Byford v State of New South Wales (Murrumbidgee Local Health District Corowa Hospital)

CERTIFICATE OF DETERMINATION OF MEMBER
CITATION:	Byford v State of New South Wales (Murrumbidgee Local Health District - Corowa Hospital) [2024] NSWPIC 424
APPLICANT:	Lorraine Byford
RESPONDENT:	State of New South Wales (Murrumbidgee Local Health District - Corowa Hospital)
MEMBER:	Fiona Seaton
DATE OF DECISION:	7 August 2024
CATCHWORDS:	WORKERS COMPENSATION - Workers Compensation Act 1987; claim for proposed surgery costs; whether applicant sustained de Quervain’s tenosynovitis in addition to accepted left wrist arthritis condition; Held – the applicant sustained an aggravation of de Quervain’s tenosynovitis in addition to the accepted left wrist injury with employment the main contributing factor; proposed surgery reasonably necessary; the respondent to pay the costs of and incidental to the proposed surgery at gazetted rates.
DETERMINATIONS MADE:	The Commission determines: 1. The applicant sustained an aggravation of de Quervain’s tenosynovitis on 20 January 2023 in the course of her employment in addition to the accepted aggravation of arthritis in her scaphotrapeziotrapezoid (STT) joint, and employment was the main contributing factor to that aggravation. 2. The surgery proposed by Dr Wang on 7 October 2023 is reasonably necessary as a result of the applicant’s left wrist injury pursuant to s 60 of the Workers Compensation Act 1987. The Commission orders: 1. The respondent is to pay the costs of and incidental to the left wrist arthroscopic open distal scaphoid/proximal trapezium excision and de Quervain’s tenosynovitis decompression surgery proposed by Dr Wang on 7 October 2023 at the SIRA gazetted rates.

STATEMENT OF REASONS

BACKGROUND

The applicant Ms Lorraine Byford was employed as a ward person by the respondent at Corowa Hospital. While lifting a full linen bag out of a skip in the hospital’s emergency department on 20 January 2023 she felt a pinch and then a shooting pain in her left wrist. The respondent accepted liability for her left wrist injury.
A request for approval for surgery was made by the applicant’s treating specialist Dr Wang on 7 October 2023. The surgery proposed is left wrist arthroscopic open distal scaphoid proximal trapezium excision and de Quervain’s tenosynovitis decompression.
A dispute notice under s 78 of the Workplace Injury Management and Workers Compensation Act 1998 was issued on 30 October 2023 disputing liability for the surgery and the diagnosis of de Quervain’s tenosynovitis.
The applicant lodged an Application to Resolve a Dispute (ARD) with the Personal Injury Commission (Commission) on 16 May 2024 claiming the cost of the surgery proposed by
Dr Wang.
The dispute was listed for conciliation conference and arbitration hearing for determination of whether the applicant sustained a left wrist injury on 20 January 2023 and the diagnosis of that injury pursuant to s 4 of the Workers Compensation Act 1987 (the 1987 Act), and whether the proposed surgery is reasonably necessary as a result of the injury.

ISSUES FOR DETERMINATION

The parties agree that the following issues remain in dispute:
(a) the diagnosis of the applicant’s left wrist injury on 20 January 2023, and
(b) whether the proposed surgery recommended by Dr Wang, being left wrist arthroscopic open distal scaphoid/proximal trapezium excision and de Quervain’s tenosynovitis decompression, is reasonably necessary as a result of injury pursuant to s 60 of the 1987 Act.

PROCEDURE BEFORE THE COMMISSION

The parties appeared for conciliation conference and arbitration hearing before the Commission on 24 July 2024. Ms Lyn Goodman appeared for the applicant instructed by
Mr Soren Bakic, legal practitioner. Mr Bill Loukas appeared for the respondent instructed by Mr Danny Koshaba, legal practitioner. Mr Mangion was present with Mr Koshaba. Ms Ennis was present for the insurer.
During conciliation the parties agreed the applicant sustained a scaphotrapeziotrapezoid (STT) arthritis injury on 20 January 2023 pursuant to s 4(b)(ii) of the 1987 Act although whether surgery is reasonably necessary for that injury remains in dispute. The diagnosis of de Quervain’s tenosynovitis is in dispute.
The applicant’s Application to Admit Late Documents dated 9 July 2024 was admitted into evidence.
I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

EVIDENCE

Documentary evidence

The following documents were in evidence before the Commission and considered in making this determination:
(a)    ARD and attached documents;
(b)    respondent’s Reply and attached documents;
(c)    respondent’s Application to Admit Late Documents dated 11 June 2024 and attached documents, and
(d)    Applicant’s Application to Admit Late Documents dated 9 July 2024 and attached document.

