The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that responsibility would not be accepted for the worker's current right knee difficulties. A hearing was held on February 24, 2022 to consider the worker's appeal.

Issue

Whether or not responsibility should be accepted for the worker's current right knee difficulties as being related to the August 1, 2014 accident.

Decision

Responsibility should be accepted for the worker's current right knee difficulties as being related to the August 1, 2014 accident.

Background

An Employer's Accident Report was received on September 18, 2014, reporting the worker injured his right foot in an incident at work on August 1, 2014. The incident was described as "A part slid off of a pallet onto the floor then tipped up and bumped his knee."

No further action was taken on the worker's file until the worker attended at the WCB on December 9, 2016 and advised he still had problems with his right knee. The worker related those problems to the August 1, 2014 workplace accident, but indicated he had not sought medical treatment for some time. The worker advised he noticed the problems with his right knee most when stepping over a curb or walking on stairs.

On February 1, 2017, the WCB contacted the worker to discuss his claim. The worker advised he did not miss time from work after the injury. He worked modified duties until September 2014, returned to regular duties for two to three weeks, then suffered an unrelated injury. The worker noted he was laid off from his employment on March 25, 2015 and had not worked since then. The worker advised he sought medical treatment immediately after the August 1, 2014 workplace accident, including follow-up treatment and diagnostic imaging, and provided the WCB with names and dates with respect to those treatments.

On February 2, 2017, the WCB received a Doctor's First Report for the worker's attendance at a walk-in clinic on August 1, 2014. It was noted that the worker reported to the treating physician that he had sustained an injury to his right thigh and knee when "…a metal plank fell on his Rt (right) thigh…", and had pain, swelling and difficulty moving. The physician noted findings of local swelling, local hematoma in the worker's quadriceps and knee, and pain with full extension. The physician referred the worker for an MRI of his right femur and right knee, and noted the worker went for light duties on or around August 5, 2014. A diagnosis of right leg pain was provided.

The WCB subsequently received a copy of a Triage Report from the worker's attendance at the local hospital emergency department on August 2, 2014. It was noted that the worker reported he "accidentally struck right knee to lateral aspect with a piece of iron", and that he was complaining of pain to the lateral aspect and decreased range of motion. An x-ray taken that same day was noted to be normal, with no bone or joint abnormality or fractures or dislocations identified, and the worker was diagnosed with musculoskeletal pain.

The WCB also received the results from an MRI performed March 17, 2015, which indicated that "No findings to suggest a quadriceps rupture can be confirmed on this examination," and that the right knee was "incompletely evaluated."

On August 4, 2017, the WCB received a report of an initial physiotherapy assessment the worker attended on August 3, 2017. Complaints of pain, difficulty with walking, prolonged standing and stair climbing, and weakness in the right leg were noted and the physiotherapist diagnosed the worker with iliotibial band pain syndrome and patellofemoral pain syndrome. It was noted the worker had not been working since 2015 due to a non-compensable motor vehicle accident.

On October 6, 2017, the WCB contacted the employer to gather further information. The employer recalled the worker told them on August 1, 2014 that he had a previous injury to his knee and the workplace accident had "re-aggravated" his previous injury. The employer could not remember if the worker had made ongoing complaints of difficulties with his right knee when he returned to work, but noted that several workers were laid off in 2015, and they believed the worker was gone at that time.

The WCB also contacted the worker on October 6, 2017 with further questions regarding his claim. The worker advised he had not had a previous injury to his right knee and that he had reported his ongoing difficulties to his employer. The worker provided further details on the medical treatment he received after the injury, including the advice of his treating physician that he had a "torn muscle" that would require surgery, which he declined.

