Templeton v Corrective Services NSW
[2022] NSWPICMP 411
•21 October 2022
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Templeton v Corrective Services NSW [2022] NSWPICMP 411 |
| APPELLANT: | Belinda Templeton |
| RESPONDENT: | Corrective Services NSW |
| Appeal Panel | |
| MEMBER: | Catherine McDonald |
| MEDICAL ASSESSOR: | Dr Mark Burns |
| MEDICAL ASSESSOR: | Dr J Brian Stephenson |
| DATE OF DECISION: | 21 October 2022 |
| CATCHWORDS: | wORKERS cOMPENSATION - Injury to right ankle and consequential condition in left ankle; scarring omitted from referral; Medical Assessor failed to consider diagnosis of Chronic Regional Pain Syndrome and to assess left ankle; re-examination required; Elsworthy v Forgacs Engineering Pty Ltd applied; Held – Medical Assessment Certificate revoked. |
BACKGROUND TO THE APPLICATION TO APPEAL
On 8 June 2022 Belinda Templeton lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Robert Kuru, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 11 May 2022.
Ms Templeton relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act):
· the assessment was made on the basis of incorrect criteria, and
· the MAC contains a demonstrable error.
The delegate was satisfied that, on the face of the application, at least one ground of appeal was made out, being that the MAC contains a demonstrable error. We conducted a review of the original medical assessment but limited to the grounds of appeal on which the appeal is made.
The WorkCover Medical Dispute Assessment Guidelines 2018 set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with the WorkCover Medical Assessment Guidelines 2018.
The assessment of permanent impairment is conducted in accordance with the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed reissued 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
RELEVANT FACTUAL BACKGROUND
Ms Templeton was employed as a correctional officer. In the period between 25 July 2016 to 7 August 2016 performed patrol duties for seven out of ten shifts, requiring her to patrol the prison for the duration of her shift, wearing heavy, stiff boots and walking on concrete floors. As a result of performing those duties, she suffered an injury to her right ankle which is deemed to have been suffered on 19 August 2016.
As a result of her altered gait during the rehabilitation process, Ms Templeton suffered a consequential condition in her left ankle. Ms Templeton was subsequently diagnosed with Complex Regional Pain Syndrome (CRPS).
The Medical Assessor was asked to assess Ms Templeton’s whole person impairment (WPI) in respect of her right and left lower extremities. The referral prepared by the Personal Injury Commission (the Commission) omitted to refer her claim for scarring.
The Medical Assessor assessed 4% WPI being 4% in respect of the right lower extremity and 0% in respect of the left lower extremity. He did not assess Ms Templeton for CRPS.
PRELIMINARY REVIEW
We conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the WorkCover Medical Assessment Guidelines 2018.
As the President’s delegate noted, the error in the referral would not be the proper subject of a medical appeal but the delegate amended it to so that we can consider it.
As a result of our preliminary review, we determined that the worker should undergo a further medical examination because the Medical Assessor was in error not to consider a diagnosis of CRPS. An examination was also required for the assessment of scarring.
Dr Stephenson of the Appeal Panel conducted an examination of the worker on 14 September 2022 and reported to us. His report forms part of these reasons.
EVIDENCE
We have all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.
The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but we have considered them.
In summary, and in submissions prepared by Ms Compton of counsel, Ms Templeton submitted that the referral contained an error because the Medical Assessor was not asked to assess scarring. She also submitted the Medical Assessor did not assess CRPS as required by Chapter 17 of the Guidelines. Though the Medical Assessor said that he did not make findings consistent with the criteria for CRPS, Ms Templeton said that he did not provide reasons and did not say that he had considered Table 17.1.
The third error relied on by Ms Templeton was that the Medical Assessor did not assess her left ankle, despite the referral. She also said that he declined to make an assessment under Table 17.37 of AMA 5 because he did not find impairment in the distribution of specific peripheral nerve branches but failed to provide his reasoning.
