Diagnostic Assessment — Right Shoulder - Acromioclavicular Joint Synovitis
Example 1 of 2 · fictitious patient (Veteran O)
Diagnostic Assessment
Right Shoulder - Acromioclavicular Joint Synovitis
Right Shoulder - Rotator Cuff Syndrome
Right Shoulder - Subacromial Bursitis
Right Shoulder - Supraspinatus Tendinopathy
Right Shoulder - Trapezius Strain
Left Shoulder - Acromioclavicular Joint Synovitis
Left Shoulder - Rotator Cuff Syndrome
Left Shoulder - Subacromial Bursitis
Osteoarthritis Statement of Principles Balance of Probabilities No.62 of 2017 and Reasonable Hypothesis No.63 of 2017
Rotator Cuff Syndrome Statement of Principles Balance of Probabilities No.110 of 2022 and Reasonable Hypothesis No.111 of 2022
Sprain and Strain Statement of Principles Balance of Probabilities No.28 of 2020 and Reasonable Hypothesis No.29 of 2020
ADF History
The veteran, Rifleman, 11/06/2013, [date withheld]
Occupational History
As a Rifleman in the Australian Army, the veteran was exposed to significant occupational hazards including repetitive heavy load bearing during pack marching with military equipment exceeding 35kg, weapon handling and carrying activities including .50 caliber weapons and 84mm weapon systems requiring sustained shoulder loading, intensive physical training for Special Forces selection involving overhead lifting and carrying exercises, and occupational demands of infantry role requiring frequent lifting, climbing, and physically demanding upper limb activities. The occupation involves repetitive overhead activities, forceful activities with upper limbs, and sustained shoulder positioning during military operations.
History
The veteran a Rifleman with the Australian Army, developed bilateral shoulder pain during his military service with symptoms becoming noticeable during pack marching and heavy load-bearing activities, with the condition developing over several years of military service.
Timeline
- 30 Jan 2013 - During SAS Selection Course exit medical examination, right shoulder involvement was documented when the veteran reported mild pain right [SO]Trapezius following course activities. Clinical examination revealed the right shoulder was tender over the upper trapezius with tightness on palpation. Normal range of motion was maintained for shoulder flexion, abduction, and rotation movements. The condition was attributed to the intensive physical demands of Special Forces selection training, representing the first specific documentation of right shoulder symptoms during his military service.
- 05 May 2013 - Pre-separation health examination documented bilateral shoulder pain as part of his inactive injuries affecting his military duties. The medical officer recorded Shoulder pain - Few years of pain. Noticed more with pack marching. FROM nil mechanical symptoms. Flared during Selection. This documentation confirms the chronic nature of bilateral shoulder symptoms over several years of service, with the condition being specifically aggravated by military-specific activities including pack marching and selection training. Assessment indicated functional limitations but no mechanical symptoms of instability or catching.
- 22 October 2015 - DVA diagnosis forms completed for both Right Upper Limb - Pain and Left Upper Limb - Pain as claimed conditions for compensation assessment. Documentation prepared at Veterans Health Centre indicates ongoing bilateral shoulder symptoms requiring medical attention. The claims recognize the service-related nature of the bilateral shoulder conditions, with forms completed as part of comprehensive veterans' affairs claim preparation representing formal recognition of both shoulders as service-related conditions.
- 09 January 2016 - Comprehensive MRI examination of bilateral shoulders performed revealing extensive bilateral pathology confirming clinical suspicions. Right shoulder imaging showed Moderate AC Joint synovitis with capsular thickening and Diffuse oedema and thickening of the subacromial-subdeltoid bursa measuring up to 2.5mm in thicknessconsistent with subacromial bursitis. Additional findings included Mild increased striated T2 signal in the posterior fibres of the supraspinatus tendon suggesting mild tendinopathy with possible tiny interstitial tears. Left shoulder demonstrated Minimal AC joint synovitis and Mild diffuse oedema and mild thickening of the subacromial-subdeltoid bursa indicating bilateral involvement, providing objective confirmation of structural pathology in both shoulders supporting the service-related nature of his symptoms.
