DETERMINATION OF REVIEW PANEL	
	
CITATION:	AAI Limited t/as AAMI v Free [2024] NSWPICMP 430	
		
CLAIMANT:	Gabrielle Free	
		
INSURER:	AAI Ltd t/as AAMI	
		
REVIEW Panel	 	
		
PRINCIPAL MEMBER:	John Harris 	
		
MEDICAL ASSESSOR:	Geoffrey Stubbs	
		
MEDICAL ASSESSOR:	Tania Rogers	
		
DATE OF DECISION:	3 July 2024	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; claimant struck by vehicle in carpark and thrown; assessment of permanent impairment; claimant alleged impairment of multiple body parts; consideration of medical records; absence of complaint of some body parts in contemporaneous records; omission of injury of some body parts in claim form; AAI Ltd v McGiffen and Bugat v Fox referred to; examination by Medical Assessors and extensive review of radiology; findings made that some body parts recovered based on records and nature of injuries; other body parts, except right shoulder, had no rateable assessment; Held – claimant assessed at 4% permanent impairment due to right shoulder; Medical Assessment Certificate revoked.
	
DETERMINATIONS MADE:  	Medical Assessment – Permanent Impairment
WHETHER THE DEGREE OF permanent impairment OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10%
The assessment made by the review panel under s 63(4) is as follows:
1.	The Review Panel revokes the medical assessment certificate of Medical Assessor Dixon dated 30 October 2023 and issues a new certificate that the following injuries caused by the motor accident give rise to a whole person impairment which is NOT GREATER THAN 10%:
•	right shoulder injury;
•	cervical spine;
•	lumbar spine, and
•	knees (resolved). 	

