Decision No.: 2021-0515  
Page 1  
Appeals Commission for Alberta Workers’ Compensation  
Docket No.: AC0163-14-88  
Decision No.: 2021-0515  
Introduction  
[1]  
[2]  
The worker is appealing the February 21, 2014 Dispute Resolution and Decision  
Review Body (DRDRB) decision that denied a recurrence of responsibility for the  
worker’s bilateral elbow problems, left shoulder problems, right wrist problems  
and denied responsibility for the worker’s bilateral forearm problems.  
By way of background:  
[2.1]  
The worker suffered a work-related progressive injury reported to her  
employer on October 4, 2000.  
[2.2]  
The WCB accepted responsibility for bilateral elbow tendonitis, left rotator  
cuff tendonitis, chronic right medial epicondylitis, right wrist flexor  
tendinosis and an aggravation of pre-existing bilateral carpal tunnel  
syndrome.  
[2.3]  
[2.4]  
The WCB did not accept responsibility for the worker’s avascular necrosis  
of the lunate and a ganglion (cyst) of the right wrist.  
The worker qualified for a wage loss supplement in the form of an  
economic loss payment. The worker’s permanent clinical impairment  
assessment did not result in a percentage award for permanent clinical  
impairment for the worker’s elbows.  
[2.5]  
[2.6]  
[2.7]  
As the worker was unable to return to her pre-accident level employment  
as a baker, the WCB provided the worker vocational rehabilitation benefits  
which included academic retraining as a human resources assistant.  
On October 3, 2006 the worker’s claim was inactivated as the case  
manager determined the worker’s earnings did not warrant the payment of  
further wage loss benefits.  
On September 26, 2011, the worker contacted the Workers'  
Compensation Board (WCB) and advised that she was experiencing  
further medical difficulties that subsequently resulted in termination of her  
employment relationship. Following further medical investigation, on  
January 3, 2012, the WCB denied that the worker’s current bilateral elbow  
and wrist symptoms and other difficulties were related to the worker’s  
compensable injury.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 2  
[2.8]  
The worker requested the case manager review the decision as the  
worker’s symptoms had progressed as she had:  
a right wrist cyst requiring surgical removal;  
possible compartment syndrome of both forearms;  
left shoulder rotator cuff tears that may require surgery.  
[2.9]  
The worker maintained that the forearms were pulling on her elbows  
causing pain.  
[2.10]  
On January 3, 2012 the case manager determined that the worker’s  
current bilateral elbow and wrist symptoms and difficulties were not related  
to the compensable injury of October 4, 2000.  
[2.11]  
On April 12, 2013, the case manager reconfirmed the original January 3,  
2012 decision that the worker’s current bilateral elbow and wrist symptoms  
were not related to the original October 4, 2000 workplace injury. The  
case manager also determined that the worker’s forearm symptoms  
(possible compartment syndrome), right wrist (cyst), and left shoulder  
(three tears) were unrelated to the claim based on the results of an  
Independent Medical Examination (IME).  
[2.12]  
[2.13]  
[2.14]  
The worker disagreed and the appeal progressed to the Appeals  
Commission for a hearing on April 28, 2015.  
The Appeals Commission rendered a decision on October 9, 2015,  
confirming the February 21, 2014 DRDRB decision.  
Under section 13.1(7) of the Workers’ Compensation Act, RSA 2000,  
c W-15 (WCA) and our Appeals Commission Rule 5.6, the Appeals  
Commission reconsidered this matter on its own motion on November 6,  
2020. On May 11, 2021, a reconsideration panel directed that a new  
hearing be convened.  
[2.15]  
Notice of the worker’s appeal was sent to the employer and WCB. The  
employer and WCB chose not to participate in the rehearing appeal  
process.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 3  
[3]  
[4]  
The Appeals Commission can hear and decide the employer’s issue of appeal  
because it is the final level of appeal for decisions made by the review body  
(Workers’ Compensation Act, RSA 2000, c W-15 (WCA), section 13.1).  
Full excerpts of the legislation and policy referenced and applied in this decision  
can be found in the Appendices. The panel has applied the WCB legislation  
currently in effect and the applicable policy that was issued and in effect when  
WCB’s adjudicative decisions were made on January 3, 2012 and on April 12,  
2013.  
Preliminary Matters  
Date of Accident  
[5]  
The WCB has referred to the worker’s date of accident as October 4, 2000 and  
elsewhere in the file as October 24, 2000. We note that the date of progressive  
injuries are established on the date the worker first seeks medical treatment. To  
this, the panel notes that the Physicians First Report is dated October 4, 2000.  
New Evidence  
[6]  
The panel noted that numerous medical reports contained in the appeal  
document package post date the DRDRB decision. The representative  
confirmed that they wished to proceed with the hearing rather than return to the  
DRDRB. The panel confirmed the hearing was de novo and would consider all  
the evidence contained in the appeal document package. The representative  
confirmed no additional evidence would be submitted.  
Jurisdiction and wording of the issues of appeal  
[7]  
Workers are compensated for an earnings loss based on their earnings at the  
time of the accident. However, if a worker experiences a recurrence of  
temporary disability related to the compensable accident and their earnings at  
the time of the recurrence are higher than the date-of-accident earnings, section  
61 of the WCA and Policy 04-03 allow the WCB to compensate the worker based  
on their current earnings.  
[8]  
[9]  
The panel also confirmed, with the worker’s representative, that the worker is not  
requesting a readjustment of the temporary total disability calculation rate.  
The DRDRB worded three appeal issues pertaining to the worker’s bilateral  
elbow problems, left shoulder problems, right wrist problems as recurrence of  
disability related to the original October 4, 2000 workplace injury and cited  
Policies 04-03 (dealing with recurrence of disability) as the relevant policies.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 4  
[10]  
The representative requested the DRDRB review the following issues:  
Denial of responsibility for bilateral elbow problems;  
Denial of responsibility for left shoulder problems;  
Denial of responsibility for right wrist problems; and  
Denial of bilateral forearm problems.  
[11]  
[12]  
In reviewing the Request for Review submitted to the DRDRB, the panel notes  
the Resolution Specialist altered the issues of appeal in their decision by adding  
the term recurrent to three of the issues of appeal.  
The panel understands the worker has not worked since March 2010 and was  
not working at the time of the requested re-activation of her claim, which she  
attributes to being physically unable to satisfy the job demands. Therefore, three  
issues before us do not concern the calculation of her compensation rate. We  
find the appeal of these three issues concerns whether the WCB has ongoing  
responsibility for the worker’s bilateral elbow problems, left shoulder problems,  
right wrist problems related to the original October 4, 2000 workplace injury.  
[13]  
We note that the DRDRB decision on the fourth issue of appeal pertaining to the  
worker’s bilateral forearm problems determined that the WCB did not have  
responsibility as it was not medically possible to establish a causal relationship to  
compensable accident which had occurred 11 or 12 years earlier.  
[14]  
In light of the panel’s review of the DRDRB decision, we are satisfied that we  
have the authority under section 13.1(1) of the WCA to examine, inquire into and  
determine all matters and questions with respect to the responsibility of the WCB  
in the broader context of responsibility in respect of decisions made by the  
DRDRB.  
[15]  
The DRDRB decided the WCB did not have responsibility for the worker’s  
symptoms as a resolution date had been determined for each of the accepted  
conditions, specifically:  
carpal tunnel syndrome – resolved on November 6, 2001  
medial epicondylitis – resolved on April 9, 2013  
bilateral elbow, left rotator cuff tendonitis, left arm and left shoulder  
problems resolved by June 13, 2002.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 5  
[16]  
As we continue our analysis of the scope and wording of this issues of appeal,  
we note the DRDRB arrived at decisions regarding the responsibility for the  
worker’s injuries based on the broad category of “body part” or “location”. The  
panel notes the evidence pertains to multiple diagnoses under these body parts  
and find that such blanket exclusionary criteria effectively disentitles  
consideration of future symptoms or diagnosis associated with the worker’s  
injuries.  
Right Wrist  
[17]  
The panel has considered the representative’s argument that the worker also has  
symptoms pertaining to the left wrist and the issue of appeal on the right wrist  
should be expanded to include the worker’s injuries to both wrists. The panel  
reviewed the January 3, 2012 and April 12, 2013 case manager’s letters.  
[17.1]  
The January 3, 2012 letter states:  
“. . . I have determined your current bilateral elbow and wrist symptoms  
and difficulties are not related to your original injury of October 04, 2000.”  
[18]  
[19]  
The April 12, 2013 case management letter states, in part:  
“. . . I reconfirm the decision of January 3, 2012 that your current bilateral  
elbow and wrist symptoms are not related [to] the original injury of  
October 4, 2000. . . .”  
In response to the January 3, 2021 WCB letter, the worker submitted a request  
for review dated December 27, 2012 indicating she wished to have the  
January 3, 2012 case manager’s decision reviewed:  
“I wish to have my wrists, forearms, elbows and left shoulder decision  
reviewed.”  
[20]  
[21]  
The worker’s obtained a representative, who in response to the April 12, 2013  
WCB decision, submitted a request for review of the April 12, 2013 decision.  
We interpret that the January 3, 2012 and April 12, 2013 letters do not limit the  
issue of appeal solely to the right wrist. We note that one request for review was  
submitted for review of the January 3, 2012 decision and a separate second  
request for review was submitted for review of the April 12, 2013 decision. Given  
the DRDRB decision considered the January 3, 2012 and April 12, 2013 case  
manager’s decisions, that pertained to both of the wrists, we utilize our broad  
authority to consider both wrists.  
Classification: Protected A  
Decision No.: 2021-0515  
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Expansion of the Issues of Appeal  
[22]  
[23]  
Given the DRDRB has used a broad basis to deny responsibility for all conditions  
under these body parts, the panel interprets that the use of the broad denial  
approach of the DRDRB effectively limits any past or future entitlement decisions  
for these conditions in these locations.  
The panel finds, based upon our broad authority that the matters before us for  
the symptoms associated with the worker’s bilateral forearms, bilateral elbows,  
left shoulder and bilateral wrists, are inclusive of ongoing responsibility and  
inclusive for additional responsibility for other diagnosed injuries within the  
specified body regions that are causally associated with the compensable injury.  
Wording of the Issues of Appeal  
[24]  
Based on the above findings and section 13.1(1) of the WCA that indicates the  
Appeals Commission has exclusive jurisdiction to examine, inquire into and  
determine all matters and questions in respect of decisions of the DRDRB, we  
have reworded the issues of appeal as follows:  
[24.1]  
[24.2]  
[24.3]  
[24.4]  
Issue 1: Does the Workers’ Compensation Board have ongoing  
and/or additional responsibility for the diagnosed conditions related  
to the worker’s bilateral forearm problems arising from the  
October 4, 2000 work accident?  
Issue 2: Does the Workers’ Compensation Board have ongoing  
and/or additional responsibility for the diagnosed conditions related  
to the worker’s bilateral elbow problems arising from the October 4,  
2000 work accident?  
Issue 3: Does the Workers’ Compensation Board have ongoing  
and/or additional responsibility for the diagnosed conditions related  
to the worker’s left shoulder arising from the October 4, 2000 work  
accident?  
Issue 4: Does the Workers’ Compensation Board have ongoing  
and/or additional responsibility for the diagnosed conditions related  
to the worker’s bilateral wrist problems arising from the October 4,  
2000 work accident?  
Legislation and Policy  
[25]  
[26]  
In making our decision, the panel has applied the current version of the WCA and  
relevant WCB policy.  
We note that the effective policies applied at the time of the case manager’s  
decisions of January 3, 2012 was the February 1, 2007 policy version and for the  
April 12, 2013, it was the February 1, 2012 policy version.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 7  
[27]  
[28]  
[29]  
Relevant sections of the WCA and policy referenced or relied upon can be found  
in the appendix of this decision and are shared amongst all issues of appeal.  
Section 24 of the WCA says compensation is payable to a worker who suffers  
personal injury by an accident.  
WCB Policy 03-01 states that WCB will determine whether an injury has occurred  
as a result of a compensable accident, and will adjudicate appropriate  
compensation and services from the date of accident.  
[30]  
[31]  
WCB policy further states, when determining its responsibility, WCB will evaluate  
the relationship between the injury and the compensable accident. Additional  
medical advice is sought on an as-needed basis.  
Questions to be Answered  
In order to address all four of the issues of appeal regarding the WCB’s  
responsibility for the worker’s injuries, we must answer the following questions for  
each issue of appeal:  
[31.1]  
Does the weight of medical evidence establish that the worker has been  
diagnosed with an injury(s)?  
[31.2]  
If so, does the weight of medical evidence establish a causal relationship  
between the diagnosed injuries and the compensable accident or  
resolution of the accepted compensable injuries compensable injury(s)  
beyond the established resolution date?  
Key Submissions  
[32]  
The following is a summary of the representative’s submissions and responses of  
the worker to questions from the panel submitted in support of all four issues of  
appeal:  
[32.1]  
[32.2]  
[32.3]  
[32.4]  
The worker’s medical history is very complex and her claim was accepted  
on a progressive basis.  
The worker had extensive job demands that involved heavy repetitive use  
of both her upper extremities.  
WCB has arbitrarily assigned “resolved” dates on this claim that does not  
align with the actual medical evidence on file.  
The causal attribution made by the WCB Medical Consultants and relied  
upon by the WCB case manager does not satisfy the “more likely than not  
test” standard within policy.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 8  
[32.5]  
[32.6]  
The WCB has not considered the complex, progressive nature of the  
worker’s conditions as a whole as the medical information is limited by the  
reasons for referral that only specify a single condition or conducted a  
limited assessment based on the referral question.  
The date the WCB has listed in the injury summary report pertaining to  
when the worker’s condition was resolved does not include any  
consideration for her post-operative recovery time, physical rehabilitation  
nor the limitations faced by the worker in her new occupation of human  
resources.  
[32.7]  
[32.8]  
[32.9]  
The WCB Medical Consultant went looking for a needle in a haystack for a  
causal explanation for the worker’s symptoms (moving from one residence  
to another or to her previous recreational softball activities) rather than  
fully considering the significant occupational exposure from the worker’s  
pre-accident occupation as a baker.  
The WCB has presumed that because the worker was able to return to  
work, their responsibility ended. This is not the case as the worker was  
unable to retain her employment. She was let go because she was  
considered “slow” because of the combined effects of her compensable  
injuries.  
