This appeal deals with the causal relationship between the worker's carpal tunnel and cubital tunnel syndrome and her workplace accident on March 10, 2003.
On March 10, 2003 the worker suffered a compensable injury to her right arm. A diagnosis of right lateral epicondylitis was accepted by the Workers Compensation Board (the "WCB"). It was later determined that the worker also suffered from carpal tunnel and cubital tunnel syndrome. The WCB refused responsibility for these other two syndromes. This refusal was upheld by Review Office in a decision dated On November 18, 2005. The worker appealed this decision to the Appeal Commission.
An appeal panel hearing was held on June 6, 2006. Both the worker and the employer appeared with representation.
After the hearing, the appeal panel directed the recording secretary to write to the WCB medical advisor for clarification on an August 23, 2004 opinion. A response to this query was received on June 14, 2006. The worker advisor provided her comments on this response on June 22, 2006. The employer's advocate provided hers on June 26, 2006. The panel then met on July 5, 2006 to discuss the appeal.
Whether or not the worker's symptoms of carpal tunnel syndrome and/or cubital tunnel syndrome are related to the compensable injury of March 10, 2003; and
Whether or not the worker is entitled to payment of wage loss benefits beyond June 23, 2004.
That the worker's symptoms of carpal tunnel syndrome and/or cubital tunnel syndrome are not related to the compensable injury of March 10, 2003; and
That the worker is not entitled to payment of wage loss benefits beyond June 23, 2004.
The worker was employed with the accident employer as a casual part-time order clerk. Her duties consisted in picking merchandise from steel warehouse racks and bins and placing it into repack containers.
On March 10, 2003, the worker was performing her regular duties. One of the items she needed to pick was a wrench set. The wrench set weighed between 2 and 4 pounds and was located on the rack 6 feet above the floor. The worker is 5 feet 3 inches tall. She reached up on her tip toes with her right arm slightly extended, with the elbow still slightly bent. As she grabbed the wrench set, lowered her feet to the ground, she brought her arm back toward her. When her elbow was still approximately 70 or 80 percent extended, she felt a pull in her elbow and dropped the wrench set.
The worker saw her family physician who found her tender along the medial and lateral olecranon. He diagnosed her with a strained right elbow and prescribed rest, ice and Advil. The worker returned to her family physician on March 14, 2003. This time the family physician found a tender lateral epicondyle. He prescribed physiotherapy.
The physiotherapist saw the worker on March 19, 2003. Her report of same date notes tingling elbow to forearm, some numbness into the thumb. She questioned whether the worker tore her exterior right tendons, had epicondylitis or nerve irritation.
The numbness and tingling in the worker’s right arm was noted on examination by her family physician on March 31, 2003. This time he referred the worker for a nerve conduction study (“NCS”). On April 7, 2003 he referred her for an x-ray.
The x-ray of the right elbow was taken on April 8, 2003. It revealed no bone or joint abnormality.
An April 10, 2003 report from the physiotherapist noted slow progress and on April 21, 2003 the family physician found the worker capable of modified duties.
On April 28, 2003 the worker was seen by a WCB physiotherapy consultant. The worker reported a tingling sensation in her right elbow when she rested her arm on the table as well as a ‘seizing’ feeling in her elbow when her arm was at her side. She also reported numbness over the front and back of the thumb since four days after the accident. The WCB physiotherapy consultant diagnosed the worker with traumatic lateral epicondylitis.
On May 2, 2003, the WCB physiotherapy consultant reviewed the “order picker” basic job description and found the worker to have an irritable lateral epicondylitis. He explained his diagnosis as follows:
“One of the key components to the physical process of this job entails the manual withdrawal of small individual units of merchandise from steel warehouse racks and bins and placing it into repack containers. This would be a repetitive job involving repeated wrist extension. The examination notes and description were discussed with [the WCB medical advisor]. We are both of the opinion that at this point [the worker] would not be able to tolerate this activity. This would be reviewed in three weeks time or when updated medical information is available.”
