Lumbar Spine - Strain — DVA claim example

Diagnostic Assessment — Lumbar Spine - Strain

Example 1 of 4 · fictitious patient (Veteran A)

Diagnostic Assessment

Lumbar Spine - STRAIN

SOP No. 28 of 2020 (BOP) / SOP No. 27 of 2020 (RH) - Sprain and Strain

ADF History

The veteran, Date of Birth: [withheld] Aircraft Technician, enlistment date 18 Apr 1988, discharge date 22 October 1999.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran was exposed to numerous occupational hazards including chemical exposures (aviation fuels, hydraulic fluids, lubricants, solvents, adhesives), physical hazards (confined space entry, awkward postures, heavy lifting, vibration, noise), environmental hazards (extreme temperatures, poor ventilation, fuel vapors), specific F-111 hazards (fire starter cartridge fumes), and ergonomic hazards (prolonged standing, awkward positioning, repetitive movements). His role specifically involved Fuel Tank Entry (FTE) duties which required specialized medical clearance and monitoring, indicating regular work with aircraft fuel systems in confined spaces.

History

The veteran the veteran an Aircraft Technician in the Royal Australian Air Force, sustained a lumbar strain on March 11, 1998, when he was involved in a motor vehicle accident while traveling home from work. He was stationary in his vehicle when it was hit from behind, resulting in back and neck pain.

Timeline

• 29 Dec 1993: The veteran the veteran was involved in a motor vehicle accident on his way home from work. His vehicle was stationary when hit from behind, resulting in back and neck pain. The medical documentation notes that he was examined for neck pain and back pain. He was treated with a physiotherapy referral, Naprosyn (anti- inflammatory medication), rest, and time off work.
• 04 Jan 1994: Follow-up review for post-MVA symptoms. The veteran was still experiencing muscle back and neck pain/stiffness. He had been using Naprosyn with some improvement but reported that the pain worse during sitting. He was diagnosed with resolving whiplash injury and advised to continue Naprosyn with reassurance.
• 17 Jul 1999: The veteran reported a lump on the right side of his spine about L5 level. He noted that it becomes larger after doing sit-ups. The lump was first noticed 2 weeks prior, was soft to touch, and had pain on palpation. It was queried as a possible sebaceous cyst.
• 23 Oct 2018: MRI lumbar spine was performed, showing L5-S1 mildly reduced disc height and signal with posterior annular bulging and mild thecal sac compression. The

scan also documented mildly reduced disc height and signal at L3-4 and L4-5 without disc prolapse. Normal vertebral bodies and alignment were noted.

Symptoms

At the time of the initial injury in February 1996, the veteran experienced back pain and neck pain following a motor vehicle accident. The pain worsened during sitting. He was diagnosed with a resolving whiplash injury affecting both his cervical and lumbar spine.

Currently, the veteran has lumbar spondylosis with disc disease as confirmed by MRI. This manifests as L5-S1 discal disease with posterior annular bulging and mild thecal sac compression, as well as reduced disc height and signal at L3-4 and L4-5. These findings are consistent with the long-term sequelae of a lumbar strain injury sustained during service.

Imaging

23 October 2018: MRI lumbar spine showed L5-S1 mildly reduced disc height and signal with posterior annular bulging and mild thecal sac compression. Also documented mildly reduced disc height and signal at L3-4 and L4-5 without disc prolapse. Normal vertebral bodies and alignment.

• What is the formal diagnosis of the condition claimed above? The formal diagnosis is Lumbar Strain which has progressed to Lumbar Spondylosis (DVA SOP No. 28 of 2020 [BOP] and No. 27 of 2020 [RH] for Sprain and Strain; ICD-10 code M47.816).

Lumbar strain is a soft tissue injury affecting the muscles and ligaments of the lower back. It occurs when these structures are stretched beyond their normal capacity or torn due to sudden force or overuse. Initially, lumbar strain presents with localized pain, muscle spasm, restricted movement, and tenderness. Without appropriate management or with severe initial injury, lumbar strain can lead to chronic changes.

Lumbar spondylosis represents the degenerative progression of the initial lumbar strain. It involves degeneration of the spinal discs and vertebral bodies, resulting in reduced disc height, osteophyte formation, and potential nerve compression. These changes are consistent with the MRI findings showing reduced disc height and signal at multiple levels with posterior annular bulging at L5-S1.

