1 April 2025. 5. An Application to Resolve a Dispute (ARD) was lodged with the Personal Injury Commission (Commission) on 4 November 2025. The applicant claims future medical or related treatment expenses for right sympathetic nerve blocks at L3 and L4 and ongoing physiotherapy treatment. 6. The dispute was listed for conciliation conference and arbitration hearing on

1. The parties agree the following issues remain in dispute:

(a) whether the proposed right lumbar sympathetic nerve blocks at L3 and L4 is reasonably necessary medical treatment as a result of the right knee injury on

7 December 2023 pursuant to s 60 of the Workers Compensation Act 1987 (the 1987 Act), and

(b) whether further physiotherapy is reasonably necessary medical treatment for the right knee injury on 7 December 2023 pursuant to s 60 of the 1987 Act.

1. The parties appeared for conciliation conference and arbitration hearing on

29 January 2026 in Sydney. The applicant attended with her son Mr Alex Aneska.

Mr Stephen Hickey of counsel appeared for the applicant instructed by Ms Jia Guo, legal practitioner. Mr Jayden Kreig of counsel appeared for the respondent instructed by Ms Laura Francis, legal practitioner. Mr Cumerlato was also present. 2. During conciliation the respondent's Application to Lodge Additional Documents dated

23 January 2026 was admitted. 3. I am satisfied the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

1. The following documents were in evidence before the Commission and considered in making this determination:

(a) ARD and attached documents;

(b) Reply and attached documents, and

(c) respondent's Application to Lodge Additional Documents (ALAD) dated

23 January 2026 and attached documents.

1. No application was made to call oral evidence or to cross examine any witness.

1. The applicant relies on her statement signed on 16 September 2025.
2. She describes the heavy nature of her work for the respondent and her right knee injury on

7 December 2023 while walking up stairs from the loading dock at the respondent's premises to return keys to the office at the end of her shift. 3. The applicant drove home but found it hard to walk and her husband took her to the hospital's emergency department where she had an X-ray. As there were long delays the applicant arranged to have a right knee ultrasound carried out the following day. 4. Her treatment included an injection to her right knee on 18 December 2023, an MRI on

2 January 2024, treatment from her general practitioner Dr Don Nguyen and Dr Daniel Rahme, orthopaedic surgeon. An injection to her right knee on 5 March 2024 helped her pain a bit but then the pain came back. 5. The applicant had another right knee MRI on 14 May 2024 and Dr Rahme recommended surgery. The applicant had surgery on 1 July 2024 and physiotherapy treatment once or twice a week from Ms Tam following the surgery. She told Dr Rahme on 14 August 2024 she felt numbness around her right knee and she was given medication for it. 6. She continued to see Dr Don Nguyen who recommended she have a scan of her back to see whether any of the pain going down to her right knee was coming from her back. The applicant had a CT scan of her lower back on 26 September 2024 and an X-ray of her right knee. On 1 October 2024 she had an injection to her lower back however the pain to her right knee did not improve. 7. The applicant consulted Dr James Yu, pain specialist, on 15 October 2024. She completed a pain management program called REGAIN that involved her seeing a physiotherapist and a psychologist to teach her how to manage her pain. 8. Dr Yu examined her scans and recommended she have nerve block injections to her right lower back, explaining the back connects to the nerves down her right knee and the injection should help with her right knee pain. 9. The applicant continued to have physiotherapy treatment with Ms Pamela Fenianos from

19 November 2024 until 1 April 2025 when the insurer denied further treatment. As a result of not seeing a physiotherapist the applicant feels her right knee is getting worse and worse and there are more flare ups of pain. 10. She had an MRI of her back on 13 February 2025 and another right knee MRI on

21 February 2025. The applicant started seeing Dr Albert Nguyen from 25 March 2025 as she was not happy with Dr Don Nguyen. She started experiencing pain in her left knee in about April or May 2025 because she puts more weight on the left knee to manage pain in her right knee. 11. The applicant then describes the impact of the constant right knee pain for which she takes Panadol and Nurofen about three times a day. 12. She has not worked since she was injured and she was medically terminated on

Dr Evan Dryson, independent occupational physician

1. In his report of 22 July 2025 Dr Dryson diagnoses the applicant with a tear of degenerate medial meniscus of the right knee on a background of medial compartment osteoarthrosis and possible referred pain and numbness to the right knee from right L3 nerve root impingement.
2. Dr Dryson notes Dr Yu has raised the possibility of referred pain from the lumbar spine due to L3 nerve impingement, which is shown on the CT scan of the lumbar spine.
3. The cause of the applicant's injury was the episode on 7 December 2023 at work when the degenerate medial meniscus of her right knee was torn. The applicant is totally incapacitated for work.
4. Asked for his opinion on the proposed right sympathetic nerve block injections at L3 and L4, Dr Dryson comments that Dr Yu's provisional diagnosis is of referred pain to the right knee due to L3 nerve root compression and the purpose of the sympathetic nerve block would be to determine whether or not that is correct.
5. Although Dr Yu is right to raise such a possibility, Dr Dryson points out a tear of the medial meniscus was identified by Dr Rahme at surgery, consistent with the "pop" sensation the applicant felt at the time of the injury. Dr Dryson's opinion is her ongoing symptoms in the right knee are most likely due to the subject accident, consequential surgery and consequential aggravation of medial compartment osteoarthrosis. As such Dr Dryson says the lumbar sympathetic blocks are not directly related to the identified injury.
6. In Dr Dryson's opinion it would nevertheless certainly be useful to determine whether there is another cause for her right knee pain and as such he would support the nerve blocks. The nerve blocks are not related to the management of the work-related injury.
7. With respect to physiotherapy treatment, Dr Dryson's opinion is that physiotherapy is clearly an appropriate management technique for osteoarthrosis of the knee.
8. A physiotherapist will be able to prescribe and supervise an ongoing exercise program for the applicant and provide her with education in self-management. Dr Dryson notes that continued hands-on physiotherapy is usually considered not to be useful.
9. Dr Dryson points out that exercise physiology is also a suitable treatment modality and he understands the applicant has recently seen an exercise physiologist.
10. When asked to comment on Associate Professor Molloy's report of 14 April 2025, Dr Dryson agrees there is no indication of complex regional pain syndrome and says that it appears Associate Professor Molloy did not find any evidence of sympathetic nerve involvement hence his position that the right lumbar sympathetic nerve blocks are not reasonably necessary.
11. Dr Dryson notes he did not have the advantage of clinically examining the applicant and he is not in a position to state that there is a sympathetically mediated pain syndrome.
12. Dr Dryson continues to believe such blocks would be advantageous in further exploring the applicant's condition but he does not see how they relate to the subject accident which is a tear of the medial meniscus.
13. When asked to comment on Dr Leaver's report of 4 February 2025, Dr Dryson comments that Dr Leaver reasonably points out that previous physiotherapy has not resulted in symptomatic improvement, and the applicant requires a self-directed exercise and activity program.
14. Dr Dryson's opinion is such a program needs to be prescribed and supervised by either a physiotherapist or an exercise physiologist. There is a clear need for continued physiotherapy and/or exercise physiology but only for the purposes of prescribing and monitoring an exercise program.

