WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20190094
OBJECTING PARTY: Employer
REPRESENTED by: Employer Representative
RESPONDENT: Worker
REPRESENTED by: Worker Representative
HEARING: Hearing in Writing
HEARD by: A. Chow, Appeals Resolution Officer
DATED: August 28, 2019
ISSUES
The employer is objecting to:
The Eligibility Adjudicator’s October 4, 2018 decision which allowed initial entitlement for bilateral carpal tunnel syndrome (CTS), left forearm tendonitis and bilateral deQuervain’s tenosynovitis. The date of injury was determined to be June 19, 2015. Entitlement to full loss of earnings (LOE) benefits from July 29, 2015 to August 25, 2015 was allowed.
The Eligibility Adjudicator’s October 31, 2018 decision that extended the full LOE benefits to 12 weeks from July 29, 2015, less the time worked on August 31, 2015 and September 1, 2015.
BACKGROUND
The worker began his employment with the employer as a food order selector in March 2012.
On or around June 19, 2015, at age 32, the worker developed bilateral wrist, left forearm injury and he attributed it to his repetitive duties as a food order picker. Initial entitlement was denied in the September 21, 2015 decision.
Upon further review of the medical documentation on record, the Eligibility Adjudicator’s October 4, 2018 decision allowed initial entitlement for bilateral carpal tunnel syndrome, left forearm tendonitis and bilateral deQuervain’s tenosynovitis. The date of injury was determined to be June 19, 2015. Entitlement to full loss of earnings (LOE) benefits from July 29, 2015 to August 25, 2015 was allowed.
The Eligibility Adjudicator’s October 31, 2018 decision extended full LOE benefits to 12 weeks from July 29, 2015, less the time worked on August 31, 2015 and September 1, 2015.
AUTHORITY
Operational Policies:
11-01-01 Adjudicative Process
11-01-04 Determining the Date of Injury
15-02-01 Definition of an Accident
18-03-02 Payment and Reviewing LOE Benefits
ANALYSIS
I have reviewed the record including the employer’s objection and considered the matter.
In reaching my conclusion, I considered the relevant policies and legislation.
1. A. Initial entitlement for bilateral carpal tunnel syndrome, left forearm tendonitis and bilateral deQuervain’s tenosynovitis.
I find that the decision to allow initial entitlement for bilateral CTS, left forearm tendonitis and bilateral deQuervain’s tenosynovitis is appropriate.
I acknowledge that the worker complained of some prior left wrist problem due to repetitive work in 2013. He was diagnosed with left wrist sprain on August 12, 2013 and left de Quervain’s tenosynovitis on August 15, 2013. The worker was off work on paternal leave around September 2013. The September 12, 2013 medical chart entry noted that the de Quervain’s tenosynovitis was largely resolved. Further medical chart entry dated November 19, 2013 showed that the left wrist was non-tender with full range of movement of wrist and thumb. The tendonitis condition was resolved. The Eligibility Adjudicator’s decision outlined that there is no indication of any ongoing medical treatment or work accommodation between November 2013 and June 2015.
The employer’s physical demands profile of a food order selector outlined that the food order selector is responsible for retrieving product from storage to shipment to various Tim Hortons locations. The food order selector works at a 12-hour shift. The essential duties include completing pre-trip inspection of skid (end rider), retrieving product from storage location, scanning the product and placing them on skid, wrapping skid with tape, transporting completed skid to be shrink wrapped.
The Eligibility Adjudicator’s Memo 3 dated September 3, 2015 provided the worker’s statement of his job duties as a food order selector. The worker stated that the employer required the food order selector to pick 170 boxes of product per hour. The products could be cases of soft drinks, soaps or different Tim Hortons’ products of varying sizes and weights. The worker would use both hands to retrieve each product from the shelves at various heights, to scan each item with a scanning gun and to load and stack the product onto the skid. He would use the end rider to transport the skid.
