DETERMINATION OF REVIEW PANEL	
	
CITATION:	Allianz Australia Insurance Limited v Sapateh [2025] NSWPICMP 261	
		
CLAIMANT:	Mohamed Osman Sapateh	
		
INSURER:	Allianz Australia Insurance Limited	
		
REVIEW Panel	 	
		
MEMBER:	Jeremy Lum	
		
MEDICAL ASSESSOR:	Mohammed Assem	
		
MEDICAL ASSESSOR:	Margaret Gibson	
		
DATE OF DECISION:	15 April 2025	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); threshold injury ; treatment dispute; vehicle failed to stop at a stop sign and hit the driver’s side of the claimant’s car; airbags deployed and claimant was taken to hospital by ambulance; claimant suffered right shoulder and bilateral knee injuries; radiology showed a partial thickness tear to the right shoulder and cartilage change to the knees; Held – the motor accident caused the partial thickness supraspinatus tear which is not a threshold injury; pathology in the knees was not accident-related; no direct blow to either knee with no objective findings recorded; claimant’s request for consultation with an orthopaedic surgeon in relation to his knees found not causally related to the motor accident and not reasonable and necessary; MAC confirmed.
	
DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
The Review Panel:
Confirms the certificate issued by Medical Assessor Sher dated 18 August 2024.

1.	

