Diagnostic Assessment — Left Shoulder - Dislocation
Example 1 of 1 · fictitious patient (Veteran AU)
Diagnostic Assessment
Left Shoulder - Dislocation
BOP Code: 56 of 2019 (Dislocation of a Joint and Subluxation of a Joint)
RH Code: 55 of 2019 (Dislocation of a Joint and Subluxation of a Joint)
ADF History
Veteran AU, date of birth 12 February 1984, Australian Army, Logistics Officer (Royal Australian Army Ordnance Corps), enlisted 15 January 2003 (Australian Defence Force Academy), medically discharged 04 December 2019. Operational service: Solomon Islands, 10 August 2006 to 18 December 2006 (non-warlike); Afghanistan, 04 February 2013 to 26 April 2013 (warlike, ended by aeromedical evacuation after a shoulder injury).
Occupational History
As a logistics officer the veteran planned and supervised the receipt, storage and distribution of equipment and supplies, worked long hours in warehouses, vehicle compounds and headquarters, and took part in field exercises carrying packs of 25 to 35 kilograms. Physical training and annual fitness assessments included load-carriage marches, push-ups and pull-up conditioning.
Logistics personnel are exposed to manual handling injuries, slips, trips and falls in warehouses and ablution facilities, vehicle incidents and load-carriage injuries including lumbar disc disease and rucksack palsy. On operations, sleep disruption, gastrointestinal illness and heat contributed to accidents.
History
Veteran AU, an Army logistics officer, sustained an anterior dislocation of the left shoulder on 18 April 2013 on warlike service in Afghanistan, when she slipped and fell onto her outstretched left arm while vomiting in an ablution block. The dislocation was accompanied by a Bankart lesion with a bony fragment and a Hill-Sachs lesion, and it worsened after reduction was delayed for eleven hours because aeromedical evacuation was grounded by a dust storm.
Timeline
- 22 Sep 2010 — During a field exercise in Australia the veteran developed low back pain radiating to the left leg after a series of load-carriage marches with a 32-kilogram pack. MRI of the lumbar spine on 05 October 2010 showed an L4/5 disc protrusion contacting the left L5 nerve root, with early facet joint degeneration. She was placed on restricted duties for three months and commenced amitriptyline and later pregabalin for radicular pain, with a gain of 18 kilograms over the following two years. "L4/5 disc prolapse, left L5"
- 14 Aug 2012 — Two days after a 40-kilometre load-carriage march with a 35-kilogram pack the veteran reported numbness over the left shoulder and weakness lifting the left arm. Nerve conduction studies and electromyography on 30 August 2012 confirmed a left upper trunk brachial plexopathy (rucksack palsy) with denervation in supraspinatus, infraspinatus and deltoid. Strength had improved by January 2013 but repeat electromyography on 17 January 2013 showed persisting reinnervation changes and weakness of the rotator cuff. "rucksack palsy, upper trunk plexopathy"
- 21 Jan 2013 — At her pre-deployment medical examination the veteran weighed 116 kilograms at a height of 1.68 metres, a BMI of 41.1, and was granted a waiver to deploy in a staff appointment. Left shoulder examination showed mild weakness of external rotation (4+/5) with a full range of movement and no instability. Ongoing low back pain from the L4/5 disc prolapse was noted. A urine pregnancy test was negative. "BMI 41.1, deployment waiver granted"
- 18 Apr 2013 — On warlike service at a multinational base in southern Afghanistan the veteran developed vomiting and diarrhoea in the early hours. While vomiting forcefully in a wet ablution block she slipped and fell onto her outstretched, abducted left arm and felt the shoulder dislocate. A dust storm grounded aeromedical evacuation, and two reduction attempts by the role 1 medical officer under limited analgesia failed. She was evacuated to the role 3 hospital eleven hours after injury, where serum beta-hCG confirmed a pregnancy of about six weeks and the shoulder was reduced under sedation. "anterior dislocation, reduction delayed 11 hours"
