WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 886/16

Transcription

1 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 886/16 BEFORE: J. P. Moore: Vice-Chair HEARING: REFERRED BY: March 30, 2016 at Toronto Written A.D.R. Officer D. Sanginesi DATE OF DECISION: May 3, 2016 NEUTRAL CITATION: 2016 ONWSIAT 1156 DECISION UNDER APPEAL: WSIB ARO decision dated October 15, 2014 APPEARANCES: For the worker: For the employer: Interpreter: J. Anampiu, Union Representative In-house Counsel Not applicable Workplace Safety and Insurance Appeals Tribunal Tribunal d appel de la sécurité professionnelle et de l assurance contre les accidents du travail 505 University Avenue 7 th Floor 505, avenue University, 7 e étage Toronto ON M5G 2P2 Toronto ON M5G 2P2

2 Decision No. 886/16 REASONS (i) Introduction [1] This appeal arises out of a claim with an accident date of June 26, According to a Report of Injury of that date, the worker complained of right shoulder pain related to workplace duties. At the time, the worker was 57 years old and employed as an assembly line worker. [2] The worker was initially diagnosed with a shoulder strain. She was given modified duties. The worker then developed symptoms of pain in her left wrist and left thumb. She subsequently complained of pain in the right wrist and throughout the left hand. The worker s Case Manager limited the worker s entitlement to a right shoulder strain. [3] The worker objected to that decision. Her objection was denied by an Appeals Resolution Officer ( ARO ) who confirmed the limitation of entitlement to a right shoulder strain from which the worker recovered. Consequently, the ARO denied entitlement for a permanent right shoulder condition and denied initial entitlement for any other areas of injury. The worker appealed that decision to the Tribunal. [4] The worker s appeal was referred to an Alternative Dispute Resolution ( ADR ) Officer for mediation. The mediation took place on October 14, As a result of that mediation, an agreement was reached which the ADR Officer had submitted as a recommended disposition of the worker s appeal. What follows is my decision on that recommended disposition. (ii) The issues in this appeal are: 1. whether the worker was left with a permanent impairment as a result of the right shoulder injury she sustained on June 26, 2012; 2. whether the worker has entitlement to a left wrist condition diagnosed as De Quervain s tenosynovitis; 3. whether the worker has entitlement for an aggravation injury affecting her left thumb; 4. whether the worker has initial entitlement for the right wrist and the left hand. (iii) The decision [5] The parties have agreed, through their representatives, to a resolution of the worker s appeal. The recommended disposition is that the worker s appeal be allowed in part and that the worker be granted ongoing entitlement for the right shoulder and initial entitlement for De Quervain s tenosynovitis and for an aggravation injury affecting the left thumb. [6] The worker withdraws her appeal for entitlement with respect to the left hand and the right wrist.

3 Page: 2 Decision No. 886/16 (iv) Analysis [7] I have reviewed the relevant evidence, law and policy, all of which are set out in detail in the Recommendation of the ADR Officer, a copy of which is attached to this decision as an Appendix. I am persuaded that the recommended disposition is consistent with the evidence in light of the applicable law and policy. [8] The ADR Officer s Recommendation contains a Mediation Summary. In that Summary, the ADR Officer notes that the worker withdraws her appeal regarding entitlement for a right wrist injury and a left hand condition. [9] The ADR Officer goes on to recommend, on the evidence, that the worker be granted ongoing entitlement for the right shoulder and initial entitlement for De Quervain s tenosynovitis and for an aggravation injury of the left thumb. I address these two issues separately below. (a) Right shoulder entitlement [10] On this issue, the parties agree that the worker should be granted ongoing entitlement for the right shoulder on the basis that the worker sustained a permanent aggravation of an asymptomatic pre-existing degenerative condition in the right shoulder, acromioclavicular ( AC ) joint arthritis. In the decision under appeal, the ARO concluded that the worker had sustained a strain injury in June 2012, and had recovered from this injury. [11] The Mediation Summary notes that the worker had been employed with the accident employer for 21 years before the June 2012 onset of right shoulder pain, performing repetitive duties on an assembly line. The parties acknowledge that the worker likely had pre-existing arthritis in the affected joint but they agree that the gradual onset shoulder strain injury of June 2012 permanently aggravated that degenerative condition. The parties note that, based on a physical demands analysis of the worker s pre-injury duties, those duties were highly repetitive, and included significant overhead work that would stress the shoulders. The parties further state that, while the worker was initially thought to have suffered just a strain injury, subsequent medical evidence concluded that the strain injury had aggravated the underlying arthritis. The parties rely on the medical opinions of two specialists and the worker s family physician. [12] In an independent medical report dated February 8, 2013, an orthopaedic specialist, Dr. Finkelstein, stated that the worker s duties would likely aggravate the underlying AC joint arthritis. Another orthopaedic specialist, Dr. Crawford, stated in a report dated September 24, 2013, that the worker s right shoulder pathology, AC joint osteoarthritis, was likely related to her chronic use at work. [13] The worker s family physician, Dr. Robson, stated in a report dated August 17, 2014, that the worker s right shoulder problems were a result of the repetitive nature of her pre-injury job. [14] On that evidence, I am persuaded that the worker s gradual onset right shoulder injury of June 26, 2012 aggravated underlying, pre-existing osteoarthritis in the AC joint and that the worker has entitlement for this aggravation injury because, in the opinion of the worker s treating physicians, the worker s work duties made a significant contribution to this injury. [15] I am also persuaded that the worker was left with a permanent impairment as a result of this aggravation injury. In so concluding, I note the following statement from the ADR Officer s Mediation Summary:

4 Page: 3 Decision No. 886/16 The parties acknowledge that since June 2012, the worker has continued to complain of right shoulder pain, she has demonstrated a decreased range of motion in her right shoulder and she demonstrated limitations in function. The worker has continued to require medical restrictions for her right shoulder throughout. As of April 16, 2014, the worker continued to have limitations in abduction of the right shoulder with signs of impingement. The worker has also continued to require the use of pain medications and conservative treatment in the form of physiotherapy to assist with her right shoulder difficulties. [16] On that evidence, I am persuaded that the worker has been left with a permanent right shoulder impairment as a result of the injury of June 26, [17] On the basis of the above findings, I agree with the recommendation of the parties that the worker should be granted entitlement to benefits from the Insurance Plan for an aggravation injury of the right shoulder, consisting of aggravation of underlying AC joint osteoarthritis, and that she be granted a non-economic loss assessment for this aggravation injury. (b) Left thumb and left wrist entitlement [18] On this issue, the parties agree that the worker has initial entitlement to benefits from the Insurance Plan for left wrist De Quervain s tenosynovitis, and for an aggravation of osteoarthritis in the left thumb. [19] In the decision under appeal, the ARO concluded that the worker did not likely sustain these injuries as a result of her employment because she was performing modified work at the time of the onset of these symptoms. However, as the parties note in their agreement, the modified duties the worker was performing at the time of the onset of these additional symptoms were designed to protect the right shoulder. The Mediation Summary summarizes the parties position on this point as follows: The parties note, however, that although the worker was on modified duties with respect to her right shoulder injury, she was still working on the F-line performing Re-work and lead hand duties when she began to develop left thumb and wrist problems. They note that, at that time, the worker was mainly using her left hand to perform these tasks given her existing right shoulder problems. [20] The Mediation Summary goes on to note the specific nature of the worker s duties and states: The parties agree that these positions all require small finite movements with the thumbs, as well as gripping activities and wrist movement. [21] This aspect of the worker s claim was reviewed by a Board Medical Advisor, Dr. Razabi who, in a memorandum dated June 17, 2013, stated that a relationship between the nature of the worker s duties and the onset of De Quervain s tenosynovitis was probable. However, Dr. Razabi went on to state that the worker had not been working on the F-line since the right shoulder injury in June Consequently, in the doctor s view, it was unlikely that the left wrist symptoms were work-related. [22] But, as the parties have agreed, the worker did modified work on the F-line. They agree that certain activities performed by the worker as part of her modified duties could well have placed undue stress on the left hand, and that the worker did, in fact, complain of left wrist pain while performing those particular work duties.

5 Page: 4 Decision No. 886/16 [23] The parties further agree that these work duties were sufficiently repetitive that they likely aggravated the arthritis in the carpal metacarpal joint of the left thumb. The parties agreement concludes: In light of the above evidence, the parties recommend that the Tribunal grant entitlement to De Quervain s tenosynovitis and entitlement to an aggravation of the worker s CMC joint arthritis. [24] In my opinion, there is persuasive evidence that, in the course of performing modified work designed to protect her right shoulder, the worker likely engaged in repetitive duties that placed excessive stress on her left wrist and left thumb, leading to the onset of a left wrist injury and an aggravation injury to the left thumb. [25] On the basis of those findings, I conclude that the worker should be granted initial entitlement to benefits from the Insurance Plan for De Quervain s tenosynovitis and for an aggravation injury of the CMC joint of the left thumb.