STATEMENT OF REASONS
introduction
1.	Mr Sapateh (the claimant) was involved in a motor accident on 29 June 2023. He says he was driving his car along a road when a vehicle failed to stop at a stop sign and ran into his car. The impact caused air bags to deploy and his car was later written off due to the damage.
2.	Following the motor accident, an ambulance took the claimant to Canterbury Hospital. He described right eye swelling with facial pain and a scratch on his neck from the seat belt.  He also had pain in his back, chest and stomach with bruising on his knees and feet. He was discharged from hospital the following day.
3.	The claimant made a claim for statutory benefits with Allianz, the third-party insurer of the vehicle that he says caused the motor accident. Allianz accepted the claim for statutory benefits (weekly payments and treatment and care) for up to 52 weeks from the date of the motor accident.
4.	Medical disputes arose about whether the claimant’s injuries were threshold or not threshold injuries and whether requested treatment and care is causally related to the motor accident and reasonable and necessary. The matter was referred to the Personal Injury Commission (Commission) for medical assessment.
5.	On 18 August 2024, Medical Assessor Doron Sher issued a certificate of assessment which found the claimant’s right shoulder injury to be not a threshold injury. The Medical Assessor also found the requested treatment and care to be not causally related to the motor accident and was not reasonable and necessary.
6.	The insurer lodged an application with the Commission seeking review of the Medical Assessor’s decision. This was allowed by the President’s delegate and this Review Panel (Panel) was convened to conduct the review.
RELEVANT STATUTORY PROVISIONS
Threshold injury
7.	Under the Motor Accidents Injuries Act 2017 (the MAI Act), there is a scheme for statutory benefits (under Part 3) for persons injured in motor accidents in New South Wales. Such benefits can include treatment and care and weekly payments.
8.	For injured persons who have “threshold injuries”, they cannot receive statutory benefits beyond 52 weeks after the accident and cannot recover damages.
9.	For physical injuries, a threshold injury is defined as a “soft tissue injury”.
10.	A “soft tissue injury” is defined as:
“An injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, facia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”
11.	A soft tissue injury includes an injury to a spinal nerve that manifests in neurological signs (other than radiculopathy).
12.	The Motor Accident Guidelines (the Guidelines) defines radiculopathy as:
“Radiculopathy means the impairment caused by dysfunction of a spinal nerve root or nerve roots when two or more of the following clinical signs are found on examination when they are assessed in accordance with ‘Part 6 of the Motor Accident Guidelines: Permanent Impairment’.
(a)	loss or asymmetry of reflexes (see the definitions of clinical findings in Table 6.8 in these Guidelines)
(b)	positive sciatic nerve root tension signs (see the
(c)	muscle atrophy and/or decreased limb circumference 
(d)	muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution
(e)	reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution.”
13.	Where the neurological symptoms associated with the injured person’s injury of the neck or spine do not meet the assessment criteria for radiculopathy, the injury will be assessed as a threshold injury.
14.	Table 6.8 of the Guidelines provides definitions for the clinical signs in (a) to (e) above.
Causation
15.	The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines and apply to both permanent impairment and threshold injury disputes.  
16.	Clauses 6.6 and 6.7 state:
“6.6 Causation means that a physical, chemical or biological 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 the worsening of the impairment, which is a medical determination.
2.	The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination
	This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident.  The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible.  Considering the question ‘Would this injury (or impairment) have occurred if not for the accident?’ may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
ASSESSMENT UNDER REVIEW
17.	Medical Assessor Sher was referred to assess injuries to the right shoulder and bilateral knees.
18.	The Medical Assessor was also referred a treatment and care dispute regarding a consultation with Dr George Kirsh, orthopaedic surgeon, with respect to the bilateral ankles and bilateral knees.
19.	Medical Assessor Sher noted that at the time of the motor accident, the claimant was employed full-time in a role that required a great deal of time spent in a squatting position and using his arms repetitively.
20.	The mechanism of the motor accident was noted to involve another vehicle impacting the driver’s side of the claimant’s car. Following the accident, the claimant initially (at two days) had pain everywhere and at six weeks, he had neck and shoulder soreness. The hospital emergency department notes stated that there was nil pain to the knees. 
21.	The first mention to the general practitioner (GP) of pain in the left leg, left knee and left ankle was on 2 August 2023. There were no further comments about the knees or ankles in the GP notes including up to 20 October 2023.
