Left Shoulder - Osteoarthritis — 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 - Osteoarthritis

Example 1 of 1 · fictitious patient (Veteran H)

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 - Osteoarthritis

Balance of Probabilities: Osteoarthritis No. 62 of 2017, Labral Tear No. 37 of 2017, Rotator Cuff Syndrome No. 110 of 2022, Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Osteoarthritis No. 61 of 2017, Labral Tear No. 36 of 2017, Rotator Cuff Syndrome No. 109 of 2022, Sprain and Strain No. 27 of 2020

ADF History

Name: The veteran
Date of Birth: [withheld]
Occupation: M113 Crewman, RAAC Assistant Instructor
Enlistment Date: 06 November 1988
Discharge Date: Continuous Full Time Service ended 30 Apr 1992, continued in General Reserves until approximately 2001, separated from Army Standby Reserve 10 May 2007

Occupational History

As an M113 Crewman and RAAC Assistant Instructor, the veteran duties involved significant physical demands including operating armoured vehicles, pack marches with heavy loads, battle physical training, manual handling of heavy equipment, weapons training, and maintenance work on vehicles requiring overhead activities and forceful movements. These activities placed considerable stress on the shoulder girdle and involved repetitive and sustained activities of the shoulder joint.

History

Mr. John the veteran, M113 Crewman and RAAC Assistant Instructor, developed multiple left shoulder pathologies including glenohumeral and acromioclavicular joint conditions during his Australian Army service from 1995 to 2013 through cumulative occupational stress and traumatic events evidenced by post-traumatic changes on imaging.

Timeline

1996 - No documented shoulder problems during Medical Board Examination, establishing baseline normal shoulder function
1995-2013 - Progressive development of shoulder pathology through cumulative occupational activities including pack marches, battle PT, vehicle work, heavy lifting
16 August 2015 - First consulted Dr. Thomas Perkins who completed DVA Diagnosis Form for Left Upper Limb - Pain
16 January 2016 - MRI confirmed extensive shoulder pathology including moderate to severe osteoarthritic changes, anteroinferior degenerative labral tear, tendinopathic changes, and post-traumatic osteolysis

Symptoms

During service, the veteran would have experienced gradual onset of shoulder symptoms related to his physically demanding duties. Current symptoms include shoulder pain and functional limitation affecting his daily activities and quality of life, as evidenced by his presentation for medical assessment and DVA compensation claim.

Imaging

16 January 2016 - MRI Left Shoulder: Moderate to severe osteoarthritic changes within the left glenohumeral joint with marginal osteophytes and joint space retraction. Anteroinferior degenerative labral tear from 4 o'clock to 8 o'clock position extending into posterior inferior labrum. Tendinopathic changes within the supra and infraspinatus as well as subscapularis. Minor subacromial subdeltoid bursitis. Hypertrophic OA changes of the ACJ with post-traumatic osteolysis at lateral end of clavicle and minor ACJ capsulitis. Intact rotator cuff tendons.

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

Left Shoulder Osteoarthritis (Glenohumeral Joint) - DVA SOP No. 62 of 2017 (BOP), ICD-10 M19.0. This is a degenerative joint disorder characterised by loss of articular cartilage, osteophyte formation, and joint space narrowing affecting the glenohumeral joint.

Left Shoulder Labral Tear - DVA SOP No. 37 of 2017 (BOP), ICD-10 S43.4. This involves tearing of the fibrocartilaginous rim of the shoulder joint resulting in local pain and altered shoulder mechanics.

Left Shoulder Rotator Cuff Syndrome - DVA SOP No. 110 of 2022 (BOP), ICD-10 M75.1. This represents a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff involving tendinopathy and bursitis.

Left Shoulder Strain - DVA SOP No. 28 of 2020 (BOP), ICD-10 S46.0. This represents the initial injury involving tearing or stretching of shoulder muscles or tendons.

Left Shoulder AC Joint Osteoarthritis - DVA SOP No. 62 of 2017 (BOP), ICD-10 M19.0. This is a degenerative joint disorder affecting the acromioclavicular joint with hypertrophic changes and post-traumatic osteolysis.

Left Shoulder AC Joint Strain - DVA SOP No. 28 of 2020 (BOP), ICD-10 S43.1. This represents the initial traumatic injury to the AC joint ligaments, evidenced by post-traumatic osteolysis on imaging.

The temporal relationship shows initial strain/injury to both glenohumeral and AC joints during service that progressed to chronic degenerative changes including osteoarthritis, labral tear, and rotator cuff syndrome over time.

