Diagnostic Assessment — Left Shoulder - Adhesive Capsulitis
Example 1 of 1 · fictitious patient (Veteran U)
Diagnostic Assessment
Left Shoulder - Adhesive Capsulitis
BOP Code: 73 of 2020 (Adhesive Capsulitis of the Shoulder)
RH Code: 72 of 2020 (Adhesive Capsulitis of the Shoulder)
ADF History
Veteran U, date of birth 14 June 1976, Australian Army, Medical Assistant (Combat Medic), enlisted 03 February 1997, medically discharged 10 March 2016. Operational service: East Timor, 20 September 1999 to 15 February 2000 (warlike); Afghanistan, 01 March 2008 to 30 September 2008 (warlike); Afghanistan, 01 June 2011 to 12 November 2011 (warlike, ended by aeromedical evacuation); Middle East Area of Operations, 01 April 2014 to 22 July 2014 (warlike, ended by return to Australia on medical grounds).
Occupational History
As a combat medic the veteran carried a patrol pack and medical kit of 30 to 40 kilograms, lifted and carried casualties on stretchers, loaded patients into vehicles and helicopters, and worked long shifts in clinics, aid posts and field hospitals. The work involved repetitive overhead and reaching tasks, prolonged kneeling over casualties and frequent heavy lifting from awkward positions.
Medics treating trauma casualties are exposed to blood and body fluids and to sharps injuries. Deployed medics also worked in areas sprayed with insecticides and herbicides for vector control, and in deployed locations specialist investigation, physiotherapy and procedural treatment were frequently unavailable.
History
Veteran U, a combat medic in the Australian Army, dislocated her left shoulder with an axillary nerve palsy while carrying a casualty in Afghanistan on 10 November 2011, and in the same month was diagnosed with carcinoma of the left breast treated by mastectomy. She developed adhesive capsulitis of the left shoulder on 02 March 2012, on a background of diabetes mellitus, Hashimoto hypothyroidism, Parkinson's disease, dyslipidaemia, antiretroviral therapy and primidone, and the condition worsened during her 2014 deployment to the Middle East after a further left shoulder injury.
Timeline
- 12 Dec 1999 — During warlike service in East Timor the veteran sustained a deep needle-stick injury from a hollow-bore cannula while resuscitating a bleeding casualty at a forward aid post. Post-exposure prophylaxis was started late because supplies were delayed. Seroconversion to HIV was confirmed on 08 February 2000 and an infectious diseases physician commenced highly active antiretroviral therapy, which has continued without interruption. "needle-stick, HIV seroconversion confirmed"
- 19 Mar 2009 — After returning from Afghanistan in 2008 the veteran's weight had risen by 14 kg. Fasting glucose 8.4 mmol/L and HbA1c 7.3 per cent confirmed type 2 diabetes mellitus, and metformin was commenced. Fasting LDL cholesterol was 4.6 mmol/L and triglycerides 2.6 mmol/L, and atorvastatin 40 mg daily was started. She had been on levothyroxine since 2007 for Hashimoto thyroiditis with raised thyroid peroxidase antibodies. "type 2 diabetes, LDL 4.6"
- 18 Aug 2010 — A neurologist diagnosed early-onset Parkinson's disease, with left-sided rigidity, bradykinesia and a rest tremor, and a reduced dopamine transporter scan. Levodopa was commenced. A coexisting action tremor of the hands was treated with primidone 250 mg at night, which continued through 2014. The neurologist recorded her repeated exposure to vector-control insecticides in East Timor. "Parkinson's disease, primidone 250 mg"
- 24 Jan 2011 — The veteran presented with six months of left shoulder pain with overhead tasks and stretcher carrying. Examination showed a painful arc and positive impingement signs, and MRI showed supraspinatus tendinopathy with a partial-thickness articular surface tear. A medical officer diagnosed left rotator cuff syndrome and referred her to physiotherapy. "left rotator cuff syndrome"
- 10 Nov 2011 — On warlike service in Afghanistan the veteran fell down an embankment while carrying a stretcher during a casualty evacuation under fire. X-ray at the role 3 hospital showed an anterior dislocation of the left shoulder with a bony Bankart fracture, and she had no deltoid contraction and numbness over the lateral shoulder. The shoulder was reduced and immobilised in a sling and she was aeromedically evacuated on 12 November 2011. A firm left breast lump, first noticed in September 2011 but not able to be investigated on deployment, was documented. "left shoulder dislocation, axillary palsy"
