Karki v Woolworths Group Limited
[2023] NSWPIC 52
•11 January 2023
| CERTIFICATE OF DETERMINATION OF MEMBER | |
Citation: | Karki v Woolworths Group Limited [2023] NSWPIC 52 |
| APPLICANT: | Chaman Karki |
| RESPONDENT: | Woolworths Group Limited |
| Member: | Michael Inglis |
| DATE OF DECISION: | 11 January 2023 |
| DATE OF AMENDMENT: | 14 February 2023 |
CATCHWORDS: | WORKERS COMPENSATION - Whether the applicant suffered a consequential condition in the lumbar spine and whether the applicant suffered a psychological injury and if so, was it was primary or secondary in nature; Held – the applicant suffered a consequential condition in the lumbar spine and a primary psychological injury; matter remitted to a Medical Assessor for assessment of whole person impairment. |
| determinations made: | 1. The applicant sustained an injury to his right foot on 24 May 2020. The applicant also suffered a frank and/or consequential injury to his right knee. 2. Following the injury to his right foot, the applicant has sustained a consequential condition in his lumbar spine, with a need to wear a cam boot for several months and thereafter developed a limp and antalgic gait. 3. The applicant suffers from post-traumatic stress disorder which is a psychological injury which is primary in nature. 4. I remit this matter to the President for referral to a Medical Assessor pursuant to s 321 of the Workplace Injury Management Act and Workers Compensation Act 1988 for assessment of whole person impairment as follows: Date of Injury; 24 May 2020 Body Systems referred; right lower extremity, lumbar spine and scarring (TEMSKI) 5. The documents to be reviewed by the Medical Assessor are: (a) Application to Resolve a Dispute and attached documents, and (b) Reply and attached documents. |
STATEMENT OF REASONS
BACKGROUND
Chaman Karki (the applicant) migrated to Australia from Nepal in 2008 and is an Australian citizen. He is presently aged 37 years.
He began working in a restaurant to support himself upon arriving in Australia and commenced an accounting course which he was unable to complete.
On or about 20 August 2016, he commenced employment with Woolworths Group Ltd (the respondent).
The applicant was classified as a general team member and his work involved replenishing stock, picking, packing, and stacking pallets.
On 24 May 2020, the applicant was performing his normal duties when he says he was instructed by his duty manager to assist with utilising a roller forklift to attend to a conveyance truck wearing safety shoes.
As he was operating the roller forklift to get inside the conveyance truck, he did not notice a yellow column, which was apparently close to the floor. He says his back hit the yellow column causing him to fall over and the forklift then ran over his right foot.
The matter proceeded to an arbitration hearing via Teams video conference on 25 October 2022.
Mr Bill Loukas of counsel appeared for the applicant and Mr Tom Grimes of counsel appeared for the respondent.
ISSUES FOR DETERMINATION
The parties agreed that the following issues remain in dispute:
(a) consequential condition in the lumbar spine, and
(b) consequential psychological injury of a primary or secondary capacity.
Matters previously notified as disputed
Consequential injury to the right knee which was originally in dispute was conceded at the hearing.
PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION (Commission)
I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.
EVIDENCE
Documentary evidence
The following documents were in evidence before the Commission and taken into account in making this determination:
(a) Application to Resolve a Dispute (ARD) and annexures W5287/22;
(b) Reply and annexures 5287/22;
(c) Application to Admit Late Documents dated 13 September 2022, and
(d) Application to Admit Late Documents dated 17 October 2022.
Oral evidence
There was no oral evidence as the applicant was not required for cross examination.
It is not disputed that the applicant suffered a severe Lisfranc type injury to his right foot and a consequential condition in the right knee.
Applicant’s statement
The applicant says that he did not have any previous injuries to his foot, knee, or back prior to the subject accident.
Similarly, he did not have any previous ongoing psychological injuries and had been able to manage his work and personal commitments without any adverse effect on his general health.
Following the accident, the applicant was taken to Royal North Shore Hospital and came under the care of Dr Terence Moopanar, orthopaedic surgeon.
He underwent surgery on 24 May 2020 to stabilise his right foot and had to wear a CAM boot for about six months after the surgery.
He was required to undertake extensive physiotherapy and recovery was slow. He says he continued to have right knee pain and lower back pain during this time.
