Diagnostic Assessment — Cervical Sprain
Example 1 of 1 · fictitious patient
Diagnostic Assessment Cervical Sprain BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Steward from 6 March 1986 to 20 December 1992
Occupational History
As a Steward in the Royal Australian Navy, the veteran performed physically demanding duties including manual handling of heavy equipment aboard naval vessels.
He played rugby in service, including organised rugby as a Steward at a supply ship in 1986, and in August 2026 he told his neurologist that he had represented the defence forces in rugby union, rugby league and boxing, although the service records do not document representative sport or boxing; these are high-impact contact sports with significant risk of cervical spine injury through tackles, scrums, collisions and blows to the head and neck
History
The veteran sustained a cervical sprain during service in the Royal Australian Navy.
The earliest documented cervical injury occurred on 4 August 1986 when he injured his back and neck playing rugby at a supply ship during initial recruit training, with tenderness over the cervical spine documented on examination.
The PM 278 Compensation Supporting Report for the same incident records that a scrum collapsed on top of him during organised sport, injuring his back, shoulder and neck
Timeline
04 Aug 1986 — PM 278 Compensation Supporting Report (the same incident as the Daily Injury Record below; both sequence number 176/84): a scrum collapsed on top of Steward the veteran, as a young adult, during organised sport (rugby) at North Beach, Sorrento, whilst serving at a supply ship, injuring his back, shoulder and neck.
Recorded as on duty.
Diagnosis ligamentous back injury; 3 days light duty. "Scrum collapsed on top of him injuring his back, shoulder and neck" 04 Aug 1986 — Steward the veteran, as a young adult, injured his back and neck playing rugby at a supply ship during initial recruit training.
Examination demonstrated tenderness over the cervical and lumbar spine with paraspinal muscle involvement and reduced range of spinal motion.
He was prescribed Brufen (ibuprofen) and placed on light duty for 3 days. "Ligamentous back injury" During service (1986 1993) — In August 2026 the veteran told Professor Panegyres that he had represented the defence forces in rugby union, rugby league and boxing and had "many concussions" playing rugby; representative sport and boxing are not documented in the service records.
The service records do document a rugby head injury on 1 April 1986, when he was struck on the left forehead in a scrum that then collapsed on top of him, blows to the face that fractured teeth on 10 January 1987 and 14 September 1988, and the incident of 26 May 1990 in which a car pinned him by the shoulders while his head and shoulders were beneath it.
Each such event can load the cervical spine through axial compression, flexion-extension and rotational forces
Symptoms
At the time of the injury of 4 August 1986, the veteran experienced acute pain in the neck and cervical region with tenderness over the cervical spine and paraspinal muscles and reduced range of spinal motion.
Current symptoms include intractable headaches (up to 20 days per month), cervical pain with suspected radiculopathy, and multilevel cervical spondylosis documented on MRI in December 2026
Imaging
19 Dec 2026 — MRI cervical spine: "C3/4 left posterolateral disc osteophyte complex with mild foraminal stenosis and left facet arthropathy.
C4/5 mild left facet arthropathy.
C5/6 mild anterior endplate spurring.
C7/T1 shallow right paracentral disc protrusion mildly narrowing the spinal canal.
Normal cervical cord."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Cervical Sprain (ICD-10: S13.4XXA).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim.
A cervical sprain involves stretching or tearing of the ligaments of the cervical spine, commonly caused by sudden acceleration-deceleration forces, direct impact, or rotational forces through the neck.
Rugby scrums, tackles, and boxing blows are well-recognised mechanisms for cervical sprain injuries.
The cervical sprain is temporally and anatomically related to the subsequent development of cervical spondylosis, with multilevel disc and facet degeneration now confirmed on MRI in December 2026
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 4 August 1986 (back, shoulder and neck injury from a rugby scrum collapse) [ [CHART REVIEW document], pages 16 17; [CHART REVIEW document], Page 17] When did the veteran first present to a health / medical provider for this condition? 6 August 1986 (treated at a supply ship for the injury of 4 August 1986) [ [CHART REVIEW document], pages 16 17] When was the condition confirmed / formally diagnosed? Approximately 4 August 1986 (formally documented as ligamentous back injury of cervical and lumbar spine) [ [CHART REVIEW document], pages 16 17] When did the veteran first present to you (or your practice) for this condition? 17 July 2017
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending medical officers at a supply ship.
