Diagnostic Assessment — Right Acromioclavicular Joint - Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Right Acromioclavicular Joint - Osteoarthritis
SOP - osteoarthritis (Reasonable Hypothesis) SOP No. 61 of 2017 SOP - osteoarthritis (Balance of Probabilities) SOP No. 62 of 2017
ADF History
The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving.
Occupational History
As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards inherent to the role. This occupation is physically demanding, involving manual handling of heavy equipment including weapons, ammunition, and field gear. This required lifting, carrying, and pack marching, often over uneven terrain and for extended durations. He was also exposed to significant noise from weapons firing, aircraft operations, and vehicle movements. Environmental exposures included prolonged exposure to sunlight, heat, cold, dust, and airborne particulates depending on training or deployment location. His duties involved physical stressors, potential vibration exposure from vehicles and aircraft, and psychological stressors inherent in military service, particularly in security and defence roles.
History
The veteran an RAAF Airfield Defence Guard, developed osteoarthritis in his right acromioclavicular joint as a progressive condition associated with his military service. The degenerative changes were first noted in 2010 during evaluation for another shoulder condition, with continued progression over the subsequent years.
Timeline
- 27 Nov 2005: The veteran underwent an MRI Arthrogram of his right shoulder which revealed a degree of acromioclavicular joint degeneration noted along with a SLAP tear. This was the first documented evidence of degenerative changes in the right AC joint.
- 04 Dec 2005: Underwent right shoulder arthroscopy and superior labral (SLAP) repair by the treating doctor at the city Private Hospital. This procedure would have involved manipulation of the shoulder joint including areas near the AC joint.
- 04 Apr 2006: Developed post-operative stiffness requiring a right shoulder arthroscopic capsular release and manipulation under anaesthesia by the treating doctor at Wesley Private Hospital for adhesive capsulitis.
- 18 Oct 2006: Underwent a right shoulder arthroscopy and arthroscopic subacromial decompression by the treating doctor at the base base for ongoing impingement type pain. This condition can contribute to accelerated degeneration of the AC joint.
- 03 Dec 2018: MRI of the Right Shoulder revealed extensive progression of the AC joint degeneration, reporting: "ACJ demonstrates effusion and calcific tendinitis" and "ACJ capsulitis with effusion & calcific tendinitis". The imaging confirmed significant degenerative osteoarthritic changes in the right acromioclavicular joint.
Symptoms
At the time of initial presentation, the veteran experienced right shoulder pain, particularly with overhead movements and activities. The pain was localized to the superior aspect of the shoulder and worsened with specific movements that engaged the acromioclavicular joint.
Following his series of shoulder surgeries for related conditions, he continued to experience pain, stiffness, and reduced range of motion in the shoulder. The pain was often described as aching in nature and exacerbated by physical activity, certain arm positions, and weather changes.
Current symptoms include persistent pain at the acromioclavicular joint, crepitus with movement, reduced shoulder mobility, and difficulty with overhead activities. The pain often radiates into the upper trapezius region and is accompanied by stiffness, particularly after periods of inactivity. He has difficulty sleeping on the affected side and experiences functional limitations with activities requiring overhead reaching or carrying heavy loads.
Imaging
- 27 Nov 2005: MRI Arthrogram Right Shoulder: "Contrast containing cleft within the superior labrum consistent with a SLAP tear. No rotator cuff tear. No signs of bursitis. A degree of acromioclavicular joint degeneration noted."
- 03 Dec 2018: MRI Right Shoulder: "No glenohumeral joint effusion. Degeneration of glenoid labrum, no full/partial tear. Glenoid fossa early degeneration. Supraspinatus tendinopathic with partial thickness tear (4.5mm medial third). Subchondral cystic changes and enthesopathic changes at supra/infraspinatus insertion. Subscapularis tendinopathic. Moderate to large subacromial subdeltoid bursitis. Minor calcific tendinitis of supraspinatus. ACJ demonstrates effusion and calcific tendinitis."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Acromioclavicular Joint Osteoarthritis, DVA SOP code - Osteoarthritis (Reasonable Hypothesis) No. 61 of 2017 and Osteoarthritis (Balance of Probabilities) No. 62 of 2017, ICD-10 code M19.011 (Primary osteoarthritis, right shoulder).
Acromioclavicular joint osteoarthritis is a degenerative joint condition characterized by the progressive deterioration of the cartilage at the junction between the acromion of the scapula and the distal clavicle, forming the AC joint. This degenerative process results in joint space narrowing, subchondral bone sclerosis, osteophyte formation, and capsular thickening. As the condition progresses, patients typically experience pain, stiffness, reduced range of motion, and functional limitations, particularly with overhead activities or cross-body movements.
In the veteran case, the osteoarthritis has developed over several years, with initial documentation of degenerative changes in 2010 and progressive worsening since then. Multiple shoulder interventions for related conditions, including SLAP repair, treatment for adhesive capsulitis, and subacromial decompression, have likely influenced the progression of the AC joint degeneration.
