Decision #81/11 - Type: Workers Compensation

Preamble

The worker is appealing a decision made by Review Office of the Workers Compensation Board ("WCB") which determined that the osteoarthritic condition in her left wrist was not related to her compensable left wrist strain of October 29, 2007 nor was it enhanced or accelerated by the compensable injury. The worker disagreed with the decision and an appeal was filed with the Appeal Commission with the assistance of the Worker Advisor Office. A hearing was held on May 4, 2011 to consider the matter.

Issue

Whether or not the worker is entitled to wage loss benefits beyond October 9, 2009.

Decision

That the worker is not entitled to wage loss benefits beyond October 9, 2009.

Decision: Unanimous

Background

During the course of her employment as a dietary aide on October 29, 2007, the worker reported that she experienced pain in her left wrist when she transferred a tray of glasses filled with water to her left hand.

When speaking with a WCB adjudicator on November 8, 2007, the worker reported that she was carrying 35 glasses of water to place into the fridge. While holding the tray with her left hand she could feel the wrist pain. She was unable to complete her shift.

On October 29, 2007, the worker saw a hospital physician who reported minimal tenderness centered on the ulnar styloid with no swelling. The diagnosis rendered was a strain to the left wrist.

On November 1, 2007, the worker sought treatment from her family physician who reported pain in the ulnar aspect of the wrist, normal range of motion and swelling that was better. The diagnosis was contusion of the left wrist.

On December 4, 2007, a physiotherapist diagnosed the worker with an ulnar collateral wrist ligament sprain and flexor strain.

An MRI of the left wrist taken January 29, 2008 showed no significant ulnar variance. The TFCC, scapholunate and luno-triquetral ligaments all appeared intact. The carpal alignment was normal. An acute or healing fracture was not evident. The report stated that the ulnar and collateral ligaments were not well visualized.

On February 11, 2008, the family physician referred the worker to a sports medicine facility, noting that the worker's wrist continued to bother her despite physiotherapy, two courses of anti-inflammatories, a splint and rest.

The worker was assessed by a WCB medical advisor on February 27, 2008. The medical advisor indicated that the worker presented with ongoing evidence of ligamentous strain of the flexor carpi ulnaris and ulnar wrist. The examination was marked by maintenance of range of motion, the absence of soft tissue swelling or other signs of inflammation as well as the absence of significant findings of impingement. It was felt that the worker had ulnar nerve entrapment at the left wrist.

On March 17, 2008 Nerve Conduction Studies ("NCS") were taken and the results showed no evidence of ulnar sensory or motor nerve entrapment at the wrist. There was no evidence of a cubital tunnel syndrome or carpal tunnel syndrome on the left.

A sports medicine specialist reported on March 27, 2008 that the worker had good range of motion of the wrist with tenderness around the TFCC and distal ulnar area. There was no laxity of the collateral ligaments but there was slight movement in the radiocarpal joint on the left compared to the right. The specialist indicated that the worker had ulnar wrist pain not yet diagnosed. It appeared to be around the TFCC area. The specialist suggested that the worker be assessed by a hand specialist.

By letter dated April 28, 2008, the hand specialist reported that clinical examination showed a normal looking wrist with good range of motion in all planes. There was tenderness over the ulnar aspect of the wrist and there appeared to be some midcarpal instability. Conservative treatment was recommended.

In a follow up report dated September 19, 2008, the hand specialist reported that clinical examination still revealed tenderness on the ulnar aspect of the wrist consistent with a TFCC tear. An arthroscopic examination of the wrist was suggested and this was performed on March 26, 2009. The operative report indicated that the etiology of the wrist pain was related to degenerative changes in both the radiocarpal and mid carpal joints.

On June 30, 2009, the worker returned to her regular duties but had to stop working on July 21, 2009 due to ongoing left wrist difficulties.

On July 24, 2009, the family physician diagnosed the worker with chronic tendonopathy that worsened when she returned to work.

In a September 14, 2009 report, the hand specialist reported that the worker's wrist pain was going to be permanent and would likely get progressively worse over the years. It was opined that the worker should be permanently restricted from doing any form of heavy and/or repetitive activities with her wrist.

A WCB orthopaedic surgeon reviewed the file on September 24, 2009. In his opinion, the compensable injury diagnosis was a left wrist sprain. He noted the findings at surgery, and indicated that the mode of injury could not have caused osteoarthritis of the wrist. There was no medical evidence that the compensable injury aggravated or enhanced the degenerative joint changes at the radio-carpal joint and the mid-carpal joint.

In a decision dated October 2, 2009, the worker was informed of the WCB's position that she had recovered from the work place injury of a wrist sprain and that wage loss benefits would be paid to October 9, 2009 inclusive.

On January 27, 2010, the family physician wrote to the WCB stating that the worker's arthritis was a direct result of her injury rather than a pre-existing condition, as x-ray and MRI of the wrist showed no evidence of arthritis of the joint. She noted that the worker had a permanent problem with her wrist and it seemed unlikely that she could ever return to her former full duties. Re-training the worker was recommended.

On February 3, 2010, the WCB's orthopaedic consultant noted that arthroscopy was a more sensitive and accurate means of diagnosing degenerative changes of osteoarthritis. He noted that the family physician believed that osteoarthritis was a direct result of the injury but offered no objective medical evidence to support that opinion. He found no evidence that the compensable injury caused some injury to the joint surfaces which caused the development of osteoarthritis.