6 Page: 5 Decision No. 886/16 DISPOSITION [26] The worker s appeal is allowed in part: 1. The worker withdraws her appeal for entitlement to the left hand and right wrist. The worker fully understands the consequences of her decision to withdraw these aspects of her appeal, particularly in light of the time-limit provisions contained in the Workplace Safety and Insurance Act. 2. The worker is granted ongoing entitlement for the right shoulder. The Board is directed to assess the worker for non-economic loss. 3. The worker is granted initial entitlement for De Quervain s tenosynovitis and entitlement for an aggravation injury to the CMC joint of the left thumb. DATED: May 3, 2016 SIGNED: J. P. Moore

7 Page: 6 Decision No. 886/16 APPENDIX RECOMMENDATION OF THE ALTERNATIVE DISPUTE RESOLUTION OFFICER THE APPEAL PROCEEDINGS [27] This is an appeal by the worker of the Appeals Resolution Officer s decision dated October 15, The decision denied the worker ongoing entitlement to right shoulder, left hand, bilateral wrists and thumbs. The decision also denied the worker entitlement to dequervain s tenosynovitis. [28] The Alternative Dispute Resolution (ADR) Officer met with the parties on October 14, 2015, in Toronto. The worker was present with her union representative, J. Anampiu. The accident employer s Human Resources Manager and in-house counsel were also present. M. Sarmiento from the Office of the Vice-Chair Registrar s office was present as an observer. [29] The parties agree that the appeal be resolved on the following basis: 1. The worker withdraws her appeal for entitlement to the left hand and right wrist. The worker fully understands the consequences of her decision to withdraw these aspects of her appeal, particularly in light of the time limit provisions contained in the Workplace Safety and Insurance Act. 2. The worker s appeal is allowed. 3. The worker is granted ongoing entitlement to the right shoulder. The Board is directed to assess the worker for a non-economic loss assessment. 4. The worker is granted initial entitlement to dequervain s tenosynovitis and entitlement to an aggravation of her left thumb carpal metal carpal joint arthritis. BACKGROUND TO THE RECOMMENDATION [30] The following is a summary of the relevant facts upon which this recommendation is based: Date Source Description September 1957 September 16/91 Date of birth Date of Hire January 19/05 Date of accident Worker complains of injury to the left shoulder sprain. Parts did not fit together and she was using excess force. January 28/09 Date of accident Worker complains of a sore right wrist because of repetitive duties. Claim is allowed.

8 Page: 7 Decision No. 886/16 Date Source Description August 2010 August 2010 August 2010 October 5/10 PDA for F-Line Packing Physical Demands Analysis of F-Line Rodding Physical Demands Analysis of F-Line Jack Assembly Date of accident Employer's Report of Injury This position requires the worker to retrieve car jacks from a conveyor line, visually inspect the part to do a quality check and pack the car jack (weighs approximately 6 lbs.). Manual work is performed approximately 9 out of 10 second cycle. There is one second of rest time. Each shift is 8 hours shift with 15 minute break, 25 minute lunch and 10 minute break. Worker will perform this job three shifts from Monday to Friday and rotate with other positions on the F-line. The position will requires worker to use her hand 6.5 hours per shift handling, gripping and reaching with both hands. Worker removed jack from paint line, inspects, checks trunnion and touches up damaged areas to place on table for jack assembly. It takes approximately 10 seconds to complete each part. Worker will work three 8 hour shifts Monday to Friday. There is a 15 minute break, a 25 minute lunch and a second 10 minute break. Activities include lifting with one hand a jack (6 lbs.) from the conveyor belt, inspecting which will involve wrist flexion, extension and deviation (each movement 1.4 hours/shift) depending on stature and work method. Worker will have to feed rod into greaser. Job requires gripping, handling, reaching above shoulder. It involves neck, elbow and wrist movement Worker retrieves jack assembly and rod/operating screw from greaser and inserts it into sub assembly. Worker will use a torque gun to secure jack and load finished part onto a rotating table. Total wrist movement is seven times per ten second cycle or five hours per shift. Worker must retrieve rod form tote and grease load fixture, assemble rods and load rotating table. She must manually handle parts and use a torque gun. Job involves handling and gripping 5.7 hours % of the time with either hand. Worker went to reach to put a car jack in the far side of the bay and felt a twinge in her right shoulder. She was off work from October 18 26/10. Initial entitlement is allowed for a right shoulder strain and LOE benefits are granted. The worker returns to her regular work. June 29/11 Date of accident Worker is packing automotive jacks and feels right shoulder pain. June 29/11 Health Professional's First Report Diagnosis rotator cuff strain. Worker s claim is allowed for no lost time. April 26/12 Date of accident While working on an assembly line packing automotive jacks worker and develops neck pain. Eligibility Adjudicator grants initial entitlement to health care benefits only. There is no entitlement to loss of earnings benefits. Worker returns to work on April 30/12. June 12/12 Right Clavicle X-ray There are no fractures. There are degenerative changes in the AC joint with no evidence of AC subluxation.