The Eligibility Adjudicator’s October 4, 2018 decision outlined that the worker was picking an average of 150 boxes per hour, approximately two to three cases per minute. The Eligibility Adjudicator noted that the work activities of picking and scanning the orders at the rate of 150 boxes per hour for the duration of a 12-hour shift, less his regular breaks, were repetitive in nature. The mechanism of using both hands to scan the item, to pull or lift the item off the storage shelf, to carry and place the item on the skid would involve frequent pinching, gripping with his hands, frequent wrist flexing in scanning, sustained forceful movements of wrists in pulling and lifting cases of product. The worker performed these work duties on a full time basis for several years. He was exposed to these risk factors for developing repetitive strain injuries.
The family physician’s chart entry dated June 19, 2015 indicated that the worker experienced bilateral wrist pain secondary to his job at the warehouse. The worker did a lot of repetitive pushing and pulling at work under time pressure. He was seen in 2013 for the wrist problem. The physician opined that the symptoms were related to repetitive strain at work. The analysis was possible CTS, tendonitis secondary to repetitive use of hands.
The chart entry of July 29, 2015 provided the findings of tenderness on palpation of right lower arm and positive Tinel’s test bilaterally. The analysis was right arm tendonitis.
Dr. Jay’s EMG report dated August 19, 2015 outlined that there is no history of diabetes mellitus or thyroid disease. The worker is a non-smoker and does not use alcohol. Based on the median ulnar distal motor studies and median ulnar sensory studies, Dr. Jay opined that there was enough evidence of a diagnosis of moderate bilateral CTS. The worker was recommended to try splinting to manage his symptoms.
Based on the above information, the Eligibility Adjudicator accepted initial entitlement for bilateral carpal tunnel syndrome, left forearm tendonitis and bilateral deQuervain’s tenosynovitis.
Bilateral CTS and left forearm tendonitis
On behalf of the employer, the representative argued that it is insufficient for the treating physician or worker to speculate upon causality of a disablement in this case. With reference to the WSIAT medical discussion paper on CTS, the data available on the onset of CTS suggests little if any relationship between the type of work activities exposure and CTS. The exception would be in instances where the repetitive activity requires both frequent and forceful movements.
According to the Alberta WCB paper on CTS, occupational risk factors for CTS have been associated with job tasks requiring forceful repetitive wrist motion (greater than 1,000 times per hour), high force, high repetition and duration.
The representative argued that the worker performed duties as a food order selector with various duties and tasks. The representative indicated that none of the tasks required forceful repetitive wrist motion (greater than 1,000 times per hour) and/or high force, high repetition and duration. The representative considered the duties sometimes involved strenuous use of the hands with repetitive movements for limited periods. However, they were varied and not continuous. The medical research and opinions offered above refute a causal relationship between the repetitive nature of work and the diagnosed CTS in this case. As such, initial entitlement to bilateral CTS should be rescinded.
On behalf of the worker, the representative indicated that the worker’s duties were repetitive and he had to meet the target of 170 picks per hour. The worker performed the duties for 12 hours minus breaks. The duties involved forceful gripping, grasping of boxes of varying sizes and weights. In addition, the worker had to grip and squeeze the scanning gun to scan each item. The duties involved awkward wrist/hand postures in loading the items.
The representative cited medical literatures from Europe PMC Funders Group which supports a positive association of CTS with highly repetitive movements and forceful movements of the hands. The Occupational Health Clinics for Ontario Workers’ report on CTS also identifies that the risk factors related to the development of CTS include awkward postures of the wrist, forceful and repetition movements of the hands. The representative argued that the worker’s job duties involved a combination of awkward, forceful and repetitive movements of his hands in the 12-hour shift. The treating physician did not indicate any non-work-related risk factors such as obesity, hypothyroidism, diabetes, alcohol consumption and smoking in contributing to the worker’s CTS. The clinical entry of June 19, 2015 supports that the possible CTS and tendonitis condition is secondary to repetitive use at work. Based on the available medical literature on CTS, medical evidence and the worker’s statement on file, the representative submitted that the significant contributing factor to the worker’s tendonitis and CTS are the repetitive and forceful nature of his job duties.
Policy 11-01-01 states in part:
All decision-makers use the same criteria for ruling on initial entitlement to WSIB benefits. This system is known as the "five point check system".
