The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that they are not entitled to further wage loss and medical aid benefits in relation to the October 24, 2014 accident. A hearing was held on January 24, 2022 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to further wage loss and medical aid benefits in relation to the October 24, 2014 accident.

Decision

The worker is entitled to further wage loss and medical aid benefits in relation to the October 24, 2014 accident.

Background

A Worker Incident Report provided to the WCB on October 28, 2014 indicated the worker injured their right wrist and lower arm in an incident at work on October 24, 2014 when the worker slipped and fell on a just-mopped floor, landing on their buttocks with their right hand extended out behind them. The worker reported difficulty holding a steering wheel that day, swelling and bruising to their right arm and that they reported the injury to the employer at the end of their shift.

The worker attended for initial physiotherapy assessment the same day, reporting bruising, swelling, hypersensitivity from their forearm to both the elbow and wrist joint, constant pain eased by icing but aggravated with movement and twisting, and difficulty with gripping with their index and middle fingers. The worker reported no numbness and tingling but noted feeling cold into their fingertips. The physiotherapist reported the injury was too acute for testing but found some medial swelling and bruising proximal to the wrist joint and diagnosed forearm strain with possible triangular fibrocartilage complex involvement. The worker sought treatment from their family physician on October 25, 2014, reporting pain, swelling and inability to squeeze their hand or extend their arm. The physician found swelling and redness, tenderness to touch and decreased range of motion, diagnosed a wrist injury and recommended the worker remain off work. On October 31, 2014, the worker attended an appointment with their treating chiropractor and was diagnosed with a cervical strain. The chiropractor also noted issues in the worker’s right wrist and rib area.

When the WCB spoke with the worker on November 5, 2014, the worker confirmed the mechanism of injury and advised they had no previous injuries to their right wrist/forearm area. The WCB advised the worker their claim was accepted.

The worker saw a sports medicine physician on November 4, 2014 and November 10, 2014 who diagnosed a resolving forearm volar strain with "…no evidence of compartment syndrome at present." At a follow-up physiotherapy appointment on November 27, 2014, restrictions for the worker's right arm/wrist were outlined and on December 10, 2014, the worker returned to work on modified duties.

On December 12, 2014, the worker attended a further appointment with the sports medicine physician reporting an episode of "…complete hand parasthesia (sic) following increased activity accompanied by forearm swelling and tautness…" The physician queried a diagnosis of exertional compartment syndrome in the worker's forearm. An MRI study conducted on the worker's right forearm on January 15, 2015 indicated normal findings.

On February 4, 2015, based on medical information received from the worker's treating sports medicine physician, the WCB advised the worker they could return to work at full hours on modified duties.

The worker underwent a nerve conduction study on February 10, 2015 that indicated "…focal ulnar neuropathy at the elbow of mild severity."

The WCB then requested a WCB medical advisor review the worker's file to determine their ability to work modified duties at full hours. On March 2, 2015, the medical advisor provided an opinion that the initial diagnosis was a probable right wrist strain, and that the worker was capable of sedentary duties that did not involve highly repetitive right arm activities or forceful right hand grasping, at full hours. The medical advisor also recommended the WCB facilitate a consultation with an upper extremity orthopedic surgeon.

On March 3, 2015, the WCB advised the worker that they were not entitled to wage loss benefits after February 4, 2015. On March 12, 2015, the worker requested reconsideration of the WCB’s decisions by Review Office. In their submission, the worker noted their treating healthcare provider recommended they only work reduced hours and that the recommended consult with an orthopedic surgeon had not yet occurred. The worker further noted that some of the modified duties offered by the employer involved forceful and repetitive tasks that aggravated their symptoms.

On March 23, 2015, an orthopedic surgeon assessed the worker, noting the recent MRI study revealed a normal examination of the forearm and that nerve conduction tests done recently showed a normal median, radial and ulnar nerve function but mild cubital tunnel syndrome at the elbow. The orthopedic surgeon offered a diagnosis of “Possible right forearm exertional compartment syndrome involving the anterior compartment” and recommended referral to a sports medicine physician for compartment pressure testing. On March 24, 2015, the worker provided a sick note from their treating family physician placing the worker off work from March 25, 2015 to April 10, 2015.