22.	On 2 November 2023, there was a note of pain in both knees and ankles which persisted since the accident.
23.	On examination, the Medical Assessor found that the clinical findings and imaging do not support any accident-related injury to the knees and ankles.
24.	The shoulder examination revealed very mildly positive impingement signs however the MRI showed a partial thickness tendon tear.
25.	The Medical Assessor concluded that the right shoulder condition was causally related to the motor accident but the bilateral knees was not. The Medical Assessor reasoned:
“The history, emergency notes and general practitioner notes as well as the knee MRI and ankle CT scan do not support an acute injury to either area. The knee condition is almost certainly chronic with no injury being found at the ankles. The shoulder condition may have been pre-existing in terms of the partial thickness tears based on the type of work he does but a neck injury will also mask any potential shoulder pain and his hands were on the steering wheel during the accident which could have created his shoulder injury.”
26.	As the MRI showed a partial thickness tendon tear, the Medical Assessor found the right shoulder injury to be not a threshold injury.
27.	In relation to the treatment and care dispute, the Medical Assessor stated that there was no accident-related injury to the ankles or knees in the clinical examination and history. The MRI findings of the knees showed chronic degenerative changes and not any acute injury. The Medical Assessor concluded that the requested treatment and care was not causally related to the motor accident and was not reasonable and necessary.
SUBMISSIONS
Insurer’s submissions 
28.	The insurer takes issue with the Medical Assessor’s finding that the pathology in the right shoulder is casually related to the motor accident. The insurer says causation was founded on the Medical Assessor’s finding that the claimant had his hands on the steering wheel at the time of the accident which “could” have created the injury. It is contended that the Medical Assessor did not comment on whether the accident made a more than negligible contribution, or whether the accident did create the injury.
29.	The insurer also refers to the Medical Assessor’s comment that “a neck injury will also mask any potential shoulder pain…” but notes that the claimant did not report any cervical spine symptoms in paragraph 12 of the certificate, which refers to the claimant’s “Current symptoms”. The Panel notes that a cervical spine injury was not referred for medical assessment. 
30.	The insurer points out that the Medical Assessor did not address the insurer’s original arguments, namely the delay in reporting the right shoulder injury, the contribution of the claimant’s employment as a spray-painter and the findings of the radiological investigations. Specifically, with respect to the claimant’s work as a spray-painter, it is asserted that the claimant worked in this role since 2006 and advised that the role required “frequent right arm use when mixing paints”.
31.	The insurer refers to the MRI of the right shoulder performed on 12 September 2023 which revealed rotator tendinopathy involving the supraspinatus with partial thickness articular surface tear. Mild acromioclavicular degeneration and subacromial bursitis was also seen. The insurer submits the MRI findings are due to overuse in the context of the claimant’s employment as a spray painter, rather than evidence of acute injury.
Claimant’s submissions 
32.	The claimant disagrees with the insurer’s submissions referring to the Ambulance Report (R6) and the Concord Hospital records which show early neck and right shoulder complaints well before the insurer’s reference to the entry by Dr Giurgius dated 20 July 2024.
33.	The claimant further states that the Medical Assessor correctly applied the two-pronged causation test as set out in the Guidelines. First, the Medical Assessor made the medical judgement that the claimant’s hands on the steering wheel at the time of the accident “could” have created the shoulder injury and second, that the right shoulder partial thickness tear “was” caused by the accident.
34.	The claimant says the insurer’s view that the claimant’s right shoulder injury could have been caused by his work as a spray painter is a baseless allegation and not supported by any of the documentation before the Medical Assessor. 
35.	It is contended that the Medical Assessor was correct to point out that where multiple injuries are sustained, including injuries to the claimant’s chest, neck, abdomen and shoulders, there is possibility that masking of some pain by other pain elsewhere can also occur.
DOCUMENTATION
36.	On 23 October 2024, the Panel issued a direction to the parties requiring indexed and paginated bundles of the information they relied upon.  Both parties duly responded with the claimant’s bundle comprising of pages 1-249 and the insurer’s 1-92. 
37.	The Panel has read all the material provided by the parties in the bundles. The relevant material is summarised below.
38.	Ambulance report dated 29 June 2023 – describes impact on driver’s side. Immediate shock and pain to face from airbags. Improvement. Then “some increasing soreness to bilateral shoulders and generalised neck”. Denied c-spine pain (nil pain on palpation), nil sensory, motor deficits. Secondary survey: left & right shoulder pain described as dull.