- 08 Dec 2011 — Open fixation of the left glenoid rim fracture was performed on 14 November 2011. Biopsy on 22 November 2011 confirmed invasive ductal carcinoma of the left breast, and on 08 December 2011 a breast surgeon performed a left mastectomy with axillary clearance. Nerve conduction studies and electromyography on 20 December 2011 showed a left axillary neuropathy with denervation of the deltoid. "left mastectomy, axillary clearance"
- 09 Mar 2012 — The veteran presented to the garrison health centre with one week of severe, constant left shoulder pain, worse at night, and rapidly increasing stiffness. Her physiotherapy review of 20 February 2012 had recorded steady improvement. Examination showed global restriction of both active and passive movement, with passive external rotation of 15 degrees. "severe night pain, global stiffness"
- 18 Apr 2012 — An orthopaedic surgeon confirmed adhesive capsulitis of the left shoulder after more than 28 days of pain and stiffness. Passive forward flexion was 90 degrees, abduction 70 degrees and external rotation 10 degrees, with a capsular end-feel, compared with full movement on the right. MRI showed thickening of the inferior capsule and coracohumeral ligament. Hydrodilatation and a supervised stretching program were commenced. "adhesive capsulitis, passive ER 10"
- 15 Jul 2014 — On warlike service in the Middle East, seven weeks after a fall onto her left shoulder from a vehicle step, the veteran reported a marked return of pain and stiffness. Passive forward flexion had fallen from 140 degrees in December 2013 to 70 degrees and external rotation from 40 to 5 degrees. No physiotherapy or hydrodilatation was available in theatre and she was returned to Australia on 22 July 2014. "flexion 70 degrees, no physiotherapy"
Symptoms
At onset the veteran had severe, constant left shoulder pain that woke her at night and could not be relieved by simple analgesia, followed within weeks by progressive stiffness so that she could not reach overhead, behind her back or across her body. She could not lift a medical pack, dress without help or carry out casualty-handling tasks.
She now reports persistent stiffness and aching of the left shoulder, difficulty with dressing, hair care and reaching high shelves, and disturbed sleep when lying on the left side. Passive movement remains restricted compared with the right shoulder.
Imaging
- 24 Jan 2011 — MRI left shoulder: "Supraspinatus tendinopathy with a partial-thickness articular surface tear. Subacromial bursal thickening. Glenohumeral capsule normal."
- 10 Nov 2011 — X-ray left shoulder: "Anterior glenohumeral dislocation with a displaced bony Bankart fracture of the anterior-inferior glenoid rim. Satisfactory reduction on post-reduction views."
- 16 Apr 2012 — MRI left shoulder: "Thickening of the inferior glenohumeral capsule in the axillary recess to 6 mm and of the coracohumeral ligament, with obliteration of the fat in the rotator interval, consistent with adhesive capsulitis. Healed glenoid rim fixation. Persisting supraspinatus tendinopathy."
- 02 Oct 2014 — MRI left shoulder: "Increased thickening of the axillary recess capsule to 8 mm and of the coracohumeral ligament compared with April 2012, with synovitis in the rotator interval. Bone bruising of the greater tuberosity. Supraspinatus tendinopathy unchanged."
Onset Date
The most likely date of onset of this condition is 02 Mar 2012.
At that date the veteran was serving full time at a garrison health facility in Australia, recovering from the left shoulder dislocation sustained on warlike service in Afghanistan on 10 November 2011, the glenoid fixation of 14 November 2011 and the left mastectomy of 08 December 2011. On that date she developed severe, constant left shoulder pain, followed by rapidly increasing stiffness of both active and passive movement.
This date is appropriate because her physiotherapy review of 20 February 2012 recorded steadily improving left shoulder movement with no night pain, and she first presented with the new symptoms on 09 March 2012, one week after they began. The restriction persisted for more than 28 days and was confirmed by an orthopaedic surgeon on 18 April 2012.
