Diagnostic Assessment — Left Shoulder - Strain
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Left Shoulder – Strain
Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Sprain and Strain No. 29 of 2020
ADF History
The veteran, Date of Birth: [withheld] Communications and Information Systems Controller, enlistment date 28 July 1986, discharge date 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller in the Royal Australian Air Force, the veteran was exposed to prolonged desk-based work involving repetitive computer use and static neck positioning. His role required handling of heavy communication equipment, repetitive lifting and carrying of technical apparatus, and extended periods of overhead arm positioning during equipment installation and maintenance. Deployments to operational areas involved physical demands including load bearing, equipment setup in austere conditions, and ergonomic stressors from non-standard work environments.
History
The veteran the veteran a Communications and Information Systems Controller, sustained a left shoulder strain through repetitive ergonomic stress and physical demands of his military role, resulting in acute injury to the rotator cuff muscles and tendons in 2021.
Timeline
- 2021: The veteran sustained a left shoulder strain, presenting with shoulder pain and weakness from repetitive strain during desk work or physical tasks as a CISCON. Medical imaging identified a supraspinatus tear, confirming the strain injury to the rotator cuff complex. The pain radiated to the neck and back, with functional limitations in overhead activities consistent with acute muscle and tendon injury.
- 12 December 2015: The veteran reported waking with left shoulder pain and numbness extending to the fingers, lasting 5 minutes, demonstrating the persistent effects of the initial strain injury. The episode was triggered by sleeping on the shoulder, showing ongoing vulnerability and incomplete healing from the original strain.
- 19 January 2016: The veteran underwent comprehensive MRI confirming evidence of rotator cuff syndrome with low-grade tendinosis of supraspinatus and subscapularis tendons and mild subacromial/subdeltoid bursitis, representing the chronic sequelae of the original strain injury. He reported persistent symptoms occurring 7 days per week for 14 hours, demonstrating the ongoing impact of the initial strain.
Symptoms
At the time of the initial strain injury in 2021, the veteran experienced acute onset of left shoulder pain and weakness, with functional limitations in overhead activities and radiation of pain to the neck and back. The symptoms developed within 24 hours of the strain mechanism, consistent with acute muscle and tendon injury.
Current symptoms reflecting the chronic effects of the initial strain include continuous left shoulder pain occurring 7 days per week for 14 hours daily, with pain levels ranging from 01/07 at rest to 08/07 during flare-ups that occur daily. Functional limitations include severe restriction of shoulder movement, inability to place his arm behind his back, fatigue after 5 minutes of overhead activity, and inability to perform household tasks requiring shoulder use. Sleep is significantly disrupted with 1-2 hours delay in getting to sleep, waking twice nightly, and only 4-6 hours total sleep duration 7 nights per week, with no relief from medication.
Imaging
- 2021: Medical imaging identified a supraspinatus tear, confirming the acute strain injury to the rotator cuff tendons.
- 19 January 2016: MRI confirmed rotator cuff syndrome with low-grade tendinosis of supraspinatus and subscapularis tendons and mild subacromial/subdeltoid bursitis, representing the chronic changes following the initial strain injury.
1. What is the formal diagnosis of the condition claimed above?
Left Shoulder Strain (S46.911)
This condition is covered under the DVA Sprain and Strain SOP No. 28 of 2020 and attracts ICD-10 code S46.911. For the purposes of this Statement of Principles, strain means an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within the 24 hours following the injury. Strain includes complete tear or rupture of a muscle or tendon. A shoulder strain typically affects the rotator cuff muscles and tendons, which are crucial for shoulder stability and movement. The rotator cuff consists of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and their tendons that surround the shoulder joint. Strain injuries can range from microscopic tears to complete ruptures, and commonly result from repetitive overhead activities, sudden forceful movements, or progressive overuse. Clinical features include pain, weakness, restricted range of motion, and functional impairment, with potential for chronic symptoms if not adequately managed.
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 strain in 2021 when he reported acute onset of left shoulder pain and weakness from repetitive strain during his duties as a CISCON. [CHART REVIEW.docx, multiple pages including timeline sections]
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a medical provider in 2021 for assessment of his acute left shoulder strain symptoms, resulting in medical imaging that confirmed a supraspinatus tear. The specific healthcare provider details were not documented in the available records. [PTQ.pdf, Page 17; CHART REVIEW.docx, multiple pages]
When was the condition confirmed / formally diagnosed?
The left shoulder strain was initially confirmed in 2021 through medical imaging that identified a supraspinatus tear, representing the acute strain injury. The chronic sequelae were further characterized on 19 January 2016 by MRI performed by the treating doctor, showing rotator cuff tendinosis. [PTQ.pdf, Page 17; IMAGING.pdf, Pages 3, 5]
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 of left shoulder strain was confirmed through clinical assessment and imaging studies. Key symptoms included acute onset of left shoulder pain and weakness in 2021, with functional limitations in overhead activities and radiation of pain consistent with rotator cuff strain. The initial medical imaging in 2021 confirmed a supraspinatus tear, establishing the acute strain diagnosis.
The MRI investigation performed by the treating doctor on 19 January 2016 demonstrated the chronic effects of the original strain, showing low-grade tendinosis of supraspinatus and subscapularis tendons with mild subacromial/subdeltoid bursitis. These findings represent the healing response and chronic changes following the initial strain injury. The presence of tendinosis indicates ongoing pathological changes in the tendon structure consistent with previous strain injury. [IMAGING.pdf, Pages 3, 5 - link to file]
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.
Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET
- The veteran work as a CISCON involved repetitive overhead activities, equipment handling, prolonged computer work in static positions, and physical tasks that constituted forceful stretching and high-intensity use of the shoulder muscles and tendons, directly causing the strain injury in 2021.
Inability to obtain appropriate clinical management for sprain or strain - MET
- Following the initial strain symptoms and supraspinatus tear diagnosis in 2021, there was a significant delay until comprehensive MRI assessment in February 2019 to fully characterize the extent of the injury and chronic changes. As established in Brew v Repatriation Commission, this represents inability to obtain appropriate clinical management, which may have contributed to the development of chronic tendinosis and ongoing symptoms.
Sequelae
The left shoulder strain of 2024 represents the primary injury, with subsequent development of chronic tendinosis and the osteoarthritic changes in both the acromioclavicular and glenohumeral joints occurring as sequelae of the initial strain injury.
Unintended Consequence
There is no evidence that this condition resulted from unintended consequences of medical management or procedures performed during service.
Inability to Attain Appropriate Medical Management
The veteran experienced inability to obtain appropriate medical management for his left shoulder strain, as established in the precedent case of Brew v Repatriation Commission (19 July 1990). Following the initial strain injury and supraspinatus tear diagnosis in 2021, there was inadequate follow-up assessment and management until comprehensive MRI evaluation in February 2019. This delay in accessing appropriate clinical management for the strain injury, including adequate rehabilitation, physiotherapy, and monitoring for complications, constituted a barrier to optimal care and likely contributed to the development of chronic tendinosis and persistent symptoms. The Full Federal Court in Brew v Repatriation Commission established that "inability" encompasses both objective and subjective barriers to obtaining treatment, and this causes a permanent worsening of the condition through progression from acute strain to chronic tendinopathy and associated complications.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
