Decision #54/11 - Type: Workers Compensation

Preamble

The worker is appealing a decision made by Review Office of the Workers Compensation Board ("WCB") when it was determined that there was no clear causal relationship between his left hip condition and the compensable accident he sustained in December 1987. A hearing was held via teleconference on March 15, 2011 to consider the matter.

Issue

Whether or not the worker is entitled to further benefits in respect of his left hip.

Decision

That the worker is not entitled to further benefits in respect of his left hip.

Decision: Unanimous

Background

On December 18, 1987, the worker reported to the WCB that he injured his left elbow, knees, back, neck and hips from the following work related accident:

I was stepping out of my truck when my foot hit a piece of ice and I continued the motion and fell out of the truck landing on my left side.

On December 30, 1987, the worker sought medical treatment and the attending physician noted that the worker fell at work landing on his left side. The diagnosis was left sacral and left knee strain. On January 20, 1988, the attending physician advised a WCB adjudicator that the worker's back was getting better but he had severe knee pain. The worker was referred to an orthopaedic specialist as it was thought that he may have suffered a meniscal tear.

In a letter to the WCB dated February 11, 1988, the orthopaedic specialist indicated that the worker was seen on January 22, 1988. The worker reported that he was driving for a courier service when he fell off the truck injuring his knee, back and neck. The examination findings pertained to the worker's knee and back difficulties.

In a second report dated March 29, 1988, the orthopaedic specialist noted that the worker had surgery to his left knee on February 2, 1988 and that he was now complaining of more pain about his left hip. He stated: "On examination the patient has a click in his left hip which is probably due to a snapping tendon but certainly this is of no concern. He has no pain with this click and a click such as this is frequently found as an incidental finding and of itself does not mean he has any pathology in his hip. The patient has a good range of motion of his hip which is painless." The specialist further indicated that a bone scan was being arranged to rule out any pathology in the hip.

In a progress report dated June 24, 1988, the attending physician reported that the worker returned to light duty work on March 28, 1988 and to his full duties on May 9, 1988. The worker had no symptoms at the time and his low back, hip and leg range of motion was normal.

A regional bone scan dated May 3, 1988 noted the following findings: "…The hips are remarkable in that increased activity is seen in the lateral lip of the left acetabulum which could be related to a degenerative or post traumatic change. The rest of the study is normal."

On February 23, 1989, the worker tripped and fell while carrying boxes out of an elevator. He filed a claim with the WCB. The diagnosis rendered by the treating physician was a lumbar strain. Four days of time loss was authorized by the attending physician.

On July 25, 1994, the worker suffered work related injuries to his back, neck, hips and right arm when he fell from the back of a van. A claim was filed with the WCB and benefits were paid to the worker to February 10, 1995. In a decision by Review Office dated October 20, 1995, it was determined that the worker suffered acute musculoligamentous strain type injuries in the July 1994 fall at work. Review Office noted that the worker was now suffering from generalized and widespread muscular pain. His symptoms and ongoing contention of disability were not supported by clinical findings in relation to the compensable injury. Review Office confirmed that the worker was not entitled to benefits beyond February 10, 1995.

In January 1998, the worker had a total replacement of his left hip. On December 29, 1998, the WCB denied compensation coverage for the left hip surgery.

On December 11, 2000, a Medical Review Panel ("MRP") was convened. The report of the MRP indicates that two specialists on the MRP (a majority) felt that they could not establish a clear relationship between the requirement for surgery and the 1987 injury. One specialist on the MRP opined that there was a probable cause and effect relationship between the work injury of 1987 and the total hip replacement in January 1988 based on the history given by the worker and the bone scan report of May 3, 1988 which noted the presence of increased uptake consistent with degenerative or post-traumatic changes.

The MRP was asked to comment on whether or not the worker had a pre-existing condition affecting his left hip prior to his 1987 and/or 1994 injuries. The MRP panelists were unable to find any evidence that the worker had a pre-existing condition affecting his left hip prior to 1987. The MRP indicated there was evidence that osteoarthritis of the hip pre-existed the 1994 injury. With regard to the 1994 injury, it was agreed that an aggravation probably occurred.

On April 20, 2001, a WCB case manager wrote to the Worker Advisor Office indicating that based on the MRP's results and further consultation with the WCB's medical department, it was determined that the worker's total hip replacement surgery was not related to the 1987 work place injury. Further, while it was accepted that the 1994 injury aggravated the pre-existing condition, it was felt that the total hip replacement would not be required because of an aggravation of a pre-existing condition. Aggravations resolve in time and do not permanently worsen a prior condition.

On December 16, 2008, the Worker Advisor Office appealed the April 20, 2001 decision on the worker's behalf, contending that the July 24, 1994 workplace injury enhanced the worker's pre-existing 1987 left hip condition resulting in a total hip replacement on January 9, 1998. Included with the submission was medical information dated July 18, 2001, July 17, 2003 and September 23, 2004.

In a letter to the Worker Advisor Office dated September 22, 2009, the WCB case manager noted that the worker's 1994 and 1987 claims were reviewed in conjunction with the new medical information that had been submitted. It was felt that the reports did not contain any new information or objective evidence. The WCB therefore remained of the opinion that there was no causal relationship between the 1994 compensable injury and the left hip replacement surgery of 1998.

