1. Revokes the certificate issued by Medical Assessor Ian Cameron dated 7 January 2025.
2. Certifies that the following injuries caused by the motor accident are threshold injuries:
   • head - soft tissue injury;
   • cervical spine - soft tissue injury;
   • lumbar spine - soft tissue injury, and
   • right shoulder - pain referral from neck and per Nguyen.
3. Certifies that the following injuries referred for assessment have been assessed and determined to be not caused by the motor accident:

right shoulder - severe injury to right shoulder with supraspinatus insertion tear.

1. Mr Ademovic (the claimant) was involved in a motor accident on 10 January 2021. He says he was the front seat passenger of a car driven by his older sister. They were stopped at a traffic light intersection and as the traffic light turned green, their vehicle commenced a left turn into the second lane from the kerb. As they were turning, a car in the kerbside lane veered into their lane and collided into the left rear side of their car.
2. As a result of the motor accident, the claimant says he sustained injuries to his head, cervical spine, lumbar spine and right shoulder.
3. The claimant made a claim for statutory benefits with GIO, the third-party insurer of the vehicle that he says caused the motor accident.
4. A medical dispute arose about whether the claimant's injuries were threshold or non-threshold injuries and the matter was referred to the Personal Injury Commission (Commission) for medical assessment.
5. On 7 January 2025, Medical Assessor Ian Cameron issued a certificate of assessment which found the claimant's right shoulder injury to be not a threshold injury. The other injuries were found to be threshold injuries.
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 (Ms Ratula Gupta) and this Review Panel (Panel) was convened to conduct the review.[1]

1. Under the Motor Accident 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.
2. For injured persons who have "threshold injuries", they cannot receive statutory benefits beyond 52 weeks after the accident and cannot recover damages.[2]
3. For physical injuries, a threshold injury is defined as a "soft tissue injury".[3]
4. 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."[4]

1. A soft tissue injury includes an injury to a spinal nerve that manifests in neurological signs (other than radiculopathy).[5]
2. The Motor Accident Guidelines (the Guidelines)[6] 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."[7]

1. 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.[8]
2. Table 6.8 of the Guidelines provides definitions for the clinical signs in (a) to (e) above.

1. 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.[9]
2. 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."

1. Further, the provisions of the Civil Liability Act 2002 apply, in particular ss 5D and 5E.

1. Medical Assessor Cameron referred to an MRI of the right shoulder dated 15 March 2024 which was reported as showing a "...possible focal partial thickness tear." The Medical Assessor observed that while the imaging was hard to interpret, there is a possible tendon tear which is a "non-threshold" injury.
2. In relation to the head injury, the Medical Assessor noted some headaches which were not consistent with occipital neuralgia. The Medical Assessor was also not satisfied that there was a brain injury. The Medical Assessor concluded that the claimant could have sustained a soft tissue injury to his head and was therefore a threshold injury.
3. The injuries to the cervical spine and lumbar spine were referred for assessment as disc protrusions. The Medical Assessor was not satisfied the imaging supported such descriptions of the spinal injuries as being caused by the motor accident. The spinal injuries were found to be soft tissue injuries and therefore threshold injuries.

1. The insurer takes issue with the Medical Assessor's finding that the pathology shown in the imaging of the right shoulder is casually related to the motor accident.
2. The insurer says the Medical Assessor failed to engage with the relevant material or explain his reasoning with respect to causation.
3. In addition, it is submitted that the Medical Assessor did not engage with the insurer's submissions which included:
   • no complaints of shoulder pain in the hospital records, the claimant's initial attendance with his GP, or the application for personal injury benefits;
   • the first shoulder complaints are not until almost two years after the subject accident in the claimant's IME report of Dr Dixon;
   • the first and only imaging of the right shoulder was not until more than three years after the subject accident;
   • the claimant had not established that the motor accident was capable of causing a "focal undisplaced chronodrolabral junction tear" as described in the MRI report of the right shoulder dated 28 March 2024;
   • the motor accident was of such a minor nature (refer to photographs) that it would not have been sufficient to have caused any significant movement of the shoulder to have caused a tear, and
   • had the claimant sustained an acute tear in the motor accident, it would be reasonable to expect that he would have experienced immediate pain in his shoulders. As mentioned, there is no record of any shoulder pain in the Fairfield Hospital records nor in the claimant's first attendance with Dr Pope.

