WCAT Decision Number:  
A1903050 (March 3, 2022)  
DECISION OF THE WORKERS’ COMPENSATION APPEAL TRIBUNAL  
WCAT Decision Number:  
A1903050  
WCAT Decision Date:  
March 3, 2022  
Introduction  
[1]  
In December 2017 and January 2018, the worker, a registered psychiatric nurse, felt discomfort  
in her left shoulder while at work. This worsened and progressed over time to the point that, in  
early 2018, she sought medical treatment for these symptoms and, on November 1, 2018, she  
submitted a claim for compensation to the Workers’ Compensation Board (Board).1  
[2]  
[3]  
[4]  
[5]  
In a March 4, 2019 decision, a Board case manager concluded that the worker was not entitled  
to compensation for her left shoulder condition.  
A review officer with the Board’s Review Division confirmed this decision on October 28, 2019  
(Review Reference #R0251024).  
The worker has appealed the Review Division decision to the Workers’ Compensation Appeal  
Tribunal (WCAT).  
I held an oral hearing by videoconference on September 9, 2020. The worker and her union  
representative participated in the appeal. The employer is not participating in the appeal.  
Issue(s)  
[6]  
[7]  
The sole issue raised by the worker in this appeal is whether her left shoulder condition is an  
occupational disease that is due to the nature of her employment.  
Jurisdiction and Standard of Proof  
This appeal was filed with WCAT under section 288(1) of the Workers Compensation Act (Act)2  
which provides for appeals of final decisions by review officers regarding compensation matters.  
1
The Board operates as WorkSafeBC.  
References to section numbers in the Act are different from those in the Board and Review Division  
2
decisions under appeal. The Act was reorganized and renumbered under the Statute Revision Act  
(RSBC 1996, c 440) effective April 6, 2020. The purpose of the revisions is to make the Act easier to  
1
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
Section 308 of the Act gives WCAT exclusive jurisdiction to inquire into, hear, and determine all  
those matters and questions of fact, law, and discretion arising or required to be determined in  
an appeal before it.  
[8]  
[9]  
I am bound to apply the published policies of the board of directors of the Board, subject to the  
provisions of section 304 of the Act. The applicable Board policies are set out in the  
Rehabilitation Services and Claims Manual, Volume II (RSCM II).3  
The standard of proof that applies in this appeal is the balance of probabilities, as modified by  
section 303(5) of the Act. Section 303(5) provides that, where WCAT is hearing an appeal  
respecting the compensation of a worker and the evidence supporting different findings on an  
issue is evenly weighted in that case, WCAT must resolve that issue in a manner that favours  
the worker.  
Background  
[10]  
[11]  
The following summary is based on: the evidence in the claim file and in a prior claim file  
relating to a low back injury the worker sustained in October 2018;4 the testimony the worker  
provided during the oral hearing; new medical evidence that was submitted by the worker in  
support of the appeal; medical records I obtained after the hearing; and, the December 13, 2021  
opinion of Dr. Leith, orthopedic surgeon.  
Overview  
The worker is right-hand dominant and, at the time she filed her application for compensation  
(on November 1, 2018), she was 58 years old. She had recently gone off work from her job at  
the employer’s hospital where she works as a psychiatric nurse. She has been employed by the  
employer for over 10 years but, from 2013 to December 2017, worked only occasional shifts at  
read and understand and they are not intended to change the legal effect of the Act. Unless otherwise  
specified, all references to the Act refer to the current version of the Workers Compensation Act, RSBC  
2019, c 1.  
3
The applicable version of the RSCM II is that which was in effect on October 28, 2019, the date of the  
Review Division decision, with the exception that changes to Chapter 4 of the RSCM II (Occupational  
Disease) that took effect on April 6, 2020 apply to all decisions, including appellate decisions, made on  
or after April 6, 2020 and so apply in this appeal. I note that several applicable policies other than those  
in Chapter 4 of the RSCM II were amended on February 1, 2020 to provide guidance on the legal  
issues of standard of proof, evidence, and causation. Those amendments apply to decisions of the  
Board and Review Division made on or after February 1, 2020. They do not apply to WCAT decisions  
unless the Board decision or Review Division decision was made on or after February 1, 2020. The  
Board and Review Division decisions in this appeal were made before February 1, 2020, so the policies  
as they read prior to these amendments apply.  
4
WCAT arranged for this file to be disclosed to the worker.  
2
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
the hospital. Throughout these years, she worked as an instructor at a university and, while she  
had some prior left shoulder concerns, these consisted of achiness. In the months leading up to  
December 2017, these symptoms did not interfere with her ability to carry out any of her job  
functions or activities of daily living.  
[12]  
[13]  
In December 2017, the worker returned to working almost full-time hours at the hospital. She is  
a casual worker, but worked essentially the same shift rotation that regular nursing staff work.  
This involves rotations of 12 hours for four nights, followed by two to three days off, 8- to  
12-hour shifts for several days, followed by two to three days off, and then a return to 12-hour  
night shifts, but the worker usually worked 12-hour night shifts.  
