WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20110015
OBJECTION BY: Worker
PARTICIPANTS: Worker, Employer
HEARING LOCATION: N/A
ISSUE
The worker claims a non-economic loss (NEL) assessment for her left knee.
HOW THE ISSUE ARISES
This claim was allowed for multiple injuries suffered on December 5, 2000 when the worker slipped and fell. The injuries suffered at the time were a fracture of the left wrist and forearm along with a strain to her left ankle and knee.
The WSIB allowed and granted a non-economic loss (NEL) award for the fracture of the left wrist however did not allow for a non-economic loss (NEL) assessment for the left knee or ankle as the medical evidence did not support that she had ongoing symptoms beyond 2001.
The worker objected to the denial of entitlement to a non-economic loss (NEL) award for the left knee and requested that this decision be made with the information on file.
AUTHORITY
Workplace Safety and Insurance Act (the Act) Operational Policy Manual (OPM) document(s):
18-05-03 – Determining the Degree of Permanent Impairment
ASSESSMENT OF THE EVIDENCE
I note the medical evidence on file which indicates that at the time of her fall, the worker suffered with an aggravation of a pre-existing osteoarthritic condition affecting her knee and other areas of her body. The medical evidence on file indicates that the worker suffered with osteoarthritis affecting her left knee, low back, neck and later on, right knee.
The allowance of the left knee was therefore on an aggravation basis.
At issue is whether the aggravation of the left knee osteoarthritis had ceased. In looking at the available medical evidence on file, I am in agreement with the conclusion of the WSIB’s decision maker that the aggravation of the osteoarthritis of the left knee had ceased by 2001. Of significance, the following is noted:
The report of Dr. R. Yovanovich dated July 27, 2000 noted that the worker had a prior injury to the knee. He noted that her symptoms tend to be more obvious when she is going up and down stairs and when she is kneeling or squatting. He noted that she has had a recurring sensation of “locking” which occurs particularly with stairs. He noted that the worker had mild patellofemoral creptitus with a bit of compression pain. She had 130 degrees of flexion from full extension without pain. She had a bit of a physiological valgus. He noted that she also had normal capsular stability. X-rays showed a bit of patellar spurring and lateral marginal spurring consistent with early degenerative change. The doctor stated: “she has probably aggravated a pre-existing minor arthritic condition in the patellofemoral and lateral compartments of her knee….”
The WSIB allowed for injections in the knee which were conducted by Dr. Yovanovich and documented in his reports of June 19, 2001 and November 7, 2001. In the November 7, 2001 report, the doctor stated: “she is very pleased with the results of viscosupplementation. She has only minor aggravating symptoms which she presently can live with. Objectively she had a full range of movement without pain, minimal tenderness medially and walked without a limp…”
There was no continuity of medical complaint or ongoing symptoms with the knee until further medical reports were received in 2004.
The x-ray examination of July 22, 2004 noted that she had an injury to her knee four years ago and was now complaining of persistent pain for six months.
The worker was seen at a hospital emergency department on September 19, 2004. The history noted that she had a fall four years ago and had lubricant injections with Dr. Yovanovich. The current onset of symptoms “started with sharp L thigh pain two weeks ago….”
A report from a walk in clinic dated 03/09/04 indicated that the worker was complaining of pain in the left lumbar area which went down the left leg. There was no indication of any left knee symptoms.
The report of the physiotherapist dated September 13, 2004 noted that the worker had suffered an original fall at work and was treated for the left knee with injections. The patient reports that the knee started to bother her three weeks ago. She adjusted gait and was now complaining of severe left hip pain. The diagnosis was bursitis of the left hip.
Another report from the emergency record of the hospital dated 09/20/2004 noted that the worker was complaining of left leg pain for sixteen days.
The worker provided a Form REO6 dated September 24, 2004 on which she noted: “left knee always a problem on and off but last six months very painful with pain shooting up to outer thigh Sept 3/04 pain became unbearable could not walk, sit.”
A nuclear medicine report of October 5, 2004 showed a bone scan with results which were presumed arthritic changes within the dorsal lumbar spine and wrists.
The worker was assessed in a functional ability evaluation (FAE) dated May 27, 2009. The report showed (on page 2, under the heading objective examination), that her active range of motion of the left wrist, elbow and knees were full.