REASONS
BACKGROUND 
1.	Ms Gabrielle Free (the claimant) suffered injury in a motor accident on 25 February 2013. The claimant was walking across a pedestrian crossing at a shopping centre carpark when she was struck by the insured vehicle.
2.	AAI Ltd (the insurer) is liable to pay Ms Free any damages under the Motor Accidents Compensation 1999 (the MAC Act).
3.	The present dispute between the parties is whether the degree of permanent impairment as a result of the injury caused by the motor accident is greater than 10%. This constitutes a medical dispute within the meaning of the MAC Act. 
4.	Section 44(1)(c) of the MAC Act provides that the State Insurance Regulatory Authority may issue guidelines with respect to the assessment of the degree of permanent impairment of an injured person as a result of an injury caused by a motor accident.
5.	The Motor Accident Permanent Impairment Guidelines (the Guidelines) were issued pursuant to s 44(1)(c) for the assessment of permanent impairment. The Guidelines adopt the fourth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.
6.	The present application is a review of a medical assessment pursuant to s 63 of the MAC Act. The medical assessment the subject of this review was conducted by Medical Assessor Dixon dated 30 October 2023 (the medical assessment). The Medical Assessor assessed that the permanent impairment caused by the motor accident is greater than 10%.
7.	The application for referral of a medical assessment to a Review Panel (the Panel) was made by the insurer within 28 days after the parties were issued with the original certificate for the medical assessment for which the review is sought.
8.	The delegate of the President referred the medical assessment to the Panel as they were satisfied that 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.
9.	Pursuant to s 63(3) of the MAC Act and Schedule 1, cl 14F(2) of the Personal Injury Act 2020 (the PIC Act), the Panel consists of two Medical Assessors and a Member of the Motor Accidents Division of the Personal Injury Commission (Commission).
CONDUCT OF THE REVIEW
10.	Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Merit Reviewer or a Medical Assessor.
11.	Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the 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.
12.	The review is by way of new assessment of all matters with which the medical assessment is concerned.
13.	The parties filed bundles for the Panel’s consideration.
14.	The Panel issued a further direction requesting documents and submissions on the nature of the motor accident. The insurer promptly replied to that request. Those submissions and further documents are addressed elsewhere in these Reasons. The claimant did not reply to the further direction.
MEDICAL ASSESSMENT UNDER REVIEW
15.	This review is from the medical assessment when the Medical Assessor determined that 
Ms Free suffered a 15% permanent impairment for the physical injuries caused by the motor accident. The impairment of the lumbar spine was assessed at 5% and the right shoulder at 11%. 
16.	The Medical Assessor found that the motor accident caused injuries to the cervical spine, lumbar spine and right shoulder, found that the injuries to the knees were “not yet” permanent and the injuries to the left and right hip and right ankle had resolved. 
STATUTORY PROVISIONS
17.	Clause 1.7 of the Guidelines provides:
“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 motor 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.” 
SUBMISSIONS
Insurer’s submissions dated 9 March 2021
18.	The insurer noted that Medical Assessor Kenna assessed the claimant on 23 June 2018 as 6% whole person impairment comprised solely of the right upper extremity. Medical Assessor Barrett provided an assessment of whole person impairment due to psychological injury in July 2018.
19.	These submissions addressed whether there had been any deterioration to justify a further assessment.
20.	The insurer submitted that the further reports of Dr Patterson do not affect the outcome.
21.	The insurer submitted that the scan evidence of the right knee dated January 2020 do not constitute evidence of deterioration related to the motor accident. It noted that the whole body bone scan dated 12 August 2011 showed mild arthritic changes in the right knee. The X-ray of the right knee taken following the motor accident showed no acute displaced fracture or dislocation and the bone scan dated 7 April 2015 showed low-grade arthritic changes in the right knee.
22.	The insurer referred to the findings of Medical Assessor Kenna in relation to the right knee when he found that there was a soft tissue injury which had essentially resolved with normal range of motion.
23.	The insurer referred to the opinion of Dr Shin-Lee which referred to a lifting incident in December 2019 when the claimant developed pain in the right leg. The insurer noted that Medical Assessor Kenna found no neurological deficit and no evidence radicular complaints in respect of the low back and lower extremities.
24.	The insurer noted that the lumbar spine CT scan dated 5 December 2013 showed no evidence of foraminal nerve root compression or central canal stenosis and any recent radiological evidence of exit foramen stenosis occurred more than six years after the motor accident.
25.	The insurer submitted that the claimant was referred to Dr Hsu for treatment associated with that undertaken by Dr Shin-Lee and this is unrelated to the motor accident.
26.	The insurer noted that the history taken by Dr Gehr is grossly inconsistent with the available clinical records which establish widespread pain and diagnoses of bilateral bursitis in both shoulders and hips one year prior to the motor accident and a long-standing history of chronic pain and arthritic complaints necessitating regular specialist intervention, radiological investigations and injections.
27.	The insurer noted the claimant was involved in a further motor accident in late 2020 which resulted in a worsening of symptoms in all regions.
Insurer’s submissions dated 30 November 2023
28.	The insurer noted that there is no legislative basis under the MAC Act to provide an interim certificate.
29.	The insurer submitted that the Medical Assessor noted that there were no significant past injuries to the neck, right shoulder, lower back or knees and failed to have regard to the material evidence including:
(a)	medical certificates and other material relating to the left knee injury in 2009;
(b)	whole body scan and lumbosacral scan dated 12 August 2011;
(c)	MRI scan of the cervical spine dated 1 December 2011;
(d)	Ultrasound dated 1 December 2011 of the right shoulder and both hips;
(e)	in 2012 the claimant was assessed in relation to bilateral bursitis involving both shoulders and hips, and
(f)	reports of Dr Podgorski in 2011 and 2012 referring to a history of chronic fatigue syndrome including reports dated 10 August 2011 and 20 February 2012.
30.	The insurer submitted that the Medical Assessor failed to have regard to the subsequent fall at work onto the left knee in 2015.
31.	The insurer referred to the post accident right knee X-ray dated 25 February 2013 which showed no acute fracture or dislocation and the bone scan dated 7 April 2015 which showed widespread arthritic changes. 
32.	The insurer submitted that the history of the motor accident described as a “severe” impact contrasted with the ambulance records and Westmead Hospital records which referred the matter accident occurring at low speed in a shopping centre carpark. It also referred to the record of superficial abrasions set out in the ambulance and hospital records.
33.	The insurer submitted that the Medical Assessor failed to correctly apply causation and refer to cls 1.6 and 1.7 of the Guidelines.
34.	The claimant had recently undergone bilateral total knee replacements and submitted that it had been denied procedural fairness because it had not been made aware of that fact. 
Insurer’s submissions dated 1 May 2024
35.	These submissions were filed in response to the further direction issued by the Panel.
36.	The insurer disputed the history of the claimant being thrown 20 feet referring to the ambulance report and hospital records which recorded a low-speed impact in a shopping centre car park. It acknowledged that the ambulance record referred to a witness stating that the claimant was thrown 20 feet.
37.	The insurer referred to the general practitioner (GP) records following the motor accident of S & P Family Medical Practice and FamCare Medical Centre. It noted the following documents:
(a)	fall onto left knee and MRI scan dated 11 July 2009;
(b)	fall onto left knee in May 2015;
(c)	no complaints of pain in knee as at 10 August 2017;
