The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board that his loss ofearning capacity or need for medical aid after February 12, 2014 was not relatedto his compensable workplace injury.  Ahearing was held on April 14, 2015 to consider the matter.

Issue

Whether or not the worker is entitled to benefits afterFebruary 12, 2014.

Decision

That the worker is not entitled to benefits after February12, 2014.

Decision: Unanimous

Background

On August 16, 2013, the worker filed a claim with the WCB for a left knee injury that developed on July 8, 2013 while unloading and carrying heavy radiators.

The employer's accident report confirmed that the worker was unloading truckloads of radiators weighing 200 pounds with another employee. The worker did not feel any pain on July 8, 2013 but the next morning his knee felt like a sprained finger. The worker kept working and on August 15, 2013 his knee swelled up so he sought medical attention.

On August 15, 2013, the treating physician diagnosed the worker with a strain to the left medial collateral ligament or a left knee meniscal tear.

X-rays dated August 16, 2013 reported moderate joint effusion with mild degenerative changes at the patellofemoral compartments. No acute fractures were identified.

On September 5, 2013, a WCB case manager recorded information she obtained from the worker with respect to his work duties and his left knee symptoms following the accident of July 8, 2013.

An MRI of the left knee dated September 13, 2013 reported moderate chondromalacia of the patellofemoral articulation, moderate chondromalacia of the medial femoral tibial compartment and degenerative fraying and attrition of the medial meniscus with no meniscal tear identified.

At the case manager's request, a WCB medical advisor reviewed the file information on October 17, 2013 and provided a medical opinion regarding the compensable diagnosis, treatment plan, prognosis and recommendations for orthotics.

On November 6, 2013, the WCB advised the worker that he was considered fit for modified duties with restrictions and that a return to work was arranged for November 12, 2013.

In a further decision dated November 8, 2013, the worker was advised that his claim for compensation was accepted for an aggravation of pre-existing osteoarthritis to his left knee. As a prescription for orthotics was related to the diagnosis of patella femoral syndrome, this was not approved.

On December 20, 2013, an orthopedic specialist reported that the worker was experiencing trouble with light duties and that he had knee pain particularly on the medial aspect. The examination showed swelling of the joint and tenderness along the medial joint line. It was felt that an arthroscopy would be appropriate.

On January 22, 2014, a WCB medical advisor outlined the following medical opinion after a WCB call-in assessment:

• the initial diagnosis of July 8, 2013 was symptomatic osteoarthritis of the left knee.
• osteoarthrosis was a common age-related degenerative condition. It may become symptomatic at any time, more often than not without trauma or a specific recognized trigger.
• the current diagnosis remained to be symptomatic osteoarthrosis of the left knee.
• review with the worker regarding the nature of his workplace duties did not indicate either a specific injury to the left knee on or about July 8, 2013 or a substantial increase in activities or demands on the knees likely to account for the symptomatic left knee osteoarthrosis since July 2013.
• the pre-existing left knee osteoarthrosis was not aggravated by a workplace exposure.
• the proposed surgery was to address the pre-existing degenerative osteoarthrosis.

By letter dated February 10, 2014, the worker was advised that the WCB was unable to establish that his ongoing left knee difficulties were related to the July 8, 2013 compensable injury based on the x-ray, MRI findings and the WCB healthcare opinion following the call-in assessment and the fact there was no specific workplace trauma to the left knee. The worker was advised that compensation benefits would end effective February 12, 2014.

In a report dated April 15, 2014, the treating orthopedic surgeon stated:

[The worker] was operated on by myself on April 9, 2014. He indicated to me pre-operatively that he had been cut off WCB. Presumably this was because there was concern that his tear was of a degenerative nature as described in the September 2013 MRI. He did however, at surgery as you will see from the operative report, have a complex type of meniscal tear with flap formation; clearly one that could have been produced in a work-related accident. He certainly had no problems prior and it came on suddenly....The September 2013 MRI report cannot identify a distinct tear. Clearly this was not the case at arthroscopy. As good as MRI assessments are, they are not the final word when it comes to this kind of business.

Following a WCB call-in examination on May 9, 2014, the WCB orthopedic consultant stated:

1. Current symptoms are caused by degenerative joint disease of the left knee. The degree of this was documented at arthroscopy.
2. It is not possible to demonstrate by objective medical evidence that there is any causative link between a workplace injury and the current knee status. Had the tear of the medial meniscus occurred during the described workplace activities, it would have caused at least momentary pain which was not the case. There is no doubt that there were degenerative changes in the articular surfaces of the left knee and in the medial meniscus prior to the onset of symptoms. It was not known what caused the complex tear of the medial meniscus. The configuration of the meniscal tear could have been either degenerative or traumatic etiology. It may well have occurred gradually over time with activities of daily living. The tear of the meniscus may have been brought about by repetitive strenuous work activities, even though there was no episode of painful trauma. There was no objective medical evidence to demonstrate that the meniscus tear or the degenerative condition of the knee generally was the result of the workplace injury.

