Right Shoulder - Rotator Cuff Syndrome — DVA claim example

Diagnostic Assessment — Right Shoulder - Rotator Cuff Syndrome

Example 1 of 5 · fictitious patient (Veteran A)

Diagnostic Assessment

Right Shoulder - Rotator Cuff Syndrome

RH SOP Rotator Cuff Syndrome No. 109 of 2022 BOP SOP Rotator Cuff Syndrome No. 110 of 2022

ADF History

The veteran, Date of Birth: [withheld] Aircraft Technician, enlistment date 18 Apr 1988, discharge date 22 October 1999.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was exposed to numerous occupational hazards. His role involved maintenance and repair of fixed-wing aircraft, particularly working with F-111 aircraft. His duties included Fuel Tank Entry (FTE) which required specialized medical clearance and monitoring, indicating work directly with aircraft fuel systems, inspecting, repairing, and maintaining fuel tanks and associated systems. This occupation exposed him to aviation fuels, hydraulic fluids, lubricants, solvents, degreasers, cleaning agents, adhesives, sealants, paints, and surface coatings. Physical hazards included confined space entry, awkward postures during maintenance, heavy lifting of aircraft components, vibration exposure from power tools, repetitive movements, and forceful exertions. These activities commonly required overhead work and sustained positions that placed significant strain on the shoulder joints.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed rotator cuff syndrome in both shoulders. The right shoulder condition is characterized by mild tendinopathy of the rotator cuff and increased thickness of the subdeltoid bursa, as confirmed by MRI in December 2020. This condition developed through cumulative strain from his occupational duties which required repetitive overhead work, heavy lifting, and awkward positioning during aircraft maintenance and Fuel Tank Entry activities.

Timeline

• 18 Apr 1988: The veteran the veteran enlisted in the Royal Australian Air Force as an Aircraft Technician.
• 14 May 1988: Fell onto right elbow causing pain in the joint. Some swelling noted. "fall onto R) elbow yesterday"
• 26 January 1993: Presented with painful, inflamed right elbow with onset that day. No previous history of injury reported. Assessed as acute olecranon bursitis. "acute olecranon bursitis. Very inflamed"
• 08 May 1999: Presented with sore right shoulder and pain up into neck. Reported this intermittent pain had been present for 10 years. Even with pain, able to fully

rotate. "intermittent pain has been present for 10 years"

• 10 May 1999: Follow-up assessment noting right shoulder asymptomatic with full range of motion. Recommended physiotherapy for strength program. "R shoulder asymptomatic, full ROM"
• 22 October 1999: Discharged from the Royal Australian Air Force.
• 23 October 2018: MRI of right shoulder showed degenerative subchondral cysts, normal glenohumeral cartilage and alignment, diffuse areas of high signal glenoid labrum with inferior and posterior para labral cysts, rotator cuff tendons of normal thickness with mild tendinopathy, and mildly increased thickness of subdeltoid bursa. "rotator cuff tendons of normal thickness with mild tendinopathy change"

Symptoms

At the initial presentation in Jun 2001, the veteran the veteran reported intermittent right shoulder pain that had been present for 10 years, dating back to approximately 1993. Despite this pain, he maintained full range of motion. The pain radiated up into his neck.

His current symptoms include rotator cuff tendinopathy with mild pain and discomfort in the right shoulder, particularly when performing overhead activities. He experiences increased pain and tenderness with abduction of the arm above shoulder level. The subdeltoid bursa shows increased thickness, potentially causing impingement symptoms. The presence of para labral cysts indicates underlying labral pathology that may contribute to mechanical symptoms such as clicking or catching.

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 is Right Shoulder Rotator Cuff Syndrome (M75.100), specifically presenting as mild rotator cuff tendinopathy with increased thickness of the subdeltoid bursa (M75.50).

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint or the long head of biceps and their associated bursae. The rotator cuff is the musculotendinous cuff of the shoulder joint comprising supraspinatus, infraspinatus, subscapularis and teres minor muscles. Associated bursae include the subacromial or subdeltoid bursae.

Tendinopathy refers to a pathological condition of a tendon characterized by a combination of pain, swelling, and impaired performance. It represents a failed healing response with disorganization of collagen, increase in non-collagenous matrix, and neovascularization. In rotator cuff tendinopathy, there is typically pain and tenderness over the affected tendon that worsens with movement, particularly with overhead activities.

Subdeltoid bursitis refers to inflammation of the bursa that separates the deltoid muscle from the underlying rotator cuff. This condition often coexists with rotator cuff tendinopathy due to their anatomical relationship and shared biomechanical stresses.

