WORKPLACE SAFETY AND INSURANCE BOARD
RECONSIDERATION DECISION
decision number: 20150010
DECISION DATE: April 17, 2015
OBJECTING PARTY: Worker
REPRESENTED by: Worker Representative
RESPONDENT: Employer
REPRESENTED by: Employer Representative
HEARING: Reconsideration in Writing
HEARD by: M. Mraz, Appeals Manager
ISSUE(S)
Recognition of recurrent bilateral hernias
Entitlement to Loss of Earnings (LOE) Benefits from April 8, 2012
BACKGROUND
On February 17, 2014, Appeals Resolution Officer, Mr. M. De Marco, rendered a decision denying the worker’s objection regarding the above issues. A reconsideration was grated on February 12, 2015 by the Appeals Manager on behalf of the ARO who had left his employment with the WSIB. This was based on the fact that significant new medical information had become available.
The worker reported that on November 9, 2011 he was working on a roof and lifted a bundle of ‘capsheet’ weighing approximately 20-30 lbs. He felt a sudden sharp pain in his groin and visited his doctor. He continued to work. Then on January 4, 2012 while removing an old roof he had to stop due to severe pain. The worker visited the hospital and was diagnosed with bilateral direct inguinal hernias.
The worker underwent bilateral laparoscopic repair of bilateral inguinal hernias and an umbilical hernia on February 21, 2012. The small umbilical hernia has not been identified for entitlement in this claim.
The claim has been accepted for bilateral inguinal hernias and Loss of Earnings (LOE) benefits paid from January 5, 2012 up to but not including April 8, 2012.
On March 21, 2012 a surgeon indicated there was no evidence of recurrence and believed the worker had fully recovered. The worker was cleared for full duties in 2 weeks. However, the worker did not return to work.
The regular job includes performing installation of various roofing systems (flat roofing), and construction work which was described as very physical in nature. A return to work meeting was held with the worker and employer on July 16, 2012. The employer indicated they were unable to accommodate the worker with modified work based on his limitations.
An ultrasound conducted on June 28, 2012 revealed no evidence of recurrent hernia.
An ultrasound of November 2, 2012 suggested the possibility of recurrent hernias. The worker’s clinical presentation was inconclusive. Therefore, the first surgeon recommended diagnostic surgery. Based on the second surgeon’s more recent account, this surgery took place in February 2013 and did not find recurrent hernias.
In a decision of November 19, 2012, the Case Manager limited entitlement to LOE benefits up to and including April 7, 2012. The decision was reconsidered and upheld on June 12, 2013 by the Case Manager who found that no objective medical evidence had been received since March 21, 2012.
In the absence of clinical findings from March 21, 2012 to November 2, 2012, the ARO concluded that there must have been an alternate, non-work-related, cause for these hernias. The ARO commented on the absence of an opinion from the treating surgeon about the relationship between the hernias identified in November 2012 and the original condition.
The worker representative has submitted a report from a second surgeon dated
October 23, 2014 which outlines the sequence of events and medical findings. Apparently, the second surgeon was called to the operating room to attend repeat laparoscopy by the first surgeon in February 2013. The second surgeon confirmed that the laparoscopic view showed no evidence of a recurrent hernia. However, the second surgeon examined the worker further on May 16, 2013 and suspected a recurrent right sided hernia. He ordered an ultrasound which was negative but arranged a repeat operation on July 3, 2013. At that time he found a recurrent right inguinal hernia. He also excised the ilioinguinal nerve in an effort to reduce the pain.
AUTHORITY
15-04-08 Hernia
15-03-01 Recurrences
18-03-02 Payment and Reviewing LOE Benefits (prior to final review)
ANALYSIS
The worker representative’s submission, dated December 22, 2014, asks the Board to accept the opinion, of the treating second surgeon, that the worker did not recover from hernia surgery. The representative also referenced the Medical Discussion Paper, prepared for the Workplace Safety and Insurance Appeals Tribunal by Dr. John H. Duff, dated January 2006 to support this position.
The employer representative, in a submission dated March 12, 2015, argued that the medical information from the second surgeon should have been previously obtained either by the worker representative or by the Board. I agree that the case record was incomplete at the time of the ARO decision. I believe that the Board shares in the responsibility to request relevant information and the worker should not be penalized in this regard.
