DECISION NUMBER:

20220077

OBJECTING PARTY:

WORKER

REPRESENTED by:

WORKER REPRESENTATIVE

RESPONDENT:

EMPLOYER (NOT PARTICIPATING)

HEARING:

HEARING IN WRITING

HEARD by:

DATED:

HELEN SHAW, APPEALS RESOLUTION OFFICER

JUNE 15, 2022

ISSUES

The worker is seeking ongoing entitlement for benefits beyond December 7, 2021 for:

1. An aggravation of pre-existing left shoulder glenohumeral osteoarthritis and left shoulder total replacement surgery on September 14, 2021; and

2. A lower back sprain/strain.

Ongoing entitlement was denied in the Case Manager decision of November 23, 2021 and the reconsideration decision dated December 31, 2021.

BACKGROUND

The worker was employed as a driver associate. On January 19, 2021, the worker was delivering packages, going up some stairs, and lost their balance on the second step. The worker fell backward, reaching out with the left arm to prevent the fall, and landed on the tailbone and left shoulder on a cement floor. The worker was 61 years old at the date of injury. They sought medical attention on

January 20, 2021 and were diagnosed with a left buttock contusion and left shoulder sprain. The worker also reported low back pain.

In a decision dated February 10, 2021, entitlement was accepted for a left shoulder sprain/strain and a lower back bruise/contusion. Full loss of earnings (LOE) benefits were paid from January 20, 2021.

On April 15, 2021, the worker was assessed at the Upper Extremity Specialty Program and the Back and Neck Specialty Program. A left shoulder rotator cuff tear was suspected. An MRI of the left shoulder on June 10, 2021 showed mild supraspinatus and subscapular tendinosis, a low grade partial articular sided tear of the supraspinatus tendon, osteoarthritis of the glenohumeral joint with associated degenerative tearing of the glenoid labrum and severe acromioclavicular joint osteoarthritis. A follow-up assessment at

the Specialty Program on July 6, 2021 diagnosed the worker with an acute exacerbation of chronic underlying glenohumeral osteoarthritis and noted that the low grade partial-thickness tearing was typical of arthritic shoulders.

The worker started a graduated return to work plan on July 5, 2021 in accommodated duties as a driver associate, delivering packages under one kilogram, with a reduced volume of packages and reduced hours. Partial LOE benefits were paid from July 5, 2021.

A report from the Upper Extremity Specialty Program dated July 20, 2021, determined it was appropriate to proceed with total left shoulder replacement surgery. In a decision dated August 3, 2021, entitlement was updated to include a lower back sprain/strain and a worsening of pre-existing left shoulder glenohumeral osteoarthritis, including the left shoulder replacement surgery. Entitlement was denied for left shoulder bursitis and lower back spina bifida.

The worker had left shoulder surgery on September 14, 2021, to perform a total shoulder replacement and long head of the biceps tenodesis. Full LOE benefits were paid beginning September 13, 2021. The worker started a Functional Treatment program for the left shoulder on October 4, 2021.

In a decision dated November 23, 2021, the Case Manager determined that the worker’s low back strain had resolved and there was no entitlement for chronic left shoulder issues and a partial tear. The previous decision to allow entitlement for shoulder surgery was overturned and it was no longer accepted as work-related. No further health care benefits were allowed in the claim and loss of earnings (LOE) benefits were to end on December 7, 2021. Return to work services were closed.

The denial of ongoing entitlement was confirmed in a reconsideration decision dated December 31, 2021.

AUTHORITY

Operational Policy Manual Published

15-02-03 Pre-existing Conditions

18-03-02 Payment and Reviewing LOE Benefits (Prior to Final Review) 17-01-02 Entitlement to Health Care

November 3, 2014

September 1, 2021

October 12, 2004

ANALYSIS

I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision.

The worker representative submitted Appeal Readiness Forms dated December 15, 2021 and

January 6, 2022, relying on a letter dated December 15, 2021. They are seeking ongoing entitlement for the low back strain and exacerbation of the pre-existing left shoulder condition.

The employer is not participating in the appeal and did not submit a Respondent Form.

Left Shoulder Entitlement

I find the worker has ongoing entitlement for the left shoulder, including the total shoulder replacement surgery on September 14, 2021. My reasons are explained below.

In the decision of November 23, 2021, the Case Manager determined that the Aggravation Basis policy was not applicable. In my view, the operational policy most applicable to this issue is operational policy 15-02-03 on Pre-existing Conditions.