On April 29, 2015, the employer provided a submission in response to the worker’s request for reconsideration.

The sports medicine physician reported on May 14, 2015 that the worker did not have elevated forearm compartment pressure syndrome but did have symptoms of ulnar neuropathy that worsened with exertion. On May 27, 2015, at the request of the WCB, a WCB medical advisor provided an opinion that the worker’s current diagnoses were mild ulnar neuropathy at the elbow and non-specific right forearm pain.

Review Office determined on June 1, 2015 that the worker was not entitled to additional physiotherapy or chiropractic treatment, nor wage loss benefits after February 4, 2015. Review Office found that the worker’s restrictions did not prohibit them from performing the meaningful and suitable modified duties on a full-time basis as offered by the employer.

The worker continued to report and seek treatment for the symptoms in their right forearm. On July 13, 2015, the treating sports medicine physician reported the worker had “Ongoing right forearm complaints with associated neurogenic type symptoms.” At a follow-up appointment on August 7, 2015, the physician reported the worker’s right forearm symptoms were resolving.

The worker was assessed by a pain clinic physician on September 10, 2015, who offered a diagnosis of complex regional pain syndrome (“CRPS”) and queried whether the worker had ulnar neuropathy. The treating sports medicine physician referred the worker to a hand, wrist, elbow and peripheral nerve surgeon, who assessed the worker on September 21, 2015, finding no gross swelling or wasting and no persistent bruising or ecchymosis. The surgeon noted the worker had “…palpable tenderness at the cubital tunnel and has a grossly positive Tinel’s sign” with tenderness “…within the flexor pronator mass and has exquisite discomfort with pronation.” The surgeon diagnosed cubital tunnel syndrome and pronator syndrome and recommended a cubital tunnel release, transposition, and pronator release.

On October 23, 2015, a WCB medical advisor reviewed the additional medical information and the worker’s file, and noted the accepted diagnosis was a right wrist/forearm sprain injury. In respect of the additional diagnoses of CRPS, pronator syndrome and cubital tunnel syndrome, the medical advisor was of the view the evidence did not support a relationship between these diagnoses and the October 24, 2014 workplace accident. On the same date, the WCB advised the worker their ongoing difficulties were not related to the workplace accident and the WCB would not accept further responsibility for those difficulties.

The worker underwent right cubital tunnel and right pronator release surgery on December 11, 2015. On January 10, 2017, the worker’s representative provided the WCB with additional medical evidence from the treating healthcare providers in support of the worker’s position they required ongoing medical aid treatment and wage loss due to the workplace injury. A WCB medical advisor reviewed the worker’s file on January 24, 2017 and concluded the further medical evidence did not change their earlier opinion that the worker’s current difficulties were not related to the workplace accident. On February 23, 2017, the WCB advised there would be no change to the earlier decisions.

The worker’s representative provided a submission to Review Office on January 15, 2018, including a report from the treating pain management clinic physician dated September 12, 2017, requesting reconsideration of the WCB’s decision. The employer provided a response in support of the WCB’s decision on January 18, 2018. On March 9, 2018, Review Office found the worker was not entitled to additional medical aid or wage loss benefits.

On November 6, 2020, the worker’s representative submitted additional medical evidence from the treating physicians confirming that the worker’s diagnosis of CRPS was related to the worker’s October 24, 2014 workplace accident. A WCB medical advisor reviewed the additional medical evidence on December 17, 2020 and provided an opinion that a causal relationship between the worker’s diagnosis of CRPS and the workplace accident could not be objectively established. A copy of the opinion was shared with the worker’s representative and the employer. On January 6, 2021, the employer provided their response and on January 21, 2021, the worker’s representative provided the worker’s response.

