Issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The issue determined by the Review Panel is whether the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%.

1. The Review Panel revokes the certificate of Medical Assessor Raymond Wallace dated

19 April 2024. 2. The Review Panel issues a new certificate determining that the following injuries caused by the motor accident give rise to a permanent impairment that is not greater than 10% (2%): * left knee; * left hip - resolved; * lumbar spine - resolved, and * left foot and heel - resolved.

1. On 21 February 2019, the claimant, Nadia Kayem, was involved in a motor accident when she fell and sustained injuries whilst travelling on a bus, insured by Allianz Australia Insurance Limited.
2. The claimant claims that she sustained multiple physical injuries in the accident. She also claims that she developed a psychological or psychiatric injury although that aspect of injury is not the subject of this matter.[1]
3. The insurer accepted liability to pay the claimant statutory benefits and damages under the Motor Accident Injuries Act 2017 (the MAI Act).
4. As part of her claim for damages, the claimant pursued damages for non-economic loss. According to s 4.11 of the MAI Act, no damages for non-economic loss may be awarded in respect of injury unless the degree of permanent impairment of the injured person as a result of the injury caused by a motor accident is greater than 10%. The insurer did not concede that the claimant's physical injuries caused by the accident, had crossed that threshold.
5. To resolve the dispute, the claimant made an application for a medical assessment by the Personal Injury Commission (Commission) pursuant to Division 7.5 of the MAI Act.
6. The nature of the claimant's physical injuries that were referred to the Commission for assessment meant that two Medical Assessors at first instance were each required to assess some of the injuries according to their area of expertise.
7. The claimant's referred injuries to the lumbar spine, left knee, left hip, left foot and heel were assigned by the Commission to Medical Assessor Raymond Wallace for assessment. The referred injury - scarring left knee, was assigned to Medical Assessor Geoffrey (Paul) Curtin for assessment.
8. On 19 April 2024, Medical Assessor Wallace issued a certificate finding that the injuries assigned to him for assessment, gave rise to a permanent impairment of 2%.
9. On 12 May 2024, Medical Assessor Curtin issued a certificate finding that the injury assigned to him for assessment, gave rise to a permanent impairment of 1%.
10. On 13 May 2024, a combined certificate was then issued by the Commission to the effect that the claimant's referred physical injuries gave rise to a permanent impairment of 3%.

1. On 4 June 2024, pursuant to s 7.26 of the MAI Act, the claimant made an application to the President of the Commission to refer the medical assessment of Medical Assessor Wallace to a review panel for review. The review application was made within the time prescribed by s 7.26(10) of the MAI Act.
2. The President referred the application to a Review Panel for review, being satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect, having regard to the particulars set out in the application.

1. According to s 7.26(5A) of the MAI Act, the Review Panel consists of two Medical Assessors and a Member of the Motor Accidents Division of the Commission. On this occasion, the Review Panel is constituted by Medical Assessor Oates, Medical Assessor Gray and Member Castagnet (the Panel).
2. Part 5 of the Personal Injury Commission Act 2020 (the PIC Act) enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.[2]
3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings. The panel may determine the proceedings solely based on the written application.[3]
4. The review is not limited to only that aspect of the assessment that is alleged to be incorrect and is by way of a new assessment of all the matters with which the medical assessment is concerned.[4]

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be made in accordance with the Motor Accident Guidelines (the Guidelines).[5] The Guidelines are issued pursuant to s 10.2 of the MAI Act. The Guidelines adopt the fourth edition of the American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[6]
2. The provisions of the Civil Liability Act 2002 (the CL Act) apply to the MAI Act in determining issues of causation, particularly ss 5D and 5E of the CL Act.[7]
3. In Raina v CIC Allianz Insurance Ltd [2021] NSWSC 13, Campbell J made the following observations at [65]:

"One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002 (NSW), ss5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely."

1. Clauses 6.5 to 6.7 of the Guidelines also address the issues of causation of injury and whether the degree of permanent impairment is caused by injury.
2. Clause 6.7 of the Guidelines provides:

"There is no simple common test of causation that is applicable in 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 the sole cause as long as it is a contributing cause, which is more than negligible."

