Lumbar Strain

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Lumbar Strain

Example 1 of 2 · fictitious patient (Veteran I)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

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

ADF History

The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly documented in records (ongoing service indicated up to at least 2021).

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran was responsible for maintenance, repair, and servicing of aircraft and associated systems. This role involved working in high-risk environments such as flight lines, engine bays, and maintenance hangars, exposing him to significant occupational hazards including heavy lifting, repetitive movements, awkward postures, prolonged kneeling or bending, and physical stressors requiring forceful stretching and high-intensity use of lumbar muscles and tendons inherent to military aviation maintenance.

History

The veteran an Aircraft Technician in the RAAF, sustained multiple episodes of lumbar strain beginning on 03 Jan 1985 during a touch football game, presenting with acute right lower back injury and muscle spasm. He subsequently experienced recurrent episodes of lumbar strain related to physical training and occupational activities throughout his military career.

Timeline

03 Jan 1985 - the veteran presented with acute right lower back pain and muscle spasm following touch football, a recreational activity encouraged in military settings. Clinical examination confirmed acute strain with muscle spasm and radiating pain to the hamstring. The injury occurred during sudden twisting or overextension during sport, representing forceful stretching of lumbar muscles. An X-ray was requested and analgesia prescribed. This incident reflects the occupational requirement to maintain physical fitness standards necessary for military service.
14 Jan 1986 - the veteran reported acute lower back trauma following a fall during mandatory physical training. The pain was localized to the lumbar region with reduced range of motion, representing strain to lumbar muscles from impact. Clinical assessment diagnosed lumbar strain with analgesia and rest prescribed. The injury resulted from forceful impact and subsequent muscle strain during compulsory military training activities.
03 Mar 1988 - Following an 8 km run as part of military fitness requirements, the veteran presented with lumbar muscular strain causing pain and stiffness. Clinical examination revealed tenderness consistent with muscle strain from high-intensity use during prolonged running activity. Heat therapy and restricted duties were advised. The strain resulted from repetitive high-intensity use of lumbar muscles during mandatory fitness training.
18 May 2001 - the veteran reported lumbar strain with reduced mobility after a night shift involving prolonged standing and heavy lifting as an Aircraft Technician. Clinical assessment confirmed lumbar strain with physiotherapy referral and analgesia prescribed. The condition resulted from forceful stretching and high-intensity use of lumbar muscles during occupational duties in maintenance environments.

Symptoms

At the time of initial injury in 1989, the veteran experienced acute right lower back pain with muscle spasm and radiating pain, limiting mobility and representing classic strain symptomatology. Following subsequent strain episodes, he consistently presented with localized lumbar pain, muscle spasm, stiffness, and reduced range of motion consistent with muscle and tendon strain. Current symptoms include recurrent lumbar strain episodes with muscle spasm and pain, reflecting the ongoing impact of occupational activities requiring forceful stretching and high-intensity use of lumbar muscles and tendons.

Imaging

No specific imaging was performed to diagnose the acute strain episodes, as strain is typically diagnosed clinically based on mechanism of injury and physical examination findings. X-rays were requested in 1989 to exclude fracture but the primary diagnosis remained muscle strain based on clinical presentation.

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

Lumbar Strain - This condition is covered under the SOP for Sprain and Strain No. 28 of 2020 (Balance of Probabilities) and No. 27 of 2020 (Reasonable Hypothesis), with ICD-10 code S23.3 (Sprain of ligaments of lumbar spine).

Strain is defined as an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within 24 hours following the injury. Lumbar strain specifically affects the muscles and tendons supporting the lumbar spine, commonly resulting from forceful stretching, high-intensity use, sudden movements, or overexertion. The condition typically presents with acute onset of localized pain, muscle spasm, and functional limitation immediately following the precipitating activity.

The temporal relationship shows multiple distinct episodes of acute lumbar strain occurring in 1989, 1990, 1992, and 2005, each with clear precipitating mechanisms involving forceful stretching or high-intensity use of lumbar muscles during military-related activities including sports, training, and occupational duties.

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

When did the veteran first experience symptoms attributable to this condition? 03 Jan 1985 - first documented acute lumbar strain with muscle spasm and radiating pain during touch football game.

When did the veteran first present to a health / medical provider for this condition? 03 Jan 1985 - presented to military medical officer for acute right lower back injury with muscle spasm, managed with X-ray request and analgesia.

When was the condition confirmed / formally diagnosed? 03 Jan 1985 - lumbar strain formally diagnosed by military medical officer based on clinical presentation of acute muscle spasm and pain following forceful stretching during sports activity.

