The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that his ongoing bilateral hand/arm issues were not causally related to his compensable injury. A hearing was held on June 16, 2014 to consider the matter.

Issue

Whether or not the worker is entitled to benefits after September 19, 2013.

Decision

That the worker is not entitled to benefits after September 9, 2013.

Decision: Unanimous

Background

The worker filed a claim with the WCB on March 9, 2012 stating that he was diagnosed with carpal tunnel syndrome ("CTS") and that he underwent surgery to his right hand on March 9, 2012. The worker reported that in early January 2012, he noticed a significant loss of strength in his right hand and by early March 2012, he felt tingling and numbness. The worker attributed his condition to the nature of his job duties as a mechanic which involved turning and pulling wrenches.

In a February 16, 2012 report to the family physician, a neurology consultant reported that the worker had been having increasing weakness of his right hand. He had difficulty using a wrench with weakness of opposition of the right thumb. He also had intermittent tingling of the right hand. The neurologist referred to nerve conduction study results and stated that the worker's symptoms were indeed consistent with a right CTS. He also stated, "However, what is rather unusual is that he has more motor than sensory symptoms...Nerve conduction studies are also abnormal, with the motor component being much more significant than the sensory component. It is my opinion that the right carpal tunnel should be decompressed surgically. Because of the discrepancy between the motor and sensory components, one must always keep in mind the possibility of a motor neuron disease although there is no evidence of this at this time...Although he is asymptomatic on the left, nerve conduction studies have also demonstrated a mild and really negligible left median neuropathy at the wrist. There is no reason to decompress his left carpal tunnel at this time since he has no symptoms on that side."

On April 2, 2012, the worker was notified that his claim for compensation was accepted for bilateral CTS. The WCB also accepted responsibility for the March 9, 2012 right carpal tunnel decompression surgery.

On April 10, 2012, the worker attended his surgeon for a follow up visit. The surgeon noted that the worker did some minor work at home over the weekend and he described gross swelling of his hand and wrist. When seen on April 10, 2012, there was no evidence of swelling. He said the worker had a good result in terms of the median nerve decompression and there was no evidence of neuropathy.

On April 23, 2012, the worker returned to modified duties at reduced hours while attending chiropractic treatment. On June 6, 2012, the worker advised the WCB that May 29, 2012 was his first day back at full time work when he experienced significant swelling in his right wrist. File records showed that the worker reduced his hours of work and the WCB authorized additional chiropractic treatment.

On August 1, 2012, the treating chiropractor reported that the worker's right wrist ached when he pushed it at work doing lifting or heavy manual labor. Examination findings showed full range of motion in the right wrist and there was tenderness of the right thenar eminence and palmar surface.

Due to ongoing wrist difficulties, the worker attended a physiatrist/neurophysiologist on November 9, 2012 and further nerve conduction studies were carried out. The specialist reported that the worker presented post-carpal tunnel surgery with right medial forearm pain and nocturnal hand paresthesias. He stated: "His electrodiagnostic findings are extremely atypical (as in I've never seen this before) for carpal tunnel syndrome. The sensory fibres are always affected both clinically and electrically to a significant extent before the motor fibres becomes affected. To me it really calls into question whether there may have been a superimposed diagnosis here. The surgery however did lead to a significant improvement in the motor response as measured by nerve conduction studies today. Strictly speaking there is no carpal tunnel syndrome any longer. I don't feel that further carpal tunnel surgery will necessarily improve any of his symptoms." The specialist further noted that the pain found in the worker's right medial forearm seemed to be mostly medial epicondylopathy (golfer's elbow). He noted that the worker's physically demanding job with his forearms may have provoked the medial epicondylopathy.

On January 9, 2012, a WCB medical advisor reviewed the November 9, 2012 report and stated:

As per the consulting Physiatrist/Neurophysiologist's November 9, 2012 report , [the worker] has neurophysiological findings at his right wrist that was not consistent with CTS. Further, [the worker's] symptoms of numbness in his entire right hand are not consistent with the sensory distribution of the median nerve, the nerve affected in CTS. The right carpal tunnel surgery was documented to have resulted in significant improvement in [the worker's] right median nerve motor conduction. It was the opinion of the consulting Physiatrist/Neurophysiologist that [the worker] did not have CTS any longer. As such, it would appear that [the worker] has recovered from his compensable carpal tunnel syndrome, and its attendant surgery.

...The Neurology report of February 16, 2012 suggests that an as yet undiagnosed motor neuron disease could not be ruled out. That opinion is currently as relevant now as it was in February 2012. While an alternate explanation for [the worker's] right hand weakness is yet to be found, medical evidence currently on file does not support that his right hand weakness is work related...It is unlikely that [the worker's] right and left elbow symptoms are related to overcompensating for his right hand. Further, the suggestion in the November 9, 2012 Physiatrist/Neurophysiology report that the March 9, 2012 carpal tunnel surgery may have provoked the right medial epicondylopathy is speculation. One would actually expect less strain at the medial epicondyle in the absence of the fulcrum offered by the transverse carpal ligament. With that said, the forceful repetitive nature of [the worker's] work duties could provide a medial epicondylopathy unrelated to his previous carpal tunnel syndrome.

