Left Shoulder - Acromioclavicular Joint Osteolysis — DVA claim example

Diagnostic Assessment — Left Shoulder - Acromioclavicular Joint Osteolysis

Example 1 of 1 · fictitious patient (Veteran AW)

Diagnostic Assessment

Left Shoulder - Acromioclavicular Joint Osteolysis

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran AW, date of birth 03 February 1990, Australian Army, Gunner (Artillery), enlisted 21 January 2008, medically discharged 10 November 2020. Operational service: Afghanistan, 15 March 2012 to 30 October 2012 (warlike); Middle East Area of Operations (Iraq), 08 June 2016 to 15 December 2016 (warlike).

Occupational History

Artillery gunners manually handle heavy ammunition every day in the field. A 155 mm projectile weighs about 43 kilograms and is lifted from pallets, carried on the shoulder and loaded by hand, often hundreds of times in a single fire mission or ammunition resupply. Gunners also emplace and dig in guns, erect overhead camouflage netting, load stores onto vehicle trays above shoulder height, and climb on and off gun platforms and vehicles, with a recognised risk of falls onto the shoulder.

The trade places a premium on upper body strength, and gunners commonly undertake heavy resistance training, including bench press, overhead press, dips and push-ups, as part of unit conditioning and to meet the physical demands of the job. On deployment gunners and force protection elements wear body armour and carry packs and weapons with shoulder straps for many hours a day, and access to imaging, physiotherapy and orthopaedic care is limited.

History

Veteran AW, an Army artillery gunner, developed osteolysis of the distal clavicle at the left acromioclavicular joint on 20 August 2012 during warlike service in Afghanistan, after a left acromioclavicular joint sprain in 2011, sustained heavy resistance training and heavy ammunition handling on the left shoulder. The condition was confirmed on MRI in January 2013 and worsened during and after his 2016 deployment to Iraq, where he continued heavy lifting and load carriage, fell onto the shoulder again and could not obtain treatment.

Timeline

• 05 Mar 2011 — During a live-fire exercise in Australia the veteran slipped from a gun platform and fell about 1.5 metres directly onto the point of his left shoulder. There was swelling and tenderness over the left acromioclavicular joint, a palpable step and painful cross-body adduction. X-ray showed slight elevation of the distal clavicle, a grade II acromioclavicular joint sprain. He was managed in a sling for two weeks and returned to full duties after eight weeks. "L ACJ sprain grade II"
• 10 Feb 2012 — Pre-deployment medical examination before Afghanistan. The veteran reported no shoulder pain since recovering from the 2011 sprain. Both shoulders had full, pain-free movement, with no acromioclavicular joint tenderness and negative cross-body adduction tests. He reported training in the gym four to five days a week, with a bench press of 140 kg. "shoulders NAD, fit to deploy"
• 27 Aug 2012 — Presentation to the role 2 medical facility in Afghanistan with one week of aching pain over the top of the left shoulder, worse with bench press, push-ups and carrying projectiles on the left shoulder. Since arriving in March he had handled ammunition daily, carrying about 60 projectiles a day on his left shoulder during resupply and fire missions, and had continued heavy gym training four days a week. There was focal tenderness at the left acromioclavicular joint, a positive cross-body adduction test and a positive O'Brien test. "L ACJ tender, cross-body positive"
• 14 Jan 2013 — After return to Australia, X-ray on 22 November 2012 showed loss of the subchondral cortex and cystic change of the left distal clavicle, and MRI on 10 January 2013 showed distal clavicular bone marrow oedema with subchondral cysts. A sports physician diagnosed osteolysis of the left distal clavicle. He was advised to stop bench press, dips and overhead lifting for six months, to avoid carrying ammunition on the left shoulder, and was given an image-guided corticosteroid injection. "distal clavicle osteolysis confirmed"
• 18 Oct 2016 — During warlike service in Iraq the veteran fell from the step of a protected vehicle onto his left shoulder while wearing body armour. There was increased pain and swelling over the left acromioclavicular joint. The role 2 medical officer prescribed analgesia and a sling for three days. No X-ray, ultrasound or orthopaedic review was available. Since July he had been lifting weights in the base gym five days a week and loading stores, and had worn body armour and a pack for four to six hours a day on force protection duties. "fall onto L shoulder, no imaging"
• 20 Jan 2017 — Review by the sports physician for constant left shoulder pain, night pain and inability to do push-ups or lift above shoulder height. QuickDASH score 52, compared with 23 in 2014. MRI the same day showed progression of distal clavicular osteolysis, with 9 mm of resorption, widening of the joint and extensive marrow oedema. He was referred to an orthopaedic surgeon. "worse, QuickDASH 52, progression MRI"
• 15 Mar 2017 — Arthroscopic excision of the left distal clavicle was performed by an orthopaedic surgeon. Operative findings were a fragmented, softened distal clavicle with an eroded articular surface. He returned to restricted duties but did not regain full strength, and he was medically downgraded in 2019. "arthroscopic distal clavicle excision"

