MEMORANDUM 171/91. DATE: June 26, 1991 TO: ALL WCAT STAFF SUBJECT: DECISION NO. 171/91. Continuity (of treatment) - Strains and sprains (ankle).

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1 MEMORANDUM 171/91 DATE: June 26, 1991 TYPE: A TO: ALL WCAT STAFF SUBJECT: DECISION NO. 171/91 Continuity (of treatment) - Strains and sprains (ankle). The worker sprained his ankle in a compensable accident in June He again sprained his ankle in a non-compensable accident in December X-rays taken at the time of the second accident indicated the presence of bone chips and surgery was performed in March The worker sought entitlement for the lost time that resulted from the surgery. The worker lost no time from work between June 1986 and December The worker did not seek medical attention for continuing ankle problems during this period despite seeking attention for other conditions. The Panel found that the worker did not have symptoms of any consequence during this period. The medical evidence did not lead the Panel to conclude that the surgery in March 1988 was causally related to the 1986 compensable accident. The worker was not entitled to benefits. [9 pages] PANEL: Hartman; Robillard; Apsey DATE: 21/06/91

2 WORKERS' COMPENSATION APPEALS TRIBUNAL DECISION NO. 171/91 This appeal was heard in London on March 19, 1991, by a Tribunal Panel consisting of: R.E. Hartman: Vice-Chairman, R.H. Apsey : Member representative of employers, M. Robillard: Member representative of workers. THE APPEAL PROCEEDINGS The worker is appealing a decision of N.J. Hiebert, Hearings Officer, dated January 11, 1989, which denied the worker entitlement to benefits subsequent to January 1988, for a right ankle disability which the worker claimed resulted from a compensable accident on June 11, The worker was represented by J. Ashton, president, C.A.W., Local 27. The employer was represented by its workers' compensation representative, J. Woolvett. The worker was present. G. Stead, with C.A.W., was present as an observer. THE EVIDENCE The Panel had before it the Case Description materials, together with an Addendum, which were entered as Exhibits #1 and #2. The Panel heard sworn testimony from the worker who was questioned by the representatives and the Panel. THE NATURE OF THE CASE The worker was employed as a machinist with the accident employer for 12½ years. On June 11, 1986, while sweeping the floor, he tripped on an air line hose and went over on his right ankle. He reported the incident to the security guard working at the building in which it occurred. The security guard was trained in first aid. He put ice on the ankle and gave the worker a Tensor bandage. The worker was seen at the emergency department of a local hospital on June 17, 1986, and a diagnosis of sprained right ankle was made. There was no lost time from work between June 1986 and December 1987, when the worker sustained a non-compensable injury at home. While working on a ladder in his driveway, the worker fell about five or six feet. He landed on his right ankle with his foot still in the rungs of the ladder. He called the doctor that day and was seen at the local emergency department early the next morning. The diagnosis was sprained right ankle.