(d)	commencement of right knee pain in December 2019 (see Abbotsford Medical Centre entry on 11 August 2020 (Insurer’s bundle, p 1073), and
(e)	subsequent motor accident on 18 August 2020 (Insurer’s bundle, p 1,380).
38.	The insurer submitted that:
“Other than the initial reference to a right knee abrasion and pain in the left knee, there appears to be no further complaints of knee pain after the accident until the fall onto the right knee in 2015 and the left knee in 2017.”
Claimant’s submissions dated 22 January 2024
39.	These submissions opposed leave to review the medical assessment. 
40.	The claimant noted that she was injured whilst walking across a pedestrian crossing in a shopping centre in Castle Hill when she was struck on the right side and thrown “several metres from the point of impact” landing on hands and knees. 
41.	The claimant alleges that she injured her neck, both shoulders, lumbar spine, right hip, right knee, left knee, right ankle and left ankle.
42.	The claimant submitted that the Medical Assessor undertook a thorough medical assessment and review of the material and provided detailed reasons.
43.	The claimant submitted that the motor accident only needs to be a contributing cause which is more than negligible to the injury.
EVIDENCE
Pre-existing conditions 
44.	An X-ray of the thoracic and lumbar spine dated 3 November 2006 showed thoraco lumbar scoliosis.
45.	Certificates of capacity in July and August 2009 referred to left knee injury. An MRI scan of the left knee dated 11 July 2009 showed chondromalacia patella.
46.	On 29 July 2009, Dr Newman, orthopaedic surgeon, noted complaints of pain in the first metatarsal probably related to pressure from shoes. Gait was described as unremarkable. The doctor recommended conservative management with change in the type of footwear.
47.	In April 2010 the claimant alleged work injuries to the right knee and ankle caused at work following a slip off a platform. A claim for compensation was made at that time.
48.	In August 2011 Dr Mark Podgorski, rheumatologist, noted widespread muscular and joint pain throughout shoulder girdles, upper arms, shoulders, hips, trunk and rib cage. A recent bone scan showed increased uptake over both wrists, shoulders and hips, slightly across several MCP joints, right AC joint but none in the spine.
49.	The whole-body bone scan and lumbosacral SPECT CT dated 12 August 2011 noted a clinical history of six-week widespread polyarthralgia in large and small joints particularly in the lumbosacral region. The scan showed non-specific pattern with mild arthritic changes, maximal in the wrists with mild arthritic changes in the finger joints, the right knee, possibly the hips and the right AC joint.
50.	An MRI scan the cervical spine December 2011 noted a clinical history of right upper arm and hand pain, possible C5 to C7 nerve root impingement. The scan showed the C5/6 disc was narrowed with early endplate marrow changes, slight impingement of the sac with no contact with the cord. There was a small unconvertable osteophyte causing slight compromise of the left C5/6 exit foramen.
51.	An ultrasound of the right shoulder dated 1 December 2011 showed supraspinatus insertional tendinopathy with overlying bursitis. The claimant underwent a bursal injection at that time.
52.	An MRI scan of the thoracic spine dated 14 December 2011 showed minor lower degenerative disc disease.
53.	In December 2011 Dr Mark Podgorski, rheumatologist, noted that the injection to the right anterior subacromial space at the shoulder was ineffective.
54.	In a report dated 20 February 2012, Dr Podgorski noted the claimant had widespread myofascial pain throughout the arm with normal muscle strength. The doctor noted a positive outcome as the claimant had responded well to prednisolone, which had lessened the chronic widespread pain.
55.	The doctor noted that radiological findings showed degenerative disc disease at C5/6 with facet joint osteoarthritis and mild foraminal stenosis with no response to foraminal injections. The right shoulder ultrasound showed supraspinatus insertional tendinopathy with bursitis, again without any significant response to ultrasound guided steroid injections.
56.	A bilateral shoulder ultrasound dated 20 February 2012 showed bilateral calf insertional tendinopathy more marked on the right side. There was no evidence of a cuff tear. 
57.	A bilateral hip joint ultrasound showed bilateral gluteal insertional tendinopathy with no tear and bilateral greater trochanteric bursitis more marked on the left side. 
58.	The clinical notes of the chiropractor in the second half of 2012 refer to pain in the thoracic and lumbar spine. 
59.	In January 2013 the claimant underwent an insertion of a stent into the biliary system. There is otherwise extensive records of longstanding epigastric discomfort. 
Motor accident claim form
60.	The motor accident claim form was completed by the claimant and is dated 
27 February 2013. A second claim form is dated 20 August 2013.
61.	The diagram in the second claim form shows the claimant walking across the pedestrian crossing between two council car parks. The description of the motor accident is as follows:
“I was crossing the pedestrian crossing between the two council car parts when a car driven by [name] made a right hand turn from McDougall Lane into street unknown and ran over me. According to the witness [named] I was thrown 20 feet down the street name unknown.”
62.	The second claim form referred to the following injuries caused by the motor accident:  
“Abrasions to palms (L&R), abrasions to R knee. Pain in R knee. R shoulder pain, neck pain and headache.”
63.	In response to the question – “How do the injuries affect you now”, the claimant replied:
“Still have shoulder pain (R), headache and neck pain.”
64.	The claimant stated that she had lost income but had returned to work and was not losing income at the time of the completion of the second claim form.
Contemporaneous medical evidence
65.	The ambulance record records:
“Pt hit by car at low speed. Up onto bonnet then down onto ground. Witness stated Pt was ?thrown through the air up to 20ft. Pt keeps referring to witness statement for events … Abrasions to hands (palms) P knee. Cleaned and dressed. Nil neck pain.”
66.	The hospital record was: 
“Ms Free was brought in by ambulance after being hit by a low-speed car while crossing a shopping centre car park. She reported being hit by the car and landed on her hands and knees. No loss of consciousness was reported. She denied any dizziness, light headedness, or significant pain other than abrasions to the palms and pain in her L knee. On examination she was alert and orientated. GCS 15. She was haemodynamically stable. She had superficial abrasions to the palmar surfaces to both hands. She also had a superficial abrasions to her right knee. The results were unremarkable. Chest x-ray showed no lung pathology or fractions. Right knee x-ray showed no fracture or dislocation. FAST ultrasound showed no free fluid around the kidneys, bladder or heart. The abrasions all hands were dressed and she was subsequently discharged.”
67.	The GP clinical note dated 26 February 2013 noted grazes on both hands and right shoulder pain.
68.	A certificate dated 28 February 2013 referred to multiple injuries with pain and abrasions in right knee, right shoulder and neck pain.
69.	The clinical note of the chiropractor dated 2 March 2013 refers to “hit side on by car”. It is unclear what body parts were treated from the notes.
70.	On 8 March 2013 the GP noted the right shoulder scans and referred the claimant for a lumbar spine X-ray.
71.	A right shoulder X-ray dated 8 March 2013 was normal. The ultrasound showed thickening of the subacromial bursa with impingement on abduction. Dr Ong recommended an ultrasound guided steroid injection in the subacromial bursa. 
72.	On 14 March 2013 the GP noted right buttock, low back, and right shoulder pain with occipital headaches.
73.	The GP referred the claimant for physiotherapy on 4 April 2013 noting the motor vehicle accident and complaints of lower back pain, bilateral buttock pain, neck pain and right shoulder pain.
74.	In August and October 2013 the chiropractor noted the neck was “V sore”. It appears, although unclear, that the chiropractor treated the lumbar spine in December 2013 and in February 2014. On 29 March 2014 the chiropractor noted “frozen shoulder R side”.
75.	An MRI scan of the brain dated 14 October 2013 showed no intracranial abnormality or haemorrhage.
76.	A CT scan of the lumbar spine and pelvis dated 5 December 2013 noted pain and stiffness in both gluteal regions and showed minor lumbar spondylosis.
Subsequent evidence
