Youi Pty Limited v Green

DETERMINATION OF REVIEW PANEL
CITATION:	Youi Pty Limited v Green [2025] NSWPICMP 425
CLAIMANT:	Margy Green
INSURER:	Youi Pty Limited
REVIEW PANEL
MEMBER:	Susan McTegg
MEDICAL ASSESSOR:	Sophia Lahz
MEDICAL ASSESSOR:	Christopher Oates
DATE OF DECISION:	18 June 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); claimant suffered injury in a motor vehicle accident; Medical Assessor (MA) certified injuries to the right knee and head caused by the accident were soft tissue injuries and therefore threshold injuries; he certified injury to the left knee was not a threshold injury; application for review by insurer; MRI following accident showed no acute tear of medial meniscus; acute tear of medial meniscus shown on MRI scan of 14 May 2024; Held – injury to head was soft tissue injury with no evidence of traumatic brain injury; accident caused soft tissue injury to both knees; acute tear of the medial meniscus of the left knee not caused by accident; soft tissue injury of head and both knees all threshold injuries; MAC revoked.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION ASSESSMENT OF THRESHOLD INJURY Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Review Panel revokes the certificate of Medical Assessor Ian Cameron dated 5 October 2024 and certifies that the following injuries caused by the accident were threshold injuries for the purpose of the MAI Act: · right knee – soft tissue injury; · left knee – soft tissue injury, and · head – soft tissue injury.

STATEMENT OF REASONS

INTRODUCTION

On 17 June 2023 Margaret Green (the claimant) was driving her vehicle down Willarong Road, South Caringbah when a small tipper truck pulled out of a driveway. The claimant braked and swerved but was unable to avoid a collision (the accident).
Youi Limited is the relevant insurer with liability to pay statutory benefits to Ms Green under the Motor Accident Injuries Act 2017 (MAI Act).
On 27 July 2023 Ms Green lodged an Application for personal injury benefits with the insurer in which she listed her injuries as whiplash, knee pain, bruising and concussion.[1]
[1] Insurer’s documents p 16.
Under the provision of the MAI Act in force at the time of the accident the statutory benefits for treatment and care cease after 52 weeks if “the person’s only injuries resulting from the motor accident were threshold injuries”.[2]
[2] Section 3.28 of the MAI Act.
Ms Green was 56 years of age at the date of accident and is now 57 years of age.

Threshold injury dispute

On 29 February 2024 the insurer determined that Ms Green had sustained a threshold injury and denied liability for statutory benefits beyond 52 weeks after the accident.
On 20 March 2024 Ms Green sought an Internal Review of the threshold injury decision and on 8 April 2024 the insurer affirmed the determination that the claimant’s injuries met the definition of a threshold injury.[3]
[3] Insurer’s bundle p 13.
Ms Green filed an application in the Personal Injury Commission (Commission) in respect of the threshold injury dispute.
Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be a medical assessment matters, including whether the injury caused by the motor accident is a threshold injury for the purposes of the MAI Act.

A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[4]
[4] Section 7.20 of the MAI Act.

THRESHOLD INJURY – STATUTORY PROVISIONS

The Motor Accident Injuries Amendment Act 2022 (the MAI Amendment Act) was assented to on 28 November 2022 with various amendments commencing on 1 April 2023. From 1 April 2023 the MAI Amendment Act provides that a “minor injury” is known as a “threshold injury” and “minor injuries” are known as “threshold injuries”.
Any reference in these reasons to “minor injury” is a reference to a “threshold injury”.
A threshold injury is defined in s 1.6 of the MAI Act and includes a “soft tissue injury” or a “psychological or psychiatric injury that is not a recognised psychiatric illness”. Section 1.6(2) of the MAI Act defines a “soft tissue injury” as:
“[A]n injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”
Section 1.6 provides that regulations may be made to exclude or include a specified injury from being a threshold injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) further defines threshold injury to include “an injury to the spinal nerve root that manifests in neurological signs (other than radiculopathy)”.
Part 5 of the Motor Accidents Guidelines (the Guidelines) are made pursuant to s 10.2 of the MAI Act. The Guidelines contain the procedure for assessing whether an injury caused by the motor accident is a threshold injury for the purposes of the MAI Act. Version 9.3 of the Guidelines commenced on 6 December 2024 and applies to motor accidents occurring on or after 1 December 2017. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly provide:
“5.3   The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological or psychiatric injury caused by the motor accident.
5.4    Insurers should not require injured persons to undergo diagnostic imaging for the purpose of the insurer determining whether the injury related to the claim is a threshold injury. Diagnostic imaging is not considered necessary to assess threshold injury.
5.5    A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.
5.6      The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:
(a) a comprehensive accurate history, including pre-accident history and pre-existing conditions
(b) a review of all relevant records available at the assessment
(c) a comprehensive description of the injured person’s current symptoms
(d) a careful and thorough physical and/or psychological examination
(e) diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”
In Briggs v IAG Limited trading as NRMA Insurance[5] his Honour Justice Wright stated at [35]:
[5] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372.
“The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:
‘Causation of injury
6.5An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
6.6Causation 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.
6.7There 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.”

DOCUMENTS CONSIDERED BY THE REVIEW PANEL

The Review Panel (Panel) issued a Direction to the parties on 17 December 2024. The insurer was directed to upload to the portal an indexed and paginated bundle of all documents sought to be relied upon in the review by 30 January 2025. In accordance with this Direction the solicitor for the insurer uploaded to the portal a bundle of documents paginated from pages 1 to 143 (insurer’s documents).
The claimant was directed to upload to the portal an indexed and paginated bundle of all documents relied upon in the review by 13 February 2025. On 20 February 2025 the claimant advised the Commission all documents had been lodged with the Commission, and she had no further evidence to submit although she sought confirmation that the Panel had access to her letter dated 17 November 2024. The Panel assumes the letter dated 17 November 2024 refers to the submissions contained in the Reply filed by the claimant.
In response to a direction from the Panel the insurer uploaded the following additional records to the portal together with an Application to Lodge Additional Documents (ALAD 13 May 2025):
(a)     the imaging report relating to the MRI scan of 4 November 2011;
(b)     clinical notes of Burraneer Family Practice including the clinical notes of Dr Emanuel Papapetros and Dr Kylie Partlin relating to treatment of the claimant in the period two years pre accident to date, and
(c)     clinical notes of the physiotherapist Mr Travis Adelerhof for the period 1 January 2024 to date.

