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

(a) whether the applicant has suffered an injury, being the aggravation, acceleration, exacerbation or deterioration of a disease to which employment was the main contributing factor to that aggravation, acceleration, exacerbation or deterioration, and

(b) Whether surgery proposed is reasonably necessary as a result of injury.

1. I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.
2. This matter proceeded to hearing on 18 February 2026. Mr Singh was represented by Mr Barter of counsel, instructed by Law Partners. The respondent was represented by Mr Murray, appearing for Integroe Partners.

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

(a) Application to Resolve a Dispute and attached documents, and

(b) Reply and attached documents.

1. The applicant provides a statement dated 28 August 2025.
2. He describes his employment with the respondent and the duties included in that employment. He describes beginning to experience pain and swelling in his calves and feet around 2017, that progressed until November 2023, when the pain and symptoms became more significant. Mr Singh goes on to describe his treatment regime, eventually leading to the recommendation of surgery now proposed.
3. Of particular relevance to the issues in dispute in this case is Mr Singh's description of his duties:

"My work as a train driver involved long hours of standing and walking on uneven surfaces, which has led to severe pain, throbbing, and constant itchiness in both my legs. This discomfort has intensified over time, and I believe that the repetitive strain from my duties is the main reason my symptoms have worsened. As Dr Conrad confirmed, studies have also shown that standing and walking for prolonged periods of time considerably aggravate the onset and progression of congenital varicose veins."

1. Dr Conrad provides three reports for the applicant. Two are dated 19 September 2024 (one of little relevance providing an assessment of whole person impairment) and a supplementary report dated 25 March 2025.
2. Dr Conrad notes a history of no problems with varicose veins prior to commencing employment. Dr Conrad records the following history: "He advised that whilst driving the train he was sitting with an option to stand." He provides the following opinion:

"Mr Singh has developed bilateral long saphenous vein incompetence, causing significant varicose veins and eczema in both legs. There is some evidence of early short saphenous incompetence. In my view, whilst the varicose veins have appeared partly because of a congenital predisposition, all the evidence points to the fact that his work as a train driver with New South Wales Trains has been the substantial contributing factor to the development and progression of his varicose veins and eczema."

3. Dr Conrad goes on to explain that he disagrees with the opinion of Dr Akroyd, and goes on to explain that "his standing and walking whilst employed by State Rail have contributed to his varicose veins and need for surgery".
4. In his supplementary report, Dr Conrad explains that he agrees with the opinion of A/Prof Vicaretti but disagrees with part of the opinion, explaining that he is of the view that walking on uneven ground can "exacerbate the development and progression of varicose veins" (in contrast with A/Prof Vicaretti, who suggests that it can only be cause by periods of long standing).
5. Dr Conrad then goes on to opine that employment was the main contributing factor (having previously answered questions in terms of "substantial contributing factor").

1. The respondent relies upon the opinion of Dr Ackroyd in a report dated 2 July 2024. He provides an opinion that Mr Singh has "congenital bilateral saphenous vein incompetence". He opines that they are not due to his workplace activities but congenital in nature. He goes on to state:

"The varicose veins are not an 'injury' and are congenital in nature. They are not a workplace injury. Employment does not appear to be a significant aggravating or exacerbating factor."

2. A series of questions were asked of Dr Ackroyd, as is commonplace in any dispute before the Commission. Those questions are unspecific and unhelpful, a point I will expand on below. This reduces the actual weight that can be given to Dr Ackroyd's opinion.

Reports and clinical records of A/Prof Vicaretti

1. A/Prof Vicaretti is the applicant's treating vascular surgeon, who has proposed the surgery Mr Singh now seeks.
2. He provides a report dated 9 May 2025 addressing questions posed by Mr Singh's solicitors. He notes a family history of varicose veins but "no other obvious pre-existing conditions or pathology that have influenced the progression of the varicose veins". He opines that Mr Singh's occupation, involving long periods of standing, make the veins more obvious and more likely to become symptomatic. He says that it is difficult to determine that his employment was the main contributing factor to the aggravation, acceleration, exacerbation or deterioration of his varicose veins.
3. He goes on to say, however, that he agrees with Dr Ackroyd that there is a congenital component to the varicose veins, but also strongly agrees with Dr Conrad's assessment that although there is a congenital predisposition, to developing varicose veins, they have been aggravated and complicated "Likely secondary to his long periods of standing".
4. In a report dated 26 March 2024, responding to questions posed by the respondent's insurer, A/Prof Vicaretti suggests it is unlikely that Mr Singh's veins are directly the result of walking on uneven floor or gravel, but that the varicose veins "will have been exacerbated with long periods of standing".

