1. On 21 March 2025 Elizabeth Allen (the appellant) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Tommasino Mastroianni, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 24 February 2025.
2. The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):
   • the assessment was made on the basis of incorrect criteria, and
   • the MAC contains a demonstrable error.
3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the ground(s) of appeal on which the appeal is made.
4. Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 - Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed

1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).

1. The appellant suffered an injury on 10 November 2018 to her left upper extremity in her employment as a physiotherapist with the State of NSW (Western NSW Local Health District) (the respondent).
2. The appellant lodged an Application to Resolve a Dispute in the Personal Injury Commission (Commission) dated 27 September 2024 in which she claimed lump sum compensation in respect of the injury to her left upper extremity.
3. In a Certificate of Determination - Consent Orders dated 25 November 2024, Member Cameron Burge remitted that matter to the President for referral to a Medical Assessor to determine the degree of permanent impairment of the left upper extremity with the date of injury being 1 March 2016 (deemed). Member Burge noted that both of the Independent Medical Examiners (IME), Dr Millons and Dr Haig, considered there was damage to the left axillary nerve.
4. The Medical Assessor examined the appellant on 12 February 2025 and assessed 16% whole person impairment (WPI) of the left upper extremity as a result of the injury deemed to have occurred on 1 March 2016.

1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
2. The appellant requested that she be re-examined.
3. As a result of that preliminary review, the Appeal Panel determined that it was necessary for the appellant to undergo a further medical examination because there was insufficient evidence on which to make a determination.

1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.

1. Dr Roger Pillemer of the Appeal Panel conducted an examination of the appellant on 8 July 2025 and reported to the Appeal Panel.

1. The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.

1. Both parties made written submissions. They are not repeated in full but have been considered by the Appeal Panel.
2. Both parties made written submissions. They are not repeated in full but have been considered by the Appeal Panel.
3. The appellant's submissions include the following:

(a) the Medical Assessor in providing his assessment of WPI relative to the axillary nerve determined:

(i) Inspection of the shoulders reveals generalised wasting of the left shoulder and obvious wasting of the deltoid.

(ii) Examination of the arm revealed abnormal sensation to light touch and sharp stimuli, and dysaesthesia in the distribution of the axillary nerve. The rest of the upper arm had normal sensation.

The Medical Assessor diagnosed left shoulder subluxation for which the appellant had a stabilisation procedure, left axillary nerve sensory lesion, and left ulnar neuritis.

(b) In dealing with the two IME opinions, the Medical Assessor noted Dr Millons assessed a complete axillary nerve deficit and Dr Haig had found diminished sensation in the distribution of the axillary nerve but had declined to make a WPI assessment. The Medical Assessor was of the view, however, there was no motor deficit of the nerve finding, but a sensory deficit without proffering an explanation as to the prominent wasting of the deltoid observed by the IMEs and the Medical Assessor.

(c) The Medical Assessor did not acknowledge that Dr Haig had found, in addition to diminished sensation in the distribution of the axillary nerve, that there was a loss of function of the shoulder due to axillary nerve damage.

(d) The Medical Assessor then, in assessed 90% sensory deficit of the axillary nerve.

(e) There has been a demonstrable error on the part of the Medical Assessor in his application of 16.5 of the Guides, the tables and in his findings relative to the axillary nerve. The Medical Assessor failed to provide a comprehensive table per 2.6 of the Guidelines and failed to apply 16.5 of AMA 5 correctly. In the first instance, the Medical Assessor has not provided a proper foundation for his determination of a sensory deficit on one hand but no suggestion of motor deficit. An explanation for the Medical Assessor's findings in this regard is absent and is a demonstrable error.

(f) The Medical Assessor also committed a demonstrable error in his failure to properly apply the Guidelines in particular his application of a grade 1 sensory deficit of the ulnar nerve in circumstances where at the same time the Medical Assessor found no motor deficit of the axillary nerve and opined that the wasting was due to disuse.

(g) The Medical Assessor does not address the interrelationship between disuse and nerve damage; Drs Millons and Haig as noted above specifically attributed disuse to axillary nerve damage.

