Decision #174/11 - Type: Workers Compensation

Preamble

The worker is appealing a decision made by the Workers Compensation Board ("WCB") which determined that his right wrist and thumb condition was not related to his workplace injury and therefore he was not entitled to medical aid benefits beyond February 19, 2009. A hearing was held on November 3, 2011 to consider the matter.

Issue

Whether or not the worker is entitled to medical aid benefits beyond February 19, 2009.

Decision

That the worker is entitled to medical aid benefits beyond February 19, 2009.

Decision: Unanimous

Background

On July 2, 2008, the worker filed a claim with the WCB for a right hand/wrist injury that occurred at work on May 2, 2008. The worker described his injury as follows:

I was using an air impact gun to push a brake pin on slack adjuster. The brake pin pusher was cross threaded causing me to twist my arm while using the air impact gun. May 2 to June 19, continued to work regular duties with some discomfort but on June 19 coworker and I, we were lifting tag arm axle assembly with drum (about 200 pounds) and right hand wrist pain became worse.

The claim for compensation was accepted based on the diagnosis of a right wrist/forearm strain and the worker was placed on modified duties while receiving treatment for his injury.

On September 11, 2008, a right wrist MRI showed no significant ulnar variance. Scapholunate, lunotriquetral and triangular fibrocartilage complex ("TFCC") all appeared intact. The ulnar styloid was a separate fragment which represented un-united ossification center or un-united fracture. Carpal alignment was normal.

A WCB medical advisor reviewed the file on September 25, 2008 at the request of primary adjudication and stated:

  • the medical findings indicated an area of tenderness near the base of the thumb and first and second metacarpals. As the MRI did not report findings in this region, the current diagnosis was a right wrist sprain.

  • the mechanism of injury may have caused a fracture of the ulnar styloid, however, as the area of the ulnar styloid was not spatially related to the symptoms/findings, the MRI finding was likely incidental.

  • there did not appear to be a condition present that would benefit from surgery as there seemed to be recent improvement, so a plastics consultation was not presently needed.

As the worker continued to experience ongoing right and left wrist pain, he was seen at a WCB call-in examination on November 19, 2008. The medical advisor reported that the worker had specific point tenderness near the base of the right second metacarpal on the radial side. The left wrist from a different WCB claim was considered resolved. The medical advisor arranged for the worker to see a sports medicine specialist to clarify the diagnosis related to the right hand and to make treatment recommendations.

On January 12, 2009, the sports medicine specialist diagnosed the worker as follows: "Bilateral wrist pain - ? related to abnormal around the scaphoid bone, ? Resolving ligamentous sprain." The treatment plan was to continue with modified duties, exercise, and to have a bone scan.

Bone scan results dated January 13, 2009 revealed suspected degenerative changes within both wrists. The scintigraphic activity was similar bilaterally.

The worker was involved in a non-work-related motor vehicle accident ("MVA") on January 5, 2009. On February 9, 2009, a WCB medical advisor reviewed the file and said:

  • the current diagnosis in the recent medical reports appear to be related to injuries secondary to the MVA and/or the degenerative changes found on the bone scan involving the wrists and first CMC joints. These conditions are not related to the area of findings identified at the call-in exam. The medical reports do not suggest a loss of function related to the compensable injury. It was concluded that the worker functionally recovered from his May 2, 2008 workplace injury.

  • the bone scan results were consistent with pre-existing degenerative conditions and were near enough to the compensable injury that would potentially hinder recovery.

  • there had been sufficient time of limited use of the right hand combined with appropriate therapy to allow for healing of a soft tissue injury. The current symptoms and findings were mostly related to the recent MVA and/or the degenerative changes of the hands. The evidence on file did not support the need for restrictions related to the compensable injury.

On February 11, 2009, the worker was advised by his case manager that wage loss benefits were being paid to February 19, 2009 inclusive. The case manager indicated to the worker that the pre-existing degenerative changes noted on the bone scan were not considered related to his workplace injury; that he had made a functional recovery and no longer required restrictions related to the May 2008 workplace accident.

