SUMMARY DECISION NO. 860/99. Morton's neuroma.

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1 SUMMARY DECISION NO. 860/99 Morton's neuroma. The worker tripped on stairs in January 1994 and injured his left foot. The worker appealed a decision of the Appeals Officer denying entitlement for Morton's neuroma. The Vice-Chair accepted the opinion of the worker's treating doctors, including the orthopaedic surgeon who performed surgery on the worker for the condition, and concluded that the Morton's neuroma resulted from the compensable accident. The appeal was allowed. [8 pages] DECIDED BY: Libman DATE: 31/05/99 ACT: WCA

2 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 860/99 [1] This appeal was heard at Toronto on May 14, 1999, by Tribunal Vice-Chair P.K. Libman. THE APPEAL PROCEEDINGS [2] The worker appeals the decision of the Workers Compensation Board Appeals Officer, Mr. R J. Biega dated December 17, 1997, which denied the worker entitlement for a condition known as Morton s Neuroma as having resulted from a work-related accident January 4, [3] The worker was present and represented by Mr. Sender Herschorn of the law firm of Orbach, Katzman & Herschorn. The accident employer was represented by Mr. Don Kirby, its Operational Manager and by Ms. Ilonka Landry, its Staff Relations Officer. [4] On January 1, 1998, the Workplace Safety and Insurance Act (WSI Act) took effect. This legislation amends portions of the Workers' Compensation Act, which continues to apply to injuries which occurred before January 1, All references to "the Act" in this decision mean the Workers' Compensation Act as it read on December 31, 1997, unless otherwise indicated. [5] An important change relevant to this appeal is that the Appeals Tribunal is now required to apply Board policy in accordance with sections 112 and 126 of the WSI Act. While the Tribunal did consider and apply Board policy previously in deciding Board appeals, the prior Act did not contain this express provision. In addition, the jurisdiction of the Appeals Tribunal is now described by section 123 of the WSI Act, with necessary modifications. THE EVIDENCE [6] The Vice Chair had before him the Case Record material prepared by the Tribunal Counsel Office. This was marked as Exhibit #1. In addition the Vice Chair had Addenda #1, #2, #3, #4, #5, #6, #7, #8 and #9 prepared by the Tribunal Counsel Office which were respectively marked as Exhibits #2, #3, #4, #5, #6, #7, #8, #9 and #10. THE ISSUES [7] The Appeals Officer has given the following as the history of the issues under appeal: (The worker), a correctional officer, tripped on a set of stairs and injured his left foot on January 1, The initial diagnosis provided by Dr. Petrie was plantar fasciitis. (The worker) was referred to the specialist Dr. Aitken whose report confirmed similar foot problems a few years prior to the January 1994 accident. Dr. Aitkin was not sure why (the worker s) foot pain was spreading to the heel and the ball of the foot and he suggested that Morton s Neuroma may be contributing to the element of plantar fasciitis that was present. The Morton s Neuroma was treated first with injections and subsequently through surgeries. Following adjudicative inquiry, the claims adjudicator received an opinion from the unit medical advisor that the Morton s neuroma was unrelated to the