MEDICAL ASSESSMENT UNDER REVIEW

Medical Assessor Cameron issued a certificate dated 5 October 2024 in which he certified that the following injuries caused by the accident were threshold injuries for the purpose of the MAI Act:
· right knee – soft tissue injury, and
· head – soft tissue injury.[6]
[6] Insurer’s documents p 124.
He certified the following injury was not a threshold injury for the purposes of the MAI Act:
· left knee – soft tissue injury.
The injuries referred for assessment to Medical Assessor Cameron were as follows:
· right and left knee injury, and
· brain injury – concussion.
Medical Assessor Cameron reported a left anterior cruciate ligament (ACL) repair in 1995, an
Achilles tendon repair in 1995, a right medial meniscectomy in 1998 and another Achilles tendon repair on the other side in 2005.
Medical Assessor Cameron reported Ms Green said she did not lose consciousness, she had a “hysterical reaction”, and she “froze”. He reported she was assessed at Sutherland Hospital and was unwell after returning home. She has nausea, vomiting and headache. She consulted her general practitioner (GP) Dr Partlin who diagnosed concussion. She returned to work the following week.
On examination he noted Ms Green was 171cm in height and weighed 120kg. Medical Assessor Cameron found no cognitive impairment and reported Ms Green scored 30/30 on Mini Mental State Examination. Medical Assessor Cameron found a full range of motion at both knees, clicks and crepitus at both knees but no instability. He found no neurological abnormalities in the lower extremities. No gait abnormality was detected. Circumferences of the lower extremities were 57cm above the right and left knee and 41cm below the right and left knee.
Medical Assessor Cameron reviewed the MRI of the knees dated 15 August 2023, the Ambulance Report, the discharge summary from Sutherland Hospital, the reports of Dr Seeto, the MRI of the brain dated 14 September 2023, and the report of Dr Partlin dated 1 September 2023 (presumably the referral by Dr Partlin to Dr Wardman dated 1 September 2023).
Medical Assessor Cameron concluded Ms Green did not sustain a traumatic brain injury but may have sustained a soft tissue injury to the head.
In relation to the knees he stated:
“It is plausible that there was a meniscal injury at the left knee in the subject motor vehicle crash, in view of forced contraction and compression of a degenerative meniscus. It is noted that the imaging study suggested a recent injury to the meniscus. There is evidence of pre-existing degenerative changes in both knees with osteoarthritis.”
In assessing threshold injury Medical Assessor Cameron stated:
“The injury to the left knee is not a threshold injury because there had been an injury (that can be termed a “rupture”) to the meniscus which is composed of cartilage”.

REVIEW PROCEDURE

The insurer lodged an application for review of the assessment of Medical Assessor Cameron within 28 days of the date on which the certificate of Medical Assessor Cameron was made available to the parties.
On 12 December 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 Panel.[7]
[7] Insurer’s documents p 141.
Part 5 of the Personal Injury Commission Act, 2020 (PIC Act) enables the Commission to make rules with regard to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.[8]
[8] Section 41(2) of the PIC Act.
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 proceedings solely based on the written application.[9]
[9] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned.
On 17 March 2025 the Panel concluded an in person medical re-examination was not required, however, a teleconference was required to obtain from Ms Green further history.

EVIDENCE
Photographs

Twenty-two photographs of the claimant’s vehicle, a red Hyundai i20 show significant damage to the front and the front passenger side of the vehicle.[10]
[10] Insurer’s documents pp 21-44.

Treating medical records

On 24 October 2022 Dr Kylie Partlin of Burraneer Family Practice reported Ms Green was thinking about the National Disability Insurance Scheme (NDIS) although she was unsure if she qualified. Dr Partlin recorded right flank, mid back pain for years.[11] She also noted a lot of joint pains, right knee and left hip. The reason for the visit was describe as “eating disorder, fatty liver”. On examination Dr Partlin reported “R knee no joint line pain”. Ms Green was referred for an X-ray of her right knee and left hip.
[11] ALAD 13 May 2025 p 15.
The report of the NSW Ambulance Service describes an attendance at the scene of an accident on 17 June 2023 involving a collision between a car and a small tipper truck. The report states:
”… History of events – Pt was driving at approx. 50kms/hr when the tipper pulled out of a driveway, the pt states she tried to swerve and brake to avoid the tipper however couldn’t avoid the collision, nil airbag deployment, pt was wearing a seatbelt, no cabin intrusion, Pt states nil LOC/headstrike, pt states she was still in the car because she was shocked not due to entrapment or pain, pt able to ambulate from vehicle to stretcher. OE A – patent and maintaining own, B – spontaneous and unlaboured, speaking in full sentences, RR and Sats BTF, chest sound clear, equal rise and fall of chest, C - warm and well perfused, no active bleeding noted, pt co chest pain on left side described more as breast pain ?from seatbelt, ECG SR, HR and BP BTFs, D - GCS 15, alert and orientated, states some pain in left breast, tender on palpation, no swelling or bruising noted, pain in bilateral knees, more so in left, able to weight bare as normal, offered paracetamol and ibuprofen which the pt has politely declined at this point, nil c-spine tenderness/headache/nausea/vomiting/dizziness …”.[12]
[12] Insurer’s documents p 4.
The report of Sutherland Hospital noted following the accident Ms Green had pain in the chest and both knees.[13] It was noted there was no headstrike. On examination it was noted she was minimally tender to the patella on the left side. She was discharged home with Panadol and Nurofen as needed for pain.
[13] Insurer’s documents p 12.
Ms Green consulted Dr Partlin of Burraneer Family Practice on 23 June 2023.[14] Dr Partlin recorded:
[14] ALAD13 May 2025 p 23.
“Truck pulled out of a driveway and hit her
Hit from passenger side
Didn't see it coming
Car is a rite off Cried, couldn't stop crying
Ambulance called
Fell asleep when she got to hospital
Felt a bit disorientated
Doesn't remember all the details of the accident
Sister and Mum both thought she was a little bit weird
Left breast bruised and painful
Right knee remains painful
Slightly tender to R temporal area
Had headaches
- sharp, shooting
- middle parietal area
- lasting a few minutes
Nausea on the train on Tuesday - almost had to get off
Lower back pain
Neck pain
Feels like her body is very sensitive - toes hurt, fingers hurt”.
In a Certificate of capacity/certificate of fitness dated 27 July 2023 Dr Emanuel Papapetros, GP recorded a diagnosis as "concussion, neck pain, bilateral knee pain” as a result of the accident. Dr Partlin referred the claimant for a bilateral knee MRI and a cervical spine MRI.
In a referral for a bilateral knee MRI and cervical spine MRI dated 27 July 2023 Dr Papapetros reported the following history:
“MVA in mid-June. Since then worsening pain in neck with some throbbing of the left arm. Tender in the midline around C7 ?Disc herniation with radiculopathy. Also worsening pain in both knees.
History of arthroscopy/meniscectomy on right and ACL reconstruction on left. Right knee pain internally on weightbearing, left knee pain worse over the lateral knee joint ?LCL ligament damage.”[15]
[15] Insurer’s documents p 46.
In a referral to Dr Seeto dated 1 September 2023 Dr Papapetros noted the referral relating to the claimant’s knees noting in particular the significant pain caused by the right knee.[16]
[16] Insurer’s documents p 54.
On 1 September 2023 Dr Papapetros referred Ms Green to Dr Daniel Wardman regarding her memory loss, some name finding difficulty and repeating herself frequently. He noted her involvement in the serious accident in June which he reported resulted in a concussion and whilst the memory lapses were presented prior to the accident he reported Ms Green thought it was significantly worse since then.
On 1 August 2023 Ms Green commenced physiotherapy with Mr Stephen Cunningham of The Healthy Body Company for bilateral knee pain, cervical neck pain and central spinal pain. In a report dated 1 August 2023 he stated, “while the accident aggravated both her knees, back and neck there were already significant degenerative processes going on in all these areas”.[17] He also noted the claimant’s weight coupled with her increased work hours and report writing exacerbated the process.
[17] Insurer’s documents p 105.

