The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker appealed the Workers Compensation Board ("WCB") decision that it would not accept responsibility for the proposed right knee surgery. A hearing took place on April 8, 2026 to consider the appeal.

Issue

Should responsibility be accepted for the proposed right knee surgery?

Decision

The WCB should accept responsibility for the proposed right knee surgery.

Background

The worker provided a Worker Incident Report to the WCB on June 26, 2025, reporting injury to their right knee that occurred at work on June 20, 2025, when they got up from a table, their foot caught on the table leg, and their foot and knee twisted, with a popping sensation. The worker reported they did not immediately seek medical treatment but self-treated with ice and rest. The worker described their current symptoms as swelling in the right knee and popping and pain with certain movement.

The worker saw an urgent care physician on June 25, 2025, reporting a popping sensation in their right knee when they bend it more than 90 degrees, and swelling and pain in the proximal/medial area. On examination of the worker, the physician noted the ligaments were intact and the worker had swelling and pain at the medial head of the quadricep. The physician provided a diagnosis of right medial quad strain and recommended rest, heat, and physiotherapy.

On June 27, 2025, the worker confirmed the mechanism of injury to the WCB and noted they continued working regular duties. The worker noted a prior WCB claim for injury to their right knee but indicated they had no symptoms of pain prior to the accident and were not receiving any ongoing treatment. The worker reported they could walk with a bit of limp and had swelling by the end of the day with soreness. The worker described a sharp, grabbing pain when their knee pops. The WCB accepted the claim and advised the worker.

At an initial physiotherapy assessment on July 10, 2025, the worker reported instant pain following the incident, and since then, persistent popping when their knee twists, a pulling sensation around the top of their kneecap when sitting, sharp pain when their knee pops and stiffness after sitting for a while. The worker also noted difficulty with deep knee flexion and an occasional buckling feeling. On examining the worker, the treating physiotherapist found swelling along the medial aspect of the knee, full range of motion with increased pain at end range and a positive McMurray test. The physiotherapist diagnosed a suspected medial collateral ligament strain with a medial meniscus tear. A right knee x-ray of that date indicated “Severe medial tibiofemoral narrowing is present from osteoarthritis. There is minimal joint fluid.”

An MRI study conducted on August 7, 2025 contained the following impressions: 

“1. Severe chondromalacia at the medial tibiofemoral compartment and mild at the patellofemoral compartment. Osteochondral bodies anteriorly. 2. Complex multidirectional tearing of both the medial and lateral menisci. 3. Chronic complete tear of the anterior cruciate ligament. 4. Moderate joint effusion.”

The worker advised the WCB on August 13, 2025 that their treating physician referred them to an orthopedic surgeon for further treatment.

An orthopedic surgeon assessed the worker on September 8, 2025, noting the worker’s report of tripping and falling on their knee, which led to ongoing symptoms of pain and disability and a sensation of their knee giving out. On examining the worker, the treating surgeon noted a stable collateral examination, a moderate to large effusion of the right knee and a noticeable Baker’s cyst posteriorly. The surgeon reviewed the diagnostic imaging for the right knee, including previous imaging in 2020, and noted degenerative changes to the worker’s medial compartment. The surgeon recommended a total right knee replacement.

A WCB medical advisor reviewed the worker's file with respect to the proposed surgery and requested review of the diagnostic imaging by a WCB musculoskeletal radiologist. The radiologist completed the imaging review on September 13, 2025 and concluded “Imaging features are entirely consistent with progression of the degenerative changes on the previous study. There are no findings to suggest a most acute traumatic injury.” The WCB medical advisor provided an opinion on September 17, 2025 that the WCB would not support a total right knee replacement as it was not the typical treatment for a possible medial collateral ligament sprain and medial meniscal tear.

The WCB advised the worker by letter dated September 19, 2025 that it would not cover the proposed knee replacement surgery. By further letter of October 2, 2025, the WCB advised the worker they are not entitled to further benefits as their ongoing knee difficulties were not related to the June 20, 2025 workplace accident.

On October 20, 2025, the worker requested Review Office reconsider the WCB’s denial of the proposed knee replacement surgery, outlining in their submission that prior to the accident, they had no difficulties with their knee which functioned normally and without symptoms. The worker acknowledged they had chronic degeneration in their knee, but noted that since the accident, they had significant and ongoing symptoms. On October 28, 2025, Review Office determined the worker is not entitled to coverage for the proposed right knee surgery.

