Neck - Left Trapezius Strain — DVA claim example (Diagnostic Assessment)

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 — Neck - Left Trapezius Strain

Example 1 of 1 · fictitious patient (Veteran D)

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

Neck - Left Trapezius Strain

Statement of Principles Instrument No. 27 of 2020 (Reasonable Hypothesis) - Sprain and Strain Statement of Principles Instrument No. 28 of 2020 (Balance of Probabilities) - Sprain and Strain

ADF History

The veteran, occupation Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear, often with lifting, carrying, and pack marching over uneven terrain and for extended durations. Exposure to noise is a significant hazard, particularly from weapons firing, aircraft operations, and vehicle movements. Environmental exposures are common, including prolonged exposure to sunlight, heat, cold, dust, and potentially other airborne particulates. Musculoskeletal loading is frequently reported, particularly during operations involving lifting and carrying heavy equipment.

History

The veteran an Airfield Defence Guard in the RAAF, experienced left cervical and thoracic pain on 25 Apr 1996 following participation in a rifle shoot. The physical demands of maintaining shooting posture combined with recoil forces likely contributed to this injury, which was diagnosed as a left trapezius strain.

Timeline

25 Apr 1996. The veteran presented with left cervical and thoracic pain following a rifle shoot. Clinical examination revealed tenderness in the left trapezius region with reduced range of motion in the cervical spine. He was diagnosed with a left trapezius strain. A treatment plan was established including physiotherapy which included joint mobilisation, soft tissue massage, stretches, ultrasound, and heat.
Jul 1998. The veteran attended multiple physiotherapy sessions for his left trapezius strain through July 1998. The physiotherapy treatment continued to include joint mobilisation, soft tissue massage, stretches, ultrasound, and heat applications to promote healing and restore function to the affected area.

Symptoms

At the time of the initial injury, the veteran experienced left cervical and thoracic pain with associated muscle tenderness in the trapezius region. He likely had reduced range of motion in his neck, particularly with rotation and lateral flexion to the right side. The pain was likely exacerbated by movement and certain postures.

Following the injury, the veteran experienced ongoing discomfort requiring multiple physiotherapy sessions through July 1998. The strain appears to have resolved with physiotherapy treatment as there are no further mentions of ongoing symptoms specific to this left trapezius strain in subsequent medical records.

Imaging

No specific imaging for the left trapezius strain is documented.

1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Trapezius Strain, which corresponds to ICD-10 code S16.1XXA (Strain of muscle, fascia and tendon at neck level, initial encounter). The applicable DVA SOP code is Statement of Principles Instrument No. 28 of 2020 (Balance of Probabilities) - Sprain and Strain.

A muscle strain is a stretching or tearing of muscle fibers, typically resulting from overuse, improper use, or excessive stretching of the muscle. Strains in the trapezius muscle are common due to its role in supporting and moving the neck and shoulders. The trapezius is a large, triangular superficial muscle that extends from the occipital bone at the base of the skull, along the spine, and to the shoulder blade. It functions to move the scapula and support the arm.

Strains are classified on a scale from Grade I (mild) to Grade III (severe), with Grade I involving stretching or minor tearing of muscle fibers, Grade II being a moderate tear with some loss of function, and Grade III involving a complete rupture of the muscle. Based on the documented treatment approach, the veteran condition appears to have been a Grade I or II strain.

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 of left trapezius strain on 25 Apr 1996, when he developed left cervical and thoracic pain following a rifle shoot.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented for medical assistance on 25 Apr 1996. While the specific healthcare provider's name is not documented, he was seen at a military medical facility where he was diagnosed with a left trapezius strain and referred for physiotherapy.

When was the condition confirmed / formally diagnosed? The left trapezius strain was formally diagnosed on 25 Apr 1996 during the initial clinical examination. The diagnosis was likely made by a medical officer based on clinical presentation and physical examination findings consistent with muscle strain, including localized pain, tenderness, and reduced range of motion.

When did the veteran first present to you (or your practice) for this condition? 16 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 left trapezius strain was confirmed through clinical examination. The key symptoms and signs included left cervical and thoracic pain following participation in a rifle shoot. The clinical examination likely revealed tenderness to palpation of the left trapezius muscle, possible muscle spasm, and reduced range of motion of the cervical spine. The temporal relationship between rifle shooting activity and symptom onset, combined with the characteristic presentation of localized muscle pain and tenderness, supported the diagnosis of muscle strain.

The diagnosis was further supported by the positive response to physiotherapy treatment, which included joint mobilisation, soft tissue massage, stretches, ultrasound, and heat therapy - all standard and appropriate interventions for muscle strain.

No specific imaging studies were documented for this condition, which is consistent with standard practice, as muscle strains are typically diagnosed clinically without the need for advanced imaging unless complications or more severe injuries are suspected.

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.

For Strain – BoP SoP 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

NOT MET
This factor applies to sprains of joint ligaments rather than strains of muscles or tendons. The veteran condition was a muscle strain, not a joint 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 veteran was participating in a rifle shoot on 25 Apr 1996, which would involve maintaining static postures and experiencing recoil forces. This constitutes high intensity use of the trapezius muscle, which is heavily engaged during shooting activities to stabilize the shoulder and support the weight of the weapon.

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

NOT MET
This factor applies to clinical worsening of joint sprains rather than muscle strains, and to clinical worsening rather than clinical onset.

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

NOT MET
This factor applies to clinical worsening rather than clinical onset of the strain.

Factor 9(5) - inability to obtain appropriate clinical management for sprain or strain

NOT MET
The veteran received prompt and appropriate treatment for his left trapezius strain, including physiotherapy with joint mobilisation, soft tissue massage, stretches, ultrasound, and heat therapy through July 1998.

For RH SoP factors (No. 27 of 2020), the factors are essentially identical to the BoP factors above with minimal differences in wording or thresholds. As the veteran meets factor 9(2) under the BoP SoP, he would also meet the corresponding factor under the RH SoP.

The % contribution of the causes is 100% and significant

Sequelae

There is no evidence to suggest that this left trapezius strain is a sequela of another condition. The temporal relationship between the rifle shooting activity and the onset of symptoms indicates that this was a primary condition.

Unintended Consequence

There is no evidence to suggest that the left trapezius strain was an unintended consequence of medical management. The condition developed following physical activity (rifle shooting) rather than as a result of any medical treatment.

Inability to Attain Appropriate Medical Management

There is no evidence to suggest an inability to attain appropriate medical management for this condition. The medical records indicate that the veteran received prompt clinical assessment and appropriate physiotherapy treatment following the onset of symptoms, with multiple physiotherapy sessions through July 1998. There was no indication of delays in diagnosis or treatment that would constitute an inability to attain appropriate medical management as outlined in the Full Federal Court case of Brew v Repatriation Commission (14 May 1993).

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

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