The worker submits that she was considered too “slow” because she was  
unable to physically hold files, would drop paper files and then struggle to  
pick up the paper from the floor. Her bilateral upper arm and hand  
symptoms impeded her computer entry ability with respect to typing  
speed, accuracy and use of the computer mouse.  
[32.10] The WCB had submitted as part of the recommendations for the worker’s  
successful integration into the role of human resources that she be  
provided with ergonomic support for working in an office setting.  
[32.11] The recommended WCB ergonomic support was never provided. While it  
was known to the worker that she could request such support, she was  
afraid that if she requested this assistance, it would expose her  
confidential medical information and WCB claim history to the new  
employers.  
[32.12] The WCB did not accept the medically prescribe massage therapy or the  
hospital based physical therapy as evidence of ongoing treatment for her  
compensable conditions.  
[32.13] The WCB has essentially denied the worker’s claim because her  
employment ended, but they never fully considered that her employment  
ended because of her ongoing and progressive compensable injuries to  
her elbows, wrists, forearms and left shoulder.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 9  
[32.14] When the worker did try to present new information, the WCB refused to  
consider it and did not pursue any investigations with regard to the  
termination of her employment or her functional capacity at that time.  
[32.15] The worker’s representative has argued that the worker had no pre-  
existing diagnosis of right carpal tunnel syndrome and therefore the WCB  
should have accepted the worker’s carpal tunnel syndrome on a direct  
basis. In addition, the representative submits that the WCB should accept  
responsibility for the worker’s wrist ganglion and the presence of avascular  
necrosis of the lunate (a bone in the wrist) both conditions that were  
associated with a stress reaction injury or fracture.  
Analysis – Issue 1  
[33]  
Does the Workers’ Compensation Board have additional responsibility  
and/or ongoing responsibility for the diagnosed conditions related to the  
worker’s bilateral forearm problems arising from the October 4, 2000 work  
accident?  
Evidentiary Findings and Reasons  
[34]  
The panel finds the weight of medical evidence supports the worker sustained a  
bilateral forearm injury diagnosed as bilateral forearm tendinosis/bilateral forearm  
tendonitis/tears of the common extensor tendon that are causally related to the  
October 4, 2000 progressive onset compensable accident that were unresolved  
on June 13, 2002.  
[35]  
The panel finds the worker does not have a confirmed diagnosis of bilateral  
compartment syndrome, it follows the WCB does not have additional  
responsibility for bilateral compartment syndrome.  
Medical evidence establishes a confirmed diagnosis of bilateral forearm  
tendinosis/bilateral tendonitis.  
[36]  
[37]  
The panel finds the weight of medical evidence establishes that the worker has  
been diagnosed with bilateral forearm injuries diagnosed as of bilateral forearm  
tendinosis/bilateral forearm tendonitis that is causally related to the October 4,  
2000 compensable injury.  
In our review of the evidence, the worker’s forearm injury has been described  
using the following medical diagnoses:  
June 13, 2002 WCB Medical Status Examination Report (Physician 1)  
- right forearm pain muscular in nature with what appeared to be  
tendinosis of the flexor carpo-radialus and ulnaris and flexor pollicis  
longus.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 10  
June 28, 2002 Sports Medicine Physician letter (Physician 2) -  
diagnosed chronic musculo-tendinosis pain and probably some scar  
tissue as a result of her activity and possibly secondary to her carpal  
tunnel surgery.  
August 26, 2003, a Cumulative Activity Related Disorder (CARD)  
(Physician 1) initial assessment was completed and noted a diagnosis  
of right forearm and wrist pain mild tendinosis of proximal flexor and  
extensor muscles.  
July 12, 2004 WCB Medical Consultant, Physician 3, opined that the  
worker suffered a repetitive strain injury.  
September 15, 2004 WCB Medical Consultant Report (Physician 3) -  
repetitive strain injury to both arms (emphasis added) as a result of  
her work duties and developed tendonitis in both forearms that was  
initially reported as pain in both forearms.  
March 3, 2011, the physiatrist (physician 4) confirmed focal tenderness  
over the common extensor origins at both elbows. The panel will  
address this opinion in the later section dedicated to the elbows.  
[38]  
We are satisfied that the medical evidence supports the worker was diagnosed  
with bilateral forearm tendinosis and bilateral tendinitis of the proximal flexor and  
extensors and that these injuries are causally attributed to the compensable  
accident:  
[38.1]  
We rely, in part, on the June 28, 2002 Physician 2, August 26, 2003  
Physician 1 and September 14, 2004 Physician 3 medical evidence that  
establishes the worker has a confirmed diagnosis of bilateral tendonitis.  
These physicians have established a causal link of the worker’s bilateral  
forearm symptoms to the cumulative and repetitive nature of the worker’s  
occupation. Two of these physicians have examined the worker and one  
provided an opinion after having conducted a thorough review of the file.  
[38.2]  
We find the findings of the above physicians are supported, in part, by the  
July 27, 2004 magnetic resonance imaging (MRI) results of the right elbow  
which revealed the worker has a partial tear injury of the common  
extensor origin (a tendon attached to extensor muscles of the forearm)  
along with a small focus of tendinosis within that specific tendon. This  
MRI finding aligns with the medical examination conducted on June 12,  
2002 by Physician 1.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 11  
[39]  
Our finding is further supported by the following medical evidence:  
[39.1]  
On May 27, 2002, Physician 5, a neurologist, assessed the worker and did  
not find a neurological cause for the worker’s diffuse right forearm pain.  
Physician 5 suggested an element of repetitive strain injury to the right  
forearm noting that there were no obvious features of complex regional  
pain syndrome.  
[39.2]  
[39.3]  
We interpret this report to establish that while a neurological cause was  
not confirmed, there were structural causes identified that informed the  
opinion of a repetitive strain injury to the right forearm.  
On June 13, 2002, Physician 1 indicated that the worker had right forearm  
pain that was muscular in nature with what appeared to be tendinosis of  
the flexor carpo-radialus and ulnaris and flexor pollicis longus. The panel  
understands these to be muscles of the forearm that are attached to the  
bones in the region by tendons. The physician arranged for an MRI to  
assess for structural abnormalities.  
[39.4]  
On June 28, 2002, Physician 2 noted that the worker has had symptoms  
in the right arm for several years occurring very specifically with her work,  
which was kneading dough. It was noted that following the surgical  
treatment for her right carpal tunnel syndrome, her symptoms changed but  
persisted. The treating physician described the worker’s symptoms as  
sharp, localized pain in the mid ventral forearm that starts immediately on  
the onset of her activity.  
[40]  
Physician 2 diagnosed chronic musculo-tendinosis pain and probably some scar  
tissue because of her activity and possibly secondary to her carpal tunnel  
surgery and speculated about the possible presence of chronic compartment  
syndrome.  
[41]  
[42]  
[43]  
On August 26, 2003, a cumulative activity related disorder (CARD) initial  
assessment (Physician 1) was completed. We note a diagnosis of right forearm  
and wrist pain mild tendinosis of proximal flexor and extensor muscles.  
The panel interprets the August 26, 2003 CARD assessment from Physician 1  
establishes that the worker was diagnosed with mild tendinosis of the right  
forearm proximal and extensor muscles.  
On July 12, 2004, Physician 3, opined in part:  
“. . . [Worker] suffered a repetitive strain injury which arose from the  
repetitive heavy gripping tasks required in her work duties. . . . full  
responsibility was accepted for tendonitis in both forearms . . . Dr. [name]  
reports that the tendonitis and epicondylitis in both forearms and elbows  
had largely resolved by May 25, 2004 . . .”  
Classification: Protected A  
Decision No.: 2021-0515  
Page 12  
[44]  
[45]  
On July 27, 2004, the MRI of the right elbow and wrist found a partial tear injury  
of the common extensor origin along with a small focus of tendinosis within the  
tendon substance. We have chosen to analyse the MRI findings associated with  
the right elbow under the section dedicated to the elbow.  
On June 22, 2005, in response to an employer’s application for cost relief,  
Physician 3 stated:  
“It is not uncommon that an inflammatory condition in the forearms  
and epicondyles is very slow to recover. . . . [The worker] was not able to  
return to her pre-accident employment based on permanent work  
restrictions against repetitive gripping activities due to the presence of  
chronic tendonitis in both forearms covered under this claim. . . .”  
[Emphasis added]  
[46]  
On March 3, 2011, Physician 4 assessed the worker’s arm and hand symptoms.  
We interpret arm symptoms to be inclusive of both forearms and note the  
physical examination confirmed focal tenderness over the common extensor  
origins of both elbows. These findings are consistent with the earlier established  
medical diagnosis that confirms the worker had a diagnosis of bilateral  
tendinosis/bilateral tendonitis of the forearms that remained symptomatic well  
beyond June 13, 2002.  
[47]  
The December 16, 2013 Orthopaedic Specialist Report states:  
“. . . review of her MRIs. This showed that she had some tears  
bilaterally of the common extensor tendons, thickening of the ulnar  
nerves in the cubital tunnels and some thickening of the radial collateral  
ligaments. I treated the tear in the right lateral epicondyle today with a  
steroid injection. I’m not sure if this will help, as this has been long  
standing. She still complains of pain in her arm and she relates this  
directly to working as a baker and lifting 5000 pounds a day. It is certainly  
possible that with repetitive strain and lifting this kind of weight a day she  
could have torn her common extensor tendons resulting in the obvious  
MRI tears that are present and causing her pain.” [Emphasis added]  
[48]  
We interpret the December 16, 2013 orthopaedic specialist opinion establishes  
that the reviews of her MRI results confirmed that she had some bilateral tears of  
the common extensor tendons which attach at the epicondyle and to muscles of  
the forearm. The specialist has indicated that the worker is still suffering  
establishing, some 13 years after the compensable injury, that the tears of the  
common extensor tendons are chronic and longstanding and required surgical  
correction.  
[49]  
As indicated above, we find the MRI and opinion of orthopaedic specialist is  
consistent with the earlier On June 13, 2002, Physician 1 findings that found the  
worker had right forearm pain that was muscular in nature with what appeared to  
be tendinosis of the flexor carpo-radialus and ulnaris and flexor pollicis longus.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 13  
The panel understands these to be muscles of the forearm that are attached to  
the common extensor tendons. We note Physician 1, who examined the worker,  
suspected structural abnormalities associated with the worker’s job duties in  
2002, that were confirmed by the December 16, 2013 MRI investigations and  
subsequent surgical interventions.  
Compartment Syndrome  
[50]  
The panel notes the June 13, 2002 Physician 1 Medical Status Examination  
references the worker’s forearm pain and subsequent consultation for testing for  
compartment syndrome of the muscles of her forearm to establish if the  
confirmed diagnosis was a form of chronic compartment syndrome arising from  
the compensable accident.  
[51]  
[52]  
We interpret this medical opinion establishes that further investigation is  
necessary to assist in determining if compartment syndrome is a confirmed  
diagnosis.  
The June 28, 2002 report from Physician 2 states:  
“It would be my assessment that she has chronic musculotendinous pain  
and probably some scar tissue in the forearm as a result of her activity  
and potentially secondary to carpal tunnel surgery. I do not think she has  
chronic compartment syndrome as her symptoms are not consistent with  
this, but in saying this, I have not seen this problem in the forearm. . . .”  
[53]  
[54]  
We interpret the statement from Physician 2 does not confirm a diagnosis nor  
definitively rule out the presence of chronic compartment syndrome.  
On December 5, 2011, Physician 6, reviewed the file and opined that the  
investigation of the worker’s forearm pain originating in the form of chronic  
compartment syndrome was a diagnostic reach.  
[55]  
[56]  
The panel finds multiple references to the presence of possible acute and/or  
chronic compartment syndrome; however, the investigation of forearm pressures  
conducted by Physician 9 found some elevation of the forearm pressure but the  
elevation was not significant enough to confirm a diagnosis.  
Given that the forearm pressure testing and guided ultrasound injections were  
intended to diagnosis and treat the worker’s symptoms, we find the evidence  
does not support a confirmed medical diagnosis of compartment syndrome in  
either forearm.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 14  
Medical evidence establishes a causal relationship between the diagnosed  
injuries and the compensable accident  
[57]  
[58]  
[59]  
The panel finds that the weight of the medical evidence supports the worker’s  
bilateral forearm injury or condition is causally related to the compensable  
accident.  
In addition to our above analysis of the forearm diagnosis, we further rely on the  
following to establish a causal and ongoing relationship that arises from the  
compensable accident.  
On July 7, 2003, Physician 8, noted the measurement of the worker’s forearms  
were equal and that provocative testing in the forearms elicited a positive  
response. The orthopaedic IME examiner stated:  
“I believe the current symptoms are related to the compensable condition  
accepted under this claim.”  
[60]  
[61]  
The panel interprets the July 7, 2003 examination establishes a causal  
relationship to the compensable injury for the bilaterally positive provocative test  
results identified by the orthopaedic IME specialist to the worker’s forearms. We  
interpret this finding supports a causal relationship to the compensable accident  
that establishes the presence of ongoing symptoms.  
On July 12, 2004, Physician 3 reviewed the file and opined that the worker  
suffered a repetitive strain injury, which arose from the repetitive and heavy  
gripping tasks required in her work. The WCB Medical Consultant reiterated that  
it was felt that the worker’s forearm symptoms and both elbows had largely  
resolved by May 25, 2004. We note the WCB Medical Consultant states, in part:  
“. . . Full responsibility was accepted for tendonitis in both forearms and  
bilateral carpal tunnel syndrome. . . .”  
[62]  
[63]  
[64]  
We interpret the opinion of Physician 3 establishes a diagnosis of chronic  
tendonitis to both forearms that was associated with the repetitive and heavy  
gripping tasks associated with her occupation, in order to state that full  
responsibility was accepted for tendonitis in both forearms.  
On March 3, 2011, the worker was assessed by Physician 4 for her arm and  
hand symptoms. We interpret arm symptoms to be inclusive of the forearm and  
note the physical examination confirmed focal tenderness over the common  
extensor origins at both elbows.  
