Ginnelly v AAI Limited t/as GIO

DETERMINATION OF REVIEW PANEL
CITATION:	Ginnelly v AAI Limited t/as GIO [2023] NSWPICMP 648
CLAIMANT:	Michael Ginnelly
INSURER:	AAI Ltd t/as GIO
REVIEW PANEL
PRINCIPAL MEMBER:	John Harris
MEDICAL ASSESSOR:	John Carter
MEDICAL ASSESSOR:	Shane Moloney
DATE OF DECISION:	1 December 2023
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; claimant involved in a motor accident on 31 October 2017 whilst riding a motor bike that struck insured vehicle and claimant impaled on bike pedal; issue as to the extent of the issues before the Panel given the limited grounds of review; review applied to all matters in the medical assessment; Allianz Australia Ltd v Ellul applied; Meeuwissen v Boden and Wood v Insurance Australia Ltd referred to; permanent impairment and multiple impairment disputes; claimant had prior neck, back and bilateral shoulder symptoms; various findings made on causation of injuries and need for treatment; assessment of bilateral shoulder condition noting prior symptoms and surgical procedures; no deduction made; IAG Ltd v Chahoud applied; Held – medical assessment revoked; finding made that impairment exceeded 10%; various findings made on treatment disputes.
DETERMINATIONS MADE:	Medical Assessment – Treatment and Care Review Panel Assessment of Treatment and Care Certificate issued under s 63 of the Motor Accidents Compensation Act 1999 The Review Panel revokes the certificate of Medical Assessor Cameron dated 27 March 2022 and issues a new certificate determining that: The following treatment and care: · a future steroid injection; · visits to general practitioner, twice yearly for the remainder of life; · past gratuitous assistance; · future domestic assistance; · left shoulder arthroscopy; · future right shoulder arthroscopy; · past gratuitous assistance; · future domestic assistance; RELATES TO THE INJURY CAUSED BY THE MOTOR ACCIDENT The following treatment and care · a future steroid injection; · visits to general practitioner, twice yearly for the remainder of life; · left shoulder arthroscopy; · left carpal tunnel decompression; · future right carpal tunnel decompression; is REASONABLE AND NECESSARY in the circumstances. The following treatment and care: · future consumption of Tramadol; · future fentanyl patches and endone; · left carpal tunnel decompression; · future left knee arthroscopy; · future right carpal tunnel decompression; DOES NOT RELATE TO THE INJURY CAUSED BY THE MOTOR ACCIDENT The following treatment and care: · future consumption of Tramadol; · future fentanyl patches and endone; · future left knee arthroscopy; · future right shoulder surgery; is NOT REASONABLE AND NECESSARY in the circumstances. The extent of any need for past gratuitous assistance and future domestic assistance, if any, is to be assessed by an Occupational Therapist. Medical Assessment – Permanent Impairment WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10% The assessment made by the review panel under s 63(4) is as follows: The Review Panel revokes the certificate of Medical Assessor Cameron dated 27 March 2022 and issues a new certificate that the following injuries caused by the motor accident give rise to a whole person impairment which is GREATER THAN 10%: · abdomen/hernia; · left shoulder; · right shoulder; · left hip; · scarring, and · left knee.

STATEMENT OF REASONS

INTRODUCTION

Mr Michael Ginnelly (the claimant) was involved in a motor accident on 31 October 2017. The claimant was travelling on a motorbike when the insured vehicle turned right across his path. The claimant’s motorbike crashed into the insured vehicle and the claimant was thrown off the bike and fell onto the motorbike pedal which impaled into the claimant’s abdomen.
The insurer is liable to pay Mr Ginnelly any damages under the Motor Accidents Compensation Act 1999 (the MAC Act).
A medical assessment matter is determined in accordance with Part 3.4 of the MAC Act. This means that the matter is determined at first instance by a Medical Assessor[1] and, pursuant to s 63 of the MAC Act, on review by a review panel.
[1] Section 60 of the MAC Act.
The present disputes between the parties are whether the degree of permanent impairment as a result of the injury caused by the motor accident is greater than 10%, whether the treatment provided or to be provided to the injured person was or is reasonable and necessary in the circumstances and whether any such treatment relates to the injury caused by the motor accident.
These constitute medical assessment matters and medical disputes within the meaning of the MAC Act.[2]
[2] See ss 57 and 58 of the MAC Act.
The medical disputes were referred to Medical Assessor Cameron who issued a Medical Assessment Certificate dated 27 March 2022 (the Medical Assessment Certificate).[3]
[3] Claimant’s bundle, p 92.
The medical disputes concerning treatment and care set out by the Medical Assessor were:
•      Whether a steroid injection in relation to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether 0-12 GP consultation sessions per year in relation to all physical injuries from the date of MAS assessment and continue for a further zero to five years is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether 0-12 GP consultation sessions per year in relation to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether 0-12 GP consultation sessions per year in relation to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Fentanyl patches (50µg) in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether 0 – 14 hours per week gratuitous care tasks in relations to all physical injuries from the date of the motor vehicle accident to the date of MAS assessment is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether 0-10 hours of domestic assistance per week tasks in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether all physical injuries give a rise to a need for domestic assistance tasks from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether 0-10 hours of domestic assistance per week tasks in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery to left shoulder arthroscopy performed by Dr Chandra Dave is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery to left wrist carpal tunnel release performed by Professor Mark Sheridan is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery of arthroscopy to the left knee and ancillary treatment from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery - repair of right rotator cuff tendonitis and ancillary treatment to the right shoulder from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery to right sided carpal tunnel decompression to the right wrist from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Fentanyl patches (50mcg) in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Fentanyl patches (50mcg) in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether the use of Endone (4-6 per day) in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is causally related to the injury sustained in the subject accident.
•      Whether the use of Endone (4-6 per day) in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Endone (4-6 per day) in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether the use of Endone (4-6 per day) in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Tramadol in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is causally related to the injury sustained in the subject accident.
•      Whether the use of Tramadol in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the use of Tramadol in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether the use of Tramadol in relations to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is reasonable and necessary related to the injury sustained in the subject accident.
•      Whether the surgery to left shoulder arthroscopy performed by Dr Chandra Dave is causally related to the injury sustained in the subject accident.
•      Whether the surgery to left wrist carpal tunnel release performed by Professor Mark Sheridan is causally related to the injury sustained in the subject accident.
•      Whether all physical injuries give a rise to a need for gratuitous care tasks in relations to all physical injuries from the date of the motor vehicle accident to the date of MAS assessment is causally related to the injury sustained in the subject accident.
•      Whether all physical injuries give a rise to a need for domestic assistance tasks in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is causally related to the injury sustained in the subject accident.
•      Whether the use of Fentanyl patches (50mcg) in relations to all physical injuries from the date of MAS assessment and continue for a further zero to five years is causally related to the injury sustained in the subject accident.
•      Whether 0-12 GP consultation sessions per year in relation to all physical injuries from the date of MAS assessment and continue for a further zero to five years is causally related to the injury sustained in the subject accident.
•      Whether the surgery of arthroscopy to the left knee and ancillary treatment from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether the surgery - repair of right rotator cuff tendonitis and ancillary treatment to the right shoulder from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether the surgery to right sided carpal tunnel decompression to the right wrist from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
•      Whether a steroid injection in relation to all physical injuries from the date of MAS assessment and ongoing for the remainder of claimant’s life expectancy is causally related to the injury sustained in the subject accident.
We observe a couple of matters concerning the “medical disputes” as phrased. First, the reference to “MAS assessment” is taken to be the assessment undertaken by the Medical Assessors as this is a new assessment.
Secondly, half of the questions correctly ask the causation question. The other half are poorly phrased and ask the combined question whether a specific treatment is “reasonable and necessary related to the injury sustained in the subject accident”. That is a joint question about two distinct issues (“reasonable and necessary” and “causation”) and reflects the erroneously understanding that the issues are complementary.
We intend, as the original Medical Assessor did, to split the various treatments and care into whether they were “related to the injury caused by the accident” and whether they were “reasonable and necessary in the circumstances”.

THE REVIEW

The application for referral of the medical assessments to a review panel were made by the claimant within 28 days after the parties were issued with the certificate for the medical assessment for which the review is sought.[4]
[4] Section 63(7) of the MAC Act.
The President’s delegate referred the medical assessments to the Review Panel (the Panel) as they were satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.[5]
[5] Section 63(2B) of the MAC Act.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provisions provide[6] that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).
[6] Section 63(3) of the MAC Act.
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.[7]
[7] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application.[8]
[8] Rule 128 of the PIC Rules.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.[9]
[9] Section 63(3A) of the MAC Act.
The claimant underwent cervical spine surgery following the provision of the medical assessment certificiate. Accordingly, at the claimant’s request, the matter was delayed until the claimant’s condition had stabilised following this surgery.
The Panel issued a direction to the parties requesting a provision of respective bundles that should be considered. Given the delay, the parties filed updated bundles of documents for the Panel’s consideration.

