Decision #17/14 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that the need for surgeries on February 28, 2013 and April 13, 2013 was not related to her compensable accident of April 18, 2012. A hearing was held on January 9, 2014 to consider the matter.Issue
Whether or not responsibility for the surgeries performed on February 28, 2013 and April 13, 2013 should be accepted in relation to the compensable accident of April 18, 2012.Decision
That responsibility for the surgeries performed on February 28, 2013 and April 13, 2013 should not be accepted in relation to the compensable accident of April 18, 2012.Decision: Unanimous
Background
On April 11, 2013, the worker filed a claim with the WCB for injury to both knees that occurred at work on April 18, 2012. The worker reported that she was running up a set of stairs wearing shoes that were wet when she fell striking both knees on the edge of the stairs. The worker did not think her injury was serious so she did not seek immediate medical attention.
The worker has a prior 2012 claim with the WCB for bilateral knee difficulties which she related to non-specific causes. The claim was not accepted as a relationship between the development of the worker's condition and her work activities could not be established.
On April 15, 2013, the worker advised the WCB that on the day of her accident, it was raining outside and her shoes were damp. The stairs were made from marble and she banged her knees on the edge of the stairs. She said she caught herself on the railing with her left hand and had coffee in her right hand. When she hit the stairs, she heard a pop and it was painful. In 2012, the worker said she had undergone knee x-rays which showed some osteoarthritic changes. The worker said she finished her shift but her symptoms progressively worsened and she went to see a physician on April 26, 2012.
On April 24, 2013, the treating physician reported that the worker attended for treatment on April 26, 2012 with the following accident description: "Slipped on marble stairs while at work - shoes were wet and landed hitting knees on the edge of the stairs. Immediate pain." The worker had decreased range of motion and local pre-patellar swelling. Arrangements were made for the worker to undergo an MRI assessment and then to see an orthopaedic surgeon for treatment. The treating physician provided the WCB with the following medical reports:
- September 7, 2012 - the physiotherapist noted the area of injury to be bilateral knees/left hip pain. The worker had "ongoing knee pain, progressively worsening over last year." The diagnosis was bilateral patella femoral syndrome and trochanteric bursitis.
- September 21, 2012 - the orthopaedic surgeon reported that the worker was seen regarding bilateral knee pain, left worse than right, which had been present for years. The pain was both medial and lateral and was troublesome with activity. The left knee showed neutral alignment and range of motion was full. The ligament exam showed no laxity. There was no effusion but there was diffuse tenderness. X-rays showed tricompartmental degeneration worse medially in both knees.
- November 29, 2012 - MRI of the right knee was read as follows:
1. New degenerative radial tear of the posterior horn of the medial meniscus.
2. Progression of tricompartmental osteoarthritis.
3. Small joint effusion with a moderate-sized Baker's cyst containing an intraarticular body.
- November 29, 2012 - MRI results of the left knee was read as follows:
1. Degenerative tearing of the menisci as described.
2. Tricompartmental osteoarthritis most prominent in the medial compartment.
3. Joint effusion and Baker's cyst. An intraarticular body is present.
- February 28, 2013 operative report - surgery was directed at the right knee for medial and lateral meniscal tears and medial femoral chondromalacia.
At the WCB's request, the treating physician provided the WCB with a copy of her chart notes and other information related to the worker's medical appointments on April 26, June 13 and July 19, 2012. Included was an April 16, 2013 operative report which indicated that surgery was directed at the left knee for medial and lateral meniscal tears and synovitis.
On May 21, 2013, a WCB medical advisor reviewed the two surgical reports and provided rationale to support that the worker's meniscal tears in both knees were not related to the compensable accident of April 18, 2012.
On May 24, 2013, the worker was advised that the WCB would not accept responsibility for time loss and medical costs related to her knee surgeries, as it was felt that the initial medical findings of April 26, 2012 immediately after the work-related accident did not support a diagnosis of right and left meniscal tears. On May 28, 2013, the worker appealed the decision to Review Office.