1. The claimant says right shoulder pain was noted in October 2021 by his treating specialist

Dr Gotis-Graham and by physiotherapist Nadir Saadi of Rehab Solutions as early as August 2021 who both refer to pain and tenderness of the upper right trapezius region on multiple occasions. 2. The claimant disputes the biomechanical engineer's opinion (Dr McIntosh) that the motor accident was a sideswipe accident and the forces involved were therefore of low magnitude. The claimant says at the time of the collision, the two cars were at right angles to each other with the point of impact being the front of the at-fault vehicle colliding with the passenger side of the claimant's vehicle. It is submitted this is a "lateral collision", commonly referred to as a T-bone accident, which was as described by Dr Baron Levi, the neuropsychologist qualified by the insurer. 3. The claimant therefore rejects the insurer's assertions that the impact was not great enough to cause the claimant's alleged injuries.

1. On 26 February 2025, 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 insurer's bundle comprising of pages 1-332 and the claimant's bundle comprising of pages 1-95.
2. The Panel has read all the material provided by the parties in the bundles. The relevant material is summarised in the Panel's re-examination report and the findings below.

1. The Panel determined that the claimant be re-examined by Medical Assessor Gibson on

13 June 2025. The re-examination report is as follows:

Mr Ademovic arrived at the assessment accompanied by his father and sister but elected to be seen alone. When asked about the need for an interpreter, he clarified that on the last occasion, when examined by the original assessor, he was accompanied by his mother and it was she that was unable to speak English. However, he was born in Australia and is fluent in English. The interpreter, Ms Jovanovic-Palic (CPN 26H485), had later arrived for the assessment but, as Mr Ademovic speaks fluent English, he did not feel it was necessary for the interpreter to remain, so she left.

He is currently 18 years of age and was 13 years at the time of the accident.

I explained the reasons for the assessment and in particular the issues raised by the insurer and his sister's statement in relation to the impact of the other vehicle as opposed to the report of Dr McIntosh.

Mr Ademovic lives with his mother and father and his 22-year-old sister, in a two-storey three-bedroom, two-bathroom house in Fairfield. He said his mother cares for their father who is unwell. His sister is attending university.

He has now qualified with his green provisional licence. He said that getting his licence was a big step forward for him. He added that over the period he was accruing his time to qualify for the licence, he had pushed himself because he was worried about being left behind by his friends.

He said if he walks for long periods (over 50 minutes) there is pain and fatigue felt in his low back, which eventually evolves into a sharper pain. He indicated the upper lumbar region as the site of the pain.

He said that prior to the subject accident he was very active in sports and was playing soccer, tennis and swimming.

He is currently in Year 12 at high school and he had been in Year 8 at the time of the subject accident. He added that during Year 10 and Year 11, he was "trying to get better" but was having some behavioural issues. There were arguments with his teachers and other students to the extent that he had to attend an anger management class and was given a warning that he may be suspended. Over time his behaviour improved.

He hopes to attend university and study Construction Management once he finishes school. He said he studies for about 30 minutes to an hour at home after school.

He said he had resumed school following the subject accident which had occurred over the school holidays. However, once he had returned he had been unable to attend school for up to several days a week due to difficulties with motivation and his PTSD and anxiety related symptoms. However, he said he pushed himself to continue and he was supported by his psychologist.

He said he sleeps poorly, usually staying up till the early hours of the morning (about 4am) and would have nightmares about the accident every few nights.

He continues to visit a psychologist on a weekly basis. His next appointment was for 22 June 2025. He said that he does a lot of exposure therapy with the psychologist. He had tried EMDR but he felt he was being pushed forward too quickly with this therapy and it in fact had made his symptoms worse as it was causing him to see clearer pictures of the accident.

Over time he had visited four different psychologists, including the two more recent ones, who he has found especially helpful.

He said that he feels he is being left behind. His friends have jobs and are going out and going to the gym. He would go out with his friends for 1 or 2 hours but then find he needs to retreat home to his "safe space." He feels more comfortable at home with his family and in his own room.

Mr Ademovic had had a fracture to his left hand, possibly metacarpal, possibly scaphoid, some years ago, but no surgical intervention had been necessary and it fully recovered. There were no other significant physical injuries prior to the subject accident. He has mild asthma and uses a preventative inhaler on a daily basis and salbutamol for exacerbations.

Despite being 13 years at the time, he was able to provide a very clear history of the accident. He had been a front-seat passenger in a Toyota 86 sedan (2020 model) being driven by his sister. He said they were going out to get some food. They were travelling in the right lane along the road.

