...felt a pain in the underside of her right wrist, which progressively got worse until she came and informed me where I told her to stop coding. Her fingers on the right hand are also very stiff and hard to being preventing any further coding of associated work.

The Applicant says she agrees with this description.

1. After this, the Applicant was moved to do manual sorting and she has not performed coding work on the machine since.
2. The Applicant lost only a day or two at work since being put on different duties but she said she continue[s] to experience pain [in] the right hand and wrist and the fingers [have] developed numbness and tingling. This she said refers mainly to fingers 4 and 5 but it affects the others as well. She said [w]hen I am working in really busy periods I feel the tingling as far as my elbow.
3. In relation to the tingling in her elbow, the Applicant gave evidence that acupuncture provided some relief, but this was only temporary for approximately an hour following treatment.
4. The Applicant is on light or restricted duties at work and is unable to use the FSM machine, the Flay Sorting Machine.
5. The Applicant said she is on a waiting list for surgery. Her pain tends to come on at night in bed. She further stated that she experiences pain in completing household tasks like cutting vegetables or doing the washing, but that now she takes [her] time doing that stuff.
6. Under cross examination the Applicant agreed that she would have started work with the Respondent in about December 2006. She agreed it would have been at about 10.15 am on 22 April 2016 that she spoke to her Process Leader. The day before she had noticed the stiffness in her fingers. A tingling sensation occurred afterwards
7. Under cross examination, the Applicant also agreed that over a period of 82 weeks she had been working 3.2 days per week and not 5. The Applicant said when asked about it that nothing outside work [had] aggravated her condition. At home she engages someone to mow her lawns. Her block is a big one on 2 levels with the back higher than the front. She said she continues to drive her car but finds it hard to reverse it. As to cleaning around the house she now uses her left hand.
8. The Applicant said when questioned that in her right hand the pain and numbness are always there. Formerly her fingers 4 and 5 were affected but now all of them are affected.

Associate Professor Felix Behan plastic and reconstructive surgeon

1. Associate Professor Behan gave sworn evidence which included verifying the contents of his Report dated 19 June 2017, a letter dated 26 October 2017 and a further report dated June 2018.
2. In his June 2017 report Associate Professor Behan expresses the view that the Applicant's condition is work related carpal tunnel syndrome (CTS). He says the cause of CTS is usually multi-factorial with more than one factor point of focus. He says there is conclusive evidence from well performed studies that the practice of using the hands and wrists at work can lead to increased risk of development of CTS. He quotes various examples in the literature supporting his view and relies on digital photography which he says verifies the clinical signs. He expresses the view that the aetiological factor of using a Coding Machine would be a significant contributing factor to the onset of CTS.
3. In the letter dated 26 October 2017, amongst other things (including taking issue with the Stapleton correspondence of 14 August 2017) Associate Professor Behan says that the neurological background for CTS is well established. He points out that it was clinically established by the Neurologist Sir Russell Brain from a diagnostic point of view and subsequently surgical release of the CTS was popularised by Dixon Wright and published a series in the British medical Journal in the late 40's.
4. In his June 2018 Report, with yet further photographs, Associate Professor Behan comments that if the Applicant had not been at work she may not have experienced the CTS development. He says I would certainly consider the patient to have a disability from an industrial loss point of view as a result of his/her injuries taking into consideration the clinical, domestic, industrial and social aspects. He says:

On the balance of probabilities the patient has a work related condition and the word 'probability' has a connotation of being more likely than the word, 'possibly' which means 'may'. He says his findings are clinical confirming the patient has the diathesis and the work related factor has contributed to the development of the CTS.

He concludes by saying the definitive procedure of surgical release [of the ulnar nerve] is indicated ...in this patient.

1. In oral evidence Associate Professor Behan confirmed the contents of his other report and letter and repeated his view that the pattern of the Applicant's symptoms and the onset of pain was consistent with his view. Her grasping, gripping and manipulating of her right hand had the potential for her to develop tenosynovitis.
2. Under cross examination Associate Professor Behan said that he had been operating on CTS two or three times a week for 20 years or more. He agreed that while the Applicant's condition could have happened in any event it was her employment which brought it to a head.

