Gutierrez nee Tamati v Smart Dental Limited Partnership; Smart Dental Limited Partnership v Gutierrez nee Tamati
[2024] NSWPICMP 514
•29 July 2024
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Gutierrez nee Tamati v Smart Dental Limited Partnership; Smart Dental Limited Partnership v Gutierrez nee Tamati [2024] NSWPICMP 514 |
| APPELLANT/RESPONDENT: | Emma Jane Gutierrez nee Tamati |
| RESPONDENT/APPELLANT: | The Smart Dental Limited Partnership |
| APPEAL PANEL | |
| MEMBER: | Catherine McDonald |
| MEDICAL ASSESSOR: | Tommasino Mastroianni |
| MEDICAL ASSESSOR: | Roger Pillemer |
| DATE OF DECISION: | 29 July 2024 |
CATCHWORDS: | WORKERS COMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; two appeals; Medical Assessor declined to assess lumbar spine and scarring and recorded range of motion results against wrong leg; re-examination; Held – Medical Assessment Certificate revoked. |
BACKGROUND TO THE APPLICATION TO APPEAL
Ms Gutierrez suffered an injury on 23 August 2019 in the course of her employment with the Smart Dental Limited Partnership (Smart Dental) and claimed permanent impairment compensation, the extent of which was disputed. The medical dispute was assessed by Medical Assessor Rob Kuru, who issued a Medical Assessment Certificate (MAC) on 22 February 2024. On 13 March 2024 Ms Gutierrez lodged an Application to Appeal Against the Decision of a Medical Assessor and on 20 March 2024 Smart Dental also lodged an appeal.
Each appeal relies on the ground of appeal under s 327(3)(d) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act) – that the MAC contains a demonstrable error.
The President’s delegate was satisfied that, on the face of the application, at least one ground of appeal was made out in respect of each appeal. We conducted a review of the original medical assessment, limited to the grounds of appeal on which the appeal is made.
Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 – Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
RELEVANT FACTUAL BACKGROUND
Ms Gutierrez was employed by Smart Dental as a dental assistant. On 26 August 2019 she fell while walking downstairs and suffered an injury to her left ankle. She was taken to hospital but discharged when no fractures were detected. A bone scan on 9 September 2019 showed a fracture of the posterior process of the talus, bony contusion and traumatic synovitis. After seeking a second opinion, Ms Gutierrez was informed that she suffered a suspected anterior talofibular ligament tear. She was referred to Dr O’Carrigan who considered that she had an ankle sprain which resulted in a significant amount of synovitis and probable bony contusions. Ms Gutierrez’s recovery was slower than Dr O’Carrigan expected and he was concerned about chronic [sic] regional pain syndrome, he referred her to Dr Ho, pain specialist.
After a series of lumbar sympathetic blocks, Ms Gutierrez found a trial of a spinal cord stimuator helpful. A permanent device was installed in mid 2020 but revision surgery was required on three occasions. It was turned off in January 2022. She continues to see a pain specialist.
The Medical Assessor was asked to assess Ms Gutierrez’s left lower extremity, lumbar spine and scarring.
The Medical Assessor prepared a MAC replete with errors, beginning with Ms Gutierrez’s date of birth and referring to her right rather than left ankle throughout. He assessed 14% whole person impairment (WPI) in respect of her right [sic] lower extremity. He said that the criteria in chapter 17 of the Guidelines for the assessment of chronic [sic] regional pain syndrome were not present. He declined to assess her lumbar spine because he said that insertion of a spinal cord stimulator did not warrant additional WPI. He also noted that the scarring was the result of the insertion of the spinal cord stimulator and paragraph 4.41 of the Guidelines directs that the insertion of such a device does not warrant additional WPI.
PRELIMINARY REVIEW
We conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
As a result of that preliminary review, we determined that it was necessary for Ms Gutierrez to undergo a further medical examination because the MAC contained a series of errors which could not be resolved without examination. Those errors included numerous references to Ms Gutierrez’s right leg rather than her left and his failure to assess her lumbar spine.
EVIDENCE
We have all the documents that were sent to the Medical Assessor for the original medical assessment and have taken them into account in making this determination.
Medical Assessor Pillemer of the Appeal Panel conducted an examination of the worker on 17 June 2024 and reported to us. The report forms part of these reasons.
The parts of the MAC that are relevant to the appeal are set out below.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but we have considered them.