During the oral hearing of the WCAT appeal, the worker explained that the work activity of  
admitting a patient requires that she fill in a number of screens on the computer. The first thing  
she does is set out a clinical profile. This involves clicking and a lot of typing to enter all of the  
patient’s medical and psychiatric history, including a history of what had happened and the  
event that brought them into the hospital. This information comes from a multitude of sources,  
including ones the worker accesses through the computer’s browser, but most of it comes from  
the initial interview she conducts with a patient when they arrive. Depending on how sick the  
patient is, the interviews can last up to an hour but, sometimes, it is not necessary to have an  
interview. The worker also has to enter information from psychiatric, police, and other reports,  
enter information the patient provides regarding whether they use drugs or substances, and, if  
the patient is suicidal, undertake a risk assessment and type up a safety plan. The worker said  
that there are about seven different screens she has to go into and entering the data is very  
time consuming. Admissions on a normal medical floor are much quicker than the mental health  
admissions she undertakes. She tries to do admissions in one sitting. However, as there are  
only a few nurses on shift at any time, the process can be interrupted by answering the  
telephone and by crises that arise. In these situations, she has to answer the telephone or go  
and deal with the crisis, and then come back and resume the admission process.  
[14]  
[15]  
By early 2018, the worker developed a burning sensation and constant pain in both shoulders,  
with the left shoulder being worse. There was no specific precipitating event, but she was  
spending multiple hours of each shift at a computer typing. Over time, the burning sensation and  
pain gradually worsened and she developed a frozen shoulder.  
During the oral hearing, the worker said that, after the burning sensation in her left shoulder  
started, she went on to feel pain around the top of her shoulder and to have difficulty moving the  
shoulder. Throughout 2018, the pain increased and became so bad that she had to take opiates  
to sleep at night. The worker said that, prior to beginning to work full-time hours at the hospital  
in December 2017, she had a stiff neck and left shoulder, but she did not experience the  
burning pain she began experiencing in the beginning of 2018 and that worsened after that  
point.  
3
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[16]  
Medical records dating back to February 1, 2016 confirm that, prior to December 2017, the  
worker had a history of bilateral shoulder complaints. On February 24, 2017, the worker saw her  
family physician (then Dr. Glaude) to discuss an upcoming right-sided hip replacement.  
Dr. Glaude noted that the worker “has much” osteoarthritis “co[m]ing out of everywhere”5 and  
shoulder pain, and was wondering why all her joints were hurting. Dr. Glaude examined the  
worker’s hand (side not specified) but saw no obvious deformity or rheumatological disease.  
X-rays of both shoulders were taken on February 24, 2017 to investigate the cause of these  
complaints. These showed that, on the left, the worker had mild glenohumeral degenerative  
changes with a small inferior glenoid osteophyte. There was marked irregularity at the greater  
tuberosity suggestive of rotator cuff pathology, as well as irregularity at the inferior acromion.  
The right shoulder images showed normal alignment and joint spacing, no definite degenerative  
changes, mild irregularity at the greater tuberosity that might be related to rotator cuff pathology,  
and a possible bone island projecting in the superior humeral head.  
[17]  
Following February 28, 2017, there is no medical documentation of shoulder complaints until  
March 15, 2018. At that time, the worker saw Dr. Popovich, orthopedic surgeon, in follow-up for  
a right hip replacement Dr. Popovich had undertaken in March 2017. Dr. Popovich administered  
corticosteroid shots into the worker’s left shoulder, but did not document any history, symptoms,  
or signs relevant to the shoulder. Following the March 2017 right hip replacement, the worker  
had taken four months off work.  
[18]  
[19]  
The worker next sought medical attention for her left shoulder on August 1, 2018, when she was  
seen by Dr. MacDonald, her current family physician. The worker reported that she had had left  
shoulder pain since December of the prior year, with no history of injury. Her pain was  
progressively getting worse, and the past month had been really bad. Dr. MacDonald queried  
whether the worker had a damaged rotator cuff and ordered x-rays.  
X-rays taken on October 5, 2018 to investigate the cause of the worker’s ongoing worsening left  
shoulder pain, were reported as normal, with no appreciable degenerative change at the  
glenohumeral or acromioclavicular (AC) joints.  
[20]  
[21]  
The worker stopped working on October 22, 2018, after sustaining a compensable low back  
strain/sprain injury.6  
An October 29, 2018 MRI of the worker’s left shoulder showed: moderately severe degenerative  
changes within the AC joint; a small bone spur from the distal end of the clavicle that was  
5
All quotations have been reproduced as written, unless otherwise indicated.  
I note that, in submission, the worker’s representative expressed the understanding that the worker  
6
went off work at this time because she could not lift her left arm. This understanding is not consistent  
with the medical evidence on file, and was not supported by oral or written evidence from the worker.  
4
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
projecting into the subacromial space; a small amount of fluid within the subacromial and  
subdeltoid bursae; a full-thickness supraspinatus tear; and, a possible partial infraspinatus tear.  
[22]  
On November 15, 2018, Dr. Arneja, orthopedic surgeon, assessed the worker. Dr. Arneja  
concluded that the worker had two main problems. The first was a traumatic rotator cuff rupture  
(the full-thickness supraspinatus tear) that would likely require surgical treatment. The second  
was that the worker had developed arthrofibrosis over the past several months and, in  
Dr. Arneja’s view, this needed to be resolved prior to proceeding with surgical treatment.  
[23]  
[24]  
The worker’s compensable low back injury resolved by November 22, 2018, but the worker  
remained off work owing to her shoulder issues.  
Starting on December 6, 2018, Dr. MacDonald began reporting that the worker was disabled  
from work due to ongoing pain and limited range of motion arising from her left shoulder  
condition.  
[25]  
[26]  
Thereafter, the worker remained off work until November 2019.7 In a November 25, 2019 chart  
note, a locum for Dr. MacDonald noted that the worker would be commencing a graduated  
return-to-work. The worker’s frozen shoulder had improved and she now had almost full range  
of motion.  
