Stanton v Insurance Australia Limited t/as NRMA Insurance

DETERMINATION OF REVIEW PANEL
CITATION:	Stanton v Insurance Australia Limited t/as NRMA Insurance [2025] NSWPICMP 369
CLAIMANT:	Shayley Stanton
INSURER:	Insurance Australia Limited t/as NRMA Insurance
REVIEW PANEL
MEMBER:	Hugh Macken
MEDICAL ASSESSOR:	Clive McKenna
MEDICAL ASSESSOR:	Michael Couch
DATE OF DECISION:	27 May 2025
CATCHWORDS:	MOTOR ACCIDENTS – Review of Medical Assessment Certificate (MAC); motorcycle struck by car; right leg deformity and bleeding; medial tibial plateau fracture; foot peg penetrated medial aspect of the knee; damage to saphenous nerve; scarring colour contrast with the surrounding areas; visible suture marks; Held –MAC revoked; permanent impairment assessed at 20%.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION ASSESSMENT OF DEGREE OF PERMANENT IMPAIRMENT Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Panel revokes the Certificate of Medical Assessor Robert Kuru dated 28 June 2024. The following injuries caused by the motor accident and give rise to a whole person impairment of 20% which is greater than 10%: · right lower extremity 8%; · cervical spine 5%; · lumbar spine 5%; · scarring 4%, and · left leg 0%.

STATEMENT OF REASONS

INTRODUCTION

Shayley Stanton (the claimant) is a 25-year-old woman who was injured in a motor vehicle accident on 31 October 2020 when she was struck by the insured’s vehicle whilst riding her motor cycle.
Following the accident the parties agreed that she had sustained non-threshold injuries. The claimant sought a concession from the insurer that her injuries exceeded 10% whole person impairment (WPI). After conducting an internal review the insurer declined to make this concession and accordingly the claimant filed an application for assessment of degree of permanent impairment.
The claimant was assessed by Medical Assessor Robert Kuru on 8 February 2024 who, in a certificate dated 28 June 2024, determined that the claimant had sustained injuries in a motor accident which gave rise to a permanent impairment of 9%.
The claimant sought a review of this determination and, in a certificate dated

21 January 2025 the President’s delegate, Ashley Payne, determined that there was a reasonable cause to suspect that the medical assessment of Robert Kuru was incorrect in a material respect.
The matter was then referred to this Panel.
The Panel met by Teams on 25 March 2025 and reviewed the material and documentation. It was determined that it was appropriate to examine the claimant before reconvening to finalise the Panel’s determination and certificate.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (Commission).
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.

STATUTORY PROVISIONS/GUIDELINES

Section 57 of the Motor Accidents Compensation Act 1999 (MAC Act) defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 and s 60 of the MAC Act together with cls 1.5-1.7 of the Guidelines set out the procedures for referral to one or more Medical Assessors and the principles to be applied at such assessments.
The claimant was examined, on behalf of the Panel, by Medical Assessor Michael Couch on 22 April 2025.
The claimant attended promptly, accompanied by her friend, Ken Smith. Mr Smith had driven her by car from Newcastle – the claimant pointed out that she has difficulty with prolonged driving because of right lower limb symptoms. I understood that Mr Smith had helped

Ms Stanton a lot since her injury. She has parents and two younger brothers in Brisbane – Mr Smith had adopted a semi-parental role since her accident. He is an intensive care paramedic who was in fact the first on the scene of her accident. She spent about six weeks back in Brisbane with her family after discharge from John Hunter Hospital, but on moving back to the Newcastle area, lived with Mr Smith and his family for a while, before again living independently, as she does now. Mr Smith apparently still helps her with some tasks such as lawnmowing and heavier household cleaning, because of her residual symptoms and restrictions.
The Medical Assessor commenced by clarifying that the claimant understood the Review Panel process and the purpose of the re-examination. The following detailed history was obtained directly from the claimant – where there is reference to documentation provided to the Panel, this has been stated.

