Sadeldeen v Allianz Australia Insurance Limited

[2024] NSWPICMP 569

DETERMINATION OF REVIEW PANEL

CITATION:

Sadeldeen v Allianz Australia Insurance Limited [2024] NSWPICMP 569

CLAIMANT:

Eyad Sadeldeen

INSURER:

Allianz Australia Insurance Limited

REVIEW PANEL

MEMBER:

Susan McTegg

MEDICAL ASSESSOR:

Clive Kenna

MEDICAL ASSESSOR:

Margaret Gibson

DATE OF DECISION:

15 August 2024

CATCHWORDS:

MOTOR ACCIDENTS – Motor Accident Injuries Act 2017 (MAI Act); whole person impairment (WPI); causation; dispute related to the assessment of WPI of cervical spine, lumbar spine, left knee, both shoulders and right hand; Medical Assessor (MA) assessed 5% WPI for injury to cervical spine and 2% WPI for injury to left knee arising out of undisplaced tibial plateau fracture; on examination injuries to both shoulders resolved; lumbar spine assessed as DRE category 1 – 0% WPI; cervical spine assessed as DRE category 1 – 0% WPI; range of motion gives rise to 4% WPI; diagnosis-based estimate gives rise to 2% WPI; method of assessment providing highest rating should be chosen; injury to right hand not caused by accident; Held – Medical Assessment Certificate revoked; 4% WPI found.

DETERMINATIONS MADE:  

MOTOR ACCIDENT INJURIES ACT 2017

WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10%

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

1.     The Review Panel revokes the certificate of Medical Assessor Alexander Woo dated
9 March 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a whole person impairment which is not greater than 10% and which is 4%:

·        cervical spine – soft tissue injury;

·        lumbar spine – soft tissue injury, and

·        left knee - medial tibial plateau microtrabecular fracture.

2.     The Review Panel finds the following injuries caused by the motor accident have resolved:

·     right shoulder – soft tissue injury, and

·     left shoulder – soft tissue injury.

3.     The Review Panel finds the following injury was not caused by the motor accident:

·     right hand – paraesthesia in the C7/8 distribution of the right hand involving the palm.

REVIEW PANEL REASONS FOR DECISION

INTRODUCTION

1. On 8 January 2020 Mr Sadeldeen (the claimant) was driving to work when another car tried to overtake him and collided with the driver’s side of his car causing it to flip. The roof top of his car hit a tree before landing on the road (the accident).

2. Mr Sadeldeen was 45 years of age at the date of accident and is now 49 years of age.

3. Mr Sadeldeen has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).

4. Allianz Australia Insurance Limited (the insurer) is the relevant insurer with liability to pay any damages to Mr Sadeldeen under the MAI Act.

5. Section 4.11 of the MAI Act provides that there is no entitlement to damages for non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.

6. The claimant commenced proceedings in the Personal Injury Commission (Commission) in respect of the dispute as to whether the degree of permanent impairment sustained as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.

7. A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[1]

   [1] Section 7.20 of the MAI Act.

8. The dispute as to permanent impairment was referred to Medical Assessor Alexander Woo who issued a certificate dated 9 March 2024. It is that certificate which is the subject of this review.

DOCUMENTS BEFORE THE REVIEW PANEL

1. On 23 February 2024 the claimant uploaded to the portal an indexed bundle of documents paginated from pages 1 to 317 (claimant’s documents). 

2. On 7 May 2024 the insurer uploaded to the portal an indexed bundle of documents paginated from pages 1 to 189 (insurer’s documents).

RELEVANT LEGAL AUTHORITY

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).

2. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[2]

   [2] Clause 1.2 of the Guidelines.

3. Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:

   “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 motor accident. The motor 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.”

4. Clause 6.138 of the Guidelines define radiculopathy as the impairment caused by dysfunction of a spinal nerve root or nerve roots. To conclude that a radiculopathy is present, two or more of the following signs should be found:

   (a)     loss or asymmetry of reflexes;

   (b)     positive sciatic nerve root tension signs;

   (c)     muscle atrophy and/or decreased limb circumference;

   (d)     muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution, and 

   (e)     reproducible sensory loss that is anatomically localised to an appropriate     spinal nerve root distribution.

CERTIFICATE OF MEDICAL ASSESSOR HERALD

1. Medical Assessor Herald issued a certificate dated 7 October 2022.[3] He certified the following injuries caused by the accident were minor (threshold) injuries for the purposes of the MAI Act:

   ·        Soft tissue injury head and thoracic spine;

   ·        Soft tissue injury to both shoulders;

   ·        Soft tissue injury to lumbar spine with radiculopathic symptoms to both legs, and

   ·        Soft tissue injury to cervical spine with radiculopathic symptoms to both upper limbs.

   [3] Claimant’s bundle p 386

2. Medical Assessor Herald certified the following injury caused by the accident was not a minor (threshold) injury:

   ·Left knee medial tibial plateau microtrabecular fracture.

