A-Ok Removals Pty Ltd v Jovic

[2023] NSWPICMP 617

DETERMINATION OF APPEAL PANEL
CITATION:	A-Ok Removals Pty Ltd v Jovic [2023] NSWPICMP 617
APPELLANT:	A-Ok Removals Pty Ltd
RESPONDENT:	Slavko Jovic
APPEAL PANEL
MEMBER:	Jane Peacock
MEDICAL ASSESSOR:	Roger Pillemer
MEDICAL ASSESSOR:	Doron Sher
DATE OF DECISION:	28 November 2023
CATCHWORDS:	WORKERS COMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; appellant employer alleged error by the Medical Assessor (MA) in the assessment on the basis of incorrect criteria; Appeal panel satisfied as to error; error also alleged in failing to make a deduction under section 323 for the lumbar spine; Appeal Panel found this was open to MA; error also alleged in failing to make a deduction for pre-existing condition of great toe; Appeal Panel found error and that deduction should have been made; Held – Medical Assessment Certificate revoked.

BACKGROUND TO THE APPLICATION TO APPEAL

1. On 12 September 2023 the employer A-Ok Removals Pty Ltd (the appellant) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr John Brian Stepheson, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 16 August 2023.

2. The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):

   ·        the assessment was made on the basis of incorrect criteria, and

   ·        the MAC contains a demonstrable error.

3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the ground(s) of appeal on which the appeal is made.

4. Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 – Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.

5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4^th ed
   1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5^th ed (AMA 5).

PRELIMINARY REVIEW

1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.

2. It is noted that the appellant sought that Slavko Jovic (the respondent worker) be re-examined by a Medical Assessor member of the Appeal Panel. As a result of the Appeal Panel’s preliminary review, the Appeal Panel determined that it was not necessary for the worker to undergo a further medical examination because although the Appeal Panel found error, there was sufficient information before the Appeal Panel for it to make a determination.

EVIDENCE

Documentary evidence

1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.

Medical Assessment Certificate

1. The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.

SUBMISSIONS

1. Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.

FINDINGS AND REASONS

1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.

2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.

3. The matter was referred to the Medical Assessor by the Personal Injury Commission (Commission) as follows:

   “The following matters have been referred for assessment (s 319 of the 1998 Act):

   ·Date of injury: 19 April 2021 19 April 2021

   ·Body parts/systems referred: Left lower extremity (great toe, ankle (consequential) and subtalar joint (consequential); lumbar spine (consequential), scarring (TEMSKI)

   ·Method of assessment: Whole Person Impairment”

4. The Medical Assessor issued a MAC as follows:

Body Part or system	Date of Injury	Chapter, page and paragraph number in NSW workers compensation guidelines	Chapter, page, paragraph, figure and table numbers in AMA5 Guides	% WPI	WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality (expressed as a fraction)	Sub-total/s % WPI (after any deductions in column 6)
1. Left lower extremity	19 April 2021	Chapter 2 Page 10 to 12	Chapter 17, Page 537, Table 17-11 to Table 17-12 and Table 17-14	11%	Nil	11%
2. Lumbar spine	19 April 2021	Chapter 3, Page 27, Paragraph 4.27, Page 28 Paragraph 4.34 and Table 4.2 Page 29	Chapter 15, Page 384, Table 15-3	12%	Nil	12%
3. Skin TEMSKI	19 April 2021	Chapter 4, Page 27, Paragraph 4.27, Page 28 Paragraph 4.37	Chapter 8	1%	Nil	1%
Total % WPI (the Combined Table values of all sub-totals)					21%

1. The employer appealed.

2. In summary, the appellant submitted on appeal that the Medical Assessor made an assessment on the basis of incorrect criteria and made demonstrable errors which included the following:

   (a)     in respect of the calculation of whole person impairment. The appellant submitted that the Medical Assessor has made a demonstrable error in calculating impairment using the Combined Values Chart, and instead of reaching a figure of 21%, should have reached the figure of 23% whole person impairment (WPI). It is noted that the respondent worker concurs that an error in calculation has been made. The Appeal Panel agrees.