On November 6, 2017, the worker's treating sports medicine physician provided a report in response to a request from the WCB. The physician noted the worker was diagnosed with a partial quadriceps tear/injury following the August 1, 2014 workplace accident and was treated conservatively. The physician indicated he first saw the worker on July 26, 2017 and he had seen him for treatment on three other times since then. The physician noted the worker reported he had experienced constant right knee pain since the time of the accident, and that the worker's current diagnosis was patellofemoral knee pain syndrome, iliotibial band friction syndrome and a possible lateral meniscus tear. The physician referred to the 2015 MRI, and noted that although a right knee MRI had been requested at the time, the results had not been reported. The treating sports medicine physician indicated that a further MRI of the right knee was being requested and recommended physiotherapy and home exercise.

On January 22, 2018, the worker underwent an MRI of his right knee, which showed:

1. Degenerative chondromalacia at the lateral femoral condyle. 

2. Truncated body and posterior horn of the lateral meniscus either from remote surgery or tearing.

At a follow-up appointment with the worker's treating sports medicine physician on February 12, 2018, the physician noted the worker had right knee osteoarthritis and a lateral meniscus tear, and recommended modified duties of not able to climb stairs or kneel frequently and no work in uneven areas. On May 4, 2018, the WCB advised the worker that they had completed a full review of the available information and determined that a causal relationship between his current difficulties and the workplace accident on August 1, 2014 could not be established, and he was not entitled to further benefits.

On June 25, 2018, the worker requested that Review Office reconsider the WCB's decision, noting he did not have any difficulties with his right knee prior to the August 1, 2014 workplace accident, but had continued to experience difficulties with his knee since then, and therefore believed he was entitled to further benefits.

On August 28, 2018, Review Office determined responsibility would not be accepted for the worker's current right knee difficulties. Review Office found the worker's description of a heavy iron item rolling off a pallet and striking his right knee would not cause a meniscal tear, and the medical evidence closest in time to the August 1, 2014 accident supported the worker suffered a soft tissue injury. Review Office found there was no causal connection between the worker's current right knee difficulties, and the injury he sustained from the accident which was initially diagnosed as a soft tissue injury.

Additional medical information was subsequently provided to the WCB, including chart notes from the worker's treating family physician, orthopedic surgeon and sports medicine physician. In a June 26, 2019 report from the worker's orthopedic surgeon, received September 19, 2019, the surgeon provided the diagnosis of a "Right knee radial tear lateral meniscus with secondary lateral compartment degenerative changes" and opined that the workplace accident of August 1, 2014 "…caused a valgus force." The orthopedic surgeon noted a report of the 2015 MRI stated the right knee was incompletely evaluated and there was no separate report for the knee MRI. The surgeon reported he had reviewed the March 17, 2015 MRI and that "…there is clear evidence of a radial tear of the lateral meniscus and subchondral impaction injury and bone marrow edema in the lateral compartment in keeping with an acute valgus injury..." The surgeon opined that the report of the 2018 MRI showed that the bone marrow edema had resolved but the evidence now supported progressive degenerative changes. The surgeon further opined that the report of the 2018 MRI confirmed that the meniscus tear was unchanged from the 2015 study.

On October 7, 2019, the worker requested that Review Office consider the additional medical evidence and reconsider their August 28, 2018 decision. On November 27, 2019, Review Office determined that responsibility would not be accepted for the worker's current right knee difficulties. Review Office noted that apart from the 2015 MRI, there were no medical reports on the worker's file from August 2014 to July 2017, which was a significant period of time without medical evidence to support any difficulties the worker may have been experiencing. Review Office further noted the worker's initial complaints were of medial side pain and swelling, but in 2017, the worker's symptoms were said to be on the lateral aspect of the right knee.

On November 28, 2019, the worker's treating orthopedic surgeon contacted Review Office to discuss the worker's claim and the medical information provided. The surgeon noted his opinion that the worker's August 1, 2014 workplace injury caused the lateral meniscus tear. Review Office advised the worker's orthopedic surgeon that part of the reason for their decision was "…inconsistencies in the mechanism of injury and concerns with the large periods of time with no medical attention sought." The orthopedic surgeon advised that he would have the March 17, 2015 MRI film read by a radiologist with regard to the worker's right knee and would submit the report to Review Office.