In reply, Corrective Services conceded that scarring was not referred to the Medical Assessor and that neither party told the Commission that there was an error in the referral. While not conceding that there was a demonstrable error, Corrective Services said that the issue could be cured by asking the Medical Assessor to reconsider the certificate.
Corrective Services said that Ms Templeton had not shown that the Medical Assessor applied incorrect criteria. The Medical Assessor was required to make a diagnosis and to set out his examination findings. Corrective Services said that if the Medical Assessor had identified the signs of CRPS he would have noted them but did not. Corrective Services said that the Medical Assessor was entitled to assume that there was no impairment of the left lower extremity if he did not diagnose CRPS 1.
FINDINGS AND REASONS
The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
In Campbelltown City Council v Vegan[1] the Court of Appeal held that an Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
The MAC
[1] [2006] NSWCA 284.
The Medical Assessor set out the history of Ms Templeton’s injury, noting the treatment that she underwent for her right ankle. He described her symptoms but only in relation to “the ankle” and made no specific reference to her left leg.
The Medical Assessor set out his findings on examination and said:
“There was a 7cm, well healed scar on the lateral aspect of the Achilles insertion extending into the heel on the right hand side. There is subjective sensory change in the lateral portion of the heel, at the inferior portion of the incision, on the dorsum over the first metatarsophalangeal joint which was not confined to the anatomical distribution of a particular nerve.”
The Medical Assessor set out the range of motion he observed. He said that he was not able to review any imaging.
His diagnosis was:
“Ms Templeton sustained an injury to her right ankle at work, ultimately diagnosed as retrocalcaneal bursitis and Achilles tendinitis. She has had 2 surgical procedures for this which unfortunately have not been helpful. She has gone on to develop similar pain in the left hind foot.”
The Medical Assessor explained his calculations:
“Ms Templeton has some restricted range of motion in her right hind foot subsequent to the 2 surgical procedures. She has been assessed according to AMA-5, page 537, Table 17-11 and Table 17-12 to give an 11% lower extremity impairment. This converts to a 4% whole person impairment.
As indicated above, I did not find sensory deficit in the distribution of a specific nerve for assessment of impairment for a nerve injury. I did not make findings consistent with the criteria for the diagnosis of a chronic regional pain syndrome.”
Scarring
Because the errors made by the Medical Assessor warranted a re-examination, the scarring was considered by Dr Stephenson at the re-examination and we adopt his assessment.
CRPS
The criteria for the assessment of CRPS in chapter 17 of the Guidelines are detailed and required more detailed consideration than the Medical Assessor afforded them. While a Medical Assessor is not required to give detailed reasons, he or she must set out the path of reasoning. In any case where a treating or qualified doctor has made or discounted the diagnosis of CRPS, the Medical Assessor is required to consider the criteria in some detail.
The Guidelines provide:
“Table 17.1 is used to determine if complex regional pain syndrome (CRPS) is a rateable diagnosis. It is important to exclude diagnoses that may mimic CRPS, such as disuse atrophy, unrecognised general medical problems, somatoform disorders and factitious disorder. Once the diagnosis is established, assess impairment as in AMA5.
For Complex Regional Pain Syndrome Type 1 (CRPS1) to be present for the purposes of assessment:
· the diagnosis is to be confirmed by criteria in Table 17.1
· the diagnosis has been present for at least one year (to ensure accuracy of the diagnosis and to permit adequate time to achieve maximum medical improvement)
· the diagnosis has been verified by more than one examining physician
· other possible diagnoses have been excluded.
· CRPS1 is to be assessed as follows:
Apply the diagnostic criteria for complex regional pain syndrome type 1 (Table 17.1).
Table 17.1 Diagnostic Criteria for Complex Regional Pain Syndrome types 1 and 2
1. Continuing pain, which is disproportionate to any causal event.
2. Must report at least one symptom in each of the four following categories:
· Sensory: Reports of hyperaesthesiae and/or allodynia.
· Vasomotor: Reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry.
· Sudomotor/oedema: Reports of oedema and/or sweating increase or decrease and/or sweating asymmetry.
