DECISION NUMBER:

20220137

OBJECTING PARTY:

WORKER

REPRESENTED by:

WORKER REPRESENTATIVE

RESPONDENT:

EMPLOYER

REPRESENTED by:

EMPLOYER REPRESENTATIVE

HEARING:

HEARING IN WRITING

HEARD by:

H. MOHAMED, APPEALS RESOLUTION OFFICER

DATED:

SEPTEMBER 29, 2022

ISSUES

The worker representative (WR), on behalf of the worker, objects to the Case Manager’s (CM) decision dated May 21, 2021, which concluded the following:

1. The worker did not have entitlement to the diagnosis of right shoulder bursitis, acromioclavicular (AC) joint osteoarthritis, impingement, right trochanteric bursitis, right lateral meniscal tear, and right knee osteoarthritis. Entitlement was also denied for a left wrist injury.

2. The worker fully recovered from their right shoulder, right hip, and right knee, soft tissue injuries by May 21, 2021, without a permanent impairment.

BACKGROUND

On January 6, 2020, this production worker for a manufacturing company rolled their left ankle at work and fell to the ground landing on their right side on an outstretched right hand. Entitlement was accepted for soft tissue injuries to the right shoulder, hip, knee, as well as a right wrist strain. X-ray of the right wrist did not identify any fracture, but a scapholunate ligament injury was suspected. Imaging studies of the right shoulder and right knee identified arthritic changes as well as a subtle tear of the lateral meniscus. The worker also began to report left wrist symptoms a few months after the injury. At the time of the accident the worker had a pre-existing permanent right knee impairment under a different WSIB claim from 2010 for which they had been granted a 3% Non-Economic Loss (NEL) award.

In a decision dated May 21, 2021, the CM limited the worker’s entitlement to soft tissue injuries to the right shoulder, right hip, right knee and a scapholunate ligament tear of the right wrist. Entitlement to a left wrist injury was denied as proof of accident could not be established given the delay in the onset of symptoms. There was also no entitlement for the diagnosis of right shoulder bursitis, AC joint osteoarthritis, impingement, right trochanteric bursitis, right lateral meniscal tear, and right knee osteoarthritis. The CM concluded that with the exception of the right wrist injury, the worker had fully

recovered from all other injuries by May 21, 2021 without any ongoing impairment. The worker has objected to this decision.

A permanent impairment for the right wrist injury was accepted with a maximum medical recovery (MMR) date of June 1, 2021. The worker went on to receive a 3% NEL benefit in recognition of a permanent right wrist injury in February 2002. This decision is not before me.

Accordingly, the following questions will be answered in this appeal:

• Does the worker have entitlement to a left wrist injury under this claim?

• What is the appropriate work-related diagnosis for the worker’s right shoulder, right knee, and right hip injuries?

• Did the worker fully recover from their work-related right shoulder, right knee, and right hip injuries by May 21, 2021?

AUTHORITY

Operational Policy Manual Published

11-01-01 Adjudicative Process November 3, 2008

11-01-05 Determining Permanent Impairment November 3, 2014

ANALYSIS

I find the worker has entitlement under this claim for right shoulder strain/sprain, right shoulder bursitis, right knee sprain/strain, and right hip greater trochanteric bursitis. There is no entitlement for right shoulder AC joint osteoarthritis, right shoulder impingement, osteoarthritis of the right knee, a tear of the lateral meniscus, or a left wrist injury. Additionally, I find the worker achieved MMR without a permanent impairment for their right knee and right shoulder injuries by May 21, 2021, and July 18, 2021 respectively. Finally, I find there is insufficient medical information to determine whether the worker fully recovered from their right hip injury. My reasons and analysis follows.

The WR did not provide any submissions along with the Appeal Readiness Form. The employer is participating in the appeals process through their representative. The employer representative provided a written submission on August 31, 2022, essentially arguing that the Operating Area decision should be upheld and that the requested diagnoses should be denied as they are all pre-existing conditions that predate the workplace injury.