The applicant underwent a second surgical procedure on 12 March 2021 to remove pins inserted at the initial surgery.
He said that because of the pain and restriction in the right foot he limped and this was also putting a strain on his back. At the time of making his statement, namely 12 May 2022 he said that he continued to suffer from right knee and back pain.
Concerning the claimed psychological consequences of the injury to his foot the applicant says that almost immediately he began experiencing nightmares about the accident and the pain he suffered formed a trigger for those nightmares.
The surgery and related treatment that he underwent caused him stress and anxiety. He had flashbacks, images and memories which were difficult to control. He would become agitated and would on edge even at home.
The applicant says that he was anxious all the time. Any sudden noise or changes around him would make him panic. There were a lot of thoughts in his head and he felt like it was going to blow his head off.
The applicant became increasingly irritable and agitated which affected his relationship with his wife and friends.
His relationship with his wife became strained and resulted in a deterioration in that relationship. The applicant said further he was sad all the time and did not want to go back to the site of the accident. He was scared of roads and noises.
Eventually, he reported the psychological issues to his general practitioner (GP), Dr Lam who referred him to Antoinette Rees, a psychologist. He underwent treatment but that did not help very much.
After being diagnosed with post-traumatic stress disorder, the applicant underwent a mental health plan and at the time of making his statement was consulting Mr Pan Tsomis, psychologist.
The symptoms described above were continuing as at the time of making the statement and he also suffered recurrent headaches.
Dr Terence Moopanar, orthopaedic and reconstructive surgeon
Dr Moopanar is the applicant’s treating surgeon. In a report dated 11 July 2022, Dr Moopanar comments upon the relationship between the claimant’s Lisfranc injury and his low back symptoms.
In his report, Dr Moopanar expresses the following opinion:
“1. Provide any commentary on the client’s lower back pain and whether or not the lower back pain was caused by the compensatory mechanical alteration resulting from the incident on 24 May 2020. For this point, I would believe the patient insofar as with the timely nature of the pain and its unremitting and unrelenting nature, I would infer that with a severity of injury to his foot that he is more than likely suffering from lower limb issues and lower back issues due to the aforementioned injury. I have not treated him particularly for this problem, nor I have investigated this problem, but I am taking the patient’s word as well as knowing what had occurred in his foot as evidence for his presenting problem.
2. Provide any commentary on any of the symptoms of our client’s lower back condition and pain. With regarding back pain, it is a very, very common complaint in society, they are asked various causes for back pain and there are various treatment options and modalities as well. Having said that, my patient has complained of back pain since the time of the injury and the complex nature and common presentation would mean that there could have been various reasons for the actual pain. I do not believe that this is neuropathic in nature insofar as it requires an operation but clearly, he is complaining of pain since the time of the surgery and according to his history, he has not had any pain before so there is no reason for me to doubt him.
3. Any other relevant comments, I do feel that regarding Mr Karki is a motivated individual who was very, very affected by his adverse event from a foot point of view, now at the time of the injury, could not have appreciated other injuries due to the distracting nature of his injury to his foot. A subsequent pain in his knee and subsequent pain in his lower back could very much be a consequence of the initial injury aforementioned and I am so pleased that he has done so well from a point of view; however, my concern is still for that for the back and knee and I would defer to colleague who is now consulting to further manage this condition. I will see him at short notice if there is any concern, but from a foot and ankle point of view, I am very pleased he has made a great recovery.”
Dr James Bodel, orthopaedic surgeon
Dr Bodel provided a medico-legal report to the applicant’s solicitor on 16 October 2021.
In that report, Dr Bodel opines relevantly.
“I note the medical record from Dr Angela Lamb, the Local Doctor at the Allianz Medical Health Care Centre. This is consistent with the medical management of this gentleman’s crushed injury to the region of the right foot. She also confirms that he did develop back pain because of the abnormal gait pattern and also anterior knee pain for which he has had appropriate investigations and treatment. I have not had the opportunity to view any x-rays or scans, but he does have clinical evidence of persisting pathology in those regions.”
Dr Bodel was asked to respond to specific questions directed to the issues to be determined by me. He responded as follows:
“1. The nature and extent of our client’s injuries.
Mr Karki suffered a crush injury to the region of his right foot in the injury that occurred at Woolworths and this happened in the manner described above.