Oral evidence

No application was made to call oral evidence or to cross examine the applicant.

Applicant’s evidence

The applicant has provided a statement signed on 1 May 2024.
She started working at Corowa Hospital in 2015 initially as an assistant in nursing and then as a ward person. On 20 January 2023 she was replacing a completely overloaded linen bag from the linen skip in the pan room in the emergency department. As she lifted it out of the skip she felt a pinch then a shooting pain in her left wrist. She reported her injury and took painkillers, worked one more night shift and then attended on her doctor.
Following an X-ray and CT scan of her left hand and wrist the applicant commenced physiotherapy and wore a splint. She had an MRI of the left wrist on 15 February 2023.
Dr Kemble Wang, her treating orthopaedic specialist, recommended the applicant have a cortisone injection for de Quervain’s tenosynovitis which she had on 13 June 2023. This unfortunately only provided temporary relief. A second injection about eight weeks later made her pain worse.
Dr Wang requested approval from the insurer for left wrist arthroscopic open distal scaphoid proximal trapezium excision and de Quervain’s tenosynovitis decompression surgery on
7 October 2023.
The applicant continued to work in a reduced capacity according to her doctor’s instructions and she has difficulty washing, showering, dressing herself as well as with cooking and cleaning. She now has to get someone to maintain her lawn and garden.
She takes medication such as Panadol Osteo and Targin on a daily basis to attempt to reduce the pain.
Dr Gehr, orthopaedic surgeon, provided a report to the applicant’s solicitor dated
6 March 2024. He diagnoses left wrist de Quervain’s along with symptomatic osteoarthritis involving the STT joint with underlying osteoarthritis previously asymptomatic, as well as a left shoulder soft tissue injury which is not the subject of these proceedings.
Dr Gehr’s opinion is that it is over a year since the accident, nonoperative management has failed and now she should proceed to surgery as recommended by Dr Wang. The surgery would address the two pathologies which are osteoarthritis of the STT joint and the de Quervain’s disease.
The Incident Report of 21 January 2023 records the injury as described by the applicant in her statement.
Dr Wang provides an estimate of fees on 21 March 2024 of $4,382.50 plus incidental costs.
The CT left hand and wrist dated 3 February 2023 finds no fracture, evidence of mild to moderate osteoarthritis in the radiocarpal joint and also in the STT joint, with relatively mild osteoarthritis in the other intercarpal joints.
The MRI report of the left wrist dated 15 February 2023 finds osteoarthritis with slightly greater osteoarthritis in the STT joint, a partial tear of the scapholunate ligament and two ganglion cysts.
Dr Eniola reports that the applicant had an ultrasound guided injection in her left wrist on
14 June 2023 with no immediate complication.
The report of the MRI of the applicant’s left wrist or hand on 2 August 2023 concludes there is positive ulnar variance with ulnar impaction syndrome, secondary low to intermediate grade partial tear of the triangular fibrocartilage complex, and low grade partial tear of the scapholunate ligament.
Dr Wang makes the request for approval of the surgery on 7 October 2023.
The applicant relies on a series of reports from Dr Wang. In his report of 27 March 2023 to the applicant’s general practitioner Dr Htun, Dr Wang diagnoses left wrist pain with likely a component of de Quervain’s tenosynovitis as well as ulnar sided pain that was of secondary onset. He recommends her wrist splint be altered to a smaller thumb splint with a trial of injection into the first dorsal compartment under ultrasound guidance.
In his report to the insurer on 5 April 2023 Dr Wang wholly attributes his diagnosis to the incident on 20 January 2023 with no pre-existing or degenerative factors. He refers to potential early onset complex regional pain syndrome and says the underlying diagnosis is not entirely clear at this stage and requires further work up.
Dr Wang reports on 24 April 2023 that the first injection the applicant had into the de Quervain’s tendon combined with the applicant attending on a hand therapist and having some rest from work lead to her pain significantly improving.
On 4 September 2023 the doctor reports that her symptoms are consistent with either de Quervain’s tenosynovitis or basal thumb arthritis which are difficult to tease apart, and he notes the second injection was not helpful.
By 7 October 2023 Dr Wang reports that he believes her symptoms come from two sources; de Quervain’s tenosynovitis and arthritis of the STT joint, which can sometimes be very difficult to tell apart.
At that stage she had truly failed all nonoperative management in his opinion. The only viable tool left is surgery to tackle both problems at the same time. The applicant is keen to proceed.
Dr Wang reported to the insurer on 2 November 2023 that he strongly disagrees with the opinion of Dr Haig discussed below, as well as disagreeing with the decision to decline the request for surgery.
The doctor says his opinion is based on a number of facts including that the applicant had no prior symptoms before the injury at work, that on multiple appointments with him she displayed consistent radial sided wrist pain, de Quervain’s disease can be precipitated and aggravated by sudden overload of the wrist such as that described in her injury, and that previously asymptomatic arthritis in multiple parts of the body can be aggravated by an acute traumatic incident and thereafter become symptomatic.
Dr Haig suggests anti-inflammatory treatment. Dr Wang says this has already been trialled for nine months, as well as other nonoperative management. It is well established in
Dr Wang’s opinion that surgical release is a reasonable option as treatment for recalcitrant de Quervain’s tenosynovitis that has failed all nonoperative management. He strongly recommends that the decision to decline the request for surgery be reconsidered.
Dr Wang confirms his opinion that the applicant has two diagnoses in his report of
6 July 2024; left de Quervain’s tenosynovitis and left wrist basal thumb arthritis aggravated by her injury. He notes the applicant’s pain is still very much present.
The doctor notes there was a temporary partial reduction in wrist pain when the applicant was commenced on a high dose of prednisolone following a recent diagnosis of polymyalgia rheumatica, however the dose necessarily had to be tapered and her wrist pain immediately returned to the same intensity. Surgery would be a reasonable next step.
The Patient Health Summary of Corowa Medical Centre and the clinical records of Redgum Medical Centre are also attached to the ARD.