Pre-accident medical history and relevant personal details

The claimant said that she grew up with her family in Brisbane. She finished high school and described her performance as “OK”. She trained as an ambulance paramedic on the Gold Coast, completing a Bachelor of Paramedicine at Griffith University over a two and a half year accelerated program of both hands-on work and study. She then worked for about one year as an ambulance paramedic – I understood initially on a casual/relief basis.
The claimant said that about six months before the subject motorcycle accident, she had moved to the Newcastle area because she had been offered a full-time paramedic position. This was at the beginning of the COVID-19 lockdown period. She had worked as a full-time ambulance paramedic based in Toronto (south of Newcastle) for about six months at the time of the accident.
The claimant denied any pre-existing medical problems relevant to the injuries referred for assessment. She had developed supraventricular tachycardia (SVT) as a teenager and various preventative medications have been tried but apparently ceased because of side effects. She said that she would now only get an episode of rapid heart rate (approximately 180 per minute) with associated symptoms once or twice a year and she has learnt how to self-manage these. In childhood she had sustained a greenstick fracture in her right forearm whilst skateboarding, and later a more severe compound fracture of the left forearm while playing soccer during Year 7. She had made a full recovery from both of these. She also said that she had been diagnosed with ADHD at age 18 and now takes Ritalin. Specifically she denied any previous knee or lower limb injuries or problems, and denied any previous neck or low back injuries or conditions. She denied having any work-related injuries to these areas.
She said that she had been very physically active and fit prior to the subject accident, including running at least 5km daily (she said that she had competed in cross country at State level when at school). She also attended the gym regularly and enjoyed mixed martial arts and indoor rock climbing.

History of the motor accident

The claimant said that on 31 October 2020 she was riding her Yamaha 700 cc motorcycle during the afternoon, near Toronto. She was wearing a helmet, gloves, leather jacket, enclosed shoes and long trousers. She was negotiating a large-radius roundabout at an estimated 60kmph when a car (possibly a Toyota Camry) in a lane to the right of her suddenly turned to the left to try and exit the roundabout. The car struck her on the right side – she did not have time to avoid the collision. Ms Stanton recalled that at the last moment: “I closed my eyes. Suddenly I felt an excruciating pain in my right knee”.
She was thrown off the bike and recalled seeing her machine lying on the road. She was unable to get up. A female bystander, who was apparently a nurse, sat with her for a while and the driver of the offending vehicle stopped but did not actually approach her. (Ms Stanton said that she later understood that he was unfamiliar with the area and had been looking at his GPS, and suddenly realised he needed to exit the roundabout). The nurse apparently telephoned Ken Smith, who was off-duty and only lived 1.5km away, and he arrived within an estimated 5 to 8 minutes – before the ambulance from the local ambulance station. She was taken to John Hunter Hospital.