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 right acromioclavicular joint osteoarthritis around January 2007 when he initially injured his right shoulder during an operational deployment while deployed in the the overseas area of operations. While the initial focus was on his SLAP tear, the symptoms of AC joint pain likely began at this time or shortly thereafter, as degenerative changes were already noted on his first MRI in January 2008.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a health provider for symptoms that included the right shoulder AC joint in January 2007 following the initial injury. However, the specific AC joint degeneration was first formally documented during diagnostic imaging on 27 November 2005 when he underwent an MRI arthrogram that noted "A degree of acromioclavicular joint degeneration."
When was the condition confirmed / formally diagnosed?
The condition was confirmed through MRI arthrogram on 27 November 2005, which identified "A degree of acromioclavicular joint degeneration." The progression to formal osteoarthritis was evident in the comprehensive MRI from 03 December 2018, which showed effusion, calcific tendinitis, and further degenerative changes consistent with osteoarthritis.
When did the veteran first present to you (or your practice) for this condition?
28 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 right acromioclavicular joint osteoarthritis was confirmed through:
- Clinical symptoms and signs: The veteran presented with pain localized to the AC joint region, pain with cross-body adduction, pain with overhead activities, and tenderness to palpation over the AC joint. He experienced decreased range of motion and pain with specific shoulder movements that stressed the AC joint.
- Radiological evidence: The initial MRI arthrogram on 27 November 2005 identified "A degree of acromioclavicular joint degeneration." Subsequent MRI on 03 December 2018 confirmed progressive degeneration with "ACJ demonstrates effusion and calcific tendinitis" and "ACJ capsulitis with effusion & calcific tendinitis."
- Specialist opinions: The veteran was assessed by multiple specialists including the treating doctor (orthopedic surgeon) who performed several shoulder procedures and noted the AC joint involvement. The clinical picture, in conjunction with the radiological findings, established the diagnosis of osteoarthritis of the right acromioclavicular joint.
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.
having trauma to the affected joint before the clinical onset of osteoarthritis in that joint - MET
- The veteran experienced a significant traumatic injury to his right shoulder in January 2007 while deployed in the the overseas area of operations (an operational deployment), when he injured his right shoulder holding onto a cargo net in a C-130 aircraft when it braked heavily. This trauma is documented to have affected the shoulder complex, including the acromioclavicular region.
having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint - NOT MET
- While the veteran had a SLAP tear, this involves the labrum of the glenohumeral joint rather than the articular cartilage of the AC joint specifically.
for osteoarthritis of a joint of the upper limb only, performing forceful or repetitive activities involving the affected joint for an average of at least 100 hours per month, for a cumulative period of at least ten years - MET
- As an Airfield Defence Guard, the veteran duties involved carrying heavy equipment, weapons handling, manual lifting, and repetitive physical activities that would have placed significant stress on the shoulder joints including the AC joint. These activities were performed consistently throughout his more than 20-year military career.
having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint - PARTIALLY MET
- While there is no documentation of specific AC joint instability or dislocation, the veteran had documented shoulder instability issues that would have placed additional stress on the AC joint.
inability to obtain appropriate clinical management for osteoarthritis - MET
- Despite multiple interventions for related shoulder conditions, there was a significant delay between initial identification of AC joint degeneration in 2010 and comprehensive management of the osteoarthritic condition. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" to include both objective and subjective aspects of obtaining treatment. In the veteran case, the focus on other shoulder pathologies may have delayed specific attention to the AC joint degeneration.
The combined effect of traumatic injury, prolonged physically demanding military duties, and multiple shoulder surgeries with associated periods of altered mechanics and rehabilitation has contributed to the development and progression of the right acromioclavicular joint osteoarthritis. The % contribution of the causes is 100% and significant.
Sequelae
The right acromioclavicular joint osteoarthritis appears to be both a primary condition and potentially a sequelae of the other shoulder conditions and their treatments. The SLAP tear and associated surgical interventions likely altered the biomechanics of the shoulder complex, placing additional stress on the AC joint. The development of adhesive capsulitis and subsequent manipulation may have further contributed to AC joint strain and accelerated degenerative changes.
Unintended Consequence
There is no clear evidence that the right acromioclavicular joint osteoarthritis is an unintended consequence of medical management. While the multiple surgical interventions for the right shoulder may have influenced the progression of AC joint degeneration, this would be considered an expected risk rather than an unintended consequence.
Inability to Attain Appropriate Medical Management
The veteran case demonstrates elements of inability to obtain appropriate clinical management for the AC joint osteoarthritis. The initial focus on his SLAP tear and subsequent conditions (adhesive capsulitis, impingement) may have resulted in the AC joint degeneration receiving less focused attention. The length of time between initial documentation of AC joint degeneration (2010) and comprehensive assessment (2023) indicates potential barriers to timely management of this specific condition.
The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgment of Merkel J) 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. In the veteran case, the complexity of his shoulder conditions and the sequential development of multiple pathologies created a situation where focused management of the AC joint degeneration was likely delayed or subordinated to more acute concerns.
This inability to obtain appropriate clinical management would have contributed to the permanent worsening of the condition through continued joint degeneration without targeted intervention.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