(h) It was incumbent upon the Medical Assessor, having made the clinical findings that he did, to provide an explanation as to why on the one hand he determined there was no deficit of the motor functions of the axillary nerve but on the other hand there was 'disuse' of the shoulder that had led to wasting as noted by Drs Millons and Haig.

(i) Further, the Medical Assessor makes no mention (or use) of the criteria seen at Table 16-11 of the Guides to identify and classify damage to the motor function as Dr Millons performed.

(j) AMA 5 provides at 16.5b the need for an evaluation of the sensory and motor deficits associated with the accepted injury to the axillary nerve; and with reference to the motor function "identifying the key muscles and relating it to the nerve involved" and multiplying or combining those deficits.

(k) The failures above to provide an explanation in this regard and to correctly apply AMA 5 amounts to a demonstrable error.

(l) With respect to demonstrable error, the error is readily apparent (Hoeben J in Merza v Registrar of the Workers Compensation Commission & Anor [2006] NSWSC 939 at [39]- [40].

(m) The MAC should be revoked.

1. The respondent's submissions include the following:

(a) The Medical Assessor provided sufficient reasons for his conclusions

(b) The Medical Assessor clearly stated that he did not find motor deficit of the axillary nerve and considered wasting in the shoulder to be a result of disuse. The Medical Assessor expressed at multiple times throughout the assessment that the restriction in range of movement was influenced by pain He stated the appellant avoided using the shoulder because of pain.

(c) The Medical Assessor accordingly provided an explanation which can be gleaned by reading of the whole report, that disuse of the shoulder was a result of pain symptoms in the shoulder.

(d) In relation to the principles associated with the Medical Assessor 's clinical observations and decision making in completing a medical assessment, the decision of State of New South Wales (NSW Department of Education) v Kaur [2016] NSWSC 346 affirmed the decision made in Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 4 with Campbell J stating:

"Essentially, the function is the same as that described by the High Court in Wingfoot Australia. That is to say, the function is in every case to form and give his or her own opinion on the medical question referred by applying his or her own medical experience and his or her own medical expertise. It is sufficient, as their Honours pointed out at [55] that: 'the statement of reason explained the actual path of reasoning in sufficient detail to enable the court to see whether the opinion does or does not involve any error of law."

(e) The Medical Assessor is not obliged to accept the medical opinion of other specialists A Medical Assessor must form their own opinion and it is within the jurisdiction of the Medical Assessor to form his own expert opinion as to the level of impairment (Glenn William Parker v Select Civil Pty Limited [2018] NSWSC 140) Paragraph 1. 6 of Guidelines provide the key principles of permanent impairment assessments which includes 'clinical assessment of the claimant as they present on the day of assessment taking account the claimant's relevant medical history and all available relevant medical information'.

(f) In addition, assessors are required to exercise their clinical judgement in determining a diagnosis when assessing permanent impairment and making deductions for pre­ existing injuries/conditions.

(g) The assessment offered by the Medical Assessor is offered under appropriate clinical judgment for which the Medical Assessor has provided an adequate explanation. Generally, the appellant's assertions involve a hypercritical assessment of the MAC, which is specifically disapproved in matters such as Bojko v ICM Property Service Ply Ltd & Ors [2009] NSWCA 175

(h) Accordingly, the Medical Assessor provided a sufficient explanation as to his finding that there was wasting as a result of disuse of the shoulder and that there was no motor deficit found of the axillary nerve. It is clear the Medical Assessor turned his mind to whether the appellant had motor deficit as a result of damage to the axillary nerve and formed his own opinion based on the evidence including his assessment that he did not find the same. There is no readily apparent error.

(i) This conclusion was a difference in opinion and there was information and material available to support this finding. It was clear that the Medical Assessor's examination revealed pain symptoms in the shoulder which the appellant explained to the Medical Assessor influenced her disuse of the shoulder.