History of symptoms and treatment following the motor accident

The ambulance’s medical record stated,
“PT motorbike rider struck right side by car turning left from right lane. PT came off 40-60 km/hr, hit head, nil LOC, PT with severe pain R leg, with deformity and bleeding. PT complained of midline C spine pain on palpation. Chest clear, abdo NAD. Pelvic binder in situ, leg splint applied. PT tx code 3 past. Obs stable and between the flags. PT nil PMHX NKA.”
The Discharge Referral from John Hunter Hospital, dated 4 November 2020, gave a similar history of the accident to that described by the ambulance officers. The principal injury was described as:
“1. Right posteromedial knee wound, medial tibial plateau avulsion fracture and 100% MCL tear à CT 31/10/2020 à There is a right-sided compound tibial plateau fracture, there may be involvement of the medial collateral ligament. Detail is obscured by extensive soft tissue injury à OT/31/10/2020 à washout and debridement of knee wound with MCL repair à wounds clean and dry at time of discharge à drain removed 02/11/2020.
2. Tertiary survey completed – nil new injuries identified, other than listed above – C-spine cleared – nil head injuries.”
High levels of post-operative pain requiring morphine and ketamine infusion were described and she required close review by the acute pain service. She was discharged home with her mother (to their home in Brisbane) with follow up by a fracture clinic at QEII Hospital in Brisbane, and analgesia and a course of antibiotic.
The claimant herself and Ken Smith, the first attender, gave some useful further information about her knee injury – a downward pointing, approximately 50 mm long metal spur on the outer end of her motorbike foot peg had separated from the main part of the foot peg and penetrated the medial aspect of the knee just below the joint-line, and probably exiting somewhat above the joint line. The metal fragment was in fact found covered in blood and dirt near the scene. Ms Stanton added that: “Fat was splattered on my cargo pants”.
The claimant was asked about any other injuries/symptoms she recalled initially after the accident. She said that she did recall neck pain while lying on the road and that was part of the reason she did not get up. She thought that she had worn a neck brace at John Hunter Hospital for about two days. She added that she ended up with her helmeted head against the front wheel of the car which had struck her, with her neck at an awkward angle. An attending police officer apparently went to push the car out of the way and when he turned the steering wheel, the movement of the front tyre struck/moved her head again.
She also recalled being sore all down her right side and recalled initial low back pain, commenting: “But it was overtaken by my knee”.
Subsequent treatment was mainly for her right knee. Ms Stanton recalled post-operative wound infection. She required intravenous antibiotics at John Hunter Hospital and then took oral Keflex for about two months. Sutures were removed after one week and the wound healed reasonably after about three weeks.
She wore a knee brace and used crutches for six to eight weeks. She then had a lot of physiotherapy and progressed to treatment with an exercise physiologist in a gym. When asked when she could first walk reasonably well, she thought this had been at least three to four months after the accident.
Follow up was initially with her general practitioner (GP) in Brisbane, while she stayed with her family there, and then with Dr Stuart MacKenzie, originally treating orthopaedic surgeon, back in his rooms in Newcastle. She also attended two different general practices in the Newcastle area. Four months after the accident on 23 February 2021, Dr MacKenzie wrote,
“I saw Shayley back in my rooms today, now almost four months since a nasty right knee injury from a motorbike accident. She underwent primary repair of the medial collateral ligament as well as all other damaged structures on the medial side of the knee at that time.”
He described reasonably good progress and said she was back at work on restricted duties. The knee was still getting sore if she walked too far, but she could walk about 2km. He described examination of the knee as satisfactory at that time.
In May 2021, Dr MacKenzie wrote that Ms Stanton was having ongoing issues in her knee with swelling and pain, and that she described intermittent episodes of the knee feeling unstable. On examination he found definite swelling of the right knee but intact ligaments. He performed diagnostic right knee arthroscopy and EUA (examination under anaesthesia) on 7 July 2021 and found no pathology in the knee.
On 14 October 2021, he described good progress and that she was now walking with a completely normal gait and was transitioning from physiotherapy to exercise physiology. She was working two days a week. I note that in early 2022 she was seconded by the ambulance service to Cobar, in western NSW – on 3 March 2022, Dr MacKenzie wrote a letter stating it was in her best interests to remain in the Hunter region for optimal treatment. Ms Stanton told me that she in fact did have to work at Cobar for about six months, before being allowed to return to the Hunter region “on merit”.
The most recent letter seen from Dr MacKenzie was on 30 August 2022, when he wrote to her GP in Newcastle (Dr Aung), saying that she had been unable to access any sort of rehabilitation or gym while at Cobar for six months, and that her knee had deteriorated somewhat. She was describing anterior knee pain and:
“When I examined her today, she does have indication of some patellafemoral chondromalacia. Her MRI of the right knee shows only a tiny bit of oedema in Hoffa’s fat pad but really not much significant. The rest of her knee looks excellent. As I will explain to Shayley, she needs to get back into working on physio and rehabbing her knee. She has really poor quads control and I think it is important that even if she is not seeing a physio, she keeps doing her exercises herself. I have encouraged her to do this. At this stage, I have not made another appointment to see her.”
The claimant was asked why there was no mention by doctors at the Aberglassyn Medical Centre (including Dr Shahid and Dr Sarki) after her return to the Newcastle area, of neck or back pain. She added the information that while back with her family in Brisbane immediately after the accident, she had attended Dr Thushara Pussella at the Mansfield Family Practice in Mansfield, Queensland, a few times over about six weeks. She recalled mentioning knee pain and pain in other areas and thought she had probably mentioned her neck and back. Apparently this doctor had started her on the strong analgesic Tapentadol (Palexia). She also said that she had attended a chiropractor for her neck and back in the Newcastle area.
As for current treatment, Ms Stanton said that she continues to attend a massage therapist – “as often as I can afford”.This is perhaps monthly and includes treatment to her neck and back. She is also attending Dr Marc Russo, pain specialist, for pain in her low back and right buttock (see below).