He has developed consequential pain in the region of the right knee and the lower part of the back as a result of his prolonged abnormal gait pattern…
3. Your diagnosis and prognosis and any probability of degeneration.
The diagnosis here is the Lisfranc fracture dislocation of the tarsometatarsal joint in the region of the right foot caused by the injury at work.
The prognosis for this is guarded.
He will develop post traumatic osteoarthritis and made a later stage require a triple arthrodesis.
He also has developed the consequential anterior and knee pain and the lower back pain because of the prolonged abnormal gait pattern that is persisting.
4. Whether there are any pre-existing injuries, conditions or pre-disposing factors contributing to our client’s condition
There is no indication of any pre-existing abnormality or condition in any of the injured areas.
6. Whether employment is a substantial contributing factor to our client’s above-mentioned injuries
His employment is a substantial contributing factor to the injury in this circumstance.
9. Your recommendations for ongoing and future treatment including an estimate of the costs of such treatment and whether they are reasonably necessary for the injury sustained;
From the orthopaedic point of view, no further specific treatment is required apart from the modified footwear as identified by Dr Moopanar, non–prescription analgesic medication and an exercise-based program.”
In a separate report of the same date, Dr Bodel assessed the applicant’s whole person impairment (WPI) at 16% made up of the following components:
“There are three individual ratings to combine;
– 7% for the Lumbar Spine
– 7% for the he Right Lower Extremity; and
– 2% for Scarring.”
Dr Patrick Mehr
Dr Patrick Mehr, radiologist, reported on an MRI of the lumbar spine to Dr Angela Lam of the Alliance Medical Healthcare Centre on 27 July 2022. The comment provided on the MRI by Dr Mehr is as follows:
“COMMENT:
Annular fissuring at L4/L5 and L5/S1 disc. Mild tightening of the lateral recess at the right L4/L5 contacting the descending right L5 nerve which could predispose to nerve impingement/irritation. CT-guided epidural injection at L4/L5 may be beneficial for the patient.”
A/Professor Peter Papantoniou, orthopaedic and spinal surgeon
A/Professor Papantoniou reported to Dr Lam on 23 August 2022.
In his report A/Professor Papantoniou records the following history:
“He was taken to Royal North Shore Hospital where he was admitted and had an operation. He apparently spent two days in the hospital. He had severe right foot pain right from the start, which is in keeping with the Lisfranc injury. This was so overwhelming that he did not notice the right knee pain and lower back pain immediately.
After the surgery, as the foot began to settle, he began to notice his right knee pain and lower back pain. He continued to have right foot pain, right knee pain and lower back pain. In March 2021, he had a second right foot operation to remove the plates and screws that have been inserted.
Mr Karki continues to complain of central and right-sided lower back pain which he describes as a sharp pain. This pain radiates into the right buttock. The lower back pain is present day and night and causes him sleep disturbance every night. He also has right knee pain and pain around the patella and the anterior joint line. He continues to use Paracetamol and sleeping tablets without any benefit.
He has not had any recent physical therapies as his insurer has stopped them. I note that Mr Karki did report his lower back pain to the doctors at Royal North Shore Hospital after his initial foot operation.”
A/Professor Papantoniou carried out an examination and referred to the MRI of the lumbar spine. He concluded:
“This demonstrates L5/S1 and L4/5 disc desiccation with a posterior disc bulge and annular tears at each level. At L3/4, there is disc desiccation and a poster [sic] disc prolapse.
Mr Karki also presents with an MRI of the right knee from 26/03/2021. This demonstrates patellar tendinosis and enthesopathy.
OPINION
Mr Karki clearly has significant pathology in the lumbar spine at the lower three levels. It is the lowest two levels L4/5 and L5/S1 that appeared to be most affected.
It appears the L5/S1 level is the most symptomatic.
He also has a quite symptomatic right knee pathology visible on the MRI.
It appears that all the pathology is directly related to his work injury given that previously he was a fit, healthy young man….
Management
I have explained my findings in the pathology to Mr Karki. I have demonstrated on the images and on models. I have sent him for a right knee MRI and a right-directed L5/S1 epidural steroid injection.
I would like him to practice the usual back precautions and avoid any lifting, bending or twisting activities.