Review Office sought medical advice from a WCB medical advisor on August 13, 2013 regarding the causes of meniscal tears. The medical advisor noted that meniscal tears can occur when a twisting force is applied to the involved knee. There would need to be a close temporal relationship between the event, knee symptoms and clinical findings consistent with a diagnosis of a meniscal tear. The clinical findings to support the diagnosis of a meniscal tear would be tenderness localized to the anatomical location of the involved meniscus and/or findings on specific testing whereby a loaded rotational force applied to the involved knee resulted in symptoms localized to the anatomical location of the involved meniscus.
On August 14, 2013, Review Office determined that the surgeries performed in February and April 2013 were not compensable. Review Office noted that the mechanism of injury that occurred on the day of the accident did not involve a twisting force applied to the knees and that the worker's reported symptoms were not localized to the meniscal area. Review Office also found that the reported medical findings in the physician's report and chart notes of April 26, 2012 were not consistent with an acute menisci injury. It found that the MRI findings of November 29, 2012 were pre-existing and were not related to the April 18, 2012 injury. On September 16, 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(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.
Worker's position:
The worker was self-represented at the hearing. The worker gave a detailed description of the timeline of events and submitted that the surgeries were directly related to the workplace accident. She stated that she had never felt that degree of pain in her knees until the day of the incident. The worker challenged the notion that the surgeries were due to a pre-existing condition. She did so based on the fact that after the fall, she experienced immediate immobilization and pain which was so severe she felt "it ruined her life." The worker was thankful that the surgeries were able to fix her pain as she had been afraid that she would lose her career. It was submitted that the fact that the pain resolved with surgical intervention substantiated that the injury was due to the workplace accident because her surgeon told her that arthritis could not be fixed with surgery. The MRI also supported that there was a new tear in the right knee, which the worker submitted was caused by the accident. With respect to the left knee, the MRI indicated the presence of bilateral tearing as well as injury to the synovial area.
Employer's position:
An employer advocate appeared on behalf of the employer. The employer's position was that it accepted that the worker had a workplace injury, but questioned whether or not the two surgeries were related to the workplace accident. It was noted that the worker had an extensive osteoarthritis condition in both of her knees and that was certainly a contributing factor to the need for surgery. What was unclear was whether the surgeries were related fully to the pre-existing degenerative conditions (osteophytes, chondromalacia and other degenerative-type findings) or whether they were partly to repair the pre-existing degeneration and partly to repair injury caused by the accident. The file was not clear as to whether or not the meniscal tears were new or degenerative in nature and it was suggested that further investigation may be warranted. Based on the information currently on file, however, the employer's position was that it agreed with the WCB's conclusion on the matter.
Analysis:
The issue before the panel is whether or not responsibility for the surgeries performed on February 28, 2013 and April 13, 2013 should be accepted in relation to the compensable accident of April 18, 2012. In order for the worker’s appeal to be successful, the panel must find that the workplace accident of April 18, 2012 caused the worker to suffer injuries to her knees which resulted in the need for the surgeries of February and April 2013. After careful consideration of both the evidence surrounding the worker's injuries and the medical reports on file, the panel is not satisfied on a balance of probabilities that the worker suffered meniscal tears and/or other structural injury to her knees on April 18, 2012, and it is therefore our decision that responsibility should not be accepted for the knee surgeries.
The panel considered the mechanism of injury described by the worker. She described walking up stairs with a bag over her left shoulder and her arms full. She was carrying a coffee in her right hand. The worker's shoes were wet and her feet slipped out from under her. She fell straight forward onto both knees, landing on the right harder than the left. The worker stated that she did not fall on her kneecaps, but rather landed more along the joint line just under the kneecap. The worker described hearing a weird "popping" noise and felt severe pain. Once she regained her wits, she was able to get to her office where she told a co-worker about the incident. She did not fill out a green incident card.