3 2 X-rays taken at the time of the second incident indicated the presence of bone chips. On December 29, 1987, the worker contacted the Board advising that he felt the bone chips were caused in the trip on the air hose in June 1986 and that surgery was a probability. Surgery was carried out in March The worker seeks initial entitlement for the injury on June 11, 1986, and claims the 1988 surgery resulted from this compensable accident. This surgery caused him to lose approximately five weeks' lost time. The worker also lost a total of about eight or nine hours when he left work early on a number of occasions in January and February 1988 to obtain physiotherapy. The issue for the Panel is the causal relationship, if any, between the surgery in March 1988 and the incident at work on June 11, THE PANEL'S REASONS There is no dispute that the incident occurred on June 11, 1986, and that the worker was seen at an emergency department for treatment on June 17, The employer disputes the medical relationship between the condition for which surgery was performed and the injury in June of 1986 and cites lack of continuity of complaint and symptoms from June of 1986 to December 1987, as well as lack of continuity in medical treatment. The worker's representative argued that the worker was a non-complainer and did not avail himself of medical attention unless the problem was considerable. It was submitted that the medical evidence suggested the fall in December 1987 was not the cause of the condition which led to surgery in March 1988 and therefore the Panel must conclude its cause was the accident on June 11, It was submitted that only if the Panel found against the worker on the basis of credibility, could the appeal be denied. (i) Worker's testimony The worker's recollection of the condition of his ankle from June 1986 to December 1987 expanded considerably at the hearing. When the worker was interviewed by a WCB Investigator on January 11, 1988, he recalled initial discomfort, from turning his right ankle in 1986, lasting "for between one and two weeks" with ongoing "sensation of weakness" with "any number of incidents" of renewed twinges of discomfort in the ankle when placing his weight on the foot the wrong way. The subsequent twinges were described as not a "big deal" as they would last for an hour or two only and then subside completely. At the hearing, on questioning from his representative, he stated that his foot would swell up on numerous occasions after 1986 and be sore at night for a day or two and then it would be fine. These incidents of swelling were triggered by stepping on his foot "the wrong way". Asked why he did not seek medical attention, he stated that he did not think the problem was serious since the doctor who examined him shortly after the June 1986 injury did not consider it to have been a serious injury. He indicated no home treatment in his direct testimony. In his submissions, his

4 3 representative stated the worker had treated himself at home with ice and Tensor bandages. When asked by the Panel at that point, the worker said he had done this but forgotten to mention it. Until the x-ray results in December of 1987, he said he attributed his problem to "loose ligaments". When x-rays in December 1987 revealed bone chips, it was the worker's testimony that his family doctor Dr. Simpson, suspected the 1986 incident as its cause and said that surgery would be required. The worker worked on two sites for the accident employer, one was served with a complete medical centre, the other was not. The original injury did not occur in the building with the medical centre. However, the worker worked for extended periods of time in the building with a complete medical centre in this period and made no complaints of any kind about his ankle. While the failure to report complaints to an employer's medical centre might suggest a non-complainer or one who wishes to keep his aches and pains to himself, the Panel notes that the worker did seek out medical attention from his family doctor in this period, without making any mention of ongoing disability from the June 1986 incident. The worker was active in sports - a "no body contact" hockey league and baseball. He said that he no longer plays baseball because it requires more physical fitness than the type of hockey he plays. He was unclear in his recollection as to whether or not he played baseball in the summer of 1986, either before or after his incident on June 11, The information on record suggests that he did play baseball in the summer of (Dr. Rock reported that the worker's shoulder injury had improved somewhat from that in 1985 as he was able to play baseball and other sports in the summer of 1986.) (ii) Assessment of worker's testimony The Panel's assessment of the worker's testimony at the hearing, together with the information in the materials, is that the worker gave his answers in a straightforward manner to most questions. However, when it came to more critical testimony regarding the nature of his right ankle condition and the effect it had on his performance of work duties or pursuit of sports activities, the worker's testimony was unreliable. The worker testified that he had no complaints or symptoms whatsoever following the surgery in March This worker was extremely active in sports and claimed to have had no injuries whatsoever from sports. Yet he states he had repeated swelling and pain episodes, unrelated to sports, which arose after The Panel finds it difficult to understand why no mention was made of these new symptoms to the family doctor when he did mention, in September of 1986, complaints of pain on the sole of his right foot which had been present for two days. (This was treated as a bruise with rest and Entrophen.) The worker was also seen by a specialist in March of 1987 with respect to a compensable shoulder injury and made no mention of ankle symptoms. The Panel notes that the worker did make mention of his ankle injury to the family doctor in the course of a regular physical examination on December 11, 1987, after the non-compensable fall from the ladder. The worker stated that he used crutches for a few days and returned to work with a second employer for a period of five weeks from December 7, 1987, to January 8, 1988.