1. Initial entitlement to a left wrist injury

Policy 11-01-01 (Adjudicative Process), states that a five-point check system is used to adjudicate initial entitlement claims. Each point must be satisfied for initial entitlement to be allowed. There must be an employer, a worker, a personal work-related injury, proof of accident and compatibility of the diagnosis to the accident or disablement history. With respect to proof of accident, the policy asks the decision maker to consider the following:

• whether an accident situation exists;

• whether there are witnesses;

• whether there are discrepancies in the date of accident and the date the worker stopped working; and

• whether there is any delay in the onset of symptoms, or in seeking medical attention

It is important to understand that the four considerations listed above are not absolutes and should not be seen as a check list that must be met before entitlement to be considered. Failure to meet one of

the considerations does not result in failure to establish an accident. If there are reasonable explanations as to delays in either layoff from work or seeking medical attention then proof of accident can still be said to be present. Therefore a ruling on proof of accident requires careful consideration of the whole of the evidence relating to the happening of the accident, including the worker’s statement, evidence of continuity, the reporting to the employer and to the WSIB and the medical reports.

Based on my review of the evidence, I am not persuaded the worker sustained a left wrist injury on January 6, 2020. The evidence shows that the worker rolled their left ankle and fell to the ground striking their right knee, palm of their right hand, and right hip on the ground. According to the initial physiotherapist report, the worker fell onto an outstretched right arm. There was no mention of the worker’s left wrist.

I note the employer completed an Employer’s Report of Injury/Disease a few days after the accident but did not identify the left wrist as an area of injury. Unfortunately, the worker did not complete a Worker’s Report of Injury and therefore the worker’s formal statement of the accident is not on file. However, the initial physician report dated January 7, 2020, did not make any reference to the left wrist or hand.

Similarly, the physiotherapist report dated February 20, 2020, also made no reference to any left wrist injury. The worker was seen by orthopedic surgeon Dr. Annisette on April 8, 2020. At this assessment, the worker complained of pain in their right hand and right shoulder but did not mention any left wrist symptoms.

The first mention of the left wrist is documented in Dr. Annisette’s report dated August 17, 2020, which noted the worker continued to report pain in “both” wrists, but the primary area was the snuffbox of the right wrist. In his subsequent report dated September 15, 2020, Dr. Annisette noted the worker had begun to notice pain in the left wrist and that when the worker had fallen, they fell on both wrists. Dr. Annisette observed that the worker did not normally use the left wrist but was forced to do so at work and noticed increased pain in the left wrist. Dr. Annisette remarked that this was related to the worker’s fall. A diagnosis for the left wrist injury was not provided. Dr. Annisette’s report of April 27, 2021, noted that an MRI of the left wrist suggested widening of the scapholunate distance and a high grade tear involving the volar and intermediate portion of the scapholunate ligament with a low grade partial tear of the ulnar attachment of the TFCC. Dr. Charron’s report of April 13, 2021, documented that the worker had previously fractured their left wrist. Additionally, according to memorandum xx dated May 20, 2021, the worker told the CM they had previously suffered a left hand crush injury at work approximately three years ago.

Given the fact that the first documented mention of left wrist issues is more than six months after the date of injury, I am unable to correlate the worker’s left wrist issues to the workplace accident under this claim. There is no evidence to suggest the worker sustained any injury to the left wrist when they fell at work on January 6, 2020. In the first six months following the accident, the worker did not report any left wrist issues to healthcare providers, their employer, co-workers, or their case manager. In my view, a six month gap in medical reporting and complaints is a significant amount of time to overlook. Additionally, the findings identified on the left wrist MRI are likely attributable to a previous injury as documented in the CM’s memo xx and the report from Dr. Charron. For these reasons, I find that proof of accident for a left wrist injury has not been established.

2. Appropriate work-related diagnosis for the worker’s right shoulder, right knee, and right hip injuries.

The initial medical report on file confirms the worker sustained multiple soft tissue injuries as a result of their fall at work. The primary area of concern was the worker’s right wrist, shoulder, and right knee. The Operating Area allowed the worker’s claim for soft tissue injuries for the right shoulder, hip and knee.

They also accepted entitlement to a right wrist scapholunate ligament tear for which the worker was eventually granted a NEL award. Entitlement was denied for a right shoulder bursitis, AC joint osteoarthritis, right shoulder impingement, right trochanteric bursitis, right lateral meniscal tear and right knee osteoarthritis.

Policy 11-01-01 states there must be medical compatibility between the diagnosis and the accident history for entitlement to be accepted. Policy 11-01-01 states that if it is not clear that the (injury or disablement) diagnosis provided is the result of the accident or disablement history described, a decision- maker may consult with the WSIB's clinical staff to assist in making this determination. I note that a medical opinion from clinical staff was not sought. Furthermore, I note the WR also did not provide any medical report or opinion discussing the issue of medical compatibility.

