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 complaints were not related to her compensable accident and therefore she was not entitled to benefits beyond May 31, 2012. A hearing was held on December 3, 2013 to consider the matter.

Issue

Whether or not the worker is entitled to benefits beyond May 31, 2012.

Decision

That the worker is entitled to benefits beyond May 31, 2012.

Decision: Unanimous

Background

On June 10, 2011, the worker slipped and fell while going down a flight of stairs and injured her right knee, low back and hip. Her claim for compensation was accepted based on the diagnosis of a right knee sprain/strain. No specific diagnoses were given with respect to the worker's right hip, thigh or low back.

On July 8, 2011, an MRI of the right knee revealed chondromalacia femoral trochlea and no evidence of a meniscal tear. An MRI of the lumbar spine and right hip taken October 6, 2011 reported no significant abnormalities.

The worker was then seen by a WCB medical advisor on September 22, 2011 for an assessment of her medical status. With respect to the accident of June 10, 2011, the worker noted that when she slipped on the staircase, she fell approximately 10 to 12 steps. She said her left leg slipped out in front of her and her right leg bent backwards and she slid down the stairs with the right leg hyperextended at the hip.

Following the medical assessment, the medical advisor reported that the diagnosis was unclear beyond the descriptor of right hip girdle pain and possible L5-S1 radicular pain. The worker's major complaint was discomfort emanating from the right buttock area extending down the right leg. There was decreased range of motion in the right hip. The reported distribution of symptoms appeared to involve multiple dermatomes but was most centered on the L5-S1 area. While significant back pain was not reported, the medical advisor felt that the mechanism of injury could account for the disc injury and associated radiculopathy. It was felt that the examination showed a number of inconsistencies and significant pain focus. The medical advisor stated that the mechanism of injury would be in keeping with contusions and strain type injuries and that the lack of any reported improvement over more than three month's time was unaccounted for.

Ongoing medical reports showed that the worker underwent physiotherapy treatment and was seen by her family physician. On January 9, 2012, the WCB medical advisor commented that the current diagnosis was non-specific low back pain and right hip pain.

In February 2012, the worker underwent a rehabilitation assessment and later underwent a trial of trigger needling treatment to the right paravertebral area and right gluteus medius muscle.

On March 26, 2012, the treating physician assessed the worker with myofascial back pain.

A Discharge Report from the reconditioning program dated April 9, 2012 indicated that the worker was in the light category of physical demands with minimal components of medium handling. It was suggested that a graduated return to work with modified duties with temporary restrictions was appropriate. Given the worker's lack of progress in clinic, the worker was discharged from treatment on April 3, 2012.

On May 23, 2012, a WCB medical advisor commented that the current diagnosis remained as non-specific right hip girdle pain based on the MRI of the lumbar spine and right hip. She stated that the worker's current presentation was not medically accounted for in relation to the workplace injury. There was no evidence of an injury-related diagnosis beyond the contusion/strain and the natural history of such conditions was for recovery over a period of days to weeks. The persistence of reported symptoms now at almost one year post injury was unaccounted for.

On May 24, 2012, it was determined by the WCB that the worker had recovered from her accident by May 31, 2012 based on the mechanism of injury, the imaging studies and the length of time since her injury.

In a report dated September 13, 2012, an occupational health physician stated:

By my assessment, she continues to be quite symptomatic in and around the right hip girdle since her June 2011 fall at work…the heavy bruising was on the left hip, but her ongoing symptoms are on the right…there is consistency between my examination and earlier ones performed, I pick up extra dural sciatic nerve impingement in the buttock with positive piriformis test and indications of ongoing SI joint irritation…By my assessment, she has considerable impairments related to her injury and she is not capable of returning to her pre-injury work load…the nature of her clinical problems of SI joint irritation, extra-dural sciatic impingement (piriformis syndrome) and myofascial pain that are consequences of her work injury are not easily detected by the imaging modalities.

The worker underwent a bone scan examination on October 11, 2012. On December 6, 2012, the occupational health physician commented that the bone scan showed radiotracer uptake within the superior and posterior aspect of the left iliac bone near the SI joint. The physician also stated:

The clinical exam is suspicious of ligament strain across both SI joints…She did sustain her fall at work, landing hard on her left hip, so the finding of the bone scan does correspond with her work injury.

On January 11, 2013, a WCB medical advisor reviewed the reports from the occupational health physician and stated that there was no change to the WCB medical opinion of May 23, 2012. It was noted that the worker previously reported symptoms in the right hip area and that the recent bone scan identified an area of moderately increased uptake on the left side near the SI joint. This finding was likely incidental and was unrelated to the effects of the compensable injury. The medical advisor indicated that the October 2011 MRI of the right hip and lumbosacral spine would have included the SI joints and no abnormalities were noted.

The medical advisor also indicated that the examination findings of the occupational health physician on September 13, 2012 differed from his examination findings after reviewing the bone scan findings in his more recent report of December 6, 2012. The report from the physical medicine and rehabilitation specialist of March 7, 2012 did not indicate concern about an SI joint issue. As well, the discharge report from the reconditioning program dated April 9, 2012 noted "Based on her diagnosis at the time of our initial assessment and her time in clinic, a return to her full time position without restrictions would be expected."

