Diagnostic Assessment — Bilateral Shoulders - Rotator Cuff Syndrome
Example 1 of 1 · fictitious patient (Veteran EH)
Diagnostic Assessment
Bilateral Shoulders - Rotator Cuff Syndrome
BOP Code: 110 of 2022 (Rotator Cuff Syndrome)
RH Code: 109 of 2022 (Rotator Cuff Syndrome)
ADF History
Veteran EH, date of birth 14 February 1966, Royal Australian Air Force, Aircraft Structural Fitter, enlisted 20 January 1984, medically discharged 18 July 2014. Operational service: Middle East Area of Operations, 10 February 2003 to 15 June 2003 (warlike); Middle East Area of Operations, 05 January 2009 to 30 June 2009 (warlike); Middle East Area of Operations, 01 June 2012 to 30 October 2012 (warlike).
Occupational History
As an aircraft structural fitter the veteran repaired and maintained airframes, which required prolonged riveting, drilling, sealing and panel work with both arms above shoulder height, use of pneumatic rivet guns, bucking bars and air hammers, lifting of panels, wheel assemblies and equipment of 20 to 35 kilograms, and crawling inside wing bays and fuel tanks supporting her weight on her arms.
These duties carry a recognised risk of rotator cuff overuse, impingement and traumatic shoulder injury from falls from maintenance stands and handling heavy components. Deployed maintenance was performed on extended shifts in extreme heat with limited access to physiotherapy and specialist care.
History
Veteran EH, an aircraft structural fitter in the Royal Australian Air Force, developed rotator cuff syndrome of both shoulders on 12 November 2012, two weeks after returning from warlike service in the Middle East, after years of overhead and vibrating tool work, a traction injury to both shoulders on deployment and a background of kidney transplantation, dialysis-related amyloidosis, rheumatoid arthritis and gout. The condition worsened to a full-thickness right supraspinatus tear by August 2013.
Timeline
- 02 Sep 1990 — The veteran dislocated her right shoulder anteriorly playing unit rugby and had an open Bankart repair on 14 May 1991. She returned to full duties as an aircraft structural fitter. Her left shoulder later developed recurrent subluxation and was stabilised arthroscopically on 22 March 2006. "right shoulder dislocation, Bankart repair"
- 20 Jun 2001 — After 7 years of haemodialysis for IgA nephropathy, during which dialysis-related amyloidosis was confirmed on synovial biopsy in 2000, the veteran received a kidney transplant. She began tacrolimus, mycophenolate and prednisolone, later changed to ciclosporin. Post-transplant diabetes and dyslipidaemia were diagnosed on 09 July 2004. "renal transplant, prednisolone ongoing"
- 15 Mar 2008 — A rheumatologist diagnosed seropositive rheumatoid arthritis with synovitis of both shoulders on ultrasound. Breast cancer was diagnosed on 15 August 2011 and treated with lumpectomy and radiotherapy, and letrozole was started on 20 September 2011. She continued smoking about 25 cigarettes a day. "RA, shoulder synovitis"
- 10 May 2012 — At her pre-deployment medical the veteran had full, painless range of motion of both shoulders with negative impingement tests, and was assessed as fit to deploy to the Middle East. "shoulders full ROM, painless"
- 05 Oct 2012 — During warlike service in the Middle East the veteran fell about 1.5 metres from a maintenance stand and caught the guard rail with both arms. The role 2 medical officer recorded pain in both shoulders and prescribed analgesia; no imaging or physiotherapy was available. Ciprofloxacin was prescribed for a urinary tract infection from 14 to 20 October 2012. She continued overhead riveting until she returned to Australia on 30 October 2012. "fall from stand, bilateral shoulder pain"
- 19 Nov 2012 — After a further traction injury holding a falling wing panel on 02 November 2012, the veteran presented to the base health centre with one week of constant pain in both shoulders, night pain, weakness and pain on overhead work. Examination showed painful arcs, positive Hawkins-Kennedy and Neer tests and weak, painful resisted abduction on both sides. "bilateral painful arc, impingement positive"
- 26 Nov 2012 — Ultrasound showed bilateral supraspinatus tendinopathy with partial-thickness tears and subacromial bursal effusions. Aspiration of both bursae grew Staphylococcus aureus and showed urate crystals. On 03 December 2012 a sports physician diagnosed bilateral rotator cuff syndrome with septic and gouty bursitis and scapular dyskinesis, and urgent orthopaedic review was requested. Emergency arthroscopic washout was performed by the on-call orthopaedic team on 07 December 2012. "bilateral partial tears, septic bursitis"
- 14 Aug 2013 — After a return to overhead work, a fall onto both outstretched arms on 28 July 2013 and a course of moxifloxacin in July 2013, MRI showed progression of the right supraspinatus tear to an 18 mm full-thickness tear with retraction, enlargement of the left partial-thickness tear and a recurrent infected right bursal collection. The elective orthopaedic referral for cuff repair had still not been actioned. "full-thickness tear 18 mm"
Symptoms
At onset the veteran had constant aching pain in both shoulders, worse with overhead work and lifting, night pain preventing her from lying on either side, weakness of shoulder elevation and a painful arc of movement. After onset she could not do overhead work for more than a few minutes, and from August 2013 she had marked weakness of right shoulder elevation.