1. Dr Tony Kostos, rheumatologist, gave sworn evidence confirming his report dated 27 February 2018.
2. In that report Dr Kostos upon examination considered the Applicant's left wrist showed a full range of pain free movement but her right wrist movements he said are all slightly restricted compared with the left ,with some minor tightness. He said her right wrist is not swollen but there is diffuse tenderness over the flexor and radial aspects of the wrist.
3. Dr Kostos says that overall his examination revealed that the Applicant does have some slight restriction of right wrist movement, although the reason for this is not apparent from the information currently available. He said he would have to suggest that her symptoms do seem quite typical of right carpal tunnel syndrome.
4. Reviewing reports from Associate Professor Behan and Mr Stapleton, Dr Kostos said as regards CTS however that it needs to be understood that it is a common idiopathic condition. He said it is more common in middle aged women and in our current society is strongly associated with obesity. He takes issue with Associate Professor Behan and the literature which he cites, saying it has been selectively quoted by him. He says the best evidence we have available does not support the contention that carpal tunnel syndrome is related to keyboard use or other physical activities. If, after trying a course of oral prednisolone or even a corticosteroid injection into the carpal tunnel, the Applicant's symptoms continue to persist, Dr Kostos said a decompression may be necessary.
5. In oral evidence, Dr Kostos said that even if the Applicant was only working an average of 19.25 hours per week, his views would not change. He repeated that the majority view is that CTS is idiopathic. In his opinion, the Applicant would have developed her condition irrespective of her employment.
6. Under cross examination Dr Kostos said the Applicant had no ulnar nerve symptoms. He said his routine was to ask patients what their symptoms were: he said I ask them what their complaints or symptoms are.
7. He was asked about whether his views about CTS were biased in that he was expressing a view in response to some of the literature but dismissing it without having read it. He denied this.
8. In re-examination, Dr Kostos repeated that in the Applicant's case there were no symptoms of ulnar nerve compression.

1. Mr Murray Stapleton gave evidence that he is a retired plastic and hand surgeon.
2. Mr Stapleton in sworn evidence confirmed the contents of his report dated 25 July 2016, his supplementary report dated 30 August 2016 and his letter to Australia Post dated 14 August 2017.
3. In his first report, Mr Stapleton expresses the view that it is likely [the Applicant] is suffering from early carpal tunnel syndrome. He said it may be a secondary problem because of flexor tendon tenosynovitis. He said the latter would be regarded as related to repetitive activities and, therefore, would be regarded as a work-related condition. The former (CTS), however, he says is a condition which is unrelated to repetitive activities or hard manual labour. Although the Applicant claims her symptoms are aggravated by using a coding machine, the suffering of symptoms when using machines such as that does not go to the question of causation or aggravation of whatever the pathological process underlying [the] condition might be. He goes on to say that he is unable to determine with accuracy whether [her condition] is a work-related condition or not. However, he says her condition is more likely a problem of CTS which will be found to be unrelated to her occupation. He says it would appear that the Applicant is not suffering from any disease process.
4. In his second report Mr Stapleton says the Applicant has early carpal tunnel syndrome on the basis of the evidence and that is not related to her occupation. He says CTS is not caused by repetitive activities or hard labour and is a condition of gradual onset which will worsen particularly as she passes through the age of menopause.
5. In his letter of 14 August 2017, Mr Stapleton refers to the oceans of reports that Associate Professor Behan has sifted through concerning CTS. He then offers a critique of each. He says that Associate Professor Behan has obviously... not taken note of the fact that [CTS] is a condition which affects females of middle age and has obviously not taken any account of the fact that of those females who suffer from carpal tunnel syndrome, half of those do not work at all. He refers to his own 2006 study Occupation and Carpal Tunnel Syndrome as the largest study of occupation and carpal tunnel syndrome published.
6. In oral evidence, Mr Stapleton indicated he had been a surgeon working in this area for 35 years. He said there is evidence in the Applicant's case that she has the beginnings of CTS. He said pins and needles at night are invariably a sign of CTS. Picking up mail items at work he said may have given her symptoms of CTS. But CTS is not related to occupation.
7. Under cross examination, Mr Stapleton said CTS is multifactorial and that there is no gold standard diagnosis. He indicated his view was that employment cannot tell us anything about CTS. The typical group suffering CTS he answered is middle aged females.

1. Mr Carey submitted on behalf of the Applicant, if I may summarise, that I should find that the Applicant's wrist condition of CTS was not in dispute as such and that I should find she had suffered an injury simpliciter arising out of or in the course of her employment_._ Alternatively, I should find she had suffered an injury in the sense of a disease, being an ailment or an aggravation of an ailment contributed to, to a significant degree, by her employment. In either case I should find she has been incapacitated by her injury and that it is compensable under section 14 of the Act. Accordingly, he submitted, the decision under review should be set aside.
2. Mr Seit on behalf of the Respondent, again if I may summarise, agreed that CTS was a valid diagnosis of the Applicant's wrist condition but he disputed that on the evidence I could find that this was an injury simpliciter. Nor should I find that she had suffered an injury in the sense of a disease. Or an ailment or an aggravation of an ailment because her condition only became worse at work and was not made worse because of it. In any event, CTS could not have been brought on given the nature of her work. In other words, I should find no connection between her work and her CTS. Therefore, the decision under review should be affirmed.