We note that on March 3, 2011, one year after the worker reported she was  
unable to perform the duties of a human resources assistant, she continued to  
report that repetitive arm use was painful, especially on the right, interfering with  
her arm and hand activities. We interpret arm activities to be inclusive of the  
forearm and note that this assessment found ongoing symptoms, beyond  
June 13, 2002 associated with the worker’s forearms.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 15  
[65]  
On August 16, 2011, Physician 9, the worker’s attending physician submitted a  
physician’s first report noting recurrent forearm pain with tenderness of the  
medial epicondyle of the right elbow and forearm pain. Physician 9 ordered an  
ultrasound of the flexor tendon, and questioned the presence of increased  
compartment pressures. We interpret that this opinion establishes that the  
worker remained symptomatic to the extend that further investigation was  
required. While this investigation was for the purposes of compartment  
syndrome, we are satisfied that the worker had ongoing symptoms (pain) to the  
bilateral forearms.  
[66]  
[67]  
The November 3, 2011 Physician 9 report indicates the worker had chronic  
ongoing forearm pain with activity. The physician indicated the worker was  
“released from her claim” and opined that she may have chronic exercise  
induced compartment syndrome, noting tenderness at the common extensor.  
On January 8, 2013, Physician 10, a plastic and reconstructive surgeon noted  
the elevated compartment pressures found by the treating physician. Physician  
10 opined that a fascial tear to the anterior compartment was a possible  
explanation for the worker’s reports of chronic pain and fullness of the forearm  
and requested an MRI of both forearms.  
[68]  
On July 3, 2013 and October 22, 2013, Physician 10 reviewed the decisions  
made by the WCB, stating in part:  
“. . . The patient continues to have pain in both forearms and her right  
wrist.  
. . .  
As she still has pain in both forearms, especially on the right feels like a  
fascial defect in the area of the forearm, I have ordered a MRI to her  
forearms.  
. . .  
I have reviewed my letters dates July 3 and January 8, 2013, as well as  
[Medical Consultant] assessment. I reviewed the fact that she was  
working as a baker when her injured occurred. She was transferring  
almost 5,000 pounds daily. She subsequently complained of pain in the  
right and left forearm as well as tender wrists. I stated this originally in my  
letter dated January 8th and reaffirm this in my letter dated July 3, 2013.”  
[69]  
The December 9, 2013 MRI of the left elbow and forearm was ordered to rule out  
the presence of fascial tears found. While no specific defect was identified in the  
musculature of the left forearm, the radiologist stated that MRI findings may not  
provided the specificity necessary to establish the presence of tiny fascial defects  
in the forearms.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 16  
[70]  
The panel acknowledges the medical evidence at times supports that the  
worker’s symptoms were more predominate in the right as opposed to the left;  
however, the contemporaneous medical information, as we have noted is clear  
and supports the worker suffered a bilateral forearm injury. This injury required  
further investigation for the presence of chronic compartment syndrome, which  
has been attributed to the worker’s job duties.  
[71]  
[72]  
The panel notes the worker submitted correspondence from the massage  
therapist, date stamped on May 26, 2008 requesting the WCB reimburse the  
costs of the worker’s prescribed massage therapy.  
While the provision of treatment receipts does not by itself establish a causal  
connection, the panel is satisfied that this evidence does support that the worker  
was prescribed treatment, in part for her bilateral forearm symptoms arising from  
the compensable injuries.  
[73]  
[74]  
The worker’s letter date stamped May 26, 2009 provides that she continually  
needs the services of a massage therapist to function in her day to day survival  
and requested reimbursement for these costs. While the WCB denied this  
request, we are satisfied, in part that the worker continued to report symptoms  
that required treatment beyond June 13, 2002.  
The worker’s letter dated July 18, 2019, confirms that the worker’s forearms were  
symptomatic, she was having trouble in her human resources job due to these  
difficulties and the treatment and symptoms pertained to the muscles in her  
forearms. The worker’s massage treatments occurred in 2002, 2005, 2006,  
2009, 2010 and 2011 and she received additional treatment from the hospital  
physical therapy department.  
[75]  
[76]  
We interpret the massage therapy treatments to confirm the worker continued to  
have symptoms in her bilateral forearms that required treatment as of July 18,  
2019 that arises from the compensable injuries.  
We also acknowledge that our decision has considered evidence that was not  
before the DRDRB and is occurring approximately seven years after the DRDRB  
decision and two years following the last medical information contained on the  
appeal documents package.  
[77]  
To arrive at our conclusion, with regard to bilateral forearm tendinosis/tendonitis,  
we have placed greater weight on the combined opinions of Physician 1, 2, 3, 8,  
9 and 10 for the following reasons:  
[77.1]  
Physician 1, a WCB Medical Examiner physically assessed the worker  
nearest the date of onset and associated the diagnosis with the worker’s  
compensable accident.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 17  
[77.2]  
[77.3]  
Physician 2, a sports medicine physician also assessed the worker near  
the date of onset and attributed the symptoms to the duties of her  
occupation.  
Physician 3, another WCB Medical Consultant, did not assess the worker,  
but did review all of the previous medical evidence on the file on two  
occasions, July 12, 2004 and September 15, 2004.  
[77.4]  
[77.5]  
[77.6]  
Physician 8, is an orthopaedic specialist who has specialty training in the  
diagnosis and treatment muscle and bone injuries.  
Physician 9, was the worker’s attending physician who has examined and  
treated the worker numerous times and  
Physician 10, a specialist in plastic and reconstructive surgery confirms  
the diagnosis, established a causal mechanism to the duties of a baker  
and confirmed that she remained symptomatic beyond the date of  
resolution established by the WCB.  
[78]  
We have placed less weight on the opinions of Physician 4, 5, 6, 7, 11, 12, 13,  
14, 15, 16, 17, 18 and 19 due in part to, or a combination of:  
the limited scope of the clinical examinations driven by adjudicative  
questions as opposed to a full examination and commentary on all of  
the structures of the worker’s bilateral arms from the shoulder  
downward, and the worker’s symptoms; or  
have provided opinions based solely on review of the medical  
documentation.  
Decision – Issue 1  
[79]  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral forearm injury (bilateral tendinosis, bilateral tendonitis and tears of the  
common extensor tendon) as a result of the October 4, 2000 work-related  
progressive injury.  
[80]  
[81]  
The Workers’ Compensation Board does not have additional responsibility for the  
worker’s bilateral forearm injury (compartment syndrome).  
The worker’s appeal is varied and the February 21, 2014 Dispute Resolution and  
Decision Review Body decision is varied.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 18  
Analysis – Issue 2  
[82]  
[83]  
Does the Workers’ Compensation Board have ongoing or additional  
responsibility for the diagnosed conditions related to the worker’s bilateral  
elbow problems arising from the October 4, 2000 work accident?  
Evidentiary Findings and Reasons  
We find the weight of medical and other evidence establishes the WCB has  
ongoing responsibility beyond June 13, 2002 for the worker’s right medial  
epicondylitis (golfer’s elbow) as a result of the October 4, 2000 work-related  
progressive injury.  
[84]  
[85]  
[86]  
We find the weight of medical and other evidence establishes the WCB has  
additional responsibility for the worker’s left medial epicondylitis (golfer’s elbow)  
as a result of the October 4, 2000 work-related progressive injury.  
We find the weight of evidence establishes the WCB has additional responsibility  
for the worker’s bilateral-lateral epicondylitis (tennis elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
We find the weight of evidence establishes the WCB has additional responsibility  
for the worker’s bilateral cubital tunnel syndrome as a result of the October 4,  
2000 work-related progressive injury.  
Ongoing responsibility for right medial epicondylitis (golfer’s elbow) and  
additional Responsibility for the worker’s left medical epicondylisis  
(golfer’s elbow) and bilateral-lateral epicondylitis (tennis elbow) and cubital  
tunnel syndrome  
Medical evidence establishes a confirmed diagnosis of bilateral medial  
epicondylitis (golfer’s elbow)  
[87]  
It is not contested that the WCB accepted that the worker sustained bilateral  
elbow injuries as a result of the progressive onset injury of October 4, 2000,  
confirmed in the DRDRB decision as:  
Bilateral elbow tendonitis (Decision letter December 29, 2000)  
Chronic right medial epicondylitis (golfer’s elbow)  
[88]  
We interpret this acceptance to establish that the worker has a confirmed  
diagnosis of bilateral elbow tendonitis and chronic right medial epicondylitis  
(golfer’s elbow).  
Classification: Protected A  
Decision No.: 2021-0515  
Page 19  
[89]  
The representative argues that the worker’s bilateral elbow tendonitis was not  
resolved on April 9, 2013 and that the right medial epicondylitis was not resolved  
by June 13, 2002. In addition, the representative submits that the medial  
epicondylitis was bilateral, the bilateral-lateral epicondylitis (tennis elbow) and  
that the bilateral cubital tunnel syndrome was never fully considered.  
Ongoing Right Medial epicondylitis and Additional Responsibility Left Medial  
Epicondylitis (golfer’s elbow)  
[90]  
We find, based on the January 19, 2019 electromyogram (EMG) studies and  
examination from Physician 7 (a physiatrist) that the worker was diagnosed with  
bilateral medial epicondylitis (golfer’s elbow) on January 19, 2001. Physician 7  
stated:  
“. . . She does have findings consistent with medical epicondylitis . . .”  
[91]  
[92]  
This information confirms the worker was diagnosed with bilateral medial  
epicondylitis. It is not known to the panel, how the WCB limited the acceptance  
to only the right and not the left epicondyle as established by the physiatry  
specialist.  
We note the June 22, 2005, Physician 3, a WCB Medical consultant who stated  
in part:  
“It is not uncommon that an inflammatory condition in the forearms and  
epicondyles is very slow [emphasis added] to recover. . . . [The worker]  
was not able to return to her pre-accident employment based on  
permanent work restrictions against repetitive gripping activities due to  
the presence of chronic tendonitis in both forearms covered under this  
claim. . . .”  
[93]  
We interpret the opinion of Physician 3 establishes that as of June 22, 2005, the  
worker’s bilateral epicondylitis (which we also interpret to be medial and lateral)  
was very slow to recover and had not recovered at this time. While we have  
applied our interpretation to the presence of bilateral tendonitis, we have  
provided a more robust analysis under the heading bilateral-lateral epicondylitis  
and cubital tunnel syndrome.  
[94]  
[95]  
We find the weight of medical evidence establishes that that the worker  
continued to have right medical epicondylitis that was not resolved as of April 9,  
2003.  
We find the weight of medical evidence establishes the worker has a confirmed  
diagnosis of left medical epicondylitis that is causally related to the progressive  
onset injury of October 4, 2000.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 20  
Confirmed diagnosis of Bilateral – lateral epicondylitis (tennis elbow) and bilateral  
cubital tunnel syndrome causally related to the compensable accident of  
October 12, 2000  
[96]  
[97]  
[98]  
We find, based upon the weight of medical evidence, there is a confirmed  
diagnosis of bilateral-lateral epicondylitis and causal relationship between the  
October 12, 2000 work-related progressive injury.  
We find, based upon the weight of medical evidence, there is a confirmed  
diagnosis of bilateral cubital tunnel syndrome and causal relationship between  
the October 12, 2000 work-related progressive injury.  
The October 4, 2000 Physician’s First Report provided a diagnosis of bilateral  
forearm/shoulder pain, and diagnosed bilateral flexor tendonitis of the elbows  
which we understand to be a form of medial tendonitis (golfer’s elbow).  
[99]  
The Physician’s Progress report dated October 24, 2000 indicates the worker’s  
injury progressed overtime as a result of her job duties as a baker.  
[100]  
On June 22, 2005, in response to an employer’s application for cost relief, the  
WCB Medical consultant (Physician 3) stated:  
“It is not uncommon that an inflammatory condition in the forearms and  
epicondyles is very slow to recover. There is no evidence that the injury  
covered under this claim caused any aggravation of the avascular  
necrosis of the lunate in the right wrist or the pre-existing and concurrent  
psoriasis. [The worker] was not able to return to her pre-accident  
employment based on permanent work restrictions against repetitive  
gripping activities due to the presence of chronic tendonitis in both  
forearms covered under this claim. . . .” [Emphasis added]  
[101]  
We interpret the WCB Medical Consultant’s statement establishes that the  
worker was suffering from an inflammatory condition to the epicondyles  
(epicondylitis), which are located on the medial and lateral aspects of the elbow  
and establishes the presence of lateral epicondylitis (tennis elbow). The use of  
the plural term “epicondyles” implies more than one, when coupled with the use  
of the plural term “forearms”, we interpret this to mean the worker has  
epicondylitis on the medial (inside aspect) and lateral (outside aspect) of the right  
and left arms.  
[102]  
On March 3, 2011, the worker was seen by Physician 4 who noted, in part, sharp  
shooting pains at both elbows that he attributed to lateral epicondylitis evidenced  
by marked tenderness over the common extensor origin, especially on the right.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 21  
[103]  
The December 16, 2013 Orthopaedic Specialist Report states:  
“. . . review of her MRIs. This showed that she had some tears bilaterally  
of the common extensor tendons, thickening of the ulnar nerves in the  
cubital tunnels and some thickening of the radial collateral ligaments. I  
treated the tear in the right lateral epicondyle today with a steroid  
injection. I’m not sure if this will help, as this has been long standing.  
She still complains of pain in her arm and she relates this directly to  
working as a baker and lifting 5000 pounds a day. It is certainly possible  
that with repetitive strain and lifting this kind of weight a day she could  
have torn her common extensor tendons resulting in the obvious MRI  
tears that are present and causing her pain.”  
[104]  
We interpret the December 16, 2013 orthopaedic specialist opinion establishes  
that the reviews of her MRI results confirmed that the worker has some bilateral  
tears of the common extensor tendons. We understand the common extensor  
tendon is on the lateral aspect of the elbow and was injured as a result of the  
worker’s job duties. We interpret the date of accident of 2000, some 13 years  
prior to the specialist report to establish that the tears of her common extensor  
tendons are attributed to her occupational duties and could be “slow to recover”.  
Given the date of accident was in the year 2000; we find that the Orthopaedic  
Specialist evidence supports a diagnosis of bilateral tears of the common  
extensor tendon that is causally related to the compensable accident and from  
which the worker is still suffering. The specialist has indicated that the worker is  
still suffering establishing, some 13 years after the compensable injury, that the  
tears of the common extensor tendons are chronic and longstanding, and thus  
unresolved.  