For the injury and surgery factors, the six months before onset run from 02 Sep 2011 to 02 Mar 2012; the dislocation of 10 November 2011, the glenoid fixation of 14 November 2011 and the mastectomy of 08 December 2011 all fall within it. For the paralysis and malignant neoplasm factors, the one year before onset runs from 02 Mar 2011 to 02 Mar 2012; the axillary nerve palsy from 10 November 2011 and the breast carcinoma, present from September 2011, fall within it. For the primidone factor, the six weeks before onset run from 20 Jan 2012 to 02 Mar 2012, during which she took primidone 250 mg nightly. Rotator cuff syndrome, diabetes mellitus, Hashimoto hypothyroidism, Parkinson's disease, dyslipidaemia and antiretroviral therapy were each established before 02 Mar 2012 and present on that date.
For the worsening factors, the documented worsening was on 15 Jul 2014. The six months before the worsening run from 15 Jan 2014 to 15 Jul 2014, and contain the fall onto the left shoulder on warlike service on 28 May 2014; the excision of a left chest wall recurrence on 06 Jan 2014 falls 9 days before that window and was followed on 03 Feb 2014 by a revision of the scar involving the left chest wall, which falls within it. The one year before the worsening runs from 15 Jul 2013 to 15 Jul 2014, during which the axillary nerve palsy persisted on electromyography and the chest wall recurrence was present. The six weeks before the worsening run from 03 Jun 2014 to 15 Jul 2014, during which she continued primidone.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Adhesive Capsulitis of the Left Shoulder (ICD-10-AM M75.0), under the Statements of Principles concerning adhesive capsulitis of the shoulder, Balance of Probabilities No. 73 of 2020 and Reasonable Hypothesis No. 72 of 2020.
Adhesive capsulitis, also known as frozen shoulder, is a condition in which the capsule of the glenohumeral joint becomes inflamed, thickened and contracted, with fibrosis of the rotator interval and coracohumeral ligament. It typically passes through a painful phase of severe constant and night pain, a stiffening phase with marked loss of both active and passive movement, particularly external rotation, and a slow thawing phase. It may last two years or more, and a proportion of people are left with permanent restriction. It is more common after shoulder injury, surgery or immobilisation, and in people with diabetes, thyroid disease and other metabolic and neurological disorders.
The condition followed the veteran's left shoulder dislocation with axillary nerve palsy on warlike service, glenoid fixation and left mastectomy in late 2011, on a background of left rotator cuff syndrome and several systemic risk conditions. It began on 02 March 2012, was confirmed on 18 April 2012 and worsened in July 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
02 March 2012.
When did the veteran first present to a health / medical provider for this condition?
09 March 2012.
When was the condition confirmed / formally diagnosed?
18 April 2012.
When did the veteran first present to you (or your practice) for this condition?
21 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by an orthopaedic surgeon on 18 April 2012, after more than 28 days of left shoulder pain and stiffness with severe restriction of both active and passive movement: passive forward flexion 90 degrees, abduction 70 degrees and external rotation 10 degrees, with a capsular end-feel. This meets the Statement of Principles definition of adhesive capsulitis of the shoulder: shoulder pain and stiffness with severe functional restriction of both active and passive motion lasting at least 28 days. The restriction of passive movement distinguishes it from weakness caused by the axillary nerve palsy, which limits active movement only.
MRI on 16 April 2012 supported the diagnosis, showing thickening of the axillary recess capsule and coracohumeral ligament with obliteration of the rotator interval fat. X-rays excluded glenohumeral arthritis. The worsening was confirmed clinically on 15 July 2014 and on MRI on 02 October 2014.
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 02 March 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 1999 and 2000, where she acquired HIV, in Afghanistan in 2011, where she dislocated her left shoulder, and in the Middle East in 2014, where the condition worsened.
Each factor must be related to the person's relevant 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.
Balance of Probabilities — Statement of Principles concerning Adhesive Capsulitis of the Shoulder, No. 73 of 2020
Causative factors
Factor 9(1): having a significant injury involving the arm or shoulder of the affected side within the six months before the clinical onset of adhesive capsulitis of the shoulder; — MET
- On 10 November 2011 the veteran dislocated her left shoulder with a bony Bankart fracture of the glenoid while carrying a stretcher during a casualty evacuation. The injury caused substantial pain, swelling and tenderness, and the arm was immobilised in a sling for six weeks. It occurred 3 months and 3 weeks before onset on 02 March 2012, within the six months from 02 September 2011 to 02 March 2012, and arose from her duties as a combat medic.