The Form 8 of the family physician dated 10/12/09 noted that the worker was seen for complaints of crepitus of the left knee and referred for MRI.
The worker had a MRI of the left knee on 02/06/10. The findings showed degenerative changes of the meniscus. There was also a finding of minor degenerative marginal hypertrophic bony osteophytes, in keeping with early degenerative osteoarthritis. In addition, there was mild cartilage loss in keeping with chondropathy involving the lateral patellar facet, associated with degenerative subchondral cystic changes near the patellar apex.
The worker also had a MRI of her right knee on 02/13/10. The findings showed degenerative changes within the patellofemoral joint manifested by high grade cartilage loss with subcondral marrow edema identified at the apex and lateral facet of the patellar regions. There was also high grade cartilage loss with adjacent bone marrow edema, subcondral cystic changes identified involving the lateral and medial facets of the trochleea of the distal femur. There was also a lobulated fluid signal intensity collection measuring up to one centimetre in size adjacent to the anterior root ligament of the medial meniscus, findings were suspicious for a parameniscal cyst although a definitive tear cannot be visualized at the anterior root ligament of the lateral meniscus.
The medical evidence therefore supports the initial adjudication decision that the worker suffered an aggravation of a pre-existing condition as diagnosed by Dr. Yovanovich on July 27, 2000. The worker was treated with the injections and by November 2001, her condition had improved to the pre-accident state. As documented by the specialist in the November 7 2001 report, she had a full range of motion without pain, minimal tenderness medially and walked without a limp. The objective medical reporting therefore confirms a return to the pre-accident state.
The worker then reported in 2004, a gradual onset of symptoms affecting the left knee which she related as developing over the previous six months to September 24, 2004. She was consistent in reporting this on her REO6 on September 24, 2004 and the same history as documented in the other medical evidence from the hospital and physiotherapist.
The worker then had ongoing symptoms culminating in the MRI findings of June 2, 2010. At that time, the findings were of degenerative changes affecting the left knee. The worker also had symptoms and significant findings of osteoarthritic changes involving the right knee as confirmed by MRI of 02/13/10.
This was also confirmed in the x-ray of both knees conducted on December 10, 2009. The findings were of mild tricompartmental degenerative ostearthritic change bilaterally.
The picture of the worker’s progression of osteoarthritis is evident not only in her left knee but also in the right knee and lower back as referenced before. The picture of the progression of the worker’s osteoarthritis in multiple areas is consistent with her age and with the progression of underlying osteoarthritis affecting multiple joints. The history is as referenced in the discussion paper prepared for the Workplace Safety and Insurance Appeals Tribunal (WSIAT) by Dr. M. Tile dated November 2008 on the subject of osteoarthritis. In that paper, the doctor noted that acute injuries could consist of: cartilage bruising, cartilage disruption, or intra-articular fracture. The evidence in this particular case is that the worker may have suffered the first type of injury – cartilage bruising. Dr. Tile stated the following about this type of injury: “damage to the joint may leave the overlying articular surface in tact on a plain x-ray, but MRI’s may show ligament tears and may show bruising and edema of the subchondral bone. It is not certain what this bruising means for the future function of the joint but it is not infrequently seen in major ligamentous injury to joint. In some instances cells which produce matrix for the hyaline cartilage may be damaged leading to secondary type osteoarthritis. At this time, secondary OA from this type of bruising is uncommon, and can only be followed by further MRI. In most cases, the bruised cartilage resolves in time, with no major sequelae.”
With respect to the role of an acute injury, the doctor stated the following: “with mild injury, recovery should proceed to pre-injury state quickly, whereas, in more major injury, the return to pre-injury state maybe more delayed. The doctor can be guided by the objective findings in each individual case, including the imaging studies.”
The weight of the evidence in this case therefore supports that the worker had returned to her pre-accident state by November 2001. The later symptoms which started the onset of left knee pain beyond 2004 are directly related to the progression of the worker’s underlying osteoarthritis. The worker therefore is not entitled to a permanent impairment assessment for the left knee.
CONCLUSION
The worker is not entitled to a permanent impairment assessment for the left knee as the aggravation had ceased by November 2001.
The worker’s objection is denied.
DATED February 28, 2011
N. Kissoore
Appeals Resolution Officer
Appeals Branch