Based on evidence currently on file, it is unlikely that referral to a neurologist is related to the January 12, 2012 CI [compensable injury]. A probable workplace injury/diagnosis in relation to [the worker's] currently reported hand symptoms is not evident. The Neurologist will likely be asked to see [the worker] in order to arrive at a diagnosis that would be consistent with [the worker's] reported symptoms and neurophysiologic findings. Once [the worker] has seen the Neurologist, his report can be reviewed to determine whether the aforementioned opinion regarding the work relatedness of [the worker's] current right hand symptoms should be altered.

On January 30, 2013, the worker was advised that based on a review of all medical information on file, the WCB determined that he had recovered from the CTS surgery of March 9, 2012 and that the WCB was not accepting responsibility for his left and right elbow/forearm difficulties as being related to his right carpal tunnel diagnosis and subsequent surgery in the absence of any further reported workplace injury. The worker was advised that the WCB would review the neurologist's report once it became available to determine if any change could be made to this decision.

On February 5, 2013, the neurologist stated: "In summary, I do not find evidence of an alternate neurological diagnosis to account for [the worker's] ongoing impairment in the right upper limb. I think his median nerve has been adequately decompressed. I suspect his ongoing complaints in the hand may be related to mechanical factors that are a consequence of carpal tunnel release, and are no doubt aggravated by his attempts to return to a physically demanding occupation." A referral to an orthopaedic consultant who specialized in hand function was suggested.

On February 11, 2013, the treating chiropractor submitted a narrative report to the WCB regarding his involvement in the worker's treatment and outlined the opinion that the worker was still experiencing carpal tunnel related symptoms.

The worker saw a plastic surgeon on March 27, 2013 who outlined the view that the worker required an open carpal tunnel incision with exposure of the median nerve to assess for possible neuroma of the recurrent motor branch to the thenar muscles.

On April 11, 2013, a WCB orthopaedic consultant reviewed the file and stated:

1. Several opinions from neurology specialists stated that a second carpal tunnel decompression would be contra-indicated because of improvement in NCS/EMG studies following simple carpal tunnel decompression.
2. A recent opinion from a plastic surgeon has advised re-exploration of the median nerve at the wrist. It is uncertain if this specialist was fully aware of the neurological testing.
3. There are arguments against further nerve dissection or epineurolysis in that scarring risks might well outweigh any possible benefits of such surgery.
4. I recommend a further hand surgery consultation, with provision of all relevant testing results.

The WCB arranged for the worker to see an orthopaedic consultant regarding the worker's right hand weakness/reduced opposition and hand tingling. The specialist was asked to comment on whether the right hand symptoms were related to altered biomechanics subsequent to the carpal tunnel release procedure and if further surgery was indicated.

In a report dated June 5, 2013, the orthopaedic specialist outlined his examination findings and reported that the worker "has signs and symptoms consistent with myofascial discomfort. His multiple previous EMG and nerve conduction studies do not demonstrate any signs of requiring surgical management. I think it is reasonable for him to consider wearing some nighttime wrist bracing and try to help him sleep. I discussed the need to consider job retraining as a heavy duty mechanic does not appear to be helping his myofascial discomfort. I unfortunately have no surgical management to offer him..."

On July 17, 2013, the WCB medical advisor suggested that the worker undergo a Functional Capacity Evaluation ("FCE") to determine grip strength. The FCE was performed on August 9, 2013.

On September 4, 2013, a WCB physiotherapy consultant and senior medical advisor reviewed the FCE results. It was concluded that the FCE results were not valid in determining the worker's functional capacity including grip strength. Over the course of the FCE, the worker demonstrated within normal limits left and right hand grip strength when matched for age and sex.

On September 11, 2013, the WCB medical advisor reviewed the file and concluded that "in light of the non-specific nature of [the worker's] reported symptoms (at any site in his upper limbs), [the worker's] currently reported limitation of right upper limb power is not substantiated, and is unlikely to be related to the January 12, 2012 CI."

By letter dated September 12, 2013, the worker was advised that no change could be made to the decision of January 30, 2013 as the WCB was unable to medically account for his ongoing symptoms in relation to his compensable injury. The decision was reached based on the findings of the orthopaedic consultant, the FCE analysis by the WCB senior medical advisor and the WCB medical opinion outlined on September 11, 2013. On January 28, 2014, the worker appealed the decision through the Worker Advisor Office.

On March 20, 2014, Review Office referred to medical evidence on file to support its conclusion that the worker's ongoing bilateral hand/arm issues were not causally related to the compensable injury. Review Office determined that the worker was entitled to benefits to September 19, 2013 as this was the date that the WCB clarified that the worker's ongoing issues were not related to the compensable injury. On April 2, 2014, 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. The worker has an accepted claim for a workplace injury and is seeking benefits beyond September 19, 2013.

