The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that her ongoing shoulder complaints are not related to her compensable injury of October 1, 2012.  A hearing was held on September 19, 2013 via teleconference to consider the matter.

Issue

Whether or not the worker is entitled to benefits beyond April 30, 2013.

Decision

That the worker is not entitled to benefits beyond April 30, 2013.

Decision: Unanimous

Background

The worker filed a claim with the WCB for a right shoulder injury that occurred at work on October 1, 2012 in the course of her employment as a healthcare aide. The worker described the accident as follows to the WCB's call centre:

I was transferring - put a sling underneath a client with a coworker. The client did not cooperative (sic) for some reason and the client went opposite of what I was doing and I felt a pull in my right shoulder.

The worker sought medical attention from her family doctor on October 4, 2012 and was diagnosed with a right shoulder strain.

On October 11, 2012, the worker spoke with a WCB adjudicator and confirmed the accident description as described to the WCB's call-in centre on October 9, 2012. The worker indicated that her shoulder pulled and was followed by immediate pain. She felt a pop when it pulled and the pain radiated down into her fingertips. The worker indicated that she had a prior WCB claim for a separated shoulder about 6 years ago.

On October 12, 2012, the worker was seen by a chiropractor who suggested a diagnosis of acute glenohumeral joint sprain and queried a muscle tear.

On October 17, 2012, the worker saw her family doctor again, who changed the diagnosis to a right rotator cuff tear.

On November 1, 2012, a WCB medical advisor reviewed the worker's file and stated:

1. The differential diagnoses would include rotator cuff strain, rotator cuff tear, glenohumeral subluxation, or labral tear. Given the limited medical information to date, the most probable diagnosis would be rotator cuff strain.
2. Rotator cuff strain recovery typically is from 1 to 3 months.

On November 29, 2012, the worker underwent an MRI of her right shoulder. The results revealed mild supraspinatus tendinosis and mild acromioclavicular osteoarthritis with lateral down sloping of the acromion.

A WCB medical advisor reviewed the file on January 21, 2013 at the request of the case manager and gave the following opinions:

• the MRI results of November 29, 2012 would be considered degenerative changes associated with aging and neither condition was caused by the workplace injury of transferring a client.
• the worker presented with shoulder pain and loss of range of motion after transferring the client. The doctor had been concerned about a rotator cuff tear and none was evident on the MRI. A symptomatic tendinosis would also present with similar findings. It is more likely that the worker aggravated the pre-existing tendinosis.
• aggravation of tendinosis should resolve in 3 to 6 months and it may require surgery to decompress. The overall prognosis should be good but the worker may not get back to heavy lifting or overhead work even with surgery.
• it was likely that the pre-existing conditions in the worker's shoulder were contributing to her delayed recovery.

In late January 2013, the worker returned to work performing light duties at three hours per day, two days per week.

On February 6, 2013, an orthopaedic specialist outlined his examination findings related to the worker's shoulder condition. The specialist's impression was that the worker had myofascial pain around the parascapular musculature. He noted that while the clinical examination was difficult to interpret because of pain complaints, it seemed that the shoulder moved freely without gross instability and there was no evidence of a structural problem on her MRI. It was felt that surgery would not be beneficial and that the worker should continue with therapy to decrease her pain and increase the functional use of her arm. An assessment by a physiatrist was suggested if the worker continued to experience persistent periscapular pain.

The worker's file was again reviewed by a WCB medical advisor on February 18, 2013. The medical advisor was of the view that the orthopaedic specialist's findings were not consistent with a structural abnormality about the shoulder and it could not be explained on the basis of a rotator cuff tendinosis. The possible diagnosis of myofascial pain just described a situation where there was pain and tenderness and did not support a specific anatomic diagnosis. The medical advisor suggested a 4 to 6 week rehabilitation program to resolve any ongoing effects from the compensable injury and lead to a return to full work duties. It was felt that the worker needed to get the shoulder moving in a more normal manner or the pain and disability would just increase.

On April 11, 2013, a WCB chiropractic consultant and a WCB physiotherapy advisor assessed the worker's shoulder at a call-in examination. The following was concluded from the assessment:

A diagnosis cannot be offered to account for today's presentation. The overreaction to light touch of the periscapular soft tissues, inconsistencies in responses to physical testing and self limited right shoulder exam cannot be accounted for by a patho-anatomical process or condition. The presentation is not medically accounted for in relation to the workplace injury as described to have occurred on October 1, 2012. The initial right shoulder sprain and strain injury would be expected to resolve in 4 to 6 weeks.

On April 22, 2013, the WCB medical advisor reviewed the recent call-in notes and commented that the presentation was not consistent with a rotator cuff strain/aggravation. Her opinion was that the worker's presentation was no longer related to the compensable injury. This was supported by the following factors:

· Her pain is centered around her shoulder blade, which is not where pain from the rotator cuff is felt.

· The clinical findings are not consistent with a rotator cuff strain from 6 months ago.

The medical advisor stated that the abnormal pain behavior was more likely to have delayed the recovery than the pre-existing tendonitis.

By letter dated April 24, 2013, the WCB case manager advised the worker that it was felt that she had recovered from the effects of her compensable injury (aggravation of pre-existing rotator cuff tendinosis) and that wage loss benefits and medical treatment costs would extend to April 30, 2013 inclusive and final. It was felt that the worker's current symptoms were not caused by the workplace accident.

