DETERMINATION OF REVIEW PANEL	
	
CITATION:	Dragas v Allianz Australia Insurance Limited [2024] NSWPICMP 180	
		
CLAIMANT:	Dusko Dragas	
		
INSURER:	Allianz Australia Insurance Limited	
		
REVIEW Panel	 	
		
MEMBER:	Terence Stern OAM	
		
MEDICAL ASSESSOR:	Margaret Gibson	
		
MEDICAL ASSESSOR:	Geoffrey Stubbs	
		
DATE OF DECISION:	26 March 2024	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; the claimant suffered injury in a motor vehicle accident on 18 November 2017; medical assessment of whole person impairment (WPI) by Medical Assessor (MA) Wallace who determined that the claimant did not have WPI of greater than 10%, namely 5% WPI; the Medical Review Panel conducted a re- examination which was not consistent with ongoing injury; there was no ongoing causal relationship with the subject accident; Held – certificate of MA Wallace revoked; the Panel substitutes the determination and certifies a 0% WPI.

DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
1.	The Medical Review Panel revokes the certificate of Medical Assessor Raymond Wallace dated 9 November 2023.
2.	The Panel substitutes its determination and certifies that there was no ongoing causal relationship with the motor vehicle accident, which gives rise to a whole person impairment of 0%. 

	

STATEMENT OF REASONS
BACKGROUND AND THE MOTOR VEHICLE ACCIDENT
1.	Mr Dragas, the claimant, was born and grew up in Croatia, moving to Australia in 1994 with his family.
2.	At the time of the accident, he was 49-years-old with two grown children who lived with him and his wife. Mrs Dragas was not working at the time of the accident but in the last six months, has been working as a self-employed gyprock subcontractor. He had done this for several years. He said that he was formerly well, and still played soccer in an amateur league. He had a past history of having suffered a fractured leg in 2014.
3.	On 18 November 2017, Mr Dragas was returning from work in a Triton utility. It was stationary when hit from behind. Both drivers were able to self-extricate. Neither police nor ambulance were called, and the vehicles involved in the accident were driven away. The Triton was repaired.
4.	Mr Dragas went to see his usual general practitioner, Dr Zaki, the next day and was assessed. At that stage he had right shoulder, neck and back pain, and injuries to both knees.
5.	He did not continue treatment with Dr Zaki but transferred to Dr Todorovic for further management. 
6.	Subsequently, he was assessed by an orthopaedic specialist, Dr Guirgis, who wrote a report to his solicitor. 
7.	Initially he was given a certificate for light duties. He returned to work and stated that he was very incapacitated, but he in fact continued working as a gyprock subcontractor on light duties for 18 months. He then ceased work, made claims on a personal income protection policy, and then went on to Centrelink benefits. The family rely on the income from his wife and two children.
8.	He alleges that he has ongoing problems, including in both knees, both shoulders neck and low back.
WHOLE PERSON IMPAIRMENT DISPUTE 
9.	Allianz is liable to pay any damages to Mr Dragas under the Motor Accident Compensation Act 1999 (the MAC Act).
10.	This dispute is in relation to whether the degree of permanent impairment sustained by Mr Dragas as a result of the injuries caused by the accident is greater than 10%. This constitutes a medical dispute within the meaning of the MAC Act.
11.	The medical dispute was referred to Medical Assessor Raymond Wallace, to complete the whole person impairment (WPI) assessment. 
12.	Medical Assessor Wallace issued a certificate dated 9 November 2023, in which he certified the following injuries caused by the accident gave rise to a permanent impairment of 5%:
(a)	cervical spine;
(b)	thoracic spine;
(c)	lumbar spine;
(d)	right shoulder, and
(e)	right knee.
13.	The claimant sought a review of the certificate of Medical Assessor Wallace.
MATERIAL BEFORE THE REVIEW PANEL 
14.	The Review Panel had all the material that was before Medical Assessor Wallace and it also had the material that was produced to Pathways by the parties in response to directions the Review Panel made, consisting of two bundles: 
(a)	the bundle produced by the insurer on 28 February 2024, and 
(b)	the bundle produced by the claimant on 15 February 2024.