· Motor/trophic: Reports of decreased range of joint motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
3. Must display at least one sign* at time of evaluation in all of the following four categories:
· Sensory: Evidence of hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement).
· Vasomotor: Evidence of temperature asymmetry and/or asymmetric skin colour changes.
· Sudomotor/oedema: Evidence of oedema and/or sweating asymmetry.
· Motor/trophic: Evidence of decreased active joint range of motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
4. There is no other diagnosis that better explains the signs and symptoms.
*A sign is included only if it is observed and documented at time of the impairment evaluation.Then consider the following in assessing CRPS1:
· If the criteria in each of the sections 1, 2, 3 and 4 in Table 17.1, above, are satisfied, the diagnosis of CRPS1 may be made.
· Rate the extremity impairment resulting from loss of motion of each individual joint involved.
· Rate the extremity impairment resulting from sensory deficits and pain, according to the grade that best fits the degree or amount of interference with ADL, as described in AMA5 Table 16.10a (p 482). Use clinical judgement to select the appropriate severity grade and the appropriate percentage from within the range shown in each grade. The maximum value is not automatically applied. The value selected represents the extremity impairment. A nerve value multiplier is not used.
· Combine the extremity impairment for loss of joint motion with the impairment for pain or sensory deficit using the Combined Values Chart (AMA5, p 604) to obtain the final extremity impairment.
· Convert the final extremity impairment to WPI using AMA5 Table 16.3, (p 439) for the upper extremity and AMA5 Table 17.3 (p 527) for the lower extremity.”
In Elsworthy v Forgacs Engineering Pty Ltd[2] Fagan J noted the four diagnostic criteria in chapter 17 are:
(a) diagnosis is confirmed by Table 17.1;
(b) present for at least one year;
(c) verified by more than one examining physician, and
(d) other possible diagnoses have been excluded.
[2] [2018] NSWSC 1638.
His Honour said
“[8] Chapter 17 of the Guidelines is entitled ‘Evaluation of permanent impairment arising from chronic pain (exclude AMA5 Chapter 18)’. Clause 17.5 includes the following:
17.5 … Table 17.1 is used to determine if complex regional pain syndrome (CRPS) is a rateable diagnosis. It is important to exclude diagnoses that may mimic CRPS, such as disuse atrophy, unrecognised general medical problems, somatoform disorders and factitious disorder. Once the diagnosis is established, assess impairment as in AMA5.
…
[41] … Of the four requirements a-d at the commencement of the criteria for consideration of CRPS, item a is that the AMS should confirm the diagnosis by application of the criteria in Table 17.1. Undoubtedly those criteria are strict and demanding. The Guidelines state at length in cll 17.1-17.5 why these strict criteria have been adopted, including the following:
17.3 [P]ain is a subjective experience and is, therefore, open to exaggeration or fabrication in the compensation setting. Assessment depends on the credibility of the subject being assessed. In order to provide reliability, applicants undergoing pain assessments require more than one examiner at different times, concordance with the established conditions, consistency over time, anatomical and physiological consistency, agreement between the examiners and exclusion of inappropriate illness behaviour.
[42] I construe the word ‘diagnosis’ in items a-d as having the same meaning each time it appears. That is, it refers to a diagnosis arrived at by application of the criteria in Table 17.1, as item a explicitly states. This means that for CRPS to be present for the purposes of assessment it must have been diagnosed according to those criteria for at least one year and the diagnosis must have been verified according to those criteria by more than one examining physician. Not only does the language of items a-d indicate, by the undifferentiated use of the word ‘diagnosis’, that the diagnosis over at least one year and the diagnosis by more than one physician must all be according to the Guidelines but, further, this construction addresses the explicit concern stated in cl 17.3. That concern would not be met if items b-d could be satisfied by other physicians’ diagnoses, spanning a year or more, made according to undefined criteria, perhaps less stringent than those of Table 17.1. This consideration supports the construction I have adopted.”