77.	The GP provided a report dated 20 January 2015. The GP noted that he assessed the claimant on 26 February 2014 [sic] for superficial abrasions to the palmar surfaces of both hands and superficial abrasions to the right knee. The claimant also complained of right shoulder pain.
78.	On 2 April 2015 Dr Podgorski, rheumatologist, recorded that the claimant presented with chronic widespread pain consistent with fibromyalgia. The doctor recommended a repeat bone scan to ascertain whether there was any major inflammatory joint disease. The doctor noted that the that he had seen the claimant in 2011 and 2012 and thoroughly investigated her for any potential inflammatory disease, widespread polyarthritis and found no evidence of same.
79.	A bone scan dated 7 April 2015 showed an overall pattern suggestive of low-grade arthritic changes in the AC joint, right wrist, joints of the hands, hips, the right knee and right ankle. When compared to the previous study in August 2011, the previously noted hyperaemia was not evident and the increased uptake in the right sesamoid region was new. The remainder of the overall scans appeared essentially similar.
80.	The claimant underwent a right greater trochanteric bursal injection on 15 April 2015.
81.	In May 2015 the claimant injured her left knee at work which was confirmed by certificates of capacity. An X-ray showed mild medial tibiofemoral compartment narrowing and bony spurring. The MRI scan dated 8 May 2015 showed mild to moderate chondral wear at the medial compartment and minor retropatellar chondral wear. The clinical records confirm the details of that incident.
82.	An MRI scan of the right shoulder dated 13 July 2015 showed minor cuff tendinopathy without a significant cuff tear and minimal hyper intensity in the subacromial bursa.
83.	In July 2015 Dr Podgorski noted there was pain throughout the right shoulder with clinical features of adhesive capsulitis. The doctor also noted ongoing right lateral hip discomfort at the trochanteric bursa and sub gluteus bursa.
84.	A bilateral ultrasound of the ankle and feet dated 30 July 2015 showed prior right sided inversion injury with avulsion of the anterior talofibular ligament. 
85.	The claimant underwent a right shoulder bursa injection on 11 August 2015.
86.	On 6 July 2016 Associate Professor Kuo noted that the claimant had been troubled by a right fasciitis for the last couple of years and recommended treatment associated with the condition.
87.	In July 2016 Dr Bokor, orthopaedic surgeon, noted the claimant had been troubled with right shoulder pain and restriction of movement since the motor accident. Previous treatment included chiropractic and physiotherapy and subacromial injections with only marginal benefit.
88.	The doctor noted that a prior MRI scan undertaken a year ago showed significant capsulitic features with a very thickened contracted inferior capsule with no major glenohumeral changes and no major cuff tear. The doctor noted the clinical picture suggested long-standing capsulitis and organised for a repeat MRI scan.
89.	An MRI scan of the right shoulder dated 7 July 2016 showed imaging features supporting the diagnosis of adhesive capsulitis with bursal tendinopathy and anterior lateral degeneration, acromioclavicular joint degeneration wear with chondral loss and synovitis.
90.	On 13 July 2016 Dr Bokor noted the MRI scan showed only some tendinosis and some degenerative changes in the AC joint with features of capsulitis without overt thickening of the inferior capsular ligaments. The doctor recommended surgery by way of manipulation and mobilisation with an arthroscopic capsular release, subacromial bursal debridement and probably an excision of the outer clavicle.
91.	The operation report by Dr Bokor dated 26 July 2016 showed evidence of a thickened inflamed capsule which was released extensively.
92.	In August 2016 Dr Podgorski noted the claimant presented with chronic widespread pain throughout hind foot areas, heels, ankle and subtalar joints. The doctor noted the recent bone scan showed increased uptake of the ankle joint noting there was a history of prior ankle sprains.
93.	An MRI scan of the cervical spine in September 2016 showed a broad-based disc bulge at C5/6 with no evidence of central canal stenosis, left sided foraminal stenosis without nerve root compression and facet joints appeared unremarkable. The other levels were essentially normal.
94.	In September 2016, Dr Podgorski noted that the claimant continued with chronic widespread pain, particularly worse on the right side, with right arm cervical critical radiculopathy symptoms radiating from the neck and shoulder girdle to the inner aspect of the right forearm as far as the thumb.
95.	In October 2016 the claimant made a claim for income protection benefits for chronic fatigue, arthritis, myalgia for the whole body including right arm, back hips and legs since October 2003.
96.	On 26 October 2016 Dr Bokor recorded that there was a little bit of improvement of the pain although restrictions were very similar to the position prior to surgery. The doctor recommended simple manipulation and injection of cortisone in the joint to break up any postsurgical scarring.
97.	On 1 November 2016 Dr Bokor performed a manipulation under anaesthesia noting there was virtually full range of motion with no audible or painful crepitus or release of adhesions. The shoulder was placed through a complete range of motion.
98.	An X-ray of the left foot dated 25 January 2017 showed enthesopathic changes of the peroneal tendon insertion and interphalangeal joint osteoarthritis involving the fifth digit.
99.	Dr Andrew Patterson, pain management specialist, provided a report dated 
25 January 2017. The doctor noted ongoing pain particularly relating to the neck and right shoulder, right hip and lower back and recommended a multidisciplinary pain management approach with psychological and physiotherapy involvement.
100.	Dr Patterson observed that there were elements of post-traumatic stress disorder involving increasing rumination about the claimant’s pain that had yet to be addressed.
101.	An Allied health recovery request dated 14 August 2017 referred to headaches, neck, right shoulder, right lumbar pelvic and left ankle pain. The insurer’s subsequent submissions highlighted that the knees were not mentioned at this time. That submission has little weight given the clinical notes refer to bilateral knee X-rays.
102.	In February 2018 Dr Patterson noted right sided diffuse pain, worst in right shoulder, lower lumbar and sacroiliac joint with significant weight gain over the last few years.
103.	An MRI scan of the right knee dated 8 March 2018 showed Grade 2 chondral wear of the medial knee compartment and the patellofemoral compartment. The clinical history was of a fall on the right knee in December 2017 with twisting and pain in the right knee.
104.	A CT scan of the lumbar spine dated 1 May 2018 noted right sided low back pain. The scan showed mild lumbar spine degenerative changes with facet joint arthropathy.
105.	An X-ray of the right ankle dated 2 May 2018 reported a history that the claimant “fell on stairs and twisted right ankle”. The X-ray showed a tiny avulsion fragment at the tip of the lateral malleolus.
106.	In May 2018 Dr Patterson noted ongoing pain in the right shoulder and sacroiliac region following diagnostic joint blocks.
107.	In July 2018 Dr Patterson noted decrease in pain over the right S1 joint following radiofrequency ablation.
108.	An MRI scan of the right knee dated 3 January 2020 noted mild interval progression of all three compartments with grade 2 to 3 changes involving the medial femoral condyle and grade 2 changes involving the weight-bearing aspect the lateral femoral condyle and the patella.
109.	An ultrasound and X-ray of the right knee dated 6 January 2020 showed moderate suprapatellar joint effusion and mild tricompartmental osteoarthritis and moderate suprapatellar joint effusion.
110.	Dr Tack-Shin Lee, orthopaedic surgeon, provided a report dated 8 January 2020. The doctor noted the claimant reported lifting furniture on 18 December 2019 with no injury but the development of pain in the right leg on the following day which have been gradually getting worse. History included the motor vehicle accident with chronic low back pain. The doctor was unable to detect any nerve root tension signs but recommended referral for an MRI scan of the lumbosacral spine.
111.	Dr Lee subsequently noted the MRI scan showed exit foramen stenosis at the right L4/5 level and recommended referral to Dr Hsu. 
112.	On 28 January 2020, Dr Hsu noted pain was related to the L4/5 intervertebral segment and recommended a foraminal injection. On 23 February 2020, Dr Hsu noted injection provided good relief and leg pain at the back pain still persisting.