He should avoid any impact or twisting activities on the right knee.
I have asked him to continue appropriate analgaesia under your supervision.
I will see him again routinely with the new MRI after his injection. Should he have any problems, queries or concerns prior to this I have asked him to contact my rooms and be seen sooner.”
Dr Aman Suman, forensic psychiatrist
Dr Suman reported to the applicant’s solicitors on 8 December 2021.
Dr Suman had available to him various medical reports which he details in his own report.
In that report, he opines relevantly:
“Summary and Impression
Mr Karki is a young gentleman living with his wife at their rental accommodation in Lane Cove.
Mr Karki was involved in a workplace accident in May 2020 where he injured his foot. He required extensive surgical treatment and physiotherapy input to help manage his physical injury.
Mr Karki has experienced post-traumatic stress disorder symptoms since the accident. He did not consult his general practitioner till six months later. Mr Karki tried to manage his mental health issues with the use of alcohol.
Mr Karki has received psychological input although he did not experience any significant benefit initially. He has been receiving psychological input since early 2021 with partial clinical benefit. It is evident that Mr Karki has not been diagnosed or treated adequately for post-traumatic stress disorder symptoms.
Mr Karki’s recent presentation indicates towards ongoing post-traumatic stress disorder symptoms. He has experienced some recovery in terms of his physical injury, although he is not back to his premorbid level of function. Mr Karki continues to use painkillers to help manage his pain symptoms.
I was not able to elicit past psychiatric history, family psychiatric history, history of addiction disorders, or any evidence indicative of Mr Karki presenting with specific personality traits or deficits contributing towards his current presentation.
Overall, as per review today, I am of the opinion that Mr Karki’s presentation/symptoms satisfy the criteria of post-traumatic stress disorder with comorbid depression as per DSM-5 Diagnostic Criteria. His presentation also satisfies the criteria of alcohol use disorder (partial remission).”
Dr Suman then summarises the various criteria applicable. He also concludes relevantly:
“6. If you are of the opinion that our client has suffered psychological injury? Is the injury primary or secondary?
As per review today, I am of the opinion that Mr Karki experienced psychological injury, i.e., post-traumatic stress disorder. His injury is to be considered primary in nature and not secondary to the physical injury or related pain symptoms….
9. Whether employment is a substantial contributing factor to our client’s injury?
As per review today, I am of the opinion that Mr Karki’s employment remains the substantial contributing factor towards his psychological injury.”
Dr Stephen Quain, orthopaedic specialist
The respondent has retained Dr Stephen Quain to provide medico-legal opinion. Dr Quain reported on 15 November 2021, 6 April 2022 and 13 October 2022.
In his report of 15 November 2021, Dr Quain expressed the opinion that symptomatically the applicant had not recovered fully from the effects of the Lisfranc injury to his foot but anatomically he had as the fractures had healed.
Dr Quain expressed the opinion that there was no relationship between symptoms complained of in the applicant’s knee and lumbar spine, resulting directly or in a consequential manner from the Lisfranc injury to the foot.
Dr Quain expressed the opinion that at the time of his examination, the applicant was fit to resume at least part-time work as an Uber driver up to 20 hours per week, although he continued to complain of right foot pain. He did not believe that the applicant would return to work as a storeman with the Woolworths Group.
Dr Quain next reported on 6 April 2022. In that report, he opined relevantly:
“d. In relation to the right knee and lumbar spine, the worker alleges he suffered consequential conditions as a result of his accepted right foot/ankle injury. More specifically, it is alleged this time that his time in a CAM boot caused an altered gait and lead to right knee and lumbar spine injuries. Please advise whether you agree. If not, please provide reasoning.
I would accept that this may have aggravated right knee pain but, in my view, it has not caused any specific injury to the lumbar spine, noting that this man is only 36 years old.”
As to the applicant’s then work capacity, Dr Quain opined:
“He is not fit for work involving standing, squatting, climbing of stairs, but in my view, is fit for sedentary work.”
Although noting that it was outside his area of expertise, Dr Quain did express the opinion that the applicant’s pain focus and other psychological factors was a factor preventing a return to employment.