- 26 Apr 2013 — The veteran was aeromedically evacuated to Australia. Post-reduction radiographs and CT at the role 3 hospital had shown a Hill-Sachs lesion and a bony Bankart fragment. An orthopaedic surgeon in Australia recorded numbness over the regimental badge area and absent deltoid contraction, consistent with an axillary nerve injury following prolonged dislocation. "axillary nerve palsy, bony Bankart"
- 20 May 2013 — MRI arthrography of the left shoulder showed an anteroinferior labral tear with a displaced bony Bankart fragment of 18 per cent of the glenoid width, an anterior capsular tear and a deep, engaging Hill-Sachs lesion. Electromyography on 27 May 2013 confirmed an axillary neuropathy with severe denervation of deltoid superimposed on the earlier upper trunk plexopathy. The orthopaedic surgeon documented that the prolonged period of dislocation had enlarged the humeral head impaction and caused the nerve injury. "engaging Hill-Sachs, axillary neuropathy"
- 11 Mar 2014 — After the birth of her child in November 2013 the veteran underwent an open Latarjet coracoid transfer of the left shoulder for the bone loss. Recovery was slow because of residual deltoid weakness. She was downgraded to a non-deployable medical classification and later medically discharged. "Latarjet procedure, non-deployable"
Symptoms
At onset the veteran had severe left shoulder pain, a visible step deformity, inability to move the arm and numbness over the outer upper arm. After reduction she had persistent pain, weakness of shoulder abduction, a sense of the shoulder being unstable and numbness over the deltoid region.
She now reports aching pain in the left shoulder with overhead and lifting activity, reduced strength and endurance, apprehension in abduction and external rotation, difficulty sleeping on the left side and a patch of numbness over the upper arm. She cannot lift more than about 5 kilograms above shoulder height.
Imaging
- 05 Oct 2010 — MRI lumbar spine: "L4/5 disc protrusion contacting the left L5 nerve root. Early L4/5 facet joint degeneration."
- 18 Apr 2013 — Left shoulder radiographs (pre- and post-reduction): "Anterior glenohumeral dislocation, subcoracoid. Post reduction: congruent joint with a Hill-Sachs impaction and a small bony fragment at the anteroinferior glenoid rim."
- 19 Apr 2013 — CT left shoulder: "Hill-Sachs lesion 14 mm deep. Bony Bankart fragment involving about 18 per cent of the glenoid width."
- 20 May 2013 — MRI arthrogram left shoulder: "Anteroinferior labral tear with displaced bony Bankart fragment, anterior capsular tear and deep engaging Hill-Sachs lesion. Fatty change in deltoid consistent with denervation."
Onset Date
The most likely date of onset of this condition is 18 Apr 2013.
At that date the veteran was on warlike service at a multinational base in southern Afghanistan in a logistics staff appointment. She was unwell with vomiting and diarrhoea, about six weeks pregnant, had a BMI of 41, and was carrying a lumbar disc prolapse and a partially recovered left upper trunk brachial plexopathy. She dislocated the left shoulder in a fall while vomiting.
This date is appropriate because the dislocation is an acute injury with a witnessed mechanism, and the shoulder was recorded as stable with a full range of movement at her pre-deployment medical examination on 21 January 2013. She presented to the role 1 medical officer within minutes of the injury on 18 April 2013. The onset falls within continuous full-time service.
Most factors for this condition operate at the time of onset. On 18 Apr 2013 she had the physical trauma of the fall, the soft tissue and bony injuries to the joint, the persisting upper trunk plexopathy, a BMI of 41.1, and the L4/5 disc prolapse; she was vomiting, with wide opening of the mouth, when she fell. For the pregnancy factor, the six weeks before onset run from 07 Mar 2013 to 18 Apr 2013; she was pregnant throughout the latter part of that window, with an estimated conception date of about 21 March 2013, confirmed by serum beta-hCG on the day of injury.
