Diagnostic Assessment — Left Shoulder - Tendinopathy
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Shoulder — Tendinopathy BOP Code: 110 of 2022 (Rotator Cuff Syndrome) RH Code: 109 of 2022 (Rotator Cuff Syndrome)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as an Airfield Defence Guard from 18 December 1985 to 3 October 1992
Occupational History
As an Airfield Defence Guard in the Royal Australian Air Force, the veteran performed physically demanding duties including lifting and handling heavy survey equipment, steel cables, and ship's stores.
These duties required repetitive overhead reaching, pulling, pushing, and carrying in the confined environment of service vessels.
He also participated in military sporting activities including rugby union, rugby league, and boxing, and sustained a shotput throwing injury during recruit training.
These activities placed sustained and repetitive loading on both shoulder joints over 6 years and 8 months of service
History
The veteran has left shoulder tendinopathy with partial subscapularis tear, medially subluxed long head of biceps tendon with tendinopathy, extensive glenoid labral tearing, a 16mm paralabral cyst, and mild AC joint degeneration.
Bilateral shoulder arthropathy with tendinopathy was first identified on whole body bone scan on 25 January 2019, and the left shoulder was comprehensively characterised on MRI on 23 February 2026
Timeline
18 May 1986 — Airfield Defence Guard the veteran was injured when a rugby scrum collapsed on top of him during organised sport whilst serving at an airbase, injuring his back, shoulder and neck (the side of the shoulder is not recorded).
3 days light duty. "Injuring his back, shoulder and neck" Sep/July 1986 — Airfield Defence Guard the veteran developed tingling and numbness in his left hand and forearm after throwing at shotput at an airbase, representing a significant upper limb loading event that also stresses the shoulder joint complex. "Shotput throwing" 1986 1993 — Throughout his service as an Airfield Defence Guard, the veteran performed repetitive heavy manual handling including cable work, equipment handling, and ship's maintenance duties that required sustained loading of both shoulders.
He also participated in rugby union, rugby league, and boxing.
25 January 2019 — Whole body bone scan demonstrated arthropathy in both shoulders with diffuse prominence over the humeral heads suggesting tendinopathy, and sternoclavicular joint arthropathy.
This was the first imaging evidence of bilateral shoulder pathology. "Tendinopathy" 23 Feb 2026 — MRI left shoulder for shoulder pain worse with abduction and overhead movement.
Demonstrated mild supraspinatus and anterior infraspinatus tendinopathy without tearing.
Attritional partial tearing of the lesser tuberosity attachment of the subscapularis.
The proximal extracapsular long head of biceps tendon was medially subluxed with intracapsular tendinopathy particularly distally.
Extensive tearing of the glenoid labrum relatively sparing the anterior labrum.
A 16mm posterosuperior paralabral cyst extending into the spinoglenoid notch was identified, with no evidence of suprascapular nerve neuritis.
Mild hypertrophic acromioclavicular joint degeneration was noted.
A small subacromial bursal effusion was present.
Normal glenohumeral articular cartilage. "Partial tearing subscapularis"
Symptoms
The veteran reports left shoulder pain that is worse with abduction and overhead movement.
The MRI findings of tendinopathy, partial rotator cuff tear, labral tearing, and biceps subluxation are consistent with chronic shoulder pain from cumulative overuse and repetitive loading
Imaging
25 January 2019 — Bone scan: "Arthropathy in both shoulders with diffuse prominence over the humeral heads suggesting tendinopathy.
Sternoclavicular joint arthropathy." 23 Feb 2026 — MRI left shoulder: "Mild supraspinatus and anterior infraspinatus tendinopathy.
Attritional partial subscapularis tear.
Medially subluxed LHBT with intracapsular tendinopathy.
Extensive glenoid labral tearing.
16mm posterosuperior paralabral cyst.
Mild AC joint degeneration.
