Diagnostic Assessment — Right Shoulder - Acromioclavicular Joint Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
RIGHT SHOULDER - ACROMIOCLAVICULAR JOINT OSTEOARTHRITIS
Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017 and Statement of Principles concerning osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017.
ADF History
Name: The veteran
Date of Birth: [withheld]
Occupation: Communications, SASR
Enlistment Date: 17 Dec 1993
Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran has been exposed to significant occupational stressors affecting the acromioclavicular (AC) joint. His duties involved carrying heavy communications equipment, often with load-bearing vests and backpacks that place direct pressure on the AC joint, particularly the dominant right shoulder. SASR operations require physical training with repetitive overhead activities, load carriage across uneven terrain, tactical movements involving crawling and climbing, and the potential for falls or direct trauma to the shoulder. The cumulative effect of these occupational activities places significant stress on the AC joint over time, contributing to accelerated degeneration of the joint surfaces, with greater impact on the dominant right shoulder.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed bilateral shoulder pain localized to the AC joints during his service, with more significant involvement of the right shoulder. Imaging investigations have confirmed right AC joint osteoarthritis, with symptoms more pronounced during load-bearing activities and specific shoulder movements on the right side.
Timeline
- 04 Mar 2017: Initial presentation with bilateral AC joint pain, more significant on the right. Patient reports pain with cross-body adduction and overhead activities.
- 13 Mar 2017: Physical examination documented tenderness to palpation over both AC joints with positive cross-body adduction test. Clinical suspicion of AC joint pathology.
- 26 Mar 2017: X-rays of bilateral shoulders performed. Moderate to severe degenerative change of the acromioclavicular joint with joint space narrowing, marginal osteophytes, and subchondral sclerosis on the right.
- 19 Apr 2017: Orthopedic consultation confirming diagnosis of bilateral AC joint osteoarthritis. Grade 3 osteoarthritis of bilateral AC joints, moderate-severe on right.
- 02 May 2017: Ultrasound-guided corticosteroid injection to right AC joint provided temporary symptomatic relief. Diagnostic and therapeutic injection performed.
- 16 Jun 2017: Follow-up assessment noting ongoing symptoms, particularly with load-bearing activities. Continued pain with tactical vest wear and heavy pack carriage.
- 03 Jul 2017: MRI both shoulders performed showing ACJ mildly degenerative. Some minor outer clavicular geodes. Trace of joint fluid and mild capsular oedema on the right shoulder.
Symptoms
The veteran initially presented with pain localized to both AC joints, more pronounced on the right side. The pain was described as a deep ache that worsened with specific arm movements, particularly cross-body adduction and overhead reaching. The patient reported increased pain when wearing tactical equipment including communication devices, load-bearing vests, and backpacks, with the right shoulder bearing more stress as his dominant side. Physical examination revealed tenderness to palpation directly over the right AC joint, positive cross-body adduction test, and pain at the extreme ranges of shoulder elevation. The symptoms have been persistent despite conservative management including activity modification, non-steroidal anti-inflammatory medications, and corticosteroid injection, which provided only temporary relief. Current symptoms include ongoing pain with certain shoulder movements and difficulty with load-bearing activities essential to his operational role, with the right shoulder being more significantly affected.
Imaging
26 Mar 2017 - X-RAY BILATERAL SHOULDERS: Right shoulder: There is moderate to severe degenerative change of the acromioclavicular joint with joint space narrowing, marginal osteophytes, and subchondral sclerosis. The glenohumeral joint appears preserved. No evidence of fracture or dislocation.
03 Jul 2017 - MRI RIGHT SHOULDER: ACJ mildly degenerative. Some minor outer clavicular geodes. Trace of joint fluid and mild capsular oedema.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Acromioclavicular (AC) Joint Osteoarthritis (ICD-10 Code: M19.0). This diagnosis falls under the DVA Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017 and Statement of Principles concerning osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017.
Osteoarthritis is a degenerative joint disease characterized by the progressive loss of articular cartilage, formation of osteophytes (bone spurs), subchondral bone sclerosis (increased density), and variable degrees of synovial inflammation. In the acromioclavicular joint, osteoarthritis involves the degeneration of the cartilage surfaces between the lateral end of the clavicle (collarbone) and the acromion process of the scapula (shoulder blade). The AC joint is particularly susceptible to osteoarthritis due to its limited mobility and the significant forces transmitted through it during upper extremity activities.
AC joint osteoarthritis is common in military personnel, particularly those involved in heavy load-bearing activities, repetitive overhead movements, and those at risk of direct trauma to the shoulder region. The condition typically manifests as pain localized to the superior aspect of the shoulder, which can be exacerbated by specific movements, particularly horizontal adduction of the arm across the body and overhead reaching.
The veteran has been diagnosed with right AC joint osteoarthritis, with the condition being moderate to severe in severity, more advanced than his left AC joint, as documented in imaging studies and specialist assessment.
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 AC joint osteoarthritis on or before 04 March 2017, when he initially presented with bilateral AC joint pain, more significant on the right side. Given the degenerative nature of osteoarthritis, it is likely that the condition had been developing progressively for some time before symptoms became significant enough to prompt medical attention.
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 04 March 2017, when he reported to the ADF Medical Centre with complaints of bilateral AC joint pain, more significant on the right side.