1. Dr Rahme's reports between 24 February 2024 and 26 February 2025 are with the ARD.
2. Dr Rahme's opinion on 26 February 2024 is that the applicant's issue now is unfortunately chronic regional pain syndrome which she was developing prior to surgery. Her management should be primarily guided by her pain specialist and pain management team.
3. Dr Rahme reports on 12 April 2024 the applicant's right knee symptoms have improved modestly with the self-directed exercises. On 2 May 2024 Dr Rahme reports the symptoms have failed to improve and are worsening. The applicant is due to commence formal physiotherapy in the coming week.
4. In answer to questions put by the insurer Dr Rahme says on 28 May 2024 the applicant will require 8 to 12 weeks of physiotherapy twice a week post the proposed right knee surgery. There is an operation report from Dr Rahme to Dr Nguyen on the right knee arthroscopy on

1 July 2024. 5. On 17 July 2024 Dr Rahme reports the applicant can commence formal physiotherapy following the surgery, focusing on range of motion and strength. 6. Dr Rahme reports on 14 August 2024 the applicant has little improvement thus far post surgery, she complains of numbness around the knee which was not present previously, and she may be developing sympathetic dystrophy. He recommends review with her pain specialist for better management of her pain. 7. On 25 September 2024 Dr Rahme reports the applicant is complaining she is not receiving any hands-on physiotherapy. He explained to her that the mainstay of physiotherapy is to educate her on an exercise regime to perform at least once a day at home, although some sessions of hands-on physiotherapy may be helpful. Dr Rahme says soon thereafter there should be consideration of transition to an exercise physiology program. 8. Dr Rahme reports on 23 October 2024 he agrees with the pain specialist's recommendations for a multimodal approach to treat the applicant's pain syndrome and she will return for review once she has had the nerve blocks performed. 9. On 7 February 2025 Dr Rahme reports the pain has worsened over the last three months in keeping with poorly treated chronic regional pain syndrome (autonomic sympathetic dystrophy). Physiotherapy alone will be insufficient and Dr Rahme also requests approval of the sympathetic nerve block to manage her condition more effectively. 10. Dr Rahme in his report dated 26 February 2025 notes the MRI shows no significant changes to the applicant's right knee. Her issue now is unfortunately chronic regional pain syndrome which she was developing prior to surgery. Her management should primarily be guided by her pain specialist and pain management team. 11. In an undated report to the insurer Dr Rahme provides his opinion that the applicant feels she is not getting any hands-on physiotherapy and physiotherapy should be altered to include hands-on treatment and transition to exercise physiology. The applicant has had 8 to 10 post-surgery physiotherapy sessions and her pain or functional capacity has not improved in line with the treatment received.

1. In the first of five reports with the ARD, Dr Yu reports to Dr Rahme on 15 October 2024 that there is right knee neuropathic pain with signs of sympathetic nerve dysfunction. Dr Yu highly recommended the evidence based multidisciplinary pain management programme REGAIN run by a team including psychological, physical and medical components conducted in an integrated fashion over eight weeks for two full days a week.
2. Dr Yu intended to request approval for and book the applicant for a series of two right lumbar sympathetic nerve blocks at L3 and L4 for her right knee neuropathic pain with sympathetic nerve dysfunction. Dr Yu started the applicant on Amitriptyline.
3. Dr Yu reports to the insurer on 1 November 2024 on the proposed nerve blocks, noting the applicant's persistent pain and associated symptoms are likely coming from the lumbar sympathetic nerves which stem from the L3 and L4 and the proposed procedure is nothing to do with any lumbar issues. The aim of the procedure is to reduce the applicant's current right knee neuropathic pain with sympathetic nerve dysfunction.
4. Dr Yu's report to the insurer on 30 December 2024 clarifies that the nerves supplying the right knee roots back from lumbar sympathetic nerves at L3 and L4. By targeting the sympathetic nerves at L3 and L4 they expect to reduce the pain severity in the applicant's right knee along with associated right knee symptoms.
5. Asked on 30 December 2024 whether conservative treatment such as physiotherapy should be trialled before engaging in invasive treatment such as lumbar spine injections, Dr Yu says the applicant reported to him she had attended bi-weekly physiotherapy sessions and she has been scheduled to start with the REGAIN program on 14 January 2025 which includes an "active" physiotherapy component. She will also be prescribed with a home-based exercise program specifically related to her chronic pain condition.
6. Physiotherapy will play a vital role in the applicant's recovery however in Dr Yu's opinion a multi-modal approach would yield the best results for her chronic pain condition. The proposed nerve block is a minimally invasive day procedure, less invasive than radiofrequency ablation or spinal cord stimulation.
7. Dr Yu understands the applicant's accepted claim includes the right knee and not the lumbar spine. The nerves supplying the right knee roots back from lumbar sympathetic nerves at L3 and L4 and by targeting those sympathetic nerves they expect to reduce pain severity and associated symptoms in the right knee. There is a 60-70% success rate that the injection would help the knee pain and associated symptoms, however there is no guarantee the pain would completely resolve and the pain may recur. The procedure generally involves minimal risks. The recovery time is one to two days of rest before resuming normal day-to-day activities and exercises.
8. Dr Yu provides a medico legal report to the applicant's solicitors on 2 July 2025. Dr Yu sets out the complaints made by the applicant and the history obtained regarding her right knee, and he provides a diagnosis of the applicant's biological, psychological and socioeconomic conditions. The applicant had completed the REGAIN program by this time.
9. Dr Yu provides his opinion that the proposed right lumbar sympathetic nerve block at L3 and L4 is clinically indicated and considered reasonably necessary in the context of the applicant's ongoing work-related right knee pain. Following her injury on 7 December 2023 and subsequent right knee surgery on 1 July 2024 she continues to experience persistent right knee pain characterised by sharp, stabbing sensations, hypersensitivity, intermittent swelling, and warmth over the right knee. These features Dr Yu says are consistent with a diagnosis of neuropathic pain with signs of sympathetic nerve dysfunction.
10. Dr Yu opines the nerves supplying the right knee originate from the lumbar sympathetic chain, specifically at the L3 and L4 levels, therefore targeting these levels via lumbar sympathetic nerve blocks is a rational and anatomically appropriate intervention. The aim of the procedure is to interrupt the sympathetic supply contributing to her neuropathic pain and vasomotor instability.
11. Dr Yu says that although the applicant's symptoms are localised to the right knee, the underlying pathophysiology involves dysregulation of the sympathetic nervous system. The sympathetic nerve fibres that innervate the right lower limb including the knee originate from the lumbar sympathetic chain, particularly at the L3 and L4 levels. When dysregulated they can contribute to chronic pain syndromes characterised by sensory, vasomotor and motor changes as seen in this case. The goal is to interrupt this aberrant sympathetic outflow to the right lower extremity.
12. The treatment is not intended to address the intra-articular knee pathology per se, but rather the sympathetic-mediated component of the chronic pain that persists despite the treatment she has received.
13. Dr Yu acknowledges that while the procedure anatomically involves the lumbar region it is important to clarify that the intervention is not intended to treat a primary spinal pathology. The rationale for the treatment is based on the established anatomical relationship between these nerves and the sympathetic innervation of the right lower limb, including the knee.
14. While the procedural access is via the lumbar spine, Dr Yu says the therapeutic target remains the compensable site, the right knee, and the treatment is directed specifically at managing symptoms arising as a direct consequence of the accepted workplace injury.
15. This intervention forms part of a broader multimodal management plan that includes pharmacology, ongoing physiotherapy and multidisciplinary pain management program.
16. The proposed sympathetic nerve blocks are a clinically justified next step that may contribute meaningfully to the management of the applicant's compensable condition. They will specifically target the neuropathic component of the applicant's persistent right knee pain which has not responded to surgical intervention or conservative treatment.
17. Dr Yu addresses the criteria discussed in Diab v NRMA Ltd[1] in support of the proposed treatment being reasonably necessary as a result of the work-related injury.

1. Ms Fenianos reports on 3 April 2025 that the applicant had attended 20 physiotherapy sessions since 19 November 2024 after numerous sessions elsewhere.
2. In Ms Fenianos' opinion the applicant will require ongoing treatment due to the nature of her surgery and her ongoing pain.
3. Both her specialist and Ms Fenianos believe physiotherapy is one tool together with other pain management strategies that will help to manage the applicant's pain in the future.