Respondent’s evidence

The respondent relies on a series of reports obtained from Dr Haig, orthopaedic surgeon.
On 14 September 2023 Dr Haig provides his opinion that the applicant’s symptoms are likely due to an aggravation of pre-existing osteoarthritis. Her underlying osteoarthritis he believes was rendered symptomatic in the work-related injury.
In his supplementary report of 26 October 2023 Dr Haig confirms that he found no signs of de Quervain’s tenosynovitis, which he says is not recognised as being a workplace injury. He does not believe surgery is indicated noting her symptoms are intermittent.
Dr Haig examined the applicant again on 24 May 2024. In his report of 5 June 2024 the doctor notes the applicant states her left wrist had improved and it is “next to nothing”.[1] There were no findings on examination of her left wrist and she was now without symptoms.
[1] Reply page 85.
Dr Haig also notes the main treatment at that time was prednisolone for her recently diagnosed polymyalgia rheumatica, and that she may need to take anti-inflammatory agents and/or analgesics as required for her left wrist. No surgery is required as her left wrist condition has returned to normal.
Dr Htun’s report of 10 February 2023 includes a diagnosis of left wrist sprain and possible ligament injury with severe pain.
Peak Conditioning provided an initial assessment to ascertain support requirements to assist the applicant’s return to work on 23 March 2023. Dr Kafataris, injury management consultant, provides a report dated 28 November 2023 regarding suitable duties.
Ms Jenny Graetz, hand therapist, reports to Dr Htun on 13 March 2023 on the applicant’s significant pain in the radial left wrist and that the splint is causing pain around the thumb. On 30 March 2023 Ms Graetz reports to Dr Wang on the applicant’s significant levels of pain in the wrist.
She also reports on 9 May 2023 that the first cortisone injection provided a week of relief but things had gone downhill since then. By 29 June 2023 the applicant reports to Ms Graetz a marked increase in pain after the second injection.
Ms Katie Waghorn, pharmacist, provided a report to the respondent on 25 January 2024 having reviewed the applicant’s medications to confirm which are reasonably necessary. Plans to implement non-opioid analgesia and a neuropathic agent were agreed with Dr Htun.
Align Work Health prepared an Initial Rehabilitation Report on 17 March 2023. The Recover at Work Plan prepared by Align Work Health of 29 April 2024 is also attached to the Reply.
Clinical records of the Redgum Group, the investigation reports discussed above and certificates of capacity are attached to the Reply.

