Diagnostic Assessment — Bilateral Shoulder - Pain
Example 1 of 1 · fictitious patient
Diagnostic Assessment Bilateral Shoulder — Pain BOP Code: 110 of 2022 (Rotator Cuff Syndrome) RH Code: 109 of 2022 (Rotator Cuff Syndrome)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as an Aircraft Technician from 4 July 1985 to 19 April 1992
Occupational History
As an Aircraft Technician, the veteran performed heavy manual handling duties aboard service vessels including lifting steel cables and survey equipment.
He participated in rugby union, rugby league, and boxing.
On 23 September 1989, a car fell off a jack and landed on his right shoulder at a maintenance squadron.
On 2 December 1985, a rugby scrum collapsed on top of him at a maintenance squadron, injuring his back, shoulder and neck.
These occupational and sporting activities placed cumulative and acute loading on both shoulders
History
The veteran has bilateral shoulder pain with extensive bilateral pathology documented on MRI in September 2025.
The right shoulder demonstrates partial thickness subscapularis tear, moderate supraspinatus and infraspinatus tendinosis, teres minor atrophy, severe AC joint degeneration, labral tears with paralabral cysts, and biceps tendinosis.
The left shoulder demonstrates mild supraspinatus and infraspinatus tendinopathy, partial subscapularis tear, biceps subluxation with tendinopathy, extensive labral tearing with a 16mm paralabral cyst, and mild AC degeneration
Timeline
02 Dec 1985 — Back, shoulder and neck injury from a rugby scrum collapse at a maintenance squadron.
3 days light duty. "Injuring his back, shoulder and neck" 23 Sep 1989 — ABSR the veteran was pinned under a car when a jack shifted at a maintenance squadron, with the car falling onto his right shoulder.
He developed pain in the right shoulder with full range of motion but pain at full flexion and tenderness over the infraspinatus muscle and lateral area.
Brufen 400mg TDS prescribed.
Light duty approximately 4 days. "Soft tissue injury, right shoulder" 11 August 2018 — Whole body bone scan demonstrated arthropathy in both shoulders with diffuse prominence over the humeral heads suggesting tendinopathy, and sternoclavicular joint arthropathy. "Bilateral shoulder tendinopathy" 08 Sep 2025 — MRI right shoulder for painful shoulder worse with abduction and overhead movement.
Partial thickness subscapularis tear (8mm, approximately one- third thickness).
Moderate supraspinatus and infraspinatus tendinosis with possible minor infraspinatus tearing.
Teres minor oedema and fatty atrophy.
Long head biceps tendinosis.
Severe AC joint degeneration with inferior osteophytes.
Labral tears from 9 to 12 o'clock and 3 to 6 o'clock.
Anterosuperior paralabral cyst 15x14x14mm.
Posterosuperior paralabral cyst 8x4x3mm.
Small glenohumeral effusion.
Posterior decentring of the humeral head. "Partial thickness tear subscapularis" 09 Sep 2025 — MRI left shoulder for shoulder pain.
Mild supraspinatus and infraspinatus tendinopathy.
Attritional partial subscapularis tear.
Medially subluxed long head biceps tendon with intracapsular tendinopathy.
Extensive glenoid labral tearing with 16mm posterosuperior paralabral cyst.
Mild AC joint degeneration.
Small subacromial bursal effusion. "Extensive labral tearing"
Symptoms
The veteran reports bilateral shoulder pain, worse with abduction and overhead movement.
Both shoulders have significant structural pathology confirmed on MRI including rotator cuff tendinopathy, partial tears, labral tearing, and AC joint degeneration
Imaging
11 August 2018 — Bone scan: "Arthropathy in both shoulders with tendinopathy.
Sternoclavicular arthropathy." 08 Sep 2025 — MRI right shoulder: "Partial subscapularis tear.
Moderate supraspinatus/infraspinatus tendinosis.
Teres minor atrophy.
Severe AC degeneration.
Labral tears 9-12 and 3-6 o'clock.
Paralabral cysts.
LHB tendinosis." 09 Sep 2025 — MRI left shoulder: "Mild rotator cuff tendinopathy.
Partial subscapularis tear.