In summary and in respect of her own appeal, Ms Gutierrez submitted that the Medical Assessor erred in stating that any impairment of her lumbar spine and scarring was not assessable because it was attributable to the implantation of a spinal cord stimulator and in stating that her lumbar spine symptoms arose after it was implanted. She said that the Medical Assessor erred in not providing adequate reasoning to support his statement that it was difficult to assess the range of motion in her left lower extremity and why he omitted it from the assessment of WPI. Ms Gutierrez said that the Medical Assessor was incorrect in his statement that she did not suffer complex regional pain syndrome in her left lower extremity.
In respect of Ms Gutierrez’s appeal, Smart Dental said that there was no error in the assessment of her lumbar spine. It accepted that the Medical Assessor made errors in the MAC when he referred to Ms Gutierrez’s left ankle as the right ankle but said that the Medical Assessor did make an accurate assessment of the range of motion of her left ankle. Smart Dental submitted that the Medical Assessor provided reasoning to explain why CRPS was not assessable.
On its appeal, Smart Dental submitted that the Medical Assessor made demonstrable errors which are readily apparent when he referred to her left lower extremity as her right. It said that the Medical Assessor failed to record the range of motion in Ms Gutierrez’s uninjured right ankle. Smart Dental also submitted that the Medical Assessor was in error to assess Ms Gutierrez’s ankle by reference to dorsiflexion and plantar flexion and did not set out compliant range of motion assessments.
In reply, Ms Gutierrez accepted that there were demonstrable errors in the MAC where the Medical Assessor incorrectly referred to her left lower extremity as her right so that it was unclear. Ms Gutierrez said that the Medical Assessor was only required to assess the contralateral joint where it would serve as a baseline to assess relative loss of motion. There was no error because there was no evidence suggesting that she had greater or lesser flexibility in her left lower limb than average. Ms Gutierrez said that the Medical Assessor made the appropriate assessment of the range of motion.
FINDINGS AND REASONS
The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
In Queanbeyan Racing Club Ltd v Burton,[1] the Court of Appeal held that an Appeal Panel is not limited to the ground held to have been made out by the delegate but may consider all grounds of appeal raised in the application. However, the panel is not permitted to look for errors which are not part of the grounds of appeal on which the appeal is made. We have only considered those grounds specifically raised by the appeal.
[1] [[2021] NSWCA 304 at [26].
In Campbelltown City Council v Vegan[2] the Court of Appeal held that an Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
[2] [2006] NSWCA 284.
The MAC
The referral asked the Medical Assessor to assess Ms Gutierrez’s left lower extremity, lumbar spine and TEMSKI scarring.
Throughout the MAC, the Medical Assessor referred to Ms Gutierrez’s right lower extremity as the injured side. That alone is a demonstrable error.
The Medical Assessor set out the range of motion measuring no movement on the right and, measuring 20° dorsiflexion, 50° plantar flexion, 20° ankle inversion and 10° ankle inversion. He said:
“Hypersensitivity of the lateral aspect of the foot was noted over the plantar surface. There were no abnormal callosities on the soles of either foot. There was no colour change in either foot. There were no trophic changes of the skin of the nails. There was no abnormal sweating or temperature difference. There was no active movement of any of the toes.
Lumbar Spine: There were well healed mid-line incisions. They were 6cm long from lead placement. They were transverse incisions, 6cm on the left, 8cm on the right. Midline and right demonstrated lines consistent with revision surgery.”
The Medical Assessor assessed 14% WPI for the right lower extremity. He said:
“Restricted range of motion in the right ankle is assessed according to the SIRA Guidelines page 15, Table 17.11, AMA 5 page 537, Table 17.12. On the basis of restricted range of motion, I assess 11% whole person impairment. For dysaesthesia over the lateral aspect of the foot, according to AMA 5 page 552, Table 17.37 I assess a further 2% whole person impairment for dysaesthesia of the lateral plantar nerve. A further 1% is assessed under AMA 5 page 537, Table 17.14 for restriction of movement of the great toe. Impairment is not assessed for restricted range of motion of the lesser toes, as it was greater than 10°.