   (b)     In respect of the calculation of impairment of the left lower extremity. In assessing impairment of the ankle and subtalar joint, the Medical Assessor has reached a figure of 18% lower extremity impairment (LEI), whereas the appellant submitted that this should be 17% LEI, as these figures should be combined.

   (d)     In respect of the lumbar spine, the assessment of Diagnosis-based Estimates  (DRE) Category III for the lumbar spine is submitted to be on the basis of incorrect criteria.

   (e)     In respect of the decision by the Medical Assessor to make no deduction under s 323 of the 1998 Act to take into account any pre-existing condition, abnormality or injury, it is submitted that the Medical Assessor has not provided any adequate reasons why a deduction under s 323 was not made for the lumbar spine and the left lower extremity.

3. In summary, the worker Mr Slavko Jovic (the respondent) submitted on appeal that the Medical Assessor did make an error in respect of the calculation of impairment at 21% when it should have been 23% and in this respect agrees with the submissions of the appellant. The Appeal Panel concurs. Otherwise the respondent submitted that the Medical Assessor did not make any other demonstrable error, did not make assessments on the basis of incorrect criteria and the MAC in all other respects should be confirmed.

4. The Medical Assessor took a history which he recorded as follows:

   “Brief history of the incident/onset of symptoms and of subsequent related events, including treatment: On date of injury 19 April 2021, Slavko Jovic was carrying a lounge as a removalist to the back of a truck. His offsider was at the front and Slavko was at the rear. Slavko was at the lower end of the walk board where the lounge was to be carried up to the truck. As he walked, he accidentally kicked the end of the walk board. Within 5 minutes his foot had swelled up. He was wearing sneaker shoes. He could not do anymore apart from help the offsider complete the job. He tried to get back to work over the next two days but could not manage. He consulted his GP for the swelling. A blood test ruled out gout and x-rays ruled out a fracture. There were steroid injections to the base of the great toe, left foot which did not help.

   He came to operation under the care of Dr Todd Gothelf. Diagnosis: Left first metatarsophalangeal joint arthritis. Operation: Left first metatarsophalangeal joint fusion with bone graft. Proposed operative follow up with x-rays undertaken by Dr Todd Gothelf. He reported 25 May 2022, x-ray, good alignment, hardware intact. ‘He walked in today with his flexible slippers not, wearing postop shoe.’ Dr Gothelf sent him for a CAM boot and was advised to wear the CAM boot for all walking at that stage.

   ·Present treatment: He was wearing a soft lumbar belt which he removed at the examination.

   ·Present symptoms: His GP at Melville Road, St Clair, prescribed Endone as recently as 19 July 2023 for pain and Palexia Slow Release 50 mg sustained release tablets, Endone and Palexia both opioid type medications.

   ·Details of any previous or subsequent accidents, injuries or condition: There were no such events.

   ·General health: He was prescribed Diabex XR 500 mg tablet extended release for stage 2 diabetes. He takes oral medication for stage 2 diabetes. His endocrinologist, Dr 26 July 2023 gave a problem list 1, diabetes mellitus type 2; 2, hypogonadism; 3, class 3 obesity-body mass index 43; 4, chronic pain left ankle, knees, lower back; 5, depression, anxiety panic attacks. For the anxiety and panic attacks he was prescribed Avanza 30 mg one tablet at night.

   ·Work history including previous work history if relevant: He has always been a removalist.

   ·Social activities/ADL: He has been having physiotherapy for lower spine, left ankle and foot. Because of the injury his wife has stopped work on 19 April 2021.

   I note he is able to remove and replace his shoes and socks. He has had an increase in weight since injury he said. He is 6 feet tall and now weighs 142 kg. He was formerly in the range 95 to 100 kg. He is consulting a dietician and an endocrinologist. Physiotherapy is twice a week. He also tried some swimming.”