9 Page: 8 Decision No. 886/16 Date Source Description June 14/12 First Aid notes Worker visits company s first aid department with complaints of right shoulder pain. She is working on the F-line. Company nurse gives her a heating pad. June 26/12 Date of accident Claim at Issue Employer's Report of Injury This 57 year old assembly line worker complains today of right shoulder pain and tender inflamed spot at the base of her neck which gradually developed over the past 6 8 weeks while working on the F-line. June 26/12 First Aid notes Worker visits company s first aid department with complains of her right shoulder pain getting gradually worse in the past 6 8 weeks. She is currently working on the F-line. June 26/12 Accident employer Worker is put on modified duties on the rework line (3 hrs), sorting gloves (1-2 hrs), N. end paint line and S. end paint line (use left arm only) (1-2 hrs). She was also on jack assembly. June 26/12 June 26/12 July 5/12 July 20/12 August 2012 Health Professional's First Report Dr. Robson Functional abilities form Dr. Robson Functional abilities form Eligibility Adjudicator Worker was first treated on June 11/12 with report of pain and swelling in the sternoclavicluar joint. The initial diagnosis is right SC joint inflammation. Dr. Robson prescribes rest and Ibuprofen. Worker should avoid repetitive work with her right shoulder. She is limited with push/pull of right shoulder. Area of injury right shoulder. Dr. Robson provides restrictions of use with right arm avoid lifting, limited push/pull and no repetitive movement of right shoulder. Eligibility Adjudicator determines that there is no causal relationship between the worker s right shoulder diagnosis of sternoclavicluar joint inflammation and her job duties. Worker does lead hand work on the following dates: August 8 10, 13 17, 20, August 7/12 Ultrasound Ganglion cyst at right sternoclavicular joint August 17/12 FA form Right shoulder restrictions. August 31/12 FA form Right shoulder restrictions. September 2012 Worker does Lead Hand work on the following dates in September: 4 7, 17, October 4/12 First Aid Worker is taking parts off the paint line and rodding. She complains of left wrist and tingling in the left thumb and two fingers. Nurse applies ice. October 11/12 Emergency Record Patient has a history of cervical degenerative disc disease. She has a job with repetitive use of hands and overhead lifting. Past medical history anxiety; depression; has had body aches for last five months. She is being treated with Celebrex for the right shoulder for the past one and half months. She was sent to a rheumatologist a week ago negative. She now complains of left shoulder pain which radiates to her left hand (1 3 digits). Positive Yergason test; Phalen and Tinel s sign is negative. Patient s symptoms worsen

10 Page: 9 Decision No. 886/16 Date Source Description November 15/12 November 29/12 December 11/12 Eligibility Adjudicator Physician's Progress Report Dr. Robson Physician's Progress Report Dr. Ng with activity at work not with other exertions. The diagnosis is shoulder/wrist strain. Eligibility Adjudicator reconsiders initial entitlement to the worker s claim. Her job duties are highly repetitive and the majority of her work is done using the arms. There are three lines that require constant reaching, pulling, pushing, carrying and lifting. The accident employer confirmed that job duties are repetitive and could have easily contributed to her right shoulder problems over time. Eligibility Adjudicator allows initial entitlement to the right shoulder and the diagnosis of ganglion cyst of right sternoclavicular joint. Worker also reported pain to shoulders, wrists and back while she was on modified duties. Eligibility Adjudicator limits entitlement to right shoulder only on the basis that there is no compatibility between the modified duties she performed since June 26/12 and the other areas of injury. LOE benefits from October 19/12 are denied on the basis that she did not seek medical attention for this time off work. Patient has had some improvement in the shoulder and wrists since the cortisone shot and vacation. Wrist pain is secondary to repetitive light duties. He also recommends she undergo chiropractic therapy. Worker complains of bilateral wrist pain. There is right shoulder decreased range of motion and grip strength. Patient is currently working. Dr. Ng recommends a cortisone injection and some chiropractic treatment. She has the following restrictions: lifting, bending, twisting and use of upper extremities. December 21/12 Case Manager Case manager notes that the claim was allowed for a right shoulder strain with date of accident listed as June 26/12. There is no entitlement to the left shoulder, either wrists or back. There is no medical support for ongoing entitlement to the left shoulder. January 22/13 First Aid notes Worker visits with complains of left wrist pain. February 8/13 Dr. Finkelstein Orthopaedic Surgeon (Independent medical evaluation) This patient has worked with the accident employer for 22 years on an assembly line making car jacks. She uses air guns, grabs, lifts and reaches activities that are repetitive. She is currently on modified work and cannot use her right arm. Using a mouse or stirring a pot causes pain. She has a secondary problem of pain in her thumb which goes over the dorsal and radial sides of the wrist. She was on light duties from June October 2012, but it was difficult. She is currently performing office duties. Her x-ray shows degenerative changes in the AC joint of the right shoulder. She also has left thumb and dequervain s tenosynovitis. There is a positive Finkelstein s test and normal neurological exam. The action she does at work will aggravate her AC joint. Dr. Finkelstein opines that the worker has findings of AC joint arthritis. She requires an MRI of the shoulder