On January 22, 2021, Review Office determined the worker was not entitled to further medical aid or wage loss benefits in relation to the October 24, 2014 workplace accident. Review Office found the only diagnosis related to the workplace accident was a strain/sprain type injury and that the current diagnosis of CRPS was speculative and a causal relationship between that diagnosis and the workplace accident could not be established.

The worker’s representative filed an appeal with the Appeal Commission on May 17, 2021. A hearing was arranged for January 24, 2022.

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.

Section 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. Payment of wage loss benefits is addressed in s 4(2) of the Act, which sets out that where a worker is injured in an accident, wage loss benefits are payable for their loss of earning capacity resulting from the accident, and s 39(2) provides that such benefits are payable until the loss of earning capacity ends, as determined by the board or the worker attains the age of 65 years. Section 27(1) of the Act allows the WCB to "…provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident."

The WCB's Board of Directors has established WCB Policy 44.10.20.10, Pre-existing Conditions (the "Policy"), which addresses eligibility for compensation in circumstances where a worker has a pre-existing condition. This policy sets out that:

The Workers Compensation Board (WCB) will not provide benefits for disablement resulting solely from the effects of a worker's pre-existing condition as a pre-existing condition is not "personal injury by accident arising 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.

Worker’s Position

The worker appeared in the hearing and was represented by legal counsel who made an oral submission on behalf of the worker and provided a written submission to the panel in advance of the hearing. The worker offered testimony through answers to questions posed by their legal counsel and by members of the appeal panel.

The worker’s treating pain clinic physician also appeared in the hearing as a witness for the worker, providing testimony in response to questions posed by the worker’s legal counsel and by members of the appeal panel.

The worker’s position, in brief, as outlined by their legal counsel, is that the worker developed CRPS as a result of the traumatic fall onto an outstretched hand that occurred on October 24, 2014, arising out of and in the course of the worker’s employment. As a result of that injury and in particular, the development of CRPS, the worker has had ongoing difficulties and has not been able to return to their pre-accident employment since fall of 2015 as the worker’s injury is completely disabling and chronic. The worker’s counsel noted that the Review Office accepted that the worker has been diagnosed with CRPS but erred in finding that the origins of that diagnosis are unknown and speculative. The worker’s position is that the evidence supports a finding that they developed CRPS as a consequence of the injury they sustained in the compensable workplace accident and that they should be entitled to further wage loss and medical aid benefits as a result.

The worker’s counsel outlined in their submission why the panel should find that the worker’s diagnosis of CRPS is related to the workplace accident. First, the panel should make this finding based upon the timing and facts of the claim, in that prior to the date of accident, the worker had no right arm difficulties at all and was fully able to meet the physical requirements of their job; whereas after the accident of October 24, 2014, described in the file as a fall on the worker’s outstretched right hand, the worker was immediately unable to meet their job requirements, and could not even close a zipper on their work jacket. Counsel noted the absence of evidence of any pre-existing condition in respect of the worker’s right arm, pointing to the reports from the treating pain clinic physician and the consulting pain clinic physician as confirming this assertion. Further, counsel noted that the job duties the worker was able to undertake on the date of the injury, prior to the accident, also confirm the worker’s pre-accident capabilities.

The worker’s counsel noted that the consulting pain clinic physician, in their August 17, 2020 report, explained how the mechanism of injury can result in the subsequent development of CRPS. The physician considered the described mechanism of the worker’s injury and stated that it:

“…is consistent with falling on an outstretched arm which can result in traction on the brachial plexus which is the nerve plexus in the patient’s arm. It could also cause injury to any of the joints in the upper extremity. CRPS is well known to be related to hyperactive nerves, particularly sympathetic nerves in any extremity, after what would otherwise have been seen as often a mild injury.”

