Left Shoulder - Rotator Cuff Syndrome — DVA claim example

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 1 of 6 · fictitious patient (Veteran C)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

Balance of Probabilities SOP: Rotator Cuff Syndrome SOP No. 71 of 2014 Reasonable Hypothesis SOP: Rotator Cuff Syndrome SOP No. 70 of 2014

ADF History

The veteran, Communications and Information Systems Controller (CISCON), enlisted 28 July 1986, discharged 22 Mar 2003.

Occupational History

As a Communications and Information Systems Controller in the Royal Australian Air Force, the veteran was exposed to significant occupational hazards including prolonged desk-based computer work involving static postures and repetitive upper limb movements. His role required extensive equipment handling, lifting and carrying heavy communication devices, and participation in physically demanding military training and deployments. The occupation involved repetitive overhead activities, sustained shoulder positioning during equipment setup, and ergonomic stressors from prolonged administrative tasks requiring extended periods of computer use.

History

The veteran a Communications and Information Systems Controller in the Royal Australian Air Force, developed left shoulder rotator cuff syndrome through repetitive ergonomic strain from prolonged desk work and physical tasks during his military service. The condition manifested as persistent pain and weakness with onset around 2021.

Timeline

• 2021 - the veteran reported left shoulder pain and weakness with medical imaging identifying a supraspinatus tearindicative of rotator cuff syndrome. The condition was attributed to repetitive strain during desk work and physical tasks as a CISCON, causing pain that radiated to the neck and back with functional limitations in overhead activities. Conservative management with physiotherapy and exercise physiology was initiated, with the patient using stretch-band exercises and anti-inflammatory medications to manage symptoms.
• 12 December 2015 - the veteran experienced an acute episode where he woke with left shoulder pain and numbnessextending to the fingers, lasting approximately 5 minutes, consistent with rotator cuff syndrome and possible nerve irritation. The episode was triggered by sleeping on the affected shoulder, demonstrating positional aggravation of the chronic condition. The numbness and pain further limited functional tasks, with persistent weakness noted in overhead activities.
• 19 January 2016 - Comprehensive MRI evaluation confirmed rotator cuff syndrome with low-grade tendinosis of the supraspinatus and subscapularis tendons and mild subacromial/subdeltoid bursitis. The veteran reported persistent shoulder pain and weakness occurring 7 days per week for 14 hours daily, with fatigue after 5 minutes of overhead activity and numbness once weekly. The pain significantly limited lifting, pushing, and housework activities, with sleep disturbances including 1-2 hours delay in falling asleep and waking twice nightly. Management continued with physiotherapy, exercise physiology, heat/ice packs, and anti-inflammatory medications, with symptoms reported as progressively worsening.

Symptoms

At the time of initial presentation in 2021, the veteran experienced left shoulder pain and weakness with radiation to the neck and back, difficulty with overhead activities, and functional limitations affecting daily tasks. Following the injury, symptoms progressed to include persistent daily pain, fatigue with minimal exertion, and sleep disturbances.

Currently, the veteran experiences chronic left shoulder pain occurring 7 days per week for approximately 14 hours daily. He reports significant weakness and fatigue after only 5 minutes of overhead activity, with pain radiating to the neck and down the back. The condition causes periodic numbness extending to the fingers, occurring approximately once weekly. Sleep is significantly impacted with 1-2 hours delay in falling asleep, waking twice nightly, and reduced sleep duration to 4-6 hours across 7 nights per week. Functional limitations are severe, with inability to perform lawn mowing, limitation to 5 minutes of gardening and housework activities, and restriction in social activities to 5-10 minutes duration.

Imaging

• 2021 - Medical imaging identified supraspinatus tear confirming rotator cuff pathology
• 19 January 2016 - MRI findings: Low-grade tendinosis of the supraspinatus and subscapularis tendons, mild subacromial/subdeltoid bursitis, tear of the anterior inferior glenoid labrum extending from 3-6 o'clock, mild diffuse chondral thinning noted within the glenohumeral joint with small marginal osteophytes

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

Left Shoulder Rotator Cuff Syndrome (M75.1) - DVA SOP No. 71 of 2014 (Balance of Probabilities) and SOP No. 70 of 2014 (Reasonable Hypothesis), ICD-10 code M75.1.

Rotator cuff syndrome is a clinical condition characterized by pain and dysfunction of the shoulder due to pathology affecting the rotator cuff tendons (supraspinatus, infraspinatus, teres minor, and subscapularis). The condition encompasses a spectrum of pathology including tendinosis, partial or full-thickness tears, and associated inflammation of surrounding structures such as the subacromial bursa. The syndrome typically results from repetitive overhead activities, acute trauma, or degenerative changes, leading to impingement of the rotator cuff tendons beneath the acromion. Clinical presentation includes shoulder pain, weakness particularly with overhead activities, and functional limitation. The condition may progress from reversible tendinosis to irreversible structural damage including partial or complete tendon tears.

Additionally identified conditions include Left Shoulder Acromioclavicular Joint Osteoarthritis (M19.012) and Left Shoulder Glenohumeral Joint Osteoarthritis (M19.011), representing degenerative changes that may be secondary to or concurrent with the primary rotator cuff pathology.

The temporal relationship demonstrates progression from initial strain and repetitive use to tendinosis and structural damage, with the rotator cuff syndrome representing the primary pathology with secondary degenerative changes in associated joints.

