APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER:
20220056
OBJECTING PARTY:
WORKER
RESPONDENT:
Employer
HEARING:
HEARING IN WRITING
HEARD by:
Chantal reid, appeals resolution officer
ISSUE
The worker objects to the case manager’s decision of April 6, 2021, which denied a recurrence for a right shoulder reverse arthroplasty.
BACKGROUND
On April 16, 2015, the worker, who was employed as a receptionist at a car dealership, was walking to their desk when they fell to the floor and injured their right shoulder, arm and elbow. The claim was allowed for a right shoulder proximal humerus fracture (comminuted). The worker was able to continue working and their claim was allowed for health care benefits only.
The case manager’s decision letter of September 21, 2015, confirmed the worker’s claim was closed as they had returned to work full duties and were deemed to be fully recovered.
The case manager’s decision letter of March 4, 2016, denied the worker’s request for more physiotherapy as there was no objective evidence to support the worker’s need for further treatment as a result of the workplace injury. The decision letter of April 6, 2021, denied the worker’s request for further health care benefits and surgical entitlement.
AUTHORITY
Section 43(1) (c) Workplace Safety and Insurance Act, 1997 (WSIA)
Operational Policy Manual
Published
11-01-05 Determining Permanent Impairment 15-02-05 Recurrences
November 3, 2014 April 9, 2021
ANALYSIS
I have carefully considered all of the available information, legislation, and relevant operational policies in reaching this decision. I find the worker is entitled to health care benefits related to their right shoulder surgery.
Employer Position
The employer is not participating in the appeal.
Worker Position
In their submission dated August 24, 2021, the worker explained that they were advised by Dr. Creech that they have developed necrosis due to a lack of blood flow because of their right shoulder fracture. The worker noted they had two part-time jobs, but their right shoulder injury prevented them from completing their assigned tasks. The worker noted they were no longer able to work due to their injury, and the injury had affected their day-to-day life and activities. The worker reported they were “seriously compromised” from this injury.
Relevant Case Details
The X-ray report dated May 25, 2015, revealed a comminuted fracture of the neck of the humerus and greater tuberosity with a wide distraction of the greater tuberosity fragment and displacement of the head of the humerus relative to the shaft of the humerus. There is also some impaction of the humeral neck into the head of the humerus. There are multiple X-ray reports on file showing the worker suffered a four-part right proximal humerus fracture. These reports were silent on degenerative changes or osteoarthritis.
On September 21, 2015, the worker advised the case manager that they were pain-free with almost full range of motion in their shoulder and that they had been able to return to work in their regular work duties. The worker’s claim was closed subsequent to the completion of their approved course of physiotherapy.
The worker opted for non-surgical management and thus their right shoulder was immobilized with a sling and the worker participated in therapy. The physiotherapy discharge report dated September 23, 2015, noted the worker reported they were “+/-pain-free” and had been able to resume their full regular duties and hours. The worker had ongoing issues with overhead activities. The worker’s range of motion was noted as follows: flexion 150-155 degrees, extension 60-65 degrees, abduction 155 degrees, and external rotation 40-45 degrees.
The X-ray report dated January 18, 2016, revealed a healed fracture. The report noted there was a rotation of the humeral head that appeared to be bridged with callus. There was more impaction noted when compared to the last examination.
Dr. Lewis’ report dated January 19, 2016, noted the worker reported pain that was radiating down their neck, to their shoulder into the back of their arm. Dr. Lewis requested repeat X-rays and recommended physiotherapy and an injection. Dr. Lewis noted that if these treatments failed, the worker may need a shoulder arthroplasty. Dr. Lewis queried if the worker had gone on to develop avascular necrosis.
A medical consultant’s report dated February 5, 2016, noted the relationship between the worker’s current symptoms and the workplace accident was difficult to discern. The report went on to note the worker did not have significant changes in their range of motion from September 2015 to January 2016, and the updated diagnostics were not available for review. However, the medical consultant also noted that avascular necrosis has been known to occur following these types of injuries and further assessment would be needed in order to determine if the worker had gone on to develop avascular necrosis.
The decision letter dated March 4, 2016, confirmed the case manager had reviewed the recent X-rays and noted the worker’s fractures had fully healed. The case manager denied entitlement to further treatment. There was no comment on the avascular necrosis.
Dr. Riley submitted a letter to the WSIB on September 18, 2017, noting the worker’s right shoulder range of motion was decreasing and the worker had increasing pain with activity. Dr. Riley stated it was “not unusual to get this late effect from the original injury”. Dr. Riley recommended more physiotherapy and opined if left untreated, the worker’s symptoms would get worse.
The X-ray report of July 30, 2020, revealed a significant deformity of the humeral head, which demonstrated collapse with flattening and associated sclerosis, findings suggestive of avascular necrosis. There were also severe degenerative osteoarthritic changes involving the glenohumeral joint.
The MRI report of October 21, 2020, revealed severe bone-on-bone arthritis of the glenohumeral joint with marked destruction of the humeral head which was likely neuropathic. The rotator cuff tendons were all torn with evident muscle atrophy.
