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Case study 1 - soft tissue injury

Our ref: MICS001/18

Introduction

The claimant, aged 47 was the driver in slow moving traffic and rear ended. The 4WD was subsequently repaired. The claimant noted symptoms several hours after the motor vehicle accident (MVA) of tight feelings across the shoulders, into the middle back and back of head plus headaches. There was also reduced upper limb strength and shoulder pain with lifting. The claimant has continued working in an office based position.

The claimant saw the GP, had physiotherapy treatment and rheumatology review. An MRI did not show any clear structural cause for ongoing symptoms. The claimant has trialed medication and continues to take Lyrica.

The medical assessment

There is a dispute about whether the injury (to the cervical spine, thoracic spine and right shoulder) is a minor injury under Schedule 2 section 2(e) of the Act.

The claimant was assessed six months after the MVA. The claimant reported neck, upper back and shoulder girdle pain of varying intensity. Physical activity has reduced due to pain.

On examination

Cervical spine

  • no focal tenderness
  • full range of motion in all planes (flexion / extension, rotation right / left, lateral flexion right / left) – pain reported at end of range
  • no dysmetria
  • no muscle spasm or guarding
  • no non-verifiable radicular symptoms in the upper limbs
  • deep pain reported throughout the upper limb is not a non-verifiable radicular complaint – symptoms are not within the distribution of a single dermatome
  • negative upper limb neural tension tests
  • no wasting of the upper limbs (shoulder girdles / arms / forearms)
  • reflexes normal and symmetrical
  • upper limb power and sensation normal
  • no signs or cervical / upper limb radiculopathy

Thoracic spine

  • no focal tenderness
  • 2/3 normal spinal extension / flexion; normal lateral flexion to either side and normal rotation to either side
  • no dysmetria
  • no spasm or guarding
  • no thoracic non-verifiable radicular symptoms and no signs of radiculopathy

Upper extremity

  • bilateral full range of shoulder movement in all planes (flexion / extension, abduction / adduction, internal rotation / external rotation)
  • negative impingement test bilaterally
  • at end range of abduction and flexion, discomfort at ipsilateral neck root and suprascapular region
  • no shoulder internal joint derangement

No evidence of injury to nerves, complete or partial rupture of tendons, ligaments, menisci or cartilage at either the neck or shoulder joints.  No evidence of radiculopathy of the upper limbs.

Review of documentation

Personal injury claim form - pain in neck, shoulder and upper back; headaches and poor concentration.

Physiotherapy reports – whiplash associated disorder grade II, neck symptoms referring to right shoulder. Also, thoracic facet joint irritation and hypomobility.

Rheumatology letter – symptoms of whiplash and headaches since MVA.  Determined ongoing pain was typical of whiplash with cervicogenic headaches.  Organised MRI and bone scan.

MRI scan – no fractures, ligamentous injury or neural compromise – evidence of multilevel degenerative change.

Bone scan showed mild C5-6 kyphosis / mild degeneration but no evidence of trauma.

Diagnosis

Soft tissue injury to the cervical spine with symptom referral to the upper thoracic spine and shoulder girdles (trapezial / suprascapular regions).

Based on the history provided by the claimant and the medical information available to the medical assessor, the following injuries were determined to be caused by the motor accident.

  • Cervical spine soft tissue injury with symptom referral to the shoulder girdles R>L and thoracic spine.

The following injuries were not caused by the motor accident:

  • Right shoulder
  • Thoracic spine

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.

The claimant has sustained a minor injury of the cervical spine with symptom referral pattern to shoulder girdles / upper back (thoracic spine). There is no clinical evidence of injury to nerves, complete or partial rupture to tendons, ligaments, menisci or cartilage at the cervical spine, thoracic spine or shoulders.

The cervical spine injury sustained in the MVA satisfies the definition of “minor injury” as per Motor Accident Guidelines.