The Medical Assessor gave extremely cursory consideration to the diagnosis and did not review the Guidelines in detail. His references to the distribution of a specific nerve suggest that he conflated the diagnoses of CRPS 1 and CRPS 2 in the Guidelines. A diagnosis of CRPS 1 does not require impairment of impairment in the distribution of a specific nerve if the diagnostic criteria are met.
CRPS was diagnosed by Ms Templeton’s treating doctors Dr Lunz and Dr Crowle and described extensively in their reports. It was referred to in the reports of other practitioners.
Dr Lai diagnosed CRPS - even though telehealth examinations would not have permitted him to make it properly. Dr Machart said that he did not observe CRPS.
The Medical Assessor mentioned only Dr Lai and Dr Machart’s reports in the MAC. The Medical Assessor did not say that he had considered the reports of the treating doctors at all. Proper preparation for the assessment required the Medical Assessor to read the reports of the treating doctors and the reports of Drs Lunz and Crowle should have alerted him to carefully consider the diagnostic criteria in Chapter 17.
A re-examination was therefore necessary and we adopt Dr Stephenson’s findings and detailed reasoning.
Left lower extremity
The Medical Assessor noted that Ms Templeton has developed pain in her left foot similar to that in the right. It appears that he did not assess any impairment because he did not diagnose CRPS.
For these reasons, the Appeal Panel has determined that the MAC issued on 11 May 2022 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.
REPORT OF THE EXAMINATION BY APPROVED MEDICAL SPECIALIST MEMBER OF THE APPEAL PANEL
Matter No: 191880
Appellant: Belinda Templeton
Respondent: Department of Communities and Justice, Corrections Officer
Examination Conducted By: Dr J Brian Stephenson and member of the Appeal Panel
Date of Examination: 14 September 2022
I note there was a recent ultrasound right ankle/or hind foot 20 May 2022.
This re-examination was conducted 14 September 2022, 12 noon to 1 pm.
Personal Details
Belinda Templeton, date of birth – 21 November 1975, aged 46 years, right-handed. She has been under the care of Dr Matthew Crawford, Pain Physician.
In the appeal there is a reference to plantar fasciitis. In that regard I refer to page 507 of AMA-5, paragraph 16.7d tendinitis, regarding several syndromes involving the upper extremity, variously attributed to tendinitis, fasciitis or epicondylitis. This reference also applies to lower extremity in terms of plantar fasciitis. In that regard, the reference is paragraph 16.7d. Although these conditions may be persistent for some time, they are not given a permanent impairment rating unless there is some other factor that must be considered.
In that regard, on this occasion I found a full range of motion of the left ankle and hind foot and no impairment there, the medical assessor had no impairment in the left lower extremity.
This examination confirmed the presence of complex regional pain syndrome type 1, and I will follow through the assessment and the examination findings in that regard.
The reference in the WorkCover guidelines is the well-known table 17.1 diagnostic criteria for complex regional pain syndrome.
Table 17.1 is in page 81 of the Guidelines.
However, the last section of page 80, on that page is headed Section 17, evaluation of permanent impairment arising from chronic pain. That is not the assessment relevant in this case but at the foot of the page, the section is important as follows: For complex regional pain syndrome type 1 (CRPS 1) to be present for the purpose of the assessment.
The diagnosis is to be confirmed by criteria in Table 17.1.
The diagnosis has been present for at least one year (to ensure accuracy of the diagnosis and to permit adequate time to achieve maximum medical improvement).
The diagnosis has been verified by more than one examining physician.
Other possible diagnoses have been excluded.
CRPS-1 is to be assessed as follows.
Apply the diagnostic criteria for complex regional pain syndrome type 1, table 17.1.
I will refer to that table and the examination findings shortly.
Meanwhile, three specialists have referred the diagnosis of CRPS-1. Dr David Lunz, 28 November 2018, referred to his operation report on Ms Belinda Templeton, date of surgery 28 November 2018, Prince of Wales Private, operation – exploration and debridement of right Achilles wound with removal of suture mass, retrocalcaneal bursa and exostectomy of the posterior calcaneus.
