The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker has an accepted claim with the Workers Compensation Board (“WCB”) for left hand de Quervain’s and bilateral strain of both hands. On January 15, 2009, the worker was advised by primary adjudication that wage loss benefits would only be paid to January 22, 2009 as it was felt that the ongoing difficulties in his hands and arms were not related to his compensable injury. The decision was upheld by Review Office. The worker disagreed and an appeal was filed with the Appeal Commission through the Worker Advisor Office. A hearing was held on April 27, 2010 to consider the matter.

Issue

Whether or not the worker is entitled to benefits beyond January 22, 2009.

Decision

That the worker is not entitled to benefits beyond January 22, 2009.

Decision: Unanimous

Background

On May 5, 2008, the worker filed a claim with the WCB for pain, tingling and numbness to both hands, wrists and thumbs which he related to the nature of his job duties at a grain elevator.

A report received from a rheumatologist dated July 27, 2007, indicated that the worker gave a two year history of gradually increasing aching in his hands, with the left hand worse than the right. The consultant suspected that the worker had osteoarthritis of the thumb base bilaterally and believed the worker had de Quervain’s tenosynovitis of the left hand.

Left hand x-rays dated June 12, 2006 indicated minor degenerative changes in the second MP joint. No other significant abnormality was identified.

An x-ray of both hands taken July 27, 2007 revealed mild osteoarthritic changes involving the first metacarpocarpal joints bilaterally. Mild degenerative changes were also seen involving the second MCP joint on the left. No other abnormality was identified. The interphalangeal joints were unremarkable.

Nerve conduction study reports dated August 29, 2007 and April 23, 2008 reported normal median nerves bilaterally.

A report received from the family physician dated July 9, 2008 indicated that the worker first presented to his office on October 5, 2006 with complaints of sore aching hands and difficulty with hand movement. The physician provided a summary of his examination findings through to May 22, 2008. When seen on May 22, 2008, the worker was having trouble with activities of daily living such as removing pills from bottles, and doing lawn and house work. The worker also had past difficulty with his wrists dating back to the 1990’s. The worker had clinical findings consistent with tenosynovitis of the wrists, predominantly in the left which had been associated with work related duties. There were no signs of vascular changes although he had some suggestion of early Raynaud’s phenomenon.

On July 9, 2008, the worker’s claim for compensation was accepted based on the diagnosis of left hand de Quervain’s and bilateral strain of both hands.

Continuing medical reports showed that the worker was seen on July 24, 2008 for subjective complaints of decreased pain in his hands with rest but an increase of pain and numbness with use. On September 2, 2008, the treating physiotherapist reported that the worker continued to report weakness and poor fine motor skills in his hands.

On November 3, 2008, a WCB medical advisor examined the worker’s wrists, hands and elbows. He noted that the worker was known to have degenerative disease, particularly at the metacarpophalangeal joints bilaterally, presumably related to the degenerative effects of the trapezium. The worker had complaints related to the radial side of both hands in terms of cold sensation and a reduction in strength. The medical advisor felt it was possible that a vascular effect was causing the problems in the worker’s fingers. He stated that one could not overlook the degenerative processes at the trapezial bones bilaterally. There was no evidence of Raynaud’s phenomenon, as per history, nor in relationship to the observations of the rheumatologist and the family practitioner.

A WCB internal medicine consultant reviewed the examination notes of November 3, 2008. It was his opinion that vascular laboratory studies would not help with a diagnosis. He stated: “The history does not suggest Raynaud’s phenomenon or compromised blood flow to the fingers. The list of medication suggests he may have hypertension. Use of Lasix continuously may lead to hypokalemia and may contribute to muscle problem.”

On December 11, 2008, the WCB medical advisor who saw the worker in November 2008 reviewed the opinion expressed by the WCB internal medicine consultant. Based on the consultant’s opinion, the medical advisor felt that the worker’s complaints were due to degenerative findings of his hands which were not work related.

The worker was seen by his family physician on December 4, 2008 with reports of pain into his elbows and numbness of his hands.

On January 14, 2009, the WCB medical advisor opined that there was no evidence to support aggravation or enhancement of the worker’s degenerative process of his hands.

