Diagnostic Assessment — Anterior Chest Wall - Costochondritis
Example 1 of 1 · fictitious patient (Veteran AS)
Diagnostic Assessment
Anterior Chest Wall - Costochondritis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran AS, date of birth 03 May 1986, Australian Army, Artillery Gunner (later Bombardier), enlisted 22 January 2005, medically discharged 11 October 2018. Operational service: Iraq, 14 May 2007 to 20 December 2007 (warlike); Afghanistan, 25 March 2011 to 06 November 2011 (warlike); Middle East Area of Operations, 18 February 2015 to 02 September 2015 (warlike).
Occupational History
As an artillery gunner the veteran lifted and carried 155 millimetre projectiles weighing about 43 kilograms and propellant charges from ammunition stacks to the breech, often hundreds of rounds during a fire mission, rammed rounds by hand, and dug and laid gun platforms. These tasks place heavy, repetitive pushing, lifting and twisting loads through the chest wall, shoulder girdle and trunk.
Gunners also wear body armour with front plates for long periods, ride in and work around heavy vehicles and gun trails that can strike the chest, and on operations live in dusty, crowded accommodation with frequent respiratory infections and gastroenteritis. Deployed health support for musculoskeletal conditions is limited, with no physiotherapist or musculoskeletal injection service at most forward locations.
History
Veteran AS, an Army artillery gunner, developed costochondritis of the left anterior chest wall on 09 September 2011 during warlike service in Afghanistan, after an improvised explosive device blast that caused a chest wall contusion, a rib fracture and a pneumothorax requiring a chest drain, on a background of heavy ammunition handling, constant body armour wear, reactive arthritis and a severe bronchitic cough. The condition worsened during his 2015 deployment to the Middle East after further chest wall trauma, heavy lifting and an influenza-related cough.
Timeline
- 18 Jan 2011 — Pre-deployment health assessment for Afghanistan. The veteran reported no chest pain and was lifting projectiles routinely in training without symptoms. Chest examination was normal with no chest wall tenderness. ECG and chest X-ray were normal. "no chest wall tenderness"
- 21 Jun 2011 — During warlike service in Afghanistan the veteran presented with five days of bloody diarrhoea and fever after an outbreak of gastroenteritis at the forward operating base. Stool culture grew Campylobacter jejuni. Three weeks later he developed painful swelling of the right knee and left heel with sacroiliac pain, and the medical officer recorded reactive arthritis. HLA-B27 was later positive. "Campylobacter, then reactive arthritis"
- 12 Jul 2011 — The veteran's protected vehicle struck an improvised explosive device and he was thrown forward against the rim of the gunner's hatch. At the role 2 facility he had severe left anterior chest pain, a 6 by 8 centimetre contusion over the left second to fifth costal cartilages, a fracture of the anterior left fifth rib and a small left pneumothorax. An intercostal catheter was inserted through the left chest wall and removed after three days. "chest contusion, rib fracture, drain"
- 22 Aug 2011 — Back on gun duties, the veteran was handling 155 millimetre projectiles for 16 to 20 hours a week during sustained fire support, wearing body armour with a front plate pressing on the anterior chest for 12 to 14 hours a day. He presented with a viral bronchitis acquired in dusty shared accommodation, with paroxysmal coughing day and night, which persisted for 24 days. "paroxysmal cough, sustained fire missions"
- 10 Sep 2011 — The veteran presented with sharp left parasternal chest pain that had begun the previous day while loading projectiles, worse with deep breathing, coughing, pushing and lying on his front. There was reproducible tenderness over the left second, third and fourth costochondral junctions without swelling. ECG and troponin were normal. The medical officer diagnosed costochondritis and advised rest from loading, which was not possible given operational tempo. "reproducible tenderness, costochondral junctions"
- 05 Dec 2011 — After return to Australia a sports physician confirmed persisting left costochondritis, with point tenderness over the second to fourth costochondral junctions and pain on the crowing rooster and horizontal arm traction manoeuvres. Bone scan showed increased uptake at those junctions. Cardiac and pulmonary causes were excluded. He was treated with anti-inflammatories, physiotherapy and a graded return to loading. "costochondritis confirmed, bone scan"
- 26 Jun 2015 — During warlike service in the Middle East the veteran was struck in the left chest by a swinging ammunition pallet on 14 May 2015 while training partner-force gunners, and in June he had influenza with paroxysmal coughing for three weeks. He was again lifting projectiles for 15 or more hours a week. His left chest pain became constant, with visible swelling over the second and third costal cartilages, and pain scores rose from 2 to 8 out of 10. "constant pain, cartilage swelling"
- 08 Oct 2015 — Sports physician review after return confirmed worsened costochondritis with swelling of the left second and third costochondral junctions and spread of tenderness to the fifth. MRI showed cartilage swelling with oedema at the left second and third costochondral junctions. Ultrasound-guided corticosteroid injections were given, and he was permanently restricted from projectile loading. "worsened, swelling, steroid injections"
Symptoms
At onset the veteran had sharp, well-localised left parasternal chest pain over the second to fourth costal cartilages, brought on by loading projectiles, pushing, deep breathing, coughing and lying face down, with tenderness to touch and no swelling. The pain eased with rest but recurred with every fire mission.