5. The Medical Assessor noted of the special investigations:

   “CT of the lumbar spine and right and left foot 28 June 2021. Prior imaging, x-ray and ultrasound study 31 May 2021. Findings were established degenerative arthropathy at the metatarsophalangeal joint of the great toe with marked loss of cartilage and marginal osteophytic lipping. Substantive subchondral bone oedema involving the metatarsal head, neck and distal shaft as well as entire length of the shaft of the proximal phalanx with surrounding oedema and capsular thickening. Subcutaneous soft tissues of the dorsum of the foot demonstrates extensive swelling especially around the first metatarsophalangeal joint extending across the entire width of the foot from the level of the metatarsals. There was an incomplete report of CT scan lumbar spine that is from Quantum Radiology St Marys, clinical nature, chronic back pain findings, minor left convexity of the lumbar spine with apex at L2/3, vertebral body heights are normal from L1 to L5, no pars defects of the lumbar vertebrae from L1 to L5. There was no posterior disc herniation or posterior disc bulge L1/2 or L2/3 on that incomplete report.

   There was report of an ultrasound guided injection left foot first metatarsophalangeal articulation. A mixture of series and local anaesthetic was injected and well tolerated as reported by Dr Abdelrahman in left foot. 12 July 2021 report, persistent pain in a 53-year-old gentleman. Conclusion: Extensive arthropathy identified, this arises the possibility of gout as a potential cause although the appearance is that of degenerative arthropathy. Uric acid level with rheumatology evaluation, Dr George Hazan, Radiologist. Comment: Mr Jovic Slavko advised of blood test that ruled out gout.

   It is reasonably clear there has been aggravation, acceleration, and exacerbation of degenerative arthropathy in the metatarsophalangeal joint of the great toe of the injury. Also, similar aggravation, acceleration, exacerbation of the lumbar spine at L5/S1 by virtue of the accident.”

6. The Medical Assessor conducted a physical examination which he recorded as follows:

   “Physical examination was of the lumbar spine and also referred to left lower extremity (great toe, ankle (consequential), subtalar joint (consequential), lumbar spine (consequential) and scarring (TEMSKI table). For the scarring about the left great toe, I found the best fit to be from TEMSKI table Page 74 WorkCover Guidelines at 1% WPI. Reference AMA-5, Page 543, Table 7-30 for great toe fusion in the position of function, there is 9% lower extremity impairment.

   There was reduced range of motion left ankle and hind foot including subtalar joint. Reference left ankle and hind foot AMA-5 Page 537, Table 17-11 and Table 17-12 including subtalar joint.

ROM	Degree	% LEI
Dorsiflexion (extension)	0 equals 10 to 0 neutral	7% Lower extremity
Plantar flexion	Ankle 20 ° equals range 11 to 20°	7% Lower extremity
Hind foot Inversion	20° equals range 10 to 20°	2% lower extremity
Hind foot Eversion	0 equals range 0 to 10°	2% lower extremity

Ankle values are added note combined so by addition of 14 with 4 for ankle and hind foot there is 18% lower extremity impairment.

Reference AMA-5 Page 537 Table 17-14 toe impairment. Great toe interphalangeal joint flexion only 5 degrees which is mild for being less than 20 degrees, 2% lower extremity. Reference great toe metatarsophalangeal joint Page 543 Table 17-30, position of function, ankylosis 9%. For the left lower extremity total impairment is combination of 18% lower extremity for ankle motion restriction with great toe fusion at tarsometatarsal joint and the position of function of 9% lower extremity. The combination of 18% lower extremity for left ankle with 9% lower extremity gains 25% lower extremity impairment. That combines with 2% for interphalangeal joint gaining 27% lower extremity.

Combination of 18 with 9 with 2 gains 27% lower extremity which converts to 11% WPI.