Ms Gutierrez has clinically been diagnosed with chronic regional pain syndrome. With referenced [sic] to SIRA page 80, Chapter 17, she does not meet the criteria listed on page 81, Table 17.1. Whilst she does have continuing pain which is disproportionate to the causal event and she reports sensory vasomotor, sudomotor, oedema and motor/trophic symptoms, she did not display one sign in each of the four categories under paragraph 3. Whilst there was evidence of hyperalgesia in the distribution of the lateral plantar nerve, there were no vasomotor, sudomotor/oedema or motor/trophic changes to meet the criteria of the diagnosis.”
Commenting on the other reports in the file the Medical Assessor said:
“With respect to the report by Dr Dias dated 7 March 2023, at the time of his assessment he was able to make a diagnosis of chronic regional pain syndrome and hence, has assessed impairment of the left lower extremity on this basis. As above, the criteria listed in SIRA Chapter 17 were not clinically present today and hence, I have not made an assessment of chronic regional pain syndrome. Dr Dias has assessed Ms Gutierrez as Lumbar DRE Category II with 2% restriction for activities of daily living. Ms Gutierrez indicates that symptoms in her back arose subsequent to implantation of her spinal cord stimulator. According to SIRA page 29, paragraph 4.41, ‘The insertion of such devices does not warrant any additional WPI’. Any impairment of the lumbar spine is attributable to implantation of the spinal cord stimulator and the injury. I disagree with the assessment of Lumbar DRE Category II for the lumbar spine.
Similarly, Dr Dias has assessed 1% for scarring / TEMSKI. The scarring is a consequence of insertion of the spinal cord stimulator and again, SIRA page 29 paragraph 4.41 directs that the insertion of such a device does not warrant additional WPI.
With respect to the report by Dr Harrington dated 22 August 2023, I am in agreement that she does not meet the criteria in SIRA Chapter 17 for the diagnosis of CRPS. Dr Harrington has not made an assessment in respect to WPI for the left ankle, as he was unable to accurately assess range of motion. I agree this is difficult in this case. I agree with Dr Harrington that impairment is not assessable for the lumbar spine but for different reasons. Dr Harrington has assessed 1% for scarring/TEMSKI. Again, the scarring is subsequent to insertion of a spinal cord stimulator, which SIRA page 29 paragraph 4.41 directs does not ‘warrant any additional WPI’.”
Lumbar spine
The Medical Assessor’s interpretation of the Guidelines with respect to Ms Gutierrez’s lumbar spine is incorrect. The Guidelines provide in paragraph 4.41 that the insertion of a spinal cord stimulator does not warrant additional WPI. The paragraph does not say that any lumbar spine condition after the insertion of the stimulator is not assessable. Smart Dental’s submission that the Medical Assessor was correct in his assessment is disingenuous, particularly when it agreed that the lumbar spine should be assessed. The Medical Assessor was required to assess Ms Gutierrez’s lumbar spine in accordance with AMA 5 and the Guidelines.
The course of Ms Gutierrez’s treatment is usefully summarised by Dr Dias in his report dated 7 March 2023:
“Ms Tamati underwent three lumbar sympathetic block procedures in early 2020 under the care of Dr Tim Ho at Hurstville Private Hospital, in an attempt to. alleviate the neuropathic pain affecting her left ankle region. She subsequently underwent a permanent implantation of a spinal cord stimulator in July 2020 under the care of Dr Tim Ho. Ms Tamati states that the spinal cord stimulator did not help her symptomatology in her left lower limb in anyway, and she recalls there were two further procedures to reposition the spinal cord leads performed in 2021. Ms Tamati states that she has turned off the battery to her spinal cord stimulator since early 2022, and is hoping to get a spinal cord stimulator removed at some stage over the course of the next one-to two years.”
Dr Ho’s final report dated 6 March 2023 proposed removal of the spinal cord stimulator.
Dr Dias assessed Ms Gutierrez in DRE lumbar category II, assessing 7% and deducting one-tenth for changes observed on radiology.
Dr Harrington assessed Ms Gutierrez on behalf of Smart Dental. He assessed her lumbar spine in DRE lumbar category 1.
Assessment of Ms Gutierrez’s lumbar spine was required by the referral and the Medical Assessor was in error to decline to do so. Re-examination was therefore required.
Medical Assessor Pillemer obtained a history of lumbar pain since the insertion the spinal cord stimulator. On his examination, straight leg raising was reduced but it was not possible to test the range of movement of Ms Gutierrez’s back because she can only stand using crutches and without weight bearing on the left.