11 Page: 10 Decision No. 886/16 Date Source Description to rule out rotator cuff pathology. He opines that the action she does at work will aggravate her AC joint. She also has dequervain s tenosynovitis of the left thumb, which he will treat with an injection. He notes that the course of the right shoulder AC joint pain is degenerative in nature. It is unlikely caused by work, but is aggravated by it. She has limitations for overhead use and loading of the AC joint. She has valid complaints for the diagnosis she has. He does not anticipate that the worker will be able to return to her regular job on the F-Line. February 27/13 First Aid notes Worker visits first aid with complains of left thumb pain. March 16/13 April 9/13 April 17/13 X-ray of Right shoulder Dr. V. Tuli Orthopaedic Surgeon Dr. Gordon Crawford Orthopaedic Surgeon There is advanced supraspinatus tendinopathy. There is mild/moderate sized focal partial thickness tear and subacromial/subdeltoid bursitis. There is moderate hypertrophic osteoarthritis of the acromioclavicular (AC) joint. Worker is right handed. She is here in regards to her left hand and thumb pain. She also has pain to the radial aspect of the wrist. She is on modified work at this time. She states that it is secondary to her work. Currently, she is on modified duties performing mostly desk work. Her wrists continue to be sore as they were last summer. There is tingling in the left thumb, second and third digits. She saw Dr. Baryshnik and she does not have carpal tunnel syndrome. X-rays of the thumb show moderate CMC (carpal metacarpal) arthritis. She is tender at the CMC of thumb. Finkelstein s testing is also positive. Her diagnosis is left thumb CMC arthritis and dequervain s tenosynovitis. Dr. Tuli agrees that the worker should be on modified duties. He prescribes a splint. Worker has documented problem going back to In 2010, she had a week off work. In 2012, she had been on modified duties from fairly heavy work on a factory line manufacturing car jacks. She has now aggravated her left wrist and developed dequervain s tenosynovitis which is being treated by Dr. Tuli. Dr. Finkelstein feels she should get a brace for the dequervain s. Small movements such as a mouse on the computer will give her discomfort. On examination, she has limited range of motion of the shoulder: forward flexion to 130 ; Codman s maneuver is difficult; left shoulder is entirely normal. She is tender over the supraspinatus insertion and over the AC joint where she has moderate osteoarthritis. Combined abduction to almost 90 is difficult. Dr. Gordon notes that lack of benefit from the local infiltration is problematic because it fails to confirm the source of her pain.

12 Page: 11 Decision No. 886/16 Date Source Description June 17/13 Initial Physician Case File review memo Dr. Razavi Board Medical Adviser is asked to review the worker s case. Employer's Report of Injury indicates a right handed worker who works as an automotive jack assembly worker. She had a right shoulder injury which she sustained on June 26/12. She complains of right shoulder tenderness and inflammation at the base of her right neck. Physical demands analysis for F-Line Rodding was reviewed. Production rate is 10 seconds per part. Worker was scheduled for three 8 hour shifts Monday to Friday. Conclusions: dequervain s is generally defined as tenosynovitis affecting the two thumb tendons at the first extensor compartment of the wrist. With regards to this worker and a review of the job demand analysis on file, a relationship to the worker is probable. June 28/13 September 24/13 September 30/13 October 9/13 Dr. Crawford Orthopaedic Surgeon Dr. Crawford Orthopaedic Surgeon Dr. Tuli Orthopaedic Surgeon Dr. Ng Rheumatologist Occupational risk factors there is some evidence of a combination of risk factors including force, repetition and awkward postures. There is insufficient evidence with respect to the length of her employment and her keyboarding activities. She has not been working on the F-Line since June Worker was on modified work of re-work which is self-paced and off-line. From August 2012 to October 2012, she also assisted with lead hand duties for four weeks with no problems. Dr. Crawford reviews the effects of the diagnostic infiltration. Worker has an MRI showing partial thickness tear of the supraspinatus tendon with advanced tendinopathy and moderate AC joint osteoarthritis. Accident employer builds car jacks. She has done this for many years on the floor with repetitive motions. Dr. Crawford recommends repeating the diagnostic infiltration in three months to characterize the source of her pain. She should continue with modified work. It is unlikely that she will return to her perivous type of work. Worker is seen with respect to right shoulder pathology. She uses ice and Motrin for relief. Dr. Crawford opines that this seems to be related to her chronic use at work. Worker visits Dr. Tuli in regards to her left thumb problem. She also has concurrent right shoulder issues. Finkelstein s test of left thumb is negative. CMC is very tender. She is a candidate to have a left thumb CMC arthroplasty. Patient does assembly line work for car parts. In Dr. Tuli s opinion, the worker is not capable of doing this work with her left thumb. He recommends that she retrain and consider sedentary desk type work. Worker is a patient of mine who I see for rheumatological care. I initially saw her on September 18/12 for symptoms in the right shoulder and sternoclavicular joint pain. She has a WSIB claim for a repetitive strain injury. She continues to exhibit right