A NCS was done on June 18, 2003 which revealed a normal right radial and median nerve.
The worker continued symptomatic and was referred by the WCB to a sports medicine physician on September 16, 2003. The sports medicine physician was of the opinion that the worker could be suffering from a variety of conditions:
“She is suffering from lateral forearm pain NYD. The differential diagnosis includes a cervical spine source, radial tunnel syndrome, and/or chronic strain. Entrapment of the radial nerve may cause this type of complaint and could arise by this mechanism of injury. She may be suffering from a cubital tunnel syndrome given the positive Tinel’s sign and again, this etiology is also consistent with her mechanism of injury. This did not appear to be a lateral epicondylitis.”
A repeat NCS was recommended specifically for nerve entrapment at the elbow. This was done on October 21, 2003. The results of the study were indicative of borderline to minimal right carpal tunnel syndrome (“CTS”) and moderate right cubital tunnel syndrome. There was no evidence of radial tunnel syndrome, Guyon’s canal syndrome, a plexopathy or a more proximal lesion.
Then an MRI of the right forearm on December 10, 2003 revealed findings consistent with an element of lateral epicondylitis.
A WCB medical advisor reviewed the file information on January 9, 2004 and offered the following opinion:
“The most probable diagnosis related to the compensable injury is right lateral epicondylitis… Although borderline right CTS and moderate cubital tunnel have been reported in the NCS, the main symptoms affecting her work duties appear due to …the right lateral epicondylitis.”
On January 28, 2004, a WCB rehabilitation specialist attended the worker’s job site and reviewed the job duties of an order picker. He noted that the worker was assigned to small parts picking which included nails, screws, light bulbs, etc… which were generally several ounces to 1 pound in weight. The popular items were generally located at the waist level but there was regular reaching above the shoulder. He noted that there was repetitive gripping and pinching but that given the very short duration and very light nature of the work, he did not consider there to be any sustained gripping involved while picking or any significant force to create increased activity of the forearm extensors.
The file was reviewed again by the WCB medical advisor. His opinion was stated as follows:
“The C.I. primarily accepted by WCB, to my knowledge, was [right] lateral epicondylitis. Subsequently other diagnosis reported – CTS, cubital tunnel [syndrome], volar wrist ganglion – and she more recently has received [physiotherapy] for multi-sites with an extension provided – unsure if these other unrelated problems have been adjudicated or not?...”
Following this opinion, the WCB advised the worker on April 19, 2004 that on a balance of probabilities, she had sufficiently recovered from the effects of her compensable right epicondylitis injury and that she could attempt a return to work on a gradual basis effective May 3, 2004 without any work restrictions. The other diagnoses of cubital tunnel syndrome and CTS were not accepted as compensable injuries.
The worker attempted a gradual return to work on May 4, 2004 for 1 ½ hours order picking. She experienced right elbow, hand and wrist pain with tingling and stopped working. She was seen again by the WCB medical advisor on June 23, 2004. Upon examination, the WCB medical advisor summarized the worker’s symptoms and his opinion as follows:
“The clinical history suggests a sudden acute injury to the right lateral epicondyle region with objective medical findings subsequently demonstrating findings consistent with right lateral epicondylitis. X-rays of the elbow were normal and an MRI subsequently demonstrated findings consistent with a right lateral epicondylitis. The [worker] also reported symptoms a few days after the compensable injury of right wrist, hand and right medial elbow symptoms, more consistent with right [CTS] and right cubital syndrome…The method of injury, the clinical findings at the time of the injury and subsequently and the current objective findings suggest that the lateral epicondylitis of the right elbow previously reported and attributable to the compensable injury, has now resolved. The right [CTS] and the right cubital tunnel syndrome appear to be symptomatic and are still to be adjudicated by the WCB case manager.”
