The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing two decisions that were made by Review Office of the Workers Compensation Board ("WCB") in regard to her claim for a right wrist injury occurring on August 5, 2008 and for a right shoulder injury that occurred on July 26, 2008. Review Office determined that the worker was not entitled to benefits after July 15, 2009 for her right wrist condition as it was felt that the worker had recovered from her compensable injury. Review Office also confirmed that the worker's claim for a right shoulder injury was not acceptable as it was unable to establish a relationship between the worker's job duties and her shoulder complaints. A hearing was held on December 15, 2010 to consider these matters.

Issue

Claim for injury occurring August 5, 2008:

Whether or not the worker is entitled to WCB benefits beyond July 15, 2009.

Claim for injury occurring July 26, 2008:

Whether or not the claim is acceptable.

Decision

Claim for injury occurring August 5, 2008:

That the worker is not entitled to WCB benefits beyond July 15, 2009.

Claim for injury occurring July 26, 2008:

That the claim is not acceptable.

Decision: Unanimous

Background

Claim for injury occurring August 5, 2008:

On August 14, 2008, the worker filed a claim with the WCB for right wrist difficulties that she attributed to the nature of her job duties as a frame assembler. The worker reported that she felt a lump on her right wrist near the thumb on August 5, 2008. She then began to lose sensation in her hand, and when she grabbed a hammer it would drop out of her hand. The worker indicated that she first noticed symptoms around July 30, 2008.

A doctor's first report showed that the worker attended for treatment on August 7, 2008 with an accident description of "lifting heavy object." Objective findings were joint stiffness, swelling, restricted range of motion, no polyarthralgia, no polymyalgia and no neck pain. There was no history of trauma or joint pain right wrist. The diagnosis was right wrist tendonitis.

When seen at a follow up appointment on August 11, 2008, the right wrist and hand examination showed no redness, it was not swollen and was not warm. There was tenderness, no lacerations, no abrasions, no fracture, no effusion and good range of motion.

On August 18, 2008, the treating physiotherapist diagnosed the worker with a right wrist extensor tendonitis and de Quervain's tenosynovitis.

On September 25, 2008, a second physician advised the WCB that the worker still had pain in her right shoulder and had right wrist pain. Objective evidence was tenderness in the radial aspect of the right wrist, with swelling at the anterolateral aspect. There was positive impingement sign left shoulder, tender acromial process area, and good range of motion at the shoulder. The physician noted continuing signs of tendonitis and overuse syndrome right wrist and right shoulder.

The file contains an MRI report of the right shoulder taken October 29, 2008.

On October 30, 2008, the attending doctor outlined his examination findings of the wrist. His impression was "Extensor tendon overuse syndrome ? Neuropathic component ? Ganglion radial aspect right wrist."

On November 13, 2008, the attending doctor noted that the worker could not supinate her right wrist due to pain and was unable to do activities like peeling vegetables. Pronation was not as painful. There was tenderness in the right acromion process of the right shoulder, pain with abduction of the right thumb versus resistance and tenderness in the central dorsum of the right wrist.

On December 10, 2008, the worker told a WCB case management representative that all four of her fingers were numb but more so her pointer finger.

On December 23, 2008, the attending doctor's impression of the worker's status was "Continuing sx (symptoms) from overuse/sprain tendonitis, possible ganglion of left wrist volar surface."

The worker underwent nerve conduction studies on January 7, 2009. The report indicated mild slowing in the right median motor and sensory conductions across the wrist consistent with right carpal tunnel syndrome ("CTS"). There was no evidence from this test of an additional right cervical radiculopathy or brachial plexopathy.

On January 16, 2009, the WCB advised the worker that no responsibility could be accepted for her right shoulder condition. It was stated to the worker that the August 5, 2008 claim was for right wrist pain only and there was no mention of right shoulder problems in the Worker's Report of Injury. The work duties outlined in her report would not tend to stress the shoulder, only the wrist. It was noted that when the worker was initially examined by a physician, physiotherapist and a chiropractor, there was no reported shoulder symptoms or findings. The case manager noted that the MRI of the shoulder reported significant degenerative changes to the right shoulder and that a WCB medical advisor opined (on January 2, 2009) that the extensive degenerative changes in the right shoulder would not be related to the claim.

