Decision #10/14 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that her right ankle injury did not arise out of her employment. A hearing was held on December 12, 2013 to consider the matter.Issue
Whether or not the claim is acceptable.Decision
That the claim is acceptable.Decision: Unanimous
Background
On April 27, 2012, the worker filed a claim with the WCB for a right ankle injury that occurred on April 20, 2012 while employed as a registered nurse. The worker reported that she was assessing a patient and when she straightened up and went to walk around the bed, she felt soreness and a cracking sound in her right ankle. The worker noted that she had a previous claim with the WCB for a right ankle injury which had healed and that her current ankle condition may be related to her old injury.
File records confirmed that the worker had a prior claim with the WCB for a right ankle injury that occurred at work in 2011. The diagnosis accepted by the WCB at that time was a right ankle sprain. Current medical reports indicated a diagnosis of a right anterior impingement syndrome.
On May 7, 2012, a WCB medical advisor opined that the worker's presentation was consistent with the diagnosis of an anterior impingement syndrome. The medical advisor noted that anterior impingement syndrome was most commonly seen as a complication of a lateral ankle sprain. A lateral ankle sprain would be apparent after an inversion injury to the ankle. An impingement could also be caused by repetitive forced dorsiflexion of the ankle.
The medical advisor commented that he reviewed the worker's prior WCB claim and the current claim and found no evidence of any work activity which would lead to the development of an anterior ankle impingement. Neither accident involved a traumatic incident with the ankle or forced dorsiflexion.
On May 9, 2012, the worker's claim for compensation was denied as the WCB adjudicator was unable to establish a causal relationship between the development of the worker's right ankle difficulties and an "accident" at work. The decision was based on the WCB medical opinion of May 7, 2012.
On May 30, 2012, the treating physician commented as follows with respect to the worker's right ankle condition:
Anterior impingement can occur as a result of acute injury with excessive compression forces, chronic injury, anatomic abnormalities, or most commonly as a result of prior injury with thickening in the anterior capsule, making the patient susceptible to impingement features. The history provided does not describe a significant physical injury, rather a normal movement that would occur in the act of stepping forward and the foot flexing upward. She also has radiologic evidence and history of prior injury to this region. On the balance of probabilities, old injury likely created a predisposition to anterior impingement in this situation and she simply performed a step that aggravated the area.
The patient describes a very specific movement that can reproduce and aggravate anterior impingement. I think there is little question that the specific movement described created the impingement and dysfunction, otherwise it would remain dormant.
Her anterior impingement developed after a specific movement at work. As the ankle dorsiflexes, the talus will impinge soft tissues against the tibia and can reproduce pain and irritability. Similar to the squeezing action of a nutcracker.
On June 19, 2012, the WCB adjudicator determined that no change would be made to the May 9, 2012 decision after reviewing the new medical information. The adjudicator felt that a relationship did not exist between the diagnosis of anterior impingement syndrome and the workplace accident. On July 24, 2012, the adjudicator's decision was appealed to Review Office by the worker's union representative.
On October 5, 2012 Review Office determined that the worker's symptoms started while she was at work and therefore her injury occurred "in the course of her employment." It was unable to find, however, that the worker's injury had arisen out of her employment.
Review Office stated that it could not give weight to the treating physician's May 30, 2012 comments as it did not find the mechanism of injury provided in his letter was accurate. Review Office accepted the WCB medical opinion of May 7, 2012 that there was no evidence of any activity at work which would have led to the development of anterior ankle impingement, and that the mechanism of injury did not involve a traumatic incident which would have resulted in a sprain or result in forced dorsiflexion of the ankle. Review Office found that the medical evidence did not support the worker's injury was caused by a hazard resulting from the nature, conditions or obligations of her employment. On February 13, 2013, the union representative appealed the 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. Subsection 4(1) of the Act provides:
4(1) Where, in any industry within the scope of this Part, personal injury by accident arising out of and in the course of the employment is caused to a worker, compensation as provided by this Part shall be paid by the board out of the accident fund, subject to the following subsections.
