Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017.

1. Revokes the certificate issued by Medical Assessor Cameron dated 14 December 2024.
2. Issues a new cerficate determining that the following injuries caused by the motor accident give rise to a permanent impairment of 8% and is not greater than 10%:
   • left leg - degloving laceration with injury to the superficial peroneal nerve;
   • left knee - soft tissue injury;
   • left ankle - soft tissue injury;
   • left foot - soft tissue injury;
   • skin - scarring;
   • left shoulder - soft tissue injury;
   • cervical spine - soft tissue injury;
   • thoracic spine - soft tissue injury, and
   • lumbar spine - soft tissue injury.

1. Jarrah Cain (the claimant) was involved in a motor accident on 28 April 2021. She had parked her car on a busy road and as she was exiting her vehicle, she was hit from behind by a car. She suffered a laceration to her left lower leg just below the knee. An ambulance attended and she was taken to Port Macquarie Hospital where her wound was sutured.
2. She made a claim for personal injury benefits with QBE, the third-party insurer of the vehicle that she says caused the accident.
3. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. This is important because if there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor/s for determination.
4. On 14 December 2024, Medical Assessor Ian Cameron found the claimant had a WPI of 3% for the injury to the claimant's left leg and the associated scarring.
5. The claimant lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Cameron's medical assessment.
6. On 6 February 2025, a delegate of the President, Ms Brittliff, accepted the application for review and referred the matter to this Review Panel (the Panel) to conduct the Review proceedings.[2]

1. Section 7.21 of the Motor Accident Injuries Act 2017 (MAI Act) provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Guidelines.
2. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides) (the Guidelines). The Guidelines are definitive with regard to the matters they address by where they are silent on an issue, the AMA 4 Guides should be followed.
3. Permanent impairment is assessed in accordance with Chapter six of the Guidelines.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the claimant's physical injuries. This would include whether the taking of pain relief medication caused or contributed to the claimant's upper and lower gastrointestinal tract dysfunction.
2. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines.
3. The provisions state:

"6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (the Commission) in considering such issues.

6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following;

1. the alleged factor could have caused or contributed to the worsening of the impairment, which is a medical determination, and
2. the alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination

This, therefore, involves a medical decision and a non-medical informed judgement.

6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes."

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

1. Medical Assessor Cameron was asked to assess an injury to the claimant's leg and scarring, framed in the following terminology:
   • Leg - degloving left calf injury with peroneal nerve, torn ligament and tendon nerve damage, and
   • Skin - scarring - scarring above left eyebrow & left leg.
2. The Medical Assessor was also asked to assess multiple other musculoskeletal injuries, described as "nervous system damage".
3. On examination, the Medical Assessor found a sensory deficit over the lateral aspect of the left lower leg. This was found to be "...suggestive of an injury to the common or superficial peroneal nerve". There was ongoing neuropathic pain.
4. Left knee range of motion was 0 to 110 degrees. The contralateral right knee had a full range of motion. There was no crepitus or instability.
5. There was also a V-shaped scar which measured approximately 10cm x 10cm. The scar was not prominent. It was present in an area that also had tattoos present. There was a slight contour deficit. There was no facial scarring.
6. With the exception of inconsistent movement at the left shoulder, movement in all other bodily joints was normal with no neurological deficits.
7. Impairment to the left leg was assessed with reference to a superficial peroneal nerve injury with dysaesthesia which amounts to 2% WPI. Scarring was assessed at 1% WPI.

1. By way of directions issued on 13 February 2025, the parties were asked to advise whether they agreed that the only issues to be determined in the Review is the degree of permanent impairment of the claimant's left leg injury and the subsequent scarring that was caused by the motor accident.[3]
2. The claimant advised, in a message on the Commission's Portal on 20 February 2025, that the parties were in agreement with the above.
3. The Panel commends the parties for narrowing the issues to be determined in the Review.

1. The claimant says the injury to the left leg should have been categorised as a common peroneal nerve injury (emphasis added). Such a finding would be consistent with the opinion of Dr Russo who has been treating the claimant since May 2023. Dr Russo provided treatment in the form of an ultrasound guided pulsed radiofrequency neurotomy which provided temporary relief, relief that wouldn't have had any effect if the injury was to the superficial peroneal nerve it is contended.
2. It is submitted that impairment of a common peroneal nerve injury would require an assessment of motor impairment, which could give rise to a further 15% WPI.
3. In summary, it is submitted that in accordance with Table 3 of the Guidelines and Table 68 of the AMA 4 Guides, a common peroneal nerve injury would be assessed at 15% WPI for motor deficit, 2% WPI for sensory deficits and 2% WPI for dysaesthesia which when combined equals 19% WPI.
4. As peripheral nerve injury impairments can be combined with other impairments of the lower extremity, it is submitted there could be other impairments that could be further combined with the 19% WPI.

