Lynch v Woolworths Group Limited
[2023] NSWPICMP 600
•22 November 2023
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Lynch v Woolworths Group Limited [2023] NSWPICMP 600 |
| APPELLANT: | Kylie Theresa Lynch |
| RESPONDENT: | Woolworths Group Limited |
| APPEAL PANEL | |
| MEMBER: | Catherine McDonald |
| MEDICAL ASSESSOR: | Mark Burns |
| MEDICAL ASSESSOR: | Drew Dixon |
| DATE OF DECISION: | 22 November 2023 |
| CATCHWORDS: | WORKERS COMPENSATION - Injury to left ankle and consequential condition in lumbar spine with development of chronic regional pain syndrome (CRPS); Medical Assessor did not set out path of reasoning to determination that CRPS not present; re-examination; strict criteria in the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 March 2021 not fulfilled; Elsworthy v Forgacs Engineering Pty Ltd considered; Held – Medical Assessment Certificate confirmed. |
BACKGROUND TO THE APPLICATION TO APPEAL
On 2 August 2023 Kylie Lynch lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Roger Pillemer, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 13 July 2023.
Ms Lynch relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):
· the assessment was made on the basis of incorrect criteria, and
· the MAC contains a demonstrable error.
The delegate was satisfied that, on the face of the application, at least one ground of appeal was made out. 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 Lynch was employed by Woolworths in a store, picking products to fulfil online orders. On 21 November 2020 she felt a popping sensation in her left ankle while reaching for some cold meat on a shelf. She was diagnosed with Achilles tendinosis and bursitis. She used crutches and then a scooter to avoid weight bearing and returned to work on selected duties while using the scooter. Whilst performing her duties in a flexed position, she began to experience significant lumbar pain. That pain was aggravated when walking up a travellator on crutches to attend work.
Ms Lynch was diagnosed with chronic regional pain syndrome (CRPS). Ms Lynch relied on Dr Kwong’s assessment of 42% whole person impairment (WPI), based on an assessment of 13% WPI in respect of her lumbar spine and 33% WPI in respect of her left lower extremity.
The Medical Assessor assessed 12% WPI in respect of Ms Lynch’s lumbar spine. He did not make any assessment in respect of her tendo-Achilles injury, having observed a full range of movement. He said that his findings do not indicate ongoing CRPS.
Ms Lynch did not allege that the Medical Assessor erred in his assessment of her lumbar spine.
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 Ms Lynch should undergo a further medical examination because the Medical Assessor did not identify the criteria used to assess whether she suffered CRPS, thus failing to show the path of his reasoning.
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.
Dr Burns of the Appeal Panel conducted an examination of the worker on 8 November 2023. The report forms part of these reasons.
The parts of the MAC that are relevant to the appeal are set out, where relevant, in the body of this decision.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but we have considered them.
In summary and in submissions prepared by Mr T Hickey of counsel, Ms Lynch submitted that the Medical Assessor misapplied the Guidelines and made a demonstrable error in failing to provide adequate reasons. Ms Lynch said that the Medical Assessor was required to acknowledge and use Chapter 17 of the Guidelines to assess CRPS. She set out her medical history with respect to the treatment for that condition and sought to explain how that history demonstrated that he criteria in Table 17.1 were fulfilled. She said it was inadequate for the Medical Assessor to simply state that the examination findings did not indicate CPRS.
In reply, in submissions prepared by Mr B Jones of counsel, Woolworths submitted that the Medical Assessor made clear that he did not identify any “symptoms” meeting the criteria in row 3 of Table 17.1 at the time of the examination. The fact that other examiners have identified CRPS does not bespeak error in what Dr Pillemer did. Relying on a series of cases, many of them with respect to the motor accidents legislation, Woolworths submitted that the relevant consideration was the presence of “symptoms” to meet the diagnostic criteria for CRPS and that it was sufficient for the Medical Assessor to state whether they were present or not.
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 Campbelltown City Council v Vegan[1] 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.
[1] [2006] NSWCA 284.
