Subsequent Injury

Subsequent Injury and Worker’s Compensation Cases

Pursuant to the Maryland Court of Appeals ruling in Mackin case, subsequent injuries are covered by workers compensation only if there is a sufficient connection between the first accident and the later injury so that one injury is determined to be a “direct and natural result” of the former.

In the Mackin case, the claimant was injured when he fell on ice on the way to a doctor’s appointment for the first injury. Applying the above rule, the court determined that there was no significant connection between the original injury and the injury from the fall on the ice. Otherwise, it is not natural to assume that work injury three years prior will result in an injury from a fall down the road.

In doing so, the court rejected the more expansive theory that as long as the employee was engaged in ‘quasi-employment’ activities such as going for treatment or taking medication for his workers comp injury then any injuries occurring during those events should be covered by worker’s compensation.

The ruling in Mackin was restated in a 2012 case opinion involving a WAMTA employee. The employee was struck by a vehicle while in a parking lot. The employee argued that the injuries from the vehicle accident were related to his earlier worker’s compensation claim. The court, however, applying Mackin, determined that the cause of the subsequent injuries were the accident itself and the negligent driver. There was no connection made between the parking lot accident and prior injuries and therefore, the claimant could not satisfy the subsequent injury requirements.

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The WAMTA case is attached below for reference.

No. 2316
September Term, 2010
Eyler, Deborah S.,
Opinion by Meredith, J.
Filed: April 26, 2012
Washington Metropolitan Area Transit Authority (“WMATA”), appellant, appeals
from the judgment of the Circuit Court for Prince George’s County which affirmed the ruling
of the Workers’ Compensation Commission that an injury to the right leg of Jan Williams,
appellee, was causally related to the prior injury to his left leg, and therefore covered by
workers’ compensation benefits.
WMATA presents one question for review:
Whether Claimant’s March 23, 2009[,] right knee injury, incurred when he
was hit by a car while returning from lunch on a day when he was attending
therapy, is causally related to the work accident of April 15, 2008, where
Plaintiff injured his back and left knee?
We will answer that question in the negative, and reverse the decision of the circuit
court. We will remand the case to the circuit court with instructions that the circuit court
remand the case to the Commission for further proceedings consistent with this opinion.
Facts and Procedural History
Mr. Williams’s position as a mechanic for WMATA is very physically demanding.
On April 15, 2008, while he was employed as a mechanic for WMATA, Mr. Williams
injured his back and left knee on the job. Mr. Williams underwent physical therapy to treat
the injury to his left knee. Prior to Mr. Williams regaining his full strength, when the
physical therapy progress had started to plateau, it was recommended that Mr. Williams
undergo work hardening, which is a more intensive form of physical therapy.
CAM Physical Therapy provided the work hardening program at a location that is not
a WMATA facility. On the second to last day of the work hardening program, March 23,
2009, Mr. Williams walked to his truck during his lunch break and ate his lunch. After he
finished eating, Mr. Williams walked through the parking lot, intending to return for another
session of the work hardening program. While Mr. Williams was walking back from lunch,
the driver of a car on the parking lot put her car into reverse and backed into Mr. Williams,
knocking him to the ground. This resulted in an injury to Mr. Williams’s right knee for
which Mr. Williams claimed workers’ compensation benefits.
The Workers’ Compensation Commission found “that the disability of the claimant’s
right leg/knee is causally related to the aforesaid accidental injury,” and awarded benefits.
WMATA filed a petition for judicial review, and requested a trial de novo in the circuit
court. At the conclusion of a bench trial, the circuit court made the following factual
The facts are very simple in this matter. The claimant injured his back
and left knee in a work-related accident on April 15th, 2008. He was going
through his rehabilitation, through [h]is doctor, through [h]is therapist. It was
recommended to do a work hardening program, which he was complet[ing].
He was I believe 19 or 20 classes into it, at which time on March the
23rd, 2009 the Claimant, Mr. Williams, in this matter, sustained an injury to his
right knee when a car backed up and hit him.
Certainly, he was not working at this time. He was, the best term of
course to use is he was rehabilitating at this point in time.