An MRI of the right thumb dated February 2, 2009 revealed findings of "Mild degenerative changes about the carpal and metacarpal articular of the thumb. There were no findings to suggest tenosynovitis was present in the study."

On February 19, 2009, the attending doctor reported objective findings of grip strength 4-5/5, mild resting tremor, sensation normal, tender on center dorsum of wrist and slight swelling on the dorsum of wrist (new).

In a report dated March 16, 2009, an orthopaedic specialist indicated that he was going to look at an x-ray of the shoulder and then would discuss further intervention such as a repeat right CTS release and further non-surgical treatment for the shoulder before going for any surgery.

On April 15, 2009, a WCB medical advisor reviewed the file and expressed the following opinions:

• the compensable diagnosis was tendonopathy of the right wrist.

• initially the worker's symptoms appeared to be related to an overuse type injury from work. Given her period of rest, the radiographic findings of the wrist MRI, and the very mild findings on NCS, no particular mechanism of injury or patho-anatomic lesion can explain her symptoms. He noted that the worker remained symptomatic since the work place injury and had not been able to progress in her rehabilitation.

• the degree of wrist osteoarthritis (OA) was mild at best and there was no evidence of aggravation or enhancement.

• it was unlikely that the wrist OA had a significant impact on recovery. He noted that the worker had right CTS surgery and more information should be obtained about this in order to determine its effects on recovery.

• there were no changes to the worker's restrictions that were identified in January 2009.

• due to the non specific pain complaints, time frame for recovery could not be determined.

• A hand program was recommended for the worker as well as education on hurt vs harm.

On April 23, 2009, a WCB physiotherapy consultant (specializing in hands) arranged for the worker to undergo a standard course of physiotherapy involving an active progressive resisted strength program and education regarding the hurt versus harm principle with return to full duties as the goal of treatment.

In a report dated April 30, 2009, the orthopaedic specialist reported that the nerve conduction studies ("NCS") showed a right CTS with no evidence of nerve root compression up in the neck or in the brachial plexus. It was felt that the worker's right hand symptoms are likely from her carpal tunnel. The plan was to perform a right carpal tunnel release with neurolysis of the median nerve.

In a letter dated May 11, 2009, the worker was advised of the WCB's position that at the conclusion of her physiotherapy program, it was anticipated that she would be recovered from the effects of her compensable injury. The worker's entitlement to wage loss and medical aid benefits would end on the last day of treatment unless new medical information was received indicating that she had not recovered.

On May 19, 2009, the treating physiotherapist advised the WCB physiotherapy advisor that it would be difficult to treat the wrist in isolation from the shoulder. She said the worker was informed by the orthopaedic specialist that she required right CTS surgery.

In a May 22, 2009 report, the orthopaedic specialist stated that the worker complained of fairly significant right shoulder pain with the onset from lifting lumber. His physical examination suggested cuff tendonitis and tendinosis with basic intrasubstance tearing. The plan was to perform a right shoulder arthroscopy, arthroscopic acromioplasty and neurolysis of the median nerve and a carpal tunnel release of the right hand.

On May 27, 2009, a WCB medical advisor advised primary adjudication that the most likely diagnosis with respect to this claim was a wrist strain. He noted that the NCS from January did show mild median nerve slowing. The initial presentation, symptoms and most recent exam by the orthopaedic specialist, however, were not consistent with CTS. He said it was premature to approve surgery at this time. If approval was to be considered, consideration should be given to the worker's previous CTS surgery and whether the NCS findings were related to her previous surgery.

In a letter dated May 27, 2009, the worker was advised that the WCB was unable to cover treatment related to her right shoulder as the right shoulder was not directly related to her claim for an accident which occurred on August 5, 2008. Wage loss benefits would only be paid for the duration of her physiotherapy program for her right wrist which was scheduled to end on July 15, 2009. On July 8, 2009, the worker appealed the decision to Review Office.