15.	The Review Panel has given consideration to all such material.
REVIEW PROCEDURE 
16.	On 1 February 2024, the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application, referred the medical assessment to the Review Panel.
17.	The Motor Accident Permanent Impairment Guidelines (the Guidelines), version 1 effective 1 June 2018 were issued pursuant to s 44(1)(c) of the MAC Act for the purposes of assessing the degree of permanent impairment. The Guidelines are based on the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed. 
18.	Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the Personal Injury Commission, Act, 2020 (PIC Act). A Review Panel determines how it conducts and determines the proceedings.
19.	The review is by way of a new assessment of all matters with which the medical assessment is concerned.
THE EVIDENCE BEFORE THE REVIEW PANEL
The reasons of Medical Assessor Wallace
20.	The Review Panel briefly summarises the Reasons of Medical Assessor Wallace. 
21.	After referring to the submissions made by the parties, Medical Assessor Wallace noted that Mr Dragas had previously been assessed by Medical Assessor Menogue on 26 July 2019, who had issued a certificate that his WPI did not exceed 10%. 
22.	He noted that Mr Dragas had successfully sought a review of that decision which was referred to a Review Panel of Medical Assessors Lahz, Dixon and Moloney on 19 December 2019 and the Review Panel certified that Mr Dragas’ WPI did not exceed 10%.
23.	Mr Dragas asserted that there had been a deterioration in his condition since the assessment by Medical Assessor Menogue. 
24.	He further noted the insurer’s submission that the Review Panel had found that Mr Dragas’ right shoulder symptoms did not emanate from the shoulder itself or from referred symptoms from the cervical spine and that having regard to the information available, it had not been established that there had been a deterioration in Mr Dragas’ pathology. 
25.	Medical Assessor Wallace examined the:
•	cervical spine;
•	thoracic spine; 
•	the upper extremity;
•	left and right knee, and
sets out the results of his testing of the range of movement in each area. 
26.	Medical Assessor Wallace then summarised his findings with respect to the relevant radiological and medical imaging and other investigations. 
27.	He found at [24], that the subject accident had resulted in: 
•	musculoligamentous strain cervical spine; 
•	aggravation of pre-existing multilevel degenerative cervical spondylosis;
•	musculoligamentous strain thoraco-lumbar spine; 
•	aggravation of pre-existing multilevel degenerative lumbar spondylosis; 
•	resolved soft tissue injury left knee;
•	soft tissue injury right knee, and 
•	aggravation of pre-existing degenerative osteoarthritis patellofemoral compartment of the right knee. 
28.	Medical Assessor Wallace concluded that Mr Dragas had sustained the injuries to the cervical spine, thoraco-lumbar spine and bilateral knees as a result of the accident, and that his current right shoulder symptoms, were due to referred pain from his cervical spinal injury but that there was no objective medical evidence that he had suffered any direct injury to the right shoulder, in view of the mechanism of injury described as a rear end motor vehicle collision and taking into account the absence of any acute pathology at the joint on MRI on investigation carried out on 15 March 2018. 
29.	Medical Assessor Wallace set out his permanent impairment conclusion at [32] finding 3% WPI for the right shoulder and 2% WPI for the right knee. 
CAUSATION
Guidelines
30.	With respect to causation, (the Guidelines) provide:
“6.5 	An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the 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 the Personal Injury Commission) in considering such issues. 
6.6 	Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows: 
‘Causation means that a physical, chemical, or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following: 
1. 	The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination. 
2. 	The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’ This, therefore, involves a medical decision and a nonmedical informed judgement.
6.7 	There is no simple common test of causation that is applicable in all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the accident. The motor accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible.”
Legislation on causation
31.	Section 5D of the Civil Liability Act 2002 (CLA) provides: 
“(1) 	A determination that negligence caused particular harm comprises the following elements—
(a) 	that the negligence was a necessary condition of the occurrence of the harm (factual causation), and 
(b) 	that it is appropriate for the scope of the negligent person’s liability to extend to the harm so caused (scope of liability). 