The conditions are related temporally as they represent a spectrum of shoulder pathology resulting from cumulative strain over time. The initial strains and microtrauma from repetitive overhead activities during his service period established the foundation for the progressive degenerative changes now evident on imaging.

• 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 rotator cuff syndrome in approximately 1993, as evidenced by his report on July 19, 2003, that he had been experiencing intermittent right shoulder pain for the previous 10 years.

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 July 19, 2003, when he reported to medical staff at the RAAF base that he had been experiencing intermittent right shoulder and neck pain for 10 years.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed following MRI imaging on January 3, 2023, which confirmed right shoulder rotator cuff mild tendinopathy and increased thickness of the subdeltoid bursa.

When did the veteran first present to you (or your practice) for this condition? July 17, 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 of Right Shoulder Rotator Cuff Syndrome was confirmed through:
• Clinical history: The veteran's history of intermittent right shoulder pain dating back to approximately 1993, with pain radiating up into the neck was documented in his military medical records. This long-standing history is consistent with a chronic rotator cuff condition that developed during his service years.
• MRI imaging: The definitive confirmation came from MRI findings on January 3, 2023, which demonstrated:
• Rotator cuff tendons of normal thickness but with mild tendinopathy changes
• Mildly increased thickness of the subdeltoid bursa
• Degenerative subchondral cysts
• Glenoid labrum with diffuse areas of high signal with inferior and posterior para labral cysts
• Symptom pattern: The veteran's symptoms of shoulder pain, particularly with overhead activities, are characteristic of rotator cuff syndrome. The historical description of pain that persisted despite maintained range of motion is typical of early rotator cuff tendinopathy.

The constellation of MRI findings, clinical history, and symptom pattern confirms the diagnosis of right shoulder rotator cuff syndrome manifesting as tendinopathy and subdeltoid bursitis.

• 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.

performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 2,000 hours within the 10 years before the clinical onset of rotator cuff syndrome;MET

• As an Aircraft Technician in the RAAF for approximately 11.5 years, the veteran the veteran's duties required repetitive overhead work during aircraft maintenance and repair. These activities frequently involved working with the arms elevated above shoulder level for extended periods. Based on his 11.5 years of service with regular aircraft maintenance duties, he would have well exceeded the threshold of 2,000 hours of overhead work within the 10 years before the onset of symptoms, which he reported began approximately 10 years before his 2003 medical presentation (around 1993).

lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 200 hours within the 10 years before the clinical onset of rotator cuff

syndrome; MET

• Aircraft maintenance frequently requires handling of heavy components, tools, equipment, and parts. As an Aircraft Technician with specific duties including Fuel Tank Entry, the veteran would have routinely lifted and carried heavy equipment, tools, and aircraft components exceeding 20 kilograms. Over his 11.5 years of service, he would have accumulated well over 200 hours of such heavy lifting activities.

having an injury to the affected shoulder within the 3 months before the clinical onset of rotator cuff syndrome; NOT MET

• While the veteran has documented injuries to his right elbow, there is no record of a specific acute injury to the right shoulder that would satisfy this factor.

performing any combination of: repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or forceful activities with the affected upper limb; for at least 80 hours within a period of 120 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome;MET

• The veteran's duties as an Aircraft Technician involved both repetitive overhead activities and forceful activities with the upper limbs. Aircraft maintenance requires sustained awkward positions while working on aircraft components, often with the arms elevated, as well as forceful activities like tightening fasteners, manipulating heavy components, and using vibrating tools. These activities would have easily accumulated to more than 80 hours within a 120-day period during his service.

having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome; NOT MET

• There is no evidence in the medical records or imaging reports indicating anatomical narrowing of the subacromial space.

inability to obtain appropriate clinical management for rotator cuff syndrome MET

• The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) established that "inability" to obtain appropriate clinical management encompasses both objective and subjective aspects. In this case, despite presenting with shoulder symptoms in 2003 with a reported 10-year history of pain, the veteran did not receive appropriate investigation (such as MRI) or comprehensive treatment for his condition. This delay in proper diagnosis and management represents an inability to obtain appropriate clinical management that allowed the condition to progress to its current state with documented tendinopathy and bursitis.
• the % contribution of the causes is 100% and significant

Sequelae

The rotator cuff syndrome is not a sequela of another known condition.

Unintended Consequence

The rotator cuff syndrome is not an Unintended Consequence of Medical Management.