The worker was assessed by Dr. Creech, Orthopaedic Surgeon, on November 10, 2020, who confirmed the worker reported increasing pain in the last year. The worker described achy pain in the superior, posterior and anterior aspects of their shoulder. The worker described pain at night, as well as pain with overhead activities, lifting, pushing, pulling and reaching. The worker reported the pain was intermittent but had gradually been getting worse. Dr. Creech noted the worker was in their early seventies and presenting with chronic right shoulder rotator cuff tear, impingement syndrome and severe glenohumeral joint arthritis. The worker consented to a reverse right shoulder arthroplasty was recommended.
The worker was seen for follow-up on May 11, 2021, to assess the outcomes of the corticosteroid injection administered on December 7, 2020. Dr. Creech noted the worker had developed avascular necrosis post-traumatic arthritis due to their workplace injury in 2015. Dr. Creech noted significant interval changes in the radiographs from 2015 to 2020.
Assessment of the Evidence
Policy 11-01-05 (Determining a Permanent Impairment) states recovery from the work-related injury/disease is considered to have been made if there is no evidence of an ongoing work-related impairment at the time maximum medical recovery (MMR) is reached.
Having reviewed the available information, I am not convinced the worker had achieved a full recovery in September 2015. I note the physiotherapy discharge report indicated the worker had ongoing issues with overhead activities. I also note the range of motion reported was slightly below normal values. While I appreciate the worker reported they were essentially pain-free and they had been able to return to their full regular duties as a receptionist, the ability to perform sedentary type work does not equate to full recovery.
I also refer to the fact that within three months of being deemed fully recovered, the worker was seeking further medical attention due to ongoing pain. The X-ray report dated January 18, 2016, revealed that the worker’s fracture had healed, however, the report also noted there was a rotation of the humeral head that appeared to be bridged with callus and that there was more impaction noted when compared to the last examination. Dr. Lewis recommended repeat X-rays and recommended physiotherapy and an injection. Dr. Lewis noted that if these treatments failed, the worker may need a shoulder arthroplasty. Dr. Lewis also queried if the worker had gone on to develop avascular necrosis.
I also note the WSIB-requested medical consultation did not conclude the worker’s symptoms were non-work-related. The medical consultant stated that due to the lack of updated medical assessments and testing, they were unable to discern if there was a relationship between the current symptoms and the workplace accident. The medical consultant also noted that avascular necrosis is known to occur following these types of injuries and that further assessments were needed in order to determine if the worker had gone on to develop avascular necrosis.
It is for the above reasons that I do not find the worker fully recovered from their workplace injury as of September 25, 2015.
Policy 15-02-05 (Recurrences) states that a worker may be entitled to benefits for a recurrence of their work-related injury if the worker suffers a significant deterioration that did not result from a significant new incident and is clinically compatible with the original injury.
In reviewing the claim file information, I acknowledge there are large gaps in the medical reports, however, I find there is sufficient information to establish the chronology of the worker’s impairment. I find there is evidence the worker’s right shoulder injury significantly deteriorated or continually deteriorated from September 2015 to October 2021. I also find this deterioration occurred in the absence of a new incident.
I note that the medical consultant had advised that avascular necrosis was compatible with the worker’s injury. I also note that all three of the worker’s health care providers maintained the worker’s ongoing presentation was directly attributed to their workplace injury. I am persuaded the work-related injury continued to be a significant factor in the worker’s impairment and need for the right shoulder arthroplasty.
I recognize that the diagnostic reports from 2020 showed severe degenerative changes and arthritic processes, however, the diagnostic reports from 2015 were silent on any degenerative changes or arthritic processes. I find this relevant when considering that a reverse shoulder arthroplasty is recommended when there is advanced arthritis in the shoulder joint and the rotator cuff tendons are gone. In the absence of any proof that the worker’s severe degenerative conditions predated the workplace injury and noting the health care providers related the worker’s impairment and need for surgery to the workplace injury, I find the surgery was directly related to the workplace injury. The preponderance of evidence indicated the worker’s need for surgery was directly related to the workplace injury and development of avascular necrosis.
It is for these reasons that I find the worker is entitled to benefits for a recurrence related to the right shoulder reverse arthroplasty.
Benefits Flowing
Section 43 (1) (c) states a worker who has a loss of earnings as a result of the injury is entitled to payments from when their loss of earnings begins until two years after the date of the injury if the worker was 63 years of age or older on the date of the injury.
The worker was 68 year old on the date of injury. I note the worker indicated they were no longer able to work as a result of their workplace injury. The medical reports did not contain any clinical authorization for the worker to be off work. The information is insufficient for me to consider entitlement to loss of earnings (LOE) benefits prior to April 16, 2017 and this is left to the discretion of the operating area. As per Section 43, the worker would not be entitled to LOE benefits beyond April 16, 2017.
The worker is entitled to health care benefits related to any treatment they paid for out of pocket, both prior to and following the surgery.
Noting the chronicity of the injury and the nature of the surgery, once the worker has achieved MMR, the worker would have a permanent impairment, as defined by policy 11-01-05 (Determining Permanent Impairment) and a Non-Economic Loss (NEL) benefit determination.
CONCLUSION
The worker’s objection is allowed.
DATED June 13, 2022.
Chantal Reid
Appeals Resolution Officer
Appeals Services Division