Applicant’s submissions

The applicant made oral submissions which have been recorded and form part of the Commission’s record. These are set out below.
As the respondent has accepted the applicant sustained the STT joint arthritis injury to her left wrist on 20 January 2023 the dispute is whether the applicant also suffered a de Quervain’s condition.
Dr Gehr refers to two sources for the applicant’s pain involving the left wrist, the de Quervain’s condition and arthritis of the STT joint, noting she was asymptomatic before the accident. Dr Gehr found markedly reduced range of motion of the left wrist and clinical signs of de Quervain’s disease.
Dr Gehr says the applicant was working in a physically demanding job which would not have been possible if the wrist was symptomatic as it is now, so it is clearly a work related injury, and she needs surgery. As all nonoperative management has failed she should now proceed to surgery as recommended by Dr Wang to address the two pathologies.
The applicant notes Dr Wang initially says the diagnosis is not entirely clear with a working diagnosis of tendonitis that remained to be confirmed. He then says the pain is related to the first dorsal compartment. After the second injection her symptoms are consistent with either de Quervain’s disease or basal thumb arthritis which are difficult to tease apart.
By 7 October 2023 Dr Wang’s opinion is that there is evidence on his clinical examination of de Quervain’s tenosynovitis as well as symptoms of arthritis of the STT joint.
The applicant notes Dr Haig has only seen the applicant once or twice and found no signs of de Quervain’s tenosynovitis and Dr Wang has examined her on a regular basis and confirms that diagnosis.
Dr Wang’s opinion is supported in the medical certificates which include the diagnoses of sprain left wrist, TFCC ligament injury and de Quervain’s tenosynovitis.
The applicant submits that there is no basis or reasoning provided for Dr Haig’s comment that de Quervain’s tenosynovitis is not recognised as a workplace injury.
Dr Wang also sets out in his reports why the proposed surgery is reasonably necessary, which is not dealt with by Dr Haig. Dr Haig says surgery is not indicated because the applicant’s symptoms are intermittent. In the applicant’s submission that is not correct as the applicant has been on Endone and Targin as well as paracetamol which she would not be taking if her condition was intermittent. She continued to complain of her symptoms from
27 March 2023 to Dr Wang and to her general practitioners.
The applicant submits that Dr Haig’s opinion on whether the surgery for the arthritic component is reasonably necessary should not be accepted.
Dr Wang’s opinion should be preferred as he has seen the applicant on a regular basis and Dr Gehr agrees with his suggestion. Dr Haig does not give his reasons for why this surgery is not warranted and his only treatment proposal is to take anti-inflammatories.
In the report of 5 June 2024 Dr Haig confirms his diagnosis of aggravation of pre-existing osteoarthritis and then says the applicant is without symptoms in her left wrist, her condition has resolved and no surgery is required.
Dr Wang then spoke with the applicant who informed him that she still had pain in her left wrist and there was a temporary partial reduction because she had commenced on a high dose of prednisolone following her recent diagnosis with polymyalgia rheumatica.
Dr Haig did in fact note that diagnosis and the high dose of prednisolone. Dr Wang says when that was tapered her wrist pain immediately returned to the same intensity and the request for surgery remains.
Dr Wang and Dr Gehr both make a clinical diagnosis of de Quervain’s tenosynovitis and confirm the surgery is reasonably necessary as a result of the injury.
Dr Haig has seen the applicant on two occasions and concludes she has recovered from the aggravation of her osteoarthritic condition without providing his reasoning. Dr Haig concludes that she does not have de Quervain’s tenosynovitis again without providing any explanation or reasoning for that opinion. The doctor also does not provide his reasoning for why the proposed surgery is not necessary.
The applicant’s submission is that the evidence from Dr Wang and Dr Gehr should be preferred to the evidence from Dr Haig and that a finding should be made in respect of the de Quervain’s disease and that the respondent should pay the costs of and incidental to the surgery proposed by Dr Wang.

