Saboune v Allianz Australia Insurance Limited
[2025] NSWPICMP 671
•4 September 2025
| DETERMINATION OF REVIEW PANEL | |
CITATION: | Saboune v Allianz Australia Insurance Limited [2025] NSWPICMP 671 |
CLAIMANT: | Sarah Saboune |
INSURER: | Allianz Australia Insurance Limited |
REVIEW PANEL | |
MEMBER: | Terence O’Riain |
MEDICAL ASSESSOR: | Ian Cameron |
MEDICAL ASSESSOR: | Michael Couch |
DATE OF DECISION: | 4 September 2025 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; permanent impairment; review; insured car drove across claimant’s path; insurer disputed causation and permanent impairment; 2014 accident; Commission referred upper limb injuries with cervical spine injury to assess permanent impairment; Medical Assessor’s certificate assessed 1% permanent impairment; referred for review; re-examination; claimant was cooperative and consistent; accident was capable of causing all referred injuries; 6% permanent impairment; different clinical findings; Held –different permanent impairment findings to original assessment; Review Panel revoked original certificate; permanent impairment not greater than 10%. |
DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Review Panel Assessment of degree of permanent impairment Replacement certificate issued under s 7.26(7) of the Motor Accident Injuries Act 2017 1. The Review Panel found the permanent impairment arising from injuries caused by the motor accident is different to that found in Medical Assessor Mohammed Assem’s assessment dated 9 October 2024. 2. Accordingly, the Review Panel revokes that certificate and issues a new Permanent Impairment Certificate. 3. The Review Panel found that the motor accident caused the following injuries and assessed them as giving rise to 6% whole person impairment: • neck – DRE Cervicothoracic Category II. • skin – carpal tunnel surgical scar 4. The accident caused injuries with a total percentage whole person impairment not greater than 10%. |
REASONS
BACKGROUND
The claimant was injured in an accident on 9 June 2022. The accident occurred on King Georges Road in Punchbowl when the insured driver towing a trailer cut across her lane resulting in a collision.
The insurer is responsible for loss arising from the claimant’s injuries from this accident under the Motor Accidents Injuries Act 2017 (MAI Act)
The insurer and the claimant dispute the level of the claimant’s permanent impairment from injuries caused by the 2022 accident.
The claimant applied to the Personal Injury Commission (the Commission) to resolve this dispute.
The Commission referred the following injuries for assessment:
· neck – pain and reduction in range of movement, radiating to right shoulder girdle. Mild to moderate degenerative changes. Cervical spondylosis aggravation.
· right shoulder – pain and decreased range of movement.
· left shoulder – pain
· right elbow – joint effusion anteriorly with soft tissue injury.
· right wrist – carpal tunnel syndrome
· right wrist – ulnar neuropathy
· skin – carpal tunnel surgical scar
Medical Assessor Mohammed Assem examined the claimant and produced a certificate dated 9 October 2024
Medical Assessor Assem assessed the right wrist, right elbow and scarring at 1% permanent impairment.
The claimant’s solicitor applied for review of that assessment. On 11 December 2024 the President of the Commission’s delegate constituted this Review Panel (the Panel) to review the original certificate (the Review).
Following r 128(1) of the Personal Injury Commission Rules, 2021 (the PIC Rules) the Panel “is to conduct and determine the proceedings in accordance with procedures determined by the panel”.
The Panel met on 3 March 2025 to discuss how this matter will proceed.
The Panel considered it was necessary to re-examine the claimant. Medical Assessor Couch arranged to examine the claimant on 8 April 2025 at the Commission’s medical suites to assess the claimant’s permanent impairment.
Legislative framework
Schedule 2(2)(a) of the MAI Act declares:
“the degree of permanent impairment of the injured person that has resulted from the injury caused by the accident (including whether the degree of permanent impairment is greater than a particular percentage) is a medical assessment matter”.