Dr Quain’s third and final report is dated 13 October 2022. At that time, Dr Quain had available to him the MRI scan and report of Dr Mehr. In relation to that report, Dr Quain commented:
“I have read the report by Dr Mehr and as noted, there are premature degenerative changes, noting Mr Karki is only 36, at the L4/5 and L5/S1 disc levels with possible lateral recess encroachment on the descending right L5 nerve root. However, my opinion remains that a crush injury to the right foot and the subsequent use post-operatively of either a CAM boot or a DARCO shoe has not caused these changes.”
Additionally, Dr Quain was asked to comment upon the report of A/Professor Papantoniou. In the report, Dr Quain commented:
“3. Dr Papantoniou stated the lumbar spine and the right knee were injured in the frank incident on 24 May 2020. Do you agree?
I do not agree, but I do accept that with a crushed foot at that time, Mr Karki may have had a minor twist injury to the right knee. I note again, however, that the MRI scan report of 29 March 2021 does not show any meniscal injury and is consistent with some mild patellofemoral tendinosis and possible patellar mal-tracking which again is not related to the incident described.”
SUBMISSIONS
Respondent’s submissions
Dealing firstly with the claimed psychological condition, Mr Grimes for the respondent pointed out that in the ARD, the alleged psychological injury was not pleaded either as a primary or secondary injury. This is correct but I am required to consider the evidence as a whole in order to determine whether or not there has been a psychological injury and if so, its genesis. Mr Grimes referred me to paragraphs 37 to 60 of the applicant’s statement wherein he details the onset of the psychological symptoms and his treatment and management. Mr Grimes indicated that that history suggested that any psychological injury could well be classified as a secondary injury.
Mr Grimes submitted that the evidence was unsatisfactory and really amounted to an unsigned summary of the notes of the treating GP which did not contain a diagnosis of a recognisable psychiatric condition.
In relation to the report of the psychiatrist Dr Suman, Mr Grimes submitted that I should not accept his opinion as the history and diagnosis contained in the report were deficient and did not establish the necessary nexus between the applicant’s injury and the need for psychological or psychiatric treatment.
In relation to the claimed injury to the low back, Mr Grimes submitted that I could not be satisfied that there was a frank injury to the lumbar spine. I agree with this submission. He also submits that I could not be satisfied that a consequential condition developed in the low back. In support of this submission, Mr Grimes submitted that the history of the onset of the abnormal gait was vague, that Dr Quain did not notice any limp at the time of his examination and that the joggers being worn by the applicant at that time showed a normal wearing tread.
In relation to Dr Quain’s final report in October 2022, when Dr Quain had available the MRI findings, Mr Grimes submitted that I could not be satisfied that the degenerative change noted on MRI was caused by the original injury to the applicant’s foot. I agree with this submission.
Applicant’s submissions
Again, dealing firstly with the alleged psychological injury, Mr Loukas, for the applicant submitted that I should accept the diagnosis and opinion of Dr Suman as set out in his report.
In particular, he submitted that the symptoms complained of by the applicant satisfied the condition as alleged in the ARD and provided a sound basis for the diagnosis of Dr Suman.
He said I should accept the diagnosis of post-traumatic stress disorder and that the applicant has not as yet been adequately treated for that condition. He pointed out that treatment on balance may well assist the applicant in recovering from the condition.
He also noted that the applicant was currently undergoing treatment by a psychologist as recommended by Dr Suman.
Not insignificantly, Mr Loukas made the point that the respondent had not arranged for the applicant to be examined on its behalf by a psychiatrist and that the only medical evidence therefore was the opinion expressed by Dr Suman in his report.
In view of the opinion expressed by Dr Suman in his report Mr Loukas withdrew an earlier made concession that the psychological condition suffered, if any, by the applicant was not primary in nature.
In relation to the claimed consequential condition in the back, Mr Loukas submitted that I would prefer the opinion expressed by Dr Bodel. He pointed to the pathology identified by the MRI, which clearly identified the presence of degenerative change and that I could be satisfied that the symptoms complained of resulted from the need by the applicant to wear a CAM boot, the development of an antalgic gait and the condition in the right knee.
DECISIONS AND FINDINGS
The respondent accepts that the applicant suffered an injury to his right foot in the form of a Lisfranc injury and did not contest the allegation of a frank injury and/or consequential condition in the right knee.