113.	In April 2020 the claimant underwent bilateral knee injections.
114.	The claimant was again seen by Dr Lee in May 2020 who assessed right leg sciatica and referred the claimant to Dr Hsu for ongoing care.
115.	The claimant was involved in a further motor vehicle accident in August 2020 from a rear end collision with injuries to the chest, neck and back. Treatment included physiotherapy. 
Dr Jefferies diagnosed that the 2020 motor accident caused whiplash associated disorder – grade II. A clinical note dated 18 August 2020 also referenced injury to the right knee.
116.	Dr Gunaratne, rheumatologist, provided a report dated 23 May 2021. The doctor noted a history that the claimant had a chronic 40-year history of fatigue, myalgia and polyarthralgia affecting the elbows, MCP joints, hips, knees and ankles which progressively worsened through time.
117.	The doctor noted the symptoms of fibromyalgia can vary from day to day and current emotional stresses were likely contributing to the condition. Dr Gunaratne opined that there was no clear evidence of an inflammatory arthritis or an active connective tissue disorder.
118.	In July 2021 Dr Gunaratne noted that a trial of Endep had not reduced pain and recommended treatment by way of ongoing pain management.
Qualified opinions 
119.	Dr Stephen Quain, orthopaedic surgeon, was qualified by the insurer and provided a report dated 20 May 2014. The doctor recorded a history that the insured vehicle turned into a roadway between the car parks and the claimant stated she believed she was thrown 20 feet according to a witness. The claimant said she did not recall the incident.
120.	The claimant complained of right shoulder and right hip pain and ongoing headaches. Examination of the cervical spine showed normal range of motion. Examination of the right shoulder showed full abduction and flexion with some mildly positive impingement signs including internal rotation in 90° of abduction.
121.	Dr Quain opined that the motor accident caused non-specific pain in the buttock and right hip area as well as some impingement possible bursitis in the right shoulder.
122.	Dr David Campion, physician, was qualified by the claimant and provided a report dated 
13 May 2015. The doctor noted that prior to the motor vehicle accident the claimant was generally well apart from a biliary duct problem affecting the abdomen.
123.	Dr Campion opined that the direct trauma from the motor accident was mainly to her right shoulder, upper arm, right hip and thigh with forced forward landing on the outstretched hands and knees. The doctor opined that the claimant sustained an injury to the cervical spine, injury to the right shoulder, onset of low back pain, aggravation of the right greater trochanter syndrome though no obvious change in the underlying pathology, aggravation of the left trochanter syndrome indirectly caused by the pain and related impairment of the right leg and right knee pain disorder.
124.	Dr Campion noted that the claimant did not meet the criteria for DRE Category II for the neck and low back and the right knee and both hips did not meet the criteria for whole person impairment. The doctor requested further investigations of the right shoulder.
125.	Dr Campion provided a further report dated 4 April 2016. The impairment of the right shoulder was then assessed at 5%.
126.	Dr Michael Ryan, orthopaedic surgeon, was qualified by the claimant provided a report dated 11 July 2017. The doctor noted ongoing right hip and right shoulder pain with the development of right ankle pain. Cervical examination showed symmetrical range of motion without evidence of muscle spasm and no evidence of upper limb irritation or compression neuropathy.
127.	Range of motion of the right shoulder was described as variable with an average consistent with abduction to 80° and flexion to 110°.
128.	The claimant continued to be troubled by pain in both knees with crepitus present.
129.	Dr Ryan diagnosed subacromial/subdeltoid arthritis in the right shoulder, right and left patella-femoral arthrosis and right chronic trochanteric bursitis with a generalised pain syndrome.
130.	Dr Enrico Parmegiani, psychiatrist, was qualified by the claimant and provided a report dated 23 August 2017. The doctor opined that the claimant presented with symptoms of chronic pain diagnosed post-traumatic stress disorder complicated by secondary depression. 
Dr Parmegiani recommended ongoing psychological treatment.
131.	Dr Anthony Samuels, psychiatrist, was qualified by the insurer and provided a report dated 14 December 2017. The doctor opined that the claimant was markedly dysthymic and angry about her situation but was not clinically depressed and anxious and was not suffering from post-traumatic stress disorder or major depression or an anxiety condition. Dr Samuels noted complaints of pain mainly involving the right shoulder and hip and with headaches and lower back pain.
132.	Dr Robin Mitchell, physician, was qualified by the insurer and provided a report dated 
14 January 2020.
133.	The claimant advised the doctor that she was thrown about 6m landing on her hands and knees with no loss of consciousness and developed symptoms in the low back, each hip, left shoulder, right elbow and wrist, and right ankle.
134.	On examination the doctor recorded reduced flexion and extension at three quarters of normal range of motion for the cervical spine and similar loss of movement in the thoracic and lumbar spine.
135.	The doctor found reduced flexion of the right shoulder at 150 degrees with all other movements, including the left shoulder, at normal. Examination of the joints of the lower extremities showed full range of movement in all directions.
136.	The doctor opined that the reported ongoing pain in the neck, right shoulder and right knee was caused by the motor accident by way of aggravation of existing conditions whilst the widespread symptoms in the thoracic and lumbar spine, left knee and left ankle and right ankle bore no relationship to the subject motor accident.
137.	Dr Loretta Reiter, rheumatologist, was qualified by the insurer and provided a report dated 
6 February 2020. 
138.	The doctor noted current symptoms in the right shoulder, upper right thigh, lumbar spine and right buttock. There was no right anterior knee pain. The claimant complained of generalised aches and pains which the doctor noted was diagnosed in 2011 and affected the left lower limb particularly the left knee and left ankle.
139.	Dr Reiter opined that the claimant was suffering from fibromyalgia unrelated to the motor accident which had not been exacerbated.
140.	The doctor opined that the claimant was suffering from pre-existing right hip pain due to age-related osteoarthritis which could have been aggravated temporarily, a few months by the motor accident. The current condition was due to the natural progression of the underlying age-related constitutional right knee osteoarthritis.
141.	Dr Reiter accepted the applicant injured her right shoulder although it was difficult to determine the reduced range of motion due to the pre-existing condition as opposed to what was caused by the motor accident.
142.	Dr Gehr, surgeon, was qualified by the claimant and provided a report dated 24 September
2020. Dr Gehr provided an extensive summary of the various records. He noted a history of the accident when the claimant was “pushed on the road” and sustained injuries to the cervical spine, both shoulders right worse than left, lumbar spine, lateral right hip and posterior buttocks on the right side and pain over both knees. The doctor noted that in the last three years the claimant had developed bilateral ankle pain.
143.	The claimant had a recent motor accident when she was hit from behind and this had “worsened the pain in all regions already described”.
144.	Dr Gehr diagnosed the following injuries caused by the motor accident:
(a)	cervical spine soft tissue injury with right sided radiculopathy;
(b)	lumbar spine soft tissue injury right sided radiculopathy;
(c)	right shoulder soft tissue injury with decreased range of motion;
(d)	left shoulder pain with no rateable impairment;
(e)	right knee pain, muscle wasting and decreased range of motion;
(f)	left knee pain, wasting and loss of range of motion;
(g)	bilateral ankle pain with loss of range of motion, and
(h)	right hip pain with no rateable impairment.
145.	Dr Gehr assessed the cervical spine at 14%, the lumbar spine at 10%, the right shoulder at 10%, the right knee at 8%, the left knee at 4%, the right ankle at 5% and appeared to conclude the left ankle loss of range of motion was not caused by the motor accident.