If there is a dispute about the degree of permanent impairment of an injured person being sufficient to award non-economic loss damages i.e. greater than 10%, then those damages may not be awarded unless the degree of permanent impairment has been assessed by a Medical Assessor under Division 7.5: s 4.12(1) MAI Act.
Division 7.5 of the MAI Act provides for the Commission to assess declared medical disputes including provisions relevant to an original medical assessment and for appointing Panels to review those medical assessments.[1]
[1] Sections 7.20, 7.24 and 7.26.
Parties may apply to the President of the Commission for review of a medical assessment on grounds that the assessment “was incorrect in a material respect” (sub-s (1)). If the President, or his delegate is satisfied “there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect” then the President refers the application to a review panel consisting of a Member of the Commission and two Medical Assessors (sub-ss (2) and (2B)) to reassess the dispute.
The review is not confined to the issues raised in the application (or the reply) but is “a new assessment of all the matters with which the medical assessment is concerned” (sub-s 3A).
Rule 128 of the Personal Injury Commission Rules 2021 (the Rules) permits the Panel to determine its own proceedings and the rules of evidence do not bind the Panel, which may inquire into relevant matters as it thinks fit, while observing procedural fairness.
The method of assessing the degree of impairment is dealt with in s 7.21, which is in the following terms:
“7.21 Assessment of degree of permanent impairment
(1) The assessment of the degree of permanent impairment of an injured person for the purposes of this Act is to be made in accordance with the Motor Accident Guidelines. The assessed degree of permanent impairment is to be expressed as a percentage.
(2) Impairments that result from more than one injury arising out of the same accident are to be assessed together to assess the degree of permanent impairment of the injured person.
(3) In assessing the degree of permanent impairment, regard must not be had to any psychiatric or psychological injury, impairment, or symptoms, unless the assessment of the degree of permanent impairment is made solely with respect to the result of a psychiatric or psychological injury.
(4) A Medical Assessor may decline to make an assessment of the degree of permanent impairment of an injured person until the assessor is satisfied that the impairment caused by the injury has become permanent.”
Pre-existing impairment is addressed in cls 6.31-6.33 of the Motor Accident Guidelines (Guidelines). Clause 6.34 deals with subsequent injuries.
The Guidelines state as follows with respect to causation of injury:
“Causation of injury
6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.
6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical, or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the accident. The accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed condition: Briggs v IAG Limited t/a NRMA Insurance [2022] NSWSC 372 at [75]. The accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible: Owen v Motor Accidents Authority of NSW [2012] NSWSC 650 at [50]. Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and s 5E.
ASSESSMENT UNDER REVIEW
Medical Assessor Assem noted the claimant was a pathology lab technician working 16 hours per week over two days. After the accident she resumed working for eight hours on each Saturday. She was away from work for four months.
He noted the claimant injured her lumbar spine in an earlier motor accident on 31 May 2014. Soon after that she began to experience neck pain.
She managed her condition with osteopath visits. Scans from that period did not demonstrate any significant abnormalities in the cervical spine, but there was mild disc space narrowing at L5 – S1 with an annular bulge at that level.
In 2015 she sustained a left shoulder injury at work. Sports and exercise physician Dr Jenny Saunders’ report dated 29 May 2015 notes a reduced range of left shoulder motion with impingement. She was cleared to resume her duties by 12 October 2015. She continued to have lower back pain which included referral for exercise physiology, physiotherapy and Pilates sessions. There were complaints regarding her cervical spine, bilateral shoulders, right elbow, right wrist, left foot and back including clinical notes between 8 March 2019 and 27 September 2021 documenting cervical spine complaints with asymmetrical range of motion.
On examination on 8 August 2021 the GP noted ongoing neck pain and unspecified shoulder blade pain. She continued to have treatment for neck, shoulders and wrist.