LHB subluxation and tendinopathy.
Extensive labral tearing.
16mm paralabral cyst.
Mild AC degeneration."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnoses are Bilateral Shoulder Tendinopathy with Partial Rotator Cuff Tears (ICD-10: M75.11, M75.12), Bilateral Labral Tears (S43.431A, S43.432A), Bilateral AC Joint Arthropathy (M19.011, M19.012), and Bilateral Biceps Tendon Pathology (M75.21, M75.22).
The relevant Statements of Principles are those concerning Rotator Cuff Syndrome (Balance of Probabilities No.
110 of 2022; Reasonable Hypothesis No.
109 of 2022), applied by analogy as this is a DRCA claim.
The right shoulder has more severe pathology than the left, consistent with the documented direct traumatic insult to the right shoulder from the car jack incident on 23 September 1989 in addition to the cumulative occupational loading
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Right shoulder: 23 September 1989 (acute right shoulder STI from car jack) [ [CHART REVIEW document], pages 12 13].
Left shoulder: insidious onset from cumulative loading during service.
When did the veteran first present to a health / medical provider for this condition? Right shoulder: 23 September 1989.
Left shoulder: 11 August 2018 (bone scan).
When was the condition confirmed / formally diagnosed? 8 September 2025 (right shoulder MRI) and 9 September 2025 (left shoulder MRI) When did the veteran first present to you (or your practice) for this condition? 14 November 2026
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnoses were confirmed on imaging.
Right shoulder soft tissue injury was clinically diagnosed during service on 23 September 1989 with pain at full flexion and infraspinatus tenderness.
Bilateral shoulder tendinopathy was identified on bone scan 11 August 2018.
Comprehensive MRI of both shoulders in September 2025 confirmed the bilateral structural pathology [ [CHART REVIEW document], pages 12 13; Reports - MRI RIGHT SHOULDER 2025-06-08, MRI LEFT SHOULDER 2025-06-09]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 1 October 2005 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The Rotator Cuff Syndrome Statements of Principles cover the veteran's bilateral rotator cuff tendinopathy with partial tears and his long head of biceps tendinopathy, with their bursae; neither MRI showed adhesive capsulitis, which is excluded.
The bilateral labral tears and acromioclavicular joint arthropathy are separate conditions that fall under the Labral Tear of the Hip and Shoulder and the Osteoarthritis Statements of Principles, and are not assessed against the factors below.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Rotator Cuff Syndrome, No.
110 of 2022) Factor 9(1): having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome — NOT MET - The car-jack injury to the right shoulder on 23 September 1989 occurred about 15 months before that shoulder's estimated clinical onset of 5 January 1991, outside the 30-day window, and no injury to the left shoulder is recorded in the 30 days before its estimated onset of 15 June 2005.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any surgical procedure involving either shoulder joint, before the estimated onset dates or at any time since.
Factor 9(3): performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome — MET - From August 1990 the veteran served in the seamanship branch at a maintenance squadron, where records from 1991 show him cutting timber with a circular saw, working with an outboard motor and doing heavy lifting; before that he scrubbed and polished decks in ships' husbandry.
These forceful activities, requiring force equivalent to lifting more than 3 kg, used both upper limbs including the non-dominant right.
A conservative estimate from these duties of 2 hours on each of about 100 working days from May to early January 1991 gives about 200 hours within the 210 days before the right shoulder's estimated onset of 5 January 1991, and the work continued to that date.
It is not shown for the left shoulder, whose pre-onset work in 2005 is not recorded.
Factor 9(4): performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - Rope work, scrubbing deckheads and ships' husbandry involved raised-arm work, but a conservative estimate (1.5 hours a day over about three and a quarter years of effective duty, with training and sport) is about 1,500 hours before the right shoulder's onset on 5 January 1991, well short of 4,000; none is recorded in the 10 years before the left shoulder's onset in 2005.
Factor 9(5): lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - His documented heavy lifting (steel cables and cable drums at sea in October 1986) and seamanship duties support a conservative estimate of about 20 minutes a day of lifting or carrying loads of 20 kg or more, about 260 hours before the right shoulder's onset on 5 January 1991, short of 400; none is recorded in the 10 years before the left shoulder's onset in 2005.
