Chand v Accident Compensation Corporation

IN THE DISTRICT COURT AT AUCKLAND [2013] NZACC 25Z. ACR 788/11 UNDER THE ACCIDENT COMPENSATION ACT 200 IN THE MATTER OF AN APPEAL UNDER SECTION 149 OF THE ACT BETWEEN SHARMILA CHAND Appellant AND ACCIDENT COMPENSATION CORPORATION Respondent Hearing: 24 May 2013 Appearances; P Schmidt for Ms Chand D Tui for the Corporation Judgment: 15 August 2013 JUDGMENT OF JUDGE RODERICK JOYCE QC Reason for appeal [1] Ms Chand suffered personal injury by accident on 3 May 2010 when she slipped on a floor falling on her right side and injuring her right arm and shoulder. She was afforded cover through WELLNZ which managed the claim for BUPA, an accredited employer, [2] She was then in receipt of weekly compensation and a range of medical attention. [3] On: 24 August 2011 WELLNZ wrote to Ms Chand to advise her that her entitlements were suspended for the reason that her ongoing symptoms related to degenerative changes rather than her accident. [4] Ms Chand sought a review the 24 August 2011 decision which resulted in the dismissal of her application. She has since appealed. Background [S] I record the following: * . An 11 May 2010 ultrasound of the right shoulder reported these findings: There is minimal thickening and heterogeneity at the border of the posterior supraspinatus and anterior infraspinatus tendons consistent with mild tendonosis. No tear is detected. The long head of biceps, subscapularis, supraspinatus and infraspinatus are otherwise intact. There is no bursal thickening, but mild bunching is noted on abduction which is associated with pain. " The left shoulder was reported on this in these terms: On the left no abnormality was seen involving supraspinatus, infraspinatus, subscapularis or the long head of biceps tendon, No fluid identified about the shoulder. The finally recorded impression, referring obviously to the right shoulder was this: Mild tendonosis at the posterior supraspinatus/anterior infraspinatus border. No bursal thickening, but minimal impingement on abduction appears to be associated with pain. A subsequent radiology report referring to the cervical spine disclosed that all 7 cervical vertebrae and the cervicothoracic junction were in normal alignment and the vertebral bodies maintained their heights. There was an ill defined subtle density at the anterior aspect of C5/6 that was unrelated to recent injury and of which it. was said "this may represent calcification within the anterior longitudinal ligament or may be related to old trauma". The report continued in terms that there was no adjacent loss of disc height, the adjacent bony cortex was well defined and unremarkable, the intravertebral formina were widely patent bilaterally and the posterior arches appeared unremarkable. The short observation was of no evidence of a recent bony injury but "probable early disc degenerative changes at C5/6 level". On 7 July 2010 Mr Shihab Faraj, orthopaedic and hand surgeon, arranged subacromial local anaesthesia as a diagnostic tool - and reported on 18 August 2010 that Ms Chand had had two weeks of good relief from the injection before the problem (most simply described as pain in the right shoulder area) was back again, Two types of pain were identified. That in the deltoid insertion at the back of the right arm was likely related, said Mr Faraj, to the shoulder, while that at the top of the shoulder shooting to the neck likely to be from the C5/6 spondylosis. A rehabilitation meeting on 3 August 2011 referred to Ms Chand advising that she had been experiencing ongoing sharp, shooting pain in her neck radiating down the right arm to the elbow ever since the accident despite which she had been continuing to work while taking physiotherapy which however had been unproductive. The minutes of the meeting include that: Sharmila described her accident as falling forwards after slipping on something on the ground landing on her knees and outstretched hand. Her right hand/arm took the brunt of the inipact and she felt a shock type of pain up to her neck. Her GP had now referred her to Mr Greg Finch, an orthopaedic surgeon specialising in the spine, who had arranged for an MRI that was performed on 22 August 2011. After WELLNZ wrote to Ms Chand on 24 August 2011 to say that, according to its medical information, her ongoing symptoms were not a result of the injury for which she had cover, but degeneratively sourced, Mr Finch responded in these terms; . I am unsure as to where you get your information regarding the lack of causatory effect between her current symptoms and the history of the fall. This lady clearly had a fall. She clearly injured her limb at the time of the fall and that has been well established. She has not had an MRI scan