On 17 May 2024 Dr Brandon Chung, GP reported left knee pain.[18] He reported:
[18] ALAD 13 May 2025 p 40.
“Left knee pain
Having a massage in Bali 2 weeks ago
Was prone and they flexed her knee and manipulated it
Felt a tear
Walked a lot on holidays
Last Monday, was walking and felt a painful pop
Could barely walk and had to be on crutches for several days
Went to TSH and Xray was clear
O/E: Appears well and comfortable Overweight Gait - relatively normal and independent Left knee: Almost full extension, flexion to 80 degrees Medial/posterior tenderness but no joint line tenderness medial joint line No significant effusion.”

Dr Bradley Seeto, orthopaedic surgeon

On 25 September 2023 Dr Seeto, noted a long history of knee problems dating back to a left knee reconstruction in about 1993 followed about six months later by a knee arthroscopy.[19] He reported the claimant underwent a right knee arthroscopy in the late 1990’s.
[19] Insurer’s documents p 65.
Dr Seeto reported over the past three to five years Ms Green had experienced pain in both knees, with the right worse than the left. The right knee pain was centrally located, present everyday and worse after walking. The left knee pain was lateral-sided, not exacerbated by walking and more intermittent in occurrence.
Dr Seeto noted plain X-rays of both knees in November 2022 showed severe medical compartment arthritis affecting the right knee. He reported the August 2023 MRI scan of the left knee showed significant retropatellar arthritis with an area of subchondral oedema and full thickness chondral loss affecting the median ridge of the patella.
Dr Seeto concluded Ms Green had bilateral knee arthritis worse on the right than the left and in a medial distribution. He recommended knee replacement.

The Healthy Body – physiotherapy records

On 1 August 2023 Ms Green commenced physiotherapy with Mr Stephen Cunningham of The Healthy Body Company for bilateral knee pain, cervical neck pain and central spinal pain. In a report dated 1 August 2023 he stated, “while the accident aggravated both her knees, back and neck there were already significant degenerative processes going on in all these areas”.[20] He also noted the claimant’s weight coupled with her increased work hours and report writing exacerbated the process.
[20] Insurer’s documents p 105.
Ms Green attended physiotherapy treatment in respect of her cervical, thoracic and lumbar spine and both knees from 9 February 2024 to 19 December 2024.[21]
[21] ALAD 13 May 2025 p 63.
On 3 May 2024 the clinical record reads:
“arrived home from bali yesterday
Last 4 days L knee has been very sore laterally/posteriorly
?increased standing/walking while on holiday
?psudo give way
No locking but very restricted movt”.[22]
[22] ALAD p 74.
On 7 May 2024 it was recorded:
“knee buckled last night and felt pop
Swollen and more sore laterally since
Using crutches.”[23]
[23] ALAD p 74.
On 10 May 2024 it was recorded:
“knee settling, able to exended better and flex quad
Still feels unsable
Using crutches.”
On 17 May 2024 it was recorded:
“knee ongoing pain has not been able to walk much
Constant ache t/o day and night
Has only been slightly better today due to resting all week.”

Imaging/investigations

MRI left knee, 4 November 2011

The comment on the report reads:
“1. Status post previous neo ACL without evidence of complication.
2. Peripheral vertical tear of the anterior root attachment of the lateral meniscus with a combined intra/superior paralabral cyst.
3. The differential diagnosis for the measured posteromedial cystic structure includes a medial gastrocnemius bursa and ganglion. …”.[24]
[24] ALAD 13 May 2025 p 2.

MRI cervical spine, 9 August 2023

The report concludes:
“There is a disc protrusion at C6/7 level contacting and slightly distorting the cord but there is no high grade neuroforaminal stenosis or central canal stenosis seen secondary to this.”