The worker underwent right shoulder subacromial decompression and right wrist median nerve neurolysis on August 4, 2009.

On August 27, 2009, Review Office received additional medical reports for consideration from the treating physician.

Prior to considering the worker's appeal, Review Office asked a WCB orthopaedic consultant to review the worker's claim file and to answer specific questions. Review Office noted in its memorandum to the medical advisor of the following:

"…On May 15, 2009, the treating doctor provided new diagnoses of tendonitis in the right shoulder, wrist and hand. The doctor attributes all these problems to the job as described by the worker (hand sanding and lifting heavy pieces), however, the worker has acknowledged to the WCB that she has not done any significant sanding since early 2007, and the employer denies that there are any heavy aspects to the job, or that there are any real overhead activities, in particular overhead reaching.

On August 4, 2009 the worker underwent surgery to the right wrist and shoulder.

Of note, the worker has an extremely high BMI (somewhere between 41 and 51); there are several doctors' reports noting activities outside of work, including dough and perogy-making. The WCB has not accepted responsibility for the shoulder condition. There have been multiple diagnoses offered and the worker is attributing all of these to the compensation injury…"

In a response dated August 27, 2009, the WCB orthopaedic consultant stated the following to Review Office:

· the probable diagnosis to have occurred from the August 5, 2008 injury was a sprain of the right wrist. There was a probable relationship between the work activities and the sprain of the wrist.

· the later reports diagnosed the worker with a ganglion of the right wrist, nerve compression at the wrist and of a progressive problem in the shoulder. There was no medical evidence that these diagnoses are related to the compensable injury.

· it is probable that the worker has now recovered from the effects of her compensable injury.

· there is no medical evidence to support that the work activities aggravated or enhanced the diagnoses of ganglion of the right wrist, DDD of the right shoulder or nerve compression in the right upper limb.

· there is no medical evidence that the two surgeries which were done on August 4, 2009 were related to the compensable injury.

On September 3, 2009, Review Office determined there was no entitlement to WCB benefits beyond July 15, 2009. Review Office made its decision based on the following factors:

· after reviewing the worker's job demands, while it may have resulted in some temporary hand symptoms, the information did not support that the work was such that it would have resulted in continued symptoms for an extended period of time once the aggravating factors were removed. The physiotherapist reported that there were progessive improvements in the wrist. The WCB orthopedic specialist's opinion was that the compensable injury had resolved.

· with respect to the worker's shoulder complaints, Review Office noted that the worker did not mention shoulder problems to the WCB until several months after September 25, 2008, when the doctor noted right shoulder pain. It accepted the opinion expressed by the WCB orthopaedic consultant and of a WCB medical advisor that there was extensive degeneration in the shoulder and no evidence of a work related diagnosis or that work activities affected the pre-existing condition. It was felt that the medical information with respect to any work related association with wrist and shoulder problems were based in part on the worker's description of her work activities (hand sanding and lifting heavy pieces). This information was inconsistent with other information which indicated that there was minimal sanding and that she did not perform heavy lifting.

· the information did not establish a relationship between the worker's current right upper extremity problems and the compensable injury.

On April 16, 2010, a worker advisor acting on the worker's behalf appealed Review Office's decision to the Appeal Commission on the grounds that the worker's wrist difficulties were causally related to her employment duties and persisted beyond July 15, 2009. He felt that the evidence also supported that the worker's pre-existing CTS was enhanced as a result of her employment demands.

Claim for injury occurring July 26, 2008

On June 9, 2009, the worker filed a claim with the WCB for a right shoulder injury that occurred on July 26, 2008. The worker provided a description of her job activities as a frame assembler. She reported that she first noticed shoulder pain in June of 2008 when building jigs at her work station. The worker said it was a sharp pain and sometimes when she would lift up a jig it was like someone was poking a needle into her right shoulder. She would feel the sharp pain in the morning and towards the evening her right shoulder was too sore to lift her right arm. It was a dull constant ache. The shop had closed down for a two week break and when she returned to work it was busy and this was when she noticed that she was favoring her right shoulder. She started using her right wrist more but then her right wrist gave out.