STATUTORY PROVISIONS/GUIDELINES

Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 of the MAC Act provides that a disagreement between a claimant and an insurer on three distinct matters is referred to as “medical assessment matters”. Medical assessment matters include “whether the treatment provided or to be provided to the injured person was or is reasonable and necessary in the circumstances” and “whether any such treatment relates to the injury caused by the motor accident”.
Section 60 of the MAC Act provides that either party may refer a medical dispute to the President who is to arrange for the dispute to be referred to one or more Medical Assessors.
These sections self-evidently provide that the issue of “reasonable and necessary in the circumstances” and “whether any such treatment relates to the injury caused by the motor accident” are different concepts.
The provisions of the Civil Liability Act 2002 (the CL Act) apply to the MAC Act in determining issues of causation. Particularly ss 5D and 5E of the CL Act apply to the MAC Act.[10] In Raina v CIC Allianz Insurance Ltd[11] Campbell J stated:
“One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002(NSW), ss5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely.”
[10] See s 3B(2) of the CL Act.
[11] [2021] NSWSC 13 (Raina) at [65].
These observations were made in the context of a review panel being constituted by three medical experts as opposed to the composition of the present panel following the amendments to the MAC Act. The observations are still pertinent to the presently constituted Panel.
Clause 1.7 of the Guidelines provides:
“There is no simple common test of causation that is applicable in all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible.”
The Panel is required to determine the issues on the balance of probabilities. The resolution of causation does not require scientific certainty: Briggs v IAG Ltd (No 2).[12]

MATERIAL BEFORE THE REVIEW PANEL

[12] [2022] NSWSC 372 (Briggs (No 2)) at [73].

Pre-accident records

The claimant was involved in a motor accident on 14 April 2004 when the motor vehicle rolled, and he went through the windscreen.
An ultrasound of the right shoulder in October 2004 was essentially normal.[13] The left shoulder ultrasound showed impingement on abduction but was otherwise normal.
[13] Insurer’s bundle, p 189.
A CT scan of the cervical spine dated 12 January 2005 was normal.[14]
[14] Insurer’s bundle, p 187.

In February 2005 Dr Rail noted recurring neck spasm, marked reduction in movement and pain spreading into the upper limbs with associated paraesthesia. The doctor noted that the CT scan of the cervical spine was normal and opined that the claimant had features of cervical radiculitis with muscle spasm and required physiotherapy.[15]
[15] Insurer’s bundle, p 185.
In September 2005 Dr Dave noted chronic pain in the cervical spine radiating down both shoulders which had been occurring for almost a year.[16] Following the provision of MRI scans of the neck and both shoulders, Dr Dave diagnosed supraspinatus tendonitis of both shoulders with no labral injuries and the neck MRI scan was essentially clear.
[16] Claimant’s bundle, p 518.
In September 2005, Dr Rail, noted that EMG studies showed bilateral carpal tunnel syndrome, more dominant of the right, which were relatively mild. The doctor suggested night splinting.[17]
[17] Insurer’s bundle, p 179.
A CT scan of the cervical spine dated 5 March 2006 following a go-cart accident revealed no abnormality.[18] The hospital record noted history of neck and back pain following a motor accident.[19]
[18] Claimant’s bundle p 38.
[19] Claimant’s bundle, p 190.
In October 2006 Dr Abraszko noted the flexion extension views of the cervical spine were unremarkable, bone scan was normal and, neurologically, Phalen and Tinnel signs were positive. The doctor recommended decompression of the right median nerve at the wrist.[20]
[20] Claimant’s bundle, p 1147.
In December 2006 the general practitioner (GP) noted the claimant remained with neck and upper limb pain, weakness and numbness two years following the motor accident.[21]
[21] Claimant’s bundle p 794.
In April 2007 Professor Sheridan noted the claimant had persisting neck pain, bilateral arm pain, paraesthesia, numbness and weakness in the arms as well as lower back pain and bilateral leg pain. Further scans were recommended.[22]
[22] Claimant’s bundle, p 1150.
Bilateral nerve conduction studies dated 30 May 2007 showed bilateral abnormalities of the median nerve of a mild to moderate degree consistent with a clinical diagnosis of carpal tunnel syndrome.[23] Professor Sheridan did not recommend surgical intervention given the EMG nerve conduction studies.[24]
[23] Claimant’s bundle p 40.
[24] Claimant’s bundle, p 1152.
In 2008 the claimant underwent right shoulder acromioplasty.[25]
[25] Claimant’s bundle, p 510.
The claimant underwent an MRI scan of the right shoulder in January 2011 with reported “recurrence of pain”.[26] Further right shoulder surgery was undertaken in October 2011.[27]
[26] Claimant’s bundle, p 511.
[27] Claimant’s bundle, p 512.
Treatment in 2012 related to a SLAP lesion in the left shoulder and further complaints of right shoulder problems with further repair in 2013.[28]
[28] Insurer’s bundle, p 32.
In December 2013 the physiotherapist noted that the shoulder had full range of motion.[29]
[29] Claimant’s bundle, p 496.
A CT scan of the lumbar spine dated 2 May 2014 noted recurrence of lower lumbar pain with no significant disc herniation demonstrated, small broad disc bulges at L4/5 and small central disc bulge at L5/S1.[30]
[30] Claimant’s bundle, p 701.
In May 2014, Dr White, rheumatologist, noted the claimant was found to be HLA-B27 positive noted worsening lower back pain in the last six weeks. The doctor opined that the claimant did not have an inflammatory spondyloarthropathy although suggested further tests.[31]
[31] Claimant’s bundle, p 1181.
In June 2014 Dr White noted that recent X-rays identified grade 3 sacroiliitis. The doctor recommended ongoing use of anti-inflammatories, particularly Celebrex.[32]
[32] Claimant’s bundle, p 1183.
In 2015 the claimant injured his right third metatarsal after a football injury.[33]
[33] Claimant’s bundle, p 174.
In June 2015 Dr White noted ongoing discomfort localised to the lumbar spine extending to the lateral hip girdles. In December 2015 Dr White noted that the claimant had recent increase of lower back pain during a period when he had ceased using Celebrex prior to undergoing a tonsillectomy.[34]
[34] Claimant’s bundle, p 1207.
In February 2016 the claimant had ongoing left shoulder symptoms and Dr Dave recommended surgical repair.[35] Surgical repair was undertaken in late 2016.[36]
[35] Claimant’s bundle, pp 494 – 500.
[36] Claimant’s bundle, p 536, p 621.
A CT scan of the cervical spine dated 29 March 2016 showed cervical spondylosis with degenerative changes.[37]
[37] Claimant’s bundle, p 725.
In June 2016 Professor Sheridan noted recent flareup of neck pain and bilateral arm pain worse on the right.[38]
[38] Claimant’s bundle, p 1213.
Bilateral motor nerve conduction studies dated 22 July 2016 showed moderate, right more than left, median nerve entrapment village wrist involving sensory and motor fibres.[39]
[39] Claimant’s bundle, p 1533.
In October 2016 the claimant underwent a C5/6 anterior cervical discectomy and fusion.[40] Follow-up review with Professor Sheridan in December 2016 noted the surgery was uneventful, pain was settling rapidly with occasional numbness in the hand.[41]
[40] Claimant’s bundle, p 384.
[41] Claimant’s bundle, p 1221.
On 15 December 2016 the claimant underwent arthroscopy and left shoulder anterior labral repair.[42]
[42] Claimant’s bundle, p 1222.
In January 2017 the GP noted recent neck and shoulder surgery with pins and needles in the right forearm and no neurological deficits.[43]
[43] Claimant’s bundle, p 620.
A CT scan of the cervical spine dated 3 January 2017 noted post-surgical changes at C5/6 but otherwise similar appearance to the previous examination of March 2016.[44]
[44] Claimant’s bundle, p 731.
In January 2017 Professor Sheridan reported that the claimant had persisting neck and right arm pain. Follow-up CT scans noted healing with no evidence of any problems at the C5/6 level. A further CT guided injection was organised with ongoing physiotherapy.[45]
[45] Claimant’s bundle, p 1237.
In February 2017 Dr Dave noted the claimant was back in the gym and doing quite well. Examination at that time showed the claimant comfortable with no neurovascular deficits. The doctor recommended ongoing exercises.[46] Professor Sheridan then noted ongoing neck and right arm pain and organised the CT guided injection.[47]
[46] Claimant’s bundle, p 537.
[47] Claimant’s bundle, p 1563.
In April 2017 the GP noted the claimant complained of sudden right knee pain while recently running during refereeing.[48]
[48] Claimant’s bundle, p 619.
On 20 June 2017 the GP noted that the claimant was “well looking, in good health today”.[49]
[49] Claimant’s bundle, p 618.
In August 2017 the GP note that the claimant had been refereeing five games in three days.[50] Clinical notes of the GP revealed swelling in both hands.
[50] Claimant’s bundle, p 617.
In September 2017 the GP noted a history of upper chest pain since last night whilst the claimant was refereeing. The GP also noted the claimant “does gym regularly” with no recollection of trauma associated with activity.[51]
[51] Claimant’s bundle, p 616.