In the panel's opinion, the fall as described by the worker did not involve any type of twisting mechanism which would typically be associated with a meniscal tear. The fall entailed a direct hit to the area below her kneecap and the force was straight on. We find that the mechanism of injury described does not support the finding of a meniscal tear caused by a loaded rotational force.
The worker's evidence was that after the fall, she experiencing swelling and difficulty mobilizing, and she developed clicking in both knees as well as grinding. Her range of motion became limited to only 50 percent. The worker stated that it was very painful. She was not able to see her doctor until April 26 (8 days later) and in the meantime she took anti-inflammatories. She went to a walk-in clinic but they were not able to do much for her other than prescribe pain medication.
The chart notes from the worker's April 26, 2012 appointment with her family physician were available for the panel's review. It is notable that the worker did report the fall on the stairs to her doctor and there was a note which indicated: "OA? Meniscal tears?" Although the chart notes queried the possible presence of meniscal tears, the panel notes that the signs and symptoms associated with the finding of an acute meniscal tear were not present. Clinical findings that would support the diagnosis of a meniscal tear were listed by the WCB medical advisor in his memo of August 13, 2013 as follows: tenderness localized to the anatomical location (e.g. medial or lateral joint line) of the involved meniscus and/or findings on specific testing (e.g. McMurray, Thessaly, Alpley) whereby a loaded rotational force applied to the involved knee results in symptoms localized to the anatomical location of the involved meniscus. The April 26, 2012 chart notes do not refer to any localized tenderness along the medial joint line or positive specific testing. The worker described experiencing clicking and grinding, but this is not referenced. The edema described is non-specific and is not localized to the areas expected. The only specific reference to edema relates to ankle edema bilaterally. The panel finds that the clinical findings are not supportive of a finding of an acute meniscal tear injury.
The worker was referred by her family physician to an orthopaedic surgeon, whom she saw on September 21, 2012. The history recorded by the surgeon was of bilateral knee pain which had been present for years. The worker denied that she had any prior knee issues and did not know why the surgeon provided that history. Despite the worker's statement that she had no prior issues with her knees, she did undergo a right knee MRI in February 2009. The worker's explanation was that this was performed due to issues she had with her right foot at the time, which was moving up into her knee. The panel feels that the existence of the MRI from 2009 is consistent with a knee condition which had been present for years.
The report from the physiotherapist's initial assessment performed September 7, 2012 also described ongoing knee pain, progressively worsening over the last year and querying whether this was secondary to workload at work. This is yet another report describing a gradual onset of knee difficulties, as opposed to an acute onset caused by a fall on the stairs. Notably, neither the orthopedic surgeon nor the physiotherapist were told about the April 18, 2012 workplace fall. This would suggest that it was not a significant event in the development of the worker's bilateral knee condition.
The treatment provided by the physiotherapist addressed the knees bilaterally and also the left hip. With respect to the knees, the condition being treated was patellofemoral pain syndrome. The worker was not treated for a meniscal tear, once again suggesting that an acute tear of the meniscus was not sustained as a result of the workplace accident.
The worker did not deny that there was pre-existing degeneration in both of her knees, but noted that the November 29, 2012 MRI indentified a new meniscal tear in her right knee which had not been present in the 2009 MRI. This is true, but the panel also notes that the new tear is described as degenerative. The operative reports from both the knee surgeries reference extensive degenerative changes and the procedures performed repaired not only the meniscal tears but also a number of other degenerative conditions. Overall, on a balance of probabilities, the panel finds that there is simply not enough support for the finding that the worker suffered bilateral meniscal tears as a result of her fall on April 18, 2012. The absence of acute clinical findings in the initial period following the incident and the fact that significance was not placed on the fall until some time later leads the panel to conclude that the workplace accident was not responsible for the bilateral knee condition which led to the need for surgical repair. We therefore find that responsibility for the surgeries performed on February 28, 2013 and April 13, 2013 should not be accepted in relation to the compensable accident of April 18, 2012.
The worker's appeal is dismissed.
Panel Members
L. Choy, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
L. Choy - Presiding Officer
Signed at Winnipeg this 7th day of February, 2014