Diagnostic Assessment — Right Shoulder - Glenohumeral Joint Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Right Shoulder - Glenohumeral Joint Osteoarthritis
Balance of Probabilities SOP: No. 62 of 2017 Reasonable Hypothesis SOP: No. 63 of 2017
ADF History
The veteran, Date of Birth: [withheld] Communications and Information Systems Controller (CISCON), enlistment date 28 July 1986, discharge date 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller (CISCON) in the RAAF, the veteran was exposed to occupational hazards including repetitive shoulder movements from equipment handling, prolonged desk work with static postures, lifting and carrying heavy communication equipment during deployments, overhead activities during field operations, and physical training requirements. His deployments to an overseas deployment (1997) and an overseas area of operations (2008) involved additional physical demands in austere environments with potential for trauma and repetitive strain.
History
The veteran a CISCON in the RAAF, developed glenohumeral joint osteoarthritis following traumatic injury to his right shoulder and subsequent surgical intervention, with degenerative changes progressing over years of service-related activities and post-surgical changes.
Timeline
- 2013: The veteran sustained right shoulder trauma from hitting a door frame with subsequent work-related aggravation, leading to surgical reconstruction including supraspinatus and subscapularis tendon repair and prior acromioplasty. This traumatic injury and surgical intervention initiated the degenerative process that would lead to glenohumeral joint osteoarthritis through altered joint mechanics and post-surgical changes.
- 19 January 2016: MRI confirmed glenohumeral joint osteoarthritis with diffuse chondral thinning and marginal osteophyte formation and a tear of the posterior glenoid labrum at the 9 o'clock position. Patient reported persistent shoulder pain and weakness occurring 7 days per week for 14 hours daily, with functional limitations including inability to place arm behind back and fatigue after 5 minutes of overhead activity. Sleep is significantly impacted with 1-2 hours delay getting to sleep and waking twice nightly due to shoulder pain.
Symptoms
Initially in 2013, the veteran experienced right shoulder pain and weakness following trauma, with progressive limitation of range of motion and functional capacity. The symptoms evolved from acute traumatic injury to chronic degenerative changes with ongoing pain and stiffness characteristic of osteoarthritis.
Currently, the veteran experiences chronic right shoulder pain and stiffness consistent with glenohumeral joint osteoarthritis. The pain occurs daily for approximately 14 hours, with significant functional limitations including inability to place his arm behind his back and reduced range of motion. He experiences pain and weakness during overhead activities, with functional capacity limited to approximately 5 minutes before requiring rest. Sleep is severely impacted with 1-2 hours delay in getting to sleep and frequent nocturnal awakening due to shoulder pain. Daily activities are significantly restricted including lifting, pushing, housework, and recreational activities.
Imaging
- 19 January 2016: MRI cervical spine, lumbar spine, sacroiliac joints, both shoulders, right wrist and right hand showed evidence of glenohumeral joint osteoarthritis with diffuse chondral thinning and marginal osteophyte formation, tear of the posterior glenoid labrum at the 9 o'clock position, chronic appearing tear of the posterior glenoid labrum at the 9 o'clock position with bony irregularity and osteophytic lipping, likely degenerative
1. What is the formal diagnosis of the condition claimed above?
Right Shoulder Glenohumeral Joint Osteoarthritis (M19.011) DVA SOP Balance of Probabilities: No. 62 of 2017 DVA SOP Reasonable Hypothesis: No. 63 of 2017 ICD-10 Code: M19.011
Osteoarthritis is a degenerative joint disorder with clinical manifestations of pain, impaired function and stiffness, along with osteophytes or loss of articular cartilage. The condition represents a complex degenerative process involving the entire joint structure, including articular cartilage, subchondral bone, synovium, and surrounding soft tissues. In the glenohumeral joint, osteoarthritis commonly develops following trauma, repetitive stress, or as a consequence of other shoulder pathology.
The pathophysiology involves progressive loss of articular cartilage, formation of osteophytes, subchondral bone sclerosis, and synovial inflammation. Other commonly associated features include sclerosis of the underlying bone, inflammation of the synovium, and degenerative tears of the labrum. The condition results in pain, stiffness, reduced range of motion, and functional impairment.