Factor 9(6): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so he has not had dialysis-related amyloidosis.
Factor 9(7): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of the veteran bearing weight through his upper limbs, for example on crutches or in a wheelchair, for a continuous year before either estimated onset date.
Factor 9(8): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - No shoulder imaging was performed near either estimated onset date; the acromioclavicular osteophytes shown on MRI in September 2025 are later degenerative findings, and the curved (type II) left acromion is a developmental shape rather than an acquired narrowing.
Factor 9(9): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - No dislocation, subluxation or instability of either shoulder is recorded before the estimated onset dates, and the right shoulder retained a full range of movement after the car-jack injury of September 1989.
Factor 9(10): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of either shoulder, and nothing in his history suggests it.
Factor 9(11): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has not been diagnosed with any of the listed autoimmune diseases, such as rheumatoid arthritis or polymyalgia rheumatica, and imaging of his sacroiliac joints has been normal.
Factor 9(12): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - Gout has never been diagnosed in the veteran, in either shoulder or elsewhere.
Factor 9(13): having diabetes mellitus before the clinical onset of rotator cuff syndrome — NOT MET - the veteran's diabetes mellitus was diagnosed in 2021, long after the estimated onset of the right (1990) and left (2005) shoulder conditions, and urinalysis in service was normal.
Factor 9(14): having dyslipidaemia before the clinical onset of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels, diagnosis of dyslipidaemia or lipid-lowering treatment are recorded before either onset date or since.
Factor 9(15): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome — NOT MET - No systemic glucocorticoid or corticosteroid injection into the shoulder tendon region is recorded before either onset date; the only earlier corticosteroids were topical, a heel cream and ear drops in 1986.
Factor 9(16): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome — NOT MET - No fluoroquinolone antibiotic, such as ciprofloxacin or norfloxacin, is recorded at any time, in service or after it.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Rotator Cuff Syndrome, No.
109 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having an injury to the affected shoulder within the 3 months before the clinical onset of rotator cuff syndrome — NOT MET - The car-jack injury to the right shoulder on 23 September 1989 preceded its estimated onset of 5 January 1991 by about 15 months, outside the 3-month window, and no injury to the left shoulder is recorded in the 3 months before 15 June 2005.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any surgical procedure involving either shoulder joint, before the estimated onset dates or at any time since.
Factor 9(3): performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 80 hours within a period of 120 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome — MET - From August 1990 the veteran served in the seamanship branch at a maintenance squadron, where records from 1991 show him cutting timber with a circular saw, working with an outboard motor and doing heavy lifting.
These forceful activities, requiring force equivalent to lifting more than 3 kg, used both upper limbs including the non-dominant right.
A conservative 2 hours on each of about 80 working days from June to early January 1991 gives about 160 hours within the 120 days before the right shoulder's estimated onset of 5 January 1991, twice the 80 hours required, and the work continued to that date.
It is not shown for the left shoulder, whose pre-onset work in 2005 is not recorded.
Factor 9(4): performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - A conservative estimate of his work with the right arm raised at least 60 degrees before 5 January 1991 (rope work, scrubbing deckheads and ships' husbandry, 1.5 hours a day over about three and a quarter years of effective duty, with training and sport) is about 1,500 hours, short of 2,000; none is recorded in the 10 years before the left shoulder's onset in 2005.
Factor 9(5): lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 200 hours within the 10 years before the clinical onset of rotator cuff syndrome — MET - the veteran's duties involved heavy lifting: he strained his back lifting steel cables and cable drums at sea in a maintenance squadron on 11 October 1986, and in June 1988 his orthopaedic surgeon expected him to be 'fully fit 100% for heavy manual work' three months after thumb surgery.
A conservative estimate from these duties (steel cable, survey equipment and batteries, fuel containers, outboard motors, mooring lines and stores) of 20 minutes a day of loads of 20 kg or more over about three and a quarter years of effective duty, with recruit training, gives about 260 hours within the 10 years before the right shoulder's onset on 5 January 1991, exceeding 200; two-handed lifts load the right upper limb.
It is not shown for the left shoulder.
