DECISION NO. 920/90. Foot deformities (spinal stenosis) - Rheumatoid arthritis.

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1 DECISION NO. 920/90 Foot deformities (spinal stenosis) - Rheumatoid arthritis. The worker suffered a low back injury in He was awarded a 15% pension that was ultimately increased to 60%. The compensable back injury resulted in the worker having spinal stenosis which left him with a neurological deficit in the lower limbs. In 1980 the worker was diagnosed as having non-compensable rheumatoid arthritis which affected several joints, including his feet. The worker sought benefits for neck, left wrist and bilateral foot disabilities. The worker began complaining of foot pain in He experienced burning, numbness and various foot deformities (including: pes cavus, drop foot and hallus valgus). Four operations were performed on the worker's feet between 1985 and The employer argued that these disabilities were due to the rheumatoid arthritis. There was no medical corroboration for the worker's claim that his carpal tunnel wrist disability and his neck disability were the result of the strain of his trying to lift himself without using his back. These disabilities were not related to the back injury and were thus not compensable. The rheumatoid nodules present in the worker's feet were a natural reaction to bony prominences in the feet of a rheumatoid arthritis sufferer. These bony prominences were the result of the foot deformities and not the cause of them. The worker's foot deformities were predominantly caused by the worker's neurological deficit which stemmed from his compensable lumbar spine injury. The worker was entitled to benefits for his bilateral foot condition. [10 pages] PANEL: McGrath; B. Cook; Preston DATE: 13/11/91

2 WORKERS' COMPENSATION APPEALS TRIBUNAL DECISION NO. 920/90 This appeal was heard on December 4, 1990, by a Tribunal Panel consisting of: J. McGrath : Vice-Chairman, K.W. Preston: Member representative of employers, B. Cook : Member representative of workers. THE APPEAL PROCEEDINGS The worker appeals the decision of the Workers' Compensation Board Hearings Officer, V.W. Ferguson, dated July 31, This decision denied the worker entitlement to benefits for bilateral foot, neck and left wrist conditions on the grounds that they were not related to a compensable accident of September 28, The worker appeared and was represented by G. McNally, vice president of the worker's local of the C.A.W. The employer was represented by D. Younan, compensation representative for the accident employer. The worker's wife attended as an observer. THE EVIDENCE The Panel had the Case Description materials prepared by the Tribunal Counsel Office together with Addendum #1 which were marked as Exhibit #1. The worker gave evidence under oath. Because the Panel felt there was some confusion about the reasons for surgery in the operative reports of Dr. F. Smith, orthopaedic surgeon, who performed four surgical operations on the worker's feet, the Panel requested a post-hearing clarification report from Dr. Smith. Both parties were invited to make submissions on the report. The Panel has considered the report and the submissions of the employer. The worker declined to make further submissions. THE NATURE OF THE CASE The worker injured his lower back when it was struck at work on September 28, Various periods of temporary total disability benefits were paid and a permanent disability award of 15% for the back disability was made on September 27, This was increased to 25% in July 1982 and to 60% on September 17, During the period from the date of the accident to the present time, the worker has experienced neck pain, left wrist pain leading to carpal tunnel surgery in May 1984, and increasing pain, numbness and deformity in his feet.

3 2 He was diagnosed as having rheumatoid arthritis in The worker was denied benefits for his neck pain, his carpal tunnel syndrome and his bilateral foot problems on the basis that none of these problems was related to his lumbar spine injuries. The worker is asking the Panel to find such a relationship. With respect to the neck and left wrist, the worker maintains that unusual use and stress were placed on these because of his lumbar injury and the resulting decreasing use of his legs. With respect to his feet, the worker maintains that their increasing pain, numbness and deformity were directly caused by the injury to his lumbar spine. The employer submits that the neck and left carpal tunnel syndrome are unrelated to the worker's lumbar spine problems and the feet problems are caused by the worker's rheumatoid arthritis, a non-compensable condition. The issue before the Panel is whether the September 28, 1973, compensable accident is, on a balance of probabilities, a significant contributing factor to his subsequent neck, left wrist and bilateral foot problems. THE PANEL'S REASONS (i) Factual background This 53 year old worker had never experienced any difficulty with his neck, arms or feet prior to his accident of September 28, On April 3, 1973, he saw Dr. A.C. Gold, orthopaedic surgeon, because he was experiencing an aching pain in his lumbar area diagnosed as degenerative disc disease at L5-S1 for which conservative treatment was prescribed. On September 28, 1973, a hoist carrying a truck front end swung and hit the worker in his back. The impact threw him forward. This accident caused immediate pain in the lumbar area, increasing to the point of surgery for a L5-S1 herniated disc on December 10, From that time until the present, pain in the lumbar area, radiating down his legs, has been an increasingly debilitating condition such that the worker can now only walk with crutches, uses an elevator chair to bring himself from a sitting to a standing position and an electric bed to raise him from a prone to a sitting position. He takes massive doses of various medications each day in order to function at all. Temporary total benefits have been paid for various periods, including the aggravation to his back condition caused by a non-work related car accident in June 1974, and spinal surgery for stenosis of the spinal canal at L4-5 level and for a lateral herniation at the L5-S1 level on September 13, The worker finally accepted early retirement on December 1, 1985, because he could no longer work. Meanwhile, in January 1980, the worker was diagnosed as having rheumatoid arthritis and in October and November 1982, he underwent in-hospital treatments for this. The worker testified that the disease floated around from joint to joint. Surgery was required on his right knee and left hip because of this non-compensable rheumatoid arthritis. The worker was given a permanent disability award of 15% for his lumbar spine disability on September 27, This was increased to 25% in

