The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that he was not entitled to benefits after January 12, 2016 in regards to his compensation claim. A hearing was held on October 4, 2016 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to benefits after January 12, 2016.

Decision

That the worker is not entitled to benefits after January 12, 2016.

Background

The worker filed a claim with the WCB for a groin injury that occurred on August 10, 2015 while employed as an electrician. The worker described the accident as follows:

We had some big rolls of wire. I was trying to unroll it in the mud. I gave it a big heave and felt an immediate pain and pop. This caused me to injure my lower groin muscle. The pain is radiating down to my testicles. I was in a lot of pain.

The worker advised that he reported the injury to his employer on the same day as the accident.

Initial medical reports showed that the worker attended a hospital facility on August 10, 2015 and was diagnosed with a soft tissue injury to the right groin and back. On August 11 and August 21, 2015, the worker was seen by a chiropractor and a physiotherapist and was diagnosed with a back sprain/strain and a lumbar disc strain, respectively.

On August 12, 2015, the worker underwent x-rays of his lumbar spine which were read as showing:

1. Lumbarization of S1.
2. Grade 1 degenerative retrolisthesis of L4
3. Grade 1 degenerative retrolisthesis of L5.
4. Degenerative disc disease at L2-3 through L5-S1.
5. Facet arthrosis at L4-5 and L5-S1.
6. Left lateral list of the lumbar spine and posterior weight bearing. These changes may be associated with myospasm. Correlate clinically.
7. Left pelvic and femoral head height unleveling. This may be due to an anatomic short left leg and/or a functional short leg due to pelvic misalignment. Correlate clinically.

A scrotal ultrasound dated August 17, 2015 revealed no abnormality.

In a progress report dated October 7, 2015, the treating nurse practitioner documented that the worker had ongoing right groin pain radiating to the buttock.

On October 15, 2015, the worker was seen at the WCB offices for a call-in assessment. The worker reported that on August 10, 2015, he was installing struts which are essentially 10 foot channels through which metal conduit runs. The weight of a strut is approximately 20 pounds. When he lifted a strut overhead, he felt a slight burning in his right groin region. He continued working. Approximately one hour later, he was told to unroll a large spool of wire outside, weighing approximately 500 pounds, so the wire could be easily pulled into the structure his crew was working on. He attempted to twist the large roll, though it was stuck in mud. His first effort did not result in enough movement of the roll. On a second attempt, he experienced a great deal of pain in his right testicle, with pain radiation from the right gluteal region to the right testicle.

Following the examination, the medical advisor opined that the mechanism of injury in relation to the workplace incident resulted in a low back sprain/strain. The worker did not exhibit current signs consistent with an inguinal hernia. There were no findings of a hernia described in any medical documentation currently on file. The worker's current reported buttock and inguinal/groin symptoms were therefore non-specific.

On October 23, 2015, the treating nurse practitioner noted that the worker complained of persistent, unrelenting groin pain, and a CT scan was ordered to rule out a hernia.

A November 5, 2015 CT scan of the abdomen and pelvis showed no evidence of an abdominal or inguinal/femoral hernia.

In early December 2015, the worker advised his case manager that he still had ongoing testicular symptoms and pain in his groin, low back and stomach.

On December 24, 2015, a WCB medical advisor answered questions related to the worker's current medical presentation and its relationship to the workplace injury, and opined the current presentation is unlikely related to the emergency room physician's diagnosis of a soft tissue injury to the right groin and low back.

In a decision dated January 5, 2016, the worker was advised that in the opinion of the WCB, he had recovered from the low back injury and was not entitled to further benefits or services beyond January 12, 2016. The decision was based on findings that the mechanism of injury resulted in a low back sprain/strain and that the natural history for recovery occurs over the course of 4 to 8 weeks. The worker's current reported symptoms were considered to be non-specific as there was no clinical or radiologic correlate to account for them.

In January and February 2016, the worker was seen by a sport medicine physician and a urologist, respectively, and the worker was referred to a physiotherapist.

On February 23, 2016, the Worker Advisor Office asked the case manager to reconsider the January 5, 2016 decision based on a report from a physiotherapist dated February 22, 2016. The worker advisor contended that the report provided evidence to support a relationship between the worker's ongoing symptoms and the August 10, 2015 compensable injury.