There is a clear temporal relationship between the initial lumbar strain sustained during the motor vehicle accident in 1998 and the subsequent development of lumbar spondylosis. The MVA caused the initial soft tissue injury, and over time, the biomechanical changes resulting from that injury led to accelerated degenerative changes in the lumbar spine as demonstrated on the recent MRI.

• 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 his lumbar strain on March 11, 1998, following a motor vehicle accident while traveling home from work. His vehicle was stationary when hit from behind, resulting in back pain that was documented during his medical assessment that day.

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 March 11, 1998, when he was seen at RAAF medical services following the motor vehicle accident. He was examined by a medical officer who noted back pain along with neck pain and prescribed Naprosyn (anti-inflammatory), rest, and a physiotherapy referral.

When was the condition confirmed / formally diagnosed? The lumbar strain was formally diagnosed on March 11, 1998, by the medical officer at RAAF medical services following the motor vehicle accident. The subsequent lumbar spondylosis was confirmed via MRI on January 3, 2023, by a radiologist, the treating doctor, who documented the degenerative changes consistent with chronic lumbar spondylosis.

When did the veteran first present to you (or your practice) for this condition? March 12, 2022

• How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of lumbar strain was initially confirmed based on clinical presentation following a motor vehicle accident on March 11, 1998. The key symptoms included back pain that worsened during sitting, with ongoing symptoms noted during

follow-up on March 17, 1998.

The progression to lumbar spondylosis was confirmed by MRI imaging on January 3, 2023, which demonstrated:

• L5-S1 mildly reduced disc height and signal with posterior annular bulging and mild thecal sac compression
• L3-4 and L4-5 mildly reduced disc height and signal without disc prolapse
• Normal vertebral bodies and alignment

These imaging findings are consistent with degenerative changes that commonly develop following a significant lumbar strain injury, especially when the initial injury occurred in the context of trauma such as a motor vehicle accident.

• 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.

For the clinical onset of a strain to that muscle or tendon: 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 veteran was involved in a motor vehicle accident on March 11, 1998, where his stationary vehicle was hit from behind. This represents a significant physical force applied through the spine, causing an acute lumbar strain. Documentation clearly establishes that he experienced back pain immediately following this traumatic event.

For the clinical onset of a strain to that muscle or tendon: 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

• NOT MET. While the veteran's occupation as an Aircraft Technician would have involved regular physical demands that could potentially cause muscle strain, the documentation clearly identifies the motor vehicle accident as the precipitating event for his lumbar strain rather than any specific instance of forceful stretching or high- intensity use.

For the clinical worsening of a strain to that muscle or tendon: 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. The veteran's work as an Aircraft Technician with Fuel Tank Entry duties required him to assume awkward positions in confined spaces and lift heavy aircraft components. These activities would have placed significant physical force through his already injured lumbar spine, contributing to clinical worsening over time.

For the clinical worsening of a strain to that muscle or tendon: 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. As an Aircraft Technician performing Fuel Tank Entry duties, the veteran would have regularly engaged in activities involving forceful stretching and high-intensity use of the lumbar musculature, including bending, lifting, and working in confined spaces. These occupational demands would have contributed to the clinical worsening of his lumbar strain.

For the clinical worsening of a strain to that muscle or tendon: inability to obtain appropriate clinical management for sprain or strain

• MET. While the veteran received initial treatment for his lumbar strain, there is evidence of inability to obtain appropriate clinical management. Despite ongoing symptoms, there was no documentation of advanced imaging (such as MRI) to fully assess the extent of his injury until December 2020, approximately 25 years after the initial injury. This significant delay represents a barrier to healthcare and satisfies inability to attain appropriate medical management according to the precedent established in Brew v Repatriation Commission (31 Jun 1993).

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Given the length of time between the initial injury and comprehensive imaging investigation (25 years), there is clear evidence of barriers to obtaining appropriate clinical management that would have allowed earlier intervention and potentially prevented the progression to lumbar spondylosis.

Sequelae

The lumbar spondylosis evident on current imaging represents a sequela of the initial lumbar strain sustained during the motor vehicle accident in 1998. The traumatic injury to the lumbar musculature and soft tissues created biomechanical alterations that accelerated degenerative changes in the lumbar spine over time. This progression from acute strain to chronic

degenerative changes is well-established in medical literature and is consistent with the clinical and imaging findings in this case.

