Decision #12/20 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that his claim was not acceptable. A hearing was held on December 10, 2019 to consider the worker's appeal.
Whether or not the claim is acceptable.
That the claim is acceptable.
On October 9, 2018, the worker filed a Worker Incident Report with the WCB indicating that he injured his groin in an incident at work on October 2, 2018. He advised that he was "…pulling the 5th wheel open and it jammed, and I really pulled hard on it and I pulled my groin apart." The worker reported that "I drove to [location] and back. I was sore and by the time I got back I could not walk."
On October 3, 2018, the worker sought medical treatment from his family physician. The worker reported "severe pain", noting it started while he was at work when he was pulling a heavy rod which stopped suddenly and he got twisted. The worker further reported that he was not able to walk properly and had pain shooting down to his groin area. The family physician noted that the worker did not have an inguinal hernia, but had severe tenderness in the area of his pubic symphysis. The physician diagnosed the worker with a pubic symphysis sprain and referred the worker for an x ray. The x-ray, taken October 4, 2018, noted that the symphysis pubis was normal.
On October 5, 2018, the worker attended a local hospital emergency department and was admitted for treatment for an infection. The October 9, 2018 Discharge Summary from the hospital noted the worker's diagnosis of mild suprapubic cellulitis, bilateral groin strain and queried a sprain of the symphysis pubis. A referral was also made to a sports medicine physician and for physiotherapy.
On October 15, 2018, the worker attended an initial physiotherapy assessment. The worker reported to the physiotherapist that he felt an immediate pull and pain in his groin area while attempting to pull a pin or a rod. He complained of a constant intense ache in his groin region with difficulty turning his trunk to the right, lying on his right side, rising from a sitting position, walking and coughing, and difficulty sleeping due to pain. The physiotherapist diagnosed the worker with pubic symphysis dysfunction and recommended treatment to increase hip mobility and strengthening.
In an initial discussion with the WCB on October 16, 2018, the worker confirmed the mechanism of the injury and the medical treatment he had sought after the workplace accident. He advised that currently his pain would come and go, and that he had mobility difficulties and was using a walker. The worker's claim was accepted and payment of benefits commenced.
On October 19, 2018, the worker was seen by a second sports medicine physician, who opined that the worker "…appears to have sustained an injury to his symphysis pubis likely at least a partial tear creating pelvic instability."
On November 26, 2018, the worker attended a call-in examination with a WCB medical advisor. Following the examination, the WCB medical advisor opined that the worker's diagnosis was "…cellulitis of the suprapubic area (i.e. the area of the symphysis pubis)…" The medical advisor noted that the worker's family physician reported the presence of pubic symphysis diastasis and the worker's sports medicine physician reported symphysis pubis disruption. The medical advisor opined that a sprain or disruption of the symphysis pubis is "relatively rare" and if the symphysis pubis were to become disrupted, it would likely occur within the context of massive pelvis trauma such as a high speed motor vehicle collision. Further, the October 4, 2018 pelvic x-rays were reported as normal, and if either of those conditions were present they would have been evident in the x-rays. The WCB medical advisor opined that "It is probable that symptoms were first experienced in the workplace and attributed to workplace activity as an example of attribution bias. Of note, in the setting of developing suprapubic cellulitis, one would anticipate pain to be experienced with activities such as pulling or pushing."
By letter dated January 11, 2019, the WCB's Compensation Services advised the worker that his claim was not acceptable. Compensation Services advised that they had accepted the WCB medical advisor's opinion that his groin condition, an infection, was not caused by a work-related event.
On March 14, 2019, the worker requested that Review Office reconsider Compensation Services' decision. The worker submitted further medical information with his request, including a copy of his October 9, 2018 referral to a sports medicine physician which queried a "groin strain" and sprain of the symphysis pubis, and an October 10, 2018 prescription from a sports medicine physician for physiotherapy which referred to the injury as "osteitis pubis."