(j) The evidence before the Medical Assessor to support this finding, including Dr Millons' report dated 24 March 2023 (Application to Resolve a Dispute (ARD) page 28). Dr Millons recorded the worker's complaint of pain under the heading "Current Situation", on page 8 of his report (ARD page 35) His WPI assessment of the shoulder on page 14 of his report (ARD page 41) was assessed on the basis that damage to the axillary nerve was not the only cause of the appellant's restricted range of motion in the shoulder. Dr Millions provided an assessment on the basis of axillary nerve deficit and abnormal movement of the shoulder. Section 16. 5a of the AMA 5 indicates if an upper extremity impairment results solely from a peripheral nerve injury, the assessor should not also evaluate impairments as a result of abnormal motion for that upper extremity. It is reasonable to infer that Dr Millons did not consider damage to the axillary nerve to be the only reason for the appellant's restricted range of movement in the shoulder

(k) Dr James Powell, in his report dated 1 March 2021 (Application to Admit Late Documents (AALD) page 38), also noted impairment of the left shoulder on the basis of stiffness arising from surgery which he stated was to be assessed by reference to abnormal movement. He does not attribute this stiffness to damage to the axillary nerve.

(l) Therefore, there was information and material to support the finding made by the Medical Assessor and this amounted to a difference in opinion. A demonstrable error does not arise in these circumstances

(m) Dr Ron Haig, in his report dated 3 May 2024 (AALD at page 36), concluded impairment arose due to the loss of range of motion and the axillary nerve lesion. During his examination, he concluded there was restricted function due to loss of range of motion and weakness with repetitive movement He noted there was minimal pain at rest however there was pain with repetitive use or forced use or with abduction. He diagnosed generalised joint hypermobility and acknowledged there was an area approximately elliptical in size in the territory of the axillary nerve of diminished sensation

(n) The appellant made an inference from Dr Haig's conclusion, that is, there was a loss of function of the shoulder due to axillary nerve damage, which is not available on the face of the report. Dr Haig clearly attributes sensory loss to damage to the axillary nerve but he does not appear to otherwise provide his opinion as to the cause of the appellant's range of motion.

(o) There was no error in the Medical Assessor 's lack of acknowledgment of a finding inferred by the appellant and not available on the face of the report.

(p) There was no demonstrable error or use of incorrect criteria in the Medical Assessor 's absence to mention or use of the criteria seen at Table 16-11 of the AMA 5 to identify and classify damage to the motor function as there was no such damage found.

(q) The assessment of the Medical Assessor was not made on the basis of incorrect criteria, nor contains demonstrable error and the MAC dated 24 February 2025 be confirmed.

1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
3. The Appeal Panel has reviewed the Medical Assessment certificate and evidence in this matter.

1. The appellant submits that the Medical Assessor erred in his assessment on the basis that he failed to provide a comprehensive Table per 2.6 of the Guidelines and failed to apply 16.5 of AMA 5 correctly. Further, the Medical Assessor has not provided a proper foundation for his determination of a sensory deficit but no suggestion of motor deficit. An explanation for the Medical Assessor's findings in this regard is absent and is a demonstrable error.
2. Specifically, the appellant submits was a demonstrable error of the Medical Assessor to not provide an assessment of motor deficit for the axillary nerve Additionally, it was submitted that a lack of explanation as to the prominent wasting of the deltoid in circumstances where this had previously been concluded, by other doctors, to be a result of axillary nerve damage was an indication of demonstrable error.
3. The appellant submits that the Medical Assessor also committed a demonstrable error in his failure to properly apply the Guidelines in particular his application of a grade 1 sensory deficit of the ulnar nerve in circumstances where at the same time the Medical Assessor stated: "I found no motor deficit of the axillary nerve. In my opinion the wasting is due to disuse". The Medical Assessor does not provide a view as to the interrelationship between disuse and nerve damage even though Drs Millons and Haig specifically attributed disuse to axillary nerve damage.
4. The Medical Assessor under "Present symptoms" noted:

"She states that her left shoulder is restricted. She describes constant pain/discomfort/awareness in the shoulder which she rates a 3 on a VAS scale of 10. She states that the symptoms flare up regularly and she avoids using the arm because of the pain.

She states that her symptoms are worse in cold weather and if she wears heavy or tight clothing. Putting pressure on the shoulder aggravates it.

Moving the shoulder generally aggravates it, more so if she abducts her shoulder. Repetitive movements of the arm aggravate her hand and her hand gets tired, she loses dexterity and her hand feels weak. She describes an aching burning sensation in the upper arm and the symptoms radiate to her neck and jaw. She gets pain radiating down her left arm with pins and needles and numbness affecting the ulnar forearm and fourth and fifth digits".