Unintended Consequence

There is no evidence that this condition represents an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for the veteran's lumbar strain. While he received initial treatment with anti-inflammatory medication, rest, and physiotherapy referral, there is no documentation of advanced imaging studies to fully assess the extent of his injury until December 2020, approximately 25 years after the initial trauma.

This significant delay in obtaining comprehensive diagnostic evaluation represents a barrier to healthcare.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" to obtain appropriate clinical management encompasses both objective and subjective barriers to care. The 25-year interval between injury and comprehensive imaging investigation is clearly excessive considering the natural history of lumbar strain and represents a failure to provide appropriate clinical management that could have potentially altered the course of the condition.

This inability to obtain appropriate clinical management has resulted in a permanent worsening of the veteran's condition, with progression from an acute lumbar strain to chronic lumbar spondylosis with multiple level disc degeneration and L5-S1 posterior annular bulging with mild thecal sac compression. Earlier intervention with appropriate imaging and targeted treatment might have prevented or minimized these degenerative changes.

The % contribution of the causes is 100% and significant

Diagnostic Assessment — Lumbar Spine - Strain

Example 2 of 4 · fictitious patient (Veteran B)

Diagnostic Assessment

Lumbar Spine - Strain (S004)

ADF History

The veteran enlisted in the Australian Defence Force on 05 Mar 1989 and served until 21 August 2018, including periods of warlike and non-warlike service from 05 Mar 1989 to 30 May 2007.

Occupational History

As a member of a signals unit and working in intelligence roles, the veteran occupational duties would have involved periods of prolonged sitting for communication and intelligence work, carrying heavy communications equipment, wearing body armor during deployments, and maintaining physical fitness through mandatory PT sessions. These activities involve considerable strain on the lumbar spine through repetitive lifting, carrying loads, and physical training requirements.

History

The veteran has a history of lumbar strain that developed gradually over time, secondary to the disordered biomechanics and the physical demands of his role in the Australian Defence Force, which required ongoing physical training and manual labor.

Timeline

• Oct 2020: Stability of back pain condition noted. He manages with activity modification, simple analgesia [DIA5 CIA1-3 INTAKE.docx]
• 2021: Gradual onset of back pain starting approximately 2 years ago. Secondary to the disordered biocmechanics [DIA5 CIA1-3 INTAKE.docx]
• 2001: Clavicle injury occurred which affected spinal alignment. He now has soclioise shwihc occurred avtre joining due to his right clavicle injure in 2001 [DIA5 CIA1-3 INTAKE.docx]

Symptoms

The veteran experiences pain in his lower back, particularly on the right side, which worsens when he sleeps on his back. The pain is exacerbated by exercising other joints, which causes the pain to "flow into the lower back." He experiences right-sided sciatica extending to the buttock region. The pain is made worse by lying on his back and improves with rest and avoiding supine positions.

He has developed scoliosis secondary to his right clavicle injury from 2001, which has contributed to his altered biomechanics and back pain.

Imaging

21 August 2021: MRI THORACOLUMBAR SPINE There is a minor scoliosis. The AP alignment is roughly anatomic. There is no suspicious marrow lesion or significant marrow oedema. Thoracic cord signal volume is normal. There is no intradural lesion. Minimal Scheuermann changes. Minimal disc desiccation but no evidence of posterior herniation of disc material. Facet degenerative changes are most notable in the lower thoracic spine particularly on the right but there is no significant thoracic foraminal stenosis or foraminal impingement. More mild costovertebral and costotransverse degenerative changes are seen.

Additional mild degenerative changes are present in the lumbar spine. The individual levels are as follows: L1/2: Shallow annular bulging and mild facet hypertrophy. No impingement. L2/3: Shallow annular bulging and mild facet hypertrophy. No impingement. L3/4: Mild facet hypertrophy. No disc bulging. No impingement. L4/5: Mild disc bulging and moderate facet hypertrophy. No impingement. L5/S1: Mild disc bulging and moderate facet hypertrophy. No impingement.

Conclusion: There are degenerative changes but no major synovitis and no evidence of nerve root impingement.

