Continuing entitlement - Delay (onset of symptoms) - Benefit of the doubt.

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1 MEMORANDUM 578/89 DATE: April 8, 1991 TYPE: A TO: ALL WCAT STAFF SUBJECT: DECISION NO. 578/89 Continuing entitlement - Delay (onset of symptoms) - Benefit of the doubt. The worker suffered an ankle sprain in May The worker appealed a decision of the Hearings Officer denying entitlement in 1986 and The worker's continuing problems were plantar fasciitis and spurs in the ankle joint. The worker was not entitled to benefits for plantar fasciitis considering delay in onset of symptoms until March Applying the benefits of doubt, the worker was entitled to benefits for the spurs on the basis of aggravation of a preexisting asymptomatic condition. [9 pages] PANEL: Strachan; B. Cook; Preston DATE: 04/04/91

2 WORKERS' COMPENSATION APPEALS TRIBUNAL DECISION NO. 578/89 This appeal was heard in Windsor on July 14, 1989, by a Tribunal Panel consisting of: I.J. Strachan: Vice-Chairman, K.W. Preston : Member representative of employers, B. Cook : Member representative of workers. THE APPEAL PROCEEDINGS The worker appeals the March 29, 1988, decision of WCB Hearings Officer W.A. Molyneux. That decision denied the worker continuing entitlement to compensation benefits for lost time between July 7 and July 29, 1986, and after January 1987 for right heel and ankle disabilities which the worker relates to an injury on May 23, The worker appeared with his representative G. Parent, financial secretary-treasurer of Local 444, CAW. The employer was represented by J. Renaud, compensation analyst. THE EVIDENCE The Panel had before it the Case Description prepared by the Tribunal Counsel Office containing documentation from the WCB file. The Case Description was marked as an exhibit. In addition the Panel heard testimony under oath from the worker together with submissions from Mr. Parent and Ms. Renaud. Following the hearing, the Panel sought additional information from Dr. G. Koppert, who had treated the worker for his foot condition. His response was circulated to the parties for comment. Written submissions were subsequently received from both representatives. THE NATURE OF THE CASE The Panel must determine: 1. Whether the worker was disabled by right heel and ankle disabilities in July 1986 and after January 1987; and 2. If so, whether these disabilities were causally related to the compensable accident of May 23, 1984.

3 2 THE PANEL S REASON (i) Background The worker was employed with the accident employer since 1971, primarily as an assembly line worker. At the time of the May 23, 1984, compensable accident, the worker was involved in a process of installing carpeting in vehicles on the assembly line. He stepped on a piece of wood, twisted his right ankle and felt pain in his right groin. The original diagnosis was "mild inversion sprain of right ankle". The right ankle sprain was acknowledged as a compensable injury, although there was no lost time from work. Subsequently, the worker had a hernia repair and received temporary total benefits from September 7 to October 29, The Board accepted that a causal relationship existed between the hernia and the May 23, 1984, accident. The worker testified that he has continued to experience pain in his right foot since the time of this accident. He specifically denies having right foot pain prior to this time as reported in the August 18, 1986, report of Dr. Bernstein. The basic medical problem, set out in the August 18, 1986, report of Dr. Bernstein and the January 7, 1987, report of Dr. Lai, the family doctor, is plantar fasciitis and inflammation around a calcaneal spur. Plantar fasciitis is essentially an inflammation in the fascia or sole of the foot. (ii) Medical evidence The first complaint to Dr. Lai, the worker's family physician, appears to have been in June Dr. Lai's June 12, 1985, letter to the Board reads: The patient was first seen on February 27, He was seen for a check-up. The first time he complained about his right foot and back was in March The pain in the back was mainly on the right side. He returned to work on March 28. He saw Dr. Pepin previously for his foot. The worker denies seeing Dr. Pepin for a foot problem. The worker's right foot was x-rayed on May 20, That report reads: There is a large spur at the insertion of the Achilles tendon on the os calcis. Smaller degenerative spurs are present at the insertion of the plantar fascia. An extra ossicle is noted anterior to the articular surface of the talus. This is not well seen on those views. The remaining structures are normal. Dr. G.I. Bernstein, an orthopaedic surgeon, examined the worker on August 14, His report dated August 18, 1986, indicates:

4 3 Thank you for asking me to see this 47 year old [worker] who was examined on August 14, He has had right foot pain for about four or five years and this has recently become more bothersome. The pain is often more severe in the morning and tends to ease off during the day; but, with prolonged standing, it tends to get worse again. The patient has no other serious past history. On examination, the patient shows a grade 2 cavus of both feet with tenderness over the plantar medial calcaneal tubercle of the right heel. The patient has a plantar fasciitis. He has already had one or two injections in the past without any major improvement, so that the heel will not be injected again. A plastic orthotic stress-reliever will be ordered for him and this should help a good deal. According to the worker the orthotic insert did not help a great deal. He testified that his foot pain was better in the morning and worse in the afternoon. The worker's right ankle and right heel were x-rayed again on March 3, That report reads: There is minimal prominence at the insertion of the Achilles tendon. There are corticated fragments anteriorly in the joint space of the ankle. The donor site of one of these is probable from the talus. The exact position and nature has not been delineated. Tomography and arthrography may be of additional value. In the oblique view, there is a questionable classification, and this may well be one of the calcific fragments noted anteriorly. The joint spaces are otherwise intact, and the mineral content is within the limits of normal. A May 26, 1987, x-ray also noted the loose bodies and degenerative changes. That report reads: The degenerative changes at the tip of the medial malleolus and the presumed loose bodies in the ankle joints anteriorly are again noted. The degenerative spur on the os calcis is unchanged.