[105]  
The April 30, 2015 Physician 11 (second specialist in physical medicine and  
rehabilitation) EMG studies revealed bilateral ulnar nerve compression at the  
elbow, indicative of and consistent with a diagnosis of bilateral cubital tunnel  
syndrome. We interpret Physician 11 findings explain the pattern of paraesthesia  
(numbness) experienced by the worker including weakness in the ulnar  
innervated territory of the right hand. The specialist opines the weakness noted  
in the finger extensors is functional due to her tennis elbow rather than  
neurogenic.  
[106]  
We interpret the findings of the Physician 11 establishes that the worker’s cubital  
tunnel syndrome is causally linked to the compensable diagnosis of tennis elbow  
(lateral epicondylitis) which is causing functional symptoms, the pain of which  
date back to the year 2000, as a result of the following statement:  
“[The worker] has been dealing with pain in the bilateral medial and lateral  
epicondyles since the year 2000, when she was a baker. . . .”  
Classification: Protected A  
Decision No.: 2021-0515  
Page 22  
[107]  
Physician 11 states in part:  
“For management of her bilateral cubital tunnel syndrome, considering  
the weakness in her right hand ulnar innervated muscles you could  
consider offering her cubital tunnel decompression surgery to preserve  
her hand function. For the left side, a cubital tunnel decompression  
surgery may alleviate the paraesthesia in the ulnar territory of the hand.  
However, I explained to her that this surgery will not address the  
symptoms pertinent to her tennis elbow and golfers elbow, and more  
importantly, it will not rectify the weakness in her finger extensors, which  
is functional rather than neurogenic. For that she needs more physical  
therapy for reconditioning.” [Emphasis added]  
[108]  
Physician 11, establishes that the worker has bilateral cubital tunnel syndrome  
and suggests a cubital tunnel release of the right and left cubital tunnel.  
Physician 11 also noted the presence of symptoms to the medial and lateral  
(tennis and golfers elbow) aspects of her arm, which we understand based on  
Taber’s Medical Dictionary to be medial and lateral epicondylitis, consistent with  
the October 27, 2000 initial diagnosis and opinion rendered by the physical  
therapist and our earlier findings.  
[109]  
We interpret the referenced medical evidence establishes the presence of lateral  
and medial epicondylitis of both the right and left elbow associated with the  
progressive onset that continue to be present in April 2015. This supports the  
worker’s symptoms not only originate with the progressive onset compensable  
injury but have also persisted over time and affect the medial and lateral aspects  
of both arms.  
[110]  
[111]  
We find the Physician 11 medical evidence supports a diagnosis broader than  
the WCB accepted diagnosis that only considered the medial aspect and not the  
lateral aspect of the worker’s tendons and did not consider the worker’s  
diagnosis of cubital tunnel syndrome, which have both become symptomatic to  
the point of possible surgical decompression.  
On June 9, 2015, the worker was referred to Physician 12, a second plastic and  
reconstructive surgeon who performed a right cubital tunnel release on July 6,  
2015. We find this evidence establishes, in combination with the opinion of  
Physician 11, a confirmed diagnosis of the worker’s bilateral cubital tunnel  
syndrome that is causally related to the compensable accident. It follows that the  
surgical intervention for this condition and the repair of the tendons, including the  
physical recovery period are subject to further adjudication.  
[112]  
In the follow-up report of July 14, 2015, Physician 12 noted the worker required  
physical therapy and that while the symptoms had improved on the surgical right  
side, the worker continued to experience symptoms on the left.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 23  
[113]  
On July 20, 2015, Physician 12 wrote to the WCB. We note the following from  
this correspondence:  
[113.1] The exact cause of cubital tunnel syndrome is unknown; however, nerve  
compression syndromes in the upper extremity often result from  
inflammation associated with repetitive use.  
[113.2] It is entirely possible that her condition resulted from her occupation. The  
pushing and pulling mechanisms described are consistent with this  
mechanism.  
[113.3] The early diagnosis of entrapment neuropathy would have been more  
effective in addressing her condition.  
[113.4] Massage therapy has been shown to improve symptoms associated with  
muscle overuse and thus could have been useful in treating the symptoms  
of her condition, especially the medial and lateral epicondylitis.  
[114]  
[115]  
We interpret the July 20, 2015 plastic surgeon’s letter to establish that the  
worker’s cubital tunnel syndrome has resulted from the repetitive mechanisms of  
pushing and pulling associated with the duties of a baker are sufficient to cause  
inflammation, a fundamental feature of bilateral medial and lateral epicondylitis  
(inflammation of the epicondyles), which we have found to be confirmed.  
On December 11, 2015, Physician 11, reported that the EMG studies (performed  
after surgical intervention) demonstrated almost (emphasis added) complete  
resolution of her right ulnar nerve function following the decompression surgery.  
Physician 11 noted that while the nerve function improved, the pain continued  
and opined that the partial tear of the radial collateral ligament of the right elbow  
maybe the cause of/or contributing to her reports of pain and recommended an  
orthopaedic specialist evaluation.  
[116]  
[117]  
We understand that radial collateral ligaments attach to the lateral epicondyle  
(elbow) and run through the forearm to attach to the radius and ulnar bones  
(bones of the forearm that also form part of the wrist).  
We do not interpret the ongoing presence of pain to be consistent with  
“resolution” as was opined by the April 30, 2015 Physiatrist as the evidence  
supports the worker’s symptoms are functional (structural) as opposed to  
neurogenic.  
[118]  
In considering the EMG results of December 11, 2015, we acknowledge the  
January 19, 2001 EMG results did not demonstrate ulnar neuropathy at that time.  
However, the worker’s condition was described as both chronic and progressive.  
We interpret the use of these terms to indicate that the condition can evolve and  
thus is consistent with the bilateral nature of the epicondylitis confirmed with the  
later EMG results of April 30, 2015.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 24  
[119]  
On May 30, 2018, the worker underwent a right elbow common extensor (lateral  
aspect of the elbow) debridement with repair and a right ulnar nerve  
decompression. The surgeon reviewed the MRI of January 2017 and opined  
that:  
[119.1] The visual examination and intraoperative findings confirm significant  
ulnar nerve compression;  
[119.2] The visual examination finding that the lateral aspect had a fairly  
(emphasis added) normal intraoperative appearance that should be left  
alone; and  
[119.3] The common extensor tendon was highly abnormal which required the  
surgical removal of parts of the tendon.  
[120]  
[121]  
We interpret the May 30, 2018 operative findings establish that lateral aspect of  
the right elbow was fairly “normal” and should be left alone and that the abnormal  
findings of the right common extensor tendon required surgical repair as a result  
of the worker’s compensable injuries.  
On July 31, 2018, the worker began physical therapy, we note the following from  
the physiotherapy report:  
[121.1] The worker has been dealing with pain for 18 years;  
[121.2] Grip strength on the right is 8 lbs and 40 lbs on the left; and  
[121.3] Tenderness to palpation with a healing incisional mark from the lateral  
elbow to the medial elbow.  
[122]  
[123]  
We interpret the physical therapists report, at the time of the examination, to  
confirm the worker has suffered pain attributable to her 18-year history related to  
her occupation. We interpret “pain” as a symptom associated with her  
compensable injuries that does not confirm full resolution.  
On August 13, 2018 the WCB approved the worker’s initial PT assessment and  
treatment, but did not approve payment beyond July 31, 2018, nor did the WCB  
approve payment for the worker’s massage therapy for:  
Thirty sessions in 2003 for $2321.90;  
Ten sessions in 2005 for $720;  
Five sessions in 2006 for $375;  
Classification: Protected A  
Decision No.: 2021-0515  
Page 25  
Ten sessions in 2009 for $800;  
Fifteen sessions in 2010 for $1200; and  
Seven sessions in 2011 for $560.  
[124]  
The issue of payment for medical aid in the form of massage therapy is not an  
issue before this panel. However, we interpret the above massage therapy  
invoices, in combination with the weight of medical evidence analysed above,  
supports that the worker was experiencing ongoing symptoms and thus seeking  
treatment to alleviate her ongoing symptoms associated with the bilateral  
compensable injuries of both elbows.  
[125]  
We find the weight of evidence of the combined opinions of Physician 10 and 13  
(Plastic and Reconstructive Surgeons) and the opinion of Physician 11  
(Physiatrist) establishes that the worker has ongoing symptoms beyond June 13,  
2003 that are causally related to the mechanism of injury of repetition and  
overuse arising from her duties as a baker.  
[126]  
[127]  
Further, the surgical specialists have examined the worker and in part, directly  
visualized the affected areas or tissues. Finally, surgeons and physiatrists  
possess advanced skills in the assessment and treatment of disorders, guided by  
their clinical examinations.  
We acknowledge and have reviewed the opinions contained in the appeal  
documents package of the various WCB Medical Consultants who have provided  
opinions based on a review of the medical documentation. As we have noted  
above, we place less weight on these opinions because their opinions were  
based solely on the assessment of medical documentation and they have less  
expertise than the above noted specialists. We also note the opinions rendered  
by the WCB Medical Consultants and other physicians, have at times, been  
limited to narrow questions of clarification from the adjudicator as opposed to a  
more holistic assessment of the chronic, progressive, complex and bilateral  
nature of all of the worker’s injuries to the wrists, elbows, forearms and to her left  
shoulder.  
[128]  
[129]  
While the WCB accepted right medial epicondylitis, and established April 9, 2013  
as the date the condition resolved, we find the weight of medical and other  
evidence establishes the WCB has ongoing responsibility beyond April 9, 2013  
for the worker’s right medial epicondylitis (golfer’s elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
We find the weight of medical and other evidence establishes the WCB has  
additional responsibility for the worker’s left medial epicondylitis (golfer’s elbow)  
as a result of the October 4, 2000 work-related progressive injury.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 26  
[130]  
[131]  
We find the weight of evidence establishes the WCB has additional responsibility  
for the worker’s bilateral-lateral epicondylitis (right and left arm tennis elbow) and  
bilateral cubital tunnel syndrome.  
While we acknowledge the representative’s submission regarding entitlement to  
wage loss benefits or the unsuitability of her employment in human resources,  
these issues are not before this panel. The decisions made by the panel on  
Issue 2, are subject to further adjudication by the WCB.  
Decision – Issue 2  
[132]  
[133]  
[134]  
[135]  
[136]  
The Workers’ Compensation Board has ongoing responsibility beyond April 9,  
2013 for the worker’s right medial epicondylitis (golfer’s elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
left medial epicondylitis (golfer’s elbow) as a result of the October 4, 2000 work-  
related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral-lateral epicondylitis (right and left arm tennis elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral cubital tunnel syndrome as a result of the October 4, 2000 work-related  
progressive injury.  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
Analysis – Issue 3  
[137]  
Does the Workers’ Compensation Board have ongoing or additional  
responsibility for the diagnosed conditions related to the worker’s left  
shoulder problems arising from the October 4, 2000 work accident?  
Evidentiary Findings and Reasons  
[138]  
[139]  
The WCB has ongoing responsibility beyond June 13, 2002 for the worker’s left  
shoulder tendonitis as a result of the October 4, 2000 work-related progressive  
injury.  
The WCB has additional responsibility for the worker’s left shoulder rotator cuff  
tears as a result of the October 4, 2000 work-related progressive injury.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 27  
Ongoing Responsibility for the Worker’s left shoulder tendonitis and  
Additional Responsibility for the Worker’s left should rotator cuff tears  
[140]  
[141]  
[142]  
[143]  
[144]  
We find the weight of evidence establishes a causal relationship between the  
October 4, 2000 work-related progressive injury and the worker’s ongoing left  
shoulder problems (tendonitis) beyond June 13, 2002.  
We find the weight of evidence establishes a causal relationship between the  
October 4, 2000 work-related progressive injury and the worker’s left rotator cuff  
tears. We rely upon the following to support our findings.  
The Worker’s First Report of Injury dated October 24, 2000 provides a pictogram  
demonstrating, in part, a circle around the left shoulder and indicates that both  
elbows and the left shoulder were affected.  
Physician 9’s First Report of October 4, 2000 identified shoulder pain from  
repetitive flexion movements, noting, in part, supraspinatus tendonitis. We find  
the injury to the left shoulder to be consistent with the Worker’s Report of Injury.  
The Employer’s Report of Injury noted that the injury developed over a period of  
time noting that the duties of a baker seems to have reacted adversely to the  
worker. We note the employer cited injuries to both elbows and both shoulders  
under the section entitled “What part of the body is injuried?”.  
[145]  
[146]  
[147]  
[148]  
The worker’s progressive injury questionnaire responses identified symptoms  
located in the right and left hand, left shoulder, fingers, right wrist and both  
elbows and both forearms.  
We interpret the Physicians, Employers, and Worker’s Reports of injury (inclusive  
of the progressive injury questionnaire) establish that the worker had symptoms  
in multiple locations, inclusive of the left shoulder.  
We note specifically the WCB Injury Summary report specifies the worker’s left  
shoulder problems resolved as of June 13, 2002 based on the opinion of the  
Physician 1 report of the same date.  
We acknowledge the undated handwritten referral letter for a neurology  
consultation booked for February 2, 2000 indicates the physician has treated the  
worker’s shoulder for historical sport related injuries. We place little weight on  
this document, as it does not specify what shoulder was treated nor provide a  
diagnosis, diagnostic findings nor evidence of a confirmed pre-existing condition.  
[149]  
The worker’s physician made an attributional link to the activities of playing  
softball, the worker is left hand dominate, but pitches right-handed. Given her left  
shoulder is affected; this attribution does not align with the activity of throwing a  
softball utilizing the opposite non-affected right shoulder.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 28  
[150]  
The January 8, 2001, Physician 13, WCB Medical Status Examiner 2 report  
found the worker’s range of motion of the shoulders was full. It is not clear to the  
panel however, if the documentation of discomfort at the extreme end of the  
ranges was solely limited to the evaluation of the elbows or if this limitation, also  
applied to the right and left shoulders.  
[151]  
Physician 1, in the Medical Status Examination of June 13, 2002 found the  
worker had normal range of motion of the shoulders. Physician 1 however noted  
that internal rotation of the shoulders could not be assessed due to pain of the  
right medial forearm. Given that this physician was unable to assess internal  
rotation, then it is unknown to the panel as to how a finding of “full range of  
motion” could be established. This limited evaluation does not rule-out the  
presence of left shoulder pain or internal rotation range of motion limitations of  
the left shoulder.  