1. Under "Findings on physical examination" the Medical Assessor noted:

"Inspection of the shoulders reveals generalised wasting of the left shoulder and obvious wasting of the deltoid.

The shoulder is tender. Pressure over the shoulder posteriorly causes pain and tingling in the axillary nerve. Tinel's sign was positive.

Examination of the arm revealed abnormal sensation to light touch and sharp stimuli, and dysaesthesia in the distribution of the axillary nerve. The rest of the upper arm had normal sensation. There is decreased sensation in the lateral forearm and fourth and fifth digits, in the distribution of the ulnar nerve. The ulnar nerve is palpable and irritable at the elbow with positive Tinel's sign.

There is no muscle wasting in the left hand and there is normal power and normal movements.

She had normal power in the left forearm with no identifiable weakness in any muscle group.

Active range of movement of both shoulders was measured with a goniometer. Right shoulder movements were normal whilst left shoulder movements were restricted.

Movement Right. % Upper extremity impairment Left % Upper extremity impairment

There was a positive impingement sign in the left shoulder. When testing for power she could exert force but very restricted because of pain. When abducting the left arm and when testing abduction with resistance there was contraction in the deltoid muscle.

She was not able to maintain pressure or go beyond the range of movement recorded because of pain in the shoulder. Pain seems to be the limiting factor and active range of movement is the same as the passive range of movement.

Reflexes were normal and symmetrical (biceps, triceps and supinator jerks)."

1. Under "Summary of injuries and diagnoses", the Medical Assessor wrote:

"As a result of the incident on 1 March 2016 the claimant sustained subluxation of the left shoulder. The shoulder became very unstable on a background of congenital ligament laxity. She had a stabilisation procedure on the left shoulder and post-operative pain management. She has had various investigations which revealed no lesion of the brachial plexus or axillary nerve.

My clinical diagnosis is left shoulder subluxation for which she had a stabilisation procedure, left axillary nerve sensory lesion, and left ulnar neuritis".

1. Under "Reasons for Assessment" the Medical Assessor wrote:

1. My opinion and assessment of whole person impairment

As per the table in Section 5 of the MAC, I assess 22% left upper extremity impairment (1) (see 10b).

The claimant has burning pain and dysaesthesia in the distribution of the left axillary nerve.

I assess Grade 1 sensory deficit (2) (see 10b). Grade 1 sensory deficit is 81 to 99%. I assess 90% sensory deficit of the axillary nerve.

The axillary nerve sensory deficit is 5% upper extremity impairment (3) (see 10b). 90% of 5% is 4.75% which rounds off to 5%.

I found no motor deficit of the axillary nerve. In my opinion the wasting is due to disuse.

I found the claimant to be suffering from ulnar nerve neuritis. The ulnar nerve below the mid-forearm is 7% sensory deficit (2) (see 10b). I assess Grade 3 sensory deficit (3) (see 10b).

Grade 3 sensory deficit is 26% to 50% sensory deficit. I assess 50% sensory deficit. 50% of 7% is 3.5% which rounds off to 4%.

The combined upper limb assessment (20% for restricted range of movement, 5% for the axillary nerve lesion and 4% for the ulnar nerve lesion), equates to 27% upper extremity impairment which equates to 16% WPI.

In making that assessment I have taken into account of the following matters: See Section 9.

1. An explanation of my calculations (if applicable)

AMA Guides to the Evaluation of Permanent Impairment, 5th Edition:

1. In commenting on the other medical opinion, the Medical Assessor wrote:

"I note the report of Dr James Bodel dated 5/02/2019. I found the left shoulder to be more restricted than when examined by Dr Bodel. I found no motor deficit in the axillary nerve. I found the same sensory deficit.

I note the report of Dr David Millons dated 24/03/23. Dr Millons assessed complete axillary nerve deficit. I found no motor deficit but did find sensory deficit (see 10a). I found the left shoulder to be more restricted than Dr Millons.

The claimant's condition appears to have deteriorated since those examinations.

I note the reports of Dr R Haig dated 3/05/24 and 28/05/24. I assessed a higher impairment for range of movement based on my clinical findings (see 10a).