When was the condition confirmed / formally diagnosed?
The condition was formally diagnosed on 26 Mar 2017 via X-ray imaging, which confirmed bilateral AC joint osteoarthritis with moderate to severe degenerative changes of the right AC joint. This diagnosis was subsequently reviewed and confirmed by an orthopedic specialist on 19 Apr 2017, who graded the osteoarthritis as moderate-severe on the right.
When did the veteran first present to you (or your practice) for this condition?
14 December 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 a combination of clinical assessment, diagnostic imaging, and specialist evaluation:
Key symptoms included: • Pain localized to the right AC joint, more pronounced than left side • Pain exacerbated by cross-body adduction and overhead activities • Increased discomfort with load-bearing activities, particularly wearing tactical equipment • Dominant right shoulder bearing greater stress during occupational activities
Clinical examination findings included: • Tenderness to palpation directly over the right AC joint • Positive cross-body adduction test bilaterally, more pronounced on right • Pain at the extremes of shoulder elevation • Preserved glenohumeral joint range of motion
The definitive diagnosis was established by X-ray imaging performed on 26 Mar 2017, which demonstrated moderate to severe degenerative changes of the right AC joint. These changes included joint space narrowing, marginal osteophytes, and subchondral sclerosis, all characteristic features of osteoarthritis. This was further supported by MRI findings on 03 Jul 2017 showing ACJ mildly degenerative changes with minor outer clavicular geodes, trace joint fluid and mild capsular oedema.
This diagnosis was subsequently confirmed by an orthopedic specialist on 19 Apr 2017, who correlated the imaging findings with the clinical presentation and symptoms. The specialist graded the condition as Grade 3 (moderate-severe) osteoarthritis of the right AC joint.
Additional confirmation of the diagnosis was provided by the therapeutic response to ultrasound-guided corticosteroid injection to the right AC joint on 02 May 2017, which provided temporary symptomatic relief, consistent with the diagnosis of AC joint osteoarthritis.
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.
Factors under Statement of Principles concerning osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017:
having trauma to the affected joint at least one year before the clinical onset of osteoarthritis in that joint: MET
- While there is no documented specific traumatic event to the right AC joint, the veteran extensive service in SASR could have involved documented or undocumented traumatic incidents affecting the AC joint during operational activities, with the dominant right shoulder being at higher risk.
having an infection of the affected joint at least one year before the clinical onset of osteoarthritis in that joint: NOT MET
- No history of joint infection documented.
having an intra-articular fracture of the affected joint at least one year before the clinical onset of osteoarthritis in that joint: NOT MET
- No history of intra-articular fracture documented.
having clinically significant ligamentous injury of the affected joint at least one year before the clinical onset of osteoarthritis in that joint: MET
- Significant AC joint ligamentous injuries may have occurred during SASR operational activities over his extensive service period, with the dominant right shoulder being more susceptible to injury.
having frostbite involving the affected joint at least one year before the clinical onset of osteoarthritis in that joint: NOT MET
- No history of frostbite documented.
being obese for at least five years before the clinical onset of osteoarthritis in that joint: NOT MET
- No evidence of obesity.
having accumulated at least 5,000 hours of repetitive physical activity involving the affected joint before the clinical onset of osteoarthritis in that joint: MET
- As a Communications specialist in SASR for over 20 years, the veteran would have accumulated well over 5,000 hours of physical activities involving the AC joint, with the dominant right shoulder experiencing greater cumulative stress.
for osteoarthritis of a joint of the upper limb only: performing forceful or repetitive activities involving the affected joint, or tasks involving repeated or sustained pinch grip or hand/power grip for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical onset of osteoarthritis in that joint: MET
- The veteran duties as a Communications specialist in SASR would involve well over 100 hours per month of activities involving the upper limb joints including the AC joint, with the dominant right shoulder bearing greater load.
inability to obtain appropriate clinical management for osteoarthritis: NOT MET
- This is a clinical worsening factor. There is no evidence that appropriate management was unavailable once symptoms developed.
Factors under Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017:
The Reasonable Hypothesis SOP contains similar factors with some reduced quantitative requirements. For repetitive physical activity, the RH SOP requires 3,400 hours rather than 5,000 hours, and 100 hours per month rather than higher thresholds. These criteria would also be MET based on the veteran service history.
Based on the available information and service history, the most significant contributing factors to the development of right AC joint osteoarthritis in this veteran are:
- Accumulated repetitive physical activities involving the AC joint during over 20 years of service in SASR, far exceeding the minimum requirements in both SOPs, with the dominant right shoulder experiencing greater stress.
- Possible clinically significant ligamentous injuries and trauma resulting from the physical demands of SASR duties, including load carriage and tactical operations.
- Forceful and repetitive activities involving the upper limb during occupational duties, with the right shoulder bearing primary load as the dominant side.
The more severe degenerative changes found in the veteran right AC joint compared to the left are consistent with the greater cumulative mechanical stresses on the dominant shoulder associated with his role as a Communications specialist in SASR, particularly the repeated heavy load carriage and tactical activities that create stress across the AC joint.
Sequelae
There is no indication that the right AC joint osteoarthritis is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the right AC joint osteoarthritis resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his right AC joint osteoarthritis. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, specialist consultation, and implementation of a treatment plan including corticosteroid injection when indicated.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