She now reports persistent bilateral shoulder pain, reduced reach and strength, difficulty dressing, washing her hair and lifting objects above shoulder height, and disturbed sleep.
Imaging
- 26 Nov 2012 — Bilateral shoulder radiographs: "Type III acromions bilaterally with inferior acromioclavicular joint osteophytes. Acromiohumeral distance 6 mm right and 7 mm left. Post-surgical changes of the right glenoid."
- 26 Nov 2012 — Bilateral shoulder ultrasound: "Supraspinatus tendinopathy with partial-thickness articular-sided tears, 6 mm right and 4 mm left. Distended subacromial-subdeltoid bursae with complex fluid. Dynamic impingement bilaterally."
- 14 Aug 2013 — MRI right and left shoulders: "Right: 18 mm full-thickness supraspinatus tear with 1 cm retraction and a 3 cm subacromial collection. Acromiohumeral distance 5 mm. Left: enlarged 9 mm partial-thickness supraspinatus tear with infraspinatus tendinopathy."
Onset Date
The most likely date of onset of this condition is 12 Nov 2012.
At that date the veteran was serving full time as an aircraft structural fitter at an RAAF base in Australia, having returned from warlike service in the Middle East on 30 October 2012, and was back on full maintenance duties with overhead work. Both shoulders became constantly painful in the week of 12 November 2012.
This date is appropriate because her pre-deployment medical on 10 May 2012 recorded full, painless shoulder movement, and she first presented with constant bilateral shoulder pain on 19 November 2012, one week after this date. Ultrasound on 26 November 2012 confirmed the diagnosis. The date falls within continuous full-time service.
For the injury factors, the 3 months before onset run from 12 Aug 2012 to 12 Nov 2012, covering the fall on deployment on 05 Oct 2012, and the 30 days run from 13 Oct 2012 to 12 Nov 2012, covering the panel injury of 02 Nov 2012. For the combined activity factors, the 120 days before onset run from 15 Jul 2012 and the 210 days from 16 Apr 2012, and the work continued to 09 Nov 2012. The 10 years before onset run from 12 Nov 2002 to 12 Nov 2012, covering her overhead, lifting and vibrating tool work. The 1 year before onset runs from 12 Nov 2011, during which she regularly bore weight on her arms in wing bays. The 60 days before onset run from 13 Sep 2012, covering ciprofloxacin, and the 2 years from 12 Nov 2010, covering letrozole from 20 Sep 2011. Dialysis-related amyloidosis, the earlier surgery and instability, rheumatoid arthritis, diabetes, dyslipidaemia, prednisolone and smoking all preceded onset, and the subacromial narrowing, infection, gout and scapular dyskinesis were present at onset.
For the worsening factors, the documented worsening is the MRI of 14 Aug 2013. The 30 days and 3 months before it cover the fall of 28 Jul 2013, the 60 days cover moxifloxacin from 01 to 10 Jul 2013, the 120 and 210 days cover her return to overhead work to 26 Jul 2013, and the 1, 2 and 10 year windows run back from 14 Aug 2013 across the same exposures. The orthopaedic referral of 03 Dec 2012 was not actioned before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Shoulders - Rotator Cuff Syndrome (ICD-10-AM M75.1), supraspinatus tendinopathy with partial-thickness tears and subacromial impingement of both shoulders, progressing to a full-thickness right supraspinatus tear, under the Statements of Principles concerning rotator cuff syndrome, Balance of Probabilities No. 110 of 2022 and Reasonable Hypothesis No. 109 of 2022.