of her right shoulder and I am going to arrange that today. The only thing that she has had is she has had an injection. The MRI scan of her cervical spine does not show that she has any nerve compression therefore I deduce the majority of her symptoms are in fact coming from her shoulder. She has had an ultrasound of her shoulder only but that has not fully quantified or clarified what is going on the shoulder joint. Furthermore the injections that she had did not actually help with this problem which therefore may call into question whether or not this subacromial bursa is in fact symptomatic. A 13 September 2011 MRI of the right shoulder was reported with this impression: There is mild subacromial/subdeltoid bursal thickening. There is some mild heterogeneity of signal intensity of the distal supraspinatus tendon with some minor bone marrow oedema of the greater tuberosity at the tendon insertion. There are also splits and swelling of the distal subscapularis tendon. There is mild prominence of the anteroinferior aspect of the acromion with mild thickening of the coracoacromial ligament intending the subacromial/subdeltoid bursa. Mr Finch wrote of that in terms that: Sharmila's MRI scan has come back showing that she has significant evidence of damage to her shoulder. There is a little bit of evidence of thickening of the subacromial bursa and there is some bone marrow oedema near the insertion of the supraspinatus tendon into the greater tuberosity with some splits and also a bit of swelling of the supraspinatus tendon. I feel the symptoms are in fact coming from her shoulder and there is clear evidence of some inflammation, some damage and this fits with her history. I would note that she has never had any symptoms prior to the fall. All her symptoms began after the fall and therefore there is cause and effect with MRI scan evidence backing up the fact that there is an injury. I have referred her to Adam Durrant who is a shoulder surgeon for ongoing treatment and management. (Emphasis added) Writing to Mr Finch on 20 September 201 1 Mr Durrant reported his understanding of the accident in terms that Ms Chand had: Landed heavily on her right side and since that time has had ongoing discomfort felt around the right shoulder, radiating over that trapezial area and down into the bicipital region ... she is unable to lift or carry any heavy object. She is also unable to sleep on the shoulder due to discomfort. She has no pins and needles and no weakness noted in the arm. Anything performed above shoulder height is incredibly uncomfortable for her and she also has a lot of difficulty internally rotating the arm to do things He then observed that: She has had an MRI scan performed which demonstrates partial thickness tearing and swelling of both subscapularis and supraspinatus associated with subacromial bursitis, Sharmila certainly could have sustained these injuries due to the fall in 2010. The pattern of fraying of the rotator cuff would certainly not be in keeping with a degenerative change and there are no other signs within her shoulder that this is due to degenerative change, My feeling is that she has sustained a traumatic partial thickness tearing of both supraspinatus and subscapularis with resultant subacromial impingement and bursitis. I have therefore organised an ultrasound guided steroid injection ... (Emphasis added) Reporting again on 13 October 2011 he wrote; .., she has failed the steroid injection which was given under ultrasound guidance. She is still getting significant impingement type symptoms and pain around the anterolateral aspect of the shoulder. She has a lot of discomfort on any forward flexing and still has strongly positive impingement signs. This would certainly correspond with her MRI finding of subacromial bursitis and partial thickness rotator cuff tearing. In essence she has failed non-operative management and she now comes requesting subacromial decompression - I will therefore apply through the ARTP process for this today. (Emphasis added) i.: On 30 October 2011 Dr Kenny, occupational medicine specialist, reported to WELLNZ in response obviously to a request for a file review. In providing that he wrote briefly of the cervical spine reporting but minimal or mild changes there entirely in keeping with age. Turning then to the right shoulder and the MRI scan he wrote; This reportedly confirmed the mild distal supraspinatus and subscapularis tendonopathy, some changes also involving the long head biceps tendon, and mild bursal thickening, but also with some signal changes at the distal end of the clavicle and acromio-clavicular joint, including thickening of the AC joint and adjacent coracoacromial ligament. It is possible that these were wide spread