Post-accident records

The ambulance report noted a 5 cm laceration above the bellybutton. The claimant stated that he had been involved in a motor accident with the spike colliding with a turning car and had impaled himself on his bike. The claimant also complained of neck, right side face and right shoulder pain.[52]
[52] Claimant’s bundle, p 12.
A CT scan of the cervical spine dated 31 October 2017 did not show any acute fracture or haematoma. The scan noted moderate degenerative changes in the cervical spine with the discectomy and fusion at C5/6.[53]
[53] Claimant’s bundle, p 111.
An X-ray of the left hip/pelvis and left femur dated 3 November 2017 did not show any acute bony or joint abnormality.[54] The clinical history noted that the claimant was complaining of significant left hip, femur and knee pain and pain on standing up.[55]
[54] Claimant’s bundle, p 84.
[55] Claimant’s bundle, p 1251.
The discharge referral from hospital dated 9 November 2017 noted trauma with multiple injuries with a principal diagnosis of penetrating trauma to the abdomen.[56]
[56] Claimant’s bundle, p 106.
On 5 December 2017 the GP noted complaints of pain in both shoulders and left knee since the motor accident.[57]
[57] Claimant’s bundle, p 612.
A referral from the GP to Dr Dave dated 5 December 2017 noted painful left knee and both shoulders since the motor vehicle accident.[58]
[58] Claimant’s bundle, p 476.
The claim form dated 21 December 2017 described the injuries caused by the motor accident as neck, both shoulders, teeth, left knee, stomach, left shin, right index finger and back of head.[59]
[59] Claimant’s bundle, p 1703.
On 3 January 2018 Professor Sheridan noted he last consulted the claimant at the beginning of 2017 and “he was going very well until he was involved in a motor vehicle accident”. The doctor noted paraesthesia and numbness extended to his hand since the motor accident.[60]
[60] Claimant’s bundle, p 1268.
The MRI scan of the left shoulder dated 9 January 2018 noted a clinical history of the motor accident injury to both shoulders. The scan showed acromioclavicular joint osteoarthritis, SLAP tear in labrum and minor rotator cuff enthesopathy with acromioclavicular joint osteoarthritis with no recurrent adhesive capsulitis or significant labral bursitis.[61]
[61] Claimant’s bundle, p 477.
The MRI scan of the right shoulder dated 9 January 2018 showed progressive acromioclavicular joint osteoarthritis with no recurrent adhesive capsulitis or significant labral tearing.[62]
[62] Claimant’s bundle, p 480.
The MRI scan of the left knee dated 10 January 2018 showed grade 2 chondromalacia patellae.[63]
[63] Claimant’s bundle, p 478.
On 25 January 2018 Dr Dave noted the claimant injured both shoulders, neck, left knee and sustained an abdominal wound in the motor accident.[64]
[64] Claimant’s bundle, p 538.
The bone scan dated 23 January 2018 showed mild to moderate active arthritic changes at C4/5 and C5/6, moderately active arthritic changes in the acromioclavicular joints bilaterally and mild active arthritic changes in the shoulders bilaterally.[65]
[65] Claimant’s bundle, p 1540.
The MRI scan of the cervical spine dated 29 January 2018 showed stable multilevel degenerative change with no progressive stenosis identified.[66]
[66] Claimant’s bundle, p 1529.
On 8 February 2018 Dr Dave noted the claimant was doing well prior to the motor accident where he was undergoing boxing classes. The doctor noted AC joint symptoms in the right side and AC joint tenderness as well as pain on stressing the biceps on the left side. The doctor noted the recent MRI scan showed AC joint pathology and possibly, a labral re-tear of the left shoulder.[67]
[67] Claimant’s bundle, p 539.
On 14 February 2018 Professor Sheridan noted the recent MRI and bone scans which showed inflammation at the side of the previous surgery but nothing else and no disc protrusion or nerve compression. The doctor noted that he suspected there had been a flareup of the underlying inflammation in the neck from the previous surgery as well as a whiplash injury. He felt that these changes would settle with time and there was no need for surgical intervention. Physiotherapy was recommended.[68]
[68] Claimant’s bundle, p 1271.
A report from Sydney pain specialist dated 23 February 2018 noted prior neck fusion at C5/6, ankylosing spondylitis, and left shoulder reconstruction. The pain caused by the motor accident included abdominal pain, neck, shoulder, lower back and hip pain with associated disabilities.[69]
[69] Claimant’s bundle, p 18.
On 5 March 2018 Dr Dave noted that the left hip subluxes and further imaging was required.[70]
[70] Claimant’s bundle, p 540.
The MRI scan of the left hip dated 13 March 2018 questioned instability in its clinical notes and showed early osteoarthritis with chondromalacia in the acetabular roof, and minimal chondrolabral separation in the anterosuperior labrum suggesting a tear.[71]
[71] Claimant’s bundle, p 485.
On 26 March 2018 Dr Dave noted the MRI scan confirmed new pathology as well as a labral tear with significant pain. Initial treatment was recommended by way of injection. The doctor noted ongoing issues in both shoulders, left knee as well as the abdomen.[72]
[72] Claimant’s bundle, p 541.
On 1 February 2019, Professor Sheridan noted worsening neck, arm and leg symptoms since the previous visit.[73]
[73] Claimant’s bundle, p 1327.
A further bone scan dated 6 February 2019 showed no significant active facet joint arthritis in the cervical spine, moderate to intense ongoing bony reaction at the site of C5/6 anterior fusion, mild to moderate active discovertebral arthritis in the cervical spine. There was no significant active discovertebral arthritis or facet joint arthritis in the lumbar spine.[74]
[74] Claimant’s bundle, p 1544.
Further motor nerve conduction studies dated 11 March 2019 showed moderate, right more than left, median nerve compression entrapment at the wrist involving sensory and motor fibres which was stable compared with the previous study of 22 July 2016.[75]
[75] Claimant’s bundle, p 1341.
The claimant was diagnosed with metastatic prostate cancer in early 2020. A report noted that the claimant had chronic pain from a motorbike injury in 2017 and was on fentanyl patches. The claimant was commenced on Targin and Endone by palliative care during that surgical admission.[76]
[76] Claimant’s bundle, p 1390.
In July 2020 Dr Dave noted the claimant’s general health had deteriorated due to treatment for malignancies and prognosis was guarded. The doctor noted recent shoulder surgery on the left side with the AC joint was excised and the biceps anchor was released. Further right shoulder surgery was planned following cervical spine surgery and carpal tunnel releases.[77]
[77] Claimant’s bundle, p 544.
On 29 July 2020 the claimant underwent left carpal tunnel decompression.[78] In August 2020 Professor Sheridan noted the operation was uneventful and symptoms were settling.[79]
[78] Claimant’s bundle, p 1419.
[79] Claimant’s bundle, p 1422.
In August 2020 the pain specialist noted that a trial of Tramadol was not effective, and the claimant was back on Duragesic and Endone.[80]
[80] Claimant’s bundle, p 1425.
Dr Kumar then assessed the claimant at 12% whole person impairment for the injury to the digestive system and a further 5% whole person impairment for scarring.[81]
[81] Claimant’s bundle, p 1729.
In May 2021, Dr Dave noted that the claimant had a good result from the left shoulder surgery and was keen to undergo right shoulder surgery. The doctor noted that the claimant had impingement of the rotator cuff and AC joint pathology on the right side.[82]
[82] Claimant’s bundle, p 1455.
In September 2020, Professor Sheridan noted the recent bone scan showed quite extensive metastatic disease from the prostate into the thoracic spine, inflammatory response and C5/6 fusion and possible metastatic deposits in the lumbar spine.[83]
[83] Claimant’s bundle, p 1435.
In April 2021 Professor Sheridan noted the injection into the neck did not help with relieving symptoms and the claimant presented with persisting neck pain and paraesthesia in the upper limb as well as pain, paraesthesia and numbness in the hand. The doctor noted that he was unsure whether the symptoms were coming from the after-effects of his neck injury, neck surgery or from his carpal tunnel. Previous imaging showed no obvious nerve compression in the neck although there was marked inflammatory reaction at the side of the previous C5/6 anterior cervical discectomy and fusion.[84]
[84] Claimant’s bundle, p 1120.
On 17 May 2021 Dr Dave noted the claimant had a good result from the left shoulder surgery and was keen to undergo right shoulder surgery. From an orthopaedic viewpoint, the doctor noted impingement of the rotator cuff and AC joint pathology.[85]
[85] Claimant’s bundle, p 543.
In September 2021, Professor Sheridan noted the claimant was bothered by neck, arm, back and left leg symptoms which were getting worse. He proposed surgery at C4/5, carpal tunnel decompression and lower back surgery.[86] The MRI scan of the cervical spine showed no change since a study on 29 August 2020. The MRI scan of the lumbar spine showed mild desiccation L4/5, desiccation at L5/S1 and mild degenerative changes in the facet joints at the lower lumbar levels.[87]
[86] Claimant’s bundle, p 1465.
[87] Claimant’s bundle, p 1468.
Professor Sheridan then recommended a laminectomy and nerve root compression from C4 to C7 followed by L5/S1 laminectomy and discectomy.[88] The doctor noted that the surgery was solely as a result of the motorbike accident with no pre-existing or pre-disposing health problems.
[88] Claimant’s bundle, p 1473.
In November 2021 Dr Kumar noted the claimant had undergone laparoscopic repair of a large incisional hernia and had dropped approximate 5 kg of weight. The doctor noted aching after eating usually in the upper abdomen along the scar tissue. The doctor considered the aches were due to recurrent bowel adhesions.[89]
[89] Claimant’s bundle, p 546.
In September 2022, Dr Shiva, neurosurgeon, consulted the claimant for the upcoming cervical laminectomy. The doctor noted the claimant had numbness in his hands which he had for a number of years as well as neck pain. The doctor explained the risks associated with the surgery.[90]
[90] Claimant’s bundle, p 1660.
In October 2022, Dr Shiva, neurosurgeon, consulted the claimant by way of follow-up for the cervical laminectomy. The doctor noted that the numbness in the hands persisted, neck pain was slowly improving and symptoms in the ring and little finger could be in keeping with an ulnar neuropathy which had developed since the surgery. The doctor noted the applicant had ongoing back and left leg pain and was due for shoulder reconstruction in the near future.[91]
[91] Claimant’s bundle, p 1652.