In the next physician’s chart note, dated December 9, 2019, the locum noted that the worker  
had been back at work for two weeks and had done a few 8-hour and 12-hour shifts involving a  
lot of computer work. The locum said that the worker had managed, but there was some burning  
to shoulders at the end of one shift after she used a non-adjustable workstation in the “nurses  
medroom.”8  
[27]  
[28]  
In a January 20, 2020 chart note, Dr. Gallagher, a family physician, who also saw the worker in  
his capacity as a locum for Dr. MacDonald during the period May 6, 2019 to March 1, 2020,  
reported that the worker’s pain got better when she was off work but had slowly returned. The  
worker had ongoing burning in her shoulder, but this was not getting worse, and the right  
shoulder symptoms were now more significant than those in the left shoulder.  
As of the hearing date, the worker had still not undergone the surgery Dr. Arneja recommended  
in November 2018. She advised me that, as she is a casual worker, she is not entitled to  
long-term disability benefits and she cannot afford to take the time off work to undergo this  
procedure. After taking just over a year off work from October 22, 2018 through to  
December 2019, she began a gradual return to work and, by January 2020, had resumed her  
7
I note that, in submission, the worker’s representative expressed the understanding that the worker  
began her return to work in December 2018. This is not the case.  
I understand this to be a reference to nurses’ workstation No. 2  
8
5
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
full work duties and hours. She said that her left shoulder had not returned to its  
pre-December 2017 status and, since returning to her full duties, she has noticed increasing  
symptoms in the left shoulder and she has also been experiencing burning pain in her right  
shoulder as well.  
[29]  
The worker believes that the increasing left shoulder pain and the deterioration in range of  
motion in that shoulder that occurred from December 2017 through to October 22, 2018 was  
because of an occupational disease that she developed due to the nature of the work she  
performed as a psychiatric nurse.  
Request for Independent Assistance from Dr. Leith, Orthopedic Surgeon  
[30]  
[31]  
Section 302 of the Act allows WCAT to retain the services of a health professional if the tribunal  
determines that independent assistance or advice would assist in reaching a decision on an  
appeal. After the oral hearing, I concluded that such assistance would be helpful. WCAT  
retained Dr. Leith pursuant to the authority in section 302.  
In the terms of reference I provided to Dr. Leith, I set out a summary of the evidence and my  
findings of fact, and I asked Dr. Leith to respond to a series of questions, based on the facts as I  
have found them. I provided Dr. Leith with a full copy of the available medical evidence,  
including additional medical records I obtained after the hearing (chart notes from the worker’s  
attending physicians and physiotherapists, Dr. Popovich’s consultation reports, and additional  
hospital records).  
[32]  
The medical evidence includes four central documents that address the potential that the  
worker’s work duties and the physical aspects of the workstations at which she performed those  
duties may have had a causal role in the progression of her left shoulder condition between  
December 2017 and October 22, 2018. I provided a detailed summary of each of these.  
i. February 12, 2019 Opinion from Dr. Karrel  
[33]  
[34]  
This opinion was based on a review of the medical and other documentary evidence then  
available, the two brief videotapes the case manager took, discussion with the case manager,  
and a brief summary the case manager provided.  
Contrary to usual Board practice, the case manager did not complete a formal activity-related  
soft tissue disorder (ASTD) evaluation report. Instead, in the February 8, 2019 request for  
Dr. Karrel’s opinion, the case manager documented only the following facts:  
The worker denied any history of an acute traumatic incident at work or away from work.  
She did note there can be aggressive patients, but could not recall or identify any particular  
event or incident where she sustained an injury to the left arm/shoulder. Instead, she noted  
6
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
that her left shoulder just gradually started hurting after she started working only and  
full-time at [the employer’s hospital] in December 2017/January 2018 and she felt discomfort  
at work; this worsened and progressed over time to the point where she sought medical  
treatment in early 2018 and then decided to submit a claim to the Board in November 2018.  
During the worksite visit, the worker showed her various job duties and workstations as well  
as how she would work on the computer doing intake and discharge reporting. She felt this  
was the cause of her left shoulder complaints as she reported increased symptoms while  
typing.  
When typing, the worker typically worked at two of the workstations observed by the case  
manager, and when working at night, primarily worked at the workstation identified as the  
unit clerk workstation because, at this station, she was able to view video cameras that  
showed activity in the work area.  
[35]  
The case manager also set out the following brief conclusion:  
Based on my observations, I identified overall low force tasks with occasional  
entries into awkward left shoulder posture (awkward is considered greater than  
60 degrees forward flexion or abduction) but these were of very brief duration  
and only intermittent through the shift allowing for tissue/tendon recovery  
between movements. There wasn’t frequently repeated or sustained awkward  
left shoulder postures or jarring identified. There has also been no change in  
the frequency, intensity or duration of the work, including no unaccustomed  
work.  
[36]  
[37]  
After viewing the videotapes and discussing the file with the Board officer, Dr. Karrel prepared a  
February 12, 2019 opinion.  
Dr. Karrel said that the worker had a number of non-occupational risk factors that were relevant  
to her presentation:  
Pre-existing left shoulder, rotator cuff syndrome, with supraspinatus full-thickness  
tendon tear, partial thickness infraspinatus tendon tear, sub-acromial bursitis,  
ACJ OA [osteoarthritis in the acromioclavicular joint] and possible sub-acromial  
impingement.  
There is also left frozen shoulder diagnosed as a consequence of the worker’s  
pre-existing left shoulder rotator cuff syndrome.  
