Decision #55/18 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that he was not entitled to benefits in relation to the right rotator cuff tear. A hearing was held on March 6, 2018 to consider the worker's appeal.
Whether or not the worker is entitled to benefits in relation to the right rotator cuff tear.
The worker is not entitled to benefits in relation to the right rotator cuff tear.
The Employer's Accident Report dated October 5, 2016 describes the worker's injury as follows:
Employee said he was climbing up engine area & grabbed the wheel chock which was stuck in the grab handle. Employee said the wheel chock shifted and he lost his balance & fell to the floor.
The worker was seen at the emergency room of the hospital on September 26, 2016 for a "lower extremity injury" and was diagnosed, in part, with:
1) Rotator cuff injury (Right)
2) Contusion of calcaneus (Right)
Further, the worker reported to the WCB that he slipped on some ice on October 11, 2016 and landed with his right arm outstretched. He saw his doctor on October 12, 2016, at which time an x-ray was conducted and it was noted that there was “No fracture, dislocation or other abnormality of bone or joint (is) identified.”
On December 9, 2016, the worker confirmed with the WCB that the accident occurred as described by his employer, stating that he "[…] fell about 5-6 feet." and that "[…] he landed on his left heel and then fell onto his left side. He is unsure if his left arm was close to his body or outstretched when he landed. He also hurt his right arm when he was falling. He reached out and tried to grab something to stop himself from falling with his right arm."
The worker saw an orthopedic surgeon on December 13, 2016. The orthopedic surgeon noted during his examination of the worker as follows:
Examining his right shoulder, he had full ROM, but impingement signs were strongly positive. There was crepitus felt in the right subacromial space immediately adjacent to the CA ligament. Rotator cuff strength was slightly diminished.
X-rays taken in the clinic today show no significant abnormalities.
Opinion: Probable right rotator cuff tear.
Recommendations: With this degree of crepitus felt in the subacromial space, almost certainly he has a torn rotator cuff. I don't know if this a complete tear or a partial tear. I am going to obtain an MRI to confirm the diagnosis and I told him I would contact him with the results of the MRI, along with treatment recommendations after I have reviewed them. I will keep you updated.
The MRI conducted on January 7, 2017 showed:
There is supraspinatus tendinosis associated with focal area of full-thickness tear in the posterior fibers which appear to involve the anterior fibers of the infraspinatus tendon. There is tendinosis of the infraspinatus tendon with articular sided fraying. Tendinosis of the subscapularis tendon with articular sided fraying. There is mild atrophy with grade II fat infiltration of the rotator cuff muscles. ACJ degeneration. Subcoracoid bursitis. Thickening and fluid signal intensity in the subacromial/subdeltoid bursa which may suggest subacromial bursitis in the appropriate clinical setting.
A WCB medical advisor provided the following medical opinion on January 20, 2017 in response to questions from the WCB:
1. What is the diagnosis as it relates to the work place accident?
The initial ER physician's report dated Sept. 26/16 (same day of accident) documents the following in relation to the right shoulder:
• Sharp right shoulder pain
• Normal on inspection
• Normal on palpation
• Normal ROM
• Positive Hawking test
• Normal Jobes test
• Normal lift off test
• Normal internal/external rotation
The documented diagnosis is right rotator cuff injury.
The above clinical findings are concordant with a shoulder sprain/strain injury possibly involving the rotator cuff.
The above findings are not concordant with an acute rotator cuff tear, as an acute tear would typically result in decreased shoulder ROM, particularly in external rotation (as the rotator cuff is responsible for this movement), as well as positive Jobes, and Lift off tests which are tests for rotator cuff pathology.
An Oct. 12/16 physician's note documents the following:
Fell off a height 3 weeks ago landed on heel however developed right shoulder pain afterwards. Also, yesterday slipped on ice and used right arm to hold onto railing which aggravated his pain more.
Clinical findings include:
• Tenderness bicipital tendon
• Normal ROM
• Painful Arc
• Positive Speeds test
• Positive Lift off test
The above report substantiates that symptoms and clinical findings related to the right shoulder worsened following the apparent Oct. 11/16 accident. Whether this accident was work related has not to my knowledge been adjudicated.
A right shoulder MRI report dated Jan. 7/17 confirmed the following:
1) Tendinosis of the supraspinatus tendon.
2) Focal area of full-thickness tear supraspinatus tendon with mild atrophy and grade 1 fatty infiltration.
3) Tendinosis of the infraspinatus tendon with tearing, mild atrophy, and grade 2 fatty infiltration.
4) Tendinosis of the subscapularis tendon with tearing, mild to moderate atrophy, and grade 2 fatty infiltration
5) Subcoracoid bursitis.
6) Mild tendinosis of the proximal long head biceps tendon.