The circuit court affirmed the decision of the Workers’ Compensation Commission,
and found that Mr. Williams’s injury to his right knee was compensable. WMATA appealed
to this Court.
Under Maryland Code (1991, 2008 Repl. Vol.), Labor and Employment Article
(“LE”), § 9-745, there are two statutorily provided options for review in the circuit court
of a decision of the Workers’ Compensation Commission — (1) either an administrative
appeal submitted on the record made before the Commission, pursuant to LE § 9-745(c) and
(e); or (2) an essential trial de novo, pursuant to LE § 9-745(d). Here, WMATA requested
an essential trial de novo, and, although the ultimate decision of the Commission is
considered prima facie correct, this Court reviews the circuit court’s decision, not the
decision of the Commission. Doe v. Buccini Pollin Grp., Inc., 201 Md. App. 409, 419-20
(2011). Under these circumstances, we review the factual findings of the circuit court for
clear error, and we review matters of law de novo. Id.
WMATA contends that reversal is required by the decision of Mackin v. Harris, 342
Md. 1 (1996), in which the Court of Appeals addressed a similar factual scenario. In Mackin,
a former employee of Mackin & Associates was undergoing physical therapy to treat an
injury which the employee incurred while employed by Mackin & Associates. Id. at 2-3.
That injury was compensable through workers’ compensation. Id. On the way to the physical
therapist’s office, the employee slipped and fell on a patch of ice and sustained an additional
injury. Id. The employee made a second claim for worker’s compensation benefits from
Mackin & Associates, arguing that the second injury “was a consequence of the first and
should likewise be compensable.” Id. at 3. At the time of the second injury, the employee
was no longer employed by Mackin & Associates. Id. at 2.
In its opinion addressing whether the second injury should be compensable under
these circumstances, the Court of Appeals took note of the analysis of Professor Larson in
this area, id. at 5, and quoted the following passage expressing Professor Larson’s view on
consequential injuries such as the injury in the Mackin case:
“Since, in the strict sense, none of the consequential injuries we are concerned
with are in the course of employment, it becomes necessary to contrive a new
concept, which we may for convenience call ‘quasi-course of employment.’ By
this expression is meant activities undertaken by the employee following upon
his injury which, although they take place outside the time and space limits of
the employment, and would not be considered employment activities for usual
purposes, are nevertheless related to the employment in the sense that they are
necessary or reasonable activities that would not have been undertaken but for
the compensable injury. ‘Reasonable’ at this point relates not to the method
used, but to the category of activity itself. . . . Quasi-course activities in this
sense would include, for example, making a trip to the doctor’s office and
reaching for aspirin in the medicine cabinet.”
But the Mackin Court adopted a narrower rule regarding compensability of
subsequent injuries:
We are in general agreement with the basic rule advocated by Professor
Larson — that a subsequent injury is compensable if it is the direct and
material result of a compensable primary injury. We do not agree,
however, that this concept of causation should be extended to embrace
every subsequent accident that may occur while going to and coming
from a doctor or other health care provider or obtaining or taking
medication for an original compensable injury. More specifically, we hold that
under the facts of this case, the fall on ice while going to a therapist’s office
for treatment of a compensable injury suffered three years earlier with a
former employer is not a direct and natural result of the earlier injury.
Professor Larson’s approach to causation in consequential injury cases
appears to rely heavily, if not almost exclusively, on the “but for” test; but for
the first injury and the need for treatment therefor, would the second accident
have occurred?
* * *
. . . This expansive view of causation, which invokes the necessity to
“contrive” the legal fiction of “quasi-course of employment” or to find implicit
conditions of employment, leads to rather extraordinary results.
Id. at 7-9 (emphasis added).
The Court enunciated the proper standard to be applied in Maryland cases as follows:
Rather, the proper approach is to view retrospectively what actually
occurred and then determine in a reasonable and practical manner
whether there is a sufficient nexus between the earlier industrial accident
and the later injury to constitute the latter as a “direct and natural
result” of the former, and to therefore establish causation. Cf. Henley [v.
Prince George’s County, 305 Md. 320, 336 (1986)].