1. The Panel is required to determine the issues on the balance of probabilities. The resolution of causation does not require scientific certainty: Briggs v IAG Ltd (No 2).[8]

1. The following injuries were referred to the Medical Assessor for assessment:
   • lumbar spine;
   • left hip;
   • left knee, and
   • left foot and heel.
2. The Medical Assessor found that the claimant's injury to the left knee - fracture lateral tibial plateau, was caused by the accident.
3. The Medical Assessor found that the injuries to the lumbar spine, left hip, left foot and heel were not caused by the accident.
4. In regard to the lumbar spine, the Medical Assessor noted firstly that the claimant did not report the onset of lumbar spinal symptoms until some five months after the accident. Secondly, he noted that prior to the accident, there was a well-documented history of injury to the lumbar spine as a result of a motor accident in 2016. Lastly, he noted that in September 2015, about five months prior to the subject accident, the claimant had reported lumbar spinal pain to her general practitioner (GP).
5. The Medical Assessor concluded the claimant's current lumbar spinal disability was due to pre-existing multilevel degenerative lumbar spondylosis, which is age related, constitutional in origin and unrelated to the subject accident.
6. The Medical Assessor was of the opinion that the claimant's left hip condition was due to pre-existing degenerative trochanteric bursitis at the left hip for which she was reviewed by her GP on 11 October 2018, some four months prior to the subject accident.
7. The Medical Assessor found that that there was no objective evidence to show that the claimant had suffered any injury to her left foot or left heel as a result of the subject accident.

1. The claimant filed a paginated and indexed bundle of documents comprising 627 pages and the insurer filed a paginated and indexed bundle of documents comprising 284 pages.
2. The parties filed the following additional documents:

(a) clinical records of Dr C Reitz (100 pages);

(b) clinical records of First Care Medical Centre;

(c) X-ray reports of the left knee and the right knee preformed on

15 November 2024, and

(d) a report of CT guided procedure to the left knee performed on 27 February 2025.

1. The claimant submitted that when conducting the assessment, the Medical Assessor did not apply the principles in Nguyen v Motor Accident Authority of NSW & Anor [2011] NSWSC 351 (Nguyen) which established that where there was no direct injury to a body part (shoulder) and its impairment had arisen as a consequence of an injury (neck) directly caused by the motor accident, both the neck and shoulder had to be taken into account when assessing permanent impairment.
2. The claimant submitted in the present circumstances, the claimant's lumbar spine and left hip impairments had arisen as a consequence of her altered gait and other movements which from her left knee injury directly caused by the subject accident.
3. In making that submission, the claimant relied on the report of her treating orthopaedic surgeon, Dr Christopher Reitz dated 17 July 2019.
4. The insurer submitted that the report of Dr Reitz does not make any reference or assessment indicative of impairment. There is no reference to reduced ranges of motion or altered gait and the like. Dr Reitz noted that the claimant was healing well and displayed an excellent range of motion in the left knee.
5. The insurer noted that the claimant's submission is not supported by any other evidence.

1. The evidence before the Panel may conveniently be summarised as follows.

1. The claimant was involved in a motor accident on 28 May 2016. She made a claim for the injuries she sustained in that accident.
2. In her personal injury claim form dated 14 June 2016, the claimant stated that on

28 May 2016, she was travelling in a vehicle as a passenger at the intersection of Stacey Street and the Hume Highway Bankstown, when her vehicle was struck at speed by a fire engine truck. 3. The claim form indicated that she sustained injuries to her neck, back and head and that she suffered concussion. 4. A medical certificate issued by GP, Dr Ali El Jaam on 7 June 2016 which accompanied the claim form, recorded a diagnosis of cervical discopathy, thoracic pain, lumbar discopathy and "PTSD". 5. A CT scan of the lumbar spine performed on 30 June 2016 showed no evidence of recent fracture, but diffuse disc bulges of lower two lumbar levels with bilateral L5 foraminal stenosis, moderately severe on the right and mild on the left, and moderate facet joint degenerative disease on the right at L5/S1. 6. An MRI scan of the lumbar spine performed on 26 January 2017 showed degenerative disc disease at L4/5 and L5/S1 with disc bulges and a right paraforaminal focal L5/S1 disc protrusion with high-grade right L5 foraminal stenosis and nerve root compression, but no S1 nerve root impingement. 7. The clinical records Dr El Jaam showed that the claimant was treated with Tramal and Lyrica in 2016, and then in March 2017 with Mobic and Endone. In May 2017, she was treated with Panadeine Forte, in August 2017 with Celebrex, and in June 2018 with Mobic. In April 2018 she had right heel pain and received a cortisone injection for plantar fasciitis. She has had previous surgery including left carpal tunnel release, ovarian cystectomy and pelvic floor repair. 8. According to the clinical records of Bankstown - Lidcombe Hospital dated 2 October 2018, the claimant was diagnosed with depression, with psychotic symptoms and Cluster B traits. 9. In a medicolegal report dated 25 May 2017, orthopaedic surgeon, Dr Vijay Maniam, expressed the opinion that in the 2016 accident, the claimant sustained a musculoskeletal strain of the cervical spine with aggravation of pre-existing degenerative disease without neurological compromise, and intervertebral disc protrusion at L5/S1 with compression of right L5 nerve root. 10. Dr Maniam assessed permanent impairment. For the cervical spine, he attributed a DRE Category II rating, giving rise to 5% whole person impairment (WPI) with 25% deduction, rounded to 4% after the deduction. For the lumbar spine, he attributed a DRE Category III rating, giving rise to 10% WPI with a 25% deduction rounded to 8% WPI after the deduction. The combined permanent impairment was assessed at 11% after deduction. 11. On 29 October 2018, a CT scan of the left hip was performed which showed a normal outline of hip joint but possible trochanteric bursitis which can be confirmed with ultrasound examination. There was a fat-containing indirect inguinal hernia in the left groin. 12. On 19 December 2018, the claimant underwent an ultrasound-guided left trochanteric bursal cortisone injection.