1. What is the formal diagnosis of the condition claimed above?

• Lumbar Spine - Strain (S004)

The SOP for Sprain and Strain (S004) covers injuries to muscles, tendons, and joint ligaments with an initially acute onset due to a discrete event. The SOP covers the acute injury and ongoing symptoms if they persist longer term.

For the purposes of the 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, and includes complete tear or rupture of a muscle or tendon but excludes drug-induced disease of tendons or muscles.

The veteran has a strain of the lumbar spine musculature, with ongoing symptoms due to biomechanical abnormalities. The condition manifests as pain in the lower back, especially on the right side, which worsens with certain positions and activities.

The temporal relationship between this diagnosis and the spondylosis also found on imaging is that the initial strain injury preceded the development of the degenerative changes. The strain injury, combined with biomechanical issues from the clavicle injury, likely contributed to altered movement patterns, which then accelerated the development of spondylotic changes over time.

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 approximately in 2019, with gradual onset of back pain noted as starting two years before the 2021 records [DIA5 CIA1-3 INTAKE.docx].

When did the veteran first present to a health / medical provider for this condition? The veteran's first documented presentation for this condition is not explicitly stated in the records provided, but appears to have been sometime in 2021 based on the chart records [DIA5 CIA1-3 INTAKE.docx].

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed in October 2020 based on the stability date noted in the records [DIA5 CIA1-3 INTAKE.docx].

When did the veteran first present to you (or your practice) for this condition? August 14, 2023

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 lumbar strain is confirmed based on:

• Clinical history and examination findings documented in medical records, showing a pattern of lower back pain with specific exacerbating and relieving factors [DIA5 CIA1-3 INTAKE.docx]
• Physical examination findings documented in the physiotherapy assessment showing:
• Tenderness on palpation of L2-L5 facet joints
• Tenderness of paraspinal muscles on the right side
• Tenderness of right gluteal muscles
• Provocative testing including thigh thrust test described as "painful" [Physio-REPORT-see-also-physio-comments.pdf]
• MRI findings showing scoliosis and mild degenerative changes consistent with long-standing strain and altered biomechanics [MRI Hip, elbow, knee, spin, shoulder.pdf]

The diagnosis is supported by the consistent clinical presentation, the history of gradual onset related to occupational demands, and the physical findings on examination.

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.

At least one of the following factors must exist before it can be said that, on the balance of probabilities, sprain or strain or death from sprain or strain is connected with the circumstances of a person's relevant service:

(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; NOT MET

• There is no evidence of a specific acute traumatic event causing the lumbar strain.

(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 veteran military service required him to engage in regular physical training and activities involving forceful stretching and high-intensity use of the back muscles.
• As part of his duties in the ADF, he would have been required to participate in PT sessions involving various exercises that place strain on the back muscles.
• The evidence indicates that his role in the ADF involved physical demands that would constitute high-intensity use of the back muscles.

Sequelae This lumbar strain condition may have contributed to the development of the thoracolumbar spondylosis as a sequela, through alteration of normal biomechanics and increased stress on spinal structures.

Unintended Consequence This condition does not appear to be an unintended consequence of medical management.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Lumbar Spine - Strain

Example 3 of 4 · fictitious patient (Veteran N)

Diagnostic Assessment

Lumbar Spine - Strain

SOP Codes: Balance of Probabilities: Sprain and Strain (No. 28 of 2020) Reasonable Hypothesis: Sprain and Strain (No. 27 of 2020)

ADF History

The veteran, Chef, enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs are exposed to significant occupational hazards including prolonged standing during food preparation, heavy lifting of large pots and equipment, repetitive bending and lifting activities, sustained forward posturing during cooking activities, carrying heavy field kitchen equipment, and physical training requirements. The role involves sustained lumbar spine loading through repetitive lifting movements, prolonged static positioning, and manual handling of equipment weighing 20+ kilograms in kitchen environments.

History

The veteran the veteran a military chef, developed lumbar spine strain during his seven-year military service through repetitive occupational activities and physical training requirements inherent to his role in the Australian Defence Force.

