Right Shoulder - Biceps Tendon Sprain — 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 — Right Shoulder - Biceps Tendon Sprain

Example 1 of 1 · fictitious patient (Veteran N)

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

Right Shoulder - Biceps Tendon Sprain

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

ADF History

The veteran, Chef (Army Catering Force), 09 January 2009, 27 Mar 2016.

Occupational History

Military chefs are exposed to various occupational hazards including repetitive overhead movements during food preparation, heavy lifting of large pots and equipment, sustained gripping activities, and physical training requirements. These activities involve forceful stretching and high intensity use of muscles and tendons, particularly the biceps during lifting, carrying, and sustained gripping activities inherent in kitchen operations and military training.

History

The veteran the veteran a military chef, developed bilateral biceps tendon pathology during his service in the Australian Defence Force from February 2011 to Apr 2018 through repetitive occupational activities involving overhead movements, heavy lifting, and sustained gripping during military duties.

Timeline

05 January 2019 - MRI bilateral shoulder revealed symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment. The long head of biceps tendons were normally positioned within the bicipital grooves and attached normally to the labral anchors. The radiologist noted these findings were consistent with chronic degenerative changes from prolonged military service activities involving repetitive shoulder and upper limb loading. The bilateral and symmetrical nature of the pathology strongly suggested occupational overuse rather than acute trauma.

Symptoms

The specific acute symptoms at the time of injury are not documented as this appears to be a chronic occupational condition developing over time during military service. From the current assessment, the veteran presents with structural biceps tendon damage characterized by partial thickness longitudinal splits affecting both shoulders symmetrically, consistent with chronic strain and degenerative changes from occupational overuse.

Imaging

05 January 2019 - Symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment. The long head of biceps tendons were normally positioned within the bicipital grooves and attached normally to the labral anchors.

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

Right Shoulder Biceps Tendon Strain with partial thickness longitudinal splits. DVA SOP: Sprain and Strain No. 28 of 2020 (Balance of Probabilities). ICD-10 code: S46.1.

Biceps tendon strain is an injury involving the tearing or stretching of the biceps tendon, associated with the onset of pain and tenderness at that site. The biceps brachii muscle has two heads - the long head and short head. The long head of biceps tendon passes through the bicipital groove and attaches to the superior labrum of the glenoid. Strain injuries can result from forceful stretching or high intensity use of the muscle or tendon, leading to partial or complete tears.

The temporal relationship shows chronic degenerative changes with partial thickness longitudinal splits, indicating chronic strain injury that developed over time through repetitive occupational activities during military service.

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

When did the veteran first experience symptoms attributable to this condition? Unknown specific date during military service 2013-2020. [Chart Review - STEPHAN MACKENZIE.docx, multiple timeline entries]

When did the veteran first present to a health / medical provider for this condition? 24 September 2018 for DVA assessment purposes. [Email - General & Service Details.pdf, page 1]

When was the condition confirmed / formally diagnosed? 05 January 2019 by Radiologist the treating doctor through MRI bilateral shoulder imaging. [IMAGING.pdf, bilateral shoulder report dated 05 January 2019]

When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018

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 by MRI imaging conducted by Radiologist the treating doctor on 05 January 2019. The imaging revealed symmetrical partial thickness longitudinal splits along the superficial surface of the biceps tendons bilaterally at the level of the upper bicipital groove and proximal intra-articular segment. The radiologist's impression noted bilateral partial thickness longitudinal tears of the biceps tendons, though noted the differential of aponeurotic expansions as a normal variant given the symmetrical appearance. [IMAGING.pdf, bilateral shoulder MRI report page 1-2]

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.

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

Military chef duties involved continuous forceful stretching and high intensity use of the biceps muscles during lifting weights, heavy equipment handling, sustained gripping activities, and physical training exercises throughout his military service.

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 - MET

Ongoing military duties throughout his 7-year service involved repeated forceful stretching and high intensity use of biceps muscles through lifting, carrying, and gripping activities that contributed to progressive strain and degenerative changes.

Sequelae

This condition is not a sequelae of another known condition but represents primary occupational strain during military service.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There is no evidence of inability to obtain appropriate clinical management for this condition. The condition was appropriately investigated with MRI imaging and diagnosed following DVA assessment process. The factor is NOT MET.

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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