Decision #88/11 - Type: Workers Compensation

Preamble

The worker has an accepted claim with the Workers Compensation Board ("WCB") based on the diagnosis of bilateral carpal tunnel syndrome. By March 2, 2010, it was the WCB's position that the worker had recovered from her bilateral carpal tunnel syndrome and that her ongoing difficulties due to de Quervain's tenosynovitis were not caused by her work duties. These findings were confirmed by Review Office on October 27, 2010. The worker disagreed with the decision and with the assistance of the Worker Advisor Office, filed an appeal with the Appeal Commission. A hearing was held on May 10, 2011 to consider the matters.

Issue

Whether or not responsibility should be accepted for the diagnosis of bilateral de Quervain's tenosynovitis as being related to the compensable injury; and

Whether or not the worker is entitled to further wage loss benefits and medical treatment beyond March 2, 2010.

Decision

That responsibility should not be accepted for the diagnosis of bilateral de Quervain's tenosynovitis as being related to the compensable injury; and

That the worker is not entitled to further wage loss benefits and medical treatment beyond March 2, 2010.

Decision: Unanimous

Background

In October 2007, the worker filed a claim with the WCB for pain in her right wrist and hand which she related to repetitive lifting and pulling during her work duties. The worker reported that in mid September 2007, she felt pain in her wrist and around her thumb and she could not close her thumb towards her palm.

The employer's accident report dated October 26, 2007 indicated that the worker went to the production supervisor on October 11, 2007 to report that her right wrist was stiff. The employer described the worker's job duties as follows:

There are 48 4 litre empty milk jugs in one plastic bag in the trailer stacked 9 high. She goes in and picks up one bag at a time and stacks it up onto the skid and she brings it to the debagging room and then one bag at a time goes into the debagging machine and then she takes out the empty plastic bag. The worker did this about 15 to 16 thousand units or approximately 350 bags. The worker had been performing this job for approximately one to two years.

On October 4, 2007, the treating physician reported that an EMG was ordered to rule out carpal tunnel syndrome ("CTS"). Subsequent file records showed that a WCB medical advisor reviewed the EMG results and it was confirmed that the compensable diagnosis was bilateral CTS. On April 25, 2008, the worker underwent left CTS release.

A report dated June 16, 2008 from a pain management centre reported that the worker was seen for increased left wrist pain following CTS release on April 25, 2008. The worker described pain in the wrist and thumb and numbness of the thumb and first 3 fingers preoperatively. The diagnosis outlined was early chronic regional pain syndrome ("CRPS").

On September 3, 2008, the treating surgeon reported: "This patient returns, having had left carpal tunnel surgery on April 25, 2008, complicated by CRPS as well as more recently the diagnosis of de Quervain's and carpal tunnel syndrome on the right side."

A WCB medical advisor stated on October 25, 2008 that the worker's left CTS release was complicated by CRPS and that it would not be advisable to undergo surgery on her other hand at this time. He noted that the worker was diagnosed with de Quervain's on the right by the treating surgeon but this had not been accepted as being related to this claim.

On December 5, 2008, primary adjudication asked the WCB medical advisor to provide an opinion as to whether the diagnosis of de Quervain's mentioned in the September 3, 2008 surgeon's report was related to the compensable injury. On December 23, 2008, the medical advisor responded: "The first time the de Quervains (sic) was mentioned was September 2008 nearly a year after the claim was submitted. There were no findings reported earlier to support this dx (diagnosis). The claim was accepted for bilateral CTS and findings presented were consistent with that diagnosis. There was no evidence to relate this current dx to the accepted dx. I believe the worker was off work at the time it was diagnosed, further supporting that it is not work related."

Primary adjudication also asked the medical advisor to provide an opinion on whether there was a pre-existing condition that was delaying the worker's recovery. The response was: "From review of studies regarding CRPS, several risk factors are noted. Among them are smoking, diabetes, and pre-x anxiety/depression; medical information on file supports these dx's in the worker. It is possible that these have delayed the worker's recovery."

On January 14, 2009, the treating surgeon reported that the worker's left carpal tunnel healed satisfactorily and that she could benefit from a de Quervain's release on the left side. On January 26, 2009, the WCB medical advisor indicated that it would be appropriate to proceed with right sided CTS release.

In a letter dated January 27, 2009, primary adjudication advised the worker that responsibility for treatment related to the diagnosis of de Quervain's was not accepted as being related to her compensable injury. It was stated that the worker's claim was accepted based on the diagnosis of bilateral CTS and it was not until September 2008 that there was any mention of de Quervain's. Also, at the time of this diagnosis, the worker had been off work and therefore the WCB was unable to establish that it was related to her work duties.

A report received from the pain clinic dated December 2, 2009 reported that prior to her carpal tunnel release the worker experienced numbness and tingling involving the palms of her hands bilaterally and since her surgery, she noted complete resolution of these neurologic symptoms. The worker continued, however, to experience an aching sensation in her wrists bilaterally radiating along the dorsal aspect of her thumbs and into her forearms. She described a burning sensation across the wrists and stabbing sensations involving the base of her thumbs. The specialist noted that the worker described symptoms that were consistent with bilateral de Quervain's tenosynovitis. Treatment suggestions were outlined.