39.	Canterbury Hospital Admission Summary – presented with right iliac crest area discomfort and left lateral rib discomfort. X-rays showing no acute injury. Mild swelling to right lateral upper eye lid. States discomfort to face, generalised pain and numbness to body at time of injury. 10-15 passed and slowly developing neck soreness, right thigh and left calf discomfort.
40.	Application for personal injury benefits dated 30 June 2023 – claimant describes injury to right eye, face, scratch on neck from seat belt. Bruise on feet and knees. Pain in back, chest and stomach.
41.	Medical and Dental Centre clinical records – entry dated 1 July 2023: Pain in flanks and chest. No spinal tenderness. Some pain on extremities [sic]. Entry dated 6 July 2023: Low back pain. Bilateral knee pains. Entry dated 20 July 2023: Pain right shoulder started after the accident but settled now came back. Pain on abduction. Pain low back after sitting and on standing. Entry dated 27 July 2023: Right shoulder bursitis partial tear. Claimant denied any right shoulder pain [sic] before. Entry dated 2 August 2023: Still right shoulder pain restricting movement. Pain left leg, left knee, left ankle since accident following opening of air bags but able to walk.
42.	Colour photographs – significant damage to the front of the claimant’s white car (DA35ZG). Especially on the driver side right corner. Airbag deployment visible. 
43.	Radiology reports – refer to Panel’s re-examination report below.
RE-EXAMINATION REPORT 
44.	The Panel determined that the claimant be re-examined by Medical Assessor Gibson on 
4 April 2025. The re-examination report is as follows:
Mr Sapateh was unaccompanied to the assessment. He brought some imaging studies with him. He is right-handed and 39 years of age.
PAST MEDICAL HISTORY
Mr Sapateh volunteered that he had suffered with some mental health issues prior to the subject accident for which he visited his general practitioner. He explained that there had been some mention of this in a psychiatric assessment and he had misunderstood the question, and hadn’t realised this also included short-term mood disturbance. 
He said there were no prior physical issues, accidents or injuries. 
However, he had visited his general practitioner occasionally for short-term illnesses and had been off work, possibly for a day or so. He was not taking any regular medications at the time of the accident and he had no prior problems with his knees, ankles or shoulders.
RELEVANT PERSONAL HISTORY
Mr Sapateh shares a house with flatmates. He said his other housemates have taken on his chores, such as general cleaning, since the accident as he finds himself unable to perform these tasks now. 
He still drives a manual car but has now a different car as the car involved in the accident had been written off. He said he drives to the shopping centre to pick up his groceries and his mother and sister, who live nearby, would prepare meals for him. 
Mr Sapateh had arrived in Australia at the age of 17yrs in 2003. He worked at Mercedes Perfect Auto Body for 10 years, where he completed his spray painting apprenticeship. He had then worked for 6 months at Rigoli Smash Repairs in Campsie and then at Silverwater Smash Repairs for almost 5 years. 
At the time of the subject accident he had been working as a spray painter with MPSR Pty Ltd for over a year. He said that his work duties involved a lot of kneeling, squatting and reaching. He said his employer had never taken him back after the accident as they were not obliged to as the injury had not occurred at work. 
He had been referred to a rehabilitation provider and was certified at some point for a 4-hour shift. They found him a job at Sharp Street Smash Repairs in Belmore. However, he said he was even having trouble coping with these hours. His right shoulder symptoms were limiting his ability to reach over the roof of the cars or even hold his spray gun securely. There were also problems with his knees and back, so he was having trouble with the required squatting and kneeling.
HISTORY OF THE SUBJECT ACCIDENT
Mr Sapateh had been driving a Suzuki Swift with manual transmission. He had his seatbelt fastened. He was on his way home from work and was driving along Armstrong St in Ashbury. He had just got around a curve and over a speed hump, which he said had meant that he had slowed down, when another driver came through on his right side and failed to stop at a stop sign thus colliding with Mr Sapateh's car and forcing into a pole. He said there was an impact on both the driver and passenger side. 
He was thrown forward and possibly to the left. He remembered a very loud noise. He felt dazed. His air bags deployed. He thought he had been killed. He opened his eyes and there was a lot of smoke coming from the air bag. He was able to self-extricate through the driver side door and then “ran away” because he was quite panicked at the time. 
Police, ambulance and some of his family members arrived. 
He was conveyed to Canterbury Hospital.
When asked about any visible injuries to his knees, he said he was wearing long pants at the time. He said the key had been bent in the ignition due to the impact, so it had been a significant force. 