During Medical Assessor Assem’s assessment she confirmed those symptoms but said that her symptoms in a right wrist, elbow and shoulder became more intense after the 2022 accident.
The Medical Assessor records she told him the accident impact was not significant but she felt the contact. She began to feel pain in the right wrist by the time she arrived home.
There are photographs of the vehicular damage. About one or two days after the accident the claimant sought medical attention.
Soon after the accident she had pain in right wrist, right hand and lower neck with discomfort in her upper trapezius. The right wrist pain worsened, which made it difficult to perform basic tasks such as gripping, chopping and writing.
She saw her general practitioner (GP) Dr Yehiah on 15 June 2022. He noted right shoulder complaints.
Her application for personal injury benefits form for this accident dated 15 June 2022 only referred to her right wrist.
Scans taken on 20 June 2022 revealed mild degeneration in the radio carpal in first carpometacarpal joints with no evidence of tenosynovitis, tendinopathy or tear in the flexible or extensor tendons.
She pursued treatment throughout June, July August and November 2022.
The right wrist eventually required surgery to release the right open carpal tunnel to alleviate pressure on the median nerve.
Medical Assessor Assem found she managed her neck pain from the 2014 accident through physiotherapy and there were no symptomatic complaints recorded directly before the accident in June 2022.
Dr Ferris made the first note about cervical spine symptoms approximately five weeks after the accident, which referred to pain radiating to the right trapezius and shoulder blade.
Neck pain was referred to on 4 November 2022. She said it had become worse after starting physiotherapy. There seemed to be agreement that the accident worsened her cervical spondylosis rather than causing a new or significant cervical spine injury occurring during the accident.
The right wrist injury was the focus of her complaints immediately after the accident, which was confirmed with scans as a partial tear and other changes.
Medical Assessor Assem declined to find the accident caused the right shoulder injury because she did not report right shoulder symptoms immediately following the accident and she waited approximately five weeks when she presented to her GP with pain radiating to her right trapezius and shoulder blade.
She was consistent with her complaint about that body part thereafter. There is no clear pathology from diagnostic tests or records that definitely link it to the motor accident.
Medical Assessor Assem did not consider whether the Nguyen principle was applicable[2].
[2] Nguyen v The Motor Accidents Authority of NSW & Zurich Australian Insurance Ltd [2011] NSWSC 351
He accepted the accident exacerbated her existing right elbow condition.
The Medical Assessor found the accident did not cause injuries to the cervical spine and right shoulder and assessed 0% for the right elbow and right wrist assessed as the right upper extremity. He assessed 1% permanent impairment for wrist scarring.
Submissions
Claimant’s submissions
The claimant submits her impairment is greater than 10% and relies on occupational physician Dr Evan Dryson's report dated 27 March 2024. Dr Dryson assessed 5% permanent impairment as DRE II for the cervical spine. He opined that the accident aggravated the claimant’s cervical spondylosis. He also assessed 7% permanent impairment in the right shoulder, 7% for the right wrist, 1% for right ulnar neuropathy and 1% for scarring, combining to 19%.
The claimant disputes Medical Assessor Assem’s conclusions that the right shoulder injury was not reported until five weeks after the accident. She refers to a GP’s clinical note on
15 June 2022 referring to shoulder pain.
The claimant submitted the Medical Assessor made an error when he addressed the neck pain before this accident, which arose from a 2014 car accident.
He describes her existing cervical pain as well-managed before this accident, but he then says this accident was unlikely to cause a new or significant cervical spine injury and relies on her existing cervical spondylosis as the cause of pain. This was contrary to his opinion about the claimant's neck pain being well-managed before the accident.
This Panel in deciding the question of causation must consider, and to give weight to, contemporaneous medical records. Although a lack of a recorded complaint of particular symptoms after an accident might indicate the accident did not cause an injury associated with the accident, it is not decisive. The Panel must consider other reasons why a complaint “might not be made, or recorded, promptly following an incident”[3].
