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Case study 4 - minor injury - soft tissue injury

This case study explores a dispute about whether an injury (to the cervical spine with referred symptoms to the shoulders and thoracic spine) is a minor injury under Schedule 2 section 2(e) of the Act.

Our ref: MICS 004/018

Introduction

The claimant was driving when they were hit from behind, resulting in their vehicle lightly hitting the vehicle in front.  The claimant’s vehicle was unable to be driven after the MVA.  Immediately after the motor vehicle accident (MVA), they reported neck pain which radiated across both shoulders and into the upper back.

After consulting the GP, they were diagnosed with whiplash to the neck with referred symptoms into the shoulders and upper back.  They had 10 physiotherapy sessions.

Upon ceasing physiotherapy, neck pain increased with radiation down both arms.  As a result, the claimant had an MRI of the cervical spine. It showed no abnormality.  They continue to take analgesia.  Symptoms have improved, but they have not resolved completely.

The assessment

There is a dispute about whether the injury is a minor injury under Schedule 2 section 2(e) of the Motor Accident Injuries Act 2017 (the Act).

Clinical examination

Cervical spine

  • No localised tenderness
  • No muscle spasm
  • No muscle guarding
  • Full range of movement in flexion and extension, rotation and lateral flexion to left and right were both 75% of normal and symmetrical.
  • Normal neurological examination with normal power, tone, sensation and reflexes
  • Circumference of both upper arms and forearms were equal

Thoracic spine

  • No localised tenderness
  • No muscle spasm
  • No muscle guarding
  • Rotation to left and right was full
  • No sensory changes

Upper extremity

  • Full range of movement of both shoulders
  • Mild tenderness in mid-trapezius muscle, no tenderness over left or right shoulders or AC joints

Review of Documentation

Capacity of fitness outlines diagnosis of whiplash injury to the neck.

GP report outlines claimant being referred to physiotherapy; complaining of pain in the neck and shoulders following the MVA.

MRI report of cervical spine outlines normal findings.

Diagnosis

The claimant sustained a whiplash injury to the cervical and upper thoracic spine with referred symptoms into the left and right shoulders following the MVA.

There is no evidence of radiculopathy or any neurological condition.  There was no injury involving torn ligaments, tendons or nerves.

Minor Injury

Section 1.6(2) of the Act

A soft tissue injury is (subject to this section) an injury to tissue that connects, supports or surrounds, other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.

Schedule 1 [2] clause 4 of the Motor Accident Injuries Regulation 2017:

  1. An injury to a spinal nerve root that manifests in neurological signs (other than radiculopathy) is included as a soft tissue injury for the purposes of the Act.

The following injury is a minor injury

  • Cervical spine – soft tissue injury with referred symptoms to either shoulder
  • Thoracic spine – soft tissue injury