Assessment of CPRS under the Guidelines
In 2004, the International Association for the Study of Pain held a conference in Budapest at which it adopted a set of guidelines for the diagnosis of CPRS. The Budapest criteria are less stringent than the requirements of Chapter 17 of the Guidelines.
The Medical Assessor was required to take into account the history and available reports but was required to assess Ms Lynch as she presented on the day of the examination.[2]
[2] Guidelines paragraph 1.6.
The Guidelines set out the requirements for a medical report and provide:[3]
“As the Guidelines are to be used to assess permanent impairment, the report of the evaluation should provide a rationale consistent with the methodology and content of the Guidelines. It should include a comparison of the key findings of the evaluation with the impairment criteria in the Guidelines. If the evaluation was conducted in the absence of any pertinent data or information, the assessor should indicate how the impairment rating was determined with limited data.”
[3] Paragraph 1.48.
The criteria for assessing the condition are set out in Chapter 17 of the Guidelines – Evaluation of permanent impairment arising from chronic pain. Chronic pain, as a separate condition, is excluded from the Guidelines, essentially because the experience of pain is subjective and tools based on self-reporting are unreliable. Some impairment ratings – such as those which apply to the spine – reflect the effect of the injury and pain on the activities of daily living.[4]
[4] Paragraph 17.3.
The Guidelines provide[5] that:
[5] Paragraph 17.5.
“Table 17.1 is used to determine if complex regional pain syndrome (CRPS) is a rateable diagnosis. It is important to exclude diagnoses that may mimic CRPS, such as disuse atrophy, unrecognised general medical problems, somatoform disorders and factitious disorder. Once the diagnosis is established, assess impairment as in AMA5.
For Complex Regional Pain Syndrome Type 1 (CRPS1) to be present for the purposes of assessment:
·the diagnosis is to be confirmed by criteria in Table 17.1
·the diagnosis has been present for at least one year (to ensure accuracy of the diagnosis and to permit adequate time to achieve maximum medical improvement)
·the diagnosis has been verified by more than one examining physician
·other possible diagnoses have been excluded.
·CRPS1 is to be assessed as follows:
Apply the diagnostic criteria for complex regional pain syndrome type 1 (Table 17.1).
Table 17.1 Diagnostic Criteria for Complex Regional Pain Syndrome types 1 and 2
1. Continuing pain, which is disproportionate to any causal event.
2. Must report at least one symptom in each of the four following categories:
· Sensory: Reports of hyperaesthesiae and/or allodynia.
· Vasomotor: Reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry.
· Sudomotor/oedema: Reports of oedema and/or sweating increase or decrease and/or sweating asymmetry.
· Motor/trophic: Reports of decreased range of joint motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
3. Must display at least one sign* at time of evaluation in all of the following four categories:
· Sensory: Evidence of hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement).
· Vasomotor: Evidence of temperature asymmetry and/or asymmetric skin colour changes.
· Sudomotor/oedema: Evidence of oedema and/or sweating asymmetry.
· Motor/trophic: Evidence of decreased active joint range of motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
4. There is no other diagnosis that better explains the signs and symptoms.
*A sign is included only if it is observed and documented at time of the impairment evaluation.Then consider the following in assessing CRPS1:
·If the criteria in each of the sections 1, 2, 3 and 4 in Table 17.1, above, are satisfied, the diagnosis of CRPS1 may be made.
·Rate the extremity impairment resulting from loss of motion of each individual joint involved.
·Rate the extremity impairment resulting from sensory deficits and pain, according to the grade that best fits the degree or amount of interference with ADL, as described in AMA5 Table 16.10a (p 482). Use clinical judgement to select the appropriate severity grade and the appropriate percentage from within the range shown in each grade. The maximum value is not automatically applied. The value selected represents the extremity impairment. A nerve value multiplier is not used.
·Combine the extremity impairment for loss of joint motion with the impairment for pain or sensory deficit using the Combined Values Chart (AMA5, p 604) to obtain the final extremity impairment.