7) Acromioclavicular severe degenerative changes with osteophytes.
8) Possible subacromial bursitis.
With respect to the above MRI findings, the following is noted:
• Tendinosis is tendon pathology of chronic degeneration, and as such the finding of tendinosis on MRI represents a pre-existing condition.
• Multiple tears are reported on the Jan. 7/17 MRI involving muscles of the rotator cuff (supraspinatus, infraspinatus, subscapularis). All of these tears are reported to have some degree of muscle atrophy and fatty infiltration associated with them. Muscle atrophy requires a moderate period of time (many weeks to months) to develop, with fatty infiltration taking a more prolonged period of time (many months to years) to develop in relation to rotator cuff tearing. The presence of atrophy and fatty infiltration substantiates that the rotator cuff tears have likely been present for a relatively long period of time. These findings would be unlikely to have developed in the time period between the Sept. 26/16 workplace accident (or the early Dec, 2016 workplace accident), and the Jan. 7/17 MRI. Further to this the clinical findings at the time to the Sept. 26/16 ER physician's assessment on the day of accident were not concordant with an acute rotator cuff tear.
In conclusion, the diagnosis likely associated with the Sept. 26/16 workplace accident was one of right shoulder sprain/strain injuries which occurred in the setting of the pre-existing right shoulder pathology identified in the Jan. 7/17 right shoulder MRI.
2. What is the natural history of this diagnosis/condition?
The natural history of a shoulder sprain/strain is material resolution over a period of days to weeks, rather than months.
3. Is the worker's current presentation medically accounted for in relation to the work place injury?
Not in relation to the Sept. 26/16 workplace accident.
A new sprain/strain injury may have occurred at the time of the Dec. 2016 workplace accident though there are no medical reports in close temporal proximity to this accident on which to substantiate a change in shoulder symptoms/clinical findings from those documented on Oct. 12 or 23, 2016 in relation to it.
4. If so, what would an appropriate treatment plan be?
Treatment for a sprain/strain typically involves physiotherapy for ROM and strengthening though it is noted that the natural history is recovery with or without treatment.
On January 20, 2017, the WCB advised the worker that his claim was accepted for a right shoulder strain/sprain only.
The WCB medical advisor reviewed the claim based on a February 14, 2017 letter from the worker's orthopedic surgeon and responded:
[…] it is likely that [the worker's] right shoulder impingement symptoms are accounted for to some degree by both the Sept. 21/16 and early December 2016 MOI's, and therefore treatment aimed specifically at addressing [the worker's] symptomatic right shoulder impingement would be reasonable to fund. This would include sub acromion decompression and bursectomy. Treatment to repair the pre-existing rotator cuff tearing would not be considered a WCB responsibility.
On March 22, 2017, the WCB revised their claim acceptance based on new medical information submitted by the worker's orthopedic surgeon and accepted a right shoulder impingement only.
The worker underwent a right arthroscopic rotator cuff repair with subacromial decompression and subacromial bursectomy on May 25, 2017.
The worker's representative, on June 27, 2017, requested reconsideration of the WCB's March 22, 2017 decision. The worker's representative relies, in part, on the worker's orthopedic surgeon's opinion of February 14, 2017 where he stated that:
It seems reasonable to assume that his right rotator cuff tear is indeed secondary to his work related injury that occurred this past fall. The shoulder never really troubled him before this injury and his should (sic) has been terribly symptomatic since the injury.
Although there is evidence of fatty infiltration within his muscle belly, which suggests some chronicity to his disease, the reality is that most RC tears do go through previously worn or degenerated tendon. I think it is reasonable to assume that his RC tear was secondary to work related injury.
The tendinosis seen w/in his RC and muscle atrophy suggests that his rotator cuff has likely been dysfunctional for some time, but there is nothing to suggest or indicate that his rotator cuff was torn prior to this accident. I do note that on his MRI there is some edema seem w/in the infraspinatus muscle. Most would agree that edema indicates an acute injury, and therefore again I think it is reasonable to assume that his recent RC tear is a direct result of his work related injury.
Review Office determined, on October 4, 2017, that the worker was not entitled to benefits in relation to his right shoulder rotator cuff tear. Review Office found that they did not agree with the worker's representative that the worker's pre-existing condition, in conjunction with the workplace accident, caused a loss of earning capacity for the worker. Review Office could not establish that the worker's pre-existing rotator cuff condition was affected or changed by the workplace accident.
The worker's representative filed an application with the Appeal Commission on October 27, 2017. An oral hearing was held on March 6, 2018.
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 of the Workers Compensation Board (“WCB”).
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. Further, subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until the worker’s loss of earning capacity ends. Subsection 27(1) of the Act provides that the WCB may provide a worker with such medical aid as considered necessary to cure or provide relief for a workplace injury.