Dr Haig found diminished sensation in the distribution of the axillary nerve but did not do an impairment assessment. There is also no reference to the abnormal sensation in the forearm and hand, where I found evidence of an ulnar nerve lesion."

1. Dr James Powell, consultant orthopaedic surgeon, in a report dated 1 March 2021 noted that the appellant had impairment at the left shoulder on the basis of stiffness arising from her surgery. He assessed as a limitation of active range of motion as per the guidelines. While Dr Power did not attribute this stiffness to damage to the axillary nerve, he noted that Dr Walker, neurologist, in April 2019 found some wasting of the deltoid with good power of abduction and no other weakness about the shoulder or in the arm and no mention of any sensory alteration in the left upper limb. Dr Powell noted that Dr Walker assessed the appellant on the basis of left axillary nerve palsy.
2. Dr James Bodel, consultant orthopaedic surgeon, in a report dated 5 February 2019 noted that the appellant had gross wasting in the shoulder girdle all in the area of the left deltoid. He expressed the opinion that the appellant appeared to have a circumflexed nerve palsy in the left shoulder affecting the deltoid that appeared to have dated from the surgery to the left shoulder 18 months earlier. Dr Bodel assessed zero grade sensory loss and zero grade motor loss with the combined motor and. sensory loss totalling 38% upper extremity impairment.
3. The MRI scan report of the cervical spine and left brachial plexus dated 1 September 2021 concluded that there was marked atrophy of the deltoid muscle but the remaining muscles of the left shoulder appeared normal.
4. Dr David Millons, consultant general surgeon, in a report dated 24 March 2023, noted that the appellant underwent arthroscopic stabilisation of the left shoulder on 17 August 2017. He noted that when Dr Bodel saw the appellant on 5 February 2019, Dr Bodel noted gross wasting of the shoulder girdle, all in the area of the deltoid and recommended the appellant see a neurologist.
5. On examination, Dr Millons noted that there was numbness down the lateral side of the shoulder and down the arm, weakness in her left hand and gross wasting of the left deltoid muscle. He stated that there was a global reduction in power through the upper left limb, particularly in the power of abduction because of the absent deltoid. Dr Millons considered that the marked wasting of the deltoid muscle and some altered sensation through the upper left limb was sufficient to indicate that the appellant had an axillary nerve palsy, resulting in marked wasting of the deltoid muscle. He noted that there was numbness over the lateral side of the arm which would fit with such a diagnosis. He noted that there were neurological symptoms through the upper limb into the hand. He assessed 17% upper extremity impairment (UEI) for loss of range of motion in the left shoulder, and 38% UEI for peripheral nerve deficit axillary nerve under T16-15, T16-10 and T16-11. (T-10 - impairment for sensory deficits, 16-11 impairment for motor and loss of power deficits, T 15- maximum upper extremity impairment due to sensory or motor deficits).
6. Dr Ron Haig, consultant orthopaedic surgeon, in a report dated 3 May 2024 noted that on examination the appellant had obvious wasting of the deltoid and associated weakness of abduction. He noted that there was an area approximately elliptical in size in the territory of the axillary nerve of diminished sensation.
7. Dr Haig wrote: "The impairment she has, and there is impairment due to the loss of range of motion and the axillary nerve lesion, is not the result of any injury on 1 March 2016. It is due to the natural history of her condition and the associated surgery."
8. In a report dated 28 May 2024, Dr Haig assessed 10% WPI of the left shoulder based on the measured range of motion in his report of 3 May 2024. He made no assessment of impairment resulting from the axillary nerve lesion.
9. The appellant submits that the Medical Assessor erred in not providing a comprehensive Table per 2.6 of the Guidelines.
10. Clause 2.6 of the Guidelines provides:

"To achieve an accurate and comprehensive assessment of the upper extremity, findings should be documented on a standard form. AMA5 Figures 16-1a and 16-1b (pp 436-37) are extremely useful both to document findings and to guide the assessment process".