The worker appealed to the Appeal Commission on December 22, 2025 and a hearing was arranged.

Reasons

Applicable Legislation

The Appeal Commission and its panels are bound by the provisions of The Workers Compensation Act (the “Act”), the regulations under the Act and the policies established by the WCB's Board of Directors.

Section 4(1) of the Act provides that the WCB will pay compensation when a worker has sustained personal injury by accident arising out of and in the course of employment. When the WCB decides that a worker has sustained a loss of earning capacity, an impairment or requires medical aid because of an accident, compensation is payable under s 37 of the Act. Section 27 of the Act allows the WCB to provide medical aid to a worker entitled to benefits that “…the board considers necessary or advisable to cure or give relief to the worker or for the rehabilitation of the worker.”

The WCB established Policy 22.00, Decision Making (the "Decision Making Policy") to outline the procedures and principles that must be applied in making decisions under the Act. In making decisions as to causation, this Policy provides that in most cases the WCB uses a "but for" test. In deciding on entitlement to compensation, the WCB must be satisfied that a worker's injury would not have occurred but for employment-related factors. 

The WCB established Policy 44.120.10, Medical Aid (the “Medical Aid Policy”) which sets out general principles regarding a worker’s entitlement to medical aid. The Medical Aid Policy outlines that the WCB will determine if medical aid is appropriate and necessary based on:

• Recommendations from recognized healthcare providers; 

• Current scientific evidence about the effectiveness and safety of prescribed/recommended healthcare goods and services; 

• Standards developed by the WCB Healthcare Department.

The objectives in providing medical aid are to promote a safe and early recovery and return to work, enable activities of daily living, and eliminate or minimize the impacts of a worker's injuries. The WCB will refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate, or harmful. Schedule F of the Medical Aid Policy outlines that the WCB will pay for the costs associated with all, or portions of, an elective surgical procedure (defined as a non-emergency surgery) if it is recommended by a recognized health care provider, the need for the procedure results, in whole or in part, from the worker's compensable injury, and the WCB determines the procedure will cure, or provide relief from, a compensable injury, but the WCB will not pay for costs associated with any portion of an elective surgical procedure that is unrelated to the worker's compensable injury. Before the WCB refuses authorization of an elective surgical procedure, the WCB normally discusses this decision with the worker's treating health care provider.

The WCB established Policy 44.10.20.10, Pre-existing Conditions (the "Pre-existing Policy") to explain when the WCB will provide compensation to a worker whose pre-existing health condition may contribute to the severity of a workplace injury or prolong a worker's recovery from such an injury. This Policy outlines that pre-existing conditions may impact the provision of medical aid, and that the WCB will consider the worker's pre-existing condition when providing medical aid to assist the worker in recovering from the effects of their workplace injury.

Worker's Position

The worker appeared in the hearing on their own behalf and made an oral submission in support of their appeal, relying as well upon their written submission and additional evidence provided in advance of the hearing. The worker's position is that they continue to experience symptoms and have not recovered to their pre-accident status since the accident of June 20, 2025, and require the proposed surgery to regain their pre-accident function and abilities.

The worker acknowledged having a prior right knee injury which resulted in a WCB claim in 2020 but stated that they recovered from that injury and resumed their normal activities thereafter. The worker confirmed they did not seek further medical attention for their right knee after that time, until this accident occurred.

The worker described their ongoing symptoms and limitations since the June 2025 accident and noted they now must brace their knee for all activity. While the worker has been able to continue with their primarily desk-based job duties, they do experience limitations and challenges related to instability when occasionally required to go to job sites. The worker described their level of pre-accident activity, including skiing, hockey, biking, hiking, and walking long distances without limitation but stated they are now unable to do such activities, experiencing "ongoing pain, swelling, clicking, and reduced mobility."

The worker relied on the reports from their treating physiotherapist dated January 27, 2026 and from the treating sport medicine physician dated February 24, 2026 as evidence that the 2020 injury resulted in permanent pathology in their right knee, which the 2025 injury further impacted by "accelerating symptom progression and functional decline." The worker submitted that the workplace injuries accelerated the degeneration due to their pre-existing osteoarthritis beyond the natural progress of that condition.