1. A series of reports from Ms Tam between 2 June 2024 and 22 October 2024 are with the ARD. In her first report on 2 June 2024 Ms Tam says she would expect the applicant's symptoms to show some improvement after six to eight weeks of treatment and it may take at least four to five months or longer for symptoms to fully resolve. Her recovery may be slower due to the chronicity of pain.
2. On 14 June 2024 Ms Tam reports to Dr Nguyen that the applicant had attended sessions twice weekly since 29 May 2024 for treatment of her right knee pain. Ms Tam notes limited range of movement of the right knee due to severe pain, antalgic gait and mild swelling and warmth with significant tenderness. So far they have not seen signs of improvement which is to be expected given the severity of her injury and the chronicity of her pain.
3. Ms Tam describes post-operative treatment in her report of 9 August 2024. The applicant reported an increase in pain levels in her knee, an expected response at that time, however unfortunately the high pain levels made progressing rehabilitation challenging.
4. On 21 September 2024 Ms Tam reports on the applicant's constant global right knee pain and occasional anterior numbness as well as global tenderness and occasional mild swelling and warmth. While the applicant continues to experience ongoing high levels of right knee pain on occasion her pain levels have been slightly better. Ms Tam continues to expect extended recovery timeframes, and plans to continue twice weekly sessions for ongoing exercise-based rehabilitation with the aim to improve knee mobility, strength and walking tolerance.
5. Ms Tam's final report of 22 October 2024 includes similar physical assessment findings with ongoing high levels of pain in the post-operative period although the applicant has shown very small improvements in pain levels and knee mobility. Ongoing twice weekly sessions are planned and Ms Tam continues to expect extended recovery timeframes.

1. The right knee X-ray and ultrasound report on 8 December 2023 refers to a moderate sized suprapatellar bursal effusion, the suggestion of a partial thickness tear and ligament strain, and a soft tissue oedema along the medial aspect of the knee. An ultrasound guided aspiration of the right knee was conducted on 18 December 2023.
2. The right knee MRI report of 3 January 2024 concludes there is no acute injury, no medial meniscus tear but mucoid degeneration of the posterior horn of medical meniscus due to degenerative changes. A CT guided injection of the right knee was carried out on

5 March 2024. 3. The right knee MRI report of 14 May 2024 concludes there is a significant tear of the medial meniscus with joint effusion and associated capsular swelling. 4. A CT scan of the lumbar spine and sacroiliac joints was carried out on 26 September 2024. Findings include moderate to marked right L3/4 bony neural exit foraminal narrowing causing contact/impingement of the exiting L3 nerve root, contact/impingement of the exiting L5 nerve roots bilaterally and encroachment/impingement of the S1 nerve roots bilaterally. 5. A right knee X-ray was carried out on 26 September 2024 with the clinical notes referring to worsening pain after the right knee surgery and apparently with no significant findings. 6. A CT-guided right L3/4 transforaminal injection was carried out 1 October 2024. 7. A lumbar spine MRI report of 13 February 2025 refers to potentially significant foraminal narrowing between L3/L4 and L5/S1 as well as potentially significant subarticular narrowing at L4/L5 and L5/S1. 8. A right knee MRI report of 21 February 2025 includes that features of medial compartment osteoarthritis have mildly progressed since the prior study and there is significant swelling of the medial joint capsule which has increased since the previous study.

1. The consultation notes of UniquePhysio between 27 May 2024 and 15 November 2024, Sportsfizz Physiotherapy and Sports Injury Centre between 19 November 2024 and

10 February 2025, and Dr Albert Nguyen between 25 March 2025 and 9 June 2025 will be referred to where relevant.

1. The applicant presented to the Bankstown-Lidcome Hospital Emergency department on

7 December 2023 with right sided calf pain. She was discharged that day provided with Endone for pain relief and for general practitioner follow up. 2. The notes include that the applicant had experienced right back of knee and calf pain for two months which was not the result of trauma and "[t]oday whilst walking up stairs heard some popping in R knee. Since then pain has worsened to 15/10".[2]

1. On 23 May 2024 Dr Nguyen referred the applicant to Unique Physiotherapy for assistance in maintaining muscle strength and reducing her pain perioperatively, describing her as a cleaner who sustained a work related injury to her right knee with an acute tear of her right meniscal and effusion.

1. The respondent relies on the s 78 notices of 13 November 2024 and 1 April 2025 and the s 287A internal review notice of 22 August 2025.

Associate Professor Allan Molloy, independent anaesthetist and pain management specialist

1. Associate Professor Molloy provides a medico legal report dated 1 April 2025 in which he sets out a brief history of the applicant's injury, her treatment and the imaging. On examination of the applicant's knee there was tenderness and hypersensitivity and it felt warm to touch.
2. The diagnosis is made of chronic primary musculoskeletal pain, a chronic pain in the muscles, bones, joints or tendons that is characterised by significant emotional distress or functional disability.
3. The diagnosis is consistent with the mechanism of injury on 7 December 2023 in Associate Professor Molloy's opinion, and her employment with the respondent is the main contributing factor to her current symptoms. There were no current problems reported with her lumbar spine.
4. While he refers to her having a chronic pain syndrome, Associate Professor Molloy's opinion is that the series of two lumbar sympathetic nerve blocks at L3 and L4 proposed by Dr Yu are not reasonably necessary to treat the applicant's right knee symptoms as she has no evidence of sympathetically maintained pain as part of complex regional pain syndrome.
5. The percentage of success is minimal and the likely outcome is of no change. Other types of treatment such as hydrotherapy or exercise physiology are unlikely to be successful in resolving her symptoms.
6. Associate Professor Molloy's opinion is that the applicant has clearly not benefited from the REGAIN program and at this point she needs to be evaluated by a clinical psychologist or psychiatrist with expertise in pain management, and to be reassessed by a surgeon and by a multidisciplinary pain team.
7. In Associate Professor Molloy's opinion it may well be that that applicant has osteoarthritis in the knee with significant depression, anxiety and stress.
8. In his supplementary report dated 19 January 2026 Associate Professor Molloy confirms his view that the proposed lumbar sympathetic nerve block is not reasonably necessary.
9. Dr Yu is correct that sympathetically maintained pain can occur as a component of neuropathic pain, however in Associate Professor Molloy's view the applicant's knee pain is consistent with osteoarthritis and with the well described mechanical components and the findings on imaging.
10. Associate Professor Molloy comments that Dr Rahme notes the MRI has excluded new pathology and suggests slight progression of her medial compartment chondropathy.

Dr Rahme notes the applicant has chronic regional pain syndrome which is different to complex regional pain syndrome. 11. The chance of a causal connection between the proposed lumbar sympathetic nerve block and the ongoing right knee symptoms is very low and he does not recommend the proposed treatment as a result of the work-related knee injury. 12. Regarding ongoing physiotherapy, Associate Professor Molloy's opinion is it is not reasonably necessary. The REGAIN program does not seem to have been successful. It is reasonably necessary the applicant be reviewed by a clinical psychologist and a psychiatrist with specific expertise in pain medicine and trauma-related conditions as this is a chronic pain syndrome and her modifiable psychosocial factors need to be optimised. 13. The applicant has a chronic pain syndrome with significant distress and disability which means that all treatments that have been trialled have failed. This failure is likely with both the proposed lumbar sympathetic nerve blocks and any ongoing physiotherapy in Associate Professor Molloy's view. 14. A new MRI of the knee is essential to exclude any new pathology or identify any progression of previously identified pathology and treatments at this stage should focus on self-management and simple analgesics.