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

The claimant denied any such injuries or conditions.

Current status

When questioned, Ms Stanton said her right knee and low back trouble her approximately equally at present. She described current symptoms in more details as follows:

Right knee

The claimant described a lot of pain in her knee, pointing to an area distal and medial to the knee in the region of the large scar. She always has some pain, and definitely never wakes in the morning free of pain. Pain increases with activity – in particular she finds kneeling very difficult. Stairs are also difficult. She finds wearing tight leg wear uncomfortable – she said that wearing tight pants on duty as an ambulance paramedic, she usually applies a 140 x 100 mm lidocaine patch over this area to numb it before putting on her pants.
On further discussion with Ms Stanton who appeared to be an intelligent, well-educated young woman with good understanding of medical issues, she was describing two sorts of pain. She notices more typical joint pain negotiating stairs or crouching, and in particular when performing CPR in her duties, and also if she walks a long distance.
The persistent pain in the described area, which is aggravated by tight clothes and for which she applies a lidocaine patch, was described with the characteristics of neuropathic pain. She described numbness in the area distal to the medial knee scar. She described definite dysaesthesia with a hot and burning sensation on rubbing or compression. This can become an excruciating pain if she knocks the area or flicks it accidentally with something. She needs to sleep with a pillow under her knee either on her back or on her side.
The claimant said that she tries to walk for 2 to 3km every day, but with some increased pain when she walks further. She cannot run more than about 800m and can no longer run for exercise as she did regularly prior to the accident.
She said that the knee still can swell at times, especially both distally and proximal to the patella- particularly after a shift at work. The knee gets hot and redder at times every day.
The knee does not lock. She described some feeling of instability, stating: “it feels like it might go if I turn too fast.” At times the knee has hyperextended somewhat and she also described the knee as sometimes “folding in”, if she turns too fast.

Lower back

The claimant described low back pain, pointing to the central lumbar area she stood to demonstrate, and then sat down again rather stiffly. The Medical Assessor also noted that earlier, after about 30 minutes of the interview, she stood up after a while from her chair to stretch.
Low back pain is aggravated by sitting for more than about 30 minutes, and she has to get up and move around regularly if sitting. She also described increased pain and “spasm” if she stands for more than about 10 minutes. She described occasions when, after holding a sustained bending position while holding an airway for CPR, she has needed help from a colleague to stand back up again. She described lifting as “tolerable”. She described sudden pain in her back if she jolts it – for example, stepping down from a high ambulance floor. She pointed out that this is quite high for her, as she is only 162cm tall.
Low back pain radiates to the right buttock and distally. She was asked to stand and carefully delineate the area of radiation – this was to the right buttock, posterior thigh and posterior calf and also the medial dorsum of the foot and great and second toes. She described sensation in this area as, “Neuropathic pain and tightness and numbness”.

She said that on multiple occasions the abnormal sensations have reached the point where she cannot feel properly while operating the foot pedals on an ambulance, and she has had to stop driving and hand over to her partner. She said this had happened on many occasions. She also added that this problem was why her friend Ken had driven her to this appointment in Sydney.