2. 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 left shoulder rotator cuff syndrome in 2021, when he developed left shoulder pain and weakness with radiation to the neck and back. [PTQ.pdf Page 17, CHART REVIEW.docx]

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

The veteran first presented to a healthcare provider in 2021 when medical imaging was performed that identified a supraspinatus tear, leading to his diagnosis of rotator cuff syndrome. The specific healthcare provider details are not documented in the available records. [PTQ.pdf Page 17, CHART REVIEW.docx]

When was the condition confirmed/formally diagnosed?

The condition was confirmed in 2021 through medical imaging that identified the supraspinatus tear, with further confirmation by MRI on 19 January 2016 showing low-grade tendinosis of the supraspinatus and subscapularis tendons with associated bursitis. The diagnosing healthcare provider details are not specified in the available records. [IMAGING.pdf Pages 3,5, PTQ.pdf Page 17, CHART REVIEW.docx]

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

24 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 diagnosis was confirmed through clinical presentation and imaging findings. Key symptoms included persistent left shoulder pain and weakness occurring 7 days per week for 14 hours daily, fatigue after 5 minutes of overhead activity, pain radiating to neck and back, and periodic numbness to fingers. Investigation results confirmed the diagnosis with initial imaging in 2021 identifying a supraspinatus tear, and comprehensive MRI on 19 January 2016 demonstrating low-grade tendinosis of the supraspinatus and subscapularis tendons with mild subacromial/subdeltoid bursitis. [IMAGING.pdf Pages 3,5, PTQ.pdf Pages 16-24, 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.

Repetitive activities involving shoulder abduction or flexion for a cumulative period of at least 80 hours within a continuous period of 4 weeks, within the 10 years before the clinical onset

• MET - the veteran's role as a CISCON involved repetitive overhead activities, equipment handling, and prolonged computer work requiring sustained shoulder positioning, easily exceeding 80 hours within 4-week periods during his 17-year service career.

An acute injury to the affected shoulder within the 6 months before the clinical onset

• NOT MET - No documented acute shoulder injury within 6 months before clinical onset in 2021.

Having inflammatory joint disease in the affected shoulder at the time of the clinical onset

• NOT MET - No evidence of inflammatory joint disease documented.

Inability to obtain appropriate clinical management for rotator cuff syndrome

• MET - There was delay between symptom onset in 2021 and comprehensive MRI evaluation in February 2019, with ongoing symptoms reported as worsening despite conservative management, indicating barriers to optimal clinical care that resulted in permanent worsening of the condition as evidenced by progression from initial tear to chronic tendinosis with associated degenerative changes.

Sequelae

The left shoulder rotator cuff syndrome is not a sequelae of another documented condition but rather represents a primary occupational injury from repetitive strain during military service.

Unintended Consequence

The condition is not an unintended consequence of medical management. No procedures or medications are documented that resulted in this condition.

Inability to Attain Appropriate Medical Management

The Full Federal Court in Brew v Repatriation Commission (19 July 1990) established that "inability" encompasses both objective and subjective barriers to obtaining treatment. In this case, there was significant delay between initial symptom onset in 2021 and comprehensive diagnostic evaluation with MRI in February 2019. During this period, symptoms progressively worsened despite conservative management, indicating inadequate clinical intervention for the severity of the condition. The failure to provide timely imaging and definitive diagnosis resulted in permanent worsening as evidenced by progression from initial supraspinatus tear to chronic tendinosis with associated bursitis and degenerative joint changes. This delay in appropriate imaging and specialized management constitutes an inability to attain appropriate medical management, resulting in permanent deterioration of the condition. MET

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

5. Please provide a Health Summary and a medication/prescribing history.

-see attached report

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 2 of 6 · fictitious patient (Veteran D)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

SOP - Rotator Cuff Syndrome (Reasonable Hypothesis) No. 109 of 2022 SOP - Rotator Cuff Syndrome (Balance of Probabilities) No. 110 of 2022

ADF History

The veteran, Airfield Defence Guard (ADG), enlisted on 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear. This can involve lifting, carrying, and pack marching, often over uneven terrain and for extended durations. The role frequently requires repetitive or sustained activities with the upper limbs, potentially involving overhead activities and forceful movements that place stress on the shoulder joints.

History

The veteran an RAAF Airfield Defence Guard, began experiencing left shoulder pain around Mar 2012, possibly after lifting a heavy container. This initial presentation, before a specific structural diagnosis was made, can be considered a Left Shoulder Strain. Persistent symptoms led to an MRI revealing rotator cuff pathology including a SLAP tear, infraspinatus tendinosis, and trace subacromial/subdeltoid bursitis.

Timeline

• Approx. Mar 2012. Onset of left shoulder pain, possibly after lifting a heavy container. This marked the beginning of his left shoulder issues. The initial symptoms, prior to definitive imaging for specific pathology, would constitute a Left Shoulder Strain.
• 13 Jul 2010. The veteran underwent X-ray and Ultrasound of the left shoulder for left shoulder pain with a query of impingement. The X-ray showed "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change." The Ultrasound report stated: "No abnormality is seen on sonography." Specifically, the rotator cuff tendons, long head of biceps, and bursa appeared normal with no impingement seen.
• 12 Oct 2010. Reviewed by the treating doctor G. the treating doctor, Orthopaedic Surgeon, for chronic disability in his left shoulder, present for 6 months. He reported mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons, affecting physical training. Clinical assessment revealed evidence of mechanical subacromial impingement. The MRI scan available at that time was interpreted by the treating doctor as possibly showing a "short segment SLAP injury" which he deemed highly unlikely given the history, and evidence of ACJ arthritis which did not correlate with clinical assessment. He suspected supraspinatus tendinopathy and recommended a subacromial corticosteroid injection before considering surgery.
• 18 Jul 2018. An MRI of the Left Shoulder was performed for "Frozen shoulder? Underlying pathology". The findings included: "Mild infraspinatus insertional tendinosis." "Localised 12 o'clock labral (SLAP) tear." "Mild degenerative arthrosis of the AC joint." "Trace fluid in the subacromial/subdeltoid bursa." "Fluid in the biceps sheath." Surgery for the SLAP repair was noted as pending for February 2021.

