WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
decision number: 20100093
OBJECTION BY: Worker
PARTICIPANTS: Worker, Worker’s representative, Employer
HEARING LOCATION: N/A
ISSUES
The worker objects to the decision of April 30, 2009 to deny entitlement to left knee and left ankle conditions.
The worker objects to the decision of April 30, 2009 to deny ongoing entitlement to a right knee condition.
HOW THE ISSUES ARISE
On February 14, 2008, this now 54 year old worker slipped while descending stairs, twisting her right knee. At the time of injury, the worker was employed as a school teacher.
The worker attended her doctor the day after the injury, reporting that she had slipped on the stairs but had not fallen. Her sole complaint was right knee pain. The injury was diagnosed as right knee strain and possible meniscus tear. The doctor noted that the worker’s recovery would be affected by a prior history of patellar dislocation and morbid obesity.
On March 28, 2008, the worker advised her doctor that she had developed left leg pain. In April 2008, the worker reported an onset of left knee pain. The worker was treated conservatively and returned to full time work on April 28, 2008.
In May 2008, the doctor documented an onset of left ankle pain precipitated by dancing activities over a recent weekend. The worker subsequently reported that both knees and the left ankle were injured at the time of the workplace accident. The worker provided a statement to a WSIB field investigator, advising, contrary to her initial reports, that she actually fell on the stairs, striking her left leg.
X-rays of the knees revealed mild osteoarthritis and degenerative changes at the patellofemoral articulation bilaterally. Ultrasound of the ankles revealed no abnormality. The doctor did not see the worker between May 2008 and October 2008. When the worker returned to the doctor on October 2008, she reported symptoms of depression. The worker changed family doctors and, in December 2008, reported an exacerbation of left knee pain.
In January 2009, the worker attended an orthopaedic surgeon for progressively worsening left knee pain. An MRI of the left knee, carried out in March 2009, demonstrated high-grade osteoarthritis in the lateral patellofemoral compartment, mild chondrosis of the medial and lateral femoral condyles, and an intra-articular body on the medial meniscus. In June 2009, the worker underwent total replacement of the left knee joint.
The adjudicator found that the only injury sustained at the time of the February 2008 accident was to the right knee. The adjudicator determined that the worker had aggravated a pre-existing right knee condition and that the aggravation ceased by April 2008. Entitlement to left knee and left ankle conditions was denied due to lack of proof that these areas were injured at the time of the accident.
The worker has objected further to the denial of ongoing right knee entitlement and the denial of entitlement to the left knee and ankle conditions.
AUTHORITY
11-01-01 – Adjudicative Process
11-01-15 – Aggravation Basis
15-02-01 – Definition of an Accident
RESOLUTION METHOD & PROCESS
The worker representative requested review of the issue based on the record and her submission of March 22, 2010. The employer expressed no objection to this process.
ASSESSMENT OF THE EVIDENCE
- Entitlement to Left Knee and Ankle Conditions
Policy
In determining initial entitlement, it is necessary to establish five points: an employer; a worker; a personal work-related injury; proof of accident; and compatibility of diagnosis to accident or disablement history.
Consideration of proof of accident may include examining whether an accident or disablement situation exists; whether there were witnesses; whether there were discrepancies in the date of accident and the date of layoff; whether there was delay in the onset of symptoms; and whether there was delay in seeking medical attention.
The definition of accident, according to operational policy, includes a wilful and intentional act, but not an act of the worker; a chance event resulting from a physical or natural cause; and disablement arising out of and in the course of employment. Disablement includes a condition that emerges over time, or an unexpected result of working duties.
Assessment
In order to consider the worker’s request for left ankle and knee conditions, it must be established whether the evidence supports that these areas were injured at the time of the February 2008 workplace accident. In making all determinations in this case, I reviewed the record and considered the evidence and submissions.
At the time of injury, the worker advised her employer and doctor that she slipped on stairs, twisting her right knee. When questioned by her doctor, the worker denied falling at the time of this accident. The doctor observed clinical signs of a right knee strain; there was no indication of other areas of complaint. The employer advised the field investigator that they were not made aware advised of any area of injury other than the right knee at the time of accident. It was not until May 2008, several months post-accident, that the worker reported to her doctor that she had fallen, injuring her left leg and ankle.
There is no contemporaneous evidence whatsoever to support the worker’s claim that she injured her left knee or ankle at the time of the workplace accident. The worker did not report such injuries at the time of accident. The first evidence of left lower extremity complaints did not arise until six weeks post-accident. Her recollection of the accident history appears to have changed to accommodate the development of left knee and ankle pain.
The worker’s left knee symptoms have been attributed to degenerative changes in the knee which, due to their advanced nature, clearly pre-dated the February 2008 accident. The spontaneous and gradual onset of left knee symptoms in April 2008 is consistent with the nature and degree of the underlying degenerative conditions.