1. Dr Leaver reports to the respondent's insurer on 4 February 2025 that there is insufficient information to determine whether further physiotherapy treatment is reasonably necessary and he recommends request for further physiotherapy treatment be declined.
2. The applicant has made poor progress with recovery more than 12 months after the accident Dr Leaver says. She had approximately 45 sessions with Unique Physiotherapy and commenced with Ms Fenianos in November 2024. Unchanged goals suggest non-attainment.
3. File information indicates the applicant has made poor progress with post-operative recovery. The treatment after November 2024 in Dr Leaver's view does not appear to be substantially different to past treatment and is likely to have the same poor results.
4. A comprehensive plan for management of knee osteoarthritis is required that involves weight loss and a self-directed exercise and activity program, and she might also benefit from specialised pain management treatment. The multidisciplinary pain management program recommended by Dr Yu might be a good alternative.
5. In his file review dated 12 January 2026, Mr Leaver broadly agrees with Dr Dryson particularly in relation to the limited value of further hands-on physiotherapy treatment. His only point of distinction with Dr Dryson is that he would suggest either physiotherapy or exercise physiology but not both concurrently. The focus should be on a structured, self-directed exercise program with appropriate oversight.
6. Ongoing physiotherapy treatment is not reasonably necessary as a result of the right knee injury and two more appropriate alternative approaches are available; a revised treatment plan by a physiotherapist or exercise physiologist which focuses on functional restoration and encourages self-directed activity and independence and that demonstrates a clear departure from previously ineffective interventions, or a multidisciplinary pain management program.

1. Dr Albert Nguyen's report to the respondent's insurer of 6 November 2025 includes diagnoses of right knee meniscal tear, chronic pain, joint pain, neuropathic pain, sympathetic nerve dysfunction and depression.
2. In Dr Nguyen's opinion further treatment is required and hydrotherapy or gentle exercise physiology could be trialled post further assessment for supportive rehabilitation, with a frequency of two to three sessions per week for 8 to 12 weeks, adjusted based on response.

1. In a report dated 25 September 2025 Mr Ryan Beetson, exercise physiologist, concludes the applicant has not been able to increase her capacity from participation in exercise physiology session.
2. Exercise physiology treatment commenced on 10 July 2025 for home-based sessions. The goal of rehabilitation was to provide self-management techniques and improve the applicant's overall functional capacity for work-related activities to seek new employment.
3. The file was closed due to pain flaring up and the applicant's ability to self-manage going forward. The applicant's demonstrated good engagement and compliance with supervised treatment and independent exercises resulted in nil improvements in her pain. She has shown some improvements in her functional tolerances, however she is still restricted in everyday activities such as walking, climbing the stairs and she is unable to drive.
4. Mr Beetson recommends the applicant continue independently so that progress is maintained, and she continue to see the psychologist for pain management strategies.

1. The applicant made oral submissions which have been recorded and form part of the Commission's record. These are set out below.
2. Applicant's counsel referred to the applicant's statement that sets out the details of her injury and its treatment. The treatment she has received to date has not relieved her chronic pain and she has chronic regional pain syndrome and a neuropathic pain that has developed.
3. Attention was drawn to the treatment the applicant has received to date, including an ultrasound on her right knee on 8 December 2023, an injection to her right knee on

18 December 2023, an MRI on 2 January 2024 and she goes on to detail her treatment from Dr Don Nguyen and Dr Rahme. 4. She progresses to have surgery on 1 July 2024 and Dr Rahme told her to restart formal physiotherapy to help with pain and getting more movement back into her right knee. She attended the physiotherapist Sabrina Tam once or twice a week. On noticing numbness around her knee she was given medication for it by Dr Rahme. 5. The applicant continued consulting Dr Nguyen and eventually he recommended a scan of her back to see if there was some pain emanating from there going down to her knee. After a CT scan of the lower back and an X-ray of the right knee on 26 September 2024 she is referred to have an injection to the lower back. The right knee pain did not improve. 6. She is referred to Dr Yu, pain specialist, who proposes the sympathetic nerve block injections. Dr Yu told her to do the REGAIN pain management program, approved by the insurer, which she says she has completed. 7. Dr Leaver also supports this REGAIN multidisciplinary pain management program recommended by Dr Yu as a comprehensive and coordinated alternative. This is particularly appropriate given the applicant's limited progress with physical treatment to date, high levels of psychosocial distress, and complex pain presentation. 8. The applicant has commented in her history that the REGAIN program did not provide any relief. 9. Associate Professor Molloy notes the treatment to date of ultrasound guided aspiration of the right knee joint effusion on 18 December 20233, approximately 46 physiotherapy sessions between two different practices, and notes the REGAIN program finished on 5 March 2025 and reviewed on 1 April 2025 with no outcomes provided. The applicant describes the program as being like a conversation about how to manage the pain. The plan was to have the nerve blocks before the program and then do the program but that did not happen. The case manager said she was concerned the applicant might get back pain problems from the injections. 10. The applicant has undertaken the REGAIN program, the outcome is of no real improvement and the applicant still has chronic pain. 11. Dr Yu describes this as chronic regional pain syndrome, whereas Dr Leaver, physiotherapist, describes it as complex pain presentation, and Associate Professor Molloy describes it as severe chronic pain syndrome. 12. Associate Professor Molloy says the series of two right lumbar sympathetic nerve blocs at L3 and L4 injections proposed by Dr Yu are not reasonably necessary to treat the right knee injury symptoms as the applicant has no evidence of sympathetically maintained pain as part of complex regional pain syndrome. 13. Dr Yu having seen the applicant in 2024 describes the pain syndrome a little differently. These sympathetic nerves modulate vascular tone, temperature regulation and pain sensitivity in the periphery. When dysregulated they can contribute to chronic pain syndrome characterised by sensory, vasomotor, and motor changes as seen in this case. 14. Dr Yu's premise is that the proposed nerve blocks at the L3 and L4 levels of the lumbar spine are specifically targeted to address the applicant's ongoing right knee neuropathic pain, not in order to rectify the physical pathology such as osteoarthritis or meniscal issues and inflammation, it is to treat the neuropathic pain that as a pain specialist he has determined exists. This presents Dr Yu says with features of sympathetic nerve dysfunction - namely hypersensitivity, intermittent swelling, temperature asymmetry and stiffness. 15. Dr Yu has not identified all of the components that would justify a complex regional pain syndrome diagnosis. He has identified sufficient components to in his view confirm a chronic pain syndrome characterised by some of those components. 16. The applicant has had surgery, multiple MRI scans on her right knee and lumbar spine, and physiotherapy from Ms Tam then changing to Pamela Fenianos who she last saw in April 2025. Ms Fenianos recommended she continue physiotherapy alongside other treatments to treat her pain but the insurer denied physiotherapy. She wants to have it and she feels she was making progress with Ms Fenianos. Now the applicant observes her right knee is getting worse and worse and there are more instances of flare ups. 17. Ms Fenianos confirms the applicant had attended 20 sessions since 19 November 2024 and that physiotherapy is one tool together with other pain management strategies. Due to the nature of the applicant's surgery she will have ongoing pain which will require ongoing treatment in her opinion. Both the specialist and Ms Fenianos believe physiotherapy is one tool together with other pain management strategies that will help to manage her pain in the future. Unfortunately the request was not approved. This decision has impacted on the applicant's ability to receive the recommended care for an optimal recovery outcome in

Ms Fenianos' view. 18. Dr Leaver notes that despite post-operative physiotherapy the treating surgeon noted little improvement by September 2024 and the applicant reported dissatisfaction with care. 19. Psychosocial barriers were identified by Dr Leaver (for example anxiety, catastrophising, fear avoidance, obesity), contributing to limited functional improvement. The treating physiotherapist requested an additional 24 physiotherapy sessions with unchanged goals and approaches from prior plans (regular passive treatments), indicating likely treatment failure in Dr Leaver's view. 20. The applicant submits this is not entirely consistent with Ms Fenianos' view that her treatment regime physiotherapy was seen as necessary in conjunction with other pain management strategies. 21. Dr Leaver says the treatment approach described in the most recent allied recovery request did not represent a meaningful change from previous treatment, and again Ms Fenianos says it is necessary to have the physiotherapy in conjunction with specialist pain management.