With regards to the right shoulder, I note that imaging studies taken a few weeks after the workplace injury revealed evidence of mild arthritic changes. There was no evidence of any acute pathology such as a fracture, dislocation, or tendon tear. The physiotherapist report dated February 20, 2020, provided a diagnosis of right rotator cuff injury. Dr. Annisette’s report dated April 8, 2020, noted the worker was reporting pain in the right shoulder and right hand. The worker described chronic clicking in the right shoulder. Dr. Annisette noted that a recent ultrasound of the right shoulder had shown some bursitis. As such, he recommended a cortisone injection.

According to medical literature, bursitis is the result of inflammation in the bursa. The bursae are potential fluid-filled sacs that cushion the space between bones and connective tissue, allowing tendons, muscle and bone to move together. The subacromial bursa cushions the area between the rotator cuff tendons and the acromion and allows the tendons and bones to glide without friction when moving or lifting the arm. Injuries or overuse can cause fluid to collect in bursae, causing bursitis. Painful swelling may come on gradually or suddenly. People with arthritis are much more likely to develop bursitis.

Given the accident mechanism described by the worker, I am satisfied on a balance of probabilities that the worker’s right shoulder bursitis was likely caused by the workplace injury. As such, the worker has entitlement to right shoulder bursitis including the cortisone injections administered by Dr. Annisette to treat this condition. However, I agree with the CM that the worker does not have entitlement to AC joint osteoarthrosis or right shoulder impingement as neither of these conditions, in my opinion, would have been caused by the workplace injury.

With regards to the right knee, I observe the worker has a 3% NEL benefit for the right knee under a previous claim (claim xxxxxxxx). The accepted diagnoses under that claim was right knee lateral condylar fracture and a lateral tibial plateau crack. Under that claim, the worker has been receiving cortisone injections in their right knee for osteoarthritis since 2011 and a request was made for a right knee brace. Following the current workplace accident, I note the worker was seen by Dr. Annisette on July 7, 2020. Dr. Annisette noted that the worker reported pain over the anterior medial aspect of the knee. Dr. Annisette observed that there was normal alignment of the knee but there was marked medial joint line tenderness with no effusion and full range of motion. An MRI was ordered which showed a subtle tear of the anterior horn of the lateral meniscus. There is no medical opinion on file that relates the subtle tear of the anterior horn to the workplace accident. Given the significant and symptomatic nature of the worker’s pre-existing knee pathology, I find it is more likely than not that the findings identified on

the MRI were not caused by the workplace accident. Accordingly, I find that entitlement has been appropriately limited to a right knee strain/sprain only.

Finally, with regards to the right hip, Dr. Charron’s report dated July 7, 2020, documented the worker had been having right hip pain dating back for some time but the worker could not recall for how long. The worker made reference to a previous injury from 2010 when they fractured their right knee resulting in a knee and back injury. However, the worker said the right hip was more symptomatic since the more recent fall in January 2020. The worker reported experiencing pain in the lateral aspect of the right hip with some radiation to the anterior upper leg. The worker reported being more symptomatic when lying on the right side or when walking. The worker also indicated that anaesthetic injections for the low back helped symptoms in the right hip. The worker indicated they had been taking Oxycocet for a few years for their low back pain and that this was also helping the hip symptoms. The worker reported having a back brace but said they did not use it often. Following a comprehensive examination, Dr. Charron felt the worker’s symptoms were likely related to trochanteric bursitis and recommended a cortisone injection.

In his follow-up report dated December 2, 2020, Dr. Charron noted the previous injection in August had helped “a lot.” The worker said the symptoms did not fully resolve, but were much improved. However, the worker said over the last few weeks the symptoms had begun to increase. As a result, another injection was recommended. In his April 13, 2021 report, Dr. Charron noted the second injection only helped a little. The worker continued to have tenderness to palpation at the right greater trochanter. Dr. Charron felt the worker’s symptoms were likely still due to trochanteric bursitis but there was a small possibility of other pathology and arrangements were made for the worker to have a bone scan to see if there was any increased uptake in the right hip. It is unclear whether the worker went for the bone scan because a copy of the bone scan report is not on file.