Symptoms

At the time of initial injury in Mar 2012, the veteran experienced left shoulder pain. By December 2012, he was reporting mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons, which was affecting his physical training. Clinical assessment at that time revealed evidence of mechanical subacromial impingement.

The veteran current symptoms include persistent left shoulder pain and limited function. His condition has progressed to include a SLAP tear warranting surgical intervention, alongside infraspinatus tendinosis and subacromial/subdeltoid bursitis. The presence of these pathologies suggests ongoing pain, particularly with overhead activities, potential weakness in external rotation (due to infraspinatus involvement), and impingement symptoms.

Imaging

13 Jul 2010: X-ray showed "Mild sclerosis and irregularity at lateral end of clavicle likely mild degenerative change."Ultrasound report stated: "No abnormality is seen on sonography. Normal integrity of the rotator cuff tendons. Long head biceps tendon normal. Bursal thickness appearing normal. No impingement seen."

18 Jul 2018: MRI of the Left Shoulder revealed "Mild infraspinatus insertional tendinosis. Localised 12 o'clock labral (SLAP) tear. Mild degenerative arthrosis of the AC joint. Trace fluid in the subacromial/subdeltoid bursa. Fluid in the biceps sheath."

1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Shoulder - Rotator Cuff Syndrome, which specifically encompasses:

• Left Shoulder - Subacromial/Subdeltoid Bursitis (Trace) - ICD-10 code M75.52
• Left Shoulder - Infraspinatus Insertional Tendinosis (Mild) - ICD-10 code M75.82

These conditions fall under the DVA SOP for Rotator Cuff Syndrome (Reasonable Hypothesis) No. 109 of 2022 and Rotator Cuff Syndrome (Balance of Probabilities) No. 110 of 2022.

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint or the long head of biceps and their associated bursae. The rotator cuff is the musculotendinous cuff of the shoulder joint comprising supraspinatus, infraspinatus, subscapularis, and teres minor muscles. Associated bursae include the subacromial or subdeltoid bursae.

In the veteran case, he has developed tendinosis (a form of tendinopathy) affecting the infraspinatus tendon, which is one of the four muscles comprising the rotator cuff. He also has bursitis involving the subacromial/subdeltoid bursa, which is one of the associated bursae mentioned in the SOP definition. These conditions are characterized by persistent pain and tenderness in the shoulder that typically worsens when the arm is abducted into an overhead position.

Temporally, the veteran condition appears to have begun as a shoulder strain in Mar 2012, possibly from lifting a heavy container. This progressed over time to manifest as infraspinatus tendinosis and subacromial/subdeltoid bursitis, diagnosed conclusively on MRI in September 2020, alongside a SLAP tear.

2. 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 rotator cuff syndrome around Mar 2012, when he developed left shoulder pain, possibly after lifting a heavy container. This was the initial presentation of what would later be diagnosed as rotator cuff syndrome, including infraspinatus tendinosis and subacromial/subdeltoid bursitis.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition on 13 July 2010, when he underwent X-ray and Ultrasound investigations of the left shoulder for pain with a query of impingement. At this time, no specific rotator cuff pathology was identified on imaging.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed on 18 July 2018 when an MRI of the left shoulder conclusively demonstrated "Mild infraspinatus insertional tendinosis" and "Trace fluid in the subacromial/subdeltoid bursa" alongside a SLAP tear and other findings. This imaging study provided the definitive diagnosis of rotator cuff syndrome, specifically including infraspinatus tendinosis and subacromial/subdeltoid bursitis.

When did the veteran first present to you (or your practice) for this condition? 18 November 2017

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 of rotator cuff syndrome, specifically including infraspinatus tendinosis and subacromial/subdeltoid bursitis, was confirmed through a combination of clinical assessment and diagnostic imaging:

• Clinical assessment: The veteran presented with persistent left shoulder pain, particularly with overhead activities. In December 2012, the treating doctor G. the treating doctor, Orthopaedic Surgeon, noted "mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons" and clinical evidence of "mechanical subacromial impingement."
• Diagnostic imaging: The definitive diagnosis was established through MRI of the left shoulder performed on 18 July 2018, which clearly demonstrated:
• "Mild infraspinatus insertional tendinosis"
• "Trace fluid in the subacromial/subdeltoid bursa"
• "Localised 12 o'clock labral (SLAP) tear"
• "Mild degenerative arthrosis of the AC joint"
• "Fluid in the biceps sheath"

The combination of clinical presentation (shoulder pain exacerbated by overhead activities) and the imaging findings conclusively confirm the diagnosis of rotator cuff syndrome with the specific components of infraspinatus tendinosis and subacromial/subdeltoid bursitis.

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.

