Diagnostic Assessment — Lumbar Sprain
Example 1 of 1 · fictitious patient
Diagnostic Assessment Lumbar Sprain 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 Australian Army as a Rifleman from 14 July 1987 to 29 April 1994.
He enlisted as a young adult and was discharged after several years of service
Occupational History
As a Rifleman in the Australian Army, the veteran was employed in physically demanding duties that included manual handling of heavy equipment such as steel cables and survey instruments, operating aboard service vessels in a maritime environment with exposure to wet and moving decks, and performing manual labour associated with Rifleman duties.
His occupation required repetitive bending, lifting, twisting, and carrying of heavy loads in confined and unstable environments.
He was posted to an infantry battalion (recruit training), an infantry battalion (survey vessel), an infantry battalion, an infantry battalion (survey vessel), an infantry battalion, and an infantry battalion across the course of his service
History
The veteran sustained a sprain of the lumbar spine during service in the Australian Army on approximately 12 December 1987 when he injured his back and neck playing rugby at an infantry battalion during initial recruit training.
It occurred approximately five months after enlistment as a young adult and was not his first back injury: on 20 October 1987 a lumbar back strain had been recorded after he was tackled heavily at rugby three days earlier.
He sustained a further soft tissue injury to the back on the night of 21 August 1989, when he fell directly onto his back at work.
In February and June 1992 he was reviewed by Consultant Orthopaedic Surgeon the treating doctor recurrent low back pain, and X-rays of 15 May 1992 were reported as showing query spondylolysis at L5 with no spondylolisthesis
Timeline
20 Oct 1987 — Rifleman the veteran, as a young adult, presented at an infantry battalion with aching of the back on parade after being tackled heavily at rugby three days earlier.
Examination showed slight tenderness of the lumbar spine with full range of movement and normal straight leg raising, and he was treated with Brufen. "Lumbar back strain" 12 Dec 1987 — Rifleman the veteran, as a young adult, injured his back and neck while playing rugby at an infantry battalion during initial recruit training.
A scrum collapsed on top of him, causing ligamentous injury to the cervical and lumbar spine.
Examination demonstrated tenderness over the cervical and lumbar spine with paraspinal muscles and reduced range of motion.
He was prescribed Brufen (ibuprofen) and placed on light duty for 3 days.
No investigations were performed at the time of the initial presentation.
It followed the lumbar back strain of 20 October 1987 and was the first documented ligamentous injury of the cervical and lumbar spine during ADF service. "Ligamentous back injury" 22 August 1989 — 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" 21 May 1992 — ABSR the veteran, as a young adult, was reviewed by Consultant Orthopaedic Surgeon the treating doctor, having been referred by the Medical Officer (the treating doctor) on 18 May 1992 for recurrent low back pain due to a motor vehicle accident three years earlier.
He reported back trouble on and off since the accident, aggravated by a fall over a floor polisher one week earlier, with pain in the low lumbar region, right buttock and testicles.
Examination showed forward flexion to mid tibia, extension firm at extremes, side-to-side movement painful but of good range, and no neurological deficit.
He was having physiotherapy (mainly heat) and was on light duties with no lifting or driving. "back trouble on and off since MVA 3 years ago" 18 Jun 1992 — At orthopaedic review by Consultant Orthopaedic Surgeon the treating doctor, X-rays of 15 May 1992 were reported as showing query spondylolysis at L5 with no spondylolisthesis.
ABSR the veteran reported that his pain was improving and he was having daily physiotherapy.
Examination showed good range of motion and no neurological deficit.
Feldene was continued and physiotherapy was reduced to twice weekly. "L5 ? spondylolysis.
No spondylolisthesis."
Symptoms
At the time of the injury, the veteran experienced acute pain over the lumbar and cervical spine with tenderness of the paraspinal muscles and reduced range of spinal motion.
He was placed on light duty for 3 days, indicating functional impairment sufficient to preclude normal duties.
Further in-service records document mild back pain radiating to the right buttock and knee after a fall onto his back at work in August 1989, and, in May 1992, back trouble on and off since a motor vehicle accident three years earlier, with pain in the low lumbar region, right buttock and testicles.