1. In her application for personal injury benefits (claim form) she stated that the date of the accident was 9 March 2019. This appears to be an error as the available evidence (for example the clinical records of Bankstown - Lidcombe Hospital) makes it clear that the accident occurred on 21 February 2019 and indeed elsewhere on the claim form, the claimant acknowledged that she was discharged from the hospital after the accident, on

1 March 2029 which is well before 9 March 2019. Nothing turns on this misdescription. 2. In her claim form, the claimant described her injuries in the following terms:

"I was a passenger on Punchbowl Bus which was turning at speed, left from Rickard Rd onto Sir Joseph Banks St. I was seated when my bags which were on the floor began to move. I bent down to hold the bags, but as the bus was travelling fast & turning sharply, I fell forward off the chair onto my left knee and face. I could not hold myself up and rolled along the floor."

1. In her claim form, the claimant outlined the injuries she received in the accident as follows:

"Injury to left shoulder, right shoulder, left knee broken, head injury, lacerations on shoulders, and a bridge in mouth was damaged, require new bridge."

1. In a certificate of fitness issued by Dr El Jaam which accompanied the claim form, the diagnosis of the motor accident related injury(ies) was recorded as "Left tibial plateau fracture".

1. An ambulance attended the scene of the accident, and the claimant was taken to Bankstown - Lidcombe Hospital for treatment where she remained until discharge on 1 March 2019.
2. According to the hospital clinical records, there was on admission, pain in the lower limb and hip. An X-ray showed a lateral tibial plateau fracture of the left knee and a CT scan showed a Schatzker 3 pure depression type fracture with a 4mm articular depression.
3. The principal diagnosis was a left tibia plateau fracture. This was treated by open reduction and internal fixation and bone grafting at the hands of Dr Reitz. No surgical complications were recorded.
4. Prior to discharge, the claimant was cleared by the physiotherapy team. She was also reviewed by the psychiatric team for ongoing suicidal ideation.
5. Upon discharge, the claimant was to be managed non-weight-bearing for six weeks until union of the fracture had been established and she was to be followed up in about two weeks by Dr Reitz in his rooms.
6. The claimant was reviewed by Dr Reitz on 14 March 2019 about two weeks post-operatively. In a report of the same date, Dr Reitz recorded that the wound was healing well. A repeat X-ray showed good hardware positioning with good positioning of the tibial plateau.
7. The claimant was further reviewed by Dr Reitz on 12 April 2019. Repeat X-ray performed on that day showed excellent hardware positioning with good reduction of fracture and signs of union, with no tenderness over the lateral joint line and a good range of motion in the knee in a stable knee joint. The claimant was advised to start weaning off crutches.
8. An Allied Health Recovery Request (AHRR) for physiotherapy, dated 12 April 2019, diagnosed left knee lateral tibial plateau fracture with open reduction and internal fixation and bone grafting, and left ankle significant ligamentous sprain laterally and medially. At the time, the claimant was using a Cam boot immobilising independently with crutches.
9. The claimant was further reviewed by Dr Reitz on 24 May 2019 with repeat X-ray which showed good alignment and union of the fracture. The claimant was able to walk into