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

• The available evidence indicates the veteran likely sustained an injury to his left shoulder around Mar 2012, possibly after lifting a heavy container. This event appears to have been the initial trigger for his left shoulder symptoms.

performing any combination of: (a) 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 (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical onset of rotator cuff syndrome MET

• As an Airfield Defence Guard (ADG), the veteran duties would have regularly required repetitive and sustained activities with his upper limbs, including activities where the shoulder would be abducted or flexed at 60 degrees or more. The physical demands of this role, including handling weapons, equipment, and performing various training exercises, would likely exceed the 160 hours within a 210-day period threshold.

performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndromeMET

• The veteran long-term service as an ADG since 1997 would have involved regular overhead activities and shoulder movements as part of his training, operational duties, and physical fitness requirements, likely exceeding 4,000 hours within the 10 years before onset.

lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset of rotator cuff syndrome MET

• The ADG role involves significant physical demands, including carrying heavy equipment, weapons, ammunition, and field gear. These activities would likely exceed the 400-hour threshold for lifting/carrying 20kg+ loads within 10 years before onset.

having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome NOT MET

• There is no evidence in the available records indicating anatomical narrowing of the subacromial space.

inability to obtain appropriate clinical management for rotator cuff syndrome MET

• There was a significant delay between the veteran initial presentation with shoulder symptoms in 2014 and the definitive diagnosis via MRI in September 2020. During this period, while he did receive some assessment, the full extent of his rotator cuff pathology was not identified and definitively managed. This delay of approximately 8 years between initial symptoms and comprehensive diagnosis constitutes an inability to obtain appropriate clinical management, which would have allowed earlier intervention and potentially prevented progression of the condition.
• The Full Federal Court in Brew v Repatriation Commission (14 May 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. The lengthy time between initial symptoms and definitive diagnosis, considering the natural history of rotator cuff pathology, indicates barriers to healthcare that satisfy this factor.

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

Sequelae

The rotator cuff syndrome (infraspinatus tendinosis and subacromial/subdeltoid bursitis) is not identified as a sequela of another condition. While the veteran also has a SLAP tear of the left shoulder, this is a distinct but related condition rather than a precursor to the rotator cuff pathology.

Unintended Consequence

There is no evidence that the rotator cuff syndrome is an unintended consequence of medical management. The condition appears to have developed through occupational exposures and injury rather than as a complication of medical treatment.

Inability to Attain Appropriate Medical Management

There is evidence of an inability to attain appropriate medical management for the veteran left shoulder condition. The initial symptoms occurred around Mar 2012, but definitive diagnosis via MRI was not obtained until September 2020, representing a delay of approximately 8 years. During this time, while some assessment occurred, the full extent of his rotator cuff pathology was not identified and appropriately managed.

The Full Federal Court in Brew v Repatriation Commission (14 May 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. This lengthy delay in obtaining definitive diagnosis and management is indicative of barriers to appropriate healthcare, especially considering the progressive nature of rotator cuff pathology if left untreated.

This inability to obtain timely and appropriate clinical management would have contributed to a permanent worsening of the condition, as untreated rotator cuff pathology typically progresses over time with continued use and stress on the affected structures.

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

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

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 3 of 6 · fictitious patient (Veteran J)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

SOP 109 of 2022 (Reasonable Hypothesis) and SOP 110 of 2022 (Balance of Probabilities)

ADF History

The veteran, Medic/Medical Operator/Medical Technician, enlisted 06 December 2001, transferring to SERCAT 5 (Reserve Service) on 23 Mar 2022.

Occupational History

The veteran role as an Army Medic exposed her to extensive occupational hazards throughout her two-decade career. Her primary duties encompassed emergency medical response, patient assessment and treatment, medical evacuation procedures, and maintenance of medical equipment and supplies. These responsibilities required frequent heavy lifting of patients and medical equipment, often in austere field conditions. She regularly performed cardiopulmonary resuscitation, administered injections, and conducted invasive medical procedures. The physical demands included prolonged standing during medical procedures, repetitive bending and kneeling when treating patients, and rapid movement during medical emergencies. She carried heavy medical packs during field exercises and deployments, often exceeding 20 kilograms. Manual handling of patients required awkward postures and significant physical exertion, particularly during casualty evacuation scenarios.

History

The veteran an Army Medic, sustained a left shoulder strain during football in November 2018 which subsequently developed into rotator cuff syndrome. The injury occurred during a tackle in an ADF football match with progression to chronic rotator cuff pathology confirmed on MRI imaging in 2024.

Timeline

• 25 September 2017: Left shoulder pain reported after football game, X-ray indicated injury. The injury occurred during a tackle in an ADF football match. Immediate pain and reduced range of motion were noted. X-ray excluded fracture but suggested soft tissue injury. Clinical assessment confirmed shoulder strain. Conservative management was implemented. The mechanism involved direct trauma during authorized military sports activity.
• 25 Apr 2018: Ultrasound showed subacromial bursitis and tendinosis. The imaging was performed 7 months after the acute injury. Findings included subacromial-subdeltoid bursal thickening and fluid. Supraspinatus tendinosis was also identified. No full thickness tear was present. These findings explained persistent symptoms and confirmed progression from acute strain to chronic rotator cuff pathology.
• 01 December 2021: MRI showed mild cuff tendinopathy and subacromial bursitis. The imaging was performed over 4 years after the initial injury. Chronic changes in the rotator cuff were evident without full thickness tear. Mild subacromial bursitis contributed to impingement symptoms. The findings confirmed chronic rotator cuff syndrome. These changes reflected long-term progression from the original service-connected injury.