(2) 	In determining in an exceptional case, in accordance with established principles, whether negligence that cannot be established as a necessary condition of the occurrence of harm should be accepted as establishing factual causation, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party. 
(3) 	If it is relevant to the determination of factual causation to determine what the person who suffered harm would have done if the negligent person had not been negligent—
(a) 	the matter is to be determined subjectively in the light of all relevant circumstances, subject to paragraph (b), and 
(b) 	any statement made by the person after suffering the harm about what he or she would have done is inadmissible except to the extent (if any) that the statement is against his or her interest. 
(4) 	For the purpose of determining the scope of liability, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party.”
Case law on causation
32.	The assessment of causation through application of s 5D of the CLA is examined in Peet v NRMA Insurance Ltd [2015] NSWSC 558, where Hidden J notes: 
“The distinction now drawn by s 5D(1) between factual causation and scope of liability should not be obscured by judicial glosses. A determination in accordance with s 5D(1)(a) that negligence was a necessary condition of the occurrence of harm is entirely factual, turning on proof by the plaintiff of relevant facts on the balance of probabilities in accordance with s 5E. A determination in accordance with s 5D(1)(b) that it is appropriate for the scope of the negligent person’s liability to extend to the harm so caused is entirely normative, turning in accordance with s 5D(4) on consideration by a court of (amongst other relevant things) whether or not, and if so why, responsibility for the harm should be imposed on the negligent party.”
33.	Hidden J refers to the High Court’s judgement in Wallace v Kam [2013] HCA 19, where the Bench unanimously explained the test of causation under s 5D(1)(a) of the CLA, at [16]: 
“The determination of factual causation in accordance with s 5D(1)(a) involves nothing more or less than the application of a ‘but for’ test of causation. That is to say, a determination in accordance with s 5D(1)(a) that negligence was a necessary condition of the occurrence of harm is nothing more or less than a determination on the balance of probabilities that the harm that in fact occurred would not have occurred absent the negligence.” 
34.	The “but-for” test is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.
35.	In Briggs v IAG Limited trading as NRMA Insurance [2022] NSWSC 372 (31 March 2022) his Honour Justice Wright stated at [35]:
“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.”
Claimant's submissions of 14 December 2023
36.	Mr Dragas submits that the certificate of Medical Assessor Wallace dated 9 November 2023 is incorrect in a material respect under s 63 (2) of the MAC Act due to Medical Assessor Wallace's errors in assessing the claimant's cervical spine injury and shoulder injuries.
37.	Mr Dragas submits that Medical Assessor Wallace has erred in finding only diagnostic- related estimates (DRE) category I for the claimant's cervical spine when there is objective radiological evidence before him of a cervical compression fracture which was caused by the subject accident is a manifest error which if corrected could place the claimant above the threshold of non-economic loss on its own.
38.	Mr Dragas submits that in a case where Medical Assessor Wallace has found that the claimant's right shoulder restriction is due to referred pain from the cervical spine, the claimant submits that Medical Assessor Wallace has erred firstly because he did not inquire whether the left shoulder restriction was also due to referred pain from the cervical spine at the time of the assessment.
39.	Secondly, Mr Dragas submits that in the claimant's case, Medical Assessor Wallace has erred in applying par 1.51 because there is no "reasonable expectation" that the claimant's left shoulder had restricted movement before the injury. The claimant submits firstly there is indeed evidence of the claimant suffering from pain and restricted movement in "both shoulders" recorded by an independent medical assessor.
40.	Mr Dragas submits secondly, that given the principle established in Nguyen v The Motor Accidents Authority of NSW & Zurich Australian Insurance Ltd [2011] NSWSC 351, it is well established that any restriction in the shoulders consequent upon referred neck pain should still be assessed and compensable. 
