Decision #37/10 - Type: Workers Compensation

Preamble

The worker is currently appealing a decision made by Review Office of the Workers Compensation Board (“WCB”) which determined that his bilateral trigger finger condition was unrelated to his work activities as an industrial mechanic. A hearing was held on April 8, 2010 to consider the matter.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is not acceptable.

Decision: Unanimous

Background

On January 6, 2009, the worker filed a claim with the WCB for injury to his right and left index finger with an accident date of April 1, 2008. The worker indicated that his injury was related to his employment duties as an industrial mechanic for many years which involved working with air tools and machinery.

The employer’s accident report dated January 15, 2009, indicated that they had no knowledge of an injury to the worker’s right or left index fingers. The employer noted that the employee had been terminated from employment in July of 2005.

On January 14, 2009, a WCB adjudicator placed a note to file indicating that the worker has a prior WCB claim for trigger finger of the left fourth finger that occurred at work on October 10, 2003. He stated that the claim contained no information to suggest that the worker complained of problems related to his left index finger.

In a telephone conversation with a WCB adjudicator on January 14, 2009, the worker indicated that he used a variety of hand and air tools in his job as a heavy duty mechanic. He also used his hands for fine manipulation and used air tools when he was placed on light duties in 1997 for a knee injury. In 2005, he stopped working for the accident employer and did not make any mention of discomfort with his index fingers. The worker indicated that he had CTS and trigger finger of his third and fourth fingers bilaterally, prior to leaving his employment. Until early 2008, he worked as a security guard but did not experience a specific injury or blow to either of his hands. The worker noted that three months prior to being scheduled for surgery (after April 8, 2008), his index fingers were locking up. The worker advised that in early 2009, his doctor told him that his trigger finger was likely due to his work with the accident employer. The worker indicated that he worked on his car for 3 to 4 hours per week approximately six months out of the year.

A report received from the family physician dated February 2, 2009 indicated that the worker first mentioned problems with his right index finger on January 31, 2008. On April 8, 2008, a plastic surgeon injected the tendon with Kenalog which afforded temporary relief. He noted that the worker previously reported gradual onset of triggering of the index finger while in flexion. There was a painful lump over the volar aspect of the index MCP. The tendon was injected a second time on September 2, 2008 with minimal improvement. The physician reported that the worker had similar problems with his right ring finger in January 2004 which required surgical release. He had left thumb triggering which responded well to an injection in January 2006. The physician indicated that the worker did not have any history of hypothyroidism or diabetes. He did have a prior history of carpal tunnel syndrome and osteoarthritis.

The file was reviewed by a WCB medical advisor on February 19, 2009. The medical advisor indicated that the symptoms reported by the worker were consistent with trigger finger (i.e. locking of the finger when flexed) and that the nodule in the palm of the hand at the MCP level was also consistent with the diagnosis. It was indicated that the condition was often idiopathic (no known cause) and was associated with activities that stress the flexor tendons to the fingers (repetitive movements of the fingers particularly against force). It could also be caused by prolonged pressure over the tendon such as in prolonged gripping, and had been associated with other conditions such as diabetes, rheumatoid arthritis, thyroid disorders, etc. The symptoms generally come on gradually with repeated exposure to the precipitating activity. The medical advisor indicated that the proposed surgery would be appropriate if the claim was accepted for the trigger finger diagnosis.

On February 23, 2009, the worker was advised that his claim for compensation was not accepted as the adjudicator was unable to establish a causal relationship between the development of his bilateral index finger difficulties which developed in early 2008 and the duties he performed as an industrial mechanic while working with the accident employer in 2005.

The worker then appealed this decision to Review Office. In a memo dated April 23, 2009, Review Office indicated that the worker’s file was discussed with a WCB medical advisor. The medical advisor’s opinion was that the work duties performed by the worker as an industrial mechanic up to 2005 would not, on a balance of probabilities, result in the onset of trigger finger symptoms in the year 2008. The medical advisor indicated that trigger fingers can be an acute response to work performed but did not believe a delayed onset of symptoms could reasonably be related to work performed in the past on a cumulative basis.

After considering the opinions expressed by two WCB medical advisors on February 19, 2009 and April 23, 2009, Review Office was unable to find that the worker’s right and left index finger condition was related to the work that he performed as an industrial mechanic ending in the year 2005.