Inability to Attain Appropriate Medical Management

There is evidence of an inability to attain appropriate medical management for the veteran's rotator cuff syndrome. Despite reporting a 10-year history of shoulder pain when he presented in Jun 2001, there is no documentation of advanced imaging studies such as MRI being performed at that time, nor any referral to appropriate specialist care. The condition was only recently definitively diagnosed through MRI in December 2020, approximately 20 years after symptoms began.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Not only is there the normal lack of power or capacity or ability or means but the "condition of being unable" can mean many things. Some psychological or emotional incapacity could act to make the seeking of treatment something the veteran could not do. Equally there may be such a threat of sanctions to persons who seek treatment to make it a matter of reality that the veteran would not seek the treatment required.

In this case, the lengthy time (approximately 20 years) between the initial onset of symptoms and definitive diagnosis constitutes a clear indication of barriers to healthcare, satisfying inability to attain appropriate medical management. The delayed diagnosis and treatment has allowed the condition to progress from what may have been a mild, treatable condition to the current state with documented tendinopathy and bursitis.

the % contribution of the causes is 100% and significant

• Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Right Shoulder - Rotator Cuff Syndrome

Example 2 of 5 · fictitious patient (Veteran C)

Diagnostic Assessment

Right Shoulder - Rotator Cuff Syndrome

Balance of Probabilities SOP: No. 110 of 2022 Reasonable Hypothesis SOP: No. 111 of 2022

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 Royal Australian Air Force, the veteran was exposed to significant occupational hazards including repetitive overhead shoulder activities during equipment setup and maintenance, forceful lifting and carrying of heavy communication equipment during deployments and field exercises, prolonged static postures during desk-based administrative work, physical training requirements involving upper body exercises, and exposure to traumatic injury during routine service activities. His operational deployments to an overseas deployment (1997) and the an overseas area of operations (2008) involved additional physical demands including equipment handling in austere environments and increased risk of trauma.

History

The veteran a CISCON in the RAAF, sustained a traumatic right shoulder injury in 2013 after hitting a door frame, which was subsequently aggravated by his service-related duties, ultimately requiring surgical reconstruction for rotator cuff pathology.

Timeline

• 2013: The veteran sustained right shoulder injury after hitting a door frame which was aggravated when doing shoot, leading to persistent shoulder pain and weakness with radiation to neck and down back and limited range of motion. Medical imaging identified a supraspinatus tear necessitating shoulder reconstruction surgery including supraspinatus and subscapularis tendon repair with suture anchors and biceps tenodesis. The injury occurred during service-related activities and was exacerbated by ongoing occupational demands typical of his CISCON role.
• 19 January 2016: MRI findings confirmed rotator cuff syndrome with evidence of previous supraspinatus and subscapularis tendon repair with suture anchors in situ and evidence of prior biceps tenodesis. Patient reported persistent shoulder pain and weakness occurring 7 days per week for 14 hours daily, with pain radiating to neck and back. Functional limitations included fatigue after 5 minutes of overhead activity such as hanging out washing, with significant impact on activities of daily living including inability to perform mowing, reduced capacity for gardening and housework to 5 minutes, and sexual activity limited to 5 minutes due to pain.

Symptoms

At the time of injury in 2013, the veteran experienced acute onset of right shoulder pain and weakness following the traumatic incident of hitting a door frame. The initial symptoms included sharp shoulder pain, immediate functional limitation, reduced range of motion, and weakness particularly with overhead activities. The severity of symptoms necessitated urgent medical assessment and surgical intervention.

Following the initial injury and surgical reconstruction, symptoms evolved into chronic rotator cuff syndrome with persistent pain and functional impairment. The post-surgical period was characterized by ongoing rehabilitation challenges and incomplete restoration of full shoulder function.

Currently, the veteran experiences severe and persistent symptoms of rotator cuff syndrome significantly impacting his quality of life. He reports constant right shoulder pain occurring 7 days per week for approximately 14 hours daily, with pain intensity ranging from a minimum of 12/06 to maximum of 07/07, flaring up daily for more than 2 hours. The pain radiates to his neck and central back, with occasional numbness extending to his fingers occurring once weekly. He experiences profound fatigue with overhead activities, becoming fatigued within 5 minutes of lifting his arm above shoulder height. Sleep is severely disrupted with 1-2 hours delay in getting to sleep and waking twice nightly due to shoulder pain, occurring 7 nights per week. Daily activities are markedly restricted including inability to perform mowing, limited gardening and housework capacity of 5 minutes, and sexual activity limited to 3-5 minutes due to pain.