[3] Norrington v QBE Insurance (Australia) Ltd [2021] NSWSC 548 [40]
Insurer’s submissions
The insurer disputes causation in respect of the cervical spine and any whole person impairment because orthopaedic surgeon Dr Matthew Giblin examined the claimant in relation to a motor accident on 31 May 2014.[4] His permanent impairment report dated
11 August 2015 assessed 5% permanent impairment (DRE category II) with respect to the cervical spine. One third of that permanent impairment was apportioned for pre-existing impairment. However, Dr Giblin’s primary report addressing causation and prognosis is not available.
[4] Dr Giblin 11 August 2015
Physiotherapy clinical notes refer to cervical pain between 8 March 2019 to about
27 September 2021. The reports included asymmetrical range of movement.
The reference to right sided neck pain arising from the 2022 accident does not appear in the Rose Meadow Medical Centre clinical notes until 4 November 2022. Cervical spine MRI scans performed the following day revealed mild to moderate degenerative changes, which were most significant at C5/6 without any significant neural compression.
In respect to the right upper extremity the claimant's medicolegal expert Dr Evan Dryson assessed 14% permanent impairment in relation to right upper extremity (0% right elbow; 11% UEI right shoulder, 11% UEI right wrist and 2% UEI for ulnar neuropathy)
The insurer's medicolegal expert Dr Robin Mitchell’s report dated 30 April 2024 assessed the claimant’s accident related conditions as fully resolved, except she assessed 0% permanent impairment in the right upper limb, being for soft tissue injuries to the right elbow and wrist.
Right wrist problems may have arisen from the claimant's work at Liverpool Hospital not the accident, because it was repetitive and may have caused irritation. Dr Dryson considered the accident triggered the symptoms.
Note there were right wrist pain complaints in physiotherapy notes from 4 August 2021.
Physiotherapy notes dated 7 August 2021 refer to right tennis elbow and wrist pain.
The claimant's application for personal injury benefits dated 15 June 2022 does not include the right shoulder, but the initial reference to right shoulder pain is noted on the same date in the GP’s clinical notes.
Even if the right shoulder is linked to this accident The Panel should apply clause 6.51 of the Guidelines in relation to contralateral uninjured joints with less than average mobility.
Re-examination
Ms Saboune attended the appointment alone. She said that she had taken the train from Lidcombe to the city. Before Medical Assessor Couch commenced the examination, which took 70 minutes, he confirmed with Ms Saboune whether she understood the medical review process and the purpose of re-examination. She told him that she understood.
Pre-accident medical history and relevant personal details
Ms Saboune said that she had grown up in Greenacre. Her parents had emigrated to Australia from Lebanon and a nearby part of Syria during the Lebanese Civil War. She attended Greenacre Public School and then the first private Islamic High School to be established in Sydney. She completed her HSC – she said that she had wanted to study pharmacy but had not obtained good enough marks and instead did a two-year diploma in pathology at TAFE. Since then, she had always worked in histopathology as a laboratory technician.
She worked at Liverpool Hospital and also at more than one private pathology laboratory. She had initially worked full-time for six years but had worked part-time since starting her family. She was working two days a week in histopathology at the time of the 2022 accident. Ms Saboune is married and her husband is an electrician, running his own business. They have four children.
As noted in Medical Assessor Assem’s certificate, Ms Saboune confirmed that she had been involved in a previous motor vehicle accident in 2014. She explained that she was driving the third car in a four-car nose to tail collision. The following car, which struck hers, was driven by her sister-in-law. She recalled she was able to alight from her car. She described the damage to her car as “not that bad” but it was towed away and she thought that it had been eventually written off. Following this, she described low back pain and “sciatica pain – that was the worst pain.”She had had treatment at the time and described a good recovery. She denied significant low back symptoms before this accident.