·Convert the final extremity impairment to WPI using AMA5 Table 16.3, (p 439) for the upper extremity and AMA5 Table 17.3 (p 527) for the lower extremity.”
The diagnosis is to be confirmed by the criteria in Table 17.1 and the assessment is made by applying the diagnostic criteria in that table. That means that it was necessary for the Medical Assessor to acknowledge the criteria in the Guidelines and explain how his observations and assessment responded to those criteria.
Table 17.1 highlights the distinction between symptoms – a worker’s subjective experience, considered under the second row of the table - and signs, which can be observed by the assessor, measured under the third row of the table.
In Elsworthy v Forgacs Engineering Pty Ltd[6] Fagan J explained the operation of Chapter 17, using the letters a - d to replace the bullet points in the paragraph with respect to diagnosis and i – iv to replace the bullet points in sections 2 and 3 the table. His Honour said:
[6] [2018] NSWSC 1638.
“[41] … Of the four requirements a-d at the commencement of the criteria for consideration of CRPS, item a is that the AMS should confirm the diagnosis by application of the criteria in Table 17.1. Undoubtedly those criteria are strict and demanding. The Guidelines state at length in cll 17.1-17.5 why these strict criteria have been adopted, including the following:
17.3 [P]ain is a subjective experience and is, therefore, open to exaggeration or fabrication in the compensation setting. Assessment depends on the credibility of the subject being assessed. In order to provide reliability, applicants undergoing pain assessments require more than one examiner at different times, concordance with the established conditions, consistency over time, anatomical and physiological consistency, agreement between the examiners and exclusion of inappropriate illness behaviour.
[42] I construe the word ‘diagnosis’ in items a-d as having the same meaning each time it appears. That is, it refers to a diagnosis arrived at by application of the criteria in Table 17.1, as item a explicitly states. This means that for CRPS to be present for the purposes of assessment it must have been diagnosed according to those criteria for at least one year and the diagnosis must have been verified according to those criteria by more than one examining physician. Not only does the language of items a-d indicate, by the undifferentiated use of the word ‘diagnosis’, that the diagnosis over at least one year and the diagnosis by more than one physician must all be according to the Guidelines but, further, this construction addresses the explicit concern stated in cl 17.3. That concern would not be met if items b-d could be satisfied by other physicians’ diagnoses, spanning a year or more, made according to undefined criteria, perhaps less stringent than those of Table 17.1. This consideration supports the construction I have adopted.
[43] The plaintiff’s submissions to the Court dwelt upon the opinions of treating clinicians predating Dr Lewington’s examination. A number of these were to the effect that the plaintiff suffered from CRPS. These opinions are apparently what is referred to in the expression ‘history and management of the worker’ in ground (e). The plaintiff’s argument is that Dr Lewington should have found the diagnosis of CRPS ‘has been present for at least one year’ (item b) and ‘has been verified by more than one examining physician’ (item c) on the basis of the ‘history and management of the worker’ reflected in his treating clinicians’ opinions, irrespective of the criteria those clinicians applied.
[44] Upon the construction of items a-d outlined above I reject this. Notably, all but one of these other diagnoses were based upon the ‘Budapest criteria’. These are set out in a report of Dr Russo, pain specialist, dated August 2011, as follows:
According to the Budapest clinical criteria for CRPS the patient must report continuing pain that is disproportionate to the inciting event… The patient must also report one symptom in three of the four following categories:
Sensory (report of hyperesthesia (sic) or allodynia) - …
Vasometer (sic) (temperature asymmetry and/or skin colour changes …
Sudomotor/oedema - …
Motor/trophic changes (decreased range of movement and/or motor dysfunction and/or trophic changes to the hair, skin, nails) - …
The patient must also display at least one sign in two of the above four categories.
[45] The Budapest criteria are less demanding for a diagnosis of CRPS than Table 17.1 of the Guidelines. Contrary to the plaintiff’s submissions I do not consider that these other opinions, based upon criteria different from those which Dr Lewington was bound in law to apply, establish error by him or by the Panel or have any relevance to the validity of their decisions. Only one of the other doctors, of Dr Glass in a report dated 18 November 2016, found all criteria of Table 17.1 satisfied. On examination in November 2016 Dr Glass found signs under items 3 i-iv which were not present at Dr Lewington’s examination on 1 May 2017.”
