Diagnostic Assessment — Lumbar Soft Tissue Injury
Example 1 of 1 · fictitious patient
Diagnostic Assessment Lumbar Soft Tissue Injury BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Boatswain's Mate from 1 July 1978 to 16 April 1985
Occupational History
As a Boatswain's Mate in the Royal Australian Navy, the veteran was required to perform physically demanding manual handling tasks aboard naval vessels and at shore establishments.
His duties included lifting heavy equipment, operating survey instruments, and performing Boatswain's Mate maintenance tasks.
The maritime working environment posed inherent risks of slipping, falling, and being struck by moving or heavy objects
History
The veteran sustained a soft tissue injury to the back on the night of 8 August 1980, when he fell directly onto his back at work; he presented the next day with mild back pain radiating to the right buttock and knee, and a lumbosacral spine X-ray showed no bone trauma.
He sustained a further soft tissue injury to the lower back on 20 September 1982 when a car fell off a jack onto his right shoulder whilst he was off duty, changing a flat tyre on his way home from work (he was then serving in a patrol boat).
The injury caused pain in the right shoulder, spine, lower back, and pain radiating down the left leg
Timeline
9 August 1980 — ABSR the veteran, as a young adult, presented after a direct fall onto his back at work the previous night, with subsequent mild back pain radiating to the right buttock and knee.
Examination showed a bruise over the right loin region, full range of motion of the back and knee, tenderness over the sacrum, SLR reduced to 50 degrees on the right and normal reflexes.
X-ray was recorded as normal.
The Medical Officer (the treating doctor) diagnosed a soft tissue injury to the back with mild irritation of the right L4 nerve root, prescribed rest, Metsal liniment and Dolobid, and excused him from duty for 2 days. "Soft tissue injury to back" 20 Sep 1982 — ABSR the veteran, as a young adult, was repairing a flat tyre on a car on his way home from work (the injury was recorded as not on duty).
The car was on a slight incline and he had placed a normal windup jack under the differential instead of the side of the car.
As he was lying on the road with his shoulders and head under the car to operate the jack, the jack shifted and the car fell, pinning him by his shoulders.
He sustained soft tissue injury to the right shoulder and lower back with pain radiating down the left leg.
Examination demonstrated right shoulder full range of motion with pain at full flexion, tenderness over the infraspinatus muscle and lateral area, and SLR of 70 degrees with hamstring tightness.
He was treated with Brufen 400mg three times daily and local heat, and placed on light duty for seven days.
The pain was subsequently exacerbated after playing football. "Soft tissue injury" 30 Sep 1982 — Admission to RANH a patrol boat for elective surgical procedures.
The admission record formally documented chronic low back pain (ICD 724.2) as a recognised secondary diagnosis, confirming that by this stage, just 10 days after the car jack incident, the lumbar pain had become chronic.
He was taking Voltaren 50mg twice daily. "Chronic low back pain"
Symptoms
Following the fall onto his back in August 1980, the veteran had mild back pain radiating to the right buttock and knee, with straight leg raise reduced to 50 degrees on the right and mild irritation of the right L4 nerve root recorded.
At the time of the September 1982 injury, he experienced pain in the right shoulder, spine, lower back, and radiating pain down the left leg.
Examination demonstrated limited straight leg raise with hamstring tightness, indicating possible nerve root irritation.
The pain was worsened by football.
Current symptoms include chronic lumbar pain with bilateral radiculopathy as documented across serial imaging and clinical presentations from 2003 to 2019
Imaging
9 August 1980 — X-ray lumbosacral spine: "No bone trauma has been demonstrated about the lumbar vertebral bodies, the disc spaces and neural foramina all have a normal appearance.
A very minor scoliosis at L.4 & 5 is convex to the left." 8 August 2003 — CT lumbosacral spine: "Right posterolateral disc herniation at L5/S1 with L5 nerve root impingement." 01 Feb 2020 — MRI lumbar spine: "High-grade facet degeneration.
L5/S1 retrolisthesis.
Left L5 nerve root contact."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Lumbar Soft Tissue Injury (ICD-10: S39.012A).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim.
A soft tissue injury encompasses damage to the muscles, ligaments, tendons, and other non- bony structures of the lumbar region.
A direct fall onto the back, as occurred at work on 8 August 1980, applies a significant force to the soft tissues of the lumbar spine; the later incident of 20 September 1982, in which a car fell onto him while he lay beneath it, applied a further compressive force to the spinal structures
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 8 August 1980 (direct fall onto the back at work on the night before presentation on 9 August 1980) [CHART REVIEW document].
A further soft tissue injury to the lower back was sustained on 20 September 1982 [ [CHART REVIEW document], pages 12 13; [CHART REVIEW document], Page 13].