Ms Saboune also confirmed that in around 2015 she gradually developed a pain in her left shoulder at work. She denied any specific accident or incident and put this down to very repetitive physical movements at work, which she described as “very busy and repetitive.” She went on to say that she thought this pain was “a normal part of my work.” She localised pain to around the left trapezius muscle, putting her right hand on it to demonstrate.
She also recalled having some right hip pain at around the same time and said that Dr Jeni Saunders had given a steroid injection with little benefit. Subsequently she had physiotherapy, which helped a lot.
She was asked about any musculoskeletal symptoms during the year before this accident. She said she was still getting pain in her neck/left trapezius, which she described as “just the nature of the job.” The Medical Assessor asked her more about her duties, and she demonstrated movements required to use a hand-operated microtome while preparing slides for microscopy. She thought that she was still experiencing some neck pain, which she related to work, at the time of the accident, again describing this as “normal for me.”
History of the motor accident
Ms Saboune said that on 9 June 2022 she had collected her children from school and was also taking a niece and nephew to their home in Greenacre. She was turning right into King Georges Road from Canterbury Road. A utility towing a low trailer was beside her in the left side and she thought it was proceeding straight ahead. She thought the driver had suddenly changed his mind - he turned right across her path. She thought that she would miss the rear of the car but had not seen the low trailer and struck this. She described her speed as “very slow – the light had just changed.”
She completed the right turn and stopped on the left side of King Georges Road. She hooted to the utility to stop, as the driver had probably not noticed the incident. They exchanged details. She was wearing a seatbelt and no airbags activated. Her child passengers were apparently uninjured. The Medical Assessor asked her how she thought she had sustained injuries and she replied, “I must have tensed up really hard.” She did not recall braking particularly violently. On questioning, she could not recall any sudden violent movement of the steering wheel and did not hit the inside of the car with any part of her body.
Ms Saboune said that she was upset straight away but could not recall any immediate onset of pain. She was able to drive home. At home she recalled “I felt pain – my right side hurts – I thought it was in my head and it would just go away.” On further discussion, she did recall having some pain in the right hand at this stage.
Subsequently neck pain was her worst symptom, particularly on the day after the accident and the next day. She said that she phoned her GP and still thought the pain would go away, but her hand also became worse.
Ms Saboune said that she was unable to obtain an early appointment with her usual GP and instead attended Dr Yehia at a different practice. She recalled having numbness in her right hand which “scared me a lot” – she pointed to her right middle, ring and little fingers when describing this, adding “it was so scary – I couldn’t feel anything.”
As noted in Medical Assessor Assem’s report, she subsequently attended her usual GP, Dr Fares, and subsequently saw Dr David Dilley, a hand surgeon, and later Dr Chris Scott, another hand surgeon. Eventually Dr Scott performed right open carpal tunnel release surgery on 27 April 2023. Ms Saboune said this improved her symptoms a lot, including both the numbness and grip strength. Dr Scott had apparently also suspected ulnar nerve compression at the elbow – on questioning, Ms Saboune recalled a lot of pain at one stage in the medial right elbow. She had not in fact had surgery for this and said that Dr Scott had preferred to perform the carpal tunnel release first and then observe her progress.
On further questioning, Ms Saboune added that since the accident she had experienced pain in the right wrist, right elbow and also the right shoulder – when describing this, she put her left hand over the right shoulder to demonstrate.
She was asked about further treatment. She said this had included a lot of physiotherapy, including for her wrist, the right shoulder and neck. She said that she had currently ceased physiotherapy, commenting:
“I’m so tired – it’s so far away and the physio that I really liked has left – I don’t want to drive – I just do exercises at home. I’ve got too much on my plate – I’d rather be at home.”
Details of any relevant injuries or conditions sustained since the motor accident
Ms Saboune denied any such accidents or incidents.
Current Symptoms
Medical Assessor Couch commenced by asking Ms Saboune which body area troubled her most. She said that this was her neck, putting her hand on the right trapezius area. She went on to describe current symptoms in more detail, as follows.