CERTIFICATE UNDER REVIEW - CERTIFICATE OF MEDICAL ASSESSOR WOO

1. Medical Assessor Alexander Woo issued a certificate dated 9 March 2024.  The following injuries were referred to Medical Assessor Woo for as assessment as to permanent impairment:

   ·        cervical spine – soft tissue injury with radiculopathy/discal injury and minor bilateral narrowing at the C4/5 and C5/6 due to slight hypertrophy of the uncovertebral joints;

   ·        lumbar spine – soft tissue injury with radiculopathy/discal injury;

   ·        left shoulder – referred pain from the cervical spine;

   ·        right shoulder – referred pain from the cervical spine;

   ·        right hand – paraesthesia in the C7/8 distribution of the right hand involving the palm, and

   ·        left leg/left knee – subchondral oedema anteromedially, bone contusion and microfracture medial tibial plateau fracture.

2. Medical Assessor Woo reported following the accident on 8 January 2020 Mr Sadeldeen did not feel much pain, but he had shaking in his head, arms and legs.  He consulted his general practitioner (GP) Dr Barich.  He had a CT of the brain and cervical spine on 10 January 2020 and an MRI of the left knee on 11 January 2020 with a history of hitting the dashboard.

3. Dr Barich referred Mr Sadeldeen to Dr Sorial, orthopaedic surgeon, who diagnosed a direct impact injury to the medical tibial plateau, mucoid degeneration of the posterior horn of the medical meniscus but no obvious meniscal tear. Mr Sadeldeen underwent a rehab and hydrotherapy programme.

4. Medical Assessor Woo reported Mr Sadeldeen obtained employment with HKA as a project manager on 5 August 2022.

5. He reported Mr Sadeldeen was involved in a further accident on 21 April 2023 (the 2023 accident). The clinical notes of Westmead Hospital document ongoing headache, and pain from the back of the neck to the right shoulder and forearm.  Medical Assessor Woo stated Mr Sadeldeen informed him he did not sustain injury in the 2023 accident. 

6. When he assessed the claimant Medical Assessor Woo reported complaints of numbness of both arms, not much pain in the neck, no back pain, a full recovery of the right shoulder, and no complaint relating to the left shoulder. He reported the main complaint was of ongoing left knee pain, swelling and clicking. Mr Sadeldeen had been using a walking stick for one months for left leg weakness and when he drives to work he has to stop and take a break when his left knee pain increases. On examination Medical Assessor Woo reported
   Mr Sadeldeen had a limping gait due to left knee pain and holds a walking stick in his right hand.

7. On examination of the left knee Medical Assessor Woo reported:

   “There was diffuse tenderness and hypersensitivity over the left knee.

   Proper examination was not possible due to excruciating pain with any movement.  Clinical signs of meniscal injury and ligamentous stability could not be carried out.

   There was mild subcutaneous swelling but no significant effusion.

   The left knee was held at 20^o to 50^o flexion by Mr Sadeldeen.

   The left knee was held at 90⁰ flexion whilst sitting in a chair.

   Quadriceps and calf circumferences were equal on both sides.”

8. Medical Assessor Woo concluded the claimant’s left knee symptoms and signs are inconsistent with his clinical findings of the left knee and the MRI findings. He noted:

   “There was no documented range of motion assessment of the left knee prior to the subsequent accident on 21/04/2023.  The current restriction of left knee movement could not be explained by the injury caused by the subject accident on 08/01/2020”.

9. Medical Assessor Woo concluded apart from the right-hand paraesthesia which occurred following the 2023 accident, Mr Sadeldeen had symptoms relating to the other alleged injuries following the accident which were caused by the accident.  He also concluded prior to the 2023 accident there was not two or more of the five clinical signs required for the diagnosis of radiculopathy in the upper and lower limbs.

10. Medical Assessor Woo found the claimant had a history of injury to the cervical spine with non-verifiable radicular complaints finding the claimant met the criteria for a cervical spine DRE II category resulting in a 5% whole person impairment (WPI). He assessed a 2% WPI of the left knee arising out of the undisplaced tibial plateau fracture under chapter 3, table 64 on page 85 of the AMA 4 Guides.

11. Medical Assessor Woo assessed a total 7% WPI.

REVIEW PROCEDURE

1. On 9 April 2024 Mr Sadeldeen sought a review of the medical assessment of Medical Assessor Woo.

2. On 21 May 2024 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel).[4]

   [4] Section 7.26 of the MAI Act, AD2 p 6, AD7 p 189.

3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the Personal Injury Commission, Act, 2020 (PIC Act). A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[5] The review is by way of a new assessment of all matters with which the medical assessment is concerned.

   [5] Rule 128 of the PIC Rules.

