The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing a decision made by Review Office of the Workers Compensation Board (“WCB”) which determined that her ongoing difficulties with her right knee and hip were unrelated to the compensable injuries that she sustained in 2000 and 2001. A hearing was held on June 17, 2010 to consider the matter.

Issue

Whether or not the worker’s ongoing symptoms are related to her compensable injuries of April 2000 or August 2001; and

Whether or not the worker is entitled to wage loss and medical aid benefits.

Decision

That the worker’s ongoing symptoms are not related to either her compensable injuries of April 2000 or August 2001; and

That the worker is not entitled to wage loss and medical aid benefits.

Decision: Unanimous

Background

On April 3, 2000, the worker reported that she slipped on a wet cooler floor and smashed her right knee. This happened twice within a couple of days. She also struck her knee cap on the corner of some stainless steel equipment.

Medical reports showed that the worker sought medical treatment on May 4, 2000 for pain and problems with her legs, arms and neck. When next seen on May 23, 2000, the worker reported that her knee did not ache as much. X-rays of the right knee taken May 23, 2000 showed minor osteophytes involving the inferior articular surface of the patella in keeping with minor degenerative changes. No bone or joint abnormality was seen.

A doctor’s first report showed that the worker sought medical treatment with a different physician on June 16, 2000 for pain, swelling and edema in the medial aspect of the knee. An x-ray of the right knee taken the same day showed no joint effusion, fracture, dislocation or erosions. No loose inter-articular body was demonstrated.

Due to ongoing knee difficulties, the family physician referred the worker to an orthopaedic surgeon. In his report dated July 27, 2000, the surgeon noted a positive McMurray test with positive pain on the medial meniscus. There was normal range of motion although there was severe swelling in the knee. An arthroscopic evaluation of the knee was suggested.

On August 29, 2000, an arthroscopy of the knee showed slight chondromalacia on the retropatellar surface. The medial meniscus was normal with early osteoarthritic changes of the medial articulate surface on both the femur and tibial plateau.

In a follow up report dated September 12, 2000, the surgeon noted that the worker was able to bear weight and walk on her leg and was instructed to continue with her exercise program.

On September 26, 2000, the surgeon reported that the worker felt a tearing sensation inside the knee and had pain on the anterior aspect of the knee itself. The examination revealed no effusion or discoloration and only tenderness over the anterior aspect of the inferopatellar tendon on hard palpation. The inferopatellar tendon was intact with no sign of rupture or disruption in the area. There was no infection or other complications detectable in the knee. It was noted that the worker’s current range of motion in the knee was 100% normal.

In a report to the family physician dated October 24, 2000, the orthopaedic surgeon stated:

“…The patient again fell on her knee. She has a positive McMurray’s test but she is showing signs of pain all over her knee to the extent that one tends to doubt the sincerity of her symptoms as there is pain at every area of the knee that is palpated. She has no effusion of the knee. She is able to contract the quadriceps of the knee and she is able to flex and extend her knee. On full assessment, the McMurray test is again positive for pain but negative for locking or clicking. The cruciate ligaments as well as the collaterals are intact with normal vasculature to the lower limb. My current option is to refer her for an MRI scan to exclude any possible new injuries or residual problems from the initial surgery”.

On October 11, 2000, x-rays were taken of the lumbar spine which showed severe degenerative disc disease at L4-5 with evidence of previous surgery. Bilateral hip x-rays revealed mild coxa valga deformity of the hips.

An MRI of the right knee taken November 24, 2000 revealed a proximal mid substance tear of the posterior cruciate ligament.

In a December 7, 2000 report, the treating orthopaedic surgeon referred to the recent MRI results and stated that the mechanism of injury was a direct blow anteriorly to the knee which might be associated with a posterior cruciate ligament rupture. The surgeon recommended that the worker continue with physiotherapy and that the likelihood of having posterior cruciate reconstruction was very slim and would probably not be beneficial. He felt the worker should return to partial employment.

On January 1, 2001, bone scan results revealed non-specific mild activity within the right knee consistent with mild post operative hyperemia or inflammatory changes. No superimposed fracture was identified.