Current symptoms include chronic lumbar pain with bilateral sciatica, reduced mobility, and functional impairment documented across serial imaging from 2012 through 2018 demonstrating progressive multilevel lumbar degeneration, facet arthropathy, synovial cyst formation, paraspinal denervation, and retrolisthesis
Imaging
22 August 1989 — X-ray at presentation with soft tissue injury to the back: "Xray - normal" 15 May 1992 — X-rays (reported at orthopaedic review on 18 Jun 1992): "L5 ? spondylolysis.
No spondylolisthesis." 20 August 2012 — CT lumbosacral spine: "Right posterolateral disc herniation at L5/S1 with L5 nerve root impingement.
Multilevel degenerative changes." 10 Jan 2020 — X-ray lumbar spine: "Multilevel degenerative disc disease particularly at lower lumbar levels.
Mild facet osteoarthropathy.
Gentle scoliosis convex to the left." 19 May 2020 — MRI lumbosacral spine: "Multilevel disc degeneration with moderate left L5/S1 facet arthropathy.
Multiple endplate Schmorl's nodes consistent with Scheuermann's disorder." 20 August 2020 — Bone scan: "Moderate focal uptake in right L4/5 facet joint." 26 Apr 2023 — MRI lumbosacral spine: "Development of new left L5/S1 facet joint synovial cyst causing mild thecal indentation." 05 Oct 2024 — MRI lumbosacral spine: "Progressive left L5/S1 facet arthropathy with 9mm synovial cyst.
New denervation oedema and fatty atrophy in left sacral paraspinal musculature." 13 Feb 2019 — MRI lumbar spine: "High-grade right L4/5 and left L5/S1 facet degeneration.
Left L5/S1 synovial cyst persistent.
L5/S1 4mm retrolisthesis.
Left L5 nerve root contact."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Lumbar Sprain (ICD-10: S33.5XXA).
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 sprain is defined as a stretching or tearing of a ligament, which is the fibrous tissue that connects bones to other bones at a joint.
Lumbar sprains involve damage to the ligaments of the lumbosacral spine and are commonly caused by acute traumatic events such as falls, sports injuries, or sudden forceful movements that place excessive stress on the spinal ligaments.
The condition may result in localised pain, tenderness, muscle spasm, and reduced range of motion.
The lumbar sprain is temporally and anatomically related to the subsequent development of lumbar spondylosis and degenerative disc disease, as acute ligamentous injury to the spine is a well-recognised precursor to accelerated degeneration
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 12 December 1987 [ [CHART REVIEW document], pages 16 17] When did the veteran first present to a health / medical provider for this condition? Approximately 12 December 1987 When was the condition confirmed / formally diagnosed? Approximately 12 December 1987 When did the veteran first present to you (or your practice) for this condition? 23 November 2018
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending medical officer at an infantry battalion following the rugby injury.
The key symptoms were pain in the lumbar and cervical spine following an acute traumatic event during a rugby game.
The key signs on examination were tenderness over the cervical and lumbar spine with paraspinal muscle involvement and reduced range of spinal motion.
No imaging was performed at the time, which was consistent with the standard conservative management approach for acute sprain injuries in the military medical setting of the 1980s.
The diagnosis was recorded as "ligamentous back injury" on the Daily Injury Record, which records that he injured his back and neck playing rugby, with tenderness of the cervical and lumbar spine [ [CHART REVIEW document], pages 16 17].
Later in-service records document further lumbar injury and recurrent symptoms.
On 22 August 1989 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, with tenderness over the sacrum, SLR reduced to 50 degrees on the right, normal reflexes and a X-ray recorded as normal [CHART REVIEW document].
In February and June 1992 Consultant Orthopaedic Surgeon the treating doctor recurrent low back pain, finding no neurological deficit, and X-rays of 15 May 1992 were reported as showing query spondylolysis at L5 with no spondylolisthesis [ [CHART REVIEW document], pages 103 104]
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.
Legislation: The clinical onset of this condition was before 11 October 2007 (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.
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 12 December 1987, while the veteran was playing organised rugby as an adult Rifleman at an infantry battalion, a scrum collapsed on top of him, as recorded in the Compensation Supporting Report.