Although, as we have discussed, there are some essential differences
between the concepts of proximate cause applicable to tort law and those
applicable in workers’ compensation cases, we find more similarities than
differences in the area of consequential injuries. Specifically, we reject the
notion that causation in such cases may be determined solely by reference
to the “but for” test, and we persist in our view that the claimant must
establish “a direct causal connection” between the original accidental
injury and the subsequent injury or condition. Unger & Mahon v. Lidston, [177 Md. 265, 269 (1939)].
Id. at 10 (emphasis added).
Purporting to apply the standard set out in Mackin to the present case, the circuit court
in this case stated: [T]he question is[: . . .] is he covered or not. And the question in [Mackin] was a situation where the person was going to his physical therapist
three years after the injury, no longer working for the company, and slips and
falls on some ice. And the question is whether or not it was compensable or
. . . And the basic rule is that a subsequent injury, whether an
aggravation of the original injury, or a new and distinct injury is compensable,
if it is the direct and natural result of a compensable primary injury.
The circuit court then recounted the portion of the Mackin opinion, set out above, in
which Professor Larson advocates that consequential injuries should be covered as part of
a “quasi-course of employment.” Yet, the circuit court failed to note that, in Mackin, the
Court of Appeals actually adopted a significantly narrower standard than the one advocated
by Professor Larson, and the Court of Appeals criticized Larson’s formulation that is based
on the “‘contrive[ed]’ . . . legal fiction of ‘quasi-course of employment’” because “it leads
to rather extraordinary results.” Mackin, supra, 342 Md. at 8-9.
The circuit court concluded that Mackin supports Mr. Williams’s workers’
compensation claim for the second injury, and stated:
In this case Mr. Williams was rehabilitating. He was ordered to be and
he was directed by a doctor to take this work hardening program. He was at
the work hardening program. In his analysis, he’s a covered employee. The
Court affirms Commissioner Adams’ finding in this matter . . . .
In our view, WMATA’s position is supported by the Mackin Court’s analysis. There
was not a sufficient nexus between Mr. Williams’s two accidents for the circuit court to
conclude that there was a direct causal connection between the first accidental injury (to the
left knee) and the subsequent injury to the right knee. If the test of causal relation which the
claimant was required to satisfy was simply the “but for” test, then it would have been
satisfied — i.e., but for Mr. Williams’s first injury, he would not have been in the parking
lot for the work hardening program, and would not have been hit by a car in that lot. But
the Court in Mackin expressly rejected that line of reasoning, and required the demonstration
of a “direct and material relationship,” which the Court said was akin to the concept of
proximate cause in tort law. Id. at 10. There must be “‘a direct causal connection’ between
the original accidental injury and the subsequent injury.” Id. Here, Mr. Williams’s second
injury was not caused by his first injury.
The appropriate method of analysis, and the method adopted in Mackin, is to view
“retrospectively what actually occurred and then determine in a reasonable and practical
manner whether there is a sufficient nexus between the earlier industrial accident and the
later injury.” Id. (emphasis added). In other words, in the context of subsequent injuries, the
key to the analysis of whether a subsequent injury is covered as an extension of the prior
covered injury is whether the first injury proximately caused the second injury.
“‘[P]roximate cause’ means that the result could have been caused by the [first injury] and
that there has not intervened, between the [first injury] and the [second injury], any other
efficient cause.” Id. at 5 (quoting Lidston, supra, 177 Md. at 269). Proximate cause requires
both cause in fact, also known as “but for” causation, mentioned above, as well as legal
causation — which can be satisfied in this context by a finding of a “direct and material
relationship” between the two injuries. Id. at 10.
Here, looking at the concept of proximate cause, and the issue of whether the second
injury was a direct and material result of the first injury, it cannot be said that Mr. Williams’s
second injury (i.e., the one to his right knee) directly resulted from the first injury (i.e., the
one to his left knee). The analysis in Mackin on this issue is on point. In both cases, the
second injury directly resulted from some cause unrelated to the first injury. In Mackin, the
second injury resulted from the icy conditions on the ground. Id. at 2. Here, the second
injury resulted from the driver’s actions in hitting Mr. Williams in the parking lot. The
negligent actions of the driver whose car hit Mr. Williams were not at all connected to the
first injury (excluding the fortuitous fact that the first injury placed Mr. Williams in the lot);
only the actions of the driver, and not the first injury, had a direct and material causal
relationship to Mr. Williams’s second injury.
