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 hip and groin complaints were not related to his compensableaccident of December 3, 2008.  A hearingwas held on June 2, 2015 to consider the matter.

Issue

Whether or not the worker's ongoing hip and groindifficulties are related to the December 3, 2008 compensable accident.

Decision

That the worker's ongoing hip and groin difficulties are notrelated to the December 3, 2008 compensable accident.

Decision: Unanimous

Background

On December 3, 2008, the worker fell off a ladder during the course of his employment as a public worker assistant. On the same day of accident, the worker attended for medical treatment with complaints of right groin and hip tenderness. The diagnosis rendered was a soft tissue injury. Pelvis and right hip x-rays taken December 6, 2008 revealed no fracture in either area. On December 18 and 30, 2008, the attending physician reported that the worker also injured his right knee and ilium.

A WCB medical advisor reviewed the claim file on January 2, 2009 and opined that the current diagnosis was a contusion of the right hip and that soft tissue injuries of this nature would resolve in 6 to 8 weeks. The medical advisor indicated that he was unable to comment on the worker's knee complaints until further information became available.

In February 2009, the worker commenced physiotherapy treatments based on the diagnosis of a muscle strain. In late April 2009, the worker was discharged from physiotherapy treatment.

In June and October 2009, the worker was seen by an orthopedic surgeon for left upper extremity complaints. On November 6, 2009, the WCB determined that the worker's left arm complaints were unrelated to the December 3, 2008 accident.

On January 13, 2010, the worker spoke with a WCB adjudicator stating that he had back and leg spasms as well as continuing pain in his right hip. The worker stated that he had CTS surgery on his left hand and no longer had left arm pain.

On February 3, 2010, the worker was treated by an orthopedic specialist for right knee complaints. On February 25, 2010, a WCB medical advisor determined that the knee complaints were more likely related to a non-compensable condition rather than the workplace accident in December 2008.

On February 26, 2010, the worker underwent a CT scan of the pelvis which read as follows:

At the right anterior pubis there is an exostosis projecting inferiorly at the anterior adductor insertion. This likely relates to a remote avulsion injury which has healed. There is no atrophy within the adductor muscles. The hips and SI joint are unremarkable.

A WCB medical advisor reviewed the claim file on April 14, 2010 and stated that the current diagnosis was a non-compensable right knee meniscus tear and possible old fracture of the right pubic ramus (pelvis).

In a decision dated April 15, 2010, the WCB advised the worker that based on WCB medical opinion, his ongoing difficulties were not related to the December 3, 2008 right hip injury and that he had recovered from the effects of his compensable injury.

On January 12, 2011, the worker underwent a regional bone scan which was read as follows: "The activity seen involving the right anterior pubis is consistent with bony remodeling related to an old avulsion injury. There is no evidence of osteomyelitis."

On April 20, 2011, a WCB medical advisor stated that the current diagnosis was healed avulsion fracture of the right anterior pubic ramis. The medical advisor also stated: " I am not able to relate ongoing pain symptoms to this injury. It is more than two years since the injury and it is most unlikely that the various complaints are causally related to the December 2008 incident. He returned to work promptly according to the file. Recovery from this type of injury is anticipated to occur in 3-4 months. In February 2009, the treating physician reported "nil" findings suggesting that the claimant had made a functional recovery at that time."

In a May 3, 2011 decision, the worker was advised that based on WCB medical opinion, it was felt that he had essentially recovered from his December 3, 2008 injury and that his ongoing difficulties (i.e. constant groin pain radiating to his whole body) was not related to his compensable right hip injury.

On May 22, 2012, the worker submitted an appeal to Review Office which included a report from a chiropractor dated March 23, 2011. The worker contended that the report supported that his current medical issues were a result of his December 3, 2008 accident.

On July 23, 2012, Review Office determined that the worker's ongoing right hip and groin problems are not related to the December 3, 2008 accident. Review Office noted that the worker did not approach the WCB regarding ongoing pain or issues in his right hip or groin until January 10, 2010, 13 months after the injury first occurred and 8 months since last recording any difficulties with his right hip or groin.