Small subacromial bursal effusion."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Shoulder Tendinopathy (ICD-10: M75.12) encompassing rotator cuff tendinopathy with partial subscapularis tear, long head of biceps subluxation and tendinopathy, extensive glenoid labral tearing (S43.432A), paralabral cyst, and mild AC joint arthropathy (M19.012).
The relevant Statements of Principles are those concerning Rotator Cuff Syndrome (Balance of Probabilities No.
110 of 2022; Reasonable Hypothesis No.
109 of 2022), applied by analogy as this is a DRCA claim.
Shoulder tendinopathy is a degenerative condition of the rotator cuff and associated shoulder tendons characterised by progressive microstructural damage from repetitive loading, overuse, and cumulative trauma.
It is commonly seen in individuals with a history of heavy manual labour and overhead activities.
The condition manifests as tendon thickening, partial tearing, and associated labral and joint degeneration
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The insidious onset of shoulder tendinopathy from cumulative loading makes precise dating difficult.
The first imaging evidence was on 25 January 2019 (bone scan), but the cumulative loading commenced during ADF service from 1986.
When did the veteran first present to a health / medical provider for this condition? 25 January 2019 (bone scan demonstrating bilateral shoulder tendinopathy) When was the condition confirmed / formally diagnosed? 23 February 2026 (MRI left shoulder) When did the veteran first present to you (or your practice) for this condition? 30 April 2017
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on imaging.
Whole body bone scan on 25 January 2019 first demonstrated bilateral shoulder arthropathy with tendinopathy.
MRI of the left shoulder on 23 February 2026 provided comprehensive confirmation of rotator cuff tendinopathy with partial subscapularis tear, biceps tendon subluxation and tendinopathy, extensive labral tearing with a 16mm paralabral cyst, and AC joint degeneration
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 17 March 2006 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The rotator cuff tendinopathy, the attritional partial subscapularis tear and the long head of biceps tendinopathy with medial subluxation of that tendon, shown on the MRI of 23 February 2026 in a shoulder painful on abduction and overhead movement, fall squarely within the definition of rotator cuff syndrome.
The extensive glenoid labral tearing with paralabral cyst and the mild acromioclavicular joint degeneration fall outside it and are covered by the separate Statements of Principles concerning labral tear of the hip and shoulder and osteoarthritis.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Rotator Cuff Syndrome, No.
110 of 2022) Factor 9(1): having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome — NOT MET - No injury to the veteran's left shoulder is recorded in the 30 days before the estimated clinical onset on 29 November 2005.
His recorded left shoulder-region injuries (the rugby scrum collapse of 18 May 1986 and the upper back strain recorded on 16 March 1990, both with tenderness over the left scapula) occurred about 20 and 16 years earlier.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had surgery on his left shoulder, before or after the estimated clinical onset on 29 November 2005.
Factor 9(3): 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, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome — NOT MET - This factor requires the activities to continue to within 30 days of onset.
The veteran's in- service forceful and shoulder-elevated work (ships' lines, rope work, steel cables, cable drums, survey equipment, scrubbing deckheads), conservatively about 1.5 hours a working day or some 225 hours in a 210-day period at sea, ceased at his discharge on 3 October 1992, more than 13 years before the estimated onset on 29 November 2005, and his post-service work before onset was described as office work.
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 of rotator cuff syndrome — NOT MET - The 10-year window runs from 29 November 1995 to the estimated onset on 29 November 2005, after all of the veteran's service (18 December 1985 to 3 October 1992) had ended.
His in-service shoulder-level and overhead work (hauling lines, rope work, scrubbing deckheads, handling survey equipment), conservatively about 1,500 hours (about 2 hours a working day over some 2.5 years at sea and in ship's husbandry, less ashore), falls outside the window, and his post-service work within it was described as office work.
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 of rotator cuff syndrome — NOT MET - The 10-year window runs from 29 November 1995 to the estimated onset on 29 November 2005, after the veteran's service ended on 3 October 1992.
His in-service lifting of loads of 20 kilograms or more with his dominant left arm (steel cables and cable drums in March 1987, survey equipment, stores, mooring lines), conservatively 20 to 30 minutes on 150 working days a year over 6.8 years, or roughly 350 to 500 hours, falls outside the window, and his post-service work within it was described as office work.
