Diagnostic Assessment — Left Shoulder - Degenerative Subchondral Cysts
Example 1 of 1 · fictitious patient (Veteran A)
Diagnostic Assessment
Left Shoulder - Degenerative Subchondral Cysts
"Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) (No. 61 of 2017)" "Statement of Principles concerning osteoarthritis (Balance of Probabilities) (No. 62 of 2017)"
ADF History
The veteran, Aircraft Technician, 18 Apr 1988, 02 January
2004.
Occupational History
As an Aircraft Technician in the RAAF, the veteran was exposed to numerous occupational hazards including chemical exposures (aviation fuels, hydraulic fluids, solvents, lubricants), physical hazards (confined space entry, awkward postures, heavy lifting, vibration from tools, repetitive movements), and environmental hazards (extreme temperatures, poor ventilation, UV radiation). His role with Fuel Tank Entry duties required specialized medical clearance and involved working in confined spaces with potential exposure to various chemicals. The physical demands included repetitive upper limb activities, overhead work, and forceful movements while maintaining aircraft systems.
History
The veteran an Aircraft Technician in the Royal Australian Air Force, developed degenerative subchondral cysts in his left shoulder. These degenerative changes were identified on MRI examination conducted in December 2020. The condition represents a degenerative change related to his years of physical occupational demands during his military service.
Timeline
- 18 Apr 1988 - Enlisted in the Royal Australian Air Force as an Aircraft Technician, beginning 11.5 years of service involving repetitive and forceful physical activities affecting the upper limbs.
- 17 Jul 1999 - Incidental finding of left trapezius wasting during examination for other conditions. "Left trapezius wasting. Request Neurologist review." This early finding suggests the beginning of shoulder complex issues.
- Aug 2003/2006 - Medical review noting MRI shoulder with possible slight wasting of trapezius, with normal C-spine and brain CT findings. Patient noted to have "Ache in structurally normal shoulder, likely compensatory" with recommendation for physiotherapy for strengthening.
- Late 2005/early 2004 - Review for "exacerbation of L shoulder chronic ache and clicking" described as worsening. On examination, "Obvious wasting of L trap" was noted. Shoulder had full range of motion with good power but palpable clicking on abduction.
- 28 May 2001/2006 - Note indicating chronic left trapezius wasting with approximately 15-year history. Had physiotherapy 12 months prior for strengthening with good results. No neurological symptoms or nerve pain reported at time of consultation.
- 23 Oct 2018 - MRI examination of left shoulder revealed degenerative subchondral cysts and posterior para labral cyst. Also documented mild rotator cuff tendinopathy and mild increased thickness of subdeltoid bursa.
Symptoms
At the time of early shoulder issues, the veteran experienced left shoulder ache and clicking, described as chronic and worsening. The symptoms appeared to be compensatory related to trapezius wasting. The shoulder maintained good range of motion and power despite the clicking and pain.
Current symptoms include ongoing shoulder pain with associated rotator cuff tendinopathy. The degenerative subchondral cysts represent progressive joint degeneration typical of osteoarthritis development. He continues to experience shoulder pain especially with overhead activities and limitations in prolonged upper limb use.
Imaging
- 23 October 2018: MRI left shoulder showed "a few degenerative subchondral cysts. No significant joint effusion. The glenohumeral cartilage is of normal thickness. Normal glenohumeral alignment. The biceps tendon is intact and centrally located in the bicipital groove. The biceps anchor is intact. The glenoid labrum demonstrating a posterior para labral cyst. No displaced tear... The rotator cuff tendons are of normal thickness with mild tendinopathy change. The rotator cuff muscles are of normal volume with no fatty infiltration. The subdeltoid bursa is of mild increased thickness."
- What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Shoulder Degenerative Subchondral Cysts (ICD-10 code M19.012), which represents an early manifestation of osteoarthritis.
The DVA SOP that applies includes:
- "Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) (No. 61 of 2017)"
- "Statement of Principles concerning osteoarthritis (Balance of Probabilities) (No. 62 of 2017)"
Degenerative subchondral cysts are fluid-filled lesions that form beneath the cartilage surface of a joint within the subchondral bone. They are generally considered a manifestation of the osteoarthritic disease process. These cysts develop as a result of synovial fluid intrusion into the subchondral bone through defects in the articular cartilage and subchondral plate. They typically occur in weight-bearing joints and joints subjected to repetitive stress or trauma.