1. The insurer says the claimant sustained a left calf laceration and soft tissue injuries to her left ankle and lower leg only. The insurer relies on the report of Dr Hyde-Page dated 2 May 2023 which found a normal examination of the left knee, ankle and foot. Impairment was assessed at 0% WPI.

1. As directed, the parties lodged bundles of the material they relied upon in the review, with the claimant's bundle comprising of pages 1-613 and the insurer's bundle comprising of

pages 1-200. 2. The Panel has read the documentation however will not refer to and summarise every document that are contained in the bundles. The Panel will only refer to the material that are relevant to the issues in dispute and matters to be determined with respect to the review of Medical Assessor Cameron's WPI assessment.

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

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

• Leg - degloving left calf injury with peroneal nerve, torn ligament and tendon nerve damage
• Knee - left knee - nervous system damage
• Ankle - left ankle - nervous system damage
• Foot - left foot - nervous system damage

Injuries not in dispute in the Panel proceedings

• Shoulder - left shoulder - nervous system damage
• Skin - scarring - scarring above left eyebrow and left leg
• Hand - left hand - nervous system damage
• Hand - right hand - nervous system damage
• Thoracic spine - nervous system damage
• Lumbar spine - nervous system damage
• Cervical spine - nervous system damage

Ms Cain (the claimant) attended for re-examination by Medical Assessor Christopher Oates, on behalf of the Medical Review Panel at the PIC Medical Suites on 19 June 2025, as arranged. She was accompanied by her partner, Ms Shaniah Hinch, who remained as a silent observer for the duration of the re-examination.

Pre-accident medical history and relevant personal details including details from the file of evidence

Ms Cain lives at Wauchope in a house with her partner. They are guardians for two of her partner's family members, females both currently aged 13.

Ms Cain worked as a primary school teacher for Year 3 at Hastings Public School prior to the accident. She had been working there for about four years.

Her general health in the past was good, apart from requiring minor surgery for a pilonidal abscess. She was also overweight. She was a light smoker of cigarettes but no alcohol.

She had had no prior accidents or injuries and was on no regular medications prior to the accident.

Ms Cain confirmed on 28 April 2021 she had arrived at her place of employment, the school, in a Commodore sedan with no passengers. She had exited her vehicle and was closing her driver's door, when she was hit from behind by a passing vehicle in the school 40km/hr speed zone and was thrown about five metres from her car, landing heavily on the road. She was stunned, but not rendered unconscious.

She recalls sitting up on the road and felt that she could not move her lower body. A bystander in a passing car, who was an off-duty fire fighter, stopped and noticed there was an injury to her left leg and assisted her until the ambulance arrived.

The driver's door had been struck by the passing vehicle and bent forwards against the front panel of the car. She was told not to look at her leg, but could not resist, and fainted when she saw a pool of blood around her leg.

The paramedics gave her Ketamine, Morphine and Methoxyflurane, and she was conveyed to Port Macquarie Base Hospital. She had x-rays on 28 April 2021 of the left ankle, tibia and fibula, and a CT pan scan for trauma. There was a large degloving laceration to the lateral aspect of the proximal left lower leg. She was taken to the theatre for washout of the degloving wound and suturing. Her leg was put in a splint. There were also bruising and abrasions to the left lower, mid and upper back.

She self-discharged the day after at her own request, as she felt she would rest more comfortably at home.

History of symptoms and treatment following the motor accident

Home nurses came to her home to change the dressings. She had follow-up from the general practitioner, which was then at the Aboriginal Medical Service in Port Macquarie.

She had medication for pain and saw a physiotherapist, Mr M Olsen, for treatment to the left leg, including the calf and ankle, the back and the trapezius area, and attended for about two years all up.

She was referred to a pain management specialist, Dr Russo. She continued to have sharp burning pain with pins and needles and numbness in the degloved area on the lateral left calf, and aching in the back of the calf, weakness in the leg, and a shooting pain from the lateral aspect of the ankle to the calf. She also had sharp ache in the left lower back which was constant, and pain in the left trapezial area and the shoulder girdle.

She first visited Dr Russo in May 2023 and he diagnosed traumatic neuropraxia of the common peroneal nerve.

She had radiofrequency of this nerve in September 2023. She had about two-or three-months relief of pain. She tried Versatis anaesthetic patches on the lateral left calf.