On March 19, 2020, the worker's representative submitted additional medical information to Review Office, including an Addendum to the March 17, 2015 MRI report. The Addendum, issued December 3, 2019, indicated that the MRI showed "There is a lateral meniscal tear…The findings within the posterior aspect of the lateral femoral condyle likely relate to a contusion related to an interval trauma." Chart notes from the worker's various healthcare providers were also included for the time period of August 2014 to November 2017.

On April 15, 2020, the worker's file and the submitted medical evidence were reviewed by a WCB orthopedic consultant. The orthopedic consultant opined that the worker's current right knee symptoms were caused by degenerative joint disease or osteoarthritis of the knee and a tear of the lateral meniscus. The consultant further opined that the reported mechanism of injury "would be an unusual mechanism for a meniscal injury" and that it was more probable the lateral meniscus injury was a pre-existing condition and the workplace injury was a contusion of the right knee region. The WCB orthopedic consultant's opinion was shared with the worker.

On May 5, 2020, Review Office determined that responsibility would not be accepted for the worker's current right knee difficulties. Review Office accepted the opinion of the WCB orthopedic consultant that a typical mechanism of injury for meniscal injury would be a twisting injury of the knee in a flexed and loaded position and the evidence did not support the worker twisted his knee at the time of the August 1, 2014 workplace accident. Accordingly, Review Office determined the evidence did not support the right knee lateral meniscus tear as indicated on the March 2015 MRI was related to the workplace accident.

On September 3, 2021, the worker's representative submitted further medical evidence to Review Office and requested reconsideration of the May 5, 2020 decision. On September 7, 2021, Review Office advised that the additional information was in keeping with information already provided to file and they would not reconsider their decision.

On September 13, 2021, the worker's representative appealed the Review Office decision to the Appeal Commission and a videoconference hearing was arranged for February 24, 2022.

Following the hearing, the appeal panel requested additional medical information prior to discussing the case further. The requested information was later received and was forwarded to the interested parties for comment. On May 11, 2022, the appeal panel met further to discuss the case and render its final decision on the issue under appeal.

Reasons

Applicable Legislation and Policy

The Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations made under the Act, and policies of the WCB's Board of Directors. The Act and regulations in effect on the date of the August 1, 2014 incident are applicable.

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.

WCB Policy 44.10.20.10, Pre-existing Conditions (the "Policy"), addresses eligibility for compensation in circumstances where a worker has a pre-existing condition. The purpose of the Policy is stated, in part, as follows:

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.

"Pre-existing condition" is defined in the Policy as "…a medical condition that existed prior to the compensable injury."

Worker's Position

The worker was represented by a worker advisor and was provided with the services of an interpreter at the hearing. The worker's representative provided several written submissions in advance of the hearing and made an oral presentation to the panel. The worker and his representative responded to questions from the panel.

The worker's position was that there is a causal relationship between the August 1, 2014 workplace accident and the worker's ongoing right knee difficulties, and his appeal should be granted.

The worker's representative submitted that the evidence shows the worker's right knee was injured in an accident at work on August 1, 2014. The representative noted the Employer Accident Report confirmed the worker was struck in the right knee by a falling object on August 1, 2014, was accommodated in modified duties, and received medical treatment as a result of the accident. The representative submitted that the clinical findings reported shortly after the accident were consistent, and the worker's evidence was that he never returned to his pre-accident duties. It was further submitted that the mechanism of injury as reported to the employer, the numerous treating healthcare providers, and the WCB was consistent throughout: that the worker was struck by a heavy object on the lateral side of his right knee/thigh area while at work on August 1, 2014.