Neck

The claimant said that her neck still troubles her from time to time and that it “locked up recently”. She said that massage therapy really helps this. She described in particular a “hot” burning pain over both medial trapezius muscles and paraspinal muscles – for example occurring at about 2 to 3.00am. on a night shift at work. She finds rotation to the left more difficult and limited than to the right. She gets associated headaches and said that she was not prone to headaches previously – these are occipital and frontal and bilateral, but she denied typical associated migrainous features.

Present activities

The claimant said that she was currently working two 12-hour shifts per week as an ambulance paramedic. She is also studying towards a degree in Medical Science at Newcastle University – she said that unfortunately she has not obtained any credits for her previous paramedic study. She said that because of her physical symptoms, she wanted to get out of working as a paramedic and work in a different health care area. She wondered about possibly eventually moving into radiography.
She lives alone in a rented duplex and does limited housework. Her friend Ken comes round and helps with some heavier cleaning and yard work. For exercise she mainly walks 2-3km most days. She said that she also tries to go to the gym three or four times a week, mainly doing upper body work – on both machines and some free weights.
On questioning, she described sleep as “terrible”. She said this had been satisfactory prior to the accident. She finds it difficult to get off to sleep and sleep is even worse without Melatonin. She typically goes to bed at 10.00pm, is slow to get off to sleep, and then wakes again at 1.00am and 4.00am – she said that she may not get off to sleep again after that. She said that her Apple watch indicated that she was averaging perhaps four hours proper sleep per night. She frequently feels tired and never wakes in the morning feeling refreshed.

Present treatment

As noted above, Ms Stanton goes to a massage therapist perhaps monthly – she pays for this herself. She said that on a typical day she takes about six Paracetamol and two Nurofen 400mg. She also takes Ketorolac one tablet three or four times a week for knee and back pain. She also has a supply of Tapentadol (Palexia) – immediate-release 50mg, and slow-release 100mg. She takes these fairly infrequently and thought that a packet of 20 would last her about three months. In addition, having been diagnosed with ADHD at age 18 years, she takes Ritalin 30mg in the morning. She also takes Valium 5mg three or four times per week as a muscle relaxant, and Melatonin at night.

Lifestyle factors

The claimant does not smoke. She said that she does drink alcohol and has drunk to excess at times for symptom relief.

Physical examination

The claimant presented as a slim young woman, at height 162cm and weight 58kg she said that her weight was essentially unchanged. This gives a BMI of 22 – in the healthy weight range. She was wearing a short-sleeved top with a long-sleeved top over it, shorts, socks and sneakers. She appeared to be intelligent, well-educated and gave a clear specific history in a very straightforward manner. There was no suggestion of exaggeration.
She was fully cooperative during the examination showing excellent effort with no abnormal pain behaviours, self-limitation or inconsistency. She looked tired. From her general presentation and pre-accident activity history, the Medical Assessor formed the impression that she probably had at least an average, or higher than average pain threshold, and was not prone to over-complain.

Cervical spine

Posture of the head and neck was within normal limits. There was no tenderness to palpation over the midline of the cervical spine. Both trapezius muscles were slightly tense and equally so – the left was also moderately tender to palpation whereas the right was not.
She showed good effort during AROM of the cervical spine, with full flexion and extension two-thirds of normal and appearing rather stiffer. Rotation was virtually full to the right and pain-free, but one-third of normal to the left and painful. Lateral flexion was also full to the right but two-thirds of normal to the left. This asymmetry of movement was reproducible-there was definite dysmetria.