Ms Gutierrez provided a history of constant and significant pain in her low back and said that she suffers referred pain down her left leg which occurs a few times per week. The pain she complains of is consistent with the consequences of the insertion of the spinal cord stimulator. That complaint and the presence of non-verifiable radicular complaints justify assessment in DRE lumbar category II and an assessment of 5% WPI. She complains of constant, significant back pain so that it is reasonable to add 2% for the activities of daily living, resulting in an assessment of 7% WPI.
Scarring
The Medical Assessor was required to assess Ms Gutierrez’s scarring under the Table for the Evaluation of Minor Skin Impairments (TEMSKI) in the same way that he was required to assess her lumbar spine. The surgery she has undergone has inevitably resulted in scarring.
Each of Dr Dias and Dr Harrington assessed 1% for scarring.
Medical Assessor Pillemer assessed Ms Gutierrez in accordance with the TEMSKI. He observed that the scarring was healed. It measured 9cm with minor contour defect and mild pigmentary changes. She also has scars on both iliac crests which are not clearly visible, with only mild pigmentary changes.
Using the principle of best fit, that description corresponds to 1% WPI under the TEMSKI.
Left ankle and complex regional pain syndrome
The Medical Assessor’s assessment is fatally flawed because of his confusion about which ankle he was assessing. He did purport to assess the range of motion of Ms Gutierrez’s injured ankle and to include it in his assessment but his reasons are so confusing that reassessment was required. Because of the references to Ms Gutierrez’s right leg where he clearly meant her left, re-examination was vital to ensure that the appropriate assessments were made.
Smart Dental’s submission that plantar flexion has no role in ankle assessment is incorrect. The range of ankle movement is measured under Table 17-11 of AMA 5, amended in paragraph 3.17 of the Guidelines. Assessments are made of plantar flexion and dorsiflexion (or extension). The measurements recorded for Ms Gutierrez’s left ankle appear to relate to her right but the figures the Medical Assessor has suggested in his table do not result in the assessment of 14% WPI that he made. His figures result in 7% impairment for loss of extension, 30% for loss of flexion, 5% for loss of inversion, and 2% for loss of eversion, giving a total of 44% lower extremity impairment which equates to 18% WPI.
Medical Assessor Pillemer observed that there was no active range of motion of
Ms Gutierrez’s foot and that the only joint that moves is her big toe. The assessment of her left lower extremity by reference to the range of motion is therefore inapplicable.The Guidelines provide in paragraph 3.2 and 3.3:
“Assessment of the lower extremity involves physical evaluation, which can use a variety of methods. In general, the method should be used that most specifically addresses the impairment present. For example, impairment due to a peripheral nerve injury in the lower extremity should be assessed with reference to that nerve rather than by its effect on gait.
3.3 There are several different forms of evaluation that can be used, as indicated in AMA5 sections 17.2b to 17.2n (pp 528–54). AMA5 Table 17-2 (p 526) indicates which evaluation methods can be combined and which cannot. It may be possible to perform several different evaluations, as long as they are reproducible and meet the conditions specified below and in AMA5. The most specific method of impairment assessment should be used.”
Paragraph 3.5 reads:
“In the assessment process, the evaluation giving the highest impairment rating is selected. That may be a combined impairment in some cases, in accordance with the AMA5 Table 17-2 ‘Guide to the appropriate combination of evaluation methods’, using the Combined Values Chart on pp 604–06 of AMA5. “
The assessment of CRPS under the Guidelines requires the strict application of the criteria in Table 17.1.[3] Medical Assessor Pillemer noted that Ms Gutierrez had been diagnosed with CRPS and his report shows that she has some typical features of the condition but that she did not have all of the signs required to make the diagnosis. She had allodynia but there was “no evidence of any temperature asymmetry or any skin colour changes, there was no evidence of swelling or sweating, and there was no evidence of any trophic changes involving her skin or nails or hair”.
[3] Elsworthy v Forgacs Engineering Pty Ltd [2018] NSWSC 1638; Windley v Workers Compensation Nominal Insurer [2021] NSWSC 1125.
While it might be appropriate to assess Ms Gutierrez’ left ankle on the basis of gait derangement, the assessment would be 20% WPI because she uses two crutches intermittently, though can sometimes use one. That assessment is less than that by reference to the range of motion so paragraph 3.5 directs us to assess by reference to the range of motion.