The worker relied on the Medical Aid Policy which provides that surgery should be approved when it is medically necessary to restore functional capacity of an injured worker. The worker noted the evidence that all conservative treatment options were attempted without success and that their condition continues to deteriorate to the point where they now require knee replacement.

Employer's Position

The employer was represented in the hearing by its workers compensation coordinator who made an oral submission on behalf of the employer. The employer's position is that the medical reporting does not support a finding that the worker requires the proposed surgery because of the compensable injury. The employer's representative submitted the evidence points to a finding that the worker requires right knee arthroplasty because of their pre-existing right knee condition, which was already evident in the imaging from 2020. The employer representative further submitted the evidence does not support a finding that there was any structural alteration or enhancement of the worker's pre-existing right knee condition caused by the recent injury.

The employer representative reviewed the medical reporting in relation to both the worker's 2020 accident claim and the current claim, noting the presence of complex meniscal tearing, severe chondromalacia, and an ACL tear in the 2020 imaging. The representative noted similarity in the MRI study findings from 2020 and 2025 and argued that any change evident in the imaging is consistent with osteoarthritic degeneration as would be expected over time, relying on the WCB radiology advisor's September 13, 2025 opinion.

The employer representative agreed with the conclusion reached by the WCB medical advisor that an arthroplasty is not appropriate to treat an MCL strain and medial meniscal tear and therefore, the worker's appeal should not be granted.

Analysis

This appeal arises out of the WCB's decision that it is not responsible for the surgical procedure, a right knee arthroplasty, as recommended by the treating orthopedic surgeon, on the basis that the proposed surgery is not required because of the compensable injury in this claim. For the worker's appeal to succeed, the panel would have to find that the proposed surgery is required to "cure or provide relief from" the injury sustained in the workplace accident of June 20, 2025. As detailed in the reasons that follow, the panel was able to make such a finding and therefore the worker's appeal is granted.

The panel noted the WCB accepted this claim in relation to a medial collateral ligament sprain with medial meniscal tearing in the worker's right knee. This is consistent with the July 11, 2025 assessment by the treating physiotherapist. At the time of that assessment, the worker reported swelling, a pulling sensation around the top of the kneecap, sharp pain with popping, which is persistent with twisting the knee, stiffness after prolonged sitting, difficulty with deep knee flexion and occasional feeling of knee buckling. The panel noted the physiotherapy progress reports indicate the worker continued to report these symptoms through the fall of 2025, and although some progress was made, the worker's symptoms did not resolve. This is further confirmed by the reports from the treating orthopedic surgeon and treating sport medicine physician.

We noted the WCB determined that the proposed right knee surgery is not the "typical treatment of an individual" with the worker's accepted diagnosis and suggested that the surgery relates to the worker's pre-existing condition. The panel considered the evidence that the worker has "…an ACL deficient knee" with degeneration in the medial compartment and well as "degenerative change involving both menisci". This is not disputed. Having reference to the Pre-Existing Policy, the panel noted the requirement that a worker's pre-existing condition must be considered when providing medical aid to assist the worker in recovering from the effects of their workplace injury. We understand this to mean that the nature and extent of the worker's pre-existing right knee condition is relevant not only to determining the compensability of the present injury, but also in relation to the kind of treatment required to address the impacts of that injury. In other words, to determine the nature of the treatment required, a worker's injury must be considered within the context of their pre-existing condition, if any.

The panel reviewed the evidence as to the worker's pre-existing right knee condition. As noted in the September 13, 2025 report of the WCB radiologist, the February 7, 2020 right knee MRI demonstrated an "ACL deficient knee with moderate degenerative change involving the medial tibiofemoral compartment. There is also degenerative change and complex tearing involving both menisci." The radiologist described the findings of the August 7, 2025 right knee MRI study as demonstrating "deterioration of the degenerative change in the medial compartment. There is degenerative change involving both menisci with slight [deterioration] in the interval." The radiologist concluded that "Imaging features are entirely consistent with progression of the degenerative changes on the previous study. There are no findings to suggest a more acute traumatic injury."