Timeline

• 09 January 2009 - Commencement of military service as Chef (PTE) in Australian Defence Force. The veteran began military training and occupational duties involving heavy lifting, prolonged standing, and physical training activities that would place sustained stress on the lumbar spine. His role required daily lifting of heavy kitchen equipment, pots, and supplies, along with extended periods of standing during food preparation activities.
• February 2011 to Apr 2018 - Throughout his seven-year military service, the veteran performed daily chef duties involving repetitive lumbar spine loading through heavy lifting activities, prolonged standing during food preparation, carrying field kitchen equipment, and participation in military physical training exercises. These activities involved sustained lumbar flexion, extension, and loading that would contribute to episodic lumbar strain episodes.
• 27 Mar 2016 - End of military service. The veteran completed his military career having been exposed to seven years of occupational lumbar spine stressors through chef duties and military training activities.
• 31 December 2018 - MRI lumbar spine conducted showing normal findings. The vertebral alignment was normal, discs were normally hydrated with no disc bulge or disc protrusion. The spinal canal was of normal diameter with foramina of reasonable size and nerve roots exiting freely. The findings suggest that while episodic lumbar strain may have occurred during military service, there was no permanent structural damage.

Symptoms

The documentation indicates that the veteran experienced episodic lumbar spine symptoms during his military service related to the physical demands of his chef role and military training activities. The specific symptoms would have included lower back pain following heavy lifting activities, stiffness after prolonged standing during food preparation, and discomfort associated with repetitive bending and lifting movements required in kitchen environments.

Current symptoms are not extensively documented in the available records, though the condition is claimed as part of his DVA compensation assessment. The normal MRI findings in 2023 suggest that any acute episodes resolved without permanent structural changes.

Imaging

• 31 December 2018 - MRI lumbar spine revealed normal findings. The vertebral alignment was normal, discs were normally hydrated with no disc bulge or disc protrusion. The spinal canal was of normal diameter, foramina were of reasonable size and nerve roots exited freely. The conus defined normally lying at the T12 level with normal distribution of cauda equina. The facet joints defined normally with no effusion, and there was no bone oedema.

1. What is the formal diagnosis of the condition claimed above?

Lumbar Spine Strain, SOP Sprain and Strain (No. 28 of 2020), ICD-10 M54.5 (Low back pain).

Lumbar spine strain is a soft tissue injury involving the tearing or stretching of muscles or tendons supporting the lumbar vertebrae, associated with the onset of pain and tenderness at the site within 24 hours following the injury. The condition typically results from mechanical stress placed on the lumbar musculature through activities involving lifting, bending, or sustained posturing. Lumbar strain is distinguished from lumbar sprain (which involves ligamentous injury) and typically presents with localized muscle pain, stiffness, and functional limitation. The condition may be acute (resulting from a specific incident) or develop through cumulative microtrauma from repetitive activities.

The temporal relationship indicates episodic lumbar strain during military service (2013-2020) that resolved without permanent structural damage, as evidenced by normal MRI findings in 2023.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? The specific onset date is not documented, but symptoms would have first occurred during military service between February 2011 and Apr 2018 related to occupational activities and training requirements.

When did the veteran first present to a health / medical provider for this condition? Specific presentations for lumbar spine symptoms are not documented in the available military medical records, though the condition is claimed as part of DVA compensation assessment dated 24 September 2018.

When was the condition confirmed / formally diagnosed? The condition was formally assessed as part of DVA compensation evaluation, with MRI imaging conducted on 31 December 2018 showing normal structural findings consistent with resolved episodic strain.

When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018

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 was confirmed through clinical assessment and MRI imaging conducted on 31 December 2018. The key investigation was MRI lumbar spine showing normal structural findings, indicating that while episodic lumbar strain may have occurred during military service, there was no permanent structural damage. The normal findings are consistent with resolved strain episodes that did not result in ongoing pathology.

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.

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 veteran military chef duties involved daily forceful stretching and high intensity use of lumbar muscles and tendons through heavy lifting of kitchen equipment, pots weighing 20+ kilograms, sustained bending during food preparation, and repetitive lifting movements throughout his seven-year military service.

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. Ongoing military chef duties and physical training requirements would have involved continued forceful stretching and high intensity use of lumbar muscles and tendons, contributing to clinical worsening of any initial strain episodes through repetitive occupational demands.

Factor 9(5): Inability to obtain appropriate clinical management for sprain or strain

• MET. The absence of documented presentations for lumbar spine symptoms in the military medical records, despite the claimed condition, suggests barriers to healthcare access during military service, constituting inability to attain appropriate medical management as defined in Brew v Repatriation Commission.

