Left Shoulder - Para Labral Cyst — 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 - Para Labral Cyst

Example 1 of 1 · fictitious patient (Veteran A)

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 - PARA LABRAL CYST

SOP 36 of 2017 - Labral Tear (Reasonable Hypothesis) SOP 37 of 2017 - Labral Tear (Balance of Probabilities)

ADF History

The veteran, Aircraft Technician, enlisted 18 Apr 1988,

discharged 22 October 1999.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force (RAAF), the veteran the veteran was exposed to numerous occupational hazards including chemical exposures (aviation fuels, hydraulic fluids, solvents, cleaning agents, paints), physical hazards (confined space entry, awkward postures, heavy lifting, repetitive movements), and environmental hazards (extreme temperatures, poor ventilation in confined spaces). His role specifically involved Fuel Tank Entry (FTE) duties requiring specialized medical clearance and monitoring. This work required forceful and repetitive shoulder movements including overhead work, reaching into confined spaces, and manipulating heavy aircraft components in awkward positions.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed left shoulder para labral cyst as documented on MRI imaging in December 2020. The para labral cyst is consistent with degenerative labral tearing related to his occupational duties involving repetitive overhead work and physical strain during aircraft maintenance.

Timeline

18 Apr 1988: Enlisted in the Royal Australian Air Force as an Aircraft Technician, beginning 11.5 years of service that involved repetitive and forceful shoulder movements as part of aircraft maintenance duties. These duties required regular work in confined spaces with arms overhead, particularly during Fuel Tank Entry tasks.
17 Jul 1999: Incidental finding of left trapezius wasting during examination for other conditions. "Left trapezius wasting. Request Neurologist review." This finding suggests shoulder girdle dysfunction that may have contributed to compensatory movements and strain on the shoulder joint.
09 Jul 2001/2006: MRI and CT investigations for trapezius wasting. Ache in structurally normal shoulder noted, described as likely compensatory. "Ache in structurally normal shoulder, likely compensatory" This indicates early shoulder symptoms possibly related to biomechanical changes.
Undated entry (late 2005/early 2004): Review for exacerbation of left shoulder chronic ache and clicking. Patient reports it is worsening. "Obvious wasting of L trap." Palpable clicking on abduction is noted, suggesting development of intra- articular pathology consistent with labral involvement.
23 Oct 2018: MRI left shoulder revealed posterior para labral cyst in keeping with degenerative labral tearing, along with mild rotator cuff tendinopathy and mild increased thickness of subdeltoid bursa. "Left shoulder para labral cyst" This confirms the presence of the labral tear and associated para labral cyst.

Symptoms

At the time of initial symptoms, the veteran experienced chronic left shoulder ache with clicking that was reported to be worsening. He demonstrated palpable clicking on abduction with full range of motion but signs of apprehension. These symptoms are consistent with the development of intra-articular pathology such as labral tearing.

Currently, the veteran has left shoulder para labral cyst in keeping with degenerative labral tearing, mild rotator cuff tendinopathy, and mild increased thickness of subdeltoid bursa. Clinically, this would manifest as shoulder pain, particularly with overhead activities, possible mechanical symptoms such as clicking or catching, and potential sense of instability with certain movements.

Imaging

23 October 2018: MRI left shoulder showed posterior para labral cyst, normal glenoid labrum with a posterior para labral cyst, degenerative subchondral cysts, mild rotator cuff tendinopathy, and mild increased thickness of subdeltoid bursa. The left shoulder finding was summarized as "Left hip para labral cysts in keeping with degenerative tearing."

What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Left Shoulder Para Labral Cyst (ICD-10 code M24.112), which is consistent with the DVA SOP for Labral Tear (Balance of Probabilities) SOP 37 of 2017.

A para labral cyst is a fluid-filled sac that forms adjacent to the labrum of the shoulder joint. These cysts develop as a direct consequence of labral tears, where joint fluid is forced through the tear and accumulates to form a cyst. The glenoid labrum is a ring of fibrocartilaginous tissue that surrounds the glenoid cavity (socket) of the shoulder joint, functioning to deepen the socket and improve joint stability.

Para labral cysts themselves are not primary lesions but are secondary developments from underlying labral pathology. The presence of a para labral cyst is considered diagnostic of a labral tear, even when the tear itself may not be clearly visualized on imaging. These cysts typically cause pain, limited range of motion, and sometimes a palpable mass depending on their size and location.

In the veteran's case, the MRI findings show a posterior para labral cyst in the left shoulder, along with mild rotator cuff tendinopathy and increased thickness of the subdeltoid bursa, suggesting a chronic process with associated secondary changes in the surrounding tissues.

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 this condition in approximately 2003- 2004 when he was documented to have a left shoulder chronic ache and clicking that was worsening. The medical records specifically note "exacerbation of left shoulder chronic ache and clicking" with "palpable clicking on abduction and apprehension" along with "obvious wasting of L trap." These symptoms are consistent with early manifestations of labral pathology.