A WCB orthopaedic consultant examined the worker’s knee on February 1, 2001. He stated:

"Although the claimant gave not (sic) history of other medical problems, she had x-rays of her hips and lumbosacral spine on October 10, 2000. These show degenerative disc disease at L4-5 and evidence of a previous laminectomy. I think there also may be signs of early degenerative change in the right hip. The claimant’s symptoms and physical findings are not typical of an injury to the right knee…Tears of the posterior cruciate ligament, I feel are of doubtful significance…Her complaints or rather subjective physical findings of tenderness throughout the lower thigh, knee and upper tibial region are not consistent with specific pathology or injury. Apart from the slight enlargement of the right knee, there are no positive objective physical findings. This enlargement of the right knee would also be present with degenerative changes and the history of having had a recent arthroscopy…As far as the knee is concerned, I am unable to demonstrate any objective reasons as to why the claimant could not return to work."

In a decision dated February 28, 2001, the worker was advised that wage loss benefits would only be paid to March 9, 2001 as it was determined from the recent test results and call-in examination that she had recovered from the effects of her workplace injury.

In a March 1, 2001 report, the family physician outlined the opinion that the worker was fit to return to work on a graduated basis given that MRI, CT scan, x-rays and bone scan results showed degenerative disease more than anything else.

In a report dated April 24, 2001, the treating orthopaedic surgeon noted that the worker was still complaining of a locking sensation in her knee and that no definitive diagnosis had been made. He said the worker had a posterior cruciate ligament tear without a positive Lochman and no sign of instability.

In a report dated May 3, 2001, a neurologist outlined the view that the worker’s right leg problem was not secondary to any involvement of the central or peripheral nervous system. He felt the worker’s pain syndrome was coming from local tissue damage at the level of the right knee. The general neurological exam was unremarkable.

On August 23, 2001, the worker filed a new claim with the WCB when she slipped and fell at work on August 8, 2001 and injured her right leg/knee. When seen for treatment on August 8, 2001, the physician reported subjective complaints of swelling and pain in the whole right leg from the ankle to the groin area. The worker was wearing a knee brace at the time of her fall. The diagnosis rendered was sprained muscles in the right leg.

In a progress report dated September 6, 2001, the physician noted that the worker complained of a swollen right thigh and a painful knee. There were no objective signs found and all tests failed to show any pathology.

The August 8, 2001 claim for compensation was accepted and three days of wage loss benefits were paid to the worker. On September 18, 2001, the worker was laid off from employment.

In a letter dated September 11, 2001, a WCB case manager advised the worker that after a review of further medical information from two treating physicians, she was unable to accept responsibility for any further costs associated with her 2000 claim.

A report was received from an orthopaedic specialist dated October 2, 2001. He stated that he did not have a good explanation for the worker’s right knee pain. He stated that a PCL tear can result in posterior knee pain and can result ultimately in degenerative changes often at the posterior medial corner of the knee but there did not appear to be any objective evidence of this at the present time.

The worker was assessed by a second neurologist in November 2001 for knee pain. The neurologist reported no objective evidence of acute neurologic involvement. He felt there were mild findings in the right leg which may be chronic. He said the sensory changes were not related to a nerve injury in the right leg or even at the level of the lumbosacral nerve roots due to the extensive proximal involvement. He felt that the worker’s symptoms, on a balance of probabilities, were more likely related to the musculoskeletal injury alone.

On November 25, 2001, a WCB medical advisor reviewed both of the worker’s files. He indicated that the worker had pre-existing chondromalacia, degenerative osteoarthritis affecting other parts of her body and her problems were to a great extent, pre-existing. The PCL tear and minor symptoms in the worker’s knee may be related to either of her compensable injuries but no experts involved in her case found any objective reason for the worker’s ongoing claimed disability. He stated that although the worker may have some discomfort, any ongoing disability was not due to her compensable injuries.

In a decision dated November 27, 2001, the WCB case manager advised the worker that her treating physicians were unable to detect any objective findings to support her ongoing pain and disability. The case manager noted that the worker may have a PCL tear but there was no evidence that this was the cause of her complaints. The case manager advised the worker that she could not find a relationship between the worker’s ongoing problems and the injuries of April 3, 2000 and August 8, 2001.