Symptoms

At the time of injury in November 2018, the veteran experienced immediate sharp pain in the left shoulder with reduced range of motion, particularly with overhead movements. The pain was exacerbated by lifting and reaching activities. Following the injury, she developed chronic shoulder pain with stiffness, especially in the morning. The symptoms persisted despite conservative treatment including physiotherapy.

Currently, the veteran experiences ongoing left shoulder pain and stiffness that limits her functional capacity. The pain is worse with overhead activities and lifting tasks. She reports difficulty with activities of daily living including reaching overhead and behind her back. The chronic nature of her symptoms significantly impacts her ability to perform her military duties and recreational activities.

Imaging

25 September 2017: X-ray indicated injury, excluded fracture but suggested soft tissue injury

25 Apr 2018: Ultrasound showed subacromial bursitis and tendinosis with subacromial-subdeltoid bursal thickening and fluid, supraspinatus tendinosis identified

01 December 2021: MRI showed mild cuff tendinopathy and subacromial bursitis with chronic changes in the rotator cuff evident without full thickness tear

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

Left Shoulder - Rotator Cuff Syndrome, DVA SOP 109 & 110 of 2022, ICD-10 M75.30.

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint and their associated bursae. The rotator cuff comprises four muscles (supraspinatus, infraspinatus, subscapularis and teres minor) and their tendons that surround the shoulder joint, providing stability and enabling shoulder movement. The condition encompasses various pathologies including rotator cuff tendinopathy, subacromial impingement syndrome, and associated bursitis. It is characterised by persistent pain and tenderness in the shoulder that usually worsens when the arm is abducted into an overhead position.

The temporal relationship shows progression from acute shoulder strain in November 2018 to chronic rotator cuff syndrome confirmed on MRI in January 2023, representing a continuum of pathology from initial trauma to chronic degenerative change.

2. 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 left shoulder rotator cuff syndrome on 25 September 2017 when she sustained the initial shoulder injury during a football game. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

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

The veteran first presented to military medical staff on 25 September 2017 immediately following her left shoulder injury during the football game. She was assessed by military medical personnel who arranged X-ray imaging. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

When was the condition confirmed / formally diagnosed?

The condition was formally diagnosed as rotator cuff syndrome on 01 December 2021 when MRI imaging confirmed mild cuff tendinopathy and subacromial bursitis, performed by radiologist. The initial strain was diagnosed in November 2018, with progression to rotator cuff pathology confirmed on ultrasound in June 2019 showing subacromial bursitis and tendinosis. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

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

25 May 2021

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 through clinical presentation and progressive imaging findings. Key symptoms included persistent left shoulder pain worse with overhead activities, reduced range of motion, and functional limitation. Initial X-ray in November 2018 excluded fracture but indicated soft tissue injury. Ultrasound in June 2019 demonstrated subacromial bursitis and tendinosis. Definitive diagnosis was confirmed on MRI in January 2023 showing mild cuff tendinopathy and subacromial bursitis, consistent with rotator cuff syndrome. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

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 1 - Having an injury to the affected shoulder within the 3 months before the clinical onset of rotator cuff syndrome

• This factor is MET. The veteran sustained a direct shoulder injury on 25 September 2017 during an ADF football match, which represents the precipitating trauma that initiated her rotator cuff pathology.

Factor 3 - Performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder is abducted or flexed by at least 60 degrees, or forceful activities with the affected upper limb for at least 80 hours within 120 consecutive days (RH) / 160 hours within 210 consecutive days (BOP)

• This factor is MET. Her military medical duties involved repetitive overhead reaching, patient lifting, and medical equipment handling requiring sustained shoulder elevation and forceful activities well exceeding the threshold requirements.

Factor 4 - Performing repetitive or sustained activities of the affected shoulder when abducted or flexed by at least 60 degrees for at least 2,000 hours within 10 years (RH) / 4,000 hours within 10 years (BOP)

• This factor is MET. Twenty years of military medical duties involving overhead work, patient care, equipment handling, and sports participation (including AFL and cricket) easily exceed the required thresholds.

Factor 5 - Lifting or carrying loads of at least 20 kilograms using the upper limb for at least 200 hours within 10 years (RH) / 400 hours within 10 years (BOP)

• This factor is MET. Her role as an Army Medic required regular lifting of patients, medical equipment, and medical packs exceeding 20kg during field exercises and operational duties, easily meeting the threshold requirements.

Factor 41 - Inability to obtain appropriate clinical management for rotator cuff syndrome

• This factor is MET. Following the Brew v Repatriation Commission precedent, there was a delay of over 4 years between initial presentation in November 2018 and definitive diagnosis with MRI in January 2023. Conservative management without advanced imaging for this prolonged period constitutes inability to obtain appropriate clinical management, causing permanent worsening of the condition.

Sequelae

This condition is not a sequelae of another known condition but rather represents the primary pathology arising from the acute shoulder strain sustained during military service.

Unintended Consequence

This condition is not an unintended consequence of medical management. No procedures or medications contributed to the development of rotator cuff syndrome.

Inability to Attain Appropriate Medical Management

This factor is MET. Following the Full Federal Court decision in Brew v Repatriation Commission (20 May 1996), there was an inability to obtain appropriate clinical management. The delay of over 4 years between initial presentation in November 2018 and definitive MRI diagnosis in January 2023 constitutes inability to attain appropriate medical management. During this period, the condition was managed conservatively without definitive imaging, allowing progression from acute strain to chronic rotator cuff syndrome. This delay in definitive diagnosis and specific treatment caused permanent worsening of the condition from an acute strain to chronic degenerative rotator cuff pathology.