On April 10, 2019, Review Office spoke with the worker's spouse, who advised that the worker had undergone an MRI on April 9, 2019. Review Office obtained the results of the MRI and requested that a WCB medical advisor review the worker's file and MRI results. The medical information was reviewed by a WCB radiology consultant on May 14, 2019, and on May 23, 2019, a WCB medical advisor provided an opinion in which he noted the MRI findings of "…partial avulsion and partial disruption of right adductor longus and partial disruption of the left adductor longus." The WCB medical advisor opined that those findings were "…generally regarded as relating to partial tearing/strain. The most common mechanism for this strain would be forced abduction (i.e. 'doing the splits')." The medical advisor noted that this mechanism was not described as the mechanism of injury for the workplace accident. The additional medical reports were provided to the worker, and on June 11, 2019, a worker advisor submitted a response to those reports on behalf of the worker.
On June 14, 2019, Review Office determined that the worker's claim was not acceptable. Review Office placed significant weight on the opinions from the WCB Healthcare Department. Review Office accepted that the worker had an incident at work but was unable to find that this caused an injury. Review Office was unable to find that the diagnoses of symphysis pubis or of a musculoskeletal injury were related to the October 2, 2018 workplace incident. Review Office was further unable to account for the April 9, 2019 MRI findings of bilateral adductor tendon disruptions in relation to the October 2, 2018 incident, and concluded that there was insufficient evidence to meet the criteria of subsection 1(1) of The Workers Compensation Act (the "Act").
On June 27, 2019, the worker's representative appealed the Review Office decision to the Appeal Commission and an oral hearing was arranged.
The Appeal Commission and its panels are bound by the Act, regulations and policies of the WCB's Board of Directors.
Subsection 4(1) of the Act provides that compensation shall be paid where a worker suffers personal injury by "accident arising out of and in the course of" employment.
What constitutes an accident is defined in subsection 1(1) of the Act, which provides as follows:
"accident" means 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,
(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.
The worker was represented by a worker advisor and was accompanied by his spouse at the hearing. The worker's representative provided a written submission in advance of the hearing, and made an oral presentation to the panel. The worker responded to questions from his representative and from the panel.
The worker's position was that he suffered an injury at work when he pulled a lever on his truck and trailer which was stuck, and his claim is acceptable.
The worker's representative noted that the claim was originally accepted for a groin/pubic symphysis strain, and wage loss benefits were paid from October 3 to 23, 2018. Benefits were subsequently suspended as the claim was placed under review, and in January 2019, the worker was advised that acceptance of his claim had been rescinded.
The worker's representative noted that the WCB did not dispute that the incident itself occurred as described. The WCB eventually concluded, however, that the worker was not injured as a result of that incident.
The worker's representative submitted that there is ample evidence that the worker was injured as a result of the October 2, 2018 workplace incident. The representative submitted that the evidence shows the worker had no pain when he arrived at work late in the afternoon of October 2, 2018. While he was preparing his trailer for departure, the 5th wheel lever became stuck, and he attempted to use his body weight to pull the lever harder. He planted his right foot close to the lever, and rapidly shifted his weight from his right to the left while simultaneously kicking his left leg out as far as possible to obtain the maximum force to pull the lever. This abduction of his leg caused the worker immediate pain.
Despite the pain, the worker proceeded to complete his scheduled round trip, driving approximately 4.5 hours each way. He arrived back from his trip at about 5:00 a.m. on October 3, 2018, at which time the pain was so extreme that he was doubled over and barely able to walk, and a co-worker had to complete his duties for him. The worker saw his doctor and was diagnosed with pubic symphysis/groin strain that same day.
The worker's representative noted that acceptance of the worker's claim was rescinded based on the WCB medical advisor's opinion that the worker's symptoms at the time were related to a potential cellulitis infection as opposed to a sprain/strain injury. The worker's representative submitted that this was refuted by the evidence and the continuity of symptoms. She noted that paperwork from the worker's attendance at the hospital emergency department on October 5, 2018 showed that the issue was suprapubic pain. The attending doctor queried musculoskeletal injury, urinary tract infection and cellulitis, and the diagnosis was later changed to cellulitis with pre-admission diagnoses of groin strain and symphysis pubis strain.