7
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[38]  
Dr. Karrel said that the radiographic appearance of the worker’s left shoulder in the  
October 2018 MRI was more consistent with longstanding injury:  
For instance the supraspinatus full-thickness tear has already been complicated  
by atrophy and retraction of the worker’s left supraspinatus muscle. This takes  
several months to occur and is not likely to be part of an acute traumatic incident  
basis. Likewise, the left infraspinatus intra substance partial thickness tear and  
bicipital tendinopathy appear to be more consistent in appearance with  
longstanding injury.  
[39]  
Dr. Karrel said that the worker’s job duties involved a combination of fluid, dynamic,  
multi-planar, and intermittent left shoulder movements that included some repetition, light  
forces, no jarring, and variable dynamic range of motion. Dr. Karrel acknowledged that there  
was a certain degree of repetition/cyclical left shoulder movements, but he could not appreciate  
the significant single presence or a combination of repetitive movements, jarring or vibrational  
forces, awkward positions, or significant force applied to the worker’s left shoulder. Dr. Karrel  
concluded that the significant variation in the worker’s work activities allowed for muscle-tendon  
recovery and for variation in the actual shoulder motions. Dr. Karrel also concluded that the  
work activities often involved the left shoulder held in neutral or close to neutral postures.  
[40]  
[41]  
Dr. Karrel acknowledged that the worker experienced her symptoms during the work activity.  
However, he said that, in the absence of a plausible biomedical mechanism of injury, the  
temporal relation alone could not support a causal link. Given the mechanism described and  
reviewed, it appeared that the work activities were revealing some symptoms but they did not  
play a role in the development of her left shoulder conditions. In addition, in the absence of  
significant risk factors, the job duties might have brought out symptoms indicating the presence  
of an underlying condition without worsening or accelerating the condition itself.  
The factual background set out in Dr. Karrel’s opinion is largely accurate. However, I noted in  
the terms of reference I provided to Dr. Leith that Dr. Karrel stated that it appeared that the  
worker was accustomed to her job duties. Consequently, it appears that Dr. Karrel overlooked  
the fact that the worker had only been performing the full-time duties to which she attributed her  
disability in October 2018 since December 2017, at or about the time the worker began  
experiencing her worsening left shoulder symptoms.  
ii. Mr. Everett’s February 20, 2020 Ergonomic Risk Assessment Report9  
[42]  
Mr. Everett, an occupational therapist and registered ergonomist, attended the worker’s worksite  
and prepared his February 20, 2020 report at the request of the worker’s representative. The  
report was provided to WCAT in support of the worker’s appeal.  
9
As corrected on March 23, 2020.  
8
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[43]  
[44]  
[45]  
Mr. Everett took video evidence and pictures, including videotapes of the worker using the two  
workstations she generally used in the period December 2017 through October 22, 2018.  
Mr. Everett referred to these workstations as “unit clerk workstation” and “nurses’ workstation  
No. 2” and, in this decision, I have used the same terminology to describe these desks.  
Mr. Everett identified that his assessment involved the use of multiple ergonomic approaches,  
methods, and techniques, including manual goniometry, electrogoniometry, and surface  
electromyography (sEMG), which he said he cross-validated through a process known as  
triangulation.  
Mr. Everett identified a number of risk factors, and assessed the worker’s exposure to these.  
These include risk factors that are not identified in the Board policy or in the practice directive  
that provides guidance to Board officers in considering ASTD claims, but Mr. Everett identified  
them as ones that are known to ergonomists and described in available medical/scientific  
research as relevant to an ASTD of the shoulder (page 7 of his report):  
E.g. reader may not be aware of awkward cervical and thoracic spine postures  
and awkward scapular postures that narrow subacromial space between humeral  
head and overlying skeletal structures (e.g. acromion process) and increase  
propensity for supraspinatus impingement.  
[46]  
Mr. Everett then discussed the risk factors he believed the worker was exposed to during her  
work activities and which he found relevant to the worker’s left shoulder conditions (pages 8  
through 17 of his report). I included a list of the factors Mr. Everett identified in my terms of  
reference.  
[47]  
[48]  
Mr. Everett concluded that the worker was not exposed to the awkward shoulder postures of  
shoulder flexion greater than 60 degrees or shoulder abduction greater than 60 degrees when  
the worker was working at the unit clerk workstation.  
In the conclusion section of his February 20, 2020 report, Mr. Everett relied on both the findings  
in the July 5, 2019 ergonomic assessment report I have summarized below and his own findings  
regarding the worker’s risk exposures. His conclusions regarding the exposures he identified in  
the worker’s use of nurses’ workstation No. 2 while standing and the unit clerk workstation were  
as follows:  
With the increased computer work the worker did in and after December 2017, there was a  
corresponding increase in the magnitude/intensity, frequency, and duration of mechanical  
exposure to undesirable and unacceptable task positioning; awkward postures; and left  
upper trapezius loading attributable to marked ergonomic deficiencies in workstation  
design(s). This meant work was likely unaccustomed.  
9
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
There was frequent composite shoulder abduction in the scapular plane and internal  
shoulder rotation when the worker moved her arms away, around, and in front of her  
relatively large chest to type on the keyboard.  
There was marked left scapular elevation, right trunk rotation, and forward rounding of the  
left shoulder when the worker worked at the unit clerk workstation.  
There was continuous and increased left scapular elevation, protraction/abduction (classic  
“winging” of the scapula), and anterior tilting of the scapula when the worker worked at both  
workstations.  
There was continuous and increased forward head, forward head rounded shoulders  
posture, and forward head scapular abducted posture when the worker sat at both  
workstations, which resulted in continuous and increased flexion of the cervical and thoracic  
vertebra and hyperextension of the upper cervical vertebra, although there was a reduction  
in these postures and a corresponding reduction in left upper trapezius muscle activity and  
static loading when the worker stood at nurses’ workstation No. 2.  