On January 15, 2009, the worker was advised that wage loss benefits would be paid to January 22, 2009 as it was the WCB’s position that his ongoing problems were unrelated to his compensable injury of June 15, 2006. The decision was based mainly on the opinions expressed by the WCB’s medical advisor and internal medicine consultant. On February 1, 2009, the worker appealed the decision arguing that the condition in his hands and wrists were work related.

Prior to considering the worker’s appeal, Review Office arranged for a WCB rehabilitation specialist to visit the work site to determine the hand/arm mechanics of a labourer/malt loading operator. The rehabilitation specialist’s findings are contained in a report dated April 29, 2009.

Review Office also asked a WCB medical consultant to review the file and provide a medical opinion as to the diagnosis of the worker’s condition and whether the diagnosis was caused, aggravated or enhanced by the hand/arm mechanics described in the April 29, 2009 report.

On May 12, 2009, the medical consultant to Review Office stated that the two most probable diagnoses to describe the worker’s hand and wrist difficulties were carpometacarpal arthrosis and de Quervain’s tendinosis/tenosynovitis. He felt that the arm mechanics required in the worker’s occupation would have caused a temporary symptomatic worsening of his underlying condition. He was of the opinion that the two diagnoses were more probably degenerative conditions which were common in the human experience. He did not believe that the workplace mechanics could be considered the probable cause of the degenerative conditions but were of significant magnitude to render the underlying degenerative conditions symptomatic.

On May 14, 2009, Review Office determined that the worker was not entitled to benefits beyond January 22, 2009 as it felt that his ongoing and increasing bilateral hand difficulties were not work related. In making its decision, Review Office relied on the opinion expressed by the WCB medical advisor who examined the worker on December 11, 2008 and the opinion expressed by the WCB medical consultant on May 12, 2009. It also considered the evidence provided by the worker that the symptoms in his hands became worse after being off work as of April 3, 2008 which suggested to Review Office that his condition was not work related. On August 27, 2009, the worker appealed Review Office’s decision to the Appeal Commission and a hearing was arranged.

In February 2010, the Worker Advisor Office submitted a report by the family physician dated January 26, 2010 for the appeal panel’s consideration.

Following the hearing held on April 27, 2010, the panel requested a copy of the worker’s claim file with Great West Life. A copy of the claim was later received and was forwarded to the interested parties for comment. On July 14, 2010, the panel met further to discuss the case and render its final decision.

Reasons

The worker advisor has submitted that the work duties have played a factor in making the worker's tenosynovitis condition chronic. The panel's understanding, however, is that with de Quervain's tenosynovitis, avoidance and cessation of aggravating activities should result in an improvement in the condition. This is contrary to the worker's experience where the overall condition of his hands has not improved, and in fact has worsened to the point where his hands will flare up even when doing basic activities of daily living.

A troubling point for the panel is the negative Finkelstein tests observed at the call-in examination in November 2008. This does not accord with the worker's position that he had progressively worsening de Quervain's tenosynovitis. It is more consistent with an improved condition after removal from the workplace in April 2008. We therefore have some doubts as to whether or not de Quervain's is the predominant diagnosis or cause of the worker's disablement.

After reviewing the evidence as a whole, the panel is not satisfied on a balance of probabilities that the worker's continuing disabling condition beyond January 22, 2009 is attributable to his job duties. A definitive diagnosis has not been identified, but to the extent that de Quervain's tenosynovitis is responsible for his disability, the panel does not accept that the work duties caused the de Quervain's. If the de Quervain's was caused by work duties, the condition would have improved after the worker ceased working in April 2008. As the condition did not improve, and in fact worsened, we do not accept that work was the cause.

The panel does accept that while he was still working, the worker's job duties caused a temporary worsening of his symptomatology. This was the opinion expressed by the WCB medical advisor to Review Office and we agree with this opinion. That being said, the worker was provided with approximately nine months of WCB benefits from April 2008 to January 2009. In the panel's opinion, the worker has already received wage loss benefits and medical aid to compensate him for any temporary worsening caused by his work duties.

Overall, the panel finds on a balance of probabilities that the worker's ongoing medical difficulties are not causally connected to his employment and that the worker's loss of earning capacity beyond January 22, 2009 is not compensable. The worker is therefore not entitled to further WCB benefits. The appeal is denied.

Panel Members

L. Choy, Presiding Officer
M. Bencharski, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 28th day of July, 2010