1. The Appeal Panel accepts that the Medical Assessor did not provide the form referred to in Cl 2.6 of the Guidelines. However, the use of such a form is not mandatory and the Appeal Panel is satisfied that the Medical Assessor did set out in the body of the MAC all findings on examination necessary for the assessment. The Appeal Panel is not persuaded that the failure to provide the standard form referred to in Cl 2.6 was a demonstrable error.
2. The appellant submits that the Medical Assessor did not provide a proper foundation for his determination of a sensory deficit but no suggestion of motor deficit. The appellant argues that an explanation for the Medical Assessor's findings in this regard is absent and is a demonstrable error.
3. The Appeal Panel noted that the Medical Assessor did find obvious wasting in the deltoid. The Medical Assessor also wrote: "I found no motor deficit of the axillary nerve. In my opinion the wasting is due to disuse". The Appeal Panel considers therefore that some explanation was provided by the Medical Assessor.
4. The appellant submits that a lack of explanation as to the prominent wasting of the deltoid in circumstances where this had previously been concluded, by other doctors, to be a result of axillary nerve damage was an indication of demonstrable error. Dr Bodel and Dr Millons both made assessments of sensory and motor deficits. Dr Haig was of the view that the appellant had impairment due to the loss of range of motion and the axillary nerve lesion, but he only assessed impairment due to loss of range of motion. However, Dr Haig was of the view that the loss of range of motion and the axillary nerve lesion was not the result of any injury on 1 March 2016 but due to the natural history of her condition and the associated surgery.
5. The Appeal Panel was satisfied on balance that the Medical Assessor failed to provide adequate reasons to explain why the wasting in the left deltoid was due to disuse and not to a motor deficit. The appellant developed significant wasting in the left deltoid following the surgery to her left shoulder on 17 August 2017. While the Appeal Panel accept that the Medical Assessor would have been unable to test for motor loss because of pain, the wasting in the deltoid is very significant and not present in other muscles of the left shoulder. The Appeal Panel does not accept that such wasting would be present merely from reduced use of the left arm and shoulder.
6. The respondent submits that the Medical Assessor found pain symptoms caused the appellant's loss of range of movement (ROM), not a motor deficit from an axillary nerve lesion. Appeal Panel accepts that the Medical Assessor and other doctors have reported pain on movement especially on repetitive movements. However, this does not explain the significant muscle atrophy in the left deltoid.
7. The Appeal Panel considers that the Medical Assessor failed to provide adequate reasons to explain the significant muscle atrophy in the left deltoid and this failure was a demonstrable error.
8. As noted above, the Appeal Panel considered that it was necessary for the appellant to undergo a further medical examination because there was insufficient evidence on which to make a determination in relation to any impairment arising from motor deficit from an axillary nerve lesion.
9. As noted above, Dr Roger Pillemer of the Appeal Panel examined the appellant on 9 July 2025. Dr Pillemer provided the following report:

"1. The workers medical history, where it differs from previous records

Ms Allen was examined by Dr T Mastroianni on 12 February 2025. I read Ms Allen the history taken by Dr Mastroianni and she felt that this was very accurate, and simply noting that at the time of her injury she had only been employed for a few weeks as a physiotherapist.

In addition, she pointed out that under the heading 'Present symptoms', Dr Mastroianni had indicated that she had pain going down her left arm '...with pins and needles and numbness affecting the ulnar forearm and fourth and fifth digits', and in fact her whole hand is involved with pins and needles and numbness in all of the digits, particularly when her symptoms are bad.

1. Additional history since the original Medical Assessment Certificate was performed

Ms Allen is complaining of discomfort which extends from the base of her neck all the way down her arm and into the fingers of her left hand. Symptoms are described as being constant and ranging between 3-8/10, and it is only on infrequent occasions that these symptoms go as high as 8/10, and then they extend all the way from the base of her neck into the fingers of her left hand. Most of the time her discomfort is around the shoulder and upper arm, but she is always aware of a feeling of 'weakness' involving the rest of her arm. When her symptoms are very bad they can extend up into her neck and also into her jaw.

Symptoms are aggravated any use of her left arm and any repetitive use, and even when doing activities such as doing puzzles or trying to play the piano, or if she is wearing any heavy clothes which press down on her shoulder region. Ms Allen also notes that she tends to drop things out of her left hand also notices lack of dexterity in her fingers, which was one of the first clinical signs that she noticed.

