Diagnostic Assessment — Left Elbow - Strain
Example 1 of 1 · fictitious patient (Veteran H)
Diagnostic Assessment
Left Elbow - Strain
Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Sprain and Strain RH SOP
ADF History
The veteran, M113 Crewman/RAAC Assistant Instructor, 06 November 1988, CFTS ended 30 Apr 1992, General Reserves until approximately 2001, Army Standby Reserve until 10 May 2007.
Occupational History
As an M113 Crewman and RAAC Assistant Instructor, the veteran service involved considerable physical demands requiring forceful stretching and high intensity use of muscles and tendons around the elbow. His duties included lifting heavy equipment, operating armoured vehicles, weapons handling, physical training activities, and manual tasks that placed significant mechanical stress on the elbow musculature and tendons through forceful and repetitive movements.
History
Mr John the veteran an M113 Crewman and RAAC Assistant Instructor, sustained left elbow strain during his Australian Army service from 1995 to 2013 through forceful stretching and high intensity use of elbow muscles and tendons during occupational activities including equipment handling, vehicle maintenance, and training exercises.
Timeline
- During Military Service (1995-2013): The veteran sustained initial left elbow strain through 'forceful stretching or high intensity use' of elbow muscles and tendons during his military duties. The acute strain represented the initial injury mechanism that subsequently contributed to the development of chronic pathology affecting his left elbow structures.
- 16 August 2015: The veteran first consulted Dr Thomas Perkins who completed a DVA Diagnosis Form for 'Left Upper Limb - Pain' based on attached report. This represented his first formal presentation addressing the chronic consequences of his service-related elbow strain for compensation purposes.
Symptoms
At the time of initial strain injury, the veteran would have experienced acute onset of pain and tenderness at the elbow site associated with the forceful activity or high intensity use of the affected muscles and tendons. The strain involved tearing or stretching of elbow musculature with associated pain and functional limitation. Current symptoms represent the chronic consequences of the initial strain injury, contributing to ongoing elbow dysfunction and the development of secondary pathology including tendinopathy and nerve involvement.
Imaging
16 January 2016: MRI Left Elbow findings provided evidence of chronic changes consistent with previous strain injury, including structural alterations and inflammatory changes affecting the elbow region.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Elbow Strain with DVA SOP Code Sprain and Strain No. 28 of 2020 and ICD-10 code S53.4.
Strain means an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within the 24 hours following the injury. The condition includes complete tear or rupture of a muscle or tendon and represents acute traumatic injury to the musculotendinous structures around the elbow joint resulting from forceful activities or high intensity use during occupational duties.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
During military service between 1995-2013, with the exact date of initial strain unknown but occurring during performance of occupational duties.
When did the veteran first present to a health/medical provider for this condition?
16 August 2015 to Dr Thomas Perkins (Medical Practitioner) addressing the chronic consequences of the strain injury.
When was the condition confirmed/formally diagnosed?
16 August 2015 by Dr Thomas Perkins, with supporting evidence from MRI imaging on 16 January 2016 demonstrating chronic changes consistent with previous strain injury.
When did the veteran first present to you (or your practice) for this condition?
15 Jun 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.
The diagnosis was confirmed through clinical assessment by Dr Thomas Perkins, who documented the history of occupational elbow injury and current symptoms consistent with chronic strain consequences. Supporting evidence was provided by MRI imaging on 16 January 2016, which demonstrated structural changes in the elbow region consistent with previous muscular and tendinous injury. The temporal relationship between military service activities and subsequent development of chronic elbow pathology supported the diagnosis of service-related strain with long-term consequences.
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.
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 role as an M113 Crewman and RAAC Assistant Instructor required forceful stretching and high intensity use of elbow muscles and tendons during lifting heavy equipment, vehicle maintenance tasks, weapons handling, physical training including battle PT and pack marches, and manual handling activities that provided the direct mechanism for strain injury to the left elbow musculature.
inability to obtain appropriate clinical management for sprain or strain - MET
- The progression from initial strain to chronic pathology with development of secondary conditions demonstrates inability to obtain appropriate early intervention and management. The Full Federal Court in Brew v Repatriation Commission established that inability encompasses both objective and subjective barriers to treatment access. The failure to obtain immediate and appropriate treatment for the strain injury during military service, resulting in chronic consequences and secondary pathology development, satisfies the inability to attain appropriate medical management factor.
Sequelae
This condition represents the initial injury that potentially contributed to the subsequent development of lateral epicondylitis and ulnar neuritis through inadequate healing and ongoing occupational stress.
Unintended Consequence
The condition is not an unintended consequence of medical management, as it resulted from occupational trauma rather than medical treatment complications.
Inability to Attain Appropriate Medical Management
There was an inability to attain appropriate medical management for the elbow strain. The progression from acute strain to chronic elbow pathology with secondary conditions demonstrates failure to obtain timely and appropriate treatment. The Full Federal Court in Brew v Repatriation Commission (10 July 1990) establishes that "inability" encompasses the lack of ability to get treatment in both objective and subjective senses, including psychological or emotional incapacity and threats of sanctions that make seeking treatment unrealistic. The failure to obtain immediate appropriate management for the strain injury during military service, with subsequent development of chronic tendinopathy and nerve pathology, demonstrates barriers to healthcare access that satisfied the inability to attain appropriate medical management factor. This inability caused permanent worsening of the condition through inadequate initial treatment and ongoing occupational exposure without proper rehabilitation.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history.
-see attached report