For the worsening, the period after onset runs from 18 Apr 2013 to the documented worsening on 20 May 2013. Reduction could not be obtained for eleven hours on 18 Apr 2013, and the MRI arthrogram and electromyography of 20 and 27 May 2013 documented an enlarged engaging Hill-Sachs lesion and an axillary nerve injury attributable to the prolonged dislocation.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Shoulder - Dislocation (ICD-10-AM S43.01), an anterior dislocation of the left glenohumeral joint with a bony Bankart lesion and Hill-Sachs lesion, under the Statements of Principles concerning dislocation of a joint and subluxation of a joint, Balance of Probabilities No. 56 of 2019 and Reasonable Hypothesis No. 55 of 2019.
A dislocation of a joint is an episode of displacement of the joint such that there is complete loss of contact between the articulating surfaces. In the shoulder, anterior dislocation is the most common type and usually follows a fall on the abducted and externally rotated arm. It frequently tears the anteroinferior labrum and capsule (the Bankart lesion), may break off a fragment of the glenoid rim, and impacts the back of the humeral head against the glenoid (the Hill-Sachs lesion). Prolonged dislocation increases the risk of axillary nerve injury and of enlargement of the bony defects, which predispose to later instability and osteoarthritis.
The dislocation occurred on 18 April 2013 on warlike service in Afghanistan, was confirmed radiologically on the same day and worsened as a result of an eleven-hour delay to reduction.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 April 2013.
When did the veteran first present to a health / medical provider for this condition?
18 April 2013.
When was the condition confirmed / formally diagnosed?
18 April 2013.
When did the veteran first present to you (or your practice) for this condition?
27 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on plain radiographs at the role 3 hospital on 18 April 2013, which showed a subcoracoid anterior dislocation of the left glenohumeral joint with complete loss of contact between the humeral head and the glenoid. This meets the Statement of Principles definition of dislocation of a joint. It was a first-time traumatic dislocation, not congenital and not a recurrent dislocation due to joint instability.
Post-reduction CT on 19 April 2013 and MRI arthrography on 20 May 2013 confirmed the associated bony Bankart fracture, anteroinferior labral and capsular tear and Hill-Sachs lesion, and electromyography on 27 May 2013 confirmed axillary neuropathy. The orthopaedic surgeon confirmed the diagnosis and its complications on 26 April and 20 May 2013.
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 18 April 2013, 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, during which the lumbar disc prolapse, the rucksack palsy and the weight gain arose. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2013, during which the dislocation occurred and reduction was delayed.
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 Dislocation of a Joint and Subluxation of a Joint, No. 56 of 2019
Causative factors
Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- On 18 April 2013 the veteran slipped on a wet ablution floor and fell onto her outstretched, abducted left arm, applying a forceful levering load through the glenohumeral joint at the moment it dislocated. The fall was witnessed by another officer and recorded by the medical officer within minutes. It occurred in Defence accommodation in the course of her service.
Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- MRI arthrography on 20 May 2013 showed a tear of the anteroinferior glenoid labrum, a fibrocartilaginous structure that contributes to glenohumeral stability, and a tear of the anterior joint capsule. The orthopaedic surgeon documented that these structures were torn at the time of the dislocation on 18 April 2013.
Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- CT on 19 April 2013 showed a fracture of the anteroinferior glenoid rim (a bony Bankart fragment involving about 18 per cent of the glenoid width) and a 14 mm Hill-Sachs impaction fracture of the humeral head, both involving the articulating surfaces of the left shoulder and both present at the time of the dislocation.
Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- Electromyography on 30 August 2012 and 17 January 2013 confirmed a left upper trunk brachial plexopathy (rucksack palsy) with denervation and incomplete reinnervation of supraspinatus, infraspinatus and deltoid, caused by a 40-kilometre load-carriage march on 12 August 2012 during peacetime service. This peripheral neuropathy weakened the dynamic stabilisers of the left shoulder and was present at onset on 18 April 2013, when external rotation strength was still recorded as 4+/5.