Counsel for the worker argued that the December 17, 2020 opinion of the WCB medical advisor was misinterpreted by the Review Office in terms of the medical advisor’s statements as to causation. Counsel noted that the WCB medical advisor accepted the diagnosis of CRPS in relation to the worker but stated that it could not be objectively established whether there was a causal relationship between that diagnosis and the workplace injury because “By definition it cannot be objectively related to the workplace injury – part of the diagnostic criteria requires continuing pain, disproportionate to any inciting event. The relationship between the CRPS diagnosis and the workplace injury is therefore speculative and subjectively based.” Counsel submitted that the message being communicated by the medical advisor was that:

“…because we are dealing with CRPS, a typical cause and effect relationship cannot be made on the basis of normal biological or pathoanatomical processes (as there is continuing, ongoing and persistent pain, even many years later, that is disproportionate to the inciting event, that being a slip and fall).

[T]he arguments made by [the treating pain clinic physician and the consulting pain clinic physician] in favour of relatedness are that i) a slip and fall occurred, and ii) [the worker] developed persistent symptoms after that slip and fall.

[Their] conclusions about there being a cause and effect relationship between [the worker’s] CRPS and [their] slip and fall in the workplace on October 24, 2014, are reasonable.”

Counsel pointed to the opinions provided by both the treating pain clinic physician and the consulting pain clinic physician as supporting the worker’s position that they developed CRPS as a direct consequence of the workplace injury. Counsel also relied upon medical research literature submitted with their written submission and the video presentations submitted to Review Office as supporting a causal link between FOOSH-type injuries and the development of CRPS. Counsel noted that the Appeal Commission has previously accepted such a diagnosis pointing the panel to consider Appeal Commission decisions 30/21, 116/08 and 48/12.

The treating pain clinic physician testified as to their qualifications, outlining their expertise in perioperative and pain medicine. The physician explained that it remains unknown why this kind of injury can cause permanent nerve changes, noting that CRPS activates the autonomic and sympathetic nervous systems and causes vasomotor and pseudomotor changes. The physician testified that immobility and loss of function of an extremity are hallmarks of CRPS. The diagnosis of CRPS is based upon criteria known as the Budapest Criteria which are as set out in the physician’s January 3, 2020 report. The first criterion is that there must be continuing pain disproportionate to any inciting event. There must also be report of symptoms in each of the following four categories and clinical display at time of evaluation in two of the following categories: sensory; vasomotor; pseudomotor edema; and motor/trophic. Finally, there must be no other diagnosis that better explains the signs and symptoms. When these criteria are all present, a patient can be diagnosed with CRPS. The physician emphasized that there must be an inciting event in order for a CRPS diagnosis to be considered and that it does not occur spontaneously.

The physician confirmed that they had been treating the worker since September 2015 and that multimodal treatment is ongoing. The physician stated that the worker meets the Budapest Criteria for a diagnosis of CRPS and did so when first assessed on September 10, 2015, as set out in the physician’s letter to the worker’s treating family physician of September 29, 2015. The pain clinic physician testified that they assisted the treating surgeon with the December 11, 2015 surgery as anaesthetist and in that context, collaborated with the surgeon to prevent any exacerbation of the worker’s CRPS symptoms. The physician confirmed that none of the diagnostic testing would have resulted in or caused the worker to develop CRPS.

The physician acknowledged that there are certain known risk factors for development of CRPS including a prior diagnosis of fibromyalgia or rheumatoid arthritis or being a female of a certain age. The physician testified that 5-10% of patients with CRPS may require surgery to treat other conditions and noted that an individual with CRPS may also have co-existing conditions. With respect to the worker in particular, the physician testified that the worker’s ulnar neuropathy could be such a co-existing condition and noted that the December 11, 2015 surgery was undertaken in hope that addressing the ulnar nerve issue could increase the worker’s function. The physician further explained that cubital tunnel release involves a single nerve extending from the pinkie finger to the elbow but that the worker’s CRPS symptoms involve the whole of their forearm. The physician noted that ulnar nerve compression could not have caused the range of symptoms presenting in the worker, which involved the entire nerve distribution in their right forearm.