Examination of Lumbar Spine

Diagnosis of lumbar spine impairment is that of diagnosis related to lumbar category 3 with baseline of 10% WPI to which I have added 2% for ADLs, that is, for assistance and avoidance of with sport, recreation, yard, garden, and home care. He complains of low back pain with left gluteal pain radiating to posterior thigh down to left calf. For back pain, specifically he uses chemist medication for milder analgesia, also uses heat packs and Endone is prescribed. There was some asymmetric loss of range of motion with standing with forward flexed with fingers to knee level with lateral flexion to thigh level only.

Reference WorkCover Guides radiculopathy Page 27, Paragraph 4.27, radiculopathy is defined as being caused by malfunction of a spinal nerve root or nerve roots.

Asymmetry of reflexes.

Right knee hyperactive

Right medial hamstring reflex sluggish.

Right ankle active.

The affected Left lower extremity reflexes

Left knee hyperactive.

Left medial hamstring reflex sluggish.

Left ankle jerk reflex sluggish.

Muscle Weakness Anatomically Localised to Appropriate Spinal Nerve Root Distribution

Dorsiflexion left foot and ankle unaffected right lower limb strong at 5/5.

Dorsiflexion left ankle and toes weaker at 3/5.

Impairment of Sensation Anatomically Localised to Appropriate Spinal Nerve Root Distribution

On sensation testing using the Neurotip pinprick device sensation is normal or sharp right lower extremity including posterolateral calf from knee to ankle whereas the left lower extremity at the same site neurotip is not sharp, but dull or absent.

Positive Nerve Root Tension

Straight leg raise right leg 80 degrees normal.

Left leg straight leg raise 30 degrees only causing acute left gluteal, posterior thigh and calf pain.

Muscle Wasting Atrophy

Circumference right mid-calf 45 cm circumference left mid-calf reduced to 43.5 cm at the same site.

Findings on Imaging Study Consistent with Clinical Signs

CT scan report of lumbar spine dated 28 June 2022 has been referenced in report of Dr James Bodel of 24 April 2023 as follows: ‘28 June 2022 CT scan lumbar spine. There is significant degenerative disc disease at L5/S1 level with narrowing of the disc spaces with osteophyte formation with disc osteophyte complex posteriorly except with L5/S1 level. The remaining discs appear intact’. My comment in that regard is that it is consistent with this has been an aggravation of discal pathology at L5/S1 level by the injury.

1. The Medical Assessor summarised his diagnosis and findings as follows:

   “•      summary of injuries and diagnoses:

   This has been referred to body part injury of left lower extremity (great toe, ankle (consequential), subtalar joint (consequential), lumbar spine (consequential) as well as TEMSKI table scarring. Diagnosis has been achieved by virtue of the history and clinical findings, radiological findings and medical and surgery reporting reference WorkCover Guidelines and AMA-5.

   ·        consistency of presentation

   Presentation was consistent with the nature of the injury and the surgery performed and the management of those relevant injury areas mentioned in the body parts referred.”    

2. The Medical Assessor explained his impairment assessment as follows:

   “My opinion and assessment of whole person impairment

   I have found for the lumbar spine consequential the diagnosis lumbar category 3 as there are significant signs of radiculopathy and sufficient signs of radiculopathy also with reference to WorkCover Guidelines Page 27 Paragraph 4.27. DRE category 3 Page 384 Table 15-3 AMA-5 for lumbar spine. Has a baseline of 10% WPI to which I have added 2% for ADL consistent with avoidance of sport, recreation, yard, garden and home care and there is a 12% WPI. For left lower extremity great toe, ankle (consequential) subtalar joint (consequential) I have referred to AMA-5 lower limb Page 537 Table 17-11 ankle impairment estimates and table 17-12, permanent impairment estimates included subtalar joint. I have also referred to Table 17-14 Page 537 for great toe interphalangeal joint flexion which is only 5 degrees and therefore less than 20 degrees, mild 2% lower extremity.