Factor 9(5): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- At the moment of the fall on 18 April 2013 the veteran was vomiting forcefully, an activity involving wide opening of the mouth, as recorded in the medical officer's note. The vomiting was due to acute gastroenteritis contracted in deployed accommodation, compounded by early pregnancy.
Factor 9(6): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, having morbid obesity at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The veteran's BMI was 41.1 at her pre-deployment medical examination on 21 January 2013 (116 kilograms, 1.68 metres) and was unchanged at onset on 18 April 2013, a level of morbid obesity. The weight gain followed the service-related lumbar injury of 2010, the enforced inactivity of restricted duties and treatment with amitriptyline and pregabalin.
Factor 9(7)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET
- The veteran was obese at the time of onset on 18 April 2013, with a BMI of 41.1, well above the threshold of 30. Her weight had risen from 98 kilograms in 2010 after the service-related lumbar disc prolapse and its treatment.
Factor 9(7)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET
- MRI on 05 October 2010 showed an L4/5 lumbar intervertebral disc prolapse contacting the left L5 nerve root, caused by repeated load-carriage marches with a 32-kilogram pack on a field exercise in September 2010. The disc prolapse was present and symptomatic at onset on 18 April 2013, recorded at her pre-deployment examination.
Worsening factors
Factor 9(8): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET
- On 18 April 2013 reduction of the dislocated shoulder could not be obtained for eleven hours because a dust storm grounded aeromedical evacuation, procedural sedation was unavailable at the role 1 facility and analgesia was limited by pregnancy. The prolonged dislocation enlarged the Hill-Sachs lesion to an engaging defect and caused an axillary nerve injury, documented on 20 and 27 May 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint, No. 55 of 2019
Causative factors
Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The physical trauma occurred on warlike service in Afghanistan on 18 April 2013, when the veteran slipped on the wet floor of a deployed ablution block and fell onto her outstretched, abducted left arm. The fall was witnessed and the dislocation was recorded by the role 1 medical officer within minutes.
Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The anteroinferior labrum and anterior capsule of the left shoulder, which contribute to joint stability, were torn at the time of the dislocation on warlike service on 18 April 2013, as shown on MRI arthrography on 20 May 2013 and confirmed by the orthopaedic surgeon.
Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The bony Bankart fracture of the glenoid rim and the Hill-Sachs impaction fracture of the humeral head, both involving the articulating surfaces, were sustained in the fall on warlike service in Afghanistan on 18 April 2013 and shown on radiographs and CT at the role 3 hospital on 18 and 19 April 2013.
Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The left upper trunk brachial plexopathy, a peripheral neuropathy confirmed on electromyography in August 2012 and January 2013, was still present when the veteran deployed and at the onset on warlike service on 18 April 2013, with weakness of the rotator cuff and deltoid that impaired the dynamic stability of the joint.
Factor 9(5): being pregnant within the six weeks before the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- Serum beta-hCG at the role 3 hospital on 18 April 2013, taken before sedation, confirmed a pregnancy of about six weeks' gestation, later confirmed by an obstetric ultrasound in Australia that dated conception to about 21 March 2013, during her mid-deployment leave in Australia. The veteran was therefore pregnant within the six weeks before the dislocation on warlike service. Pregnancy-related ligamentous laxity and the nausea and vomiting of early pregnancy contributed to the fall.
Factor 9(6): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- At the time of the dislocation on warlike service on 18 April 2013 the veteran was vomiting forcefully, an activity involving wide opening of the mouth, from gastroenteritis acquired in deployed accommodation and the nausea of early pregnancy.
Factor 9(7): for dislocation of a patellofemoral joint only, being obese at the time of the clinical onset of dislocation of a joint; — MET
- The veteran was obese at the time of the dislocation on warlike service on 18 April 2013, with a BMI of 41.1 recorded at her pre-deployment medical examination on 21 January 2013 and unchanged on the role 3 hospital admission weight.