13 Page: 12 Decision No. 886/16 Date Source Description shoulder pain and is scheduled for surgery with Dr. Crawford. She also has left dequervain s tenosynovitis and will have CMC osteoarthritis surgery with Dr. Tuli. October 31/13 Case Manager Upon receipt of additional medical information, the Case Manager is asked to reconsider areas of entitlement. She confirms that there is no entitlement for left shoulder, bilateral wrist and back. Worker has not done F-Line work since June The primary diagnosis is that of right AC joint arthritis. Entitlement to the right shoulder remains for a strain only and the worker s ongoing issues are related to a degenerative condition which is not recognized. There is no medical evidence to support a ganglion cyst. As for entitlement to left hand and thumb, worker tested positive for Finkelstein test. Dr. Kelly diagnosed CMC joint arthritis of thumb. Since the worker has been on modified duties, the Case Manager does not find risk factors associated with the worker s job and her diagnosis of left dequervain s symptoms. She finds that the worker s symptoms are likely related to the osteoarthritis of the thumb. Therefore, she denies entitlement to left hand or thumb. December 12/13 Operative Report Dr. Tuli performs a left thumb arthroplasty. January 10/14 Dr. Crawford Patient has right shoulder pain with certain activities. In spite of positive findings on the X-ray and MRI suggesting tendinopathy, impingement and AC joint arthritis. Dr. Crawford did a trial injection in both the right AC joint and deltoid, but it did not provide her with relief. She does not have a frozen shoulder. On examination forward flexion is full and abduction at 45 gives her impingement pain. We have two other issues: Dr. Tuli gave her a partial triquerel resection and she is in a thumb spica cast. Also complicating the outcome is that she is a smoker. April 16/14 August 27/14 Dr. Shaw for Dr. Crawford Dr. Robson Family Physician Dr. Shaw examines worker with Dr. Crawford. Worker has been struggling with right shoulder pain for some time. She sustained an injury at work while lifting car jacks at about 90*. Her MRI showed several potential sources of pain. On examination, she still has same limited range of motion of the shoulder: abduction is 40 ; has 180 of forward flexion; of extension; internal and external rotation are normal. Dr. Shaw recommends that the worker continue with physiotherapy. Worker has been his patient since She complains of pain to the right shoulder, left thumb and both wrists. She complained of shoulder pain as early as December 28/01; Health Professional's First Report submitted January 22/02. The next problem occurred October 2010 when she reported an increase in pain to her shoulder while reaching to put in car jacks in boxes. She was reviewed again on October 25/10 and had improved

14 Page: 13 Decision No. 886/16 Date Source Description and returned to regular work. On June 30/11, she was seen again with complaints of pain to the right shoulder. Dr. Finkelstein says arthritis is the cause of her pain but nowhere in his report does he deny that it could be work related. The repetitive nature of her work and recurrent injuries to her right shoulder may well have contributed to the arthritic change. There is no doubt her shoulder pains are a result of her work injuries. She also suffers from dequervain s this too can be attributed to repetitive work. Her shoulder and wrist are likely to worsen if she continues to work in repetitive work situation. September 3/14 Accident employer Accident employer provides a chronology of worker s complains of pain over the years. August 12/12 worker visited First Aid with complains of pain. She was put on a trial of 3 jobs strap trunnion, load rest press, gauging and nummi handles. These jobs involve small finite movements and are causing pain. October 15/14 September 9/15 Appeals Resolution Officer Appeals Resolution Officer Reconsideration Worker reported having problems with pain in her right shoulder which gradually got worse while performing her regular duties on the F-Line. Initial entitlement was allowed for a right shoulder strain. Claim was not allowed for the left shoulder, wrists or back. Worker testified that she had problems in 2010 and She returned to regular employment thereafter and her pain worsened in 2012 due to repetitive work causing multiple impairments. She works on a line assembling automotive jacks. She has been on modified duties since June 2012 doing re-work. Appeals Resolution Officer denies the claim on the basis that the worker s degenerative changes are unassociated with her employment activities. Additional areas of entitlement are denied. Upon receipt of substantial new evidence, the Appeals Resolution Officer reconsiders his decision of October 15, Appeals Resolution Officer concludes that he is unable to establish that the worker s multiple diagnoses are caused directly by her work activities. In addition, he is unable to establish that her ongoing impairments are compatible with her employment or that the worker aggravated her pre-existing conditions. He concludes that the worker fully recovered from her right shoulder strain of June 26, 2012.