The worker's representative noted that the worker sought medical attention immediately after the accident, attending a walk-in clinic the day of the injury and a hospital emergency department the following day. The representative submitted that the worker reasonably sought medical treatment for his right knee injury through 2014, 2015 and 2016 to the present, but his right knee difficulties continued. He followed up with the treating physician and was seen by a chiropractor for several visits. He underwent an MRI of his right knee and quadriceps in March 2015, but the report on the right knee was not completed. The representative noted that the missing MRI report was not noticed until the worker began seeing the sports medicine physician in 2017, and it was not until 2018 that the worker had a follow-up MRI on his knee, and December 2019 that he had his first consultation with an orthopedic surgeon with respect to his knee.

The representative submitted that the March 17, 2015 MRI showed a tear which was consistent with the mechanism of injury. It was submitted that the treating orthopedic surgeon and the radiologist who ultimately read the March 17, 2015 MRI agreed that the mechanism of injury was consistent with a lateral meniscus tear. The orthopedic surgeon opined that the original MRI supported the tear was caused by the heavy blow to the lateral knee or valgus impact on August 1, 2014. The representative noted that while the WCB orthopedic consultant opined that a direct blow to the knee is an unusual mechanism of injury, he did not deny that a valgus mechanism can cause a meniscal tear. The representative submitted that greater weight should be given to the opinion of the treating orthopedic surgeon, who examined the worker and performed surgery on his knee, and provided an explanation as to how the mechanism of injury was consistent with a meniscal tear caused by a valgus impact.

The worker's representative noted that the WCB orthopedic consultant, the treating orthopedic surgeon and the radiologist all agreed that the meniscal injury caused the degenerative chondromalacia. The representative further argued that there is no evidence of a pre-existing condition. The representative noted that the diagnostic imaging confirmed the worker had no pre-existing conditions, and the worker was capable of performing a physically demanding job prior to the workplace injury.

In conclusion, the worker's representative submitted that the evidence strongly supported a causal relationship between the worker's accident and his ongoing and current right knee difficulties. It was therefore submitted that on a balance of probabilities, the worker suffered a meniscal tear in his right knee as a result of the workplace accident on August 1, 2014, and the WCB should accept responsibility for his ongoing right knee difficulties.

Employer's Position

The employer did not participate in the appeal.

Analysis

The issue before the panel is whether or not responsibility should be accepted for the worker's current right knee difficulties as being related to the August 1, 2014 accident. For the worker's appeal to be successful, the panel must find, on a balance of probabilities, that the worker's ongoing right knee difficulties are causally related to the worker's August 1, 2014 workplace accident. The panel is able to make that finding, for the reasons that follow.

There is no dispute that the worker was involved in a workplace accident on August 1, 2014. A claim was accepted based on a hospital report and an Employer Accident Report, but no further action was taken on the worker's file until the worker attended at the WCB on December 9, 2016 and advised he still had problems with his right knee.

The panel is satisfied that the medical evidence on file indicates the worker continued to experience difficulties with his right knee and to seek medical attention and treatment for his right knee injury following his workplace accident, but there was a lack or failure of any real investigation into his right knee injury prior to 2017. The worker was referred for an MRI of his right thigh and right knee which was performed on March 17, 2015, but the report from that MRI did not include findings with respect to the worker's knee, indicating only that the knee was "improperly evaluated on this examination." This omission went unnoticed until the worker saw the sports medicine physician in mid-2017. A further MRI of the worker's right knee was then ordered and performed on January 22, 2018, which identified a tear of the lateral meniscus and triggered a referral to the orthopedic surgeon, who first saw the worker in July 2019.

The panel places weight on the July 26, 2019 report of the treating orthopedic surgeon, who indicated that he reviewed the March 17, 2015 MRI and noted that:

Although not reported there is clearly evidence of a radial tear of the lateral meniscus and subchondral impaction injury and bone marrow edema in the lateral compartment in keeping with an acute valgus injury such as he described. A repeat MRI in 2018 continues to show the significant radial tear of the lateral meniscus with complete absence of the posterior horn...

In my opinion, the injury noted is in keeping with the mechanism he described namely a valgus directed blow from a heavy object to the knee. This would cause compression of the lateral compartment and the radial tear of the lateral meniscus as well as the subchondral impaction injury noted on his original MRI that was not reported in 2015.