The MAC
The Medical Assessor set out Ms Lynch’s present symptoms:
“Ms Lynch’s main concern is severe pain in her low back radiating down both lower limbs as far as her feet on both sides. Back pain is described as being constantly present, ranging between ‘4-20/10’, and her leg symptoms are also constantly present and going as high as 8-9/10. She is aware of paraesthesias in both feet and is also aware that she is unable to spread the toes of her right foot. Symptoms are aggravated by all forms of activity and she does get some relief by resting.”
Setting out his findings on examination, the Medical Assessor said:
“Ms Lynch is an adult female with a significant increase in her body mass index particularly centrally. She walks with a slow measured gait with a slight limp on the left side and was able to walk on heels and toes but with difficulty.
She shows significant restriction of back movement only getting her fingertips some 6cm below her knees in flexion and lateral flexion to the left was slightly more restricted than to the right.
Straight leg raising became uncomfortable at 40° bilaterally mainly because of back pain, knee and ankle reflexes are present and equal, her right medial hamstring reflex is present but I was unable to elicit her left medial hamstring reflex.
She does have distinct hypoesthesia to pinprick over the lateral border and sole of her right foot in an S1 distribution and in addition was unable to abduct her toes (intrinsic function). On the left side she has fairly diffuse hyperaesthesia to pinprick involving particularly the L5 and S1 regions and extending up her leg on the lateral side.
Range of ankle and subtalar joint movements were equal bilaterally and there was no particular tenderness to palpation of the tendo-Achilles today.
Ms Lynch’s findings do not indicate any ongoing complex regional pain syndrome (CRPS).”
When commenting on the medical evidence in the file the Medical Assessor said:
“I note the reports of Dr F Machart, orthopaedic surgeon of 28 March 2023 who felt that Ms Lynch’s lumbar spine symptoms were not a consequential injury and therefore did not suggest any impairment for the lumbar spine. He did not find evidence of CRPS. He notes a full range of movement of ankle and subtalar joint and of toes.
There is a report of Dr A Porteous, occupational physician of 25 November 2021 placing Ms Lynch in DRE Category III of her lumbar spine with 10% WPI, but making a one-tenth deduction for her previous problems. As noted, I have elected not to make any deduction.
He has added an additional 3% for ADLs, giving a final total of 12% WPI, whereas noted I have added an additional 2% for ADLs. He notes ‘normal ankle movements, except for plantar flexion’, for which he awards 1% WPI. He makes no comment regarding CRPS.
There is a report of Dr T Kwong, rheumatologist of 13 December 2022 once again placing Ms Lynch in DRE Category III which I would agree with, but also suggesting an additional 33% WPI for CRPS. As noted in my opinion features were not in keeping with CRPS.
There are a number of reports of other specialists including Drs Mittle, Wallace, Darwich, and Gorman, none of whom suggest figures of impairment.” (emphasis in original).
Medical evidence
CRPS was diagnosed by Ms Lynch’s orthopaedic surgeon, Dr Mittal in 2021.
Ms Lynch was referred to Dr Wallace, a pain specialist, for treatment in March 2022. He diagnosed CRPS and recommended treatment. In his first report dated 24 March 2022 he said that the “Budapest criteria for CRPS is fulfilled with swelling, dysaesthesia, excess sweating, temperature and colour changes, trophic changes (increased hair/dry skin) and decreased strength and ROM.”
Dr Wallace prepared a report to Ms Lynch’s solicitors dated 23 May 2023. He was not referred to the criteria in Chapter 17. Asked if he still considered, that Ms Lynch still suffered CRPS, Dr Wallace said:
“Yes, when I examined Kylie on 24 March 2022 she definitely fit the criteria for complex regional pain syndrome. She had signs and symptoms in each of the four domains. When I examined her most recently in April 2023 she was still suffering from left ankle complex regional pain syndrome. She was still having flareups.”