Review Office noted that the worker's claim was accepted for an acute injury arising out of and in the course of employment on December 3, 2008 and was diagnosed with an avulsion injury to the right anterior pubic ramus (pelvis) at the adductor muscle attachment site. An injury of this sort would not be expected to still cause aggravation three and a half years later. Review Office felt the medical information on file showed that the worker's hip and groin injuries resolved which was in keeping with the medical opinions on file. Review Office commented that the "existence and degree of disability" the worker was now claiming was not in keeping with an avulsion injury. On February 3, 2015, the worker appealed the decision to the Appeal Commission and an oral hearing was arranged.

Reasons

Applicable Legislation and Policy

In considering this appeal, the panel is 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 1(1) of the Act defines “accident” to mean “a chance event occasioned by a physical or natural cause; and includes

(a) a wilful and intentional act that is not the act of the worker,

(b) any

(i) event arising out of, and in the course of employment, or

(ii) thing that is done and the doing of which arises out of, and in the course of, employment, and

(c) an occupational disease,

and as a result of which a worker is injured.”

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 earnings 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) of the Act provides that the WCB “… may provide a worker with such medical aid as the board considers necessary to cure and provide relief for an injury resulting from an accident.”

Worker’s Position

The worker, who participated by teleconference, represented himself in this appeal.

Employer’ Position

The employer did not appear and did not take a position.

Analysis

The issue before the panel is whether or not the worker’s ongoing hip and groin difficulties are related to the December 3, 2008 compensable accident. The diagnosis accepted as compensable was a contusion to the right hip.

In order for the appeal to succeed, the panel must find that that the worker’s accident of December 3, 2008 caused or contributed to the worker’s ongoing hip and groin difficulties. On a balance of probabilities, we are not able to make that finding.

On December 3, 2008, the worker fell off a ladder while attempting to repair the employer’s overhead door. He testified that he fell on his right hip and his right shoulder. He was taken by truck to the healthcare facility in his remote community where he was examined, and then he took the train to Thompson where he was seen at the hospital emergency department.

Upon examination, the worker demonstrated tenderness in his right hip and groin. There was no swelling or bruising present. The worker demonstrated a full range of movement. X-rays were taken of the worker’s pelvis and right hip. They failed to demonstrate any fracture. The worker was diagnosed as having a soft tissue injury. He was prescribed pain killers and was advised to remain off work for seven to ten days.

The worker’s right hip was x-rayed for a second time nine days after the accident, but again, no fracture was identified. The worker was on crutches, and was advised to remain off work until the end of the year.

X-rays taken on December 30, 2008 again confirmed that there was no fracture of the pelvis. There was a “slight widening of the symphysis pubis” but the radiologist was unable to determine whether it was acute or chronic. The x-rays of the right knee revealed that “very tiny osteophytes [were] identified consistent with early osteoarthritis.” At that time, the worker was referred to a physiotherapist.

The Physiotherapy Initial Assessment of February 8, 2009 noted that the worker had complained of constant right hip pain that reached medially to his testicles. He was diagnosed as having a muscle strain. The therapist prescribed a home program consisting of heat, stretching, balancing, rest and activity, and gentle massage.

On April 28, 2009, the physiotherapist commented that the worker had occasional right inguinal pain that was easily resolved with heat, and occasional left buttock tightness that was resolved with stretching. The worker was discharged from physiotherapy, with it being noted that his condition was manageable with a home program.

The worker was subsequently referred to a Winnipeg surgeon who examined him on June 9, 2009. At that time, the worker complained that his entire left arm was numb. He advised that with therapy, his right hip pain had ceased. He stated however that he was now having pain on the left side. He demonstrated that the pain was in his lateral lower buttock region. He advised that it did not radiate further down his legs.

In examining the worker, the surgeon observed that the worker had an incision mid line lower lumbar. The worker could not remember when or why he had undergone surgery, but he then recalled that it was for pain in his back rather than his leg. The surgeon’s examination suggested that the worker’s present symptoms were primarily limited to numbness going down his whole left arm. The surgeon stated that he would obtain a nerve conduction study for the left arm.