On February 27, 2009, the sports medicine specialist was of the opinion that the MVA the worker was involved in did not result in any significant increase in his symptoms or result in a new medical condition. He said it was not medically probable that the worker's present symptoms were secondary to the MVA.

On May 5, 2009, the sports medicine specialist reported that the worker's right wrist and thumb symptoms were increasing as a result of his work duties. He noted that the worker's symptoms were the result of inflammation around the CMC joint and there were no clinical findings to suggest an underlying arthropathy. The specialist opined that the worker had never fully recovered from the workplace injury to his wrist and as such a temporal relationship between the workplace incident and his present symptoms existed.

A WCB medical advisor stated the following on June 16, 2008:

· the treating sports medicine specialist advised him that the only findings on his examinations involved the first CMC joint. The most likely diagnosis to account for the current symptoms is the CMC osteoarthritis ("OA") of the right thumb identified on the bone scan.

· the call-in examination in November 2008 did not identify any significant findings with the CMC joint of the right thumb. On a balance of probabilities, the CMC OA was not related to the May 2008 workplace injury.

On June 17, 2009, the case manager advised the worker that in the opinion of the WCB, his current right thumb and wrist difficulties were not related to the May 2, 2009 workplace injury.

On September 13, 2010, the worker asked the WCB to reopen his claim as he was prescribed physiotherapy for his sore thumb which he related to the May 2008 workplace accident. On September 17, 2010, the case manager confirmed to the worker that his right hand/thumb difficulties would not be considered a WCB responsibility. On January 12, 2011, a worker advisor acting on the worker's behalf appealed the decision to Review Office.

At the request of Review Office, a WCB senior medical advisor was asked to review the file and provide an opinion as to the diagnosis related to the May 2008 workplace accident and the diagnosis in May 2009. His report to Review Office is dated February 4, 2011 and a copy was provided to the worker advisor for comment. On February 18, 2011, the worker advisor provided Review Office with a further submission.

On February 23, 2011, Review Office determined that the worker was not entitled to medical aid benefits beyond February 19, 2009. Review Office noted that its medical consultant expressed the opinion that the worker's ongoing right thumb difficulties were an inflammation of the CMC joint and there was no documentation of tenderness at the CMC joint prior to February 2009 by the worker's physician or in the examination notes of November 19, 2008. Review Office concluded that the evidence on file including the findings of the November 19, 2008 examination, the bone scan results and the time that had passed did not support a causal relationship between the worker's current right thumb difficulties and the May 2, 2008 compensable injury. On March 28, 2011, the worker advisor 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. 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.

The Worker’s Position

The worker was assisted by a worker advisor at the hearing. The worker's position was that he needed more medical treatment than the WCB had allowed in order to address the ongoing effects of his compensable injury. It was submitted that there was continuity between the workplace accident and his symptoms after February 19, 2009. The area of injury where the worker identified the pain remained the same as was indicated during his first discussion with the WCB in July 2008. Although some of the medical reports indicated there was some movement in the symptoms, the WCB medical advisor acknowledged that there were consistent findings and that it was very difficult at times to delineate the specific area within the hand where the symptoms originated. The MRI report showed only very minimal degenerative changes, which would tend to refute that the worker's symptoms came from a degenerative condition. Through the course of the claim the worker consistently experienced increased symptoms when the demands on his wrist and thumb were increased, and then became more manageable when he was working on modified duties. The symptoms have remained problematic and the worker was prescribed physiotherapy by his doctor. It was submitted that the compensable injury caused ongoing symptoms and the need for treatment and the worker asked that the panel grant his appeal for additional medical benefits.