A right hip x-ray taken December 10, 2001 showed moderate osteoarthritis.

On February 28, 2002, a WCB case manager advised the worker that the December 10, 2001 x-ray report was considered by a WCB medical advisor and that she was unable to find a cause and effect relationship between the worker's current symptoms and her two previous accidents. On March 11, 2002, the worker appealed the decisions dated September 11, 2001, and November 27, 2001 and February 28, 2002 to Review Office.

Prior to considering the worker’s appeal, Review Office sought the medical advice of a WCB orthopaedic consultant as to the worker’s right knee difficulties and the relationship to her two work related accidents.

On August 8, 2002, the orthopaedic consultant opined that the compensable injury occurring on April 3, 2000 was a contusion and possible weight bearing rotational injury to the right knee. He indicated that the worker sustained a rotational weight bearing injury in the accident occurring on August 8, 2001. The consultant noted that the worker was wearing a protective knee brace when she was injured on August 8, 2001 and therefore it was unlikely that she sustained any significant intra-articular injury to the knee joint. The consultant also indicated that the worker had pre-existing osteoarthritis, which may have been temporarily aggravated by the April 3, 2000 work injury and that some of the worker’s right knee pain could be related to degenerative joint disease in her right hip. He stated that the possible tear of the posterior cruciate ligament reported on the MRI exam had not been shown on previous examinations and was not confirmed at the subsequent arthroscopy procedure. The consultant opined that the worker’s knee problems were due to progressive degenerative arthritis of the right knee joint and possibly the adjacent right hip joint.

In a decision dated August 16, 2002, Review Office confirmed that the worker was not entitled to wage loss benefits and medical aid after March 9, 2001. In the opinion of Review Office, the worker had recovered from the effects of her compensable injuries and her ongoing complaints are not related to either accident. Review Office noted that the worker’s degenerative arthritis that pre-existed the compensable injury of April 3, 2000 was likely temporarily aggravated and that the weight of evidence did not support that the aggravation was the cause of her ongoing claimed disability.

Further file records showed that the worker had a right knee arthroscopy on April 14, 2003. The results showed a normal knee examination.

On August 22, 2003, the worker underwent a right total hip arthroplasty.

Based on an appeal submission by the worker, Review Office referred the file to the WCB orthopaedic consultant to review the new information. The consultant outlined the view that the worker’s conditions were degenerative arthritis of the right hip and mild degenerative arthritis of the right knee. He felt that the worker’s right knee pain was probably referred pain from her arthritic hip and that her hip condition was unrelated to her compensable injuries.

On May 21, 2004, Review Office confirmed that the worker’s ongoing symptoms were not related to her compensable injuries of April 2000 or August 2001. Review Office indicated that it relied on the opinion expressed by the WCB orthopaedic consultant that the worker’s right hip complaints were not related to her compensable injuries and that a great deal of her knee problems were due to referred pain from her arthritic hip. On November 18, 2009, the worker appealed Review Office’s decisions to the Appeal Commission and an oral hearing was arranged.

Reasons

There is simply no medical evidence upon which to conclude that the worker's current problems are work-related. The panel notes that the worker has been seen by many doctors since 2000 for her right knee and hip. None of the doctors in their medical reports identify or support the position that the worker has an ongoing work related injury to her right knee or hip. Instead, the doctors point to osteoarthritis and natural degenerative aging processes as being the source of the worker's knee and hip pain.

The presence of osteoarthritis in the worker’s right knee was identified quite soon after her first workplace fall in April 2000. The surgeon who performed the arthroscopy in August 2000 described finding osteoarthritic changes in the worker’s knee. Osteoarthritis is a condition which develops over a long period of time and given the short time frame between the worker’s injury at work and the first arthroscopy, we cannot conclude that the osteoarthritis was caused by the workplace injury.

It is therefore the panel's decision that the worker’s ongoing symptoms are caused by osteoarthritis/natural degenerative aging processes and are not related to her compensable injuries of April 2000 or August 2001. As a result, we find that the worker is not entitled to any further wage loss or medical aid benefits. The worker’s 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 29th day of July, 2010