In addition, Board policy 18.104.22.168, Pre-Existing Conditions, provides further direction to this Panel with respect to this matter:
Where, in any industry within the scope of this Part, personal injury by accident arising out of and in the course of the employment is caused to a worker, compensation as provided by this Part shall be paid by the Board out of the accident fund, subject to the following subsections.
The WCB will not provide benefits for a disablement resulting solely from the effects of a worker’s pre-existing condition as a pre-existing condition is not “personal injury by accident out of and in the course of the employment”. The WCB is only responsible for personal injury as a result of accidents that are determined to be arising out of and in the course of employment.
The worker’s right shoulder surgery was on May 25, 2017. Two months of his recovery time was not covered by the WCB as that time period was determined to be associated to be the recovery of the rotator cuff tear which had been determined by the WCB to be non-compensable. The worker was requesting that responsibility for his rotator cuff tear be accepted in association to the September 21, 2016 and October 11, 2016 injuries.
The WCB initially accepted responsibility for the worker’s September 21, 2016 right shoulder injury as a strain/sprain injury. A decision letter from Compensation Services dated March 22, 2017 said after reviewing the January 7, 2017 MRI result the Board determined it would accept responsibility for the worker’s right shoulder impingement but not his rotator cuff tear. Compensation Services stated in a memorandum on file dated April 3, 2017:
“I stated that we have approved surgery for the impingement only and will pay for normal recovery time following. I stated once he has surgery I will have the operative report reviewed and then advise of recovery time.”
The worker had an accepted claim for an injury however is seeking benefits in relations to what is now alleged to be a right rotator cuff tear.
In summary, the worker’s representative provided the following as evidence to support an association between the rotator cuff tear and the injuries:
• There is no medical history to indicate that the worker was symptomatic of a rotator cuff tear prior to September 21, 2016.
• The worker was fully functional of his regular duties prior to the September 21, 2016 injury.
• The mechanics of the September 21, 2016 and October 11, 2016 injuries match the diagnosis for the rotator cuff tear.
• The worker reported a sharp pain in his right shoulder to the emergency attendants following the September 21, 2016 incident.
• The September 26, 2016 emergency report provided diagnosis of rotator cuff tear.
• Medical and file information show the worker reported difficulty with overhead activity, pain with sleeping, and a crunching sound in his right shoulder following his injuries.
• His orthopedic surgeon noted impingement at the December 13, 2016 examination but his main concern was the degree of crepitus which was highly suggestive of a rotator cuff tear.
• The January 7, 2017 right shoulder MRI confirmed a rotator cuff tear.
• His orthopedic surgeon noted in his February 14, 2017 report that rotator cuff tears can occur on previously worn or degenerative tendons.
The employer did not participate in the appeal.
For the worker to be successful in his appeal, this panel must find, on a balance of probabilities, that the development of his right rotator cuff tear(s) are a direct consequence of the compensable injury that occurred on September 21, 2016 or October 11, 2016.
The panel finds the worker’s rotator cuff tear(s) were not caused or enhanced by the compensable injury on September 21, 2016 or October 11, 2016. Rather, the panel confirms the diagnosis as a rotator cuff sprain/strain that resolved.
The panel comes to this conclusion based on the medical evidence on file.
In particular, contrary to the position stated by the worker, the emergency report form does not make reference to a rotator cuff tear. Rather, the emergency report form makes reference to a rotator cuff injury. As well, it also states that the ROM (Range of Motion) for the worker was normal.
The panel finds that if the worker indeed suffered a rotator cuff injury at that time, his ROM would not be normal. This is further supported by the MRI dated January 7, 2017, which confirmed tearing in three (3) of the four (4) tendons of the rotator cuff (notably, the supraspinatus, infraspinatus and subscapularis). Indeed, had one or all three of these tears been acute tears (which the evidence establishes they were not), then some degree of impaired shoulder function would necessarily have been evidence upon the clinical exam. They were not.
While the worker’s orthopedic surgeon did note on December 13, 2016 that in his opinion it was a “Probable right rotator cuff tear” and again noted on February 14, 2017 that it “seems reasonable to assume that his right rotator cuff tear is indeed secondary to his work related injury”, the Panel finds the post-operative report dated May 25, 2017 is telling. In that report, the findings are there was “extensive wear and tear involving the bursal side of his supraspinatus tendon”.
The panel is unable to find, on a balance of probabilities, that the worker’s right rotator cuff tear(s) were caused, aggravated or enhanced by his compensable injury.
The worker’s appeal of this issue is therefore dismissed.
C. Monnin, Presiding Officer
A. Finkel, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, J. Lee
C. Monnin - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 3rd day of May, 2018