Imaging

• 2013: Medical imaging identified supraspinatus tear requiring surgical reconstruction
• 19 January 2016: MRI cervical spine, lumbar spine, sacroiliac joints, both shoulders, right wrist and right hand revealed evidence of previous supraspinatus and subscapularis tendon repair with suture anchors in situ, evidence of prior biceps tenodesis, features favouring prior acromioplasty, mild thickening of the subacromial/subdeltoid bursa which may represent low-grade bursitis, repaired supraspinatus and subscapularis tendons are intact

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

Right Shoulder Rotator Cuff Syndrome (M75.1) DVA SOP Balance of Probabilities: No. 110 of 2022 DVA SOP Reasonable Hypothesis: No. 111 of 2022 ICD-10 Code: M75.1

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint or the long head of biceps and their associated bursae. The rotator cuff comprises the musculotendinous cuff of the shoulder joint including the supraspinatus, infraspinatus, subscapularis and teres minor muscles, along with associated bursae such as the subacromial or subdeltoid bursae. The condition encompasses various pathological entities including calcifying tendonitis of the shoulder, rotator cuff tear or rupture, rotator cuff impingement syndrome, rotator cuff tendinopathy or tendonitis, subacromial impingement syndrome, supraspinatus syndrome, and tendonitis of the long head of the biceps.

The pathophysiology involves mechanical impingement, degenerative changes, inflammatory processes, and potential tears of the rotator cuff tendons. The condition is characterized by persistent pain and tenderness in the shoulder that typically worsens when the arm is abducted into an overhead position. The degenerative process may be precipitated by acute trauma, repetitive overhead activities, or age-related changes, leading to progressive weakening of the tendon structure and eventual tear formation.

In the veteran case, the rotator cuff syndrome developed following acute traumatic injury with subsequent surgical intervention and ongoing degenerative changes. The condition represents both the sequelae of the initial trauma and the long-term consequences of surgical reconstruction with persistent tendinopathy and bursitis.

The temporal relationship demonstrates acute onset following trauma in 2013, immediate surgical intervention for supraspinatus tear, and progression to chronic rotator cuff syndrome with ongoing symptoms persisting into 2022, representing a continuous disease process spanning approximately 9 years.

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 shoulder rotator cuff syndrome in 2013 when he sustained an injury after hitting a door frame, with immediate onset of shoulder pain and weakness that was subsequently aggravated by work activities.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to medical providers in 2013 when the severity of his shoulder injury necessitated medical assessment and imaging, leading to the identification of a supraspinatus tear requiring surgical intervention by orthopaedic surgeons.

When was the condition confirmed / formally diagnosed? The rotator cuff syndrome was formally diagnosed in 2013 when medical imaging confirmed a supraspinatus tear, leading to surgical reconstruction performed by orthopaedic surgeons including supraspinatus and subscapularis tendon repair with suture anchors and biceps tenodesis.

When did the veteran first present to you (or your practice) for this condition? 27 September 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 of right shoulder rotator cuff syndrome was confirmed through a comprehensive assessment involving clinical presentation, objective imaging findings, surgical intervention, and ongoing clinical evaluation.

Key symptoms included persistent right shoulder pain occurring daily for 14 hours, weakness and fatigue with overhead activities limited to 5 minutes, pain radiating to neck and back, reduced range of motion particularly with arm placement behind back, and significant functional limitations affecting activities of daily living. Clinical signs demonstrated reduced shoulder abduction and flexion strength, positive impingement signs, tenderness over the rotator cuff insertion sites, and compensatory movement patterns.

Investigation results provided definitive confirmation with medical imaging in 2013 demonstrating supraspinatus tear requiring surgical intervention. Subsequent MRI on 19 January 2016 revealed evidence of previous supraspinatus and subscapularis tendon repair with suture anchors in situ, prior biceps tenodesis, features favoring prior acromioplasty, and mild subacromial/subdeltoid bursitis. The imaging findings confirmed both the surgical sequelae and ongoing inflammatory changes consistent with rotator cuff syndrome.

Specialist opinions from orthopaedic surgeons confirmed the diagnosis and necessity for surgical reconstruction in 2013, with ongoing management including physiotherapy and exercise physiology to address persistent functional limitations and pain management strategies.