The discharge summary from Canterbury Hospital had noted that he had presented with right iliac crest area discomfort, left lateral rib discomfort. X-rays had shown no acute injury. There was mild swelling to right lateral upper eyelid. He had also reported some neck soreness, right thigh and left calf discomfort.
As explained to Mr Sapateh today, there was no mention made of any knee or shoulder injuries at the hospital. In fact it was noted his clavicles were normal, cervical spine was normal to examination and he had full range of movement of his neck. Also they noted no joint or long bone pain to both upper limbs. Knee flexion and extension 5/5, no pain, ankle power 5/5. The x-rays have been done of chest, right hip and pelvis and all had revealed no abnormality. When asked about the lack of any reference to shoulders, knees or ankles, he said there was a lot of adrenaline going at the time and he had been quite shocked after the accident. 
PROGRESS MEDICAL HISTORY
Mr Sapateh visited his general practitioner the following day at Punchbowl. The Personal Injury Claim form was completed 30 June 2023 at which stage it was noted that his right eye was swollen, face was sore, scratch on the neck from the seat belt, bruising feet and knees, pain back, chest and stomach.
The first entry in the general practitioner’s clinical notes following the subject accident was on 1 July 2023 by Dr Natalie Selim and she recorded complaints of pain in flanks and chest with movement. On examination, there was a full range of movement with some pain on extremities, no spinal tenderness, abdomen soft and nontender. She concluded he had sustained a muscular injury. 
Mr Sapateh returned to the practice on 6 July 2023 and this time was seen by Dr Giurgius, at which stage he was reporting chest wall, low back, bilateral knee and bilateral thigh pains. 
He was referred for plain x-ray imaging of chest and lumbar spine. Then on 20 July 2023, Dr Giurgius notes "pain RT shoulder started after the accident but settled, now came back. Pain on abduction, pain low back after sitting and on standing after the accident." On examination of the right shoulder, there was tenderness, restricted range of motion but no swelling.” He was referred for an ultrasound right shoulder and CT scan of the lumbar spine.
Mr Sapateh was referred to a physiotherapist in Marrickville. He attended the practice over several months. He was receiving treatment of neck, back, right shoulder and low back. He said they were not looking at his knees or ankles as the insurer was not paying for those regions. 
He had also attended a supervised gymnasium therapy over several months. 
He was referred to Dr Simon McKechnie, Neurosurgeon, who suggested he have an MRI of his shoulder and he said that the doctor advised him against returning to panel beating. He had referred him for a C6-guided right perineural injection on 5 January 2024. Dr Simon McKechnie had seen Mr Sapateh on 8 December 2023, noting complaints of pain at the right side of neck radiating across the right shoulder and upper arm with reduced range of movement, left low back pain with intermittent radiation through the left leg. Right shoulder ultrasound had demonstrated partial supraspinatus tear with bursitis and tendinitis.
CURRENT TREATMENT
Mr Sapateh visits a physiotherapist twice weekly. The physiotherapy is currently only directed to the right shoulder, back and neck. He takes a Mobic tablet every second day and melatonin to assist with sleeping. He attends counselling. 
CURRENT COMPLAINTS
Mr Sapateh reported neck pain with no radiation to the upper limbs. 
There was right shoulder pain felt over the right deltoid and trapezius region most of the time especially when reaching or getting dressed and in particular tucking in his shirt. 
He said his left shoulder was fine but he feels there is some left trapezial discomfort as he is using the left arm a lot more than previously. 
In relation to the knees, there is no swelling but there is pain with movement, felt over the medial and lateral joint lines. He said the knees give way at times. He said he can walk for 5-10 minutes. He has difficulty climbing stairs but finds he manages descending stairs. 
He said there was a shooting pain from his low back over both posterior thighs and extending down the back of the leg. 
There was pain over both ankles in a circumferential distribution which is worse when walking. He has difficulty sleeping on his right side due to the shoulder pain.
PHYSICAL EXAMINATION
On examination of the cervical spine, there was no specific tenderness. Neck movements were to full normal range. There was no asymmetry, muscle spasm or guarding. 
On examination of the upper limbs, circumferential measurements were consistent with right hand dominance, arms measuring 28cm (10cm above the olecranon process), forearms measuring 26cm (10cm below the olecranon process). There was normal power, sensation and reflexes bilaterally.
On examination of both shoulders, there was mild impingement of the right shoulder. Active movements were consistent as follows:
Shoulder Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	140 °	180 °	
Extension	50 °	50 °	
Internal Rotation	40 °	80 °	
External Rotation	80 °	80 °	
Abduction	140 °	180 °	
Adduction	50 °	50 °	