Dr Reitz's rooms, and she reported in doing so, her knee was not painful. On examination, the claimant had a full range of motion in the left knee, which was not painful on palpation, range of motion or weight-bearing. There was some weakness in her quadriceps, and she was advised to perform strengthening exercises. Further follow-up was arranged only an as-needs basis. 10. A further AHRR for physiotherapy, dated 21 June 2019, was for further treatment with the same diagnoses affecting the left knee and left ankle. 11. According to the clinical records of Dr El Jaam, the claimant attended a consultation on

28 June 2019, complaining of back pain and neck pain. On examination, the back was tender, restriction was present but there was a full range of motion. The reason for contact was noted as "Degeneration L4-5, L5 -S1, L5 Foraminal Stenosis". The claimant was prescribed with Mobic medication. 12. The claimant was further reviewed by Dr Reitz on 17 July 2019. On this occasion, the claimant reported that pain in the left leg had been increasing over the last few weeks and seemed to be associated with lower back pain and signs of sciatica. There was also pain in the left hip on the lateral aspect with clinical signs of trochanteric bursitis. On examination, the left knee itself showed a well-healed wound with excellent range of motion and only very mild lateral knee tenderness. 13. Dr Reitz believed that most of the pain in the left leg appeared to arise posteriorly consistent with left leg sciatica, and pain in the left hip clinically appeared to be trochanteric bursitis. 14. X-rays of the pelvis, left hip and left knee performed on the same day, showed symmetrical left hip joint with no osteoarthritis, degenerative changes at the lumbosacral junction, with evidence of osteitis pubis. At the knee, a plate transfixes the lateral tibial plateau where the articular surface appears intact and the joint space is maintained. 15. Dr Reitz referred the claimant for an ultrasound of the left hip and an MRI of the lumbar spine. He reviewed the claimant on 6 August 2019 with the results. 16. The ultrasound of the left hip showed tendinosis of left gluteus minimus and medius tendons with partial-thickness tear at the insertion of gluteus medius and some thickening in the greater trochanteric bursa. The MRI scan of the lumbar spine showed multi-level degenerative change with possible nerve root impingement on the left, raising symptoms of left leg sciatica. 17. Dr Reitz gave the claimant a referral for a CT-guided L5/S1 cortisone injection. He also referred the claimant to neurosurgeon, Dr Simon McKechnie, to monitor the lumbar spine pathology. However, there is no evidence before the Panel of any treatment received by the claimant for Dr McKechnie. 18. On 14 August 2019, the claimant undertook an ultrasound-guided injection of cortisone to the left trochanteric bursa and on 21 August 2019, a CT-guided left L5/S1 perineural injection of cortisone. 19. According to the clinical records of Bankstown-Lidcombe Hospital, the claimant presented at the emergency department on 26 August 2019 with right shoulder pain. It was recorded that the claimant fell on a tiled floor. She had got up to go to the toilet, felt dizzy and fell. She had an X-ray of the right shoulder showing fracture of the humerus. This was treated conservatively. The fracture involved the humeral neck and the greater tuberosity. 20. A progress X-ray of bilateral knees performed on 22 December 2020 showed internal fixation of proximal tibial fracture on the left with anatomical alignment. No significant depression of the tibial plateau was demonstrated, with no complications of hardware. 21. On 13 January 2021, the claimant underwent a further CT-guided left L5 perineural injection of cortisone. 22. A progress X-ray of bilateral knees performed on 29 March 2022 showed internal fixation in the left tibia with no features of complication, very minor articular surface irregularity within the lateral compartment of left knee and medial aspect of patellofemoral compartment of right knee, with no significant osteoarthritic degenerative changes otherwise noted, and no significant joint effusion. 23. On 6 September 2022, the claimant was admitted to St George Private Hospital under the care of Dr Reitz for the removal of the hardware at her left knee. 24. On 25 October 2022, the claimant was seen by Dr Reitz post-surgery. The claimant reported that her left knee pain had improved but she was still struggling with ongoing back issues. 