They had approached an intersection and a Ford Raptor was in a left-only-turn lane. Mr Ademovic and his sister were in the next lane. When the lights changed, the other vehicle had attempted to go straight ahead and in the process had struck the rear left side of their car, he said, where the lights were. He said their car had been travelling at low speed and with the impact had "drifted." His sister managed to control the vehicle and avoid them colliding with a post.

He recalled being thrown around with the impact and feeling some pain in his head. He couldn't recall if he had hit his head but couldn't recall having any bleeding or bruises. He said he had "just whiplash" but there was "a lot of adrenaline at the time."

His sister moved the car to a safe place and got out of the car, he remained. There were apparently five young men in the other car and they were attempting to blame his sister for causing the accident. She had asked for their driving licences and they said they didn't have one, and there was some suggestion they exchange details at a nearby 7-Eleven. However, the other vehicle, driver and passengers then absconded.

His sister had then driven the car to a nearby police station. Mr Ademovic had fortunately taken a photo of the licence plate of the other car, so the police were able to track the it down.

Mr Ademovic said he had a lot of pain in his head and neck. He had visited Fairfield Hospital. He maintained that he also had right shoulder discomfort, however, he was less concerned about that at the time.

I note the discharge records from Fairfield Hospital dated 11 January 2021. These described a rear-end accident with a utility travelling at 50km/h. No airbag deployment, seat belts were fastened, and Mr Ademovic was able to get out of the car immediately without any loss of consciousness and had "felt dazed initially and later headaches set in with some associated nausea. He denies vomit/bleeding from nose or ears. He notes generalised aches, normal neck ROM, nil midline tenderness, moving arms and legs in normal ROM, nil other injuries noted." Clinical examination was unremarkable. He was discharged home with simple analgesia and head injury advice, for followup with his regular doctor.

Dr Harry Pope had recorded on 13 January 2021 that Mr Ademovic had hit head on the headrest and he had frontal and temporal headache and sore back, but normal range of movement of his neck. No mention was made of the shoulder.

When asked about this, Mr Ademovic stated that he was more troubled by his headache and low back pain and was also emotionally affected by the accident. In relation to the right shoulder he said the pain had been present since the accident and that he had had physiotherapy treatment and been provided some shoulder stretches. An exercise physiologist had visited him at home over several months.

On 29 November 2022, he was seen by Dr Drew Dixon for a medicolegal report on referral from his solicitors. Dr Dixon had noted that he had in the past been treated for ankle injury and Sever's disease in 2017 and there is a history of fractured left scaphoid in May 2019, which required cast mobilisation. Dr Dixon had also concluded there had been right shoulder impairment secondary to the neck injury. He had assessed the right shoulder at 4%WPI based on range of movement. He assessed 0% DRE Category 1 for the cervical spine and DRE Category 1 for the lumbar spine. The head injury was assessed at 5% WPI.

Mr Ademovic was referred to Dr Ian Gotis-Graham who wrote a report on 26 August 2021. He noted a history of complaints of neck and low back pain and noted normal range of cervical and lumbar spine movements, some spasming of the right paracervical spinal muscle bellies and right paralumbar spinal muscle bellies. Cervical and lumbar spine movements are accompanied by some localised pain. Normal neurology. He advised that the Panadeine Forte be reduced and he use Celebrex or celecoxib tablets intermittently.

Regional bone scan with SPECT CT, 2 July 2021 showed "No evidence of C7 right pars fracture. No significant finding in cervical spine."

Dr Hyde-Page provided a medico-legal report dated 4 July 2023. He found soft tissue injuries for the cervical spine, lumbar spine and shoulders and rated impairment at 0%WPI.

Mr Ademovic said he is troubled by headache which can occur several times a week and last for several hours. He finds he takes his medication and then has to go to bed and rest. He indicated the headaches as being felt over the temples bilaterally and over the top of his head. He said it was "like a helmet" and at times headaches are accompanied by nausea. He said on one occasion, several months ago, he had gone to Liverpool Hospital due to the headaches and was told he had a hemiplegic migraine. He said at the time there was weakness in one side and his speech was abnormal. He said he was told to have a scan of his head but he is waiting for insurance approval to go ahead.

He said his neck is much improved, but still uncomfortable sometimes but "not often." At times his neck is a bit stiff. He finds his symptoms worse after a full day of activities, such as at school. He said that he carries his school bag which can be quite heavy with his computer and books, but he is dropped off at school and picked up of an afternoon.