The worker’s position:
The worker was assisted by a labour relations officer at the hearing. It was submitted that the two issues in dispute were whether or not an accident or hazard was encountered at work and whether an injury was sustained as a result of encountering that accident or hazard. The worker explained that the WCB did not properly understand the mechanism of injury. The worker was not merely walking around the bed of a patient when she felt pain in her ankle, but rather had been standing by the edge of the patient's bed while performing a head to toe assessment. In order to do so, she had to lean forward with her right foot planted and due to the positioning of the furniture, her center of gravity was shifted to her right side. When she stood upright, she felt that her right ankle was sore. When she walked around the patient's bed, she had persistent pain in her foot.
It was submitted that there was no contention over the worker's actual diagnosis. Both the treating physician and the WCB medical advisor acknowledged an anterior impingement syndrome. Forced dorsiflexion was a factor which may lead to development of this condition. Further, the worker's prior injury pre-disposed her to a secondary injury. The hazard that the worker encountered was the fact that she had to reach across the patient to complete her assessment which caused her ankle to be in the position of forced dorsiflexion. The worker clearly injured herself while performing her tasks as a nurse and her claim should be accepted.
The employer’s position:
The employer did not appear at the hearing but a written submission was provided by an employer advocate prior to the hearing for the panel's consideration. The employer's position was that it agreed with the WCB's decision. The employer did not believe that the worker's anterior impingement condition was caused by a hazard due to the nature, conditions or obligations of employment. It was submitted that the worker's evidence was that she was not sure of the mechanism of injury, and despite not knowing the details of the injury, the treating physician indicated that on a balance of probabilities, an old injury created a predisposition to anterior impingement. It was submitted that this opinion was purely speculative and the panel was asked to place greater weight on the opinion of the WCB medical consultant who indicated that anterior impingement syndrome is usually a complication of a lateral ankle sprain which is apparent after an inversion injury to the ankle. No such event occurred on April 20, 2012 or the year before in April 2011. The employer agreed with the WCB medical advisor's comments that neither this nor the 2011 claim involved any activity which would have led to the development of anterior ankle impingement as neither incident involved trauma or forced dorsiflexion of the ankle. Although the worker's symptoms may have started at work, her condition did not arise out of employment and her claim should be denied.
Analysis:
The issue before the panel is claim acceptability. For the worker’s appeal to be successful, we must find on a balance of probabilities that the worker's right ankle injury was caused by her work duties performed during the course of her employment on April 20, 2012. We are able to make that finding.
At the hearing, the worker carefully explained the mechanism of injury. It was not the act of walking and stepping on her right foot which caused the injury, but rather it was the fact that she had been leaning forwards with her weight predominantly shifted to her right foot which caused the injury. The worker demonstrated that when she was leaning forward, her right ankle was in dorsiflexion and it was the sustaining of this position for a period of time which caused the pain and swelling in her ankle.
The panel accepts the worker's evidence and finds on a balance of probabilities that the duties being performed by the worker when her pain developed involved maintaining a sustained position of dorsiflexion with her weight predominantly centered on her right leg.
The medical opinions on file from the WCB medical advisor and the treating physician both identify forced dorsiflexion as a factor which may cause anterior impingement syndrome. The treating physician specifically referred to a documented history of "dorsiflexion and axial load injury to her right ankle while leaning/moving forwards to perform patient care" when opining that the specific movement at work created the worker's impingement and dysfunction. The
panel also takes note of the treating physician's comments that the history provided did not describe a significant physical injury but given the worker's radiologic evidence and history of prior injury in this region, the "old injury likely created a predisposition to anterior impingement in this situation and she simply performed a step that aggravated the area."
The panel therefore finds that the worker's claim for her right ankle anterior impingement syndrome is acceptable. The worker's appeal is allowed.
Panel Members
L. Choy, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
L. Choy - Presiding Officer
Signed at Winnipeg this 23rd day of January, 2014