On January 22, 2010, a WCB case manager wrote to the worker to advise that medical information had been reviewed on all his compensation files, namely, December 18, 1987 left knee and back injuries; February 23, 1989 back and left hip injuries; December 27, 1989 low back injury; May 14, 1993 neck and low back injuries; July 25, 1994 back, neck hips and right arm injuries. Based on this review, it was the WCB's position that his left hip replacement of January 9, 1998 was the result of the natural progression of the pre-existing left hip osteoarthritis. There was no medical evidence that supported either an aggravation or enhancement of the pre-existing degenerative condition of the left hip resulting from the above injuries. It was confirmed that the WCB would not accept responsibility for the January 9, 1998 left hip replacement or any wage loss related to that surgery. On February 3, 2010, the Worker Advisor Office appealed this decision to Review Office.

On March 29, 2010, Review Office determined the following:

  • Regarding to the worker's 1989 accident when he fell on his left side when exiting an elevator, the treating physician diagnosed a lumbar strain and made no mention of a hip injury. Review Office was of the opinion that the evidence did not establish that this accident in any way contributed to the worker's long term left hip condition.

  • Regarding to the July 1994 accident when the worker reported injuring his hips, Review Office noted the MRP opinion that the accident resulted in "aggravation of pre-existing osteoarthritis of the left hip, despite the total lack of supporting information on file." Review Office indicated that it accepted this and was of the opinion that any aggravation, which by definition is time limited, resolved quickly and played no part in the worker's long term left hip problems.

Review Office had a WCB medical advisor review the worker's 1987 file on April 15, 2010. The medical advisor's comments were forwarded to the worker and his worker advisor. In its decision dated May 4, 2010, Review Office quoted the following from the April 15 report:

At this time, I will provide my medical opinion that, on a balance of probabilities, the disease process which led to the worker's January 1998 left hip arthroplasty was not causally related to his 1987 accident, or enhanced by it. There was no probable pre-accident condition to be enhanced. The worker did have probable transiet (sic) left hip joint findings which recovered from the symptomatic and objective perspective by the summer of 1998.

On May 4, 2010, Review Office determined that the worker was not entitled to further wage benefits in respect of his left hip. Review Office indicated that it had long been accepted that a compensable accident occurred in December 1987. As to whether the worker's surgery could be related to this accident, Review Office indicated that it preferred the opinions of its medical advisor and the majority of the MRP who found that there was no clear causal relationship. On May 13, 2010, the Worker Advisor Office appealed Review Office's decision to the Appeal Commission and a hearing was arranged.

Reasons

Applicable Legislation

The issue before the panel is whether the worker is entitled to further benefits in respect of his left hip. Under subsection 4(2) of The Workers Compensation Act (as it existed at the time of the accident in 1987, herein referred to as the “Act”), a worker who suffers a personal injury by accident is entitled to compensation for so long as the injury disables them.

Worker’s position:

A worker advisor appeared on behalf of the worker and the worker participated in the hearing via teleconference. It was submitted that the evidence supported a relationship between the December 18, 1987 compensable injury and the worker's 1998 total left hip replacement. It was noted that the 1987 injury was significant and the presence of any other pre-existing conditions was ruled out when the worker was examined by an MRP. The worker's treating physician, surgeon and one of the MRP panelists supported a causal relationship. Medical reports indicated early left hip symptoms including clicking and pain which are initial symptoms in the development of osteoarthritis. Finally, it was noted that the bone scans in 1988 and 1996 detected traumatic changes in the hip. It was submitted that this evidence supported, on a balance of probabilities, that the left hip replacement was related to the 1987 injury and that the worker should be entitled to further benefits in respect to his left hip.

Analysis:

In order for the worker’s appeal to be successful, the panel must find that the worker's need for left hip replacement surgery in January 1998 was related to the injuries he sustained in the workplace accident of December 18, 1987. We are not able to make that finding.

In the panel's opinion, the evidence does not satisfy us on a balance of probabilities that the 1987 injury significantly affected his left hip such that a total hip replacement was required in 1998. In coming to our decision, the panel relied on the following:

  • The mechanism of injury of slipping and falling on his left side while stepping out of his truck, while no doubt caused the worker injury, was not particularly severe;
  • The initial clinical findings were left sacral and left knee strain. There were no findings of a significant structural pathology to the hip resulting from the fall;
  • The worker was subsequently diagnosed in early 1988 as having suffered a ligamentous injury to his knee and surgery was performed. At that time, the examination findings were focused on the knee, with some report of lower back pain;
  • The orthopedic surgeon who performed the knee surgery identified a click in the worker's hip, but dismissed the click as not being an issue of concern;
  • By approximately May, 1988, the attending physician indicated the worker had basically recovered and that the problem had resolved;
  • Since May 9, 1988, the worker returned to full regular duties in his pre-accident occupation which was a physical job requiring constant mobility;
  • In February, 1989, the worker suffered a work-related fall, but the panel finds that this was only a minor injury warranting only a few days of time loss. A mild lumbar strain was the only reported finding and there was no mention of difficulties with the hip;
  • Although there are medical opinions on file supporting both positions, the majority of the MRP determined that a clear relationship could not be established. Further, the panel found that the case review and analysis performed by the WCB medical advisor on April 15, 2010 to be the most thorough and comprehensive on file, and we accept his conclusion that on a balance of probabilities, the disease process which led to the worker's January 1998 left hip arthroplasty was not causally related to his 1987 accident or enhanced by it.

For the foregoing reasons, the panel is not able to find that the worker's total left hip replacement was related to the injuries he sustained in the workplace accident of December 18, 1987. We therefore find that the worker is not entitled to further benefits in respect of his left hip. The worker's appeal is denied.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 4th day of May, 2011

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