1. There are other clinical records of Mr Singh's treating general practitioner attached, that bear little relevance to the issues in dispute which are really of a medical causation nature. Also attached are the results of the doppler studies conducted on Mr Singh's lower limbs, dated 30 November 2023, which have been commented on by the treating and medicolegal doctors in this case.

1. The parties provided oral submissions at the hearing, which were recorded. As such I do not intend to repeat their submissions in great detail.
2. The applicant's case is that Mr Singh's employment involved long periods of standing, walking and moving over uneven ground, and there is no lay evidence to the contrary. The varicose veins were not caused by work, but were rendered symptomatic by that work. By being rendered symptomatic, the injury is properly described as an aggravation, acceleration, exacerbation or deterioration of an underlying condition. There does not appear to be any doubt that work did render the condition symptomatic. The applicant referred to AV v AW [2016] NSWWCCPD 9.
3. The applicant referred to A/Prof Vicaretti's opinion, noting that long periods of standing are more likely to cause the condition to become symptomatic. A/Prof Vicaretti says that long periods of standing are a contributing factor, but there are no other factors identified.
4. With respect to Dr Ackroyd, the applicant submits that he did not take a history of symptoms similar to that of A/Prof Vicaretti, and his report is now out of date. The symptoms were not present on the day, and it is not outside the realms of logic that if there were symptoms on the day it would have been dealt with. He has not addressed the issue in s 4 of the Workers Compensation Act 1987 (1987 Act).
5. The applicant submits that treatment is a necessary conclusion based on symptoms, and Dr Conrad accepts that the injury results from long periods of standing associated with employment.
6. The respondent commenced by submitting that Dr Ackroyd's opinion can't be diminished because of the presence or otherwise of symptoms. He is well aware of the presence of varicose veins, and provides a clear and direct opinion of the matter, that they are congenital. He concludes that the varicose veins are not an injury. He was not ignorant of the applicant's report of symptoms.
7. The respondent referred to the first attendance in the clinical records for this complaint, which does not record prolonged standing. The applicant's statement sets out that he has extended periods of standing but there is no attempt to explain what this means. The statement does not greatly assist.
8. The respondent submits that A/Prof Vicaretti doesn't support the applicant. The attendance of 28 February 2024 does not take a history of a work related cause. The precise pathology sought to be treated by the surgery recommended has not been commented on. The respondent then referred to the report of 26 March 2024, where A/Prof Vicaretti suggests that varicose veins will be exacerbated by long periods of standing. The respondent submits it is necessary to inquire whether there was, in fact, long periods of standing. The report of 9 May 2025 suggests it is difficult to determine the main contributing factor. Thus the applicant falls short, and A/Prof Vicaretti is not supportive of the claim the applicant brings.
9. The respondent then referred to the report of Dr Conrad, submitting that the history does not deal with the periods of long standing. Dr Conrad uses development/progression, but not aggravation. Dr Conrad has not engaged with the question in s 4(b), and refers to studies that are supportive but those studies are not referenced or put before the Commission. Reasonably necessary in a broad sense is not in dispute - the issue is the need for surgery as a result of injury. There is no opinion provided about the contribution made by the aggravation. The respondent says Dr Conrad's opinion is a bare ipse dixit. On the other hand, Dr Ackroyd has provided a clear, precise and consistent opinion. There are deficiencies in the opinion of Dr Conrad and significant doubt about what I should do with his opinion.
10. The applicant provided brief submissions in response. The question is, is the purpose and potential effect of the treatment proposed by A/Prof Vicaretti to alleviate the consequences of injury, the consequence being the rendering of the veinous insufficiency symptomatic? The applicant submits that there is no evidence to the contrary of the applicant standing for long hours. If I were to accept that the applicant was standing for long hours, I would accept A/Prof Vicaretti's comments. There is no competing contributing factor identified and A/Prof Vicaretti's opinion is consistent with the opinion of Dr Conrad.