According to operational policy 15-02-03, entitlement for a work-related injury 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. A pre-existing condition is any condition that existed prior to a work-related injury, and may include injuries, diseases, degenerative conditions, and psychiatric conditions.

There is clear evidence of a pre-existing left shoulder condition. Based on pre-injury clinical notes and records from the worker’s doctor, on October 6, 2020 the worker was seen for a three to four month history of left shoulder pain with no history of trauma or injury. An ultrasound on October 9, 2020 showed some degenerative changes in the AC joint, mild rotator cuff tendinosis and mild bursitis. There was no indication of a tear.

Post-injury clinical information also supported the presence of a pre-existing left shoulder condition. The left shoulder MRI on June 10, 2021 showed tendinosis, a low grade partial articular sided tear of the supraspinatus tendon, osteoarthritis of the glenohumeral joint with associated degenerative tearing of the glenoid labrum and severe acromioclavicular joint osteoarthritis. The Upper Extremity Specialty Program indicated that the low-grade partial-thickness tearing was typical of arthritic shoulders. The operative report of September 14, 2021 confirmed the worker had left shoulder primary glenohumeral osteoarthritis.

Operational policy 15-02-03 states in part that the presence of a pre-existing condition does not necessarily mean it is a cause of the worker’s impairment or that the impairment is no longer work- related. When a pre-existing condition is evident, or becomes evident, the work-relatedness of the ongoing impairment must be monitored. If the pre-existing condition is impacting the worker’s impairment, benefits will generally continue as long as the work-related injury continues to significantly contribute to the worker’s impairment. 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.

I am satisfied the evidence establishes that the worker’s pre-existing left shoulder condition was aggravated as a result of the work-related fall. It was the opinion of the Upper Extremity Specialty Program in the report dated July 6, 2021, that the workplace incident had resulted in an acute exacerbation of chronic underlying glenohumeral osteoarthritis. The operative report of

September 14, 2021, also considered the worker’s ongoing left shoulder pain to be secondary to the work-related injury. I accept the opinion from the Upper Extremity Specialty Program, noting there is no conflicting medical opinion. I also find the aggravation of the pre-existing left shoulder osteoarthritis is compatible with the workplace accident. The worker fell backward from two steps, landing on their low back and left shoulder, after trying to break the fall with their left arm. I am satisfied that the forces involved in the fall would be sufficient to cause a significant worsening of the underlying arthritic condition in the left shoulder.

I also find, based on the clinical evidence, that the worker did not return to the pre-injury level of impairment after the work-related aggravation of the left shoulder osteoarthritis. The evidence suggests that the left shoulder episode in October 2020 had largely settled and was not causing significant problems for the worker prior to the workplace accident in January 2021. A chart note from

October 16, 2020 noted that left shoulder range of motion was normal, there was no tenderness and the worker was negative for impingement and for the empty can test. A chart note from October 29, 2020 indicated there was not much improvement with a corticosteroid injection, but there is an absence of evidence of treatment for the left shoulder from October 29, 2020 until the fall on January 20, 2021. On February 10, 2021, the worker reported that prior to the workplace accident there was some soreness in the left shoulder, but the worker was not in treatment and the soreness did not hinder the performance of normal work duties. At the Specialty Program assessment on April 15, 2021, the worker claimed that at the time of the workplace accident, the left shoulder was 90% recovered from the episode of left shoulder pain in October 2020.

The worker’s prior history featured episodes of left shoulder pain that would improve over time, but after the workplace injury, the worker’s left shoulder pain and loss of function worsened and did not improve. The evidence suggests that the pre-injury episodes of left shoulder pain did not cause a significant level of sustained impairment or an inability to continue with usual workplace activities. After the workplace accident in January 2021, the worker was unable to perform their pre-injury job duties. The Upper Extremity Specialty Program report of July 6, 2021 confirmed that the worker continued to have symptoms at six months post-injury and that it was unlikely the worker would return to normal full work duties, with an extremely high likelihood of permanent restrictions. The worker tested positive for impingement and empty can test for the left shoulder, which was a change from the pre-injury findings.

Noting the level of chronic underlying glenohumeral osteoarthritis, it is quite possible that the worker would eventually have required left shoulder total replacement surgery regardless of the workplace injury, but I am satisfied the workplace fall hastened the progression of the underlying condition and resulted in surgery sooner than would have otherwise been expected. Prior to the workplace injury, the medical evidence made no reference to surgical interventions being considered. In the Upper Extremity Specialty Program report of July 20, 2021, the orthopaedic specialist identified other options for conservative treatment, such as a cortisone treatment, but noted that shoulder replacement surgery was really the only option available to improve the worker’s pain and function in a predictable and durable way.