Reference to CRPS-1
Dr David Lunz, 12 March 2018, referring this patient to Dr Matthew Crawford, Pain Management, Prince of Wales Private Hospital. Belinda Templeton has CRPS affecting the right foot and ankle following surgery 12 months ago. She has allodynia and increased sweating on that side. She has a tender scar. I would appreciate your assessment and management. Dr David Lunz.
Comment: Allodynia is one of the four required diagnostic criteria.
Point 1: Allodynia and hyperesthesia must be found both regarding symptoms and signs.
Sweating asymmetry is point 3 of the required symptoms and signs under sudomotor/oedema.
Following injury to right foot in 2011, there was initially physiotherapy, then referral to Dr Host, Orthopaedic Surgeon, Bathurst, who operated with an osteotomy and ostectomy for Haglund’s bony deformity of the right heel. Pain and swelling developed after that and she was referred on to Dr Crawford, Pain Specialist. He referred her to Dr Lunz, who operated her on 29 November 2018, as I have noted above.
The recent ultrasound of right ankle and hind foot of 20 May 2022, referred to above, confirmed right Achilles tendinitis and right plantar fasciitis which are pre-existing conditions, and referred to the methodology of assessment for right plantar fasciitis, there is also complaint for the left foot. It is appropriately managed conservatively. The Achilles tendinitis was a diagnosis following the initial injury.
Five days ago on Friday, Belinda Templeton was crossing a road and she suddenly had to quicken up her pace to avoid an approaching car. She stated she put her right foot down hard. Because of the discomfort in the right foot and ankle, she attended the Prince of Wales Hospital Emergency where an x-ray excluded a fracture.
Hence the ultrasound study was undertaken 20 May 2022. Interpretation: Right Achilles tendinitis and right plantar fasciitis. Dr Dang Lam, Radiologist.
The worker's medical history, where it differs from previous records
I have noted the worker’s medical history where it differs from previous records, due to a long walk on patrol at Wellington Prison, developing pain right foot.
Additional history since the original medical assessment certificate was performed.
This is significant and refers to 3, the findings on clinical examination, which include the history of the symptoms and then the findings of the symptoms, both of which relate to the finding of CRPS-1 of right lower extremity.
Findings on clinical examination.
These are set out on page 2.
Results of any additional investigations to original medical assessment certificate.
I have noted the recent ultrasound right foot and ankle noted above. In that regard, it was not my opinion that that incident materially aggravated or exacerbated or increased the impairment rating which relates to a diagnosis of CRPS-1.
Three Specialist Opinions
I confirm their findings which point to a diagnosis of CRPS-1 and look at different aspects of the diagnostic criteria.
As I have noted, Dr Crawford found allodynia and hyperalgesia. He also found marked increase in deep pressure sensation. Allodynia and hyperalgesia are point 1 of the symptoms and signs of CRPS-1.
Dr Louise Crowle, Occupational Physician, 29 August 2019.
Summary of Presenting Medical Factors/Injuries
Chronic right ankle pain in association with limited presentation of Achilles tendinitis and complicated by chronic pain with features of complex regional pain syndrome.
Treatment includes involvement of two orthopaedic surgeons, surgeries of April 2017 Dr Host, surgery November 2018 Dr Lunz, steroid injections, physical therapy with adjustment of pain modifying medications, pain specialist review Dr Crawford, psychiatric review Dr Reznik.
Dr David Lunz 12 March 2018 to Dr Crawford.
CRPS affecting her right foot and ankle. She has allodynia and increased sweating on that side. Allodynia is point 1 sensory and sweating is point 3 sudomotor/oedema.
Conclusion
In my opinion the requirements for CRPS type 1 as set out at chapter 17, page 80 of the Guidelines are met and I have referred to the three specialists involved. Note that each have not been required to make an assessment of CRPS-1 but I am required to do so.