The worker indicated that she reported to her supervisor that her right shoulder was bothering her and that she was not able to lift the jigs anymore. The supervisor advised that if she needed to change the jigs to call another worker to help her. Sometimes the supervisor himself would change them for her.

On June 26, 2009, a WCB adjudicator spoke with the owner of the accident employer. He stated that the worker's supervisor had no record of the report and that the worker did not report a shoulder injury to him.

On July 29, 2009, the worker told the WCB adjudicator that she attributed her shoulder difficulties to the work she did with furniture jigs and frames in 2008. She first felt symptoms while working with jigs at work. The adjudicator wrote:

"The jigs sit on the floor and sometimes have to be flipped or lifted onto a table or easel. There are a number of sizes. The worker was most concerned about the heavy jigs. The heavy jigs are approximately 4 x 6', and weigh 40 to 50 pounds, and are constructed out of ¾" pressboard.

I asked the worker how she has to 'flip' the jigs. She said that one side was a 7 drawer dresser and the opposite side was set up for a 9 drawer and that the jig must be turned depending on which unit is to be built. She has not been turning jigs by herself since the beginning of 2008. She said that [a co-worker] and [a co-worker] helped her change jigs.

When she has to lift jigs from the floor she places then on a table above her waist. When this became difficult her employer made up a jig that she could put on an easel which required less lifting as it was lower to the ground. She said that by July 2008 she could not even put her jigs on the easel. She said she could only handle small jigs like the ones for nightstands.

She also works with dresser frames. She is 5'6" and reports that some frames are taller than her. She estimates they are 4' x 8'.

Her job duties related to the frames involve reaching, hammering, puttying, and stapling. She also says she does some sanding.

...the worker said she is required to reach over her head to fire staples into the tops of the tall frames. She has a platform to stand on to reduce the span she is required to reach. She estimates there are between 38 and 42 staples in the frame total, about 20 of them would require her to reach to the top of the frame. She works with an air stapler, which she says is light and estimates it weighs 2 pounds. She said she used to have an old, heavy staple gun which was replaced in December 2007. She said she started complaining about her wrist at that time and the gun was replaced as a result."

The worker indicated that her supervisor knew she was having problems and he assisted her with lifting while she was working in the summer of 2008. The worker stated that she did not report the shoulder injury when she started having problems in July of 2008 and did not mention her problems to her employer until after seeing her doctor in September of 2008. He told her that it was work related at that time. She said her symptoms were present in July but she did not realize the connection and stated that it took a medical opinion for her to realize her problems were work related. The worker indicated that she has not made perogies by herself since 2008. She can't roll the dough or mix it because of her wrist trouble. Someone else made the dough, then she stuffs the perogies and pinches them closed. She noted that household chores like vacuuming and sweeping irritate her shoulder.

The WCB adjudicator called the worker's supervisor on July 29, 2009. The supervisor said he was well aware the worker had a problem with her wrist but that she never mentioned having any shoulder problems at any time prior to going off work for her wrist.

On August 11, 2009, primary adjudication advised the worker that her claim for her right shoulder was not compensable. The case manager indicated that the worker's supervisor and the owner of the accident employer maintained that they were not aware of her having shoulder problems at any time. They were only aware of her wrist trouble and they indicated that her wrist was the reason she was receiving assistance at work. The adjudicator indicated that a WCB medical advisor opined that the worker's ongoing shoulder trouble was most likely due to extensive degeneration indicated in MRI results.

The case manager indicated that as the worker did not report shoulder trouble despite having the opportunity to do so when notifying her employer about her wrist, the inconsistency of the degenerative findings with the described mechanism of injury and the persistence and increase of symptoms experienced while off work, it could not be reasonably concluded that a relationship existed between the job duties and her shoulder difficulties.

