Decision #32/10 - Type: Workers Compensation

Preamble

This appeal deals with a decision that was made by Review Office of the Workers Compensation Board (“WCB”) which determined that the worker’s diagnosed condition of de Quervain’s tenosynovitis was unrelated to her work duties of typing and handwriting. The worker disagreed with the decision and an appeal was filed with the Appeal Commission. A hearing was held on February 18, 2010 to consider the matter.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is not acceptable.

Decision: Unanimous

Background

The worker filed a claim with the WCB for a wrist injury that she related to her job duties as a receptionist/shipper/receiver, with an accident date of May 1, 2009.

When applying for compensation benefits, the worker advised the WCB that she first noticed soreness in her right hand and wrist while typing around March of 2009. She also noticed that her whole right hand was swollen. The worker stated that her workload increased in April 2009 and that she worked a lot of overtime. The worker reported that she underwent surgery about six years ago for de Quervain’s tendonitis in her right hand but has not had any further problems since.

Information obtained from the employer was that they were not aware of an injury occurring during the week of April 27, 2009 and that the worker did not report an injury to her wrist on May 1, 2009. The employer reported that the worker’s primary tasks were receptionist duties and she performed very limited data entry or handwriting tasks. Typical computer data entry was limited to 5 to 15 minutes at a time several times a day.

On May 12, 2009, a WCB adjudicator contacted the worker to gather additional information regarding her claim. The worker reported that she began employment with the accident employer in August 2008 and that she performed data entry for 8 hours per day. During the first two weeks in April 2009, her workload increased and she performed data entry for 100% of her workday and worked approximately 20 hours of overtime. Prior to her surgery in 2002, the worker reported that she was assembling and lifting books with another employer and that her symptoms began within four months after starting the job. The worker reported that the surgery was successful and she was symptom free until April 2009.

In a May 12, 2009 report, the treating physician confirmed that the worker reported pain in her thumb and wrist in August 2002 and was diagnosed with de Quervain’s tenosynovitis. He reported that the worker had no problems with her right wrist until May 2009 when she reported right wrist difficulties in keeping with early de Quervain’s tenosynovitis which started as a result of typing and writing in her job.

On May 19, 2009, a WCB medical advisor was asked to comment on whether “typing” was a likely contributor to the aggravation/appearance of symptoms. He responded on May 28, 2009 as follows:

“No. The reported dx [diagnosis] is de Quervain’s tenosynovitis, attributed to workplace activities, in this case, typing/data entry. Typically, the development of de Quervain’s tenosynovitis is attributed to repetitive and forceful gripping, grasping and/or wrist movements of ulnar/radial deviation. The repetitive but not forceful nature of typing would not typically be recognized as a likely provocative factor.”

On May 29, 2009, the worker was advised that her claim for compensation was not accepted as the WCB was of the opinion that the repetitive but non-forceful nature of typing was not typically associated with the development of de Quervain’s tenosynovitis.

The worker provided the WCB with internet pages which linked de Quervain’s syndrome to typing/writing.

On June 28, 2009, the plastic surgeon who operated on the worker’s wrist in 2002 reported that the worker was seen on June 17, 2009 complaining of signs of de Quervain’s disease involving the right wrist that came about during a recent period of increased activity.

On July 9, 2009, a WCB medical advisor commented that the diagnosis of de Quervain’s tenosynovitis was not in dispute. The issue was whether there was a relationship between the diagnosis and the worker’s work duties. The medical advisor noted that the development of de Quervain’s tenosynovitis was attributed to a combination of forceful and repetitive wrist/thumb movements and that the workplace duties of keyboarding and mousing seemed unlikely to have made a material contribution to the development of the condition. The medical advisor indicated that the work duties performed by the worker in 2002 involved assembling and lifting heavy books and that these duties would be consistent with the development of de Quervain’s tenosynovitis.

On July 14, 2009, the WCB case manager confirmed the earlier decision that the worker’s work duties of typing were not a provocative factor in the development of de Quervain’s tenosynovitis. The worker disagreed with the decision and the case was forwarded to Review Office.

In a decision dated August 6, 2009, Review Office confirmed that the claim for compensation was not acceptable based on the WCB medical advisor’s comments that the non-forceful nature of typing would not typically be recognized as a likely factor in the creation or aggravation of de Quervain’s symptoms.