When did the veteran first present to a health / medical provider for this condition? 9 August 1980.
He presented again with a further soft tissue injury to the lower back on 20 September 1982.
When was the condition confirmed / formally diagnosed? 9 August 1980 (clinical diagnosis of soft tissue injury to the back by the Medical Officer, with a lumbosacral spine X-ray the same day showing no bone trauma) [ [CHART REVIEW document], pages 72, 154].
When did the veteran first present to you (or your practice) for this condition? 11 November 2019
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was first made on clinical grounds on 9 August 1980, when the Medical Officer diagnosed a soft tissue injury to the back with mild irritation of the right L4 nerve root after a direct fall onto the back at work.
Findings were a bruise over the right loin region, tenderness over the sacrum, SLR reduced to 50 degrees on the right and normal reflexes, and a lumbosacral spine X-ray the same day showed no bone trauma, normal disc spaces and neural foramina, and a very minor scoliosis at L4 5 convex to the left [ [CHART REVIEW document], pages 72, 154].
The further soft tissue injury of 20 September 1982 was confirmed on clinical grounds by the attending medical officer at a patrol boat.
The key symptoms were acute onset of right shoulder and lower back pain with left leg radiation following a car falling onto his shoulders.
The key signs were right shoulder pain at full flexion, infraspinatus tenderness, SLR 70 degrees with hamstring tightness.
The injury was documented on both the Daily Injury Record and the PM 278 Compensation Supporting Report [ [CHART REVIEW document], pages 12 13; [CHART REVIEW document], Page 13]
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 28 September 1998 (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: Soft tissue injury is not a diagnosis named in the Sprain and Strain SOP; it is assessed under that SOP because the fall of 8 August 1980 injured the ligaments and muscles of the lower back, with pain from the time of the fall and tenderness recorded the next day.
The bruise over the right loin is a contusion, which is assessed separately.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - On the night of 8 August 1980 the veteran fell directly onto his back at work, as recorded in the Outpatient Health Record of 9 August 1980.
A direct fall onto the back applies a significant physical force through the lumbar and lumbosacral joints.
The next day he had back pain radiating to the right buttock and knee, tenderness over the sacrum, bruising over the right loin and straight leg raising reduced to 50 degrees on the right; the Medical Officer diagnosed a soft tissue injury to the back with mild irritation of the right L4 nerve root and excused him from duty for two days.
The force coincided with the clinical onset of the injury.
Factor 9(2): 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 fall onto his back at work on the night of 8 August 1980 also injured the veteran's lumbar muscles.
A sudden, uncontrolled fall forcibly stretches the lumbar paraspinal and loin muscles as they contract to break it, and the Outpatient Health Record of 9 August 1980 records bruising over the right loin and back pain radiating to the buttock, diagnosed as a soft tissue injury to the back, a diagnosis that includes the muscles.
The muscle component of the injury began with this forceful stretching.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) 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): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - The Outpatient Health Record of 9 August 1980 records that the veteran fell directly onto his back at work the night before, a significant physical force through the lumbar and lumbosacral joints.
He had tenderness over the sacrum, back pain radiating to the right buttock and knee and reduced straight leg raising, and a soft tissue injury to the back was diagnosed at that time.
Factor 9(2): 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 - When the veteran fell directly onto his back at work on 8 August 1980, his lumbar paraspinal and loin muscles were forcibly stretched as they contracted against the fall.
The Outpatient Health Record of the next day records loin bruising and back pain diagnosed as a soft tissue injury to the back, which includes the muscle injury that began with the fall.
Other Plausible Links to Service The injury arose in the course of the veteran's employment: the Outpatient Health Record of 9 August 1980 records that he fell directly onto his back 'at work' the previous night, while he was serving in a patrol boat.
An injury sustained at work meets the DRCA test of an injury arising out of, or in the course of, employment.
Service later aggravated the injury.
The fall of 2 May 1983 occurred on duty while he was scrubbing and polishing a deck at the Fleet Intermediate Maintenance Activity at Alexandria, and the injury of 20 September 1982 occurred, according to the Daily Injury Record, while he was repairing a flat tyre on his way home from work, which may bring it within the journey provisions that applied to Commonwealth employees in 1982, although the same form ticks 'No' for duty and for travelling to or from duty.
Under the DRCA, an aggravation that arises out of, or in the course of, employment is itself an injury.
The lower back had already been injured twice in service, in a rugby scrum collapse on 29 November 1978 and in lifting steel cables on 8 October 1979.
The series of in-service lumbar injuries was followed by lumbar degenerative disease, first shown on the CT of 8 August 2003 and progressing on MRI to 2019, of which this injury, with its right L4 nerve root irritation, is a contributing precursor.