MRI both knees, 15 August 2023

The report of Dr Faisal Rashid reads:[25]
[25] Insurer’s documents p 48.
“Clinical History
History of arthroscopy/meniscectomy on right and ACL reconstruction on let. Right knee pain. Internally on weight bearing, left knee pain wore over the later knee joint? LCL ligament damage.
Technique:
Routine MRI of both knees.
Findings:
Left knee
Comparison 4/11/2011
Alignment is unchanged and unremarkable.
There is physiologic joint fluid.
A 6.8 x 1.2cm (SI x trans x A-P) complex Baker’s cyst has progressed demonstrating some superomedial decompression demonstrating loculation and septations within the posterior femoral fat pad medically deep to the sartorius distal MTJ.
Status post remote bone patellar tendon bone neo ACL with some mature scar remodelling along the line of tendon harvest and a little reactive bony overgrowth along the bone plaque harvest sites which is slightly progressed. Some stable susceptibility artefact along the femoral tunnel and tibial interference screw fixations. The neo ACL remains maturely ligamentised, and intact.
The PCL also defines normally.
The previously documented peripheral vertical tear of the anterior horn of the lateral meniscus has healed. The associated anterior parameniscal cyst has slightly changed in configuration today measuring 1.2 x 0.6 x 1.1cm(SI x AP x trans) extending into the midline. No acute tear is identified. A little nonspecific but likely degenerative signal has developed at the free edge of the body.
Lateral compartment articular cartilage, subchondral bone, the lateral collateral ligament and visualised lateral capsule remain intact.
The medial meniscus also remains intact. Medial compartment articular cartilage, subchondral bone and the visualised MCL are stable in appearance. There is trace tibial collateral and bursal fluid.
The remaining components of the extensor mechanism are intact.
Close to the superior joint line, a full thickness chondral fissure has developed at the lateral patellar facet close to the median ridge contiguous laterally with a short segment of deep surface chondral delamination measuring up to 0.2cm associated with a small focus of subchondral bone marrow oedema signal. Adjacent new 20% oblique chondral fissures just causal to the full thickness chondral fissure have also developed.
Some surface chondral fissuring at the mid medial patellar facet adjacent to the median ridge is now evident. Trochlear articular cartilage is intact allowing for a little new surface chondral fissuring at the medial joint line medical trochlea superiorly. The anterior fat pads define normally. The proximal tibiofibular articulation is intact.
The visualised static and dynamic posterolateral and posteromedial corner stabilisers define normally. No neurovascular abnormality is appreciated. Intact visualised ITB.
Comment:
1.Progressed complex Baker’s cyst.
2.Intact bone patellar tendon bone neo ACL.
3.Interval healing of the peripheral vertical tear of the anterior horn of the lateral meniscus with some change in the configuration of the associated anterior parameniscal cyst.
4.Progressed features of chondromalacia patellae (grade 2).
Right knee:
Mild static lateral patellar subluxation is evident associated with an increased lateral patellar tilt. Negligible (1cm) tibial tuberosity lateralisation.
There is physiological joint fluid in the suprapatellar pouch demonstrating synovitis.
A 1.3 x 0.7 x 1.7cm (trans x AP x S-I) ovoid sclerotic ossicle demonstrating some heterogeneous intermediate T2 signal is evident anteriorly overlying the mid lateral trochlea along the lateral joint line (series 3 image 19 and series 6 and 7 images 27). There are also two adjacent corticated marrow signal intensity intra-articular bodies measuring 0.4cm and 0.7cm within the deep midline anterior joint recess deep to the ligamentum mucosum outlined by trace fluid. Mild further loculation in the posterior joint recess where there is a synovitis and two further corticated marrow signal bodies measuring 0.4cm and 0.5cm just posterior to caudal fibres of the PCL. Minimal popliteus sheath loculation. No Baker's cyst.
There is some diminution in the volume of the medial meniscus suggesting a prior meniscectomy relatively sparing the root ligament attachments. Superimposed degenerative fraying and signal within the diminutive posterior horn, heterogeneous degenerative intrasubstance signal in the diminutive body posteriorly and blunted free edge truncation and a little heterogeneous degenerative signal within the diminutive anterior horn are evident. There is also confluent degenerative signal at the posterior horn posterior root ligament. junction and some static extrusion of the body (0.2cm) suggesting a degree of static dysfunction. Enthesophytes at the anterior ligament attachment.
Grade 4 medial femorotibial compartment OA with denudation of the medial weight bearing MFC and MTP articular cartilage extending to the medial joint line. Erosion and remodelling of the exposed subchondral plates with associated subchondral bone marrow oedema signal more confluent at the exposed medial joint line MTP with patchy involvement at the exposed MFC. Bulbous medial joint line MFC and transversely oriented MFC notch osteophytes. Tiny medial tibial spine osteophyte formation is also noted. There is medial bowing of the MCL which is otherwise intact.
There is the suggestion of a partially healed horizontal intermediate T2 signal tear involving the anterior horn of the lateral meniscus medially measuring up to 0.7cm extending to the inferior articular surface 0.5cm from the free edge.
Lateral compartment articular cartilage is preserved. There are small lateral joint line and LFC notch osteophytes. The lateral collateral ligament is intact. Intact lateral capsule.
Some degenerative signal in the PCL particularly at and proximal to its genu. Some medial displacement of the ACL by LFC notch osteophyte formation. The ACL is otherwise unremarkable.
The extensor mechanism is intact allowing for mild tendinosis at tuberosity and insertional fibres of the patellar tendon.
There is a button osteophyte at the upper medial trochlea laterally extending close to the trochlear sulcus measuring up to 0.7 x 0.6cm (SI x trans) reconstituting in the surface chondral contour. There is also a tiny deep chondral blister caudally at the medial patellar facet adjacent to the median ridge measuring 0.2cm. Marginal trochlear osteophytes larger medially. Intact anterior fat pads and proximal tibiofibular articulation.
The visualised static and dynamic posterolateral and posteromedial corner stabilisers define normally allowing for a small pes anserine bursal effusion having a depth of 0.3cm.
Draped anteromedially about the proximal tibial epiphysis, there is a 3.9 x up to 2.1 x 0.5cm (trans x SI x A-P) multiloculated septated cystic appearing structure demonstrating some synovitis (see discussion below).
Comment:
1.Small joint effusion with synovitis and multiple intra-articular bodies raising the possibility of a degree of secondary synovial osteochondromatosis in the appropriate clinical context.
2.Evidence of a prior medical meniscectomy with extensive degenerative signal, fraying and truncation of the medical meniscus associated with evidence of static dysfunction.
3.Locally advanced medial femorotibial compartment OA with up to grade 4 involvement on the background of tricompartmental involvement.
4.Old partially healed tear of the anterior horn of the lateral meniscus as detailed.
5.Pes anserine bursal effusion.
6.The complex cystic appearing structure draped anteromedially about the proximal tibia could represent a DeNovo ganglion or old dissected parameniscal cyst.”

MRI brain, 14 September 2023

The report concludes:
“There is mild cerebral hemispheric microvascular ischaemic change which is somewhat in excess of what would normally be expected. …
There is a lesion of the superficial lobe of the left parotid gland…”.[26]

MRI left knee, 14 May 2024[27]
[26] Insurer’s documents p 63.
[27] Insurer’s documents p 138.