An allowable claim must have the following five points
- an employer
- a worker
- personal work-related injury
- proof of accident, and
- compatibility of diagnosis to accident or disablement history.
Policy 15-02-01 states in part:
Accident includes
- a willful and intentional act, not being the act of the worker
- a chance event occasioned by a physical or natural cause, and
- a disablement arising out of and in the course of employment.
I have thoroughly reviewed all available documentation on record including the disablement history in memo 3. The worker reported returning to his regular duties in November 2013. There is no indication of any ongoing medical treatment for the left wrist between November 2013 and June 2015. The worker reported bilateral wrist pain to the treating physician on June 19, 2015. I note that the worker had to use both hands in retrieving products, scanning products, loading and stacking the products onto the skid. I find that there were repetitive, forceful movements with some awkward positions of both wrists and hands in maneuvering the products at the rate of approximately 150 boxes per hour for a 12-hour shift period. The target was 170 boxes per hour. The EMG studies of August 2016 showed bilateral CTS.
The WSIAT medical discussion papers with these medical topics frequently arise in appeals. The papers are intended to provide the parties with a broad, general overview of the medical topics. I am not bound by any information provided by the WSIAT medical discussion paper or other cited medical discussion papers. In addition, the mention of repetitive wrist motion of 1,000 times per hour in the Alberta WCB paper is not a basis of adjudication under the Ontario WSIB policy. Every appeal decision must be based upon the facts of the particular case.
In this case, I note that there is no indication in any available medical documentation that the worker has bilateral CTS prior to June 2015. His left wrist tendonitis was fully resolved by November 2013. There is no indication of any other non-work-related activities or medical risk factors in contributing to his bilateral CTS. The worker reported the gradual onset of bilateral wrist pain associated with repetitive use of both hands at work. The worker was diagnosed with bilateral CTS in August 2015.
Based on the disablement history on record, I am satisfied that the worker was engaged in work activities which involved both repetitive and forceful movements with both hands. The treating physician supports that the symptoms are related to repetitive strain at work. Noting the chronology of the events, I find that on the balance of probabilities, the worker’s repetitive job duties as a food order selector and the repetitive use of both hands significantly contributed to the development of his bilateral CTS and left forearm tendonitis. As such, I find that the worker has entitlement to bilateral CTS and left forearm tendonitis.
Bilateral deQuervain’s tenosynovitis
On behalf of the employer, the representative argued that deQuervain’s tenosynovitis is an acceptable injury if the job tasks involved frequently repeated motions on the affected tendons, significant flexion, extension or deviation of the wrist or forceful exertion of the muscles of affected wrist. The representative submitted that none of the risk factors are present in this case.
On behalf of the worker, the representative outlined that the Mayo clinic suggests chronic overuse of the wrist is commonly associated with deQuervain’s tenosynovitis. Risk factors include jobs involving repetitive hand and wrist motions. The representative argued that the worker’s job duties involve frequent wrist movements, gripping, grasping and lifting boxes with various weights and sizes. Gripping is involved when using the scanning gun.
The physician’s chart entry dated September 14, 2015 stated that the worker’s symptoms seem to be both related to deQuervain’s tenosynovitis and CTS. They were all likely work related. The worker was referred to a specialist for further testing. Based on the above, the representative supports the allowance of deQuervain’s tenosynovitis in this case.
In this case, I note that the worker’s left wrist tendonitis was fully resolved by November 2013. There is no indication of any other non-work-related activities or medical risk factors in contributing to his bilateral deQuervain’s tenosynovitis. The worker reported the gradual onset of pain when flexing thumbs associated with repetitive use of both hands at work. The worker was diagnosed with bilateral deQuervain’s tenosynovitis in September 2015.
Based on the disablement history on record, I am satisfied that the worker was engaged in work activities which involved both repetitive and forceful gripping and lifting with both hands. Noting the chronology of the events, I find that on the balance of probabilities, the worker’s repetitive job duties as a food order selector and the repetitive use of both hands significantly contributed to the development of his bilateral deQuervain’s tenosynovitis. As such, I find that the worker has entitlement to bilateral deQuervain’s tenosynovitis.