By letter dated May 16, 2014, the worker was advised that the WCB was unable to establish that his current left knee difficulties requiring surgery were related to his compensable injury of July 8, 2013. The case manager indicated that the worker's accident history and the WCB medical opinions of January 22 and May 9, 2014 did not demonstrate that a specific trauma occurred to the worker's left knee on July 8, 2013. Therefore the meniscal tear found at surgery on April 9, 2014 was not work-related.

On July 3, 2014, the Worker Advisor Office requested Review Office to reconsider the decisions made on February 10 and May 16, 2014. The worker advisor argued that the file evidence supported a relationship between the worker's left knee injury and his employment duties and that the tear found at surgery was work-related.

On September 3, 2014, the employer's representative submitted to Review Office that the worker's knee injury was not work-related. The employer's submission was then provided to the worker advisor and a response is on file dated September 11, 2014.

On September 19, 2014, Review Office determined that there was no entitlement after February 12, 2014. Review Office stated:

• the x-ray and MRI findings represent a pre-existing condition that was not caused by the July 8, 2013 accident.
• it accepted the employer's earlier reports regarding the weight of the radiators and the information provided by the worker's supervisor, instead of the information provided by the employer on September 3, 2014, as more probable.
• the diagnosis in relation to the compensable injury was a left knee strain and aggravation of the worker's pre-existing osteoarthritis or osteoarthrosis.
• it accepted the January 22, 2014 WCB medical opinion that the current diagnosis remained symptomatic osteoarthrosis of the left knee and that the worker's pre-existing left knee osteoarthrosis was no longer aggravated by his workplace activities.
• it did not find that the sub-acute tearing of the meniscus was caused by the accident. It accepted the May 9, 2014 WCB medical opinion that the worker's current symptoms were caused by left knee degenerative joint disease.

On October 7, 2014, the worker advisor 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 appeared at the hearing accompanied by a worker advisor. The worker's position was that his left knee injury should have remained as compensable as the evidence supported that he had an ongoing medial joint injury, along with symptoms and difficulties which had not resolved as of February 12, 2014. It was submitted that there was more than a strain injury from the beginning of the claim, and that there was an ongoing relationship between the compensable knee strain, a medial meniscus tear and the pre-existing condition which, in concert, continued to cause a loss of earning capacity for which wage loss benefits should have been continued.

Analysis:

The issue before the panel is whether or not the worker is entitled to benefits after February 12, 2014. In order for the worker's appeal to succeed, the panel must find that the workplace injury to the worker's left knee remained symptomatic after February 12, 2014 and either caused or contributed to a meniscal tear which necessitated arthroscopic surgery on April 9, 2014. On a balance of probabilities, we are not able to make that finding.

At the hearing, the worker described the mechanism of injury. He had consistently indicated that he did not recall any twisting of his knee. He had been lifting heavy items, which was a usual task for him and then started to experience pain in his knee. The next morning, his knee was noticeably stiff and sore. The worker continued to work for the next six weeks and found that his knee was getting worse and worse. Finally, on August 15, 2013, his knee swelled up and so he went to a walk-in clinic for medical attention after work. The worker indicated that the onset of the knee difficulties was gradual and that he did not experience any sudden or sharp incidents of pain.

Unfortunately, the mechanism of injury described by the worker is not consistent with a finding that the worker suffered a meniscal tear while at work on July 8, 2013. Typically the panel would expect there to be a twisting action of the knee while weight bearing for a mensical tear to occur. Further, the WCB orthopedic consultant indicated that if a tear occurred during workplace activities, one would reasonably expect the tear to have caused at least momentary pain. On the facts of this case, there was no report of acute pain. The onset was always reported to have been gradual.

The panel finds that the worker's description of his knee difficulties is more consistent with a degenerative condition than an acute tear. Although the treating surgeon indicated that the complex type of meniscal tear found at surgery was "clearly one that could have been produced in a work-related accident" (emphasis added), the WCB medical advisor indicated that the configuration of the meniscal tear could be either degenerative or traumatic. In the panel's opinion, other indicators suggest a degenerative condition. The MRI of September 13, 2013 reported degenerative fraying and attrition of the medial meniscus, thus indicating the presence of a significant degree of degenerative change in the knee. At that time, no distinct tear of the medial meniscus was identified. At the October 15, 2013 medical appointment, the attending physician reported that the range of motion was normal and that McMurray's test was negative. This is of importance as both of those clinical findings are used to identify the presence of a meniscal tear. Both indicated a negative presence.

The overall picture described by the worker is more consistent with a degenerative etiology for his meniscal tear in that the worker was not aware when the tear occurred, the onset developed gradually, and that the pain would increase with activity. The worker did not describe a sudden dramatic onset of symptoms with significant pain, which would have been anticipated had the tear been acute. For the foregoing reasons, the panel finds that the worker's injury was limited to a strain/aggravation which resolved and that he is not entitled to benefits after February 12, 2014. The worker's appeal is dismissed.

Panel Members

A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Finkel - Presiding Officer

Signed at Winnipeg this 8th day of May, 2015