The worker testified to their ongoing condition in which their right hand and wrist remains positioned in a contracted state at a nearly 90-degree angle, with little ability to bend or extend their arm from that position. The worker’s counsel directed the panel’s attention to the photographs provided with their submission to the Review Office, noting the images portray the worker’s right arm as swollen, shiny and transparent.

With respect to the post-accident return-to-work, the worker testified that the WCB did not provide any option but for a return to modified duties and that although the worker attended work until late fall of 2015 to participate in the offered modified duties, those duties were not suitable, requiring use of both arms and as such, the worker was not able to do the tasks assigned. In the result, the worker’s colleagues ended up covering and doing the worker’s work. The worker further indicated they did not return to work after the WCB terminated their benefit entitlement in late 2015 as they were no longer “forced” to work.

The worker confirmed to the panel that they were physically active with a wide range of activities outside of work prior to the workplace accident, but they did not incur any prior injury to their right arm, noting that they would not have been able to do their job with pain or injury.

In sum, the worker’s position is that they developed CRPS as a result of the workplace accident of October 24, 2014, and that they continue to require medical aid and continue to sustain a loss of earning capacity such that they are entitled to further medical aid and wage loss benefits arising out of the workplace accident.

Employer’s Position

The employer was represented in the hearing by its workers compensation specialist who made an oral submission on behalf of the employer and provided answers to questions posed by members of the appeal panel.

The employer’s position is that although there is evidence of the worker’s diagnosis of CRPS, the evidence before the panel does not establish that the workplace accident of October 24, 2014 is the dominant cause of the worker’s continuing disability, and therefore the worker is not entitled to further wage loss and medical aid benefits in relation to that accident.

The employer’s representative noted that until just prior to the worker’s surgery in the fall of 2015, the worker participated in the modified duties offered by the employer to accommodate the medical restrictions in place, as confirmed by the August 21, 2015 memo to file from the WCB case manager. This is further supported by the September 17, 2015 recommendation of the treating psychologist that given the worker’s presentation and strong desire to be working, it is in the worker’s “best interest to continue working.” As the claim file establishes, the worker continued in their accommodated role undertaking modified duties until late November 2015. But, the employer’s representative noted, after the right cubital tunnel and right pronator release surgery on December 11, 2015, the worker did not return to their employment.

The employer’s representative further stated that although in late September 2015 a surgeon recommended the right cubital tunnel and pronator release surgery, the WCB determined that these conditions were not related to the compensable workplace injury, as set out in the October 23, 2015 opinion of the WCB medical advisor. Therefore, the WCB did not approve those procedures. The same surgeon in August 2016 confirmed that the worker has chronic, persistent CRPS. The employer’s representative noted that in some cases, CRPS is known to arise out of or as a result of a surgical procedure. The employer therefore questioned whether the worker’s non-compensable surgery could have caused the worker to be unable to return to work and whether this procedure is the dominant cause of the worker’s continuing disability. The employer’s position is that the evidence is not sufficient to determine that the worker’s CRPS resulted from the workplace accident and is not due to an intervening event such as the non-compensable surgery.

The employer’s position, in sum, is that the evidence is not sufficient to establish that the cause of the worker’s continuing disability, the diagnosis of CRPS, is a result of the compensable workplace injury of October 24, 2014, and therefore the worker should not be entitled to further wage loss and medical aid benefits in relation to that accident.

Analysis

This appeal deals with the question of whether the worker is entitled to further benefits, specifically wage loss and medical aid, in relation to the compensable injury sustained on October 24, 2014. For the worker’s appeal to succeed, the panel would have to determine that the cause of the worker’s continuing disability is a consequence of the injury sustained in that accident. As outlined in the reasons that follow, the panel was able to make such a determination and the worker’s appeal is therefore granted.