1. I consider that it is proper for me to make a finding that the Applicant has a condition in her right wrist that has lead to some incapacity for work or impairment.
2. I consider it proper also to find that her condition is correctly described as CTS. This was the view of both Associate Professor Behan and Mr Stapleton. Dr Kostos described her condition as quite typical of CTS. Particularly as she reported pain or discomfort at night in bed.
3. In my view the Applicant, although female, suffers CTS despite not being obese or middle aged or of menopausal age.
4. There is no doubt I may find that she reported her condition at work on 22 April 2016 so that it may be said that while at work she experienced symptoms of her condition. However, I cannot agree I should find that her condition is a case of injury simpliciter.
5. I cannot see any particular action that caused her condition to flare up on that day as opposed to any previous day. I note, as was pointed out, that the Applicant was off- work the day before and that she reported her condition one hour into her employment on the day in question. I am unable to identify any specific event or occurrence which took place on that day which caused her to be injured such as by way of trauma, for instance, if she slipped and fell or suddenly dropped a tub of letters, or if the moving part of a machine had struck her. In other words, I cannot identify clearly any injurious event or occurrence.
6. I therefore reject the notion that her condition is a case of injury simpliciter.
7. I consider, however, that CTS falls within the definition of an ailment under section 4(1) of the Act in that I regard it as a physical or mental ailment, disorder, defect or morbid condition. An ailment which is not of sudden onset but is of gradual development such as CTS, is not excluded from that definition but is included within it.
8. Also, subject to what I have yet to say, I regard the Applicant's CTS as a disease under section 5B(1) of the Act either because it is an ailment suffered by the Applicant or because it is an aggravation of an ailment suffered by her and is, therefore, on this basis, an injury by reason of section 5A(1) of the Act. An aggravation by section 4(1) of the Act includes an acceleration or recurrence. I do not consider that this analysis is weakened at all by showing, as the Respondent sought to do, that the number of days at work nominated by the Applicant must be reduced to some extent in light of employee attendance records which I have noted.
9. It is relevant in this regard to ask whether in respect of an aggravation of an ailment an applicant's condition became worse or was made worse by reason of employment. See Comcare v Reardon (2015)148 ALD 356. Thus, as stated by Kitto J in Federal Broom Co Pty Ltd v Semlitch [1964] HCA 34; (1964) 110 CLR 626 at 634 if salt be applied to an open wound, making the wound no worse but causing it to smart as it had not smarted before ,it is proper to say there has been an exacerbation of the wound.
10. Kitto J in that case also quoted Moffitt J that there is an exacerbation of a disease where the experience of the disease by the patient is increased or intensified by an increase or intensifying of symptoms. Clearly, however, it will not be in every case that a worker with a pre-existing injury who carries out work and as a result suffers pain will have suffered an aggravation of their injury. For example, a worker whose fractured leg is encased in plaster will be unable to put it to the ground without suffering pain and other disability: per the Court in Commonwealth v Beattie [1981] FCA 88; (1981) 53 FLR 191.
11. I should indicate I regard the word aggravation as synonymous with exacerbation. See Wiegand v Comcare Australia [2002] FCA 1464 at [21] per von Doussa J. And I am clear however that an aggravation of an ailment may show itself by pain. In Tippett v Australian Postal Corporation [1998] FCA 335; (1998) 27 AAR 40 Finkelstein J explained at 44:

[p]ain is the most common form of an injury [and] if the pain from an underlying condition is aggravated, that is increased or intensified, as a result of an employee's employment then the employee will have suffered a compensable injury.