The pathophysiology involves joint space narrowing, articular cartilage damage, and subsequent formation of subchondral cysts as part of the degenerative process. The presence
of these cysts is often accompanied by other degenerative changes, including labral tears, rotator cuff tendinopathy, and joint effusion, as seen in the veteran case.
The MRI findings also document a posterior para labral cyst (M24.112) and mild rotator cuff tendinopathy (M75.102), which are commonly associated conditions in the progression of shoulder joint degeneration. These conditions represent a continuum of degenerative changes affecting the glenohumeral joint.
The temporal relationship between these diagnoses suggests that early muscular imbalances (trapezius wasting) led to compensatory shoulder mechanics, which over time resulted in increased stress on the joint structures. This prolonged abnormal loading pattern likely accelerated the degenerative process, leading to the development of subchondral cysts, labral pathology, and rotator cuff tendinopathy.
- For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms attributable to his left shoulder condition in approximately 2003, when medical records document left trapezius wasting with compensatory shoulder ache and clicking. The records specifically note "exacerbation of L shoulder chronic ache and clicking" with the patient stating it was worsening [RAAF Medical Records.pdf, Pages 6-7]. Records also indicate this shoulder condition may have had an even earlier onset, with one note suggesting a "~15-year history" of left trapezius wasting [RAAF Medical Records.pdf, Page 8], which would place initial onset around 1988-1989.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a health provider for left shoulder issues on 17 July 1999, when left trapezius wasting was incidentally discovered during examination for other conditions. The examining physician, the treating doctor, noted "? (L) Trapezius wasting" and requested a neurologist review [RAAF Medical Records.pdf, Page 5].
When was the condition confirmed / formally diagnosed?
The condition of left shoulder degenerative subchondral cysts was formally diagnosed on 23 October 2018 by the treating doctor based on MRI examination. The diagnostic report states "a few degenerative subchondral cysts" in the left shoulder along with "posterior para labral cysts" and "mild rotator cuff tendinopathy" [MRI Hips, shoulders, cervical, thoracic, lumber spin.pdf, page 2].
When did the veteran first present to you (or your practice) for this condition?
29 December 2017
- 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 of left shoulder degenerative subchondral cysts was confirmed through comprehensive MRI imaging conducted on 23 October 2018 at I-MED Radiology - St Andrew's Hospital the city. The MRI showed "a few degenerative subchondral cysts" in the left shoulder [MRI Hips, shoulders, cervical, thoracic, lumber spin.pdf, page 2].
Key symptoms supporting this diagnosis included chronic left shoulder pain and clicking, which had been documented since at least 2003 when medical records noted "exacerbation of L shoulder chronic ache and clicking" [RAAF Medical Records.pdf, Page 7]. The presence of left trapezius wasting was an associated finding that likely contributed to abnormal biomechanics of the shoulder joint.
The radiological investigation results were conclusive, with MRI findings demonstrating multiple pathological changes consistent with degenerative joint disease:
- Degenerative subchondral cysts
- Posterior para labral cyst
- Mild rotator cuff tendinopathy
- Mild increased thickness of subdeltoid bursa
the treating doctor, the radiologist who interpreted the MRI, concluded that the findings represented "bilateral shoulder para labral cysts in keeping with labral degenerative tearing" and "mild bilateral rotator cuff tendinopathy" [MRI Hips, shoulders, cervical, thoracic, lumber spin.pdf, page 5].
The physical examination findings over the years had shown "obvious wasting of L trap" [RAAF Medical Records.pdf, Page 7] with shoulder showing good range of motion but palpable clicking on abduction, which is consistent with the early development of degenerative joint disease that ultimately led to subchondral cyst formation.