The focus of the submissions made on behalf of the worker was on the diagnosis of CRPS and its relationship to the compensable workplace accident. As outlined in the testimony and written opinions of the treating pain clinic physician, a diagnosis of complex regional pain syndrome is made with reference to the diagnostic criteria known as the Budapest Criteria. The treating pain clinic physician first determined that the worker met these criteria on initial assessment on September 10, 2015. At that time the physician noted that the worker had fallen “with arm outstretched” with immediate swelling in their right wrist and forearm. Various differential diagnoses were ruled out in the 11 months prior to that assessment and the physician recorded that the clinical findings were consistent with a diagnosis of CRPS. On October 21, 2015, the treating pain clinic physician wrote to the WCB confirming this diagnosis and stating that the worker, a previously healthy individual, “…fell on an outstretched arm at work October 24, 2014. [The worker’s] injury and [their] resulting pain is clearly as a result of [their] fall at work…. [I]t is most certainly [their] fall at work that has resulted in [their] current arm pain and disability.” In a further letter to the WCB of November 29, 2016, the treating pain clinic physician noted that they had been treating the worker since September 2015 and again stated that the workplace injury of October 24, 2014 resulted “…in a significant injury to [the worker’s] right arm. This has developed into a Complex Regional Pain Syndrome of [their] right hand. This has significantly disabled [the worker] in that [they have] limited function of this extremity.” The physician again confirmed this opinion in their letter to the worker’s legal counsel of September 12, 2017.

The worker’s treating sport medicine physician indicated their agreement with this diagnosis on reporting to the WCB of September 11, 2015 and on August 15, 2016, the treating surgeon also provided an opinion that the worker continued to present with “obvious CRPS….”

The treating pain clinic physician testified to the panel that they referred the worker to another pain clinic physician for a second opinion with respect to the worker’s continuing right arm pain and disability. That physician assessed the worker on October 17, 2018 and provided a report the same date based upon that assessment. In their report, the consulting pain clinic physician confirmed the details of the mechanism of injury and outlined the worker’s medical history since the injury. The physician further noted their examination findings and concluded:

“This patient presents with all of the clinical criteria for complex regional pain syndrome Type 1. [They meet] all the Budapest criteria including vasomotor, sudomotor (sic), and motor changes. The degree of disability is significant related to the function of the arm. This is a late complex regional pain syndrome with all of the signs and symptoms related to prolonged disease.”

The consulting pain clinic physician provided a further opinion dated August 17, 2020 in response to questions posed by the worker’s legal counsel. In that report, the physician again confirmed that the worker met the Budapest diagnostic criteria and stated:

“It is my opinion that [the worker’s] CRPS symptoms resulted from [their] slip and fall in the workplace on October 24, 2014…. With respect to the mechanism of injury, I would suggest that the description of [the worker’s] fall is consistent with falling on an outstretched arm which can result in traction on the brachial plexus which is the nerve plexus in the patient’s arm. It could also cause injury to any of the joints in the upper extremity. CRPS is well known to be related to hyperactive nerves, particularly sympathetic nerves in an extremity, after what would otherwise have been seen as often a mild injury.”

The WCB medical advisor, in their opinion provided to the Review Office on December 17, 2020 also confirmed that the worker met the diagnostic criteria for CRPS based upon the reported findings of the treating physicians.

The panel accepts and relies upon these opinions and is satisfied that the worker’s current diagnosis of CRPS is appropriate.

The panel also considered the evidence as to whether this diagnosis is related to and arising out of the compensable workplace injury. There is evidence before the panel to confirm that a fall on an outstretched hand resulting in a sprain/strain type of injury, such as the worker sustained on October 24, 2014, is a common inciting event that can result in a diagnosis of CRPS. The consulting pain clinic physician, in their August 17, 2020 report explained how this can occur and the treating pain clinic physician also testified to the known link between such injuries and the development of CRPS. The treating pain clinic physician noted in their January 3, 2020 report that CRPS “…is a chronic painful condition that occurs after any tissue injury, be it fracture, sprain or surgery of the upper or lower extremities. It has been well established in the pain literature that even minor injury can result in the development of [CRPS]. This condition can be induced by surgery, trauma, or minor injury….”