degenerative changes within the acromio clavicular joint and rotator cuff apparatus became symptomatic, or more symptomatic, as a result of a fall directly on to the outstretched right arm on 3 May 2010, transmitting force through to the right . shoulder and acromion-clavicular joint. (Emphasis added) He found it: ... difficult to explain Ms Chand's multiple shoulder pathologies and ongoing symptoms in terms of an indirect injury some 15 months ago (a fall onto her outstretched right upper limb), This incident did not lead to significant structural pathology in either the neck or the shoulder, as far as can be determined, .. it appears more likely that the right shoulder (and specifically the right acromioclavicular joint) is the source of her symptoms, rather than the cervical spine or trapezius muscles. ... It is also very likely that Ms Chand's symptoms were indicative of underlying pathological changes, as noted originally in the ultrasound scan, and confirmed on MR scan, and that her fall simply precipitated or triggered these symptoms. (Emphasis added) He shortly added that: Ms Chand has clinically and radiological evidence for more widespread shoulder/AC joint/rotator cuff/biceps pathology of a degenerative nature, including prominence/thickening of acromio-clavicular joint and coracoacromial, mixfor thickening of the sub-acromial bursa, and tendonosis involving the supraspinatus, subscapularis and long head biceps tendons. It is not biomechanically or pathologically plausible. that all of these pathologies arose at the same time, or as a result of a single incident or action. These pathologics are all consistent with age-related degenerative changes in the various shoulder structures involved, and in my persons may be present without symptoms, without any functional impairment, and without any history of trauma. (Emphasis added) In his ARTP dated 27 October 2011 Mr Durrant had written of her problems: Sharmila certainly could have sustained these injuries due to the fall in 2010 and I do not think that the changes can wholly and substantially be attributed to degenerative change alone. The pattern of fraying at the rotator cuff (involving mainly scapularis) would certainly not be in keeping with a degenerative change and there are no other signs within her shoulder that this is due to degenerative change. My feeling is that she has sustained a traumatic partial thickness tearing of both supraspinatus and subscapularis with resultant subacromial impingements and bursitis ... (Emphasis added) Mr Schmidt had commissioned a report from Mr Durrant which was provided on 31 March 2012. In responding he first of all acknowledged that he had initially been under the misapprehension that Mis Chand had fallen down: some stairs. At a subsequent visit she had corrected him explaining that it had been a slip fall on food product on the floor of a cool store. He considered that both (kinds of) falls would be counted reasonably significant and rehearsed her description that she had landed heavily on her right side with an outstretched hand and had ongoing discomfort about the right shoulder. Writing later of the mechanism of the accident he rehearsed that this involved an axial load with the shoulder driven upwards into the glenohumeral and subacromial space which, in his view, had been demonstrated at the initial ultrasound in the form of some minimal thickening and heterogeneity of the border of the posterior supraspinatus and antero-infraspinatus tendon consistent with mild tendinosis. . He observed that tendinosis could be seen on MRI as a swelling of the tendon which could be the result of a sprain or strain (a possibility that Dr Kenny had in fact noted). As to the "progression" of the condition of the shoulder from the time of the accident until surgery, he wrote: The ultrasound scan that was initially taken of Ms Chand's shoulder after the injury was closely related to the time of the injury, and at that stage showed no signs of bursal thickening or swelling, however it did show swelling of the rotator cuff tendon, It would not be uncommon for swelling of the bursa to occur later from irritation from a thickened, swollen rotator cuff. Certainly at the time when I first examined her she was displaying signs of subacromial impingement syndrome, both clinically, radiologically and diagnostically with good response to steroid injections. Ultrasound scan is obviously highly operator dependent and nowhere near as sensitive or specific as an MRI scan. I would place much greater faith in the findings of the MRI scan which demonstrated some mild fraying of the rotator cuff tendons, unfortunately radiology cannot date the changes in these, I note that one of the reviewers (occupational