From mid-2015 the pain became constant, with visible swelling over the second and third costal cartilages, night pain when turning in bed and inability to lift, push or do push-ups. He now reports daily left anterior chest wall pain of 4 to 6 out of 10, flaring to 8 with lifting, carrying, prolonged driving with a seatbelt or upper respiratory infections.
Imaging
- 12 Jul 2011 — Chest X-ray: "Small left apical pneumothorax. Non-displaced fracture of the anterior left fifth rib."
- 15 Jul 2011 — Chest X-ray after drain removal: "Resolution of the left pneumothorax. Healing anterior left fifth rib fracture."
- 05 Dec 2011 — Whole-body bone scan: "Focal increased tracer uptake at the left second, third and fourth costochondral junctions and at the healing anterior left fifth rib. No other abnormal uptake."
- 08 Oct 2015 — MRI anterior chest wall: "Swelling and increased signal of the left second and third costal cartilages with adjacent bone marrow and soft tissue oedema at the costochondral junctions. No mass or infection."
Onset Date
The most likely date of onset of this condition is 09 Sep 2011.
At that date the veteran was on warlike service in Afghanistan with an artillery battery providing sustained fire support, loading 155 millimetre projectiles for 16 to 20 hours a week in body armour. He had sustained a left chest wall contusion, a left fifth rib fracture and a chest drain on 12 July 2011, had reactive arthritis since July, and had been coughing paroxysmally from bronchitis since 22 August. On 09 September, while loading, he developed sharp left parasternal pain that has persisted since.
This date is appropriate because his pre-deployment examination of 18 January 2011 recorded a normal chest with no tenderness, the trauma records of July 2011 describe acute contusion and fracture pain that had settled by mid-August, and he presented on 10 September 2011 with reproducible costochondral junction tenderness after excluding cardiac causes. The date falls within warlike service and continuous full-time service.
For the trauma causes, the 6 months before onset run from 09 Mar 2011 to 09 Sep 2011 and the 1 year before onset from 09 Sep 2010 to 09 Sep 2011; the blast contusion, rib fracture and chest drain of 12 July 2011 fall within both. For the loading and body armour causes, the 3 months before onset run from 09 Jun 2011 to 09 Sep 2011, during which he handled projectiles for 16 to 20 hours a week and wore armour with a front plate for 12 to 14 hours a day. For the cough cause, the 1 month before onset runs from 09 Aug 2011 to 09 Sep 2011, and his paroxysmal cough began on 22 August. Reactive arthritis was present from July 2011 and on the date of onset.
For the worsening, the documented clinical worsening occurred on 26 Jun 2015, during warlike service in the Middle East, with constant pain, new cartilage swelling and a pain score rising from 2 to 8, confirmed on MRI on 08 October 2015. The 6 months before the worsening run from 26 Dec 2014 to 26 Jun 2015 and include the pallet strike of 14 May 2015; the 3 months before the worsening run from 26 Mar 2015 to 26 Jun 2015, during which he lifted projectiles for at least 15 hours a week; and the 1 month before the worsening runs from 26 May 2015 to 26 Jun 2015, during which he had three weeks of influenza with paroxysmal coughing.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Costochondritis of the left anterior chest wall (ICD-10 M94.0). No Statement of Principles has been determined for costochondritis.
Costochondritis is inflammation of the costochondral or costosternal junctions, where the ribs join the costal cartilages and the cartilages join the sternum. It causes sharp, localised anterior chest wall pain, usually affecting several adjacent junctions from the second to the fifth, reproduced by pressing on the junctions and aggravated by deep breathing, coughing, pushing, lifting and movement of the arms and trunk. When the junctions are also visibly swollen, the condition overlaps with Tietze syndrome. Recognised causes include direct trauma to the chest wall, repetitive strenuous upper limb and trunk activity, severe coughing, thoracic procedures and inflammatory arthritis. Cardiac, pulmonary and gastrointestinal causes of chest pain must be excluded before the diagnosis is made.
The condition began on 09 September 2011 during warlike service in Afghanistan, after a blast-related chest wall injury, heavy ammunition handling, a severe cough and the onset of reactive arthritis, was confirmed by a sports physician with a bone scan on 05 December 2011, and worsened during warlike service in the Middle East in June 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
09 September 2011.
When did the veteran first present to a health / medical provider for this condition?
