Right Shoulder - Degenerative Labral Tear/Osteoarthritis — 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 - Degenerative Labral Tear/Osteoarthritis

Example 1 of 1 · fictitious patient (Veteran A)

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 - Degenerative Labral Tear/Osteoarthritis

Balance of Probabilities SOP: Osteoarthritis (62 of 2017) Reasonable Hypothesis SOP: Osteoarthritis (61 of 2017)

ADF History

The veteran, Aircraft Technician, enlisted on 18 Apr 1988, discharged on 22 October 1999.

Occupational History

As an Aircraft Technician in the RAAF with Fuel Tank Entry (FTE) duties, the veteran was exposed to numerous occupational hazards. His role involved maintenance and repair of aircraft, particularly working on F-111 aircraft systems, which required repetitive and forceful upper limb movements, awkward postures in confined spaces, lifting and handling heavy components, and extended periods of work with arms elevated. These activities placed significant biomechanical stress on his shoulder joints. He was also exposed to aviation fuels, solvents, hydraulic fluids, and other chemicals during maintenance procedures. The physically demanding nature of his duties involved climbing, crawling, and maneuvering in tight spaces, which contributed to cumulative stress on his musculoskeletal system.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed right shoulder pathology including para labral cysts and rotator cuff tendinopathy over the course of his service. His earliest documented right shoulder symptoms occurred on July 19, 2003, when he presented with right shoulder and neck pain that he reported had been present intermittently for 10 years, suggesting an onset around 1993. He also experienced right elbow injuries including a fall in Jun 1990 and olecranon bursitis in March 1995.

Timeline

14 May 1988: Fell onto right elbow causing pain in the joint and swelling. Some swelling noted over right elbow joint. Assessed as possible hematoma. Treated with ice, Tubigrip support, and Panadol.
26 January 1993: Presented with painful, inflamed right elbow with onset that day. No previous history of injury reported. Temperature 37.0. Acute olecranon bursitis. Very inflamed. Treated with 3 days sick leave, Brufen (ibuprofen), and rest.
08 May 1999: Presented with sore right shoulder and pain up into neck. Noted this intermittent pain had been present for 10 years. Even with pain, able to fully rotate. Plan made to arrange Medical Officer appointment for possible physiotherapy referral.
10 May 1999: Follow-up noting "N/R shoulder asymptomatic," full range of motion. No history of injury in past reported at this consultation. Recommended physiotherapy for strength program.
23 October 2018: MRI right shoulder showed few degenerative subchondral cysts, normal glenohumeral cartilage and alignment, intact biceps tendon, glenoid labrum with diffuse areas of high signal with inferior and posterior para labral cysts, rotator cuff tendons of normal thickness with mild tendinopathy change, and mildly increased thickness of subdeltoid bursa.

Symptoms

At the time of initial presentation in 2003, the veteran complained of intermittent right shoulder and neck pain that he reported had been present for approximately 10 years. Despite the pain, he maintained full range of motion. He did not report a specific traumatic event triggering these symptoms.

Current symptoms as documented in the 2023 MRI findings include degenerative changes in the shoulder joint consistent with osteoarthritis, including labral degeneration with inferior and posterior para labral cysts, rotator cuff tendinopathy, and degenerative subchondral cysts.

Imaging

23 October 2018: MRI right shoulder showed few degenerative subchondral cysts, normal glenohumeral cartilage and alignment, intact biceps tendon, glenoid labrum with diffuse areas of high signal with inferior and posterior para labral cysts, rotator cuff tendons of normal thickness with mild tendinopathy change, and mildly increased thickness of subdeltoid bursa.
What is the formal diagnosis of the condition claimed above? The formal diagnosis for the veteran right shoulder condition is:
Right shoulder degenerative subchondral cysts (ICD-10 code: M19.011)
Right shoulder diffuse areas of high signal glenoid labrum with inferior and posterior para labral cysts (ICD-10 code: M24.119)
Right shoulder rotator cuff mild tendinopathy (ICD-10 code: M75.100)

These diagnoses collectively represent early osteoarthritis of the right shoulder joint. Osteoarthritis is a degenerative joint disorder characterized by loss of articular cartilage, osteophyte formation, and subchondral bone changes. In the shoulder, it often begins with labral tears and degeneration, which can lead to para labral cysts. The presence of subchondral cysts is indicative of early degenerative changes in the joint.