4 3 July 1982, and further increased to 60% on September 17, This latter award, recommended by Dr. W. Parliament in consultation with Dr. Horsey and Dr. W. Young, was for a "failed" back. (a) The neck The worker testified that his neck began to bother him shortly after his accident. He attributed this to straining his neck to help him sit up in bed from a prone position. He used his arms and his neck because he could not use his back. He finally obtained a hospital bed in 1979 which operated at the push of a button so that he did not have to use his neck for this. The neck discomfort did not go away, however, until his second lumbar surgery in Occasionally now he wears a neck brace for headaches. Dr. F.A. Bianchi, rheumatologist, reported on October 17, 1983: The patient has done extremely well after spinal cord decompression and, in fact, surprisingly, his cervical neck pain has disappeared. I am not sure what the connection is but the main thing is he is better. Dr. F. Smith, the orthopaedic surgeon who performed the spinal surgery in 1983 and all subsequent orthopaedic operations to the present time. In a letter to the Board on August 21, 1989, Dr. Smith states "the neck and wrist problems I have never tried to relate to his back injury." Dr. D. de Demeter, the Board's orthopaedic consultant, in a post-hearing report to the Hearings Officer stated that the worker's cervical problems stem from his rheumatoid arthritis. (b) The left wrist The worker stated there was additional strain to his arms because he used them to push himself up in bed, to lift himself up from a chair and off the toilet because he could not use his back to do this after his accident. He further emphasized that the left arm was subject to considerably more strain than his right because he would pull himself out of his car, which he used to drive himself to work every day until his retirement, by grasping the roof rail with his left hand. He then made a roof strap that he could grab with his left hand to pull himself up out of the car. The worker stated that the pain in his left wrist came on about one year before the carpal tunnel syndrome was diagnosed by Dr. D.L. Chew, neurologist, on May 2, There were no medical reports relating this carpal tunnel syndrome to the worker's spinal injury and its sequellae. As reported above, Dr. Smith stated that he had never tried to relate the wrist problem to his back injury. Dr. de Demeter specifically related the worker's carpal tunnel syndrome to his rheumatoid arthritis. (c) The feet The worker was complaining of pain in both feet as early as In 1977 he saw Dr. S. Gershon, rheumatologist, for his back, but complained of pain in both feet. Dr. Gershon, in a report dated November 16, 1977, stated:

5 4 He describes now a low back pain that will radiate all the way down his left lower limb to his left foot. He also described right foot pain.... Briefly I buy that we are looking at lumbar discogenic back mechanical pain here. The story is very clean and neat.... Dr. Gershon had the worker tested for rheumatoid arthritis with clinically negative results. The worker experienced burning pain in the balls of both feet, numbness in the toes and heels and found himself walking on his heels. He told Dr. Hepburn, orthopaedic surgeon, in October 1979, that it felt as if "it is going to explode in the bottom of his feet." Dr. Hepburn reported on January 7, 1980: He notices symptoms, however, when he pulls up the great toe on the left foot.... It has also recently been noted that he has developed very prominent great toes with perhaps a certain amount of bursa formation over the metatarsal phalangeal joint especially on the right great toe. There was bilateral pes cavus present. [Stedman's Medical Dictionary, 24 ed., defines pes cavus as a "contracted foot; an exaggeration of the normal arch of the foot."] It is very difficult to know what is going on with this man. We know for certain he has had a lumbar discotomy and probably has some residual stenosis at this level, perhaps associated with fibrosis of the nerve foot sheath, and this may account to some extent for his pes cavus. The worker was admitted to the Chedoke-McMaster Hospital in March and April 1980, under the overall direction of Dr. J.I. Frid, rheumatologist, where the diagnosis of rheumatoid arthritis was made. In early 1981 the worker developed a right foot drop. In reporting on this on May 1, 1981, Dr. Frid stated: I was very pleased to see [the worker] today, as usual accompanied by his very supportive wife. He looks much better in general than I have every seen him. Unfortunately, in the meantime, he has developed a foot drop on the right which I understand is being followed carefully, by Dr. Chew, with an EMG next Thursday. I would have to assume that this is due to nerve root compression at the lumbar level and that this in turn may well be due to the long established back problem which is the basic reason for his compensation from the WCB.