4. On 24 June 2024 the Panel agreed an examination was necessary.

EVIDENCE BEFORE THE REVIEW PANEL

Application for personal injury benefits (the application)

1. In the application dated 3 March 2020, Mr Sadeldeen listed the injuries he sustained in the accident as follows:

   “head:

   neck;

   radiculopathy into upper limbs;

   back;

   left knee fracture;

   psychological sequelae (PTSD/anxiety); and

   Injury to right eye.”

Treating medical evidence

1. Mr Sadeldeen has a pre-accident history of back pain. Back pain was reported on
   12 November 2018.  On 21 November 2019 Mr Sadeldeen had a stiff lower back. He underwent a CT of the lumbar spine on 21 November 2018.

2. On 8 January 2020 Dr Barich recorded;

   “Very agitated. The other car pushed him from driver seat door the car rolled over and hit a tree from the L side and rolled back. He hit the top of his head on the roof and L knee hit the dashboard. Sore L neck. Numbness L hand. No LOC only dizzy, shaking, agitated.

   OE sore medially L knee, limping, L neck pain stiff, burning sensation, tender…”.[6]

[6] Claimant’s bundle p 72

Dr Rami Sorial, orthopaedic surgeon

1. On 13 May 2020 Dr Sorial, orthopaedic surgeon, reported Mr Sadeldeen reported pain in the knee the evening of the accident with ongoing symptoms, now improving.[7] He reported the MRI of the left knee demonstrated “subchondral oedema anteromedially and across the medial tibial plateau, consistent with a direct impact injury”. He also reported mucoid degeneration of the posterior horn of the medial meniscus but no obvious meniscal tear. He reported the collateral and cruciate ligaments were intact and both the lateral and patellofemoral compartments were normal.

   [7] Claimant’s bundle p 103.

2. On 8 July 2020 Dr Sorial reported the left knee continued to improve. He reported a week earlier he felt a clicking sensation that correlated with a known tear of the posterior horn of the medial meniscus.[8]

   [8] Claimant’s bundle p 99.

3. On 3 August 2020 Dr Sorial furnished a report to the insurer.[9] He described the injury as a combination of a bone contusion and a likely medial meniscal tear. He stated he had viewed the images associated with the MRI report and felt based on Mr Sadeldeen’s symptoms the most likely diagnosis was a tear sustained through the meniscus. He noted the MRI was not always 100% accurate and it was not uncommon to explore pathology through the knee by arthroscopy.  He recommended non-operative management but if his symptoms persisted suggested a repeat MRI scan and an arthroscopy.

   [9] Claimant’s bundle p 253.

4. On 2 November 2020 Dr Sorial reported the claimant’s current symptoms were minimal and concluded:

   ‘Based on his current presentation and assessment, I have made the recommendations he continues with all normal work activities with no restrictions and returns to all normal social and personal activities without restrictions. He may experience the occasional discomfort but on the whole, he can get back to his normal gym activities.’[10]

   [10] Claimant’s bundle p 242.

5. Mr Sadeldeen initially saw Mr Pennel of Connect Physiotherapy on 8 March 2023 for chronic left knee pain post medial tibial plateau fracture.[11]

   [11] Claimant’s bundle p 124.

6. Mr Sadeldeen was discharged from Westmead Hospital on 22 April 2023 following his admission on 21 April 2023 after a motor vehicle accident where he was rear ended by a truck.[12]  He was reported to have a right shoulder injury and neck pain.  His past history was noted to be a motor vehicle accident three years ago with a left knee injury.

   [12] Claimant’s bundle p 114.

7. On 24 April 2023 Dr Barich reported Mr Sadeldeen felt much better after the motor vehicle accident on 21 April 2023.  She considered he was fit for his normal work.[13]  However, on
   

   [13] Claimant’s bundle p 185.

   [14] Claimant’s bundle p 186.

   29 April 2023 Dr Barich reported Mr Sadeldeen was concerned about right neck pain radiating to the right deltoid area as well as numbness in the right thumb, index finger and little finger.[14]

8. On 3 July 2023 Mr Pennel reported improvement and noted the current range of motion through the left knee was 125º of flexion and 4º of extension.[15]  He reported Mr Sadeldeen was continuing to experience a sharp pain at the medial tibial plateau associated with slight swelling.

   [15] Claimant’s bundle p 110.

9. On 8 December 2023 Mr Sadeldeen attended Western Sydney Pain Clinic in respect of his left knee pain.[16]  He was provided with a TENS machine to support his activity, function and pain management.

   [16] Claimant’s bundle p 359.

10. On 9 February 2024 Mr Sadeldeen again attended the pain clinic for his chronic left knee pain. He was due to return to physiotherapy. On 10 May 2024 the pain clinic reported
    

    [17] Claimant’s bundle p 364.

    Mr Sadeldeen had “bouts of intense searing pain on load-bearing and when he is on his feet for a persistent period of time”.[17]  Further investigation of the saphenous nerve was suggested by way of nerve conduction studies and EMG studies.  