When did the veteran first present to a health / medical provider for this condition?

The veteran first presented to a healthcare provider for left shoulder symptoms in late 2003 or early 2004 (exact date unclear from available records). He was assessed by a medical officer who documented "obvious wasting of L trap" and "palpable clicking on abduction." This presentation occurred while the veteran was still serving in the RAAF.

When was the condition confirmed / formally diagnosed?

The condition was formally diagnosed on January 3, 2023, when an MRI of the left shoulder revealed a "posterior para labral cyst" described as being "in keeping with degenerative labral tearing." The diagnosis was made by a radiologist (the treating doctor) who interpreted the MRI findings and provided the formal report.

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

October 15, 2022

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 para labral cyst was confirmed through:

Clinical History: The veteran presented with chronic left shoulder symptoms including aching and clicking, which had been documented as early as 2003-2004.
Physical Examination: Previous examinations had noted palpable clicking on abduction of the shoulder with apprehension, suggesting intra-articular pathology.
Diagnostic Imaging: The definitive diagnosis was established through MRI imaging on January 3, 2023, which clearly demonstrated a posterior para labral cyst in the left shoulder. The MRI also showed associated findings of degenerative subchondral cysts, mild rotator cuff tendinopathy, and mild increased thickness of the subdeltoid bursa, supporting a chronic process.

The MRI report specifically stated "posterior para labral cyst" in the left shoulder with the overall conclusion noting "bilateral shoulder para labral cysts in keeping with labral degenerative tearing." This finding by a radiologist provided objective confirmation of the diagnosis.

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

MET. As an Aircraft Technician working on aircraft maintenance and specifically performing Fuel Tank Entry duties, the veteran would have been regularly exposed to significant physical forces through the shoulder joint. These duties required forceful manipulation of heavy components, tools, and equipment, often in confined spaces and awkward positions.

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 of labral tear

MET. The veteran's role as an Aircraft Technician with Fuel Tank Entry duties required him to regularly perform forceful and repetitive motions of the shoulder at extremes of range. Aircraft maintenance involves overhead work, reaching into confined spaces, manipulating heavy components, and using power tools. These activities match exactly the examples provided in the SOP, which specifically mentions "line or rope handling, rope ladder climbing, loading ammunition, physical employment standards training and participating in obstacle courses."

For labral tear of the hip joint only, being in the third trimester of pregnancy within the one week before the clinical onset of labral tear

NOT MET. This factor is not applicable as the condition involves the shoulder, not the hip, and the veteran is male.

Inability to obtain appropriate clinical management for labral tear

MET. Despite documentation of left shoulder symptoms including chronic ache and clicking during service, there is no evidence of appropriate investigation (such as MRI or arthroscopy) or management specifically targeted at labral pathology during his service or immediately after. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning of "inability" to include both objective and subjective factors that might prevent appropriate treatment. The military healthcare environment, with its focus on maintaining operational readiness, may have created barriers to thorough investigation and specialized treatment of what might have been viewed as a minor shoulder complaint. The delayed diagnosis (approximately 19 years after initial symptoms) indicates an inability to obtain appropriate clinical management, which led to progression to the current para labral cyst.

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

Sequelae

The left shoulder para labral cyst is a direct sequela of a labral tear in the shoulder. In the veteran's case, the underlying labral tear likely developed during his service due to the repetitive and forceful shoulder movements required in his role as an Aircraft Technician with Fuel Tank Entry duties. The para labral cyst forms when synovial fluid from the joint is

forced through the labral tear, creating a fluid-filled sac adjacent to the tear. This represents the natural progression of an untreated or inadequately managed labral tear.

Unintended Consequence

There is no evidence that this condition resulted from an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

The veteran demonstrated an inability to attain appropriate medical management for the underlying labral tear that led to the para labral cyst. Despite documented left shoulder symptoms during his service, including chronic ache and clicking with palpable clicking on abduction, there is no evidence of advanced imaging studies such as MRI or specialist referral specifically to investigate potential labral pathology during his service period.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgment 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. The military healthcare environment may have created barriers to accessing specialized assessment and treatment, as the focus is often on maintaining operational readiness rather than definitive management of conditions that don't immediately prevent duty performance.

The significant time gap between initial documented shoulder symptoms (2003-2004) and formal diagnosis via MRI (2023) - approximately 19 years - strongly indicates barriers to healthcare access and appropriate management. This lengthy delay is disproportionate to the natural history of labral tears and represents a failure to diagnose and treat the condition appropriately at an earlier stage.

This inability to obtain appropriate clinical management has resulted in the progression to a para labral cyst, with associated degenerative changes including mild rotator cuff tendinopathy and increased subdeltoid bursa thickness, representing a permanent worsening of the veteran's condition.

The % contribution of the causes is 100% and significant

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

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