The only way she can get some relief of symptoms is by resting, taking her tablets, and by applying ice. She now takes Naprosyn and Panadol, and was taking Lyrica but she found that this upset her, and she stopped these. Ms Allen's symptoms are fairly stable at this stage.

Ms Allen is an adult female who keeps her left arm rather protectively at her side.

She has a satisfactory range of cervical movement and a full range of right shoulder movements, with very significant restriction of left shoulder movements.

The most noticeable clinical sign on inspection is wasting of the left deltoid muscle. Reflexes are generally depressed.

Importantly Ms Allen has hypoaesthesia to pinprick which extends from the base of her neck over the top of her shoulder as well as onto the anterior and posterior chest walls to the level of the anterior and posterior axial lines. The hypoaesthesia also extends to involve the whole of the rest of her left arm apart from the medial aspect of her left upper arm where she feels normal sensation. Please note that this area is supplied by the intercostobrachial nerve (T2) and is not part of the brachial plexus.

Most importantly percussion in the supraclavicular region causes immediate intense paraesthesias to radiate down into the fingers of her left hand and percussion of the supraclavicular nerve where it enters the posterior triangle causes intense paraesthesias to radiate from the base of the neck over the top of the shoulder. These are both very positive Tinel's signs.

Percussion of her ulnar nerve behind the medial epicondyle and her median nerve over the carpal tunnel, causes paraesthesias to radiate both proximally and distally.

Importantly, the sensory loss over the lateral aspect of her left upper arm in the distribution of the axillary nerve was very much more dense than in the rest of her arm.

Ms Allen informed me that in the past she has had two nerve conduction studies carried out and as far as she can recall these were felt to be within normal limits.

1. Results of any additional investigations since the original Medical Assessment Certificate

Ms Allen has not had any further investigations carried out."

1. The Appeal Panel adopts the report and findings of Medical Assessor Pillemer.
2. The Appeal Panel finds that the appellant has widespread neurological involvement of her supraclavicular nerve where it enters the posterior triangle behind the posterior border of sternomastoid. In addition, she has evidence of involvement of the whole of her brachial plexus with hypoaesthesia of the whole of the left upper extremity apart from the medial aspect of her upper arm which is supplied by the intercostobrachial nerve. She therefore has sensory loss from C3 to T1.
3. Medical Assessor Pillemer noted that the appellant informed him that when her symptoms are really bad (which occurs infrequently), the symptoms extend up her neck and to the back of her head and also to her lower jaw, suggesting involvement of all the sensory nerves that enter the posterior triangle with involvement from C2 to T1.
4. The Appeal Panel is satisfied that the appellant has a complete lesion of the axillary nerve. With regard to assessment of impairment, the Appeal Panel finds that that the appellant has involvement of her axillary nerve which is a combined motor and sensory loss of 38% UEI (AMA 5, page 492, Table 16-15), Under Table 16-3 of AMA 5 38% UEI is converted to 23 % WPI.
5. The Appeal Panel considers that although part of the restricted range of shoulder movement could be related to the appellant's underlying problem with her shoulder for which she had surgery carried out, the significant restriction is neurologically based. Therefore, the Appeal Panel does not consider it appropriate to add an additional amount for loss of range of motion as the impairment resulting from any abnormal motion for the left shoulder has already been taken into account in the assessment of the auxillary nerve lesion.
6. The Appeal Panel finds that the appellant has 23% WPI as a result of her axillary nerve lesion.
7. Finally, the Appeal Panel considers that the appellant should consult her general practitioner for referral to a neurologist with a specific request that the neurological involvement from C3 to T1 (as evidenced by the very objective clinical findings of Medical Assessor Pillemer) be investigated.
8. For these reasons, the Appeal Panel has determined that the MAC issued on 24 February 2025 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.

State of NSW (Western NSW Local Health District)

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act 1998.

The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor Tommasino Mastroianni and issues this new Medical Assessment Certificate as to the matters set out in the Table below:

Chapter, page and paragraph number in NSW workers compensation guidelines

Chapter, page, paragraph, figure and table numbers in AMA 5 Guides

Proportion of permanent impairment due to pre-existing injury, abnormality or condition

Sub-total/s % WPI (after any deductions in column 6)

Total % WPI (the Combined Table values of all sub-totals)