Rotator cuff syndrome is a symptomatic inflammatory or degenerative disorder of the rotator cuff tendons, the long head of biceps and the subacromial bursa. It includes tendinopathy, impingement, calcific tendonitis and partial or full-thickness tears. It presents with shoulder pain on elevation, night pain, a painful arc and weakness. Repetitive overhead and forceful work, vibration, trauma, subacromial narrowing, inflammatory and metabolic disease, glucocorticoids, smoking and some drugs all contribute.
The condition began in both shoulders on 12 November 2012, after warlike service in the Middle East, was confirmed on ultrasound on 26 November 2012 and worsened to a full-thickness right tear by 14 August 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 November 2012.
When did the veteran first present to a health / medical provider for this condition?
19 November 2012.
When was the condition confirmed / formally diagnosed?
03 December 2012.
When did the veteran first present to you (or your practice) for this condition?
30 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a sports physician on 03 December 2012 on the clinical findings of bilateral painful arcs, positive impingement tests and painful weakness of resisted abduction, and on ultrasound of 26 November 2012, which showed supraspinatus tendinopathy with partial-thickness tears and subacromial bursitis in both shoulders. This meets the Statement of Principles definition of rotator cuff syndrome, which includes rotator cuff tendinopathy, tear and subacromial impingement syndrome. Adhesive capsulitis was excluded clinically, with preserved passive external rotation.
MRI on 14 August 2013 confirmed progression to an 18 mm full-thickness right supraspinatus tear and enlargement of the left partial-thickness tear.
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.
Legislation: the clinical onset of this condition was on 12 November 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Middle East in 2003, 2009 and from June to October 2012, where the shoulder injury, the fluoroquinolone treatment and much of the overhead work that preceded onset occurred.
Each factor must be related to the person's relevant 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.
Balance of Probabilities — Statement of Principles concerning Rotator Cuff Syndrome, No. 110 of 2022
Causative factors
Factor 9(1): having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome; — MET
- On 02 November 2012, back at her RAAF base in Australia, a 25-kilogram wing access panel she was holding overhead slipped and she took its weight suddenly with both arms, a violent traction injury to both shoulders recorded in the base health centre the same day. This was 10 days before onset on 12 November 2012, within the 30 days from 13 October 2012 to 12 November 2012.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome; — MET
- The veteran had an open Bankart repair of the right shoulder on 14 May 1991 after a dislocation playing unit rugby, and arthroscopic stabilisation of the left shoulder on 22 March 2006 for recurrent subluxation from heavy maintenance work, both before onset on 12 November 2012.
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
- Maintenance logs record more than 500 hours of overhead riveting, drilling and sealing and forceful lifting with both arms in the 210 days from 16 April 2012 to 12 November 2012, at her base in Australia and on deployment, and the work continued until 09 November 2012, 3 days before onset.
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; — MET
- Her duty statements and maintenance logs show about 3 hours a shift of overhead work with both arms above 60 degrees, about 6,600 hours in the 10 years before onset, from 12 November 2002 to 12 November 2012, well above the 4,000 hours required.
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; — MET
- Lifting and carrying of loads of 20 to 35 kilograms with each arm totalled about 1,100 hours in the 10 years before onset, from 12 November 2002 to 12 November 2012, above the 400 hours required.
Factor 9(6): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome; — MET
- After 7 years of haemodialysis from 1994, dialysis-related amyloidosis was confirmed on synovial biopsy in 2000, with amyloid deposits in both shoulders on ultrasound, before onset on 12 November 2012. The deposits persist despite her kidney transplant of 20 June 2001.
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; — MET
- The veteran regularly supported her body weight on both arms while crawling inside wing bays and fuel tanks for 2 to 3 hours a shift, recorded in her duty statements, throughout the year before onset, from 12 November 2011 to 12 November 2012.
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; — MET
- Radiographs on 26 November 2012 showed type III acromions and acromioclavicular osteophytes narrowing the subacromial space on both sides, with acromiohumeral distances of 6 and 7 mm, present at onset.