Respondent’s submissions

The respondent says there are two issues; whether there is sufficient evidence for a diagnosis to be made of de Quervain’s tenosynovitis and secondly the need for surgery that flows.
With regard to the first issue, the clinical records of Corowa Medical Centre include a note by Dr Wheeldon on 24 January 2023 that the applicant probably sprained her left wrist and that it looks like a sprain. On 30 January 2023 Dr Htun notes left wrist sprain with sudden onset pop, pain to the left wrist and a good range of left wrist joint movement.
On 4 February 2023 Dr Murray notes there is no fracture and on 10 February 2023 Dr Htun records left wrist sprain, ongoing left wrist pain, good range of movement but she can have severe sharp pain mainly at the base of the thumb and radial end.

Dr Wang in his report of 27 March 2023 says there is potentially some tenosynovitis in the first dorsal compartment, or de Quervain’s tenosynovitis, but he does not say why that is likely.
The diagnostic materials show osteoarthritis but no evidence of de Quervain’s tenosynovitis.
Dr Gehr provides a very comprehensive report but he does not actually provide any rationale as to why he believes the applicant has de Quervain’s tenosynovitis.
Dr Haig records the applicant stating that her wrist is fine, it has improved and there is “next to nothing”.[2] There were no findings made on examination, her condition has returned to normal and no surgery is required.
[2] Reply page 85.
The respondent submits that the applicant’s condition has improved, she has returned to suitable duties and the lifting restriction has been lifted. She works 32 hours per week over four days and she is about to return to pre-injury duties. The objective evidence supports the conclusion that she is making a significant recovery.
Dr Haig importantly also finds within that context that the surgery may in fact make it worse. The doctor says “I believe if the surgery was performed that would set her back in her recovery.”[3]
[3] Reply page 66.
The respondent’s submission is that there is no compelling evidence that the applicant has de Quervain’s tenosynovitis, not being revealed on the X-ray, CT scan or MRI, and secondly whatever her condition might be it has improved to the point where surgery is not reasonably necessary and possibly even contraindicated in Dr Haig’s opinion.
The applicant has most recently been diagnosed with a completely different condition of polymyalgia rheumatica affecting the shoulders. It was originally said that the shoulder was an osteoarthritic condition for which the respondent should be responsible, but the recent diagnosis is not a work related condition and perhaps the applicant needs further examination of her conditions.
The respondent submits that the applicant has not discharged her burden to prove the surgery is reasonably necessary. Any flare up of the osteoarthritis has resolved, there is no compelling evidence of de Quervain’s tenosynovitis and even if there was the respondent submits the surgery is not reasonably necessary as she has made improvements according to the evidence and her own admissions to Dr Haig.

Applicant’s submissions in reply

An attack has been made on Dr Gehr and Dr Wang on the diagnosis of de Quervain’s tenosynovitis on the basis that they have not explained how they have come to that diagnosis.
The applicant’s submission is that it is a clinical diagnosis and it is not a 100% diagnosis as Dr Wang has explained.
Dr Haig does not explain on a clinical basis or any other basis why the applicant does not have that condition.
The applicant submits that the opinions of Dr Gehr and Dr Wang, both orthopaedic surgeons, should be accepted, that is that one part of the applicant’s condition is probably de Quervain’s tenosynovitis.
The diagnosis of polymyalgia rheumatica has nothing to do with this case. It affects a different part of the body and there is no suggestion that it affects the applicant’s wrist.
Dr Wang provides an explanation in response to Dr Haig’s report following his consultation in May 2024 of the applicant’s description of her symptoms. The applicant did have high doses of prednisolone and as a result her symptoms were masked for a short period of time, but as the medication was reduced the symptoms in her wrist are still there.
The applicant submits that she still has symptoms and still requires the surgery as a result of having the same intensity of pain according to Dr Wang in his most recent report.