In the panel's view, it is significant that following his review of the 2015 MRI, the orthopedic surgeon arranged to have March 17, 2015 MRI film read and reported by the radiology department, who provided an Addendum to the original report, confirming the presence of the lateral meniscus tear on the original MRI study in 2015.

The panel also places weight on the March 31, 2021 letter from the treating orthopedic surgeon, who opined, in part that:

…Based on my review of the imaging, I feel that the original MRI does support that the meniscal injury occurred on the day reported by the worker. As noted, x-rays were normal with no degenerative changes. The MRI (once finally reported) confirms a radial tear of the lateral meniscus with acute findings such as a subchondral impaction fracture and bone contusion that would be in keeping with a recent traumatic impact. If these findings were preexisting, one would expect degenerative changes in the knee/lateral compartment to be present. These findings developed over time after the injury and are now only noted on the more recent diagnostic studies.

…In my opinion, the worker's described mechanism is quite consistent with the lateral meniscus tear. A heavy blow to the lateral knee causing a valgus impact and force would result in compression of the lateral femoral condyle against the lateral tibial plateau with the potential shearing mechanism to the meniscus causing a complete radial tear. A radial tear pattern is more consistent with acute trauma in comparison to complex or degenerative tears which would be expected if this were a chronic degenerative process.

The panel accepts the orthopedic surgeon's opinion that the mechanism of injury was consistent with the lateral meniscal tear that was identified on the 2015 and 2018 MRIs, and his explanation of how this mechanism of injury would have caused such a tear, and finds that the worker suffered a right knee meniscal injury as a result of the August 1, 2014 workplace accident.

The panel is further satisfied that the evidence supports that the meniscal tear or injury was the cause of the degenerative joint disease or chondromalacia which developed in the worker's right knee. The panel again places weight on the March 31, 2021 letter from the treating orthopedic surgeon, who opined that:

…The cause of the worker's right knee chondromalacia is the acute radial lateral meniscus tear. This results in a complete loss of meniscal shock absorption function. Without the meniscus, the contact pressures in the lateral compartment can be increased by over 70% and lead to rapid cartilage loss/chondromalacia and arthritis in the involved compartment. This has clearly occurred in this patient with the findings of a normal joint space in 2015 and progressive degeneration in the lateral compartment in his later more recent studies…

The treating orthopedic surgeon also noted in this regard that there was no evidence of a pre-existing degenerative condition, stating as follows:

…There is no evidence of chondromalacia or degenerative changes prior to August 1st, 2014. As noted, this original x-ray on August 2nd, 2014…was normal with no joint abnormality (no degeneration). In addition, his original MRI on March 17th, 2105 [sic] clearly reports that the overlying cartilage in the lateral compartment is intact therefore no chondromalacia or degeneration at that time early post injury.

The panel notes that the orthopedic surgeon further commented that "…in my experience the acute tear likely would have been painful enough to have prevented him from performing heavy work and twisting/pivoting/squatting from the initial time of injury." The panel is also satisfied that the evidence indicates the worker was performing heavy, physical work prior to the workplace accident, and that there is a lack of any clear evidence of a pre-existing condition or that the worker was unable to perform his full, regular duties or experiencing right knee difficulties or symptoms prior to the workplace accident.

Based on the foregoing, the panel finds, on a balance of probabilities, that the worker's ongoing right knee symptoms or difficulties are caused by a lateral meniscus tear and chondromalacia or degenerative joint disease and are causally related to his August 1, 2014 workplace accident. The panel therefore finds that responsibility should be accepted for the worker's current right knee difficulties as being related to the August 1, 2014 accident.

The worker's appeal is allowed.

Panel Members

M. L. Harrison, Presiding Officer
J. Peterson, Commissioner
S. Briscoe, Commissioner

Recording Secretary, J. Lee

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

Signed at Winnipeg this 30th day of June, 2022