On September 28, 2009, a worker advisor acting on the worker’s behalf, provided Review Office with the following information to support that the worker’s right hand diagnosis of de Quervain’s had a relationship to her job duties as of April 30, 2009:

“…[the worker] remembered that in association with the increase in hours worked, her job duties also involved gripping and twisting in the removal of industrial sized staples, an increase in handwriting of information with a narrow black pen which required gripping, as well as the actions of repetitive thumb pressure required in the action of thumbing through invoices.

With respect to these job duties, [the treating surgeon] has provided his supportive report dated September 23, 2009, in which he supports the described work related job duties or actions support a relationship in that:

…the use of the thumb and index in such strain including activities such as writing excessively and staple removal likely contributed to her injury. …

[the treating surgeon] has also provided a full rationale to support his medical opinion as to how the worker actions have caused reinjury is clearly supported by his opinion that:

…The work duties directly caused inflammation of the previously released APL tendon in the wrist leading to swelling and tendonitis, with subsequent constriction and scarring in the first dorsal compartment, rendering the pain chronic. The fact that she has been well for 7 years previously infers the activity as causative. …”

On October 5, 2009, the worker advised Review Office that she had just started a new job without computers being involved. The job involved quite a bit of handwriting and after working a week she ended up in the emergency area at a hospital as she was in terrible pain. On October 15, 2009, the worker advised a WCB adjudicator that she quit the job due to painful symptoms.

On October 28, 2009, Review Office stated that it was unable to alter its previous decision of August 6, 2009. Review Office noted that the dominant work duty being performed by the worker was keyboarding. It stated that keyboarding would not provide the type of force the WCB was looking for to explain the worker’s diagnosis. It noted that the worker’s treating physician stated on September 23, 2009, “I don’t have an opinion regarding mousing and keyboarding as these activities are generally torsionally straining on the CMC and extensor tendons. The subsequent light workplace duties are non-contributory as the damage is already done.”

Review Office was further of the view that handwriting and photocopying would not place the type of stress on the worker’s wrist that Review Office was looking for nor would there be the ulnar/radial deviation that generally is part of the picture when looking for an explanation for a diagnosis of de Quervain’s tenosynovitis.

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. Subsection 4(1) of the Act provides:

4(1) Where, in any industry within the scope of this Part, personal injury by accident arising out of and in the course of the employment is caused to a worker, compensation as provided by this Part shall be paid by the board out of the accident fund, subject to the following subsections. (emphasis added)

The key issue to be determined by the panel deals with causation and whether the worker’s de Quervain’s tenosynovitis arose out of and in the course of her employment.

Worker’s position

The worker was assisted by a worker advisor at the hearing. The position advanced on behalf of the worker was that a relationship did exist between the worker’s employment and her personal injury. The provocative factors which may lead to the development of de Quervain’s tenosynovitis are generally accepted to be repetitive forceful wrist movements of ulnar deviation and/or repetitive forceful gripping and grasping, involving thumb flexion. The work duties being performed by the worker did have these factors. There was forceful gripping and grasping of a pen, on a repetitive basis, and the requirement to make the imprint go through a three part form required pressure on the thumb and wrist. Further, forceful twisting movements were involved in removing industrial staples, which held together a number of sheets of paper. A pinch-type staple remover was used, together with some degree of force. The specialist’s report of September 23, 2009 identified that work duties, such as excessive writing and staple removing, likely contributed to the worker’s reinjury. It was submitted that when work duties are a contributing factor to an injury, either based on a direct causal relationship or as an aggravating factor, there is WCB responsibility. On a balance of probabilities, the work stressors resulted in the recurrence of the worker’s de Quervain’s tenosynovitis, and therefore the appeal should be allowed.