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 attended the hearing with his wife. The worker explained his position and answered questions from the panel.

The worker advised that he received his "Red Seal" as an auto mechanic in 1996 and that he has been employed as a mechanic in a small business in rural Manitoba. He advised that prior to the injury he was fit, active in his community and had no work problems.

He advised that in January 2012 he started to lose strength in his right hand and had problems performing his duties. He was ultimately diagnosed with carpal tunnel syndrome and had surgery on his right hand. He had no follow-up until week 5. He said that initially his recovery seemed to go smoothly. He returned to work on a graduated basis in April 2012. His hours were increased in May 2012 and his right hand became swollen and painful. By August 2012 he had developed twitching in the thumb.

He advised that he received treatment from his chiropractor and saw several different medical experts, including a plastic surgeon who recommended that he undergo surgery in the carpal tunnel area. He noted that the WCB denied the surgery and sent him to see another surgeon.

Regarding the Functional Capacity Evaluation he participated in, the worker advised that he was told not to perform tests if it hurts. He feels the results are inconclusive.

The worker advised that he returned to work and since October 2013 has been able to work various terms at a local high school as a substitute vocational teacher. He works at his pre-accident employer between teaching positions and is being accommodated by the employer. He works 4 hour shifts at this position. He also advised that he has enrolled in upgrading to improve his teaching qualifications.

He advised that there are no issues with his left arm affecting his ability to work.

Employer's Position

The employer did not attend the hearing but wrote to the WCB on February 17, 2014 indicating that it supported the worker's claim. The employer wrote, in part:

"In summary, [worker] has a problem with his hand. He went to the doctor, had surgery and now is worse off than before. His hand should be seriously looked at and possibly surgically repaired...If the hand is permanently damaged, possible retraining for another line of work should be made available to him."

Analysis

The issue before the panel is whether or not the worker is entitled to wage loss benefits after September 19, 2013. In order to determine the appeal, the panel must consider whether or not the worker suffered a loss of earning capacity due to his workplace injury beyond this date. On a balance of probabilities, the panel finds that the worker does not have a loss of earning capacity as a result of his workplace injury and is not entitled to wage loss benefits after September 19, 2013.

In reaching this decision the panel notes the original diagnosis for the worker's injury was bilateral carpal tunnel syndrome. Surgery was recommended and performed on the right hand. The worker's left hand was symptom free and no treatment was recommended. The panel finds, on a balance of probabilities and based upon the medical evidence on file, that the accepted condition has resolved. The panel accepts the following opinions on this issue:

• medical report dated November 9, 2012 from a physiatrist/neurophysiologist who opined that "Strictly speaking there is no carpal tunnel syndrome any longer. I don't feel further carpal tunnel surgery will necessarily improve any of his symptoms."
• medical report dated February 5, 2013 from a neurologist who examined the worker and concluded:

  

"In summary, I think it is quite clear that [name] had right carpal tunnel syndrome, which from an electrophysiological perspective responded well to the release last March...Clinically he does not demonstrate any neurological deficits on examination...In summary, I do not find evidence of an alternate neurological diagnosis to account for [worker's] ongoing impairment in the right upper limb...."medical report dated June 5, 2013 from an orthopedic surgeon who examined the worker and concluded that the worker's "...multiple previous EMG and nerve conduction studies do not demonstrate any signs of requiring surgical management."

• The panel notes there is discussion in the file about the variety of symptoms which the worker has reported. The panel also notes the physicians, who have examined the worker, have offered comments on the nature of the condition. However, at this time there is no clear diagnosis of the condition and no probable causal link between the worker's original accepted injury and his current symptoms has been established. In this regard, the panel accepts the September 11, 2013 opinion of the WCB medical advisor that "... in light of the non-specific nature of [the worker's] reported symptoms (at any site in his upper limbs), [the worker's] currently reported limitation of right upper limb power is not substantiated, and is unlikely to be related to the January 12, 2012 CI.

The panel also notes the physicians, who have examined the worker, have offered comments on the nature of the condition. However, at this time there is no clear diagnosis of the condition and no probable causal link between the worker's original accepted injury and his current symptoms has been established. In this regard, the panel accepts the September 11, 2013 opinion of the WCB medical advisor that "... in light of the non-specific nature of [the worker's] reported symptoms (at any site in his upper limbs), [the worker's] currently reported limitation of right upper limb power is not substantiated, and is unlikely to be related to the January 12, 2012 CI."

One of the conditions referenced in the medical reports is epicondylitis of both arms. The worker advised that it was more prominent in his left arm but that it did not affect his ability to work. The file evidence at this time does not, on a balance of probabilities, support a causal relationship between the left arm condition and the worker's employment. The worker's appeal is dismissed.

Panel Members

A. Scramstad, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer

Signed at Winnipeg this 27th day of June, 2014