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; — MET
- The right shoulder dislocated anteriorly on 02 September 1990 and the left shoulder subluxed recurrently from 2005, both before onset.
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; — MET
- Aspiration of both subacromial bursae on 26 November 2012 grew Staphylococcus aureus with a neutrophilic aspirate, confirming bursal infection present at onset.
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; — MET
- Seropositive rheumatoid arthritis involving both shoulders, with glenohumeral synovitis on ultrasound, was diagnosed on 15 March 2008, before onset.
Factor 9(12): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome; — MET
- Monosodium urate crystals were found in both subacromial bursal aspirates on 26 November 2012, confirming gout involving the shoulders at onset.
Factor 9(13): having diabetes mellitus before the clinical onset of rotator cuff syndrome; — MET
- Post-transplant diabetes mellitus was diagnosed on 09 July 2004 and was present before onset, with an HbA1c of 8.1 per cent in 2012.
Factor 9(14): having dyslipidaemia before the clinical onset of rotator cuff syndrome; — MET
- A fasting lipid profile on 09 July 2004 showed an LDL cholesterol of 4.6 mmol/L and triglycerides of 3.1 mmol/L, and dyslipidaemia was present before onset.
Factor 9(15): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome; — MET
- Prednisolone was taken continuously from 20 June 2001, at 7.5 to 20 mg daily, for transplant immunosuppression, more than 11 years before onset.
Factor 9(16): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome; — MET
- Ciprofloxacin 500 mg twice daily was taken from 14 to 20 October 2012, ending 23 days before onset, within the 60 days before it.
Worsening factors
Factor 9(17): having an injury to the affected shoulder within the 30 days before the clinical worsening of rotator cuff syndrome; — MET
- The fall onto both outstretched arms on 28 July 2013 was 17 days before the worsening on 14 August 2013, within 30 days.
Factor 9(18): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome; — MET
- Bilateral arthroscopic subacromial washout and bursectomy on 07 December 2012 was a surgical procedure involving the shoulder joints before the worsening.
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
- Her logs record about 380 hours of overhead and forceful work in the 210 days before the worsening, from 16 January 2013 to 14 August 2013, continuing to 26 July 2013, within 30 days of the worsening.
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; — MET
- Overhead work above 60 degrees totalled about 6,500 hours in the 10 years before the worsening, from 14 August 2003 to 14 August 2013.
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; — MET
- Lifting of 20 to 35 kilograms with each arm totalled about 1,050 hours in the 10 years before the worsening.
Factor 9(22): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome; — MET
- Dialysis-related amyloidosis of both shoulders preceded the worsening.
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; — MET
- Regular upper-limb weight-bearing in wing bays and fuel tanks continued through the year before the worsening, from 14 August 2012 to 14 August 2013.
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
- Anatomical narrowing of the subacromial space was present at the worsening, with a right acromiohumeral distance of 5 mm on 14 August 2013.
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 right shoulder dislocation of 1990 and left subluxations from 2005 preceded the worsening.
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; — MET
- A recurrent Staphylococcus aureus subacromial bursal infection was present at the worsening, confirmed on aspiration on 16 August 2013.
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; — MET
- Rheumatoid arthritis involving both shoulders preceded the worsening.
Factor 9(28): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome; — MET
- Gout involving the shoulders was present at the worsening, with urate crystals on aspiration on 16 August 2013.
Factor 9(29): having diabetes mellitus before the clinical worsening of rotator cuff syndrome; — MET
- Post-transplant diabetes mellitus preceded the worsening.
Factor 9(30): having dyslipidaemia before the clinical worsening of rotator cuff syndrome; — MET
- Dyslipidaemia preceded the worsening.
Factor 9(31): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome; — MET
- Continuous prednisolone and bilateral subacromial triamcinolone injections on 04 February 2013 preceded the worsening.
Factor 9(32): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome; — MET
- Moxifloxacin 400 mg daily from 01 to 10 July 2013, for pneumonia, ended 35 days before the worsening, within the 60 days before it.