Symptoms

At onset the veteran had aching pain localised to the top and front of the left shoulder, worse with bench press, push-ups, dips, carrying loads on the shoulder and reaching across the body, and pain when lying on the left side. The acromioclavicular joint was tender and the cross-body adduction test was painful.

After the worsening in 2016 and 2017 the pain became constant, with night pain, weakness and inability to lift above shoulder height, do push-ups or carry loads on the left shoulder. Since distal clavicle excision he has persisting pain with overhead and heavy work, reduced strength and difficulty with sleeping on the left side, carrying shopping and playing with his children.

Imaging

• 05 Mar 2011 — X-ray left shoulder and acromioclavicular joint: "Slight superior displacement of the distal clavicle relative to the acromion, consistent with a grade II acromioclavicular joint sprain. No fracture. Distal clavicle cortex intact."
• 22 Nov 2012 — X-ray left acromioclavicular joint: "Loss of the subchondral cortex of the distal clavicle with small cystic lucencies and widening of the acromioclavicular joint to 7 mm."
• 10 Jan 2013 — MRI left shoulder: "Bone marrow oedema confined to the distal clavicle with subchondral cysts and irregularity of the articular surface. Small acromioclavicular joint effusion. Acromion normal. Rotator cuff intact. Appearances consistent with distal clavicular osteolysis."
• 20 Jan 2017 — MRI left shoulder: "Progression of distal clavicular osteolysis with 9 mm resorption of the distal clavicle, joint widening, extensive marrow oedema and fragmentation. Rotator cuff intact."

Onset Date

The most likely date of onset of this condition is 20 Aug 2012.

At that date the veteran was serving on warlike service in Afghanistan as a gunner. He was handling artillery ammunition daily, carrying about 60 projectiles of 43 kg a day on his left shoulder during resupply and fire missions, wearing body armour and webbing, and continuing heavy resistance training in the base gym four days a week. On 20 August 2012 he developed aching pain over the left acromioclavicular joint that persisted.

This date is appropriate because his pre-deployment medical examination of 10 February 2012 recorded pain-free shoulders with no acromioclavicular joint tenderness, and he first presented with the symptoms on 27 August 2012, one week after they began. It falls within uninterrupted full-time warlike service.

For the resistance training and overhead work factors, the 6 months before onset run from 20 Feb 2012 to 20 Aug 2012; he trained four to five days a week throughout and erected camouflage nets and loaded vehicle trays daily from March 2012. For the heavy load carriage factor, the 3 months before onset run from 20 May 2012 to 20 Aug 2012, during which he carried projectiles on the left shoulder daily. For the acute sprain and direct trauma factors, the 2 years before onset run from 20 Aug 2010 to 20 Aug 2012; the fall onto the left shoulder and grade II sprain occurred on 05 Mar 2011. For the strap loading factor, the 4 weeks before onset run from 23 Jul 2012 to 20 Aug 2012, during which he wore body armour and webbing for more than four hours a day.

For the worsening factors, the condition was confirmed on MRI on 10 Jan 2013. The worsening is documented on 20 Jan 2017 by progression on MRI and a rise in the QuickDASH score from 23 to 52. The 6 months before the worsening run from 20 Jul 2016 to 20 Jan 2017; during this period he lifted weights five days a week and wore body armour and a pack for four to six hours a day in Iraq from July to December 2016, and he fell onto the left shoulder on 18 Oct 2016. From June to December 2016 he could not obtain appropriate clinical management in Iraq.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Left Shoulder - Acromioclavicular Joint Osteolysis, osteolysis of the left distal clavicle (ICD-10-AM M89.51). No Statement of Principles has been determined for this condition.