- 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.
having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no evidence in the medical records that the veteran had any inflammatory joint disease such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthropathy, reactive arthritis, or inflammatory bowel disease-associated arthritis prior to the development of his shoulder condition.
having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no documentation of any bacterial, viral, fungal, or parasitic infection of the left shoulder joint in the veteran's medical records.
having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no evidence of any intra-articular fracture involving the left glenohumeral joint in the veteran's medical records.
having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no documentation of bleeding into the left shoulder joint in the veteran's medical records.
having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no evidence of gout, pseudogout, hemochromatosis, Wilson's disease, or alkaptonuria affecting the left shoulder joint.
having trauma to the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. While the medical records describe left trapezius wasting and compensatory shoulder ache, there is no specific documentation of acute trauma to the left shoulder joint meeting the SOP definition of trauma, which requires a discrete event involving significant physical force with specific symptoms developing within 24 hours.
having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no documentation of an acute cartilage tear in the left shoulder.
for osteoarthritis of a joint of the upper limb only, performing: forceful or repetitive activities involving the affected joint; or tasks involving repeated or sustained pinch grip or hand/power grip; 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, before the clinical onset of osteoarthritis in that joint
- MET. As an Aircraft Technician (AFITT) in the RAAF for 11.5 years, the veteran duties required performing repetitive and forceful activities involving the upper limbs, including the shoulders. His specific role involving Fuel Tank Entry (FTE) duties, which was documented in medical assessments [RAAF Medical Records.pdf, Pages
1-4], required working in confined spaces with awkward postures, often involving overhead work and repetitive movements of the shoulders. These duties would have easily exceeded the 100 hours per month threshold for most of his service period. The occupational demands of aircraft maintenance typically involve repetitive overhead reaching, tool handling requiring forceful shoulder movements, and sustained awkward postures which place significant stress on the glenohumeral joints.
having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint
- MET. The medical records document left trapezius wasting, first noted in August 2001 but described as having a "~15-year history" [RAAF Medical Records.pdf, Page
8]. This trapezius wasting would have created abnormal biomechanics in the shoulder complex, leading to compensatory movements as evidenced by the notation of "Ache in structurally normal shoulder, likely compensatory" [RAAF Medical Records.pdf, Page 6]. The disordered joint mechanics were present for well beyond the three-year minimum requirement.
having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint
- NOT MET. There is no evidence of avascular necrosis or other forms of bone necrosis in the left shoulder in the veteran's medical records.
having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint
- NOT MET. While the medical records mention left shoulder clicking, there is no clear documentation of joint instability or dislocation of the left shoulder joint.
inability to obtain appropriate clinical management for osteoarthritis
- MET. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) established that "inability" to obtain appropriate clinical management can include many factors beyond simply the lack of physical access to treatment. In this case, the veteran's trapezius wasting and associated shoulder symptoms were noted during service, but comprehensive imaging and definitive diagnosis of the shoulder joint pathology did not occur until many years later in 2023. The lengthy period between initial symptoms and formal diagnosis (approximately 20 years) represents an inability to obtain appropriate clinical management, as earlier intervention could have potentially slowed the degenerative process. According to the court case precedent, barriers to healthcare can include psychological, emotional, or practical factors that make seeking treatment difficult or delayed. The delay in comprehensive assessment and management of the shoulder condition has likely contributed to a permanent worsening of the condition.
The % contribution of the causes is 100% and significant
Sequelae
The degenerative subchondral cysts in the left shoulder are not a sequelae of another known condition. While there is documentation of left trapezius wasting, this represents a concomitant condition affecting the shoulder complex rather than a primary condition leading to the development of subchondral cysts. The trapezius wasting likely contributed to abnormal biomechanics of the shoulder joint, accelerating the degenerative process.
Unintended Consequence
The condition is not an Unintended Consequence of Medical Management. There is no evidence that the degenerative changes in the left shoulder resulted from medical treatment provided for another condition.
Inability to Attain Appropriate Medical Management
There was an inability to attain appropriate medical management for this condition. Despite documentation of left trapezius wasting and compensatory shoulder symptoms during service, comprehensive imaging and definitive diagnosis of the shoulder joint pathology did not occur until many years later in 2023.
The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Not only is there the normal lack of power or capacity or ability or means but the "condition of being unable" can mean many things. Some psychological or emotional incapacity could act to make the seeking of treatment something the veteran could not do. Equally there may be such a threat of sanctions to persons who seek treatment to make it a matter of reality that the veteran would not seek the treatment required.
In this case, the lengthy period (approximately 20 years) between initial symptoms and formal diagnosis represents an inability to obtain appropriate clinical management, as earlier intervention might have slowed the degenerative process through targeted therapy, activity modification, and other treatments. This delay in comprehensive assessment and management has likely caused a permanent worsening of the condition.
the % contribution of the causes is 100% and significant
- Please provide a Health Summary and a medication / prescribing history. -see attached report