Mr. Williams’s case is distinct from scenarios under which Maryland courts have held
that a subsequent injury is attributable to a previous covered injury. For instance, Mr.
Williams does not contend that the April 15, 2008, injury reduced his mobility and thereby
prevented him from avoiding the car. Therefore, Mr. Williams’s case does not fall into line
with Maryland cases that allow workers’ compensation recovery when a compensable injury
physically leads to a second injury. See, e.g., Lidston, supra, 177 Md. at 270 (holding that
the question of whether a compensable ankle injury caused a later hip injury should be
decided by the jury); Williams Constr. Co. v. Garrison, 42 Md. App. 340, 342-43, 348
(1979) (affirming the circuit court’s decision to allow recovery for a second injury when
dizziness resulting from a prior, compensable injury caused the second injury, despite the
fact that the employee was no longer employed with the same company at the time of the
second injury). Nor does Mr. Williams’s case fit into the category of cases where recovery
has been allowed for subsequent injuries that occurred as a result of medical malpractice in
the treatment of a prior compensable injury. See Nazario v. Washington Adv. Hosp., 45 Md.
App. 243 (1980). The Mackin Court drew these distinctions. 342 Md. at 4-5.
Furthermore, the Mackin Court rejected the contention that the statutory requirement
that an employer pay for medical treatment for injuries covered by workers’ compensation
sufficiently connects the treatment of the injuries to the employment to furnish the requisite
“direct causal connection.” Id. at 10-11.
We conclude that the circuit court committed legal error when it failed to recognize
and apply the more narrow view of compensability adopted by the Court of Appeals in
Mackin, and that failure led to an incorrect result in this case. Therefore, we reverse the
decision of the circuit court.
As we have explained above, our review of the trial record persuades us that the claim
relative to the 2009 accident should not have been considered compensable as an injury
caused by the first injury. But the Commission did not reach the question of whether the
As noted by Mr. Williams, in  1 situations involving injuries caused by the negligence
of third parties, a claimant is only required to show that the injury occurred in the course of
employment, and need not demonstrate that the injury arose out of employment. LE § 9-
101(b)(2); Bd. of Educ. v. Spradlin, 161 Md. App. 155, 208 (2005); see also Doe, supra, 201
Md. App. at 424-25.
second injury, standing alone, was compensable. Cf. Good Samaritan Hosp. v. Jacobson,
98 Md. App. 587, 595 (1993) (“We hold that, if an employer requires an individual to
receive a physical examination on its premises and the reason for the physical examination
is for the employer’s benefit, there exists sufficient direction and control by the employer for
the examination to be within the scope of coverage by the workers’ compensation law.”);
Austin v. Thrifty Diversified, Inc., 76 Md. App. 150, 162 (1988) (“The benefit expected by,
or accruing to, the employer as a result of allowing personal projects to be done using its
equipment and on its premises is no different than that flowing to the employer as a result
of its sponsorship of recreational or social events.”).
Unlike the employee in the Mackin case, Mr. Williams was still employed by
WMATA at the time of the second injury. Mackin, supra, 342 Md. at 3-4. Whether Mr.
Williams’s second injury could be considered to have occurred in the course of employment,
standing alone, has not yet been adjudicated.1
The following discussion occurred at the hearing before the Commission: [Mr. Williams’s counsel]: The third issue that we’re asking for, Your
Honor, is causal relationship of the right knee to this case. Although both
knees were listed on the claim form, the claimant was leaving his last session
of work hardening on March 23rd of 2009 when a vehicle was backing out of
a parking spot and struck him in the right knee, and that’s going to be a legal
issue, I suspect. We’re basing our claim on the positional risk test, and I know [WMATA’s counsel] has a case included in her packet, and I guess we’ll deal
with that later.
* * * [WMATA’s counsel]: And, Your Honor, our position is exactly as [claimant’s counsel] stated. It’s a legal issue for you to make a decision on.
