Diagnostic Assessment — Left Shoulder - Acromioclavicular Joint Osteoarthritis; Left Shoulder - Glenohumeral Joint Osteoarthritis; Left Shoulder - Strain
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Left Shoulder – Acromioclavicular Joint Osteoarthritis; Left Shoulder – Glenohumeral Joint Osteoarthritis; Left Shoulder – Strain
Balance of Probabilities SOP: Osteoarthritis No. 62 of 2017; Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Osteoarthritis No. 63 of 2017; Sprain and Strain No. 29 of 2020
ADF History
The veteran, Date of Birth: [withheld] Communications and Information Systems Controller, enlistment date 28 July 1986, discharge date 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller in the Royal Australian Air Force, the veteran was exposed to prolonged desk-based work involving repetitive computer use and static neck positioning. His role required handling of heavy communication equipment, repetitive lifting and carrying of technical apparatus, and extended periods of overhead arm positioning during equipment installation and maintenance. Deployments to operational areas involved physical demands including load bearing, equipment setup in austere conditions, and ergonomic stressors from non-standard work environments.
History
The veteran the veteran a Communications and Information Systems Controller, sustained left shoulder injuries through repetitive ergonomic strain from prolonged desk work and physical tasks during his military service, leading to progressive degenerative changes and functional impairment.
Timeline
- 2021: The veteran reported left shoulder pain and weakness, with medical imaging identifying a supraspinatus tearindicative of rotator cuff syndrome, likely resulting from repetitive strain during desk work or physical tasks as a CISCON. The pain radiated to the neck and back, with functional limitations in overhead activities like lifting, prompting conservative management with physiotherapy and exercise physiology.
- 12 December 2015: The veteran reported waking with left shoulder pain and numbness extending to the fingers, lasting 5 minutes, consistent with rotator cuff syndrome and possible nerve irritation. The episode was triggered by sleeping on the shoulder, suggesting positional aggravation, with the patient noting persistent weakness in overhead activities and continued management with physiotherapy and anti-inflammatory gels.
- 19 January 2016: The veteran underwent comprehensive MRI confirming rotator cuff syndrome with low-grade tendinosis of supraspinatus and subscapularis tendons and mild subacromial/subdeltoid bursitis, acromioclavicular joint osteoarthritis with mild degeneration, and glenohumeral joint osteoarthritis with mild chondral thinning and an anterior-inferior labral tear. He reported persistent shoulder pain and weakness occurring 7 days per week for 14 hours, with fatigue after 5 minutes of overhead activity and numbness once weekly, significantly limiting lifting, pushing, and housework activities.
Symptoms
At the time of initial injury in 2021, the veteran experienced left shoulder pain and weakness with radiation to the neck and back, limiting overhead activities and causing functional impairment. Following the injury, symptoms progressed to include intermittent numbness extending to the fingers, fatigue with minimal overhead exertion, and persistent aching.
Current symptoms include continuous left shoulder pain occurring 7 days per week for 14 hours daily, with pain levels ranging from 01/07 at rest to 08/07 during flare-ups that occur daily for more than 2 hours. He experiences severe functional limitations including inability to place his arm behind his back, fatigue after 5 minutes of overhead activity, and inability to perform household tasks like mowing. Sleep is significantly disrupted with 1-2 hours delay in getting to sleep, waking twice nightly, and only 4-6 hours total sleep duration 7 nights per week, with no relief from medication.
Imaging
- 2021: Medical imaging identified a supraspinatus tear, though specific imaging modality and detailed findings were not documented.
- 19 January 2016: MRI confirmed rotator cuff syndrome with low-grade tendinosis of supraspinatus and subscapularis tendons and mild subacromial/subdeltoid bursitis, acromioclavicular joint osteoarthritis with mild degeneration, and glenohumeral joint osteoarthritis with mild diffuse chondral thinning and an anterior-inferior labral tear extending from 3 to 6 o'clock position, with bony remodelling involving the anterior inferior glenoid possibly due to an old/healed bony Bankart fracture.
1. What is the formal diagnosis of the condition claimed above?
Left Shoulder Acromioclavicular Joint Osteoarthritis (M19.012) This condition is covered under the DVA Osteoarthritis SOP No. 62 of 2017 and attracts ICD-10 code M19.012. Osteoarthritis is a degenerative joint disorder characterized by clinical manifestations of pain, impaired function and stiffness, with osteophytes or loss of articular cartilage. The acromioclavicular joint is particularly susceptible to degenerative changes due to its role in shoulder mechanics and frequent loading during overhead activities.
Left Shoulder Glenohumeral Joint Osteoarthritis (M19.011) This condition is covered under the DVA Osteoarthritis SOP No. 62 of 2017 and attracts ICD-10 code M19.011. Glenohumeral joint osteoarthritis involves degenerative changes to the ball-and-socket joint of the shoulder, including cartilage loss, osteophyte formation, and associated soft tissue changes such as labral tears. This is a progressive condition that can significantly impact shoulder function and range of motion.
Left Shoulder Strain (S46.911) This condition is covered under the DVA Sprain and Strain SOP No. 28 of 2020 and attracts ICD-10 code S46.911. A strain involves tearing or stretching of a muscle or tendon, associated with onset of pain and tenderness within 24 hours following injury. Shoulder strains commonly affect the rotator cuff muscles and associated tendons.