physician) Dr Kenny) feels that her whole problem is related to her acromio- clavicular joint. I find this very difficult to substantiate considering she had no clinical findings related to her acromio- clavicular joint, in particular no tenderness around the acromio- clavicular joint, no pain on horizontal cross body abduction, and her MRI changes showed no signs of ligament strain pattern around the acromio clavicular joint with no signs of disruption or dislocation of the acromio clavicular joint. Also no signs or changes within the coraco-clavicular ligament. The only change on the MRI was oedema of the outer end of the clavicle. Changes on the MRI on which he has placed great emphasis, are all age related changes and asymptomatic after the fall, so I am unable to establish how he has come to his conclusions. As to the issue of a causal nexus between accidental injury and surgery he then wrote: I believe on the balance of medical probability that the changes as noted. at the time of surgery were as a result of her injury. Whether Ms Chand had underlying early degenerative changes in her rotator cuff prior to the surgery or not, I still feel that the injury was wholly or substantially the cause of her subacromial bursitis. A recent review of subacromial impingement syndrome by Dis Harrison and Flatow in the Journal of the American Academy of Orthopaedic Surgery (2011; 19:701-708) concludes that subacromial impingement syndrome and bursitis aetiology is most likely multifactorial one of these factors being trauma. Ms Chand had a perfectly normal shoulder prior to the injury and the force of said injury would certainly be of enough magnitude to have caused damage to the rotator cuff, subsequent swelling of he cuff tendons, and resultant inflammation of the subacromial bursa causing subacromial impingement. There is no clinical, radiological, or operative evidence that she had any acute damage to the acromio-clavicular joint. At the time of surgery the shoulder was thoroughly examined as would be usual. There were no intra-articular findings, however on the subacromial surface it was noted that there was a dense subacromial bursa. This showed some changes consistent with steroid injections ("spider webbing") and the under surface of the acromion corresponded to the radiological slightly curved nature. There was some minor surface fraying of the rotator cuff tendons as corresponded to the MRI scanning, but certainty no evidence of rotator cuff tear requiring operative intervention. Arthroscopy of the acromio clavicular joint revealed minor degenerative changes, but nothing that I would not feel would be consistent with Sharmila's age. Certainly at the time of examination of the shoulder under anaesthesia there was no instability of the clavicle. (Emphasis added) He then continuing: I believe that the recent surgery was required to treat the injury suffered in the fall ... the fall has generated a subacromial bursitis due to contusion and trauma to the shoulder, This in turn resulted in subacromial impingement syndrome. The surgery was aimed at addressing the bursal thickening and creating a wider subacromial space. ... Sharmila is a 44 year old fit and well person working in what would be considered a moderate to heavy manual job. Findings on MRI and arthroscopy did not show any significant degenerative changes within Sharmila's shoulder ... with only mild fraying of the rotator cuff and mild degenerative change within the acromio clavicular joint, again all of which would be consistent with Sharmila's age and none significant enough to be considered a pre-existing degenerative condition of magnitude significant enough to have caused Ms Chand's symptoms post injury. (Emphasis added) Ms Chand's case was considered by a CAP on 12 March 2013 in terms of the understanding that Ms Chand fell whilst at work landing on an outstretched right hand which CAP considered was a plausible mechanism for a right shoulder injury. On 16 April 2013 it wrote: The right shoulder ultrasound approximately one week after the accident did not identify any clear signs of acuity .ag. no evidence of bursal fluid/debris (no bursal thickening noted) and no evidence of rotator cuff tear (only mild tendinosis at the posterior supraspinatus/anterior infraspinatus border). MRI (13/09/2011) reported similar findings of the supraspinatus tendon, The MRI (more sensitive than an ultrasound) also identified multiple splits of the upper third of the distal biceps, splits and swelling of the distal subscapularis and . mild subacromial/subdeltoid bursal thickening. These widespread findings appear in keeping with a gradual process i.e. tendinosis and subacromial impingement. CAP was aware of the by then performed surgery, and