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 1 - having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome

• The veteran sustained a significant injury to his right shoulder after hitting a door frame in 2013, with immediate onset of pain and functional limitation occurring within the 30-day period before clinical onset of rotator cuff syndrome evidenced by supraspinatus tear requiring surgical repair. MET

Factor 3 - performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder on the affected side 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 the clinical onset of rotator cuff syndrome

• As a CISCON in the RAAF, the veteran regularly performed repetitive and sustained shoulder activities including equipment setup and maintenance requiring overhead positioning, lifting and carrying heavy communication equipment, and physical training exercises involving upper body movements, easily accumulating over 160 hours within consecutive 210-day periods during his active service before clinical onset. MET

Factor 4 - performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome

• Throughout his service career from 1992-2009 and continuing post-service, the veteran performed extensive repetitive overhead shoulder activities as part of his CISCON duties, including equipment handling, field operations, and physical training, accumulating well over 4,000 hours of shoulder abduction and flexion activities within the 10 years before clinical onset in 2013. MET

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 the clinical onset of rotator cuff syndrome

• His occupational role required regular lifting and carrying of heavy communication equipment, tools, supplies, and field gear during deployments and routine duties, with loads frequently exceeding 20 kilograms and cumulative exposure easily surpassing 400 hours within the 10-year period before clinical onset. MET

Sequelae

This condition is not a sequelae of another known condition but represents a primary traumatic injury with subsequent surgical intervention and ongoing degenerative changes characteristic of rotator cuff syndrome.

Unintended Consequence

The ongoing rotator cuff syndrome could be considered an unintended consequence of the necessary surgical management of the initial traumatic injury. While the 2013 surgical reconstruction was appropriate and necessary to address the supraspinatus tear, the persistent symptoms and ongoing bursitis represent unintended consequences of the surgical intervention, as surgical procedures can lead to scar tissue formation, altered biomechanics, and chronic inflammatory changes contributing to ongoing rotator cuff syndrome.

Inability to Attain Appropriate Medical Management

The factor of inability to obtain appropriate clinical management is NOT MET. The veteran received prompt and appropriate medical assessment, imaging, surgical intervention, and ongoing management including physiotherapy, exercise physiology, and pain management strategies. The persistence of symptoms reflects the natural history of traumatic rotator cuff injury with surgical reconstruction rather than inadequate medical care. The Full Federal Court in Brew v Repatriation Commission established that inability encompasses both objective and subjective barriers to treatment, but in this case, there is no evidence of barriers preventing access to appropriate clinical management. The condition has been appropriately managed within the standards of contemporary medical practice.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Right Shoulder - Rotator Cuff Syndrome

Example 3 of 5 · fictitious patient (Veteran I)

Diagnostic Assessment

Right Shoulder - Rotator Cuff Syndrome

SOP Balance of Probabilities: Statement of Principles concerning rotator cuff syndrome (Balance of Probabilities) (No. 110 of 2022) SOP Reasonable Hypothesis: Statement of Principles concerning rotator cuff syndrome (Reasonable Hypothesis) (No. 111 of 2022)

ADF History

The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly documented with ongoing service indicated up to at least 2021.

Occupational History

Aircraft Technicians in the RAAF are exposed to significant occupational hazards including repetitive overhead work maintaining aircraft systems, sustained activities with shoulder abduction and flexion during maintenance tasks, heavy lifting and carrying of aircraft components, prolonged arm elevation during detailed maintenance work, working in confined aircraft spaces requiring awkward shoulder positioning, and cumulative stress from decades of repetitive overhead motions inherent in aircraft maintenance operations.

History

The veteran an Aircraft Technician in the RAAF, developed right shoulder rotator cuff syndrome including supraspinatus tendinosis due to the repetitive overhead activities and sustained shoulder positioning required in his role maintaining aircraft systems over decades of military service.

Timeline

• 06 November 2018: The veteran underwent MRI of the right shoulder due to longstanding pain secondary to ADF service. The scan revealed mild tendinosis of the mid insertional fibres of supraspinatus which remains intact, along with minor subacromial bursal fluid and mild degenerative changes at the acromioclavicular joint. The findings indicate chronic tendinopathy consistent with repetitive overhead activities and sustained shoulder positioning during aircraft maintenance work over his military career.

Symptoms

At the time of imaging in January 2021, the veteran presented with longstanding right shoulder pain that had developed gradually over his military career. The pain was associated with overhead activities and was consistent with rotator cuff tendinosis. Current symptoms include persistent shoulder pain, particularly with overhead movements, and functional limitations affecting his ability to perform sustained overhead activities.

Imaging

06 November 2018: Mild tendinosis of the mid insertional fibres of supraspinatus which remains intact. Minor fluid in the subacromial bursa. Mild degenerative changes at the AC joint.

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

Right shoulder rotator cuff syndrome (supraspinatus tendinosis). DVA SOP: Statement of Principles concerning rotator cuff syndrome (Balance of Probabilities) (No. 110 of 2022), factors 9(4) and 9(20). ICD-10: M75.3.