In summary, I find the worker has ongoing entitlement for the left shoulder for an aggravation of the pre- existing left shoulder glenohumeral osteoarthritis, including the left shoulder replacement surgery on September 14, 2021.

Low Back Entitlement

I find the worker had not fully recovered from the work-related lower back sprain/strain by November 23, 2021.

The medical evidence establishes that the worker had some significant pre-existing low back problems. Based on pre-injury clinical notes and records, on September 5, 2017 the worker reported some numbness in the left toes with a history of spina bifida. On February 1, 2018, the worker was seen for chronic low back pain with a history of previous back injuries and spina bifida correction. An MRI of the lumbar spine on November 24, 2019 showed retrolisthesis of L4 on L5 and mild to moderate degenerative disc disease at multiple levels.

Although there was evidence of a symptomatic pre-existing condition in the low back, the evidence also suggests the work related lower back sprain/strain had not fully resolved by November 23, 2021. The Back and Neck Specialty Program assessment on April 15, 2021 diagnosed the worker with an unresolved lumbar strain and contusion. The prognosis was for a full functional recovery in three to six months. Although the prognosis for a full functional recovery from the work-related low back strain in six months would suggest a full recovery by November 2021, it is likely the recovery was delayed by a delay in treatment. In a Specialty Program report dated July 27, 2021, an Enhanced Functional Treatment (EFT) integrated pain rehabilitation program was recommended for the management of the worker’s pain, after participation in a post-surgical Functional Treatment program. In a Case Manager decision dated October 25, 2021, the worker was approved to participate in a final block of EFT in the integrated pain rehabilitation program. The treatment was not completed because the claim was closed.

Noting the absence of updated medical evidence regarding the status of the worker’s recovery from the work-related lower back sprain/strain, I find it was premature to conclude the work-related low back injury had fully resolved by November 23, 2021.

Benefits Flowing

According to operational policy 18-03-02, if the nature or seriousness of the injury completely prevents a worker from returning to any type of work, or if the worker is able to return to some form of work but the WSIB determines no suitable work is available, the worker is generally entitled to full LOE benefits providing the worker co-operates in health care measures and all aspects of the return-to-work (RTW) process.

LOE benefits ended on December 7, 2021. In a memo dated November 22, 2021, a Return to Work Specialist (RTWS) noted that a return to work with the employer was unlikely, noting no alternate work was available and permanent restrictions were anticipated for the left shoulder. Noting that in

December 2021, the worker was still recovering from the left shoulder surgery, no suitable work was available with the employer and permanent restrictions were anticipated for the left shoulder, I find the worker is entitled to restoration of full LOE benefits from December 8, 2021. The nature and duration of ongoing LOE benefits is to be determined by the operating area, pending updated information regarding the worker’s return to work and recovery status.

Regarding healthcare treatment, operational policy 17-01-02 states in part that a worker entitled to benefits under the insurance plan is entitled to such health care as may be necessary, appropriate, and sufficient as a result of the injury. The last medical report on file was a Treatment Transition Report from the Upper Extremity Specialty Program dated November 23, 2021. According to the report, the rehabilitation team supported and advocated for further treatment for the worker, but further treatment was not approved.

I find an updated medical assessment should be obtained to determine the status of the post-operative recovery for the left shoulder and to determine if additional treatment for the low back is necessary, appropriate and sufficient to assist the worker with a return to the pre-injury level of function.

CONCLUSION

I conclude:

1. The worker has ongoing entitlement for an aggravation of pre-existing left shoulder glenohumeral osteoarthritis and for the left shoulder total replacement surgery on September 14, 2021. The worker is entitled to restoration of full LOE benefits from December 8, 2021 and healthcare benefits to assist with the post-surgical recovery. The nature and duration of LOE and healthcare benefits is to be determined by the operating area, pending receipt of updated information regarding the worker’s return to work and recovery status.

2. The worker was not fully recovered from the work-related lower back sprain/strain by November 23, 2021. Updated medical information should be obtained to determine if additional treatment is needed to assist the worker with a return to the pre-injury level of function.

The worker’s objection is allowed.

DATED June 15, 2022

Helen Shaw

Appeals Resolution Officer Appeals Services Division