The employer representative also asks that a medical opinion be obtained to confirm that subsequent hernia surgeries were related to the worker’s injury and to clarify any discrepancies between the first surgeon’s opinion and the second surgeon’s. I also note the information provided by the representative with the respondent form which indicates they do not believe there is compatibility between the worker’s condition in November 2011 and his condition in November 2012. The representative indicates that the February 21, 2012 surgery was for a moderate sized defect in the myopectineal orifice and the July 3, 2013 surgery was related to weakness in the transversalis facia.
I do not believe a medical opinion is necessary and trust that the second surgeon, believed the surgeries were for the same area of the body and condition as the compensable surgery. In addition, I did not find the opinions of the surgeons to be conflicting. Rather the action undertaken by the second surgeon was in response to the worker’s ongoing presentation.
Recurrent Bilateral Hernias
In the decision letter dated November 19, 2012, the Case Manager limited entitlement to LOE benefits up to and including April 7, 2012 on the basis that any ongoing problems the worker was having were not caused by the work-related inguinal hernias. This decision was reconsidered on June 12, 2013 by the Case Manager who found there to be no objective medical evidence on file to support that the possible recurrent hernias on November 2, 2012 were related to injury that occurred on November 9, 2011 or to the surgery of
February 21, 2012.
Initial entitlement is not in question. However, it is constructive to consider how inguinal hernias generally occur and the work-relationship in this case.
On page 4 of the Medical Discussion Paper submitted by the worker representative, it is stated that,
“Since the majority of hernias appear without a history of an accident or sudden strain, it is difficult to be certain that single specific accidents cause hernias. Some accidents, by virtue of their severity and immediate appearance of a hernia are clearly the primary cause. Case reports support this conclusion. There is also evidence that prolonged and strenuous physical activity may be at least a contributing cause of hernia. In a cross-sectional study, Kang found a higher rate ratio for hernia in male workers performing strenuous, heavy manual labour.”
Page 4 also states that,
“direct inguinal hernias come directly through a weakened area of the abdominal wall medial to the inguinal canal.”
Page 5 states that,
“… the sudden occurrence of bilateral hernias following a single injury would be an extremely rare event.”
It is further noted that the worker also had a non-compensable umbilical hernia.
The case was referred for a Physician Case File Review to consider if a pre-existing condition impacted or prolonged the worker’s recovery. In Memorandum #46 the doctor indicated that there was no prior history of inguinal symptoms or known hernias before the compensable lifting incident and that the medical reports do not indicate that the non-compensable small umbilical hernia impacted recovery in this case. The medical consultant did not comment on the nature of inguinal hernias in general.
Hernia conditions occur as a result of a physiological weakness and a precipitating event. The worker had a physically demanding job and suffered an onset of bilateral inguinal hernias following two specific, work-related events as described.
The worker was seen for post-surgical follow up by the first surgeon on March 21, 2012. This was one month after his laparoscopic repair. At that time, the worker had minimal pain and his physical activity was approaching baseline. There was no recurrent bulge. The worker was having considerable urinary difficulties and a further referral was suggested in this regard. Otherwise, the doctor declared the worker to have recovered from his bilateral inguinal hernias with no evidence of recurrence. One month post-surgery, it appeared that the worker had achieved full recovery following successful surgery.
I believe a more accurate picture of recovery will be seen at three months post- surgery when one would expect the worker to have returned to regular work. At three months post-surgery, the worker had remained off work.
It is noted that the worker’s pain and restrictions increased sometime between May 4, 2012 and June 28, 2012. There is no information in the case record to suggest that a new event intervened to cause the worker to become worse. The worker’s doctor indicated on May 4, 2012 that the worker continued to be restricted and was to avoid heavy or sudden lifting and restrict lifting to 5-10 Kgs.
In a submission dated August 27, 2013, the worker representative argued that initial hernias provide continuity for the purpose of establishing entitlement to a recurrence because they can recur spontaneously without any type of trauma. I note this is also true of hernias in genera. As such, I have not placed significant weight on this particular argument.
A recurrent condition was confirmed on the right side.
The worker was referred for an ultrasound on June 28, 2012. The worker described pain which started 3 weeks prior, corresponding roughly to the first week of June, and that it had been persistent for about 2 weeks. The worker did not relate the increase in pain to any specific incident. Recurrent bilateral hernias were not identified at that time.