5 4 (The worker was on lay-off from April 13, 1987, to October 5, 1987, and from November 9, 1987, to January 11, 1988.) In summary, with respect to continuity of complaint to the employer or co-workers, the Panel accepts that this worker was perhaps a non-complaining type at work and therefore does not place too much emphasis on the lack of continuity of complaint at work. The Panel does have difficulty accepting the worker's explanation for the lack of medical continuity of treatment from June of 1986 to December After reviewing the medical evidence, the worker's testimony at the hearing as well as the information given to doctors and investigators in the materials, the Panel feels it is more probable than not that the worker did not seek out medical treatment as he had no symptoms of consequence between June of 1986 and December of 1987, contrary to his testimony that recurrent symptoms were an ongoing problem. (iii) Assessment of medical evidence The worker's family doctor, Dr. Simpson, reported that the worker had no other injuries involving his right ankle but could not: state positively that his present ankle problem (that in February of 1988) stems from his work injury in However, I also, from his past history of no previous ankle problems, am unable to state that it is not work-related. This is the extent of Dr. Simpson's opinion as to a causal relationship. The report from the hospital emergency department on June 17, 1986, gives the date of accident as June 11, 1986, and the history as follows: Twisted (ankle) at (work 6 days ago). C/O swelling and difficulty walking (at) times. Appears to be walking normally (at) present. The diagnosis was "inversion (right) ankle - joints. C/O intermittent pain (and) swelling C/O (right) ankle swollen but stable, non tender". The final diagnosis was sprain of the right ankle. The report from the emergency department after the fall in December 1987 give a history as: "fell off ladder yest. inj. lt. ring finger (and) rt. ankle". The x-rays were described as negative but bone chips were noted in the right ankle. The diagnosis was sprain; treatment was Tensor bandage and crutches. The worker was first seen by an orthopaedic specialist with respect to his ankle on January 14, Dr. M. Rock referred to the fall from the ladder, in a letter to the family doctor on January 14, 1988, and added: X-rays apparently were taken at that time which revealed an old osteochondral fracture off (sic) the anterior medial aspect of the neck of the talus as well as a slight osteophyte from the distal aspect of the tibia. He has been slow to respond to the inversion injury to his ankle. He still has some intermittent discomfort in the ankle.

6 5 On examination today he has some swelling over the anterior lateral aspect of his ankle joint. Range of motion of his ankle and subtalar joint is good. There was no evidence of excessive instability of the subtalar or even ankle joint. Direct palpation along the anteromedial aspect of his ankle joint causes him some discomfort. This is presumably in the area of his osteochondral lesion. There is no evidence of an effusion however of the ankle joint. Dr. Rock felt that the osteochondral injury was old and had no bearing on his rehabilitation for his inversion injury. He added that if the "medial side becomes symptomatic then it would not represent a major operative procedure to remove the osteochondral lesion as well as possibly osteophytes of the distal tibia". As to the relationship between the ankle condition for which he examined the worker on that date, and the worker's employment, Dr. Rock commented: I guess the claim is whether the injury radiographically that we are seeing was a work related situation. Apparently he can only recall one other injury to his ankle and that was work related. It is obviously difficult to assume that the osteochondral injury that we are seeing was in fact that one associated with his previous industrial injury. However one also cannot say that there is no association. The Tribunal's Medical Liaison Office obtained the x-ray performed on December 3, 1987, and forwarded this together with the medical reports contained in Exhibit #1, to Dr. E. English, a 86h assessor and orthopaedic specialist. Dr. English was asked to explain the nature of an inversion injury and sprain together with the usual symptoms and course of healing. Dr. English responded: First of all, an ankle inversion injury is an injury where the foot and heel are forced inwards so as the patient stands...the patient comes down on... the outside of the foot and ankle. A sprain...is a soft tissue injury, stretching or elongating the ligamentous support of the ankle.... In relation to the ankle, a stretching of the outer ligament of the ankle is usually caused by an inversion strain, causing swelling and tenderness in the area of the ligament making it difficult to walk on the foot, even in the normal position.... Usually with any significant ankle sprain the patient is unable to walk or weight bear on the foot from 1 day to a couple of weeks.... The usual result is a fully normal ankle within 6 weeks to 6 months following that type of injury.... with no long term residual problems following a significant inversion strain. Secondly, Dr. English was asked whether the mechanism of injury in December 1987, and in June 1986 were the same and whether the location of injury was the same. Dr. English responded:

7 6 The medical information supplied in this chart is probably a little inadequate, basically because the physicians who recorded the notes did not give an expanded physical examination. However, it appears that they were both inversion injuries and they both had lateral complaints around the lateral ligament. This is the same for both injuries. The medial side of the ankle joint was not really referred to until Doctor Rock mentioned it in his letter of January 14, I think that the injuries mentioned are probably the same.... The only difference was that in the 2nd injury a month following the injury Dr. Rock found a tender area on the inner aspect of the ankle joint, just anterior to the medial malleolus, that is the inner bump of the ankle joint. This identifies a completely different area of complaint that was not present on the first physical examination or history of complaint. This is also the area where the patient had the operation, that is on the inner aspect of the ankle joint which was not the original area of injury, nor did the patient complain of problems on the inner side of the ankle joint. (emphasis added) Thirdly, Dr. English was asked to explain the x-ray findings in December 1987, specifically the significance of the old united fracture at the tip of the medial malleolus and the old osteochondral injury. Dr. English replied that an un-united fracture of the tip of the medial malleolus was not a "significant injury to the function of the ankle joint", and may or may not create pain. The age of the fracture could not be identified by x-ray. Noting the worker's statement, Dr. English commented: [The worker] stated that he only had one other injury in his ankle before December 2, 1982 and that was in June However, it is not uncommon to see this type of injury in a person who has been athletically very active as [the worker] had indicated. These injuries can happen from a minor twist or strain that the patient will not be aware of as being a significant injury. It could have happened in his teenage years so that it would never show up in his memory of an injury he has had as an adult. Usually the patient has symptoms for a few weeks before they subside. Then further injuries could create symptoms of a totally asymptomatic problem before the injury. Dr. English described osteochondral injury as a "fracture of the bone and the overlying cartilage that cannot be seen on the x-ray". Such fractures are "always related to an accident". Dr. English commented that he did not see any evidence of an osteochondral fracture in the worker's x-rays. Finally, regarding the compatibility of the findings during surgery on March 21, 1988, and the 1986 or 1987 injuries, Dr. English stated: First of all, I previously said that the only time the patient ever had an inner ankle (medial) complaint was in

8 when Dr. Rock examined the patient. Even before that time when he went to the Emergency it wasn't commented on. It is possible that neither of these accidents (December 2, 1987 and July 11, 1986) created the patient's symptoms and that his symptoms may be related to osteoarthritis developing in the ankle joint and secondary osteoarthritic loose bodies in the ankle joint. Dr. English felt that the problem had probably developed within the past ten years and could not identify it as being related to something in 1986 or He added: Usually a patient has osteoarthritis that is brought on by wear and tear in a localized area which causes localized inflammation. This is usually what causes the symptoms. The patient was not talking about locking or catching in the ankle joint related to a mechanical derangement and a loose fragment of bone jamming the ankle joint. This is not what the patient was complaining about and therefore probably his complaints of pain in the ankle do not go along with loose bodies in the ankle joint but relate to local inflammation or synovitis in the joint. Dr. English felt that the un-united fracture was not giving the worker "any symptoms at all", and that the loose bodies were a manifestation of early osteoarthritis, which "can be brought on by an injury" but "also by basic wear and tear of the joint, probably again caused by recurrent minor injuries, not just one specific injury". He did not feel that "there is very much likelihood that the accident of June 11, 1986 was a significant contributing factor to the patient's complaints" and "certainly was not the one causative factor creating the patient's disability". (iv) Conclusions The Panel, after reviewing the worker's testimony, the information in the materials, and the medical evidence, cannot conclude that the surgery in March 1988 was causally related to the worker going over on his ankle while sweeping a floor on June 11, Whether or not it was related to the non-compensable accident in December of 1987 is not an issue before the Panel.

9 8 THE DECISION The appeal is denied. DATED at Toronto, this 21st day of June, SIGNED: R.E. Hartman, R.H. Apsey, M. Robillard.