Left Shoulder - Biceps Tendon Sprain — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Left Shoulder - Biceps Tendon Sprain

Example 1 of 1 · fictitious patient (Veteran N)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Left Shoulder - Biceps Tendon Sprain

SOP Balance of Probabilities: Sprain and Strain No. 28 of 2020 SOP Reasonable Hypothesis: Sprain and Strain No. 29 of 2020

ADF History

The veteran, Chef, 09 January 2009, 27 Mar 2016.

Occupational History

Military chef duties involve repetitive forceful gripping and pulling movements with kitchen equipment, heavy lifting requiring biceps muscle activation, sustained activities involving elbow flexion during food preparation, and overhead movements that stress the biceps tendon. Physical training activities including pull-ups, climbing, and weapon handling place additional stress on the biceps tendon complex. The long head of the biceps tendon is particularly vulnerable to injury during repetitive overhead activities and forceful lifting movements.

History

The veteran the veteran developed left shoulder biceps tendon sprain during his military service as a Chef in the Australian Defence Force from February 2011 to Apr 2018. The condition likely developed through repetitive occupational activities involving forceful stretching and high intensity use of the biceps tendon during military duties.

Timeline

05 January 2019 - MRI bilateral shoulder revealed chronic structural changes affecting the biceps tendons bilaterally. There were symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment. The long head of biceps tendons were normally positioned within the bicipital grooves attached normally to the labral anchors. The findings were consistent with chronic occupational biceps tendon pathology from prolonged military service activities involving repetitive forceful use of the biceps muscles.

Symptoms

The veteran developed insidious onset of left shoulder and anterior arm pain during his military service. Current symptoms include anterior shoulder pain, particularly with lifting and pulling activities, pain with biceps muscle contraction, and discomfort during overhead movements. The symptoms are consistent with biceps tendon pathology and chronic tendon dysfunction.

Imaging

05 January 2019 - MRI bilateral shoulder: Symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment.

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

Left Shoulder Biceps Tendon Sprain (Partial Thickness Longitudinal Split), DVA SOP: Sprain and Strain No. 28 of 2020, ICD-10: S46.1.

A biceps tendon sprain involves tearing or stretching of the biceps tendon, associated with the onset of pain and tenderness. The long head of the biceps tendon originates from the superior labrum and bicipital groove of the humerus and is subject to injury during forceful contractions or repetitive overhead activities. Partial thickness longitudinal splits represent incomplete tears of the tendon fibers, which can occur due to repetitive stress, forceful stretching, or high intensity use of the muscle-tendon unit.

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

When did the veteran first experience symptoms attributable to this condition? Unknown specific date during military service 2013-2020. No specific documentation of symptom onset found in the provided records.

When did the veteran first present to a health / medical provider for this condition? 24 September 2018 during DVA assessment with Dr Thomas Perkins at Veterans Health Centre [Email - General & Service Details.pdf, page 1].

When was the condition confirmed / formally diagnosed? 05 January 2019 by Radiologist the treating doctor via MRI bilateral shoulder imaging [IMAGING.pdf, page 1].

When did the veteran first present to you (or your practice) for this condition? 09 January 2018.

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 by MRI imaging conducted by Radiologist the treating doctor on 05 January 2019. The imaging revealed symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment [IMAGING.pdf, page 1]. The radiologist noted these as bilateral partial thickness longitudinal tears, representing structural damage to the biceps tendon complex.

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.

Factor 9(2): 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. Military chef duties involved continuous forceful stretching and high intensity use of the biceps tendon through heavy lifting, pulling movements with kitchen equipment, carrying large pots and supplies, and repetitive overhead activities requiring forceful biceps muscle contractions.

Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon

MET. Ongoing military duties throughout his 7-year service continued to involve forceful stretching and high intensity use of the biceps tendon, contributing to progressive worsening and development of the partial thickness longitudinal splits observed on imaging.

Sequelae

This condition is not a sequelae of another known condition but represents primary occupational biceps tendon strain from military service activities.

Unintended Consequence

This condition is not an unintended consequence of medical management. No procedures or medications were administered that contributed to the development of this condition.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management during military service. The condition was not diagnosed or treated during the veteran's 7-year military service despite ongoing occupational exposure to causative factors. Per the Full Federal Court in Brew v Repatriation Commission (07 July 1993), inability encompasses both objective and subjective lack of ability to obtain treatment. The absence of presentations for biceps tendon pain during military service indicates barriers to healthcare, satisfying inability to attain appropriate medical management. This inability resulted in permanent worsening as the condition progressed from reversible inflammation to irreversible structural changes including partial thickness longitudinal splits as demonstrated on MRI imaging.

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

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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