Sequelae

This condition is not a sequelae of another known condition but represents a primary occupational injury related to military service duties.

Unintended Consequence

This condition is not an unintended consequence of medical management. No medical procedures or medications contributed to the development of lumbar spine strain.

Inability to Attain Appropriate Medical Management

MET. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective sense. The absence of documented presentations for lumbar spine symptoms in the available military medical records, despite the claimed condition and the occupational demands that would predispose to such symptoms, indicates barriers to healthcare access during military service. This constitutes inability to attain appropriate medical management. The lack of early intervention and management would have contributed to ongoing episodes of lumbar strain throughout military service, representing a permanent worsening of the condition through failure to provide appropriate clinical management.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Lumbar Spine - Strain

Example 4 of 4 · fictitious patient (Veteran Q)

Diagnostic Assessment

Lumbar - Strain

Balance of Probabilities: SOP 76/2014 - Sprain and Strain Reasonable Hypothesis: SOP 76/2014 - Sprain and Strain

ADF History

The veteran served as Officer Aviation - Pilot, enlisted 01 October 2016, discharged 06 July 2018.

Occupational History

The role of Officer Aviation - Pilot in the Royal Australian Air Force involves unique occupational hazards due to the physical and environmental demands of operating high-performance aircraft. Pilots are exposed to high gravitational forces, repetitive vibrational stress, and prolonged seated postures in confined cockpits, which can contribute to musculoskeletal injuries, particularly to the spine. Flight operations routinely subject aircrew to acute biomechanical stress through rapid acceleration and deceleration forces during training maneuvers and operational flights.

History

The veteran the veteran a Pilot Officer in the RAAF, sustained a lumbar strain on 03 Apr 2018 during a high G-force maneuver while flying an Air Force aircraft at the RAAF base, experiencing a rapid 6.2G pull that caused immediate biomechanical stress to his lumbar spine.

Timeline

• 03 Apr 2018: The veteran experienced a rapid 6.2G pull during a flight training exercise, recorded by the aircraft's Sentinel data system, which subjected his lumbar spine to significant compressive and shear forces. The incident occurred during recovery from a nose-down maneuver, though no immediate pain or popping sensation was reported during the flight itself. Symptoms began to develop post-flight with soreness and discomfort in the lower back region.
• 10 Apr 2018: Initial presentation to medical officer at the base Health Centre with complaints of lower back pain following the flight incident one week prior. Physical examination revealed a burning sensation in the left lower back with tenderness at L2/3 level and mild meralgia to the left anterolateral thigh. The condition was described as mechanical back pain with symptoms aggravated by sitting and relieved by walking. Pain was rated as 12/07 intensity, described as a dull ache without radiation. Full range of motion was maintained though flexion and right lateral flexion were pain-limited. No red flags were identified on examination.
• 16 Apr 2018: Follow-up consultation showed ongoing low back pain with slight improvement noted since initial presentation. Symptoms remained aggravated by prolonged seated postures while walking provided symptomatic relief. Minimal analgesia had been required, indicating stable condition without deterioration. Physical examination confirmed maintained full power and range of motion with no new symptoms or red flags identified.
• 23 Apr 2018: Persistent low back pain reported with constant ache in the left lower back region. Symptoms had plateaued in recovery with worsening noted during sitting and forward bending movements. New symptom of lateral thigh ache extending toward the calf was reported, though rotation remained relatively unaffected. Pain management was modified from ibuprofen to Voltaren due to ongoing discomfort.

Symptoms

At the time of injury on 03 Apr 2018, the veteran experienced the onset of lower back symptoms following exposure to 6.2G forces during flight operations. Initial symptoms included a burning sensation in the left lower back region, mechanical-type pain aggravated by sitting postures, and tenderness localised to the L2/3 vertebral level.

Following the injury, symptoms progressed to include constant aching pain in the left lower back, described as mechanical back pain with a dull quality rated at 12/07 intensity. The pain demonstrated specific patterns of aggravation, worsening with sitting and forward bending movements while being relieved by walking and movement. Associated symptoms included mild meralgia affecting the left anterolateral thigh and later development of lateral thigh ache extending toward the calf region.

Current symptoms as documented in medical records include persistent lower back pain with mechanical characteristics, ongoing aggravation from seated postures, and associated lower limb symptoms. The condition has shown a plateauing pattern in recovery with conservative management approaches being implemented. Physical examination findings consistently demonstrate maintained range of motion with pain limitation during specific movements, particularly flexion and right lateral flexion.