Statements

A statement by Scott Borg dated 3 September 2020 advised that he was the regional manager of game development within the national rugby league. He was familiar with the claimant who had previously worked as a subcontractor refereeing games. Mr Borg stated that the frequency of games referred by the claimant varied. He stated that the claimant was both physically and psychologically capable of refereeing prior to the motor accident.[92]
[92] Claimant’s bundle, p 1697.

Qualified opinions

Dr Neil Berry, surgeon, provided a report dated 12 February 2019.[93] The doctor opined that the motor accident caused soft tissue injury of the neck, injury to both shoulders, a penetrating injury to the abdomen and injuries to the left hip and left knee.
[93] Claimant’s bundle, p 1737.
In terms of treatment, Dr Berry recommended further surgery to the gastrointestinal system, a corticosteroid injection to the left hip, arthroscopy to the left knee, and bilateral shoulder surgery.
In a further short report Dr Berry agreed with the opinion of Professor Sheridan that the suggested bilateral carpal tunnel releases, neck surgery and lumbar spine surgery were reasonable and necessary.
Dr Phil Truskett, surgeon, was qualified by the insurer and provided a report dated
[94] Insurer’s bundle, p 130.
12 March 2019.[94] The doctor noted the claimant’s complaints of ongoing pain in the abdomen, left hip, left knee, right shoulder, left shoulder, neck and left leg.
Dr Truskett opined that the claimant had suffered soft tissue injuries to the left hip, left knee, both shoulders and neck with a penetrating injury to the left rectus muscle which did not enter the perineal cavity. The doctor recommended that the symptoms were “best controlled by the judicious use of simple analgesics”. Dr Truskett assessed whole person impairment of each shoulder at 2% and the scar at 1%, resulting in a combined whole person impairment of 5%.
Dr Grant Walker, neurologist, was qualified by the insurer and provided a report dated
[95] Insurer’s bundle, p 124.
19 August 2020.[95] The doctor opined that there did not appear to be any evidence of any new injury to the spine and large joints and all the current symptoms were present prior to the motor accident.

The doctor noted that the claimant walked with a slight limp which was said to be due to the left hip pain. It was noted, despite the cancer, that the claimant had recently undergone left shoulder reconstruction and left carpal tunnel decompression.
Dr Walker also opined that there were no neurological symptoms as a result the motor accident.

OTHER MEDICAL ASSESSMENTS

Medical Assessment Certificates issued by Medical Assessor Sykes,[96] which were confirmed by a Medical Review Panel,[97] concluded that the claimant impacted his face in the motor accident which caused a temporary exacerbation of pain with no ongoing dental injury.
[96] Insurer’s bundle, p 67.
[97] Ginnelly v AAI Ltd [2023] NSWPICMP 199.
Medical Assessor Home provided a certificate dated 7 August 2023.[98] The Medical Assessor concluded that the C4/7 laminectomy and nerve root decompression and the proposed L5/S1 laminectomy, discectomy and decompression did not result from the injury caused by the motor accident.
[98] Insurer’s bundle, p 108.
The Medical Assessor found that the motor accident caused a soft tissue injury to the cervical spine as diagnosed by Professor Sheridan in the post-accident report. It was noted that the imaging demonstrated no additional pathology beyond the pre-accident findings and that symptoms of upper limb paraesthesia in pain may have progressed over time which subsequently led the treating surgeon to recommend decompression surgery at various levels. The Medical Assessor concluded that the progression of symptoms did not relate to the motor accident.
The Medical Assessor noted restriction in left hip movement.
The Medical Assessor noted that the there was no evidence the claimant suffered injury to lumbar spine in the subject accident and there was no record of back pain in the post-accident. He otherwise concluded that there were no clear clinical signs of radiculopathy in the assessment and the imaging did not reveal evidence of nerve root compression that would warrant surgical management.

SUBMISSIONS

Claimant’s submissions dated 29 April 2022[99]

[99] Claimant’s bundle, p 6.

These submissions were filed seeking leave to review the medical assessment.
The claimant submitted that the findings by the Medical Assessor about future domestic assistance were “internally inconsistent”. This is because the Medical Assessor referred the claimant for past care to an occupational therapist but did not do the same for the claim for future care. Furthermore, the Medical Assessor, noted the claimant was in chronic pain which is not inconsistent with a claim for domestic assistance.
It was submitted the Medical Assessor erred in finding that there was no evidence concerning the existence of a knee injury. The Medical Assessor failed to consider the MRI scan of the left knee dated 11 January 2018 which noted grade II chondropatellar and the report of Dr Dave dated 25 January 2018.
In respect of the finding that the right shoulder surgery was not reasonable and necessary, the Medical Assessor has overlooked the opinion of Dr Dave dated 17 May 2021.

Claimant’s submissions dated 16 August 2022[100]

[100] Claimant’s bundle, p 1.

The claimant submitted that the Panel “is bound to conduct and assessment of all disputes between the parties” and referred to ss 58 and 63 of the MAC Act and the decision of the Court of Appeal Meuwissen v Boden.[101]
[101] [2010] NSWCA 253 at [24].
The claimant further submitted that the Medical Assessor had not discharged his statutory duty by failing to assess the impairment from the bilateral shoulder injuries. It was noted that the Medical Assessor found that the left shoulder arthroscopy and right shoulder treatment were related to the motor accident and therefore, “on any rationale interpretation”, must have found that there were bilateral shoulder injuries.

Insurer’s submissions dated 13 January 2021[102]

[102] Insurer’s bundle, p 2.