In the hospital, the worker's infection responded to antibiotics, but his mobility did not improve. The emergency room documentation and reports indicated that the infection (whether cellulitis or urinary tract) was co-occurring and unrelated to the musculoskeletal pain from the sprain/strain injury, as the pain did not decrease when the infection was successfully treated. Physiotherapy was prescribed, which would not have been necessary if the pain was simply due to infection, nor would an infection have resulted in the worker's need to use a walker to assist with mobility. It was submitted that the infection being the sole cause of those symptoms was therefore very improbable. As the symptoms started with the accident, they were likely caused by it.
The worker's representative also noted that none of the treating healthcare providers felt that the worker's infection was the cause of his musculoskeletal pain. She submitted that the hospital physician, and the worker's attending physician and sports medicine physician confirmed their opinions that the accident mechanism of injury caused the sprain/strain symptoms the worker was experiencing. The sports medicine physician also opined that a tear was likely, and this was confirmed on the MRI. The attending urologist further certified that the worker's pain was musculoskeletal on December 3, 2018.
The worker's representative further noted that the WCB external radiologist confirmed that the tear was an avulsion tear, and also confirmed the likely mechanisms of injury to cause such a tear. The representative submitted that these likely mechanisms were a close match to the series of events that took place at the workplace on October 2, 2018.
The worker's representative noted that the MRI also showed pre-existing degenerative changes in the worker's pelvis. She submitted that degenerative changes do not shield workers from sustaining new acute injuries. Rather, they heighten an individual's susceptibility to injury, such that less force is required to sustain an injury and injuries tend to be more severe. The representative submitted that in this case, less force would have been required to tear the worker's tendons or cause a sprain/strain injury given the degeneration in the worker's pelvis.
The employer did not participate in the appeal.
The issue before the panel is claim acceptability. For the worker's appeal to be successful, the panel must find, on a balance of probabilities, that the worker suffered an injury by accident arising out of and in the course of his employment. For the reasons that follow, the panel is able to make that finding.
At the hearing, the worker's representative and the panel carefully reviewed the mechanism of injury and the series of events which occurred on October 2 to 3, 2018 with the worker. The worker indicated that when he went to unhook his truck, the truck was pulled away from the trailer, and "was tight to pull. And I give it a good, real hard pull, threw my leg out to pull it, and threw all my weight and my leg, and yanked on that bar to open it up, and that's when I felt the pain. It was like a sharp pain in this area…right across…atop the [pelvic] bone…and ran down into my leg a little bit…" The worker agreed that he was using his leg for momentum and "that's when I'm getting the extra pull." The worker described how he was able to hook the final trailer, and continue with his trip but that every time he stepped up into the truck during the trip "it got a little worse…and then it ended up I was pulling myself on the bar by the end of the night to try and get in and out of the truck." He said that he "had to use all my strength to pull myself up onto the step," and when he got back, he was in "…real, real pain, sweating pain coming off, sick feeling." He said he did not even remember that his co-worker had helped him put his stuff away after he arrived.
Based on our review of the evidence which is before us, and the mechanism of injury as described and demonstrated by the worker, the panel accepts that the worker suffered a groin injury as a result of the October 2, 2018 workplace accident.
In arriving at our conclusion, the panel finds that the infection which the worker experienced and which resulted in his attendance at the emergency department on October 5, 2018 was a complicating and confusing factor. The panel is not satisfied that the infection was relevant to the October 2, 2018 workplace accident or injury. The evidence shows that the infection was successfully treated with antibiotics to the point that the worker was discharged within a few days of his admittance to hospital. The worker's pain and mobility problems, however, remained.