FINDINGS AND REASONS

Does the applicant have de Quervain’s tenosynovitis

The applicant pleads her left wrist injury as a personal injury that occurred on
20 January 2023. The respondent accepts liability for her STT joint arthritis condition as a disease injury aggravated in the course of her employment but does not accept liability for de Quervain’s tenosynovitis.
The dispute turns on whether the diagnosis of de Quervain’s tenosynovitis is established on the evidence.
The applicant bears the onus of proof to establish on the balance of probabilities that she has sustained the injury of de Quervain’s tenosynovitis.[4]
[4] Nguyen v Cosmopolitan Homes (NSW) Pty Ltd.
The respondent’s submission that there is no compelling evidence for the diagnosis of de Quervain’s tenosynovitis is not accepted for the reasons below.
Dr Wang describes the progress of his investigation of the applicant’s left wrist pain in his reports. In his first report of 27 March 2023 his diagnosis is “[l]eft wrist pain, with likely component of de Quervain’s tenosynovitis, as well as ulnar sided pain that was of secondary onset”.[5]
[5] ARD page 53.
The respondent submits that Dr Wang does not explain why he is of the opinion at this time that there is a likely component of de Quervain’s tenosynovitis. I do not agree with that submission.
The doctor records on examination that the applicant’s most severe pain is on the radial side over the first dorsal component, she has pain on restricted thumb abduction and she has pain with positive Finkelstein’s test. I understand the doctor’s physical examination is directed at determining whether the applicant has de Quervain’s tenosynovitis or any other condition.
The conclusion Dr Wang comes to in this first report is that overall he thinks the applicant’s symptoms are “most likely due to first dorsal compartment tenosynovitis, AKA de Quervain’s tenosynovitis”.[6]
[6] ARD page 54.
In his report to the insurer of 5 April 2023 he again states that the diagnosis is not entirely clear at this stage.
The doctor arranges for the applicant to have a trial of a cortisone injection to the first dorsal compartment. He tells the insurer on 5 April 2023 that this will help to confirm the diagnosis of de Quervain’s tenosynovitis and also treat it (and he notes it may not work at all), and it is part of the diagnostic work up.
The first cortisone injection into the de Quervain’s tendon provided some relief to the applicant and when Dr Wang examined her on 24 April 2023 he comments that overall she had significantly improved.
On 4 September 2023 Dr Wang refers to a second MRI showing evidence of ulnar abutment syndrome but in his opinion that clinically does not match up with the applicant’s most symptomatic side which is the radial side. Her symptoms on examination were consistent with either de Quervain’s tenosynovitis or basal thumb arthritis, which the doctor says can be quite difficult to tease apart. He thought a CT scan focusing on the applicant’s left thumb base would help to decide the diagnosis.
By 7 October 2023 the doctor forms the view that the two sources of the applicant’s pain, de Quervain’s tenosynovitis and STT joint arthritis, can co-exist. With regard to de Quervain’s tenosynovitis Dr Wang says “she has evidence of this on clinical exam with tenderness over the 1^st dorsal compartment, as well as partial response to cortisone injection.”[7]
[7] ARD page 61.
In his report of 6 July 2024 Dr Wang confirms his opinion that the applicant has two work injuries as a result of the injury on 20 January 2023; left wrist de Quervain’s tenosynovitis and left wrist basal thumb arthritis aggravated by the injury on that date.
Dr Wang provides compelling evidence that the applicant suffers with de Quervain’s tenosynovitis as a result of the injury on 20 January 2023 and he provides his rationale for forming that opinion.
Dr Gehr supports the diagnosis of de Quervain’s tenosynovitis. The doctor reports on