Following consultation with a WCB physical medicine specialist on March 23, 2016, Compensation Services advised the worker on March 29, 2016 that there was no change to the January 5, 2016 decision, as there continued to be no evidence of a physical or pathoanatomic diagnosis to explain his reported symptoms and difficulties as related to the work incident of August 10, 2015.

On April 18, 2016, the worker advisor submitted new information from the treating nurse practitioner dated April 5, 2016 to support that the worker's compensable injury was pelvic floor muscle dysfunction. Also submitted was a report from the consulting sport medicine physician dated April 14, 2016 to support that the worker continued with treatment of his injury and was not ready to return to work.

On April 25, 2016, a WCB medical advisor opined:

Pain and tenderness are common symptoms for which people attend healthcare practitioners. When such symptoms are not associated with objective signs of tissue pathology, i.e. are non-specific in nature, a variety of non-evidence based diagnoses are often applied. One such diagnosis is "pelvic floor dysfunction", a term utilized by some healthcare practitioners when pain and tenderness are ascribed to non-specific pelvic soft tissue sources of pain…

Upon review of medical literature through a Pubmed search, it is apparent that the diagnosis of pelvic floor dysfunction is speculative, with little if any unbiased supporting science in the medical literature upon which to base a diagnosis of pelvic floor dysfunction. I am unable to account for the nature or severity of [the worker's] non-specific pelvic symptoms in relation to the August 10, 2015 mechanism of injury.

On April 25, 2016, the worker was advised that after review of the April 5 and 14, 2016 medical reports, there would be no change to the decision provided on March 29, 2016.

On May 2, 2016, the worker advisor appealed the case manager's decision to Review Office. On May 24, 2016, the worker advisor submitted a report from the treating physiotherapist dated May 20, 2016, for consideration.

Prior to considering the appeal, Review Office obtained additional medical information and medical advice from the WCB's healthcare branch dated July 4, 2016. On July 7, 2016, the worker advisor provided Review Office with a final submission with respect to the new information.

On July 7, 2016, Review Office determined that the worker was not entitled to further benefits. Review Office referred to medical information on file to support that the worker's compensable injuries were strains/sprains involving his lower back and groin.

Review Office noted that the medical information indicated the worker had a history of chronic back ache and imaging studies identified multiple level degenerative changes. Review Office found that the worker had a pre-existing condition involving his back, and the pre-existing condition was not structurally altered as a result of the workplace accident.

Review Office accepted the December 24, 2015 opinion of the WCB medical consultant that sprain/strain injuries typically recover over the course of 4 to 8 weeks and that structurally based workplace restrictions in relation to the August 10, 2015 mechanism of injury could not be applied.

Review Office also considered the other diagnoses recorded on file regarding the worker's pelvis, but was unable to account for them as being caused by the workplace accident. Review Office concluded that an injury to the worker's pelvis was limited to a groin strain/sprain, and there was no entitlement to benefits for the worker's other complaints, i.e. pelvic floor dysfunction.

On July 20, 2016, the worker appealed Review Office's decision to the Appeal Commission and an oral 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 WCB's Board of Directors.

Subsection 4(1) of the Act provides that 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.

Under subsection 4(2), a worker who is injured in an accident is entitled to wage loss benefits for the loss of earning capacity resulting from the accident, but no wage loss benefits are payable where the injury does not result in a loss of earning capacity during any period after the day on which the accident happens.

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 from an injury resulting from an accident."

Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such 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 and made a presentation that he had not recovered from the August 10, 2015 compensable injury. It was his position that the diagnosis of pelvic floor dysfunction was related to that injury.

The worker said that he had worked hard all his life, averaging no less than 50 hours of work a week. On August 10, 2015, he "gave it all I had" to try to pull the roll of wire out of the mud. Given the effort he exerted and the accumulated stress from working over the years, something had to give and he got hurt. When he gave a heave, something just pulled, and he dropped like a hot potato, like somebody had kicked him in the groin.

The worker submitted that when he said he had shooting pain from the groin, the doctors assumed that he had a lower back injury and kept insisting that was the case, even though he told them the problem was elsewhere. In his submission, the doctors were looking at the wrong problem, and the WCB kept looking at all the doctors' guesses and assumptions and ignored the real problem and cure.

The worker said it took seven months to arrive at the proper diagnosis and treatment. The injury had affected his whole life, he was not eating and was unable to work or do anything else. The physiotherapist started fixing him with the first treatment in January, 2016 and gave him his life back. He stated that since then, his mental and physical health have been coming back.