Factor 9(6): using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - The powered tools recorded in service (a floor polisher, a circular saw and a lawn mower) are not heavy percussive industrial tools, and no use of such tools approaching 2,000 hours is recorded before either onset date.
Factor 9(7): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so he has not had dialysis-related amyloidosis.
Factor 9(8): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of the veteran bearing weight through his upper limbs, for example on crutches or in a wheelchair, for a continuous year before either estimated onset date.
Factor 9(9): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - No shoulder imaging was performed near either estimated onset date; the acromioclavicular osteophytes shown on MRI in September 2025 are later degenerative findings, and the curved (type II) left acromion is a developmental shape rather than an acquired narrowing.
Factor 9(10): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - No dislocation, subluxation or instability of either shoulder is recorded before the estimated onset dates, and the right shoulder retained a full range of movement after the car-jack injury of September 1989.
Factor 9(11): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of either shoulder, and nothing in his history suggests it.
Factor 9(12): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has not been diagnosed with any of the listed autoimmune diseases, such as rheumatoid arthritis or polymyalgia rheumatica, and imaging of his sacroiliac joints has been normal.
Factor 9(13): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - Gout has never been diagnosed in the veteran, in either shoulder or elsewhere.
Factor 9(14): having acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - No abnormal scapular position or motion, such as winging, and no injury to the long thoracic or spinal accessory nerve or scapulothoracic mass, is recorded for either shoulder at the estimated onset dates.
Factor 9(15): having smoked at least 20 pack-years of tobacco products before the clinical onset of rotator cuff syndrome — MET - the veteran reported in December 2025 that he had smoked 50 cigarettes a day until 2010; the only in-service record, on 27 November 1991, notes about 5 a day.
Counting 2.5 packs a day from 1985, he had smoked about 50 pack-years by the left shoulder's estimated onset of 15 June 2005, and about 35 pack-years even if the in-service rate of 5 a day is used until discharge, well above 20.
The factor is met for the left shoulder only: by the right shoulder's onset on 5 January 1991 he had smoked at most about 14 pack-years.
Factor 9(16): having diabetes mellitus before the clinical onset of rotator cuff syndrome — NOT MET - the veteran's diabetes mellitus was diagnosed in 2021, long after the estimated onset of the right (1990) and left (2005) shoulder conditions, and urinalysis in service was normal.
Factor 9(17): having dyslipidaemia before the clinical onset of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels, diagnosis of dyslipidaemia or lipid-lowering treatment are recorded before either onset date or since.
Factor 9(18): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome — NOT MET - No systemic glucocorticoid or corticosteroid injection into the shoulder tendon region is recorded before either onset date; the only earlier corticosteroids were topical, a heel cream and ear drops in 1986.
Factor 9(19): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome — NOT MET - No fluoroquinolone antibiotic, such as ciprofloxacin or norfloxacin, is recorded at any time, in service or after it.
Factor 9(20): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical onset of rotator cuff syndrome — NOT MET - No aromatase inhibitor has ever been prescribed to the veteran, and nothing in his history, such as a hormone-sensitive cancer, suggests it.
Other Plausible Links to Service The right shoulder condition began with the injury of 23 September 1989: while the veteran was changing a flat tyre on his car, the jack shifted and the car came down on him, pinning him by the shoulders and landing on his right shoulder.
The Medical Officer at a maintenance squadron recorded pain at full flexion with tenderness over infraspinatus and the lateral shoulder, and prescribed Brufen, local heat and seven days' light duties.
The Daily Injury Record answers 'No' to being on duty and to travelling to or from duty, but the Medical Officer's history on the same record states that he was repairing the tyre 'on way home from work', at 1650 on a Thursday.
Whether the injury is covered as a journey injury under the provisions then applying is a matter for the delegate; if it is not, it was an off-duty injury that did not itself arise out of, or in the course of, his employment.
Even so, the DRCA definition of injury includes an aggravation of a physical injury, whether or not that injury arose out of employment, where the aggravation arose out of, or in the course of, employment.
After September 1989 the veteran returned to heavy seamanship work for most of the two and a half years until discharge: ships' husbandry at the Fleet Intermediate Maintenance Activity, Sydney (scrubbing and polishing decks), then general seamanship at a maintenance squadron with heavy lifting, timber cutting and work with outboard motors.