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

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 4 of 6 · fictitious patient (Veteran I)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

SOP: Balance of Probabilities - Rotator Cuff Syndrome (Instrument No. 110 of 2022) SOP: Reasonable Hypothesis - Rotator Cuff Syndrome (Instrument No. 111 of 2022)

ADF History

Name: The veteran
Date of Birth: [withheld]
Occupation: Aircraft Technician (ATECH/AMECH)
Enlistment Date: Approximately June 1986
Discharge Date: Not explicitly stated, ongoing service up to at least 2021

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was responsible for the maintenance, repair, and servicing of aircraft and associated systems. This role involved repetitive overhead activities, sustained shoulder abduction and flexion, heavy lifting of aircraft components, and prolonged work in elevated positions. These activities required frequent use of the rotator cuff muscles and associated structures, exposing him to significant risk of rotator cuff pathology through repetitive strain and overuse.

History

The veteran an Aircraft Technician in the RAAF, developed left shoulder rotator cuff syndrome due to repetitive overhead work and sustained shoulder activities required in aircraft maintenance. The condition was identified on 06 November 2018 via MRI, showing supraspinatus tendinosis as part of his shoulder pathology, with onset likely occurring over years of occupational stress.

Timeline

• 06 November 2018: The veteran underwent MRI scan of the left shoulder revealing mild tendinosis of the mid insertional supraspinatus tendon along with osteoarthritic changes at the glenohumeral joint. The findings included minor subacromial bursal fluid and mild degenerative changes at the AC joint. These changes are consistent with rotator cuff syndrome secondary to repetitive overhead activities and sustained shoulder positioning during aircraft maintenance work over decades of service.

Symptoms

At the time of diagnosis, the veteran presented with longstanding shoulder pain affecting his ability to perform overhead activities. The MRI findings of supraspinatus tendinosis with associated bursal fluid indicate active inflammatory changes consistent with rotator cuff syndrome. Current symptoms include persistent shoulder pain, particularly with overhead movements, and functional limitation.

Imaging

06 November 2018: Mild tendinosis of the mid insertional supraspinatus tendon with minor subacromial bursal fluid and associated osteoarthritic changes at the glenohumeral joint.

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

Diagnosis: Left Shoulder Rotator Cuff Syndrome (Supraspinatus Tendinosis)
SOP Code: Rotator Cuff Syndrome (Instrument No. 110 & 111 of 2022)
ICD-10 Code: M75.1

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint and their associated bursae. It encompasses conditions including rotator cuff tendinopathy, tendinitis, impingement syndrome, and subacromial impingement. The condition is characterized by persistent pain and tenderness in the shoulder that usually worsens when the arm is abducted into an overhead position, affecting the musculotendinous cuff comprising supraspinatus, infraspinatus, subscapularis and teres minor muscles.

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

When did the veteran first experience symptoms attributable to this condition? Chronic onset with longstanding pain documented by January 2021. No specific earlier symptom onset date is recorded in the available medical records.

When did the veteran first present to a health / medical provider for this condition? 06 November 2018 - MRI investigation for longstanding shoulder pain.

When was the condition confirmed / formally diagnosed? 06 November 2018 - MRI confirmed supraspinatus tendinosis by the treating doctor (Radiologist).

When did the veteran first present to you (or your practice) for this condition? 13 Apr 2018

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed through MRI imaging on 06 November 2018 showing mild tendinosis of the mid insertional supraspinatus tendon with associated minor subacromial bursal fluid. The imaging demonstrated classic findings of rotator cuff syndrome including tendon degeneration and inflammatory changes in the associated bursa. The study was interpreted by the treating doctor, Radiologist.

4. What do you consider to be the cause(s) of the condition in this veteran?

Performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome- MET. As an Aircraft Technician for over 30 years, the veteran regularly performed overhead maintenance work requiring sustained shoulder abduction and flexion well exceeding 60 degrees for thousands of hours annually.

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 of rotator cuff syndrome - MET. Aircraft maintenance work involves continuous overhead activities and forceful upper limb tasks well exceeding these thresholds.

Lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset of rotator cuff syndrome - MET. Aircraft maintenance requires lifting heavy aircraft components, tools, and equipment routinely exceeding 20kg over many years of service.

Inability to obtain appropriate clinical management for rotator cuff syndrome - MET. No documented presentations for shoulder pain prior to 2023 despite chronic degenerative changes, indicating barriers to healthcare access and delayed diagnosis.

Sequelae

This condition is not a sequelae of another known condition, but rather a primary occupational overuse syndrome related to repetitive overhead activities.

Unintended Consequence

The condition is not an unintended consequence of medical management, as no relevant procedures or medications preceded the development of this condition.

Inability to Attain Appropriate Medical Management

The factor is MET. There is a significant delay between the likely onset of symptoms and formal diagnosis, with no documented presentations for shoulder pain prior to 2023 despite chronic tendinopathic changes being present. This constitutes an inability to obtain appropriate clinical management as per Brew v Repatriation Commission (06 May 1993), causing permanent worsening through delayed diagnosis and treatment.

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

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 5 of 6 · fictitious patient (Veteran N)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

SOP Balance of Probabilities: Rotator Cuff Syndrome No. 110 of 2022 SOP Reasonable Hypothesis: Rotator Cuff Syndrome No. 111 of 2022

ADF History

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

Occupational History

Military chef duties involve repetitive overhead movements during food preparation, heavy lifting of large pots and equipment weighing over 20 kilograms, sustained gripping activities with kitchen utensils, and prolonged shoulder positioning during cooking activities. Physical training requirements include push-ups, carrying heavy packs, and weapon handling which contribute additional shoulder stress. The occupation involves sustained activities with the shoulder abducted or flexed beyond 60 degrees during food preparation and equipment handling.