These awkward postures were generally sustained postures associated with repeated  
muscular effort.  
There was significant or more than significant static loading of the left upper trapezius when  
the worker worked at both workstations, although less when the worker stood at nurses’  
workstation No. 2. There was also significant static loading for the left middle trapezius  
(superficial to rhomboids which contribute to scapular elevation).  
There was 2% of work cycle for left upper trapezius to return to relaxed or resting level of  
muscle activity when the worker worked at the unit clerk workstation and 0% of work cycle  
when the worker worked at nurses’ workstation No. 2, which was substantially less than the  
50% of work cycle required for physiological recovery of muscles. The percentage of work  
cycle for the left middle trapezius was of a similar magnitude.  
The fact that the worker uses trifocal lenses resulted in repetitive movement as well as  
increased static loading of the neck muscles.  
The relatively small font of electronic medical records resulted in overall forward rounding of  
the cervical, thoracic, and lumbar vertebrae.  
Marked ergonomic deficiencies at the workstations contributed to awkward postures, more  
than significant static postural loading of the left upper trapezius and non-optimal work  
techniques.  
[49]  
Based on his assessment, Mr. Everett concluded as follows (on page 22 of his report):  
Therefore, it is my professional opinion, based on the triangulation of findings  
from multiple ergonomic approaches, methods and techniques and the available  
10  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
medical scientific research, to the effect, that [the worker] was exposed to  
significant occupational risks over a prolonged period that, alone and or in  
combination, more likely than not, contributed to a marked increase risk to  
musculoskeletal structures of the left (and right) shoulder, scapulae and cervical,  
thoracic and lumbar vertebra.  
iii. July 5, 2019 Ergonomic Assessment Report that was Completed by an Ergonomic  
Consultant at the Employer’s Request.  
[50]  
At the employer’s request, the ergonomic consultant (a kinesiologist) assessed nurses’  
workstation No. 1 and nurses’ workstation No. 2 on July 5, 2019. The consultant did not assess  
the unit clerk station. Overall, the consultant found nurses’ workstation No. 1 and nurses’  
workstation No. 2 were not ergonomically set up and adjustments could not be made to change  
this. In particular, the fixed heights of the desks did not fit most employees when sitting or when  
standing for both charting and computer work. Despite the availability of a height-adjustable  
stool, the individual workers had to accommodate with “awkward, static postures at the back,  
neck, shoulder, elbows, and wrist.” However, the consultant did not specify what these postures  
were, and there are no pictures of them. The consultant also noted that there were issues with  
the stools, including that, because they did not have castors, awkward postures had to be used  
to forcibly move them. The consultant recommended that the employer purchase  
height-adjustable workstations to accommodate the multiple users of the workstations.  
iv. April 26, 2020 Medical-Legal Opinion from Dr. Gallagher  
[51]  
In support of the worker’s appeal, the worker’s union obtained an April 26, 2020 medical-legal  
opinion from Dr. Gallagher. Dr. Gallagher concluded that the ergonomic reports from Mr. Everett  
and the ergonomic consultant gave a more complete picture of the reasons the worker  
developed shoulder pathology than did the Board officer and Dr. Karrel, and that Mr. Everett’s  
report was persuasive. In summary, he said that there were multiple plausible biomedical  
mechanisms for stressing of the worker’s tendons/tissues to occur and, in his opinion, the  
timeline of symptoms reported by the worker fit well with a rotator cuff injury due to the activities  
in her job:  
I feel that given this, the temporal relation instead provides further evidence that  
change in her work environment and increase in hours she described could have  
contributed to her condition. I agree that it is still not possible to prove this with  
certainty, but I feel the evidence presented is compelling clinically.  
The mechanisms suggested in the ergonomics reports are more likely to  
represent a rotator cuff injury provoked by her increase in work which eventually  
led to a frozen shoulder.  
11  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[52]  
[53]  
Dr. Gallagher agreed with Mr. Everett’s conclusion that the worker’s nursing duties could have  
caused or contributed to both rotator cuff injury and frozen shoulder. He also felt that the sudden  
increase in pain the worker experienced one month prior to August 1, 2018 fit with a possible  
progressive tear in and around July 2018.  
Dr. Gallagher disagreed with most aspects of Dr. Karrel’s opinion. He said that:  
Dr. Karrel did not have the benefit of the July 5, 2019 ergonomic assessment report or of  
Mr. Everett’s report, which he said support that the increase in workload following  
December 2017 likely caused or contributed to the worker’s left shoulder condition and  
provide evidence that is contrary to Dr. Karrel’s view that there was no significant single  
presence or combination of repetitive movements, jarring or vibrational forces, awkward  
positions, or significant force applied to the worker’s shoulders; in particular, he said that  
Mr. Everett’s report provided clinically compelling evidence of multiple plausible biomedical  
mechanisms for stressing of the tendons and tissues in the worker’s left shoulder.  
Dr. Karrel based his opinion on the understanding that there was no increase in workload  
following December 2017, which is not accurate.  
The non-occupational risk factors Dr. Karrel identified constitute a list of diagnoses that were  
not confirmed with 100% certainty until the October 2018 MRI was completed; they were not  
“risk factors” and, further, the medical evidence does not support that the worker had a  
frozen shoulder prior to December 2017.  