Distal clavicular osteolysis is a painful resorption of the outer end of the clavicle at the acromioclavicular joint. It occurs in two recognised forms: post-traumatic osteolysis, following an acute injury to the joint such as a sprain, separation or direct blow, and atraumatic or stress osteolysis, caused by repetitive microtrauma to the subchondral bone from heavy resistance training (classically bench press, dips and push-ups), heavy manual handling and loads on the shoulder. Repeated stress causes subchondral microfractures, bone oedema and an attempt at repair that outpaces itself, leading to cysts, erosion and resorption. It causes localised pain, weakness and loss of function, and continued loading causes progression.

In this veteran the condition began on 20 August 2012 during warlike service in Afghanistan, following a grade II acromioclavicular joint sprain in 2011, was confirmed on MRI in January 2013, worsened in 2016 and 2017 and required distal clavicle excision.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

20 August 2012.

When did the veteran first present to a health / medical provider for this condition?

27 August 2012.

When was the condition confirmed / formally diagnosed?

14 January 2013.

When did the veteran first present to you (or your practice) for this condition?

26 August 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by a sports physician on 14 January 2013 on the clinical findings and imaging. The veteran had pain localised to the left acromioclavicular joint, focal joint tenderness and positive cross-body adduction and O'Brien tests. X-ray on 22 November 2012 showed loss of the subchondral cortex and cystic change of the distal clavicle with joint widening, and MRI on 10 January 2013 showed bone marrow oedema confined to the distal clavicle with subchondral cysts and an intact rotator cuff, the characteristic appearance of distal clavicular osteolysis.

MRI on 20 January 2017 confirmed progression to 9 mm of resorption with fragmentation, and the operative findings at distal clavicle excision on 15 March 2017 confirmed a fragmented, softened distal clavicle. Acromioclavicular joint osteoarthritis, rotator cuff disease, infection and inflammatory arthritis were excluded on imaging and blood tests, including a normal ESR, CRP, calcium and parathyroid hormone.

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.

Legislation: the clinical onset of this condition was on 20 August 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. No Statement of Principles has been determined for distal clavicular osteolysis, so the claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits of a Statement of Principles. The reasonable hypothesis standard applies to the veteran's warlike service in Afghanistan in 2012, where the condition began, and in Iraq in 2016, where it worsened. The balance of probabilities standard applies to peacetime service, including the 2011 acromioclavicular joint sprain and training in Australia.

Each cause must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: undertaking heavy resistance training involving bench press, overhead press, dips or push-ups with the affected arm on at least 3 days per week for at least the 6 months before the clinical onset of acromioclavicular joint osteolysis; — MET

- Throughout the 6 months before onset, from 20 February 2012 to 20 August 2012, the veteran trained in the gym four to five days a week, with a bench press of 140 kg, weighted dips and overhead press, together with daily push-ups in unit physical training. This training was part of unit conditioning before and during his warlike service in Afghanistan, to meet the physical demands of ammunition handling. Heavy bench press and dips are the classic cause of atraumatic distal clavicular osteolysis.

Cause 2: having an acute sprain or separation of the affected acromioclavicular joint within the 2 years before the clinical onset of acromioclavicular joint osteolysis; — MET

- On 05 March 2011, during a live-fire exercise in Australia, the veteran sustained a grade II sprain of the left acromioclavicular joint, confirmed clinically and on X-ray, when he fell from a gun platform. This was 17 months before the onset on 20 August 2012. Post-traumatic osteolysis of the distal clavicle typically follows such an injury within months to a few years.

Cause 3: having direct trauma to the point of the affected shoulder within the 2 years before the clinical onset of acromioclavicular joint osteolysis; — MET

- The fall of 05 March 2011 was a direct blow to the point of the left shoulder from a height of about 1.5 metres onto the gun platform base, with swelling, tenderness and a palpable step at the joint. It occurred during service training, within the 2 years before onset.

Cause 4: lifting and carrying loads of at least 25 kilograms on the affected shoulder on at least 20 occasions per day for at least the 3 months before the clinical onset of acromioclavicular joint osteolysis; — MET

- During warlike service in Afghanistan from March 2012 the veteran carried 155 mm projectiles of about 43 kg on his left shoulder from pallets to the gun about 60 times a day during resupply and fire missions, as recorded in the role 2 notes of 27 August 2012. This continued throughout the 3 months before onset, from 20 May 2012 to 20 August 2012. The load is transmitted directly through the acromioclavicular joint.