On January 29, 2010, a worker advisor requested Review office to reconsider the adjudicator's decision to deny her claim for benefits related to her right shoulder condition. The position taken by the worker advisor was that the new report from the treating orthopaedic specialist (January 19, 2010), along with the worker's own description of her work duties and other information on her WCB claim, supported that the worker's shoulder injury arose out of and in the course of her employment.

On January 19, 2010, the orthopaedic specialist stated in part, "…There is certainly a direct relationship between [the worker's] employment duties and the right rotator cuff tendonitis. The onset of pain was preceded by working doing a lot of sanding and lifting of lumbar (sic), which caused the rotator cuff tendonitis."

On March 29, 2010, Review Office determined that the worker's claim was not acceptable. Review Office indicated that the January 19, 2010 opinion by the orthopaedic specialist was based in part on the worker's description of her job duties. Review Office found that the description provided to the specialist was not accurate. Review Office indicated that the worker did not do a lot of sanding or heavy lifting and was of the opinion that the worker's job duties did not involve prolonged overhead work.

Review Office stated that it accepted the following opinion expressed by a WCB medical advisor on January 2, 2009:

There really is considerable degeneration of this shoulder which could account for the difficulties she's having. Unless there was a serious injury to this shoulder in the past or a long history of prolonged overhead work, the degeneration would not be work related.

Review Office also accepted the WCB orthopaedic consultant's opinion that was outlined on August 27, 2009:

There is no medical evidence that work activities aggravated or enhanced the diagnoses of …degenerative joint disease of the right shoulder…There is no medical evidence that the two surgeries of August 4, 2009, are related to the CI (compensable right wrist injury).

Review Office concluded that there was insufficient evidence to support a causal relationship between the worker's right shoulder difficulties and the work place activities. It also found insufficient evidence to support that the worker's job duties aggravated the worker's pre-existing condition. On April 16, 2010, the worker advisor appealed Review Office's decision and a hearing was requested.

Reasons

The first difficulty with this claim relates to the delay in reporting any right shoulder problems, despite the fact that the worker had been in extensive contact with medical providers and the WCB in the context of her claim for her right wrist tendonopathy. The explanation provided by the worker at the hearing was that there were no shoulder symptoms reported when she first saw the general practitioner on August 7, 2008 because her regular doctor was on holidays and this general practitioner was just filling in. He filled out her WCB forms for the wrist injury only and told her to discuss the shoulder when her regular doctor returned. The difficulty the panel has with this assertion is that the worker also saw a physiotherapist, a chiropractor and spoke with a WCB adjudicator, as previously outlined. All of those discussions centered on her right wrist tendonopathy and made no mention of shoulder difficulties. The panel has difficulty accepting that a significant shoulder problem existed given that no report of pain or restriction was given to any of the treatment providers she was meeting with at the time.

Another difficulty the panel has with acceptance of the right shoulder claim was the nature of the work being performed by the worker. At the hearing, the worker's evidence was that she was responsible for building furniture frames and doors. This involved attaching the parts using a jig, then gluing and nailing the joints together. The frame would then be assembled to the furniture using an air staple gun. Some, but not all, of the stapling had to be done overhead. The worker may also have to apply putty and sand the product as necessary.

In the panel's opinion, the worker's testimony regarding her job duties may involve extreme flexion of the hands while stapling which would tend to put strain on the worker's wrist, but would not load the shoulder in the same manner. The panel did not view the worker's duties as causing undue strain on her shoulders. Although her job entailed some overhead work, there was very little weight or force involved with the overhead movements. In her submission, the worker referred to difficulties with changing jigs, but this was not done repetitively throughout the day, such as to cause injury to the shoulder.

The panel agrees with and accepts the assessment of the WCB medical advisor that the worker's right shoulder problems are most likely attributable to extensive degeneration which would not be related to her workplace duties. It therefore follows that her claim is not acceptable. The worker's appeal on the second issue 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 10th day of February, 2011