This repeated loading of an injured shoulder is likely to have aggravated it, and if the condition is regarded as a disease, those duties contributed to it to a significant degree.
The right (non- dominant) shoulder now shows more advanced rotator cuff disease than the dominant left, with partial-thickness subscapularis tearing, moderate supraspinatus and infraspinatus tendinosis and teres minor atrophy; handedness does not explain this, but the 1989 injury and its aggravation by service do.
The veteran's dominant left shoulder region was injured twice during service.
On Saturday 2 December 1985, when he was an adult Aircraft Technician at a maintenance squadron, a scrum collapsed on him during organised rugby, recorded as duty ('organised sport'); the report describes injury to his back, shoulder and neck, and the Medical Officer recorded tenderness of the left scapula.
On 30 September 1989, a week after the car-jack incident in which he was pinned by the shoulders, tenderness of the left scapular and upper back muscles was recorded.
As a left-hand-dominant Aircraft Technician, his left upper limb also bore the greater share of rope work, lifting and throwing (shot put with the left hand in 1985) over 6 years and 8 months of physically demanding service from the age of 16.
Although the left shoulder's onset is estimated in 2005, symptomatic rotator cuff disease at about 36 years of age, with no recorded post-service shoulder injury, is consistent with a contribution from these in-service injuries and the cumulative loading of the dominant shoulder.
Conclusion the veteran's right shoulder rotator cuff and biceps tendon disease arose in service: it followed the injury of 23 September 1989, when a car slid off a jack onto that shoulder, and developed during heavy seamanship duties that satisfy the forceful-activity factor before its estimated onset on 5 January 1991, and those duties continued to aggravate it until discharge.
His dominant left shoulder condition began after service (estimated 15 June 2005), but at an age young for rotator cuff disease and after two in-service injuries to the left scapular region and nearly seven years of physically demanding service loading the dominant arm from the age of 16, which are likely to have contributed to it together with heavy smoking.
Smoking, diabetes from 2021, degenerative narrowing of the right subacromial space, glenohumeral instability and a 36-year delay between the first in-service presentation and diagnosis have contributed to the later worsening of both shoulders.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's rotator cuff syndrome is found not to have arisen out of his service, the following factors address whether anything after its clinical onset aggravated it or contributed to it in a material degree.
For the right shoulder (estimated onset 5 January 1991) this includes his seamanship duties at a maintenance squadron until discharge on 19 April 1992; for the left shoulder (estimated onset 15 June 2005) no ADF service was rendered after onset, and the factors are nevertheless addressed on the post-service facts.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Rotator Cuff Syndrome, No.
110 of 2022) Factor 9(17): having an injury to the affected shoulder within the 30 days before the clinical worsening of rotator cuff syndrome — NOT MET - No injury to either shoulder is recorded after the estimated onset dates; in the workplace accident of 8 April 2018 a falling strut struck his face and he fell onto his back, with no shoulder injury recorded.
Factor 9(18): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of any surgical procedure involving either shoulder joint, before the estimated onset dates or at any time since.
Factor 9(19): performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome — MET - After the right shoulder's estimated onset on 5 January 1991, the veteran continued general seamanship duties at a maintenance squadron until discharge on 19 April 1992, including cutting timber (May 1991), heavy lifting (October 1991) and work with an outboard motor (February 1992).
A conservative 2 hours a day of such forceful activity gives about 200 hours in any 210-day period, continuing until discharge, so the timing is satisfied for a worsening during that service.
This loading of an injured, non-dominant shoulder is likely to have aggravated it: a soft-tissue injury with full movement in 1989 had progressed by September 2025 to partial-thickness subscapularis tearing, moderate supraspinatus and infraspinatus tendinosis and teres minor atrophy, more advanced than in the dominant left.
Post-service truck loading (April 2018) is a possible non-service contributor.
Factor 9(20): performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome — NOT MET - Including his seamanship duties after January 1991, a conservative estimate of work with the right arm raised at least 60 degrees in the 10 years before a worsening during or soon after service is about 1,850 hours, well short of 4,000, and no such post-service work is recorded for either shoulder.