Neck
As noted above, Ms Saboune described this as mainly on the right side, putting her left hand over the right trapezius muscle to demonstrate. She said that it had been worse recently and mentioned seeing a chiropractor the previous week. The chiropractor had apparently performed a manipulation with relief. (In discussion she said that she was apprehensive of having further manipulation.)
She said that the neck had been constantly sore recently. On further discussion, pain was definitely localised more to the right side, rather than in the midline. The pain is worse when lying in bed and sleep is poor – she has tried various different pillows.
Driving also aggravates her neck pain. She had been getting occipital headaches, but these had improved since the chiropractic manipulation the previous week. On further questioning, she denied any typical radiation to either upper limb, although she said that she does get pain in the right neck/trapezius and also the right wrist, at the same time.
Right Shoulder
On questioning, Ms Saboune (who presented as an intelligent and well-educated woman) denied any specific pain in the shoulder joint proper. She again said the pain was “in the muscle,” putting her left hand on the right trapezius. She denied any specifically painful shoulder movements, and on questioning said that she can still fasten a bra behind her back.
Right Elbow
She described no current pain in the elbow, although it had been painful earlier. She said that it can still be tender to touch on the medial aspect of the elbow.
Right Wrist
Ms Saboune said the right wrist still gets painful, particularly with repetitive movements – as an example, she said that her children very much like salad-she finds chopping parsley finely for a salad aggravates her wrist. She also finds handwriting painful – she said that she had been doing various short on-line courses and finds it painful to write notes after about five minutes. She also finds washing dishes painful. She denied any current numbness in the fingers.
Left Shoulder
This area had been referred to Medical Assessor Assem for assessment. In his certificate, Medical Assessor Assem had not described any left shoulder symptoms. On further questioning, Ms Saboune said that she had never had any pain in the left shoulder since the accident and did not have any now.
Activities since the accident and present activities
Ms Saboune thought she had been off work for about four months after the accident, explaining that “I had a lot of brain fog.” She returned to work one day a week and said that she later left this job for personal reasons.
At the time of this Panel re-examination, she said she was working one day a week on a casual basis at a private pathology laboratory in Bella Vista – she said that she works on a Saturday, so the drive to and from is easier. At this stage of the interview, she also commented “my whole life was turned upside down – I didn’t expect my life to be like this at 40 years old – I had hoped to become a laboratory manager”.
At home she does most of the housework, but her children and husband also help. She had started a degree in Islamic Studies through Charles Sturt University but found this too taxing. She said that she had done some short courses online for interest – for example, in parenting.
Ms Saboune again said that her sleep is poor. Typically, she will go to bed at 10:30 – 11:00 pm but is slow to get off to sleep and may wake in the night (she did add that her husband snores). She rises at 5:30 am and thought she was only getting six hours sleep per night, “if I’m lucky.” She gets tired during the day and needs a nap at 2:00 or 3:00pm in the afternoon.
She was asked about exercise. She commented that “I need to” but is not currently engaged in any exercise beyond her daily routine.
Lifestyle factors
Ms Saboune does not smoke cigarettes or drink alcohol.
Current Treatment
Ms Saboune said that she was not having any regular physiotherapy or other treatment. She had attended a chiropractor once the previous week. She prefers to avoid medication and takes nothing regularly but takes Nurofen if her neck/right shoulder are particularly bad.
Physical Examination
Ms Saboune presented as a rather tired-looking, slim 40-year-old woman wearing modest long dress, including a head scarf and long-sleeved top. She was able to loosen the head scarf for adequate examination of the cervical spine and shoulders, and a loose top enabled full examination of the upper limbs. General mobility was normal.
She appeared to be intelligent and well-educated and was sensible and cooperative throughout. She showed a normal sense of humour and could smile and share a joke appropriately. (At the end of the assessment she commented on how difficult she had found it dealing with the insurer).