Conclusion the veteran's lumbar soft tissue injury was caused by a direct fall onto his back at work on the night of 8 August 1980, a significant force that injured the ligaments and muscles of his lower back and irritated the right L4 nerve root.
After onset, further injuries during service in 1980, 1982 and 1983, including a fall on duty in May 1983, with management limited to medication and light duties until 1983, aggravated the injury into chronic low back pain.
The injury arose in the course of his service and was aggravated by it.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's lumbar soft tissue injury is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 8 August 1980 aggravated it or contributed to it in a material degree.
He served for more than four and a half years after that date.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After 8 August 1980, significant forces were again applied through the veteran's lumbar joints in service: a motor vehicle accident near Cooktown in late 1980, to which he later attributed his recurrent back pain; a car sliding off a jack onto him on 20 September 1982, with lower back pain radiating down the left leg; and a fall onto a floor polisher while scrubbing a deck on duty on 2 May 1983, with tenderness over L4 to S1.
The injury measurably worsened: 'chronic low back pain' treated with Voltaren was recorded in October 1982, and in February and June 1983 recurrent pain required light duties without lifting or driving, physiotherapy, orthopaedic review and X-rays that showed a possible L5 spondylolysis.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - After 8 August 1980 the veteran's lumbar muscles were forcibly stretched and loaded in service when a car slid off a jack onto him on 20 September 1982 as he lay beneath it, and when he slipped on wet soapy water and landed on a floor polisher while scrubbing a deck on duty on 2 May 1983; his ordinary duties of handling ships' lines, rope work and scrubbing decks also used these muscles intensively.
The injury measurably worsened, with 'chronic low back pain' on Voltaren recorded in October 1982 and, in May 1983, recurrent low back pain with movement limited in all ranges, five days' light duty, physiotherapy and orthopaedic referral.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - No follow-up was recorded of the right L4 nerve root irritation found on 9 August 1980.
The veteran's back pain recurred in 1982 and 1983 and was managed with anti-inflammatory medication and light duties, without specialist referral until May 1983, after 'chronic low back pain' had been recorded; in September 1982 the treating doctor 'no history of back problems', suggesting his earlier injuries were unknown to him.
Sea service, a command signal of 21 August 1981 suspecting him of malingering and the loss of his medical record in May 1984 were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions, so this factor is met.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) 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(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After the fall of 8 August 1980, the veteran's lumbar joints were subjected to further significant forces in service, notably a car falling from a jack onto him on 20 September 1982 and a fall onto a floor polisher on duty on 2 May 1983.
The injury worsened to chronic low back pain treated with Voltaren by October 1982 and to recurrent pain requiring light duties, physiotherapy and orthopaedic review in 1983.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - the veteran's lumbar muscles were forcibly stretched when a car fell from a jack onto him on 20 September 1982 and when he slipped and landed on a floor polisher on duty on 2 May 1983, and they were used intensively in his shipboard duties.
The injury of August 1980 worsened to chronic low back pain by October 1982 and to recurrent pain requiring light duties and physiotherapy in 1983.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - The right L4 nerve root irritation found on 9 August 1980 was not followed up, and recurrent low back pain in 1982 and 1983 was managed with medication and light duties without specialist referral until May 1983.
With sea service, the 1981 malingering signal and the loss of his medical record in 1984, this amounts to an inability to obtain appropriate clinical management under Brew v Repatriation Commission (Full Federal Court, 10 September 1999)
Sequelae
The lumbar soft tissue injury is a contributing factor to the progressive lumbar degenerative disease documented on serial imaging.
The compressive mechanism of a car falling onto the veteran's torso is a significant additional traumatic insult to the lumbar spine
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This only applies to worsening factors.
The lumbosacral spine was X-rayed on 9 August 1980, but no follow-up of the right L4 nerve root irritation was recorded, and the veteran's recurrent low back pain in 1982 and 1983, including after the car-jack incident of 20 September 1982 with pain radiating down the left leg, was managed with anti-inflammatory medication and light duties, without imaging or specialist referral until May 1983.
In September 1982 the treating doctor "no history of back problems", and a command signal of 21 August 1981 suspecting him of malingering and the loss of his medical record in May 1984 were further barriers.
As held by the Full Federal Court in Brew v Repatriation Commission (10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions — MET
Date of Clinical Onset
Lumbar soft tissue injury is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 8 August 1980 — direct fall onto the back at work, for which he presented on 9 August 1980 (a further soft tissue injury to the lower back followed on 20 September 1982) [CHART REVIEW document].
The later records, including the CT of the lumbosacral spine on 8 August 2003 and the MRI of 1 February 2020, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 8 August 1980.
This date falls within the veteran's ADF service (1 July 1978 16 April 1985).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