11. Mitchel Pennell, physiotherapist, provided a report dated 1 May 2024.[18] He reported
    

    [18] Claimant’s bundle p 397.

    Mr Sadeldeen continued to have swelling at the anteromedial aspect of the left knee which increases in size with loading of the left leg.  When assessing range of motion in supine he reported Mr Sadeldeen could actively achieve 45º of flexion and 15º of flexion.  He suggested he would grade his strength as 2/5 in both knee flexion and extension. He thought his presentation was a reflection of learned disuse of the limb during COVID to avoid pain which has led to a decreased ability for him to recruit the key muscles in his leg now.

Imaging

1. CT lumbar spine, 21 November 2018 – the report concludes:

   “L4/5 5mm central disc protrusion resulting in mild spinal canal narrowing.  Shallow disc bulging at L3/4 and L5/S1.”[19]

   [19] Claimant’s bundle p 83.

2. MRI brain and cervical spine, 10 January 2020 - the report concludes:

   “There is no intracranial haemorrhage, mass effect or cervical fracture.  There is no paravertebral collection or haematoma in the neck.  No epidural collection seen.  The central canal and neural exit foramen are adequate”.[20]

   [20] Claimant’s bundle p 91.

3. MRI left knee, 11 January 2020 – the report concludes:

   “No evidence of internal derangement detected.  Anterior medial tibial plateau demonstrates a small area of subchondral marrow oedema and subchondral sclerosis from microtrabecular fracture”.[21]

   [21] Claimant’s bundle p 93.

4. MRI left knee, 8 July 2023 - the report concludes:

   “No evidence of internal derangement.  Interval resolution of bone marrow oedema in the medial tibial plateau.  Stable mild degenerative change in the medical meniscus posterior horn”.

Medico-legal evidence

Dr Evan Dryson, occupational physician

1. Dr Dryson assessed the claimant and provided a report dated 24 January 2023.[22]

   [22] Claimant’s bundle p 60.

2. Dr Dryson diagnosed the following injuries:

   ·        soft tissue injury cervical spine;

   ·        soft tissue injury lumbar spine, and

   ·        bone contusion/microfracture medical tibial plateau left knee.

3. He found asymmetric loss of range of motion in both the cervical and thoracic spines.  There was no evidence of radiculopathy.  He reported shoulder movement was normal.  There was a reduced range of movement in the left knee with pain on depressing the patella.

1. Dr Dryson assessed a DRE cervicothoracic spine impairment category II on the basis there were signs of injury with no radiculopathy. He assessed a 5% WPI.

2. He assessed a DRE lumbosacral spine impairment category II on the basis there were signs of injury with no radiculopathy. He assessed a 5% WPI.

3. Utilising Table 41 on page 3/78 of the AMA 4 Guides he found moderate impairment of flexion of the left knee and assessed 8% WPI.

SUBMISSIONS

Claimant’s submissions

1. The claimant provided submissions dated 9 April 2024 in support of the application for review.

2. The claimant submits Medical Assessor Woo failed to correctly assess the left knee injury. The claimant submits Medical Assessor Woo incorrectly relied on chapter 3, table 64 on page 85 of the AMA 4 Guides to assess WPI of the left knee when he should have utilised table 41 on page 78 of the AMA 4 Guides, that is, he should have evaluated the permanent impairment based on the claimant’s range of motion. The claimant notes that paragraph 3.2e of the AMA 4 Guides stated that evaluating permanent impairment of the lower extremity according to its range of motion is a suitable method.

3. The claimant submits where Medical Assessor Woo reported “the left knee was held at 20 degree to 50 degree flexion by Mr Sadeldeen” it would at the very least equate to a 14% WPI where the claimant’s range of motion (flexion) was assessed at less than 60 degrees.

4. Further, the claimant submits Medical Assessor Woo failed to set out his path of reasoning as to why he adopted Table 64 of the AMA 4 Guides and not table 4.1 of the Guides.

5. The claimant noted that it seems as if Medical Assessor Woo found the claimant was inconsistent in his presentation concerning his left knee, where he exhibited a different range of motion during the formal assessment when compared to the range of motion shown when he was sitting down in a chair. The claimant submits there was a denial of procedural fairness where those inconsistencies were not brought to the claimant’s attention in breach of the Guidelines.

Insurer’s submissions

1. The insurer provided submissions dated 1 May 2024 in response to the application for review.

2. The insurer notes Medical Assessor Woo diagnosed subchondral oedema, bone contusion, and medial tibial plateau microfracture at the left knee as a result of the accident.

3. The insurer pointed out that in undertaking an assessment of the left knee Medical Assessor Woo was unable to perform an examination due to the pain behaviour of the claimant. 