Based on the WCB's orthopaedic consultant's opinion, the worker was advised on February 10, 2010, that it was still the WCB's opinion that she had recovered from her compensable injury of a wrist strain. On March 6, 2010, the worker appealed the decision and the case was forwarded to Review Office for consideration.

On May 10, 2010, Review Office determined that the worker was not entitled to wage loss benefits beyond October 9, 2009. Review Office accepted the opinion of the WCB orthopaedic consultant outlined on September 24, 2009 and February 3, 2010. Review Office was of the opinion that there was no medical evidence to support that the worker's pre-existing condition was enhanced or accelerated by the compensable injury which was diagnosed as a sprain. It concluded that the diagnosis of a sprain, the normal MRI and NCS, the operative report that showed degenerative changes and the time that had passed did not support that there was a causal relationship between the worker's current difficulties and the compensable injury of October 29, 2007. On October 12, 2010, the Worker Advisor Office appealed Review Office's decision to the Appeal Commission and a hearing was arranged.

Reasons

Applicable legislation:

The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.

Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB. Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such a time as the worker’s loss of earning capacity resulting from the accident ends.

Worker’s position:

The worker was assisted by a worker advisor at the hearing. It was submitted that the evidence supported that the worker had not recovered from her compensable injury when the WCB ended responsibility on October 9, 2009. While Review Office accepted the WCB orthopaedic consultant's opinion that the cause of the worker's symptoms were solely from degenerative changes, it was submitted that the evidence contradicted this conclusion. The panel was asked to consider the facts that the worker's left wrist symptoms only emerged after the workplace injury, that those symptoms remained consistent and ongoing since that time, and that the worker had no symptoms on the right side, despite the fact that there was more than likely the same level of degenerative changes in the right (dominant) wrist. The medical opinions of the WCB medical advisor (dated September 19, 2009), the family physician and the hand specialist were cited as support. Overall, the worker's position was that the effect of her injury continued to be acting in combination with a pre-existing condition and contributing to her symptoms and limitation and to the current corresponding loss of earning capacity.

Employer’s position:

An advocate appeared to represent the interests of the employer at the hearing. The employer agreed with the WCB's decision to end responsibility on the claim. It was submitted that, the evidence indicated that the worker primarily sustained a sprain injury as a result of the workplace accident. The MRI and nerve conduction studies were normal and the only definitive diagnosis for the compensable injury was a sprain. The degenerative changes noted in the worker's wrist pre-existed the workplace injury and were not caused by the workplace injury itself. While the worker may have permanent physical restrictions related to her wrist, it was submitted that these were due entirely to a pre-existing degenerative condition. The employer relied on the opinion of the WCB orthopaedic consultant that the mode of injury would not have caused osteoarthritis and that there was no evidence that the pre-existing conditions were enhanced or accelerated on a permanent basis by the workplace injury.

Analysis:

In order for the worker’s appeal to be successful, the panel must find that the difficulties the worker experienced with her left wrist after October 9, 2009 are related to the injuries she sustained in the workplace accident of October 29, 2007. We are not able to make that finding. On a balance of probabilities, the panel finds that the compensable injury was limited to a sprain/strain of the left wrist which would have resolved well before October 9, 2009 and that the worker’s ongoing difficulties are attributable to degenerative changes in her wrist.

In coming to our decision, the panel relied on the following:

  • Medical reports on file show early improvement in the worker's condition after the initial injury. When the worker saw her regular family physician on November 1, 2007 (three days post accident), swelling was better and objective findings included normal range of motion and only slight pain. This would suggest that the injury was relatively minor.
  • This is consistent with the mechanism of injury which was a torque/twist motion which did not involve a great degree of force or impact to the wrist. The movement by which the worker injured herself was relatively subtle.
  • The WCB file material reflects a waxing and waning condition which improved at times, then became worse with activity. In the panel's opinion, this is more consistent with a degenerative osteoarthritic condition rather than with the progression of a strain injury.
  • There was some question as to whether the worker suffered a ligamentous or neurological injury, but investigations in this regard ruled out these differential diagnoses.
  • The operative report dated March 26, 2009 clearly identified the etiology of the wrist pain as being related to degenerative changes in both the radiocarpal and mid-carpal joints.

The panel acknowledges that there is a divergence of medical opinion on the file. We choose to rely on the opinion of the WCB orthopaedic consultant. He is a specialist in the field. The other specialist is the treating surgeon, who provided an opinion dated March 10, 2010, in which he stated that while it was difficult to prove that work activities caused the degenerative changes in the worker's wrist, it could be documented that work activities and the recent injury made the symptoms worse. He did not, however, detail how the workplace injury would have made the degenerative joint changes at the radio-carpal and mid-carpal joint worse. The panel is therefore inclined to agree with the WCB orthopaedic surgeon who noted that there was no medical evidence of aggravation or enhancement of these joint changes. He stated that there was no evidence that the workplace sprain/strain caused some injury to the joint surfaces which caused the development of osteoarthritis and we agree that there does not appear to be any such evidence.

Overall, the panel is left with an impression of a fluctuating wrist condition which is consistent with degenerative joint changes. We did not identify sufficient support in the medical evidence to be satisfied on a balance of probabilities that the worker’s degenerative joint changes were enhanced or aggravated by the sprain/strain injury. We therefore find that wage loss benefits are not payable beyond October 9, 2009. 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 22nd day of June, 2011

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