On December 9, 2009, a WCB sports medicine consultant was asked to review the December 2, 2009 report and to comment on whether the treatment outlined was related to the accepted compensable diagnosis of bilateral CTS. On December 17, 2009 the consultant stated that the treatment suggestions were directed toward the diagnosis of bilateral de Quervain's tenosynovitis which was a diagnosis not accepted by the WCB.

On January 20, 2010, the WCB sports medicine consultant provided primary adjudication with further comments upon his review of the file. He stated that the report from the pain specialist did not give evidence of ongoing CTS or complex regional pain syndrome and it appeared that the worker's signs and symptoms were based on de Quervain's tenosynovitis. The consultant indicated that there were no restrictions required upon the diagnosis of bilateral CTS.

In a decision dated February 24, 2010, primary adjudication advised the worker that wage loss benefits would be paid to March 2, 2010 as it was felt that she had recovered from the effects of the work related injury related to the diagnosis of bilateral CTS. It was felt that her current difficulties and treatment were based on de Quervain's which had not been accepted as a compensable diagnosis.

A report was received from an occupational health physician dated June 22, 2010. The consultant stated that the determination of whether de Quervain's was a work related condition should consider whether the worker's work duties involved significant load, strain or repetitive use on the abductor pollicis longus and extensor pollicis brevis tendons. The specialist noted there was no such description or discussion on the WCB file. The consultant noted that the description of the worker's job duties since 2006 indicate light but very repetitive pinching actions of the left hand and thumb alone (her dominant side), or with both hands. He did not identify significant stressors of her thumb tendons from non-occupational sources. Based on his clinical impression, the worker's left hand and thumb condition was work related and involved diagnoses of de Quervain's tenosynovitis and local myofascial dysfunction, over and above the diagnosis of CTS recognized by the WCB. There was no radiographic evidence of underlying CMC joint degeneration.

On September 13, 2010, primary adjudication advised the worker that no change would be made to the decision dated February 24, 2010 following its review of the medical report dated June 22, 2010. The letter referred to the physician's comments that the worker's job duties were light but repetitive. This confirmed that there was no significant load in her duties to contribute to the de Quervain's diagnosis. As the worker's symptoms appeared approximately one year from the original injury and while the worker was off work for four months, it could not establish that the work related duties were an aggravating factor which contributed to the de Quervain's diagnosis. On September 24, 2010, the worker appealed this decision to Review Office.

On October 27, 2010 Review Office agreed with the position taken by the WCB medical advisor and the case manager that the diagnosis of de Quervain's tenosynovitis was not related to the worker's employment and that responsibility should not be accepted for wage loss and medical treatment beyond March 2, 2010. It was noted that by March 2, 2010, the vast majority of the medical evidence on file was with regard to the worker's de Quervain's tenosynovitis and not the condition of bilateral CTS. On November 24, 2010, the worker 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(1) of the Act provides that wage loss benefits will be paid: “…where an injury to a worker results in a loss of earning capacity…” 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 ends, or the worker attains the age of 65 years. Subsection 27(1) provides that medical aid will be paid by the WCB for so long as is necessary to cure and provide relief from the injury.

Worker’s position

The worker was assisted by a worker advisor at the hearing. The position advanced on behalf of the worker was that there was a relationship between the worker's employment duties and the development of both bilateral carpal tunnel syndrome and de Quervain's tenosynovitis. The worker worked for many years performing repetitive duties involving her wrists, hands and thumbs. While there was a delay of almost a year for the medical diagnosis of de Quervain's, the worker should not be penalized for this delay. It was submitted that it is likely that the focus for medical treatment was on the most prominent symptoms of CTS, as there were neurological symptoms of numbness and tingling. Following the CTS surgeries, the diagnosis of de Quervain's was made. It was argued that the worker very clearly described thumb symptoms which were consistent with de Quervain's in the first memorandum of the adjudicator on October 30, 2007. The occupational health physician also had confirmed that the worker's duties involved significant load, strain or repetitive use of the abductor pollicis longus and extensor pollicis brevis tendons. Although the worker had some pre-existing conditions which may have contributed to the condition, it was submitted that the worker's long standing repetitive work duties were the more likely cause of her carpal tunnel syndrome and de Quervain's. The WCB had accepted the carpal tunnel diagnosis and it was suggested that if the work duties caused the CTS, then the duties could also have caused repetitive strain injury to the thumbs, namely the de Quervain's tenosynovitis.

At the hearing, the worker gave detailed evidence regarding her job duties as a jug debagger on the assembly line. Her job involved working with packages of 48 jugs held together in a plastic sleeve. She would unload the sleeves from a trailer by grabbing them with her thumb and finger and pull four or five off the trailer at a time. She would then place them on a pallet. When the sleeves were about seven high, she would transport the pallet to a debagger area using a hand jack to help move the pallet. Each sleeve would then be loaded onto the conveyor belt. Once on the belt, the worker had to grip the plastic sleeve with her thumb and index finger on each hand to guide the sleeve through a cutter. Throughout the 10 hour shift, the worker would constantly be walking back and forth between the trailer and the debagging room and putting the jugs on the line. This would work out to approximately 600 plastic sleeves per day.