Factor 9(2): undergoing a surgical procedure involving the shoulder, chest wall or neck of the affected side within the six months before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The veteran underwent open fixation of the left glenoid rim fracture on 14 November 2011 and a left mastectomy with axillary clearance on 08 December 2011. Both procedures involved the shoulder or chest wall of the affected side and fell within the six months before onset, from 02 September 2011 to 02 March 2012. The glenoid fixation treated a service injury and both operations were carried out by Defence-funded surgeons while she was serving.
Factor 9(3): having paralysis of the affected shoulder within the one year before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The dislocation of 10 November 2011 caused a left axillary nerve palsy with paralysis of the deltoid, confirmed by electromyography on 20 December 2011, which showed denervation and no voluntary motor units. The paralysis was present from 10 November 2011 to onset on 02 March 2012, within the one year before onset, from 02 March 2011 to 02 March 2012.
Factor 9(4): having rotator cuff syndrome of the affected side at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- A medical officer diagnosed left rotator cuff syndrome on 24 January 2011, with a painful arc, positive impingement signs and MRI evidence of supraspinatus tendinopathy with a partial-thickness tear. It arose from years of stretcher carrying, casualty lifting and overhead loading as a combat medic, and it was still present at onset on 02 March 2012.
Factor 9(5): having a malignant neoplasm involving the region of the affected shoulder or the adjacent thoracic region, including the breast, within the one year before the clinical onset of adhesive capsulitis of the shoulder; — MET
- Invasive ductal carcinoma of the left breast was confirmed on biopsy on 22 November 2011, with axillary nodal involvement at mastectomy on 08 December 2011. The lump had been present since September 2011. The carcinoma involved the breast and axilla adjacent to the affected shoulder within the one year before onset, from 02 March 2011 to 02 March 2012. Her prolonged night shift work in clinics and field hospitals was recorded by the treating oncologist.
Factor 9(6): having diabetes mellitus at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Type 2 diabetes mellitus was diagnosed on 19 March 2009, with a fasting glucose of 8.4 mmol/L and an HbA1c of 7.3 per cent, after weight gain during and after her 2008 deployment, and she remained on metformin. HbA1c was 7.8 per cent in February 2012. The diabetes was present at onset on 02 March 2012.
Factor 9(7): having a thyroid disease from the specified list of thyroid diseases at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Hashimoto thyroiditis with hypothyroidism was diagnosed in 2007, with a TSH of 14 mU/L and raised thyroid peroxidase antibodies, and she took levothyroxine continuously. Hashimoto's thyroiditis and hypothyroidism are both on the specified list. The condition was present at onset on 02 March 2012, with a TSH of 6.8 mU/L in January 2012.
Factor 9(8): having Parkinson's disease at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- A neurologist diagnosed Parkinson's disease on 18 August 2010, with left-sided rigidity, bradykinesia and rest tremor and an abnormal dopamine transporter scan, and commenced levodopa. The rigidity and reduced arm swing of the left side reduced the use of the left shoulder. The disease was present at onset on 02 March 2012.
Factor 9(9): taking highly active antiretroviral therapy for human immunodeficiency virus infection at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- The veteran has taken highly active antiretroviral therapy continuously since 08 February 2000 for HIV infection acquired from a needle-stick injury while treating a casualty as a medic on 12 December 1999. She was taking it at onset on 02 March 2012.
Worsening factors
Factor 9(10): having a significant injury involving the arm or shoulder of the affected side within the six months before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- On 28 May 2014 the veteran fell from the step of a vehicle onto her outstretched left arm, sustaining bone bruising of the greater tuberosity with substantial pain, swelling and tenderness, and the arm was immobilised in a sling for three weeks. The injury fell within the six months before the worsening, from 15 January 2014 to 15 July 2014.
Factor 9(11): undergoing a surgical procedure involving the shoulder, chest wall or neck of the affected side within the six months before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- A local recurrence of the breast carcinoma on the left chest wall was excised on 06 January 2014, and a revision of the left chest wall scar with release of tethering was performed on 03 February 2014. The revision fell within the six months before the worsening, from 15 January 2014 to 15 July 2014, and both procedures were performed by Defence-funded surgeons while she was serving.