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

When did the veteran first experience symptoms attributable to this condition? The exact onset is unknown, but symptoms developed gradually during military service and became significant enough to prompt medical attention by September 2018.

When did the veteran first present to a health / medical provider for this condition? 16 August 2015 to Dr. Thomas Perkins (General Practitioner) [CHART REVIEW .docx].

When was the condition confirmed / formally diagnosed? 16 January 2016 via MRI imaging performed at I-MED Radiology Forest Lake, reported by the treating doctor [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf].

When did the veteran first present to you (or your practice) for this condition? 15 Jun 2015

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 diagnoses were confirmed through MRI imaging on 16 January 2016 demonstrating moderate to severe osteoarthritic changes in the glenohumeral joint, anteroinferior degenerative labral tear, tendinopathic changes in multiple rotator cuff tendons with associated bursitis, and post-traumatic osteolysis at the AC joint. Dr. Thomas Perkins conducted clinical assessment correlating imaging findings with symptoms of shoulder pain and functional limitation [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, CHART REVIEW .docx].

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.

GLENOHUMERAL OSTEOARTHRITIS FACTORS:

Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET

The veteran role involved significant trauma risk from military activities including vehicle operations, physical training, and manual handling, with MRI evidence of post-traumatic osteolysis confirming previous shoulder trauma.

For osteoarthritis of a joint of the upper limb only, performing forceful or repetitive activities involving the affected joint 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, within the 25 years before the clinical onset - MET

His duties as M113 Crewman involved extensive forceful and repetitive shoulder activities including vehicle maintenance, heavy lifting, weapons handling, and pack marches exceeding the required thresholds during his service period.

AC JOINT OSTEOARTHRITIS FACTORS:

Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET

MRI demonstrates post-traumatic osteolysis at the lateral end of the clavicle, providing direct evidence of previous AC joint trauma during military service.

Military duties involved extensive overhead activities and heavy lifting that placed significant stress on the AC joint, exceeding required thresholds during service.

LABRAL TEAR FACTORS:

Having a significant physical force applied to or through the affected shoulder joint at the time of the clinical onset of labral tear - MET

Military duties involved significant physical forces through shoulder activities including vehicle work, heavy lifting, and battle physical training.

Performing forceful and repetitive motions of the affected shoulder joint, involving extremes of the normal range of motion, for at least four hours per week for the one month before the clinical onset - MET

Military training and operational duties involved forceful repetitive shoulder motions including overhead activities, pack marches, and weapons training exceeding required thresholds.

ROTATOR CUFF SYNDROME FACTORS:

Performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or forceful activities with the affected upper limb for at least 160 hours within a period of 210 consecutive days before the clinical onset - MET

Military duties involved extensive overhead activities, forceful upper limb use, and sustained shoulder activities during training and operations exceeding required thresholds.

Having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome - MET

Military service involved injury risk to shoulders from training activities, vehicle operations, and physical demands.

SHOULDER STRAIN FACTORS:

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 duties involved forceful stretching and high intensity use of shoulder muscles during training, manual handling, and operational activities.

AC JOINT STRAIN FACTORS:

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET

The post-traumatic osteolysis evidenced on MRI confirms significant physical force was applied to the AC joint during military service, consistent with sprain/strain injury.

INABILITY TO OBTAIN APPROPRIATE CLINICAL MANAGEMENT:

All conditions - MET

There were no presentations for shoulder pain during service despite the physically demanding nature of his role and development of degenerative changes, indicating barriers to healthcare access. The lengthy period between service and formal diagnosis demonstrates inability to obtain appropriate clinical management. As established in Brew v Repatriation Commission, this constitutes a permanent worsening of the conditions.

Sequelae

The glenohumeral osteoarthritis, AC joint osteoarthritis, labral tear, and rotator cuff syndrome represent sequelae of the initial shoulder and AC joint strain/injury sustained during military service, with progressive degenerative changes occurring over time.

Unintended Consequence

No unintended consequence of medical management identified. The conditions were not caused by medical treatment but rather by occupational activities during military service.

Inability to Attain Appropriate Medical Management

MET - There were no documented presentations for shoulder pain during the veteran military service despite the physically demanding nature of his duties and the development of significant degenerative changes. This absence of healthcare seeking for a condition that would have been symptomatic during service indicates barriers to healthcare access, satisfying the inability to attain appropriate medical management factor. The lengthy period between service exposure and formal diagnosis in 2022 demonstrates inability to obtain timely appropriate clinical management. As established in Brew v Repatriation Commission (10 July 1990), this inability encompasses both objective and subjective barriers to seeking treatment. This caused permanent worsening of the conditions by allowing progressive degenerative changes to occur without intervention.

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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