Dr Faisal Rashid regarding the left knee reports:
“History
?ACL ? lateral meniscus. One day ago felt pop in knee, gave way. Swelling and pain lateral/posterior. History of ACL reconstruction and degenerative OA.
Technique
Routine MRI of the left knee
Comparison
9/08/2023
Findings:
Alignment is unchanged.
A small possible haemarthrosis has developed loculated in the suprapatellar pouch demonstrating some synovitis. Mild extension of the lateral meniscosynovial recess.
The moderate complex Baker’s cyst is stable, again demonstrating some superomedial loculation. Some posterior periscapsular oedema signal about the posterior oblique ligament is evident without clear periscapsular oedema signal associated with the Baker’s cyst to suggest a leak/rupture.
Since the previous study, a full thickness radial tear at the junction of the posterior horn and posterior root ligament of the medical meniscus has developed (series 7, images 11-12 and series 9, image 22 also visible on series 10, image 23) demonstrating a ‘ghost sign’. Associated static extrusion of the body by up to 0.25cm is evident.
Medial compartment articular cartilage, subchondral bone and the MCL remain intact.
There has been further healing of the peripheral vertical/longitudinal tear of the anterior horn of the lateral meniscus which is now almost indiscernible. It is again contiguous with an under surface partially healed horizontal tear of the anterior horn/anterior root ligament junction. The associated dorsal parameniscal cyst overlying the meniscocapsular junction extending to the midline has slightly change in configuration, today measuring 1.4 x 0.5cm (trans x SI x AP).
The lateral compartment articular cartilage, subchondral bone, the lateral collateral ligament and lateral capsule define normally.
The remote patellar tendon bone neo ACL remains intact with a stable appearance at the graft harvest site. Uncomplicated tunnel. Clear anterior intercondylar notch. Intact PCL.
The remaining components of the extensor mechanism define normally.
The previously documented features of Grade II chondromalacia patellae are unchanged allowing for slightly reduced bone marrow oedema signal in association with a full thickness chondral fissure at the lateral patellar facet close to the superior joint line adjacent to the median ridge.
Intact proximal tibiofibular articulation.
The visualised static and dynamic posterolateral and posteromedial stabilisers also remain intact. No neurovascular abnormality has developed.
Comment:
1.The main interval change is development of a full thickness radial tear at the junction of the posterior horn and posterior root ligament of the medial meniscus with new static dysfunction.
2.Some progressive healing of the peripheral vertical/longitudinal tear of the anterior horn of the lateral meniscus.
3.Essentially stable features elsewhere.”

SUBMISSIONS

Insurer’s submissions

The insurer provided submissions dated 19 June 2024 in reply to the threshold injury dispute. It was submitted the available evidence including the MRI of both knees dated 9 August 2023 failed to demonstrate that the claimant had sustained an accident-related fracture, nerve injury, complete or partial rupture of a tendon, cartilage, meniscus or ligament as defined by s 1.6 of the MAI Act. It was also submitted there was no evidence of radiculopathy as required by the Guidelines.[28]
[28] Insurer’s documents p 122.
The insurer provided submissions dated 29 January 2024 (2025) in support of the application for review.[29]
[29] Insurer’s documents p 1.
The insurer noted Medical Assessor Cameron found the injury to the left knee was not a threshold injury because there had been an injury (that can be termed a “rupture”) to the meniscus which is composed of cartilage. After referencing the findings of the MRI of the left knee of 14 August 2023 Medical Assessor Cameron stated:
“MRI of the left knee on 15 August 2023 is reported as showing a Baker’s cyst and intact bone patellar tendon knee OA ACL, an interval healing of a peripheral vertical tear of the anterior horn of the medial meniscus with some change in the configuration of the associated anterior parameniscal cyst, features of progressed chondromalacia”.
Further at paragraph 19 on page 5 Medical Assessor Cameron stated:
“It is plausible that there was a meniscal injury at the left knee in the subject motor vehicle crash, in view of forced contraction and compression of a degenerative meniscus. It is noted that the imaging study suggested a recent injury to the meniscus. There is evidence of pre-existing degenerative changes in both knees with osteoarthritis.”
The insurer submits the MRI of the left knee of 15 August 2023 did not record a tear of the medial meniscus of the left knee.
The insurer notes that Ms Green submitted Medical Assessor Cameron had referred to the findings of an MRI scan of the left knee dated 14 May 2024 which had not previously been seen by the insurer. The insurer notes that on page 3 of 5 of the Reply form Ms Green referred to the development of left knee symptoms in April 2024 which led to the MRI scan of 14 May 2024 and the diagnosis of a medial meniscus tear.
The insurer submits the reports for the MRI scans of 15 August 2023 (just under two months after the accident) and 14 May 2024 were both completed by Dr Faisal Rashid. The insurer submits the MRI report of 15 August 2023 does not outline any accident related complete or partial rupture of a meniscus in either knee and nor does it evidence any accident-related fracture, nerve injury, complete or partial rupture of a tendon, ligament or other cartilage.
Further, the insurer submits the report of Dr Seeto dated 26 September 2023 confirmed that Ms Green had not sustained an injury to the menisci in either knee at the time of the accident.
The insurer notes the history recorded in the report of the left knee MRI of 14 May 2024 on referral from Mr Adelerhof, physiotherapist is as follows:
“? ACL? Lateral meniscus. One day ago felt pop knee, gave way. Swelling and pain lateral/posterior. History of ACL reconstruction and degenerative OA”.
The insurer submits that the medial meniscal tear in the left knee identified in the MRI scan of 14 May 2024 was not caused by the accident.

Claimant’s submissions

The claimant’s submissions are contained in the Reply dated 17 November 2024.[30]
[30] Insurer’s documents p 134.
Ms Green submitted the impact of the accident needs to be considered when considering the injury to the knees. Ms Green stated she agreed with the statement on page 3 and para 9 of YOUI response that ‘I did not lose consciousness’ and ‘I did not hit my knees’ but submits this does not mean she did not have concussion or significant other injuries.
In relation to the concussion Ms Green states whilst her head did not contact anything, the impact was so abrupt she was thrown hard jolting her neck, knees and brain which resulted in a concussion according to her GP and physiotherapist. Ms Green states she was sent home from hospital with a concussion after being asleep for hours in a busy hospital. After waking up she did not know what was going on and when she got home, she was unsteady and confused and continued sleeping. Ms Green said she kept repeating to her husband, “something is not right” but she couldn’t explain was it was. Ms Green states her memory and concentration were impacted for several months afterwards. By the time she finally got an appointment to see a neurologist Dr Lee in November 2023 it had been six months since the accident and things had settled down.
In relation to her knees Ms Green says whilst she did not hit anything with her knees, she knew at the time of the accident the bottom half of her legs had stayed in the same space as she braced herself and the top part of her legs had gone over her shins from the force of the impact. Ms Green refers the Panel to the photographs of her vehicle to demonstrate the force of impact.

Ms Green submits she underwent all recommended treatment for her knees, but they have continued to deteriorate. In April whilst on holidays and attempting to resume normal activities Ms Green states she felt a pain to her knee although she was able to walk unaided despite the incredible ache. A few weeks later whilst walking on a flat surface on her way to work, Ms Green states there was a sharp pain, and she felt a pop. Ms Green presented to the Emergency Department at the time as the pain was excruciating and she required crutches to walk. Ms Green subsequently underwent a further MRI in May 2024 she demonstrated the full thickness radial tear in the meniscus of the left knee.
Ms Green states she required very little treatment for her knees from a physiotherapist before the accident but now requires ongoing physiotherapy for her neck and knees.
Ms Green submits that the conclusion reached by Medical Assessor Cameron as to non-threshold injury in respect of the left knee is correct.