Factor 9(6): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so dialysis- related amyloidosis cannot have been present.
Factor 9(7): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome — NOT MET - There is no record that the veteran used crutches, a wheelchair or any other form of upper- limb weight-bearing for a continuous year before November 2005, and he walks without aids.
Factor 9(8): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - No shoulder imaging was performed near the estimated onset in 2006.
The MRI of 23 February 2026 showed a curved (type II) acromion, generally regarded as a developmental shape rather than an acquired reduction of the subacromial space, and no subacromial spur.
Factor 9(9): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of instability, dislocation or subluxation of the veteran's left shoulder joint before November 2005, and nothing in his history suggests it.
Factor 9(10): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of the veteran's left shoulder at any time, and nothing in his history suggests it.
Factor 9(11): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome — NOT MET - None of the specified autoimmune diseases (such as rheumatoid arthritis, polymyalgia rheumatica or systemic lupus erythematosus) has been diagnosed in the veteran; no inflammatory arthritis is recorded and his sacroiliac joints were normal on imaging.
Factor 9(12): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of gout in the veteran's left shoulder or any other joint, and nothing in his history suggests it.
Factor 9(13): having diabetes mellitus before the clinical onset of rotator cuff syndrome — NOT MET - the veteran's diabetes mellitus was diagnosed in 2022, about 16 years after the estimated onset on 29 November 2005, so it was not present before onset.
Factor 9(14): having dyslipidaemia before the clinical onset of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels or lipid-lowering treatment are recorded before November 2005 or since, so dyslipidaemia as defined is not established.
Factor 9(15): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any systemic glucocorticoid before November 2005; the only corticosteroid recorded in service was topical Celestone-V cream to his heels in 1987, which is not a mode or dose specified in the SOP.
Factor 9(16): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any fluoroquinolone antibiotic (such as ciprofloxacin or norfloxacin) in the 60 days before the estimated onset on 29 November 2005, and nothing in his history suggests it.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Rotator Cuff Syndrome, No.
109 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having an injury to the affected shoulder within the 3 months before the clinical onset of rotator cuff syndrome — NOT MET - No injury to the veteran's left shoulder is recorded in the 3 months before the estimated clinical onset on 29 November 2005.
His recorded left shoulder-region injuries (the rugby scrum collapse of 18 May 1986 and the upper back strain recorded on 16 March 1990, both with tenderness over the left scapula) occurred about 20 and 16 years earlier.
Factor 9(2): undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had surgery on his left shoulder, before or after the estimated clinical onset on 29 November 2005.
Factor 9(3): 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 80 hours within a period of 120 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome — NOT MET - This factor requires the activities to continue to within 30 days of onset.
The veteran's in- service forceful and shoulder-elevated work (ships' lines, rope work, steel cables, cable drums, survey equipment, scrubbing deckheads), conservatively about 1.5 hours a working day or some 125 hours in a 120-day period at sea, ceased at his discharge on 3 October 1992, more than 13 years before the estimated onset on 29 November 2005, and his post-service work before onset was described as office work.
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 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - The 10-year window runs from 29 November 1995 to the estimated onset on 29 November 2005, after all of the veteran's service (18 December 1985 to 3 October 1992) had ended.
His in-service shoulder-level and overhead work (hauling lines, rope work, scrubbing deckheads, handling survey equipment), conservatively about 1,500 hours (about 2 hours a working day over some 2.5 years at sea and in ship's husbandry, less ashore), falls outside the window, and his post-service work within it was described as office work.
Factor 9(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 — NOT MET - The 10-year window runs from 29 November 1995 to the estimated onset on 29 November 2005, after the veteran's service ended on 3 October 1992.
His in-service lifting of loads of 20 kilograms or more (steel cables and cable drums in March 1987, survey equipment, stores, mooring lines), conservatively roughly 350 to 500 hours and above the 200 hours required, falls wholly outside the window, and his post-service work within it was described as office work.