Ms Fenianos says she and the applicant's specialist agree it is one tool with other pain management strategies to improve her ongoing pain. 22. Dr Leaver recommends the proposed physiotherapy was not reasonably necessary based on the lack of evidence of benefit, lack of progression, and absence of provider engagement. He suggests an appropriate physiotherapy program would include training in self-directed exercise and activity program alongside weight loss and broader osteoarthritis self-management education. He suggests Dr Yu's recommended multidisciplinary pain management program was a reasonable alternative. 23. Dr Leaver is broadly supportive of the applicant's claim, and he is also broadly supportive of Dr Dryson's opinion particularly of the limited value of further hands-on physiotherapy treatment. 24. It is not featured in the consideration, at least expressly, as to whether ongoing physiotherapy would assist in the applicant's improvement of fitness and bodily functioning. 25. Dr Leaver says Dr Dryson concurs that the applicant has undergone a substantial course of physiotherapy with minimal progress and further sessions of the same nature are unlikely to offer meaningful benefit. The applicant herself has identified that in her statement and changed physiotherapists for that reason. 26. Dr Leaver says one point of distinction with Dr Dryson is that he considers both physiotherapy and exercise physiology to be appropriate and Dr Leaver suggests either could be reasonable but not both concurrently. The focus should be on a structured, self-directed exercise program with appropriate oversight from a single allied health provider to minimise duplication. This is also what the applicant wishes for, physiotherapy treatment as part of pain management. 27. Dr Leaver's report dated 12 January 2026 is a little at odds with Dr Yu's view that it is necessary to have a regime of pain management under his direction and not the applicant's self-direction, although obviously the applicant cannot administer the blocks he wishes to perform. 28. Dr Leaver's opinion is that the ongoing physiotherapy proposed by Ms Fenianos is not reasonably necessary as a result of the work-related right knee injury. He discusses a revised treatment plan that focuses on functional restoration, encourages self-directed activity and independence, addresses psychosocial barriers, and demonstrates a clear departure from previously ineffective interventions. 29. The applicant says she was benefitting from physiotherapy from Ms Fenianos and wishes it to be maintained. 30. Associate Professor Molloy says Dr Yu is correct that sympathetically maintained pain can occur as a component of neuropathic pain but the applicant's knee pain is consistent with osteoarthritis, with well described mechanical components and the findings on imaging. 31. If you accept Dr Yu, it has progressed to a further dimension of neuropathic pain and sympathetically maintained. Dr Yu describes why he needs to perform the L3 and L4 sympathetic lumbar nerve block injections, not to treat the physiology of the knee but the further condition that is a neuropathic progression. 32. Associate Professor Molloy does not directly address that but seems to maintain this is not reasonably necessary because the blocks will not treat the physical condition. 33. Dr Rahme notes the recent MRI excludes new pathology, the report suggested slight progression of her medial compartment chondropathy and he notes she has chronic regional pain syndrome which is different to complex regional pain syndrome. 34. The applicant submits this does not matter as there are components of regional pain syndrome found by Dr Yu that he wishes to control. 35. Associate Professor Molloy also says in his opinion the chance of a causal connection between the proposed lumbar sympathetic nerve block and the ongoing right knee symptoms is very low. It is not clear what he means by that. 36. All treatments that have been tried have failed Associate Professor Molloy says, and this will be the same with the lumbar sympathetic blocks and ongoing physiotherapy. This is a chronic pain syndrome and her modifiable psychosocial factors need to be optimised. 37. The recommendation is to focus on self-management and simple analgesics, and that is what is happening right now and it is not working. The applicant in her statement says she is currently taking Panadol and Nurofen about three times a day to manage her pain and she describes her symptoms. 38. Dr Yu's opinion on the proposed treatment should be accepted. He takes a detailed approach to the applicant's history, injury and treatment of her symptoms. 39. Dr Yu says in his report dated 2 July 2025 the nerve blocks are clinically indicated and considered reasonably necessary in the context of the ongoing right knee pain. Her symptoms are consistent with a diagnosis of neuropathic pain with signs of sympathetic nerve dysfunction of the right knee. Dr Yu also notes physical deconditioning secondary to reduced physical activity mixed with fear avoidance. She has completed the multidisciplinary pain management program. 40. Dr Yu recommends the right lumbar sympathetic nerve blocks and L3 and L4 to further address the sympathetically mediated neuropathic pain in the applicant's right knee as clinically indicated and considered reasonably necessary. He describes her symptoms as consistent with right neuropathic pain with signs of sympathetic nerve dysfunction. He then explains the nerves supplying the right knee originate from the lumbar sympathetic chain, specifically the L3 and L4 levels. 41. That is why targeting those levels with the blocks aims to reduce pain severity and the associated symptoms. 42. It is minimally invasive treatment and forms part of a broader multimodal management plan that includes pharmacology, ongoing physiotherapy and multidisciplinary pain management. The intent is to reduce the overall pain burden, improve functional capacity and facilitate her eventual progression towards reconditioning and return to meaningful activity including occupational duties. The intention is to include the physiotherapy with the blocks as part of the multidisciplinary pain management program. 43. Dr Yu notes the applicant's inadequate response to previous conservative measures and her significant physical and psychological impairment. The proposed sympathetic blocks are a clinically justified next step to manage her compensable condition. 44. The 60% to 70% response rate is considered clinically meaningful, and in terms of effectiveness Dr Yu says sympathetic nerve blocks are supported by clinical literature and specialist guidelines. 45. Dr Yu considers the blocks as necessary, explains in distinction from Associate Professor Molloy why they are designed to treat the neuropathic sympathetic response to the injury, and it is his speciality, noting Associate Professor Molloy is also a pain management specialist. Dr Yu does actually outline specifically why he considers they will have some measure of success in a lady that to date has not improved with the significant treatment that has been carried out. 46. Dr Yu explains when the nerve response is dysregulated they can contribute to chronic pain syndrome characterised by vasomotor and motor changes as seen in this case. By administering the blocks the goal is to interrupt this aberrant sympathetic outflow to the right lower extremity. This can help reduce pain intensity, alleviate temperature asymmetry and swelling, and improve sensory thresholds in the knee. 47. The lumbar approach is therefore anatomically and clinically appropriate as it directly targets the source of the sympathetic contribution to the right knee pain. 48. Dr Yu explains why the approach is to the lumbar to control the pain issues. It forms part of the broader multimodal strategy aimed at reducing neuropathic symptoms, improving function and facilitating recovery. 49. His earlier reports confirm this view, although attention was drawn to Dr Yu's report to the insurer of 30 December 2024 where he says there is no guarantee the pain would completely resolve post injections and her pain may recur. A multi-modal pain management approach would yield the best results with the proposed interventional treatment, pharmacotherapy and multidisciplinary pain management. It is a simple day procedure with minimal risk of infection. 50. The applicant's submission is that on all the evidence the applicant has attempted to improve on treatment, and she has self-assessed that the earlier physiotherapy was not effective and she wishes to have the new physiotherapist who was effective. That is to be seen in the evidence from Dr Yu proposing multi-disciplinary treatment including physiotherapy. 51. Under s 60(5) you would determine on the principles expressed in Diab, Rose v Health Commission (NSW),[3] and Bartolo v Western Sydney Area Health Service[4] that the proposed treatment is reasonably necessary in terms of the two sets of L3 and L4 sympathetic nerve injections and incidental costs thereto, and that the applicant is entitled to a regime of ongoing physiotherapy that is reasonably necessary and ought be ordered in those broad terms on a declaratory basis, as a result of the injury the subject of the claim.