4. The insurer notes clause 6.84 of the Guidelines states:

   “6.84        Although range of motion (pages 77-78, AMA 4 Guides) appears to be a suitable method for evaluating impairment, it can be subject to variation because of pain during motion at different times of examination and/or a possible lack of cooperation by the injured person being assessed …

   (e) if range of motion measurements at examination cannot be used as a valid parameter of impairment evaluation, the medical assessor should then use discretion in considering what weight to give other evidence available to determine if an impairment is present.”

5. Therefore, Medical Assessor Woo used his discretion and assessed the impairment at the left knee by reference to the plateau fracture in accordance with clause 6.84 of the Guidelines.

MEDICAL EXAMINATION

1. Mr Sadeldeen was examined by Medical Assessor Kenna on 17 July 2024 at the Medical Suites at the Commission.  The claimant attended alone. An Arabic speaking interpreter (NAATI No. CPN1RP72)) was present throughout the assessment.

HISTORY

Pre-accident medical history and relevant personal details

1. Mr Sadeldeen is a 50-year-old male, married with four children aged from two to 10. His wife does not work. He emigrated from the Middle East and is Syrian by birth. He has been in Australia eight years. He left Syria in 2007 and then worked in Dubai for some 10 years (possibly as an engineer).

2. In 2016 he immigrated to Australia and worked in a jewellery shop for two years (presumably during this time he was upgrading his engineering qualifications). He then became a testing engineer for a company and then moved to HKA where he worked with WestConnex. He is now on a new project and is a permanent employee of HKA.

3. With regards to any relevant past history, he denies any prior history of left knee problems prior to the accident and no problems relating to either shoulder, neck or back.

4. He previously worked out in the gym which he enjoyed. He states he has not done this now for some four years.

History of the accident on 8 January 2020

1. He stated that the accident occurred on 8 January 2020. He was the driver of a car, with no passengers. It was 6am and he was going to work. The conditions were dry. He stated he was driving in a southerly direction along Canal Road when all of a sudden a white car in the lane to his right merged into his lane. That driver’s car hit his car on the side door. The impact was such that it caused his car to flip and subsequently the roof hit a tree that was on the edge of the footpath. His car then fell back onto its four wheels.

2. In greater detail he stated his car was travelling in the stated lane with a truck in front of him, when the other car tried to pass and beat the red light.

3. Neither police nor ambulance attended. He states he was shaken up but didn’t feel any immediate pain at the time. His car was a write-off and surprisingly he walked to work. Two hours later, shock set in and was advised to see his general practitioner.

History of symptoms and treatment following the motor accident

1. Mr Sadeldeen saw his normal GP, Dr Barich, the following day who ordered a number of tests including a CT of the brain and cervical spine. At that point in time, he was also complaining of headaches, although there was no head strike.

2. There was a complaint of left knee pain, and an MRI was ordered for the left knee, as the left knee hit the dashboard.

3. He was also referred to Dr Sorial, an orthopaedic surgeon, who he saw on 13 May 2020.

4. The MRI confirmed a direct impact injury to the medial tibial plateau with mucoid degeneration of the posterior horn of the medial meniscus but no obvious meniscal tear.

5. He was advised that a conservative approach would be best initially. Hydrotherapy was recommended as well as a cycling program to improve his strength and stamina. This he underwent in a structured physiotherapy program.

6. He was reviewed by Dr Sorial on 8 July 2020, who noted that the left knee had continued to improve. Following the accident, he worked from home but kept working and didn’t lose employment time.

7. At that time, he was also experiencing a clicking sensation which Dr Sorial considered correlated with the known tear of the posterior horn of the medial meniscus.

8. He was reviewed several months later in November 2020 when Dr Sorial noted there had been further improvement. That current symptoms were minimal, and it was considered he had made a good recovery in relation to the left knee. He was continuing with his normal work activities with no restrictions.

9. Dr Sorial recommended he get back to his normal gym activities. Mr Sadeldeen said this didn’t happen and he has not done any gym work for the last four years (which he stated has resulted in considerable weight gain).

Details of any relevant injuries or conditions sustained since the motor accident

1. Mr Sadeldeen was involved in another motor vehicle accident on 21 April 2023. He was on the way home from work. It was 3pm. He was a driver with no passengers. He was wearing a seatbelt at the time. He was on the M4 when traffic slowed and then stopped. A truck then rear-ended his car which he described as high impact. He was driving a CHR Toyota at the time and the car was written off.

2. Both police and ambulance attended the scene, and he attended Westmead Hospital. He didn’t injure the left knee, but he experienced pain over the right shoulder which he felt was secondary to the seatbelt impact. He stated he has made a full recovery and sustained no further aggravation or injury to the injuries sustained in the 2020 motor accident. Whilst he was hit from behind, he didn’t hit any vehicle in front.

3. He was reviewed by his general practitioner the following day, Dr Barich, who noted there was a complaint of neck pain with radiation towards the right shoulder and associated headache.