In relation to the right shoulder, he indicated the subacromial region. He notes this is particularly uncomfortable if he lifts anything heavy in a repetitive fashion such as his school bag. He added that his shoulder is "much improved."

He notices some low back pain when walking and if he continues the pain becomes sharper.

There were no other issues with upper or lower limbs.

None was brought to the assessment, the following was on file:

MRI scan cervical spine 12 May 2021, which noted "at C7 right pars, there is subtle T2W/STIR hyperintensity. This is not well defined and can be artifact, although with trauma stress fracture is not entirely excluded. No evidence of disc protrusion or nerve root impingement in the cervical or lumbar spine. There is loss of lordosis in the cervical spine and lumbar spine, possibly musculoskeletal in origin."

MRI cervical spine performed 15 May 2023, showed "focal hyperintense T2 5-3mm lesion is seen at the junction of right lateral mass and pars articularis without associated bone destruction or mass lesion. This is consistent with a stress injury. Further followup or comparison with previous film is suggested. A CT scan would also be helpful."

MRI lumbar spine performed 25 March 2024 showed T11 vertebral body shows mild 20% wedging anteriorly. Endplates show mild depression consistent with Schmorl's nodes. Disc bulges are seen at the L4/5 and L5/S1. Foramina are clear and the facet joints normal.

Addendum to CT cervical spine 25 March 2024 showed C2-T1 discs normal in height, epiphyseal ring is not yet fused, no disc protrusion, no vertebral body compression.

MRI scan right shoulder performed 15 March 2024, "focal central glenoid pit, possible anatomical variation and clinical correlation, followup MRI or comparison with the other side may be helpful. Anterior supraspinatus insertion shows 3cm tendon flap, possible focal partial thickness tear. Minor joint effusion with a little thickened capsule on subacromial bursitis."

Mr Ademovic had a normal gait. He could walk on heels and toes. He was 185cm tall and weighed 95kg. He presented in a very straightforward fashion and was consistent on examination.

On examination of the neck, there was some tenderness posteriorly and over the right side of the neck and right trapezial region, however movements were to full normal range. There was no asymmetry, muscle spasm or guarding.

On examination of the upper limbs, arms measured 31cm bilaterally (10cm above the olecranon). Right forearm measured 29cm, left forearm 28cm (10cm below the olecranon) consistent with right hand dominance. Upper limb reflexes, sensation and power were bilaterally normal.

On examination of both shoulders, active movements were measured as follows:

On examination of the upper back, there was full normal range of rotation bilaterally. There was no asymmetry, muscle spasm or guarding.

On examination of the low back, there was full normal range of movement in all planes. There was no asymmetry, muscle spasm or guarding.

On examination of the lower limbs, circumferential measurements were bilaterally 44cm at the thighs (10cm above the upper pole of patella) and maximal girth at the calf was 39cm bilaterally. Lower limb reflexes, sensation and power were bilaterally normal.

No inconsistencies were identified throughout the medical assessment."

1. 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.[10]
2. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[11]
3. The Panel refers to the above re-examination report of Medical Assessor Gibson and adopts the findings in their entirety. The Panel reconvened on 25 June 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. Mr Ademovic is an 18-year-old young man who was involved in the subject accident on