During physical examination she showed excellent effort, with no evidence of abnormal pain behaviours, inconsistency, or self-limitation. At height 163 cm and weight 46 kg, she was below the usual healthy weight range, with a BMI of 17.
Cervical Spine
Posture of the cervical spine was within normal limits. When Ms Saboune was standing, the right shoulder girdle was noted to be 10-20mm lower than the left. On gentle palpation there was no significant tenderness over the midline of the cervical spine. Both trapezius muscles were slightly and equally tense to palpation. The left was not tender but the right trapezius muscle was moderately tender to palpation.
AROM of the cervical spine was carefully observed with repetition. Flexion and extension were both two-thirds of normal. Lateral flexion was very full to the right but about two-thirds of normal to the left, accompanied by grimacing and apparent discomfort.
Rotation was almost full to the right, but only half of normal to the left. This dysmetria in both lateral flexion and rotation was reproducible. There was no detectable muscle guarding or spasm and she was not describing non-verifiable radicular complaints in the upper limbs. As can be seen below under “Upper Extremities”, there were no signs of cervical radiculopathy.
Upper Limbs
Hands were clean and soft without any callouses. Both upper arms measured equally in girth at 23cm, the right (dominant side) forearm 21 cm and the left 20.5cm. Biceps, triceps and brachioradialis reflexes were normal and symmetrical.
Power of all muscle groups in both upper limbs was normal and symmetrical, including grip strength and hand intrinsic muscles. Sensation was normal in both upper limbs. Tinel’s provocation test for carpal tunnel syndrome was negative at both wrists.
In the shoulders, there was no tenderness to palpation over either glenohumeral joint, although as noted above, the right trapezius muscle was moderately tender. There was a completely full range of AROM in both shoulders, except for very slight, apparent symmetrical restriction of internal rotation, as measured with a goniometer and tabulated.
Right Left Flexion 180° 180° Extension 60° 60° Abduction 180° 180° Adduction 40° 40° External Rotation 100° 100° Internal Rotation 70° 70°
Although conventional measurement of internal rotation (at 90 degrees shoulder abduction) was slightly restricted bilaterally at 70 degrees, function appeared to be normal – Ms Saboune could reach each thumb symmetrically up to about T6 level behind her back. Medical Assessor Couch concluded that the bilateral measurement of internal rotation of 70 degrees did not represent an assessable impairment.
The elbows were normal in appearance. On gentle palpation, Ms Saboune described slight tenderness over the medial right elbow but Tinel’s provocation sign over the ulnar nerve was negative. There was a completely full AROM of both elbows.
Right Left Flexion 140° 140° Extension 0° 0° Pronation 100° 100° Supination 100° 100°
The wrists were both normal to inspection. There was a completely full AROM, as tabulated.
Right Left Flexion 70° 70° Extension 60° 70° Ulnar Deviation 30° 30° Radial Deviation 20° 20°
The only detectable abnormality in either upper limb was a pale, narrow 30mm volar longitudinal scar over the right wrist from carpal tunnel decompression. There were no visible suture marks. There was no adherence to underlying tissues. Ms Saboune said that she had applied cream to the scar initially but no longer does so. She said that it does not affect her choice of clothing.
Comment on Consistency
Ms Saboune presented in a very straightforward, cooperative, and consistent manner.
Conclusions following assessment
Sarah Saboune was involved in a low speed accident nearly three years before the Panel
re-examination, when her car hit a trailer towed behind by a utility, which had cut across her path when both were turning right at traffic lights. She was upset at the time but noticed no immediate pain but soon developed pain mainly in the right neck/trapezius region and also in her right hand. She was not sure herself how she had injured her right hand/wrist.
