Workplace Safety and Insurance Board
Appeals Resolution Officer Decision
Decision number: 20170003
OBJECTING PARTY: Worker
REPRESENTED by: Paralegal
RESPONDENT: Employer
HEARING: Hearing in Writing
ISSUE
The worker is requesting entitlement to a right knee meniscal tear and ongoing entitlement.
BACKGROUND
On May 19, 2016, this then 55 year old truck driver began to experience throbbing in her right knee as she was driving back after unloading/loading linen at work. The worker reported the injury to the employer at the end of her shift. A Form 8 completed at a walk-in clinic on May 22, 2016 provides a diagnosis of a right knee strain. The family doctor assessed the worker on May 24, 2016.
Operations granted initial entitlement for a right knee strain on June 1, 2016. The Eligibility Adjudicator’s decision letter of July 27, 2016 confirmed entitlement to health care benefits for a right knee strain as a gradual onset disablement.
A right knee MRI was performed on July 27, 2016. An orthopaedic assessment performed on August 18, 2016 provides the diagnosis of right knee medial meniscal tear and medial arthritis.
The administrative decision dated February 13, 2017 determined that the criteria for an oral hearing have not been met. The issue is now before me as a hearing in writing.
Case Manager’s decision
The Case Manager’s decision letter dated August 22, 2016 limited entitlement to the diagnosis of right knee strain. The Case Manager denied entitlement beyond July 21, 2016 on the basis that strain injuries normally resolve within six to eight weeks and that the mechanism of injury did not support the diagnosis of right meniscal tear.
A reconsideration letter dated November 22, 2016 confirms the decision to limit entitlement.
Worker’s position
The worker suggests the medical evidence supports an ongoing work-related injury to the right knee. The worker argues that the right knee injury did not resolve despite treatment and that further investigations revealed a meniscal tear.
Employer’s position
The employer submits that ongoing entitlement is not in order as there was no specific incident and the mechanism of injury does not support the diagnosis of a right meniscal tear. The employer presents the view that that the worker did not indicate twisting her right knee until four months after providing statements that there was no specific incident.
AUTHORITY
The following Operational Policies apply:
11-01-01 Adjudicative Process
15-02-03 Pre-existing Conditions
ANALYSIS
I find for the reasons outlined below that ongoing entitlement is in order beyond July 21, 2016. I additionally find that the diagnosis of right meniscal tear is clinically compatible with the disablement history.
Is there a pre-existing right knee condition?
I appreciate the employer’s concerns raised in the written submission of February 1, 2017. On the other hand I afford the most weight to the objective clinical evidence provided in the right knee MRI report of July 27, 2016 and the expertise of the assessing orthopaedic surgeon.
Policy 15-02-03 outlines that a pre-existing condition is any condition that existed prior to a work-related injury and may include degenerative conditions. Policy confirms that the existence of such a condition may be confirmed by post-injury clinical evidence.
I note that the MRI shows chondromalacia in the medial compartment. The orthopaedic surgeon’s assessment of August 18, 2016 documents the presence of arthritis in the medial compartment of the right knee. I observe that the MRI and orthopaedic report are dated approximately three months after May 19, 2016. Therefore, I accept that the identified chondromalacia and medial arthritis represent pre-existing, non-work-related right knee conditions.
Clinical compatibility and entitlement to a right medial meniscal tear
I accept that clinical compatibility is established for a right medial meniscal tear. The worker representative relies on the clinical opinions provided by the assessing orthopaedic surgeon and treating physiotherapist. The employer highlights the Medical Consultant’s review completed on November 9, 2016.
Policy 15-02-03 requires that initial entitlement be established prior to considering the impact, if any, of pre-existing conditions on the worker’s ongoing impairment. Policy 15-02-03 also confirms that entitlement is not granted for injuries such as non-work-related pre-existing conditions. Policy 11-01-01 requires clinical compatibility between the disablement history and diagnosis. In this case, the diagnosis to be considered is medial meniscal tear of the right knee.
Disablement history
There is general agreement that the worker did not identify a single specific event to either the employer or the Case Manager. At the same time, I must consider that the worker’s Form 6 dated June 1, 2016 clarifies that she first experienced right knee symptoms as she was making the return drive from work on May 19, 2016. Additionally, I have considered that the orthopaedic surgeon’s assessment dated August 18, 2016 documents the worker as being 5’4” tall and weighing 170 pounds.
I recognize the employer’s argument that the worker did not refer to twisting of the right knee from the date of the Form 7 signed on May 22, 2016 until the Case Manager’s decision letter of August 22, 2016. Notwithstanding, it is my opinion that the worker’s reporting to the treating medical professionals must also be reviewed.
In particular, I observe that the orthopaedic surgeon’s assessment of August 18, 2016 documents a history of the worker pushing heavy carts around a curve on May 19, 2016. The orthopaedic report of September 2, 2016 similarly records a history of the worker pushing heavy carts around a turn in a rapid manner. Accordingly, I accept that there is sufficient evidence of the worker having to maneuver the linen carts rapidly around a curve during the delivery on May 19, 2016.
The worker’s Form 6 of June 1, 2016 describes the linen delivery/pick-up as being very fast paced as three porters receive the clean linen carts from her and feed her carts of soiled linen. The worker representative’s submission of March 15, 2017 further describes the linen delivery as involving going around a tight “S”-curve with two carts in single file. The worker would quickly push with her body going into the curve then a quick pull towards her body using her right foot to pull carts to herself coming through the end of the S-curve.