In the veteran case, the glenohumeral joint osteoarthritis developed following traumatic injury and surgical intervention, with progressive degenerative changes evidenced by diffuse chondral thinning, marginal osteophyte formation, and posterior labral tears.
The temporal relationship shows initial trauma in 2013 with subsequent surgical intervention, followed by progressive degenerative changes over approximately 9 years, culminating in the radiological and clinical evidence of osteoarthritis documented in 2022.
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 that progressed to osteoarthritis in 2013 following his right shoulder trauma, though the specific osteoarthritic symptoms likely developed progressively in the years following the initial injury and surgical intervention.
When did the veteran first present to a health / medical provider for this condition? The veteran initial presentation for shoulder problems was in 2013 for the traumatic injury that subsequently led to osteoarthritis, though the specific diagnosis of osteoarthritis was established through imaging and clinical assessment in subsequent years.
When was the condition confirmed / formally diagnosed? The osteoarthritis was formally diagnosed on 19 January 2016 through MRI imaging that demonstrated diffuse chondral thinning, marginal osteophyte formation, and posterior labral tears consistent with glenohumeral joint osteoarthritis.
When did the veteran first present to you (or your practice) for this condition? 24 July 2015.
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 clinical presentation and definitive imaging findings. Key symptoms included chronic right shoulder pain occurring daily for extended periods, significant functional limitations including inability to place arm behind back, reduced range of motion, stiffness, and pain with overhead activities. Clinical signs included restricted glenohumeral joint motion, pain on passive and active movement, and weakness in shoulder function.
Investigation results were definitive, with MRI performed on 19 January 2016 demonstrating clear evidence of glenohumeral joint osteoarthritis including diffuse chondral thinning throughout the joint, marginal osteophyte formation, and a chronic appearing tear of the posterior glenoid labrum at the 9 o'clock position with bony irregularity and osteophytic lipping. These findings are pathognomonic for osteoarthritis and represent advanced degenerative changes.
The imaging findings were consistent with the clinical presentation and provided objective evidence of the structural changes underlying the patient's symptoms and functional limitations.
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 6 - having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint
- The veteran sustained significant trauma to his right shoulder in 2013 after hitting a door frame, with subsequent work-related aggravation, occurring well within 25 years before the clinical onset of osteoarthritis evidenced on 2022 imaging. This trauma caused immediate damage requiring surgical intervention and initiated the degenerative cascade leading to osteoarthritis. MET
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 of osteoarthritis
- As a CISCON serving from 1992-2009 (17 years active service), the veteran performed forceful and repetitive activities involving the right shoulder including equipment handling, lifting communication gear, overhead tasks during field operations, and physical training requirements, easily exceeding 100 hours per month for well over 10 years within the 25 years before clinical onset. MET
Factor 22 - having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis
- Following the 2013 trauma and surgical reconstruction with tendon repairs and biceps tenodesis, the veteran experienced ongoing joint instability and altered mechanics, occurring more than one year before the formal diagnosis of osteoarthritis in 2022. MET
Sequelae
This osteoarthritis represents a sequelae of the initial traumatic injury sustained in 2013 and subsequent surgical intervention, with progressive degenerative changes developing as a natural consequence of the joint trauma and altered biomechanics.
Unintended Consequence
This condition could be considered an unintended consequence of the surgical management of the initial rotator cuff injury, as surgical intervention, while necessary and appropriate, can lead to altered joint mechanics and progressive degenerative changes resulting in osteoarthritis.
Inability to Attain Appropriate Medical Management
The factor of inability to obtain appropriate clinical management is NOT MET. The veteran received appropriate medical assessment, surgical intervention, and ongoing management for his shoulder condition. The development of osteoarthritis represents the natural progression of degenerative changes following trauma and surgery rather than inadequate medical management. Following the precedent established in Brew v Repatriation Commission, there is no evidence of objective or subjective inability to access required treatment.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