10 September 2011.
When was the condition confirmed / formally diagnosed?
05 December 2011.
When did the veteran first present to you (or your practice) for this condition?
28 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by a medical officer on 10 September 2011 and confirmed by a sports physician on 05 December 2011 on the basis of sharp left anterior chest wall pain localised to the second, third and fourth costochondral junctions, reproduced by palpation and by the crowing rooster and horizontal arm traction manoeuvres, and aggravated by breathing, coughing and pushing. A normal ECG and troponin, a normal chest examination and chest X-ray excluded cardiac and pulmonary causes, and the bone scan showed focal increased uptake at the affected junctions.
The worsening was established clinically on 26 June 2015, with constant pain, visible swelling over the second and third costal cartilages, spread of tenderness to the fifth junction and a pain score rising from 2 to 8 out of 10, and was confirmed by MRI on 08 October 2015 showing cartilage swelling and oedema at the left second and third costochondral junctions. The need for corticosteroid injections and a permanent restriction from loading confirms a lasting increase in severity.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for costochondritis, so the claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the medical literature on costochondritis and anterior chest wall syndromes, and each is set out in the form used by the Repatriation Medical Authority.
Legislation: the clinical onset of this condition was on 09 September 2011, after 1 July 2004, during continuous full-time service that included warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Operational service is relevant to the veteran's warlike service in Afghanistan in 2011, where the condition began, and in the Middle East in 2015, where it worsened, and his peacetime service covers his training and garrison duties. Each cause must be related to service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having blunt trauma to the anterior chest wall within the 6 months before the clinical onset of costochondritis; — MET
- On 12 July 2011 the veteran was thrown against the rim of the gunner's hatch when his protected vehicle struck an improvised explosive device during warlike service in Afghanistan. The role 2 facility recorded a 6 by 8 centimetre contusion directly over the left second to fifth costal cartilages. This was eight weeks before onset, within the 6 months from 09 March 2011 to 09 September 2011, and the costochondritis developed at the same junctions.
Cause 2: having a fracture of a rib or of the sternum within the 1 year before the clinical onset of costochondritis; — MET
- Chest X-ray on 12 July 2011 showed a non-displaced fracture of the anterior left fifth rib from the same blast on warlike service. The fracture was within the 1 year before onset, from 09 September 2010 to 09 September 2011, adjacent to the affected costochondral junctions, and the bone scan of December 2011 showed uptake at both the healing fracture and the inflamed junctions.
Cause 3: having an intercostal catheter, thoracotomy or sternotomy through the anterior chest wall within the 1 year before the clinical onset of costochondritis; — MET
- A left intercostal catheter was inserted for the blast-related pneumothorax on 12 July 2011 at the role 2 facility in Afghanistan and removed on 15 July 2011. The procedure, within the 1 year before onset, traumatised the left chest wall soft tissues and intercostal attachments near the affected junctions.
Cause 4: undertaking repetitive heavy lifting, carrying or pushing that loads the chest wall, for at least 10 hours per week for at least the 3 months before the clinical onset of costochondritis; — MET
- Throughout the 3 months before onset, from 09 June 2011 to 09 September 2011, the veteran lifted and carried 43 kilogram 155 millimetre projectiles and rammed rounds by hand for 16 to 20 hours a week during sustained fire support on warlike service in Afghanistan, recorded in the battery duty rosters and the medical officer's note of 22 August 2011. Repetitive lifting and pushing places shear and compressive loads through the costochondral junctions.
Cause 5: wearing body armour or a load-bearing harness with a rigid front plate or chest strapping for at least 8 hours per day on most days for at least the 3 months before the clinical onset of costochondritis; — MET
- On warlike service in Afghanistan the veteran wore body armour with a ceramic front plate resting over the parasternal region for 12 to 14 hours a day, seven days a week, throughout the 3 months before onset. The direct pressure and the restriction of chest wall movement under load contributed to inflammation of the junctions beneath the plate.
Cause 6: having severe or paroxysmal coughing on most days for at least 2 weeks within the 1 month before the clinical onset of costochondritis; — MET
- The veteran developed viral bronchitis in dusty shared accommodation on warlike service in Afghanistan and had paroxysmal coughing day and night from 22 August 2011 for 24 days, recorded by the medical officer. This fell within the 1 month before onset, from 09 August 2011 to 09 September 2011. Forceful repeated coughing strains the costochondral junctions through the intercostal and pectoral muscles.
Cause 7: having reactive arthritis, ankylosing spondylitis, psoriatic arthritis or another spondyloarthropathy at the time of the clinical onset of costochondritis; — MET
- The veteran developed Campylobacter jejuni gastroenteritis in an outbreak at his forward operating base on warlike service in June 2011, followed three weeks later by reactive arthritis with knee synovitis, heel enthesitis and sacroiliac pain, and he was HLA-B27 positive. The reactive arthritis was active on 09 September 2011, and spondyloarthropathies characteristically involve the costochondral and costosternal joints.