OTHER MEDICAL ASSESSMENTS
146.	Medical assessment certificates were provided by Medical Assessor Kenna dated 
23 June 2018 and Medical Assessor Barrett dated 15 July 2018.
147.	Medical Assessor Kenna found that the motor accident caused soft tissue injuries to the right leg which essentially resolved. Regarding the cervical spine the Medical Assessor found that there was no muscle guarding, symmetrically reduce range of motion, no neurological deficit in either upper limb and distal symptoms which did not follow the distribution of any specific nerve root and no indication of non-verifiable radicular complaint.
148.	The range of motion of the right shoulder was assessed at 6% whole person impairment. The range of motion of the left shoulder was normal.
149.	Regarding the lumbar spine the Medical Assessor found that there was no muscle guarding, full range of motion and no neurological deficit in either lower limb. There was a full range of mobility in both the right and left hip. Examination of both knees and ankles were normal.
150.	Medical Assessor Kenna opined that the claimant suffered soft tissue injuries with management complicated by the fact that the conditions had morphed into a chronic pain type scenario noted by Drs Champion and Patterson. The claimant was assessed at 6% whole person impairment solely relating to reduced range of motion of the right shoulder.
151.	Medical Assessor Barrett opined that the motor accident caused an adjustment disorder with depressed and anxious mood, chronic and assessed impairment at 8%.
EXAMINATION
152.	The claimant was examined by both Medical Assessors. The examination report is as follows.
“The reason for the examination was explained to Ms Free.
Ms Free is 61-year-old lady lives in Kellyville. She was terminated from her job as a teacher four to five years ago as she could not carry out her role. She has been unemployed since and has lived off savings. 
Her last job was as a career’s advisor/commerce teacher at a high school for six years. 
Before that, she was a regional vocational education and training coordinator, which was a higher-paying job, but she took a pay cut in about 2010 due to biliary strictures.
At the time of the subject motor accident, Ms Free was working three days a week due to previous health issues with biliary strictures at the time and had been doing so for about a year. She had been working for three days a week for a year before hand. She always had the intention of increasing to five days a week. 
She had also taken time off at the time for severe whooping cough at some stage before the accident, possibly around the time of polyarthralgia. 
She has been divorced since the accident. She lives in her own home, a two-storey four-bedroom home, and still has a mortgage. 
She has lived by herself since 2019 since her divorce. When married, she paid for assistance with gardening. Currently, her daughter and husband help whenever they can. A friend drove her to the assessment.
Ms Free reported that she is right hand dominant.
Dr Stubbs noted a history of scoliosis, a left knee injury requiring an MRI scan and pain in her feet in 2009. 
Ms Free confirmed that in 2010 she injured her right knee and ankle falling off a platform in a science lab. She was writing on the whiteboard and didn’t realise that the platform had finished at the side and she fell off the side of the platform. She reported it as an accident at school but never received any payout. She recalled she probably took a day off or two. 
Dr Stubbs noted that she was sent to see Dr Mark Podgorski, a rheumatologist, in August 2011 and was referred for a bone scan, which showed evidence of intake at multiple joints. An MRI of her cervical spine was also noted in 2011 which Dr Stubbs noted was unremarkable. MRI of the thoracic spine in 2011 was also noted. This suggested generalised aches and pains. 
Ms Free recalled she had pain down the right arm, and the MRI showed a pinched nerve at the back of her neck, which was resolved after a cortisone injection into her cervical spine. She was diagnosed with biliary strictures and was in a huge amount of pain for a year about 2012. The pain would go into her back.
Dr Stubbs noted she had an ultrasound for her hip which would suggest insertional tendinopathy. Ms Free noted that she had biliary strictures for at least 12 months and caused severe pain. Her common bile duct was blocked by 90%, and she had biliary stents every 3 months. Just before the accident, she had her first metallic stent, which would stay in for a year. 
At the time of the subject motor accident, she was working 3 days a week as she had to reduce due to a 12-month history of biliary stent. Dr Stubbs noted she was having migratory pains. She had been trialling Plaquenil, which did not make much difference, so she was taking Panadol around the time of the subject motor accident. She was on Lyrica for her right anterior arm and shoulder pain and was on Panadeine forte when she needed it.
Ms Free said that Dr Podgorski could not work out the cause of right shoulder pain then had a cervical spine MRI showing a pinched nerve in her neck and the pain resolved after a corticosteroid injection.
Ms Free confirmed that multiple pain problems were ongoing for a number of years before the subject motor accident, but she maintained that she was still able to function and was on restricted hours at work due to the biliary condition. 
She had some bursitis in the hip before the subject motor accident. The right hip hurts more than the left. She saw a pain specialist and had interventional pain treatments, including RF ablation, but the effect of the treatments lasted at most a few weeks. 
History of motor vehicle accident
The accident occurred in Feb 2013. She was a pedestrian at a crossing when a Great Wall utility vehicle accelerated around a corner and knocked her to the ground. She went underneath the vehicle. The car wheels did not run over her. She was trapped under the engine. It was a turbo diesel engine. 
The issue of how far she was thrown was discussed with Ms Free. She maintained that she was thrown six metres. The road was sloping, and she felt that she was sliding down the road. She then stated that she was hit on the right, fell onto her hands and knees, slid down the road and found herself under the vehicle as it had continued forward slightly before stopping. 
A witness who was sitting in his car helped her up. The driver stayed on the scene. She was taken to hospital by ambulance to Westmead Hospital Emergency Department. 
Ms Free recalled she had an x-ray of her knee, but this was normal. She had US of her biliary stent, which was confirmed still in situ. 
Dr Stubbs noted that the hospital report indicated she had abrasions to her palms. Ms Free noted that she landed on both her hands and knees and had pain in both knees.
After she went home, she could not obtain an appointment with her usual normal doctor, so she saw another GP, Dr Salib. Dr Salib referred her for shoulder imaging. 
Ms Free said she went back to work within days of the accident as she was only working three days. She would soldier on and then come home and rest. She finally stopped work in 2017. 
She saw a chiropractor who she had been seeing on and off since at least 2012 occasionally for arm pain and pain across her shoulder blades.
Ms Free recalled that she developed a frozen right shoulder and attended Dr Bokor. She had an arthroscopy in 26 July 2016 that showed a tear in the shoulder which was repaired. This did not significantly improve the shoulder pain. 
She had manipulation under anaesthesia of the shoulder on 1 November 2016, which she noted was temporarily effective than the shoulder ‘seized up again’.
Ms Free recalled seeing Dr Patterson, a pain management specialist; however, the treatment did not improve her pain.
Ms Free noted that she had severe right buttock pain, developed a limp, and developed pain in her right knee, and then she started to get severe pain in her left knee. 
The report by Dr Tack Shin Lee, 8 Jan 2020, is noted regarding another knee injury. Ms Free noted that the day before, she picked up a box of Christmas decorations and then went shopping and went to walk the stairs to her house and found she had pain in the right knee. 
Dr Lee told her it was her back and referred her to Dr Hsu. Dr Hsu did an injection into the lower back which relieved the pain for six months. The pain then returned spontaneously.
She then saw Dr Lee again and ‘begged’ him for an L4/5 injection which was arranged and she was referred back to Dr Hsu
Ms Free then confirmed when driving, her car was rear-ended by another car in August 2020, and she sustained a whiplash injury. She was sent to a whiplash clinic and the pain resolved. She stated that the other injuries were not aggravated. 
Her back pain deteriorated in 2021 and Dr Hsu suggested she have a spinal fusion. She booked in for surgery however then cancelled. She got a second opinion from Dr Seex, a neurologist who suggested an SI joint fusion. 
She said that her knee pain had become severe. She went back to Dr Lee to have her knee looked at again as her knee pain was so severe she couldn’t walk upstairs. 
Dr Lee did bilateral knee replacements a year ago in March 2023 at Norwest Private Hospital. She spent two weeks there for pain management. 
She was in intensive care due to hypertension. She was seen by a pain specialist. She has paid for everything. The insurer only paid for the shoulder arthroscopy.   
She has attended extensive physiotherapy sessions and did attend hydrotherapy at one stage. 
Current symptoms
Ms Free still has severe lower back pain radiating into the buttock. She recently had injections into her SI joints. She has had a trial of blocks.
The knee replacements improved the knee pain, although recently, she has had some increased pain. 
She continues to have right shoulder pain and stiffness.
She can drive with limitations on distance and has a disabled parking permit.
It was brought to her attention that her claim form did not indicate any back pain. Ms Free stated that she has a printout of her attendance at physiotherapy and chiro on the 28/8/13 for either her back or shoulder. She said she was preoccupied with other injuries. 
Ms Free takes the following medications: Ativan, Fluoxetine, a cholesterol tablet, medication for a stomach condition, Panadol, and Voltaren.
Ms Free has a history of familial hypercholesterolemia, hypertension, depression, and borderline sleep apnoea. She uses a CPAP machine and has insomnia.
On examination, Ms Free was a well-groomed and very pleasant lady of stated age. She was mildly emotionally labile and close to tears at one stage. She brought along a bundle of carefully sorted documents and imaging reports and a suitcase full of imaging studies.
Her height was 161 centimetres, and her weight was 84.8 kg. The gait was regular with no limp. She was able to walk on her toes and heels, and although she reported knee pain, she was able to stand on her right and left leg. She squatted to 90° hip flexion.
Regarding the lumbosacral spine, the knee and ankle reflexes were normal. She could bend over and reach her ankles. There was a 100% normal range of motion in lumbosacral flexion, extension, lateral flexion, and rotation to the right and left with no dysmetria.
Regarding the cervical spine, flexion was 50°, and extension was 60°. Rotation and lateral flexion were symmetrical. Overall there was no dysmetria. Grip strength was normal. Power in resisted elbow flexion, shoulder external rotation, and internal rotation was grade 5/5. Biceps, supinator, and triceps reflexes were normal and symmetrical.  
Range of motion of the shoulders was assessed with a goniometer:
Shoulder Movement	Active ROM RIGHT	Active ROM LEFT	
Flexion	140	180	
Extension	50	50	
Abduction	90 (active ROM) standing)
120° (active ROM, supine, hands behind head)
140° (passive ROM)	180	
Adduction	40	40	
Internal Rotation	60	60	
External Rotation	70 (standing)
90° (supine)	70
90° (supine)	

