Diagnostic Assessment — Left Shoulder - SLAP Tear (12 o'clock)
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Left Shoulder - SLAP Tear (12 o'clock)
SOP - LABRAL TEAR - Reasonable Hypothesis (No. 36 of 2017) SOP - LABRAL TEAR - Balance of Probabilities (No. 37 of 2017)
ADF History
The veteran, Date of Birth: [withheld] occupation Airfield Defence Guard (ADG), enlistment date 29 July 1993, discharge date Currently Serving.
Occupational History
As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was 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. Environmental exposures are common, including prolonged exposure to sunlight, heat, cold, dust, and potentially other airborne particulates depending on the location of training or deployment.
History
The veteran an RAAF Airfield Defence Guard, began experiencing left shoulder pain around Mar 2012, possibly after lifting a heavy container. The condition progressed over time, and an MRI on 18 July 2018 confirmed a localised 12 o'clock SLAP tear, with surgery for the SLAP repair pending for February 2021.
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."
- 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.
- 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
During the initial presentation, the veteran experienced left shoulder pain following a possible lifting injury. Over time, his symptoms progressed to include mechanical anterior shoulder pain, particularly over the junction of the biceps and supraspinatus tendons. The pain was significant enough to affect his physical training activities.
Currently, the veteran's symptoms include ongoing shoulder pain and functional impairment consistent with a SLAP tear, with possible symptoms of clicking, catching, or instability. The condition has progressed to the point where surgical intervention (SLAP repair) has been recommended and is pending for February 2021.
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."
18 Jul 2018: MRI of the Left Shoulder: "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? Left Shoulder SLAP (Superior Labrum Anterior to Posterior) Tear, localized at the 12 o'clock position, ICD-10 code S43.422A (Sprain of left rotator cuff capsule, initial encounter). This condition is covered under the DVA SOP for Labral Tear (RH No. 36 of 2017 and BOP No. 37 of 2017).
A SLAP tear (Superior Labrum Anterior to Posterior) is an injury involving tearing of the fibrocartilaginous rim (labrum) of the shoulder joint. The labrum is a ring of cartilage that surrounds the glenoid (socket) of the shoulder joint, providing stability and serving as an attachment site for the biceps tendon and various ligaments. A SLAP tear specifically affects the superior (top) portion of the labrum, where the biceps tendon attaches. The "12 o'clock" position indicates the tear is located at the most superior aspect of the labrum.
SLAP tears typically cause pain, especially with overhead movements, and may be accompanied by mechanical symptoms such as clicking, catching, or a sense of instability in the shoulder. They can result from acute trauma (such as a fall onto an outstretched arm or forceful pulling on the arm) or from repetitive overhead activities that place stress on the superior labrum and biceps anchor.
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 this condition around Mar 2012, when he developed left shoulder pain, possibly after lifting a heavy container.
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, approximately 6 months after the onset of symptoms, when he underwent X-ray and Ultrasound assessment of the left shoulder with a query of impingement.
When was the condition confirmed / formally diagnosed? The condition was formally diagnosed through MRI imaging on 18 July 2018, which confirmed a "Localised 12 o'clock labral (SLAP) tear" along with associated findings of mild infraspinatus insertional tendinosis, mild degenerative arthrosis of the AC joint, trace subacromial/subdeltoid bursitis, and fluid in the biceps sheath.
When did the veteran first present to you (or your practice) for this condition? 24 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 a Left Shoulder SLAP Tear was confirmed primarily through MRI imaging performed on 18 July 2018. The MRI definitively identified a "Localised 12 o'clock labral (SLAP) tear" along with associated findings including mild infraspinatus insertional tendinosis, mild degenerative arthrosis of the AC joint, trace fluid in the subacromial/subdeltoid bursa, and fluid in the biceps sheath.
The key symptoms that led to the investigation included chronic left shoulder pain, particularly mechanical anterior shoulder pain over the junction of the biceps and supraspinatus tendons, which affected the veteran's physical training. These symptoms were persistent enough to warrant specialist consultation with the treating doctor G. the treating doctor, Orthopaedic Surgeon, on 12 October 2010, who noted evidence of mechanical subacromial impingement.
The condition has been deemed significant enough to warrant surgical intervention, with SLAP repair surgery noted as pending for February 2021.
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 a significant physical force applied to or through the affected shoulder joint or the affected hip joint at the time of the clinical onset of labral tear
- MET. The records indicate that the veteran left shoulder pain may have begun after lifting a heavy container around Mar 2012. While not explicitly documented with extensive details, this event could reasonably be considered a significant physical force applied through the shoulder joint. As an Airfield Defence Guard, his duties regularly involved handling heavy equipment and physical exertion.
performing forceful and repetitive motions of the affected shoulder joint or the affected hip 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. As an Airfield Defence Guard (ADG) in the RAAF, the veteran occupational duties would regularly involve forceful and repetitive motions of the shoulder joints. The SOP specifically lists examples relevant to military service, including "loading ammunition, physical employment standards training and participating in obstacle courses, infantry minor tactics courses and high rope courses." Given the nature of ADG duties described in his occupational history, including manual handling of heavy equipment, weapons, ammunition, and field gear, it is highly probable that he was performing such activities for at least four hours per week in the period before the onset of symptoms.
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 affects the shoulder joint, not the hip joint.
inability to obtain appropriate clinical management for labral tear
- MET. There was a significant delay between the initial onset of symptoms (Mar 2012) and the definitive diagnosis (September 2020) - a period of over 8 years. Initial imaging in September 2012 (X-ray and Ultrasound) did not identify the SLAP tear. Although he was reviewed by an orthopedic surgeon in December 2012, who suspected supraspinatus tendinopathy, the SLAP tear was not definitively diagnosed until the MRI in September 2020. This lengthy delay in obtaining appropriate diagnostic imaging (MRI) that could properly visualize the labral tear constitutes an inability to obtain appropriate clinical management, as per the Full Federal Court decision in Brew v Repatriation Commission (14 May 1993). This decision recognizes that inability to obtain appropriate clinical management can occur when a condition is misdiagnosed or not fully diagnosed. The lack of appropriate diagnosis for 8+ years prevented the veteran from receiving targeted treatment for his SLAP tear, allowing the condition to persist and potentially worsen over this extended period.
The % contribution of the causes is 100% and significant.
Sequelae
The Left Shoulder SLAP Tear is not considered a sequela of another condition. It appears to be a primary injury related to the veteran's military service activities.
Unintended Consequence
There is no evidence that this condition is an unintended consequence of any medical management provided by the ADF.
Inability to Attain Appropriate Medical Management
There is evidence of an inability to attain appropriate medical management in this case. The veteran first experienced symptoms around Mar 2012, had initial imaging in September 2012 (X-ray and ultrasound) which did not identify the SLAP tear, and was not definitively diagnosed until an MRI in September 2020 - a period of over 8 years.
The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" to include situations where a condition is misdiagnosed or where appropriate diagnostic procedures (in this case, MRI imaging which can properly visualize labral tears) are not provided in a timely manner. This delay of over 8 years between initial symptoms and definitive diagnosis constitutes an inability to attain appropriate medical management.
This inability to obtain appropriate and timely diagnosis and treatment would have resulted in a permanent worsening of the condition, as untreated SLAP tears can lead to ongoing pain, functional limitations, and potential progression of associated pathology such as tendinopathy and degenerative changes, which are now evident on the veteran's imaging.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