5 4 Summary No change from March 3. The worker was examined on a number of occasions by Dr. Koppert who eventually concluded that the "loose bodies" should be removed. In his July 3, 1987, report to Dr. Lai, he states: This gentleman underwent AP and lateral tomograms of the right ankle, which demonstrates spur at the distal anterior tibia, an enlarged loose body, lying in the dorsum of the neck of the talus, were measuring roughly one centimetre in diameter. Spurring of the tip of medial malleolus is noted. On speaking with him today, most of his pain is anterior, in the area of the loose body, although he also has discomfort inferior to the medial malleolus, and behind the lateral malleolus. Today, gave him the option of arthrotomy of the right ankle, for purposes of removal of the loose body. I am not convinced that removing the minimal spurring from the tip of the medial malleolus would be of significant benefit for him. He is unsure as to whether or not he wishes to follow up on surgery at the present time, and is also concerned about whether or not Compensation Board is going to cover his claim, relative to right ankle injury. Also, I understand that he is going to Italy in a week's time, and he wishes to gain a further opinion in Italy. The one sentence opinion from the Italian doctor indicated that the worker suffered from pain in his heel due to arthrosis. (iii) Conclusions The evidence establishes that the worker suffers from an ongoing disability in his right foot. The question is whether this disability is related to his employment. Both Dr. Bernstein and Dr. Lai indicate that the worker's principal problem is a right plantar fasciitis which is an inflammation of the sole of the foot. In addition, the worker suffers from heel pain which appears to be caused by a large spur at the base of the Achilles tendon and some smaller spurs. The x-rays indicate degenerative changes at the tip of the ankle and "loose bodies" in the ankle joint. With respect to the plantar fasciitis, Dr. J. McGuire, a WCB Surgical Consultant, offered the following opinion in his June 24, 1987, report: In my opinion the diagnosis of plantar fasciitis is not related to any of the health care problems in the above three claims and indeed from the job description outlined

6 5 above, I fail to see that such would cause a plantar fasciitis. In my opinion [the worker's] plantar fasciitis is a non-compensable health care problem and I fail to agree with Dr. Lai's, family doctor's interpretation of the health care situation. Dr. Lai had indicated that, in his opinion, the worker's foot problem was related to his work. Essentially the same opinion is offered by Dr. Macfarlane in his August 14, 1987, report:... we have a diagnosis of plantar fasciitis which I cannot relate to that accident. I really suspect that he had pain in his ankle from nerve root irritation, most likely coming from his back. I agree that there is no entitlement for the plantar fasciitis. I cannot see that it is work-related. I also cannot see that there is entitlement for the removal of the loose body on the anterior aspect of his foot and ankle. Although other doctors, including Dr. Bernstein, repeat the diagnosis of plantar fasciitis, none of the doctors - with the exception of Dr. Lai - relate the plantar fasciitis to the worker's employment. Even Dr. Lai indicates in his report of June 12, 1985, that the first complaint of right foot pain was in March This suggests that any connection between the plantar fasciitis and the May 23, 1984, accident is remote. The Panel finds, on a balance of probabilities, that the plantar fasciitis is not related to the worker's employment. The medical evidence suggests that the major cause of the worker's foot discomfort are the bone spurs in the worker's heel and the "loose bodies" floating in the ankle joint. With respect to the bone spurs, there is no medical evidence relating the development of the spurs to the worker's employment. Dr. M. Rock, in a report to Dr. Lai dated October 22, 1987, does suggest that the "loose bodies" are causing the worker's pain and that the unusual positions which the worker would adopt while performing his work would aggravate his condition. Because the Panel wished to have further information on effect of these loose bodies and any relationship to the May 23, 1984, compensable accident, the Panel instructed the Tribunal Counsel Office to contact Dr. G. Koppert for a supplementary report and listed a series of questions for Dr. Koppert to answer. In his report Dr. Koppert stated that it was not clear whether the more significant difficulty on March 3, 1987, was the worker's heel pain or ankle pain. However he noted: "on the subsequent office examinations of May 26 and July 3, 1987, attention was directed to the anterior ankle pain, which certainly appeared to be his major problem on those occasions".