The worker additionally describes a change involving being “bumped” off her route three weeks prior to May 19, 2016. The worker indicates that she had been driving to xxxxxx and unloading/loading with the assistance of one linen porter. Hence, the worker would be driving approximately 4.5 hours per eight hour shift. In contrast, the worker describes her duties on May 19, 2016 as being within the xxxxxx area, working with three linen porters and being very rushed.
Further, I have considered the employer’s fax of October 19, 2016 which provides specific details of the worker’s job duties. The listed initial pushing force to get a cart moving is stated to be between 5 – 18 kilograms. Nevertheless, I must consider that the worker describes the linen carts as weighing between 250 – 300 pounds and that the reported injuring process relates to rapidly moving the carts around a curve. There is general agreement that the delivery involved 38 carts. The employer clarified that 38 carts of clean linen were unloaded while 33 carts of soiled linen and five empty carts were loaded.
Finally, I find that the maneuverability of the linen carts must be examined. The employer’s fax of October 19, 2016 explains that each cart has two wheels for steering which are able to turn 360 degrees and two wheels to keep control of the cart that only move forward or backward. Thus, I accept the worker’s indication that she must push with her body going into the curve and use her right foot to pull the carts towards her body coming through the end of the curve.
Based on these reasons, I accept that the worker is claiming a gradual onset disablement history relating to a recent increase in work duties involving rapidly moving heavy linen carts with only two steerable wheels around a tight S-curve.
I note that the family doctor indicated on May 24, 2016 that a MRI would be considered if the worker’s right knee did not appear to improve. I observe that the physiotherapist’s initial assessment report of June 23, 2016 clearly provides a working diagnosis of meniscal tear. Therefore, I will now turn to the question compatibility of the above accepted disablement history to the diagnosed right knee medial meniscal tear.
Compatibility
I accept that the work duties performed on May 19, 2016 were a significant contributing factor to the diagnosed right knee medial meniscal tear.
I acknowledge that the Medical Consultant’s opinion of November 9, 2016 indicates that the meniscal tear is more related to degenerative changes given the gradual onset with no specific incident. The Medical Consultant explains that the horizontal tear involving the posterior horn of the medial meniscus was more than likely present prior to the onset of symptoms and due to degeneration within the right knee. The Medical Consultant’s November 9, 2016 opinion also outlines that degenerative meniscal tears are asymptomatic and are found as an incidental finding on imaging.
The assessing orthopaedic surgeon’s report of September 19, 2016 provides the opinion that the worker’s right medial meniscus was torn on May 19, 2016 as a result of pushing heavy carts around a curve. The treating physiotherapist’s report of September 23, 2016 confirms that the worker was initially assessed on June 20, 2016 and that the clinical presentation indicated meniscus injury. The physiotherapist suggested that it is extremely likely that pulling and pushing linen carts caused the meniscus injury.
In weighing the evidence, I note that the onset of right knee throbbing occurred as the worker was driving back from completing the linen delivery. I also observe that the opinions of the orthopaedic surgeon and physiotherapist are based on direct observation of the worker. I further consider it significant that the family doctor indicated the possible requirement of a MRI as early as May 24, 2016.
Therefore, I accept the opinion of the orthopaedic surgeon and treating physiotherapist that the diagnosed right knee medial meniscal tear is clinically compatible with the job duties performed on May 19, 2016. In reaching this determination I have considered the recent change in the worker’s route three weeks prior to May 19, 2016 and the disablement history reviewed above. As a consequence, I find that entitlement for a right knee medial meniscal tear is in order.
Ongoing entitlement beyond July 21, 2016
I find that there is sufficient clinical evidence of an ongoing work-related right knee injury beyond the date of July 21, 2016. I additionally find that there is currently insufficient clinical evident to determine ongoing entitlement beyond September 19, 2016.
The physiotherapist’s Program of Care outcome summary dated August 16, 2016 documents that fully knee extension was not achieved with therapy and that an exercise program only exacerbated the worker’s symptoms. The physiotherapist’s report of September 23, 2016 confirms that range of motion was not restored with physiotherapy. The orthopaedic surgeon’s report of September 8, 2016 indicates that the worker still has mechanical symptoms. The orthopaedic report dated September 19, 2016 indicates the possibility of surgery if all non-operative modalities fail.
For these reasons, I find that ongoing entitlement is in order for the period of July 21, 2016 to September 19, 2016 (inclusive). Operations is requested to obtain all outstanding medical reporting prior to determining any potential ongoing work-related entitlement beyond the date of September 19, 2016.
CONCLUSION
I conclude the following:
Entitlement is in order for a right knee medial meniscal tear.
There is pre-existing, non-work-related, right knee conditions consisting of chondromalacia and medial arthritis.
Ongoing entitlement for a work-related right knee injury is in order for the period of July 21, 2016 to September 19, 2016 (inclusive).
Operations is requested obtain any outstanding medical documentation prior to determining any potential ongoing work-related entitlement beyond September 19, 2016.
The worker’s objection is allowed in part.
DATED March 30, 2017
K. MacMillan
Appeals Resolution Officer
Appeals Services Division