On 4 August 1986, after a rugby scrum collapsed on top of him injuring his back, shoulder and neck, a ligamentous back injury affecting the cervical and lumbar spine was diagnosed, with tenderness over the cervical spine and paraspinal muscles and reduced range of motion.
Mild multilevel cervical degeneration, with a C3/4 disc-osteophyte complex and facet arthropathy at C3/4 and C4/5, was subsequently shown on MRI on 19 December 2026, although the radiologist identified no cause for his symptoms [ [CHART REVIEW document], pages 16 17; [CHART REVIEW document], Page 17; Report - MRI CERVICAL SPINE - 2017-01-16]
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 3 June 2006 (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.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - The Compensation Supporting Report of 4 August 1986 records that, during organised rugby at a supply ship, a scrum collapsed on top of the veteran, 'injuring his back, shoulder and neck'.
A collapsing scrum bearing down on a player's head and shoulders applies a significant compressive and bending force through the cervical spinal joints, a recognised mechanism of neck ligament injury in rugby.
On 6 August 1986 the Medical Officer, recording that he had 'injured back and neck playing rugby', found tenderness of the cervical spine and paraspinal muscles with reduced range of movement and diagnosed a ligamentous injury, whose onset coincided with this force.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — MET - The scrum collapse of 4 August 1986 at a supply ship also strained the veteran's neck muscles.
As the weight of the scrum bore down on him, the cervical paraspinal and shoulder girdle muscles were forcibly stretched while contracting against the load, and on 6 August 1986 the Medical Officer recorded tenderness of the paraspinal muscles and over the left scapula as well as of the cervical spine, with reduced range of movement.
The cervical sprain was therefore accompanied by a muscle strain that began with this forceful stretching.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) 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): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - A rugby scrum collapsed on top of the veteran at a supply ship on 4 August 1986, injuring his back, shoulder and neck, a significant force through the cervical spinal joints.
The Daily Injury Record records cervical spinal tenderness with reduced movement and a ligamentous injury diagnosed at that time.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — MET - When a scrum collapsed on top of the veteran on 4 August 1986, his cervical paraspinal and shoulder girdle muscles were forcibly stretched under the load; the Daily Injury Record records paraspinal and left scapular tenderness, so a muscle strain accompanied the cervical sprain from that time.
Other Plausible Links to Service The cervical sprain arose in the course of the veteran's employment.
The Compensation Supporting Report of 4 August 1986 records that he was on duty, in organised sport, when the scrum collapsed on him during his initial training as an adult Steward at a supply ship, which meets the DRCA test of an injury arising out of, or in the course of, employment.
It was his second recorded rugby injury in five months in which a scrum collapsed on him: on 1 April 1986 he was struck on the left forehead in a scrum, which then collapsed on top of him, with suspected loss of consciousness and vomiting requiring admission for neurological observation.
The veteran told his neurologist in August 2026 that he represented Defence in rugby and boxing and had many concussions; the service records do not document representative sport or boxing, but they do record the rugby injuries of 1986, blows to the face in 1987 and 1988 and the car-jack incident of May 1990, each of which loaded the neck during service.
The MRI of 19 December 2026 shows straightening of the cervical lordosis and mild multilevel degeneration, most marked at C3/4.
Early ligamentous injury to the cervical spine is a plausible contributor to later degeneration, but the changes are mild, were found more than 40 years after the injury and followed a significant non-service facial injury in December 2018, so any sequela of the in-service sprain is likely to be partial.
Conclusion the veteran's cervical sprain was caused by the significant force of a rugby scrum collapsing on top of him on 4 August 1986, while he was on duty in organised sport as an adult Steward at a supply ship; the same event strained his neck and shoulder girdle muscles.
After onset, further in-service forces through the neck and shoulders, and the absence of any cervical investigation in service, are consistent with aggravation by service, although the neck was not re-examined in service and a non-service facial injury in 2019 also loaded it.