41.	Mr Dragas submits that frank injury to the left shoulder is not necessary for causation of the left shoulder restriction to be a consequence of the subject MVA, and if restricted movement in the left shoulder is caused by referred pain from the claimant's cervical spine injury, it should not be used to deduct from the "injured" right shoulder using par 1.51 of The Guidelines as Medical Assessor Wallace has erroneously done in the claimant's submission.
42.	Mr Dragas submits that to the extent the claimant's left shoulder was restricted, it was due to the consequences of referred pain from his cervical spine injury, and Medical Assessor Wallace's failure to inquire as to the cause of the restriction means he did not execute the clinical examination with "the entire gamut of clinical skill and judgement in assessing whether or not the results of measurements or tests are plausible and relate to the impairment being evaluated" as required by par 1.40 of The Guidelines. 
43.	Mr Dragas submits that Medical Assessor Wallace improperly deducted the left shoulder impairment from the right shoulder without making proper enquiries of the claimant as to the source of the restriction, especially in circumstances where there are prior reports of Medical Assessor Cameron showing restricted movement of both shoulders.
44.	Finally, Medical Assessor Wallace's finding that Mr Dragas had left shoulder restriction where he stated there was no "objective medical evidence" is an inconsistency under par 1.41 of The Guidelines which must be put to the claimant to ensure procedural fairness.

Insurer’s submissions in Reply of 15 January 2024 
45.	It is the insurer’s position that a Medical Assessor can and should exercise his clinical judgement based on the available material and the examination of the claimant. 
46.	The insurer refers to clause 1.121 of the Motor Accident Permanent Impairment Guidelines. The clause prescribes that: 
“…To be of diagnostic value, imaging findings must be concordant with clinical symptoms and signs, and the history of injury. In other words, an imaging test is useful to confirm a diagnosis, but an imaging result alone is insufficient to qualify for a DRE category.” 
47.	The insurer submits that whilst Medical Assessor Wallace can have regard to the available imaging, he is not required to solely rely on the imaging when assessing impairment. The insurer submits that the claimant has failed to establish that the Medical Assessor’s certificate is infected by error.
48.	The insurer notes that Mr Dragas did not refer a left shoulder injury for assessment of permanent impairment. 
49.	It is the insurer’s position that there is no contradiction between Medical Assessor Wallace’s clinical findings with respect to the claimant’s left shoulder and the available medical evidence. The balance of the medical evidence confirms that Mr Dragas sustained no direct injuries to the left and right shoulders.
50.	The insurer maintains that it is reasonable and appropriate for a Medical Assessor to compare Mr Dragas’ uninjured left shoulder with his injured right shoulder. Such an approach is wholly consistent with impairment assessment guidelines in the context of the injuries listed for assessment by the claimant in the application for assessment of permanent impairment. The insurer submits that Mr Dragas had failed to establish that the Medical Assessor’s certificate is infected by error.
51.	It is the insurer’s position that Medical Assessor Wallace’s decision is appropriately based on his clinical examination and the available medical evidence.
Medical examination by the Review Panel 
52.	The Review Panel did not assess Mr Dragas again, given that it had recently conducted a medical examination on 14 February 2024. The Review Panel relies on the results of that examination which are set out below. 
53.	Medical Assessor Stubbs considered that Mr Dragas was a fit looking man of 177cm, weighing 85kg. 
54.	He had a normal standing posture and gait and tiptoed, and heel toe walked comfortably.
55.	He was noted to be able to undress without assistance to his underpants and climb on and off the examination table without difficulty.
56.	He had a very athletic build for a 50-year-old male.
57.	He was very lean and had excellent muscle definition is all muscle groups. 
58.	Mr Dragas had good standing balance. He was unwilling to move either his neck or low back in any direction. To the extent that he moved, such movements in both neck and upper and lower back were symmetrical and there was no reflex spasm or guarding. The movement was voluntarily restricted and when this was pointed out to Mr Dragas that he was moving much more freely when speaking with the interpreter and undressing, Mr Dragas stated that moving further would cause pain. 
59.	Medical Assessor Stubbs noted other inconsistencies in the informal examination and a lack of voluntary movement in the clinical examination. 