Factor 9(6): using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome — NOT MET - There is no record that the veteran used heavy hand-held vibrating or percussive industrial tools, such as jackhammers, between November 1995 and November 2005, when his work was office-based; the only powered tools recorded in service (a floor polisher and a circular saw) were outside this window and not of this kind.
Factor 9(7): having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so dialysis- related amyloidosis cannot have been present.
Factor 9(8): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome — NOT MET - There is no record that the veteran used crutches, a wheelchair or any other form of upper- limb weight-bearing for a continuous year before November 2005, and he walks without aids.
Factor 9(9): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - No shoulder imaging was performed near the estimated onset in 2006.
The MRI of 23 February 2026 showed a curved (type II) acromion, generally regarded as a developmental shape rather than an acquired reduction of the subacromial space, and no subacromial spur.
Factor 9(10): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of instability, dislocation or subluxation of the veteran's left shoulder joint before November 2005, and nothing in his history suggests it.
Factor 9(11): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa of the veteran's left shoulder at any time, and nothing in his history suggests it.
Factor 9(12): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome — NOT MET - None of the specified autoimmune diseases (such as rheumatoid arthritis, polymyalgia rheumatica or systemic lupus erythematosus) has been diagnosed in the veteran; no inflammatory arthritis is recorded and his sacroiliac joints were normal on imaging.
Factor 9(13): having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of gout in the veteran's left shoulder or any other joint, and nothing in his history suggests it.
Factor 9(14): having acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome — NOT MET - There is no record of winging or abnormal movement of the left scapula, or of injury to the long thoracic or spinal accessory nerve; the left scapular tenderness recorded in 1986 and 1990 was local, with no abnormal scapular position or motion noted.
Factor 9(15): having smoked at least 20 pack-years of tobacco products before the clinical onset of rotator cuff syndrome — MET - In June 2026 the veteran reported smoking 50 cigarettes a day until he stopped in 2011; the only service record, of 12 May 1992, notes about 5 a day.
On his account, 50 a day from enlistment in December 1985 to the estimated onset on 29 November 2005 is about 50 pack- years, and even at the recorded in-service rate followed by his stated rate after discharge, 20 pack-years was passed by about 2000.
His stated duration of 41 years cannot be right (it would begin in his birth year), but the factor is met on any reading, mostly from post-service smoking.
Factor 9(16): having diabetes mellitus before the clinical onset of rotator cuff syndrome — NOT MET - the veteran's diabetes mellitus was diagnosed in 2022, about 16 years after the estimated onset on 29 November 2005, so it was not present before onset.
Factor 9(17): having dyslipidaemia before the clinical onset of rotator cuff syndrome — NOT MET - No abnormal blood lipid levels or lipid-lowering treatment are recorded before November 2005 or since, so dyslipidaemia as defined is not established.
Factor 9(18): taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any systemic glucocorticoid before November 2005; the only corticosteroid recorded in service was topical Celestone-V cream to his heels in 1987, which is not a mode or dose specified in the SOP.
Factor 9(19): taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome — NOT MET - There is no record of any fluoroquinolone antibiotic (such as ciprofloxacin or norfloxacin) in the 60 days before the estimated onset on 29 November 2005, and nothing in his history suggests it.
Factor 9(20): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical onset of rotator cuff syndrome — NOT MET - There is no record that the veteran has ever taken an aromatase inhibitor, a drug used mainly in the treatment of breast cancer, and nothing in his history suggests it.
Other Plausible Links to Service the veteran's left shoulder girdle was injured in the course of his service.
On 18 May 1986, as an adult Airfield Defence Guard at an airbase, he was on duty in organised sport when a rugby scrum collapsed on top of him, "injuring his back, shoulder and neck" (Compensation Supporting Report); the Daily Injury Record of 18 May 1986 recorded tenderness of the cervical and lumbar spine and of the left scapula, treated with Brufen and three days' light duty.