THE MEDICAL EXAMINATION

Ms Green was assessed by Medical Assessor Lahz and Medical Assessor Oates by MS Teams video conference on 4 June 2025 as arranged. Her husband was present as a silent observer. The technology functioned satisfactorily.

History

Pre-accident medical history and relevant personal details

Ms Green and her husband live in the southern region of Sydney. She was working as a social worker in private practice.
Before the accident, she had had a left knee ACL reconstruction in approximately 1993, for an injury from playing netball. She did not go back to playing netball but did play State representative touch football after this. She also did City to Surf runs.
She recalls being knocked off a bicycle when she was a little girl and had concussion at that time.
She had non-Hodgkin’s lymphoma in 2013 and this was successfully treated.
She had an Achilles tendon repair in 1995.
She had a right medial meniscectomy in 1998 after she fell down some steps.
She had an Achilles tendon repair on the other side in 2005. The knee operations were carried out by Dr Pincevski.
The Medical Assessors asked the claimant about an MRI scan of the left knee dated 4 November 2011, ordered by Dr Shane Waddell, orthopaedic surgeon. She recalled having the MRI scan but could not recall seeing Dr Waddell.
The 2011 left knee scan was done because of increasing posteromedial knee pain with walking, on a background of previous ACL reconstruction. The ACL reconstruction was intact. There was a peripheral vertical tear of the anterior horn of the lateral meniscus and associated multi-loculated combined intra and para meniscal cyst demonstrating limited medial extension. The lateral meniscal body posterior horn and posterior root attachments were intact. The medial meniscus was intact, and the medial compartment articular cartilage defined normally. There was some degenerative thickening of the medial collateral ligament. The posterior cruciate ligament was intact. The differential diagnosis for the cystic structure included a medial gastrocnemius bursa and ganglion.
No action was taken after this MRI scan in terms of treatment for the left knee.
The Medical Assessors referred Ms Green to an entry by Dr Partlin dated 24 October 2022 referring to right flank and mid-back pain for years, and “getting a lot of joint pains, right knee and left hip, but not using any analgesia. There was no joint line pain in the right knee”. She recalled this. Ms Green was asked why she had been thinking about applying for NDIS and she said it was on account of an eating disorder. Dr Partlin ordered X-rays of the bilateral hips and of the bilateral knees because of osteoarthritis causing worsening hip and knee pain.
Ms Green said at the time of the accident, she was returning from having walked a 10km bushwalk and had noticed no symptoms in the left or right knee and could not recall having any treatment to either knee in the period prior to the accident.
In terms of medication, she was taking Nexium for reflux, hormone replacement therapy, Thyroxin and a statin drug, and a preventive aerosol for asthma.

History of the accident

Ms Green confirmed on 17 June 2023 in the morning; she was driving a vehicle. It was a Saturday, as she recalls. A truck, travelling forwards, pulled out from a driveway on her left and though she swerved and braked to try and avoid it, she collided with the truck, which
T-boned the left front corner of her vehicle. She had a seatbelt on. The airbags did not deploy.
The Medical Assessors asked Ms Green how she hurt her knees, and she said that she felt that her knees moved forward and over the top of her shins at the time of the impact, but she didn’t have any actual impact of the knees on the dashboard or other object.
Ms Green had sore knees after the accident, especially the left knee. She doesn’t recall any bruising to the knees, although she had bruising to the chest from the seatbelt. She recalls having some sort of shock reaction and she “just froze” and sat in her car. Bystanders assisted her out of the car.
The ambulance arrived and the paramedics assessed her, and she was found able to walk to the ambulance. Ms Green said she does not recall the paramedics palpating her knees, but she did report pain in the knees and chest. Police and fire brigade were also on scene.