The panel places weight on the report of the worker's treating physician, who examined the worker on October 3, 2018, the day after the injury. The physician noted the area of injury at that time as pubic symphysis - groin, and diagnosed the worker with a pubic symphysis sprain.
The panel also places weight on the hospital Discharge Summary from October 9, 2018, where the attending hospital physician wrote that it was "strongly suspected" that the majority of the worker's pain was related to a musculoskeletal injury from the work incident when he was pulling the bar under the truck, with a "bilateral groin strain and possible sprain of the symphysis pubis." Prior to the worker's discharge, an appointment was scheduled with a sports medicine physician, who saw the worker on October 10, 2018, the day after his release from hospital, and diagnosed him with osteitis pubis and prescribed physiotherapy.
The panel notes the worker's evidence at the hearing was that following his release from hospital on October 9, 2018, he had to use the walker for almost two months, even in the house. He said they had to buy an air mattress which was about two feet high as he could not get into bed, and his spouse would help him in and out of bed like that for two months. He could not get his legs up on a stair, and would have to use two canes, putting all his weight on the canes, to get up and down stairs. He said that his pain level when he was seated would be at about a 5 or 6 out of 10, but with any movement, the level would instantly jump to a 9 or 10 which would go all over his legs.
The panel further notes that the worker's treating healthcare providers do not suggest that the worker's continuing problems were the result of, or a sequela of, an infection or cellulitis. This includes the worker's original treating urologist, who saw the worker for a follow-up visit on December 3, 2018, and who concluded that the worker had "pubic pain which is MSK [musculoskeletal] after pulling on a trailer."
The panel places weight on the report of the second sports medicine physician who first saw the worker on referral from the treating hospital physician on October 19, 2018. The sports medicine physician reported that on examination, the worker had marked tenderness of his symphysis pubis which increased with stress of the pelvis. The physician stated that the worker "…appears to have sustained an injury to his symphysis pubis likely at least a partial tear creating pelvic instability" and in referring the worker for physiotherapy identified the worker's diagnosis as symphysis pubis disruption. While it was suggested on the file that it appeared the sports medicine physician was unaware of certain medical information, the panel notes that this was based on an assumption, and that in his report, the physician twice indicated that he had reviewed the worker's e-chart, including the results of the worker's previous pelvic x-ray. The panel notes that a partial tear of the right common adductor was subsequently confirmed by MRI on April 9, 2019, and in a letter dated June 6, 2019, the sports medicine physician opined that the right rectus and hip adductor tears were consistent with and the result of the worker's work-related injury.
The panel questioned the worker and his representative at the hearing as to their position with respect to the proper diagnosis or nature of the worker's injury. In response, the worker's representative observed that the issue is claim acceptance, and submitted that looking at the evidence on file, the mechanism of injury, the fact that there was intense, immediate pain, and that the worker had trouble walking, indicated that there was an acute injury, which is the basis of claim acceptance. The representative stated that beyond that point it starts to get confusing, given the discussion as to symphysis pubis and the adductor longus tendon and tears in that tendon, all of which, in her understanding, were within what she referred to as the groin strain area. The representative noted that given the mechanism of injury, she believed there was a strain/sprain injury. She further noted that tears were found, and the treating sports medicine physician believes that this is consistent with the mechanism of injury. In conclusion, the worker's representative submitted that the worker sustained a workplace injury in this case, but she was not in a position medically to say whether this was the adductor longus tendon as opposed to a groin or a symphysis pubis sprain.
The panel acknowledges and agrees with the worker's comment with respect to the nature of the issue on this appeal. Based on the foregoing, the panel finds, on a balance of probabilities, that the worker suffered a groin injury as a result of his October 2, 2018 workplace incident.
The panel therefore finds that the worker suffered an injury by accident arising out of and in the course of his employment, and the worker's claim is acceptable.
The worker's appeal is allowed.
M. L. Harrison, Presiding Officer
R. Hambley, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, J. Lee
M. L. Harrison - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 7th day of February, 2020