Left Acromioclavicular Joint - Osteoarthritis — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Left Acromioclavicular Joint - Osteoarthritis

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Left Acromioclavicular Joint - Osteoarthritis

Osteoarthritis (Reasonable Hypothesis) (No. 61 of 2017) Osteoarthritis (Balance of Probabilities) (No. 62 of 2017)

ADF History

The veteran, occupation Airfield Defence Guard (ADG), enlisted on 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards. This role involves providing security and ground defence for RAAF assets, personnel, and installations. The duties are physically demanding and include manual handling of heavy equipment, weapons, ammunition, and field gear. This often involves lifting, carrying, and pack marching over uneven terrain for extended periods. Exposure to noise is significant, particularly from weapons firing, aircraft operations, and vehicle movements. Environmental exposures include prolonged exposure to sunlight, heat, cold, dust, and airborne particulates. The occupation involves substantial physical loading on joints, including repetitive movements, carrying heavy loads, and operating in physically demanding environments.

History

The veteran an Airfield Defence Guard in the RAAF, began experiencing left shoulder pain around Mar 2012, possibly after lifting a heavy container. Over time, his condition evolved to include acromioclavicular joint degeneration, which was confirmed on imaging.

Timeline

13 Jul 2010. The veteran underwent X-ray and Ultrasound of the left shoulder for pain with a query of impingement. The X-ray showed "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change."
12 Oct 2010. Reviewed by the treating doctor G. the treating doctor, Orthopaedic Surgeon, for chronic disability in his left shoulder, present for 6 months. He reported mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons. the treating doctor noted the patient had evidence of ACJ arthritis on MRI scan.
18 May 2011. The veteran underwent a Periodic Health Examination. Musculoskeletal assessment noted ongoing shoulder pathology with "AC joint osteoarthritis" documented in the medical history.
18 Jul 2018. An MRI of the Left Shoulder was performed. The findings included: "Mild degenerative arthrosis of the AC joint" along with other shoulder pathologies including a SLAP tear.

Symptoms

At the time of initial presentation, the veteran experienced mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons, affecting his physical training. Clinical assessment revealed evidence of mechanical subacromial impingement.

Current symptoms include ongoing shoulder pain with certain movements, particularly overhead activities. The acromioclavicular joint degenerative changes contribute to his shoulder discomfort and functional limitations. The condition affects his ability to perform certain physical training activities and duties requiring overhead arm positioning or heavy lifting.

Imaging

13 Jul 2010: X-Ray showed "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change. Glenohumeral articular margins appearing normal." Ultrasound showed "No abnormality is seen on sonography."
18 Jul 2018: MRI Left Shoulder report indicated "Mild infraspinatus insertional tendinosis. Localised 12 o'clock labral (SLAP) tear. Mild degenerative arthrosis of the AC joint. Trace fluid in the subacromial/subdeltoid bursa. Fluid in the biceps sheath."

1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Acromioclavicular Joint Osteoarthritis (M19.012), which meets the criteria under the Statement of Principles concerning Osteoarthritis (Balance of Probabilities) (No. 62 of 2017) and Statement of Principles concerning Osteoarthritis (Reasonable Hypothesis) (No. 61 of 2017).

Osteoarthritis is a degenerative joint disorder characterized by clinical manifestations of pain, impaired function, and stiffness, along with osteophytes or loss of articular cartilage. In acromioclavicular joint osteoarthritis, these degenerative changes occur at the junction where the acromion process of the scapula meets the clavicle (collarbone). The condition typically develops gradually over time and can result from repetitive strain, trauma, or overuse of the shoulder. Common features include sclerosis of the underlying bone, osteophyte formation, and narrowing of the joint space. As the condition progresses, it can lead to increasing pain with movement, decreased range of motion, and functional limitations, particularly with overhead activities.

The temporal relationship indicates that the veteran first experienced left shoulder symptoms around Mar 2012, with radiographic evidence of mild degenerative changes at the acromioclavicular joint documented in September 2012. These changes were confirmed and noted to persist in subsequent medical evaluations and imaging studies, with the most recent MRI in September 2020 continuing to demonstrate "mild degenerative arthrosis of the AC joint."

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to his left acromioclavicular joint osteoarthritis around Mar 2012, when he developed left shoulder pain, possibly after lifting a heavy container.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition in September 2012 (approximately 6 months after symptom onset), as indicated by the referral for X-ray and ultrasound imaging performed on 13 July 2010.