Upper arm circumference was 36.5 cm in the left and 35.5 cm in the right. 
Forearm circumference was 28.5 cm in the right and 28 cm in the left arm. The slightly increased right upper arm circumference is consistent with right arm dominance.
Knee reflexes in the lower limbs were present and symmetrical. Ankle reflexes were present and symmetrical.
Thigh circumference was 52 cm in the left and 54 cm in the right thigh 10 cm from the superior patellar border.  Left calf circumference was 39.5 cm, and right calf circumference was 40.5 cm, measured at the largest calf girth.  
Well-healed bilateral knee replacement scars were noted which were pale and atrophic.
Skin temperature and colour in the lower limbs were normal. 
Trendelenburg sign was negative bilaterally. Range of motion of the hips was assessed with a goniometer:
Hip Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	115	115	
Extension	No flexion contracture	No flexion contracture	
Adduction	25	25	
Abduction 	60	60	
Internal Rotation	30	30	
External Rotation	30	30	

Range of motion of the knees was assessed with a goniometer:
Knee Movements	Active ROM RIGHT	Active ROM LEFT	
Flexion	115	115	
Extension	0	+5	

Impairment
Right shoulder – Reduced range of motion in the R shoulder is rated as 7% impairment of the upper extremity or 4% impairment of the whole person (AMA 4 pp 3/41 – 3/45; Figs 38, p 3/43; Fig 41, p 3/44, Fig 44, p 3/45, Table 3, p 3/20)
Lumbar spine – 0% WPI
There is no dysmetria on examination. There are no symptoms relating to non-verifiable radicular complaints. Lumbar pain in the absence of objective signs of dysmetria, non-verifiable radicular complaints, radiculopathy, fractures, multilevel structural compromise or previous spine operation meets the criteria for DRE Lumbosacral Category I which is 0% WPI (AMA 4th edition, p 3/102-103; SIRA Motor Accident Permanent Impairment Guidelines 2018 Table 7
Cervical spine 
There is no dysmetria on examination. There are no symptoms relating to non-verifiable radicular complaints. Neck pain in the absence of dysmetria, non-verifiable radicular complaints, radiculopathy, fractures, multilevel structural compromise or previous spine operation meets the criteria for DRE Cervicothoracic Category I which is 0% WPI. (AMA 4 p. 3/104; SIRA Motor Accident Permanent Impairment Guidelines 2018 Table 7, page 27, page 27.
Scan review 
Spine
Scan radiology and nuclear medicine 12 January 2020 MRI.
Well preserved annular signal on this basis with modest age-related degeneration principally L4-L5 and L5 S1 neural foramina and clear. Early senile disc bulging is at L4 five and L5 S1 minor facet arthritis. Transverse sections show marked fatty degeneration involving not only the multifidus is but the erector spinae musculature as well. Fatty degeneration very marked and involves all of the muscular groups. Spinal canal is well preserved and there is normal sequestration of the cauda equina.
Synergy radiology Rouse Hill medical imaging lumbar spine 26 August 2021 MRI hard copy. Senile bulging more pronounced at L4 five and L5 S1 with a senile bulge reaching approximately 60% of the vertical height.
North-West Medical Imaging CT lumbar spine 12 September 2022 – hard copy with 3D reconstruction. Good preservation of the intervertebral foramina at all levels. Modest marginal lipping on most of the lumbar vertebrae. – Minimal scoliosis concave to the left but overall good balance.
CT scan spine 1 May 2018 including CT reconstruction – as above.
Synergy radiology MRI lumbar spine 20 January 2013 unchanged.
North-west medical imaging CT lumbar spine 21 August 2017 hard copy including 3D as above.
Imaging specialists 16 April 2024 plain x-ray of the thoracic spine showing multilevel degenerative changes and continuation of the lumbar scoliosis into the thoracic spine with the concavity to the right in the thoracic spine.
Conclusion – there are imaging studies of the thoraco- lumbar spine beginning in January 2013 up till January 2024. These show –
•	double primary adolescent idiopathic scoliosis which does not progress
•	gradual progression of lumbar and thoracic spondylosis typical distribution with no traumatic features
•	marked and progressive fatty atrophy of the postural muscles of the spine from disuse
Bankstown Hospital imaging department MRI cervical spine 14 September 2016 – hard copy – good spinal canal. No cord compression. Foramina and clear and transactional images. Extensive fatty degeneration in the deep muscular and subcutaneous regions. Disc annulus dark in most views with a slight angular increase in extension seen at 56. No nerve root compression.
Conclusion –
•	Age-related spondylosis in keeping with lumbar spine changes
•	an unusual degree of fatty atrophy in the postural musculature for the cervical spine
North-west medical imaging MRI head under WorkCover 11 October 2013 – normal study.
PRP diagnostic imaging CT brain ultrasound right hip injection right shoulder. Bag includes plain x-rays lumbar spine showing modest marginal osteophytes of the intervertebral body. Confirms the presence of the scoliosis. Ultrasound of the right buttock unremarkable. Ultrasound shows subacromial injection with some mild bursal thickening. Diagnostic ultrasound right hip shows very variegated signal from the deep musculature and the presence of the degenerative insertional tear of the gluteus medius with some bursitis.
Conclusion –
•	the brain studies are normal
•	the ultrasound showed trochanteric bursitis with an unusual degree of fatty infiltration amongst the muscles
Right knee Synergy radiology plain x-ray 8 February 2023. Weight-bearing films so presence of marginal osteophytes and the patter low for joint and medial joint space narrowing with a loss of about two thirds of the articular cartilage and sub chondral sclerosis.
MRI the right knee 18 March 2018. Sub chondral cysts with bright fluid signal seen in the lateral medial compartment. Medial meniscus shows degenerative changes in the posterior horn but no definite tear. No effusion. Lateral meniscus in good condition. Marginal osteophytes about the patella femoral joint for joint and medial compartment AP film shows the cyst is very central seems to be benign fibro chondroma. Lateral tracking of the patella and medial compartment osteoarthritis but less severe than on the left.
PRP radiology mobile x-ray both knees 30 March 2013. Total knee replacement probably cemented tibial component in alignment. Include cemented patella replacement.
PRP diagnostic imaging right knee 6 January 2020 better preserved medial compartment and seen on the left knee. There is also patella/femoral maltracking and marginal osteophytes.
Left knee Synergy radiology 9 February 2023 MRI – degenerative vertical tear of the margin of the medial meniscus extending into the posterior horn and possibly arising from their. Mucoid degeneration. Grade 2 to 3 chondral loss over the medial compartment and the patellofemoral joint. Principal fighting is the grade 3 chondral aware of the medial compartment. The lateral compartment is normal. There is no effusion.
CT study left knee 1 February 2023 Synergy radiology paper copy including 3D reconstruction – degree of varus is less pronounced since this is a supine study period lateral patter low for arthritis is seen together with medial compartment osteoarthritis. Period x-ray of the left knee shows medial compartment osteoarthritis.
Imaging specialists x-ray and ultrasound left knee 16 June 2024 period well-positioned total knee replacement with a moderate pre-patella infusion. Plain x-rays confirm cemented tibial and patella components.
MRI of the left knee PRP radiology 8 May 2015. Some lateral extrusion of the lateral meniscus. Moderate loss of joint cartilage in the distal medial femoral condyle intact cruciate ligaments some intra-meniscal cyst formation in the posterior horn of the medial meniscus and a small signal of an intrasubstance tear doesn’t reach the meniscal surface.
Plain x-ray left knee PRP radiology 7 May 2015. Medial marginal osteophytes patter low femoral joint. Shows a well-preserved lateral compartment.
North-west medical imaging x-ray both knees with contrast injection weight-bearing films showed medial compartment osteoarthritis. On these views the arthritis is more advanced on the right than the left side.
Conclusion –
•	the imaging sequences show progression of constitutional osteoarthritis mainly affecting the medial compartment. Over an eight-year period the arthritis progresses from barely detectable to quite marked. The weight-bearing films show the joint space loss and the progressive changes.
•	the medial meniscal tear scene involving as part of the osteoarthritis process it is not traumatic.
•	the later x-rays showed to well-positioned highbred total knee replacements.
Auburn medical imaging MRI right shoulder 7 July 2016 – delaminating tear in the outer third of the supraspinatus. Good preservation of the inferior capture recess. Minor acromioclavicular arthritis well-positioned humeral head. Rotator cuff muscle bellies well preserved minor fluid in biceps tendon sheath.
PRP radiology MRI right shoulder 13 July 2015 good preservation of glenohumeral cartilage. Intact rotator cuff. Supraspinatus tendon appears to be intact.
PRP radiology ultrasound right shoulder showing some bursal thickening and tendinosis in the intact supraspinatus though there is some insertional fraying at the insertion and the beginnings of a horizontal split at this point.
Conclusion –
•	there is progressive age-related degeneration of the rotator cuff beginning in the earliest ultrasound showing tendinosis with some limited insertional tears of the supraspinatus and progressing to delamination. There are no traumatic features.
Synergy radiology bone scan with SPECT 27 August 2021 – modest diffuse uptake in the lumbar spine.
Image guided injections.
San radiology 26 February 2020 epidural steroid lumbar spine.
North-west medical imaging CT guided injection cervical spine nerve root C5/6 C4/5 21 September 2016.
North-west medical imaging 15 April 2015 CT guided injection into left trochanteric bursa.
North-west medical imaging 19 August 2015 CT-guided injection into the right hip.
North-west medical imaging 28 August 2015 ultrasound guided injection right shoulder.
North-west medical imaging 11 August 2015 ultrasound guided injection into right shoulder.
North-west medical imaging 16 December 2015 ultrasound guided injection into right shoulder.
North-west medical imaging 22 December 2015 ultrasound injection probably into the knee.
North-west medical imaging 19 August 2016 ultrasound injection left ankle.
Adventist Hospital CT and guided injection cervical spine 18 December 2021.
Scan radiology CT injection lumbar spine 5 February 2020.
North-west medical imaging CT injection right hip 18 December 2015.
Rouse Hill medical imaging ultrasound guided injection into right shoulder 13 April 2015.
North-west medical imaging ultrasound guided injection 6 October 2017 left shoulder.
North-west medical imaging ultrasound guided injection into right ankle 23 August 2016 knee
Conclusion –
Ms Free has had a series of injections at various sites without benefit.
Summary – there are no traumatic features seen in any of the imaging.”
FINDINGS 
153.	The review is a new assessment of all matters with which the medical assessment is concerned. 
154.	The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen and Insurance Australia Ltd v Marsh. 
155.	The Panel adopts the extensive reasons provided by the Medical Assessors and adds the following reasons.
Nature of the accident
156.	Our further direction requested submissions on the nature of the motor accident, specifically whether the claimant was thrown up to 6m. 
157.	The parties did not assist in providing any statement from the witness identified in the ambulance report. There is otherwise no statement before us from the driver of the motor vehicle.
158.	Whilst the accident likely occurred at low speed as the insured was driving in carpark, we accept that the claimant was thrown some distance onto the bonnet of the vehicle and then onto the ground.  
159.	We have proceeded to assess the matter based on an acceptance of the claimant’s version of the motor accident.
Lumbar spine
160.	There is a history of pre-accident lumbar spine pain. Whilst not mentioned in the claim form, there are early references following the motor accident to lumbar pain.
161.	The motor accident caused soft tissue injury to the lumbar spine. We cannot identify any aggravation of pre-existing pathology caused by the motor accident.
162.	The examination findings of the Medical Assessors were that the lumbar spine had no assessable impairment (0%). Accordingly, it is unnecessary to comment further on the relationship between the motor accident and the lumbar spine symptoms.
Cervical spine
163.	We note that there were extensive pre-existing changes in the cervical spine.
164.	The motor accident would likely cause soft tissue injury to the cervical spine evidenced by the contemporaneous complaint of cervical spine symptoms. From the review of the scans, we did not identify any aggravation of pre-existing pathology caused by the motor accident.
165.	The findings of the Panel are that there is no assessable impairment (0%) of the cervical spine meaning that there is no need to address the various issues relating to the cause of the present symptoms. 
Right shoulder 
166.	The right shoulder is mentioned in the contemporaneous notes as being injured in the motor accident. The right shoulder is referenced in the claim form. 
167.	There is consistent right shoulder treatment including operative treatment following the motor accident.
168.	The mechanism of the fall in the motor accident could cause cuff tendinopathy and the symptoms of a thickened inflamed capsule observed by Dr Bokor in July 2016.
169.	Whilst there were pre-existing symptoms in the right shoulder, there is no objective evidence of a pre-existing symptomatic permanent impairment in the right shoulder at the time of the accident within the meaning of cl 1.31 of the Guidelines. Accordingly, no deduction is made.
170.	We acknowledge the insurer’s submissions of inconsistency and the varied measurements of loss of range of movement of the right shoulder over time. Further, the Medical Assessors were aware of this issue and undertook the examination to ensure consistency in accordance with cl 1.50 of the Guidelines. To the extent that there are other examination findings of the right shoulder significantly inconsistent with ours, we are obliged to use the clinical expertise within the Panel and form our own opinion.
171.	The claimant presented to the Medical Assessors in a consistent manner and her loss of range of movement of the right shoulder was less than previously assessed. 
172.	We are satisfied that the impairment is permanent within the meaning of cls 1.19 and 1.20 of the Guidelines because the condition is well stabilised, the claimant does not require surgery and treatment in the foreseeable future, and the Medical Assessors’ clinical examination of the claimant is that there is unlikely to be a change greater than 3% impairment over the next year.
173.	There was a further motor accident in late 2020 which appeared to worsen the claimant’s pain symptoms. However, the right shoulder problems were well established prior to that motor accident which otherwise did not cause any further pathological changes. Accordingly, there is no deduction pursuant to cl 1.34 of the Guidelines.
Left shoulder
174.	It is unclear whether it is asserted that the motor accident caused a left shoulder injury. 
175.	There is an absence of contemporaneous complaint, and the left shoulder is not mentioned in the claim form.
176.	In 2020 Dr Gehr diagnosed pain in the left shoulder with no rateable impairment. His opinion differs from all other qualified doctors who do not record a history of left shoulder injury caused by the motor accident. 
177.	Given the absence over many years, the absence of record of injury in the claim form, the absence of identifiable pathology and the fact that Dr Gehr found no loss of range of movement in 2020, we do not accept that the motor accident caused any left shoulder injury.

