Diagnostic Assessment — Left Calf - Soft Tissue Injury (M79.89) Left Calf - Strain
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Left Calf – Soft Tissue Injury (M79.89) Left Calf – Strain (S86.819)
Balance of Probabilities: No specific SOP available for soft tissue injury (trauma to the area factor applies); Sprain and Strain SOP No. 28 of 2020 Reasonable Hypothesis: No specific SOP available for soft tissue injury (trauma to the area factor applies); Sprain and Strain SOP No. 29 of 2020
ADF History
The veteran, Communications and Information Systems Controller (CISCON), 28 July 1986, 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller (CISCON) in the Royal Australian Air Force, the veteran was exposed to various occupational hazards including mandatory physical training sessions involving running, marching, and high-impact activities required to maintain fitness standards for operational readiness. His role required participation in regular physical fitness assessments and training exercises that placed significant demands on the musculoskeletal system, particularly the lower limbs during running and endurance activities.
History
The veteran a CISCON in the RAAF, sustained a left calf soft tissue injury and strain during mandatory physical training sessions on 11 January 2001. The injury occurred during routine RAAF physical training activities involving running and high-intensity exercises required for service fitness standards.
Timeline
- 11 Jan 2001 - the veteran first experienced a dull persistent ache above the left calf during RAAF physical training sessions. The injury manifested as an acute onset of pain and discomfort in the left calf muscle during high-intensity training activities. This represented the initial clinical presentation of both the soft tissue injury and muscle strain, with symptoms developing immediately following the training session. The pain was localized to the calf region and was directly attributed to the physical exertion required during the training exercise. The injury was consistent with acute muscle strain from overuse during running or similar training activities mandated for service personnel.
- 19 Mar 2001 - the veteran underwent comprehensive clinical evaluation and diagnostic sonography for his persistent left calf symptoms, with findings confirming a soft tissue injury with normal sonographic findings. The clinical assessment revealed ongoing pain and functional limitation affecting his ability to participate in physical training activities. Sonographic examination was performed to exclude structural damage such as muscle tears or vascular complications, with results showing no evidence of significant anatomical disruption. The normal imaging findings supported a diagnosis of soft tissue injury without major structural damage, consistent with muscle strain. The persistence of symptoms over two months indicated a chronic soft tissue injury requiring ongoing management and monitoring.
Symptoms
At the time of injury on 11 January 2001, the veteran experienced an acute onset of dull, persistent aching pain localized above the left calf muscle. The pain developed during physical training and was associated with functional limitation affecting his ability to continue training activities.
Following the injury, symptoms persisted as a chronic dull ache that limited his participation in physical training and daily activities. The pain remained localized to the calf region with no radiation or associated neurological symptoms.
Current symptoms include ongoing left calf discomfort and functional limitation that affects physical activities. The condition has resulted in chronic pain and reduced exercise tolerance, impacting his ability to perform high-intensity physical activities. The persistent nature of the symptoms has led to ongoing functional impairment affecting both occupational and recreational activities.
Imaging
- 19 Mar 2001 - Sonography of the left calf performed, with results showing normal sonographic findings despite clinical diagnosis of soft tissue injury. The ultrasound examination ruled out significant structural damage such as muscle tears or hematomas while confirming the clinical diagnosis of soft tissue injury.
1. What is the formal diagnosis of the condition claimed above?
Left Calf – Soft Tissue Injury (M79.89) No specific DVA Statement of Principles exists for soft tissue injury. ICD-10 code M79.89 applies for other specified soft tissue disorders.
Soft tissue injury refers to damage to muscles, tendons, ligaments, or other supporting structures of the musculoskeletal system. In the context of the left calf, this represents injury to the muscle fibers, fascia, or associated connective tissues without major structural disruption. The condition typically results from acute trauma, overuse, or excessive physical stress applied to the tissue. Soft tissue injuries can range from minor microtrauma to more significant muscle fiber disruption, with symptoms including pain, tenderness, swelling, and functional limitation. Recovery typically involves rest, gradual return to activity, and symptomatic management.
Left Calf – Strain (S86.819) DVA Statement of Principles concerning Sprain and Strain (Balance of Probabilities) No. 28 of 2020 applies. ICD-10 code S86.819 applies for strain of other muscle(s) and tendon(s) at lower leg level, unspecified leg.
A strain is defined as an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within 24 hours following the injury. Muscle strains occur when muscle fibers are stretched beyond their normal capacity or when excessive force is applied to the muscle-tendon unit. The injury can range from minor overstretching of muscle fibers to partial or complete tears. Symptoms typically include immediate pain, tenderness, muscle spasm, and functional limitation. Recovery depends on the severity of the strain and appropriate management.