In a decision dated January 22, 2013, the worker was advised that the WCB was unable to accept further responsibility for her claim based on the WCB medical opinion of January 11, 2013 and therefore the decision to terminate WCB wage loss benefits remained unchanged. On March 20, 2013, the worker appealed the decision to Review Office.

On May 23, 2013, Review Office determined that the worker was not entitled to benefits beyond May 31, 2012. Review Office preferred to place significant weight to the information collected in the closest proximity to the worker's accident, which occurred on June 10, 2011. It found that the worker sustained strain/sprain injuries that affected her right hip, right knee and low back. It felt that the worker's x-rays and MRI results did not demonstrate any structural changes related to the compensable injuries. Review Office determined that a causal relationship between the worker's reported ongoing difficulties and her compensable injuries could not be established. On May 28, 2013, the worker appealed Review Office's decision to the Appeal Commission and a hearing was arranged.

Following the hearing, the appeal panel met to discuss the case and requested additional medical information from the treating anesthesiologist. On March 21, 2014, the worker was provided with a copy of the additional medical information and she was asked to provide comment. On April 9, 2014, the panel met further to discuss the case and render its decision.

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.

Worker’s position

The worker was self-represented at the hearing. It was submitted by the worker that she suffered a terrible fall as a result of which she injured her lower back. Since the fall her symptoms had never stopped and were always consistently complained of as pain radiating down her right side. The worker felt that the bone scan arranged by the occupational health physician proved that an injury did occur and that the injury was still hampering her recovery. The worker also felt that if the proper exams had been done when the accident first happened, there would have been more proof to tie the fall, injury and diagnosis together.

Overall, it was submitted that the worker did sustain an injury from the fall which was still affecting her up until the present time.

Analysis

To accept the worker’s appeal, we must find on a balance of probabilities that she continued to suffer from the effects of her workplace accident beyond May 31, 2012. We are able to make that finding.

There is no question that the worker suffered a significant trauma when she fell on the stairs. At the hearing, the worker described mis-stepping when she was descending a second flight of stairs which caused her left leg to go out in front of her. She grabbed the railing while her right leg crumpled behind her, almost in a "splits" position. The initial point of impact between the stairs and her body was her lower back, just above her buttocks. She then slid all the way down to the bottom of the stairs, approximately nine steps.

Following the hearing, the panel requested additional medical information from a treating anesthesiologist, who began treating the worker in November 2013. In his report to the panel dated March 19, 2014, the anesthesiologist indicated that the worker was trialed with a right sacroiliac ("SI") joint injection, which provided her with partial relief of her pain. As the injections tend to wear off over a period of 2 1/2 to 3 months, the treatment plan was to repeat these injections at 3 to 4 month intervals.

It is notable that the SI joint injections have been met with some success since all of the treatment modalities previously undergone by the worker, including segmental neuropmyotherapy, chiropractic therapy, physiotherapy, and review by a neurologist, have not provided any relief.

On review of the medical file, it would appear the SI joint has been consistently identified as a problem area for the worker, including:

• Call-in Examination of September 22, 2011 - the worker indicated her discomfort was felt not at the spine, but in the right buttock area at approximately the area of the SI joint. She reported that this discomfort radiated around to the anterior hip area and down the right leg as far as the foot.
• Rehabilitation Assessment of February 8, 2012 - there was discomfort at the lumbo-sacral junction to pressure and also of the right SI joint complex. However, SI mobility was equally bilaterally when tested in a standing position and specific SI stress testing was negative.
• The occupational health physician's examination on August 15, 2012 identified extra dural sciatic nerve impingement in the buttock with positive piriformis test and indications of ongoing SI joint irritation. As a result of these findings, the worker was sent for a bone scan to investigate possible SI joint abnormalities. Although the October 11, 2012 bone scan showed uptake within the left iliac bone near the SI joint, the occupational health physician felt that the clinical exam was suspicious of ligament strain across both SI joints with evidence of ensethopathy of the left upper SI ligaments and the worker was referred for the SI joint injections, which, as noted earlier, have been met with success.

Fortunately, it appears that the worker's condition is slowly improving, with greater abilities reported since the time of her discharge from the Rehabilitation program in April 2012. The worker has been able to return to work to her regular position, albeit with the need to modify the way she performs her job duties in order to remain at work on a full-time basis. It is hoped that the SI joint injections will help maintain her return to the workplace.

On a balance of probabilities, the panel finds that the continuity of symptoms identified in the SI joint is sufficient to satisfy us that the worker suffered injury to her SI joint when she fell down the stairs on June 10, 2011.

The panel notes that the treating anesthesiologist indicated that the most likely diagnosis for the worker's ongoing pain is right SI joint arthritis. The panel's understanding is that arthritis is a progressive condition which develops slowly over time and does not immediately develop as the result a single acute incident. We therefore do not accept that right SI joint arthritis itself is compensable. We do, however, accept that the worker's SI joint arthritis was a pre-existing condition which was aggravated and made symptomatic by the workplace fall. Since the time of the accident, there has been ongoing SI joint irritation, which the panel finds is compensable.

We therefore find that the worker is entitled to benefits beyond May 31, 2012. The worker's appeal is allowed.

Panel Members

L. Choy, Presiding Officer
C. Devlin, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 13th day of May, 2014