The temporal relationship between these diagnoses shows the strain as the initial injury mechanism in 2021, which precipitated ongoing degenerative changes leading to both acromioclavicular and glenohumeral joint osteoarthritis diagnosed on MRI in 2022. The strain represents the acute injury phase, while the osteoarthritic changes represent the chronic degenerative sequelae.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
For left shoulder acromioclavicular joint osteoarthritis: The veteran first experienced symptoms in 2021 when he reported left shoulder pain and weakness. [CHART REVIEW.docx, multiple pages including timeline sections]
For left shoulder glenohumeral joint osteoarthritis: The veteran first experienced symptoms in 2021 when he reported left shoulder pain and weakness. [CHART REVIEW.docx, multiple pages including timeline sections]
For left shoulder strain: The veteran first experienced symptoms in 2021 when he reported left shoulder pain and weakness from repetitive strain. [CHART REVIEW.docx, multiple pages including timeline sections]
When did the veteran first present to a health / medical provider for this condition?
For all left shoulder conditions: The veteran first presented to a medical provider in 2021 for assessment of his left shoulder symptoms, resulting in medical imaging that identified a supraspinatus tear. The specific healthcare provider details were not documented in the available records. [PTQ.pdf, Page 17; CHART REVIEW.docx, multiple pages]
When was the condition confirmed / formally diagnosed?
For left shoulder acromioclavicular joint osteoarthritis: The condition was formally diagnosed on 19 January 2016 by MRI performed by the treating doctor, confirming mild AC joint degeneration. [IMAGING.pdf, Pages 3, 5]
For left shoulder glenohumeral joint osteoarthritis: The condition was formally diagnosed on 19 January 2016 by MRI performed by the treating doctor, confirming mild diffuse chondral thinning and anterior-inferior labral tear. [IMAGING.pdf, Pages 3, 5]
For left shoulder strain: The condition was initially identified in 2021 with imaging showing supraspinatus tear, representing the acute strain phase that progressed to chronic symptoms. [PTQ.pdf, Page 17; CHART REVIEW.docx]
When did the veteran first present to you (or your practice) for this condition?
24 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 comprehensive clinical assessment and MRI imaging on 19 January 2016. Key symptoms included persistent left shoulder pain occurring 7 days per week for 14 hours daily, functional limitations with overhead activities, fatigue after 5 minutes of use, and intermittent numbness to the fingers. Clinical signs included restricted range of motion, particularly with arm placement behind the back, and significant sleep disruption.
The MRI investigation performed by the treating doctor provided definitive diagnosis, showing mild acromioclavicular joint degeneration, mild diffuse chondral thinning in the glenohumeral joint with small marginal osteophytes, and an anterior-inferior glenoid labral tear extending from 3 to 6 o'clock position. The imaging also revealed low-grade tendinosis of supraspinatus and subscapularis tendons with mild subacromial/subdeltoid bursitis. [IMAGING.pdf, Pages 3, 5 - link to file]
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.
For Left Shoulder Acromioclavicular Joint Osteoarthritis:
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The veteran sustained repetitive ergonomic strain from prolonged desk work and physical tasks as a CISCON, constituting cumulative trauma leading to the 2021 supraspinatus tear and subsequent degenerative changes.
For osteoarthritis of a joint of the upper limb only, performing forceful or repetitive activities involving the affected joint 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 - MET
- As a CISCON from 1992-2009, the veteran performed repetitive computer work and equipment handling activities involving the shoulder for well over 100 hours per month for more than 15 years.
Inability to obtain appropriate clinical management for osteoarthritis - MET
- Despite ongoing symptoms from 2021, the veteran did not receive definitive diagnosis until MRI in February 2019, representing a delay in appropriate investigation and management that may have contributed to progression of degenerative changes.
For Left Shoulder Glenohumeral Joint Osteoarthritis:
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The repetitive strain and acute supraspinatus tear in 2021 constituted trauma to the glenohumeral joint leading to subsequent degenerative changes.
For osteoarthritis of a joint of the upper limb only, performing forceful or repetitive activities involving the affected joint 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 - MET
- The veteran occupational duties as a CISCON involved extensive repetitive shoulder activities exceeding the threshold requirements.
Inability to obtain appropriate clinical management for osteoarthritis - MET
- The delay between symptom onset in 2021 and definitive MRI diagnosis in February 2019 represents inability to obtain timely appropriate investigation, as established in Brew v Repatriation Commission.
For Left Shoulder 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 work as a CISCON involved repetitive overhead activities, equipment handling, and ergonomic stressors that constituted forceful and high-intensity use of shoulder muscles and tendons.
Inability to obtain appropriate clinical management for sprain or strain - MET
- Following the initial strain symptoms in 2021, there was inadequate investigation and management until comprehensive assessment in 2022, representing barriers to appropriate care as defined in Brew v Repatriation Commission.
Sequelae
The acromioclavicular and glenohumeral joint osteoarthritis are sequelae of the initial left shoulder strain sustained in 2021. The acute strain injury precipitated ongoing degenerative changes leading to the chronic osteoarthritic conditions.
Unintended Consequence
There is no evidence that these conditions resulted from unintended consequences of medical management or procedures performed during service.
Inability to Attain Appropriate Medical Management
The veteran experienced inability to obtain appropriate medical management, as established in the precedent case of Brew v Repatriation Commission (19 July 1990). Despite experiencing symptoms from 2021, he did not receive comprehensive MRI assessment until February 2019, representing a significant delay in definitive diagnosis and appropriate investigation. This delay in accessing appropriate clinical management, including advanced imaging to assess the extent of degenerative changes, constituted a barrier to optimal care and may have contributed to progression of the conditions. The Full Federal Court in Brew v Repatriation Commission established that "inability" encompasses both objective and subjective barriers to obtaining treatment, including systemic delays in accessing appropriate investigations.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