[152]  
We note, the July 2002 clinical note from Physician 9 regarding left shoulder  
pain. The treating physician opines that it was unclear if the workers symptoms  
were related to the WCB injury. We specifically note however, the treating  
physician indicated the worker’s shoulder was not problematic prior to the injury  
event at work and as we have determined, she was a right-handed softball  
pitcher.  
[153]  
[154]  
We interpret the July 2002 note from Physician 9 to indicate, that the worker did  
not have a contributory left shoulder history associated with being a softball  
pitcher.  
Physician 1, in the Return to Work Medical Status Examination report dated  
August 26, 2003 notes the worker’s report of left shoulder discomfort with  
anterior tenderness when lifting her shoulder up above her head. The physical  
examination noted pain with abduction with a limited range of motion, anterior  
tenderness and pain with impingement testing. The rotator cuff power was  
determined to be normal.  
[155]  
Physician 15, in the July 26, 2004 Orthopaedic IME report, found the physical  
examination of the worker was valid noting the presence of findings, in part,  
suggestive of mild impingement in the left shoulder. We note the statement  
“virtually” recovered does not equate with fully recovered. The orthopaedic IME  
specialist opined that the worker’s symptoms fit within the category of a chronic  
over-use type problem, noting the history of prolonged use of her arms in her job  
as a baker.  
[156]  
We note that Physician 15, in the following from the Medical Services  
Memorandum dated September 4, 2004:  
“There is a slight degree of loss of range of motion in the left shoulder  
compared to the right, but I have no diagnosis with which to work.”  
Classification: Protected A  
Decision No.: 2021-0515  
Page 29  
[157]  
The panel interprets the statement from Physician 15 to mean that the physical  
findings of the worker’s left shoulder as depicted on the original “c60 form”  
(worker’s report of accident form) remained present at the time of the  
investigation. While the Medical Consultant indicated he had no diagnosis to  
work with, we note the claim was accepted for a left shoulder tendonitis problem.  
[158]  
On September 15, 2004, Physician 3 reviewed the worker’s file and opined:  
“. . . It is my opinion that the injury covered under this claim did cause an  
inflammatory condition in both elbows and the left rotator cuff. This  
inflammatory condition also caused an aggravation of the pre-existing  
asymptomatic bilateral carpal tunnel syndrome to become symptomatic  
in the right hand . . .  
. . . It is my opinion that this current condition in the left shoulder is not a  
late complication of the injury covered under this claim or a continuation  
of the injury covered under this claim, since several physicians had noted  
a complete resolution of the left arm symptoms between June 2002 and  
the spring of 2004. . . . Therefore, it is my opinion that the current  
symptoms in the left shoulder are not related to the injury covered under  
this claim.” [Emphasis added]  
[159]  
The time between the September 4, 2004 Physician 3 memorandum and the  
September 15, 2004 Physician 15 Memorandum is 14 days. The panel was  
unable to identify any diagnostic testing completed in this 14-day time span to  
support the WCB Medical Consultant’s opinion that the worker’s left shoulder had  
fully recovered. Given the opinion of Physician 3 did not include a physical  
examination; we place greater weight on the opinion of Physician 15.  
[160]  
[161]  
As we have noted above, the Physicians First Report provided a diagnosis  
pertinent to the left shoulder and subsequent medical examinations were either  
pain limited or found to be full range of motion with the presence of pain.  
On May 17, 2005, the worker was examined by Physician 10, an orthopaedic  
specialist for pain of the right wrist, medial and lateral epicondylitis and for left  
shoulder persistent weakness. We note Physician 10 used the phrase “ worse  
with flexion” however, the panel is unable to determine if this reference pertains  
to the worker’s right wrist or the worker’s left shoulder.  
[162]  
An undated letter, submitted to the WCB in October 2011, from the massage  
therapist, indicates the worker had received treatment “through the entire  
shoulder girdle” of the right arm and some treatment to the left shoulder to  
release “restrictions” with improvement in range of motion to 75%. We interpret  
the massage therapist memorandum, submitted in October of 2011, establishes  
the worker initiated treatment from July 28, 2003 into 2005, 2006, 2009, 2010  
and 2011 that was inclusive of the left shoulder.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 30  
[163]  
In response to questions from the panel, the worker indicated that she also  
received physical therapy through the public health care system, but was limited  
to approximately 1 session per month as that is all that she could afford as she  
did not qualify through the provincial health services criterion for fully paid  
treatment.  
[164]  
[165]  
We accept the worker’s treatment through the public health system, supported in  
part by the reports submitted to the file, confirm she was seeking and received  
treatment for her symptomatic left shoulder.  
On March 3, 2011, Physician 4 assessed the worker’s arm and hand symptoms.  
The panel notes that while the physiatrist indicated the worker’s shoulder was  
symptom free, we are unable to determine if this pertains to her symptomatic left  
shoulder or her non-symptomatic right shoulder as the word shoulder is referred  
to in the singular. This report does not assist the panel in this regard.  
[166]  
On September 24, 2011, an X-ray was performed that did not demonstrate any  
skeletal or soft tissue abnormalities of the shoulders. We note the X-ray was  
ordered for “weakness in abduction” and is consistent with the earlier August 26,  
2003 Medical Status Examination (Physician 1) findings that noted in part:  
“On upper limb examination on the left side, she has pain with abduction.  
She can lift it to about 150 degrees but no further and on flexion, she can  
lift it to 160 degrees approximately. There is tenderness anteriorly over  
the shoulder and on impingement testing there is pain felt anteriorly.  
Rotator cuff power, however, appears to be normal.”  
[167]  
On December 5, 2011, Physician 6, a WCB Medical Consultant, indicates that  
left rotator cuff tendinitis was accepted by the WCB. We interpret the acceptance  
to establish in part, at this time and in the absence of a MRI or computed  
tomography scan, a causal connection of her ongoing symptoms (as discussed  
above) to the mechanism of injury that persisted some 11 years after the onset of  
her compensable claim.  
[168]  
On January 13, 2012, the MRI was completed for loss of range of motion of the  
left shoulder for abduction and forward flexion. The left shoulder MRI  
demonstrated:  
A supraspinatus tendinosis and a full thickness tear (1 cm) of this  
tendon at the greater tuberosity attachment site;  
A significant infraspinatus tendinosis and a partial thickness tear;  
A mild subscapularis tendinosis and partial thickness tear of this  
tendon;  
A mild bicipital tendinosis;  
Classification: Protected A  
Decision No.: 2021-0515  
Page 31  
Degenerative osteoarthritis of the acromioclavicular (AC) joint without  
any impingement of the supraspinatus outlet.  
A subacromial/subdeltoid bursitis was also seen.  
[169]  
[170]  
[171]  
[172]  
The January 19, 2012, Physician 9 clinical notes confirm a referral for  
orthopaedic specialty examination, noting specifically the worker could not  
abduct the left shoulder and lie on the left side. Physician 9 noted the original  
injury of October 2000. We interpret the reference to the earlier October 4, 2000  
Physician’s Report, establishes in part, a causal connection to the compensable  
accident and her ongoing symptoms.  
On April 4, 2012, the physical therapy assessment report notes a 10-year history  
of problems with the arms attributable to the occupational history of a baker and  
a rotator cuff tear confirmed by MRI. The physical assessment noted limitations  
in both range of motion and strength testing. We interpret that in the opinion of  
the Physical Therapist, there is a causal connection to the worker’s compensable  
accident.  
The March 23, 2013, objective findings section of the Physicians Progress  
Report provides that the worker could not abduct her left shoulder and noted  
range of motion limitations with active and passive testing associated with  
weakness and pain. The worker was referred to physical therapy for a  
supraspinatus tear, consistent with the area first identified by Physician 9 in the  
Physicians First Report of October 4, 2000.  
The April 1, 2013, physician progress report provides the worker presented with  
left shoulder pain with lifting. The examination noted in part, weak abduction  
(ability to lift the arm laterally away from the body) and an open (positive) can  
sign, and limitations in the worker’s range of motion:  
[172.1] We understand that the “can test or sign” is used to assess the function of  
the supraspinatus muscle and tendon of the shoulder. A positive sign or  
test can, described as open, can be the result of a tear in the  
supraspinatus muscle or tendon and result in weakness or pain with range  
of motion testing.  
[172.2] We note, the worker was limited with this aspect of range of motion testing  
and is consistent, in part, with the MRI findings and the earlier findings that  
were first attributed to tendonitis. We also note, at this time, the worker  
was awaiting a surgical consultation and was working in a full-time role in  
human resources, a role in which she submits she was struggling with the  
physical demands.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 32  
[173]  
On April 9, 2013, an IME was conducted by Physician 17 who noted the worker’s  
involvement as a competitive softball pitcher had ended at the time of her injury  
and noted her continuation in an instructional role:  
[173.1] The IME examiner noted that the worker was able to demonstrate a full  
range of motion of the shoulders but winced when bringing her arm down  
to her side. The report does not specify what shoulder produced the  
wincing pain response nor does it provide specific range of motion  
measurements of either shoulder.  
[173.2] We note the IME examiner did not appear to be aware that the WCB had  
accepted the worker’s claim for left shoulder problems nor of the diagnosis  
of left rotator cuff tendinitis accepted by the WCB. We therefore find the  
opinions of the IME examiner does not assist the panel with respect to the  
left shoulder.  
[174]  
We acknowledge the WCB Adjudicator’s April 12, 2013 correspondence relied  
upon the IME examiners opinion to conclude the worker’s current bilateral upper  
extremity symptoms were not causally related to the original injuries sustained on  
the claim. We find such a broad and sweeping conclusion is not supported by  
the opinion of Physician 17, the IME examiner.  
[175]  
[176]  
[177]  
The WCB adjudicator added that the reported left shoulder symptoms (three  
tears) were also unrelated to the worker’s compensable accident based upon the  
conclusion of the IME examiner. We are unable to locate the evidence within the  
IME examiners April 9, 2013 report that supports this conclusion.  
Our review of the IME examiner’s report does not identify any exclusionary  
opinion used by the IME examiner that would negate the causal connection to  
the worker’s date of accident and the worker’s left shoulder symptoms. It is for  
this reason; we place little weight on the IME opinion of April 9, 2013.  
On April 26, 2013, Physician 6, a WCB Medical Consultant reviewed the file and  
opined on the MRI results of the worker’s left shoulder, relying specifically on the  
medical assessment reports dated December 20, 2007 and March 3, 2011. We  
note the WCB Consultant indicated, in part, the following:  
“It would appear that these are attributable to tendinosis and tearing of  
the rotator cuff. . . .  
Consequently, it would not be reasonably argued, in my opinion, that her  
current shoulder pathology, as demonstrated on MRI scan, could have  
been caused by or contributed to by the [date of accident] work duties on  
this claim.”  
[178]  
We disagree, the worker reported an injury to the left shoulder at the time of the  
accident, and WCB accepted a diagnosis of left shoulder tendonitis. The  
evidence as we have outlined above supports that the worker remained  
symptomatic either in range of motion limitations or pain limitations or both.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 33  
[179]  
As we have noted, the worker’s injuries are complex, the worker was not  
provided with a MRI or ultrasound of the shoulder at the time of onset or through  
numerous medical examinations in the intervening years and we unable to  
identify evidence that confirms a pre-existing causal explanation or an alternative  
causal explanation for the worker’s MRI confirmed findings.  
[180]  
The panel reviewed the reports dated December 20, 2007 and March 3, 2011,  
referred to by Physician 6 and note:  
[180.1] The December 20, 2007 report does not provide evidence that the  
orthopaedic specialist examined the right or left shoulder. We note only  
that the surgeon reported “no obvious clinical deformities of the right upper  
limb; however, it is the worker’s left shoulder that is symptomatic. We  
note this referral was for evaluation of the worker’s wrist and forearms, not  
the shoulder.  
[180.2] Our review of the March 3, 2011, report provides that the physiatrist noted  
the worker’s shoulder to be symptom free; however, we note the this  
report makes no mention of assessment of the worker’s shoulder or  
provides range of motion measurements. The physiatrist used the  
singular term shoulder and did not specify if the symptom free shoulder  
was the symptomatic left shoulder or her non-symptomatic right shoulder.  
We further note, the referral to this specialist was for the evaluation of her  
carpal tunnel and lower arms, specifically epicondylitis.  
[181]  
[182]  
We find the underlying reports relied upon by Physician 6, a WCB Medical  
Consultant does not support the conclusion of no causal or contributory link to  
the shoulder injury and the accepted diagnosis of left shoulder tendonitis. It is for  
this reason we place little weight on the WCB Medical Consultant’s January 30,  
2013, and April 26, 2013 medical opinions findings.  
We note the objective findings of February 26, 2015, from Physician 9 (attending  
physician) who noted left shoulder scapular dyskinesia (abnormal movement)  
with forward elevation and no dyskinesia with abduction. Physician 9 noted pain  
with subscapular testing and opined that the worker’s symptoms seemed to be  
progressing in the left shoulder. Physician 9 ordered a repeat left shoulder X-ray  
and associated the worker’s symptoms to the “ORIGINAL INJURY SEVERAL  
YEARS AGO” and provided a progressive injury date of October 4, 2000. We  
interpret this report supports a causal connection to the compensable accident.  
[183]  
The February 26, 2015 X-ray report of the left shoulder revealed, in part, chronic  
changes.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 34  
[184]  
The July 2, 2015 ultrasound results of the worker’s left shoulder revealed the  
following:  
Complete tear of the supraspinatus with mild fatty infiltration of the  
muscle belly;  
Low-grade partial thickness insertional tear of the mid fibres of the  
subscapularis on a background of mild tendinosis;  
Moderate infraspinatus tendinosis;  
Moderate biceps tendinosis; and  
Moderate acromioclavicular joint degeneration change with a small  
amount of capsular vascularity.  
[185]  
On January 6, 2016, the worker was assessed by Physician 18, an orthopaedic  
surgeon who noted, in part:  
winging of the left scapula;  
weakness of resisted abduction with associated pain;  
left acromioclavicular joint and long head of biceps tenderness to  
palpation; and  
reduced range of motion of the left shoulder in forward flexion,  
abduction when compared to the right shoulder.  