At the hearing, the worker gave detailed evidence regarding her job duties. The employer was an agricultural producer and the worker’s position was in the office area. Her job duties included the following:

  • Completing the paperwork needed to ship the employer’s product. This involved completing several forms, either manually by hand, or by keyboarding information into pre-loaded forms on the computer. Some of the manual forms were in triplicate and the worker had to press very hard to ensure that the writing showed on all three forms. Sometimes photocopies had to be made of the forms. During the approximately 3 week busy shipping season in April, it took the worker between 45 minutes and 1 hour to fill out all the forms.
  • Preparing invoices on the computer.
  • Answering telephones (20 to 30 calls per day) and greeting the people who come into the office.
  • Walking out to the weigh scale to record load weights.
  • During the week of April 14, 2009, the worker prepared spreadsheets based on data dating back to 2002. This project involved more computer data entry work than the worker normally performed.
  • In early May 2009, the worker was assigned the task of making copies of documents for audit purposes. This involved removing large industrial sized staples from 2-3 inch bundles of paper. The worker used a pinch-type staple remover and it would take between 30 seconds and 1 minute for the worker to extricate the staples from the papers. The worker also had to flip through a large number of documents, and her method involved pushing down on the stack of paper with her thumb while flipping, in order to keep the stack from sliding around.

Employer’s Position

Legal counsel and a representative from the employer appeared at the hearing. The employer did not dispute the fact that the worker suffered from some form of injury to her hand, but it did take issue with the assertion that her condition was caused by the workplace activities in which she engaged. Legal counsel reviewed the nature of the de Quervain’s tenosynovitis and its generally accepted causes, the nature of the workplace activities, the activities the worker was involved in during the last week of April when she claimed the condition arose and the timing of the onset of the worker’s complaints of pain in her right wrist. It was submitted that the nature of the duties the worker performed for the employer were inconsistent with those generally accepted as being those that are known to cause or contribute to de Quervain’s tenosynovitis. The work duties were simply not the sorts of activities which could reliably or reasonably lead to the conclusion that there was a causal relationship between the de Quervain’s tenosynovitis and what the worker was doing in the workplace. It was noted that de Quervain’s tenosynovitis can be caused by all sorts of factors and it can just develop on its own. It can be idiopathic. It can also be caused by a blow or a fall, and the worker did suffer a non-work related fall in March 2009, at which time she injured her right wrist. Overall the employer submitted that the evidence established that there was no causal relationship and the appeal should be dismissed.

Analysis

To accept the worker’s appeal, we must find on a balance of probabilities that she suffered injury by a workplace accident within the meaning of subsection 4(1) of the Act. In order to do so, we must find that her de Quervain’s tenosynovitis arose out of and in the course of her work duties. We are not able to make that finding.

After considering the evidence as a whole, the panel is of the opinion that the worker’s right de Quervain’s tenosynovitis is not causally connected to her work duties. The administrative duties being performed by the worker were not of the kind which are typically associated with the development of de Quervain’s tenosynovitis. A de Quervain’s condition is typically associated with activities involving a combination of forceful and repetitive wrist or thumb movements. Although some of the office duties being performed by the worker involved some degree of forceful gripping with pressure (most notably, the filling out of triplicate forms), the amount of time that the worker spent doing this was minimal. At best, she spent 1 hour completing forms, many of which were not in the triplicate format. On the triplicate forms themselves, the amount of information which had to be handwritten was minimal. Further, while the office environment was busy, there was variety in the jobs the worker performed and there was sufficient time for rest and recovery between and during tasks.

With respect to computer keyboarding/mousing duties, the letter of the treating surgeon dated September 23, 2009 specifically acknowledged that these duties are not generally torsionally straining on the CMC and extensor tendons and therefore he did not provide an opinion that these duties were contributory to her injury.

The surgeon did identify excessive writing and staple removal as likely contributing to the re-injury, however, as noted above, the panel found that the amount of writing the worker was required to perform was not excessive.

With respect to staple removal, the onset of the worker’s pain did not match the time when she performed these duties. The two days of removing staples was done by the worker in early May, 2009. Although the evidence is somewhat unclear as to exactly when the worker first noticed pain, the panel is satisfied that by early May 2009, she was already experiencing pain. The initial Worker’s Incident Report dated May 11, 2009 identified that she first noticed that her right hand/wrist was getting sore “a couple of months ago”, in approximately March, 2009. At the hearing, the worker stated that this information was incorrect and that she first noticed the pain on the weekend of April 5th, during the busy shipping season. Regardless of whether the initial onset was in March or April, it is clear that prior to May 2009, the condition had already manifested itself, and therefore cannot be attributed to the staple removing duties performed in May 2009.

Based on the foregoing, the panel is unable on a balance of probabilities to relate the worker’s de Quervain’s tenosynovitis to the work duties which were being performed by her for the accident employer in April and May of 2009. The worker’s appeal is therefore denied.

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 April, 2010

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