Factor 9(12): having paralysis of the affected shoulder within the one year before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Electromyography on 12 November 2013 showed persisting partial denervation of the left deltoid with incomplete recovery, and the treating neurologist recorded persisting weakness and partial paralysis of shoulder abduction. This was present within the one year before the worsening, from 15 July 2013 to 15 July 2014.
Factor 9(13): having rotator cuff syndrome of the affected side at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Left rotator cuff syndrome persisted and was present at the worsening on 15 July 2014, with supraspinatus tendinopathy unchanged on MRI on 02 October 2014.
Factor 9(14): having a malignant neoplasm involving the region of the affected shoulder or the adjacent thoracic region, including the breast, within the one year before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- A local recurrence of the breast carcinoma was found in the left chest wall in November 2013 and excised on 06 January 2014. It was present within the one year before the worsening, from 15 July 2013 to 15 July 2014.
Factor 9(15): having diabetes mellitus at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Type 2 diabetes mellitus persisted and was poorly controlled on deployment, with an HbA1c of 8.6 per cent in June 2014, at the worsening on 15 July 2014.
Factor 9(16): having a thyroid disease from the specified list of thyroid diseases at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Hashimoto hypothyroidism persisted on levothyroxine and was present at the worsening on 15 July 2014.
Factor 9(17): having Parkinson's disease at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Parkinson's disease persisted and had progressed, with increased left-sided rigidity recorded by the neurologist in March 2014, and was present at the worsening on 15 July 2014.
Factor 9(18): taking highly active antiretroviral therapy for human immunodeficiency virus infection at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- The veteran was taking highly active antiretroviral therapy at the worsening on 15 July 2014, having continued it since February 2000.
Factor 9(19): inability to obtain appropriate clinical management for adhesive capsulitis of the shoulder. — MET
- After the fall of 28 May 2014 on deployment the veteran had no access to physiotherapy, image-guided hydrodilatation or orthopaedic review for seven weeks, and her stretching program lapsed. Passive forward flexion fell from 140 to 70 degrees and external rotation from 40 to 5 degrees. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Adhesive Capsulitis of the Shoulder, No. 72 of 2020
Causative factors
Factor 9(1): having a significant injury involving the arm or shoulder of the affected side within the six months before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The left shoulder dislocation with a glenoid rim fracture was sustained on warlike service in Afghanistan on 10 November 2011, while carrying a stretcher during a casualty evacuation under fire. The arm was immobilised for six weeks. The injury fell within the six months before onset, from 02 September 2011 to 02 March 2012.
Factor 9(2): undergoing a surgical procedure involving the shoulder, chest wall or neck of the affected side within the six months before the clinical onset of adhesive capsulitis of the shoulder; — MET
- Open fixation of the glenoid rim fracture on 14 November 2011 treated the injury sustained on warlike service in Afghanistan, and the left mastectomy of 08 December 2011 followed a breast lump that arose on that deployment and could not be investigated there. Both procedures fell within the six months before onset, from 02 September 2011 to 02 March 2012.
Factor 9(3): having paralysis of the affected shoulder within the one year before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The axillary nerve palsy with deltoid paralysis resulted from the dislocation on warlike service in Afghanistan on 10 November 2011 and was confirmed on electromyography on 20 December 2011. It was present within the one year before onset, from 02 March 2011 to 02 March 2012.
Factor 9(4): having rotator cuff syndrome of the affected side at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Left rotator cuff syndrome, diagnosed on 24 January 2011, arose from casualty handling and load carriage that included her warlike service in Afghanistan in 2008, and was aggravated by stretcher carrying on warlike service in Afghanistan in 2011. It was present at onset on 02 March 2012.
Factor 9(5): having a malignant neoplasm involving the region of the affected shoulder or the adjacent thoracic region, including the breast, within the one year before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The carcinoma of the left breast was first noticed as a lump in September 2011 during warlike service in Afghanistan, where it could not be investigated, and was confirmed on 22 November 2011 after her evacuation. It was present within the one year before onset, from 02 March 2011 to 02 March 2012.