[186]  
Physician 18, diagnosed a chronic rotator cuff tear of the left shoulder and based  
upon the presence of fatty filtration, opined the tear of the rotator cuff is:  
“. . . likely chronic in nature. In addition, we have also talked about the  
etiology of this tear. In the absence of a traumatic incident, it is likely that  
the repetitive heavy use of her arms ten to fifteen years ago likely resulted  
in the eventual tear in her rotator cuff . . .”  
[187]  
[188]  
We find the opinion of Physician 18 establishes a causal connection to the  
compensable accident, as we are unable to identify any other traumatic events  
within the evidence before us to account for the ultrasound findings.  
On April 20, 2016, Physician 19, an orthopaedic specialist examined the worker  
for bilateral epicondylitis. While the worker’s range of motion was found to be  
excellent and painless in the left shoulder, we are unable to ascertain if the  
shoulder range of motion was tested actively, passively or if the range of motion  
Classification: Protected A  
Decision No.: 2021-0515  
Page 35  
was assessed under resistance. Given this examination was for the purposes of  
bilateral epicondylitis and not the identification of shoulder pathology, we place  
little weight on this opinion, noting that it appeared to be completed by a medical  
resident as opposed to the orthopaedic specialist.  
[189]  
We acknowledge the adjudicator attributed the onset of the worker’s problems  
with regard to the left shoulder to a residential move made by the worker. In  
response to questioning from the panel, the worker explained the WCB never  
asked her how the move occurred. She indicated that approximately 20 people  
assisted with the packing and moving of her belongings to her new residence, we  
are unable to find evidence within the appeal document package that suggests  
otherwise.  
[190]  
We accept the worker’s evidence at the hearing, and therefore place little weight  
on the speculative causal attribution to the worker’s move in light of the submitted  
massage therapy receipts demonstrating her left shoulder was symptomatic  
prior to moving and remained symptomatic during the intervening period.  
[191]  
[192]  
The panel also places greater weight on the January 6, 2016 opinion of  
Physician 18, an orthopaedic surgeon, as opposed to the WCB Medical  
Consultants and Physician 17, an IME examiner.  
We do so as Physician 18 was aided by the presence of X-rays, ultrasound and  
MRI results and linked the presence of fatty infiltration to the repetitive heavy  
activities of her occupation as a baker back to the time of the progressive onset  
of the claim. We interpret the orthopaedic surgeon’s opinion establishes the  
chronic nature of the worker’s left shoulder tendinosis and left shoulder chronic  
rotator cuff tears are attributable to the compensable accident and confirm her  
symptoms were ongoing.  
[192.1] It follows; the WCB has additional responsibility for the worker’s confirmed  
left shoulder rotator cuff tears.  
[193]  
[194]  
While we acknowledge the opinions of the WCB Medical Consultant and IME  
examiner, we do not find them persuasive for the reasons identified above.  
As we have established the WCB has:  
[194.1] ongoing responsibility beyond June 13, 2002 for the worker’s left rotator  
cuff tendonitis; and  
[194.2] additional responsibility for the worker’s left shoulder MRI confirmed tears.  
[195]  
While we acknowledge the representative’s submission regarding entitlement to  
wage loss benefits or the unsuitability of her employment in human resources,  
these issues are not before this panel. The decisions made on this issue are  
subject to further adjudication by the WCB.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 36  
Decision – Issue 3  
[196]  
[197]  
[198]  
The Workers’ Compensation Board has ongoing responsibility beyond June 13,  
2002 for the worker’s left shoulder tendonitis as a result of the October 4, 2000  
work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
left shoulder rotator cuff tears as a result of the October 4, 2000 work-related  
progressive injury.  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
Analysis – Issue 4  
[199]  
[200]  
Issue 4: Does the Workers’ Compensation Board have ongoing and/or  
additional responsibility for the diagnosed conditions related to the  
worker’s bilateral wrist problems arising from the October 4, 2000 work  
accident?  
The panel has chosen to address each diagnosis for the worker’s wrists in their  
entirety as to minimize the duplication of the evidence. We do so to reflect the  
chronological nature of the worker’s symptoms, the medical evidence and the  
pertinent WCB decisions.  
[200.1] We find the weight of evidence establishes a direct causal relationship  
between the October 4, 2000 work-related progressive injury and the  
worker’s bilateral carpal tunnel syndrome as originally accepted by the  
WCB.  
[200.2] We find the weight of medical evidence establishes that the worker’s right  
carpal tunnel syndrome had not resolved as of November 6, 2001.  
[200.3] The find weight of evidence establishes that the WCB has additional  
responsibility for the worker’s right wrist scaphoid lunate injury with  
avascular necrosis and a right wrist cyst as a result of the October 4, 2000  
work-related progressive injury. We rely on the following analysis and  
reasons to support our findings.  
[201]  
[202]  
The WCB initially accepted the claim, in part, for bilateral carpal tunnel  
syndrome.  
On January 4, 2000, Physician 9 completed the Physicians Report of Accident  
and provided a treatment plan for carpal tunnel syndrome and nerve conduction  
studies. The panel accepts the WCB Physician Report of accident inherently  
conveys a causal relationship to the worker’s occupation as the WCB report was  
filed by the Physician 9 in support of the worker’s injuries.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 37  
[203]  
On January 19, 2001, Physician 7, a physiatrist conducted bilateral EMG studies  
and determined in part, that the worker had bilateral median neuropathy at the  
wrist compatible with a clinical diagnosis of very mild carpal tunnel syndrome.  
We note in the history section that the worker was a baker who first noticed the  
onset of symptoms to the spring of 2000.  
[204]  
On November 6, 2001, the worker underwent a right carpal tunnel  
decompression. We note the indications for the surgical procedure states:  
“A 42 year-old lady with EMG-proven bilateral carpal tunnel syndrome,  
worse on the right side, which is more problematic.” [Emphasis added]  
[205]  
[206]  
We find the combined weight of evidence establishes that the worker has a  
confirmed diagnosis of bilateral carpal tunnel syndrome.  
On September 15, 2004, Physician 3, a WCB Medical Consultant noted that the  
WCB had accepted full responsibility for bilateral carpal tunnel syndrome.  
Physician 3 opines that:  
“. . . It is my opinion that the inflammatory condition also caused an  
aggravation of the pre-existing asymptomatic bilateral carpal tunnel  
syndrome to become symptomatic in the right hand.” [Emphasis added]  
[207]  
We are unable to identify in our review of the evidence that the worker had a  
pre-existing confirmed diagnosis of carpal tunnel of either the right or the left  
wrist to support the change in the level of responsibility for the worker’s bilateral  
carpal tunnel syndrome. It is for this reason, we place little weight on the WCB  
Medical Consultant’s opinion and find the weight of the other medical evidence  
above supports that the worker was diagnosed with bilateral carpal tunnel  
syndrome that arose from the compensable job duties.  
[208]  
We find, the evidence supports the worker was diagnosed with bilateral carpal  
tunnel syndrome on a progressive basis arising from the repetitive hazards of her  
occupation as a baker.  
[209]  
[210]  
The WCB injury summary report indicates the carpal tunnel condition was  
considered “resolved” on November 6, 2001.  
The panel does not know how this resolution date came to be established, as this  
is the date the worker underwent decompression surgery of the right wrist.  
Given the worker’s sutures were not scheduled to be removed until  
November 16, 2001; we find the worker’s symptoms and recovery period  
extended beyond November 6, 2001.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 38  
[211]  
On May 27, 2002, Physician 5, a neurologist, examined the worker and was  
unable to find a neurologic cause for the worker’s right forearm pain extending  
from the elbow to the wrist. From this report, we note, in part, the worker:  
does a lot of pulling with her right hand and cutting with her left hand  
over time, she began developing pain around her elbow, in the right  
forearm and into the right wrist  
began experiencing numb sensations in her right hand which woke her  
at night  
underwent a right wrist carpal tunnel release in November 2001  
continues with pain around the wrist as well as in the forearm and the  
medial elbow  
suffers pain in the wrist with flexion and extension  
has no history of trauma to the forearm, neck or wrist  
has slower fine finger movements on the right when compared to the  
left.  
[212]  
We interpret the May 27, 2002 Physician 5 finding of no confirmed neurologic  
cause for the worker’s symptoms, does not negate the presence of structural  
causes for the worker’s wrist pain as noted by Physician 1 in the June 13, 2002  
WCB Medical Status Examiner report that recommended a MRI be conducted.  
The findings of Physician 5 supports the worker continues to suffer pain in the  
right wrist with flexion and extension. In other words, the worker’s right wrist  
remained symptomatic. We note, however, this specialist only examined the  
worker’s right wrist.  
[213]  
A June 25, 2002 MRI of the right wrist found, in part, a tiny cyst at the base of the  
ulnar styloid process a few millimetres in diameter, suspected of being a tiny  
ganglion cyst. The report found an area of abnormality on the proximal medial  
aspect of the lunate with a tiny cyst and bone marrow edema either due to  
degenerative changes or to a stress reaction.  
[214]  
[215]  
The panel notes the radiologist did not provide an interpretation for the term  
“stress reaction” and we find no evidence to support a diagnosis of “stress  
fracture” as argued by the representative.  
However, the panel interprets the term “stress reaction” to confirm the presence  
of a stress related injury had occurred to the proximal medial aspect of the lunate  
with bone marrow edema and a tiny cyst.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 39  
[216]  
On July 25, 2002, Physician 18, an orthopaedic surgeon reviewed the June 25,  
2002 MRI of the right elbow and wrist and opined, in part, that the worker seems  
to have developed an ulnar neuropathy and suggested EMG/Nerve Conduction  
studies.  
[217]  
[218]  
On August 26, 2002, Physician 1 noted, in part, the worker’s pain along the ulnar  
border of the right wrist.  
On November 22, 2002, Physician 18 noted that the worker has pain on the ulnar  
aspect of the right wrist with numbness and tingling in the distribution of the ulnar  
nerve and that further neurologic testing of the right ulnar nerve was indicated.  
[219]  
[220]  
On July 3, 2003, an MRI of the worker’s right wrist demonstrated significant  
resolution of the previously noted (June 25, 2002) small ganglion cyst at the base  
of the ulnar styloid process and degenerative changes/stress reaction at the  
proximal-ulnar aspect of the lunate. The radiologist suspected early avascular  
necrosis of the lunate.  
On January 24, 2004, an X-ray study was completed to “rule out Keibock  
disease”. The findings revealed dorsal angulation of the lunate on the lateral  
view implying the presence of dorsal intercalated segment instability (DISI). The  
panel relies on the Merck Manual Professional Edition to understand that  
Keinbock disease is:  
“avascular necrosis of the lunate bone.”  
[221]  
[222]  
The panel was unable to identify evidence that confirms the presence of a pre-  
existing stress injury to the right wrist.  
On July 12, 2004, Physician 3 noted the worker’s right wrist pain and evidence of  
early avascular necrosis in the lunate bone and opined these conditions did not  
arise from the injury covered under this claim. We note the WCB Medical  
Consultant indicates there is no evidence of any pre-existing conditions that were  
aggravated by the injury covered under this claim. We interpret the WCB  
Medical Consultant report to establish that the worker did not have any pre-  
existing conditions, including carpal tunnel syndrome, avascular necrosis, dorsal  
intercalated segment instability (DISI) that were aggravated by the injuries  
associated with this claim.  
[222.1] We were unable to identify within Physician 3’s July 12, 2004 Medical  
Consultant’s report the rationale for an exclusionary opinion regarding the  
worker’s stress injury diagnosis in light of the prior association made by on  
May 27, 2002, by the Neurologist related to the heavy manual activities of  
a baker.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 40  
[222.2] We interpret this report to support that the worker’s confirmed bilateral  
carpal tunnel syndrome was not aggravated by the work duties as there is  
no evidence to support that the worker’s bilateral carpal tunnel pre-existed  
the compensable injury.  
[223]  
A July 27, 2004 MRI of the right wrist revealed degenerative changes at the  
proximal ulnar aspect of the lunate with a subcortical osseous cyst formation.  
The radiologist suspected a scapholunate ligamentous injury or sprain in view of  
the widened scapholunate joint space. There was also a suspicion for early DISI  
(dorsal intercalated segment instability). The radiologists indicated that some of  
the changes were suggestive of a mild sprain injury and suggested an MRI/  
arthrogram would help to clarify the presence or absence of any scapholunate  
joint communication.  
[224]  
[225]  
We interpret the radiologists opinion establishes that an injury had occurred,  
consistent with original January 24, 2004 x-ray referral for “Kleinbock” disease or  
avascular necrosis and a scapholunate ligamentous injury.  
On October 15, 2004, the MRI/Arthrogram of the worker’s right wrist found a  
focal area of complete absence of marrow fat associated with a subchondral cyst  
formation in the proximal lunate that is consistent with a previous osteochondral  
injury and secondary cyst formation with some persistent bone marrow edema.  
The radiologist opined, that the patient’s symptoms may be related to this  
abnormality. Subtle disruption of the lunotriquetral ligament with communication  
between radiocarpal and mid carpal compartments but this does not appear to be  
associated with any significant instability.  
[226]  
The panel interprets the MRI/Arthrogram establishes the presence of a  
subchondral cyst consistent with a previous an osteochondral (bone) stress  
injury. The evidence supports there were no pre-existing conditions or injuries of  
significance to the worker’s right wrist. In the absence of any other pre-existing  
history, as opined by the specialist, of a bone/stress injury to the right wrist, we  
find these changes to be attributable to the compensable injury.  
[227]  
[228]  
On May 17, 2005, Physician 10 an orthopaedic surgeon indicated the worker had  
pain of the right wrist and left shoulder and medial and lateral epicondylitis, with  
persistent right wrist weakness. We interpret the May 17, 2005 orthopaedic  
assessment establishes the worker continued to experience symptoms, among  
other locations, in the right wrist.  
On June 22, 2005, in response to an employer’s application for cost relief,  
Physician 3 stated:  
“It is not uncommon that an inflammatory condition in the forearms and  
epicondyles is very slow to recover. There is no evidence that the injury  
covered under this claim caused any aggravation of the avascular  
Classification: Protected A  
Decision No.: 2021-0515  
Page 41  
necrosis of the lunate in the right wrist or the pre-existing and concurrent  
psoriasis. [The worker] was not able to return to her pre-accident  
employment based on permanent work restrictions against repetitive  
gripping activities due to the presence of chronic tendonitis in both  
forearms covered under this claim. . . .”  