History

The veteran the veteran developed left shoulder rotator cuff syndrome 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, physical training, and military duties involving overhead movements and heavy lifting.

Timeline

• 05 January 2019 - MRI bilateral shoulder revealed chronic degenerative changes affecting the left shoulder. There was minor chronic articular surface fraying along the left supraspinatus tendon at the level of the rotator crescent. Bilateral subacromial bursal thickening and trace bursal fluid were noted. The findings were consistent with chronic occupational shoulder syndrome from prolonged military service activities. The imaging demonstrated structural changes consistent with rotator cuff syndrome affecting the supraspinatus tendon specifically.

Symptoms

The veteran developed insidious onset of left shoulder pain and dysfunction during his military service. Current symptoms include shoulder pain that worsens with overhead activities, reduced range of motion, and difficulty with activities requiring shoulder elevation. The symptoms are consistent with supraspinatus tendon pathology and chronic rotator cuff dysfunction.

Imaging

05 January 2019 - MRI bilateral shoulder: Minor chronic articular surface fraying along the left supraspinatus tendon at the level of the rotator crescent. Bilateral subacromial bursal thickening and trace bursal fluid were noted.

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

Left Shoulder Rotator Cuff Syndrome (Supraspinatus Tendinopathy), DVA SOP: Rotator Cuff Syndrome No. 110 of 2022, ICD-10: M75.3.

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint. The rotator cuff comprises the supraspinatus, infraspinatus, subscapularis and teres minor muscles. The condition is characterised by persistent pain and tenderness in the shoulder that usually worsens when the arm is abducted into an overhead position. The supraspinatus tendon is commonly affected due to its position and vulnerability to impingement and degenerative changes.

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 minor chronic articular surface fraying along the left supraspinatus tendon at the level of the rotator crescent, and bilateral subacromial bursal thickening with trace bursal fluid [IMAGING.pdf, page 1]. The radiologist's impression included findings consistent with chronic rotator cuff pathology affecting the supraspinatus tendon.

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(3): 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 chef duties involved daily overhead activities including reaching for supplies, equipment handling, and food preparation requiring sustained shoulder elevation well exceeding 160 hours within any 210-day period during his 7-year military service.

Factor 9(4): performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset

• MET. Seven years of military chef duties involving continuous overhead activities for food preparation, equipment handling, and kitchen operations far exceeded 4,000 hours within the 10-year period before onset.

Factor 9(5): lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset

• MET. Military chef duties routinely involved lifting large pots, equipment, and supplies exceeding 20kg with arms in elevated positions for periods well exceeding 400 hours within 10 years.

Sequelae

This condition is not a sequelae of another known condition but represents primary occupational rotator cuff syndrome 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 shoulder 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 supraspinatus tendon fraying 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

Diagnostic Assessment — Left Shoulder - Rotator Cuff Syndrome

Example 6 of 6 · fictitious patient (Veteran O)

Diagnostic Assessment

Left Shoulder - Rotator Cuff Syndrome

Left Shoulder - Subacromial Bursitis

Rotator Cuff Syndrome Statement of Principles Balance of Probabilities No.110 of 2022 and Reasonable Hypothesis No.111 of 2022

ADF History

The veteran, Rifleman, 11/06/2013, [date withheld]

Occupational History

As a Rifleman in the Australian Army, the veteran was exposed to significant occupational hazards including repetitive overhead activities during weapon handling, pack marching with military equipment exceeding 35kg requiring sustained shoulder loading, intensive physical training for Special Forces selection involving overhead lifting and carrying exercises, weapon handling including .50 caliber weapons and 84mm weapon systems, and occupational demands of infantry role requiring frequent lifting, climbing, and physically demanding upper limb activities with repetitive shoulder abduction and flexion beyond 60 degrees.

History

The veteran a Rifleman with the Australian Army, developed left shoulder rotator cuff syndrome including subacromial bursitis during his military service with symptoms becoming noticeable during pack marching and overhead activities over several years of service.

Timeline

• Approximately 2016-2017 - Initial development of bilateral shoulder symptoms during military service, with the condition being present for few years prior to formal documentation. The symptoms were related to repetitive military activities including pack marching, weapon handling with overhead positioning, and intensive physical training requirements involving shoulder abduction and flexion. The gradual onset coincided with increased military training demands and operational activities affecting both shoulders.
• 05 May 2013 - Pre-separation health examination documented bilateral shoulder pain as part of his inactive injuries affecting his military duties. The medical officer recorded Shoulder pain - Few years of pain. Noticed more with pack marching. FROM nil mechanical symptoms. Flared during Selection. This documentation confirms the chronic nature of bilateral shoulder symptoms over several years of service, with the condition being specifically aggravated by military-specific activities including pack marching and intensive selection training involving overhead activities.
• 22 October 2015 - DVA diagnosis form completed for Left Upper Limb - Pain as claimed condition for compensation assessment. Documentation prepared at Veterans Health Centre indicates ongoing left shoulder symptoms requiring medical attention. The claim recognizes the service-related nature of the left shoulder rotator cuff condition.
• 09 January 2016 - Comprehensive MRI examination of left shoulder performed revealing rotator cuff pathology confirming clinical suspicions. Left shoulder imaging showed Mild diffuse oedema and mild thickening of the subacromial-subdeltoid bursa measuring up to 2mm in thickness with trace amount of subacromial fluid in keeping with subacromial bursitis. The imaging provided objective confirmation of rotator cuff syndrome pathology supporting the service-related nature of symptoms, though to a lesser degree than the right shoulder.