The case was again considered by Review Office on July 30, 2009 based on a report received from the family physician dated June 24, 2009. Review Office noted that the family physician outlined the view that the worker’s employment as an industrial mechanic was the probable cause for the development of his right index trigger finger in 2008 given the lack of any other predisposing factors. Review Office indicated that it consulted with a medical consultant to the Review Office, who noted that trigger fingers are related to a condition known as flexor tendinopathy of the flexor tendons to the fingers, with the cause of the condition not always being known. It was the medical consultant’s opinion that given the long time delay between the worker’s last work exposure as an industrial mechanic and the onset of his right index trigger finger symptomatology, a probable association with his work duties could not be established, on a balance of probabilities. Given this opinion, Review Office indicated that its previous decision would remain unchanged. On July 30, 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. 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 worker’s position:

The worker was self represented at the hearing. His written submission to the Appeal Commission identified the following points for consideration:

  • The letter from the family physician dated June 24, 2009 supported that conditions such as trigger finger can take years to develop and become symptomatic and that the worker’s only identifiable risk factor was his years of heavy manual labour as a mechanic;
  • The worker was never examined by a WCB medical advisor;
  • There was no family history of a trigger finger condition;
  • The type of work performed by the worker throughout his life is known to cause trigger finger;
  • During the worker’s last years of work with the accident employer, the WCB accepted responsibility for 4 other trigger finger surgeries and two carpal tunnel releases;
  • The worker had undergone knee replacement surgery and this condition preoccupied his attention; his index trigger finger issues were small in comparison;
  • The anti-inflammatory/pain killer medications taken by the worker for his left knee injury are the same as those used to treat symptoms of trigger finger and may have masked the symptoms.

Analysis:

The issue before the panel is claim acceptability and whether the worker’s bilateral index trigger finger condition arose out of and in the course of his employment. In order for the appeal to be successful, the panel must find that the worker’s condition is causally related to the job duties he performed for the accident employer. On a balance of probabilities, we are not able to make that finding.

When considering the appeal, the panel was primarily concerned with the time delay in the onset of the worker’s symptoms. Although he had worked as a heavy mechanic for many years, he had not been performing that work since the late 1990’s. When he returned to work with the accident employer in March 2003, he worked at a bench which involved use of vibratory air tools. He continued to perform this work until November 2003, when he began a vocational rehabilitation program. In July 2005, his position with the employer was formally terminated.

The panel considered the evidence regarding when the index trigger finger conditions started. According to the family physician, the first mention of a trigger finger problem in the worker’s right index finger was on January 31, 2008. At the hearing, the worker could not recall when the symptoms first appeared, but surmised that it must have been some time prior to the January 31 appointment. He did not recall experiencing any symptoms in his index fingers while he was still working for the accident employer. In late 2007 and early 2008, the worker was seeing his family physician every two weeks in connection with his left knee problems. Given the frequency of his medical appointments and the worker’s familiarity with the symptoms of trigger finger (he had had 4 prior surgeries for this condition), the panel finds that the right index trigger finger condition must have manifested in or about January 2008. By the time the worker consulted with the specialist in April 2008, the left finger had also become symptomatic.

There is therefore a gap between the last performance of the air tool duties in November, 2003 and the first onset of symptoms in January, 2008. This is a delay of approximately 4 years.

There is agreement among the medical experts that activities which stress the flexor tendons of the fingers may precipitate trigger finger. There is not, however, consensus regarding time delay. Two WCB medical advisors indicate that trigger finger can be an acute response to the activity, but delayed onset cannot reasonably be related to work performed in the past on a cumulative basis. Meanwhile, the family physician’s opinion is that: “Conditions such as trigger finger can take years to develop and become symptomatic, even years after initial instigating factors.” The family physician does not directly comment on whether there could be a delay between performance of the work and the onset of symptoms, but nevertheless he appears to support a relationship between the worker’s years of heavy manual labour as a mechanic and the index trigger finger symptoms.

Given the WCB medical advisors’ familiarity with repetitive strain injuries and the lack of specific comment on delayed onset of symptoms by the family physician, the panel prefers the WCB medical advisors’ opinion that there is no probable relationship between the worker’s index trigger finger conditions and his work with the accident employer.

With respect to the worker’s argument that the medications he was taking “masked” the trigger finger symptoms in his index fingers, the panel notes the worker’s evidence that there were no real changes to his medications in 2007 and 2008, other than changes to the type of anti-inflammatories he was taking. He had been taking the same medications for his knee since he injured it in 1997. Given that there was no discontinuation or change in the medications in late 2007 or early 2008, the panel questions why the symptoms would cease to be masked in January 2008. We also note that the worker’s medications were the same when he was diagnosed with the other four trigger finger conditions, plus a left thumb triggering which was successfully treated by steroid injection in January 2006. The panel questions why these conditions would not also have been masked. We therefore do not accept the knee medications as an explanation as to why there was a delay in onset of symptoms.

For the foregoing reasons, the panel finds that the worker’s claim for trigger finger in the left and right index finger is not acceptable. 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 27th day of April, 2010

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