The Employer’s Position

A disability specialist from the employer appeared at the hearing. The employer's position was that following the 2008 workplace strain, the worker was performing full time modified duties. He was improving and was expected to return to his pre-injury duties. Unfortunately, on January 5, 2009, he was involved in a motor vehicle accident following which he was no longer able to do even the lightest of modified work. The worker was off for three months before returning to modified work in April of 2009. It was submitted that medical reports and diagnostic testing on file supported that the worker's ongoing difficulties were unrelated to the 2008 workplace strain. Both WCB and Review Office medical consultants had determined that the worker's current difficulties were not related. There was no clear and convincing evidence to refute the very clear findings by these two medical consultants who were experts in making these kinds of determinations. It had not been shown that these physicians missed any relevant fact or medical test in forming their opinions. It was therefore submitted that the WCB's decision should be upheld.

Analysis

The issue before the panel is whether or not the worker is entitled to medical aid benefits beyond February 19, 2009. In order for the appeal to be successful, the panel must find that after February 19, 2009, the worker has continued to suffer from the effects of the injuries he sustained in the May 2, 2008 work related accident. We are able to make that finding.

At the hearing, the worker indicated that he continues to have problems with his right hand. He identified a very specific area which he described as: "right in between the joints; right in the joint right here, where my thumb area meets the wrist." He pointed generally at the area of the 1st metacarpal, on the dorsal side of the hand. The worker's evidence was that after the workplace accident, he also had pain in the wrist area, and while that condition had largely resolved, he has had continuing pain in the identified area below his thumb. The pain has varied in intensity, with the condition improving when he was on light duties and receiving physiotherapy, and getting considerably worse whenever he tried to perform any kind of gripping or twisting work with his right hand.

After considering both the file material and the evidence provided at the hearing, the panel is satisfied, on a balance of probabilities, that there is a causal relationship between the worker’s hand symptoms beyond February 19, 2009 and the workplace injury. In coming to this conclusion, we relied on the following:

· There is continuity in the worker's complaints of pain. Although initially there was greater focus on the injury to the right wrist, the panel finds that the worker also consistently complained of pain in his hand in the area below his thumb. At the time of the initial contact between the worker and his adjudicator on July 9, 2008, the worker indicated he had: "sharp pain where thumb bone goes into wrist joint."

· Similarly, the family physician's report of August 12, 2008 indicated objective findings of: "R hand tender between 1 & 2 metacarpals, grip about normal but tender." The panel therefore finds that complaints of pain in the general area were present at the outset of the claim.

· The February 4, 2011 report by the medical advisor to Review Office differentiated between tenderness at the base of the second metacarpal joint as opposed to the carpo-metacarpal joint. In the panel's opinion, the two areas are close enough together that the specific location of the pain could be imprecise and we are not prepared to exclude the worker's claim based on this subtle difference.

· The worker had no prior difficulties with his right hand before the workplace accident and frequently used an air impact gun in the course of his regular duties. This would have required a significant amount of strength in his hand and thumb, which tends to confirm that he had no prior hand issues.

· It was suggested that osteoarthritis may be the cause of the worker's symptoms. Prior to the hearing, the worker submitted a recent MRI report dated June 23, 2011. The MRI indicated there was very minimal degenerative change noted involving the outer aspect of the trapezium-metacarpal articulation. Given the minimal findings, the panel does not feel that the worker's symptoms should be solely attributed to osteoarthritis.

· The panel also notes that the bone scan identified increased focal activity bilaterally, thus suggesting that the degenerative changes were present in both hands. The worker's complaints, however, are limited to his right side only. As this is the side of the injury, this would further support that the workplace injury is the cause of his symptoms.

· It was admitted by the worker that the motor vehicle accident of January 2009 caused a worsening of his right hand and wrist symptoms, but given that the worker was still modifying the way he performed his duties at work at the time of the MVA, the panel accepts that his compensable injury was not yet resolved.

Based on the foregoing, the panel finds that as of February 19, 2009, the worker continued to suffer from the effects of his compensable injury and therefore he is entitled to medical aid benefits beyond that date. The worker's appeal is allowed.

Panel Members

L. Choy, Presiding Officer
P. Marsden, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 16th day of December, 2011

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