10 January 2021. Based on the available documentation, it appears he struck his head on the headrest and had whiplash injury to his cervical spine and soft tissue injury to his low back. There were no immediate complaints recorded of right shoulder symptoms. However, he maintains there had been some discomfort following the accident but he was more troubled by his other symptoms, therefore the shoulder symptoms were not prominent or mentioned to his doctors. 2. The Panel accepted the claimant's contention that there had been some right shoulder symptoms following the accident. The Panel also accepted that there was a distracting environment, with there being some conflict at the time of the accident with the refusal of the at fault driver to exchange details. The claimant was also young at the time of the accident and was particularly affected by headaches, but also had symptoms in his neck and lower back. Another point of distraction were the claimant's psychological symptoms, for which he was referred to a psychologist a few months after the motor accident and was recommended for eight sessions of Trauma-Focused Cognitive Behavioural Therapy, which has continued to date. 3. The claimant ultimately had MRI imaging performed on his right shoulder, which occurred three years after the accident, and this demonstrated some tendon abnormality. The claimant attributes this pathology as being caused by the motor accident. 4. The Panel, however, observed counter arguments and evidence that weighed against the right shoulder pathology being caused by the motor accident. 5. Foremost was the delay of any right shoulder complaints contemporaneous with the motor accident. There was no evidence of any direct impact to the shoulder in the motor accident, nor complaints of shoulder pain in the hospital records or during the claimant's initial visit to his general practitioner. There were no right shoulder injury or complaints mentioned in the application for personal injury benefits. While the claimant told the Panel Medical Assessor that he had seen a physiotherapist who showed him some shoulder stretches, the Allied Health Recover Request from Dr Pope and the Physiotherapy initial Assessment Report in March 2021 only mentioned neck and low back pain. The Panel noted that it was not until the claimant saw Dr Drew Dixon on 29 November 2022, almost two years after the motor accident, that there was mention of right shoulder symptoms. 6. The Panel then turned to the report of Dr Dixon itself. Dr Dixon had noted "He was wearing a seat belt at the time and sustained a facial injury with nose bleeds and a neck strain injury with right shoulder brachalgia and a low back strain injury." On examination, Dr Dixon found "There was stiffness of his right shoulder with active abduction 130 degrees, forward flexion 150 degrees, extension 40 degrees, adduction 40 degrees, external rotation 80 degrees and internal rotation 60 degrees and there appeared to be mild impingement on abduction which was associated with trapezial muscle pain which he identified." He concluded a diagnosis of "Post traumatic stiffness of the right shoulder due to trapezial muscle pain as per Nguyen".[12] 7. In other words, Dr Dixon had concluded that whilst there was right shoulder pain, this was explicable based upon there being a whiplash injury to the neck, and he did not diagnose a separate injury to the right shoulder. 8. Dr Gotis-Graham on 21 December 2022 also did not diagnose a separate right shoulder injury and noted complaints of pain in "his neck (right paracervical spine region"). 9. This was also consistent with the clinical records from the treating physiotherapist. 10. Also weighing against a finding of accident-related causation was the report of Dr Andrew McIntosh, biomechanical expert, dated 24 October 2024. The Panel accepts that the motor accident was low speed. The Panel also accepts that the biomechanical forces were likely to be of low magnitude and notes Dr McIntosh's opinion that the forces involved could not have caused a partial tear of the supraspinatus tendon in the right shoulder. 11. The claimant maintained at the time of the panel examination that he had noticed some right shoulder discomfort since the subject accident. Whilst the Panel accepts that he may have had some discomfort in the region of the right shoulder, they were not persuaded this represented either a supraspinatus tendon tear or a labral tear. In the Panel's medical opinion, a tendon or labral tear would have produced immediate and specific shoulder symptoms. It is inexplicable that the claimant would not have mentioned right shoulder symptoms at the time he complained of neck and low back symptoms or shortly thereafter. 12. The Panel therefore found that the motor accident could not have caused or contributed to the possible partial thickness tear of the supraspinatus tendon. 13. The Panel were of the view that the pattern of right shoulder complaints following the subject accident was of a secondary, rather than primary right shoulder condition. The findings on the imaging of 25 March 2024 were incidental rather than related to the accident over three years earlier. Therefore, whilst the Panel accepted the claimant's contention that there had been some right shoulder symptoms following the subject accident they were of the view these were explicable based upon his neck injury rather than a separate right shoulder condition. 14. The Panel therefore concluded that the injury caused by the motor accident is right shoulder pain referred from the neck. 15. The Panel was also satisfied that there were accident-related soft tissue injuries to the head, cervical spine and lumbar spine.

1. The following injuries WERE caused by the motor accident:
   • head - soft tissue injury;
   • cervical spine - soft tissue injury;
   • lumbar spine - soft tissue injury, and
   • right shoulder - pain referral from neck and per Nguyen.

1. The above injuries are threshold injuries because they fit the definition of threshold injury as set out in the Act and the Regulation. Radiculopathy has not been present following the motor vehicle injury and is not currently present.
2. For the above reasons, the Panel disagreed with Medical Assessor Cameron's finding that the possible tendon tear shown in the MRI was caused by the motor accident.
3. The certificate issued by Medical Assessor Ian Cameron dated 7 January 2025 is therefore revoked. A new certificate is issued at the front of these reasons.

[2] The terminology for accidents that occurred before 1 April 2023 (such as the present) was "minor" injury and statutory benefits were only paid for up to 26 weeks.

[5] Section 4(1) of the Motor Accident Injuries Regulation 2017.

[6] For motor accidents that occurred from 6 December 2024, the applicable version of the Guidelines is version 9.3.

[9] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372 per Wright J at [35].

[12] Nguyen v Motor Accidents Authority of New South Wales and Anor [2011] NSWSC 351.