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 there was no relationship between her arm complaints and the accident she sustained in September 2008. A hearing was held on April 13, 2011 to consider the matter.

Issue

Whether or not responsibility should be accepted for the worker's healthcare treatment.

Decision

That responsibility should be accepted for the worker's healthcare treatment.

Decision: Unanimous

Background

On April 2, 2009, the worker filed a claim with the WCB for a left forearm/hand injury that she related to the following work related activity that occurred on September 24, 2008:

I was in the kindergarten class and taking a Rubbermaid container that had blocks in it. I went to put the lid on. My fingers were under the lip. My finger got caught under it and I had a shooting pain from that finger to my elbow. Then, I couldn't close my hand. I started rubbing my arm. I had excruciating pain and the zinger wouldn't stop. I guess the way my finger had twisted underneath the lid. It was really sore all day long.

On May 5, 2009, the worker advised a WCB adjudicator that the tote she lifted on September 24, 2008 was about 18 inches long by 10 inches wide by 9 inches deep. Her left middle and ring fingers got caught under the lip. She felt immediate shooting pain up to her elbow and called them "zingers". The worker reported the incident to her employer and continued to perform all of her regular duties as she was right hand dominant. After a few weeks when the "zingers" continued to bother her, she decided to seek medical treatment.

In a doctor's first report dated April 9, 2009, it was reported that the worker sought medical treatment in November 2008 and described the incident that occurred at work on September 24, 2008. After examining the worker's hand and forearm, the treating physician diagnosed the following conditions: "Query left CTS" and median neuropathy and ulnar neuropathy.

Nerve conduction studies taken December 9, 2008 revealed the following findings:

Normal study. The clinical presentation does suggest a recent left ulnar neuropathy possibly superimposed on bilateral carpal tunnel syndrome, but the electrodiagnostic examination did not identify any abnormalities. It is possible that symptoms are arising from the left ulnar nerve without any physiologic impairment. This examination also noted that the right median function was normal and that the electrodiagnostic criteria for CTS were not met.

On December 22, 2008, the treating physician reported that the worker's symptoms had not changed and she continued to wear bilateral wrist braces.

A chiropractor's first report showed that the worker was assessed on April 22, 2009. The chiropractor noted, "Lt forearm problems since lifting tupperwear container in October 2008. Numbness in hand present, varies in duration/pattern. Agg with lifting/pressure on forearm. Pain will radiate from elbow to hand. At work, can aggravate." The chiropractor's examination findings were noted as full range of motion in the left elbow. Resisted flexion caused pain at the medial elbow, resisted extension tender laterally. There was tenderness over the flexor carpi ulnaris/ulnar nerve. The diagnosis outlined was left medial tendinosis with ulnar nerve irritation.

On April 28, 2009, the worker underwent further nerve conduction studies and the results were read as follows:

Nerve conduction study of the left ulnar nerve is normal across the wrist and elbow. Left median motor distal latency is within normal limits but distal latency of left median sensory responses are mildly delayed which suggests left median neuropathy at or distal to the wrist (e.g. CTS).

A WCB chiropractic consultant was asked to review the file and comment on whether the active release treatment ("ART") which the worker was receiving from her chiropractor was related to the compensable injury. On May 28, 2009, the consultant stated that there appeared to be a myofascial involvement of the left forearm muscles and was of the opinion that the ART was appropriate.

On May 29, 2009, the worker sought treatment from a second physician who reported objective findings of tenderness over the ulnar groove. The diagnosis outlined was left ulnar neuropathy and left CTS.

In a report dated June 11, 2009, the first treating physician reported that the worker had chronic left median and ulnar neuropathy, median neuropathy less symptomatic currently and ulnar neuropathy persisted.

On July 6, 2009, a WCB medical consultant reviewed the file and stated that the diagnosis appeared to be CTS and possible ulnar neuropathy and both conditions appeared to be of mild severity. He noted that CTS may be caused by repetitive forceful movements at the wrist. Ulnar neuropathy may be caused by local trauma or may be related to other conditions including rheumatoid arthritis and other general medical conditions. He stated that neither diagnoses would be compatible with the mechanism of injury, i.e. catching a finger under a rubber maid container lid.

On July 13, 2009, primary adjudication advised the worker that it was unable to accept responsibility for her left arm complaints. Based on the WCB medical opinion outlined on July 6, 2009, primary adjudication determined that that there was no direct relationship between the diagnoses of CTS or ulnar neuropathy and the mechanism of injury described by the worker. On August 11, 2009, the worker appealed this decision to Review Office.

On October 15, 2009, Review Office confirmed that responsibility should not be accepted for the worker's healthcare treatment. Review Office was of the opinion that there was no relationship between the worker's left upper extremity complaints for which she started to seek treatment in November 2008 and her September 2008 accident. Review Office placed weight on the history provided by the treating physician in his report of April 9, 2009, the medical advisor's opinion of July 6, 2009, the various diagnoses noted and the mechanism of injury.