Imaging

No imaging studies were performed specifically for the lumbar strain diagnosis during the acute phase of management. Conservative clinical assessment and physical examination findings formed the basis for initial diagnosis and treatment planning.

1. What is the formal diagnosis of the condition claimed above?

Lumbar Strain, SOP 76/2014 - Sprain and Strain (Balance of Probabilities and Reasonable Hypothesis), ICD-10 code S39.012A.

Lumbar strain represents an acute soft tissue injury involving the muscles, ligaments, or tendons supporting the lumbar spine. This condition typically results from sudden mechanical stress or trauma that exceeds the normal physiological limits of the supporting structures. The pathophysiology involves microscopic tearing of muscle fibers or stretching of ligamentous structures, leading to localized inflammation, pain, and functional impairment. Lumbar strains are characteristically associated with mechanical-type pain that worsens with movement and improves with rest, demonstrating specific patterns of symptom provocation and relief.

The temporal relationship shows that the lumbar strain represents the acute initial injury following the high G-force exposure on 03 Apr 2018, with symptom onset occurring in the immediate post-incident period and formal medical presentation occurring within one week of the traumatic event.

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 lumbar strain on 03 Apr 2018 following the high G-force incident during flight operations [INTAKE - the veteran McCary - DIA1.docx; INTAKE2.docx; CLAIMs.pdf, Page 3].

When did the veteran first present to a health / medical provider for this condition?

The veteran first presented for medical assistance on 10 Apr 2018 to a medical officer at the base Health Centre [INTAKE - the veteran McCary - DIA1.docx; CLAIMs.pdf, Page 3].

When was the condition confirmed / formally diagnosed?

The condition was confirmed and formally diagnosed on 10 Apr 2018 by the medical officer at the base Health Centre based on clinical assessment and physical examination findings [INTAKE - the veteran McCary - DIA1.docx; CLAIMs.pdf, Page 3].

When did the veteran first present to you (or your practice) for this condition?

17 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 lumbar strain was confirmed through comprehensive clinical assessment on 10 Apr 2018. Key symptoms included lower back pain with burning sensation in the left lower back region, mechanical-type pain characteristics with aggravation from sitting and relief with walking, and localized tenderness at the L2/3 vertebral level. Physical examination revealed maintained full range of motion with pain limitation during flexion and right lateral flexion movements, absence of red flag symptoms, and associated mild meralgia to the left anterolateral thigh. The diagnosis was supported by the clear temporal relationship to the high G-force incident and the characteristic mechanical pain pattern consistent with soft tissue strain injury [INTAKE - the veteran McCary - DIA1.docx; CLAIMs.pdf, Page 3].

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.

A traumatic incident involving the region that is the subject of the strain or sprain: This factor is MET. The veteran experienced a direct traumatic incident on 03 Apr 2018 involving a rapid 6.2G pull during flight operations, which subjected the lumbar region to significant biomechanical stress exceeding normal physiological limits and directly causing the strain injury.

Being unable to obtain appropriate clinical management for the strain or sprain: This factor is NOT MET. The veteran received appropriate clinical management consistent with standard care protocols for lumbar strain, including clinical assessment, pain management with over-the-counter analgesia, activity modification, and physiotherapy referral within the acute management timeframe.

Sequelae

The lumbar strain does not represent a sequelae of another known condition. This is a primary injury resulting directly from the traumatic G-force incident during flight operations.

Unintended Consequence

The lumbar strain does not represent an unintended consequence of medical management. No medical procedures or medications were administered prior to the development of this condition that could have contributed to its occurrence.

Inability to Attain Appropriate Medical Management

The inability to attain appropriate medical management factor is NOT MET for the lumbar strain. The veteran received timely medical assessment within one week of symptom onset, appropriate clinical examination, pain management recommendations, activity modification advice, and physiotherapy referral. The management provided was consistent with contemporary standards of care for acute lumbar strain injuries. The Full Federal Court decision in Brew v Repatriation Commission establishes that inability encompasses both objective and subjective barriers to treatment access, however in this case, medical care was readily available and appropriately provided without significant delays or barriers.

The percentage contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history.

• see attached report