The sprain arose in the course of his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's cervical sprain is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 4 August 1986 aggravated it or contributed to it in a material degree.
He served for more than six years after that date.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After 4 August 1986 further significant forces passed through the veteran's cervical spine in service: blows to the face that fractured teeth on 10 January 1987 and 14 September 1988, and on 26 May 1990 a car slid off a jack and pinned him by the shoulders while his head and shoulders were beneath it, with pain in the shoulder and 'spine' recorded.
His neck was not examined after these events, but the absence of a record does not show that it was unaffected, and he later reported neck pain and has mild multilevel cervical degeneration on the MRI of 19 December 2026.
A strut striking his face at work on 9 December 2018, after discharge, applied a further non-service force through the neck.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - On 26 May 1990 a car slid off a jack and pinned the veteran by the shoulders, forcibly stretching the muscles that link the neck to the shoulder girdle, and on 2 June 1990 the Medical Officer diagnosed a strain of the left scapular and upper back muscles, the region that was tender with his neck after the scrum collapse of 1986.
The strain deteriorated with climbing stairs in ships, and treatment was escalated to Voltaren 50 mg twice daily and Messal cream with time off duty.
He later reported neck pain, discomfort and cracking of the neck (August 2026).
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - After a scrum collapsed on top of him on 4 August 1986, a recognised mechanism of serious neck injury, the veteran had cervical spinal tenderness and reduced movement, yet no cervical X-ray was taken to exclude a bony or unstable injury and no follow-up was recorded.
His neck was not imaged in service, even after a car pinned him by the shoulders in May 1990, or until 19 December 2026.
His youth as a Steward, a command signal of 26 April 1989 suspecting him of malingering and the loss of his medical record in January 1992 were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions, so this factor is met.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) 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(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After August 1986 the veteran's neck was subjected to further significant forces in service, including blows to the face that fractured teeth in 1987 and 1988 and a car pinning him by the shoulders, with his head beneath it, on 26 May 1990.
Although no neck examination followed, he later reported neck pain and has mild multilevel cervical degeneration on MRI.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - When a car pinned the veteran by the shoulders on 26 May 1990, the muscles linking the neck and shoulder girdle were forcibly stretched, and a strain of the left scapular and upper back muscles, tender with his neck in 1986, was diagnosed on 2 June 1990 and worsened with climbing stairs in ships, requiring Voltaren and time off duty.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - The cervical injury of 4 August 1986, caused by a collapsing scrum and with cervical spinal tenderness, was not X-rayed or followed up, and the neck was not imaged until December 2026.
With his youth as a recruit, later sea service, the 1989 malingering signal and the loss of his medical record in 1992, this amounts to an inability to obtain appropriate clinical management under Brew v Repatriation Commission (Full Federal Court, 10 September 1999)
Sequelae
The cervical sprain is a plausible contributor to the mild multilevel cervical degeneration shown on the MRI of 19 December 2026, with a C3/4 disc-osteophyte complex and facet arthropathy at C3/4 and C4/5.
Because those changes are mild, were found more than 40 years after the injury and followed a significant non-service facial injury in December 2018, any sequela of the in-service sprain is likely to be partial
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
After a scrum collapsed on top of him on 4 August 1986, a recognised mechanism of serious neck injury, the veteran had cervical spinal tenderness and reduced movement, yet no cervical X-ray was taken to exclude a bony or unstable injury and no follow-up was recorded; his neck was not imaged in service, even after a car pinned him by the shoulders in May 1990, and was first imaged by MRI on 19 December 2026.
His youth as a Steward, a command signal of 26 April 1989 suspecting him of malingering and the loss of his medical record in January 1992 were further barriers.
As held by the Full Federal Court in Brew v Repatriation Commission (10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions — MET
Date of Clinical Onset
Cervical sprain is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 4 August 1986 — rugby scrum collapse at a supply ship that injured his back, shoulder and neck [ [CHART REVIEW document], pages 16 17; [CHART REVIEW document]].
The later records, including the MRI of the cervical spine on 19 December 2026, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 4 August 1986.
This date falls within the veteran's ADF service (6 March 1986 20 December 1992).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