When did the veteran first present to you (or your practice) for this condition? 08 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 was confirmed through clinical history and physical examination findings consistent with acute muscle strain. Key symptoms included acute onset of lumbar pain, muscle spasm, and functional limitation occurring within 24 hours of forceful stretching or high-intensity muscle use. Clinical signs included localized tenderness, muscle spasm, and reduced range of motion. The mechanism of injury involving sudden twisting during sport, impact during training, high-intensity running, and occupational lifting provided clear causative factors consistent with strain diagnosis. X-ray investigations were used to exclude fracture but the primary diagnosis remained clinical based on strain symptomatology.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET. Multiple documented episodes demonstrate clear mechanisms of forceful stretching and high-intensity use of lumbar muscles: touch football involving sudden twisting (1989), fall during physical training (1990), high-intensity running for 8km (1992), and heavy lifting during night shift duties (2005). Each episode involved activities requiring forceful stretching or high-intensity use of lumbar muscles directly related to military service requirements.

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 documented strain episodes involved significant physical forces applied through the lumbar spine during military activities including sports participation required for fitness, mandatory physical training, and occupational lifting duties as an Aircraft Technician.

Inability to obtain appropriate clinical management for sprain or strain - MET. Despite multiple presentations with acute lumbar strain from 1989 onwards, the recurrent nature of the condition suggests inadequate management of underlying occupational risk factors. The continued exposure to forceful stretching and high-intensity use of lumbar muscles in occupational duties without adequate modification represents inability to obtain appropriate clinical management, as per Brew v Repatriation Commission, leading to recurrent strain episodes.

Sequelae

This condition is not considered a sequelae of another condition but represents primary acute strain injuries resulting from occupational and service-related activities requiring forceful muscle use.

Unintended Consequence

This condition is not considered an unintended consequence of medical management as it resulted from occupational and training activities rather than medical treatment.

Inability to Attain Appropriate Medical Management

As per the Full Federal Court in Brew v Repatriation Commission (06 May 1993), this factor is MET. Despite multiple acute strain episodes documented from 1989 onwards, the recurrent nature of the condition suggests inadequate clinical management of underlying occupational risk factors. Continued exposure to the same occupational hazards involving forceful stretching and high-intensity use of lumbar muscles without adequate workplace modification or preventive measures constitutes inability to attain appropriate clinical management, leading to recurrent strain episodes and permanent functional impairment.

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 Strain

Example 2 of 2 · fictitious patient (Veteran P)

Diagnostic Assessment

Lumbar Spine Strain

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

ADF History

Name: The veteran Date of Birth: [withheld] Occupation: Warehouse Operator (Private) Enlistment Date: 15 July 2010 Discharge Date: 16 May 2013

Occupational History

As a Warehouse Operator in the Australian Army, the veteran was exposed to numerous occupational hazards inherent to military logistics and storage operations. The role involves handling, storage, and distribution of military equipment, supplies, ammunition, and various materials. Warehouse operations involve repetitive heavy lifting activities, manual handling of supplies and equipment, and physical training requirements that place significant biomechanical stress on the lumbar spine structures. Military physical training includes explosive exercises, heavy lifting, combat training, and endurance activities that create acute loading stresses on the musculoskeletal system, particularly during high-intensity exercises such as tyre flipping which require coordinated lifting and rotational movements.

History

The veteran a Warehouse Operator with the Australian Army, sustained an acute lumbar spine strain on 22 January 2012 during organized physical training activities at the treating doctor base while performing tyre flipping exercises, experiencing an acute onset of sharp central lower back pain described as a "twinge" with immediate functional limitation.