When was the condition confirmed / formally diagnosed? The condition was first confirmed radiologically on 13 July 2010 when X-ray showed "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change." The formal clinical diagnosis of AC joint arthritis was documented during his orthopaedic consultation with the treating doctor G. the treating doctor on 12 October 2010.

When did the veteran first present to you (or your practice) for this condition? The veteran first presented to me on 24 December 2017 with ongoing left shoulder pain and limited range of motion, particularly with overhead activities.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of Left Acromioclavicular Joint Osteoarthritis was confirmed through a combination of clinical assessment and imaging findings:

Clinical presentation: The veteran presented with mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons, affecting his physical training.
Radiological confirmation: X-ray on 13 July 2010 demonstrated "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change." This is consistent with early osteoarthritic changes in the acromioclavicular joint.
Specialist assessment: the treating doctor G. the treating doctor, Orthopaedic Surgeon, reviewed the veteran on 12 October 2010 and noted evidence of AC joint arthritis from imaging studies.
Advanced imaging: MRI of the Left Shoulder on 18 July 2018 confirmed "Mild degenerative arthrosis of the AC joint" along with other shoulder pathologies.
Periodic Health Examination: The condition was documented as "AC joint osteoarthritis" in the medical history section during his 18 May 2011 examination.

The diagnosis meets the criteria for osteoarthritis as defined in the Statement of Principles, with clinical manifestations of pain and impaired function, along with radiological evidence of degenerative changes.

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.

having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET

The veteran developed left shoulder pain around Mar 2012, possibly after lifting a heavy container. This represents a discrete event involving the application of significant physical force to or through the affected joint, which likely caused damage to the joint and led to the development of symptoms within 24 hours.

having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint - NOT MET

While the veteran has shoulder pathology that could potentially affect joint mechanics, there is insufficient evidence in the records to establish disordered joint mechanics specifically affecting the acromioclavicular joint for the required duration of at least five years prior to onset.

for osteoarthritis of a joint of the upper limb only, performing: (a) forceful or repetitive activities involving the affected joint; or (b) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical onset of osteoarthritis in that joint - MET

As an Airfield Defence Guard, the veteran duties involved carrying, lifting, and handling heavy equipment, including weapons, ammunition, and field gear. These activities would have placed significant stress on the shoulder joints, including the acromioclavicular joint. With over 15 years of service prior to symptom onset in 2014, the veteran would have performed these forceful activities for the required duration and timeframe.

for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint - NOT MET

The veteran medical records document his waist circumference measurements, which do not exceed 102 centimetres for the required duration.

being overweight for at least ten years before the clinical onset of osteoarthritis in that joint - NOT MET

While the veteran BMI was recorded as 25.1 (Overweight) in August 2001, his BMI fluctuated throughout his service, often in the normal range. There is insufficient evidence to establish that he was consistently overweight for the required ten-year period before clinical onset.

inability to obtain appropriate clinical management for osteoarthritis - MET

Despite presenting with shoulder symptoms in 2014, the veteran condition continued to progress over several years. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both an objective and subjective sense. While the veteran received some conservative management, there appears to have been a delay in offering comprehensive treatment options for his acromioclavicular joint osteoarthritis. The military healthcare setting may have presented barriers to accessing specialized care, particularly given his ongoing deployments and operational requirements.

The % contribution of the causes is 100% and significant.

Sequelae

The left acromioclavicular joint osteoarthritis is not considered a sequela of another condition. Rather, it appears to be a primary condition that developed due to occupational factors and trauma.

Unintended Consequence

There is no evidence that the left acromioclavicular joint osteoarthritis is an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

The veteran condition demonstrates evidence of inability to attain appropriate medical management for osteoarthritis. Despite initial presentation in 2014, there was a significant delay before comprehensive assessment and management were offered. The condition continued to progress over the years, as evidenced by persistence of symptoms and ongoing imaging findings.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgment of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. In the veteran case, this appears to be influenced by operational demands and the military healthcare system's priorities.

This inability to obtain timely and appropriate clinical management has likely contributed to the permanent worsening of his acromioclavicular joint osteoarthritis, as the condition has persisted and potentially progressed when earlier intervention might have limited its development.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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