WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20100173
OBJECTION BY: Worker
EMPLOYER: Not Participating
REPRESENTATIVE: Worker
HEARING DATE: July 14, 2010
ATTENDEES: Worker, Worker Representative
ISSUE
The worker objects to the decision dated October 19, 2009 and seeks entitlement for left carpal tunnel syndrome (CTS).
HOW THE ISSUE ARISES
This claim was accepted for right shoulder tendonitis related to repetitive movements in the worker’s job duties. The date of accident was established as October 26, 1998. Following treatment and investigations, the worker underwent excision surgery of the right acromiale on August 28, 2000.
The worker returned to work on March 19, 2001, however, had a recurrence of symptoms and full loss of earnings (LOE) was restored from November 9, 2001. The worker attended the WSIB Upper Limb Speciality Clinic and a permanent right shoulder impairment was recognized with a 9% Non-Economic Loss (NEL) award.
The employer could not provide permanent modified work and the worker was referred for Labour Market Re-Entry (LMR) services. The worker completed a LMR plan in the Suitable Employment or Business (SEB) of Human Resources Specialist, National Occupational Code (NOC) 1121 and LOE benefits were closed effective July 15, 2009.
The worker made a claim for bilateral CTS and following a review by the WSIB Medical Consultant, entitlement was denied as outlined in the correspondence of October 19, 2009. This decision was reconsidered and upheld on February 9, 2010.
AUTHORITY
Operational Policy Document 11-01-01 Adjudicative Process
15-02-01 Definition of an Accident
15-05-01 Resulting from Work-Related Disability
ASSESSMENT OF THE EVIDENCE
The worker provided testimony. The worker stated that her college courses involved note taking of up to five to six pages during class time. She acknowledged that some professors used Power Point and she would have to simply highlight important facts, whereas other professors used the blackboard and she was required to take notes.
The worker stated that she did not have a laptop and all her notes were hand written. She acknowledged that she did not experience any problems while writing notes. The worker testified that over the years her course load got heavier and she was required to do more projects and more note taking.
In the summer of 2007 she noticed discomfort in both wrists with tingling, numbness and pain. She found herself rubbing her hands to try to relieve the discomfort. It was at this time she started experiencing symptoms while note taking. After 15 or 20 minutes of writing she would have to stop and rub her hands to try to get the feeling back. She would then resume note taking.
In September 2007 she spoke to her family doctor and he informed her she had CTS and referred her to Dr. Desai. The worker confirmed she was in a motor vehicle accident in November 2007 and sustained a whiplash type injury. She stated she had a short period of physiotherapy for this.
The worker stated that she informed the Service Provider (SP) of her discomfort and pain and the SP suggested wrist splints and voice-activated software, DRAGON. The worker testified that the WSIB covered her for both the software and the splints. The worker stated she used the DRAGON at home for projects and assignments but could not use it in the classroom as she did not have a laptop.
The worker stated that she overcompensated for the right shoulder and began to experience left elbow pain diagnosed as tennis elbow. She confirmed that this resolved following a cortisone injection. However, the bilateral wrist problems continued. The worker acknowledged that the left wrist symptoms were always less than the right and her most recent EMG showed the left had resolved. However, the right wrist continues to deteriorate and Dr. Charron informed her that she requires surgery. Currently she is continuing with cortisone injections.
The worker denied any hobbies or sports that would stress the wrists and denied any underlying medical conditions.
The worker’s representative submitted that entitlement should be granted as a secondary condition. He submitted that his client did have some right hand symptoms in early 2000 but no sign of CTS. He submitted that her symptoms arose from the LMR retraining and the progress reports from the SP support the worker’s testimony. The worker’s representative pointed out that the family doctor supported a relationship between the CTS and overuse due to the original injury.
The worker’s representative opined that there is a casual link between the CTS and the work injury and entitlement should be extended to include both wrists.
I have had regard for the claim file evidence, the testimony of the worker, the closing remarks from the worker’s representative and the applicable law and policy.
I will first address the issue of initial entitlement for the left CTS. On November 10, 1998 the worker completed a Worker’s Report of Injury (Form 6). This form specifically asks what parts of the body were injured. The worker responded by writing, “My right arm is injured (right from the upper to lower arm).” On January 12, 1999 the worker provide a statement to the Nurse Case Manager and stated that she had continual throbbing in her right arm from her shoulder down.
The Health Professional’s First Report (Form 8) noted pain from the posterior right shoulder down to the hand. Tenderness was noted in the right shoulder and elbow. There were no findings for the hand or wrist and the only diagnosis rendered was tendonitis of the right arm. The worker was referred for physiotherapy treatment and the diagnosis on the Physiotherapy Assessment Report was right shoulder tendonitis – muscle strain.