Following the accident, she had about two months away from work and then returned to work one day per week. She had difficulty with driving because of her left leg and back. She was assigned to a Year 3 class.

She had a second nerve block for lateral left knee pain in March 2024. This was given for irritation of the lateral genicular nerve.

At review after this in March 2024, Dr Russo suggested pulsed radiofrequency neurotomy of the common peroneal nerve with hydro-dissection to the area to aim for 12 months of pain relief. This was undertaken in mid-2024 and worked for a couple of months. She had no further procedures after that and no further specialist review, as Dr Russo did not feel that the benefit obtained was worth undergoing a further procedure. However, she intends to discuss the way forward with her GP.

Note: A physiotherapy report from 9 February 2023 noted normal range of movement in the hips, knees and ankles bilaterally but decreased strength of left knee extension and left ankle eversion.

Details of any relevant injuries or conditions sustained since the motor accident

She recalled attending the GP, on 15 October 2021, after her left leg gave way and she fell in the bathroom. As she fell, she grabbed the side of the bath but still hit the lateral left calf on the vanity basin support. She had follow-up after this at Port Macquarie Base Hospital on 30 October 2021 and was told to continue with physiotherapy.

This was after a fall at her school, which is located on quite hilly terrain, on 29 October 2021 when she rolled her left ankle. She had an x-ray and ultrasound of the left ankle, and also MRI scan of the left knee, because these were sites of pain.

In February 2022, she rolled her right ankle whilst she was visiting her "nan" in Toowoomba. She went to the Toowoomba Base Hospital and had an x-ray, and was diagnosed with a sprain. The right ankle was bandaged and she was given crutches, but then changed to a walking frame as she found it easier with more balanced weight-bearing through both lower limbs.

Note: I asked the claimant and she did not recall any previous injury to the right ankle.

She has pain in the lateral left leg, calf and ankle which disturbs her sleep. The pain is constant at 7-8/10 at its worst, and reduces to 5-6/10 when she has a chance to have a rest on the weekend.

She feels she has less strength in the leg and can no longer play her sport of rugby league, which she enjoyed in the past. She shares home duties with her partner, however has had to give up outside work of mowing, gardening and cleaning the pool, and two people are employed to do these jobs, payment for which is covered by the insurance company.

She was unable to stand for long periods at work, so she was given a chair to use. Her left calf and ankle start to go "dead" if she sits in one position too long.

She gets apprehensive when she has to lift her legs over the edge of the bath to access the shower over bath and she gets her partner to help, as she is frightened of falling and re-injuring herself.

Although there is pain and numbness present in the left leg, she can move the leg OK as far as she knows. These symptoms are worse in cold weather and the leg swells in hot weather.

The scar of the degloving injury goes red and raised in hot weather. She was pleased that when the degloving flap laceration was repaired that the integrity of her tattoo was preserved by the surgeon.

She is currently working four days as a classroom teacher on a composite class 5 and 6. She struggles at work, as the terrain is hilly. She uses a chair provided to her in the classroom but still has difficulty getting down to low tables and chairs to interact individually with the children, and there are a lot of steps in the school yard. She works four days a week with Wednesdays off.

She can drive for about 20 - 30 minutes but her partner does any longer drives for them. She notes she is more withdrawn socially now and can't play with younger members of the family or visit relatives interstate.

She attends physiotherapy once a week with treatment to the leg. The physiotherapist did attempt to treat back discomfort, but her back was too tender for them to touch. She also has some light massage to the left trapezial area. She takes breaks from physiotherapy at times.

She uses a wheelie walker to transport her teaching supplies round the school and this is also used for shopping.

She changed GP's and now attends Dr Sherif Meena at Port Macquarie. She sees him monthly. She takes ibuprofen as required. She has Panadol and codeine compound tablet about 12 - 14 tablets per week. She has escitalopram as an anti-depressant and amitriptyline to help with pain and assist her to sleep.

She takes a walking stick to school in case she needs it during the day.

She confirmed she had used Ozempic to attempt weight loss in the past but this was ceased because of side-effects. She no longer uses the Versatis patches.

She was of heavy build with height 174cm and weight 115kg. She is right hand dominant.

Due to an administrative error, no chaperone was booked to attend this appointment, however the claimant agreed to proceed with the examination without a chaperone.

There was no guarding. There was tenderness in the left upper trapezius. There was full range of movement in flexion, extension, lateral flexion bilaterally and rotation bilaterally in the cervical spine. There was no dysmetria. There were no non-verifiable radicular complaints. Reflexes, power and sensation in the upper limbs were normal.

Upper arm girth at 10cm above the elbow - right 46cm, left 45cm.