[229]  
[230]  
We interpret the opinion of Physician 3 establishes that there was no aggravation  
to the worker’s avascular necrosis as a pre-existing condition, as we are unable  
to find evidence that supports that the worker’s AVN pre-existed the  
compensable injury.  
The October 26, 2006 WCB Medical Consultant Memorandum, documented a  
conversation with the family physician indicating that the worker’s previous  
recreational softball activity had  
“likely caused this condition [AVN] in the right wrist.”  
[231]  
[232]  
We note the worker’s physician wrote to the WCB Medical Consultant and  
clarified that it was possible that playing softball had contributed to the right wrist  
condition. The worker’s treating physician noted however, that such an  
attribution did not account for the bilateral nature of the worker’s wrist injuries at  
the time of onset.  
We place greater weight on the opinion of the worker’s treating physician, who  
has examined the worker prior to the onset of this claim and has continued to do  
so. It is not known to the panel, how an aggravation to the avascular necrosis  
(AVN), described as a stress injury, could pre-date the compensable mechanism  
of injury, as we can find no evidence to support a non-occupational injury had  
occurred or medical evidence that confirmed the worker’s AVN predated the  
compensable accident.  
[233]  
The panel notes a second letter from Physician 9 dated October 10, 2007 to the  
WCB medical consultant that states:  
“To clarify, I said it was possible that the sports activity could have  
aggravated her wrist just as working would. As you are aware, [the  
worker] was employed as a baker. There was repetitive flexion,  
extension when working with the dough, which is a likely cause of her  
carpal tunnel injury. Repetitive injury can also cause scaphoid lunate  
dissociation.  
I recommend that you seek the opinion of an upper extremity orthopaedic  
surgeon in regards to the causality of the scaphoid lunate dissociation  
and avascular necrosis of the wrist. . . .”  
[234]  
We interpret this to mean the worker’s physician disagreed with the causal  
conclusion of the WCB Medical Consultant and suggested that the worker’s job  
demands are a more likely cause of the worker’s bilateral carpal tunnel injury,  
scaphoid lunate dissociation, AVN and cyst than her involvement in softball.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 42  
[235]  
On December 20, 2007, Physician 18, an Orthopaedic specialist assessed the  
worker and suggested, in part, that a subtle injury to the lunotriquetral ligament (a  
ligament that makes up part of the wrist) may be an explanation for the worker’s  
persistent ulnar sided wrist pain.  
[236]  
[237]  
We interpret the December 20, 2007 orthopaedic specialists use of the term  
injury, in the absence of any other confirmed injury to the worker’s right wrist,  
establishes than an “injury” had occurred to the worker’s right wrist.  
In light of the above, we conclude the worker was able to return to human  
resource work from 2006 to 2010. However, we also accept that during this time,  
the worker remained symptomatic. Moreover, the worker indicated she struggled  
to maintain her employment because she was “slow” and was never aided by the  
provision of the WCB recommended ergonomic assessment.  
[238]  
The July 18, 2009 letter from the worker to the DRDRB states in part:  
“Since my injury I have taken the Human Resources Management  
Diploma Program through [name of post-secondary institution] and have  
been working in an office environment. I have physical limitations in my  
job and have difficulties picking up the phone, turning the pages in a book  
or documents in a file. Something as simple as holding onto a phone  
receiver tightens up the muscles in my forearms, elbows and I am in need  
to continually change arms and use my shoulder/neck muscles which in  
turn tightens up the muscles in my arms and when this occurs it causes  
pain and limits my physical abilities within my job duties. When I am on  
the phone I have difficulty taking notes when speaking to employees and  
continually have to ask people on the phone to repeat themselves as I  
have missed parts of the conversations which is important to my job and  
in turn upsetting the people who I have been hired to assist.”  
[239]  
The panel in review of the December 5, 2011 WCB Medical Consultant’s  
Memorandum notes:  
The October 10, 2007 correspondence from the Physician 9 rebuts the  
WCB Medical Consultant’s opinion that the avascular necrosis who  
opined the worker’s symptoms were more attributable to playing  
softball as opposed to the worker’s occupation.  
[240]  
It is not known how the WCB came to accept the worker’s carpal tunnel  
syndrome on an aggravation basis as we cannot identify and nor was the  
representative able to direct the panel to evidence that confirms the worker had a  
pre-existing diagnosis of carpal tunnel syndrome in either wrist.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 43  
[241]  
We are not persuaded by the Medical Consultant’s opinion that a non-  
occupational cause may have contributed to the worker’s injury. We find there is  
no compelling evidence indicating that other causes have been investigated to  
sufficiently rule out the worker’s occupational exposure. As such, we find the  
non-occupational causal relationship made by the Medical Consultant to be  
speculative.  
[242]  
On April 3, 2013 Physician 17, an IME plastic surgeon examined the worker and  
determined the examination was invalid. Given the invalid examination, the  
panel places little weight on the opinions rendered from this report.  
[242.1] We note that despite the invalid nature of the examination, the WCB  
adjudicator (April 3, 2013) relied upon the conclusions of this specialist  
when it decided that the worker’s bilateral elbow and wrist symptoms were  
not related to the original workplace injury of October 4, 2000.  
[243]  
[244]  
The panel interprets that invalid or inconclusive examinations cannot be used to  
reliably support or refute causal opinions. If the examiner has established the  
physical examination is invalid, then it follows that any conclusions based on an  
invalid assessment, would also be of limited value in establishing a causal  
connection.  
On July 3, 2013 and October 22, 2013, Physician 10, a plastic surgeon, reviewed  
the decisions made by the WCB. The orthopaedic surgeon provides in part, the  
following:  
The worker continued to have pain in both forearms and her right wrist.  
The pain in both forearms, especially on the right felt like a fascial  
defect in the area of the forearm, this palpated defect resulted in the  
order for a MRI examination of the forearms.  
[244.1] The plastic surgeon goes on to state:  
“I have reviewed my letters dates July 3 and January 8, 2013, as well as  
[Medical Consultant] assessment. I reviewed the fact that she was  
working as a baker when her injured occurred. She was transferring  
almost 5,000 pounds daily. She subsequently complained of pain in the  
right and left forearm as well as tender wrists. I stated this originally in my  
letter dated January 8th and reaffirm this in my letter dated July 3, 2013.”  
[245]  
The panel interprets the July 3, 2013 and October 22, 2013 opinion of Physician  
10 establishes a causal connection to the mechanism of injury and the worker’s  
ongoing forearm and right wrist symptoms.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 44  
[246]  
On December 16, 2013, the plastic surgeon reviewed the worker’s MRI findings  
and states:  
“The patient was seen in the clinic today for review of her MRIs. This  
showed that she had some tears bilaterally of the common extensor  
tendons, thickening of the ulnar nerves in the cubital tunnels and some  
thickening of the radial collateral ligaments. I treated the tear in the  
lateral epicondyle today with a steroid injection. I’m not sure if this will  
help as this has been long standing. She still complains of pain in her  
arm and she relates this directly to working as baker and lifting 5000  
pounds a day. It is certainly possible that with repetitive strain and lifting  
this kind of weight a day she could have torn her common extensor  
tendons resulting in the obvious MRI tears that are present and causing  
her pain.”  
[247]  
The panel interprets the treating plastic surgeon’s letter, which included a review  
of his past opinions, examination of the worker and a review of the WCB Medical  
Consultant’s report to establish that the worker’s symptoms were ongoing and  
attributable to her occupational duties. We note the provision of treatment for the  
worker’s injuries are occurring 13 years following the compensable accident and  
are well beyond the dates of “resolution” established by the WCB.  
[248]  
The presence of the July 30, 2015, hospital and hand clinic report supports the  
worker’s submissions that she remained symptomatic and sought treatment from  
the public health system. We interpret this evidence establishes the worker has  
a complex history noting the presence of a radiating burning type pain as well as  
the diagnoses of bilateral carpal tunnel syndrome, bilateral medical epicondylitis  
(golfers elbow), bilateral lateral epicondylitis (tennis elbow), and bilateral cubital  
tunnel syndrome.  
[249]  
On November 9, 2015, Physician 12 (plastic and reconstruction surgeon 2 stated  
the following:  
“. . . She also complains of significant wrist pain on the right side. Review  
of her previous MRI demonstrates a previous fracture of the lunate and  
possible avascular necrosis of the lunate. This has not been assessed  
since her MRI in 2004. . . .  
It was discussed with [worker] that this diagnosis would pertain to her  
wrist pain only and would not explain her elbow and shoulder pain  
. . .”  
[250]  
The panel notes the November 9, 2015 specialist report utilized the term  
“previous fracture” as opposed to stress reaction used in the previous MRIs. We  
note the December 3, 2015 MRI results found no features to suggest avascular  
necrosis. The report found degenerative changes were present and queried if a  
prior impaction injury occurred to the worker’s proximal ulnar lunate. The panel,  
in review of the worker’s reported past medical history was unable to locate  
evidence confirming a past injury to the worker’s right wrist that would otherwise  
provide a non-compensable explanation for these findings.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 45  
[251]  
We note the term stress reaction, not stress fracture was utilized to describe the  
injury to the worker’s right wrist. In the absence of any other causal explanation,  
we interpret the term stress reaction to be synonymous with a compensable  
stress injury:  
[251.1] The panel relies upon the weight of opinions from the Physician 9,  
Physician 18 to establish there is a causal relationship between the  
October 12, 2000 work-related progressive injury and the worker’s  
ongoing right wrist problems (carpal tunnel syndrome, AVN, cyst and  
scaphoid lunate injury).  
[251.2] We find the weight of evidence supports the worker’s carpal tunnel  
syndrome had not resolved as of November 6, 2001.  
[252]  
We find the weight of evidence establishes a direct causal relationship between  
the October 4, 2000 work-related progressive injury and the worker’s bilateral  
carpal tunnel syndrome as originally accepted by the WCB.  
[253]  
[254]  
We find the weight of medical evidence establishes that the worker’s right carpal  
tunnel syndrome had not resolved as of November 6, 2001.  
We find the weight of medical evidence establishes that the WCB has additional  
responsibility for the worker’s impaction/stress reaction injury to her right wrist  
that has been diagnosed as a scapholunate ligamentous injury with avascular  
necrosis and a cyst attributable to the work-related progressive injury of  
October 4, 2000.  
[255]  
While we acknowledge the representative’s submission regarding entitlement to  
wage loss benefits or the suitability of her employment in human resources,  
these issues are not before this panel. The decisions made on this issue are  
subject to further adjudication by the WCB.  
Decision – Issue 4  
[256]  
[257]  
[258]  
The Workers’ Compensation Board has ongoing responsibility beyond  
November 6, 2001 for the worker’s right carpal tunnel syndrome as a result of the  
October 4, 2000 work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
right wrist scaphoid lunate injury with avascular necrosis and a right wrist cyst as  
a result of the October 4, 2000 work-related progressive injury.  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 46  
Overall Conclusion – Issues 1 through 4  
[259]  
The worker’s medical issues are complex and are primarily located in the lower  
region (elbow to wrists) of both arms as well as the left shoulder. In our review,  
while numerous diagnosis have been proposed and investigated, we find the  
weight of evidence supports the progressive effect of her job duties have resulted  
in multiple injuries that are not only ongoing but injuries that are causally related  
to the compensable accident.  
[260]  
The historical investigations and opinions, have not considered the full scope of  
all of the worker’s injuries and thus the medical information has not considered  
the effects of the worker’s injuries in their entirety at the time of the individual  
medical assessments or adjudicative decisions. While this is an artifact of the  
adjudication process that seeks specific answers to specific questions, it must be  
remembered that the worker, as evidenced by the medical findings, has  
sustained multiple complex injuries involving similar overlapping and inter-related  
structures.  
[261]  
[262]  
Finally, we acknowledge that a significant period of time has passed since the  
date of the DRDRB decision in which new medical evidence has been generated  
and thus considered by this panel.  
We have reviewed the appeal documents package in its entirety, we have  
presented the medical evidence that either supports or is contrary and provided  
our explanations for weighting this evidence and the our reasons that support our  
conclusions and our findings.  
Decision Summary  
[263]  
[264]  
Issue 1: Does the Workers’ Compensation Board have ongoing or  
additional responsibility for the diagnosed conditions related to the  
worker’s bilateral forearm problems arising from the October 4, 2000 work  
accident?  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral forearm injury (bilateral tendinosis, bilateral tendonitis and tears of the  
common extensor tendon) as a result of the October 4, 2000 work-related  
progressive injury.  
[265]  
[266]  
The Workers’ Compensation Board does not have additional responsibility for the  
worker’s bilateral forearm injury (compartment syndrome) as a result of the  
October 4, 2000 work-related progressive injury.  
The worker’s appeal is varied and the February 21, 2014 Dispute Resolution and  
Decision Review Body decision is varied.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 47  
[267]  
Issue 2: Does the Workers’ Compensation Board have ongoing or  
additional responsibility for the diagnosed conditions related to the  
worker’s bilateral elbow problems arising from the October 4, 2000 work  
accident?  
[268]  
[269]  
[270]  
[271]  
The Workers’ Compensation Board has ongoing responsibility beyond April 9,  
2013 for the worker’s right medial epicondylitis (golfer’s elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
left medial epicondylitis (golfer’s elbow) as a result of the October 4, 2000 work-  
related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral-lateral epicondylitis (right and left arm tennis elbow) as a result of the  
October 4, 2000 work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
bilateral cubital tunnel syndrome as a result of the October 4, 2000 work-related  
progressive injury.  
[272]  
[273]  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
Issue 3: Does the Workers’ Compensation Board have ongoing or  
additional responsibility for the diagnosed conditions related to the  
worker’s left shoulder arising from the October 4, 2000 work accident?  
[274]  
[275]  
[276]  
The Workers’ Compensation Board has ongoing responsibility beyond June 13,  
2002 for the worker’s left shoulder tendonitis as a result of the October 4, 2000  
work-related progressive injury.  
The Workers’ Compensation Board has additional responsibility for the worker’s  
left shoulder rotator cuff tears as a result of the October 4, 2000 work-related  
progressive injury.  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 48  
[277]  
[278]  
Issue 4: Does the Workers’ Compensation Board have ongoing or  
additional responsibility for the diagnosed conditions related to the  
worker’s wrist arising from the October 4, 2000 work accident?  