The surgeon again examined the worker on October 28, 2009. His report of October 30, 2009 stated that the nerve conduction study which had now been done revealed that the patient had moderately severe involvement on the left side. He opined that the patient would benefit from a decompression surgery of the left median nerve. He stated that the patient did have bilateral decompression of the carpal tunnels in 2000. There had now been a recurrence on the left side but not the right.

The surgeon noted that since the accident, the worker had complained of numbness in his left hand, and that he did have moderately severe median nerve compression. The worker elected to undergo decompression surgery.

The surgeon’s report of February 3, 2010 stated that the worker had made an excellent recovery from decompression surgery of the left median nerve that was performed on December 22, 2009. The surgery provided complete relief from his complaint of numbness. The surgeon noted however that the worker was complaining of continuing pain in his right knee. The surgeon stated that that the pain might be attributable to a tear of the posterior horn of his medial meniscus. Degenerative changes were also present. The panel notes that throughout this period of time, the worker's complaints were with respect to other parts of his anatomy that were not related to the hip/groin area.

A CT scan conducted at the Thompson General Hospital on February 26, 2010 revealed that the hips and joints were unremarkable. However, in respect of the pelvis, there was, at the right anterior pubis, an exostosis projecting inferiorly at the anterior adductor insertion. It was stated that this likely related to a remote avulsion injury which had healed.

A WCB medical advisor’s opinion of April 14, 2010 noted that the pain that the worker relayed with respect to his right hip and right knee appeared to be a consequence of a right knee medial meniscus tear and a possible old fracture of the right pubic ramus (pelvis). The medical advisor stated that neither of those diagnoses nor the existence of left carpal tunnel syndrome could be related to the December 2008 fall from the ladder.

On May 22, 2012, the worker submitted an appeal to Review Office, in which he contended that a chiropractic report that he had now submitted, and which was dated March 23, 2011, supported that his current medical issues were as a result of his December 3, 2008 accident. In the March 23, 2011 report, the treating chiropractor reported that the worker was seen on December 3 and 10, 2010. His clinical impression was that the worker's pain "appears attributable to a boney osteophyte projecting off the right symphysis pubis which is the result of a previous adductor avulsion fracture. Given the onset of this well localized pain immediately following the accident, with no prior history of groin or hip pain, it would appear that this has arisen as a result of the trauma of December 3, 2008."

Prior to considering the worker’s appeal, the Review Office asked a WCB orthopedic consultant to provide a diagnosis in relation to the worker’s landing on his hip after falling from the ladder in the December 3, 2008 accident.

The opinion, provided on July 8, 2012, stated that symptoms related to the fall “could possibly persist for six to nine months.” In response to the question of whether the diagnosis would continue to cause aggravation 3.5 years after the injury, the consultant stated:

Negative. These symptoms would at most relate to minor local irritation due to the partial tear of the abductor muscle attachment, but, in the absence of any imaging evidence of degenerative changes in the adjacent hip joint, would not result in ongoing functional loss or a source of disabling pain.

Note also from the information on this file, the existence of degenerative disc disease in the lumbar spine and a history of previous spinal surgery, and evidence of degenerative changes with possible meniscus tearing in the right knee joint, which could be a source of continuing symptoms.

After a review of all the evidence in the file, and especially the lack of continuing symptomotology in the worker's hip and groin area, the panel concurs with and adopts the opinion of the WCB orthopedic consultant. An avulsion injury to the right anterior pubic anus would not be expected, three and a half years later, to still cause symptoms. The medical information on file supports the view that by April 28, 2009, the worker’s hip and groin injuries had resolved to the point that he was able to be discharged from the physiotherapy program.

Based on the foregoing, the panel cannot find that the worker’s accident of December 3, 2008 caused or contributed to the worker’s ongoing hip and groin difficulties.

The worker’s appeal is therefore dismissed.

Panel Members

D. Kells, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

D. Kells - Presiding Officer

Signed at Winnipeg this 23rd day of July, 2015