1. The respondent made oral submissions which have been recorded and form part of the Commission's record. These are set out below.
2. The respondent notes the CT guided right L3/4 transforaminal injection on 1 October 2024 of dexamethasone and Marcain. There is evidence the injection into the L3/L4 area did not work. There is no evidence as to why the sympathetic nerve block at L3 and L4 will work and the respondent's submission is that would be somewhat fatal to the applicant's case.
3. Dr Yu is well aware of this injection as it is referred in his report of 2 July 2025 but he does not give any opinion as to why the proposed treatment to the sympathetic nerve will work despite previous treatment in the same area not working.
4. In relation to the proposed blocks, you would find they are not reasonably necessary as a result of the right knee injury.
5. First, the applicant's own expert does not support the treatment arises from the injury.

Dr Dryson says the applicant's present symptoms result from the knee pathology rather than any nerve issues associated with the lumbar spine. 6. Commenting on Dr Yu's proposed treatment, Dr Dryson points out that a tear of the medial meniscus was identified at surgery by Dr Rahme. It is Dr Dryson's opinion that the ongoing symptoms in the right knee are most likely to be due to the subject accident, consequential surgery and consequential aggravation of the medial compartment osteoarthritis. 7. There is quite a significant contest between the applicant's treating pain specialist and the applicant's expert Dr Dryson on the cause of the current issues, the sympathetic nerve issue or what Dr Dryson says which is entirely different. 8. Dr Dryson says the lumbar sympathetic blocks are not directly related to the identified injury. 9. Dr Dryson says it would be useful to determine this and there may be another cause but what he is saying is effectively not for work-related tear of the medial meniscus. The nerve blocks are not related to the management of the work-related injury, which is the applicant's case. 10. Dr Dryson, who is an expert occupational physician, then says he does not consider there are actually any signs of sympathetic pain syndrome requiring nerve blocks. I prefer Dr Yu's opinion on this issue however as his speciality is pain management and as the treating specialist he has reviewed the applicant and the investigations more regularly. 11. Dr Dryson comments on Associate Professor Molloy's report. Dr Dryson notes Associate Professor Molloy states there is no evidence of sympathetically maintained pain as part of a complex regional pain syndrome, there is no indication here of a complex regional pain syndrome, and Dr Dryson agrees with him. 12. Dr Dryson did not have the benefit of actually examining the applicant face to face and he cannot categorically state one way or another, but he cannot see an indication that this sympathetic nerve syndrome exists. 13. That is entirely consistent with Associate Professor Molloy's opinion, and he has most recently examined the applicant. The applicant's own expert disagrees that the proposed treatment results from the accepted knee injury. 14. Second, Dr Yu has not fully explained how the need for this treatment does result from the right knee injury. 15. Dr Yu describes the applicant's condition as being consistent with sympathetic nerve dysfunction. The applicant made reference to some material saying some refer to chronic regional pain and some refer to complex pain syndrome, but the respondent says that is a red herring. 16. Dr Yu says the applicant's clinical presentation is characterised by neuropathic pain, hypersensitivity, temperature asymmetry, and intermittent swelling consistent with sympathetic nerve dysfunction. He goes on to say the sympathetic nerve dysfunction is caused by issues with the fibres supplying the right knee that originate from the lumbar sympathetic nerve chain, particularly the L3 and L4 level. In essence what he is saying is there is this sympathetic nerve dysfunction and it is caused by this dysfunction on these nerve roots from the L3 and L4. 17. Dr Yu goes on to say the proposed nerve block is targeted at alleviating the symptoms of the sympathetic nerve disrupt into the right knee from that L3/L4 area. 18. What Dr Yu does not say is how the dysfunction or the dysregulation of the lumbar sympathetic nerve chain actually came to be. We do not have any opinion that suggests the right knee injury has in some way caused the nerve path to become problematic, or that as a consequence of the knee injury there is now this dysregulation or dysfunction in this nerve root. 19. We do not know why there is a dysfunction of the sympathetic nerve, and in the absence of any evidence in that regard the respondent submits the applicant cannot establish the sympathetic nerve blocks are treatment that results from the accepted right knee injury. 20. The third reason why you would find in the respondent's favour on the nerve blocks is that if you accept the overwhelming evidence in support of there not being a sympathetic pain condition then you are very likely to accept Associate Professor Molloy's opinion that all these nerve blocks address a problem that does not exist and so there is no need to address the problem. 21. In relation to physiotherapy, you would not accept that is reasonably necessary treatment notwithstanding what the applicant says in her statement that she has obtained a benefit from physiotherapy. 22. That assertion is not accurate and when you try to reconcile that with the records of the physiotherapist you actually see that the applicant had no benefit whatsoever. 23. The starting point is that the applicant saw two physiotherapists between 24 July 2024 and April 2025, so nearly 12 months of two sessions a week. The UniquePhysio records show the manual portion of the physiotherapy, the soft tissue work for example, was discontinued in August 2024 because it was ineffective. 24. Ms Tam in her report of 9 August 2024 refers to gentle manual therapy in the post-operative period for swelling and pain management which has been ineffective. The plan is to continue physiotherapy for two sessions per week for ongoing exercised-based rehabilitation, so not the manual therapy or soft tissue massage because it is not giving any benefit. 25. There were some further sessions and Ms Tam's report of 22 October 2024 includes that the manual therapy element of the physiotherapy was re-introduced, soft tissue work and scar massage of the knee in session, however this has so far had no significant changes in her recovery. 26. There is consistent reporting that the manual therapy element of physiotherapy is having absolutely no impact and demonstrating no improvement in the applicant's condition. 27. The plan in that report is to continue with two sessions a week but just looking at ongoing exercise-based rehabilitation and not manual therapy element. 28. The applicant says in her statement she was not content with that treatment, the fact that there was no hands-on therapy despite the reported lack of improvement from it, and so in about November 2024 we see the applicant changes over to Ms Fenianos. 29. These records show the manual element of physiotherapy is having no effect. It does not appear there was any real treatment in the first session on 19 November 2024, but on