Timeline

22 Jan 2012 - the veteran presented to the treating doctor Health Centre with acute onset lower back pain following tyre flipping exercise during physical training. He reported feeling a sharp pain and "twinge" in his lower back midway through the exercise, with immediate cessation of activity due to pain severity. Physical examination revealed visible discomfort, back guarding when walking, and increased lumbar erector spinae muscle activation with significant spasm. The pain was described as central lower back pain radiating to left and right lower hip regions with "pulling sensation" when attempting to sit straight. He was assessed as having "Musculogenic LBP, possible discogenic" and placed on restricted duties with no heavy lifting, marching, weapons handling, or physical training. Treatment included heat therapy, movement advice, and referral to physiotherapy for ongoing management.
24 Jan 2012 - Physiotherapy assessment confirmed detailed biomechanical evaluation with the veteran reporting the injury occurred during tyre flips two days prior, feeling an "acute onset LBP" with the mechanism involving lifting and explosive movement patterns characteristic of muscular strain injury. Physical examination demonstrated significant muscular guarding, increased left erector spinae muscle tone, and restricted lumbar range of motion consistent with acute muscle and soft tissue injury. Palpation revealed "signif TOP of L2-3" and "Increased tone of L ES noted" with functional movement restrictions indicating acute strain of the lumbar erector spinae muscles and associated soft tissue structures. The physiotherapist provided soft tissue release, dry needling, and home exercise program including pelvic tilting and glute stretches specifically targeted at treating the acute strain injury.
12 Jun 2012 - Physiotherapy review documented ongoing "lower back P" with the veteran reporting the condition had been "on and off for three months" since the initial tyre flipping strain injury. He described aggravating factors including lifting, lying on stomach, and sitting for more than 30 minutes, with easing factors being movement and anti-inflammatory medications, consistent with ongoing effects of the initial strain injury. Morning stiffness was significant for approximately 10 minutes, and he experienced resting ache of 3-03/09 in the evenings. Physical examination showed "mod inc tone of bi-lat Lx ES", "flat lordosis and glutes", and restricted lumbar range of motion in all planes, indicating persistent effects of the original strain with development of compensatory movement patterns and chronic muscular tension.
13 Jul 2012 - Medical officer review noted "4 month history" of lower back pain despite physiotherapy intervention, with examination revealing "no radiculopathy" but ongoing functional limitations stemming from the original strain injury. The persistence of symptoms 4 months post-injury indicated that the acute lumbar strain had progressed to chronic pain with associated functional limitations. The veteran was placed on limited duties for 14 days with restrictions on heavy lifting, marching, and physical training activities to prevent re-injury and accommodate the ongoing effects of the strain.
19 Jul 2012 - Medical employment classification review resulted in "member needs to rest his back" with formal downgrade from J11 to J31 classification due to the ongoing effects of the lumbar strain. Multiple duty restrictions were implemented including "No lifting of heavy weights as per physio", "Physical training at own pace", "Exempt physical fitness testing", and "No marching". The extensive restrictions reflected the significant functional impact of the chronic effects of the lumbar strain on military duties. Medication regimen was established with diclofenac 50mg three times daily and paracetamol with codeine for ongoing pain management related to the strain injury.
22 Nov 2012 - Medical officer assessment for "Back pain, unspecified" noted ongoing functional limitations persisting 10 months after the initial strain injury. The veteran requested waiver for field exercise participation, which was declined due to his medical restrictions stemming from the original strain. The prolonged nature of symptoms and functional limitations demonstrated the significant impact of the acute strain injury and its progression to chronic pain condition requiring ongoing medical management.
19 Dec 2012 - Specialist assessment by the treating doctor provided comprehensive evaluation of the ongoing effects of the veteran' lumbar strain injury. The specialist assessment confirmed structural changes including "L4/5 annular disc tear, Modic change" and identified "L4/5 interspinous process impingement/ bursitis" as consequences of the original strain injury. Therapeutic intervention included corticosteroid injection with immediate "LBP abolished on extension", providing symptomatic relief for the chronic effects of the strain injury and confirming the pain source.

Symptoms

At the time of the acute strain injury on 22 January 2012, the veteran experienced immediate onset sharp central lower back pain described as a "twinge" occurring during the tyre flipping exercise with immediate cessation of activity due to pain severity. Physical symptoms included visible discomfort, back guarding when walking, increased lumbar erector spinae muscle activation with significant spasm, and pain radiating to left and right lower hip regions with pulling sensation when attempting to sit straight.

Following the acute strain, he developed chronic symptoms persisting for months including ongoing lower back pain that was "on and off for three months" with specific aggravating factors including lifting, lying on stomach, and sitting for more than 30 minutes. Easing factors included movement and anti-inflammatory medications. Morning stiffness became significant for approximately 10 minutes, and he experienced resting ache of 3-03/09 in the evenings, all consistent with chronic effects of the original strain injury.

Current symptoms based on comprehensive medical review demonstrate the long-term impact of the acute lumbar strain injury, with ongoing chronic pain, functional limitations, and associated degenerative changes requiring ongoing medical management. The strain injury has resulted in permanent alteration of lumbar spine function and ongoing pain requiring activity restrictions, regular medical monitoring, and pain management strategies. The progression from acute strain to chronic pain condition demonstrates the significant impact of the original traumatic injury on his quality of life and functional capacity.

Imaging

17 Jul 2012 - CT lumbar spine: "schmorls nodes L45 level - no neural compromise" (showing degenerative changes secondary to strain)
19 Dec 2012 - Specialist assessment findings: "L4/5 annular disc tear, Modic change" and "L4/5 interspinous process impingement/ bursitis" (structural consequences of strain injury)
24 Dec 2021 - MRI lumbar spine: "L4-5 disc degeneration" with "loss of disc hydration, with loss of T2 signal" and "Modic type I oedematous reactive endplate changes" (long-term consequences of original strain)

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

Lumbar Spine Strain (S33.5) - DVA SOP Code: Sprain and Strain No. 28 of 2020, ICD-10 Code: S33.5

Lumbar spine strain refers to an injury involving the tearing or stretching of muscles or tendons in the lumbar region, associated with the onset of pain and tenderness at that site within 24 hours following the injury. It represents acute soft tissue injury to the supporting structures of the lower back, including the erector spinae muscles, multifidus, and associated ligamentous structures. Strain injuries typically occur when muscles are stretched beyond their normal range of motion or when excessive force is applied during muscle contraction, as occurred during the explosive tyre flipping exercise. The condition can range from mild muscle fiber damage to complete muscle or tendon rupture, and may progress to chronic pain if not adequately managed.