Symptoms
At the time of initial presentation in Mar 2016, the veteran experienced mild right trapezius pain with tenderness and tightness on palpation following intensive Special Forces selection activities. Subsequently, he developed bilateral shoulder pain noticed particularly with pack marching activities, with symptoms flaring during selection training. The pain was described as chronic, present for few years, with functional limitations but no mechanical symptoms. Currently, the veteran continues to experience ongoing bilateral shoulder symptoms requiring medical attention and affecting his quality of life, with MRI imaging confirming structural pathology including acromioclavicular joint synovitis, subacromial bursitis, and supraspinatus tendinopathy requiring ongoing medical management.
Imaging
- 09 January 2016 - MRI bilateral shoulders performed by I-MED Radiology the city revealing Moderate AC Joint synovitis with capsular thickening. Low-lying acromion with type 2 morphology. Diffuse oedema and thickening of the subacromial-subdeltoid bursa measuring up to 2.5mm in thickness with associated mild subacromial bursal fluid consistent with subacromial bursitis. Mild increased striated T2 signal in the posterior fibres of the supraspinatus tendon suggesting mild tendinopathy with possible tiny interstitial tears for the right shoulder. Left shoulder demonstrated Minimal AC joint synovitis. AC joint alignment congruent Type 2 acromion. Mild diffuse oedema and mild thickening of the subacromial-subdeltoid bursa measuring up to 2mm in thickness with trace amount of subacromial fluid in keeping with subacromial bursitis.
1. What is the formal diagnosis of the condition claimed above?
Right Shoulder Acromioclavicular Joint Synovitis - Osteoarthritis SOP No.62 of 2017 (M15-M19), ICD-10 code M25.511 Right Shoulder Rotator Cuff Syndrome - Rotator Cuff Syndrome SOP No.110 of 2022 (M75.1, M75.2, M75.3, M75.4, M75.5), ICD-10 code M75.30 Right Shoulder Subacromial Bursitis - Rotator Cuff Syndrome SOP No.110 of 2022, ICD-10 code M75.51 Right Shoulder Supraspinatus Tendinopathy - Rotator Cuff Syndrome SOP No.110 of 2022, ICD-10 code M75.31 Right Shoulder Trapezius Strain - Sprain and Strain SOP No.28 of 2020, ICD-10 code M62.11 Left Shoulder Acromioclavicular Joint Synovitis - Osteoarthritis SOP No.62 of 2017 (M15-M19), ICD-10 code M25.512 Left Shoulder Rotator Cuff Syndrome - Rotator Cuff Syndrome SOP No.110 of 2022 (M75.1, M75.2, M75.3, M75.4, M75.5), ICD-10 code M75.30 Left Shoulder Subacromial Bursitis - Rotator Cuff Syndrome SOP No.110 of 2022, ICD-10 code M75.52
Acromioclavicular joint synovitis represents inflammatory changes affecting the acromioclavicular joint, which connects the clavicle to the acromion process of the scapula. This condition involves inflammation of the joint capsule and synovial membrane, leading to pain, stiffness, and functional limitation. When chronic, it may progress to degenerative changes consistent with osteoarthritis.
Rotator cuff syndrome encompasses a spectrum of inflammatory and degenerative disorders affecting the rotator cuff tendons and associated bursae. This includes subacromial bursitis, which involves inflammation of the bursa beneath the acromion, and supraspinatus tendinopathy, characterized by degenerative changes in the supraspinatus tendon. These conditions typically result from repetitive overhead activities and mechanical impingement.
Trapezius strain involves injury to the trapezius muscle fibers, characterized by tearing or stretching of muscle tissue with associated pain and tenderness.
The temporal relationship demonstrates initial presentation with right trapezius strain during intensive training in Mar 2016, followed by recognition of chronic bilateral shoulder symptoms in May 2016, with subsequent MRI confirmation of structural pathology in January 2019 showing progression from acute strain to chronic inflammatory and degenerative changes.