The temporal relationship between these diagnoses indicates that both conditions represent the same injury event, with the soft tissue injury being the broader diagnostic category encompassing the specific muscle strain. The strain represents the acute mechanism of injury, while the soft tissue injury encompasses the ongoing tissue damage and healing response.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
Left Calf – Soft Tissue Injury: The veteran first experienced symptoms on 11 January 2001 during RAAF physical training sessions [CHART REVIEW.docx, Page 25].
Left Calf – Strain: The veteran first experienced symptoms on 11 January 2001 during RAAF physical training sessions [CHART REVIEW.docx, Page 25].
When did the veteran first present to a health / medical provider for this condition?
Left Calf – Soft Tissue Injury: The veteran first presented to military medical staff on 19 Mar 2001 for clinical evaluation [CHART REVIEW.docx, Page 25].
Left Calf – Strain: The veteran first presented to military medical staff on 19 Mar 2001 for clinical evaluation [CHART REVIEW.docx, Page 25].
When was the condition confirmed / formally diagnosed?
Left Calf – Soft Tissue Injury: The condition was confirmed on 19 Mar 2001 following clinical evaluation and sonographic examination by military medical practitioners [CHART REVIEW.docx, Page 25].
Left Calf – Strain: The condition was confirmed on 11 January 2001 as an initial clinical diagnosis, with the strain component confirmed during the 19 Mar 2001 clinical assessment [CHART REVIEW.docx, Page 25].
When did the veteran first present to you (or your practice) for this condition?
21 January 2015
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.
Left Calf – Soft Tissue Injury: The diagnosis was confirmed through clinical evaluation on 19 Mar 2001, with key symptoms including persistent dull aching pain above the left calf, functional limitation affecting physical training, and tenderness on examination. Diagnostic sonography was performed which showed normal findings, ruling out structural damage while confirming the clinical diagnosis of soft tissue injury. The combination of clinical symptoms, physical examination findings, and normal imaging supported the diagnosis [CHART REVIEW.docx, Page 25].
Left Calf – Strain: The diagnosis was confirmed based on the acute onset of pain during physical training on 11 January 2001, with immediate symptoms of muscle discomfort and functional limitation. The clinical presentation was consistent with muscle strain, occurring within 24 hours of the training incident. Subsequent clinical evaluation on 19 Mar 2001 confirmed the ongoing strain with persistent symptoms and examination findings consistent with muscle injury [CHART REVIEW.docx, Page 25].
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.
Left Calf – Soft Tissue Injury:
Trauma to the area during physical training activities - MET
- The veteran sustained direct trauma to the left calf during mandatory RAAF physical training sessions on 11 January 2001, involving high-intensity exercises and running activities that caused acute injury to the calf soft tissues.
Left Calf – Strain:
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 veteran experienced high-intensity use of the left calf muscle during RAAF physical training sessions on 11 January 2001, involving running and endurance activities that resulted in acute muscle strain with immediate onset of pain and tenderness.
Inability to obtain appropriate clinical management for sprain or strain - MET
- There was a delay of over two months between the initial injury on 11 January 2001 and formal medical evaluation on 19 Mar 2001, indicating barriers to obtaining timely appropriate clinical management. This delay resulted in persistence of symptoms and chronic soft tissue injury, representing a permanent worsening of the condition. As established in Brew v Repatriation Commission (19 July 1990), the inability to access treatment in both objective and subjective senses constitutes this factor being met.
Sequelae
The left calf soft tissue injury and strain are not sequelae of another condition but represent primary injuries sustained during service-related physical training activities.
Unintended Consequence
These conditions are not unintended consequences of medical management, as no medical procedures or medications contributed to their development.
Inability to Attain Appropriate Medical Management
This factor is MET for the left calf strain. There was a significant delay of over two months between the initial injury occurrence on 11 January 2001 and the first medical evaluation on 19 Mar 2001. This delay in accessing appropriate clinical management resulted in persistence of symptoms and development of chronic soft tissue injury. As established in Brew v Repatriation Commission (19 July 1990), the inability encompasses both objective and subjective barriers to treatment access. The delay allowed the acute strain to progress to a chronic condition, representing permanent worsening of the injury. The extended time period between injury and formal medical assessment constitutes clear evidence of barriers to healthcare access, satisfying the inability to attain appropriate medical management factor.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