The temporal relationship between these diagnoses is consistent with a pattern of progressive degeneration. The labral degeneration and para labral cysts likely developed first as a result of repetitive microtrauma to the shoulder joint during his service as an Aircraft Technician. This led to compensatory changes in the rotator cuff tendons, resulting in mild tendinopathy. The subchondral cysts represent more advanced degenerative changes in the bone itself.

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 this condition around 1993, approximately one year into his RAAF service. This is based on his statement during the July 19, 2003 medical

consultation where he reported the intermittent right shoulder pain had been present for 10 years.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a healthcare provider specifically for his right shoulder condition on July 19, 2003, when he reported to a Medical Officer at RAAF Medical Records with sore right shoulder and neck pain.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed through MRI findings on January 3, 2023, which confirmed the presence of degenerative changes including subchondral cysts, labral degeneration with para labral cysts, and rotator cuff tendinopathy.

When did the veteran first present to you (or your practice) for this condition? April 15, 2022

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:
Clinical history: Long-standing history of right shoulder pain dating back to approximately 1993, with documented presentation in Jun 2001 describing 10 years of intermittent pain.
Imaging findings: MRI study from January 3, 2023, which revealed:
Degenerative subchondral cysts in the right shoulder
Diffuse areas of high signal in the glenoid labrum with inferior and posterior para labral cysts
Mild rotator cuff tendinopathy
Mildly increased thickness of the subdeltoid bursa
Clinical examination: During presentation in Jun 2001, full range of motion was noted despite pain, which is consistent with early degenerative changes.

The combination of long-standing symptoms, physical examination findings, and advanced imaging results confirming structural changes to the joint are all consistent with the diagnosis of early osteoarthritis.

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 within the 25 years before the clinical onset of osteoarthritis in that joint MET. - the veteran fell onto his right elbow in Jun 1990 and developed right olecranon bursitis in March 1995. While these injuries primarily affected the elbow, trauma to one part of the upper limb can affect biomechanics throughout the kinetic chain, including the shoulder.

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. - As an Aircraft Technician with FTE duties for 11.5 years, the veteran regularly performed forceful and repetitive activities involving his shoulder joints. Aircraft maintenance requires sustained overhead work, handling of heavy components, use of power tools, and work in confined spaces, all of which place significant mechanical stress on the shoulder joints. His work would have easily exceeded the required 100 hours per month threshold for the cumulative period required.

for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint NOT MET. - This factor applies to hand, wrist, or elbow joints, not the shoulder joint.

having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint MET. - The documented left trapezius wasting would have created asymmetric biomechanical forces across both shoulder girdles, affecting joint mechanics bilaterally. Compensation for the left-sided weakness would have placed additional stress on the right shoulder joint.

having a condition or procedure that has resulted in the loss of, or alteration to, normal structure or function in the affected joint MET. - The cumulative effects of repetitive overhead work, forceful activities, and compensation for left trapezius wasting would have altered normal function in the shoulder joint over time.

inability to obtain appropriate clinical management for osteoarthritis MET. - The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get treatment in both an objective and subjective sense. Despite presenting with shoulder pain in 2003 with a reported 10-year history of symptoms, advanced imaging was not performed at that time. Earlier diagnosis and management might have allowed for interventions to slow the progression of joint degeneration.

the % contribution of the causes is 100% and significant

Sequelae

The right shoulder osteoarthritis is not a sequela of another known condition.

Unintended Consequence

The condition is not an Unintended Consequence of Medical Management.

Inability to Attain Appropriate Medical Management

There was an inability to obtain appropriate clinical management for this condition. Despite presenting with a 10-year history of shoulder symptoms in 2003, the veteran did not receive advanced imaging studies or specialized treatment for his shoulder condition at that time. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" encompasses both objective and subjective factors that may prevent access to appropriate care. In this case, there was a failure to provide timely diagnostic imaging and appropriate intervention for chronic shoulder symptoms, which likely contributed to the

progression of degenerative changes. Earlier diagnosis and management might have allowed for interventions that could have slowed the progression of joint degeneration.

The % contribution of the causes is 100% and significant

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