When asked about the opinion of Dr Machart, qualified for Woolworths, who said in March 2023 that Ms Lynch’s CRPS appeared to be improving with few signs still evident, Dr Wallace said:
“CRPS can definitely have periods of exacerbation and periods where some sign and symptoms are less severe or even absent. The fact she was already diagnosed by myself and Dr Mittal is compelling. I have examined her on enough occasions to be confident in the diagnosis. Diagnosing and treating CRPS falls within my speciality and area of expertise.
I cannot explain why Dr Machart was unable to find any signs or symptoms of CRPS on the date that he examined Kylie other than the fact that some days the signs and symptoms will be more obvious than others.”
Dr Kwong prepared reports with respect to CRPS at the request of Ms Lynch’s solicitors. His first report is dated 13 December 2022 and in it he noted that Dr Wallace had confirmed CRPS based on the Budapest criteria. Dr Kwong said that Ms Lynch fulfilled the “Budapest, WorkCover and AMA5 criteria for CRPS.” In a supplementary report of the same date, Dr Kwong assessed Ms Lynch under chapter 17 of the Guidelines, assessing the loss of motion of her left ankle and left lower extremity impairment from sensory deficit and pain. He assessed 82% left lower extremity impairment which converted to 33% WPI.
Dr Kwong said:
“The assessment is based on Table 17.1: Diagnostic criteria for complex regional pain syndrome Chapter 17, page 81, WorkCover Guides.
She fulfils the objective diagnostic criteria for CRPS based on (Table 17.1):
-She has continuing pain which is disproportionate to any causal event.
-She has sensory symptoms with hyperaesthesia and allodynia.
-She has skin discolouration in her left foot.
-She reports decreased range of motion and trophic changes in left foot, ankle and toes.
-She has evidence of hyperalgesia and allodynia.
-She has evidence of vasomotor changes on examination.
-She has oedema in her left foot and ankle
-The diagnosis has been present for 18 months.
-The diagnosis has been verified by more than one examining physician. The diagnosis was made by her treating orthopaedic surgeon, Dr Rajat Mittal. The diagnosis was confirmed by her treating pain specialist, Dr Wallace Laurent.
-Other diagnoses have been excluded clinically and with imaging. There is no other diagnosis that better explains her signs and symptoms.
The impairment determination of Complex Regional Pain Syndrome is based on combination of loss of joint motion and sensory deficits and pain.”
As that quote illustrates, Dr Kwong did not clearly set out the way he made his assessment in that he does not identify a symptom in each of the four categories of the second row of Table 17.1 nor a sign in each of the categories in the third row. He did not identify how the symptoms and signs were manifest, merely noting their presence.
Dr Kwong re-examined Ms Lynch to prepare a further report dated 18 May 2023. He said that she continued to fulfil the criteria for the assessment of CRPS under the Guidelines.
Consideration
The Medical Assessor did not refer to Chapter 17 or Table 17.1 and therefore failed to disclose the path of reasoning which led to his conclusion. It is not possible to discern from the MAC which criteria he used to determine that CRPS was not present.
Dr Burns conducted his examination in accordance with the Guidelines, taking into account the obligation to assess Ms Lynch as she presented on the day of his examination. He noted that she reported past or present symptoms in all of the four relevant categories in the second row of Table 17.1.
Dr Burns set out the physical signs he observed in accordance with the third row of the table, noting that there was no sign in the vasomotor or sudomotor/odema categories. While there was evidence of a decreased active range of joint motion of Ms Lynch’s left ankle and hindfoot, it was symmetrical with the range of active movement of her uninjured right foot and ankle.
As set out above, Dr Wallace observed that CRPS can have periods of exacerbation and periods where signs and symptoms are less severe or absent.
On the day of Dr Burns’ examination, Ms Lynch’s symptoms and signs were sufficient to fulfil the Budapest criteria and confirm that treatment for CRPS was appropriate. However, the symptoms and signs did not fulfil the more demanding criteria in Chapter 17 to permit an assessment of permanent impairment.
