Medical assessment of Medical Assessor Jonathan Herald dated 6 October 2023

1. Medical Assessor Herald examined the claimant on 25 August 2023 in the context of a threshold injury dispute. He determined that a soft tissue injury to the lumbar spine and both elbows was a threshold injury for the purposes of the MAI Act.
2. In respect of current symptoms, the Medical Assessor records the claimant as experiencing right elbow medial-sided pain.
3. The claimant was noted to be 80kg and a height of 152cm.
4. On examination of the lumbar spine, the claimant was noted to have mild tenderness over the lumbar spine but a good range of motion with forward flexion to 75% of the range and lateral flexion to 75% of the range or below her knees to her mid-thigh level. Extension was limited to 50% of range and she had a normal neurological examination to the lower limbs which were intact to tone, power and reflexes.
5. In respect of the elbows, the Medical Assessor found right elbow tenderness over the medial epicondyle and positive medial epicondyle shear test. The left elbow had a negative medial epicondyle shear test, and the elbow was noted to have otherwise a good range of motion.
6. In his conclusions, the Medical Assessor stated the claimant had features of medial epicondylitis in both elbows and aggravation of underlying lumbar spondylosis. Her symptoms were noted to be then predominantly related to the right medial epicondylitis, although there were flareups of medial epicondylitis affecting both elbows and her lumbar spine over the previous year or so prior to the motor accident.
7. The Medical Assessor noted the following summary of radiological and medical imaging that was brought to the assessment:
   • 20 April 2019 - ultrasound left shoulder - tendinopathic change involving the supraspinatus;
   • 14 November 2019 - MRI scan right elbow - mild common flexor origin tendinosis with a tiny interstitial tear and some features of ulnar nerve thickening as it enters the cubital tunnel which may represent neuritis;
   • 1 March 2022 - MRI scan lumbar spine - mild lumbar spondylosis;
   • 4 April 2022 - ultrasound left hip - trochanteric bursitis;
   • 7 October 2022 - ultrasound right elbow - common flexor origin thickening consistent with medial epicondylitis;
   • 24/10/2022 - ultrasound left elbow - common flexor origin tendinosis with medial epicondylitis
   • 7 January 2023 - ultrasound left elbow - common flexor origin tendinosis with medial epicondylitis;
   • 6 April 2023 - MRI scan lumbar spine - lumbar spondylosis, and
   • 22 June 2023 - ultrasound right elbow - mild flexor tendinosis.

General practitioner (GP) records - St Andrews Medical Centre

1. The file includes a report of Macarthur Physiotherapy dated 14 April 2023. It states the claimant attended for physiotherapy,

"...for the management of low back pain and bilateral medial elbow pain. The lower back pain is related to an incident in December 2022. Dulka has a history of elbow pain which was aggravated by her having to manage her back pain."

1. The author of the report concluded that a full time pre-injury duties return to office based employment was appropriate, on a graded basis.
2. Dr Nguyen noted on 10 March 2023 a case conference occurred with the rehabilitation provider. A history of the motor accident is recorded. Symptoms arising, besides psychological, include back pain - mainly left sided and occasional mild headaches. Both elbows are noted to involve pain with tenderness at the right lateral epicondyle.
3. Ongoing consultations include notes of psychological symptoms, back pain and predominantly right elbow pain.

1. The Panel has considered the issue of causation in respect of the elbows. There appears to be no controversy on the material that the claimant did not suffer a direct injury to the elbows as a result of the accident. The claim form mentions an injury to the lower back and hip.
2. The material demonstrates a clear pre-existing history of bilateral elbow conditions. Approximately two months prior to the accident radiology confirmed epicondylitis in both elbows.
3. At the time of his examination in February 2024, Medical Assessor Kenna, noted that the claimant had retained full functional mobility in the back and both elbows. The Panel, acknowledges, however that the relevant period in dispute is between June and November 2023. It is relevant that Medical Assessor Herald, who examined the claimant as part of a threshold dispute, did so during the relevant period, in August 2023. He found features of medial epicondylitis in both elbows and aggravation of underlying lumbar spondylosis. He also noted that the symptoms at that stage related predominantly to the right medial epicondylitis. Whilst he did not include any specific reasoning on the issue of causation, he did comment that there were flareups of the medial epicondylitis affecting both elbows and the lumbar spine over the previous year.
4. Accordingly, on the evidence, the Panel finds that the predominant issue affecting the claimant's functional capacity at the relevant time relates to the right medial epicondylitis. This is a documented pre-existing condition. The Panel notes the claimant's assertion that she aggravated this condition by altering her activities on account of the lumbar spine injury. However, the Panel is not satisfied, on the balance of probabilities, that minor alterations to the claimant's activities gives rise to an injury to the elbows causally related to the motor accident. The claimant had symptoms in the weeks leading up to the motor accident in both elbows to the point that radiology was ordered. The Panel finds that it is more likely than not that the claimant's elbow symptomatology at the relevant period was not altered by the motor accident to any material degree.
5. The Panel finds that the motor accident is more likely than not to have not caused any material contribution to the elbow symptomatology.
6. The Panel also finds that on the basis of the clinical findings of Medical Assessor Herald that were recorded during the relevant period, the lumbar spine injury is not such that it would deem domestic assistance to be reasonable and necessary.

1. The certificate of Medical Assessor Kenna is confirmed.

[1] See Division 7.5 and Schedule 2, cl 2 of the MAI Act.

[6] Section 60 of the Workers Compensation Act 1987.

[7] See Briggs v IAG Limited t/as NRMA Insurance [2022] NSWSC 372 at [35].