Right Shoulder - Strain — 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 - Strain

Example 1 of 1 · fictitious patient (Veteran C)

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 - Strain

Balance of Probabilities SOP: No. 28 of 2020 Reasonable Hypothesis SOP: No. 29 of 2020

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, lifting and carrying heavy communication equipment during deployments, overhead activities during field operations, physical training requirements, and potential for acute trauma during service activities. His deployments to an overseas deployment (1997) and an overseas area of operations (2008) involved additional physical demands in austere environments.

History

The veteran a CISCON in the RAAF, sustained an acute right shoulder strain in 2013 when he hit a door frame, with the injury subsequently aggravated by work-related activities involving forceful stretching and high intensity use of shoulder muscles and tendons.

Timeline

2013: The veteran sustained an acute right shoulder strain when he hit a door frame, resulting in immediate onset of pain and tenderness consistent with muscle and tendon injury. The initial strain was subsequently aggravated by work-related activities including equipment handling and overhead tasks typical of his CISCON role. The severity of the strain was evidenced by the development of a supraspinatus tear requiring surgical intervention including tendon repair and biceps tenodesis.
19 January 2016: Patient continues to report persistent right shoulder pain and weakness occurring 7 days per week for 14 hours daily, with pain radiating to neck and back, representing the chronic sequelae of the initial strain injury. Functional limitations persist including fatigue after 5 minutes of overhead activity, reduced range of motion, and sleep disturbances with 1-2 hours delay getting to sleep and waking twice nightly due to shoulder pain.

Symptoms

At the time of the acute strain in 2013, the veteran experienced immediate onset of right shoulder pain and tenderness following the trauma of hitting a door frame. The strain involved tearing or stretching of shoulder muscles and tendons, resulting in pain, weakness, and functional limitation, with symptoms developing within 24 hours of the injury as consistent with the definition of strain.

Following the acute strain, symptoms persisted and evolved into chronic pain and functional impairment. The initial strain led to progressive tissue damage requiring surgical intervention, indicating the severity of the muscle and tendon injury.

Currently, the veteran experiences chronic symptoms representing the long-term sequelae of the initial strain injury. He reports persistent right shoulder pain and weakness occurring daily for approximately 14 hours, with pain radiating to the neck and central back. Functional capacity is severely limited with fatigue occurring after only 5 minutes of overhead activity. Sleep is significantly impacted with 1-2 hours delay in getting to sleep and frequent nocturnal awakening due to shoulder pain. Daily activities are restricted including lifting, pushing, housework, and recreational activities.

Imaging

2013: Medical imaging identified consequences of the strain injury including supraspinatus tear requiring surgical repair
19 January 2016: MRI cervical spine, lumbar spine, sacroiliac joints, both shoulders, right wrist and right hand showed ongoing sequelae of the initial strain including evidence of previous supraspinatus and subscapularis tendon repair with suture anchors in situ, evidence of prior biceps tenodesis, features favouring prior acromioplasty

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

Right Shoulder Strain (S46.911) DVA SOP Balance of Probabilities: No. 28 of 2020 DVA SOP Reasonable Hypothesis: No. 29 of 2020 ICD-10 Code: S46.911

Strain is defined as an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within the 24 hours following the injury. The definition includes complete tear or rupture of a muscle or tendon but excludes drug-induced disease of tendons or muscles.

In the context of the shoulder, strain involves injury to the muscles and tendons of the rotator cuff complex, deltoid muscle, biceps tendon, or other muscles crossing the shoulder joint. The mechanism typically involves forceful stretching, sudden loading, or high intensity use of the affected muscles and tendons beyond their normal capacity.

The pathophysiology involves disruption of muscle fibers and/or tendon tissue, resulting in local inflammation, pain, weakness, and functional impairment. The severity can range from minor fiber disruption to complete muscle or tendon rupture.

In the veteran case, the strain occurred when he hit a door frame in 2013, resulting in forceful stretching and injury to the shoulder muscles and tendons, specifically involving the supraspinatus and associated structures. The severity of the strain was evidenced by the development of a complete supraspinatus tear requiring surgical repair.

The temporal relationship shows acute onset in 2013 with immediate development of pain and functional impairment, consistent with the definition of strain as an acute injury with onset within 24 hours.

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 strain in 2013 when he hit a door frame, with immediate onset of pain and tenderness consistent with acute muscle and tendon injury.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a medical provider for this strain in 2013, when the severity of the injury necessitated medical assessment and imaging that revealed a supraspinatus tear requiring surgical intervention.

When was the condition confirmed / formally diagnosed? The strain was confirmed in 2013 when medical imaging demonstrated the consequences of the acute injury including supraspinatus tear, confirming the severity of the muscle and tendon strain that required surgical repair by orthopaedic surgeons.

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 the clinical presentation of acute onset shoulder pain and weakness following trauma, with subsequent investigation revealing structural damage consistent with severe strain injury.

Key symptoms included immediate onset of right shoulder pain and tenderness following the trauma of hitting a door frame, with rapid development of weakness and functional limitation within 24 hours of the injury. The pain was localized to the shoulder region with radiation to the neck and back, consistent with muscle and tendon strain.

Clinical signs included reduced range of motion, weakness in shoulder elevation and rotation, and tenderness over the affected muscles and tendons. The functional impairment was immediate and severe, indicating significant tissue disruption.

Investigation results confirmed the severity of the strain with medical imaging in 2013 demonstrating a supraspinatus tear, representing complete disruption of tendon tissue as a consequence of the acute strain injury. Subsequent MRI in 2022 showed evidence of surgical repair including suture anchors and biceps tenodesis, confirming the extent of the original strain injury.

Specialist opinion from orthopaedic surgeons confirmed the need for surgical intervention to repair the consequences of the strain, including tendon reconstruction and biceps tenodesis to restore shoulder function.

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 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

The veteran experienced forceful stretching of the right shoulder muscles and tendons when he hit a door frame in 2013, resulting in immediate strain injury with pain and tenderness developing within 24 hours. The mechanism involved sudden impact and forceful loading of the shoulder complex beyond normal capacity, directly causing the muscle and tendon strain. MET

Factor 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

The initial strain was subsequently aggravated by work-related activities as a CISCON involving equipment handling, lifting, and overhead tasks that involved forceful stretching and high intensity use of the already injured shoulder muscles and tendons, contributing to clinical worsening of the strain. MET

Sequelae

This strain represents the primary injury that subsequently led to the development of rotator cuff syndrome and osteoarthritis, making this the initial condition from which other shoulder pathology developed.

Unintended Consequence

This condition is not an unintended consequence of medical management but represents the primary traumatic injury sustained during service activities.

Inability to Attain Appropriate Medical Management

The factor of inability to obtain appropriate clinical management is NOT MET. The veteran received immediate and appropriate medical assessment, imaging, and surgical intervention for the strain injury. The persistence of symptoms represents the natural history of severe strain injury with tissue disruption 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

Need a Diagnostic Assessment like this written from your own medical record? A VHC Chart Review finds every claimable condition in your file, and each one is written up against its Statement of Principles. Fixed fee $600 + GST per stage — see all fees or book an appointment.