60.	Medical Assessor Stubbs bought these two matters to Mr Dragas’ attention and he made a similar comment that he was frightened that any movements would cause him pain. 
61.	On cervical and lumbar spine examination, there was a voluntary restricted symmetrical reduction in the range of motion. Mr Dragas complained of pain, diffusely over the whole of the back, neck, and both shoulders, including the upper part of his low back, from the neck and across the small of his back, equally on both side into the buttocks. When sitting he could lean forward across the edge of the table and fully extend both knees individually and together from this position without discomfort. The slump test was negative. 
62.	When lying, he could flex his knees to only 80 degrees. Straight leg raising was voluntarily resisted at 30 degrees. Nerve root traction tests were therefore negative.
63.	Sensory mapping did not follow dermatomal distribution in either the upper or lower limbs. 
64.	Noting as before, that Mr Dragas’ upper and lower limb muscles were well defined, it was further noted that his legs had thigh circumference of 55cm, mid patella circumference of 38cm and calf circumference of 38cm in both legs. The equivalent forearm measurements are 37cm mid arm, forearm right equals left. 
65.	There was diffuse but not localised pain complained of on palpation of the shoulders. 
66.	Reflexes, biceps triceps and supinator jerks in the arms and knee and ankle jerks in the lower limbs were of modest amplitude but are symmetrical.
67.	Lower limb, hip and knee movements were voluntarily limited.
68.	In the knees, there was normal temperature, no effusion on either side, no bony prominences or spurs and no crepitus or instability. In short, the lower limb examination was normal and there were no clinical signs of knee injury on either side. 
69.	Upper limb shoulder movements were voluntarily restricted. 
70.	In summary, there were no noticeable abnormalities in the upper limbs. 
Treating medical practitioners
71.	The Review Panel briefly summarises the medical evidence of treating medical practitioners. 
72.	Mr Dragas went to see his usual general practitioner (GP), Dr Zaki, the day after the accident and was assessed. At that stage he had right shoulder, neck and back pain, and injuries to both knees.
73.	He did not continue treatment with Dr Zaki but transferred to Dr Todorovic for further management. 
74.	He complained to the treating doctor of ongoing pain in the neck, back, knees and right shoulder. He received physiotherapy for approximately nine months, and he also attended the gym for an exercise programme although little difference was made to persistent symptoms. The doctor also prescribed painkillers including Panadeine Forte and Celebrex. In addition, he received injections to the right knee and right shoulder with little effect.
75.	The medical certificate of Dr Todorovic dated 22 November 2017 referred to soft tissue injuries of the cervical spine, thoracic spine, lumbar spine, right shoulder, and knees. The pain diagrams showed shading of the right shoulder, both knees and whole spine.
76.	Subsequently, he was assessed by orthopaedic specialist, Dr Guirgis, who wrote a report to his solicitor. 
Qualified opinions
77.	The Review Panel briefly summarises the qualified expert opinions. 
78.	Dr Robin Mitchell, consultant occupational health physician, noted that Mr Dragas had developed pain in the neck, right shoulder, mid back, and lower back with radiation to the lateral upper right leg, and also pain in each knee, after a motor vehicle accident on 18 November 2017, when he hit the dashboard with both knees.
79.	The doctor acknowledged that Mr Dragas’ pain continued, and in February 2018, he was referred to orthopaedic surgeon, Dr Medhat Guirgis, who diagnosed mechanical derangement of the cervical spine, causing right C6/7 radiation and impingement into the right shoulder, and mechanical derangement of the lumbar spine causing left proximal L5/S1 radiation.
80.	Dr Mitchell found Mr Dragas’ symptoms appeared to be of a soft tissue nature, in the absence of any apparent significant underlying injury, either clinically or radiologically.
81.	He further noted that there were no lasting injuries caused by the subject motor vehicle accident and that work in a full-time capacity, would not have any potential to aggravate his symptoms. 