25. A progress X-ray of the left knee performed on 25 October 2022 showed there had been interval removal of the plate and screw fixation across the lateral tibial plateau and proximal metadiaphysis of the tibia, with no fracture or periosteal reaction and anatomical alignment. There was mild degenerative change involving the medial and lateral compartment of both knees, slightly more prominent in the medial compartment of the right knee, which has only been assessed on the Rosenberg projection. 26. On examination, Dr Reitz found a good range of motion in the left knee, which was stable. He referred the claimant for further physiotherapy and knee strengthening exercises. 27. On 4 January 2023, the claimant returned to see Dr Reitz with ongoing pain issues after the left knee arthroscopy and removal of lateral tibial hardware. Dr Reitz noted there was a lot of pain issues but objectively there was a well-healed wound with minimal osteoarthritic change only. He referred the claimant to interventional pain specialist, Dr James Yu for further management. 28. Dr Yu saw the claimant on 21 March 2023. The claimant reported persistent left knee pain since the accident. She described her pain as aching stabbing pain, associated with swelling and skin temperature changes, and there was dark blue to purplish skin colour changes in the knee region. She rated her pain at 10/10 on a visual analogue scale. 29. Dr Yu noted that the claimant underwent a left knee arthroscopy and removal of lateral tibial hardware in September 2022. The claimant reported that she had tried acupuncture and analgesia for ongoing pain in the knee, but her pain continued to deteriorate. She has tried different analgesic medications, including Avanza and Endone. It appears that the claimant reported to Dr Yu that there was a complication of infection in the knee although the Panel could not verify this on the available evidence. The claimant reported that she had also been seeing a psychologist every three weeks. 30. Dr Yu noted psychometric screening tests showed extremely severe depression, anxiety and stress with significantly low self-efficacy and severe catastrophising. The claimant reported significant sleep disturbance associated with her pain condition. 31. Examination showed a visible purplish scar from the previous operation on her left knee, with swelling in the knee which was warmer than the right knee, and range of movement of left knee was restricted on full flexion. 32. Dr Yu recommended an evidence-based multi-disciplinary pain management program called "RESTORE", which involves a one-on-one pain program incorporating psychological, physical and medical components. He also referred the claimant to a pain specialist psychiatrist, Dr Noore, for supportive psychotherapy and pain management. He recommended that the claimant continue her analgesics at the same dose and if the pain persisted, he discussed possible future treatment options including a left lumbar sympathetic nerve block. 33. A further follow-up X-ray of the left knee performed on 28 March 2023 showed minimal degenerative osteoarthritis of the medial and lateral compartments of the left knee joint, but there was no evidence of an acute fracture or dislocation of the left knee. 34. The claimant was further reviewed by Dr Reitz on 23 April 2024 after an MRI scan of the left knee was performed in March 2024. Dr Reitz was of the view that the imaging showed the previous lateral tibial plateau fracture which was united. There was a small radial tear of the free edge of the body of the lateral meniscus, but this appeared to be stable. There was a small degree of knee joint effusion with more marked bone oedema involving the medial femoral condyle with some degenerative change and full thickness cartilage defects. 35. Dr Reitz diagnosed post-traumatic osteoarthritis in the left knee. He provided the claimant with a referral for a cortisone injection and indicated that should symptoms not settle in the mid to long term, a knee replacement would address the symptoms. 36. A further X-ray of bilateral knees were performed on 15 November 2024 showing mild degenerative changes in the right knee joint, but the joint space was maintained. In the left knee, there were joint minimal osteophytic changes in the lateral tibial plateau but no significant joint space narrowing and no suprapatellar effusion. There was no acute bony injury. 37. On 27 February 2025, the claimant underwent a CT-guided cortisone injection to the left knee.