7 6 Dr. Koppert also confirmed that, in his opinion, the worker's plantar fasciitis was not related to his work accident of May 23, Dr. Koppart went on to discuss the right ankle injury: In [the worker's] case, I can appreciate where if he stepped on a piece of wood or plastic (dog leg), that he may have experienced an inversion injury of his right ankle, but it would be very doubtful that he would have experienced adequate trauma to the heel at that time to cause plantar fasciitis. Therefore, I would feel that the plantar fasciitis is not due to injuries incurred in the work accident of May 23, Regarding the right ankle injury, at the time that he stepped on the dog leg, by description, he experienced a twisting injury of the ankle, with the foot and ankle inverted (heel turned underneath), and the forefoot likely plantar flexed (turned down). Such an injury would cause stretching or tearing of the ligaments on the lateral side of the ankle, most specifically the anterior talo-fibular (most anterior of the three supporting ligaments on the lateral side of the ankle), and perhaps also the fibulo-calcaneal (middle of the three supporting ligaments on the outer side of the ankle). It is most unlikely that he would have torn the most posterior of the three supporting ligaments (posterior talo-fibular). Associated with the tearing of the ligaments, may be stretching or tearing of the ankle capsule, anterolaterally and laterally. With the tearing of soft tissues, bleeding occurs into those soft tissues. That blood is usually resorbed, and healing occurs with scarring of the tissues. Occasionally, that blood is not resorbed, but rather calcification occurs in those injured soft tissues, which could account for the calcification noted over the dorsum (top) of the neck of the talus (one of the bones of the ankle joint). I have had the opportunity to review [the worker's] radiographs of the following dates: 1. May 23, May 20, March 3, May 26, Tomograms, Hotel Dieu Hospital, June 3, 1987 The following is a summary of the radiographic review: 1. May 23, Chrysler Films. Minimal spurring at tip of medial malleolus, and on the lateral film, a loose body is identified, overlapping with a distal

8 7 anterior tibia, which would appear to be roughly 1 cm x 5 mm. The way the projection is done,it lays over the anterior aspect of the dome of the talus, rather than specifically over the neck. 2. May 20, Radiographs of right foot, lateral films shows a 7 or 8 mm loose body lying over the dorsum of the neck of the talus. Ankle films are not available. 3. March 3, There appears to be two loose bodies on this picture. The lateral films demonstrates one of 1 cm x 8 mm in size, lying at the distal anterior tibia, with a second loose body over the neck of the talus, roughly 5 mm x 7 or 8 mm. There is again some irregularity at the tip of the medial malleolus, but I am not impressed that there is any significant progression of degenerative change. No significant joint space narrowing. 4. May 26, Loose body over the dorsum of the neck of the talus. Irregularity at the tip of the medial malleolus, minimal calcification in the interval between the tip of the malleolus and the body of the talus. 5. Tomograms, Hotel Dieu Hospital, June 3, There is a spur arising off the distal anterior tibia, as well as a large loose body, 1 cm x 7 mm in size, lying over the dorsum of the neck of the talus. This was seen especially well on the AP - 10 cm cut. He is also noted to have a calcaneal spur, as well as tendoachilles spur. It is obvious that the loose body at the anterior aspect of the ankle joint was present before the May 23, 1984, injury. On the presumption that [the worker] had not experienced previous injury of his right ankle, and that he was not symptomatic of any right ankle difficulties before the May 23, 1984, accident, then I believe that the situation is one of previously asymptomatic condition which is made symptomatic (brought to light) by his work injury. That is, the loose body at the anterior aspect of the ankle joint was asymptomatic to [the worker], but with his inversion injury of May, 1984, he became symptomatic of the loose body. Admittedly, I am not a general surgeon, but from the records provided it would appear that the W.C.B. was most gratuitous in allowing right inguinal hernia to be compensable. In summary, I would suggest the following:

9 8 1. The right plantar fasciitis is not compensable and not related to the work accident of May 23, The anterior ankle discomfort which [the worker] experiences is a direct sequelae of the work accident of May 23, The injury at that time appears to have been an inversion injury of the right ankle. However, the anterior calcification or loose body was definitely present at the time of the May 23, 1984, accident. Although Dr. Macfarlane indicated that he could not see there was entitlement for the removal of the loose body on the anterior aspect of the worker's ankle, we are prepared to extend to the worker the benefit of the doubt on the basis of Dr. Koppart's supplemental report, and conclude that the worker does have entitlement to compensation benefits for lost time and medical expenses, subsequent to July 7, 1986, on the basis that the anterior ankle discomfort is a "direct sequelae" of the May 23, 1984, accident. Dr. Koppert was a treating physician and his supplemental report explains the basis for his opinion and supports the worker's contention. THE DECISION The appeal is allowed. DATED at Toronto, this 4th day of April, SIGNED: I.J. Strachan, K.W. Preston, B. Cook.

MEMORANDUM 377/87. DATE: April 5, 1988 TO: ALL WCAT STAFF SUBJECT: DECISION NO. 377/87

MEMORANDUM 377/87. DATE: April 5, 1988 TO: ALL WCAT STAFF SUBJECT: DECISION NO. 377/87 MEMORANDUM 377/87 DATE: April 5, 1988 TYPE: A TO: ALL WCAT STAFF SUBJECT: DECISION NO. 377/87 Aggravation (preexisting condition) (degenerative disc disease) - Disc, herniated (L4-5). - Bricklayer not