Factor 9(8): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, being severely obese at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The veteran's BMI was 41.1 at onset on 18 April 2013, above the threshold of 35 for severe obesity, recorded at her pre-deployment medical and on admission to the role 3 hospital in Afghanistan.
Factor 9(9)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET
- The veteran was obese at the time of the dislocation on warlike service in Afghanistan on 18 April 2013, with a BMI of 41.1.
Factor 9(9)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET
- The L4/5 lumbar intervertebral disc prolapse shown on MRI of 05 October 2010 was present and symptomatic at onset on warlike service on 18 April 2013, recorded at her pre-deployment medical examination. Her low back pain limited her ability to break the fall.
Factor 9(10): for dislocation of a total knee joint prosthesis only, having morbid obesity at the time of the clinical onset of dislocation of a joint; — MET
- The veteran's BMI of 41.1 at onset on 18 April 2013 is within the range of morbid obesity, recorded at her pre-deployment medical examination and on the role 3 hospital admission in Afghanistan.
Worsening factors
Factor 9(11): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET
- On warlike service on 18 April 2013 a dust storm grounded aeromedical evacuation, the role 1 facility could not provide procedural sedation and analgesia was limited by pregnancy, so the shoulder remained dislocated for eleven hours. The delay enlarged the Hill-Sachs lesion into an engaging defect and caused an axillary nerve injury, documented on 20 and 27 May 2013. This is an inability to obtain appropriate clinical management arising from operational service.
The % contribution of the causes is 100% and significant.
Sequelae
The left shoulder dislocation has the following sequelae, each of which should be considered for acceptance: left axillary neuropathy from the prolonged dislocation, post-traumatic glenohumeral instability, the Latarjet procedure and its consequences, and a risk of later osteoarthritis of the left shoulder. The dislocation itself was contributed to by the accepted lumbar disc prolapse and left upper trunk brachial plexopathy and by the weight gain that followed treatment of the lumbar condition.
Unintended Consequence
Met. The weight gain to a BMI above 40, which contributed to the fall and the dislocation, was an unintended consequence of amitriptyline and pregabalin prescribed and paid for by the Commonwealth for the service-related lumbar radiculopathy (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On 18 April 2013 a dust storm grounded aeromedical evacuation from the base, the role 1 facility had no capacity for procedural sedation, and analgesia was limited because the veteran was pregnant. Two reduction attempts failed and the shoulder remained dislocated for eleven hours. The MRI arthrogram and electromyography in May 2013 showed an enlarged engaging Hill-Sachs lesion and an axillary nerve injury attributed by the orthopaedic surgeon to the prolonged dislocation. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely reduction amount to an inability to obtain appropriate clinical management, and it materially worsened the condition.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 05 Oct 2010, MRI lumbar spine, Radiologist
- 12 Oct 2010, Outpatient health record, Medical Officer, Garrison health centre
- 30 Aug 2012, Nerve conduction studies and electromyography, Neurologist
- 17 Jan 2013, Repeat electromyography, Neurologist
- 21 Jan 2013, Pre-deployment medical examination, Medical Officer, Garrison health centre
- 18 Apr 2013, Deployed health record, Medical Officer, Role 1 facility, Afghanistan
- 18 Apr 2013, Emergency admission, radiographs and pathology, Role 3 hospital, Afghanistan
- 19 Apr 2013, CT left shoulder, Radiologist, Role 3 hospital
- 26 Apr 2013, Orthopaedic consultation, Orthopaedic surgeon
- 20 May 2013, MRI arthrogram left shoulder, Radiologist
- 27 May 2013, Electromyography, Neurologist
- 11 Mar 2014, Operation report, Orthopaedic surgeon
- Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Balance of Probabilities) No. 56 of 2019, Repatriation Medical Authority
- Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Reasonable Hypothesis) No. 55 of 2019, Repatriation Medical Authority