15 Page: 14 Decision No. 886/16 RELEVANT LAW AND POLICY [31] The workplace accident, which is the subject of this appeal, occurred on June 26, Accordingly, the Workplace Safety and Insurance Act, 1997 governs the worker s entitlement to benefits. [32] The relevant section of the Act states: 2. (1) In this Act, accident includes, (a) (b) (c) a wilful and intentional act, not being the act of the worker, a chance event occasioned by a physical or natural cause, and disablement arising out of and in the course of employment; ( accident ) 13. (1) A worker who sustains a personal injury by accident arising out of and in the course of his or her employment is entitled to benefits under the insurance plan. Presumptions (2) If the accident arises out of the worker s employment, it is presumed to have occurred in the course of the employment unless the contrary is shown. If it occurs in the course of the worker s employment, it is presumed to have arisen out of the employment unless the contrary is shown. 15. (1) This section applies if a worker suffers from and is impaired by an occupational disease that occurs due to the nature of one or more employments in which the worker was engaged. Entitlement to benefits (2) The worker is entitled to benefits under the insurance plan as if the disease were a personal injury by accident and as if the impairment were the happening of the accident. Presumption re causation (3) If, before the date of the impairment, the worker was employed in a process set out in Schedule 3 and if he or she contracts the disease specified in the Schedule, the disease is presumed to have occurred due to the nature of the worker s employment unless the contrary is shown. Causation of disease (4) If, before the date of the impairment, the worker was employed in a process set out in Schedule 4 and if he or she contracts the disease specified in the Schedule, the disease shall be deemed to have occurred due to the nature of the worker s employment. 46. (1) If a worker s injury results in permanent impairment, the worker is entitled to compensation under this section for his or her non-economic loss. 1997, c. 16, Sched. A, s. 46 (1).

16 Page: 15 Decision No. 886/16 [33] The ADR Officer notes that, in accordance with s.126 of the Workplace Safety and Insurance Act, the Workplace Safety and Insurance Board has stated that a number of policies apply to the subject matter of this appeal. [34] Operational Policy Manual Document No , Adjudication Principles Aggravation Basis, states in part: In cases where the worker has a pre-accident impairment and suffers a minor work-related injury or illness to the same body part or system, the WSIB considers entitlement to benefits on an aggravation basis. Permanent impairment In some cases, workers never return to the pre-accident state. If there is a permanent worsening of the pre-accident impairment, the decision-maker may determine that the work-related injury/illness has permanently aggravated the pre-accident impairment. If medical evidence confirms that the work-related injury/illness permanently increased the worker's pre-accident impairment, the worker may be entitled to a non-economic loss benefit. (For more information, see , Determining the Degree of Permanent Impairment.) [35] Operational Policy Manual Document No , Tenosynovitis, states that tenosynovitis is accepted as a Schedule 3 industrial disease resulting from direct trauma or repetitive movement. Policy Tenosynovitis is accepted as a schedule 3 industrial disease resulting from direct trauma or repetitive movement. Repetitive movement If tenosynovitis is caused by repetitive movement the decision maker must establish the exact mechanics of the work performed. All of the following information is required to adjudicate claim. Job description The exact mechanics of the work performed Frequency of repetitive motion Sustained tension or pressure of risks whether one hand is used more than the other while working Whether vibratory or rotary tools are used Length of time performing the particular job Whether there is a change in work just prior to the onset of symptoms The worker s production) our shift in comparison to co-workers performing the same duties In addition the adjudicator determines if any of the worker s activities outside of work involve any of the above.

17 Page: 16 Decision No. 886/16 TRIBUNAL JURISPRUDENCE [36] In WSIAT Decision No. 1857/08, a worker appealed a decision of the Appeals Resolution Officer denying entitlement for de Quervain's tenosynovitis. The worker had no symptoms of de Quervain's tenosynovitis prior to commencing employment. The Panel accepted that the worker did not fully understand the operation of the machine, with the result that he was required to exercise more physical force to control the machine. For the worker, it required a degree of repetitive motion and sustained pressure on the wrists. Tenosynovitis is a Schedule 3 occupational disease. According to s. 15(3) of the WSIA, if a worker is employed in a process set out in Schedule 3 and contracts a Schedule 3 disease from which he was previously unimpaired, the disease is presumed to have occurred due to the nature of the employment unless the contrary is shown. MEDIATION SUMMARY ONGOING ENTITLEMENT FOR RIGHT SHOULDER [37] The parties agree that this appeal should be resolved by granting the worker ongoing entitlement to the right shoulder as a permanent aggravation of an essentially asymptomatic pre-existing degenerative acromioclavicular (AC) joint arthritis. The parties note that the following facts are established in the claim file documents in support of this agreement. [38] The parties note that the worker has been employed with the accident employer since Over these 21 years she, has worked on the assembly F-line performing various duties including assembling car jacks, rodding and packing. In her decision dated November 15, 2012, the Eligibility Adjudicator reconsidered initial entitlement to the right shoulder. She acknowledged that the worker s duties on the assembly line were highly repetitive and required her to use her arms to reach overhead, pull, push, carry and lift. Entitlement, however, was limited to the right shoulder and the diagnosis of ganglion cyst at the sternoclavicluar joint. The Case Manager was then asked to reconsider the areas of entitlement. In her decision dated October 13, 2013, the Case Manager noted that the primary diagnosis was AC joint arthritis of the shoulder. However, she limited entitlement to a strain. [39] The parties agree that while the worker s arthritis is a pre-existing degenerative condition, the question that the question to ask is whether the worker's work on the assembly line was a significant contributing factor that permanently aggravated her right shoulder AC joint arthritis. The parties agree that, on the balance of probabilities, the answer to this question is yes. [40] The parties note that in the Employer's Report of Injury form dated June 26, 2012, the employer distinctly noted two areas of pain right shoulder and the base of the neck (at the sternoclavicluar joint). The parties acknowledge that the physical demands analysis of the F-line duties show that the worker s duties are highly repetitive. There are three positions from which the worker rotates: rodding, jack assembly and packing. The worker is required to grease on screw rods, inspect jacks for defects and pack car jacks