Lumbar spine

With Ms Stanton standing, posture of the lumbosacral spine was normal. On palpation with her lying prone on the couch, she reported moderate tenderness both in the midline and to the right of the midline, maximal at the L4/5 level. When she stood and slowly moved her bodyweight from one foot to the other, the lumbar paraspinal muscles on the weightbearing side relaxed in the normal manner – thus there was no spasm.
AROM was measured with repetition, with Ms Stanton standing with knees straight. She could flex forward approximately three-quarters of normal range with fingertips to her knees, although she did this slowly and tentatively, complaining of some low back pain. Extension was more restricted and painful at only one-third of normal. Lateral flexion was approximately symmetrical.
This dysmetria, with extension more painful and restricted than flexion was reproducible. The Medical Assessor also considered that her description of radiating symptoms to the right lower limb described in detail above was consistent with non-verifiable radicular complaints.
The claimant added the information that Dr Russo, pain specialist, was planning to perform bilateral L4-S1 dorsal ramus blocks again. She said that she had had these done in 2024 with good pain relief for up to nine months. She also mentioned that piriformis muscle injections had been helpful in the past.

Upper extremities

Hands showed small callouses over the metacarpal heads, which she related to her gym work. The right (dominant side) upper arm measured 27cm in circumference, the left 26cm. The right forearm measured 24cm, the left 23.5cm.
Biceps, triceps and brachioradialis reflexes were normal and symmetrical. Power of all muscle groups in the upper limbs, including grip strength, hand intrinsic muscles and flexion and extension of the elbows was normal and symmetrical. There was a full AROM of both shoulders.

Lower extremities

The right (dominant side) thigh measured 44.5cm in circumference, 10cm above the patella. The left measured 44cm. The right calf measured 34cm and the left 33.5cm.
Both knee jerks and ankle jerks were normal and symmetrical and both plantar responses flexor (normal). Power of extensor hallucis longus was full on the left. Effort when testing this on the right was somewhat variable but power was considered to be within normal limits. Power of ankle dorsiflexion was normal and symmetrical, as was power of ankle eversion.
Consistent with normal power, Ms Stanton could walk normally with weight on the balls of her feet and heels off the floor, and then on her heels with forefeet off the floor. She could do a full squat to the floor and recover, although described increasing low back pain. The Medical Assessor demonstrated a squat-walk (duck walk) to her – she was able to perform this but did it slowly and with apparent difficulty, complaining of low back pain and right knee pain.
Straight-leg-raising in the supine position was full on the left at 60 degrees, with some pulling in the hamstring only. On the right it was slightly restricted to 50 degrees with a positive sciatic stretch test – Ms Stanton described pain radiating down to the right foot, increased further by passive ankle dorsiflexion.
Thus the signs in relation to the lumbar spine were dysmetria and positive nerve root tension.
Both knees measured 36cm in circumference. The left knee appeared to be completely normal in appearance. In the right knee there was a long, J-shaped, widened scar approximately 140mm long, inferomedial to the patella. At the medial end of this there was a 30mm wide, slightly raised scarred area – apparently from where the foot peg fragment had penetrated.
Surrounding this scar there was an approximately 150 x 100mm oval area which, during the examination, developed a “goosebump” appearance and became cooler than surrounding skin. This was presumably due to sympathetic activity and piloerection. This area felt palpably different from surrounding normal skin. Ms Stanton went on to explain that this “goosebump” phenomenon in this area sometimes develops when she is in fact hot.
She said that, paradoxically, if she develops “goosebumps” elsewhere on her body (for example in the cold), the affected area does not react in the same way as the rest of her skin.
Sensation to light touch and pin prick was absent over a similar area and she was also describing dysaesthesia-mainly to firmer touch.
Describing the scar in more detail, there was a pale central area. The scar was very easily visible. Some suture marks were visible. There were also some areas of darker colouration. It was not adherent to underlying tissues. Ms Stanton said that earlier she wore a “second skin” neoprene garment for about two months, but not recently. She is bothered by the appearance and commented that she had not been to a beach since the accident. Although she was wearing shorts at the examination, she said that she had done so to facilitate the Medical Assessor’s examination – she said that she in fact had some tracksuit pants that she would put on before leaving. She usually covers this area up and wears tights at the gym.
The left knee showed a full range of movement from 0 to 140 degrees flexion. The right knee showed full extension (0 degrees) but slightly restricted flexion to 120 degrees. Cruciate ligaments were clinically intact bilaterally. There was however mild laxity on testing of the right medial collateral ligament (MCL), compared with no laxity on the left. There was no evidence of patellofemoral irritability on this occasion – patellofemoral grinding and Clark’s apprehension sign were negative bilaterally. Ms Stanton did describe some right knee pain on performing (rather slowly and awkwardly), a squat-walk.