Factor 9(21): lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical worsening of rotator cuff syndrome — NOT MET - Adding the heavy lifting of his seamanship duties after January 1991 (recorded in October 1991) to his earlier lifting, a conservative estimate of lifting or carrying loads of 20 kg or more in service is about 340 hours for the right shoulder, short of 400; post-service heavy lifting is recorded only once, loading a truck in April 2018, and cannot be quantified.
Factor 9(22): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so he has not had dialysis-related amyloidosis.
Factor 9(23): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran walks normally, and no use of crutches, a walking aid or a wheelchair for a continuous year is recorded at any time.
Factor 9(24): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome — MET - The MRI of the right shoulder on 8 September 2025, performed for pain worse with abduction and overhead movement, showed severe acromioclavicular joint degeneration with small inferior osteophytes.
Inferior acromioclavicular osteophytes project downward into the supraspinatus outlet, reducing the space between the coraco-acromial arch and the humeral head, and are a recognised acquired cause of subacromial narrowing; although the report does not measure the space, this acquired narrowing was present at the time of the worsening documented in 2025.
The left shoulder showed milder hypertrophic acromioclavicular degeneration.
Factor 9(25): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome — MET - The MRI of the right shoulder on 8 September 2025 showed the humeral head posteriorly decentred in relation to the glenoid, a static posterior subluxation, with labral tears from 9 to 12 o'clock and from 3 to 6 o'clock and paralabral cysts up to 15 mm; the left MRI of 9 September 2025 showed extensive labral tearing with a 16 mm paralabral cyst.
Paralabral cysts form over time from established labral tears, so this glenohumeral instability is likely to have preceded the clinical worsening of the rotator cuff that led to the 2025 MRIs, which showed partial-thickness subscapularis tearing in both shoulders.
Factor 9(26): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of either shoulder; the small subacromial bursal effusions seen on MRI in September 2025 were not attributed to infection.
Factor 9(27): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has not been diagnosed with any of the listed autoimmune diseases, such as rheumatoid arthritis or polymyalgia rheumatica, and imaging of his sacroiliac joints has been normal.
Factor 9(28): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - Gout has never been diagnosed in the veteran, in either shoulder or elsewhere.
Factor 9(29): having diabetes mellitus before the clinical worsening of rotator cuff syndrome — MET - the veteran was diagnosed with diabetes mellitus in 2021 and is treated with metformin (Diaformin).
His diabetes preceded the clinical worsening of both shoulders that led to MRI in September 2025 for pain worse with abduction and overhead movement, which showed partial- thickness subscapularis tears in both shoulders with rotator cuff and long head of biceps tendinosis.
The factor is met for both shoulders.
Factor 9(30): having dyslipidaemia before the clinical worsening of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels or lipid-lowering treatment are recorded, and his medication list of December 2025 includes no lipid-lowering drug.
Factor 9(31): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome — NOT MET - His only corticosteroid injections, Celestone in 2018 to the right lateral cutaneous nerve of the thigh, right greater trochanteric bursa and right L4/5 facet joint, and a further injection for lumbar pain before January 2023, were not in the shoulder tendon region and total well under 0.5 g of prednisolone equivalent; no systemic course is recorded.
Factor 9(32): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome — NOT MET - No fluoroquinolone antibiotic, such as ciprofloxacin or norfloxacin, is recorded at any time, in service or after it.
Factor 9(33): inability to obtain appropriate clinical management for rotator cuff syndrome — MET - The right shoulder injury of September 1989, like the left scapular injuries of 1985 and 1989, was treated only with anti-inflammatory medication, heat and light duties, without follow-up or imaging, and neither shoulder was presented again in service despite continuing heavy duties, indicating barriers to care: his medical record could not be located in May 1991, and an August 1988 command signal suspecting him of malingering was a sanction-type pressure against reporting.
MRI confirmation came only in September 2025, 36 years after the first presentation and seven years after an incidental bone scan finding.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Rotator Cuff Syndrome, No.