Factor 9(6): having diabetes mellitus at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Type 2 diabetes mellitus was diagnosed on 19 March 2009, after a 14 kg weight gain during her warlike service in Afghanistan in 2008, when she worked prolonged night shifts and had limited access to fresh food. It was present at onset on 02 March 2012.
Factor 9(7): having a thyroid disease from the specified list of thyroid diseases at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Hashimoto hypothyroidism, treated with levothyroxine since 2007, was present at onset on 02 March 2012, which followed her warlike service in Afghanistan in 2011.
Factor 9(8): having Parkinson's disease at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- Parkinson's disease was diagnosed on 18 August 2010. The neurologist recorded her repeated exposure to vector-control insecticides sprayed in and around her accommodation and aid post during warlike service in East Timor in 1999 and 2000. The disease was present at onset on 02 March 2012.
Factor 9(9): having dyslipidaemia before the clinical onset of adhesive capsulitis of the shoulder; — MET
- On 19 March 2009 a medical officer diagnosed dyslipidaemia with an LDL cholesterol of 4.6 mmol/L and triglycerides of 2.6 mmol/L, and commenced atorvastatin 40 mg daily, which she continued. Both the LDL level and the regular drug therapy meet the definition of dyslipidaemia. The weight gain that preceded it followed her warlike service in Afghanistan in 2008, and the dyslipidaemia was present before onset on 02 March 2012.
Factor 9(10): taking highly active antiretroviral therapy for human immunodeficiency virus infection at the time of the clinical onset of adhesive capsulitis of the shoulder; — MET
- The HIV infection was acquired from a needle-stick injury while resuscitating a casualty on warlike service in East Timor on 12 December 1999. Highly active antiretroviral therapy has continued since 08 February 2000 and she was taking it at onset on 02 March 2012.
Factor 9(11): taking phenobarbital or primidone within the six weeks before the clinical onset of adhesive capsulitis of the shoulder; — MET
- The veteran took primidone 250 mg at night from August 2010, prescribed for the action tremor accompanying her Parkinson's disease, and took it throughout the six weeks before onset, from 20 January 2012 to 02 March 2012. Primidone is metabolised to phenobarbital, which is associated with capsular fibrosis.
Worsening factors
Factor 9(12): having a significant injury involving the arm or shoulder of the affected side within the six months before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- The fall from a vehicle step onto her left arm on 28 May 2014 occurred on warlike service in the Middle East. It caused bone bruising of the greater tuberosity and three weeks of sling immobilisation, within the six months before the worsening, from 15 January 2014 to 15 July 2014.
Factor 9(13): undergoing a surgical procedure involving the shoulder, chest wall or neck of the affected side within the six months before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- The revision of the left chest wall scar on 03 February 2014 followed excision of a recurrence of the breast carcinoma first noticed on warlike service in Afghanistan. It fell within the six months before the worsening, from 15 January 2014 to 15 July 2014, which was documented on warlike service in the Middle East.
Factor 9(14): having paralysis of the affected shoulder within the one year before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Partial paralysis of the left deltoid from the axillary nerve injury sustained on warlike service in Afghanistan persisted on electromyography on 12 November 2013, within the one year before the worsening, from 15 July 2013 to 15 July 2014.
Factor 9(15): having rotator cuff syndrome of the affected side at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Left rotator cuff syndrome was present at the worsening on 15 July 2014, aggravated by carrying medical equipment on warlike service in the Middle East.
Factor 9(16): having a malignant neoplasm involving the region of the affected shoulder or the adjacent thoracic region, including the breast, within the one year before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- The left chest wall recurrence of the breast carcinoma was present from November 2013 until its excision on 06 January 2014, within the one year before the worsening on warlike service, from 15 July 2013 to 15 July 2014.
Factor 9(17): having diabetes mellitus at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Type 2 diabetes mellitus, with an HbA1c of 8.6 per cent on warlike service in the Middle East in June 2014, was present at the worsening on 15 July 2014.
Factor 9(18): having a thyroid disease from the specified list of thyroid diseases at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Hashimoto hypothyroidism was present at the worsening on warlike service in the Middle East on 15 July 2014.
Factor 9(19): having Parkinson's disease at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Parkinson's disease, linked to insecticide exposure on warlike service in East Timor, was present and progressing at the worsening on 15 July 2014.