In late July 1986 he threw the shot put with his left hand in recruit training, after which a left ulnar neuropraxia developed (Daily Medical Record of 24 July 1986).
Neither event was investigated as a shoulder injury, but both show the demands placed on his dominant left upper limb in service, and the scrum collapse directly involved the shoulder girdle in which the tendinopathy later developed.
Rotator cuff tendinopathy with attritional partial tearing, as shown on the MRI of 23 February 2026, is the product of cumulative tendon load.
The veteran is left-hand dominant, and from the age of 16 his service loaded that shoulder heavily and repeatedly for almost seven years: working ships' lines, rope work, operating survey equipment and scrubbing decks and overhead deckheads (his member's statement of 21 October 1988), lifting steel cables and cable drums at sea in an airbase (11 and 28 March 1987), scrubbing and polishing decks in ship's husbandry (November 1990), and recruit rugby and shot put.
His only recorded work between discharge and the estimated onset was office work, so his naval service is the principal recorded heavy and overhead loading of that shoulder before onset.
The SOP loading factors are not met principally because the estimated onset, the midpoint of a 26-year gap in the records, places his service outside their time windows, not because the exposure was absent; under the DRCA, which does not depend on the SOP, this loading plausibly contributed to the condition to a significant degree.
Conclusion the veteran's left shoulder tendinopathy is a degenerative (attritional) disorder of the rotator cuff and long head of biceps of his dominant arm, caused by cumulative tendon loading.
Because its clinical onset is estimated at 29 November 2005, more than 13 years after discharge, the SOP factors for shoulder injury and occupational loading fall outside their time windows, and the only onset factor met is heavy smoking (reasonable hypothesis standard only); diabetes, smoking and the absence of timely care bear on its later, post-service worsening.
Outside the SOP, almost seven years of heavy and overhead naval work with that arm from the age of 16, including the on-duty scrum injury of 18 May 1986 with left scapular tenderness, is the principal recorded loading of the shoulder before onset and plausibly contributed to the condition to a significant degree.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left shoulder tendinopathy is found not to have arisen out of his service, the following factors address whether anything after its clinical onset (estimated 29 November 2005) aggravated it or contributed to it in a material degree.
No ADF service was rendered after that date, which is more than 13 years after his discharge on 3 October 1992, but the factors are nevertheless addressed on the facts, including the progression between the bone scan of 25 January 2019 and the MRI of 23 February 2026.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Rotator Cuff Syndrome, No.
110 of 2022) Factor 9(17): having an injury to the affected shoulder within the 30 days before the clinical worsening of rotator cuff syndrome — NOT MET - No injury to the veteran's left shoulder is recorded after the estimated onset in 2006.
The workplace accident of 22 September 2018 was recorded as a blow to the face from a falling strut with a fall onto his back and buttocks; no left shoulder pain, tenderness or restriction was recorded after it, and no worsening of the shoulder is documented in the 30 days after it.
Factor 9(18): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has not had surgery on his left shoulder at any time, so no surgical procedure preceded the worsening documented between 2019 and 2026.
Factor 9(19): 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 worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The veteran's post-service work was described as office work in the transport sector and running car yards, with "helping to load a truck" recorded only on the day of his accident on 22 September 2018, after which he has not worked; 160 hours of shoulder-elevated or forceful work in a 210-day period ending within 30 days of a documented worsening cannot be shown.
Factor 9(20): 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 worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The veteran's recorded post-service work (office work in the transport sector, running car yards, and helping to load a truck in October 2018) does not support an estimate of 4,000 hours of repetitive or sustained work with the shoulder raised to 60 degrees or more within the 10 years before the worsening documented between 2019 and 2026, and he has not worked since October 2018.
Factor 9(21): 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 worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The only recorded post-service manual handling is that the veteran was "helping to load a truck" for a transport company when injured on 22 September 2018, in work otherwise described as office work; how often he lifted loads of 20 kilograms or more is not recorded, so 400 hours within the 10 years before the worsening documented between 2019 and 2026 cannot reasonably be estimated.