22 November 2024 there was soft tissue massage and ice and Compex (designed to stimulate healthy muscles to improve muscle performance), stretching and range of movement exercises and quad strengthening exercises. 30. The session on 25 November 2024 records no improvement in symptoms and treatment includes soft tissue massage. On 6 December 2024 there is no improvement recorded. Throughout the records despite the soft tissue massage there is consistent reporting of nil improvement in the applicant's knee. By mid-December there is no changes in the range of motion despite the manual therapy and the exercise based therapy. That is consistent throughout December and into early January 2025. 31. On 24 January 2025 it is recorded that pain and weakness remained unchanged and at that consultation soft tissue massage seems to not have been undertaken. 32. There is consistent reporting by the physiotherapist that there is no improvement in pain or range of motion resulting from these two sessions a week. 33. Contrary to what the applicant says in her statement that she was receiving benefit from these sessions that is not made good by what is reported by the physiotherapist. 34. The second reason why you would not find in favour of the applicant in relation to ongoing physiotherapy as reasonably necessary is that the applicant is presently receiving exercise physiology and so there is simply no need. 35. The Healthivia report says that from 10 July 2025 to 10 September 2025 there was a total of eight sessions during that period. There is a summary of treatment. Under the subheading Work Capacity there is a comparison of initial tolerances and program completion tolerance and there is improvement in almost all of the tolerances. There is an increase for example in lifting of 5 kg for 10 repetitions to 5kg for 18 repetitions, and similarly for above shoulder lifting and carrying. There is increased function in pushing but not in pulling. Postural tolerances have remained the same. 36. The exercise based program actually did improve some of these functions, and the respondent submits this is the first time they actually start to see any sort of functional improvement, which is from the exercise physiology. 37. The second thing about this report is that following a discussion with the insurer it was agreed that the file be closed partly due to pain flaring up and also due to the applicant's ability to self-manage. 38. The respondent submits there is an exercise physiology program presently being funded by the respondent's insurer but ultimately the evidence shows the improvement comes from exercise physiology. 39. Physiotherapy would just be duplication as the applicant is receiving the same sort of exercise based treatment just from different providers. There is no reason then to make an award declaring physiotherapy is reasonably necessary. In cases like Diab or Bartolo the availability of a reasonable alternative mitigates against a finding of the treatment being reasonably necessary. 40. The third point is that the most recent report from the general practitioner Dr Albert Nguyen includes that the applicant requires further treatment to address her multifaceted pain and functional limitations which includes new imaging of the right knee to assess progression of osteoarthritis and capsular swelling, a second orthopaedic opinion, the referral to a multidisciplinary team and support from a psychologist or psychiatrist. Hydrotherapy or gentle exercise physiology could be trialled, but what is not here is physiotherapy. The respondent submits this is because the doctor has recommended exercise physiology which is presently being provided. 41. Section 60(5) does not give the Commission the power to make a declaration about future treatment carte blanche the respondent submits. There is no evidence as to the exact extent of the physiotherapy being sought, for example there is no opinion that there should be two sessions or one per week, and in those circumstances an order cannot be made for ongoing physiotherapy because there is no evidence about what kind of physiotherapy regime would be declared as reasonably necessary.

1. The applicant submits Dr Dryson appears to have taken the view that Dr Yu wishes to carry out the L3 and L4 blocks because he raised the possibility that the right knee pain arises from referred pain from the lumbar spine due to L3 nerve root impingement.
2. Dr Dryson refers to the CT of the lumbar spine that showed moderate to marked right L3/4 bony neural exit foraminal narrowing causing contact/impingement of the exiting right L3 nerve root, and he then seems to reinforce what he understands Dr Yu's motivation for the nerve block proposed. Dr Dryson includes the diagnosis of possible referred pain and numbness to the right knee from right L3 nerve root impingement.
3. The applicant submits that this is not evident from reading the report from Dr Yu.
4. In Dr Yu's report of 15 October 2024 he records the CT lumbosacral of 26 September 2024 and there was contact/impingement of exiting right L3 nerve root, but there is no view expressed by Dr Yu in that report that the nerve blocks are required to test the referred pain which Dr Dryson seems to say Dr Yu considered was a cause of the pain into the knee.
5. Dr Dryson seems to be inferring something that is not the intent of Dr Yu. Dr Yu says there is right knee neuropathic pain with sympathetic nerve dysfunction and he will book her in for a series of two right lumbar sympathetic nerve blocks. He does not say he will do the blocks to test whether she is getting referred pain from the L3 nerve root.
6. Dr Dryson says he has not had the advantage of clinically examining the applicant and he is not in a position to say there is a sympathetically mediated pain syndrome, but he continues to believe that such blocks would be advantageous in further exploring her condition but he does not see how they relate to the tear of the medial meniscus.
7. The applicant submits Dr Dryson is taking a stance that Dr Yu is really testing a pain path from L3 nerve irritation due to lumbosacral injury at that level and it is clear from Dr Yu's opinion that he is testing for a neuropathic sympathetic nerve response, not a discrete radiculopathy.

Are the proposed sympathetic nerve blocks at L3 and L4 reasonably necessary medical treatment as a result of the right knee injury on 7 December 2023

1. Section 60 of the 1987 Act provides that if as a result of an injury it is reasonably necessary that a worker receives any medical or related treatment or any hospital treatment the employer is liable to pay the cost of that treatment or service.
2. Section 60(5) of the 1987 Act includes that the jurisdiction of the Commission with respect to a dispute about compensation payable under this section extends to a dispute concerning any proposed treatment or service and the compensation that will be payable under this section in respect of any such proposed treatment or service.
3. While the essential question remains whether the treatment is reasonably necessary, the relevant matters to consider, according to the criteria of reasonableness of the proposed treatment discussed in Rose and set out in Diab, are;

(a) the appropriateness of the particular treatment;

(b) the availability of alternative treatment, and its potential effectiveness;

(c) the cost of the treatment;

(d) the actual or potential effectiveness of the treatment, and

(e) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.