Current symptoms

1. Mr Sadeldeen stated his current symptoms are directly related to the accident in 2020 and that he incurred no ongoing symptoms in relation to the 2023 motor accident

2. He stated he continues to experience ongoing symptoms in the cervical spine, both shoulders and lower back, but has had no surgery, no injections and no procedures. His symptoms are managed purely by analgesics on an as needs basis and he acknowledges they have substantially improved.

3. With regards to his current symptoms, he describes mild to moderate pain involving the cervical spine but no referral to either shoulder or into either upper extremity. There is associated mild to moderate central low back pain but no referral into either lower extremity.  His main complaint is pain relating to the left knee but inferior to the knee joint over the anterior medial aspect of the left knee, just over the medial tibia.

4. In appearance, he acknowledges weight gain. He has not attended the gym for the last four years. His tolerance for activity is primarily limited by the left knee. He states he can walk for only 10-12 minutes on average and stand for 10-12 minutes. If possible, he avoids bending and squatting but finds it is often unavoidable.

5. Medical Assessor Kenna got the impression Mr Sadeldeen doesn’t wish to present at work as disabled in any way. He stated he wears a knee brace at home, but he does not wear it to or at work. Mr Sadeldeen reported that 100% of his work is now essentially in the office and Medical Assessor Kenna gained the impression he no longer does site work due to his reduced activity tolerance limit of 10-15 minutes.

6. The intermittent pins and needles involving both wrists involve the 4th and 5th fingers, and this happens only intermittently once every week to 10 days. Whilst he experiences pain in the neck, it is not consistent or severe.

7. There is no ongoing lower back pain and Mr Sadeldeen acknowledged he has made a full recovery pertaining to symptoms involving the left and right shoulder.

8. Mr Sadeldeen’s main complaint continues to be the left knee. He has stopped physiotherapy as it was no longer providing any benefit.

Current and proposed treatment

1. He takes Panadeine Forte for the left knee when he is not at work (due to his engineering activities, he does not take it during the working week). For mild pain he will take Panadol or Nurofen.

CLINICAL EXAMINATION

General presentation

1. Findings on clinical examination including specific measurements of range of movement (ROM), where applicable, of each of the injuries assessed.

2. He weighs 115kg and there is an associated limping gait.

Cervical spine (cervicothoracic)

1. No muscle guarding or muscle spasm was present, he had full range of motion and there was no asymmetry present.

2. There was no neurological deficit evident in either upper limb.

3. Any distal symptoms did not follow the distribution of any specific nerve root and there was no indication of a non-verifiable radicular complaint. 

4. On formal examination of range of movement there was full range of movement as follows:

MOVEMENTS	RANGE EXHIBITED
Flexion	100% full
Extension	100% full
Rotation to the right	100% full
Rotation to the left	100% full
Lateral bending to the right	100% full
Lateral bending to the left	100% full

Neurological tests

Reflexes         

REFLEX	LEFT	RIGHT
TRICEPS JERK	Normal	Normal
BICEPS JERK	Normal	Normal
BRACHIORADIALIS	Normal	Normal

Sensation  

1. Sensation was normal.

2. Two-point discrimination sensation was normal and a point separation of some 6mm and sensitivity to light and firmer touch was normal throughout both upper limbs.

Muscle wasting – Nil

LEFT (cm)	RIGHT (cm)
UPPER ARM	Equal	Equal
FOREARM	Equal	Equal

Muscle power

LEVEL	MOTOR POWER	LEFT	RIGHT
C4	5/5	NORMAL	NORMAL
C5	5/5	NORMAL	NORMAL
C6	5/5	NORMAL	NORMAL
C7	5/5	NORMAL	NORMAL
C8	5/5	NORMAL	NORMAL
T1	5/5	NORMAL	NORMAL

5 is active movement against gravity with full resistance

4 is active movement against gravity with some resistance

3 is active movement against gravity only, without resistance

Dural tension tests:

TEST	RIGHT	LEFT
PASSIVE NECK FLEXION	Normal	Normal
BRACHIAL PLEXUS STRETCH	Normal	Normal

Thoracic spine (thoracolumbar)

1. On inspection of the thoracic spine posture was normal.  No tenderness on palpation of the thoracic spine and no muscle guarding or spasm.  No neurological deficit evident in either upper limb. On formal examination of range of movement there was full range of movement as follows:

MOVEMENT	RANGE OF MOTION
Flexion	100% full
Extension	100% full
Side bending to the right	100% full
Side bending to the left	100% full
Rotation to the left	100% full
Rotation to the right	100% full

Lumbar spine (lumbosacral)

1. No muscle guarding or spasm was present, there was full range of motion and no asymmetry was present.

2. No neurological deficit was evident in either lower limb.

3. Any distal symptoms did not follow the distribution of any specific nerve root and there was no indication of a non-verifiable radicular complaint. 

