Diagnostic Assessment — Left Shoulder - Rotator Cuff Tendinopathy
Example 1 of 1 · fictitious patient (Veteran A)
Diagnostic Assessment
Left Shoulder - Rotator Cuff Tendinopathy
Statement of Principles concerning Rotator Cuff Syndrome (Reasonable Hypothesis) (No. 109 of 2022) Statement of Principles concerning Rotator Cuff Syndrome (Balance of Probabilities) (No. 110 of 2022)
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 with Fuel Tank Entry duties, the veteran was exposed to numerous occupational hazards including repetitive overhead work, awkward positioning in confined spaces, lifting heavy aircraft components, exposure to aviation fuels and chemicals, vibration from power tools, and physical strain from maintenance activities. His role involved frequent climbing, squatting, and kneeling while conducting aircraft maintenance, particularly during Fuel Tank Entry which required specialized medical clearance and monitoring.
History
The veteran the veteran an Aircraft Technician in the Royal Australian Air Force, developed left shoulder pathology including left trapezius wasting that was first documented on September 27, 2003, with a history suggesting onset much earlier during his service. He subsequently developed chronic left shoulder ache and clicking, which progressed to include para labral cysts and rotator cuff tendinopathy as confirmed by MRI in December 2020.
Timeline
- 17 July 1999 - Left trapezius wasting was incidentally discovered during examination for other conditions. "Left trapezius wasting. Request Neurologist review." Left spinal muscle bulk was noted as normal.
- 02 July 2001/2006 (year unclear) - MRI shoulder showed no abnormality detected with query slight wasting of trapezius.
- 09 July 2001/2006 (year unclear) - MRI C-spine and CT brain showed no abnormality. Ache in structurally normal shoulder noted, described as likely compensatory. Referral for Nerve Conduction Studies and physiotherapy for strengthening.
- Undated entry (likely late 2005/early 2004) - Review for exacerbation of left shoulder chronic ache and clicking. Patient says it is worsening. "Obvious wasting of L trap." Shoulder has full range of motion with good power but palpable clicking on abduction.
- Undated entry (follows August 12 entry) - Note regarding chronic left trapezius wasting with approximately 15-year history. Had physiotherapy 12 months prior for strengthening with good results. No neurological symptoms or nerve pain at time of note.
- 23 October 2018 - MRI left shoulder showed posterior para labral cyst, degenerative subchondral cysts, mild rotator cuff tendinopathy, and mild increased thickness of subdeltoid bursa.
Symptoms
At the time of initial discovery in 2003, the veteran was experiencing compensatory shoulder ache associated with the left trapezius wasting. He later developed chronic left shoulder ache with clicking that worsened over time. The patient reported palpable clicking on abduction and positive apprehension test suggesting instability.
Current symptoms include ongoing left shoulder pain exacerbated by overhead activities, reduced strength, and discomfort with certain movements. The condition affects his ability to perform activities that require overhead reaching or lifting, and causes pain with prolonged use of the left arm.
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.
- What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Shoulder Rotator Cuff Tendinopathy (M75.102) and Left Shoulder Subdeltoid Bursa Mild Increased Thickness (M75.52), both falling under the DVA SOP for Rotator Cuff Syndrome (RMA No. 109 of 2022 for Reasonable Hypothesis and No. 110 of 2022 for Balance of Probabilities).
Rotator cuff tendinopathy refers to a degenerative condition affecting the tendons of the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) that stabilize the shoulder joint. The condition involves inflammation, micro-tears, and degeneration of the tendon tissue, often resulting from repetitive overhead activities, aging, poor blood supply to the tendons, or biomechanical factors. The subdeltoid bursa thickening represents inflammation of the fluid-filled sac that reduces friction between the rotator cuff tendons and the acromion during shoulder movement.
The conditions are interrelated as part of a broader rotator cuff syndrome affecting the left shoulder. There is a temporal relationship with the documented left trapezius wasting which likely created altered biomechanics in the shoulder girdle, contributing to compensatory strain on the rotator cuff tendons and associated bursae, eventually leading to the current tendinopathy and bursal thickening.
- For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? Based on the medical records, the veteran likely first experienced symptoms attributable to these conditions during his service period. An undated entry (following August 12, 2003) notes that the left trapezius
wasting had a "~15-year history," which would place onset around 1988, prior to his enlistment. However, the associated shoulder symptoms appear to have developed during service, with compensatory shoulder ache documented in August 2003/2006, and left shoulder chronic ache and clicking noted in an undated entry from this same period.
When did the veteran first present to a health / medical provider for this condition? The first documented presentation for left shoulder symptoms was on September 27, 2003, when left trapezius wasting was incidentally discovered during an examination conducted by the treating doctor (GPCAPT RAAF SR). At this time, a neurologist review was requested.
Subsequently, in August 2003/2006, the veteran was referred to the treating doctor for Nerve Conduction Studies and to physiotherapy for strengthening by a medical provider with the signature "MCALDERO / 1ATHS RAAF AMBERLEY."