The WCB medical advisor reiterated his opinion that the CTS and cubital tunnel syndrome were not related to the workplace accident of March 10, 2003, in an August 23, 2004 memorandum:
“Considering the [mechanism of injury] – acute injury, the CTS and cubital tunnel [syndrome] would not be related to this specific injury. She had been [with the accident employer] for 8 months prior to symptom onset. The CTS and cubital tunnel [syndrome] would likely be pre-[existing], on balance of probability.”
He expanded on this opinion on June 14, 2006, in response to a request by the appeal panel:
“1. The predominant symptom reported following the workplace incident of March 10, 2003 was proximal lateral elbow pain. The initial and subsequent reports refer to the proximal lateral elbow as the symptomatic area. The symptoms were reported following the reaching and lifting episode at work and are consistent with the subsequent diagnosis of lateral epicondylitis.
2. Note that symptoms from ulnar neuropathy at the elbow occur on the medial side of the elbow (not lateral) and often occur secondary to other causes, such as habitual leaning on the elbow, repetitive flexion and extension of the elbow, congential variations of the humerolulnar aponeurotic arcate (HUA), diabetes, herediatary neuropathy, rheumatoid arthritis, old fracture with joint deformity, or habitual flexion during sleep...”
The worker’s family physician did not agree with this opinion. In a report to a worker advisor dated November 6, 2004, the treating physician stated:
“Cubital tunnel syndrome could be a result of her occupation. Cubital tunnel syndrome can result from repetitive movements involving the upper extremities. [The worker’s] occupation involves moving boxes of varying sizes and weights from different heights. This type of movement could result in the condition. [The sports medicine physician] supports this in his letter of September 17, 2003…
Her diagnosis of lateral epicondylitis is also consistent with her symptoms and was also likely sustained at work. Again, the repetitive nature of her job and the lifting that she does would put her at risk for this type of injury.
To my knowledge, [the worker] does not have any non-work related pre-existing conditions…None of her previous illnesses have any bearing on her symptoms regarding her right arm… ”
The worker underwent decompression of her right carpal tunnel and cubital tunnel on September 21, 2004. The operative report lists the post-operative diagnosis as compression neuropathy of the right median and ulnar nerves. It also notes a “constriction deformity” in both the carpal tunnel and cubital tunnel. An October 6, 2004 report by the plastic surgeon who did the operation noted that since the surgery the worker had a new problem of triggering in her left ring finger. Though she has had some relief since the surgery, she still has some parasthesia.
The worker says that her cubital tunnel syndrome is related to her March 10, 2003 workplace accident given the mechanism of injury and the immediate symptom of a “pulling” in her elbow. No position was provided at the hearing with respect to her CTS. She relies on the medical opinions of the sports medicine physician and her family physician.
The employer says that the worker’s CTS and cubital tunnel syndrome are not causally related to the acute injury of March 10, 2003. It relies on the opinion of the WCB medical advisor.
To accept the worker’s appeal we must find that her CTS and cubital tunnel syndrome were caused, aggravated or enhanced by her workplace accident on March 10, 2003. We are unable to make these findings.
The workplace injury on March 10, 2003 was an acute injury not a repetitive strain type injury; the worker had partially flexed her elbow when she felt a snap and pain.
The medical opinions on the file all concur that this mechanism of injury is consistent with lateral epicondylitis. The symptoms of lateral tenderness and pain are also consistent with this diagnosis and the MRI of December 10, 2003 confirms it.
In our opinion, the worker’s CTS and cubital tunnel syndrome are not causally related to her March 10, 2003 workplace accident; they are merely coincidental to the worker’s March 10, 2003 workplace accident. There is specifically no sufficient evidence that immediately prior to the March 10, 2003 accident, the worker was working in a capacity that would cause a repetitive type injury on that day:
Given the WCB medical advisor’s June 23, 2004 examination findings of resolved right lateral epicondylitis symptoms, we find that the worker is not entitled to benefits beyond June 23, 2004.
Accordingly, the worker’s appeal is denied.
L. Martin, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner
Recording Secretary, B. Kosc
(on behalf of the panel)