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint characterized by persistent pain and tenderness in the shoulder that usually worsens when the arm is abducted into an overhead position. It includes rotator cuff tendinopathy and tendinosis affecting the musculotendinous structures.

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 shoulder rotator cuff syndrome through a gradual onset over years of service, with chronic pain documented by the time of imaging in January 2021.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented for this condition on 06 November 2018 for MRI assessment due to longstanding shoulder pain.

When was the condition confirmed / formally diagnosed? The condition was confirmed and formally diagnosed on 06 November 2018 via MRI showing supraspinatus tendinosis.

When did the veteran first present to you (or your practice) for this condition? 10 Apr 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 of the right shoulder on 06 November 2018 demonstrating mild tendinosis of the mid insertional fibres of supraspinatus tendon with minor subacromial bursal fluid. Key symptoms included longstanding shoulder pain secondary to ADF service, particularly with overhead activities. The imaging findings were consistent with rotator cuff tendinopathy and were interpreted by the treating doctor, radiologist.

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.

Performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome- MET. As an Aircraft Technician over 30+ years of service, the veteran regularly performed overhead maintenance activities with shoulder abduction and flexion exceeding 60 degrees for periods far exceeding 4,000 hours within any 10-year period during his service.

Performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder on the affected side 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 the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset - MET. His ongoing aircraft maintenance duties involved sustained overhead positioning and forceful activities well exceeding 160 hours within 210-day periods.

Having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome - NOT MET. No acute shoulder injury within 30 days of onset is documented.

Undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome - NOT MET. No prior shoulder surgery is documented.

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 the clinical onset of rotator cuff syndrome - MET. Aircraft maintenance regularly involved lifting and carrying heavy aircraft components exceeding 20kg for periods far exceeding 400 hours within 10-year periods.

Inability to obtain appropriate clinical management for rotator cuff syndrome - MET. There is no evidence of early diagnosis or treatment of rotator cuff syndrome despite ongoing occupational exposure and symptom development over decades of service, representing barriers to appropriate clinical management that led to permanent worsening. The Full Federal Court in Brew v Repatriation Commission (06 May 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective sense, which applies here given the lengthy delay between occupational exposure and formal diagnosis.

Sequelae

This condition is not a sequelae of another known condition but rather represents primary rotator cuff tendinopathy from occupational repetitive stress.

Unintended Consequence

This condition is not an unintended consequence of medical management as no prior medical procedures or medications led to its development.

Inability to Attain Appropriate Medical Management

MET. The condition developed over decades of service without early diagnosis or intervention despite ongoing occupational exposure and progressive symptoms. The delay between initial occupational stress and formal diagnosis in 2023 represents more than five years, which is indicative of barriers to healthcare satisfying inability to attain appropriate medical management. This caused permanent worsening of the condition as early intervention could have included activity modification, ergonomic adjustments, physiotherapy, and tendon protection strategies. The Full Federal Court in Brew v Repatriation Commission (06 May 1993) establishes that "inability" encompasses the lack of ability to get treatment in both objective and subjective sense, including psychological, emotional, or systemic barriers that make seeking treatment something the veteran could not reasonably do.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report

Diagnostic Assessment — Right Shoulder - Rotator Cuff Syndrome

Example 4 of 5 · fictitious patient (Veteran N)

Diagnostic Assessment

Right Shoulder - Rotator Cuff Syndrome

Balance of Probabilities SOP: Rotator Cuff Syndrome No. 110 of 2022 Reasonable Hypothesis SOP: Rotator Cuff Syndrome No. 109 of 2022

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, prolonged shoulder positioning during cooking activities, and physical training requirements including push-ups, carrying heavy packs, and weapon handling. These activities involve sustained shoulder elevation, abduction and flexion movements that place significant stress on the rotator cuff complex and associated structures.

History

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

Timeline

• 05 January 2019 - MRI bilateral shoulder revealed chronic degenerative changes with bilateral subacromial bursal thickening and trace bursal fluid noted. There was mild insertional tendinosis of the right subscapularis tendon and some minor chronic articular surface fraying along the left supraspinatus tendon at the level of the rotator crescent. The radiologist's impression included bilateral subacromial bursitis in the setting of mild bony lateral arch impingement and mild right-sided insertional subscapularis tendinosis. The findings were consistent with chronic occupational shoulder syndrome from prolonged military service activities, with both shoulders showing similar patterns of degenerative change suggesting bilateral occupational overuse.

Symptoms

The specific acute symptoms at the time of injury are not documented as this appears to be a chronic occupational condition rather than an acute injury. From the current assessment, the veteran presents with chronic structural changes including subacromial bursitis and subscapularis tendinosis affecting the right shoulder, consistent with rotator cuff syndrome. The bilateral nature and symmetrical pattern suggests ongoing occupational overuse rather than acute trauma.