6 5 I don't believe there is anything that is active as far as the rheumatoid arthritis is concerned at the present time. Along with the foot drop, the worker's right leg would sometimes give out on him. As well as the pes cavus the worker developed bilateral hallux valgus. [the curving outward of the big toe toward the second toe]. Dr. Chew reported on May 5, 1981 "he is unable to dorsiflex the [right] foot or toes nor is he able to avert the foot". Dr. Chew noted a right peroneal [outside of leg] nerve lesion which he thought could be due to a compression injury, but stated that he was somewhat suspicious of more widespread problems. Dr. Hepburn, orthopaedic surgeon, reported on June 15, 1981, as follows: He has seen Dr. D. Chew, who has assessed the foot drop as due to a spinal problem. He has definite weakness and wasting in the right lower limb, with a droplike foot. Dr. Bianchi, the rheumatologist in direct contact with the worker at the Chedoke-McMaster Hospital reported on June 6, 1983: Because of the one episode of weakness which he had and the numbness in the webbed space of the first and second left toe, and the sole of the foot, I was concerned that there was something further going on in the back. Accordingly, I had him seen by Dr. Frank Smith, an orthopaedic surgeon, today and Dr. Smith concurred that he was concerned about the lower back, and he has ordered the CT Scan which will be done at the McMaster Division on June 28, Dr. Smith then reported as a follow up to the above on July 11, 1983: This gentleman has a complicated history of back problems and has had surgery some ten years ago for disc extrusion of L the CT Scan shows that he has stenosis of the spinal canal at L4-5 level and a lateral herniation at the L5-S1 level on the left which fits in absolutely with his clinical presentation. The worker then underwent four operations on his feet between May 1985 and October Because the operative reports included, in the detailed descriptions of the worker's feet problems and deformities, the words "rheumatoid arthritis" and "rheumatoid nodule", some confusion was created as to whether these operations on the worker's feet were necessitated as a result of his lower back condition or as a result of rheumatoid arthritis. Dr. Smith reported on April 26, 1988: [The worker] has been seen for follow up regarding his foot surgery with resultant lesion from extrinsic muscle imbalance in the feet, secondary to his spinal injury. He

7 6 is making satisfactory progress with this, and has special shoes made for him, which he requires to accommodate the foot deformity, and this of course, should be covered under his claim. Dr. de Demeter, the Board's Orthopaedic Consultant, in her March 9, 1989, post-hearing report to the Hearings Officer, described how feet become deformed, including pes cavus deformity and bilateral hallux valgus, as a result of rheumatoid arthritis. She then states: "This patient's multiple bilateral forefoot surgeries have been performed to correct the deformity caused by rheumatoid arthritis." Upon reading the Hearings Officer's decision, Dr. Smith wrote to the Board on August 21, 1989, stating: This gentleman's foot problems were not at all related to his rheumatoid arthritis. They are on the basis of spasm rather than joint deformity from rheumatoid disease. Because of the confusion referred to above in the operative reports of the worker's feet surgeries, the Panel requested post hearing clarification from Dr. Smith. His post-hearing report in response to questions from the Panel states: The underlying feature of this patient is that he has several diseases going on at the same time. Namely, he has a spinal injury resulting in him having spinal stenosis and this has left him with a neurological deficit in the lower limbs. Secondly, he has rheumatoid arthritis and he has also been diagnosed as having ankylosing spondylitis at one stage by another physician. (Dr. Smith goes on to discuss that the worker also has medical problems unrelated to the issue before the Panel.) In answer to question #1 [about what caused the foot problems] - I unequivocally state that [the worker's] foot problems are due to his back injury. This is on the basis of the clawing of the toes. Rheumatoid arthritic victims suffer callous formation on the base of the foot but the characteristic lesion of that is dislocation of the metatarsal phalangeal joints rather than the neurological type of clawing that [the worker] exhibited. The features that are mixed in with the diagnosis had been those of a nodule forming type of rheumatoid arthritis. When a patient has this type of arthritis and a constitution that forms rheumatoid nodules, wherever there is a bony prominence a nodule tends to form as a protective layer between the skin and the bone and therefore whatever the cause of the bony protrusions neurologically pes clawing or just a naturally occurring bony prominence such as the elbow, for example, or the knee cap or the heel bone then