Reference page 80, table 17.1, diagnostic criteria for complex regional pain syndrome type 1.
There is continuing pain which is disproportionate to any causal event.
Must report at least one symptom in each of the following four categories.
There is report of hyperesthesia and allodynia, right lower extremity.
Vasomotor. There is a report of temperature asymmetry with coolness of right foot and leg and reports skin colour changes with a purplish hue developing on dependency of the foot, as it is removed from the Cam boot she is temporarily wearing. There are skin colour changes reported and also skin colour asymmetry.
Sudomotor/oedema. There is reported oedema with swelling of the foot and also sweating increase and sweating asymmetry. The right sock was damp from the sweating. She is aware of the right sock being damp from the sweating when removed.
Motor/trophic. Reports decreased range of joint motion, right lower extremity.
Must display at least one sign at the time of evaluation of all the following four categories.
Sensory. There is hyperalgesia to pinprick using the Neurotip device. There is allodynia to light touch. There is allodynia to deep somatic pressure at the calf and there is reduced joint movement in the large joints of the right lower extremity extending to the toes.
Vasomotor. There is evidence of temperature asymmetry, the right foot and leg are cooler than the left. There are asymmetric skin colour changes with a purplish hue developing on dependency.
Sudomotor/oedema. There is evidence of oedema with pitting oedema about the ankle and there is evidence of sweating asymmetry with a damp sock noted on removal from the right foot.
Motor/trophic. There is evidence of decreased active range of motion in the large and small joints of the right lower extremity.
There is no other diagnosis that better explains the signs and symptoms.
Range of Motion Findings Right Lower Extremity
At the right ankle there is reduced range of motion.
Right Ankle
Range of Motion
Plantar Flexion
10° only
Extension
0°
Inversion
10°
Eversion
10°
On examination, I confirmed the diagnosis of CRPS-1. Examination of right lower extremity range of motion for right hip, knee, ankle, hind foot and toes. Reference AMA-5 page 537, table 17-9 hip motion impairment paragraph, table 17-10 knee impairment paragraph, table 17-11 ankle motion impairment, table 17-12 hind foot impairment estimates and table 17-14 toe impairments.
On examination right hip, AMA-5 page 537, table 17-9.
Right Hip
Range of Motion
LEI
External Rotation
20°
5%
Internal Rotation
30°
0%
Abduction
40º
0%
Adduction
20º
0%
Flexion
120º
0%
Extension
20º
0%
The 5% lower extremity right hip is found.
Right knee table 17-10, page 537, flexion contracture 15 degrees equals moderate, 20% lower extremity. Flexion 105 degrees equals less than 110 degrees equals mild 10% lower extremity.
Right hip 5% lower extremity, then the right knee by addition we have 30% lower extremity, adding 20 with 10.
Right ankle and hind foot, table 17-11 and table 17-12, page 537.
Right Ankle
Range of Motion
LEI
Extension
10º
7%
Flexion
10º
7%
Total ankle is 14% lower extremity.
Hind foot inversion 10 degrees 2% lower extremity, hind foot eversion 10 degrees 2% lower extremity. By addition 4% lower extremity.
Hind foot and ankle values are added, reference page 10 AMA-5, the addition of 14 with 4 gaining 18% lower extremity.
Reference now to toes, AMA-5 page 537, table 17-14, toe impairments.
Great toe metatarsophalangeal joint extension equals 0 equals less than 15 degrees equals 5% lower extremity.
Great toe interphalangeal joint flexion 10 degrees equals less than 20 degrees equals 2% lower extremity.
Total toes impairment equals 7% lower extremity.
Now the combined values from greater through lesser, combining right knee 30% lower extremity, combined knee 30% with ankle 18%, toes 7% and hip 5%.
The lower extremity values are combined in descending order, that is right knee 30% with right ankle 18%, toes 7% and hip 5%, total combined value of 13, 18, 7 and 5 is 49% lower extremity.