Medical investigation of the worker’s left ankle complaints has revealed no underlying abnormality. These complaints were diagnosed as ankle sprain. The first notation in clinical notes of left ankle discomfort was made on May 29, 2008. The doctor wrote, “…danced over the weekend. Now really sore. Had to take 2 days off work. C/O pain in left ankle.” The evidence suggests that the left ankle condition arose as a consequence of non-occupational activities well after the workplace accident.
After careful consideration of the evidence, I find that there is no proof to support the worker’s claim that she injured her left knee and left ankle in the course of employment. Entitlement to these areas of complaint is denied.
- Ongoing Right Knee Entitlement
Policy
In cases where the worker has a pre-accident impairment and suffers a minor work-related injury or illness to the same body part or system, the WSIB considers entitlement to benefits on an aggravation basis.
The intent is to limit entitlement to the injury that is work-related. If a claim is allowed on an aggravation basis, the claim is paid for the acute episode only (temporary period of time) and entitlement ends when the worker's condition returns to the pre-accident state.
Entitlement is not limited in cases where there is no pre-accident impairment, or the severity of the accident/exposure on its own would have resulted in additional impairment. This is the case where the impairment is temporary or permanent despite the presence of the pre-accident impairment.
In some cases, workers never return to the pre-accident state. If there is a permanent worsening of the pre-accident impairment, the decision-maker may determine that the work-related injury/illness has permanently aggravated the pre-accident impairment and a non-economic loss benefit is in order.
Assessment
In order to consider the worker’s request for ongoing entitlement to right knee complaints, the following issues must be considered: whether the worker had a pre-existing impairment; if so, whether the workplace accident caused an aggravation of this impairment, and; whether the aggravation has ceased.
Review of the medical record indicates that the worker had two prior right knee injuries. In 2002, the worker fell at work while employed in another jurisdiction, sustaining a dislocation of the right patella which required surgical correction. Medical records for this condition are reportedly unavailable due to the effects of Hurricane Katrina.
In August 2005, the worker struck her right knee when she was involved in a head-on collision with another vehicle. The worker attended her doctor in June 2006 due to recurrent right knee pain. According to the doctor’s clinical note for that visit, the worker had continued physiotherapy since the 2002 motor vehicle accident. She was still using a cane for walking. The doctor observed medial collateral ligament laxity and expressed concern about a possible medial meniscal tear. Clinical notes did not comment on knee problems either before or after the June 2006 incident and are not, therefore, a particularly good indicator of impairment or recovery.
An X-ray of the right knee, carried out in August 2005, demonstrated mild degenerative changes in the medial and lateral compartment, moderate degenerative changes in the patellofemoral compartment, and mild patella alta. Patella alta refers to an abnormally high positioning of the patella in relation to the femur.
The evidence supports that the worker had an underlying degenerative condition affecting the right knee. She had a history of significant knee trauma in August 2005 which led to chronic knee pain and impairment of function. In her statement to the investigator, the worker confirmed that she had an ongoing restriction on stair-climbing resulting from the 2005 injury. She denied any other problems associated with the right knee and, contrary to her report to the doctor in June 2006, denied requiring a cane for this condition after 2005.
The preceding circumstances support that the worker had a pre-existing right knee impairment which affected stair-climbing and likely affected prolonged walking activities. It is apparent that the February 2008 workplace injury aggravated this pre-existing condition. At issue is whether the worker recovered from the aggravation. If the evidence supports the worker returned to her pre-existing condition, then a compelling argument can be made that the aggravation ceased. If the worker did not recover to her pre-injury state, then it may be established that the accident affected the natural course of the underlying condition and further entitlement is in order. This assessment can be made by comparing the level of the worker’s pre-injury and post-injury impairments.
The February 2008 injury was diagnosed as a right knee strain. After a course of physiotherapy, the worker returned to pre-injury duties on April 28, 2008. The employer relocated the worker’s classroom to the first floor, accommodating the pre-existing restriction on stair-climbing and the development of left lower extremity symptoms. The worker continued in this capacity until she developed left knee pain and requested further workplace accommodations.
After examining the worker on January 15, 2009, the orthopaedic surgeon wrote, “Her right knee showed good range of motion from 0 to 120 (degrees) with valgus malalignment and no medial or lateral joint line tenderness whatsoever…” The balance of his report was directed at the non-compensable left knee. Findings pertaining to the right knee support full recovery from the work-related right knee sprain.
Review of the medical evidence supports that the worker was substantially recovered from the work-related right knee strain by the time she returned to work on April 28, 2008. She was certainly fully recovered by the time of the January 2009 orthopaedic assessment. The worker’s request for further right knee entitlement is denied.
CONCLUSION
The worker’s request for left knee and left ankle entitlement is denied.
The worker’s request for ongoing right knee entitlement is denied.
The worker’s objections are denied.
DATED May 28, 2010
D. M. Shepherd
Appeals Resolution Officer
Appeals Branch