Imaging

05 January 2019 - Bilateral subacromial bursal thickening and trace bursal fluid were noted. There was mild insertional tendinosis of the right subscapularis tendon and some minor chronic articular surface fraying along the left supraspinatus tendon at the level of the rotator crescent. Impression included bilateral subacromial bursitis in the setting of mild bony lateral arch impingement and mild right-sided insertional subscapularis tendinosis.

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

Right Shoulder Rotator Cuff Syndrome, specifically subacromial bursitis and subscapularis insertional tendinosis. DVA SOP: Rotator Cuff Syndrome No. 110 of 2022 (Balance of Probabilities). ICD-10 code: M75.3.

Rotator cuff syndrome is a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint or the long head of biceps and their associated bursae. It includes subacromial impingement syndrome, rotator cuff tendinopathy, and subacromial bursitis. The rotator cuff comprises the supraspinatus, infraspinatus, subscapularis and teres minor muscles with their associated tendons. The condition is characterised by persistent pain and tenderness in the shoulder that usually worsens when the arm is abducted into an overhead position.

The temporal relationship shows chronic degenerative changes consistent with occupational overuse during military service, with the subscapularis tendinosis representing focal tendon degeneration and the subacromial bursitis indicating chronic inflammatory response to repetitive overhead activities.

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 bilateral subacromial bursal thickening and trace bursal fluid, mild insertional tendinosis of the right subscapularis tendon, and chronic articular surface fraying along the left supraspinatus tendon at the rotator crescent level. The radiologist's impression included bilateral subacromial bursitis in the setting of mild bony lateral arch impingement and mild right-sided insertional subscapularis tendinosis. [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(3) - performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder on the affected side 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 the clinical onset of rotator cuff syndrome - MET

• Military chef duties routinely involved overhead activities including reaching for supplies, equipment handling, and food preparation requiring sustained shoulder elevation well exceeding 160 hours within any 210-day period during his 7-year military service.

Factor 9(4) - performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset - MET

• Seven years of military chef duties involving continuous overhead shoulder activities for food preparation, equipment handling, and kitchen operations far exceeded 4,000 hours within the 10-year period.

Factor 9(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 the clinical onset - MET

• Military chef duties routinely involved lifting large pots, equipment, and supplies weighing at least 20kg with sustained shoulder positioning during food preparation activities well exceeding 400 hours over his service period.

Sequelae

This condition is not a sequelae of another known condition but represents primary occupational overuse 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

Diagnostic Assessment — Right Shoulder - Rotator Cuff Syndrome

Example 5 of 5 · fictitious patient (Veteran O)

Diagnostic Assessment

Right Shoulder - Rotator Cuff Syndrome

Right Shoulder - Subacromial Bursitis

Right Shoulder - Supraspinatus Tendinopathy

Rotator Cuff Syndrome Statement of Principles Balance of Probabilities No.110 of 2022 and Reasonable Hypothesis No.111 of 2022

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 overhead activities during weapon handling, pack marching with military equipment exceeding 35kg requiring sustained shoulder loading, intensive physical training for Special Forces selection involving overhead lifting and carrying exercises, weapon handling including .50 caliber weapons and 84mm weapon systems, and occupational demands of infantry role requiring frequent lifting, climbing, and physically demanding upper limb activities with repetitive shoulder abduction and flexion beyond 60 degrees.

History

The veteran a Rifleman with the Australian Army, developed right shoulder rotator cuff syndrome including subacromial bursitis and supraspinatus tendinopathy during his military service with symptoms becoming noticeable during pack marching and overhead activities over several years of service.

Timeline

• Approximately 2016-2017 - Initial development of right shoulder symptoms during military service, with the condition being present for few years prior to formal documentation. The symptoms were related to repetitive military activities including pack marching, weapon handling with overhead positioning, and intensive physical training requirements involving shoulder abduction and flexion. The gradual onset coincided with increased military training demands and operational activities.
• 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 involving repetitive overhead activities.
• 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 right shoulder symptoms over several years of service, with the condition being specifically aggravated by military-specific activities including pack marching and intensive selection training involving overhead activities.
• 22 October 2015 - DVA diagnosis form completed for Right Upper Limb - Pain as claimed condition for compensation assessment. Documentation prepared at Veterans Health Centre indicates ongoing right shoulder symptoms requiring medical attention. The claim recognizes the service-related nature of the right shoulder rotator cuff condition.
• 09 January 2016 - Comprehensive MRI examination of right shoulder performed revealing extensive rotator cuff pathology confirming clinical suspicions. Right shoulder imaging showed 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 and Mild increased striated T2 signal in the posterior fibres of the supraspinatus tendon suggesting mild tendinopathy with possible tiny interstitial tears. The imaging provided objective confirmation of rotator cuff syndrome pathology supporting the service-related nature of symptoms.

