WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
decision number: 20150048
DECISION DATE: June 4, 2015
OBJECTING PARTY: Worker
REPRESENTED by: Worker Representative
RESPONDENT: Employer
REPRESENTED by: Employer Representative
HEARING: Hearing in Writing
HEARD by: J. Cantwell, Appeals Resolution Officer
ISSUE
Entitlement for right knee total replacement surgery.
BACKGROUND
On February 19, 2008, the worker, an electrician, descended an 8 foot ladder when his right knee locked and he fell. As he was falling, he jumped from the third step of the ladder to the ground brushing the wall with his left shoulder and tumbling onto the floor. Entitlement was accepted for a right knee strain superimposed on advanced osteoarthritis.
The worker participated in treatment but did not make a full recovery. A permanent impairment was accepted as of October 21, 2009.
The worker was compensated for his permanent impairment with an 11 percent non-economic loss (NEL) award; he was provided with labour market re-entry (LMR) assistance, and he received partial loss of earnings benefits until age 65 for his wage loss.
Right total replacement knee surgery was recommended in October 2013. The worker was placed on a waitlist. He sought entitlement for this surgery under the claim. On August 8, 2014, the Case Manager found the right total replacement knee surgery was required for pre-existing non-compensable osteoarthritis and therefore, was not the responsibility of this claim.
AUTHORITY
15-05-01 Resulting from Work-Related Disability
Entitlement for any secondary condition is accepted when it is established that a causal link exists between it and the work-related injury.
ANALYSIS
I conclude entitlement for right knee replacement surgery is not in order. The worker representative argued surgery should be allowed under the claim as the work injury was a significant contributing factor to the surgical condition, the NEL award recognized arthritis, and the causes of injury necessitating surgery are indivisible. I am not persuaded the need for surgery arose out of the injury.
I do not conclude the worker is entitled to total knee replacement surgery because the NEL award rated for the arthritis in his knee. The AMA guides are used to rate permanent impairment as directed by law and policy. The AMA guides provide a tool for measuring impairment. The guides include a rating for arthritis. The fact the worker received a rating for arthritis in his knee does not mean he has further entitlement in the claim if the arthritis worsens. Any entitlement in the claim after the NEL award has been determined must be adjudicated. The decision maker must determine if the worsening arose out of the work injury. In this case, the case manager did not accept the worsening arthritis, which necessitated surgery, was due to the work injury.
The medical evidence does not lead me to conclude the surgery was necessitated or hastened by the work injury. The worker was seen an orthopaedic surgeon at the WSIB Knee and Hip Specialty Clinic in June 2008 and October 2009. The same specialist saw the worker again in October 2013 and waitlisted him for a total knee arthroplasty. Based on his medical reports, I conclude the arthroscopic surgery was required due to degenerative changes in the knee and not the work injury.
In June 2008, the specialist identified the worker had a significant injury 30 years prior that required surgery. The exact nature of the surgery was not known. He found signs of an old ligament injury and it looked like the worker had a combination of an anterior cruciate and medial collateral ligament repair. He thought the worker also had a medial meniscectomy.
The specialist noted the worker functioned extremely well and was essentially asymptomatic at the time of his work injury in February 2008. He was an electrician and frequently used ladders and did low level work. The family doctor was asked for documentation regarding the right knee in the two years prior to the work injury. The worker was not seen by the family doctor for his right knee in that time. I conclude the right knee was asymptomatic at the time of the work injury.
When the orthopaedic specialist examined the worker’s range of motion, it had not changed much since his surgery thirty years prior. His range of motion was 10 to 110 degrees. There was no significant effusion. The quads measured equally. The doctor identified a medial femoral condyle osteophyte, varus alignment. The right knee was almost down to bone on bone in the medial compartment on varus stress. He reviewed the worker’s x-rays and found the worker had almost end stage medial compartment arthritis of his right knee with varus alignment. The doctor described the osteoarthritis as advanced stage arthritis. He indicated the only surgical option would be to have a total knee replacement. The specialist did not recommend surgery in June 2008. He noted the worker’s pain was subsiding and he was not disabled enough to consider a knee replacement at that time.
In October 2009, medical reports indicated the worker was left with a permanent impairment. The doctor provided permanent restrictions for ladder climbing, squatting, kneeling, and heavy lifting. The specialist noted the worker had a home exercise program but he did not expect the worker’s range of motion or strength to increase. The doctor found the medial compartment of the worker’s knee was almost bone on bone and he would require a right total knee arthroplasty. However, the worker walked with a relatively normal gait pattern and the doctor concluded the worker was not quite ready for a total knee replacement.
Therefore, the facts are: 1) the worker received physiotherapy which improved his condition but he did not return to his pre-injury status. 2) The strain injury caused the worker to be symptomatic but not to the extent surgery was recommended.
In October 2013, the specialist recommended surgery. He noted the worker was 65 years old and retired. The worker had a long history of right knee pain. His function was not limited. He had an excellent range of motion, 3 to 100. There was a large loose body in the suprapatellar pouch. The worker had end stage medial compartment arthritis, clinically and radiographically.
Arthritis is a degenerative condition which progresses over time. The medical consultant who reviewed the employer’s entitlement for Second Injury and Enhancement Fund relief identified the pre-existing arthritis as a major pre-existing condition. The worker was 60 years old at the time of injury. He was 65 years old when surgery was recommended. He had almost end stage arthritis at the time of the injury which progressed to end stage arthritis by age 65 years.
I conclude the strain injury, which resulted in a permanent impairment, did not hasten the need for a total knee arthroplasty. Even after the injury, the worker continued to walk with a relatively normal gait pattern. He had excellent range of motion and his function was not limited. Based on these findings, I am not persuaded the strain injury was a significant contributing factor to the worsening arthritis in the worker’s knee.
The worker’s arthritis was at an advanced stage at the time of the work injury such that the specialist indicated the worker would require a total knee replacement in the future. I conclude the remote injury from 30 years prior described in medical reports as significant, and the surgery, which involved ligament repairs and possibly a meniscectomy, was far more likely to have significantly contributed to the worker’s arthritis than the strain injury that occurred when the worker fell. I conclude the remote non-compensable injury was likely a significant contributing factor to the development of arthritis in the right knee over time.
I conclude the worker would have required surgery for his non-compensable progressing arthritis even if he had not had the work injury.
CONCLUSION
Entitlement is denied for right total knee replacement surgery.
The worker’s objection is denied.
DATED June 9, 2015
Judy Cantwell
Appeals Resolution Officer
Appeals Services Division