Factor 9(22): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so dialysis- related amyloidosis cannot have been present.
Factor 9(23): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record that the veteran has used crutches, a wheelchair or other upper-limb weight-bearing for any continuous year; in June 2026 he stood and walked normally.
Factor 9(24): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome — NOT MET - The MRI of 23 February 2026 reported a curved (type II) acromion, a developmental shape rather than an acquired narrowing, no subacromial spur and only mild hypertrophic acromioclavicular joint degeneration, and did not report any reduction of the subacromial space.
Factor 9(25): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - No instability, dislocation or subluxation of the veteran's left shoulder joint is recorded.
The medial subluxation reported on the MRI of 23 February 2026 is of the long head of biceps tendon, not of the shoulder joint, and the labral tearing was not accompanied by any recorded instability.
Factor 9(26): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa; the small subacromial bursal effusion on the MRI of 23 February 2026 was not reported as infective, and no fever, aspiration or antibiotic treatment for the shoulder is recorded.
Factor 9(27): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome — NOT MET - None of the specified autoimmune diseases (such as rheumatoid arthritis, polymyalgia rheumatica or systemic lupus erythematosus) has been diagnosed in the veteran; no inflammatory arthritis is recorded and his sacroiliac joints were normal on imaging.
Factor 9(28): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of gout in the veteran's left shoulder or any other joint, and nothing in his history suggests it.
Factor 9(29): having diabetes mellitus before the clinical worsening of rotator cuff syndrome — MET - the veteran's diabetes mellitus was diagnosed in 2022 and is treated with Diaformin.
It preceded the worsening documented on the MRI of 23 February 2026, which showed progression from the tendinopathy suggested on the bone scan of 25 January 2019 to attritional partial tearing of the subscapularis and long head of biceps tendinopathy with medial subluxation, in a shoulder painful on abduction and overhead movement.
Diabetes impairs tendon collagen and healing and is a recognised contributor to the progression of rotator cuff disease.
This is a post-service factor, unrelated to his ADF service.
Factor 9(30): having dyslipidaemia before the clinical worsening of rotator cuff syndrome — NOT MET - No abnormal lipid results or lipid-lowering medication (such as a statin) are recorded, including on his pharmacy list of 10 June 2026, so dyslipidaemia as defined is not established.
Factor 9(31): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome — NOT MET - No systemic glucocorticoid course is recorded.
The only corticosteroids recorded are local Celestone injections of 1 mL in March and January 2019 at the right thigh, right greater trochanteric bursa and right L4/5 facet joint, and a lumbar steroid injection mentioned in 2023; none was in the left shoulder tendon region, and together they amount to well under 0.5 grams of prednisolone equivalent, so the specified doses are not reached.
Factor 9(32): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of any fluoroquinolone antibiotic at any time, including in the 60 days before the worsening documented between 2019 and 2026, and none appears on his pharmacy list of 10 June 2026.
Factor 9(33): inability to obtain appropriate clinical management for rotator cuff syndrome — MET - Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity.
No left shoulder presentation is recorded between his discharge in 1993 and 2019, and the shoulder arthropathy suggestive of tendinopathy on the bone scan of 25 January 2019, requested for his back and right leg, was followed by no recorded shoulder assessment, treatment or referral until the MRI of 23 February 2026, over seven years later, when partial subscapularis tearing and long head of biceps tendinopathy with subluxation were present.
Throughout, he had morbid obesity, chronic spinal pain, post-traumatic stress disorder with depression and anxiety and, later, an amnestic syndrome, barriers of the practical and psychological kind recognised in Brew.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Rotator Cuff Syndrome, No.
109 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(21): having an injury to the affected shoulder within the 3 months before the clinical worsening of rotator cuff syndrome — NOT MET - No injury to the veteran's left shoulder is recorded after the estimated onset in 2006.
The workplace accident of 22 September 2018 was recorded as a blow to the face from a falling strut with a fall onto his back and buttocks; no left shoulder pain, tenderness or restriction was recorded after it, and the next shoulder finding, on the bone scan of 25 January 2019, was more than 4 months later.