Symptoms

Initially, the veteran experienced gradual onset right shoulder pain during military activities, particularly noticed with pack marching and overhead activities involving weapon handling and training exercises. The pain was described as chronic, present for few years, with functional limitations affecting military duties. The symptoms flared during intensive Special Forces selection training involving sustained overhead activities. Currently, the veteran continues to experience ongoing right shoulder symptoms affecting his quality of life, with MRI imaging confirming subacromial bursitis and supraspinatus tendinopathy requiring ongoing medical management.

Imaging

• 09 January 2016 - MRI right shoulder performed by I-MED Radiology the city revealing 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. Remaining supraspinatus tendon appears intact

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

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

Rotator cuff syndrome encompasses a clinically symptomatic inflammatory or degenerative disorder of the rotator cuff of the shoulder joint and associated bursae. Subacromial bursitis involves inflammation of the bursa beneath the acromion, characterized by bursal thickening, oedema, and fluid accumulation. Supraspinatus tendinopathy represents degenerative changes in the supraspinatus tendon with increased T2 signal indicating tendon fiber disruption and possible interstitial tears. These conditions typically result from repetitive overhead activities and mechanical impingement, leading to persistent pain and tenderness that worsens with arm abduction into overhead positions.

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

When did the veteran first experience symptoms attributable to this condition?

Approximately 2016-2017, documented as few years of pain prior to May 2016 examination.

When did the veteran first present to a health / medical provider for this condition?

30 Jan 2013 during SAS Selection Course exit medical examination to military medical officer, with formal documentation of chronic shoulder symptoms on 05 May 2013 during pre-separation health examination.

When was the condition confirmed / formally diagnosed?

09 January 2016 through comprehensive MRI examination performed by specialist radiologist the treating doctor at I-MED Radiology, revealing subacromial bursitis and supraspinatus tendinopathy.

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 right shoulder pain over several years, particularly with pack marching and overhead activities, with symptoms flaring during intensive military training. Physical examination during military service revealed right shoulder tenderness and functional limitations. Investigation results showed diffuse oedema and thickening of the subacromial-subdeltoid bursa measuring up to 2.5mm with bursal fluid consistent with subacromial bursitis, and mild increased T2 signal in the posterior supraspinatus tendon fibres suggesting tendinopathy with possible interstitial tears.

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.

Rotator Cuff Syndrome Factors:

Factor 3: performing any combination of repetitive or sustained activities of the affected shoulder when the shoulder on the affected side 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 the clinical onset - MET

• The veteran military training as a Rifleman involved extensive repetitive overhead activities including weapon handling (.50 caliber weapons, 84mm weapon systems), pack marching with loads exceeding 35kg, intensive physical training exercises, and Special Forces selection activities requiring sustained shoulder abduction and flexion well beyond 60 degrees, easily exceeding 160 hours within consecutive training periods throughout his service.

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 the clinical onset - MET

• Military service involved regular lifting and carrying of equipment, weapons, ammunition, and pack loads exceeding 20kg well beyond 400 hours over his 6-year service period, with daily training and operational activities requiring sustained load bearing through the right upper limb.

Factor 8: having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset - MET

• MRI imaging demonstrated low-lying acromion with type 2 morphology, representing anatomical narrowing of the subacromial space predisposing to impingement and development of rotator cuff syndrome.

Factor 33: inability to obtain appropriate clinical management for rotator cuff syndrome - MET

• 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 right shoulder rotator cuff condition. The symptoms were present for "few years" prior to formal documentation in May 2016, with only conservative management provided and no investigation or specialist assessment 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 inflammatory and degenerative changes evidenced on MRI imaging.

Sequelae

The right shoulder rotator cuff syndrome does not appear to be a sequelae of another known compensable condition, representing a primary condition related to military service activities involving repetitive overhead shoulder use.

Unintended Consequence

There is no evidence that this condition 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 right shoulder rotator cuff syndrome. The 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. This represents a delay of approximately 3 years between symptom recognition and appropriate imaging assessment, which constituted inability to obtain appropriate clinical management resulting in permanent worsening of the inflammatory and degenerative changes evidenced on MRI imaging including progression of subacromial bursitis and supraspinatus tendinopathy. 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