1. The claimant was assessed by orthopaedic surgeon, Dr Murray Hyde-Page, on

23 March 2021 at the request of the insurer. 2. In his report dated 15 April 2021, Dr Hyde-Page recorded his examination findings as follows:

(a) there was 1cm wasting of the left thigh compared with the right, with a well-healed 8cm anterolateral surgical scar over the left knee, with range of motion of both knees 0 - 120° of flexion, strong quadriceps muscle power, and no swelling or tenderness in the left knee with normal alignment;

(b) the left hip was normal with full range of movement and no evidence of trochanteric bursitis;

(c) normal examination of the left ankle and foot, and

(d) the claimant had good spinal movement with no evidence of muscle guarding or stiffness, normal straight leg raising, no neurological signs in the lower limbs, with normal power, sensation and reflexes. There was some discomfort around the left knee where she had a surgical scar from the plating of the lateral tibial plateau.

1. Dr Hyde-Page assessed a WPI of 5% WPI for a displaced fracture of the left tibial plateau. He was of the opinion that the claimant's other symptoms are unrelated to the motor accident.
2. In a subsequent report dated 19 March 2024, Dr Hyde-Page reconsidered the permanent impairment arising from the fractured tibial plateau and revised his previous assessment of WPI to 2% WPI for an undisplaced tibial plateau fracture.

1. The claimant was scheduled to be re-examined by Medical Assessor Oates and Medical Assessor Gray on behalf of the Panel at the medical suites of the Commission on

13 March 2025. 2. On that day, the claimant attended the scheduled appointment accompanied by her son. As the claimant entered the examination room, she "collapsed". Upon examination by the Medical Assessors, pulse, colour and breathing were satisfactory. There was no chest pain or loss of consciousness. The Medical Assessors believed that the episode was consistent with a stress reaction. The Medical Assessors advised the claimant and her son that they will not be proceeding with the scheduled examination and that an ambulance should be called to transport the claimant to a hospital for a clinical assessment. The claimant's son insisted that he will take the claimant to her GP for an assessment. 3. The examination was re-scheduled for 8 May 2025 at the medical suites of the Commission. The claimant attended on this second occasion, accompanied by her son. On that day, she was re-examined by Medical Assessor Oates and Medical Assessor Gray on behalf of the Panel. 4. An Arabic interpreter (NAATI No. CPN8JS05R) was in attendance for the duration of the assessment, and a female chaperone, a registered nurse, was present for the physical examination. 5. The examination was conducted over an hour and a half period. The examination report of the Medical Assessors of the Panel now follows.

Pre-accident medical history and relevant personal details

1. The claimant is a widow aged 62 and is a disability support pensioner. Her son is her full-time carer. She previously worked as a teacher in her native Iraq and then for some years in Syria when she was a refugee.
2. She came to Australia in 2013 and lives with her son in a unit. Her son assists her with her activities of daily living since the accident.
3. She receives help from NDIS twice weekly with the garden and housework. Her son has children who live with their mother.
4. She had had no prior left knee or left foot problems but had had prior left hip and lumbar spine problems.
5. She had a previous motor vehicle accident as a passenger on 28 May 2016 and had neck pain radiating to both arms and back pain radiating to both legs. There was an eight month history of continuing neck and back pain.
6. She takes medications for depression, high blood pressure, diabetes, and pernicious anaemia.

1. The claimant confirmed an accident on a bus on 21 February 2019. She had got on the bus carrying groceries in her hands and there was only a middle seat with three places for disabled passengers available. As she went to sit down, there was a sudden movement of the bus and she lost her balance and was thrown forwards, landing heavily on her left knee.

History of symptoms and treatment following the motor accident

1. The Medical Assessors of the Panel noted the history of symptoms and treatment received by the claimant as summarised earlier in these reasons.
2. The Medical Assessors of the Panel asked the claimant whether the hip, knee and low back injections had been of benefit, and she replied in the affirmative. However, the claimant said that the latest CT-guided left knee joint cortisone injection given on 27 February 2025 only gave her two- or three-days relief of pain.

1. The claimant said there was no pain in the back or left hip. She said she had continuing pain in the left knee but no pain anywhere else.
2. Her sleep is disturbed by left knee pain. She gets emotional when she looks at the scar on the left knee and when she is in pain.
3. She gets colour changes in the left knee and left leg.

1. The claimant said that there were no further appointments scheduled with Dr Reitz, but she remains under the care of GP, Dr Ali Al-Jaam and she follow-ups.
2. The claimant takes Ozempic, Diaformin, Nexium, Panadol Osteo, Zyprexa, Duloxetine, Mirtazapine and Voltaren Gel.

1. The claimant is right hand dominant.
2. The female chaperone assisted her to undress from her traditional Muslim attire. She had difficulty getting out of a chair because of left knee pain. She showed prominent pain behaviour with repeated moaning, groaning and grimacing. She appeared unstable when trying to walk, which she said was due to dizziness and left knee pain.

1. While standing, there was no tenderness and no guarding.
2. Flexion and extension were both one-half normal. Lateral flexion was two-thirds of normal bilaterally.
3. Supine straight leg raising was negative on the right but could not be tested on the left because the claimant would not raise her left leg at all because of complaint of knee pain. Reflexes were symmetrical and of normal amplitude, and plantar responses were both flexor.
4. Power in the lower limbs was equal bilaterally. Sensation was intact. There was no wasting in the legs, with right equals left equals 37.5cm, and there was 1cm wasting in the left thigh compared with the right.
5. There were no non-verifiable radicular complaints and no radiculopathy. There was no dysmetria.
6. She moved with the assistance of a four-wheeled rollator walker.