Factor 9(22): undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has not had surgery on his left shoulder at any time, so no surgical procedure preceded the worsening documented between 2019 and 2026.
Factor 9(23): 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 80 hours within a period of 120 consecutive days before the clinical worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The veteran's post-service work was described as office work in the transport sector and running car yards, with "helping to load a truck" recorded only on the day of his accident on 22 September 2018, after which he has not worked; 80 hours of shoulder-elevated or forceful work in a 120-day period ending within 30 days of a documented worsening cannot be shown.
Factor 9(24): 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 worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The veteran's recorded post-service work (office work in the transport sector, running car yards, and helping to load a truck in October 2018) does not support an estimate of 2,000 hours of repetitive or sustained work with the shoulder raised to 60 degrees or more within the 10 years before the worsening documented between 2019 and 2026, and he has not worked since October 2018.
Factor 9(25): 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 worsening of rotator cuff syndrome — NOT MET - No ADF service followed the estimated onset in 2006.
The only recorded post-service manual handling is that the veteran was "helping to load a truck" for a transport company when injured on 22 September 2018, in work otherwise described as office work; how often he lifted loads of 20 kilograms or more is not recorded, so 200 hours within the 10 years before the worsening documented between 2019 and 2026 cannot reasonably be estimated.
Factor 9(26): using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record that the veteran used heavy hand-held vibrating or percussive industrial tools after 2006; his post-service work was office work, running car yards and helping to load a truck in October 2018, and he has not worked since then.
Factor 9(27): having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome — NOT MET - the veteran has never had renal failure, haemodialysis or peritoneal dialysis, so dialysis- related amyloidosis cannot have been present.
Factor 9(28): regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record that the veteran has used crutches, a wheelchair or other upper-limb weight-bearing for any continuous year; in June 2026 he stood and walked normally.
Factor 9(29): having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome — NOT MET - The MRI of 23 February 2026 reported a curved (type II) acromion, a developmental shape rather than an acquired narrowing, no subacromial spur and only mild hypertrophic acromioclavicular joint degeneration, and did not report any reduction of the subacromial space.
Factor 9(30): having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome — NOT MET - No instability, dislocation or subluxation of the veteran's left shoulder joint is recorded.
The medial subluxation reported on the MRI of 23 February 2026 is of the long head of biceps tendon, not of the shoulder joint, and the labral tearing was not accompanied by any recorded instability.
Factor 9(31): having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of infection of the subacromial or subdeltoid bursa; the small subacromial bursal effusion on the MRI of 23 February 2026 was not reported as infective, and no fever, aspiration or antibiotic treatment for the shoulder is recorded.
Factor 9(32): having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome — NOT MET - None of the specified autoimmune diseases (such as rheumatoid arthritis, polymyalgia rheumatica or systemic lupus erythematosus) has been diagnosed in the veteran; no inflammatory arthritis is recorded and his sacroiliac joints were normal on imaging.
Factor 9(33): having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of gout in the veteran's left shoulder or any other joint, and nothing in his history suggests it.
Factor 9(34): having acquired scapular dyskinesis of the affected side at the time of the clinical worsening of rotator cuff syndrome — NOT MET - No winging or abnormal movement of the left scapula is recorded.
The 16 mm paralabral cyst on the MRI of 23 February 2026 lies at the glenoid and spinoglenoid notch, not in the scapulothoracic area, and the radiologist found no suprascapular nerve involvement.
Factor 9(35): having smoked at least 20 pack-years of tobacco products before the clinical worsening of rotator cuff syndrome — MET - On his own account the veteran smoked 50 cigarettes a day until he stopped in 2011, about 62.5 pack-years counted from his enlistment in 1986, and well over 20 pack-years on any reading of the record.
This preceded the worsening documented between the bone scan of 25 January 2019 and the MRI of 23 February 2026, when attritional partial subscapularis tearing and long head of biceps tendinopathy with subluxation were present.