Date of injury
I find that the date of injury is correctly determined as June 19, 2015.
The Eligibility Adjudicator indicated that although the worker had prior problems with his left wrist in 2013, the medical notes on November 19, 2013 showed that the condition had fully resolved. The worker resumed regular duties without any medical restrictions. There is no indication of any ongoing medical treatment or formal work accommodation between November 2013 and June 2015. Based on the available medical documentation on record, the worker reported an onset of his wrist and hand pain to the medical provider on June 19, 2015. The worker was diagnosed with left forearm tendonitis, bilateral wrist repetitive strain and possible bilateral CTS in the June 19, 2015 medical visit. As such, the date of injury for the bilateral wrist injury is established as June 19, 2015.
On behalf of the employer, the representative submitted that the date of first treatment leading to the diagnosis and ongoing treatment was documented as early as December 2012 but most certainly during 2013. The worker was self-modifying his work duties until June 19, 2015.
The worker representative submitted that the accident date of June 19, 2015 is correct as per policy 11-01-04. There were no ongoing complaints or need for active treatment since November 2013. A confirmed diagnosis of CTS was not provided until later in 2015. There is no evidence to support ongoing issues between November 2013 and 2015.
Policy 11-01-04 states in part: In a gradual onset disablement claim, the date of injury is established using the date of first medical attention which led to the diagnosis, or the date of diagnosis, whichever is earlier. An example of a gradual onset disablement claim is where a worker gradually develops left wrist and hand symptoms from work-related duties and is diagnosed with carpal tunnel syndrome.
In this case, I note that the medical information only revealed left wrist pain and sprain in 2013. The documentation clearly stated that the tendonitis was resolved in November 2013. There is no indication of any ongoing medical treatment for both hands between November 2013 and June 2015. There is no record of any formal medical restrictions or work accommodation for the worker. The worker reported an onset of his wrist and hand pain symptoms on June 19, 2015 with bilateral wrist repetitive strain and possible CTS findings. The bilateral CTS was confirmed in the 2015 EMG report. On this basis, I find that the Eligibility Adjudicator correctly determined the date of injury as June 19, 2015 in this case.
2. LOE benefits
The worker began to lose time from work on July 29, 2015. I find that the decision to allow LOE benefits from July 29, 2015 for 12 weeks is appropriate.
The Eligibility Adjudicator’s October 31, 2018 decision extended full LOE benefits to 12 weeks from July 29, 2015, less the time worked on August 31, 2015 and September 1, 2015. The decision outlined that a written modified job offer was on file on August 26, 2015. The modified duties included clerical work, order picking, replenishing boxes, dry mopping and cutting wraps. The worker commenced the modified duties on August 31, 2015 and worked one full shift and one partial shift. He reported worsening of symptoms. He was assigned clerical duties for four hours on August 31, 2015 and no further modified duties were available. He was then assigned other duties including dusting racks with a long pole and regular manual work on September 1, 2015. Further medical note dated September 3, 2015 indicated that the worker was unable to do work involving his bilateral forearms. Noting the worsening of the worker’s symptoms and the lack of available modified duties for the worker, entitlement to LOE benefits was allowed from July 29, 2015 for 12 weeks.
On behalf of the employer, the representative requested that the initial entitlement should be rescinded with no associated LOE benefits.
The worker representative concurs with the decision to allow LOE benefits in this case.
I have thoroughly reviewed the documentation on record, I note that the worker attempted to return to modified job with the employer on August 31, 2015. However, there is indication that there is no further modified duties available for the worker after the first day of modified duties.
On this basis, I concur with the Eligibility Adjudicator’s decision to allow for LOE benefits for the period in question.
CONCLUSION
I conclude that:
The worker is entitled to bilateral carpal tunnel syndrome, left forearm tendonitis and bilateral deQuervain’s tenosynovitis.
The decision to allow LOE benefits from July 29, 2015 for 12 weeks is appropriate.
The employer’s objection is denied.
DATED: August 28, 2019
A. Chow
Appeals Resolution Officer
Appeals Services Division