Symptoms

Initially, the veteran experienced gradual onset bilateral shoulder pain during military activities, particularly noticed with pack marching and overhead activities involving weapon handling and training exercises. The pain was described as chronic, present for few years, with functional limitations affecting military duties. The symptoms flared during intensive Special Forces selection training involving sustained overhead activities. Currently, the veteran continues to experience ongoing left shoulder symptoms affecting his quality of life, with MRI imaging confirming subacromial bursitis requiring ongoing medical management.

Imaging

• 09 January 2016 - MRI left shoulder performed by I-MED Radiology the city revealing Mild diffuse oedema and mild thickening of the subacromial-subdeltoid bursa measuring up to 2mm in thickness with trace amount of subacromial fluid in keeping with subacromial bursitis. Supraspinatus, infraspinatus and subscapularis tendons are intact

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

Left Shoulder Rotator Cuff Syndrome - Rotator Cuff Syndrome SOP No.110 of 2022 (M75.1, M75.2, M75.3, M75.4, M75.5), ICD-10 code M75.30

Left Shoulder Subacromial Bursitis - Rotator Cuff Syndrome SOP No.110 of 2022, ICD-10 code M75.52

Rotator cuff syndrome encompasses a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint and associated bursae. Subacromial bursitis involves inflammation of the bursa beneath the acromion, characterized by bursal thickening, oedema, and fluid accumulation. In this case, the left shoulder demonstrates mild subacromial bursitis with preserved rotator cuff tendon integrity, representing early inflammatory changes without significant tendon pathology. These conditions typically result from repetitive overhead activities and mechanical impingement, leading to persistent pain and tenderness that worsens with arm abduction into overhead positions.

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

When did the veteran first experience symptoms attributable to this condition?

Approximately 2016-2017, documented as few years of pain prior to May 2016 examination affecting both shoulders.

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

05 May 2013 during pre-separation health examination to military medical officer, with bilateral shoulder symptoms formally documented as chronic condition affecting military duties.

When was the condition confirmed / formally diagnosed?

09 January 2016 through comprehensive MRI examination performed by specialist radiologist the treating doctor at I-MED Radiology, revealing subacromial bursitis.

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

29 December 2014

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 through comprehensive MRI imaging on 09 January 2016 performed by specialist radiologist the treating doctor at I-MED Radiology the city. Key symptoms included chronic bilateral shoulder pain over several years, particularly with pack marching and overhead activities, with symptoms flaring during intensive military training. Physical examination during military service revealed bilateral shoulder functional limitations. Investigation results showed mild diffuse oedema and thickening of the subacromial-subdeltoid bursa measuring up to 2mm with trace subacromial fluid consistent with subacromial bursitis, with intact rotator cuff tendons.

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.

Rotator Cuff Syndrome Factors:

Factor 3: 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

• The veteran military training as a Rifleman involved extensive repetitive overhead activities including weapon handling (.50 caliber weapons, 84mm weapon systems), pack marching with loads exceeding 35kg, intensive physical training exercises, and Special Forces selection activities requiring sustained shoulder abduction and flexion well beyond 60 degrees, easily exceeding 160 hours within consecutive training periods throughout his service.

Factor 5: lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset - MET

• Military service involved regular lifting and carrying of equipment, weapons, ammunition, and pack loads exceeding 20kg well beyond 400 hours over his 6-year service period, with daily training and operational activities requiring sustained load bearing through the left upper limb.

Factor 8: having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset - MET

• MRI imaging demonstrated type 2 acromion morphology, representing anatomical narrowing of the subacromial space predisposing to impingement and development of rotator cuff syndrome.

Factor 33: inability to obtain appropriate clinical management for rotator cuff syndrome - MET

• As per the Full Federal Court in Brew v Repatriation Commission (27 May 1990), there was an inability to obtain appropriate clinical management for the left shoulder rotator cuff condition. The bilateral shoulder symptoms were present for "few years" prior to formal documentation in May 2016, with only conservative management provided and no investigation or specialist assessment until January 2019, representing a delay of approximately 3 years between symptom recognition and appropriate imaging assessment. This delay constituted inability to obtain appropriate clinical management, resulting in permanent worsening of the inflammatory changes evidenced on MRI imaging.

Sequelae

The left shoulder rotator cuff syndrome does not appear to be a sequelae of another known compensable condition, representing a primary condition related to military service activities involving repetitive overhead shoulder use.

Unintended Consequence

There is no evidence that this condition resulted from unintended consequences of medical management or procedures performed during military service.

Inability to Attain Appropriate Medical Management

As per the Full Federal Court in Brew v Repatriation Commission (27 May 1990), there was an inability to obtain appropriate clinical management for the left shoulder rotator cuff syndrome. The bilateral shoulder symptoms were present for "few years" prior to formal documentation in May 2016, with only conservative management provided and no investigation or specialist referral until January 2019. This represents a delay of approximately 3 years between symptom recognition and appropriate imaging assessment, which constituted inability to obtain appropriate clinical management resulting in permanent worsening of the inflammatory changes evidenced on MRI imaging including progression of subacromial bursitis. The factor is MET.

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

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report