Smoking impairs tendon blood supply and healing and is associated with progression of rotator cuff disease to tearing.
Most of this smoking occurred after his discharge.
Factor 9(36): having diabetes mellitus before the clinical worsening of rotator cuff syndrome — MET - the veteran's diabetes mellitus, diagnosed in 2022 and treated with Diaformin, preceded the worsening shown on the MRI of 23 February 2026, by which time the tendinopathy suggested on the bone scan of 25 January 2019 had progressed to attritional partial subscapularis tearing and long head of biceps tendinopathy with subluxation, with pain on abduction and overhead movement.
Diabetes impairs tendon quality and healing.
This is a post-service factor, unrelated to his ADF service.
Factor 9(37): having dyslipidaemia before the clinical worsening of rotator cuff syndrome — NOT MET - No abnormal lipid results or lipid-lowering medication (such as a statin) are recorded, including on his pharmacy list of 10 June 2026, so dyslipidaemia as defined is not established.
Factor 9(38): taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome — NOT MET - No systemic glucocorticoid course is recorded.
The only corticosteroids recorded are local Celestone injections of 1 mL in March and January 2019 at the right thigh, right greater trochanteric bursa and right L4/5 facet joint, and a lumbar steroid injection mentioned in 2023; none was in the left shoulder tendon region, and together they amount to well under 0.5 grams of prednisolone equivalent, so the specified doses are not reached.
Factor 9(39): taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record of any fluoroquinolone antibiotic at any time, including in the 60 days before the worsening documented between 2019 and 2026, and none appears on his pharmacy list of 10 June 2026.
Factor 9(40): taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical worsening of rotator cuff syndrome — NOT MET - There is no record that the veteran has ever taken an aromatase inhibitor, a drug used mainly in the treatment of breast cancer, and nothing in his history suggests it.
Factor 9(41): inability to obtain appropriate clinical management for rotator cuff syndrome — MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability includes psychological or emotional incapacity and is assessed objectively and subjectively.
The shoulder arthropathy suggestive of tendinopathy found incidentally on the bone scan of 25 January 2019 was followed by no recorded shoulder assessment, treatment or referral until the MRI of 23 February 2026, over seven years later, when partial subscapularis tearing and long head of biceps tendinopathy with subluxation were present; morbid obesity, post-traumatic stress disorder with depression and anxiety, and later an amnestic syndrome were barriers to his seeking and obtaining care
Sequelae
The left shoulder tendinopathy may be considered a sequela of the cumulative occupational and sporting loading during ADF service
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity.
No left shoulder presentation is recorded between his discharge in 1993 and 2019, and the shoulder arthropathy suggestive of tendinopathy on the bone scan of 25 January 2019, requested for his back and right leg, was followed by no recorded shoulder assessment, treatment or referral until the MRI of 23 February 2026, over seven years later, when partial subscapularis tearing and long head of biceps tendinopathy with subluxation were present.
Throughout, he had morbid obesity, chronic spinal pain, post-traumatic stress disorder with depression and anxiety and, later, an amnestic syndrome, barriers of the practical and psychological kind recognised in Brew
Date of Clinical Onset
Left shoulder tendinopathy is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with symptoms in the left shoulder: 25 January 2019 — whole body bone scan demonstrating shoulder arthropathy with tendinopathy [CHART REVIEW document].
End of ADF service: 3 October 1992.
First imaging / formal diagnosis (confirmation, not onset): 23 February 2026 (MRI of the left shoulder).
The precise date of clinical onset cannot be determined from the records.
The condition was present, and symptomatic, before it was first documented, so its clinical onset is estimated as the midpoint between the end of the veteran's ADF service (3 October 1992) and the first documented presentation with symptoms in the left shoulder (25 January 2019).
Estimated date of clinical onset: 29 November 2005.
This date falls after the veteran's ADF service (18 December 1985 3 October 1992), so the in- service events and exposures described in this report all preceded clinical onset