that Mr Durrant had reported: Findings: Intact rotator cuff, biceps anchor intact, anterior labrum sound, no signs of degenerative change in the glenohumeral joint. Some mild fraying of supraspinatus on the bursal surface, dense bursitis and a hooked anterior acromion. Of this CAP said: ... the arthroscopy performed on 01/02/2012 did not identify any rotator cuff tears (reported an intact rotator cuff). It was reported only minor surface fraying of the rotator cuff tendons but "certainly no evidence of rotator cuff fear requiring operative intervention" (Mr Durrant 31/03/2012). The most recent diagnosis from the treating surgeon appears to be subacromial bursitis with impingement (which was surgically addressed on 01/02/2012). The treating surgeon suggests that this condition is of traumatic aetiology. The view of the CAP is that this condition is unlikely to have been caused by the single event trauma on 03/05/2010, given the initial clinical presentation and imaging findings. (Emphasis added) Points then made by CAP included that: The initial clinical presentation did not appear typical of a traumatic rotator cuff contusion or bursal injury/subacromial impingement. The arthroscopy findings were not indicative of a traumatic causal event, The supraspinatus tendon pathology appeared to have been relatively consistently reported and was in keeping with mild tendinosis. The unilateral nature of ultrasound findings (no abnormality noted on the left shoulder ultrasound 11/05/2010) did not prove traumatic causation as unilateral findings were not uncommon, particularly in this younger demographic. Historically bursal thickening was thought to be due to inflammation of the subacromial bursa, accounting for the frequent use of the term subacromial bursitis. However histological studies of the thickened subacromial bursa in patients with impingement show degeneration and fibrosis of the subacromial bursa without inflammation being present. Observation of the bursa during surgery (macroscopic observation) was unable to predict whether fibrosis was present or absent on microscopic testing i.e. visual test inspection of the bursa could not establish the cause of bursal thickening. The most likely cause of the mild bursa, thickening was fibrosis on the basis of gradual process rotator cuff tendonopathy/subacromial impingement. In conclusion CAP wrote that it agreed with Dr Kenny's view that the symptoms were likely due to the underlying pathology adding, however, this proviso: It should however be noted that Dr Kenny appears to infer that symptoms may be arising from the acromio clavicular joint seemingly due to the identification of changes at this site on imaging and the poor response to the subacromial injections). We agree with the opinion expressed by the treating surgeon Mr Durrant (31/03/2012) on this matter. Mir Durrant notes that the documented clinical examination findings do not appear to suggest symptoms from the acromio-clavicular joint and the acromio-clavicular joint changes noted on MIRI are not in common, even in a young asymptomatic population. Case for Ms Chand [6] After reviewing the background Mr Schmidt submitted that: Mr Durrant had the advantage of having been the surgeon who actually operated on Ms Chand and had viewed at first hand the internal condition of her shoulder. There had been a positive response to the surgery which had been aimed at addressing the bursal thickening and creating a wider subacromial space. At surgery a dense subacromial bursa with changes consistent with steroid injections had been observed. There was minor surface fraying of the rotator cuff tendons and the arthroscopy of the acromio-clavicular joint simply revealed minor degenerative changes consistent with age. Mr Durrant had pointed out that the findings at MRI and arthroscopy did not show significant degenerative changes within the shoulder and the articular surface of the rotator cuff was sound, the biceps anchor intact and there was no tendinosis of the bicipital tendon nor degenerative change to the articular surfaces at either the glenoid or humeral heads; and It was Mr Durrant's opinion that there was nothing in the history, or indeed examination radiology or physical findings, supporting Dr Kenny's conclusion that the pain was coming from the acromion-clavicular joint. [7] Counsel further submitted that; Mr Durrant had observed that the short period of time between the injury and the initial ultrasound may not have allowed enough time for bursa swelling and thickening to develop; and Mr Durrant had been entitled to put greater faith in the MRI as more reliable for the reasons he explained; and Mr Durrant had paid careful attention to the mechanics of the accident which in his