Contrary to Dr. Karrel’s view that the radiographic appearance of the worker’s left shoulder  
in the October 2018 MRI was consistent with a longstanding injury and that it was most  
likely that the MRI findings constituted degenerative changes that occurred gradually over  
time, the medical evidence suggested that the tear occurred a minimum of three to four  
months prior to August 1, 2018, when the worker first saw Dr. MacDonald about her left  
shoulder condition (with signs and symptoms that were consistent with a tear), and possibly  
occurred as long as ten months prior, from the beginning of the increase in workload/pain  
the worker experienced. Further, the February 28, 2017 x-ray is not necessarily a reliable  
indicator of pre-existing left shoulder pathology, given that the x-ray on October 5, 2018 did  
not identify such pathology.  
Contrary to Dr. Karrel’s opinion that the worker’s job duties may have been enough to  
provoke her left shoulder symptoms but they did not alter the course of the pre-existing left  
shoulder condition, this cannot be assumed given the temporal association between the  
onset of left shoulder pain and the increase in work duties involving the risk factors identified  
in Mr. Everett’s report and the ergonomic consultant’s report. Also, the mechanisms  
suggested in the ergonomic reports are more likely to represent a rotator cuff injury provided  
by the worker’s increase in work activity, which eventually led to a frozen shoulder.  
12  
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Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
While the scenario in Dr. Karrel’s opinion is possible (and it is impossible to know without  
having had an MRI before her condition arose), it is less likely given the medical evidence  
and the ergonomic evidence that is now available.  
[54]  
Dr. Gallagher also said that:  
While elevated body mass index is a risk factor for frozen shoulder, “frozen shoulder  
secondary to an injury/immobilization (e.g. pain) is a common mechanism and seems likely  
and at the very least plausible in this case.”  
Even if the worker had arthritis in her left shoulder prior to December 2017, this condition  
appeared to have been worsened/accelerated after her hours of work were increased in an  
ergonomically deficient environment.  
Dr. Leith’s December 13, 2021 Independent Health Professional Report  
[55]  
[56]  
Dr. Leith responded to my request for assistance in the December 13, 2021 report. My terms of  
reference, which set out the reasons for the findings of fact I made, and Dr. Leith’s report were  
disclosed to the worker. As the content of my terms of reference are known to the worker, I will  
not repeat the full factual background here.  
In summary, based on my review and consideration of all of the evidence, I found as a matter of  
fact that:  
Prior to December 2017, the worker had some pain in both shoulders and a stiff neck and  
left shoulder. However, in the months leading up to December 2017, these symptoms did  
not interfere with her ability to carry out any of her job functions or activities of daily living  
and she was not experiencing the sharp left shoulder pain she later developed.  
Starting in December 2017, the worker developed a burning pain in her left shoulder. There  
was no precipitating cause, but she was spending multiple hours of her workday in the  
hospital at a computer typing.  
Although Dr. Arneja diagnosed a “traumatic” rotator cuff tear in the November 15, 2018  
consultation report, there is no evidence of the worker having developed a rotator cuff tear  
through exposure to any specific traumatic event.  
Over time, the left shoulder pain increased and the worker went on to develop a frozen  
shoulder.  
The worker was unaccustomed to working the increased amount of shifts and at the desks  
she used in and after December 2017, as she had previously only worked the occasional  
shift at the hospital.  
13  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
From December 2017 through to October 2018, the worker generally worked at nurses’  
station No. 2 while in a standing position, with the keyboard positioned on the desk, and at  
the unit clerk workstation, again with the keyboard positioned on the desk.  
The worker could spend up to two hours at a time at either of these workstations, for a total  
of four hours and, occasionally six hours, per shift, but she spent more time at the unit clerk  
workstation because she worked more night shifts than day shifts and primarily used the unit  
clerk workstation on those shifts.  
The worker’s use of nurses’ workstation No. 1 was very limited during the period relevant to  
this appeal.  
As the worker usually stood when using nurses’ workstation No. 2, her use of this station  
while seated was very limited during the time relevant to this appeal.  
The worker uses her dominant right hand for mousing and handwriting.  
The worker’s posture while working and the nature of her work duties were accurately  
represented for purposes of assessing cause, activation, or acceleration of her left shoulder  
conditions, in specific portions of the videotapes taken by Mr. Everett (as set out in my terms  
of reference) and in two brief videotapes the Board officer took during the worksite visit.  
[57]  
[58]  
In addition to reviewing the documents I had provided to Dr. Leith and my terms of reference,  
Dr. Leith interviewed the worker and undertook a physical examination. By way of background  
to his conclusions, Dr. Leith set out my findings of fact, additional information the worker  
provided to him during the examination, and his examination findings. He then provided a  
response to each of the questions I had asked him.  
In my first question, I asked Dr. Leith to identify the diagnosis that best accounts for the worker’s  
worsening left shoulder symptoms in the period December 2017 through October 22, 2018 and  
left shoulder disability after October 22, 2018. Dr. Leith stated that, at the time of his evaluation,  
there was no real clinical diagnosis that could be applied to the worker, given the fact that her  
examination was mostly normal:  
Her history would be most consistent with that of myofascial pain or with the  
onset of an idiopathic frozen shoulder which in the early phase begins with pain  
followed by stiffness. This then evolves to a lessening of pain followed by  
thawing and improved range of motion and eventual return to near normal range  
and no pain or weakness.  
While MRI imaging reported a rotator cuff tear, this was an incidental finding. The  
tear was not caused by her work activities and could not have been caused by  
her work activities since there was no acute onset of pain which would be  
expected with an acute traumatic tear of the rotator cuff tendons. There was also  
14  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
no possible mechanism from her work activities to cause injury to the rotator cuff  
tendons or any of the structures of the shoulder joints.  
Also, the majority of rotator cuff tears reported on MRI are not caused by any  
traumatic event. Most rotator cuff tears are secondary to age related attritional  
tearing that increases with each decade after the age of 40.  