The medico-legal report of Dr Medhat Guirgis 
82.	Dr Guirguis, who provided a medico-legal report on 2 October 2018, arranged scans and performed physical examination of Mr Dragas. However, no specific treatment recommendations flowed from the latter consultations.
Detailed findings of the Review Panel 
Investigations reviewed
83.	Medical Assessor Stubbs then proceeded to list out the medical investigations. 
84.	He noted that on 19 November 2021, an MRI of the lumbar spine with T1 and T2, was a normal MRI study in a 50-year-old male, without evidence of injury. The comments made by the radiologists did not indicate injury and were best considered as normal age-related changes. 
85.	He commented on the MRI scan of the lumbar spine of 5 March 2018 and observed that the radiological features were identical to the MRI features of one year later. The conclusion is the same i.e. normal age-related changes. 
86.	Medical Assessor Stubbs commented on the MRI of the left knee, ordered by Dr Medhat Guirgis, that the pigmented villonodular synovitis was an inflammatory condition not caused by the trauma. There were some minor changes to the articular cartilage of the patellofemoral joint which were consistent with normal wear and tear in a physically active male of age 50.
87.	With respect to the MRI of the right knee of 17 May 2018, the findings were old cruciate ligament with early secondary degenerative changes of the right knee joint. This was not a new injury and probably reflected the fracture of 2014. There were no signs of recent injury that could have been caused by the motor vehicle accident. 
88.	The MRI of the cervical spine and right shoulder of 15 March 2018, requested by Dr Guirgis, showed some thickening and some reactive marrow oedema around the right acromioclavicular joint. There was mild bursitis and some tendinosis of possible intrasubstance tears in the superior rotator cuff and distal ganglion cyst. The radiological signs were not of an acute injury, but consistent with heavy use and commonly found in manual labourers. 
89.	With respect to the MRI of the cervical spine, there were no radiological features of acute injury. 
90.	Medical Assessor Stubbs also referred to the MRI cervical and lumbar spine and right shoulder of 13 September 2022, requested by Dr Guirgis. There was only limited viewing available and that of the right shoulder showed essentially the same features as those recorded on 15 March 2018. There was also similar access to the MRI cervical and lumbar spine. The official report was in keeping with the changes seen on the MRI lumbar spine of 2018-19. 
Discussion
The Review Panel 
91.	The Review Panel took into account the history of the accident, as given by Mr Dragas. 
92.	This was a low energy rear end impact with a small vehicle imparting energy to a larger vehicle. Both parties were able to exit the vehicles and drive them away. 
93.	The mechanics of the accident for Mr Dragas would have been relative rearward motion of the pelvis and trunk, into the seat squab and some extension of the cervical spine as far as the head restraint allowed. His knees would have moved away towards the dashboard, and there would not have been any significant steering input, as there was no secondary collision.
94.	It was plausible that there was a soft tissue injury to the cervical spine caused by the accident. Such injuries are commonly reported, but it was not likely that there would have been injuries to the lumbar spine, both shoulders and both knees. 
95.	Further, Mr Dragas gave a history of continuing to work for 18 months in light duties after the motor vehicle accident.
96.	The Medical Review Panel also considered the available clinical signs. Some signs are quite unequivocal indications of prior injury. These include muscle wasting, bony distortion and thickening, joint swelling with redness and crepitus and chronic vascular changes, pigmentation, and scarring. Mr Dragas had none of these findings. 
97.	Mr Dragas also lacked the findings in provocative tests such as, nerve root tension signs.
98.	Note was made of the absence of nerve root tension signs and the normal slump test is performed by straightening the knees whilst sitting bending forward and a marked resistance to straight leg raising. 
99.	Tension and compression tests needed to be consistent if they are to indicate tissue injury.
100.	There were a number of inconsistent findings in the clinical examination. Firstly, was the apparent ease with which the claimant undressed on the examination table compared to the marked reluctance he showed to undertake active movement in any of the joints examined. This inconsistency was pointed out to Mr Dragas. Note was made of clause 6.50.4, that for inconsistency in range of motion (or testing of muscular strength) then range of motion should not be used as a valid parameter of impairment evaluation. This was the case with Mr Dragas. 