Review of other treating practitioner’s documentation

GP records were received from Aberglassyn Medical Centre (Dr Shahid and Dr Sarki) from August 2020 until October 2021. There is nothing relevant prior to the subject accident. Entries after the accident refer to ongoing right knee pain, and also anxiety after the accident.
It appears that subsequently she attended Cameron Park Medical Practice (Dr Htet Aung). On 6 October 2022, Dr John Prickett, pain physician, wrote a lengthy (four-page) letter to

Dr Aung. He described generally good recovery from her severe right knee injury with some recently increasing right knee pain, some secondary mechanical left knee pain,
“as well as some lower back pain and right buttock pain with intermittent radiating pins and needles into her legs after prolonged sitting, consistent with dynamic piriformis syndrome outside an area of hypoaethesia on the anteromedial aspect around her knee arising in the post-operative setting.”
On examination he notes marked tenderness in the right piriformis region and the buttock area. He considered but discounted the possibility of complicating CRPS following her knee injury and gave various recommendations for treatment.
On 10 October 2022, Dr Aung referred Ms Stanton to Dr Marc Russo, another pain specialist in Newcastle, stating that:
“Due to the effect of right knee pain and instability of the gait, she is now experiencing back pain and left knee pain.”
In reply on 17 October 2022, Dr Russo described burning type pain over the anteromedial aspect of the right knee:
“in the distribution of the infrapatellar branch of the saphenous nerve.”
He stated:
“Shayley presents with infrapatellar branch of saphenous neuralgia in conjunction with sympathetic instability.”
In April 2023, Dr Russo stated that Ms Stanton was also having difficulty with buttock muscle spasm, intermittently radiating down her leg. Subsequently he considered this to be originating from piriformis muscle spasm rather than the lumbar spine, and planned right saphenous nerve pulsed radiofrequency neurotomy with right piriformis injection. Following this he reported elimination of the knee pain.

Conclusions following re-examination

The claimant was a previously fit and healthy and very physically active young woman, aged 21 years, who had been working as an ambulance paramedic for about 18 months at the time of the subject accident in late 2020. There was a previous history of treated ADHD and well-managed SVT (supraventricular tachycardia), but she had no musculoskeletal conditions or restrictions.
The claimant suffered significant injuries to the right knee when she was struck from the right side by a car on a roundabout and knocked off her motorbike. Documented injuries to the right knee included complete rupture of the MCL, an open (compound) avulsion fracture of the medial tibial plateau, and extensive soft tissue injury, with penetration by a 50mm broken fragment of her motorbike foot peg. She had appropriate and technically successful surgical treatment at John Hunter Hospital, complicated by post-operative infection and a lot of pain.
Her knee has mechanically recovered fairly well, but with some ongoing joint pain on activity, as detailed above – this has affected her in her work as an ambulance paramedic. She has persistent and troublesome dysaesthesia in an area close to the knee because of saphenous nerve damage and has benefited temporarily from one nerve block to this area.
The claimant herself recalls immediate neck pain, and struck her head and had subsequent sudden movement of the head and neck when the offending car, against whose front wheel her head was resting, was moved after the accident. Ambulance officers reported neck pain and tenderness, although subsequent investigations excluded significant serious injury. She now has clinical features of whiplash associated disorder Grade 2 (WAD II). The pain in this area was probably overshadowed initially by her serious knee injury.
The claimant herself recalls the early onset of lower back pain. Treating practitioners documented this later and considered that it might be secondary to her disturbed gait following her knee injury. Dr Marc Russo, treating pain specialist, and also Dr Prickett, pain specialist, considered this likely to be due to piriformis syndrome. Current examination shows dysmetria and positive nerve root tension on the right. Apparently, Dr Russo is planning lumbar dorsal ramus blocks – this would suggest that he is now considering a lumbar spine origin for her pain, rather than simply the piriformis syndrome.