According to medical literature, trochanteric bursitis is inflammation of the bursa at the outside (lateral) point of the hip known as the greater trochanter. When this bursa becomes irritated or inflamed, it causes pain in the hip. There are various factors that can cause this condition including falling onto the hip, bumping the hip into an object, or lying on one side of the body for an extended period. While there is evidence to support that the worker had some pain in their right hip prior to the workplace accident, there is no medical evidence to suggest that the worker was ever diagnosed with trochanteric bursitis prior to the workplace injury. Based on the mechanism of accident described by the worker, I find that trochanteric bursitis is medically compatible with the fall onto the right hip.

In summary, I find the worker has entitlement under this claim for right shoulder strain/sprain, right shoulder bursitis, right knee sprain/strain, and right hip greater trochanteric bursitis. There is no entitlement for right shoulder AC joint osteoarthritis, right shoulder impingement, osteoarthritis of the right knee or a tear of the lateral meniscus.

3. Ongoing entitlement for the worker’s right shoulder, right knee and right hip

Policy 11-01-05 (Determining Permanent Impairment) states that workers are considered to have reached MMR when they have reached a plateau in their recovery and it is not likely that there will be any further significant improvement in their medical impairment. In all cases, decision-makers identify when MMR is reached. Decision-makers consider whether

• recent clinical evidence indicates any change in the work-related injury/disease

• the worker is receiving or will receive treatment that is likely to improve the work-related injury/disease, or

• the worker is receiving treatment or using medication to maintain the current level of recovery.

In order to determine that a permanent impairment exists, the decision-maker must confirm that

• MMR has been reached

• evidence of ongoing impairment exists, and

• the ongoing impairment is a result of the work-related injury/disease.

As noted above, entitlement in this claim has been accepted for a right shoulder sprain/strain and right shoulder bursitis. I note the worker received cortisone injections in their right shoulder by Dr. Annisette to treat the worker’s bursitis. Dr. Annisette’s report dated May 11, 2021, indicated that the previous ultrasound had shown bursitis and therefore the worker was given another steroid injection in the right shoulder. In the meantime, an MRI was scheduled. The MRI dated July 18, 2021, confirmed there was no rotator cuff tear and there was also no evidence of any bursitis. The only pathology identified on the MRI was AC joint osteoarthrosis. In his follow-up report dated August 10, 2021, Dr. Annisette no longer recommended any further cortisone injections in the right shoulder. Instead, the worker was told to continue with physiotherapy. Since there was no evidence the worker was suffering from bursitis in the right shoulder after July 2021, and noting that the worker’s ongoing right shoulder diagnosis was changed from bursitis to mild AC joint osteoarthrosis, I find the worker fully recovered from their work related right shoulder injury by July 18, 2021.

Concerning the worker’s right knee, entitlement has been limited to a strain/sprain injury only. Based on my review of the evidence, I find the worker’s ongoing right knee issues are related to their pre-existing chronic right knee condition that includes osteoarthritis as well as a meniscal tear. Accordingly, I agree with the CM that the worker fully recovered from their right knee strain by May 21, 2021, without any evidence of an ongoing impairment related to the workplace injury under this claim.

Finally, with regards the worker’s right hip injury, I have accepted entitlement to greater trochanter bursitis. The last medical report on file mentioning the right hip is from Dr. Charron dated

April 13, 2021. This report indicates the worker was going to return for another injection to the right hip. However, there are no follow-up reports after this date. The report also indicated the worker was going to be referred for a bone scan to see if there was any other underlying pathology in the right hip. This report is also not on file. In the absence of any medical reports after April 13, 2021, I am unable to determine whether the worker fully recovered from their work-related right hip injury. As such, the worker’s entitlement to ongoing right hip issues after April 13, 2021, is remitted back to the Operating Area for further adjudication.

CONCLUSION

Based on the foregoing reasons, I find:

1. The worker does not have entitlement to a left wrist injury.

2. The worker has entitlement to right shoulder strain/sprain, right shoulder bursitis, right knee strain/sprain, and right hip greater trochanter bursitis. There is no entitlement to right shoulder AC joint osteoarthritis, right shoulder impingement, right knee osteoarthritis, and right knee lateral meniscus tear.

3. The worker achieved MMR without a permanent impairment for their right knee and right shoulder injuries by May 21, 2021, and July 18, 2021 respectively. There is insufficient medical information on file to determine whether the worker fully recovered from their right hip injury by May 21, 2021. As such, the issue of MMR and a possible permanent impairment for the right hip is remitted back to the Operating Area for further adjudication.

The worker’s appeal is allowed in part.

DATED September 29, 2022

Mr. H. Mohamed

Appeals Resolution Officer Appeals Services Division