It is well settled that the applicant does not need to prove that he suffered a s 4 injury to the claimed body parts in addition to the right foot and knee. The Commission has considered claims of this kind in several decisions (Cadbury Schweppes Pty Ltd v Davis [2011] NSWWCCPD 4; Moon v Conmah Pty Ltd [2009] NSWWCCPD 134; Australian Traineeship System v Turner [2012] NSWWCCPD 4) and has consistently applied the principles in Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452.
The applicability of those established principles was discussed by Roach, Deputy President as he then was in Kumar v Royal Comfort Bedding Pty Ltd [2012] NSWWCCPD 8.
As Roach DP said at [61] in Kumar:
“61. It was not necessary to determine if Mr Kumar suffered an injury to his right shoulder under Section 4 of the 1987 Act. Nor was it necessary to determine if Mr Kumar had suffered ‘significant right shoulder pathology’, as Dr Wallace suggested. It was only necessary to determine if the right shoulder condition resulted from the accepted back injury. That question was a straightforward causation issue. On an objective view of the whole of the evidence, the compelling conclusion is that Mr Kumar’s right shoulder condition resulted from stress placed on it due to mobilising and transferring during his recuperative period following his back surgery. It follows that the right shoulder condition has resulted from the back injury on 19 March 2009. The claim for the cost of the proposed surgery cannot be finalised until the matter is assessed by the Approved Medical Specialist and the matter will be remitted to the Registrar for that purpose.”
Lumbar spine
The applicant was not required for cross examination on his statement. In that statement, the applicant concedes that he did not report symptoms in his lumbar spine to his GP, Dr Angela Lam until November 2020.
The unchallenged evidence is that he was required to wear a CAM boot for several months and was forced to limp. He said that the lower back pain that he developed persisted including when sitting, standing, driving and walking. He said that he could not bend over without experiencing pain in his back.
In my opinion, it is significant that the MRI performed on 24 July 2022 confirmed the presence of pathology that can be described in general terms as degenerative change. As was noted by Dr Quain in his initial report, the applicant at that time was only 36 years old, suggestive of a degenerative change in a man of that age would be unusual. However, as we know, the subsequent MRI indicated that degenerative changes were in fact present.
I accept that it is unlikely that the degenerative change was caused by the mechanism of the accident which gave rise to the injury to the applicant’s right foot. However, that does not preclude the consideration of the degenerative changes being aggravated by the applicant wearing of the CAM boot, altered gait and symptoms in the right knee such that the degenerative changes became symptomatic. There is no history of any back symptoms prior to the injury to the foot.
It is not unusual for persons who have suffered foot or knee injuries which impacts upon their gait to develop symptoms in the lumbar spine. I prefer the opinion of Dr Bodel that the applicant has developed consequential pain in the lower part of the back as a result of his prolonged abnormal gait pattern. I do not accept the view expressed by A/Prof Papantoniou that the pathology is directly related to his work injury. However, it is sufficient that the degenerative change was aggravated and rendered symptomatic by the altered gait and symptoms in the right knee.
I would add that in rejecting the opinions expressed by Dr Quain, I note that his opinion that there is no causal connection between the injury to the right foot and the low back symptoms, seems to be predicated on the assumption that the applicant’s case is that degenerative changes were caused by the incident which gave rise to the Lisfranc injury to the right foot. He does not provide any opinion as to whether or not those changes could have been rendered symptomatic by the wearing of the CAM boot, the altered gait and the symptoms in the right knee as I have found.
Psychological condition
The only expert evidence that I have is contained in the report of Dr Suman which is discussed above.
I am satisfied that the applicant experiences post-traumatic stress disorder symptoms which should be considered primary in nature and not secondary to the physical injury or related pain symptoms as opined by Dr Suman.
There is no psychiatric evidence to the contrary and I see no reason to disregard or discount the clinical diagnosis and opinion of Dr Suman.
SUMMARY
The applicant sustained an injury to his right foot on 4 May 2020. The applicant either sustained a frank injury to his right knee and/or a consequential condition.
Following the injury to the right foot, the applicant was required to wear a CAM moon boot for several months and thereafter developed a limp and antalgic gait. As a result, the applicant suffers a consequential condition in the lumbar spine, most likely in the form of aggravation of pre-existing degenerative changes.
The applicant suffers from post-traumatic stress disorder, a psychological injury, which is primary in nature.
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