109 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(21): having an injury to the affected shoulder within the 3 months before the clinical worsening of rotator cuff syndrome — NOT MET - No injury to either shoulder is recorded after the estimated onset dates; the workplace accident of 8 April 2018 injured his face and back, with no shoulder injury recorded.
Factor 9(22): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of any surgical procedure involving either shoulder joint, before the estimated onset dates or at any time since.
Factor 9(23): performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 80 hours within a period of 120 consecutive days before the clinical worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome — MET - After the right shoulder's estimated onset on 5 January 1991, the veteran continued general seamanship duties at a maintenance squadron until discharge on 19 April 1992, including cutting timber (May 1991), heavy lifting (October 1991) and work with an outboard motor (February 1992).
A conservative 2 hours a day of such forceful activity gives about 160 hours in any 120-day period, twice the 80 hours required, and it continued until discharge, so the timing is satisfied for a worsening during that service.
This loading of an injured shoulder is likely to have aggravated it, consistent with the partial-thickness subscapularis tearing, moderate tendinosis and teres minor atrophy found on MRI in September 2025, more advanced than in the dominant left shoulder.
Factor 9(24): performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 2,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome — NOT MET - Including his seamanship duties after January 1991, a conservative estimate of work with the right arm raised at least 60 degrees in the 10 years before a worsening during or soon after service is about 1,850 hours, short of 2,000, and no such post-service work is recorded for either shoulder.
Factor 9(25): lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 200 hours within the 10 years before the clinical worsening of rotator cuff syndrome — MET - After the right shoulder's estimated onset on 5 January 1991, the veteran's seamanship duties at a maintenance squadron continued to involve heavy lifting (recorded on 10 October 1991) and work with outboard motors until discharge on 19 April 1992.
With his earlier documented heavy lifting (steel cables and cable drums at sea in October 1986), a conservative estimate of 20 minutes a day of loads of 20 kg or more gives about 340 hours in service within the 10 years before a worsening during or soon after service, exceeding 200, about 80 of them after onset.
This loading of an injured shoulder is likely to have contributed to its progression to the partial-thickness tearing and tendinosis shown on MRI in September 2025.
Factor 9(26): using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome — NOT MET - The powered tools recorded after the right shoulder's onset (a circular saw and a lawn mower in 1991) are not heavy percussive industrial tools, and no use of such tools approaching 2,000 hours is recorded in service or after it.
Factor 9(27): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so he has not had dialysis-related amyloidosis.
Factor 9(28): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran walks normally, and no use of crutches, a walking aid or a wheelchair for a continuous year is recorded at any time.
Factor 9(29): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome — MET - The right shoulder MRI of 8 September 2025, performed for pain worse with abduction and overhead movement, showed severe acromioclavicular joint degeneration with small inferior osteophytes, which project downward into the supraspinatus outlet beneath the coraco- acromial arch.
This is a recognised acquired narrowing of the space between the arch and the humeral head, present at the time of the worsening documented in 2025, although the report does not measure the space.
Factor 9(30): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome — MET - The right shoulder MRI of 8 September 2025 showed posterior decentring of the humeral head on the glenoid (a static posterior subluxation) with superior, posterosuperior and anteroinferior labral tears and paralabral cysts up to 15 mm, and the left showed extensive labral tearing with a 16 mm cyst.
Paralabral cysts form over time from established tears, so this instability is likely to have preceded the worsening of the rotator cuff documented in 2025.
Factor 9(31): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of either shoulder; the small subacromial bursal effusions seen on MRI in September 2025 were not attributed to infection.
Factor 9(32): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has not been diagnosed with any of the listed autoimmune diseases, such as rheumatoid arthritis or polymyalgia rheumatica, and imaging of his sacroiliac joints has been normal.
Factor 9(33): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - Gout has never been diagnosed in the veteran, in either shoulder or elsewhere.
Factor 9(34): having acquired scapular dyskinesis of the affected side at the time of the clinical worsening of rotator cuff syndrome — NOT MET - No winging or other abnormal scapular position or motion is recorded; the 16 mm left paralabral cyst lies at the spinoglenoid notch, not in the scapulothoracic space, with no evidence of suprascapular nerve involvement.