Impairment assessment

Right knee

Referring to the multiple possible methods for impairment assessment listed in the MAG and AMA4, there is no impairment for muscle wasting. Although right knee flexion was slightly reduced to 120 degrees, Table 41 of AMA4 gives no impairment for flexion less than 110 degrees. There was no current gait derangement. The arthritis method does not apply – there was no detectable patellofemoral crepitus (see footnote to Table 62 of AMA4).
Referring to Table 64 (impairment estimates of certain lower extremity impairments), mild collateral ligament laxity gives 7% LEI. There was also an undisplaced medial tibial plateau fracture. The Panel notes there has been debate about the nature of this: often tibial plateau fractures occur from direct impact (e.g. the “bumper bar” fracture from impact with the lateral aspect of the knee). In this case the fracture was thought to be associated with the sudden severe strain, resulting in rupture on the MCL. The Panel considers that this is still a tibial plateau fracture. This attracts 5% LEI from Table 64.
There has also been damage to a branch of the saphenous nerve – noting the unusual and quite extensive soft tissue injury to the medial aspect of the right knee, with penetration by a separated fragment of her motorcycle foot peg.
There is both sensory loss and dysaesthesia in this area (and also objective evidence of autonomic dysfunction). Referring to Table 68 of AMA4 (Impairments from Nerve Deficits), the saphenous nerve is not specifically listed. The two Medical Assessors on the Panel discussed this, and considered that the best analogy is with the superficial peroneal nerve. From Table 68, sensory loss of this nerve gives 5% LEI for sensory loss. There is also 5% LEI for dysaesthesia, giving a total of 10% LEI.
Referring to Table 6.5 (Permissible Combinations of Lower Extremity Assessment Methods) in the MAG, diagnosis based estimates may be combined with peripheral nerve injuries. The above figures for ligament laxity, the tibial plateau fracture and nerve injury are combined to give a total of 20% LEI, which converts to 8% WPI.

Cervical spine

There was early documentation of injury to the cervical spine, and such injury is entirely consistent with the subject motorcycle accident. Examination showed dysmetria. The injury is assigned a DRE Cervicothoracic Category II, giving 5% WPI.

Lumbar spine

Low back pain and associated right lower limb symptoms are a major component of

Ms Stanton’s ongoing symptomatology and also restrict her activities – including her work as an ambulance paramedic. Although there was some delay in medical documentation of this, the Panel considers that there was certainly the possibility of lumbar spine injury in the subject motorcycle accident. Alternatively, as suggested by some of her treating doctors, the lumbar spine condition may have developed secondarily to her knee injury and altered gait. Examination showed reduced range of movement, dysmetria and positive nerve root tension. This injury is assigned a DRE Lumbosacral Category II, giving 5% WPI.

Scarring

Referring to the criteria in the TEMSKI table, Ms Stanton is conscious of the scar. There is colour contrast with the surrounding area and there are visible suture marks. The location is visible with shorts or bathing wear and she tends to avoid these. The contour defect is readily visible. It has limited effect on ADL. She initially required specific treatment but no longer does so. This scar could be assigned to either the 2% or the 3-4% category. This is a quite unsightly, easily visible scar in a young woman, and the Panel considered that 4% WPI is preferable.

Left leg

The Panel has seen no evidence of an injury to the left leg. The claimant did not mention any symptoms in the left leg at the examination. The examination of this body part was entirely normal. The Panel determined that there was no injury to the left leg in the subject accident, and there were no symptoms or conditions occurring secondary to her other injuries.
The above figures are combined sequentially using the Combined Values table to give a total of 20% WPI.

Conclusion

The Panel assesses the claimant’s degree of WPI at 20%.

[2025] NSWPICMP 369

27 May 2025