1. There was no hip tenderness and no evidence of trochanteric bursitis and no instability.
2. The left hip range of movement appeared unimpeded within the limited range permitted by restriction imposed by complaints of left knee discomfort.
3. The right hip showed full range of movement.
4. The right and left ankle and subtalar joints showed full range of movement in plantar and dorsiflexion, inversion and eversion.

1. The right knee was normal to examination with full range of movement.
2. The left knee was allodynic, meaning there was a complaint of extreme tenderness to feather light palpation. There was tenderness especially over the lateral aspect of the left knee to light stroking.
3. There was no colour or temperature changes over the knee and no abnormal sweating, however there was some colour change and heat reported in the knee at times, and there was some bluish discolouration of the left foot noted by the Medical Assessors. The claimant reported that her left knee would get red and blue at various times.
4. There was no flexion contracture in the left knee and flexion was permitted actively only to 30-40° because of complaints of pain and voluntary guarding of movement.

1. The Medical Assessors of the Panel asked the claimant why Dr Reitz had said in several reports post-operatively that the fracture was healing well and she was walking well on crutches, and that the knee felt OK. The claimant replied that she agreed her knee did feel OK at this time, but later on the knee started becoming hot, swollen and red and blue in colouration, but she can't recall exactly when this started.
2. She says she was never able to walk without the assistance of the walker. When the knee pain came back like this, she had some hip and back pain.
3. She did have injections for the disc condition in the back, which was pre-existing. The low back pain came on and then would resolve intermittently.
4. She continued to see Dr Reitz as required for five years since the accident after regular three-monthly appointments from 2022 to 2024.
5. As noted above, the claimant doesn't have any further appointments with Dr Reitz. She has had no follow-up with Dr Yu, the pain medicine specialist, who allowed Dr Noore, the pain specialist psychiatrist, to take over her pain management.
6. Imaging brought to the assessment**:**
   • 14 August 2019 - ultrasound-guided cortisone left trochanteric bursa injection;
   • 21 August 2019 - CT-guided left L5/S1 perineural injection of cortisone;
   • 13 January 2021 - CT-guided left L5 perineural injection of cortisone, and
   • 25 October 2022 - X-ray of the left knee.

1. The Panel reconvened for a further conference to deliberate on the re-examination report of the Medical Assessors of the Panel and the evidence generally. The Panel's determinations now follow.

1. Based on the available evidence and the re-examination findings, the Medical Assessors of the Panel consider that the back has pre-existing degenerative disc disease in the lower lumbar discs.
2. The motor accident was not a cause of this condition and did not cause aggravation, that is, permanent worsening of the pathology, of this pre-existing condition.
3. The Medical Assessors of the Panel note that there was an initial report of symptoms in the low back about five months after the accident. Whilst a limp may have exacerbated some symptoms of the pre-existing lumbar spine condition temporarily, the Medical Assessors of the Panel consider that limping alone would not cause an aggravation in the lumbar spine, so as to cause permanent impairment.
4. At the re-examination, the claimant reported that the lumbar spine is no longer symptomatic and this indicates that any temporary exacerbation of lumbar spine symptoms associated with the left knee injury has resolved.
5. The Panel adopts the findings of the Medical Assessors of the Panel in relation to the lumbar spine.

1. Based on the available evidence and the re-examination findings, the Medical Assessors of the Panel consider that this body part has a pre-existing condition of trochanteric bursitis dating from 2018.
2. The Medical Assessors of the Panel accept that there was a likely exacerbation of symptoms of this pre-existing condition in the subject accident, as hip pain on admission is mentioned in the hospital records of Bankstown- Lidcombe Hospital.
3. The Medical Assessors of the Panel note that the left hip is no longer symptomatic, the claimant having had injections.
4. The Medical Assessors of the Panel consider that the temporary exacerbation of symptoms of the pre-existing condition related to the accident has resolved.
5. On re-examination, there was no evidence of trochanteric bursitis and no evidence of intrinsic hip problem, although there was restricted range of movement on account of complaints of left knee pain.
6. The Medical Assessors of the Panel are of the view that it is not medically plausible that knee pain would restrict active movements of the hip.
7. Because the hip ROM is affected by pain, ROM cannot be used as a reliable indicator of permanent impairment. The Medical Assessors of the Panel conclude that there is no assessable impairment arising from the hip condition because this injury has resolved.
8. The Panel adopts the findings of the Medical Assessors of the Panel in relation to the left hip.