We adopt Dr Burns’ report. On the basis of that examination, it is not possible to assess permanent impairment as a result of CRPS.
For these reasons, we have determined that the MAC issued on 13 July 2023 should be confirmed.
PERSONAL INJURY COMMISSION
APPEAL AGAINST MEDICAL ASSESSMENT
REPORT OF THE EXAMINATION BY MEDICAL ASSESSOR
MEMBER OF THE APPEAL PANEL
Matter Number: | M1-W3734/23 |
Appellant: | Kylie Theresa Lynch |
Respondent: | Woolworths Group Ltd. |
Date of Determination: | 10 November 2023 |
|
The workers medical history, where it differs from previous records.
Ms Lynch confirmed the history obtained by Assessor Pillemer with minor amendments. She stated that she was employed working in online shopping but was not in charge of online shopping. With respect to the development of her low back pain and lower limb symptoms she stated that this was on 23 March 2021 rather than 21 March recorded by Assessor Pillemer.
Ms Lynch reported that the following history was also not recorded in the Medical Assessment Certificate by Assessor Pillemer.
She reported that she was referred to Dr Mittal for left ankle pain and discomfort in February 2021. An MRI scan of the ankle revealed that she had inflammation of the Achilles tendon. She reported that the area was swollen and she was placed in a moon boot. She was initially referred to physiotherapy but due to slow improvement she was eventually referred to an exercise physiologist. She was followed up by Dr Mittal on a regular basis and in his correspondence dated 6 October 2021 it was stated that there was minimal tenderness around the medial aspect of the joint of the big toe and that neurovascular examination was unremarkable. Ms Lynch reported that by December 2021 she had noted a mottled change in the skin around her left ankle as well as significant swelling and pain to touch. The report of Dr Mittal on 14 December 2021 confirmed that she reported that there were colour changes (red or/purple), temperature changes and pain at night with the doona/sheets affecting her. The swelling increases after walking and a day at work. There is paraesthesia in the feet as well. Dr Mittal went on to state that Kylie is developing CRPS in both feet. Following this diagnosis by Dr Mittal she was referred to Dr Wallace, a Pain Specialist. Dr Wallace also made a diagnosis of Complex Regional Pain Syndrome involving her left foot and ankle. Following the diagnosis she has had a number of different treatments arranged by Dr Wallace. These have included the following:
· Variations in medications including the use of Pregabalin, Palexia and Panadeine Forte. She has also over the last 6 months commenced using Cannabis Oil on a regular basis.
· She reported having a number of lumbar sympathetic blocks in her back on the left side. She reported having 3 blocks carried out over time. She also had one injection on the right side but this was for her condition of the lumbar spine and not due to CRPS.
· She has also attended a 12 week course at Campbelltown on CRPS.
· A spinal cord stimulator trial was recommended by Dr Wallace but was rejected by the insurance company.
· She has not had a Ketamine infusion nor was this treatment recommended by her specialist.
Additional history since the original Medical Assessment Certificate was performed.
She reported that there has been no significant change in her treatment for her left lower extremity. She stated though that she had developed a ganglion over the medial aspect of the left great toe and on returning to see Dr Mittal it was recommended that the ganglion be removed surgically. Dr Mittal carried out the operation on 10 October 2023. It appears that this surgery did not have any significant impact upon her symptoms at the time and has not caused a significant flare up in her reported CRPS.
Current symptoms:
She reported that she tends to crab walk due to pain mostly in her left ankle. The pain is over the outside of her ankle and is worse in the left ankle than the right. She reported having an occasional mottled appearance over the left foot but this is not always present. She also reported ongoing swelling in the left ankle greater than the right ankle. Again the swelling is not always present. She also stated today that she has occasional sweating asymmetry with sweating of the left foot and not the right.
Current treatment:
She continues to see Dr Ibrahim, her General Practitioner on a monthly basis mostly for certificates of capacity and prescriptions. She is also receiving a prescription for Cannabis Oil via a teleconference prescription. She continues to see Dr Mittal on a regular basis and following his recent surgery she will be seeing him for follow up next week.