carefully justified view was clearly linked causally speaking to the need for surgery which had in fact provided relief, It was apparent from the GP's notes (which I have not set out in the course of this judgment) that Ms Chand had been going back regularly to her GP for assistance with pain medication until ultimately 'Mr Durrant bad found the source of the problem and fixed it. [8] Thus, submitted Mr Schmidt, on the basis of Mr Durrant's "well reasoned, cogent explanation for Ms Chand's shoulder condition based on an accurate clinical history, a clear explanation of the mechanism of injury, and with reference to the clinical evidence by way of radiological and surgical findings" the appeal should be allowed. Case for Corporation [9] Mr Tui also presented and spoke to carefully prepared andi (as with those of Mr Schmidt) very helpful written submissions. [10] He identified the main differences between the opinions of Mr Durrant and of CAP (which in themselves Mr Schmidt had not dwelled upon) as being that: CAP had considered Ms Chand's clinical symptoms in the period immediately following the accident whereas Mr.Durrant had not. Mr Durrant had relied on the MRI findings as supporting a causal nexus and had downplayed those from the ultrasound. CAP had relied on both and then considered a number of possible explanations for the differences between the two investigations. Mr Durrant had relied on a temporal connection between the accident and the onset of symptoms. CAP had recognised the temporal symptomology but had then noted that; In the absence of evidence to support an acute injury, these symptoms are likely due to the underlying pathology. [11] Counsel's fundamental submission was that Mr Durrant appeared to have started with an effectively concluded view that the material pathology was injury related and had then sought to identify evidence to support that decision but, on analysis, the support he offered did not cogently, let alone persuasively, support his conclusion or hypothesis. Discussion [12] I first of all make clear that this judgment proceeds upon the basis that Ms Chand did not fall down any stairs but rather, having slipped on something, fell forwards with her right hand/arm taking the brunt of the impact and then felt a shock type pain up to her neck, [13] I next recognise that at surgery Mr Durrant (who specialises in shoulders) made these findings: Intact rotator cuff, biceps anchor intact, anterior labrum sound, no signs of degenerative change in the glenohumeral joint. Some mild fraying of supraspinatus on the bursal surface, dense bursitis and a hooked anterior acromion . Here I particularly recognise the fact that the rotator cuff turned out to be intact whereas Mr Durrant, pre-surgery, had set some store on MRI indications of it being in a worse state than proved so. [14] That information was before CAP on 12 March 2013 when it wrote: The most recent diagnosis from the treating surgeon appears to be subacromial bursitis with impingement (but) the view of the CAP is that this condition is unlikely to have been caused by the single event trauma of 03/05/2010, given the initial clinical presentation and imaging findings. The day it met. [15] The reference to imaging findings is undoubtedly to the right shoulder ultrasound that was performed soon after the accident and which did not, at that time, disclose any clear signs of acuity whereas the subsequent MRI was considered by CAP to evidence widespread findings in keeping with a gradual process, i.e. tendonosis and subacromial impingement. [16] Mr Durrant was also conscious of the fact that the ultrasound was taken at a time closely related to that of the injury and that it showed no signs of bursal thickening or swelling, but he then said that: It would not be uncommon for swelling of the bursa to occur later from irritation from a thickened, swollen rotator cuff, [17] Here I take particular cognisance of the fact that he is a specialist shoulder surgeon. That, indeed, was obviously why Mr Finch had referred Ms Chand to him. I also call to mind Mr Schmidt's point about the GP's notes of Ms Shand attending frequently over a significant period seeking pain relief. [18] I interpolate here that Dr Kenny had appeared to consider the problem to be one significantly related to the acromio clavicular joint but CAP was in agreement with Mr Durrant when he said that documented clinical examination findings did not suggest symptoms from there and the changes noted on MRI were not uncommon even in a young, asymptomatic population. [19] To my understanding, Mr Durrant allows for the possibility of underlying early degenerative changes in the rotator cuff but remains of the view that the injury was wholly or substantially the