1. In Murphy v Allity Roche DP stated an injured worker has to establish, applying the commonsense test of causation in Kooragang,[5] that the treatment being considered is reasonably necessary as a result of the injury, that is, that the injury materially contributed to the need for the treatment_.[6]_
2. The respondent accepts liability for the applicant's right knee injury on 7 December 2023. The nature of her right knee injury was confirmed as a medial meniscal tear following surgery. It is uncontentious that this occurred on a background of medial compartment osteoarthrosis as described by Dr Dryson.
3. The applicant has had extensive treatment for her right knee injury. She relies on painkilling medications, she has had three right knee MRIs, an aspiration of the right knee, two CT-guided injections and surgery on 1 July 2024.
4. Dr Nguyen arranged a CT scan of her lumbar spine to see if the right knee pain was referred pain from her lumbar spine. The applicant had a lumbar spine CT scan in September 2024, an injection into her lumbar spine at L3/4 followed by an MRI on 13 February 2025.
5. She has completed the REGAIN program, she has had approximately 46 sessions of physiotherapy, and most recently she has received treatment from an exercise physiology.
6. The applicant's right knee pain and symptoms persist.
7. Dr Rahme diagnoses the applicant with chronic regional pain syndrome as a result of her right knee injury, and says her management should be primarily guided by her pain specialist and pain management team.
8. Dr Yu describes the applicant's persistent pain as being characterised by sharp, stabbing sensations, hypersensitivity, intermittent swelling, and warmth over the right knee, features Dr Yu says are consistent with a diagnosis of neuropathic pain with signs of sympathetic nerve dysfunction.
9. As part of a broader multimodal management plan Dr Yu recommends the applicant has two right lumbar sympathetic nerve blocks to investigate whether her persistent knee pain results from damage to the sympathetic nerve with its roots in L3 and L4.
10. I do not agree with the respondent's submission that Dr Yu has not fully explained how the proposed treatment results from the right knee injury. Dr Yu states the applicant's pain, consistent with neuropathic pain with signs of sympathetic nerve dysfunction, followed her right knee injury on 7 December 2023 and the surgery on 1 July 2024.
11. Dr Yu describes the aim of the procedure as to interrupt the sympathetic supply contributing to her neuropathic pain and vasomotor instability. The proposed treatment aims to reduce the applicant's right knee neuropathic pain with sympathetic nerve dysfunction by targeting the lumbar sympathetic nerves which stem from the L3 and L4, which is likely where the pain and associated symptoms are coming from. The therapeutic target remains the right knee. This is a rational and anatomically appropriate intervention in his opinion.
12. I accept Dr Yu's opinion and find the proposed treatment is reasonably necessary as a result of the injury, and that the applicant's right knee injury materially contributed to the need for the proposed right lumbar sympathetic nerve blocks at L3 and L4.
13. Associate Professor Molloy agrees with Dr Yu that sympathetically maintained pain can occur as a component of neuropathic pain, however he finds no evidence of sympathetically maintained pain as part of complex regional pain syndrome.
14. There is no evidence that the applicant has complex regional pain syndrome, although the applicant submits she has components of regional pain syndrome that Dr Yu wishes to control, and there is also no evidence that sympathetically maintained pain may only occur as part of complex regional pain syndrome.
15. In Associate Professor Molloy's view the applicant's knee pain is consistent with osteoarthritis and with the well described mechanical components and the findings on imaging. The diagnosis is made of chronic primary musculoskeletal pain.
16. I am not persuaded by that view however. The right knee MRI in February 2025 shows only mild progression of her osteoarthritis. The applicant has had two injections into her right knee, an aspiration and surgery, all of which afforded her no relief.
17. I accept the applicant's submission that she has progressed to a further dimension of neuropathic pain and sympathetically maintained pain on the basis of Dr Yu's opinion, and I do not accept Associate Professor Molloy's opinion that the nerve blocks will address a problem that does not exist.
18. Associate Professor Molloy's opinion is that the chance of a causal connection between the proposed lumbar sympathetic nerve block and the ongoing right knee symptoms is very low. As the applicant submits it is not clear what is meant by this, and at the least a possible causal connection may be inferred.
19. I accept Dr Yu's opinion that there is a causal connection between the right knee pain and symptoms and the treatment he proposes.
20. Dr Rahme agrees with Dr Yu's approach and supports the request made for approval of the sympathetic nerve block to manage the applicant's right knee condition more effectively.
21. Dr Dryson was not in a position to state the applicant has sympathetically mediated pain syndrome as he did not clinically examine her.
22. Dr Dryson provides his opinion on the basis that the proposed right sympathetic nerve block injections at L3 and L4 are to determine whether there is referred pain from the lumbar spine due to L3 nerve root compression.
23. I accept the applicant's submission that this appears to infer something that does not accord with Dr Yu's opinion. I do not place weight on Dr Dryson's opinion that the proposed treatment is not related to the management of the work-related injury as a result.
24. Dr Yu states the proposed blocks are not to treat lumbar issues but are aimed at reducing pain in the applicant's right knee.
25. Although it has been investigated, the evidence indicates the applicant does not have referred pain from the lumbar spine. She had a lumbar spine CT scan in September 2024 that shows contact/impingement of the exiting L3 and L5 nerve roots and encroachment of the S1 nerve roots. She had a CT-guided right L3/4 transforaminal injection of dexamethasone mixed with Marcain on 1 October 2024. The applicant's statement evidence is that the pain to her right knee did not improve.
26. The MRI lumbar spine report of 13 February 2025 found potentially significant foraminal narrowing between L3/L4 and L5/S1 as well as potentially significant subarticular narrowing at L4/L5 and L5/S1, and advised clinical correlation. In April 2025 Associate Professor Molloy takes a history that the applicant's pain is just in the knee and there is no back pain.
27. Associate Professor Molloy's view is that a right knee MRI is essential to exclude any new pathology or identify progression of pathology, and at this stage treatment should focus on self-management and analgesics.
28. The evidence indicates this approach taken over the last two years has failed to address the applicant's right knee symptoms. Dr Yu notes the lack of meaningful response to conservative measures. Associate Professor Molloy accepts that all treatments tried to date have failed.[7]
29. The potential effectiveness of any available alternative treatment including self-management and simple analgesics appears to be low.
30. With regard to cost Dr Yu says the procedure is comparatively modest when weighed against the potential benefits. The cost of the proposed treatment would be at the SIRA gazetted rates.
31. I accept the respondent's submission that there is no evidence the proposed right lumbar sympathetic nerve blocks at L3 and L4 will work. In terms of effectiveness Dr Yu's opinion is sympathetic nerve blocks are supported by clinical literature and specialist guidelines for patients presenting with neuropathic and sympathetically maintained pain.
32. Dr Yu refers to a 60% to 70% reported response rates as considered clinically meaningful, particularly in patients with refractory symptoms and significant functional impairment, although there is no guarantee the applicant's pain would completely resolve and it may recur.
33. Dr Yu refers to the proposed treatment as well-accepted within the field of interventional pain medicine as a standard option for managing chronic regional and neuropathic pain syndromes. Dr Yu and Dr Rahme, both treating specialists, accept the proposed treatment as being appropriate and likely to be effective and I prefer this opinion as discussed above.
34. Having considered the available evidence, I find the proposed right lumbar sympathetic nerve blocks at L3 and L4 is reasonably necessary medical treatment as a result of the right knee injury on 7 December 2023 pursuant to s 60 of the 1987 Act.

Is further physiotherapy reasonably necessary medical treatment as a result of the right knee injury on 7 December 2023

1. The applicant's statement evidence is that she was dissatisfied with the physiotherapy treatment she received from Ms Tam and she wants to continue with physiotherapy treatment she had been receiving from Ms Fenianos.
2. The applicant felt she was making progress with Ms Fenianos and since treatment ceased she feels her right knee is getting worse and the pain has more instances of flare ups.
3. Dr Yu refers to ongoing physiotherapy as part of a broader multimodal management plan. Ms Fenianos believes physiotherapy is one tool together with other pain management strategies to help to manage the applicant's pain.
4. Dr Rahme discusses the mainstay of physiotherapy as being to educate the applicant on an exercise regime to perform at home, although some sessions of hands-on physiotherapy may be helpful, and she should transition to an exercise physiology program.
5. Dr Leaver says ongoing physiotherapy treatment is not reasonably necessary and there should be either a multidisciplinary pain management program, which the applicant has received with Dr Yu and with the REGAIN program, or a revised treatment plan by a physiotherapist or exercise physiologist which encourages self-directed activity and independence.
6. Dr Dryson notes that Dr Leaver reasonably points out previous physiotherapy has not resulted in symptomatic improvement, and the applicant requires a self-directed exercise and activity program prescribed and supervised by either a physiotherapist or exercise physiologist. There is a clear need for this but only for the purpose of prescribing and monitoring an exercise program.
7. Associate Professor Molloy's opinion is that ongoing physiotherapy is not reasonably necessary, as one of the treatments that has been trialled and failed.
8. As the respondent submits, Dr Nguyen discusses hydrotherapy or gentle exercise as future treatment options and not physiotherapy.
9. While the applicant submits there is no express consideration that includes whether ongoing physiotherapy would assist in improving the applicant's fitness and bodily functioning, the weight of evidence is that the applicant has received extensive physiotherapy treatment which has not been effective in managing or alleviating her right knee symptoms.
10. I accept the respondent's submission that the Healthivia report records some improvement in the applicant's functional tolerances although she is still restricted in everyday activities. The recommendation was made that the applicant continue independently and continue to see the psychologist for pain management strategies.
11. The respondent submits the applicant continues to receive exercise physiology treatment following the Healthivia report in September 2025.
12. Given the medical opinions that the applicant should receive either physiotherapy or exercise physiology treatment and not both at the same time, and that there is evidence of some functional improvement with the exercise physiology treatment received, exercise physiology appears to be the better option.
13. Having considered the available evidence, I find further physiotherapy is not reasonably necessary medical treatment as a result of the right knee injury on 7 December 2023 pursuant to s 60 of the 1987 Act at this time.

1. The right lumbar sympathetic nerve blocks at L3 and L4 proposed by Dr Yu is reasonably necessary medical treatment as a result of the applicant's right knee injury on

7 December 2023 pursuant to s 60 of the 1987 Act. 2. Further physiotherapy is not reasonably necessary medical treatment for the applicant's right knee injury on 7 December 2023 pursuant to s 60 of the 1987 Act at this time.

[1] [2014] NSWWCCPD 72 (Diab).

[3] [1986] NSWCC 2; (1986) 2 NSWCCR 32 (Rose).

[4] [1997] NSWCC 1; (1997) 14 NSWCCR 233 (Bartolo).

[5] Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452; 10 NSWCCR 796.

[6] Murphy v Allity Management Services [2015] NSWCCPD 49 at [58].