There was no treatment to the right knee. There were no problems with the
right knee. Dr. Manderson specifically states that the cause of injury to the
right knee is being hit by a car, and he was hit by a car as he was leaving
And yes, the therapy was the work-related injury, but our position
would be based on Mackin and Associates vs. Harris. . . . [C]ausal relationship
is not established based on those facts.
THE COMMISSIONER: All right. And you’re relying on what case? [Mr. Williams’s counsel]: Yes, Your Honor. If I could just give you the
case of Montgomery County vs. Smith. That’s 799 A.2d, page 406, and that’s
a 2002 case. What the Court held there, Your Honor, the employee in this case
was a prison guard and he was off duty. He was playing basketball on the
prison site.
The Court found that he was not in the course of his employment and
his injury did not arise out of his employment because he was not playing
basketball due to some incident related to his employment and due to some
obligation to the employer. That is a complete contrast to this case, Your
On March 23 , 2009, Mr. Williams rd was attending his final session of
work hardening to enable him to return to work for the employer in this case.
And as I indicated earlier, he was able to return to full duty employment with
his employer on March 6th, 2009.
The work hardening was based on the order of the employer in this
case. It was scheduled through the nurse case manager who was hired and
paid for by the employer in this case.
Moreover, Your Honor, Mr. Williams was paid wages by the employer
in this case, as Your Honor knows is self-insured. Mr. Williams would not
have been at work hardening but for his work injury of April 15th, 2008.
* * *
Clearly WMATA had required Mr. Williams to be in the parking
lot at the work hardening facility at the time that he was struck by the
vehicle on March 23rd, 2009. He wouldn’t have been there had WMATA
not required him to be there. And he needed to be there in order to get
back to work with WMATA, which he successfully was able to do on
April 6th, 2009. And that’s what we base our case on, Your Honor.
(Emphasis added.)
The order issued by the Commission did not reach the question of whether the second
injury could be considered, standing alone, to have occurred in the course of employment
because the Commission instead made a finding that “the disability of the claimant’s right
leg/knee is causally related to the aforesaid accidental injury.”
In Trojan Boat Co. v. Bolton, 11 Md. App. 665 (1971), this Court examined the
procedure to be followed when a decision of the Commission makes moot additional issues
that were presented to the Commission but not reached. When the Commission decides a
claim based on one issue that obviates the need to address remaining issues, the remaining
issues are moot. Id. at 672 (“The issue was obviously not implicitly decided by the
Commission because in the logical process of disposing of the claim by deciding it was not
accidental in the course of employment, the Commission did not reach the issue of
causation.”). We addressed the procedure for dealing with moot issues as follows:
2 Although Mr. Williams did not explicitly argue that the second injury should be
analyzed independently of the first injury, the basis of Mr. Williams’s argument for finding
that Mr. Williams was acting in the course of employment (i.e., that WMATA required Mr.
Williams to attend work hardening) would support such an assertion.
We note that, pursuant to LE § 9-709(b 3 )(2), the Commission may exercise its
discretion in determining whether a separate claim must be filed before deciding whether the
second injury, standing alone, occurred in the course of employment. In addition, we note
that, even if a separate claim is required to be filed, pursuant to LE § 9-708(b), the two-year
statute of limitations for the bar on claims does not begin to run until an employer files an
injury report.
Neither the Court of Appeals nor this Court has specifically decided the
proper procedure for determining issues originally and properly presented to
the Commission but rendered moot by the Commission’s decision to disallow
the claim on other grounds, which decision is later reversed by a court on
appeal. The practice, however, seems to have developed that in such cases,
the proper procedure is to remand the proceedings to the Commission
for original determination of the remaining issues which were thought to
be moot in the earlier Commission proceedings.
Id. at 668-69 (emphasis added).
Here, because the Commission decided that the second injury was causally related to
the first injury, it did not need to address whether, standing alone, the second injury could
be said to have occurred in the course of employment. Therefore, that issue of whether the
second injury occurred in the course of employment became moot.2 Accordingly, following
the “proper procedure” prescribed in Trojan Boat, id. at 669, we remand the case to the
circuit court with instructions to remand the case to the Commission for it to address the
issue of whether the second injury, standing alone, could be said to have occurred in the
course of employment.3


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