The worker visited his doctor on September 12, 2012 for bilateral inguinal area pain secondary to prior surgery. The proposed treatment was conservative and Tylenol 3 was prescribed. Although the worker was not working at the time, his limitations appeared to have increased to include standing, lifting, climbing and operating heavy machinery.
The doctor completed a Functional Abilities Form on October 19, 2012 indicating the worker should perform modified work.
A repeat ultrasound was conducted on November 2, 2012 and suggested a small recurrent inguinal hernia bilaterally containing omental fat. The first surgeon assessed the worker and reviewed the CT scan results. He described, “possibly bilateral fat containing recurrent hernia”. On physical examination the worker was still quite tender bilaterally with no palpable recurrence on either side. Diagnostic surgery was booked to determine possible recurrent hernias.
The second surgeon’s letter of October 23, 2014, addressed to the worker’s representative, explained it is sometimes difficult to detect a recurrent hernia. With laparoscopy, the mesh used may cover some possible hernias.
The worker underwent repeat laparoscopy by the first surgeon in February 2013 due to ongoing pain in both groins. Apparently, the second surgeon was called in to the operating room at the time. With the laparoscopic view, there was no evidence of a recurrent hernia. If he was concerned that the mesh was ‘hiding’ recurrent hernias this was neither explored at the time nor shortly thereafter. In addition, no comment was made regarding nerve involvement or compression.
The second surgeon examined the worker on May 16, 2013 and suspected a recurrent right sided hernia. He ordered an ultrasound which was negative but arranged a repeat operation which took place on July 3, 2013. He found a recurrent right inguinal hernia and excised the ilioinguinal nerve in an effort to reduce the worker’s pain.
The medical documentation confirms the presence of a recurrent right-sided inguinal hernia. There is no evidence of recurrence on the left side.
Entitlement for Recurrent Bilateral Hernias
Although the evidence suggests the worker suffered a recurrent right-sided inguinal hernia, I do not believe the recurrence is work related.
Policy 15-04-08 states that where there is a recurrent hernia and no new accident, the recurrent hernia is considered under the initial claim. This is not to say it will be automatically accepted as work-related. A decision is required to establish the relationship of the recurrence to the initial injury.
I find it significant that the worker’s pain and restrictions increased sometime between May 4, 2012 and June 28, 2012 while he was not working. I also place weight on the fact that the worker described that his pain started three weeks before June 28, 2012.
This, taken with the fact that an onset of bilateral hernia is rare and the presence of an umbilical hernia, suggests the worker had a greater than normal predisposition to these types of conditions irrespective of the physical demands of his occupation as a roofer.
The evidence does not support entitlement for recurrent bilateral hernias.
Entitlement for LOE Benefits from April 8, 2012
In the previous submission dated August 27, 2013, the worker representative suggested that the worker did not return to work after April 7, 2012 because the employer did not have modified work available.
The employer representative contends that there is insufficient information to address entitlement to LOE benefits beyond April 7, 2012, specifically, medical information regarding the worker’s level of impairment, if any, his restrictions and the employer’s ability to provide accommodated work.
I find that the worker’s recurrent hernia condition is not the responsibility of this claim. In addition, the evidence on file suggests the worker was not physically limited from returning to his roofing job on April 8, 2012 as a consequence of the hernia condition for which entitlement was granted in this claim. Therefore, entitlement to LOE related to recurrent hernias is denied.
In her letter of December 22, 2014, requesting a reconsideration of the ARO decision dated February 27, 2014, the worker representative presents the position that the worker did not recover from the hernias and developed complications from the surgeries. However, there is no evidence that the initial surgery compromised a nerve or resulted in any organic complications.
Although the focus has been on recurrence, the worker representative has raised the issue of the worker’s pain. The representative has underlined sections in the Medical Discussion Paper regarding other complications following inguinal hernia repair such as persistent groin or testicular pain; also that chronic groin pain following hernia repair is not usually due to recurrence, that there are few if any findings, and that the pain is refractory to conservative and operative treatment. The second surgeon’s letter of October 23, 2014 states the worker is suffering from severe pain that prevents him from performing the duties of a roofer. The issue of entitlement to neuropathic pain is not before me. As such I am unable to rule on this issue.
CONCLUSION
Entitlement to bilateral recurrent inguinal hernias is denied
Entitlement to LOE Benefits related to bilateral recurrent inguinal hernias is denied
The objection is denied.
DATED April 17, 2015
M. Mraz, Manager
Appeals Services Division