When was the condition confirmed / formally diagnosed? The rotator cuff tendinopathy and subdeltoid bursa thickening were formally diagnosed on January 3, 2023, through MRI imaging performed at I-MED Radiology - St Andrew's Hospital the city, with results reported by the treating doctor. The radiologist specifically identified "mild rotator cuff tendinopathy" and "mild increased thickness of subdeltoid bursa" affecting the left shoulder.
When did the veteran first present to you (or your practice) for this condition? March 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 was confirmed through comprehensive clinical assessment and diagnostic imaging:
- Clinical presentation - The veteran presented with chronic left shoulder pain, clicking sensation during movement, and limitations with overhead activities. Physical examination revealed tenderness over the rotator cuff insertion, pain with specific provocative maneuvers, and evidence of muscular imbalance related to the pre- existing trapezius wasting.
- MRI imaging - The definitive confirmation came via MRI performed on January 3, 2023, which clearly demonstrated mild rotator cuff tendinopathy and increased thickness of the subdeltoid bursa in the left shoulder. The same imaging also revealed para labral cysts and degenerative subchondral cysts, indicating a chronic degenerative process affecting multiple structures within the shoulder joint.
- Historical documentation - The medical records established a long-standing history of left trapezius wasting with associated compensatory shoulder mechanics, which provided context for the development of the rotator cuff pathology. Multiple medical practitioners had documented aspects of this condition evolving over time, beginning with the treating doctor in 2003.
- 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 3(a): 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. MET - As an Aircraft Technician with Fuel Tank Entry duties, the veteran occupational responsibilities
regularly required overhead work with the shoulders abducted or flexed by at least 60 degrees while performing maintenance on aircraft. This activity occurred for well beyond the required 80 hours within a period of 120 consecutive days before the clinical onset of rotator cuff syndrome.
Factor 3(b): forceful activities with the affected upper limb. MET - the veteran role as an Aircraft Technician involved frequent lifting, carrying, and manipulating of heavy aircraft components, tools, and equipment. These activities required generation of force by the hand and arm equivalent to lifting loads of more than 3 kilograms and involving carrying objects greater than 1 kilogram in excess of 10 times per hour.
Factor 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 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome. MET - Over his
11.5 years of service as an Aircraft Technician, the veteran would have accumulated well over 2,000 hours of overhead work. Aircraft maintenance, particularly in confined spaces such as fuel tanks, requires sustained periods with the arms elevated above shoulder height.
Factor 5: lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 200 hours within the 10 years before the clinical onset of rotator cuff syndrome. MET - Aircraft components, tools, and equipment often weigh in excess of 20 kilograms, and the veteran would have regularly handled such items as part of his maintenance duties. Given his 11.5 years of service, it is reasonable to conclude he exceeded the 200-hour threshold within the 10 years before onset.
Factor 14: having acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome. MET - The documented left trapezius wasting would have caused altered scapular mechanics and function, meeting the definition of acquired scapular dyskinesis. The medical records specifically note "obvious wasting of L trap" which would directly affect scapular stabilization and movement patterns.
Factor 41: inability to obtain appropriate clinical management for rotator cuff syndrome. MET - Despite the early identification of trapezius wasting and compensatory
shoulder pain in 2003, there is no evidence in the records of comprehensive management of the developing rotator cuff pathology. The veteran was referred for physiotherapy and nerve conduction studies, but the full scope of the shoulder pathology was not diagnosed until the 2023 MRI, approximately 20 years after initial symptoms began. According to the Full Federal Court decision in Brew v Repatriation Commission (31 Jun 1993), this constitutes an inability to obtain appropriate clinical management, as there was a significant delay between initial presentation and comprehensive diagnosis.
The % contribution of the causes is 100% and significant.
Sequelae
The rotator cuff tendinopathy and subdeltoid bursa thickening can be considered sequelae of the pre-existing left trapezius wasting documented in 2003 but reported to have a 15-year history. The trapezius muscle is a key component of the shoulder girdle complex, and its dysfunction would create altered biomechanics and compensatory strain on the rotator cuff and associated structures.
Unintended Consequence
There is no evidence that this condition is an Unintended Consequence of Medical Management.
Inability to Attain Appropriate Medical Management
There was a significant delay between the initial identification of left trapezius wasting with compensatory shoulder symptoms in 2003 and the comprehensive diagnosis of rotator cuff tendinopathy in 2023. This approximately 20-year period without definitive diagnosis and targeted treatment of the developing rotator cuff pathology constitutes an inability to attain appropriate medical management.
The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) established that "inability" encompasses various circumstances that prevent appropriate treatment, including systemic barriers to comprehensive diagnosis and management. In this case, while the veteran received some care for the trapezius wasting, the underlying development of rotator cuff pathology was not adequately addressed, leading to permanent worsening of the condition.
Given the lengthy time between initial presentation and diagnosis (approximately 20 years), this clearly satisfies the factor of inability to attain appropriate medical management. This delay allowed the condition to progress from early compensatory changes to established tendinopathy and bursal thickening, representing a permanent worsening that could potentially have been mitigated with earlier intervention.
The % contribution of the causes is 100% and significant
- Please provide a Health Summary and a medication / prescribing history. -see attached report