1. There are two issues I must determine in this case - whether Mr Singh has suffered an injury, and whether the proposed surgery is as a result of the injury (if found). In those circumstances it is appropriate that I deal with the injury issue first.

1. The applicant's claim for injury is on the basis of an aggravation, acceleration, exacerbation or deterioration of a disease, where employment was the main contributing factor to that aggravation.
2. Based on the medical evidence before me, from the applicant's treating doctor and independent medical expert, is that the aggravation has been caused by long periods of standing. This is consistent with the applicant's statement, where he explains:

"My work as a train driver involved long hours of standing and walking on uneven surfaces, which has led to severe pain, throbbing, and constant itchiness in both my legs."

3. There is some doubt about whether medically periods of walking on uneven surfaces can cause the exacerbation of varicose veins. A/Prof Vicaretti suggests that it is "unlikely" that the symptomatic varicose veins are directly the result of walking on uneven floor or gravel. Dr Conrad suggests that it can, "especially on uneven ground".
4. At the hearing, the applicant confirmed that the causal factor in this case was the long periods of standing, rather than walking on uneven ground. There is no factual evidence to contradict Mr Singh's claim that his work as a train driver involved long periods of standing. His statement deals with this issue. Whilst the respondent points out that the statement is quite thin on this point, with no concrete explanation of what "long hours of standing" means, I am not of the view that this fatally undermines Mr Singh's case. It is a phrase of common parlance that is easily understood - Mr Singh spent many hours during the day standing. It does not need to be explained further. The respondent has not produced any evidence to cause me to doubt Mr Singh's account.
5. The applicant's legal case is that he had varicose vein problems that were rendered symptomatic by work, by being rendered symptomatic, the injury is properly described as an aggravation, acceleration, exacerbation or deterioration of the underlying condition. To satisfy the requirement of s 4(b)(ii) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act), the applicant must prove that employment was the main contributing factor to the aggravation (not to the disease itself).
6. This brings into some doubt the opinion provided by Dr Ackroyd. In particular, the questions he was asked in preparing his report of 2 July 2024 do not specifically go to the definition of an aggravation of a disease injury in s 4. Question 3 addresses a causation issue:

"3. Your opinion as causation of the bilateral foot pain and bilateral varicose vein injury whether there is an aggravation/exacerbation to a pre-existing injury and if employment remains the substantial contributing factor? Timeframe for any aggravation/exacerbation symptoms to cease? Any symptoms not related to work?"

7. To which Dr Ackroyd replied "the varicose veins are not an 'injury' and are congenital in nature".
8. The next question addresses the main contributing factor test:

"4. Are there any pre-existing/degenerative conditions or pathology that may have influenced the progression of the injury? If so, is employment the main contributing factor? If employment is the main contributing factor, what is the timeframe for the symptoms to cease?"

"There are no pre-existing degenerative conditions. The varicose veins are not an injury but rather a congenital condition. Employment is not the main contributing factor."

10. The problem with Dr Ackroyd's opinion here is that in essence, he is answering a question not raised by the legislation. The clumsy phrasing of question 4 suggests that there is a "pre-existing" or "degenerative" condition that has "influenced the progression of injury". The next question is whether "employment is the main contributing factor", but that begs the question of the main contributing factor to what? In a case where the applicant is suggesting his employment aggravated a disease, to which employment was the main contributing factor to that aggravation, questions must be specific so that an independent medical expert can provide an appropriate answer. The shortcomings of the questions asked of Dr Ackroyd really undermine his opinion.
11. This is further evidenced by the first sentence of his response to question 4. He answers that there are no pre-existing conditions but then goes on to say that varicose veins are a congenital condition. This answer is internally inconsistent - a congenital condition obviously pre-exists employment as it is inherited. Further, the fact that Mr Singh may have had a congenital varicose vein condition does not preclude him succeeding on an injury claim, if that congenital condition has been aggravated by his employment. Of course Mr Singh must prove that assertion on the balance of probabilities. It is appropriate to consider the medico-legal and treating evidence that he relies upon in support.
12. Dr Conrad provides a series of reports. Questions 1 and 2 in the report dated 25 March 2025 appropriately address the issue in question in this case (in contrast with Dr Ackroyd's opinion), and Dr Conrad supports the causal question raised in s 4 of the 1987 Act:

"It is my view that Mr Singh's employment with Sydney Trains is the main contributing factor to that exacerbation, aggravation, deterioration and acceleration."