The worker also gave evidence regarding the duties she performed in other positions she held with the employer during her 35 year work history with this employer. On reviewing the previous decisions made by both the adjudicator and Review Office, it would appear that their consideration was limited to the effect the jug debagger position had on the worker's condition. As the WCB has not previously given consideration to the effect of the worker's entire work history on her hands and wrists, the panel does not have the jurisdiction to make a decision on this issue. It remains open to the worker to have this issue adjudicated by the WCB.

Analysis

There are two issues before the panel. We will address each one separately.

  1. Whether or not responsibility should be accepted for the diagnosis of bilateral de Quervain's tenosynovitis as being related to the compensable injury.

To accept the worker’s appeal, we must find on a balance of probabilities that she suffered injury by a workplace accident within the meaning of subsection 4(1) of the Act. In order to do so, we must find that her de Quervain’s tenosynovitis arose out of and in the course of her work duties. We are not able to make that finding.

After considering the evidence as a whole, the panel is of the opinion that the worker’s bilateral de Quervain’s tenosynovitis is not causally connected to her work duties. The jug debagger duties being performed by the worker did not involve the kind of movement which tends to lead to the development of de Quervain’s tenosynovitis. A de Quervain’s condition is typically associated with activities involving a combination of forceful and repetitive wrist or thumb movements. Although the duties being performed by the worker were certainly repetitive and involved a thumb to forefinger pinch grip, there was very little force/weight involved and there was little in the way of lateral twisting motion. Further, the pinch grip was not sustained for any significant length of time, as there were several other motions involved in lining up the sleeves onto the conveyor belt.

Medically, it would appear that the diagnosis of de Quervain's did not appear on the WCB file until mentioned by the attending surgeon in his report of September 3, 2008. It was submitted by the worker advisor that the worker's de Quervain's symptoms were present from the outset, however the attention was drawn away by the investigations into CTS. The worker advisor specifically relied upon notations from the WCB file of complaints of thumb pain by the worker. In the memo to file dated October 30, 2007, it states: "The worker describes her wrist pain is a sharp pain and around the fat part of the thumb she can't bend it in and gets sharp pain. Goes all around thumb and goes back into wrist."

The panel is unable on a balance of probabilities to accept this submission. The area of thumb pain described by the worker in the early file notations and again at the hearing was focused on the muscled area at the base of the thumb (ie. the abductor pollicis brevis), as opposed to pain on the side of the wrist, where pain from de Quervain's would typically be expected to manifest. We therefore question whether this early thumb pain was due to de Quervain's, or whether it was part of the CTS symptomatology. It is also notable that the worker was examined by both her general practitioner and the surgeon and it is difficult to accept that both physicians would have missed this diagnosis. Finally, the panel notes that when the surgeon did finally make the diagnosis of de Quervain's in his report of September 3, 2008, he referred to "more recently the diagnosis of de Quervain's" thus suggesting that this was a new condition.

Based on the foregoing, the panel finds that the worker’s bilateral de Quervain’s tenosynovitis is not causally connected to her work duties and therefore responsibility should not be accepted for the condition as being related to the compensable injury. The worker's appeal on this issue is dismissed.

  1. Whether or not the worker is entitled to further wage loss benefits and medical treatment beyond March 2, 2010.

In view of the panel's finding that the bilateral de Quervain's is not causally related to the worker's job duties as jug debagger, the second issue involves only the diagnosis of bilateral CTS. In order for the worker's appeal on this issue to succeed, the panel must find that either the worker's earning capacity continued to be impaired or that the worker required further medical treatment after March 2, 2010 due to her bilateral CTS. We are not able to make that finding.

The medical evidence on file shows indicates that by March 2, 2010, the bilateral CTS condition resolved and that her ongoing problems were related to de Quervain's. In the report dated December 2, 2009 from a pain clinic specialist, it was noted: "Prior to her carpal tunnel release she did experience numbness and tingling involving the palms of her hands bilaterally and since her surgery, she has noted complete resolution of these neurologic symptoms. She has, however, continued to experience what she describes as an aching sensation in her wrists bilaterally radiating along the dorsal aspect of her thumbs and into her forearms … a presumptive diagnosis of bilateral de Quervain (sic) tenosynovitis has been made."

Similarly, the memo dated January 20, 2010 of the WCB medical advisor notes that the worker's signs and symptoms are materially on the basis of de Quervain's tenosynovitis and that the specialist's report did not give evidence of ongoing CTS or complex regional pain syndrome.

Based on the foregoing, the panel finds that by March 2, 2010, the worker's compensable CTS condition was largely resolved and no longer affected her earning capacity or required medical aid. Accordingly, the worker is not entitled to further wage loss benefits or medical treatment beyond March 2, 2010. The worker's appeal is dismissed.

Panel Members

L. Choy, Presiding Officer
B. Simoneau, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 5th day of July, 2011

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