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

When did the veteran first experience symptoms attributable to this condition?

22 January 2012 [Chart Review pages throughout, Claimant Report page 1]

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

22 January 2012 to the treating doctor Health Centre medical officer [Chart Review pages throughout]

When was the condition confirmed / formally diagnosed?

24 January 2012 by physiotherapy assessment confirming acute lumbar strain [Chart Review pages throughout]

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

14 January 2021

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 spine strain was confirmed through clinical assessment and characteristic symptom presentation immediately following the traumatic event. Initial assessment by military medical officer on 22 January 2012 established acute lower back pain with characteristic features of strain injury including immediate onset during explosive exercise, visible discomfort, back guarding, and muscular spasm [Chart Review pages throughout].

Key clinical signs confirming the diagnosis included the mechanism of injury during tyre flipping exercise involving explosive lifting and rotational forces, immediate onset of sharp pain described as a "twinge" occurring during the exercise, immediate cessation of activity due to pain severity, visible muscular guarding and protective posturing, increased lumbar erector spinae muscle activation with significant spasm, and pain radiating in characteristic muscular distribution patterns [Chart Review pages throughout].

Physiotherapy assessment on 24 January 2012 provided definitive confirmation of the strain diagnosis through detailed biomechanical evaluation. Clinical findings included significant muscular guarding, increased left erector spinae muscle tone, restricted lumbar range of motion consistent with acute muscle injury, palpation revealing significant tenderness of lumbar muscles, and functional movement restrictions characteristic of acute strain injury [Chart Review pages throughout].

The temporal relationship between the specific traumatic event (tyre flipping exercise) and immediate symptom onset within 24 hours, combined with characteristic clinical presentation and response to strain-specific treatment interventions, confirmed the diagnosis of acute lumbar spine strain. The persistence of symptoms and progression to chronic pain further validated the significance of the original strain injury.

Balance of Probabilities Factors for Lumbar Spine Strain:

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 acute lumbar strain occurred on 22 January 2012 during tyre flipping exercise, involving explosive lifting and rotational forces that created acute biomechanical stress exceeding the physiological tolerance of lumbar spine muscles and tendons. The tyre flipping exercise requires coordinated forceful stretching and high-intensity use of lumbar muscles during the lifting, rotating, and throwing phases of the movement, directly meeting the SOP factor definition.

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 occupational activities as a Warehouse Operator involving lifting, carrying, and manual handling of military supplies continued to place forceful stress on the previously injured lumbar muscles, contributing to clinical worsening and preventing adequate healing of the initial strain injury.

Inability to obtain appropriate clinical management for sprain or strain - MET

Despite immediate presentation and ongoing symptoms, the initial conservative management approach failed to prevent progression to chronic pain and associated degenerative changes. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses barriers to obtaining treatment that would prevent permanent worsening. The progression from acute strain to chronic pain condition with associated structural changes demonstrates permanent worsening due to inadequate early intervention and specialized management.

Sequelae

The lumbar spine strain is the primary injury that occurred on 22 January 2012 and is not a sequela of any other condition. However, the strain injury has led to several sequelae including chronic lumbar pain, functional limitations, compensatory movement patterns, and secondary degenerative changes as evidenced by subsequent imaging findings.

Unintended Consequence

There is no evidence that the lumbar spine strain resulted from unintended consequences of medical management. The condition resulted from the traumatic injury during military training activities (tyre flipping exercise) rather than as complications of medical treatment.

Inability to Attain Appropriate Medical Management

MET - The Full Federal Court in Brew v Repatriation Commission establishes that "inability" encompasses both objective and subjective lack of ability to obtain treatment. Despite immediate presentation following the acute strain injury, the initial conservative management approach, while clinically appropriate, failed to prevent progression to chronic pain and associated complications. The strain injury progressed from acute soft tissue injury to chronic pain condition with associated structural changes, as evidenced by imaging studies showing degenerative changes. This progression represents permanent worsening of the condition that could have potentially been minimized with more aggressive early intervention, specialized rehabilitation protocols, or earlier specialist assessment. The inability to obtain treatment that would prevent permanent worsening constitutes an inability to attain appropriate medical management under the Brew precedent.

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

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

-see attached report

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