The weight of the collapsing scrum bore down on his back and applied a significant physical force through the joints of the lumbar spine.
When he was examined on 14 December 1987 the Medical Officer found tenderness of the cervical and lumbar spine and the paraspinal muscles with reduced range of movement, diagnosed a 'ligamentous back injury' and ordered three days' light duty.
The force was applied at the time of the clinical onset of the lumbar sprain.
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 scrum collapse of 12 December 1987 at an infantry battalion, in which a scrum fell on top of the veteran during organised rugby, also strained the muscles of his lower back.
The weight of the scrum forcibly stretched the paraspinal muscles as they contracted against the load, and on 14 December 1987 the Medical Officer recorded tenderness of the paraspinal muscles as well as of the cervical and lumbar spine, with reduced range of movement.
The ligamentous injury was therefore accompanied by a strain of the lumbar paraspinal muscles, which 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 Compensation Supporting Report and Daily Injury Record of 12 December 1987 record that a scrum collapsed on top of the veteran during organised rugby at an infantry battalion, injuring his back and neck.
The weight of the scrum applied a significant physical force through the lumbar spinal joints, and the Medical Officer found lumbar spinal tenderness with reduced movement and diagnosed a ligamentous back injury arising 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 a scrum collapsed on top of the veteran during organised rugby at an infantry battalion on 12 December 1987, his lumbar paraspinal muscles were forcibly stretched under the load.
The Daily Injury Record records tenderness of the paraspinal muscles as well as the spine, so the ligamentous injury was accompanied by a muscle strain that began at that time.
Other Plausible Links to Service The lumbar sprain arose in the course of the veteran's employment as a member of the Australian Army.
The Compensation Supporting Report of 12 December 1987 records that he was on duty, in organised sport, when the scrum collapsed on top of him; he was then a 16- year-old Rifleman in initial training at an infantry battalion.
Under the DRCA, an injury arising out of, or in the course of, employment is compensable without reference to the SOP.
It was his second lower back injury in recruit rugby within two months: on 20 October 1987 a lumbar back strain was recorded after he had been tackled heavily at rugby three days earlier, with his back aching on parade.
Service then aggravated the injury.
The later lumbar injuries of 20 October 1988 (lifting steel cables during survey work at sea in an infantry battalion), 21 August 1989 (a fall at work) and 14 May 1992 (a fall while scrubbing and polishing a deck on duty) arose in the course of his duties, and the injury of 3 October 1991 occurred, according to the Daily Injury Record, while he was repairing a flat tyre on his way home from work, 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, so these in-service aggravations are a further basis of liability.
The series of in-service lumbar injuries that began with this sprain was followed by degenerative disease of the lumbar spine: the CT of 20 August 2012 showed a probable L5/S1 disc herniation impinging on the right L5 nerve root, with facet arthropathy, and MRI from 2020 to 2018 shows progressive multilevel disc degeneration, facet arthropathy, a left L5/S1 synovial cyst and L5/S1 retrolisthesis.
Trauma to the lumbar spine is a recognised contributor to later lumbar spondylosis, so that degenerative disease is in part a sequela of this sprain and of the service injuries that followed it.
Conclusion the veteran's lumbar sprain was caused by the significant force of a rugby scrum collapsing on top of him on 12 December 1987, while he was on duty in organised sport as an adult Rifleman at an infantry battalion; the same event strained his lumbar paraspinal muscles.
After onset, service aggravated the condition through further lumbar injuries during service in 1988, 1989, 1991 and 1992, most of them on duty, and through recurrent presentations managed without timely investigation, leading to chronic low back pain in service and later lumbar degenerative disease.
The sprain 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 sprain is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 12 December 1987 aggravated it or contributed to it in a material degree.
He served for more than six years after that date, during which further lumbar injuries and recurrent, then chronic, low back pain were recorded.
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 the sprain of 12 December 1987, further significant forces passed through the veteran's lumbar joints during service: a direct fall onto his back at work on 21 August 1989, a motor vehicle accident in 1989 to which he later attributed his recurrent back pain, a car sliding off a jack onto him on 3 October 1991, and a fall onto a floor polisher while scrubbing a deck on duty on 14 May 1992.