The insurer submitted that the claimant’s claim for future care and future treatment was neither related to the injuries caused by the motor accident nor were reasonable and necessary in the circumstances.
In respect of past and future domestic assistance, the insurer made various submissions in relation to the lack of need for same. In relation to causation, the insurer submitted that any gratuitous care required as a result of the motor accident would not exceed any more than approximately two months from the time of the accident. It noted the claimant did not serve any substantive evidence in support of the claim for future care.
The insurer submitted that any future domestic assistance is not attributable to the subject accident. This view is supported by the opinions provided by Dr Walker, neurologist and
Dr Truskett.
The insurer submitted that the injury sustained in the motor accident to the cervical spine, left hip, left knee, right shoulder, left shoulder and abdomen have recovered. It otherwise submitted that any ongoing injury from the subject motor accident, if at all, is not of sufficient magnitude to restrict the claimant’s domestic capacity.
The insurer disputed that the operation of the left shoulder performed by Dr Dave and the left wrist carpal tunnel release performed by Professor Mark Sheridan were not caused by the motor accident. The insurer referred to the history of pain in both shoulders dating back to 2004. The conditions and injuries require the claimant to undergo three right shoulder reconstructions and to left shoulder reconstructions performed by Dr Dave. It otherwise referred to the pre-accident contemporaneous complaint of bilateral shoulder pain which was “persuasive and conclusive as to the onset and long-standing nature of that condition”.
The insurer noted that the claimant had a history of pain in both carpal tunnels dating back to 2006 which included a diagnosis of bilateral carpal tunnel syndrome. It disputed any causal relationship between the carpal tunnel conditions and the motor accident.
The insurer disputed that there was a causal relationship between the number of treatment modalities, save possibly simple analgesics injuries related to the significant abdominal wall trauma. The insurer disputed the following claims:
•      left knee arthroscopy and ancillary treatment;
•      right shoulder repair;
•      buffer for attendances on gastroenterologist;
•      monthly attendances on GP for the remainder of the claimant’s life;
•      Fentanyl patches;
•      Endone 4-6 per day;
•      Duragesic, and
•      Tramadol.
The insurer also disputed that the treatment was reasonable and necessary due to the extensive pre-existing conditions of the claimant including but not limited to:
•      chronic ankylosing spondylitis including fusion at C5/6;
•      bilateral shoulder repairs;
•      bilateral carpal tunnel syndrome;
•      arthritis, and
•      prostate carcinoma.
The insurer submitted that the accident related injuries do not create a need for treatment or domestic assistance and no amount of future treatment or future care which was causally related to the accident nor reasonable and necessary in the circumstances.

Insurer’s submissions dated 24 February 2021[103]

[103] Insurer’s bundle, p 9.

These submissions principally discuss the claimant’s alleged psychological injury with some reference to the alleged orthopaedic injuries in the context of how that impacted on the assessment of psychological impairment.
The insurer referred to the pre-accident records which showed bilateral shoulder pain since 2004, cervical spine pain including C5/6 fusion in 2016, ankylosing spondylitis diagnosed in 2014 and bilateral carpal tunnel syndrome diagnosed in October 2006.
The insurer referred to the hospital notes and submitted that the penetrating injury to the abdomen was the main issue during admission. These submissions were largely directed to the absence of complaint of psychological injury.
The insurer referred to the opinion provided by Dr Walker, dated 19 August 2020, which included a diagnosis a significant abdominal wall trauma. Dr Walker was of the opinion that the claimant’s problems were essentially due to degenerative disease and a rheumatological disorder, with symptoms likely to continue to worsen. The doctor opined that any shoulder, cervical, carpal tunnel surgery that was planned had no relationship directly to the accident.
The insurer referred to the opinion of Dr Truskett dated 12 March 2019 who diagnosed soft tissue injuries to the claimant’s left hip, both shoulders and neck. The doctor noted that the claimant had penetrating injury to the left rectus muscle which did not enter the perineal cavity and assessed that impairment at 0%. Dr Truskett otherwise assessed 1% for scarring and 2% for each shoulder.
The insurer noted that Dr Kumar opined that the bleeding resulting from the haemorrhoids and the infected diverticulosis.

Insurer’s submissions dated 27 May 2022[104]

[104] Insurer’s bundle, p 19.

These submissions were filed opposing the application to review the Medical Assessment Certificate.
The insurer submitted that the claimant’s submissions only alleged errors pertaining to the treatment dispute and submitted “that any review application should be limited to the treatment dispute is there has been no allegation of material error in the permanent impairment component” of the certificate.
The insurer otherwise submitted there were no errors as alleged in the medical certificate.
The insurer made further submissions concerning the alleged left shoulder injury. It noted that the claimant had a pre-existing medical history which included a reconstruction of the left shoulder and labral tear in 2016.
It submitted that the Medical Assessor had not provided sufficient reasoning to understand the process by which he determined that the claimant required surgery to the left shoulder and carpal tunnel release in circumstances where he did not provide a diagnosis of any injury to the left shoulder. It further submitted that the Medical Assessor made no attempt to delineate why this pathology was not relevant to the further procedures performed on the claimant particularly when there was no diagnosis of injury caused by the motor accident.

Insurer’s submissions dated 11 August 2021[105]

[105] Insurer’s bundle, p 29.

The insurer provided a detailed chronology of medical treatment. We have referred to portions of this evidence in our summary of the material.

RE-EXAMINATION

Mr Ginnelly was medically examined by both Medical Assessors on 10 November 2023. The examination report is as follows:
“Pre-accident history
At the time of the accident, Mr Ginnelly had been on a long-term disability pension due to ankylosing spondylitis. This originated due to a positive blood test and persistent back pain.
There was a past history of severe neck pain and numbness in the upper limbs which resulted in a C5/6 anterior cervical discectomy and fusion under the care of Prof Sheridan in 2016. There was also a past history of rotator cuff injuries which had resulted in arthroscopic repairs of both shoulders. The left shoulder arthroscopy was repeated after premature starting of physiotherapy after the first operation according to Mr Ginnelly. There was also a past history of bilateral carpal tunnel syndrome.
Mr Ginnelly states that during 2017 he was very active and regularly refereeing rugby league football matches including several grand finals. He also stated that he had returned to boxing in the gym in the few weeks prior to the accident.
History of motor accident
Mr Ginnelly states that he was riding his motorbike and was actually returning from a session at the gym when a car failed to give way causing him to have a front on collision hitting the front passenger wheel of the car. He states that he hit his face and was wearing a helmet and was thrown onto the bonnet then landed on the foot peg of his bike which embedded into his abdomen. He was taken by ambulance to Liverpool Hospital.
Subsequent history and treatment
At Liverpool Hospital, he was investigated with scans of the cervical spine which were unchanged and the abdominal wound was initially repaired. This subsequently became infected which required a 2^nd admission with antibiotic treatment and a later surgical repair. He initially remained in hospital for 11 days.
After discharge from hospital, Mr Ginnelly states that he had pins and needles in both arms and legs and consulted his GP who referred him back to Prof Sheridan who organised several cortisone injections into the cervical spine which gave temporary improvement. He was also referred to his shoulder surgeon, Dr Dave for his persistent shoulder and hip pain. Dr Dave did a repeat arthroscopic repair of the left shoulder with a good result but the right shoulder had no improvement after surgery. He also underwent a surgical repair of the left carpal tunnel syndrome with no benefit and was then told it was due to his cervical spine. He was later referred to another neurosurgeon Dr Shiva who undertook laminectomies at C4 – C7 levels in 2022 which gave no noticeable improvement.
Due to persistent pain related to the initial abdominal injury, apparently an umbilical hernia was diagnosed and repaired with the mesh insertion.
Current symptoms
Mr Ginnelly has constant neck pain which increases with any walking and radiates into the intrascapular region. He gets pins and needles in his fingers including the thumbs but especially in the 4^th and 5^th fingers of both hands. He has frequent headaches which radiates to the frontal area at least 2 or 3 per week and recently has developed pain over the right temporomandibular joint region. There is persistent pain in the shoulders particularly with abduction of the right shoulder above 90°. He continues to have pain in the left hip region and in particular numbness and pain over the left lateral thigh above the knee. He has discomfort with the left knee which occasionally locks or gives way which is more apparent when walking upstairs. The right leg is asymptomatic, and he states that there is no pain in the lower back region. However, there is an occasional occurrence of pins and needles globally in the lower legs including the feet which is relieved by movement.
Current treatment
At present, he uses fentanyl patches 75 mg every 3 days, Endone 5 mg 6 per day and Panamax 4 to 6 per day. He has metastatic prostate cancer and has been under a clinical trial with a new medication which, he says has resulted in his PSA going from 500 to less than one which is a very good response. He continues to consult his GP for medications and his pain specialist, Dr Mohabbati.
Clinical examination m kl
Mr Ginnelly walked into the medical suite with a normal gait and sat comfortably during the interview. He presented as a reliable historian and was consistent in our examination findings. He states that he is right-handed and weight was 88.5 kg and height 185 cm. He mentioned that he has lost nearly 20 kg since the accident due to deconditioning.
Cervical spine
On palpation there was tenderness over the paravertebral muscle bilaterally and in particular some guarding over the medial right trapezius muscle and right acromioclavicular joint. On testing range of movement flexion was 70% of expected range with extension 30% of expected range. Rotation and side bending were both 50% of expected range.
On neurological examination the upper limbs, reflexes were weak but symmetrical with normal power and a global decrease in sensation in the right upper limb and in particular the 4^th and 5^th fingers. No muscle wasting was apparent from the intrinsic muscles of his hands. The circumference of the upper arms were 28 cm bilaterally (10 cm above the olecranon process) and in the upper forearms 27 cm bilaterally. There were no clinical signs of ulnar neuropathy.
Lumbar spine
Mr Ginnelly walked with a normal gait and was able to stand on his heels and toes. Squatting was limited to 50% of a normal range due to generalised stiffness in the lumbar spine and hips. On testing range of movement flexion/extension and side bending was 50% of expected range with no asymmetry. Straight leg raise when supine was 80° bilaterally with negative sciatic nerve root tension signs. Mr Ginnelly commented that this manoeuvre caused abdominal pain over the surgical site. On palpation of the lumbar musculature, no guarding or spasm was noted.
On neurological examination of the lower limbs, reflexes were equal bilaterally with normal power and normal sensation except for decreased sensation over the lateral left thigh above the knee. No muscle wasting was apparent with the circumferences of the lower thighs 40 cm bilaterally (10 cm above the superior patella pole) and at the maximum circumference of the calves 35 cm bilaterally.
Shoulders
On inspection of the shoulders no muscle wasting was apparent and on passive movement no crepitus was detected. Active movement was measured using a goniometer and repeated 3 times. Mr Ginnelly stated that the limitation of movement of the right shoulder in particular was due to pain occurring at the top of his right shoulder. Impingement tests were negative.

