When the History Is as Complex as the Injury: Dr Pamela Boekel on Multi-Cause Cases

In medico-legal practice, the clean case is the exception. Single incident, no prior history, clear causation. The rule is complexity: claimants who arrive with years of pre-existing pathology, multiple active claims, and a new incident layered on top of all of it.

Establishing a baseline in complex medico-legal assessments

Dr Boekel's first move in a multi-cause assessment is to establish a baseline: what the claimant was like before the incident, how much pain medication they were on, what they could and couldn't do functionally. She reads the file beforehand to orient herself, but always begins the assessment by listening to the

patient directly.

"I always start off with a baseline that I believe the person when they come and talk to me about what's happened to them. The key is trying to elicit what symptoms are new in comparison to what they've had as a baseline."

That process becomes more complicated when a claimant has multiple active claims. Separating what's attributable to a knee from what's attributable to a shoulder, and then assessing each within the constraints of the AMA Guides, can obscure the full picture of a person's disability, even when each individual assessment is accurate.

"I'll try and get an overall picture of a person. So you can't sit down with your grandchildren. Is that because of your knee complaint or because of your shoulder complaint or because of your back complaint? And the reality is, in life, it's pretty much everything."

Apportionment, pre-existing conditions and the importance of medical records

For the AMA Guides to support apportionment of an upper limb condition, documented range of motion prior to the incident is required. Without it, even clear pre-existing degeneration may have to be treated as a new injury. GP notes are often too brief to provide this. Physiotherapy notes sometimes bridge the gap.

"The GP notes are quite brief, and so they often don't document a range of motion. But sometimes a physio does. And so then it's possible to try and work out what the difference has been."

This matters in practice. Dr Boekel describes cases where patients presented with patellofemoral arthritis following a fall onto both knees. The arthritis was almost certainly pre-existing, but because no clinician had documented crepitus prior to the fall, the guide required her to apportion 2% impairment per side to the new incident.

When records are missing, the Guides don't allow for inference. They require documentation.

Prognosis in compensable injury claims

Predicting what a pre-existing condition would have done absent the incident is, as Dr Boekel acknowledges, genuinely difficult. The literature is clear that compensable cases trend worse than equivalent non-compensable presentations: more pain, more disability, slower recovery, likely due to the psychological load of the claims process itself.

"Every compensable case tends to have a worse prognosis. They tend to have more pain and disability than someone who doesn't have a compensable case. It's probably something to do with some brain body connection that we don't fully understand."

There is evidence that once a case closes, outcomes tend to improve regardless of the result. Dr Boekel tells patients this directly. But it can't be written into a report, and it doesn't change the clinical picture at time of assessment.

Understanding delayed presentation and complex regional pain syndrome

One of the most contested issues in multi-cause cases is timing. Dr Boekel pushes back against default skepticism about delayed presentation. A baggage handler who tears his rotator cuff mid-shift and keeps working on adrenaline before stiffening up hours later isn't fabricating. He's responding the way many workers in physically demanding roles respond.

"Everyone's got lots of things going on in their lives. They don't want to take time off work. A lot of these people are casual workers, so they just can't physically take time off. And so they struggle on for a long time, until they hit critical mass."

Casual employment, cost of living pressure, and wishful thinking all contribute to delays that are clinically understandable even when they complicate the legal picture.

For complex regional pain syndrome, Dr Boekel applies the Budapest criteria: tracking sensory, autonomic, motor and trophic signs, cross-referencing observed findings with patient-reported symptoms, and ruling out alternative explanations. The condition is real, the mechanism is incompletely understood, and the impairment framework for assessing it requires mapping sensory disturbance across nerve root distributions and combining scores with range of motion findings to reach a percentage.

"We think that it's the brain and the nerves becoming hypersensitive to things like light touch. They'll feel something like light touch is pain. They'll often have their hand changing colour, more swollen than the other side, sweating changes, nail changes, hair changes, skin changes. It's all due to the nerve response, we think."

It's among the most clinically demanding assessments in orthopaedic IME work, and she's direct about the uncertainty involved.

Women in orthopaedic surgery: progress and ongoing challenges

Dr Boekel is one of fewer than 100 female orthopaedic surgeons in Australia, under 6% of the specialty. The episode closes with an honest account of what that's meant in training and in practice: less overt discrimination than unconscious bias, a training pipeline that until recently was failing female registrars at a rate of one in five compared to one in sixteen men, and a projected date of 2500 for gender parity in the specialty at current rates.

"In our society, we raise boys to be brave and girls to be perfect. I see it now in my juniors. The girls, even though they've got great knowledge, they're afraid to pick up the knife because they want to do it perfectly. But the only way you can learn is by practising."

She's vocal about her own struggles during training, and deliberate about mentoring the women coming

through behind her.

Listen to the full interview with Dr. Pamela Boekel here, or find Medico-Legal Mastery wherever you get your podcasts.