In response to questions from the panel, the worker said that he is no longer hurting or dealing with pain and is probably at about 75%. He agreed that it was fair to say that he could probably do almost everything as long as he took his time and took it easy. He said the physiotherapist told him to listen to his body, and his body is telling him that he needs a break. His job right now is still resting his body. He indicated that perhaps in six months or a year he could think about going back to work, but if he had to go back at this point, he would feel pushed into a corner.

Employer's Position

The employer did not participate in the appeal.

Analysis

The issue before the panel is whether or not the worker is entitled to benefits after January 12, 2016. For the worker's appeal to be successful, the panel must find that the worker suffered a loss of earning capacity and/or required medical aid benefits after January 12, 2016 as a result of his August 10, 2015 workplace accident. The panel is unable to make that finding for the reasons that follow.

The panel carefully reviewed the medical information on file and finds that the compensable injuries were sprains/strains to the worker's groin and lower back. The panel notes those diagnoses are consistent with the initial medical information on file, including the August 10, 2015 report from the emergency department where the attending physician diagnosed the worker with a soft tissue injury to the right groin and back. Medical information on file also shows that a number of alternate diagnoses were investigated and ruled out over the weeks and months that followed the incident, including testicular torsion and hernia.

On January 7, 2016, the consulting sport medicine physician noted that the worker had a difficult problem to objectify and stated:

I have a clinical suspicion that [he] has perhaps injured his symphysis pubis and may have some residual osteitis pubis with sacroiliac joint dysfunction related to disruption of pelvic ring. It would be an unusual mechanism however without high velocity event.

The sport medicine physician went on to suggest various options and possibilities which could be explored.

The panel notes that when the sport medicine physician first saw the worker in January 2016, it was five months after the incident. His possible diagnosis at that time was based on a suspicion and was essentially exploratory in nature. On March 18, 2016, after further investigations had been pursued without any other diagnoses having been identified, the physician reported this possible diagnosis as a new differential diagnosis of pelvic floor and lumbar strain, regional myofascial pain. In the circumstances, and given the lack of clinical findings to support such a diagnosis, the panel is unable to attach weight to the proposed diagnosis.

The panel places greater weight on the responses from the consulting urologist with respect to the worker's symptoms and pelvic pain syndrome, as follows:

• Specific pathology was not known in relation to chronic pelvic pain syndrome in men. The area of study is vague with no real explanation or etiology for the syndrome.
• Some of the worker's described symptoms might be accounted for based on pelvic pain, but the majority of those symptoms could not be accounted for on the basis of a diagnosis of chronic prostatitis/chronic pelvic pain syndrome.
• In his experience, chronic pelvic pain syndrome in men typically resolves over a course of a few months, and a one year duration to resolution would be atypical. The severity of the worker's reported symptoms were likewise atypical in relation to a diagnosis of chronic prostatitis/chronic pelvic pain syndrome in men.
• (When asked whether trauma, such as that which might be accounted for in relation to the August 10, 2015 mechanism of injury, was likely responsible for the worker's chronic pelvic pain, the urologist responded in the negative.) In his 30 years of experience he had not seen chronic pelvic pain in men initiated by trauma, barring a high velocity injury/pelvic fracture/penetrating trauma, as the pelvic structures were well protected in the boney pelvis.

The panel also understands that there is little supporting science in the medical literature on which to base a diagnosis of pelvic floor dysfunction in men, and that most of the medical literature in relation to pelvic pain/pelvic dysfunction relates to women.

In addition, the panel notes that information on file and at the hearing indicates that the worker had previous issues in the groin area. Based on the evidence, the panel is unable to find, however, that the workplace injury aggravated or enhanced any pre-existing groin issues.

Based on the foregoing analysis, the panel finds, on a balance of probabilities, that the worker's pelvic issues were not causally related to his August 10, 2015 workplace injury.

The panel further finds, based on our review of all of the information before us, that the worker had recovered from his original sprain/strain injuries by January 12, 2016.

Accordingly, the panel finds that the worker is not entitled to benefits after January 12, 2016.

The worker's appeal is dismissed.

Panel Members

M. L. Harrison, Presiding Officer
P. Challoner, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

M. L. Harrison - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 1st day of December, 2016