13. Dr Conrad also considers the opinion of A/Prof Vicaretti, in particular agreeing that varicose veins will be exacerbated by long periods of standing, and addressing the contribution question:

"Prof Viceretti whilst agreeing that his occupation involve long periods of standing which would have contributed to the varicose veins. He was not able to quantify the degree of contribution. My own view is that prolonged standing and walking is a significant contributing factor to the development of varicose veins."

14. Dr Conrad explains why he disagrees with the opinion of Dr Ackroyd:

"I disagree with Dr Ackroyd's views in his report dated 2 July 2024. I confirm that I have specific expertise in the diagnosis and treatment of varicose veins and venous disease and confirm that my OAM was awarded for services to vascular medicine and in particular I have had a significant interest in Phlebology, the study of venous disease having been a past President of the Australian & New Zealand Society of Phlebology as well as a President of a World Congress of Phlebology in Sydney. This makes me competent to express my view that whilst Mr Singh has a congenital tendency to form varicose veins, his conditions of work significantly contributed to these I disagree that congenital flatfeet cause foot pain. It has been repeatedly confirmed in the past that flatfeet do not cause any major problems. The standing and walking would have contributed to Mr Singh's foot pain. In conclusion, I disagree with Dr Ackroyd that varicose veins are not an injury but rather a congenital condition and employment is not the main contributing factor. This is simply not true and there are many studies which show that standing and walking for prolonged periods of time considerably aggravate the onset and progression of congenital varicose veins."

15. The respondent made submissions about this opinion, in particular Dr Conrad's reliance on studies that are not before me. Again, I do not believe this undermines his opinion. He is expressing his clinical views as an expert in the field, explaining the basis for the conclusion he has reached. Whilst the studies are not before me, Dr Ackroyd's opinion is not couched in terms that long periods of standing cannot exacerbate varicose veins (which is the nature of the studies Dr Conrad refers to) but rather a conclusion on injury in this specific case. That is, the debate is not a medical one, about whether standing can aggravate symptoms of varicose veins, that may be elucidated by studies (that I accept are not before me). The issue is whether Mr Singh's employment was the main contributing factor to the aggravation, acceleration, exacerbation or deterioration of a disease. Dr Ackroyd disagrees, but for the reasons given above his opinion has significant flaws.
16. The respondent also submits that Dr Conrad's opinion is unhelpful because he simply regurgitates the words of s 4(b)(ii) of the 1987 Act. I do not accept that submission. Dr Conrad has considered the specific circumstances of the case, and using his medical expertise has addressed the question asked of him. He answers a question about whether employment is the main contributing factor to the aggravation, exacerbation, deterioration or acceleration of Mr Singh's disease by using those specific words. This is not something that can be criticised. Dr Conrad is required to answer the causation questions posed by the legislation, and unlike Dr Ackroyd, he has done so. His opinion must be read fully to understand it, but he has gone to great lengths to explain the connection between Mr Singh's employment and the aggravation of the varicose vein condition he suffers.
17. Finally Mr Singh's case finds significant support in the opinion of his treating specialist, A/Prof Vicaretti. In his report of 9 May 2025, he sets out that long periods of idle standing are recognised as an exacerbating factor towards the acceleration of varicose veins. He suggests it is "difficult to determine" if employment was the main contributing factor to the aggravation, acceleration, exacerbation or deterioration of varicose veins. He goes on to say that he agrees with Dr Ackroyd that there is a congenial component to the varicose veins but additionally agrees with Dr Conrad's assessment that the varicose veins have been aggravated "likely secondary to his long periods of standing".
18. I accept that A/Prof Vicaretti's opinion is somewhat equivocal. Ultimately I find that he supports the applicant. It must be acknowledged that he is not a medico-legal expert and not providing an opinion as such. When read as a whole, A/Prof Vicaretti supports a causal connection between long periods of standing (which it is undisputed Mr Singh completed) and the aggravation of varicose veins. When read with Dr Conrad's opinion, this is supportive of the applicant's case.
19. For the above reasons, I am satisfied that Mr Singh has suffered an injury in the course of employment having aggravated, exacerbated, accelerated or deteriorated a disease, being congenital varicose veins, and employment was the main contributing factor to that aggravation, acceleration, exacerbation or deterioration.