Forearm girth at 5cm below the elbow - right equals left equals 31cm.

There was some complaint of soreness in the left shoulder with discomfort on the end-range of abduction and flexion. Sensation about the shoulder girdle was intact.

Sensation over the trunk was intact. There was full range of thoracic rotation bilaterally. There was no dysmetria, no guarding and no spasm or tenderness.

Flexion and extension were three-quarters of normal range with complaint of left low back pain at the end of flexion and extension. Lateral flexion was three-quarters of normal range bilaterally. There was no guarding and no spasm.

There were no non-verifiable radicular complaints. The sensory and dysaesthesia complaints in the left lower extremity are the result of a peripheral nerve injury, rather than being evidence of nerve root irritation or radicular complaints.

Power - right equals left. This was tested carefully and there was no diminution of power in the left ankle, foot and toes, dorsiflexion or plantar flexion, inversion or eversion.

There was tenderness at left L5/S1 area. Reflexes were symmetrical with plantar responses both flexor. Sensation was intact in the lower limbs, apart from being partially reduced in the lateral left calf and dorsum and plantar aspect of the lateral left foot to both light touch and pin prick. There was also complaint of dysaesthesia on light stroking of the lateral distal left leg and lateral foot.

Slump test negative bilaterally. Supine straight leg raising was negative bilaterally.

Thigh girth; right 65cm, left 64cm at 10cm above the superior patellar pole.

Calf girth; right equals left equals 46cm at 14cm below the inferior patellar pole, the point of maximal circumference.

There was no instability. There was no crepitus in the right knee but there was some crepitus in the left knee.

There was full range of movement of 0 - 130° in both knees.

There was full range of movement bilaterally in flexion, extension, abduction, adduction, external and internal rotation.

There was tenderness in the lateral aspect of the left ankle but no ligamentous instability.

The right ankle and hind foot showed full range of movement in dorsiflexion, plantar flexion, inversion and eversion.

At the left ankle, dorsiflexion was 0°, plantar flexion 40° and at the left hind foot inversion was 30° and eversion was 15°.

There is a pale V-shaped scar from the degloving laceration over the proximal one-third of the left lateral calf measuring 8cm x 8cm and 5mm wide. The scar was flat and was not tethered. The scar was visible when looked for within the tattoo, whose border lines had been preserved intact following the surgical repair of the laceration."

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[4]
2. The parties may, however, agree on whether a particular injury is caused by the motor accident and the associated degree of permanent impairment. Where there is agreement, the particular injuries need not be subject of assessment in the review.[5]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[6]
4. The Panel refers to the above re-examination report of Medical Assessors Oates and adopts the findings in their entirety. The Panel reconvened on 11 July 2025 and discussed the

re-examination report findings before collectively making the below determinations.

1. As noted above, the dispute concerns the assessment of the left lower extremity with there being agreement on the other injuries not being the subject of the review proceedings. For completeness however, Panel Medical Assessor Oates did examine the other injuries originally referred for assessment with the findings briefly discussed below.
2. Based on consideration of the evidence in the file, the accident is considered a cause of the degloving left calf injury with damage to the superficial peroneal nerve, and associated scarring of the left leg. The accident is also considered to be a cause of soft tissue injury to the left shoulder, cervicothoracic and lumbar spines, and left knee.
3. The accident is also considered to be a cause of soft tissue injury to the left ankle and foot area, which were bruised by contact with the road.
4. The left ankle, cervical spine, left foot, left knee, left leg, lumbar spine, left shoulder, thoracic spine and scarring are mentioned in the physiotherapy records dating from 28 April 2021, and also the ambulance record refers to the left leg injury and lumbar spine symptoms.
5. The Panel found no reference to injury to either hand in the contemporaneous medical evidence available.

1. For the left leg, the diagnosis is degloving laceration with injury to the superficial peroneal nerve. There was no evidence of ligamentous instability or tendon damage.
2. The superficial peroneal nerve provides sensory supply to the lateral distal leg and foot and toes, but not to the hallux, and also motor function to the evertors of the foot.
3. Following careful clinical examination, there was sensory and dysaesthesia loss arising from damage to the superficial peroneal nerve, but there was no motor loss.
4. The common peroneal nerve supplies motor function to the dorsiflexors of the ankle and foot, sensation to the hallux area of the foot, and motor function to the plantar flexors of the ankle and foot.
5. Clinical examination showed no loss of sensation to the area innervated by the common peroneal nerve and no loss of motor function of this nerve.