8 7 the body will respond in the rheumatoid victim who suffers from this by forming nodules. In answer to paragraph 3 of your questions regarding the bilateral forefoot deformity I think I answered above as being predominantly due to his neurological deficit and we would probably expect to find rheumatoid changes in the joint as this is a generalized disease and effects multiple joints in his body. I have read the photocopy of Dr. de Demeter's report sent along with the letter. On page 2 of his note to V. Ferguson, Hearings Officer, he states that in rheumatoid arthritis the transvers metatarsal arch of the foot collapses so the weight bearing goes on his second, third and fourth metatarsals rather than on the first and fifth. This is not a unique condition to rheumatoid arthritis in fact by far the commonest cause of it is an intrinsic problem in the foot rather than rheumatoid disease. He does go on to mention that the proximal phalanx is dorsally subluxed on the metatarsal heads. In fact, this commonly goes on to a dislocation. As I stated this was not the case in [the worker's] foot. The other feature is that his spinal injury dates back to 1974 and the rheumatoid arthritis is considerably later in onset than that. His x-rays show that he has severe spinal stenosis confirmed by a CT Scan. Furthermore, [in] a consultation from Dr. F. Bianchi on June 6, 1983, he notes that he had increased numbness in the webbed space of the first and second toes of the left foot and the sole of the foot. All of this is strong evidence to support long standing neurological problems with his feet which would support a neurological basis for the clawing of his toes rather than metatarsal phalangeal joint subluxation. (ii) Conclusions With respect to the worker's neck pain, the Panel is unable to find, on a balance of probabilities, that such was related to his lumbar spine injury. There is no medical corroboration of the worker's explanation about using his neck to help raise himself in bed. Indeed the doctors seem unable to account for or explain the neck discomfort, including the fact that the pain disappeared subsequent to the second lumbar spinal surgery. The only exception is Dr. de Demeter who states categorically that the neck pains stem from the worker's rheumatoid arthritis. We therefore find that we are unable to conclude, on the evidence before us, that the neck pain, was due to the worker's compensable low back injury. Similarly, with respect to the worker's left arm carpal tunnel syndrome, there is no medical corroboration of the worker's explanation that it was brought about by the excessive use and strain on his left arm as a result of using it for lifting his body rather than using his back. Dr. de Demeter relates the carpal tunnel syndrome to his rheumatoid arthritis. Again we must

9 8 state that, whatever the cause of the left carpal tunnel syndrome, on the evidence before us, the Panel is unable to conclude that it was related to the worker's compensable low back injury. With respect to the worker's pain and deformity in his feet, which led to four operations, the Panel has carefully reviewed all the medical evidence including the obviously conflicting opinions of Dr. de Demeter and Dr. Smith. It is clear to the Panel that the Hearings Officer relied on Dr. de Demeter's report in denying benefits for the foot problems. Although before the foot operations the doctors had some difficulty pinpointing the specific cause of the worker's bilateral foot problems, Dr. Gershon, Dr. Hepburn, Dr. Frid, Dr. Chew and Dr. Bianchi, all suspected a link to the injured lumbar spine and a consequent neurological deficit. Dr. Smith is categorical in his post-operative confirmation of this. He explains that rheumatoid nodules tend to form on any bony prominence when a person has rheumatoid arthritis, and this is the reason for the references to rheumatoid nodules in the operative reports of the foot operations. He is very clear, however, that the bony prominences are a result of the foot deformities and not a cause of them. He further states that the bilateral fore-foot deformity is predominantly caused by the neurological deficit stemming for the worker's compensable lumbar spine injury, even though he would expect to find rheumatoid changes in the joint because of the general nature of that disease. The Panel is of the view that Dr. Smith's report obtained post-hearing by the Tribunal Counsel Office contradicting the medical explanation outlined by Dr. de Demeter ought to carry more weight than that of Dr. de Demeter, because Dr. Smith is the treating specialist. It is also significant that the surgeon who carried out the lumbar spine and bilateral foot surgery on the worker would necessarily have more intimate knowledge of the worker's condition. Given the above, it is the Panel's view that, on a balance of probabilities, the worker's compensable lumbar spine condition due to the 1973 accident was a significant contributing factor to the development of bilateral pain and deformity in his feet, necessitating four surgical procedures.

10 9 THE DECISION The appeal is allowed in part. The worker is entitled to benefits for his bilateral foot condition which culminated in four surgical procedures between 1985 and This matter is referred back to the Board to establish the nature and level of benefits to flow from this decision. DATED at Toronto, this 13th day of November, SIGNED: J. McGrath, K.W. Preston, B. Cook.