The worker’s counsel also relied upon medical literature and video presentations submitted in support of their position that CRPS is commonly initiated through slip and fall incidents like the compensable accident in this case. The panel noted that the information submitted is supportive of the worker’s position in this regard and is not disputed by the employer, but the employer’s representative also noted that the evidence as to the kind of inciting or triggering events that may result in a diagnosis of CRPS includes surgery and queried whether the worker’s diagnosis might have been the result of the December 11, 2015 right cubital tunnel and right pronator release procedures. The treating pain clinic physician did not agree that there was any causal relationship between these procedures and the diagnosis of CRPS, noting that the diagnosis had already been made prior to this surgery and further, that the surgical procedure was undertaken with care to avoid any aggravation of the worker’s CRPS. The treating pain clinic physician further testified that the diagnostic testing undertaken would not have caused the worker to develop CRPS.

The panel is satisfied on the basis of the evidence before us that there is no basis for a finding that the worker’s non-compensable December 11, 2015 surgery was the inciting event for the worker’s development of CRPS. The evidence confirms that the CRPS diagnosis was already made several months before those procedures. Furthermore, the panel noted there is a lack of evidence before us of any other event subsequent to the workplace injury, that could account for the worker’s development of CRPS.

The panel also considered whether there is any evidence of a pre-existing right arm injury or condition that might have been aggravated or enhanced by the workplace injury. We noted the worker’s evidence that prior to the workplace accident, they had no issues or concerns with respect to their right arm and were capable of their physically demanding job, including on the very day of the accident. The panel also noted the lack of medical evidence of any prior right arm, elbow or wrist issue. Further, the medical reporting and worker’s own reports confirm that immediately after the accident and since that time, the worker has not been capable of doing their pre-accident job, and has reported continuing right arm symptoms, including persistent pain and ongoing mobility deficits, for which the worker continues to receive and require medical treatment.

The panel is satisfied that there is no evidence to support a finding that the worker’s development of CRPS is causally related to any pre-existing injury or condition in the worker’s right arm.

On the basis of the evidence before us, and on the standard of a balance of probabilities, the panel is satisfied that the worker developed CRPS as a consequence of the compensable workplace slip and fall injury of October 24, 2014.

In making this finding, the panel confirms the WCB’s position that the diagnoses of pronator syndrome and cubital tunnel syndrome are not related to the compensable workplace injury of October 24, 2014. We accept and rely upon the October 23, 2015 opinion of the WCB medical advisor that these conditions were not causally related to the workplace accident, although occurring in the same anatomic region as was injured at that time. The medical advisor specifically stated that pronator syndrome “would not be an anatomic consequence of a wrist/forearm sprain” and further, that cubital tunnel syndrome is also “not a pathoanatomic consequence of a wrist/forearm sprain”, although it could occur as a result of trauma to the elbow, but in this case “there is no evidence of an elbow injury in relation to the” compensable accident. We note as well the testimony of the treating pain clinic physician who described these conditions to the panel as “co-existing diagnoses” but did not link them to the workplace injury. The panel therefore accepts that these diagnoses and the surgical treatment of the worker’s right elbow undertaken on December 11, 2015 do not relate to the workplace accident.

The panel further noted that the worker’s WCB claim file documents that the WCB previously authorized provision of psychological treatment to the worker for issues related to and arising out of the worker’s compensable injury. The panel makes no additional findings in respect of this aspect of the worker’s claim and note that further adjudication may be required with respect to any further or ongoing entitlement to such medical aid.

The panel determines on the basis of the evidence before us and on a balance of probabilities, that the worker’s continuing disability is a consequence of the injury sustained in the workplace accident of October 24, 2014. Therefore, the worker is entitled to further wage loss and medical aid benefits in relation to the October 24, 2014 accident and the appeal is granted.

Panel Members

K. Dyck, Presiding Officer
J. Peterson, Commissioner
M. Kernaghan, Commissioner

Recording Secretary, J. Lee

K. Dyck - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 23rd day of February, 2022