Factor 9(33): inability to obtain appropriate clinical management for rotator cuff syndrome; — MET
- After diagnosis on 03 December 2012 the sports physician requested urgent elective orthopaedic review of the cuff tears and a graded rehabilitation program, but the referral was not actioned by the base health centre for 7 months, physiotherapy was limited to three sessions, and surgery was deferred pending immunosuppression clearance. The right partial-thickness tear progressed to an 18 mm full-thickness tear by 14 August 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Rotator Cuff Syndrome, No. 109 of 2022
Causative factors
Factor 9(1): having an injury to the affected shoulder within the 3 months before the clinical onset of rotator cuff syndrome; — MET
- On 05 October 2012, during warlike service in the Middle East Area of Operations, the veteran fell about 1.5 metres from an aircraft maintenance stand and caught the guard rail with both arms, sustaining a sudden traction injury to both shoulders with immediate pain recorded at the role 2 facility. This was 38 days before onset on 12 November 2012, within the 3 months from 12 August 2012 to 12 November 2012.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome; — MET
- The veteran had an open Bankart repair of the right shoulder on 14 May 1991 after a dislocation in unit sport, and arthroscopic stabilisation of the left shoulder on 22 March 2006 for recurrent subluxation, both surgical procedures involving the affected shoulder joints, before onset. The 2006 instability followed heavy overhead work on warlike service in the Middle East in 2003.
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
- On warlike service in the Middle East from 01 June 2012 the veteran spent about 5 hours a shift riveting, drilling and sealing on the undersides of aircraft with both arms above shoulder height, and lifting panels and wheel assemblies. In the 120 days from 15 July 2012 to 12 November 2012 her maintenance logs record more than 300 hours of such work, and it continued at her base in Australia until 09 November 2012, 3 days before onset, so it had not ceased more than 30 days before onset.
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; — MET
- As an aircraft structural fitter the veteran worked with both arms flexed or abducted above 60 degrees for about 3 hours a shift, 220 shifts a year, about 6,600 hours in the 10 years before onset, from 12 November 2002 to 12 November 2012, including on warlike service in the Middle East in 2003, 2009 and 2012.
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 lifted and carried aircraft panels, wheel assemblies, toolboxes and ground equipment of 20 to 35 kilograms with each arm for about 30 minutes a shift, about 1,100 hours in the 10 years before onset, including on warlike service in the Middle East.
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; — MET
- As an aircraft structural fitter the veteran worked with both arms flexed or abducted above 60 degrees for about 3 hours a shift, 220 shifts a year, about 6,600 hours in the 10 years before onset, from 12 November 2002 to 12 November 2012, including on warlike service in the Middle East in 2003, 2009 and 2012.
Factor 9(7): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome; — MET
- The veteran received haemodialysis for end-stage kidney failure from IgA nephropathy from 1994 to 20 June 2001. Dialysis-related beta-2 microglobulin amyloidosis was confirmed in 2000 by synovial biopsy, with bilateral carpal tunnel syndrome and amyloid deposits thickening both rotator cuffs on ultrasound, and was present before onset.
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; — MET
- For more than 5 years before onset, including on warlike service in the Middle East in 2012, the veteran's duties included daily work inside wing bays and fuel tanks, crawling and supporting her body weight on her hands and forearms for 2 to 3 hours a shift. She did so regularly throughout the year before onset, from 12 November 2011 to 12 November 2012.
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; — MET
- Radiographs on 26 November 2012 showed bilateral type III hooked acromions with inferior acromioclavicular joint osteophytes and an acromiohumeral distance of 6 mm on the right and 7 mm on the left, anatomical narrowing of the subacromial space present at onset.
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; — MET
- The veteran dislocated the right shoulder in 1990 and had recurrent subluxation of the left shoulder from 2005, before onset, as recorded in her service health record and confirmed at surgery.
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; — MET
- Ultrasound-guided aspiration of both subacromial bursae on 26 November 2012 grew Staphylococcus aureus, in a veteran immunosuppressed after her kidney transplant, and septic subacromial bursitis was diagnosed. The infection was present at onset, the bursal effusions having been seen with the first symptoms.
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; — MET
- Rheumatoid arthritis was diagnosed on 15 March 2008, with synovitis of both shoulders on ultrasound and positive anti-CCP antibodies, before onset.