On May 6, 2013, the worker requested Review Office to reconsider the case manager's decision of April 24, 2013. The worker contended that the current pain in her shoulder was in the exact same area as was injured on October 1, 2012 and that she was entitled to further benefits.

In decision dated July 5, 2013, Review Office determined that the worker was not entitled to benefits beyond April 30, 2013. Review Office indicated that the medical evidence supported that the compensable diagnosis was a right shoulder strain/sprain and that a causal relationship had not been established between the worker's current difficulties and the compensable injury. Review Office accepted the opinion of the WCB medical consultants in making its decision. On July 15, 2013 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 self-represented at the hearing and participated by teleconference. The worker described the workplace accident where she was putting a sling under a resident who was sitting in a wheelchair when the resident suddenly got agitated and he moved the opposite way of where she was going. The worker heard and felt a "snap, crackle and pop" in her shoulder. When she felt the pop, it was on the top of her shoulder, but her whole shoulder hurt. The pain went down her arm and into the front of her chest and into her shoulder blade.

The worker did not understand why the WCB was saying that the shoulder problems she was still having were not part of the initial October 2012 injury. The worker felt that her shoulder was her shoulder, and that she had always complained about that area to her medical practitioners. When she told them that she was having problems with her shoulder, she meant the whole thing, including the shoulder blade, and not just a certain spot on the shoulder. The worker's position was that she was still experiencing pain in the same area that was originally assessed and that as she was not able to return to work on a full time basis and still required treatment after April 30, 2013, she should be entitled to further benefits.

Analysis

The issue before the panel is whether or not the worker is entitled to benefits beyond April 30, 2013. In order for the worker’s appeal to be successful, the panel must find that after that date, the worker continued to suffer from the effects of her compensable injuries. On a balance of probabilities, we are not able to make that finding.

At the hearing, the worker was asked to describe the symptoms which caused her the most difficulties. The worker advised that just prior to the date of the hearing (September 19, 2013), she had returned to work at her full time position. Up to that point, however, she had been attending physiotherapy once per week and she was also seeing a chiropractor. The main problem was with her shoulder blade area. It felt like her shoulder blade was rotating and would not lie flat. The worker would attend the chiropractor who would perform a manipulation which made it feel like the shoulder blade was flat again. Then she would see her physiotherapist who would work on exercises to help her strengthen the area. Eventually, however, she would feel the shoulder blade moving out again so she would have to see the chiropractor again.

When the initial medical reports are reviewed, it would appear that the original symptoms recorded by the worker's medical practitioners related to the glenohumeral joint (ball and socket joint at the shoulder) and the top of the shoulder. The October 17, 2012 report from the family physician indicated a diagnosis of rotator cuff tear. This would suggest that the complaints at that time related to the joint itself.

The chiropractor's first report of October 12, 2012 referred to a diagnosis of acute glenohumeral joint sprain and queried a muscle tear. The report did list subjective complaints of "neck, upper back, chest and shoulder pain" with pain going down into the right arm, but there was no specific reference to the scapula. The handwritten chart notes from the chiropractor indicate musculature H/T (presumably this refers to hypertonicity or tightness) in the trapezius, cervical spine, biceps, deltoid and rotator cuff. None of these areas would be considered the scapular area. It is notable that in his later notes, the chiropractor did make a specific reference to the scapula. The entry for January 17, 2013 appears to indicate: "R scap rot." The panel interprets this to mean right scapula rotated. This would be consistent with the worker's description of her more recent difficulties.

The physiotherapist started treating the worker on November 19, 2012. In the initial assessment, the physiotherapist noted that the right scapula was held abnormally but no other symptoms in the scapula were noted. It was only in the subsequent report of December 17, 2012 that the physiotherapist reported "++ pain in scapular region and acromioclavicular joint."

We have considered the worker's submission that when she complained of her "shoulder" to her medical practitioners, she meant the whole shoulder, including her scapula. Given the detailed nature of the medical reports, we are not able to accept this submission. The medical reports referred to above are sufficiently detailed and specific that the panel is satisfied that the entire shoulder area was examined by the practitioners, and that only the areas which demonstrated symptomatology were noted. The findings are specific, and we are of the view that if scapular pain was present at the outset, it would have been specifically noted.

Overall, a review of the medical reports would suggest that the scapular problems which caused the worker pain and disability beyond April 30, 2013 were not part of her original injury. The initial reports were all focused on the top of the shoulder and glenohumeral joint. This would also be consistent with the mechanism of injury described by the worker, which involved a "pop" at the top of her shoulder. By the time of the call-in examination of April 11, 2013, the worker indicated that in the first few weeks following the accident, the pain seemed more focused at the top and front of the shoulder joint, but that this had improved and at the time of the examination, the current complaint was of right shoulder blade pain.

On a balance of probabilities, the panel finds that by April 30, 2013, the compensable injury of a right shoulder strain which caused pain at the top of the shoulder had resolved and any ongoing difficulties the worker had with her right scapula were not related to the workplace injury of October 1, 2012. It therefore follows that the worker is not entitled to benefits beyond April 30, 2013. The worker's appeal is dismissed.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
C. Anderson, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 6th day of November, 2013