity beyond the dates in issue was no longer attributable to the compensable accident. The employer representatives noted that the worker initially reported her problems as first starting as a swollen elbow, which then became inflamed and she developed a jabbing pain in her shoulder. When asked what she believed was the cause of the problems, the worker indicated that she thought it was from the keyboard and the workstation and the fact that there was no room to move on her desk. The panel was urged to consider the compensable components, which were the right forearm, the right elbow and the right shoulder. It was noted that the medical reports on file had found that the epicondylitis and the right forearm issues were either very mild in nature, nonexistent, or without clinical evidence of a problem. The major issue seemed to be the shoulder, but it was argued that if keyboarding and an improper chair were the cause, the body mechanics should have acted on both right and left arms. The employer submitted that the explanation for the ongoing shoulder complaints related to degenerative processes and that the compensable components of the claim had long since resolved. As a result the worker should not be entitled to any further benefits and services.

Analysis

The issues before the panel are whether or not the worker is entitled to wage loss benefits beyond March 24, 2006 and medical aid benefits beyond May 16, 2006. In order for the appeal to be successful, the panel must find that by those dates, the worker continued to experience the effects of the injuries she sustained in August 2005 as a result of her workplace duties. We are not able to make that finding.

The file information indicates that the worker’s claim was accepted for injury to her right elbow, arm and shoulder which she attributed to keyboarding and the set up of her workstation.

With respect to the injury to her right elbow, it was not argued by the worker that the right lateral epicondylitis was still symptomatic. This is consistent with the symptoms reported at the WCB call in examination of January 30, 2006. The call in examination notes indicate that: “At the outset of the original complaint in August 2005, symptoms in the area of her right elbow were most prominent. These have resolved with time and are not currently causing her significant distress. The claimant notes that any discomfort in her right forearm and/or elbow is not of a disabling nature nor is it interfering with her ability to function.” Given the foregoing, the panel finds that by the time of the January 2006 call-in examination, the worker had recovered from her elbow injury.

With respect to the worker’s right arm and shoulder pain, while the panel acknowledges that the worker experiences pain and limitation, the panel is of the view that these symptoms are referable to the degenerative changes in her shoulder joint which were reflected in the MRI of September, 2008. The dramatic reduction in symptoms resulting from a subacromonial injection performed by an orthopedic surgeon (as reported in the surgeon’s February 13, 2009 consult report) suggests that the shoulder joint is most probably the cause for the worker’s ongoing pain in that area. The February 13, 2009 report also refers to the worker being very pain focussed and describes that the worker: “has cuff pain by history and unfortunately she has developed a fear of this pain, which has stopped her from moving through it.”

The panel gave consideration as to whether the job duties performed by the worker may have caused or aggravated the continuing shoulder/arm condition. At the hearing, the worker described her job duties in detail and it would appear that she had a highly varied job which did not involve intense repetition for extended periods of time. She was not required to work while sustaining her arms in a raised or awkward position. There was minimal lifting of heavy weights, particularly at or above shoulder height. There was ample opportunity for her to take rest breaks and change position as required. The worker’s primary complaint about modifications made to her workstation related to the height of the chair and desk, and the delay in making these adjustments. While the panel acknowledges that this may have been frustrating for the worker, we do not see the improper height (of approximately one inch) as affecting her shoulder joint. The worker referenced having to “wing out” her arms in order to type, but her periods of keyboarding were typically short, with 15-20 minutes being the maximum amount of time that she would have to sustain this type of activity. The panel does not view any of her job requirements as being causative or aggravating to a shoulder joint condition.

There was a significant lapse of time between the first report of injury in August 2005 and the diagnosis of myofascial pain syndrome. This would suggest that the myofascial pain condition is not causally related to the compensable injury. The first time the myofascial pain diagnosis appeared on the file was in an August 31, 2006 report from the occupational health physician who examined the worker in July 2006.

The panel also notes that six months prior, the treating massage therapist reported on January 9, 2006 that since he had started treating the worker on September 27, 2005, the worker had shown tremendous improvement and that her muscles were more relaxed, with a reduction in inner tension by 75-80%. He reported that most of the pain she was experiencing had been alleviated. A few weeks later, at the January 30, 2006 call-in examination, indications were that the worker was largely recovered from her injuries, and there only remained some slight residual symptoms. The medical evidence would suggest that the worker had achieved considerable recovery before the myofascial diagnosis arose.

There seems to be a change in presentation between the time of these reports of recovery in January 2006 and July 2006, when the myofascial pain diagnosis is proposed. Although the worker did return to work before the appropriate adjustments to her workstation were effectively implemented, the panel does not accept that the myofascial pain complaints can be related to working at the sub-optimal work station from January to July, 2006. We are of the view that the deficits complained of at the worker’s station following her return to work were not so extensive as to be causative of a myofascial pain syndrome, particularly when her original symptoms were reportedly almost resolved.

The panel also notes the worker’s evidence was that the pain has become more widespread and diffuse, extending to her low back, thighs and hand. This would further suggest that the pain is not related to the compensable injury, as the condition has worsened despite improvements to her work station and now affects parts of the body which should not have been impacted by the improper set up of her work station.

The report from an assessment by a physical medicine specialist in June 2006 indicated he was not able to determine whether her condition was due to her work environment. An alternate diagnosis of spontaneous degenerative changes associated with aging was suggested. This alternate diagnosis seems to be confirmed by the MRI which was later taken in September, 2008.

For the foregoing reasons, we find on a balance of probabilities that the elbow, arm and shoulder injury which the worker suffered in August 2005 was short term in nature and was largely resolved by early 2006. It is therefore the panel’s decision that the worker’s ongoing complaints are not related to the August 10, 2005 compensable injury and the worker is not entitled to further wage loss or medical aid benefits. The appeal is dismissed.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 16th day of September, 2009

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