3 Page: 2 workplace accident. The Decision Review Specialist referred the matter for further medical review and accepted the opinion the condition was not related to the accident even on an aggravation basis. That decision is before the appeals officer for review and determination. [8] The Appeals Officer, without holding an oral hearing, issued a written decision dated December 17, 1997, denying the worker s objection. [9] The worker has appealed the Appeals Officer s decision to this Tribunal. THE PANEL'S REASONS (i) Preliminary Issues [10] In Addendum #9 is a letter from the Board dated February 22, 1999, certifying that the following policy packages apply to this appeal: #1 (Initial Entitlement (Accident On Or After January 2, 1990)), #37 (Recurrences Entitlement- Completely Recovered From Original Accident), and #107 (Aggravation Basis Or SIEF). The parties agreed that these policies applied to this appeal. (ii) Evidence Presented [11] The worker gave sworn evidence. The worker stated that he was age 42, married with two children, had a diploma from Sheridan College and started working with the accident employer on December 16, 1986, where he is still employed. [12] The worker described his job duties and stated that 70% of the time he was standing or walking. The worker stated that prior to the accident he wore a standard police boot and he had no physical problems prior to the accident. [13] The worker stated that Dr. Aitken, his orthopaedic surgeon treated him three years prior to the accident for plantar fascitis (flat feet) which he had in both feet and which were cured by the use of orthotics. [14] The worker stated that the location of the flat feet pain was different from the Morton s Neuroma which was only in his left foot. [15] The worker described the accident of January 1, 1994, where he injured his left foot tripping on a stair. The worker stated that he reported the accident to his supervisor who indicated to him he could go to the emergency department of the hospital as the nurse was not on duty at that time. [16] The worker stated that he finished his shift and continued working until January 4, 1994, which was the earliest date he could see his family doctor, Dr. Petrie, because of the holiday week-end. [17] The worker stated that Dr. Petrie thought that the injury had aggravated the plantar fascitis but when the pain continued, he was referred to Dr. Aitken who diagnosed Morton s Neuroma and performed surgery in 1994.

4 Page: 3 [18] The worker stated that the problem recurred in 1997 and Dr. Prior (who had taken over Dr. Aitken s practice after he moved to the United States) performed surgery again on the left foot and took out a nerve trunk during this surgery. [19] The worker stated that the problem has not recurred and he now wears loose fitting shoes instead of police boots although he still wears the orthotic devices in his shoes. The worker stated that during his physiotherapy treatments he was instructed in walking properly as he was favouring his left foot. [20] The worker stated that between January and April 1994, he continued to work because he wanted to do his share of work and he did not lightly take time off work. The worker stated that between September 1994 and January 1997, the accident employer provided modified work for him. [21] Following completion of the evidence, submissions were made on behalf of the parties. As part of those submissions Mr. Herschorn referred to the following Tribunal Decisions: Nos. 761/90, 99/92, 780/97 and 182/92. (iii) Panel's Findings [22] I have carefully reviewed the evidence presented, the material in the Exhibits and the submissions made on behalf of the parties. [23] The issue to be determined in this appeal is the worker s request for benefits for a condition described as Morton s Neuroma. In the Appeal Application the worker has asked for temporary total disability benefits for the periods of April 12, 1994 to September 15, 1994 and April 16, 1996 to May 30, 1996 [24] In Addendum #8 is an extract from Entrapment Neuropathies, Second Edition by Drs. Dawson, Hallett and Millender, which gives the following: Morton s toe neuroma is a painful lesion of the foot that was the first entrapment neuropathy to be clearly described. It involves a lesion of the interdigital nerve, usually between the third and fourth digits of one foot. The pain is located over the head of the metatarsal on that side, radiating most often into the fourth toe. Morton describes 15 patients and gave a clear description of the clinical features of the illness in He felt the condition was caused by a pinching of the lateral plantar nerve, and his suggestion for cure was to remove the metatarsal head, on operation with a relatively good record of success for that era. Throughout the remainder of the nineteenth century and the first four decades of the twentieth, Morton s toe neuroma was a well-recognized condition, and the same procedure was applied for its relief The clinical features of Morton s toe neuroma is burning pain over the head of the fourth metatarsal that radiates into the toe. The pain may be quite intense. It is made worse by standing and walking, and is somewhat relieved by lying down or elevating the foot The etiology of the condition is presumably traumatic in all cases. The nerve is in a vulnerable position, and chronic pressure on it as it goes past the metatarsal head causes a scar to form. People who walk, jog, or squat a great deal are probably more likely to develop Morton s toe. High-heeled shoes are also a factor, and this may account for the greater incidence in women [25] In making this determination, I have considered the following medical documentation:

5 Page: 4 a) The memo of Dr. A. MacArthur, Board s Medical Consultant, dated November 27, 1997, which provides the following: Looking at the new information on Morton s neuroma, I would not consider that this injury of January 1, 1994 is the cause of Morton s neuromata. The reason for this is that in the original form 8, there is no description of any swelling in this particular area and there is absolutely no reaction present as described by the physician. With lack of this information, I could not see how this trauma could create perineural fibrosis. One would expect to have seen crushing injury to the foot in this area and one would have expected a fair deal of swelling. This particular injury, by tripping on a set of stairs, would not cause a Morton s neuroma. But I have feeling that any constricting shoes can cause Morton s neuroma and often, the interdigital nerve is caught between the metatarsal heads because of the tightness of the shoes. I support Dr. Malayil s contention that this is not related to this particular injury of January 1, The plantar fascia does arise from the base of the toes but plantar fascitis is not a precursor of Morton s neuroma. b) The memo by Dr. A. Malayil, Board s Medical Consultant, dated May 11, 1995, provides the following: On January 1 st, 1994 this now thirty-eight year old worker tripped on a set of stairs and injured his left foot. He sought medical attention on January 4 th, 1994 and the diagnosis by the family physician at that time was left plantar fasciitis. The report indicated that examination revealed tenderness over margin of plantar fascia left foot. He was advised to see a podiatrist for an orthotic. There was no lost time due to this injury. Dr. Aitken s report of April 15 th, 1994 indicates that this worker had previous problems with his foot a few years ago and Dr. Aitken felt at that time worker had plantar fasciitis. Morton s neuroma is normally not a work-related condition and the etiology of this lesion is questionable. In case of crushing-type of injury to the forefoot the Board accepts a Morton s neuroma on the basis that a crush injury can give rise to a neuroma of the digital nerve. In this case when this worker was seen on January 4 th, 1994, three days after the compensable injury, examination revealed tenderness over the margin of plantar fascia and the diagnosis was left plantar fasciitis. There was no mention of any pain or tenderness in the forefoot at that time. Worker also had a history of prior left foot problems as per Dr. Aitken s report of April 15, Noting the fact that worker was able to carry on with his regular duties without any lost time or medical attention for about three months after the injury of January 1 st, 1994 it appears that the injury was of minor nature. Based on the medical reports on file it appears that this worker probably had longstanding problems related to a Morton s neuroma and which got worse gradually leading to the surgery of June 30 th, Noting the minor nature of the injury to the left foot on January 1, 1994 in my opinion compatibility of the diagnosis of Morton s neuroma even on an aggravation basis with the compensable injury of January 1 st, 1994 appears doubtful. c) The report of Dr. George Aitken, Orthopaedic Surgeon, dated September 15, 1994, provides the following: (The worker) initially injured his foot on January 1, He had continued pain, an ongoing problem, when I saw him on April 15, This is confirmed in your letter of August 23, 1994, when you mention that his co-worker had confirmed he had ongoing left foot problems. My examination on April 15, suggested an indeterminate cause of his pain, however, I did consider that he had elements of a metatarsagia and/or Morton s neuroma. My subsequent care, and operative procedure, confirmed the fact that he had Morton s neuroma, at the 2,3 and 3,4 interspace, consistent with the symptoms that he initially presented to me.