Cause 8: having repeated direct pressure or impact on the anterior chest wall from equipment, weapon recoil or vehicle restraints for at least the 3 months before the clinical onset of costochondritis; — MET
- In addition to the body armour plate, the veteran's duties on warlike service from June to September 2011 involved bracing the chest against the projectile tray and breech while ramming, and riding in a protected vehicle with a four-point harness crossing the anterior chest over rough tracks for several hours most days. These repeated impacts on the left anterior chest wall continued throughout the 3 months before onset.
Worsening factors
Worsening 1: having blunt trauma to the anterior chest wall within the 6 months before the clinical worsening of costochondritis; — MET
- On 14 May 2015, during warlike service in the Middle East, the veteran was struck on the left anterior chest by a swinging ammunition pallet while training partner-force gunners, with bruising over the second and third costal cartilages recorded by the medic. This was six weeks before the worsening, within the 6 months from 26 December 2014 to 26 June 2015, and the swelling developed at the junctions struck.
Worsening 2: undertaking repetitive heavy lifting, carrying or pushing that loads the chest wall, for at least 10 hours per week for at least the 3 months before the clinical worsening of costochondritis; — MET
- Throughout the 3 months before the worsening, from 26 March 2015 to 26 June 2015, the veteran lifted 155 millimetre projectiles and demonstrated loading drills for 15 or more hours a week while training partner forces on warlike service in the Middle East, as no alternative duties were available in the training team.
Worsening 3: having severe or paroxysmal coughing on most days for at least 2 weeks within the 1 month before the clinical worsening of costochondritis; — MET
- The veteran had laboratory-confirmed influenza A in an outbreak in shared accommodation in the Middle East from 02 June 2015, with paroxysmal coughing day and night for three weeks, within the 1 month before the worsening, from 26 May 2015 to 26 June 2015. His chest wall pain became constant during the coughing illness.
Worsening 4: inability to obtain appropriate clinical management for costochondritis. — MET
- On warlike service in the Middle East in 2015 there was no physiotherapist, no musculoskeletal injection service and no alternative duty that removed the veteran from loading, so his known costochondritis could not be managed by load modification, physiotherapy or injection, and he continued lifting through the pallet injury and influenza. The condition worsened to constant pain with cartilage swelling before he could be treated in October 2015. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The costochondritis is a sequela of the veteran's accepted blast injuries of 12 July 2011, namely the left anterior chest wall contusion, the left fifth rib fracture and the pneumothorax treated with an intercostal catheter, and of his accepted reactive arthritis following deployment-acquired Campylobacter gastroenteritis. The chronic chest wall pain has in turn restricted his upper limb and trunk activity and contributed to the deconditioning and disturbed sleep recorded from 2016.
Unintended Consequence
Met. The intercostal catheter inserted at the role 2 facility on 12 July 2011, a procedure provided and paid for by the Commonwealth on warlike service, traumatised the left anterior chest wall adjacent to the junctions that became inflamed (section 6A of the DRCA and the equivalent provisions of the MRCA). The medical officer's return of the veteran to full loading duties in August 2011, while he still had chest wall pain from the blast, was a further treatment decision that contributed to onset.
Inability to Attain Appropriate Medical Management
MET. On warlike service in Afghanistan in 2011 the advice to rest from loading could not be followed because of operational tempo, and on warlike service in the Middle East in 2015 there was no physiotherapy, no musculoskeletal injection service and no alternative duty available, so the veteran kept lifting projectiles through a fresh chest wall injury and an influenza cough. The costochondritis worsened to constant pain with visible cartilage swelling before treatment could be given in October 2015. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the absence of appropriate treatment and of any means of offloading the chest wall in the operational area amounted to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 Jan 2011, Pre-deployment health assessment, Medical Officer, Garrison health centre
- 21 Jun 2011, Deployed health record and stool culture, Medical Officer, Afghanistan
- 12 Jul 2011, Role 2 trauma record and chest X-ray report, Afghanistan
- 22 Aug 2011, Deployed health record, Medical Officer, Afghanistan
- 10 Sep 2011, Deployed health record, ECG and troponin, Medical Officer, Afghanistan
- 05 Dec 2011, Sports medicine consultation and bone scan report, Sports physician and Nuclear medicine physician
- 14 May 2015, Medic treatment record, Middle East Area of Operations
- 26 Jun 2015, Deployed health record, Medical Officer, Middle East Area of Operations
- 08 Oct 2015, Sports medicine review, MRI chest wall report and injection record, Sports physician and Radiologist