On February 23, 2010, the Worker Advisor Office submitted a report from the worker's treating chiropractor dated February 15, 2010 for Review Office's consideration. The chiropractor stated the following:

1. The worker was given the diagnosis of a left medial tendinosis with ulnar nerve irritation. At examination on April 22, 2009 [the worker] had medial elbow pain with resisted flexion and tenderness of the ulnar nerve to palpation at the flexor carpi ulnaris. These are consistent with a medial flexor muscle/tendon irritation.
2. On September 24, 2008, [the worker] was lifting a container using her finger tips on the lip of the lid. This would require her flexor digitorum superficialis and profundus to contract. While these muscles were activated the container dropped and her ring and middle finger were caught on the container. The force of the container on the fingers could cause strain on the tendons and muscles. This could cause injury to the tendons and the muscles at the common flexor origin. [The worker] would initially have inflammation over the flexor muscles/tendons which could eventually lead to scar tissue formation (if not healed quickly). The diagnosis would then be a left medial tendinosis.
3. The treatment that I provided consisted of ART and gua Sha. These treatments are used to address scar tissue formation in muscles, tendons and the nerves that may be trapped in the scar tissue. The treatments, along with her home exercises, have helped [the worker] improve to about 80% of her pre-injury status. She has had mild to moderate flare-ups when she overuses her flexor muscles.

Review Office sought medical advice from a WCB medical consultant. On April 5, 2010, the consultant stated:

"The writer clarified the proposed diagnosis with [the treating chiropractor], which is left medial epicondylosis.

Impression:

The proposed diagnosis of a left medial tendinosis (left medial epicondylosis) and left ulnar nerve irritation is not likely related to the October 6, 2008, removal of a rubber maid lid. On this matter the following is noted:

· All tendons that flex the wrist and fingers attach to the medial epicondyle of the humerus (common flexor region). Every bending (flexion) movement of the wrist and fingers causes some degree of pulling on the common flexor region. Similarly, the described MOI would have imparted some degree of pulling on the common flexor region.

· The magnitude of the force generated by the described MOI would not likely have been of sufficient force to cause a material injury of the common flexor tendon.

· On February 15, 2010, the treating chiropractor suggested that the October 6, 2008, injury could have lead to inflammation and subsequent scar tissue formation. This is considered speculative rather than probable in light of the reported mechanism of injury. Additionally, a review of the medical reports from various practitioners over the course of the file does not reveal clinical features suggestive of inflammation, such as heat, redness or swelling."

On April 12, 2010, Review Office accepted the medical advisor's opinion outlined on April 5, 2010 and confirmed its previous decision that responsibility should not be accepted for the worker's healthcare treatment beginning in November 2008.

On June 7, 2010, the worker advisor provided Review Office with a December 13, 2009 note from the worker which provided more details of the mechanism of injury. The worker advisor advanced the position that the chiropractor's opinion outweighed that of the WCB medical advisor which was based on the wrong mechanism of injury.

In a letter to the worker dated July 20, 2010, Review Office stated that the new information provided on June 7, 2010 was reviewed with the WCB medical advisor and there would be no changed to the previous Review Office decision. On August 11, 2010, the worker advisor appealed Review Office's decision to the Appeal Commission and a hearing was arranged.

Reasons

The worker provided a detailed description of the accident as well as the symptoms she first noticed and how those symptoms progressed and eventually resolved.

Analysis

For the worker's appeal to be successful we must find that the worker required additional healthcare treatments. We found that the worker is entitled to additional healthcare treatment, specifically we find that the worker required ART treatments up to September 23, 2009.

In determining this appeal we note that the worker's claim for injury was accepted and that healthcare benefits were paid up to July 13, 2009 including 8 active release treatments that had already been authorized. We have determined that the WCB is responsible for benefits up to September 23, 2009. At the hearing we obtained a more comprehensive description of the accident and resulting symptoms than was available to the WCB and Review Office.

We note that the June 11, 2009 report of the treating physician indicates that there was less symptoms related to the median neuropathy but the worker's ulnar neuropathy persists and further notes that the worker will continue with a few more sessions.

The panel has determined that the worker is entitled to medical aid for healthcare treatments to September 23, 2009. We base this on our assessment that the accident resulted in an irritation of the ulnar nerve which caused a persistent numbness that took time to fully resolve. We note that the June 24, 2009 report of the treating chiropractor indicates that the worker continues to be treated for her ulnar nerve condition. The September 23, 2009 report from the chiropractor notes an 80% improvement was reported and makes no mention of symptoms or treatment directed at the ulnar nerve. We find that by this date the worker had recovered from the ulnar nerve irritation.

The worker's appeal is allowed.

Panel Members

A. Scramstad, Presiding Officer
C. Devlin, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer

Signed at Winnipeg this 9th day of June, 2011