4. On formal examination of range of movement there was full range of movement as follows:

MOVEMENTS	RANGE EXHIBITED
Flexion	100% full
Extension	100% full
Rotation to the right	100% full
Rotation to the left	100% full
Lateral bending to the right	100% full
Lateral bending to the left	100% full

Neurological tests
Reflexes

REFLEX	LEFT	RIGHT
KNEE JERK	Normal	Normal
ANKLE JERK	Normal	Normal

Dural tethering/irritability signs

LEFT	RIGHT
Sciatic nerve stretch      (straight leg raise)	Negative	Negative
Femoral nerve stretch     (prone knee bending)	Negative	Negative

Sensation

1. Sensation was normal.

2. Two-point discrimination sensation was normal and a point separation of some 6mm and sensitivity to light and firmer touch was normal throughout both upper limbs.

Muscle wasting

LEFT (cm)	RIGHT (cm)
THIGH (measured 10cm above the superior pole of the patella)	50	50
CALF	43	43

Muscle power

LEVEL	MOTOR POWER	LEFT	RIGHT
L3	5/5	NORMAL	NORMAL
L4	5/5	NORMAL	NORMAL
L5	5/5	NORMAL	NORMAL
S1	5/5	NORMAL	NORMAL

5 is active movement against gravity with full resistance

4 is active movement against gravity with some resistance

3 is active movement against gravity only, without resistance

Muscle atrophy

THIGH	LEFT = RIGHT
CALF	LEFT = RIGHT

1. No unilateral muscle atrophy present.

Dural tension tests

TEST	RIGHT	LEFT
PRONE KNEE BEND	Normal	Normal
STRAIGHT LEG RAISE	Normal	Normal
SLUMP	Normal	Normal

Upper extremity

Right Shoulder

Measurement	Reference (4th ed.)	Normal	Upper Extremity Impairment
Flexion	180°	Figure 38 (43)	180°	0
Extension	50°	Figure 38 (43)	50°	0
Adduction	50°	Figure 41 (44)	50°	0
Abduction	180°	Figure 41 (44)	180°	0
Internal Rotation	90°	Figure 44 (45)	90°	0
External Rotation	90°	Figure 44 (45)	90°	0
Total	0

Goniometer measured

1. Inspection of the right shoulder was normal. Arc, resisted motions, and passive motions were pain free on the right. There was no abnormal tenderness. Impingement tests were negative.

Left Shoulder

Measurement	Reference (4th ed.)	Normal	Upper Extremity Impairment
Flexion	180°	Figure 38 (43)	180°	0
Extension	50°	Figure 38 (43)	50°	0
Adduction	50°	Figure 41 (44)	50°	0
Abduction	180°	Figure 41 (44)	180°	0
Internal Rotation	90°	Figure 44 (45)	90°	0
External Rotation	90°	Figure 44 (45)	90°	0
Total	0

Goniometer measured

1. Inspection of the left shoulder was normal. Arc, resisted motions, and passive motions were pain free on the left. There was no abnormal tenderness. Impingement tests were negative.

Lower extremity

Knees

1. Mr Sadeldeen was tender below and medial to the left patella with slight evidence of induration.

2. There was no muscle wasting. 

3. There was symmetry between right and left legs above and below the knee. 

4. He had an abnormal gait, protecting the left knee

5. There was no use of a cane or brace and no redness, warmth, swelling, effusion or deformity.

6. Measurement of the involved calf (43cm) and thigh (50cm) were symmetrical with the contralateral side. 

7. Ligamentous and meniscal stress tests were normal and painless. 

8. The left knee had full extension and flexion was limited to 105°. 

9. Manual muscle testing shows normal strength in the extremity. Patellofemoral examination was normal. 

10. The knees had normal alignment.

11. There was no crepitus of either the tibiofemoral or patellofemoral joint

Right Knee

Left Knee

Extension 0°

¯

Flexion 135°

0

¯

105°

1. Medical Assessor Kenna observed the following:

   Normal motion

   Scars  Nil

   Quadriceps Wasting  Nil

   Swelling  Nil

   Collateral Ligaments  Intact

   Cruciate Ligaments  Intact

   McMurray’s Test  Normal

   Patello-femoral joint  Normal

   Lateral patellar tilt  Nil

   Lateral drift (with quadriceps contraction)                  Nil

   Gait     Limp

   Short leg       Nil

   Atrophy               Negative

   Weakness  Negative

   Range of movement       Reduced in flexion

   Osteoarthritis       Nil

   Amputation  Nil

   Neurological deficit  Nil

   Reflex sympathetic dystrophy     Nil

   Vascular   Normal

Right hand

1. The referral to Medical Assessor Woo included the right hand, namely paraesthesia in the C7/8 distribution of the right hand involving the palm. 

2. There was no evidence of a direct or discreet injury to the tight hand. Symptoms were non-radicular and did not follow a specific nerve root pattern. 