[59]  
[60]  
Second, I asked Dr. Leith to advise whether, having regard to the evidence, including the  
relevant video evidence, the tendon(s) and tissue(s) associated with the diagnosed condition  
were involved in the activities the worker performed at work and whether those activities would  
potentially cause injury to these tendons and tissues.  
Dr. Leith said that, while there may be some activation of the rotator cuff and deltoid while using  
a computer, it is usually very low grade and of low contraction power. None of the activities  
noted would cause injury to the rotator cuff tendons or to the tissues of the shoulder joint.  
Further, in his opinion, the videos did not show any posture or use of the upper extremity that  
would cause any injury to the shoulders or the structures of the shoulders.  
[61]  
[62]  
Third, I asked Dr. Leith to comment specifically on whether the worker’s work duties at nurses’  
workstation No. 2 (while standing) and at the unit clerk workstation involved abduction or flexion  
of the shoulder joint greater than 60 degrees. Dr. Leith concluded that the workstation videos  
did not demonstrate this position or any position of the shoulders or arms that would result in an  
injury.  
Fourth, I asked Dr. Leith to comment more generally on whether the worker’s work duties from  
December 2017 through to October 22, 2018 were capable of stressing the tendon(s)/tissue(s)  
and, if so, whether it was at least as likely as not that this stress was at the level that would be  
of causative significance (more than trivial or insignificant) to the development of the  
pathological condition(s) defined in the diagnoses he had identified in response to my first  
question.  
[63]  
Dr. Leith provided the opinion that the worker’s duties from December 2017 through to  
October 22, 2018 were not capable of stressing the relevant tendon(s)/tissue(s) and would not  
have been of causative significance to the development of a frozen shoulder, since frozen  
shoulder is an idiopathic condition not caused by any known activity or trauma. He said that it  
was extremely unlikely that the worker suffered an ASTD, given that the evolution of the frozen  
shoulder was very clear and consistent with the disorder. In his opinion, the frozen shoulder was  
not affected by the worker’s work activities, which were incidental and contemporaneous, but  
were in no way contributory or causative of her left shoulder complaints.  
[64]  
In Dr. Leith’s opinion, the imaging that was ordered was not indicated by the history and  
examination findings, and it reported age-related changes to the tissues that were unaffected by  
15  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
the work activities. Dr. Leith said that the worker’s complaints could have been caused by sleep  
positioning, any activity of daily living involving use of the shoulders repetitively at or above  
shoulder level, or any other movement that caused a muscular strain. He said that the frozen  
shoulder symptoms have no specific cause, since this diagnosis is idiopathic, and confirmed his  
view that the worker’s condition was not due to the work conditions or activities.  
[65]  
In response to my fifth question, Dr. Leith repeated his view that the imaging reports were  
misguided and had no relevance to the worker’s claim:  
Imaging should never be used in isolation to determine causation or even make  
the diagnosis. Diagnosis should be made based on a thorough clinical history  
and physical examination. Imaging is only then used to confirm the diagnosis or  
support the diagnosis.  
[66]  
[67]  
I also asked Dr. Leith to discuss whether he agreed or disagreed with specific aspects of the  
opinions from Dr. Karrel and Dr. Gallagher regarding the causal role the worker’s work activities  
played in development of her left shoulder condition.  
With regard to Dr. Karrel’s opinion on causation, I noted in the terms of reference, that  
Mr. Everett had raised a number of issues at page 19 of his report upon which, in his view, the  
validity of Dr. Karrel’s opinion and the reliability of the observations and video evidence of the  
Board officer could be put in issue. I asked Dr. Leith consider Mr. Everett’s comments in  
discussing his agreement or disagreement with Dr. Karrel’s opinion regarding causation of the  
worker’s left shoulder condition.  
[68]  
Dr. Leith said that, for the reasons he had already provided, he agreed with Dr. Karrel’s opinion  
regarding the absence of a plausible biomedical mechanism and the absence of significant risk  
factors that would have caused a worsening or acceleration of the worker’s shoulder condition.  
He also wrote:  
The opinion of Mr. Everett does not offer any relevant information to the  
symptoms experienced by [the worker]. They indicate mostly left upper trapezius  
muscle use. There is nothing from this report that would be consistent with  
pathology being related to the rotator cuff.  
The writer’s review10 of the videos of the work stations and use at those stations  
does not show any mechanism for injury or cause for symptoms to the shoulders.  
[footnote added]  
10  
Dr. Leith was referring to himself as “the writer.”  
16  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[69]  
[70]  
With regard to Dr. Gallagher’s opinion on causation, I asked to Leith to discuss the reliability of  
the findings and conclusions Dr. Gallagher relied on in Mr. Everett’s report.  
Dr. Leith said that the rationale Dr. Gallagher provided for supporting Mr. Everett’s opinion on  
causation (that the multiple ergonomic risk factors noted in Mr. Everett’s report suggest it was at  
the very least plausible and more likely probable that the worker’s duties could have precipitated  
her left shoulder rotator cuff syndrome) was incorrect. Dr. Leith explained as follows:  
As indicated, the Everett ergonomic report has no bearing on the imaging  
pathology or the development of an idiopathic frozen shoulder. Dr. Gallagher  
indicated that frozen shoulder secondary to an injury/immobilization is a common  
mechanism and seems likely and at the very least plausible in this case.  
Unfortunately, a frozen shoulder caused by an injury/immobilization has a very  
obvious acute event causing pain to the shoulder joint resulting in immobilization  
immediately. This is not what occurred in this matter.  