101.	Given the lack of unequivocal positive confirmation of injury on clinical examination the Review Panel could not find evidence of continuing injury from the accident. On clinical examination, the Review Panel concluded that the injuries had resolved, and Mr Dragas appeared to be, a fit, physically active male.
102.	Further, there was the evidence presented on the basis of medical imaging. The Review Panel noted the Guidelines, including clause 6.121 concerning the use of the imaging studies and the assessment of the spine. This clause notes that many people have imaging studies that show normal age-related changes. In such circumstances, diagnosis cannot be made on the imaging studies. They only have value in supporting information found in the clinical examination. 
103.	The Review Panel considers that this principle should also extend to other joints, where there were known findings such as tendinitis, acromioclavicular degeneration and so forth, in the shoulders found in healthy subjects without symptoms. 
104.	The imaging studies did not support the concept that there had been lasting injury caused by the motor vehicle accident in either the neck or back, nor either shoulder or either knee.
105.	There were some abnormal findings of note in both knees on MRI that did relate to the motor vehicle accident. For instance, the finding of chronic anterior cruciate ligament injury in the right knee and probable villonodular synovitis in the left knee. Arthroscopy may help establish the diagnosis that in both cases the indication was not related to the motor vehicle accident. There was a possible recent injury to the cervical spine seen in the 2022 MRI however this was not disclosed during the history taking.
106.	The Review Panel further discussed the role of radiology in determining injury and reconsidered the medical opinions offered. Their views are the same.
107.	The history of the severity and mechanism of the motor vehicle accident may have caused transient soft tissue injury to the cervical spine but would not otherwise have caused injury to any of the other areas complained and was further supported by the history of return to work.
108.	The clinical examination was not consistent with ongoing injury.
109.	The radiological examination was mostly findings that were normal for age.
Conclusion
110.	The imaging studies taken after the motor vehicle accident did not show changes of recent injury in the cervical or lumbar spine. 
111.	The changes reported were consistent with normal ageing and are typical changes in a 
50-year-old asymptomatic male. 
112.	The changes seen on the MRI of the right shoulder were typical changes in a 50-year-old manual labourer. They may not be the cause of symptoms and they were not changes one would expect with a motor vehicle accident. 
113.	The changes seen in the right knee were consistent with a chronic anterior cruciate ligament, and early osteoarthritis. There was considerable fluid seen in this joint, not present on the clinical examination. The knee had improved, and no effusion was detected clinically. These changes were not due to the motor vehicle accident but represent long-term effects of a prior injury and some early osteoarthritis. 
114.	On the present clinical examination, there was a positive anterior draw sign confirming the anterior cruciate ligament but no signs of present joint distress. The synovial fluid seen in 2018 was not present. 
115.	The changes seen on the left knee MRI were also synovitis with the likely diagnosis of villonodular synovitis. This was not a traumatic condition either. There were new changes on the CT of the cervical spine performed in September 2022, not seen on the prior MRI of the cervical spine. These were consistent with a new injury, but Mr Dragas did not give a history of this.
116.	Finally, when these issues were considered together, the Review Panel concluded that there was no ongoing injury from the motor vehicle accident in any area of the body. The Review Panel considered that Mr Dragas had sustained soft tissue injuries which had resolved and to the extent that there were ongoing complaints, these were probably not caused by this motor vehicle accident. 
117.	There was no ongoing impairment related to the subject accident resulting in no assessable impairment. Given the current physical findings give 0% WPI. 
118.	Further, there was no ongoing causal relationship with the motor vehicle accident. 
119.	Given the current physical findings, the Review Panel concluded that there was a 0% WPI. 
DETERMINATION
120.	The Medical Review Panel revokes the certificate of Medical Assessor Raymond Wallace dated 9 November 2023.
121.	The Panel substitutes its determination and certifies that there was no ongoing causal relationship with the motor vehicle accident, which gives rise to a whole person impairment (WPI) of 0%.