Factor 9(13): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome; — MET
- The bursal aspirates of 26 November 2012 contained negatively birefringent monosodium urate crystals, with a serum urate of 0.62 mmol/L from ciclosporin, confirming gout involving both shoulders at onset.
Factor 9(14): having acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome; — MET
- A sports physician recorded bilateral acquired scapular dyskinesis, with medial border prominence and early scapular elevation on flexion and a positive scapular assistance test, on 03 December 2012, present at onset after years of overhead work including on warlike service.
Factor 9(15): having smoked at least 20 pack-years of tobacco products before the clinical onset of rotator cuff syndrome; — MET
- The veteran smoked 25 cigarettes a day from 1982 to the onset in 2012, about 37 pack-years, and heavier smoking on deployment was recorded in 2003, 2009 and 2012.
Factor 9(16): having diabetes mellitus before the clinical onset of rotator cuff syndrome; — MET
- Post-transplant diabetes mellitus was diagnosed on 09 July 2004, with an HbA1c of 7.8 per cent, from tacrolimus and prednisolone, before onset.
Factor 9(17): having dyslipidaemia before the clinical onset of rotator cuff syndrome; — MET
- Dyslipidaemia was diagnosed on 09 July 2004, with a fasting LDL cholesterol of 4.6 mmol/L and triglycerides of 3.1 mmol/L, before onset, treated with atorvastatin.
Factor 9(18): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome; — MET
- The veteran took prednisolone continuously from her transplant on 20 June 2001, 7.5 mg daily by 2012, more than 11 years before onset.
Factor 9(19): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome; — MET
- On warlike service in the Middle East the role 2 medical officer prescribed ciprofloxacin 500 mg twice daily from 14 to 20 October 2012 for a urinary tract infection, 23 days before onset, within the 60 days from 13 September 2012 to 12 November 2012.
Factor 9(20): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical onset of rotator cuff syndrome; — MET
- Letrozole 2.5 mg daily was started on 20 September 2011 for breast cancer diagnosed on 15 August 2011 and taken continuously, including on warlike service in the Middle East in 2012, for more than 13 months within the 2 years before onset, from 12 November 2010 to 12 November 2012.
Worsening factors
Factor 9(21): having an injury to the affected shoulder within the 3 months before the clinical worsening of rotator cuff syndrome; — MET
- On 28 July 2013, at her base, the veteran slipped on hydraulic fluid in the hangar and fell onto both outstretched arms, injuring both shoulders, 17 days before the worsening on 14 August 2013 and within 3 months of it. The original rotator cuff disease followed her overhead work on warlike service in 2012.
Factor 9(22): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome; — MET
- Arthroscopic washout and bursectomy of both shoulders for septic bursitis was performed on 07 December 2012, before the worsening, in addition to the earlier stabilisation surgery.
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 a subacromial injection she returned to full duties in February 2013 and her logs record about 240 hours of overhead and forceful work in the 120 days before the worsening, from 16 April 2013 to 14 August 2013, continuing to 26 July 2013, 19 days before the worsening.
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; — MET
- Overhead work above 60 degrees totalled about 6,500 hours in the 10 years before the worsening, from 14 August 2003 to 14 August 2013, including warlike service in 2009 and 2012.
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
- Lifting of 20 to 35 kilograms with each arm totalled about 1,050 hours in the 10 years before the worsening.
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; — MET
- Overhead work above 60 degrees totalled about 6,500 hours in the 10 years before the worsening, from 14 August 2003 to 14 August 2013, including warlike service in 2009 and 2012.
Factor 9(27): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome; — MET
- Dialysis-related amyloidosis of both shoulders, confirmed in 2000, preceded the worsening.
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; — MET
- She continued to support her body weight on her arms in wing bays and fuel tanks throughout the year before the worsening, from 14 August 2012 to 14 August 2013, apart from 8 weeks of restricted duties.
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 type III acromions and acromioclavicular osteophytes were present at the worsening, with the acromiohumeral distance reduced to 5 mm on the right on MRI on 14 August 2013.
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 earlier dislocation and subluxations preceded the worsening.
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; — MET
- MRI on 14 August 2013 showed a recurrent infected right subacromial collection, which grew Staphylococcus aureus on aspiration on 16 August 2013, present at the worsening.
