WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
Decision Number: 20170009
DATE: March 9, 2017
OBJECTING PARTY: Worker
REPRESENTED BY: Worker Representative
RESPONDENT: Employer
HEARING: Hearing in Writing
ISSUE
The worker objects to the decision of the case manager (CM) dated October 8, 2015 which denied any ongoing entitlement or treatment for the right knee injury beyond April 21, 2015.
BACKGROUND
On July 10, 2014, this then 50 year old electrician reported twisting his right knee as he was turning and descending the stairs. The hospital emergency physician diagnosed a right knee medial collateral ligament (MCL) strain. The worker was able to continue on modified duties. Given the worker’s lack of response to conservative treatment, an MRI was completed on August 28, 2014 which confirmed, among other findings, a complex medial meniscal tear.
Surgical repair of the meniscal tear was eventually carried on November 5, 2014. The worker was cleared to return to sedentary duties once again on December 10, 2014. The worker received additional physiotherapy treatment following his surgery; however, he continued to experience significant swelling in the lower leg. By March 10, 2015, the worker was cleared to resume his regular work duties, albeit with some graduated restrictions related to the amount of time spent on a ladder. The worker was deemed to have reached maximum medical recovery (MMR) as of this date and the file was closed.
A Health Professional’s Progress Report (Form 26) dated June 22, 2015 was submitted to the file with reports of persistent medial joint line knee pain. The worker was reassessed at the Altum Health Surgical Specialty Program on July 14, 2015 and one week later he was administered a cortisone injection to the knee. It was suggested that the worker might benefit from Synvisc injection. A WSIB Physician Case File Review memo on September 14, 2015 concluded that the recommended Synvisc injection was required for treatment of osteoarthritis and the Baker’s cyst. It was not required to treat the work injury (i.e. medial meniscal tear). The physician also concluded that MMR had been achieved with respect to the work injury as of April 21, 2015. Given the pre-existing findings noted on the MRI, the cortisone injection was allowed on a one-time basis only and any continuing entitlement beyond April 21, 2015 was denied.
The worker’s request for additional treatment (Synvisc injection) and continuing entitlement for the right knee was denied. The worker’s objection to these decisions is now before me.
AUTHORITY
Workplace Safety & Insurance Board Operational Policy Manual (OPM) documents:
15-02-03 – Pre-existing Conditions
Policy 15-02-03 states that entitlement for a work-related injury/disease will not be denied due to the existence of a pre-existing condition. Once initial entitlement is established, the decision-maker considers the impact, if any, of pre-existing conditions on the worker’s ongoing impairment.
When assessing the impact of the pre-existing condition on the worker’s ongoing impairment, the decision-maker determines whether the work-related injury continues to be a significant contributing factor. To make this determination, the decision-maker considers the significance of the work-related injury and the pre-existing condition, relative to each other.
If it is determined that the significance of the pre-existing condition is so great it has overwhelmed the impact of the work-related injury, thereby rendering it insignificant, then the work-related injury cannot be considered to be of sufficient significance in comparison to the pre-existing condition, for benefits to continue.
When determining if a pre-existing condition has overwhelmed the work-related injury, the decision-makers consider whether the worker’s current level of impairment would continue despite the work-related injury and whether the work-related injury on its own would cause a similar level of impairment. If the work-related injury would likely have caused a similar level of impairment, it is still considered a significant cause of the ongoing impairment.
In cases where the pre-existing condition is not contributing to the ongoing impairment but is prolonging the recovery from the work-related injury, benefits continue as long as the ongoing impairment is work-related, even if recovery takes longer due to the pre-existing condition.
Where the clinical evidence demonstrates that a pre-existing condition has been aggravated as a result of a work-related injury, benefits continue until the worker recovers from the aggravation of the pre-existing condition.
Workplace Safety & Insurance Act (The Act) - Section 43(1)
Section 43(1) of The Act states,
43 (1). A worker who has a loss of earnings as a result of the injury is entitled to payments under this section beginning when the loss of earnings begins. The payments continue until the earliest of,
a) the day on which the worker’s loss of earnings ceases;
b) the day on which the worker reaches 65 years of age, if the worker was less than 63 years of age on the date of the injury;
c) two years after the date of the injury, if the worker was 63 years of age or older on the date of the injury;
d) the day on which the worker is no longer impaired as a result of the injury.
ANALYSIS
In reviewing this objection, I have had regard for the claim file information, relevant policy and legislation and for the arguments presented. Based on the information before me, I find sufficient evidence to support ongoing entitlement and treatment for the worker’s right knee injury beyond April 21, 2015.
The worker’s representative presented a medical report from the family physician dated April 30, 2016 in support of the worker’s appeal. The family physician noted that although the worker was cleared to resume full, regular duties by the Altum Health Surgical Specialty Clinic on April 21, 2015, he sought further medical attention for recurring medial right knee pain on June 22, 2015.
Based on the following evidence, I am persuaded that the recurring symptoms in June 2015 were medically compatible with, and directly attributable to, the work injury:
The surgical report noted findings of Grade 2 chondral and articular cartilage changes. Grade 2 changes normally denote changes of a mild to moderate severity. The Altum Health report dated November 20, 2014 confirmed that the surgery revealed only some “mild chondrosis”. There is no evidence of any moderate or severe pre-existing arthritic condition impacting the knee;
Post-surgery, the worker went on to experience complications related to post-operative bleeding and persistent swelling of the calf. The Specialty Clinic noted the presence of a large baker’s cyst in the right knee. Although the initial MRI showed a small baker’s cyst, the cyst had evidently increased in size since the surgery.