History of symptoms and treatment following the accident

Ms Green was taken by ambulance to Sutherland Hospital for assessment. After the assessment, she felt very tired and slept for three to four hours. She was discharged about 2.00 or 3.00pm on the same day as the accident.
The hospital records noted pain in the chest and knees, no head strike and no knee pain. There was full range of movement in flexion of the knees, with no fibular head tenderness and minimal tenderness in the patella on the left side.
Glasgow Coma Score (GCS) was 15/15 on two occasions when performed by the paramedics.
Ms Green was discharged from hospital with Panadol and Nurofen as required for pain.
Ms Green felt unwell when she went home from hospital but worked on the Monday. She had to go by train to a court case and felt sick on the train.
Ms Green went to her GP, Dr Partlin, for the first time after the accident on 23 June 2023, a Friday from memory. She said she was diagnosed with concussion, which was said to be from a jolting to the head at the time of the collision, although there was no actual impact to the head. The GP record does state slight tenderness to the right temporal area, along with right knee pain, bruising and soreness to the left breast, and neck and low back pain, with a diagnosis of concussion. Ms Green noted that the concussion symptoms were starting to settle by that time.
Ms Green continued working in her private practice as a social worker, but for the first six months after the accident didn’t take any new clients, so her income was reduced by about 50%. After six months, she returned to her normal workload as a full-time self-employed social worker.
From the record, Ms Green next saw a GP, Dr Papapetros, at the same practice on 27 July 2023, when it was recorded that she had had a motor vehicle accident on 17 June 2023 whilst driving at about 60kmph and was struck from the left by a truck pulling out of a driveway, with no airbags deployed and “Margy was feeling a little spaced out afterwards” and diagnosed by Dr Partlin with concussion. Since then, she had had gradually worsening neck pain and bilateral knee pain, with no history of neck pathology, but a previous left ACL reconstruction and right arthroscopy with meniscectomy. The claimant felt the pain was deep inside the right knee and on the lateral aspect of the left knee. There was some C7 mid-line cervical spine tenderness, with normal upper limb neurology, left knee lateral tenderness over the joint space but no specific right knee tenderness, and ligament and meniscus tests were negative bilaterally.
Dr Papapetros ordered MRI scans of the cervical spine and bilateral knees, and suggested a physiotherapy review of the neck pain, with a further medical review to consider the results of the scans. The MRI cervical spine on 9 August 2023 showed a C6/7-disc protrusion contacting and slightly distorting the cord but there was no high-grade neuroforaminal stenosis or central canal stenosis seen secondary to this.
The physiotherapy record from 1 August 2023 indicated bilateral knee pain with gradual loss of range of movement in the right knee and low back pain and neck pain.
Thereafter, Ms Green saw the physiotherapist for about two years, mainly for her knees. She attended the gym for strengthening exercises but had little overall improvement. The physiotherapist said she would need knee surgery eventually and that the pain would continue according to how much physical activity and walking she undertook.
Ms Green had an MRI scan of both knees on 15 August 2023. This MRI was compared with a previous MRI of the left knee performed on 4 November 2011. The left knee 2023 scan showed a complex Baker’s cyst had progressed. The prior ACL reconstruction remained intact, and the PCL was normal. The previously documented peripheral vertical tear of anterior horn of lateral meniscus had healed. No acute meniscal tear was identified. Lateral compartment articular cartilage, subchondral bone, lateral collateral ligament, and the visualised lateral capsule remained intact. The medial meniscus remained intact, and the medial compartment articular cartilage subchondral bone and the visualised medial collateral ligament were stable in appearance. There was a full-thickness chondral fissure in the lateral patellar facet, which had developed since the previous scan, along with some surface chondral fissuring at the mid-medial patellar facet adjacent to the median ridge. Progressed features of chondromalacia patellae Grade 2 were diagnosed. Interval healing of the peripheral vertical tear of anterior horn of lateral meniscus, with some change in the configuration of the associated anterior parameniscal cyst was noted.
The MRI of the right knee showed changes in the medial meniscus, suggesting a prior meniscectomy. There was Grade 4 medial femorotibial compartment osteoarthritis with denudation of the medial weight-bearing medial femoral condyle and MTP (medial tibial plateau) articular cartilage extending to the medial joint line. There was suggestion of a partially healed horizontal intermediate T2 signal tear involving the anterior horn of lateral meniscus. The radiologist commented there was evidence of prior medial meniscectomy with extensive degenerative signal of the medial meniscus, locally advanced medial compartment osteoarthritis with up to Grade 4 involvement on the background of tri-compartmental involvement with osteoarthritis. Old partially healed tear of anterior horn of lateral meniscus. A complex cystic appearing structure draped anteromedially about the proximal tibia could represent a de novo ganglion or old dissected parameniscal cyst.
Ms Green said she had the onset of memory difficulties about three months after the accident and saw a neurologist, Dr James Lee at Caringbah, who did a thorough examination and reassured her there was no serious problem.
An MRI scan of the brain done on 1 September 2023 showed mild cerebral hemispheric microvascular ischaemic change which is somewhat in excess of what would normally be expected for age. The distribution and morphology are most in keeping with a vascular aetiology. The question of underlying vascular risk factors was raised.
Ms Green reported that the concussion symptoms settled by about six months after the accident.
Ms Green was referred back to Dr Seeto, orthopaedic surgeon, at Edgecliff, whom she had previously seen in November 2022, and she had an X-ray of the right knee showing severe medial compartment osteoarthritis. He noted a three-to-five-year history of bilateral knee pain but did not mention the accident. When questioned by the Medical Assessors Ms Green said that she told Dr Seeto about the accident.
Ms Green explained that at the last review with Dr Seeto in November 2022, he told her that she would need knee replacements at some stage, perhaps in the next 10 years, and to come back when she was ready for this, so he was somewhat surprised when she returned earlier than expected, after the accident.
At specialist review, there were varicose veins affecting both legs, with correctable varus deformity in the right leg and the left leg was in neutral alignment. Both knees had full extension and could flex to 120° and were stable. Both legs were neurovascularly intact. Dr Seeto noted that plain X-rays of both knees in November 2022 had shown severe medial compartment arthritis affecting the right knee. Ms Green had more recent MRI scans of both knees in August 2023, with the MRI of the left knee showing significant retropatellar arthritis with an area of subchondral oedema and full-thickness chondral loss affecting the median ridge of the patella although there was no evidence of any acute meniscal tear.
Dr Seeto diagnosed essentially bilateral knee arthritis, with the right more affected than the left, and the distribution medial compared to patellofemoral. He noted she was keen to avoid knee replacement, which he recommended as a good idea, and he outlined other methods of controlling symptoms non-operatively for as long as possible, including weight loss, activity modification, anti-inflammatories and leg muscle strengthening. When she had functionally disabling pain interfering with her quality of life, Ms Green would require a total knee replacement. He discharged her from his care, but said she could re-present in future at any time if required.

Details of any relevant injuries or conditions sustained since the accident

The physiotherapy records indicate continuing treatment for bilateral patellofemoral dysfunction in the knees.
Ms Green visited Dr Papapetros, on 11 April 2024 and it was noted she was going to Bali in 12 days’ time. He noted that the workers compensation had refused to pay for more physio sessions for her, but Ms Green felt her knee pain had worsened substantially since the accident, however, she did have prior osteoarthritis. The GP noted that the insurer felt her pain was pre-existing. He advised continuing weight loss and noted she had lost 20kg under her eating disorder plan already. Ultimately, if she still had significant knee pain despite weight loss, physio and analgesia, Ms Green would need to consider knee replacement surgery.
The physiotherapy record from 12 April 2024 noted that Ms Green went on holidays and did a bit more walking, and the bilateral knees were now flared up, but she was swimming a few times a week, and she was trying to contest the insurer’s decision to cease treatment.
Active range of movement of the knees in flexion was 95° on the right and 105° on the left, with extension -10° bilaterally, with stiff patellofemoral joints bilaterally. The provisional diagnosis was bilateral patellofemoral dysfunction, left greater than right, with degenerative right knee.
A physiotherapy record of 3 May 2024 noted she had “arrived home from Bali yesterday” (2 May 2024) and for the last four days her left knee had been very sore laterally and posteriorly. ? increased standing and walking while on holidays. ? pseudo giving way. No locking but very restricted movement with knee flexion 30° with much pain, and extension was OK with slight pain, and there was tenderness in the lateral joint line.
A further physiotherapy visit on 10 May 2024 noted the left knee was settling and able to extend better and flex the quads but still felt unstable. There was a positive McMurray’s and positive Lachman’s test bilaterally.
An MRI scan of left knee was ordered. The provisional diagnosis was, as well as the existing bilateral patellofemoral dysfunction, a new diagnosis of acute lateral meniscal patellofemoral aggravation and ? ACL re-tear in an old reconstruction.
An MRI of the left knee of 14 May 2024 ordered by the physiotherapist, Travis Adelerhof, noted a history ? ACL, ? lateral meniscus. One day ago felt pop in knee, gave way. Swelling and pain lateral posterior. History of ACL reconstruction and degenerative osteoarthritis. The moderately complex Baker’s cyst was stable. Since the previous study of 9 August 2023, a full-thickness medial meniscus radial tear at the junction of posterior horn and posterior root ligament had developed, with associated static extrusion of the body by up to 0.25cm being evident. There has been further healing of the previously demonstrated peripheral vertical/ longitudinal tear of the anterior horn of the lateral meniscus, which was now almost indiscernible. The remote ACL reconstruction remained intact, and the previously documented features of Grade 2 chondromalacia patellae were unchanged, apart from slightly reduced bone marrow oedema signal, in association with a full-thickness chondral fissure at the lateral patellar facet, close to the superior joint line, adjacent to the median ridge.
The Medical Assessors asked the claimant about an entry from GP, Dr Brandon Chung, at the same practice dated 17 May 2024. Ms Green could not recall seeing a doctor by that name. The presenting complaint was left knee pain and the report referred to her having a massage in Bali two weeks ago. Was prone and they flexed her knee and manipulated it and she felt a tear. She walked a lot on holidays. Last Monday (prior to 17 May 2024), she was walking and felt a painful pop and could barely walk thereafter. She said she was outside a Salvos shop and someone went inside with the credit card she had given them to get her some crutches, so that she could walk. Until this, she was propped up against a wall.
Dr Chung found almost full extension in the left knee, with flexion to 80° and medial posterior tenderness but no joint line tenderness in the medial joint line. He diagnosed a left medial meniscal tear.
The Medical Assessors asked Ms Green about previous recommendations of the GP for cortisone injections in the knee. Ms Green said she had decided not to go ahead with this, as her physiotherapist advised exercises for strengthening as a preferred management tool rather than injections.
There was no further subsequent incident after the Bali incident affecting the left knee of May 2024.