Knees
178.	There is a pre-accident history of a right knee injury and left knee chondromalacia patella.
179.	There were complaints of right knee pain and abrasions immediately following the motor accident.
180.	There is no complaint of ongoing knee symptoms in the second claim form dated 
20 August 2013. This is consistent with the absence of record of complaint after the initial post-accident complaints until mid-2015 when the right knee is discussed by Dr Campion. The claimant also sustained a left knee injury at work in May 2015. 
181.	There was no recorded complaint of knee pain when Dr Quain examined the claimant in 
May 2014.
182.	The discussion of the scans in the Medical Assessors’ examination findings show a gradual deterioration of bilateral knee pathology which is not traumatic. The scans show a deterioration in degenerative pathology which is constitutional and unrelated to the motor accident.
183.	We are satisfied that the motor accident caused a transient soft tissue injury which resolved after a short period of a few months. In those circumstances there is no contribution between the motor accident and the current knee condition.
Ankles
184.	There is no contemporaneous report of ankle injuries. There is no mention of ankle injuries in the claim forms. 
185.	The absence of complaint is relevant but not determinative of the issue of causation: Norrington v QBE Insurance (Australia) Ltd, and AAI Ltd v McGiffen. 
186.	An inclusion of injury in the claim form is relevant to establishing causation: Bugat v Fox. Similarly, the omission of any reference to a body part must also be relevant, but not determinative, of the causation issue. 
187.	The ankles are not referenced as injuries caused by the motor accident in medico-legal reports obtained by the parties in 2014 (Dr Quain) and 2015 (Dr Campion).
188.	The left ankle is referenced in August 2017 and the right ankle in May 2018 in the context of a right ankle injury at that time.
189.	The claimant has a chronic history of symptoms of fibromyalgia affecting various joints including the ankles. Given the absence of contemporaneous complaints extending over two years and the more likely explanation of another cause, we are satisfied that the bilateral ankle condition was not caused by the motor accident and is likely due to the underlying fibromyalgia. 
Hips
190.	The hips are mentioned in the pre-accident history as part of the conditions affected by the widespread polyarthralgia.
191.	The is an absence of references to the hips in the contemporaneous notes and the claim form although there is reference to right hip pain by Dr Quain in 2014. There is early reference to bilateral buttock pain which presumably is to referred pain from the lumbar spine. 
192.	Given the existence of pre-existing hip symptoms, the absence of direct trauma to the hips, the absence of contemporaneous complaints and the likely cause of any hip problems being due to the underlying fibromyalgia, we are not satisfied that the motor accident caused any injury to the hips.
CONCLUSION
193.	The medical assessment certificate issued by Medical Assessor Dixon is revoked. A replacement certificate is attached at the commencement of these Reasons.