Shoulder Movements

Active ROM Measured

RIGHT

Active ROM Measured

LEFT

Flexion

150°= 2% UEI

100°= 5% UEI

Extension

30°= 1% UEI

30°= 1% UEI

Adduction

50°= 0% UEI

40°= 0% UEI

Abduction

150°= 1% UEI

90°= 4% UEI

Internal Rotation

80°= 0% UEI

80°= 0% UEI

External Rotation

90°= 0% UEI

80°= 0% UEI

The loss of range of movement was appropriately measured and re-tested to ensure consistency.
This gives an impairment of 4% UEI for the right shoulder and 10% UEI for the left. The right shoulder 4% UEI converts to 2% WPI using table 3 of AMA 4^th edition and 10% UEI converts to 6% WPI.
Knees
On palpation of the knees, no effusions were apparent and on ligament testing no laxity was noted. The right knee flexed 130° with 0° extension in the left knee flexed 120° with 0° extension. There was tenderness over the medial side of the left knee on palpation with no crepitus noted.
Hips
There was a full pain free range of movement of the right hip that reduced flexion of the left due to pain. On palpation there was tenderness over the left greater trochanter.

Hip Movements

Active ROM Measured

RIGHT

Active ROM Measured

LEFT

Flexion

120°

90° = 2% WPI

Extension

0°

0°

Adduction

20°

20°= 2% WPI

Abduction

30°

20°

Internal Rotation

30°

20°= 2% WPI

External Rotation

40°

30°= 2% WPI

Under the MAA guidelines when assessing range of movement of hip, the most limited range of movement is selected which results in a total of 2% WPI for range of movement of the left hip (table 40). There is sensory loss over the distribution of the lateral cutaneous nerve which is 1% wpi (table 68).
There has been an exacerbation of his cervical symptoms after the accident but at the time of the examination by the Panel no radiculopathy was apparent.
Mr Ginnelly does not consider that he has had an injury to his lumbar spine and is presently asymptomatic in his opinion.
There were pre-existing carpal tunnel syndrome documented with no evidence that the motor vehicle accident changed this.
Mr Ginnelly had a penetrating wound in his anterior abdominal wall at the time of the accident on 31 October 2017. This did not penetrate through to the peritoneal cavity but was associated with multiple hematomas in the rectus abdominis muscles. The wound was repaired surgically on 31 October 2017, but his post operative course was complicated by a wound infection. This settled with antibiotic treatment but subsequently he developed an incisional hernia which was surgically repaired. In 2021 the incisional hernia recurred, and this was repaired surgically with mesh. Since then, he has had constant generalised abdominal pain with intermittent sharp corkscrew pains in the left lower abdominal region. They last two to 10 minutes, occur at least twice per day, and can be precipitated by movement or ‘getting into an uncomfortable position’. The background pains mildly affect his activities of daily living (ADL) but the sharp pains significantly affect his ADL.

Examination revealed that he was mildly tender over the left side of his abdomen, greatest in the left lower quadrant. There were no masses, but irregular scarring was noted.
The Panel believes he has an impairment of the whole person due to the effects of the pain on his ADL. Reference is made to Table 7, page 247, of AMA 4. He has Class 1 impairment (Range 0% to 9%) due to the intermittent nature of the severe pain following repairs of his incisional hernia with palpable defect in the supporting structures.[106] We have assessed the impairment within the middle of Class 1 at 4% WPI.
There was an irregular scar 10 cm horizontal scar over the mid-abdomen just below the umbilicus with a 1.5 cm scar extending superiorly from the midpoint and a 4 cm scar extending inferiorly from the midpoint. There are minimal trophic changes. The scars are not visible with usual clothing and had no effect on his activities of daily living. There is no need for ongoing treatment.
The scars are light coloured and relatively flat. Faint staple marks are visible.
The surgical scars on his shoulders were hidden in the tattoos and would not be any higher than the abdomen.
Based on the TEMSKI scale, it is assessed at 1% WPI."
[106] See cl 1.249 of the Guidelines.

REASONS

The review is a new assessment of all matters with which the medical assessment is concerned. Our role is not to correct error in the decision of the Medical Assessor. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[107] and Insurance Australia Ltd v Marsh.[108]
[107] [2021] NSWCA 287 at [40], [41] and [45].
[108] [2022] NSWCA 31 at [11], [21], [64].
The Panel adopts the Medical Assessors’ examination report and adds the following reasons.

Medical dispute before the Panel

The parties made extremely brief submissions on the extent of the disputes before the Panel. Neither party referred to relevant legislation or authority.
In Allianz Australia Insurance Ltd v Ellul[109] a Review Panel discussed the relevant provisions of the Motor Accident Injuries Act 2017 (MAI Act) when it concluded:[110]
“The wording in s 7.26(6) states that it is an unlimited review of ‘all the matters with which the medical assessment is concerned’. Our view is that the meaning of ‘matters’ means all the medical assessment matters that were considered by the medical assessment.”
[109] [2023] NSWPICMP 338 (Ellul) at [88]-[113].
[110] Ellul at [108].
The Panel in Ellul discussed the provisions of the 2017 Act and was based upon the reasoning of the Court of Appeal in Meeuwissen v Boden[111] and the observations of Wright J in Wood v Insurance Australia Ltd.[112] Those decisions addressed the almost identical provisions under the MAC Act.
[111] [2010] NSWCA 253 (Meeuwissen).
[112] [2022] NSWSC 1290 (Wood).
Since the decision of Ellul, Rothman J reached a similar conclusion in Shaw v Insurance Australia Group Limited[113] when his Honour concluded:[114]
“Further, the jurisdiction of the Review Panel (and, in that regard, the delegate to the President) is not confined to the difference between the parties as to a particular issue. Further again, expressly, the Review Panel’s jurisdiction is not confined to those issues raised by the parties.
If, for example, one party raised that a WPI should be assessed at 10% and another party raised that it should be assessed at 15%, a Review Panel, properly seized of the review, is not bound to reach a conclusion between 10% and 15%, subject, always, to the principles of procedural fairness. Each party has the right to make application for review and each such application gives rise to a separate and independent jurisdiction in the Review Panel. The applications for review are not interdependent and the Review Panel is entitled to deal with the whole of the assessment and each issue arising in it.”
[113] [2023] NSWSC 1273 (Shaw).
[114] Shaw at [89]-[90].
As noted, the provisions of the MAC Act are in similar form[115] to the MAI Act. The authorities relied upon in Ellul discussed the provisions of the MAC Act and not the MAI Act.
[115] See ss 58, 60, 63 and in particular s 63(3A).
Accordingly, we adopt the reasons in Ellul and conclude that we are required to undertake a review of the medical assessment and every issue arising in it. Whilst this is grossly inefficient and contrary to the efficiencies of the motor accident scheme, the conclusion reflects the clear wording, context and intent of the legislation concerning reviews of medical assessments.

Injury findings

Bilateral carpal tunnel injury

We do not accept that the motor accident caused or aggravated the claimant’s bilateral carpal tunnel condition.
First, we do not accept that it is medically plausible that the motor accident caused or aggravated the bilateral carpal tunnel condition.
Secondly, the claimant had a pre-existing bilateral carpal condition. The motor nerve conduction studies dated 11 March 2019 stated the condition was unchanged when compared with the previous study of 22 July 2016. The condition was first diagnosed in 2006.
Thirdly, there was no contemporaneous complaint of aggravation of this condition, and it is otherwise not mentioned in the claim form. An absence of complaint is relevant but not determinative of the issue of causation: Norrington v QBE Insurance (Australia) Ltd;[116] AAI Ltd v McGiffen.[117] An inclusion of injury in the claim form is relevant to establishing causation: Bugat v Fox.[118] Similarly, the omission of any reference to a body part must also be relevant, but not determinative, of the causation issue.
Fourthly, the claimant consulted both Professor Sheridan and Dr Dave in January 2018 and did not suggest that he aggravated this condition.
[116] [2021] NSWSC 548 (Norrington).
[117] [2016] NSWCA 229 at [64]-[66].
[118] [2014] NSWSC 888 at [31]-[32].