The assessment of the range of motion is undertaken on the basis of ankylosis of all of the joints of Ms Gutierrez’s foot and ankle. Paragraph 3.18 of the Guidelines reads:
“Ankylosis is to be regarded as the equivalent to arthrodesis in impairment terms only. For the assessment of impairment, when a joint is ankylosed (AMA5 section 17.2g, pp 538-543), the calculation to be applied is to select the impairment if the joint is ankylosed in optimum position (see table 3.1 below), and then if not ankylosed in the optimum position, by adding (not combining) the values of percentage of WPI using tables 17-15 to 17-30 (pp 538-543 AMA5).”
Under table 3.1 of the Guidelines, ankle arthrodesis results in 37% lower extremity impairment (LEI). The note under that paragraph reads:
“Note that the figures in Table 3.1 suggested for ankle impairment are greater than those suggested in AMA5.
Ankylosis of the ankle in the neutral/optimal position equates with 15 (37) [53]% impairment as per Table 3.1. Table 3.1(a) is provided below as a guide to evaluate additional impairment owing to variation from the neutral position.”Ms Gutierrez’s left ankle position varies from the neutral in that her ankle is in 10° of plantar flexion. Under table 3.1a of the Guidelines, this results in an extra 10% LEI, which is added, giving a total of 47% LEI for the ankle range of motion.
Also under Table 3.1, Ms Gutierrez is assessed with 15% LEI for the equivalent of a triple fusion because of the lack of range of motion in the joints of her foot. The table requires that the ankle and subtalar joints be assessed separately. Because she also lacks movement in the mid tarsal joints, the impairment of her foot is described as a triple fusion, rather than an isolated sub-talar fusion, and added to the loss in respect of her ankle, giving a total of 62% LEI.
The only active movement observed by Medical Assessor Pillemer was flexion of Ms Gutierrez’s big toe and there was no active extension. Under Table 17-14 of AMA 5, the restricted extension of Ms Gutierrez’s big toe which is less than 15° provides an assessment of 5% LEI. In addition, under Table 17-30, she is entitled to 6% LEI for ankylosis of her second, third, fourth and fifth toes in a position of function.
When those figures (62, 6 and 5) are combined, the LEI is 66% which converts to 26% WPI.
Conclusion
The assessment of 26% WPI in respect of Ms Gutierrez’s left lower extremity is then combined with 7% for her lumbar spine and 1% for scarring, resulting in 32% % WPI.
For these reasons, we have determined that the MAC issued on 22 February 2024 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.
WORKERS COMPENSATION DIVISION
APPEAL PANEL
MEDICAL ASSESSMENT CERTIFICATE
Injuries received after 1 January 2002
Matter number: | W8649/23 |
Applicant: | Emma Jane Gutierrez nee Tamati |
Respondent: | The Smart Dental Limited Partnership |
This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.
The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor Rob Kuru and issues this new Medical Assessment Certificate as to the matters set out in the table below:
Table - whole person impairment (WPI)
| Body Part or system | Date of Injury | Chapter, page and paragraph number in NSW Workers Compensation Guidelines | Chapter, page, paragraph, figure and table numbers in AMA 5 Guides | % WPI | Proportion of permanent impairment due to pre-existing injury, abnormality or condition | Sub-total/s % WPI (after any deductions in column 6) |
| Left Lower Extremity | 23/08/19 | Chapter 3 Pages 13-19 | Chapter 17 Pages 523 to 564 | 26% | Nil | 26% |
| Lumbar Spine | 23/08/19 | Chapter 4 Page 20-25 | Chapter 15 Page 384 Table 15-3 | 7% | Nil | 7% |
| Scarring (TEMSKI) | 23/08/19 | 1% | Nil | 1% | ||
| Total % WPI (the Combined Table values of all sub-totals) | 32% | |||||
PERSONAL INJURY COMMISSION
APPEAL AGAINST MEDICAL ASSESSMENT
REPORT OF THE EXAMINATION BY MEDICAL ASSESSOR
MEMBER OF THE APPEAL PANEL
Matter Number: | M1-W8649/23 |
Appellant: | EMMA JANE GUTIERREZ (nee TAMATI) |
Respondent: | The Smart Dental Limited Partnership |
Examination Conducted By: | Roger Pillemer |
Date of Examination: Attendance: | 17 June 2024 Ms Gutierrez attended alone today |
The workers medical history, where it differs from previous records.
