WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20100189
OBJECTION BY: Worker
REPRESENTATIVES: Worker
EMPLOYER: Not participating
ISSUES
The worker requests:
Recognition that her left hip and left knee conditions are accident-related on a secondary basis under this claim.
A non-economic loss (NEL) assessment of the left hip and left knee conditions.
HOW THE ISSUES AROSE
This claim recognizes a workplace accident on September 20, 2004, in which the worker injured her left ankle. The attending health care practitioners diagnosed a severe left ankle strain and treated the condition conservatively. The employer provided accommodated work duties from October 25, 2004 and worker remained in the workplace.
She saw a foot specialist in February 2005 who identified significant instability of the left ankle, a calcaneal subluxation secondary to the strain, a Morton’s neuroma between the 1^st^ and 2^nd^ toes and an abnormal gait pattern. The foot specialist recommended orthotics and taping of the ankle for the immediate future.
The worker also attended an assessment at a foot and ankle specialty clinic on June 15, 2005. The foot and ankle specialty clinic team identified neuritis of the worker's left foot and left ankle pain. It did not note ankle instability and recommended she continue on the accommodated work duties while receiving desensitization and range of motion therapies for a six week period.
A follow-up assessment on August 15, 2005 resulted in the foot and ankle specialty clinic team extending the desensitization and range of motion therapies for a further three weeks. The clinic team concluded the worker had neuropathic pain of left ankle and foot and it referred her to neurologist. The neurologist ruled out peripheral nerve entrapment and lumbosacral radiculopathy and he concluded her mild generalized peripheral neuropathy and pain was musculoskeletal in nature.
An MRI scan on December 16, 2005 identified a ganglion cyst medial to the calcaneus and complete tears of the anterior ligaments. The foot and ankle specialty clinic team recommended arthroscopic surgery to repair the ligament tears and examine the ankle joint. The orthopaedic specialist carried out a partial synovectomy and ligament reconstruction of the worker's left ankle on June 13, 2006. The worker experienced a flare up of complex regional pain syndrome (CRPS) post surgery that complicated her recovery and further return to work.
The foot and ankle specialty clinic team recommended a graduated return to work at appropriately accommodated work duties at its review of the worker on October 19, 2006. The pain specialist at the clinic also reviewed her on October 27, 2006; he concluded she no longer had active CRPS and termed her pain symptoms neuropathic and somatic in nature. Further nerve testing in January 2007 confirmed that the worker's nerve dysfunction in the lower left leg remained stable; the operating orthopaedic specialist reassessed her on March 5, 2007 and he concluded she had reached maximal medical recovery by the follow-up visit on June 5, 2007.
The operating area arranged for the worker to attend a NEL assessment of her left ankle on October 31, 2007. A NEL clinical specialist determined a 4% permanent impairment rating for the left ankle and lower leg conditions on February 6, 2008. The worker had experienced left hip pain and she also developed left knee pain in 2008. A second orthopaedic specialist who had previously assessed and treated her left hip problems as trochanteric bursitis reviewed her on June 19, 2008. He concluded that her left knee symptoms were likely related to a meniscus tear and recommended arthroscopic surgery for the condition.
The worker's representative asked the operating area to consider the worker's left hip and left knee conditions as accident-related on a secondary basis due to altered gait. The claims adjudicator advised the workplace parties on August 12, 2008 that a relationship to the accepted left ankle conditions was not evident and it denied a NEL assessment of the worker's left hip and left knee. On appeal the NEL clinical specialist increased the worker's permanent impairment rating to 6% on September 4, 2008.
The worker's representative objected to the operating area decision of August 12, 2008 on September 8, 2008. He also submitted an objection form on May 22, 2009 and the operating area referred the issues to the Appeals Branch on February 1, 2010.
AUTHORITY
Operational Policy Manual documents:
11-01-05 Determining Maximum Medical Recovery (MMR)
15-05-01 Resulting from Work-Related Disability
18-05-03 Determining the Degree of Permanent Impairment
RESOLUTION METHOD AND PROCESS
The worker's representative requested that I deal with the presenting issues through a decision without a hearing. He understood that I would base my decision on the file documentary evidence only.
ASSESSMENT OF THE EVIDENCE
The operating area has reviewed the medical evidence from the treating and assessing health care practitioners. It notes that the October 1, 2007 assessment by the second orthopaedic specialist reported the worker's gait as normal with a normal progression of the walking cycle and a normal wear of the soles of her shoes. As such, it has concluded that the left ankle condition has not caused or contributed to the development of the worker's left hip or left knee conditions.
The worker's representative has asked the second orthopaedic specialist to comment on whether the worker's left ankle conditions could have caused the left hip trochanteric bursitis or tear of the left medial meniscus knee to develop. In a report dated August 18, 2009, he provided his reply to this question. I have considered this report and the file evidence as a whole.
The mechanics of the workplace accident on September 20, 2004 involve a slip on stairs with a twisting injury to the left ankle. None of the originating records mention involvement of the left hip or left knee. The continuing reports from the attending health care practitioners up to 2008 make no mention of the left hip or left knee. They focused entirely on the worker's left ankle pain and instability with the secondary neuropathy affecting the anterior of the left foot.
Most importantly, the report from the second orthopaedic specialist states the following:
At this stage, it is very difficult to find a cordial relationship direct or indirect in this patient’s right knee as well as left hip pain and ankle injury that she sustained.
There is, however, the possibility of a relationship between the left pain and the ankle problems that she had, although this is not something that we can prove clinically.
I rely on the patient’s history in which she does say that it is related to one another as the most accurate way of telling whether there is a relationship between these two problems or not.
The evidence as a whole is not very supportive of a relationship, in my view. The worker had left ankle instability prior to the surgery of June 13, 2006 but clearly achieved a good result thereafter. If she had complaints before or after this surgery, they are not documented in the file medical evidence before June 19, 2008. Furthermore, the test for causality remains the probability and not the possibility of a connection. For these reasons, I conclude that the worker's left hip and left knee conditions are not accident-related on a secondary basis due to altered gait. A NEL assessment of these conditions is not appropriate.
CONCLUSION
I conclude that:
The worker's left hip and left knee conditions are not accident-related on a secondary basis due to altered gait.
A NEL assessment of these conditions is not appropriate.
The worker's objection is denied.
DATED August 31, 2010
L. J. Vaccarello
Appeals Resolution Officer
Appeals Branch