Lumbar spine

We are not satisfied that the claimant injured his lumbar spine for the following reasons.
There is a clear history of chronic pre-existing symptoms in the lumbar spine with referred left leg symptoms and ankylosing spondylitis which had been diagnosed and treated since at least 2014.
There is an absence of contemporaneous complaint of lumbar spine symptoms. The claimant also did not allege that he injured the lumbar spine in the claim form. It appears that the lumbar spine is first mentioned after the motor accident by the pain specialist on
23 February 2018.
The claimant otherwise consulted both Professor Sheridan and Dr Dave in January 2018 and did not suggest that he aggravated the lumbar spine condition.
The frequent and increasing back and left leg symptoms are explainable based on the chronic pre-existing condition with longstanding ankylosing spondylitis.
Finally, we note that the claimant candidly advised the Medical Assessors that he did not believe the motor accident caused injury to the lumbar spine.

Neck

The claimant had a longstanding pre-existing condition of neck pain and radicular symptoms and underwent a neck fusion a C6/7 in late 2016. In February 2017 Professor Sheridan then noted ongoing neck and right arm pain and organised a CT guided injection.[119]
[119] Claimant’s bundle, p 1563.
The claimant reported neck pain following the motor accident.
The subsequent MRI scan and bone scans following the motor accident showed inflammation at the side of the previous surgery but nothing else and no disc protrusion or nerve compression. In January 2018 Professor Sheridan noted that he suspected there had been a flareup of the underlying inflammation in the neck from the previous surgery as well as a whiplash injury. He then felt that these changes would settle with time and there was no need for surgical intervention. We agree with the doctor’s initial assessment which is consistent with the effects of the nature of the motor accident.
The claimant has had chronic neck symptoms for many years and underwent serious spinal surgery prior to the motor accident. We also agree with the opinion expressed by Medical Assessor Home that the progression of radicular symptoms post-accident was unrelated to the motor accident and that the multi-level surgery to the cervical spine was unrelated to the accident.
The Panel finds that the ongoing neck symptoms are unrelated to the motor accident and are solely due to the severe pre-existing pathology and chronic next condition. Whilst we are satisfied that the claimant exacerbated the neck condition, we conclude that this was of short duration of some three to six months with no aggravation of the underlying degenerative pathology. The ongoing symptoms beyond that period reflect the underlying chronic degenerative condition unrelated to the motor accident.

Shoulders

We accept that the claimant had pre-existing bilateral shoulder surgeries and a chronic condition.
The ambulance record referred to complaints of right shoulder pain. On 5 December 2017 the GP noted complaints of bilateral shoulder pain following the motor accident.
The MRI scan of the left shoulder dated 9 January 2018 noted a clinical history of the motor accident causing injury to both shoulders. The scan showed acromioclavicular joint osteoarthritis, SLAP tear in labrum and minor rotator cuff enthesopathy with acromioclavicular joint osteoarthritis with no recurrent adhesive capsulitis or significant labral bursitis.[120]
[120] Claimant’s bundle, p 477.
The MRI scan of the right shoulder dated 9 January 2018 showed progressive acromioclavicular joint osteoarthritis with no recurrent adhesive capsulitis or significant labral tearing.[121]
[121] Claimant’s bundle, p 480.
On 8 February 2018 Dr Dave noted the claimant was doing well prior to the motor accident where he was undergoing boxing classes. The doctor noted AC joint symptoms in the right side and AC joint tenderness as well as pain on stressing the biceps on the left side. The doctor noted the recent MRI scan which showed AC joint pathology and possibly, a labral re-tear of the left shoulder.[122]
[122] Claimant’s bundle, p 539.
We accept that the nature of the motor accident involving a fall onto the ground would have likely caused an aggravation of acromioclavicular joint osteoarthritis in both shoulders and a further tear of the labrum in the left shoulder. It is medically plausible and we accept that the bilateral shoulder condition is ongoing based on the claimant’s consistent and ongoing complaints since the motor accident.
The present bilateral shoulder symptoms are due, in a relevant causal sense, to the motor accident.

Left knee

We accept that the motor accident caused a left knee injury for the following reasons.
First, there was no evidence of any prior left knee condition.
Secondly, there were complaints of left knee injury recorded in the hospital notes. The contemporaneous complaint of injury is corroborated by the claimant’s statement in his claim form that he injured his left knee.
Thirdly, the injury to the left knee is explicable by the nature of the motor accident involving a fall off a bike. That injury is consistent with the pathology shown on the subsequent MRI scan.
Fourthly, we accept the explanation by Dr Dave that the motor accident caused the left knee injury shown in the MRI scan.

Left hip

We accept that the motor accident caused a left hip injury for the following reasons.
First, there was no evidence of any prior left hip condition save as to a reference to an X-ray in 2003.
Secondly, there were complaints of left hip injury in the hospital notes. The contemporaneous complaint of injury is corroborated by the claimant’s statement in his claim form that he injured his left hip.
Thirdly, the injury to the left hip is explicable by the nature of the motor accident involving a fall off a bike.
Fourthly, the post-accident MRI scan noted instability and showed early osteoarthritis with chondromalacia in the acetabular roof, and minimal chondrolabral separation in the anterosuperior labrum suggesting a tear.
We accept that the pathology shown on the MRI scan was likely caused by the nature of the motor accident and caused the loss of range of motion and sensory loss identified by the Medical Assessors.

Treatment disputes

The dispute is whether the treatment is “reasonable and necessary in relation to the injury sustained in the subject accident”.
The issue of reasonable and necessary is distinct from the issue of causation. These principles have been discussed elsewhere by Review Panels.[123] The MAC Act otherwise characterises the medical disputes as separate issues.
[123] See for example the discussion in Venizelou v AAI Ltd [2021] NSWPICMP 215 at [106]-[132].
The motor accident need only be a material contribution between the motor accident and the need for treatment: AAI Limited v Phillips.[124]
[124] [2018] NSWSC 1710 (Phillips) at [29].
Mr Ginnelly is required to establish that the treatment is both “reasonable and necessary”. This test differs from the workers compensation legislation which requires a worker to establish that the treatment is “reasonably necessary”. There is a stricter requirement under the motor vehicle accidents legislation because there is no moderation of the requirement that the treatment is “necessary”.
When discussing the meaning of “reasonably necessary” under s 60 of the Workers Compensation Act 1987 in Clampett v WorkCover Authority of NSW,[125] Grove J stated:[126]
“22 I return to the expression ‘reasonably necessary’ in s60. Dictionaries stipulate that ‘necessary’ has relevant definition as ‘indispensable, requisite, needful, that cannot be done without’ - (Shorter) Oxford English Dictionary, 3rd Ed and ‘that cannot be dispensed with’ - Macquarie.
23 The essential issue is what effect flows from conditioning such qualities as ‘reasonably’. The consequence is to moderate any sense of the absolute which might otherwise be conveyed by the word ‘necessary’ if it stood alone. In order to contemplate such moderation, it is apt to consider surrounding circumstances, but the question to be addressed is whether modification of a worker's home, having regard to the nature of the worker's incapacity, is reasonably necessary. In contemplation of what might be ‘reasonably necessary’ there is this statutory obligation specifically to have regard to the nature of the worker's incapacity. It provides emphasis towards moderating the meaning of ‘necessary’ in this context.”
[125] [2003] NSWCA 52 (Clampett).
[126] Clampett at [22]-[23], Meagher & Santow JJA agreeing.
Similar observations have been subsequently made by the Court of Appeal on the meaning of “reasonably necessary” under other legislation.[127]
[127] See ING Bank (Australia) Ltd v O’Shea [2010] NSWCA 71 at [48]; Moorebank Recyclers Pty Ltd v Tanlane Pty Ltd [2012] NSWCA 445 at [113].
Factors relevant to, but not determinative, of the criteria of reasonableness in the context of the workers compensation legislation are well settled.[128] They include:
(a)   the appropriateness of the particular treatment;
(b)   the availability of alternative treatment;
(c)   the cost of the treatment;
(d)   the actual or potential effectiveness of the treatment, and
(e)   the acceptance by medical experts of the treatment as being appropriate or likely to be effective.
[128] See Diab v NRMA Ltd [2014] NSWWCCPD 2 (Diab) at [88].
Whilst the observations in Diab were directed to the test of “reasonably necessary” in the workers compensation legislation, we adopt it insofar as they have relevance, although not determinative, of the stricter test of “reasonable and necessary”.
The words “in the circumstances” in the context of whether the treatment is “reasonable and necessary” must refer to the particular circumstances of the claimant.
The test of “reasonable and necessary in the circumstances” does not direct attention to the relationship between the accident and the treatment. That issue arises from consideration of the issue of whether treatment “relates to the injury caused by the accident”.