The Workers’ Compensation Board has ongoing responsibility beyond  
November 6, 2001 for the worker’s right carpal tunnel syndrome as a result of the  
October 4, 2000 work-related progressive injury.  
[279]  
[280]  
The Workers’ Compensation Board has additional responsibility for the worker’s  
right wrist scaphoid lunate injury with avascular necrosis and a right wrist cyst as  
a result of the October 4, 2000 work-related progressive injury.  
The worker’s appeal is granted and the Dispute Resolution and Decision Review  
Body decision of February 21, 2014 is varied.  
This decision is made with the full agreement of the hearing panel.  
Decision signed in Edmonton, Alberta on March 30, 2022.  
S. Jacobi  
Hearing Chair  
(on behalf of the panel)  
Hearing Panel:  
S. Jacobi  
C. Fisher  
P. Paquette  
– Hearing Chair  
– Commissioner  
– Commissioner  
Typed by: jag  
E_DEC08D (20210701)  
Classification: Protected A  
Decision No.: 2021-0515  
Page 49  
Appendix A  
Legislation – Workers’ Compensation Act, RSA 2000, c W-15 (WCA)  
[A1]  
Preamble  
“. . . WHEREAS the purpose of the workers’ compensation system is to  
provide appropriate compensation to workers who suffer workplace-  
related injuries and illnesses; . . .”  
[A2]  
[A3]  
Section 1(1)(a) provides the interpretation of “accident” as meaning an accident  
that arises out of and occurs in the course of employment.  
Section 13.1(1) of the WCA states:  
“13.1(1) Subject to sections 13.2(11) and 13.4, the Appeals Commission  
has exclusive jurisdiction to examine, inquire into, hear and determine all  
matters and questions arising under this Act and the regulations in  
respect of  
(a) appeals from decisions of a review body under section 9.4,  
(b) repealed 2020 c32 s3(8),  
(c) appeals from determinations of the Board under section 21(3), and  
(d) any other matters assigned to it under this or any other Act or the  
regulations under this or any other Act,  
and the decision of the Appeals Commission on the appeal or other  
matter is final and conclusive and is not open to question or review in any  
court.”  
[A4]  
Section 13.2(6) of the WCA states:  
“(6) In the hearing of an appeal under this section, the Appeals  
Commission  
(a) shall give all persons with a direct interest in the matter under  
appeal an opportunity to be heard and to present any new or  
additional evidence,  
(b) is bound by the board of directors’ policy relating to the matter  
under appeal,  
(c) shall, subject to subsection (6.1), permit the Board to make  
representations, in the form and manner that the Appeals  
Commission directs, as to the proper application of policy  
determined by the board of directors or of the provisions of this Act  
or the regulations that are applicable to the matter under appeal,  
(d) may confirm, reverse or vary the decision or determination  
appealed,  
Classification: Protected A  
Decision No.: 2021-0515  
Page 50  
(e) may direct that its decision be implemented within a specified time  
period, and  
(f) may refer any matter back to the review body or the Board, as the  
case may be, for further action or decision, with or without  
directions.”  
[A5]  
Section 24(1) of the WCA states:  
“24(1) Subject to this Act, compensation under this Act is payable  
(a) to a worker who suffers personal injury by an accident, unless the  
injury is attributable primarily to the serious and wilful misconduct  
of the worker, and  
(b) to the dependents of a worker who dies as a result of an accident”  
Section 61 of the WCA addresses recurrence of disability:  
“61(1) The Board may, if  
[A6]  
(a) a worker who was awarded compensation in respect of an  
accident ceases to receive that compensation by reason of  
recovery from the disability,  
(b) there is a recurrence of disability in the form of temporary disability  
and that disability is due to the same accident,  
(c) the worker has, at the time of recurrence of the disability, earnings  
in an amount that is greater than the amount of the worker’s net  
earnings at the time of the accident, and  
(d) more than 12 months have elapsed since the date of the accident,  
pay compensation on and from the date of the recurrence on the same  
basis as if the worker had suffered another accident and been disabled  
on the date of the recurrence of disability.  
(2) Subsection (1) applies regardless of whether the accident that gave  
rise to the right to compensation occurred before or after the coming into  
force of this Act.”  
Classification: Protected A  
Decision No.: 2021-0515  
Page 51  
Appendix B  
Workers’ Compensation Board Policy  
Issue 1  
[B1]  
[B2]  
We note that the effective policies applied at the time of the case manager’s  
decisions of January 3, 2012 (February 1, 2007 policy) and April 12, 2013  
(February 1, 2012 policy) changed. The panel has provided the policy versions  
considered in rendering our decision.  
Policy 03-01, Part I, General (issued February 1, 2012) states:  
“WCB will determine whether an injury has occurred as the result of a  
compensable accident, and will adjudicate appropriate compensation and  
services from the date of accident. WCB may also consider a second  
injury compensable if it is the direct result of the original compensable  
injury.  
When determining its responsibility, WCB will evaluate the relationship  
between the injury and the compensable accident. In second injury  
cases, WCB will evaluate the relationship between the original  
compensable injury and the second injury.  
. . .  
1.0  
Injury  
Under s. 24 of the Workers’ Compensation Act (WCA), compensation is  
payable to a worker who suffers personal injury by an accident. Injuries  
may be either physical or psychological. They may be the immediate  
result of an accident or develop over time.  
. . .  
4.0  
Relationship Between the Injury and the Compensable  
Accident  
Many injuries (e.g., strains, sprains, burns, cuts, etc.) have an obvious  
relationship to the compensable accident; consequently, determining  
WCB’s level of responsibility is relatively simple. However, there are  
other injuries which, because of their progressive nature or less obvious  
relationship to employment, require consideration of relevant factors both  
in and outside employment which may have contributed to or caused the  
injury (see Part II, Application 1, Relationship to Compensable Accident).”  
Classification: Protected A  
Decision No.: 2021-0515  
Page 52  
[B3]  
Policy 03-01, Part II, Application 1: Relationship to Compensable Accident,  
(issued February 1, 2007) states:  
“1. Why is the relationship of injury to compensable accident  
important?  
To be compensable, an injury must be the result of an accident as  
defined under Policy 02-01, Arises Out of and Occurs in the Course of  
Employment. Therefore, when adjudicating the eligibility of a claim, WCB  
looks at the nature of the injury and its relationship to the compensable  
accident.  
Often there is an obvious relationship between the nature of the injury  
and the compensable accident (e.g., a firefighter is burned when fighting  
a fire). However, the relationship is not always obvious. In these cases,  
there is a need for additional information, especially medical information,  
to establish the relationship to the compensable accident. For example,  
many occupational diseases have a long latency period. WCB's inquiries  
must establish whether the work-related exposure was sufficient to cause  
the condition (see Application 3, Occupational Disease).  
2.  
How does WCB adjudicate injuries?  
In general, every claim is subject to a similar adjudicative process. The  
relationship between the injury and the compensable accident is  
examined to determine entitlement. Additional medical advice is sought  
on an as-needed basis. Complex claims may require additional  
investigation to determine work-relatedness.  
Special requirements for some types of injuries (e.g., cardiac,  
occupational disease) are given in Applications 2 to 8 and in the following  
questions.”  
Issues 2 through 4  
[B4]  
[B5]  
The panel applies the WCB policy version in effect at the time of the January 3,  
2012 and April 12, 2013, WCB case manager’s decisions.  
Policy 03-01, Part I – Injuries (Issue Date: September 5, 2018) states:  
“POLICY:  
WCB will determine whether an injury has occurred as the result of a  
compensable accident, and will adjudicate appropriate compensation and  
services from the date of accident. WCB may also consider a second  
injury compensable if it is the direct result of the original compensable  
injury.  
. . .  
Classification: Protected A  
Decision No.: 2021-0515  
Page 53  
INTERPRETATION  
. . .  
4.0  
Relationship Between the Injury and the Compensable  
Accident  
Many injuries (e.g., strains, sprains, burns, cuts, etc.) have an obvious  
relationship to the compensable accident; consequently, determining  
WCB's level of responsibility is relatively simple. However, there are  
other injuries which, because of their progressive nature or less obvious  
relationship to employment, require consideration of relevant factors both  
in and outside employment which may have contributed to or caused the  
injury (see Part II, Application 1, Relationship to Compensable Accident).”  
[B6]  
Policy 03-01, Part II, Application 1: Relationship to Compensable Accident  
(Issue Date: July 4, 2018) states:  
“1.  
Why is the relationship of injury to compensable accident  
important?  
To be compensable, an injury must be the result of an accident as  
defined under Policy 02-01, Arises Out of and Occurs in the Course of  
Employment. Therefore, when adjudicating the eligibility of a claim, WCB  
looks at the nature of the injury and its relationship to the compensable  
accident.  
Often there is an obvious relationship between the nature of the injury  
and the compensable accident (e.g., a firefighter is burned when fighting  
a fire). However, the relationship is not always obvious. In these cases,  
there is a need for additional information, especially medical information,  
to establish the relationship to the compensable accident. . .  
2.  
How does WCB adjudicate injuries?  
In general, every claim is subject to a similar adjudicative process. The  
relationship between the injury and the compensable accident is  
examined to determine entitlement. Additional medical advice is sought  
on an as-needed basis. Complex claims may require additional  
investigation to determine work-relatedness.”  
[B7]  
Policy 03-02, Part II, Application 1: Aggravation of a Pre-existing Condition  
(Issue Date: April 3, 2018) states:  
“2.  
How does WCB determine if a pre-existing condition has  
been aggravated?  
There must be clear documentation of a pre-existing condition and it must  
be apparent from the objective medical information available that the  
compensable accident caused some worsening of this condition, at least  
on a temporary basis.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 54  
WCB will consider the relationship between the pre-existing condition and  
the accident, including the mechanism of injury (for example, twisting,  
lifting heavy objects), the extent or severity of the underlying condition,  
and the degree to which the injury may have affected the condition.  
3.  
How long are temporary benefits payable?  
Temporary benefits will be paid until:  
• the aggravation has ended and the weight of evidence shows that  
ongoing temporary disability is solely due to the pre-existing condition  
or some other unrelated, non-compensable health problem, or  
• the compensable aggravation reaches a medical plateau, at which  
time WCB will evaluate whether there is any permanent impairment  
caused by the compensable accident.  
. . .  
5.  
When a claim is adjudicated under this policy, how does WCB  
determine its responsibility for permanent disability?  
If the aggravation was temporary and the worker recovers to a  
pre-accident state there is no compensable permanent disability.”  
[B8]  
Policy 04-03, Part I, which was issued on January 1, 2003, states, in part:  
“POLICY:  
The WCB will pay compensation when there is a recurrence of temporary  
disability due to a previous compensable disability from which a worker  
had apparently recovered. Provided all the conditions set out s.61 of the  
Act are met, the rate of compensation may be based on the worker's  
earnings at the time of the recurrence.  
As the provisions of s.61 of the Act are intended to recognize the impact  
of recurrence of temporary disability on current earning capacity, the rate  
of compensation established under s.61 applies only to wage  
replacement benefits (e.g., temporary disability benefits, earnings loss  
supplements, economic loss payments).  
This consolidated policy is effective February 15, 1997 unless noted  
otherwise. Any exceptions are noted within the specific policy sections.  
INTERPRETATION  
1.0  
Recurrence of Temporary Disability  
A recurrence is a clinically demonstrated increase in physical impairment  
or disability, resulting in temporary disability, which can be directly related  
to a previously stabilized compensable condition.  
For the purposes of the WCB, it is important to differentiate between a  
recurrence of temporary disability and a continuation. This is because the  
provisions of s.61 apply only to recurrences. Compensation for a  
continuation is calculated using date of accident earnings.  
Classification: Protected A  
Decision No.: 2021-0515  
Page 55  
If an intervening incident is considered significant and capable of causing  
the injury or aggravating a susceptibility to injury, the WCB does not  
consider the incident a recurrence, but rather a new and separate incident  
subject to the provisions of Policy 02-01 (Arises Out of and Occurs in the  
Course of Employment).  
2.0  
Recovered  
A worker is considered to have recovered from a compensable disability  
when the medical recovery reaches a plateau at which no further  
significant change in condition is anticipated. Consequently, temporary  
compensation benefits are no longer being paid. The presence of a  
permanent impairment or periodic medical follow-up because of the  
compensable injury is not a bar to considering application of the  
provisions of s.61.”  
[B9]  
Policy 04-03, Part II, which was issued on May 15, 2008, states, in part:  
“1. How does WCB determine if a disability is a recurrence?  
The WCB considers a disability to be a recurrence when:  
a worker experiences difficulties with the same (or directly related)  
medical condition as the original compensable injury (or injuries),  
the condition was considered resolved,  
an intervening cause for the further problems cannot be shown, and  
it is medically reasonable that the difficulties are related to the  
compensable injury.  
2.  
How long does WCB pay compensation for a recurrence of a  
temporary disability?  
In keeping with the provisions of s.56(12) of the WCA, when a recurrence  
results in a temporary disability the WCB pays compensation as long as  
the disability lasts. This is the case regardless of whether the worker is  
employed or unemployed at the time of the recurrence.  
In the case of an unemployed worker, the WCB pays compensation for  
the duration of the compensable disability even if the period coincides  
with an employment insurance entitlement.  
3.  
Under what circumstances will WCB adjust the rate of  
compensation to use current earnings?  
Before the WCB will consider adjusting the rate of compensation to reflect  
earnings at the time of a recurrence, all four conditions of s.61 must be  
met:  
Classification: Protected A  
Decision No.: 2021-0515  
Page 56  
the worker stopped receiving temporary compensation by reason of  
recovery from the original disability. For the purposes of this policy,  
recovery means when the worker has reached a medical plateau and  
further changes are not expected (a worker may be in receipt of a  
permanent partial disability award and still meet the criteria for s.61),  
and  
the recurrence is due to the same accident and is in the form of  
temporary disability, and  
the worker's earnings at the time of recurrence are greater than the  
earnings at the time of the accident (including applicable cost-of-living  
adjustments), and  
the recurrence occurs more than 12 months after the date of  
accident.”  
Classification: Protected A  


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