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 right shoulder symptoms in Mar 2016 during SAS Selection Course activities, with bilateral shoulder symptoms being present for "few years" prior to May 2016, suggesting onset approximately 2016-2017. [CHART REVIEW.docx - multiple pages documenting shoulder timeline]
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented for right shoulder symptoms on 30 Jan 2013 during SAS Selection Course exit medical examination to military medical officer, with bilateral shoulder symptoms formally documented on 05 May 2013 during pre-separation health examination by military medical officer. [CHART REVIEW.docx - pages detailing medical presentations]
When was the condition confirmed / formally diagnosed?
The conditions were confirmed through comprehensive MRI examination on 09 January 2016 performed by specialist radiologist the treating doctor at I-MED Radiology, revealing objective structural pathology including acromioclavicular joint synovitis, subacromial bursitis, and supraspinatus tendinopathy. [IMAGING.pdf - pages 1-2, CHART REVIEW.docx - timeline sections]
When did the veteran first present to you (or your practice) for this condition?
29 December 2014
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 comprehensive MRI imaging on 09 January 2016 performed by specialist radiologist the treating doctor at I-MED Radiology the city. Key symptoms included chronic bilateral shoulder pain over several years, particularly with pack marching activities, with symptoms flaring during intensive military training. Physical examination revealed right trapezius tenderness and tightness on palpation. Investigation results showed moderate right AC joint synovitis with capsular thickening, bilateral subacromial bursitis with bursal thickening and fluid, and right supraspinatus tendinopathy with possible interstitial tears. [IMAGING.pdf - pages 1-2 (link to IMAGING.pdf), CHART REVIEW.docx - timeline and diagnosis sections (link to CHART REVIEW.docx)]
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.
Osteoarthritis Factors (AC Joint Synovitis):
Factor 6: having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The veteran experienced repetitive microtrauma to both shoulders through intensive military training, pack marching with heavy loads exceeding 35kg, and Special Forces selection activities over his 6-year military service, constituting cumulative trauma to the shoulder joints.
Factor 12: 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 within a continuous period of 15 years, within the 25 years before the clinical onset - NOT MET
- While the veteran performed intensive military activities, his service period was 6 years, not meeting the 10-year cumulative requirement.
Factor 22: having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint - NOT MET
- No documented shoulder instability or dislocation prior to onset.
Rotator Cuff Syndrome Factors:
Factor 3: performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder is abducted or flexed by at least 60 degrees or forceful activities with the affected upper limb for at least 160 hours within a period of 210 consecutive days before clinical onset - MET
- The veteran military training involved repetitive overhead activities, weapon handling, pack marching, and intensive physical training exceeding 160 hours within consecutive training periods.
Factor 5: lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before clinical onset - MET
- Military service involved regular lifting and carrying of equipment, weapons, and pack loads exceeding 20kg well beyond 400 hours over his service period.
Factor 8: having anatomical narrowing of the subacromial space on the affected side at the time of clinical onset - MET
- MRI imaging demonstrated type 2 acromion morphology bilaterally with low-lying acromion, representing anatomical narrowing predisposing to impingement.
Strain Factors:
Factor 2: forceful stretching or high intensity use of a muscle or tendon at the time of clinical onset of strain - MET
- Right trapezius strain occurred during intensive SAS Selection Course activities involving high-intensity physical demands and forceful muscle use.
Sequelae
The bilateral shoulder conditions represent progression from initial acute strain to chronic inflammatory and degenerative changes. The right trapezius strain may have contributed to altered shoulder mechanics, predisposing to subsequent rotator cuff syndrome and acromioclavicular joint synovitis.
Unintended Consequence
There is no evidence that these conditions resulted from unintended consequences of medical management or procedures performed during military service.
Inability to Attain Appropriate Medical Management
As per the Full Federal Court in Brew v Repatriation Commission (27 May 1990), there was an inability to obtain appropriate clinical management for the shoulder conditions. The bilateral shoulder symptoms were present for "few years" prior to formal documentation in May 2016, with only conservative management provided and no investigation or specialist referral until January 2019, representing a delay of approximately 3 years between symptom recognition and appropriate imaging assessment. This delay constituted inability to obtain appropriate clinical management, resulting in permanent worsening of the degenerative and inflammatory changes evidenced on MRI imaging. The factor is MET.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