1. This is defined as soft tissue injury. There was no evidence of nervous system damage to the left knee.
2. The evidence of peripheral nerve damage did not involve the knee, but commenced in the mid-calf level on the left lateral leg, according to the results of sensory testing with both light touch and pin prick.

1. There was soft tissue injury to the left ankle from contact with the road. The nervous system damage was confined to the effects of peripheral nerve injury to the superficial peroneal nerve.

1. There was no evidence of nervous system damage apart from what is mentioned above, being a peripheral nerve injury involving the superficial peroneal nerve. There was initial soft tissue bruising to this area.

1. There was no visible scarring above the left eyebrow, but there was visible scarring in the left leg at the site of repair of the degloving laceration.

1. The left shoulder is diagnosed as soft tissue injury. There was no evidence of nervous system damage.

1. There was full range of movement in both hands with normal grip strength and no evidence of nervous system damage.

1. The diagnosis is a soft tissue injury. There was no evidence of nervous system damage.

1. The diagnosis is soft tissue injury with no evidence of nervous system damage.

1. The diagnosis is soft tissue injury with no evidence of nervous system damage. There were normal neurological findings in the upper extremities and in the lower extremities, apart from deficits arising from injury to the superficial peroneal nerve in the left lower extremity.

1. The following injuries were caused by the motor accident:
   • left leg - degloving laceration with injury to the superficial peroneal nerve;
   • left knee - soft tissue injury;
   • left ankle - soft tissue injury;
   • left foot - soft tissue injury;
   • skin - scarring;
   • left shoulder - soft tissue injury;
   • cervical spine - soft tissue injury;
   • thoracic spine - soft tissue injury, and
   • lumbar spine - soft tissue injury.
2. The following injuries were not caused by the motor accident:
   • left and right hands - nervous system damage.

1. The findings at the cervical, thoracic and lumbar spines of symptoms, but no non-verifiable radicular complaints, no spasm or guarding, and no dysmetria, place her in DRE Cervical Category I (0% WPI), DRE Thoracic Category I (0% WPI), and DRE Lumbar Category (0% WPI).
2. With respect to superficial peroneal nerve, the sensory and dysaesthesia is graded at Grade 3 (60% of the maximum). From AMA 4 Guide, chapter 3, Table 11, this refers to decreased sensibility with or without abnormal sensation of pain which interferes with activity. Table 68 indicates the maximum lower extremity deficit from superficial peroneal nerve for sensory loss is 5% lower extremity impairment and that for dysaesthesia is also 5% lower extremity impairment.
3. 60% of 5% is 3%. Combining 3% with 3% is 6% lower extremity impairment.
4. There is tenderness and crepitus in the left knee which gives 5% lower extremity impairment from footnote of Table 62. It is plausible that the left knee would have been injured when she was thrown forcefully to the roadway after being hit by the motor vehicle.
5. Regarding the left ankle, there is loss of active range of motion. Dorsiflexion 0° gives 7% lower extremity impairment. Inversion 30° and eversion 15° do not result in any assessable impairment.
6. A physiotherapy record of 9 February 2023 did refer to marginal decrease in strength in left knee extension and ankle eversion, however these findings were not reproduced on today's examination, indicating clinical improvement since that time.
7. For the lower extremity, combining 7% from the left ankle with 6% from the superficial peroneal nerve with 5% from the left knee, gives 17% lower extremity impairment. 17% multiplied by 0.4 gives 6.8% rounded to 7% whole person impairment.
8. For scarring, there is 1% whole person impairment according to the "best fit" principle of the TEMSKI table, as follows.
9. The claimant is conscious of the scar, and can readily locate the scar, there is colour contrast with surrounding skin, the scar is atrophic, there are clearly visible suture marks, the anatomic location is visible with usual clothing, there is no contour defect, no effect on ADL's, no requirement for treatment and no adherence.

1. The combined WPI is 7% by 1% giving 8%.
2. The Panel agrees with Medical Assessor Cameron's finding that with the exception of the left leg, there was no "nervous system damage" to the other claimed bodily areas. The Panel however, accepted that there were soft tissue injuries to these bodily areas as a result of the motor accident.
3. The Panel's impairment findings in relation to the left lower extremity differed from Medical Assessor Cameron, although the final total combined impairment of 7% WPI did not result in any material change in the outcome, namely WPI being not greater than 10%.
4. As a result, the Panel revokes the certificate of Medical Assessor Cameron and issues a new certificate in accordance with the Panel's above findings and reasons for assessment.
5. The new certificate is located at the front page of this decision.

[3] Direction paragraph 1 is made pursuant to section 7.25 'Agreement between parties as to matters in dispute - further assessments and reviews' of the MAI Act.