On examination of the back, there was no specific tenderness. He had three-quarters normal range of movement in all planes. There was no asymmetry, muscle spasm or guarding. 
On examination of the lower limbs, thighs measured 40cm (10cm above the superior pole of the patella), calves measured 34cm at maximal girth. There was normal power, sensation and reflexes bilaterally.
On examination of both knees, flexion 120°, extension 0° bilaterally. There was no crepitus or instability. 
IMAGING
CT scan of the lumbar spine demonstrated a small right foraminal L4/5 disc protrusion. This is in relation to the first review on 18 September 2023. On review on 6 December 2023, the doctor noted there had been little improvement with physiotherapy and medication. They offered him a CT-guided right C7 perineural cortisone injection which had a good chance of improving the pain, at least on a temporary basis. He felt that he was unsuitable to return to his previous employment as a spray painter.
CT lumbar spine performed 25 July 2023 showed right lateral disc protrusion L4/5 causing right-sided neural foraminal narrowing with compression upon right exiting L4 nerve root.
Ultrasound of the right shoulder performed 25 July 2023 showed partial thickness tear supraspinatus on a background of tendinopathy and subdeltoid bursitis.
MRI scan cervical and lumbar spine performed 29 September 2023 showed right L4/5 exit foraminal stenosis abutting the right exiting L4 nerve root. No left-sided radiculopathy was identified. Cervical spine desiccated with mild posterior annular bulges, mild right-sided C6/7 exit foraminal stenosis due to uncovertebral osteophyte abutting the right exiting C7 nerve root. Cervical cord retained normal calibre and signal with no extrinsic compression.
MRI scan knees performed 4 January 2024 showed cartilage, ulcerative change in the posterior aspect of the lateral femoral condyles bilaterally and the posterior aspect of the medial femoral condyle on left side.
Bilateral knee and ankle x-ray performed 09/11/2023 showed no abnormality.
FINDINGS
45.	The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.
46.	The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.
47.	The Panel refers to the above re-examination report of Medical Assessor Gibson and adopts the findings in their entirety. The Panel reconvened on 11 April 2025 and discussed the re-examination report findings before collectively making the below determinations.
Causation and reasons
48.	The Panel concluded that the claimant sustained soft tissue injuries to his neck, both knees and a ligamentous injury to his right shoulder. There was contemporaneous evidence of these injuries in the medical documentation. 
49.	The Panel disagreed with the insurer’s assertion that the MRI findings of the right shoulder are due to overuse in the context of the claimant’s employment as a spray painter. While some mild degeneration is noted, there was no prior imaging to suggest the partial supraspinatus tear was pre-existing nor in the GP records which date back to 2017. The Panel also accepted the claimant’s given history that he had no prior problems with his shoulders, which was consistent with what he reported to his GP within a month of the motor accident.
50.	Photographic evidenced showed a significant impact to the right side of the car with airbag deployment hitting the claimant in the face, causing injury and shock. The Panel accepts that this could affect the accuracy of the claimant’s initial reporting of all injuries sustained in the motor accident. Notwithstanding this, the claimant mentioned shoulder complaints to the attending ambulance officers and had “aching shoulders” on the day of his admission at Concord Hospital. Shoulder complaints were also mentioned to his GP, Dr Guirgis. 
51.	The Panel therefore concluded that the motor accident could have and in fact did cause a ligamentous injury to the right shoulder which included, on balance, the partial supraspinatus tear shown on the MRI imaging, performed some six weeks after the motor accident.
52.	In relation to the bilateral knees, while the Panel felt there may have been a temporary soft tissue strain, this had not caused any intraarticular injury. There was no evidence of a direct blow to either knee, no objective findings recorded, such as bruising or swelling and no immediate or severe pain that would produce the type of pathology demonstrated in the MRI scan of the knees. 
53.	The Panel concluded the imaging findings were incidental, degenerative and unrelated to the subject accident. Furthermore, the Panel were not of the opinion an orthopaedic opinion was related to the motor accident or reasonable and necessary.
54.	The Panel found no convincing evidence of any subject accident-related ankle injuries. There was no mention of the ankles in the ambulance notes or the Concord Hospital notes. The ankles were reported as normal in the CT findings. Thus, the Panel were not of the opinion an orthopaedic opinion was causally related to the motor accident or reasonable and necessary.
Summary
55.	The following injuries WERE caused by the motor accident:
•	right shoulder supraspinatus partial thickness tear, pain, reduced range of movement
•	right knee soft tissue injury, and
•	left knee soft tissue injury.
56.	The following injuries WERE NOT caused by the motor accident:
•	the injury to the left knee – cartilage ulceration with subchondral microcytic change at the posterosuperior aspect of each of the medial and lateral femoral condyles, and
•	the injury to the right knee – cartilage ulcerative changes, grade 4 chondromalacia.
57.	The following treatment and care DOES NOT relate to the injuries caused by the motor accident and ARE NOT reasonable and necessary:
•	consultation with Dr George Kirsh, orthopaedic surgeon, regarding bilateral ankles, and
•	consultation with Dr George Kirsh, orthopaedic surgeon, regarding bilateral knees.
Threshold injury
58.	The Panel considers the right shoulder supraspinatus partial thickness tear to fall outside the definition of a soft tissue injury as defined in s 1.6 of the MAI Act.
59.	The right shoulder injury is therefore NOT a threshold injury.
60.	The certificate issued by Medical Assessor Doron Sher dated 18 August 2024 is confirmed.