There was documented persistent pain in the right wrist and development of carpal tunnel syndrome, with a question of additional ulnar neuropathy at the right elbow. She did have some right elbow pain. Carpal tunnel release surgery has been successful and she no longer has any neuropathic symptoms or abnormal neurological signs in the hand, but she does have a faint scar on the wrist. This could be assessed at 1% on the TEMSKI scale.
Her principal residual symptom is pain in the right side of the neck/trapezius muscles. Examination showed convincing dysmetria. This injury is classified as DRE Cervicothoracic Category II, giving 5% WPI.
There was no residual abnormality of the right elbow.
With regard to the right shoulder, Ms Saboune was not describing any typical glenohumeral joint/rotator cuff symptoms.
Pain was really in the right trapezius region and related to her cervical spine injury (she has a past history of pain in this region which she relates to repetitive manual tasks in the pathology laboratory, and this could be a contributing factor).
The examination elicited full AROM of both shoulders – minimally restricted internal rotation on formal examination was not considered to be relevant. In any case, Ms Saboune all denied any injury to, or symptoms in the left shoulder.
Internal rotation was completely symmetrical between both shoulders. Therefore, if 1% UEI was assessed for internal rotation in the right shoulder, this would be bilateral and there would be no net impairment of the right shoulder.
Ms Saboune denied this accident caused any left shoulder injury, or that it became symptomatic after the accident.
PERMANENCY OF IMPAIRMENT
Statement about permanent impairment
The determination as to permanent impairment is made in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment (Fourth Edition) (AMA4 Guides) and the Guidelines version 9.3. Permanent impairment is defined in the AMA4 Guides (p 315) as follows:
“Permanent impairment is impairment that has become static or well stabilised with or without medical treatment and is not likely to remit despite medical treatment. A permanent impairment is considered to be unlikely to change substantially and by more than 3% in the next year with or without medical treatment.”
It is now over three years since the accident. The claimant’s injuries are stable so her permanent whole person impairment is considered to be unlikely to change substantially by more than 3% in the next year with or without medical treatment.
Determinations – permanent impairment
Summary of injuries referred for assessment
The following injuries WERE caused by the accident:
• neck – DRE Cervicothoracic Category II.
• Right shoulder – pain and decreased range of movement.
• Right elbow – joint effusion anteriorly with soft tissue injury.
• Right wrist – carpal tunnel syndrome
• Right wrist – ulnar neuropathy
• skin – carpal tunnel surgical scar
The following injuries have resolved:
• Right shoulder – pain and decreased range of movement.
• Right elbow – joint effusion anteriorly with soft tissue injury.
• Right wrist – carpal tunnel syndrome
• Right wrist – ulnar neuropathy
Apportionment
All of the calculated impairment is the outcome of the accident.
Pre-existing/subsequent impairment
The Panel considered the insurer’s submissions that the 2014 accident caused permanent impairment that could be assessed to deduct from any finding from the 2022. However, there was no objective evidence available at the time of the accident that would support a finding of permanent impairment, which could be deducted from the current assessment.
Panel deliberations
The Panel adopted Medical Assessor Couch’s examination and permanent impairment assessment.
The Panel considered that the mechanism of the accident was sufficient to cause the referred injuries except for the left shoulder.
Further, the cervicothoracic aggravation and right shoulder injury were sufficiently contemporaneous with the subject accident to be causally related. There was no disagreement that the ulnar neuropathy and carpal tunnel syndrome with subsequent scarring were accident related.
CONCLUSION
The Panel found the permanent impairment arising from injuries caused by this accident is different to that found in Medical Assessor Mohammed Assem’s assessment certificate dated 9 October 2024.
Accordingly, the Review Panel revokes that certificate and issues a new Permanent Impairment Certificate.
The Review Panel found that the motor accident caused the following injuries and assessed them as giving rise to 6% whole person impairment:
· neck – DRE Cervicothoracic Category II.
· skin – carpal tunnel surgical scar
The accident caused injuries with a total percentage WPI not greater than 10%.
OutcomeDocumentSignee
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