6 Page: 5 On the basis of the history recorded in my notes, that is, the presence of pain in the mid and forefoot, occurring subsequent to his accident of January 4 th, and persisting, and increasing to the time of my examination on April 15, 1994, I would feel that (the worker s) problem is directly related to his compensable injury of January 1, Although the initial, diagnosis, by a different treating physician, and the subsequent diagnosis by myself are different, I believe that the problem has been the same. I, therefore feel, that his treatment from April, 1994, would be compensable d) The letter from the worker s family doctor, Dr. Rosemary Petrie, dated September 15, 1994, provides the following: (The worker) originally injured his left foot at work when he slipped on January 1, 1994, which resulted in symptoms of plantar fascitis. (The worker) did not have neuromas until after his incapacity for plantar fascitis. I suspect that these neuromas developed as a consequence of his limping and altered gait due to his plantar fascitis and therefore feel that it is a reasonable to conclude that the neuromas were as a consequence of his WCB injury, namely his plantar fascitis. I have asked him to obtain the opinion of his Orthopaedic Surgeon, Dr. George Aitken, in this regard. e) The report from Dr. Prior, Orthopaedic Surgeon, dated March 12, 1998, provides the following: You have asked me to relate the condition of Morton s neuromata that you have had to your occupation and in particular, the pathological findings clinically in the foot at the time of surgery. When you first came under my care on February 11, 1997, I had the benefit of Dr. Aitken s notes relating to your original problems. In January 1994 you sustained an injury to the fore foot of the stepping down a stair and became aware of increasing pain over the left fore foot and subsequently a diagnosis of a left Morton s neuroma was made. After a failure to respond to management, Dr. Aitken did surgery with a resection of the Morton s neuroma of the left 2 nd and 3 rd and 3 rd and 4 th spaces of your foot. You advised me that in fact you improved following although the recovery period was somewhat prolonged. Your occupation requires prolonged walking and standing and despite using orthotics, gradually you had a recurrence of symptoms of a Morton s neuroma between the left 2 nd and 3 rd interspace and I saw you in February 1997 You underwent surgery subsequently on April 16, 1997 and had findings in keeping with a recurrence of the neuroma between the left 2 nd and 3 rd interspace and the subsequent pathology report revealed soft tissue changes consistent with Morton s neuroma Morton s neuromata occur because of either following acute trauma to the interspace in the metatarsal area of the foot or repetitive trauma or both. Your occupation produces repetitive trauma in that area The relationship of the Morton s neuroma to your WSIB claim is based on the precipitating injury by history. You have drawn to my attention a letter from the WSIB (incorporating the opinions of the UMAs cited above) which states there is no description of any swelling in this particular area and there is absolutely no reaction as described by the physician with the lack of information I could not see how this trauma could create perineural fibrosis, and slipping on a set of stairs would not cause a Morton s neuroma. I disagree with this statement. The majority of patients with Morton s neuroma who present are in an occupation which involves a lot of standing, particularly on concrete surfaces and often have a very minimal

7 Page: 6 precipitating trauma to the fore foot which results in the development of the neuromata which then progresses. f) The further report of Dr. Aitken, dated August 10, 1998, provides the following: Based on the information provided to me by (the worker) and fully outlined in notes previously provided to (the Board) I believe that there is a direct correlation between (the worker s) injury and the subsequent development of painful and persistent Morton s neuroma. From the history provided to me and on the basis of my physical examinations as previously reported, I do believe his injury of January 1, 1994, caused the formation of his Morton s neuroma. [26] In reviewing the medical reporting I prefer the opinions of the worker s treating physicians who had an opportunity to examine the worker and in the case of Dr. Aitken who is an orthopaedic surgeon and performed surgery on the worker. [27] I also find that the opinion of Dr. Aitken is consistent with the etiology as described in Exhibit #8 in the text book cited. [28] I find that the worker has testified in a straight forward and credible fashion and I accept that he is a stoic individual and was not inclined to take time off work unless the foot pain became intolerable. [29] I note that, had the worker s previous representative been able, after receiving the opinion of Dr. MacArthur, to obtain the medical reporting which has now been forthcoming due to the diligent efforts of the worker and his legal counsel, it might have obviated the need for this appeal. I now have that new medical reporting and I am satisfied, on a balance of probabilities, of the worker s initial entitlement. [30] The appeal of the worker is therefore allowed.

8 THE DECISION [31] The appeal of the worker is allowed and the file is remitted back to the Board to calculate the benefits that flow to the worker from this finding of initial entitlement for Morton s Neuroma as arising from the compensable accident of January 1, DATED: May 31, 1999 SIGNED: P.K. Libman,