FINDINGS ON TREATMENT DISPUTES

The Panel notes that there are a number of treatment disputes which include issues of both “causation” and “reasonable and necessary”. The issues were not separated as they should have been meaning that if the answer to part of the question was no, then the entire question is answered no.
These reasons should be considered in light of the absence of any proper assistance by the claimant and that he bears the onus of proof.
We adopt the principles set out earlier to each of the disputes.

A steroid injection – causation and reasonable and necessary

This dispute asks whether “a” future steroid injection is “reasonable and necessary” and caused by the accident. The claimant presented with trochanteric bursitis which may respond to a steroid injection.
The clinical findings of the Medical Assessors show left hip symptoms that may respond to a steroid injection at some future point in time. That treatment is caused by the motor accident given our early findings of injury and ongoing symptoms.
The treatment is reasonable and necessary as accepted medical treatment, of minimal cost with no adverse consequences.

Future GP visits up to five years after the assessment and/or for the remainder of the claimant’s life

There is a need for future GP visits (either up to five years or for the balance of the claimant’s life expectancy) based on future treatment for the left hip, left knee, shoulders and abdomen.
The difficult issue is what is reasonable and necessary given the claimant’s multiple other health issues unrelated to the motor accident. Doing the best we can noting the various non accident related medical issues for which the claimant will otherwise require assessment by a medical practitioner, we assess the further need at twice per year. We have not limited the duration of this treatment because of the less than normal life expectancy caused by the underlying cancer.

Fentanyl patches/endone – future need up to five years and/or balance of the claimant’s life

The Panel does not accept that a future need for any fentanyl patches or endone is necessary because of the nature of the injuries sustained. Further it is five years since the motor accident and long-term use of opioid medication is inappropriate because it is addictive and is likely to only provide marginal if any benefit over time.

Tramadol – future need up to five years and/or balance of the claimant’s life

In August 2020 the pain specialist noted that a trial of Tramadol was not effective, and the claimant was back on Duragesic and Endone.[129] Furthermore, the use of Tramadol is an opioid and inappropriate in the long term for the same reasons discussed above in relation to fentanyl patches and endone.
[129] Claimant’s bundle, p 1425.
In these circumstances where the claimant is not taking this medication, it is neither reasonable and necessary nor caused by the motor accident.

Domestic assistance - past gratuitous assistance

We accept that the claimant suffered injuries to the cervical spine (short term aggravation), bilateral shoulders, abdomen, left hip and left knee. These injuries created some need for domestic assistance by way of gratuitous assistance.
The original Medical Assessor stated that the question of need “will be determined by the Occupational Therapist appointed by the Personal Injury Commission.” We confirm that order.

Domestic assistance – future domestic assistance either for five weeks or life

The claimant has ongoing effects of the motor accident to the shoulders, abdomen, left hip and left knee. There is a casual relationship between the ongoing effects of injury and some aspects of domestic assistance such as heavier lifting.
The original Medical Assessor stated that the question of need “will be determined by the Occupational Therapist appointed by the Personal Injury Commission.” We confirm that order noting that the extent of the need, if any which is probably modest at best, can be determined by an appropriate expert.

Past left shoulder arthroscopy

We accept that the motor accident exacerbated the underlying pathology and probably caused a labral tear resulting in the need for the left shoulder surgery undertaken by Dr Dave.
This treatment as reasonable and necessary give the nature of the symptoms and is an appropriate medical procedure. The claimant otherwise reported a good outcome from the surgery supporting the effectiveness of the procedure.

Past left carpal tunnel decompression

Based on our findings of an absence of injury to the left carpal tunnel caused by the motor accident, there is no causal relationship between the decompression surgery and the motor accident.
The decompression was reasonable and necessary to treat the underlying carpal tunnel condition. The surgery is the recognised treatment option once treatment options have failed (such as splinting). This was the case in this matter.

Future left knee surgery - arthroscopy

We refer to the Medical Assessors’ findings of the left knee condition which exhibited a good range of movement and only mild tenderness. Although we have found injury to the left knee, we are not satisfied that the proposed surgery is necessary and caused by the accident due to the claimant’s present symptoms which shows that the surgery is not clinically indicated.

Future right shoulder surgery

The claimant had a reasonable range of movement on examination which had been stable for the last few years. There is no present need for this surgery based on the clinical examination by the Medical Assessors.
The proposed surgery would address the arthritis in the shoulder joint which has been aggravated by the motor accident. Accordingly, there is a relevant causal nexus between the surgery and the motor accident.

Future right carpal decompression

Based on our findings of an absence of injury to the right carpal tunnel caused by the motor accident, there is no causal relationship between the proposed decompression surgery and the motor accident.
Proposed right sided carpal tunnel decompression is reasonable and necessary to treat the underlying carpal tunnel condition. The proposed surgery is the recognised treatment option once other treatment options have failed. This is the case in this matter.

Permanent impairment

The examination findings of the Medical Assessors show assessable impairments of both shoulders and abdomen/hernia which are discussed in the medical examination findings.
The loss of range of motion of the left hip is assessed at 2%. There is sensory loss over the distribution of the lateral cutaneous nerve which is 1%.[130]
[130] AMA 4, Table 68.
As for the assessment of the scar, the Panel is required to use the principle of best fit under Table 18 of the Guidelines.
The abdomen scars suggest an impairment of 2% due to the claimant being conscious, there is noticeable colour change and it is easily locatable.
Minimal trophic changes and staple marks are visible (1%). The anatomic location is not clearly visible with usual clothing, there is no contour defect, no effect on ADLs, no treatment is required and no adherence (0%).
Applying the principle of best fit, we assess the skin impairment at 1%.
The aggregation of the various impairments means that the claimant has exceeded the 10% threshold.

Deduction

The only relevant body parts for which there may be a deduction for a pre-existing condition is the assessment of the impairment of the shoulders.
Clause 1.31 of the Guidelines requires a deduction for “pre-existing impairment” if “there is objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident”.
Whilst there have been previous bilateral shoulder surgeries, we do not accept that there is “objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident”.[131] There is clear evidence of shoulder symptoms prior to the motor accident which suggests previous symptomatic loss of range of motion.
[131] Clause 1.31 of the Guidelines.
However, there are references in the clinical notes in 2017 that the claimant was refereeing touch football and doing gym regularly. These activities are otherwise consistent with the claimant’s account that his health was reasonable in 2017 and do not support the basis for a deduction.
Further, the fact that the claimant had prior shoulder surgeries does not mean that he had loss of range of movement at the time of the motor accident. The desired outcome of those surgeries is to increase function and restore range of movement. It is reasonable to accept, given the claimant’s history corroborated by the clinical notes, that this occurred in this matter.
The decision of Bell P (as his Honour then was) in IAG Ltd v Chahoud[132] noted the distinction between the date of the records and the date of the pre-existing impairment. His Honour stated:[133]
“IAG submitted that in so finding, the proper officer wrongly construed cl 1.31 as requiring that the evidence itself be dated ‘at the time of the accident’. It submitted that the clause should instead be read as requiring that there be ‘evidence of pre-existing impairment at some time prior to the accident, that likely still existed at the time of the accident’. What was ‘likely still to exist’, in other words, were not records of any pre-existing impairment but the pre-existing impairment itself.”
[132] [2019] NSWSC 767 (Chahoud).
[133] Chahoud at [70].
Whilst there is evidence of previous symptoms and impairment at some earlier point, we are not satisfied that there was pre-existing impairment of either shoulder at the time of the motor accident.
For these reasons we have not made a deduction pursuant to cl 1.31 of the Guidelines because we are not satisfied that there was objective evidence of impairment at the time of the motor accident.
We are satisfied that the impairment is permanent given the duration of symptoms, the conditions and impairments are well stabilised and are unlikely to change substantially in the next year.[134]

CONCLUSION
[134] Clause 1.19 of the Guidelines.

For these reasons the Medical Assessment Certificate is revoked. A replacement certificate is issued at the commencement of these Reasons.

Shoulder Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
Flexion	150°= 2% UEI	100°= 5% UEI
Extension	30°= 1% UEI	30°= 1% UEI
Adduction	50°= 0% UEI	40°= 0% UEI
Abduction	150°= 1% UEI	90°= 4% UEI
Internal Rotation	80°= 0% UEI	80°= 0% UEI
External Rotation	90°= 0% UEI	80°= 0% UEI

Hip Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
Flexion	120°	90° = 2% WPI
Extension	0°	0°
Adduction	20°	20°= 2% WPI
Abduction	30°	20°
Internal Rotation	30°	20°= 2% WPI
External Rotation	40°	30°= 2% WPI

[2023] NSWPICMP 648

1 December 2023