18 Page: 17 Decision No. 886/16 that weigh approximately 6 lbs. These positions require the worker to perform overhead work. The parties acknowledge that the worker was initially thought to have developed a strain, but upon further testing of her right shoulder, she was found to have AC joint arthritis. [41] They rely on Dr. Finkelstein s report of February 8, 2013, in which he opined that the actions performed on the F-line would aggravate the worker s AC joint arthritis. The parties acknowledge that it was difficult to delineate the worker s right shoulder problems initially. The Orthopaedic Surgeon, Dr. Crawford, attempted to perform diagnostic infiltration in order to characterize the source of the worker s right shoulder pain. It was not until September 24, 2013, in which he expressed that the worker s right shoulder pathology appears related to her chronic use at work. The parties also note the worker s family physician, Dr. Robson also noted in his report of August 27, 2014, that the worker s right shoulder problems are a result of the repetitive nature of the worker s job duties. [42] The parties acknowledge that since June 2012, the worker has continued to complain of right shoulder pain, she has demonstrated a decreased range of motion in her right shoulder and she demonstrated limitations in function. The worker has continued to require medical restrictions for her right shoulder throughout. As of April 16, 2014, the worker continued to have limitations in abduction of her right shoulder with signs of impingement. The worker has also continued to require the use of pain medications and conservative treatment in the form of physiotherapy to assist with her right shoulder difficulties. [43] In light of the above, the parties agree that the worker should be entitled to a permanent aggravation of an underlying degenerative AC joint arthritis and should be assessed for a non-economic loss award. ENTITLEMENT TO LEFT THUMB & WRIST [44] The parties also agree that the worker s repetitive duties on the assembly line significantly contributed to the development of the left wrist dequervain s tenosynovitis and an aggravation of the osteoarthritis in her left thumb. In support of this agreement, the parties rely on the physical demands analysis for the pre-accident jobs, the information provided on the modified work as well as the following medical documentation supporting a relationship. [45] The parties acknowledge that the positions of packing, rodding and jack assembly on the F-line require the worker to use her hands for the majority an eight hour shift. Although she rotates amongst these positions, the worker is required her to grip, handle, reach and use a torque gun. The parties agree that there is very little down time between each rotation of a 10 second cycle. The parties also note that the Board doctor, Dr. Razavi, was asked to review the worker s medical file and provide an opinion as to the relationship between the worker s left thumb/wrist problems and the nature of her work. In his memorandum dated June 17, 2013, Dr. Razavi opined that the relationship between the worker s job demands and the relationship to the dequervain s is probable.

19 Page: 18 Decision No. 886/16 The parties note that the standard for entitlement is on the balance of probabilities. They agree that the worker has met the standard and should be entitled to the dequervain s tenosynovitis. [46] The parties note that the Case Manager and Appeals Resolution Officer found that the worker was on modified duties at the time and therefore could not have developed dequervain s or aggravated her left thumb arthritis. The parties note, however, that although the worker was on modified duties with respect to her right shoulder injury, she was still working on the F-line performing re-work and lead hand duties when she began to develop left thumb and wrist problems. They note that, at that time, the worker was mainly using her left hand to perform these tasks given her existing right shoulder problems. The parties agree that as a lead hand, the worker would be filling in for individuals on breaks on the F-line, which could have resulted in her working on the line for an entire shift on many days. The parties also note that as early as August 21, 2012, the worker went into the company s first aid department to complain of pain to her left wrist after strapping trunnions, performing load rest press and gauging nummi handles. The parties agree that these positions all require small finite movements with the thumbs, as well as gripping activities and wrist movement. They also note that the worker has carpometacarpal (CMC) joint arthritis. They submit that the work activities that the worker engaged in during this time period were sufficiently repetitive and would likely have aggravated her CMC joint arthritis. In light of the above evidence, the parties recommend that the Tribunal grant entitlement to dequervain s tenosynovitis and entitlement to an aggravation of the worker s CMC joint arthritis. [47] The ADR Officer is satisfied that the above recommendation is consistent with law, policy and findings that would be reasonably made by the Tribunal. DATED: December 24, 2015 RECOMMENDED BY: Diana Sanginesi, ADR Officer