Current symptoms

Ms Green has bilateral knee pain. She says the right knee has deteriorated, as it has been carrying more of the weight to protect the painful left knee. She didn’t notice any locking or giving way in the right knee, although either knee can swell at times. The left knee remains problematic.
The Medical Assessors asked Ms Green about the incident after she had returned from Bali, when she was walking along and felt the painful pop in the knee and then could barely walk after that outside the Salvos shop. Ms Green said there was no slip or twist to the knee involved, she was just walking on flat ground.
Ms Green said since this popping episode, pain has been located more in the back of the left knee, along with adjacent calf and posterior thigh.
Ms Green had referrals to Dr MacDessi, orthopaedic surgeon, St George Hospital Kogarah, and Dr Leung, orthopaedic surgeon, Kareena Private Hospital Caringbah, to get further opinions about her knees. She was told that she would require a double total knee replacement and is trying to do prehabilitation work to get her knees in their best state prior to undertaking surgery. She has also started Ozempic injections, which is helping her lose more weight. She has lost 25kg in the last two years and is now 115kg.
Ms Green commented she knew her left knee had been strained when she was in Bali, but she did not claim on travel insurance after the deterioration because she knew that her knee was not normal before the episode in Bali.
She then added that Dr MacDessi had suggested Synvisc injections as an option to try and put off the need for total knee replacement, but she has not proceeded with this.

Current and proposed treatment

Ms Green takes Panadol, Nexium, Thyroxin, Symbicort, hormone replacement therapy, a statin drug and Ozempic.
She is attending physiotherapy once or twice a week with Steve Cunningham, and she goes to a gym to do quadriceps strengthening exercises and rides an exercise bike.
Ms Green uses the Panadol at night sometimes to get to sleep if her knees are particularly painful. She knows her knees were not perfect before the accident, but they are worse since the accident.

DIAGNOSIS AND CAUSATION

Head injury

The head injury consists of a soft tissue injury with no evidence of traumatic brain injury.
GCS was consistently 15/15 and there is no evidence of a medically confirmed post-traumatic amnesia (PTA) period. There was no brain imaging of the claimant undertaken during the acute period whilst at Sutherland Hospital because she displayed a clear sensorium, there had been no blow to the head and there was no reason to suspect a traumatic brain injury. There was no investigation of the brain until later, being an MRI scan which was done for complaints of memory loss, showing vascular changes. The cognitive symptoms subsequently settled about six months after the accident.

Injury to the left and right knees

The diagnosis for the right and left knees is a soft tissue injury caused by the accident. The Panel is satisfied the accident caused injury to both knees noting they were referenced in the Application for personal injury benefits and accompanying medical certificate, in the ambulance and hospital records, and in the GP records and physiotherapy records.
After the accident, there was an exacerbation of symptoms of the pre-existing degenerative changes in both knees.
There was a pre-accident lateral meniscal tear of the left knee demonstrated on MRI scan as far back as 2011, and this was shown to have partially healed in the interval between the 2011 scan and the post-accident scan of 15 August 2023. There was also a history of left-sided ACL reconstruction in 1993 due to a sporting injury. The 2023 left knee MRI scan after the accident showed no acute tear involving either the lateral meniscus or the medial meniscus. There were features of chondromalacia patellae Grade 2, which is a degenerative pathological condition consisting of softening of the cartilage surface on the posterior aspect of the patella.
However, the subsequent left knee MRI scan of 14 May 2024 showed an acute tear of the medial meniscus, which had not been evident on the previous scans. The Panel concludes this new finding is related to an episode of twisting of the knee during a massage in Bali whilst Ms Green was lying prone with the knee bent; this is a medically plausible mechanism by which a meniscal tear could occur, that is twisting of a semi-flexed knee joint. Following this incident, when Ms Green returned for assessment by her physiotherapist and GP there was marked deterioration in the active range of movement of the left knee.
It is the Medical Assessors’ opinion that the acute medial meniscal tear of the left knee is not related to the accident, but rather related to the incident which occurred while Ms Green was on holidays in Bali. This was followed by an exacerbation of symptoms of the acute meniscal tear whilst she was merely walking along on a flat surface after returning home to Australia a few days later, with no evidence of twisting or slipping at that time. Ms Green mentioned she had felt a tear in the left knee at the time of the massage procedure, and this was recorded by her general practitioner.
The Panel finds the left knee acute medial meniscal tear is not related to the accident.

THRESHOLD INJURY

Head

The head injury is a threshold injury, being a soft tissue injury. There was no evidence of head strike or loss of consciousness. The GCS was normal, thus there was no evidence of brain injury, and the post-accident MRI scan showed no intracerebral post-traumatic lesion.

Right knee

The injury to the right knee caused by the accident is a soft tissue injury. This is a threshold injury. There had been a previous arthroscopy which was not affected by the accident. The right knee MRI scan post-accident did not show any acute tear of ligament, meniscus or cartilage.

Left knee

The Panel has concluded the acute tear of the left medial meniscus shown on the post-accident MRI scan of 14 May 2024 but not evident on previous scans was caused by an episode of twisting of the knee during a massage in Bali and was not caused by the accident.
The injury to the left knee caused by the accident is a soft tissue injury. This is a threshold injury.

CONCLUSION

The Panel revokes the certificate of Medical Assessor Ian Cameron dated 5 October 2024 and certifies that the following injuries caused by the accident were threshold injuries for the purpose of the MAI Act:
·        right knee – soft tissue injury;
·        left knee – soft tissue injury, and
·        head – soft tissue injury.

[2025] NSWPICMP 425

18 June 2025