3. The Panel finds the claimant did not sustain any injury to the right hand.

CONSISTENCY

1. Mr Sadeldeen’s presentation was straightforward with no inconsistencies.

DIAGNOSIS AND CAUSATION

1. Mr Sadeldeen is a 50-year-old engineer involved in a motor vehicle accident on
   8 January 2020, a period now of over four years ago, in which he sustained soft tissue injuries to the cervical spine, both shoulders and lumbar region. He sustained a non-threshold injury to the left knee involving a microfracture of the medial tibial plateau (since healed). He continues to work, largely pre-injury duties as an engineer, has since ceased conservative therapy but remains symptomatic in respect of left knee pain.

2. In summary the Panel finds the claimant sustained the following injuries caused by the accident:

   ·        cervical spine – soft tissue injury;

   ·        lumbar spine – soft tissue injury;

   ·        right shoulder – soft tissue injury (now resolved);

   ·        left shoulder – soft tissue injury (now resolved), and

   ·        Left knee – microfracture of the medial tibial plateau.

3. The Panel finds the claimant did not sustain injury to the right hand caused by the accident.

PERMANENT IMPAIRMENT

Cervical spine (cervicothoracic)

1. The spine is assessed under Chapter 3 of the AMA 4 Guides in accordance with the DRE method of assessment.

2. At the time of his examination of the cervical spine, Medical Assessor Kenna found there was pain but there was no dysmetria, no guarding on palpation, no radiculopathy or non-verifiable radicular complaints in the upper limbs. The claimant is assessed as DRE cervicothoracic category 1 giving a 0% WPI.

Lumbar spine (lumbosacral)

1. At the time of his examination of the lumbar spine, Medical Assessor Kenna found there was pain but there was no dysmetria, no guarding on palpation, no radiculopathy or non-verifiable radicular complaints in the upper limbs. The claimant is assessed as DRE cervicothoracic category 1 giving a 0% WPI.

Upper Extremities

Right shoulder

1. The left shoulder was asymptomatic with no restriction of movement. The Panel finds the soft tissue injury to the right shoulder has resolved. Accordingly, there is no assessable impairment.

Left shoulder

1. The left shoulder was asymptomatic with no restriction of movement. The Panel finds the soft tissue injury to the left shoulder has resolved. Accordingly, there is no assessable impairment.

Left knee

1. Clause 6.70 of the Guidelines notes there are several different forms of evaluation that can be used to assess impairment of the lower extremity as indicated in sections 3.2a to 3.2m on pages 75 to 89 of the AMA 4 Guides.  However, when more than one equally specific method or combination of methods of rating is available, the method providing the highest rating should be chosen.

2. Utilising the range of motion method requires the assessment to be undertaken in accordance with table 41, chapter 3, page 78 of the AMA 4 Guides. The Panel notes flexion less than 110º is a mild impairment giving rise to 10% lower extremity impairment (LEI) or 4% WPI.

3. Utilising the diagnosis based estimates requires the assessment to be undertaken in accordance with table 64, chapter 3, page 85 of the AMA 4 Guides. An undisplaced tibial plateau fracture gives rise to 5% LEI which equates to 2% WPI.

4. Table 6.5 of the Guidelines defines the permissible combinations of lower extremity methods. It is not permissible to combine range of motion and diagnosis-based estimates in calculating permanent impairment. 

5. Therefore, the method of assessment providing the highest rating should be chosen. The greater individual impairment, that is range of motion gives rise to a 4% WPI for injury to the left knee.

Permanent Impairment Table

Body Part or System	AMA Guides/ The Guidelines References (chapter/ page/table)	Permanent (YES/NO)	Current %WPI*	%WPI* from pre-existing OR subsequent causes	%WPI* due to motor accident
1	Cervical Spine DRE I	Ch 3, pgs 102-107, AMA 4 Guides Tables 7 & 8 The Guidelines	Yes	0	0	0
2	Lumbar Spine DRE I	Ch 3, pgs 102-107, AMA 4 Guides Tables 7 & 8 The Guidelines	Yes	0	0	0
3	Left knee	Ch 3, pg 78, Table 41, AMA 4 Guides T37	Yes	4	0	4

* 4%WPI = percentage whole person impairment

CONCLUSION

1. The Panel revokes the certificate of Medical Assessor Alexander Woo dated 9 March 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a whole person impairment which is not greater than 10% and which is 4%:

   ·        cervical spine – soft tissue injury;

   ·        lumbar spine – soft tissue injury, and

   ·        left knee - medial tibial plateau microtrabecular fracture.

2. The Panel finds the following injuries caused by the motor accident have resolved:

   ·        right shoulder – soft tissue injury, and

   ·        left shoulder – soft tissue injury.

3. The Panel finds the following injury was not caused by the motor accident:

   ·        right hand – paraesthesia in the C7/8 distribution of the right hand involving the palm.