   The left lower extremity great toe ankylosis and restriction of motion left ankle subtalar joint consequential I have combined the following values. Ankylosis hallux reference Page 543 Table 7-30 9% lower extremity. Ankle joint and subtalar joint including subtalar joint at the hind foot 18% lower extremity and for the hallux interphalangeal joint 2% lower extremity the combination of 18 with 9 with 2 in descending order gains 27% lower extremity which converts to 11% WPI. That combines then with 12% WPI for the diagnosis category 3 lumbar spine a combination of 12 with 11 gains 20% WPI which combines with 1% WPI at TEMSKI table finding a total combined value of 21% WPI there was no deductible proportion.

   In making that assessment I have taken account of the following matters:-

   I have listed the examination findings.

   I have referred to the investigation findings.

   I refer to matters of history done at the time of the assessment. There is no pre-existing relevant condition.

   An explanation of my calculations (if applicable)

   Explanation given in the text.

1. The Medical Assessor made brief comment on the other evidence and medical opinion which was before him as follows:

   “Dr James Bodel 24 April 2023 found diagnosis of category 2 for the lumbar spine however I have set out all the requirements for diagnosis category 3 have been met based on the clinical examination, he did find 1% WPI for TEMSKI table and did give 2% for ADLs for lumbar spine. Combined 9% lower extremity for the fusion of the table 7% for the ankle and 2% for subtalar joint totalling 17% lower extremity and the total combined value was 15% WPI including the TEMSI table for the lumbar spine and for the skin scar.

   I have found that my findings are greater than Dr Bodel particularly in view of the presence of radiculopathy affecting the left lower extremity.

   Dr Roger Rowe, 31 May 2023 stated that ‘Mr Jovic did not report an injury restriction of pain in the left ankle at the time of my assessment, on 2 December 2022’, however, I am able to differ from Dr Rowe as I find radiculopathy left lower extremity and confirming the referral for great toe and ankle.

   With the operative findings. Operation report left first metatarsophalangeal joint arthritis operation left first MTP joint fusion with bone graft by Dr Todd Gothelf 12 April 2022. He explained the addition as follows: ‘Operative Findings. Mr Slavko Jovic is a 54-year-old male with severe left first metatarsophalangeal joint arthritis and severe symptoms consistent with hallux rigidus. Hallux rigidus is a condition of arthritis in the first metatarsophalangeal joint that causes stiffness in the toe’. Dr Gothelf.

   ‘In Slavko’s case the first metatarsophalangeal joint fusion would be most appropriate due to the deranged pain’. I agree with Dr Gothelf who is the surgeon managing the left great toe.”

2. The Medical Assessor did not consider there was a pre-existing condition, abnormality or injury in respect of any of the injured body parts which warranted a deduction under s 323.

3. The appellant is correct in their submission the overall impairment assessed should be 23% WPI.

4. In respect of the calculation of impairment of the left lower extremity. In assessing impairment of the ankle and subtalar joint, the Medical Assessor has reached a figure of 18% lower extremity impairment, whereas the appellant submitted that this should be 17% LEI, as these figures should be combined. When combining the three figures given (18,9, 2), instead of reaching a total of 11% WPI, this should have been 10%. The appellant’s submissions in this regard are incorrect as impairments for the ankle and subtalar joint are added, and the figure of 18% is in fact correct (Page 10, AMA 5). Accordingly the 11% assessed by the Medical Assessor is correct in this regard.

5. The appellant complains on appeal that the Medical Assessor erred in assessing DRE Category III for the lumbar spine. The appellant is not correct. The Medical Assessor has clearly indicated why he placed the respondent worker in DRE Category III noting that while the right ankle jerk was active, the left was sluggish, there was weakness of dorsiflexion of the ankle and toes, there was sensory loss in the L5 distribution, and straight leg raising was limited. There was also wasting. These factors are all in keeping with a diagnosis of radiculopathy, and accordingly there is no error.