1. The Medical Assessors of the Panel consider that the accident was a cause of this injury, which consists of a lateral tibial plateau fracture with 4mm articular depression, indicating a fracture with displacement. Following expert surgical treatment, the fracture healed without displacement.
2. This fracture has healed but has been the source of continuing pain complaints intermittently, which first resulted in removal of internal fixation in late 2022, along with ongoing complaints of pain resulting in referral to a pain management specialist in 2023.
3. The Panel adopts the above findings of the Medical Assessors of the Panel in relation to the left knee.
4. The claimant underwent a one-on-one multi-disciplinary pain management program, and her pain management care was passed over to a pain management psychiatrist.
5. The Panel notes when she was seen by the pain medicine specialist, Dr Yu, he alluded to the possibility of a lumbar sympathetic nerve block in future to assist with the neuropathic left knee pain.
6. The Panel notes that this specialist, Dr Yu, has discharged her from his care, as have all her treating specialists.
7. The Medical Assessors of the Panel found a subjective complaint, allodynia, (which is not a criterion for complex regional pain syndrome [CRPS] diagnosis) at the knee and intermittent cyanotic skin colour at the left foot, but no other evidence in support of a diagnosis of CRPS. The Guidelines require at least 8 of 11 specified criteria to be present for a diagnosis of CRPS (see: cls 6.108, 6.61 to 6.64). The Medical Assessors of the Panel attributed the colour change to non-specific vasomotor instability, secondary to dependency of the foot, but did not find CRPS to be present.
8. In any event, the Panel notes that CRPS was not a referred injury in the medical dispute that was assigned to the single Medical Assessor for a medical assessment that is now under review. Therefore, in accordance with the finding in Mandoukos v Allianz Australia Insurance Ltd [2024] NSWCA 71 (see: Stern JA at [73] and [78]) the Panel cannot consider this aspect of injury in this review.

1. The Medical Assessors of the Panel consider that a soft tissue injury to this part was caused by the accident, as it is mentioned in the early records, specifically AHRR for physiotherapy soon after the accident. On examination there were normal findings, apart from transient cyanotic skin colour, indicating non-specific vasomotor instability, and the Medical Assessors of the Panel consider that the soft tissue injury, caused by the accident, has resolved.
2. The Panel adopts the findings of the Medical Assessors of the Panel in relation to the left foot and heel.

1. The determination as to permanent impairment is made in accordance with the AMA 4 and Part 6 of the Guidelines.
2. Permanent impairment is defined in the AMA 4 (p.315) as follows:

"Permanent impairment is impairment that has become static or well stabilised with or without medical treatment and is not likely to remit despite medical treatment. A permanent impairment is considered to be unlikely to change substantially and by more than 3% in the next year with or without medical treatment. This is based on history, physical examination, review of documentation."

1. The Medical Assessors of the Panel find there is no permanent impairment arising from the resolved lumbar spine, left hip, or left foot and heel conditions.
2. With respect to the left knee, Medical Assessors of the Panel assess a 2% WPI from the tibial plateau fracture, which has healed without displacement.
3. The Panel adopts the finding of the Medical Assessors of the Panel in relation the assessment of permanent impairment of the left knee injury.

1. The Panel conducted a new assessment of all the matters with which the medical assessment is concerned.
2. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: See Insurance Australia Group Ltd v Keen [2021] NSWCA 287 at [40], [41] and [45] and Insurance Australia Ltd v Marsh [2022] NSWCA 31 at [11], [21] and [64].
3. Although the Panel has reached the same conclusion on the assessment of permanent impairment as Medical Assessor Wallace in relation to the left knee injury, it has reached different conclusions on causation of injury in regard to the lumbar spine, left hip and left foot and heel. The Panel therefore revokes the certificate of the single Medical Assessor and issues a new certificate. The replacement certificate of the Panel is attached at the commencement of these reasons.

[1] There was also a dispute regarding the permanent impairment of the claimant's psychological injury and that was dealt with by the Panel in a separate determination. See matter number RM 20151/24.

[5] The Motor Accident Guidelines applied by the Panel is Version 10 which is effective from 15 September 2025.

[8] [2022] NSWSC 372 (Briggs (No 2)) at [73].