Factor 9(35): having smoked at least 20 pack-years of tobacco products before the clinical worsening of rotator cuff syndrome — MET - the veteran reported in December 2025 that he had smoked 50 cigarettes a day until 2010; the only in-service record, on 27 November 1991, notes about 5 a day.
Counted from 1985, his account gives about 62.5 pack-years by 2010 (102.5 as he stated it), so he had smoked well over 20 pack-years before the clinical worsening of both shoulders documented on the bone scan of August 2018 and the MRIs of September 2025.
Smoking is a lifestyle factor.
Factor 9(36): having diabetes mellitus before the clinical worsening of rotator cuff syndrome — MET - the veteran's diabetes mellitus, diagnosed in 2021 and treated with metformin (Diaformin), preceded the clinical worsening of both shoulders that led to MRI in September 2025 for pain worse with abduction and overhead movement, which showed partial-thickness subscapularis tears in both shoulders with rotator cuff and biceps tendinosis.
The factor is met for both shoulders.
Factor 9(37): having dyslipidaemia before the clinical worsening of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels or lipid-lowering treatment are recorded, and his medication list of December 2025 includes no lipid-lowering drug.
Factor 9(38): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome — NOT MET - His only corticosteroid injections, Celestone in 2018 to the right lateral cutaneous nerve of the thigh, right greater trochanteric bursa and right L4/5 facet joint, and a further injection for lumbar pain before January 2023, were not in the shoulder tendon region and total well under 0.5 g of prednisolone equivalent; no systemic course is recorded.
Factor 9(39): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome — NOT MET - No fluoroquinolone antibiotic, such as ciprofloxacin or norfloxacin, is recorded at any time, in service or after it.
Factor 9(40): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical worsening of rotator cuff syndrome — NOT MET - No aromatase inhibitor has ever been prescribed to the veteran, and nothing in his history, such as a hormone-sensitive cancer, suggests it.
Factor 9(41): inability to obtain appropriate clinical management for rotator cuff syndrome — MET - Neither shoulder was investigated in service: the right shoulder injury of September 1989 and the left scapular injuries of 1985 and 1989 were managed with anti-inflammatory medication and light duties only, and the shoulders were not presented again despite continuing heavy duties, against a background of a medical record that could not be located (May 1991) and an August 1988 command signal suspecting malingering.
Diagnosis by MRI came only in September 2025, 36 years after the first presentation.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Sequelae
The bilateral shoulder pathology is a sequela of the cumulative occupational loading during ADF service and the acute right shoulder injury from the car jack incident on 23 September 1989
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — The right shoulder injury of September 1989, like the left scapular injuries of 1985 and 1989, was treated only with anti-inflammatory medication, heat and light duties, without follow-up or imaging, and neither shoulder was presented again in service despite continuing heavy duties, indicating barriers to care: his medical record could not be located in May 1991, and an August 1988 command signal suspecting him of malingering was a sanction-type pressure against reporting.
MRI confirmation came only in September 2025, 36 years after the first presentation and seven years after an incidental bone scan finding.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Date of Clinical Onset
Bilateral shoulder pathology is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
Right shoulder: first documented presentation 23 September 1989 — soft tissue injury to the right shoulder when a car slid off a jack onto it (a maintenance squadron) [ [CHART REVIEW document], pages 12 13]; first imaging / formal diagnosis 8 September 2025 (MRI of the right shoulder) (confirmation, not onset).
Left shoulder: first documented presentation 11 August 2018 — whole body bone scan demonstrating shoulder arthropathy with tendinopathy [CHART REVIEW document]; first imaging / formal diagnosis 9 September 2025 (MRI of the left shoulder) (confirmation, not onset).
The precise dates of clinical onset cannot be determined from the records.
For each shoulder, the date is estimated as the midpoint between the first documented presentation with shoulder symptoms and the end of the veteran's ADF service (19 April 1992).
Estimated date of clinical onset — right shoulder: 5 January 1991.
Estimated date of clinical onset — left shoulder: 15 June 2005.
The estimated date for the right shoulder falls within the veteran's ADF service (4 July 1985 19 April 1992); the estimated date for the left shoulder falls after it.
In-service events and exposures before each date relate to clinical onset, and those after it to clinical worsening