I find 49% lower extremity for range of motion loss right lower extremity. That combines with the pain classification reference page 482 table 16-10a. The clinical findings are consistent with grade 3, that is distorted superficial tactile sensibility (diminished light touch and two-point discrimination) with some abnormal sensations or slight pain that interferes with some activities. The range is 26% to 60%. A nerve multiplier not used when the maximum is chosen at 60% sensory deficit.
We then combine 60% lower extremity with 49% lower extremity for range of motion loss. The combination of 60 with 49 gains 80% lower extremity. 80% lower extremity converts to 32% Whole Person Impairment. Maximum medical improvement has been achieved. Impairment for plantar fasciitis left lower extremity (foot), I find 1% WPI for plantar fasciitis.
There is no deductible proportion under Section 323 in the absence of previous injury, condition or abnormality.
That is consistent with the requirement of page 80 CRPS-1, WC Guidelines.
The diagnosis is confirmed by criteria in table 17.1.
The diagnosis has been present for at least one year to ensure accuracy of the diagnosis and to permit adequate time to achieve maximum medical improvement.
The diagnosis has been verified by more than one examining physician, in fact three in this instance.
Other possible diagnoses have been excluded.
For example, Dr David Lunz, dated 12 March 2018, referred Ms Templeton to Dr Matthew Crawford, Pain Management.
Dr Louise Crowle, Occupational Physician, 29 August 2019, referred to presenting medical factors/injuries.
Chronic right ankle pain associated with initial presentation of Achilles tendinitis and complications by chronic pain with features of complex regional pain syndrome, CRPS.
Dr Matthew Crawford, who advised anti-neuropathic pain medication, 20 March 2018, noting a marked increase in deep pressure sensation.
For scarring, I noted approximately 6 cm linear scar at the posterior aspect of the right heel and the best fit following the TEMSKI table is 1% Whole Person Impairment, reference WorkCover Guidelines, chapter 14, table 14.1.
Before the final assessment, the 49% lower extremity for range of motion loss combines with 60% for CRPS1. The combination now of 60% with 49% lower extremity still gains the 80% lower extremity value and therefore that then combines with 1% Whole Person Impairment for the plantar fasciitis left heel. I have noted 80% lower extremity converts to 32% Whole Person Impairment for the total right lower extremity and that combines with 1% Whole Person Impairment for the TEMSKI table for the left lower extremity. The combination of 32 with 1 gains 33% Whole Person Impairment. There is no deductible portion.
For opposite left foot plantar fasciitis, because there are persistent symptoms and clinical findings after 18 months, this is rated at 2% LEI (1% WPI), reference WorkCover Guidelines paragraph 3.28. These conditions may be present for some time best treated by comfortable shock absorbing footwear. That 1% WPI combines with 33% WPI for CRPS 1, gaining 34% WPI in total.
PERSONAL INJURY COMMISSION
APPEAL PANEL
MEDICAL ASSESSMENT CERTIFICATE
Injuries received after 1 January 2002
Matter Number: | W1194/22 |
Applicant: | Belinda Templeton |
Respondent: | Corrective Services NSW |
This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.
The Appeal Panel revokes the Medical Assessment Certificate of Dr Robert Kuru and issues this new Medical Assessment Certificate as to the matters set out in the Table below:
Table - Whole Person Impairment (WPI)
| Body Part or System | Date of Injury | Chapter, page and paragraph number in WorkCover Guides | Chapter, page, paragraph, figure and table numbers in AMA 5 Guides | % WPI | Proportion of permanent impairment due to pre-existing injury, abnormality or condition | Sub-total/s % WPI (after any deductions in column 6) |
| Right lower extremity | 19 August 2016 | Chapter 17 | N/A | 32% | 0 | 32% |
| Left lower extremity | 19 August 2016 | Paragraph 3.28 | N/A | 1% | 0 | 1% |
| Skin (TEMSKI) | 19 August 2016 | Chapter 14 | N/A | 1% | 0 | 1% |
| Total % WPI (the Combined Table values of all sub-totals) | 34% | |||||
0