I read her the history that was taken by Dr R Kuru (orthopaedic surgeon) at the time of his examination on 6 February 2024. Ms Gutierrez points out numerous errors in the report including the date of birth and age, which is given as 14 June 1964, aged 59, whereas the actual date of birth is in January 1996, and she is 28 years old.
She also notes that the MA repeatedly refers to her right leg whereas the problem is actually with her left leg.
She also notes that the MA indicates that she was referred to a foot and ankle specialist Dr Musgrove, but this was actually a Dr T O’Carrigan.
She agrees that her injury occurred on 23 August 2019. She fell downstairs at work and was taken by ambulance to Blacktown Hospital and that she has had significant ongoing problems with her left lower limb ever since then.
She had had lumbar sympathetic blocks carried on as well as the insertion of a spinal cord stimulator which had to be revised on three occasions and eventually Ms Gutierrez decided that she did not want this replaced again.
As far as treatment is concerned, she was breastfeeding her first child and therefore was not taking any oral medications but was continuing to wear a boot on her left foot (and not her right foot).
Ms Gutierrez was complaining of significant discomfort all around her left foot and ankle region and she was significantly restricted with activities of daily living.
Additional history since the original Medical Assessment Certificate was performed.
Ms Gutierrez informs me that her first child is now 18 months old, and she had a second daughter some four weeks ago.
As far as treatment is concerned, her physiotherapy has been cancelled, she sees a psychologist once every couple of weeks and she continues to take Panadeine Forte. She is not having any other particular treatment at the moment.
Complaints
Ms Gutierrez is complaining of pain in her low back which has been present since the first spinal cord stimulator was inserted in June 2020. The discomfort is felt in the lower lumbar region and described as being constantly present ranging between 5/10 and 9/10. She does get some referred pain down her left lower limb which occurs a few times a week and can last anything from 5 minutes to up to 2 hours.
Symptoms are aggravated by sitting or standing for long or bending or lifting. She does get relief of her back symptoms by lying down and the tablets “take the edge off”.
Left Foot and Ankle
Ms Gutierrez has constant pain in the left foot and ankle region ranging between 7/10 and 10/10 involving the whole of the foot and ankle and extending halfway up her calf. She cannot stand anything touching her left leg and when she does not have her boot on, she has to use two crutches and cannot take weight on her left foot. When she has her boot on, she can take very partial weight on the left foot. She says occasionally when she is having a reasonable period, she can go with only one crutch whereas most of the time she has to use two crutches.
Foot and ankle symptoms are aggravated by cold, sitting or standing for long. She feels the symptoms are not improving and she cannot think of anything that gives her relief of the symptoms.
Findings on clinical examination
Ms Gutierrez is a young adult female who presented with two crutches today and on removal of her jeans and her boot, as noted, she is unable to take any weight on her left leg because of the significant discomfort.
It is not possible to test her range of back movement because she can only stand using two crutches and not weight bearing on the left side.
Straight leg raising was present to 80° on the right and 70° on the left. Knee reflexes were present, equal and right ankle reflexes present and it is not possible to test for her left ankle reflex because of her significant discomfort.
Importantly, Ms Gutierrez has marked hyperaesthesia/allodynia of the whole of the left leg from approximately 8 cm below the knee extending down into her foot. In addition, there was no active movement of her foot and ankle region and the only joint that moves was active flexion of her big toe, that is, there is no extension of her big toe. She does not move any of the other joints in her left foot and ankle.
Her ankle is in 10° of plantar flexion.
Importantly I note that Ms Gutierrez has been diagnosed with having complex regional pain syndrome, but even though she does have the allodynia present today, there was no evidence of any temperature asymmetry or any skin colour changes, there was no evidence of swelling or sweating, and there was no evidence of any trophic changes involving her skin or nails or hair.
There was certainly decreased joint range of motion as noted above and she does say she has photographs of when her foot and ankle region “were purple”.
Ms Gutierrez does have scarring in the lumbar region with healed scarring in the lower lumbar area measuring 9 cm with minor contour defect and mild pigmentary changes.
She has two further transverse scars of her both iliac crests that are not clearly visible with mild pigmentary changes. No contour defects are present.
Results of any additional investigations since the original Medical Assessment Certificate
Ms Gutierrez has not had any further investigations carried out.
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