1. Beyond satisfying other requirements it must be plain for the purposes of section 5B(1) of the Act that an ailment suffered by an employee or the aggravation of one must have been contributed to, to a significant degree, by the employee's work. That is to say, by section 5B(3) of the Act, to a degree substantially more than merely material.
2. I am satisfied on the balance of probabilities that the Applicant's condition of CTS is an ailment or is an aggravation of an ailment contributed to, to a significant degree, by her work with the Respondent.
3. The ailment or aggravation of an ailment was signified by pain especially on 22 April 2016 when the Applicant came to report it. On that day in my view her pain increased or intensified to use Moffitt J's expression. For that was why she had occasion to report it. I regard the occasion of her report as plainly one where she was reporting the acceleration of symptoms or their recurrence within section 4(1) of the Act
4. I take the view, based on this aspect of the evidence of Mr Stapleton, that CTS is a condition of gradual onset. That means the Applicant would have had symptoms going back over a period of time. That accords with the facts as I see them. The Applicant had for some time before her report of her condition on 22 April 2016,a short or a long time before then, I am unable to specify, been suffering symptoms. The Report says that the pain had progressively got worse to the time of her reporting it. This is consistent with her own evidence, that it was in the course of that month, but earlier on I note, that she had noticed pain and stiffness in her right wrist.
5. Therefore, although on 22 April 2016 the Applicant reported that she was experiencing pain at work I am satisfied that it was not only on that day that she was experiencing it. But on that day, as I say, her pain, which symptomized her condition, increased or intensified. Or, as a result, her condition accelerated or recurred within section 4(1) of the Act
6. I am satisfied also, on the balance of probabilities, that there was more than a mere temporal association between the Applicant's symptoms and her work. In my view her work contributed to her symptoms and thus to her condition to a significant degree so that her work with the Respondent was relevantly causative.
7. I appreciate there is profound disagreement between the medical experts on the question of whether the Applicant's work, particularly in coding, could have caused her CTS. Associate Professor Behan is strongly of the view that it could and did, but this view is not shared by either Dr Kostos or Mr Stapleton.
8. My role is not to establish or defend a particular scientific proposition: my role is to decide this case on the balance of probabilities. A fact which is found by me is found according to this standard. I am not strictly finding scientific facts as such at all.
9. On the balance of probabilities I am satisfied that I should follow Associate Professor Behan's view and hold that the Applicant's work did cause her condition. It may be correct that he has sifted through an ocean of views and has selected those which support his position. I make no findings in that regard. But his position seemed entirely tenable in light of the evidence before me and seemed also to agree with a view not unable to be reasonably held. That is that the Applicant's highly repetitive work done at a fast pace especially on the coding machine either initiated her CTS as an ailment or more likely made it worse and was an aggravation of an ailment.
10. I consider that seeing a connection between the two is not fanciful or unreal and may be respectably made. I note that Associate Professor Behan has been performing operations on CTS suffering persons each week over a long period of years. I must indicate I regard Dr Kostos, a respected rheumatologist, as not having an open mind at all to the possibility that CTS could arise in the workplace. I note he could not even countenance the possibility, despite not reading some of the literature which does not seem very satisfactory. I do not regard Mr Stapleton, a respected retired plastic and hand surgeon, however, in the same way. Nonetheless I prefer the views of Associate Professor Behan as being in accord with the evidence before me -of repetitive work done at a fast pace over a lengthy period of time - bearing in mind the standard which I must apply.
11. I note that Associate Professor Behan also addressed the meaning of the probabilities. In his view, to paraphrase it, probabilities being more likely than possibly meaning only may. This is a little inexact, although I consider his meaning was clear and I take no exception to it. However, it was not something addressed by either Dr Kostos or Mr Stapleton at all. It became evident to me, as I viewed their evidence, that they were using a different standard altogether by which to express their opinions. They were looking at the question of whether CTS is causally related to work as a matter of undeniable scientific fact.
12. I have indicated that it is not my role to decide the science on the subject. My role is more limited and it is one aided by the various definitions exceptions and stipulations in the Act. I do not consider that either Dr Kostos or Mr Stapleton took those into account properly or at all or realised fully the standard of proof which applies in proceedings of this kind. In any event it seems to me even on a cursory read that medical opinion is divided on the actual science.
13. It is then a question as I see it of whether the connection between the Applicant's work and her condition is a significant one. In my view it plainly is. I am unable to identify any other factor in her life which could have produced her CTS. I have indicated my view that she is not obese or middle aged or menopausal. This means to my mind only her employment is implicated causationally. I note Associate Professor Behan's evidence in that regard. Therefore, I consider her condition was contributed to, to a significant extent, by her employment.
14. It was submitted that the Applicant's condition would have occurred anyway irrespective of her work. This certainly was the view of Dr Kostos. However, I reject this analysis, which is one frequently encountered. To say the Applicant would have suffered this condition even though not working is to give or to accord to her a history she has not and never will have. She will never be a person who did not work with the Respondent. It is in my view hypothetical in the extreme and unsustainable in reality.

1. My analysis above leads me inevitably to the conclusion that the Applicant's CTS condition in her right wrist is compensable under section 14 of the Act as an injury occurring to her in the course of work, resulting in incapacity or impairment. In my view it is an injury in the sense of a disease meaning an ailment or an aggravation of an ailment to which her employment with the Respondent contributed to a significant degree.
2. It follows that the reviewable decision must be set aside and substituted by a decision to the appropriate effect.

1. I certify that the preceding 76 (seventy-six) paragraphs are a true copy of the reasons herein of Dr Damien Cremean, Senior Member

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