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Assessment of minor injury - soft tissue injury

This case study looks at a specific example of injuries sustained in a motor vehicle accident and whether those injuries meet the definition of a soft tissue injury.

Our ref: MICS002/18

Introduction

The claimant was involved in a rear end motor vehicle accident (MVA) and immediately reported neck pain which radiated across to both shoulder and into the upper back. Review with GP indicated whiplash injury to cervical spine with referred pain and referral for physiotherapy.

The claimant underwent 10 sessions of physiotherapy and was referred for an MRI of the cervical spine due to increasing neck pain. The MRI showed no obvious abnormality.

The claimant remains in pre-MVA employment and is managing with occasional discomfort.

On examination

Ongoing neck symptoms with referral to upper back and shoulders – improved but not resolved completely.

Cervical spine

  • No localised tenderness, muscle spasm or guarding
  • Full range flexion / extension
  • Rotation to left and right was 75% normal and symmetrical
  • Lateral flexion left and right 75% normal and symmetrical
  • Neurological examination bilateral upper limbs showed normal muscle power, tone, sensation and reflexes
  • No muscle wasting of upper arms and forearms

Thoracic spine

  • No localised tenderness, muscle spasm or guarding
  • Rotation left and right was full and pain free
  • No sensory changes to chest wall

Upper extremity

  • Mild tenderness mid trapezius muscle but no tenderness over bilateral shoulder joints or AC joints
  • Bilateral shoulder movement was full and pain free

Documentation

  • Personal injury claim form listed injuries as sore neck and soreness in both shoulders
  • GP report – whiplash to neck treated with pain relief and physiotherapy
  • MRI report – normal findings

Diagnosis

The claimant sustained a whiplash injury to the cervical and upper thoracic spine with referred symptoms into the left and right shoulder regions. This is classified as a soft tissue injury.

There is no evidence of radiculopathy or 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.

The following injury is a minor injury:

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