6 March 2024 that the applicant has markedly reduced range of motion of the left wrist and clinical signs of de Quervain’s. Forming a fist causes pain and the applicant has a positive provocative test for de Quervain’s. Dr Gehr diagnoses left wrist de Quervain’s along with symptomatic osteoarthritis involving the STT joint and underlying osteoarthritis which was previously asymptomatic.
Dr Gehr provides the rationale for his opinion that the applicant suffers with de Quervain’s tenosynovitis in his report and I do not accept the respondent’s submission in this regard.
The respondent submits that there is no reference to de Quervain’s tenosynovitis on X-ray, CT scan or MRI. Dr Wang and Dr Gehr rely mainly on physical examination to diagnose the condition. Neither doctor comments on the lack of reference to the condition in the investigation reports as providing evidence that contradicts the diagnosis.
The records of the applicant’s general practitioner include that she was waiting for a cortisone injection for her de Quervain’s tenosynovitis on 31 March 2023.[8] The diagnosis of de Quervain’s tenosynovitis is also included in the certificates of capacity from
[8] ARD page 84.
[9] ARD page 146.
31 March 2023,[9] apparently reflecting Dr Wang’s opinion.
Dr Haig did not find evidence of de Quervain’s tenosynovitis on his physical examination of the applicant. He notes in his report of 14 September 2023 that her left wrist was slightly swollen and there was a little tenderness over the radial side of the wrist. He found the range of motion was equal to that on the contralateral side. He reports that the applicant has continued with symptoms and the pain is intermittent, although he comments on her having taken Endone for six months. The doctor believes it is likely her left wrist symptoms are due to an aggravation of pre-existing osteoarthritis, rendered symptomatic in the work related injury.
Dr Haig’s supplementary report of 26 October 2023 addresses Dr Wang’s report of
7 October 2023 in which he confirms the diagnoses of de Quervain’s tenosynovitis. Dr Haig reports that when he examined the applicant he found no signs of that condition. There is no further information provided regarding the nature of the physical examination caried out by
Dr Haig. When asked about any causal link Dr Haig says de Quervain’s tenosynovitis is not recognised as being a workplace injury.
On 5 June 2024 Dr Haig confirms his earlier diagnosis.
Dr Wang examined the applicant in his Melbourne rooms on three occasions and twice by telephone, and Dr Haig examined the applicant on two occasions in his Albury rooms. I accept the submission made by the applicant that Dr Wang’s opinion ought to be preferred as Dr Wang has examined the applicant on a more regular basis.
I prefer the opinion of Dr Wang as the applicant’s treating specialist, noting he has examined her on a regular basis and that his opinion is supported by Dr Gehr. In my view there is sufficient evidence to support the diagnosis of de Quervain’s tenosynovitis.
The respondent submits that an inference was available from the more recent diagnosis of polymyalgia rheumatica that the diagnosis of de Quervain’s tenosynovitis should be further investigated. I agree with the applicant’s submission that this is a different condition in a different part of the applicant’s body and it does not affect Dr Wang’s diagnosis.
Dr Wang says on 5 April 2023 that the applicant’s left wrist pain with a likely component of de Quervain’s tenosynovitis as well as ulnar sided pain is wholly related to the incident of
20 January 2023.[10] Dr Wang’s opinion is that de Quervain’s tenosynovitis can be precipitated and aggravated by sudden overload of the wrist such as that described by the applicant.[11]
[10] ARD page 55.
[11] ARD page 62.
[12] ARD page 16.
Dr Gehr’s opinion is that the employment caused the left wrist injury.[12] There is no evidence to that contradicts that the employment was the main contributing factor to the injury.
I make the finding based on the evidence that the applicant has sustained an aggravation of de Quervain’s tenosynovitis in the course of her employment on 20 January 2023 and that the employment was the main contributing factor to that aggravation.