The condition measurably worsened: right L4 nerve root irritation in August 1989, 'chronic low back pain' treated with Voltaren by October 1991, and in 1992 recurrent pain requiring light duties without lifting, physiotherapy, orthopaedic review and X- rays showing 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 12 December 1987 the veteran's lumbar muscles were forcefully used in his duties as a Rifleman.
On 20 October 1988, at sea in an infantry battalion, he bent over to lift steel cables and strained his lower back, and the Daily Medical Record of 21 October 1988 diagnosed 'pulled' lumbar musculature from lifting cable drums the day before, with numbness down the leg; he was placed on light duty and then off duty for two days.
His routine work of handling ships' lines, rope work and scrubbing decks continued to load these muscles, and the condition progressed to recurrent and then chronic low back pain treated with anti- inflammatory medication from 1988 to 1992.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - the veteran's low back pain, recorded in 1987, 1988, 1989, 1991 and 1992, was managed each time with anti-inflammatory medication, liniment and light or excused duties, with one plain X-ray in August 1989 and no specialist referral until May 1992, after 'chronic low back pain' had been recorded; in September 1991 the treating doctor 'no history of back problems', suggesting his earlier injuries were unknown to him.
Sea service, a command signal of 3 September 1990 suspecting him of malingering and the loss of his medical record in May 1993 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 12 December 1987 the veteran sustained further significant forces through the lumbar spine during service, including a fall onto his back at work on 21 August 1989, a car falling from a jack onto him on 3 October 1991 and a fall onto a floor polisher on duty on 14 May 1992.
The sprain worsened to chronic low back pain treated with Voltaren by October 1991 and to recurrent pain requiring light duties, physiotherapy and orthopaedic review in 1992.
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 - On 20 October 1988 the veteran strained his lumbar muscles lifting steel cables at sea in an infantry battalion, recorded the next day as 'pulled' lumbar musculature, a forceful use of the same muscles after the onset of the injury of 12 December 1987.
With his continuing heavy deck and rope work, this was followed by recurrent and then chronic low back pain through to 1992.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - the veteran's recurrent low back pain from 1987 to 1992 was managed with anti- inflammatory medication and light duties, with one plain X-ray in August 1989 and no specialist referral until May 1992, despite chronic pain recorded in 1991.
Sea service, a 1990 command signal suspecting malingering and the loss of his medical record in 1993 were further barriers which, under the principles in Brew v Repatriation Commission (Full Federal Court, 10 September 1999), amount to an inability to obtain appropriate clinical management
Sequelae
The lumbar sprain of December 1987 was one of a series of in-service injuries to the lower back: it followed a lumbar strain from a rugby tackle recorded on 20 October 1987 and was followed by further injuries in 1988, 1989, 1991 and 1992, with chronic low back pain recorded by October 1991.
The veteran's later lumbar spondylosis, with multilevel disc degeneration, facet arthropathy, a left L5/S1 synovial cyst and L5/S1 retrolisthesis on imaging from 2012 to 2018, is in part a sequela of this sprain and of the service injuries that followed it, as trauma to the lumbar spine is a recognised contributor to later spondylosis
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 lumbar sprain was managed conservatively with NSAIDs and light duties, without imaging or specialist referral.
The recurrent presentations with lumbar pain throughout the remainder of service (1988, 1989, 1991, 1992) were managed conservatively, with investigation limited to plain X-rays (22 August 1989 and 15 May 1992) and orthopaedic review by the treating doctor in February June 1992, representing a pattern of inadequate medical management that may have contributed to the progression from acute sprain to chronic degenerative disease — MET.
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.
In the veteran's case the treating doctor "no history of back problems" in September 1991, suggesting that his earlier injuries were unknown to him, and further barriers were sea service in survey ships, a command signal of 3 September 1990 suspecting him of malingering, and the loss of his medical record in May 1993
Date of Clinical Onset
Lumbar sprain 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: approximately 12 December 1987 — ligamentous back injury sustained playing rugby at an infantry battalion [ [CHART REVIEW document], pages 16 17].
The later records, including the CT of the lumbosacral spine on 20 August 2012 and later lumbar imaging, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: approximately 12 December 1987.
This date falls within the veteran's ADF service (14 July 1987 29 April 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