cause of her subacromial bursitis, he considering that the forces involved in the accident would have been of enough magnitude to do such damage - 'damage leading, over time , to swelling of the cuff tendons, resultant inflammation of the subacromial bursa and subacromial impingement, So not apparent at the time of the carly CT, [20] Speaking both of the MRI and the arthroscopy that he performed, he opined that that did not show any significant degenerative changes within the shoulder - only mild fraying of the rotator cuff and like degenerative change within the (agreed by Mr Durrant and CAP to be unrelated to the case) acromion-clavicular joint. [21] Quite clearly, however, he counted none of what he saw significant enough to evidence a pre-existing degenerative condition sufficient to be substantially responsible for Ms Chand's post accident symptomology. [227 I note CAP's reference to histological studies of thickened subacromial bursa in patients with impingement showing degeneration and fibrosis of the subacromial bursa without inflammation being present. [23] I also note its contention that macroscopic observation of the bursa during surgery was not reliable in terms of determining whether fibrosis would be present or absent on microscopic testing - in 'plain speak' a visual inspection of the bursa could not. establish the cause of thickening. [24] In my view it comes down to the fact that CAP considers the most likely cause of such as the thickening was fibrosis borne of gradual process, rotator cuff tendonopathy/subacromial impingement, while Mr Durrant maintains that, to the contrary and in this particular case, the picture and pattern is consistent with trauma being the clearly predominating factor. [25] Which of these two opposing views is the Court to accept? Mr Durrant refers to medical literature concerning subacromial impingement syndrome and bursitis actiology as noting that causes can be multifactorial, including that of trauma, [26] He has also observed that: Ms Chand had a perfectly normal shoulder prior to the injury and the force of said injury would certainly be of enough magnitude to have caused damage to the rotator cuff, subsequent swelling of the cuff tendons, and resultant inflammation of the subacromial bursa causing subacromial impingement ... [27] At the time of surgery the shoulder was thoroughly examined as would be usual. There were no intra-articular findings, however on the subacromial surface it was noted that there was a dense subacromial bursa. [28] I acknowledge yet again CAP's reservation about the utility of macroscopic observation but I should also, and particularly, respect the fact that of all the medical professionals involved in this case, Mr Durrant appears as the only one especially well qualified in the area of shoulders, so his views - particularly when so carefully expressed and in the absence of any clearly confounding of them evidence - are deserving of considerable weight, [29]. A regular problem in this kind of case is that of finding on one side a view held by those closest to it in terms of attendance to the patient (the individual so placed in this case being Mr Durrant) and on the other side CAP, or another file reviewer at a remove from the actualities, providing a contrary opinion." [30] It may sometimes be that he or she who is closest is, in consequence, deprived of some degree of objectivity or misses that which is apparent to others standing back so as to take in a wider picture. [31] But in this case I see no reason at all to discount the specialist evidence of Mr Durrant on that or any other account. To the contrary. what I particularly notice with his evidence is every sign of an even handed approach to the task of assessment. [32] On the other hand, so it seems to me, CAP has read too much into - overly focused on - the initial CT scan. [33] Thus in the end, and on balance, I find by a perfectly sufficient margin that a case has been made (when the evidence as a whole is appraised) such as tips the scales in Ms Chand's direction. [34] In short, I find that, as at 24 August 2011, the substantial, indeed effective, cause of Ms Chand's symptomology was the injury she had suffered on 3 May 2010. Result [35] Thus the appeal is allowed and the review decision of 24 August 2011 accordingly quashed. [36] That means that the Court finds that as of 24 August 2011 there was no justification to suspend entitlements for Ms Chand so that the Corporation (after due enquiry into what has transpired in the meantime) must afford her entitlement redress .accordingly. Costs (37} Mr Schmidt and Mr Tui will undoubtedly be able to agree a fair and reasonable award of costs in favour of Ms Chand. Roderick Joyce QO District Court Judge