1. The respondent also disputes the surgery claimed by Mr Singh pursuant to s 60 of the 1987 Act, on the basis that it does not result from any injury, but rather is due to a congenital condition.
2. There is no real dispute that Mr Singh needs the surgery proposed. Dr Ackroyd states the following:

"The small area of venous eczema on the left lateral calf is of some importance and it would be reasonable to offer him a left short saphenous vein tie and strip with phlebectomies to the feeding varicosities. While he does have some left LSVI I think the principal problem is the SSVI provided a comprehensive venous US did not show a pseudo-SSVI from the left LVVI. > > I don't think the left LSVI requires treatment provided the possibility of a pseudo-SSVI has been considered unlikely. This is on the basis of not overtreating the condition in a largely asymptomatic patient. I do of course accept that Dr Vicaretti will have his own views on the extent of treatment and I would defer to those. > > As for the right side I was only able to detect right LSVI today. However, the right side is asymptomatic and I don't think this warrants treatment at this stage. He is not troubled by any cosmetic issues and the pruritis is not a symptom of VV's."

3. Ultimately, per that opinion, Dr Ackroyd defers to the opinion of A/Prof Vicaretti. It is noted, and has been submitted upon, that at the time of Mr Singh's consultation with Dr Ackroyd, he was not particularly symptomatic, which has potentially influenced his opinion. I do not think that bears great weight on Dr Ackroyd's opinion in relation to the injury issue, which I have dealt with above. However, it does have some relevance to Dr Ackroyd's opinion in respect of what would be considered reasonably necessary, as symptoms can fluctuate. At the time of the assessment with Dr Ackroyd, it may have been that Mr Singh's symptoms were not as florid. In spite of this, in his report of 9 May 2025, A/Prof Vicaretti still opines that the "proposed intervention is reasonably necessary as the varicose veins are contributing to Mr Singh's symptoms".
4. Dr Vicaretti provides consistent and persuasive opinions in support of the conclusion that the surgery proposed is reasonably necessary. Dr Conrad supports this opinion on a number of occasions:

"The sooner he has surgery the better as in my view should his varicose vein condition not be treated by surgery it may progress to the extent that Mr Singh will not be able to continue his pre-accident occupation as a train driver... > > I do not believe that conservative treatment is any longer an option for Mr Singh's treatment and he definitely needs surgery."

5. I am satisfied that the surgery proposed by A/Prof Vicaretti is reasonably necessary.
6. The remaining question is whether the surgery is as a result of injury, the causation question posed in s 60 of the 1987 Act. As the respondent submits, this question is one of material contribution. The respondent submits that there is no opinion provided about the contribution towards the proposed surgery made by the aggravation.
7. I do not agree with the respondent's submissions. A/Prof Vicaretti, particularly in his report of 9 May 2025, discusses the balance between the competing factors of the congenital nature of Mr Singh's varicose veins and the contribution from his work. He states that long periods of standing is recognised as an exacerbating factor towards the worsening of varicose veins, and goes on to state:

"This is as a result of increasing venous pressures associated with long periods of standing which contribute to worsening varicose veins visually and the associated symptoms".

8. Dr Conrad, although answering a "but for" question, also provides an opinion that supports the conclusion that employment materially contributes to the need for surgery:

"Should he not have been doing this work whilst he may have eventually developed varicose veins, the conditions at work at State Rail significantly aggravated the onset and progression of this disease."

9. It is my view that the material contribution test is clearly satisfied in this case. Mr Singh had a congenital predisposition to the development of varicose veins. That condition was aggravated by his employment causing his varicose veins to become symptomatic. Over time the symptoms became worse. He has now proceeded to the point where he needs surgery, and remains employed in the same employment. There is a clear path of material contribution. The surgery would not be necessary at this point in time "but for" his employment; that is employment has materially contributed to the need for his surgery. The condition may have a congenital component, but the aggravated has caused it to become symptomatic and the surgery is treating the now symptomatic condition. The surgery, using the language of s 60, is as a result of injury.
10. Accordingly I am satisfied that the proposed surgery is reasonably necessary and will make an award that the respondent pay the costs of an incidental to that surgery.