Factor 9(20): having dyslipidaemia before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Dyslipidaemia, treated with atorvastatin since March 2009, was present before the worsening on 15 July 2014, with an LDL cholesterol of 4.2 mmol/L in March 2014.
Factor 9(21): taking highly active antiretroviral therapy for human immunodeficiency virus infection at the time of the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Highly active antiretroviral therapy for HIV acquired on warlike service in East Timor continued throughout her warlike service in the Middle East and was being taken at the worsening on 15 July 2014.
Factor 9(22): taking phenobarbital or primidone within the six weeks before the clinical worsening of adhesive capsulitis of the shoulder; — MET
- Primidone 250 mg nightly continued throughout the six weeks before the worsening, from 03 June 2014 to 15 July 2014, while she was on warlike service in the Middle East.
Factor 9(23): inability to obtain appropriate clinical management for adhesive capsulitis of the shoulder. — MET
- On warlike service in the Middle East from 28 May to 22 July 2014 no physiotherapy, hydrodilatation or orthopaedic review was available, and operational demands prevented her return to Australia until 22 July 2014. The condition worsened during this period, with passive forward flexion falling from 140 to 70 degrees.
The % contribution of the causes is 100% and significant.
Sequelae
The adhesive capsulitis of the left shoulder is a sequela of the veteran's accepted left shoulder dislocation with axillary nerve palsy and glenoid fixation, her accepted left rotator cuff syndrome, and the left mastectomy for a breast carcinoma that could not be investigated on deployment. In turn it has caused compensatory overuse of the right shoulder and neck, with right-sided neck and trapezius pain recorded from 2013, and sleep disturbance from night pain.
Unintended Consequence
Met. The glenoid fixation of 14 November 2011 and the mastectomy with axillary clearance of 08 December 2011 were performed and paid for by the Commonwealth while the veteran was serving, and adhesive capsulitis is a recognised complication of shoulder and chest wall surgery and the immobilisation that follows it. The capsulitis is therefore also an unintended consequence of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After her fall of 28 May 2014 on warlike service in the Middle East the veteran had no access to physiotherapy, image-guided hydrodilatation or orthopaedic review for seven weeks, and operational demands delayed her return to Australia. Her adhesive capsulitis, which had been improving with treatment, worsened, with passive forward flexion falling from 140 to 70 degrees and external rotation from 40 to 5 degrees. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of the treatment her condition required, because of her service circumstances, amounts to an inability to obtain appropriate clinical management. The inability to investigate her breast lump on deployment in 2011 also delayed the diagnosis and treatment that preceded the onset.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Dec 1999, Casualty and exposure report, Forward aid post, East Timor
- 08 Feb 2000, Specialist letter, Infectious diseases physician
- 19 Mar 2009, Outpatient health record and pathology, Medical Officer, Garrison health centre
- 18 Aug 2010, Neurology consultation and dopamine transporter scan report, Neurologist
- 24 Jan 2011, Outpatient health record and MRI left shoulder report, Medical Officer and Radiologist
- 10 Nov 2011, Trauma admission and X-ray report, Role 3 hospital, Afghanistan
- 14 Nov 2011, Operation report, Orthopaedic surgeon
- 22 Nov 2011, Histopathology report and breast surgery consultation, Breast surgeon
- 08 Dec 2011, Operation report, Breast surgeon
- 20 Dec 2011, Nerve conduction and electromyography report, Neurophysiologist
- 20 Feb 2012, Physiotherapy review, Physiotherapist
- 09 Mar 2012, Outpatient health record, Medical Officer, Garrison health centre
- 16 Apr 2012, MRI left shoulder report, Radiologist
- 18 Apr 2012, Specialist consultation, Orthopaedic surgeon
- 12 Nov 2013, Electromyography report, Neurophysiologist
- 06 Jan 2014, Operation report, Breast surgeon
- 15 Jul 2014, Deployed health record, Medical Officer, Role 2 facility, Middle East
- 02 Oct 2014, MRI left shoulder report, Radiologist
- Statement of Principles concerning Adhesive Capsulitis of the Shoulder (Balance of Probabilities) No. 73 of 2020, Repatriation Medical Authority
- Statement of Principles concerning Adhesive Capsulitis of the Shoulder (Reasonable Hypothesis) No. 72 of 2020, Repatriation Medical Authority