A baker’s cyst is produced when excess joint fluid is pushed into one of the small sacs of tissue behind the knee, causing the sac to fill with fluid and bulge out. Given the post-operative bleeding which occurred, it is possible that this may have contributed to the exacerbation of the baker’s cyst;
- The April 21, 2015 Altum Health Surgical Specialty Clinic Discharge report noted the following:
o Although it was concluded that the worker had “recovered” by the time of this assessment, the report noted persistent ongoing stiffness in the right lower extremity from mid-thigh to mid-calf which tended to gradually increase throughout the day. His symptoms were affected by the level of activity throughout the day;
o He continued to experience difficulties going down the stairs (specifically pain in the right patellar tendon);
o There remained some residual swelling in the right calf. The worker continued to don compression stockings to help reduce the swelling;
o Examination revealed slight tenderness to the medial aspect of the patellar tendon. He was able to perform a full squat with slight patellar tendon pain at the end range;
o The worker endorsed only a moderate (70 to 75 percent) improvement in his pain.
Although the examiner concluded that the worker was “fully recovered”, and that he was able to resume full work duties, the report would suggest that there was some residual symptomology which persisted;
The Form 26 of June 22, 2015 noted persistent medial joint line pain with an intensity of 4 out of 10 by the end of the workday. The worker has not described any new, acute injury or any significant change in findings since his last Altum Health Clinic assessment. Rather, his symptoms continued unabated. Other treatment alternatives were investigated in an effort to minimize or resolve those residual symptoms;
On July 14, 2015, the worker was reassessed at the WSIB Surgical Specialty Program. Similar to his last assessment in April 2015, the worker endorsed pain along the medial joint line. His symptoms were worse with use of the right leg when walking, climbing stairs, standing and general use/activities at work. Deep squatting, kneeling and crouching remained limited and painful. The worker described some worsening of his symptoms since the last assessment as the pain was now more constant.
Findings noted at the time of examination were similar to those in April 2015, except that the worker was only able to perform a half squat. The surgeon concluded that some of the worker’s symptoms were related to the postsurgical healing process as well as the osteoarthritis and meniscal tear. He was offered a cortisone injection in an effort to reduce some of the inflammation;
- The worker was reassessed on August 20, 2015. The worker noted that while he found some benefit from the cortisone injection initially, this was now wearing off. The surgeon noted that the diagnosis remained unchanged – diffuse right knee pain post medial meniscal tear and arthroscopic debridement, partial meniscectomy on a background of osteoarthritis. It was determined that the worker might benefit from Synvisc injection.
The definition of a pre-existing condition as outlined in policy 15-02-03, “Pre-existing Conditions”, includes underlying or asymptomatic conditions which only become manifest post-accident. The worker has denied any right knee symptoms prior to the work accident and there is no evidence on file to suggest the presence of a pre-accident impairment. By all accounts, there is no evidence that the worker ever reported difficulties in carrying out his job duties due to a pre-existing knee condition before the work accident.
In assessing the worker’s entitlement under policy 15-02-03, I am not persuaded that the pre-existing osteoarthritic condition has overwhelmed the work-related injury. On the contrary, given the continuity of complaint, the compatibility of symptoms with the original injury and the absence of any objective medical information to support that the worker’s symptoms had resolved following surgery, I find that the work injury continues to present a significant contributing factor to the ongoing right knee impairment.
The WSIB Consulting Physician noted that the Synvisc was recommended to treat the underlying osteoarthritis. As per policy 15-02-03, where the clinical evidence demonstrates that a pre-existing condition was aggravated as a result of a work-related injury, benefits continue until the worker recovers from the aggravation of the pre-existing condition. In light of the fact that the right knee was asymptomatic prior to the work accident but has remained persistent since the accident, there is no evidence to suggest that the aggravation of the underlying condition has ended.
The Altum Health report dated July 14, 2015 concluded that some of the worker’s symptoms were related to the postsurgical healing process as well as the osteoarthritis and meniscal tear. The opinion of the surgeon would suggest that the meniscal tear and postsurgical healing process continued to be contributing factors impacting the worker’s persistent right knee symptoms. In this case, I am satisfied that the work-related injury continued to present as a primary factor in the worker’s ongoing impairment.
In his review, the WSIB Consulting Physician noted that the Synvisc was also being used to treat the Baker’s Cyst. Given the fact that the size of the Baker’s cyst had increased significantly after the surgery, I find that the increase in symptoms related to the Baker’s cyst is likely attributable to the work injury, the surgery and the complications which arose following surgery.
CONCLUSION
I find sufficient evidence to support that the worker’s compensable right knee injury continued to present as a major contributing factor to the persistent right knee symptoms and the need for further treatment (including Synvisc injection) beyond April 21, 2015. The worker’s request for continuing entitlement and treatment (i.e. Synvisc injection) beyond April 21, 2015 is granted.
The worker’s objection is therefore allowed.
DATED March 9, 2017
R. Calvert
Appeals Resolution Officer
Appeals Services Division