The panel also reviewed the treating orthopedic surgeon's September 8, 2025 report, in which they outlined the worker's history of prior right knee injury with degenerative changes in the medial compartment and a deficient ACL. In that report, the surgeon described the worker as having "acute on chronic injury" to their right knee with ongoing symptoms of discomfort and pain. The panel finds this conclusion to be inconsistent with the conclusion of the WCB that there was no evidence of an acute injury. We also note that the surgeon would have had access to the worker's imaging as well as undertaking an in-person assessment of the worker. The surgeon further outlined that the "realistically only surgical option from my standpoint would be joint replacement." In making this recommendation, it is clear the orthopedic surgeon was aware of the worker's history of conservative treatment. The panel considered that following the worker's 2020 right knee injury, the then treating orthopedic surgeon outlined that if non-surgical options were not successful, surgical options would include "high tibial osteotomy or potentially an arthroplasty option" but it is evident from the current surgeon's report that there is presently no other option to the arthroplasty. As explained by the treating sports medicine physician in their February 24, 2026 report, the surgeon "felt that a meniscal repair would not be effective due to the osteoarthritis." Based on these reports, the panel accepts that at present, the only possibly effective treatment for the worker's right knee condition is arthroplasty.

The WCB Decision Making Policy outlines that when determining entitlement to compensation, such as medical aid, the WCB must be satisfied that a worker's injury would not have occurred but for employment related factors. Extrapolating from that standard to the present question, the panel considered whether, but for the accepted compensable accident, the worker would now require right knee arthroplasty. The employer's position is that the worker would have required this surgery eventually in any case, given their pre-existing right knee condition and the comments of the orthopedic surgeon in 2020. However, the worker testified that after recovering from their 2020 injury, they resumed their usual activities and had no ongoing symptoms or further treatment until this injury occurred. This is consistent with their reports to their treatment providers and to the WCB. The worker also testified that they have had ongoing right knee symptoms since the 2025 accident occurred, despite completing a course of physiotherapy treatment. As noted by the worker in their written submission:

"Since the injury, there has been a significant decline in my functional ability. I now experience ongoing pain, swelling, clicking, and reduced mobility, which have substantially impacted both my work and personal life. …This level of decline clearly demonstrates a material and permanent change in my knee function.

In addition, due to the ongoing instability in my knee, I have experienced multiple episodes where my knee has completely collapsed causing me to fall, further reinforcing the severity of my condition and the functional limitations I now face."

While there is evidence from 2020 that the worker's right knee condition might have required surgical intervention in the future, after the June 20, 2025 accident, this was no longer hypothetical. We find that it was only after the recent injury to the worker's already compromised right knee that the worker was referred to the orthopedic surgeon who recommended arthroplasty as the only treatment option. In these circumstances, the panel is satisfied that but for the compensable injury sustained in the June 20, 2025 accident, it is more likely than not that the worker would not require right knee arthroplasty at this time.

Schedule F of the Medical Aid Policy outlines that the WCB will pay for the costs associated with all or portions of an elective (i.e. non-emergency) surgical procedure if it is recommended by a healthcare provider, the need for the procedure results, in whole or in part, from the worker's compensable injury and the WCB determines the procedure will cure or provide relief from a compensable injury. The panel finds that the evidence before us supports the surgery under these conditions. The treating orthopedic surgeon believes this surgery is the only viable option for resolution of the worker's ongoing right knee complaints, which are related, at least in part to the worker's compensable right knee injury. While the WCB did not consider whether the recommended surgical procedure would provide relief from the compensable injury, the panel is satisfied, based on the opinion of the treating surgeon, that it is the only treatment that would provide relief from the worker's ongoing right knee symptoms. As such, we find that all criteria for an elective surgical procedure as set out under Schedule F are met.

In reviewing this claim, the panel also noted that the WCB did not discuss the proposed surgery with the treating surgeon before refusing authorization as anticipated by Schedule F of the Medical Aid Policy, and therefore, there was no opportunity to address the conflicting perspectives of the treating orthopedic surgeon and the WCB medical advisors as to the need for this procedure and its relationship, in whole or in part, to the worker's compensable injury. We would have expected such a discussion to take place, particularly when the WCB medical advisors have not themselves examined the injured worker.

Based on the evidence before the panel, and applying the standard of a balance of probabilities, we are satisfied that the WCB should accept responsibility for the proposed right knee surgery. The worker's appeal is therefore 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 17th day of April, 2026