6. The appellant complains on appeal about the failure to make a deduction under s 323.

7. In respect of the lumbar spine, the respondent worker did have longstanding changes at the lumbosacral level. On the evidence he was asymptomatic prior to the injury whereas he now has evidence of radiculopathy as a result of his work injury. In these circumstances the available evidence is such that the Appeal Panel does not consider that the pre-existing condition or abnormality has contributed to the overall level of permanent impairment assessed and considers it would be inappropriate to make a s 323 deduction. The finding that there was no deductible proportion under s 323 was open to the Medical Assessor and discloses nor error.

8. In respect of the failure to make a deduction under s 323 in respect of the great toe, notwithstanding the longstanding and advanced osteoarthritis of the base of the great toe, the Appeal Panel considers that a deduction should which in fact he should have been made. The Medical Assessor has made a demonstrable error in not deducting for the fusion of the MP joint of the great toe, which was obviously of longstanding, noting that the treating specialist [Dr Gothelf] made a diagnosis of hallux rigidus, and the operation was carried out for this condition and the bump at work would simply have been a minor aggravation of this longstanding advanced condition.

9. On the available evidence the pre-existing problems with the MP joint of his great toe where he had the advanced osteoarthritic change have contributed to the overall level of permanent impairment assessed and a one-fifth deduction should be made. A one-fifth deduction would lead to 7.2% which rounds to 7% LEI.

10. The Medical Assessor has indicated combining from highest to lowest, but in this case the impairments of the great toe should be combined first prior to combining with the impairment for the ankle and subtalar joints, and the impairments for the great toe combined (7:2) which equals 9% LEI. Combining this with the 18% for the ankle and subtalar problems noted above, gives a total of 25% LEI which equates with 10% WPI rather than the 11% assessed by the Medical Assessor in the MAC.

11. Accordingly the Appeal Panel will revoke the MAC and issue a new MAC as follows:

Body part	Date of Injury	Chapter, page and paragraph number in WorkCover Guides	Chapter, page, paragraph, figure and table numbers in AMA5 Guides	% WPI	% WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality	Sub-total/s % WPI (after any deductions in column 6)
Left lower extremity	19/04/21	Chapter 3 Pages 13-23	Chapter 17 Pages 523- 564	10%	nil*		10%
Lumbar spine	19/04/21	Chapter 4 Pages 24-29	Chapter 15 Page 384 Table 15-3	12%	nil		12%
Scarring (TEMSKI)	19/04/21	Chapter 14 Pages 73-74	1%	nil		1%
Total % WPI (the Combined Table values of all sub-totals)					22%

*Please note that the only deduction for the left lower extremity was in relation to the MP joint of the big toe. There was no deduction for the IP joint, the subtalar joint or the ankle joint. Therefore these figures were not able to be included in the column with regard to deductions for pre-existing condition.

1. For these reasons, the Appeal Panel has determined that the MAC issued on 16 August 2023 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.

APPEAL PANEL

MEDICAL ASSESSMENT CERTIFICATE

Injuries received after 1 January 2002

Matter number:	W1953/23
Applicant:	Slavco Jovic
Respondent:	A-Ok Removals Pty ltd

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.

The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor John Brian Stephenson and issues this new Medical Assessment Certificate as to the matters set out in the table below:

Table - whole person impairment (WPI)

Body part	Date of Injury	Chapter, page and paragraph number in WorkCover Guides	Chapter, page, paragraph, figure and table numbers in AMA5 Guides	% WPI	% WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality	Sub-total/s % WPI (after any deductions in column 6)
Left lower extremity	19/04/21	Chapter 3 Pages 13-23	Chapter 17 Pages 523 to 564	10%	nil*	10%
Lumbar spine	19/04/21	Chapter 4 Page 24-29	Chapter 15 Page 384 Table 15-3	12%	nil	12%
Scarring (TEMSKI)	9/04/21	Chapter 14 Pages 73-74	1%	nil	1%
Total % WPI (the Combined Table values of all sub-totals)					22%

*Please note that the only deduction for the left lower extremity was in relation to the MP joint of the big toe. There was no deduction for the IP joint, the subtalar joint or the ankle joint. Therefore these figures were not able to be included in the column with regard to deductions for pre-existing condition.