Is the proposed surgery reasonably necessary as a result of injury

Dr Wang recommends the applicant have left wrist arthroscopic open distal scaphoid/proximal trapezium excision and de Quervain’s tenosynovitis decompression surgery.
Dr Gehr says;
“It is my opinion that it is now over a year since the subject accident and nonoperative management has failed and now she should proceed to surgery as recommended by Dr. Wang. That would be to address the two pathologies which are the osteoarthritis of the STT joint and the de Quervain’s disease.”[13]
[13] ARD page 17.
First with regard to the applicant’s accepted STT joint arthritis condition, Dr Wang is of the opinion that it is well established that distal scaphoid pole excision is a reasonable treatment option for recalcitrant STT arthritis that has failed all nonoperative management.[14]
[14] ARD page 62.
In Dr Wang’s opinion the applicant has truly failed all nonoperative management including rest, activity modification, anti-inflammatories, splinting, hand therapy, exercise and cortisone injection.
Dr Haig’s opinion in his report of 5 June 2024 is that the aggravation of the applicant’s pre-existing osteoarthritis in her left wrist has resolved, she states the wrist is fine, there were no findings made on examination regarding the left wrist and no surgery is required.
The applicant’s submission is that her left wrist symptoms were temporarily masked by the high dosage of prednisolone she was taking for her recent diagnosis of polymyalgia rheumatica at the time of Dr Haig’s examination.
Dr Wang spoke to the applicant after Dr Haig provided his report and says the applicant complains of wrist pain that is still very much present. Once the high dose of prednisolone tapered her wrist pain immediately returned to the same intensity. Dr Wang confirms his opinion that surgery would be the next reasonable step.
In the respondent’s submission the applicant’s symptoms are noted by Dr Haig as being intermittent so that surgery is not required.
The applicant refers to her reliance on pain relieving medications in support of her submission that her symptoms are not intermittent.
The medical records disclose ongoing prescribing of Endone and Targin from February 2023 in addition to the use of paracetamol and anti-inflammatories. The applicant suffered with other conditions such as the frozen left shoulder and also required pain relief from time to time unrelated to her left wrist pain. Ms Waghorn notes in January 2024 that Dr Htun planned to reduce her intake of opioids. Dr Haig notes in his report of 5 June 2024 that the applicant has discontinued taking Endone and she takes Panadol as required and Targin rarely, although that record is to be considered in the light of Dr Wang’s later report.
In her statement of 1 May 2024 the applicant says she continues to take medication such as Panadol Osteo and Targin on a daily basis to attempt to reduce the pain.
I do not accept on the evidence that the applicant’s left wrist symptoms are intermittent.
The respondent submits there is further objective evidence that the applicant’s left wrist condition has significantly improved in her increased capacity to work. In his report of
5 June 2024 Dr Haig states that he believes the applicant could return to pre-injury duties as of the present time.
A review of the certificates of capacity shows her capacity for work after the injury increased up to 18 hours per week until 26 June 2023 when she had no work capacity. In October 2023 she was certified as having capacity to work for eight hours per week, increasing to 15 hours per week by February 2024. The applicant’s statement evidence of 1 May 2024 is that she is continuing to work at a reduced capacity in accordance with her doctors’ recommendations.
I do not accept the submission that there is objective evidence that the applicant no longer has symptoms related to her left wrist condition so that surgery is no longer required.
Dr Haig’s opinion is that the proposed surgery could set back her recovery however he does not provide an explanation for that opinion and that opinion is not accepted.
On reviewing the evidence I find the proposed surgery to treat the applicant’s STT joint arthritis condition is reasonably necessary as a result of the injury.
Second, having found the applicant has de Quervain’s tenosynovitis as a result of injury,
[15] ARD page 62.
Dr Wang’s opinion is that it is well established that surgical release is a reasonable option as treatment for recalcitrant de Quervain’s tenosynovitis that has failed all nonoperative management.[15]
The respondent submits that if the finding is made that the applicant has sustained the injury of de Quervain’s tenosynovitis, the surgery proposed by Dr Wang is not reasonably necessary.
Dr Haig does not comment directly on the surgery proposed for decompression of de Quervain’s tenosynovitis as he makes no diagnosis of that condition.
Considering the criteria in Diab v NRMA Ltd [2014] NSWWCCPD 72 I accept that the proposed de Quervain’s tenosynovitis decompression surgery is also reasonably necessary as a result of the injury.
The proposed surgery is accepted by two orthopaedic surgeons, Dr Wang and Dr Gehr, as being appropriate and likely to be effective, and all nonoperative management has failed.
Dr Haig’s opinion is that the applicant may need to take anti-inflammatory agents and/or analgesics as required however Dr Wang comments in his report of 23 November 2023 that she has already trialled this for nine months. No submissions have been made regarding the cost of the proposed surgery.
On the basis of the evidence I find the surgery proposed by Dr Wang, being left wrist arthroscopic open distal scaphoid proximal trapezium excision and de Quervain’s tenosynovitis decompression, is reasonably necessary as a result of injury pursuant to s 60 of the 1987 Act.

SUMMARY

The applicant sustained an aggravation of de Quervain’s tenosynovitis on 20 January 2023 in the course of her employment in addition to the accepted aggravation of arthritis in her STT joint, and employment was the main contributing factor to that aggravation.

The surgery proposed by Dr Wang on 7 October 2023 is reasonably necessary as a result of the applicant’s injury.
There will be an order that the respondent pay the costs of and incidental to the left wrist arthroscopic open distal scaphoid/proximal trapezium excision and de Quervain’s tenosynovitis decompression surgery proposed by Dr Wang at the SIRA gazetted rates.

[2024] NSWPIC 424

7 August 2024