Cause 5: performing repetitive work with the affected arm at or above shoulder height for at least 1 hour per day for at least the 6 months before the clinical onset of acromioclavicular joint osteolysis; — MET

- From before deployment and throughout his service in Afghanistan the veteran erected and adjusted overhead camouflage netting over the gun position and loaded ammunition and stores onto vehicle trays above shoulder height for one to two hours a day. This continued throughout the 6 months before onset, from 20 February 2012 to 20 August 2012.

Cause 6: carrying a load of at least 20 kilograms suspended from straps over the affected shoulder for at least 4 hours per day for at least the 4 weeks before the clinical onset of acromioclavicular joint osteolysis; — MET

- During warlike service in Afghanistan the veteran wore body armour of about 12 kg and loaded webbing and carried his rifle on a sling over the left shoulder, a total of more than 20 kg, for at least four hours a day on gun position and security duties. This continued throughout the 4 weeks before onset, from 23 July 2012 to 20 August 2012. Strap pressure compresses the acromioclavicular joint.

Worsening factors

Worsening 1: undertaking heavy resistance training or heavy lifting with the affected arm on at least 3 days per week for at least 3 months within the 6 months before the clinical worsening of acromioclavicular joint osteolysis; — MET

- During warlike service in Iraq from July to December 2016 the veteran lifted weights in the base gym five days a week, including push-ups and pressing movements, and loaded stores daily as part of his duties. This continued for five months within the 6 months before the worsening on 20 January 2017, from 20 July 2016 to 20 January 2017.

Worsening 2: having direct trauma to the affected acromioclavicular joint before the clinical worsening of acromioclavicular joint osteolysis; — MET

- On 18 October 2016, during warlike service in Iraq, the veteran fell from the step of a protected vehicle onto his left shoulder while wearing body armour, with increased pain and swelling at the acromioclavicular joint recorded by the role 2 medical officer. This was three months before the worsening documented on 20 January 2017.

Worsening 3: carrying a load of at least 20 kilograms suspended from straps over the affected shoulder for at least 4 hours per day for at least 8 weeks within the 6 months before the clinical worsening of acromioclavicular joint osteolysis; — MET

- On force protection duties in Iraq from June to December 2016 the veteran wore body armour, a pack and a slung rifle, more than 25 kg in total, for four to six hours a day. More than 20 weeks of this fell within the 6 months before the worsening, from 20 July 2016 to 20 January 2017.

Worsening 4: inability to obtain appropriate clinical management for acromioclavicular joint osteolysis. — MET

- During warlike service in Iraq from June to December 2016 the veteran had no access to imaging, physiotherapy or orthopaedic review, and operational duties required him to keep lifting and carrying loads that he had been advised to avoid. After the fall of 18 October 2016 he was treated only with analgesia and a sling. The osteolysis progressed from early cystic change to 9 mm of resorption by January 2017. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

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

Sequelae

The left distal clavicular osteolysis led to arthroscopic distal clavicle excision in March 2017, with persisting pain and weakness. Compensatory overuse of the right arm and altered scapular mechanics have produced right shoulder pain and left-sided neck and trapezius pain. These are sequelae of the condition and should be considered in any related claim.

Unintended Consequence

Met. Persisting weakness and pain after the arthroscopic distal clavicle excision of 15 March 2017, which was performed and paid for by Defence while the veteran was serving, is an unintended consequence of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. From June to December 2016, during warlike service in Iraq, the veteran's diagnosed distal clavicular osteolysis could not be managed. There was no imaging, physiotherapy or orthopaedic care, the activity restrictions recommended in 2013 could not be followed because his duties required heavy lifting and load carriage, and after a fresh fall onto the shoulder he received only analgesia and a sling. The condition progressed on MRI and his QuickDASH score rose from 23 to 52. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent prescribed treatment and activity modification amount to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 05 Mar 2011, Training injury record and X-ray report, Medical Officer, Garrison health centre
2. 10 Feb 2012, Pre-deployment medical examination, Medical Officer, Garrison health centre
3. 27 Aug 2012, Role 2 medical facility record, Medical Officer, Afghanistan
4. 22 Nov 2012, X-ray left acromioclavicular joint, Radiologist
5. 10 Jan 2013, MRI left shoulder, Radiologist
6. 14 Jan 2013, Sports medicine consultation, Sports physician
7. 18 Oct 2016, Role 2 medical facility record, Medical Officer, Iraq
8. 20 Jan 2017, MRI left shoulder, Radiologist
9. 20 Jan 2017, Sports medicine review, Sports physician
10. 15 Mar 2017, Operation report, Orthopaedic surgeon