Idiopathic frozen shoulder occurs without any apparent or acute event, is gradual  
in onset usually beginning with pain followed by stiffness then slow resolution of  
pain then progressive resolution of the stiffness. This presentation is most  
consistent with what occurred in this matter. [The worker] unfortunately most  
likely developed an idiopathic frozen shoulder with an incidental imaging findings  
of a degenerative rotator cuff tear.  
Therefore, the report of Dr. Gallagher is also incorrect and fails to recognize this  
diagnosis of an idiopathic frozen shoulder.  
[71]  
[72]  
Finally, I asked Dr. Leith to discuss the conflicting opinions of Dr. Karrel and Dr. Gallagher  
regarding whether the worker had a pre-existing left shoulder condition of medical significance  
prior to her presentation in December 2017/early 2018 through October 2018 and, if so, whether  
the worker’s employment activated or accelerated the pre-existing disease to the point of  
disability in circumstances where such disability would not have occurred but for the  
employment.  
Dr. Leith agreed with Dr. Karrel’s opinion that the worker had pre-existing left shoulder  
pathology, and he said that none of the pre-existing degenerative changes noted on imaging  
were aggravated or caused by her working conditions or activities:  
The left frozen shoulder being idiopathic would have occurred in the absence of  
her working and therefore none of the pre-existing anatomy has contributed to  
her symptoms.  
17  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
[73]  
Dr. Leith also agreed with Dr. Gallagher’s opinion that the frozen shoulder was not a  
pre-existing condition and that it developed after December 2017. However, as he had  
previously noted, Dr. Leith said that the worker’s work activities did not have any impact on the  
idiopathic frozen shoulder or the pre-existing left shoulder pathology. Dr. Leith also stated that,  
contrary to Dr. Gallagher’s opinion, he agreed with Dr. Karrel that the findings reported in the  
October 2018 MRI were age-related degenerative changes and were not acute or caused by the  
worker’s work activities at the computer stations.  
Additional Evidence from the Worker  
[74]  
[75]  
I arranged for disclosure of Dr. Leith’s December 13, 2021 independent health professional  
report along with the terms of reference I had prepared. In response, the worker’s  
representative provided WCAT with two emails the worker had sent to him.  
In the first, dated January 10, 2022, the worker said that:  
Because of her left shoulder condition, she has suffered financial hardship and had to sell  
her house.  
She had been discouraged by the amount of time the appeal process took and she noted  
that she had done whatever was asked of her by WCAT, but said that her prior belief that  
the WCAT process was neutral has been severely tarnished by her experience in this  
appeal.  
She believes Dr. Leith had a bias and that WCAT arranged the assessment by him “with the  
intention of finding someone who would finally agree with their assumptions.”  
Dr. Leith did not mention that, when she returned to her old position at work, her symptoms  
started to come back and she also started to get pain in her right shoulder.  
Although her time off work allowed for some healing and for her pain to be manageable, she  
never did regain full use of her left arm.  
When she changed jobs to one where she rarely used a computer, she had no symptoms.  
She was deeply hurt and sickened when she read Dr. Leith’s report and, some time back,  
started to think that WCAT would never approve her claim and would “continue to delay this  
process until they find someone to disclaim me and agree with them that I should not be  
compensated.”  
[76]  
In the second, dated January 12, 2022, the worker added that:  
When she first made her claim for compensation, a Board officer advised her that she would  
never get compensated because of her age and that, if the Board accepted claims from  
18  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
Fax: (604) 664-7898 | wcat.bc.ca  
WCAT Decision Number:  
A1903050 (March 3, 2022)  
everyone with shoulder injuries, that would mean most of the public would have a claim  
accepted.  
Dr. Leith had also made a similar statement referencing her age and she knew from that  
moment that her claim would be refused.  
She believed that Dr. Leith was biased and showed a lack of care and concern for her,  
including by reason of the fact that he disagreed with the opinions on diagnosis and  
causation provided by her own doctors and appeared to believe that only his own opinion  
mattered.  
She believes that, if either Dr. Arneja or Dr. Popovich had been asked to provide their  
opinions, they would have supported her claim:  
Rather I am forced to accept the final words [from] a doctor who clearly will  
favour on the side of WCAT and not the patient despite the documentation  
from other professionals who extensively assessed, diagnosed and without  
prejudice, documented the truth.  
Submissions  
[77]  
[78]  
The worker’s representative provided oral submissions at the end of the hearing and also  
provided a written submission.  
In summary, he submitted that:  
The case manager’s assessment of risk factors was so flawed and abysmally deficient that it  
should be given no weight. The case manager was not professionally qualified to conduct an  
ergonomic assessment of risk factors or to provide expert evidence regarding workplace  
exposures to risk factors relevant to development of an ASTD. Further, the case manager  
did not produce a report and so there is no record of the measurements or methods used  
during the assessment and, given the fact that the videos the case manager took were very  
short, they cannot be relied on as a reliable basis to assess the risk factors the worker was  
exposed to.  
As it was based on the case manager’s unreliable assessment of risk factors and only two  
very brief videotapes (1 minute and 26 seconds and 57 seconds in length), Dr. Karrel’s  
opinion should also be given no weight.  
There is no evidence the case manager had any professional qualifications to perform  
ergonomic assessments; in contrast, the ergonomic consultant and Mr. Everett are  
professionally qualified by post-secondary degrees.  
As Dr. Gallagher relied on the “detailed” reports of the ergonomic consultant and  
Mr. Everett, and provided a “well detailed” opinion that was based upon a much more  
19  
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1  
Tel: (604) 664-7800 | 1-800-663-2782  
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