The family doctor referred his patient to Dr. M. Dziedzic and the report is dated January 25, 1999. The worker described pain and numbness on the right side of the neck radiating to the suprascapular area and down to the mid arm. Her symptoms were aggravated by cervical spine range of movement and elevation of the right arm. Dr. Dziedzic diagnosed a myofascial right sided strain of the neck and shoulder girdle.
A Regional Evaluation Centre (REC) assessment was carried out on March 19, 1999. Under Current Complaints the doctor wrote, “She continued to complain of pain in the area of the right shoulder blade with radiation to the anterior/superior aspect of the shoulder and the lateral aspect of the proximal arm. She sometimes gets some numbness in the hand involving all digits. The numbness is transient.” The diagnosis rendered was probable right rotator cuff tendinopathy and cervical strain.
The worker continued to have investigations and treatment for the right shoulder. In a report dated January 11, 2000 Dr. Koppert referred to intermittent numbness in all fingers of the right hand.
The family doctor referred to CTS on the Physician’s Progress Report (Form 26) dated September 7, 2007 and the worker referred to the CTS on the Worker’s Progress Report (Form 41) dated September 20, 2007.
The EMG studies showed bilateral median neuropathies at the wrists consistent with CTS, moderate on the right and mild on the left side.
The onus is on the worker to provide sufficient evidence to support that bilateral CTS rose out of and in the course of employment. In considering the evidence, this burden has not been met. There was no reporting to the employer or health professionals regarding bilateral wrist symptoms consistent with CTS and by the worker’s testimony, the symptoms of numbness and tingling did not surface until the summer of 2007. In the absence of evidence to the contrary, I must conclude that the bilateral CTS did not arise out of and in the course of the worker’s employment on or about October 26, 1998.
The next issue to address is whether there is secondary entitlement for bilateral CTS.
A discussion paper on CTS was prepared for the Workplace Safety and Insurance Appeals Tribunal (WSIAT) and is available on their website. This discussion paper states, in part:
- “The relationship between sensory symptoms and strenuous hand use is less well defined but may be prominent. The literature indicates that the hand activity must be repetitive and forceful. Activities characterized by a high frequency but low force, such as computer key pad use, have not been shown to be an important precipitating factor despite the overwhelming volume of information in the lay media to the contrary. The fact is that actual evidence of this relationship, by valid medical or epidemiological studies, is lacking. Where the relationship between exposure to repetitive hand use and carpal tunnel syndrome has been carefully studied, no significant increase in the risk of developing this condition can be identified. In rare circumstances, where a clear temporal linkage between the development of symptoms and their relief, in relation to a given exposure, can be reliably and repeatedly identified, then a major criterion for causality may be met. Other issues which should have an impact on establishing causality include a dose response relationship and a plausible biologic basis, both of which are largely lacking in most, though not all, instances where there is held to be a work-related etiology for carpal tunnel syndrome.”
I have concluded that the first evidence of right CTS was the summer of 2007 according to the worker’s testimony. Prior to this her schedule as outlined in the LMR Progress Report of March 27, 2007 showed she was attending classes for two hours per day. In a letter dated May 18, 2007 the worker acknowledged that writing was not constant yet she had concerns regarding working in an office setting for eight hours a day due to her arm limitations. In the summer of 2007 the worker was taking two online courses only and therefore, there was no note taking at the time of the onset of symptoms.
I note the WSIAT discussion paper suggests that the hand activity must be repetitive and forceful and the risk factors for the development of CTS involve a combination of repetitive, forceful, and awkward motions of the hands and wrists. In considering the evidence available, I am unable to conclude that the activities involved in the LMR program meet this criteria.
Although the family doctor opined that the CTS and left arm problems were related to overuse brought on by her original injury, he does not qualify his opinion with any evidence to substantiate repetitive use.
There is a three year delay from the start of the college program to the onset of symptoms. I find this is a significant delay in terms of causation. I further find a lack of evidence to support that writing and note taking quantifies as repetitive, forceful or awkward. I am therefore unable to establish secondary entitlement for bilateral CTS.
In the absence of sufficient evidence of repetitive and forceful gripping and wrist movements, I am unable to establish secondary entitlement for left CTS arising out of the work accident or the LMR program.
CONCLUSION
I conclude there is insufficient evidence to establish entitlement for left CTS on an initial or secondary entitlement basis.
The objection is denied.
DATED August 19, 2010
P. Luck
Appeals Resolution Officer
Appeals Branch