She last saw Dr Wallace the Pain Specialist several months ago. She did though have a telephone consultation with him the day before my examination.
She last saw the exercise physiologist in April 2023 but has re-booked further exercise physiology appointments starting from the 24 November 2023.
She currently takes both Vitamin B and Vitamin C. She is using Cannabis Oil 0.25mls 3 times a day. She also takes Panadeine Forte for breakthrough pain. She uses the Panadeine Forte probably twice a week and normally takes 2 tablets at night.
Findings on clinical examination
Ms Lynch was 157cms tall and weighed 91kgs. She was noted to walk with a slightly antalgic gait favouring her left foot. She was wearing shorts and thongs. It was noted that she had a mild abrasion over the left knee and also a second abrasion of the anterior aspect of the right foot. She stated that this was due to a fall she had the previous day. She reported that the fall happened when her left ankle gave way.
Examination of both knees revealed no evidence of localised tenderness on either side. Active range of movement in both knees was measured using a goniometer.
| Knee Movements | Active ROM Measured RIGHT | Active ROM Measured LEFT |
| Flexion | 120° | 110° |
| Extension | 0° | 0° |
It was noted that both knees were in 5° valgus angulation. There was no evidence of patellofemoral crepitus on either side.
Examination of both ankles revealed mild tenderness on the left side and also a recent scar of the medial aspect of the left big toe from surgery. There was no tenderness reported on the right side. Active range of movement in both ankles and hindfeet were measured using a goniometer. Range of movement was symmetrical in the left and right ankle and hindfoot.
| Ankle Movements | Active ROM Measured RIGHT | Active ROM Measured LEFT |
| Dorsiflexion | 10° | 10° |
| Plantarflexion | 30° | 30° |
| Hindfoot Movements | Active ROM Measured RIGHT | Active ROM Measured LEFT |
| Inversion | 20° | 20° |
| Eversion | 10° | 10° |
She reported having some degree of pain and discomfort mostly on movement of the left ankle and hindfoot but not on the right side.
CRPS:
Under symptoms she reported past or present symptoms in all 4 categories of point 2.
Under Table 17.1 of the New South Wales Guidelines, I noted the following physical signs in the categories listed in point 3.
· Sensory – There was no evidence of hyperalgesia (using a monofilament) and no evidence of allodynia to light touch. There was though report of significant pain to deep somatic pressure over the ankle joint medially.
· Vasomotor – There was no evidence of temperature asymmetry and or asymmetric skin colour changes. No mottling (colour change) was noted in the skin on either side and temperature was equal on both sides.
· Sudomotor/oedema – There was no evidence of sweating asymmetry with no sweating on either side. There was also no evidence of oedema in the left foot but there was some mild thickening of the Tendo Achilles consistent with her previous Achilles tendon injury.
· Motor/trophic - There was evidence of decreased active joint range of movement in the ankle and hindfoot on the left side, but this was equal to the range of movement on the right side. There was no evidence of motor dysfunction with no tremor or dystonia.
Results of any additional investigations since the original Medical Assessment Certificate
Ms Lynch reported no further investigations since being assessed by Assessor Pillemer.
Conclusion:
Whilst Ms Lynch does have reported symptoms, which would fulfil all 4 categories of point 2 of Table 17.1 of the New South Wales Guidelines on physical examination (point 3) she only displayed physical signs in 2 of the 4 categories. She therefore does not meet the criteria for an assessment of Complex Regional Pain Syndrome with respect to the New South Wales Guidelines.
She does continue to have a decrease in range of movement in the right and left ankle as well as in the right and left hindfoot. I noted today that the decrease in range of movement was symmetrical on both sides. On the right side it was not associated with pain or discomfort but on the left side she did report pain and discomfort. On questioning she did report that she had sustained no frank injury to her left foot or ankle so I believe that under the Guidelines the left foot and ankle can be used as a baseline. Using the left foot and ankle as a baseline would mean that she has no whole person impairment associated with the decrease in range of movement in her right hindfoot and ankle.
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