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; — MET
- Rheumatoid arthritis involving both shoulders preceded the worsening.
Factor 9(33): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome; — MET
- Urate crystals were again found in the right bursal aspirate on 16 August 2013, with gout present at the worsening.
Factor 9(34): having acquired scapular dyskinesis of the affected side at the time of the clinical worsening of rotator cuff syndrome; — MET
- Bilateral acquired scapular dyskinesis was still recorded at physiotherapy on 05 August 2013, at the worsening.
Factor 9(35): having smoked at least 20 pack-years of tobacco products before the clinical worsening of rotator cuff syndrome; — MET
- About 38 pack-years of smoking preceded the worsening.
Factor 9(36): having diabetes mellitus before the clinical worsening of rotator cuff syndrome; — MET
- Post-transplant diabetes mellitus preceded the worsening.
Factor 9(37): having dyslipidaemia before the clinical worsening of rotator cuff syndrome; — MET
- Dyslipidaemia preceded the worsening.
Factor 9(38): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome; — MET
- Prednisolone was taken continuously before the worsening, and a subacromial injection of triamcinolone 40 mg was given into each shoulder on 04 February 2013.
Factor 9(39): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome; — MET
- Moxifloxacin 400 mg daily was taken from 01 to 10 July 2013 for pneumonia, 35 days before the worsening, within 60 days.
Factor 9(40): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical worsening of rotator cuff syndrome; — MET
- Letrozole was taken continuously throughout the 2 years before the worsening, from 14 August 2011 to 14 August 2013.
Factor 9(41): inability to obtain appropriate clinical management for rotator cuff syndrome; — MET
- On warlike service in the Middle East from October 2012 no physiotherapy, imaging or orthopaedic care was available for her shoulder symptoms. After her return, the sports physician's urgent request for elective orthopaedic review of her partial-thickness tears on 03 December 2012 was not actioned for 7 months, and the recommended surgery was deferred while immunosuppression clearance was sought. The tears progressed to a full-thickness tear before treatment. 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 bilateral rotator cuff syndrome is a sequela of the veteran's accepted conditions: the earlier right shoulder dislocation and left shoulder instability and their surgery, dialysis-related amyloidosis of the shoulders, rheumatoid arthritis, and gout from ciclosporin after her kidney transplant.
Unintended Consequence
Met. The condition is in part an unintended consequence of treatment paid for by the Commonwealth while the veteran was serving: long-term prednisolone and subacromial corticosteroid injections, ciprofloxacin and moxifloxacin, letrozole, and the ciclosporin-induced hyperuricaemia that caused shoulder gout (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On deployment in the Middle East from October 2012 no physiotherapy, imaging or orthopaedic assessment was available after her shoulder injury. After diagnosis on 03 December 2012 the urgent elective orthopaedic referral for the cuff tears was not actioned for 7 months, physiotherapy was limited, and surgery was deferred pending immunosuppression clearance, while the right partial-thickness tear progressed to an 18 mm full-thickness tear. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational and administrative barriers that prevent prescribed treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 May 1991, Operation report, right shoulder, Orthopaedic surgeon
- 20 Jun 2001, Transplant operation report, Transplant surgeon
- 22 Mar 2006, Operation report, left shoulder, Orthopaedic surgeon
- 15 Mar 2008, Rheumatology consultation, Rheumatologist
- 20 Sep 2011, Oncology consultation, Medical oncologist
- 10 May 2012, Pre-deployment medical, Medical Officer
- 05 Oct 2012, Role 2 treatment record, Medical Officer, Middle East Area of Operations
- 19 Nov 2012, Outpatient health record, Medical Officer, Base health centre
- 26 Nov 2012, Shoulder radiographs, ultrasound and aspirate reports, Radiologist and pathologist
- 03 Dec 2012, Specialist consultation, Sports physician
- 07 Dec 2012, Operation report, bilateral arthroscopic washout, Orthopaedic surgeon
- 14 Aug 2013, MRI shoulders report, Radiologist
- Statement of Principles concerning Rotator Cuff Syndrome (Balance of Probabilities) No. 110 of 2022, Repatriation Medical Authority
- Statement of Principles concerning Rotator Cuff Syndrome (Reasonable Hypothesis) No. 109 of 2022, Repatriation Medical Authority
