Diagnostic Assessment — Right Shoulder - Superior Labral Anterior Posterior (SLAP) Tear
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
RIGHT SHOULDER - SUPERIOR LABRAL ANTERIOR POSTERIOR (SLAP) TEAR
Statement of Principles concerning labral tear (Reasonable Hypothesis) Instrument No. 36 of 2017 and Statement of Principles concerning labral tear (Balance of Probabilities) Instrument No. 37 of 2017.
ADF History
Name: The veteran Date of Birth: [withheld] Occupation: Communications, SASR Enlistment Date: 17 Dec 1993 Discharge Date: Still Serving
Occupational History
As a Communications specialist within the Australian Defence Force's a specialist regiment (SASR), the veteran occupational duties would have exposed him to significant physical demands. SASR operators are required to perform physically demanding tasks including load carriage of heavy communications equipment, climbing, training exercises involving repetitive overhead activities, and operations requiring rapid upper body movements. These activities frequently place the shoulder joints, particularly the labrum, under significant strain. The SASR role also involves tactical maneuvers that may require falling or bracing with outstretched arms, which creates shearing forces across the shoulder joint that can damage the labrum, particularly the superior portion where SLAP tears occur.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed right shoulder pain characterized by mechanical symptoms during overhead activities and weight-bearing exercises consistent with a superior labral tear. Diagnostic imaging revealed a right shoulder superior labral anterior posterior (SLAP) tear affecting the superior portion of the glenoid labrum.
Timeline
- 26 Apr 2017: Initial complaint of right shoulder pain and mechanical symptoms during training exercises. Patient reports discomfort with overhead activities.
- 08 May 2017: Primary Care assessment documented limited range of motion and positive O'Brien's test. Clinical suspicion of labral pathology noted.
- 20 May 2017: Orthopedic consultation. Recommendation for MRI based on continued mechanical symptoms and positive provocative testing.
- 29 May 2017: MRI Right Shoulder performed. Type II SLAP tear identified affecting the superior labrum with minimal paralabral cyst formation.
- 14 Jun 2017: Orthopedic follow-up confirming diagnosis and discussing management options. Conservative management with physical therapy recommended initially.
- 28 Jul 2017: Physical therapy assessment documenting continued symptoms with overhead activities and resistance training. Pain with specific labral loading maneuvers.
- 09 Oct 2017: Follow-up assessment showing minimal improvement with conservative management. Consideration of surgical intervention discussed.
Symptoms
At initial presentation, the veteran reported sharp pain in the superior aspect of the right shoulder, particularly during overhead activities, weight training, and load-bearing exercises. He described mechanical symptoms including catching and clicking with certain movements, and weakness when attempting to maintain positions with the arm elevated. Pain was exacerbated by pushing activities and during certain rotational movements of the shoulder. These symptoms have persisted despite conservative management, with continued functional limitations for occupational tasks requiring overhead work or significant loading of the shoulder joint. The patient reports that symptoms are most noticeable during tactical training exercises and when carrying communications equipment during field operations.
Imaging
29 May 2017 - MRI RIGHT SHOULDER: The rotator cuff tendons appear intact without evidence of high-grade partial or full-thickness tearing. Type II SLAP tear is identified affecting the superior labrum from approximately 11 o'clock to 1 o'clock position with minimal paralabral cyst formation. The biceps tendon remains anchored to the superior labrum but there is detachment of the labrum from the glenoid rim. No evidence of Bankart lesion or significant Hill-Sachs lesion. The acromioclavicular joint shows mild degenerative changes without significant subacromial impingement. Glenohumeral joint cartilage appears preserved. IMPRESSION: Type II SLAP tear with minimal associated paralabral cyst formation. Intact rotator cuff tendons. Mild AC joint degenerative changes.
03 Jul 2017 - MRI BOTH SHOULDERS: There is some degenerative signal relating to the superior labrum with early degenerative SLAP lesion noted. Remaining labrum satisfactory.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Shoulder Superior Labral Anterior Posterior (SLAP) Tear, Type II (ICD-10 Code: S43.43). This diagnosis falls under the DVA Statement of Principles concerning labral tear (Reasonable Hypothesis) Instrument No. 36 of 2017 and Statement of Principles concerning labral tear (Balance of Probabilities) Instrument No. 37 of 2017.
A SLAP tear is a specific injury to the superior (upper) part of the labrum of the shoulder, which is a ring of fibrocartilage that surrounds the glenoid (socket) of the shoulder joint. The labrum deepens the socket and helps stabilize the shoulder joint while allowing for the extensive range of motion that characterizes this joint. In a Type II SLAP tear, which is the most common type, the superior labrum and the attachment of the biceps tendon to the labrum are detached from the glenoid rim. This creates instability in the biceps anchor and can lead to mechanical symptoms and pain, particularly with overhead activities or when the biceps muscle is actively engaged.
SLAP tears typically result from either acute trauma (such as a fall onto an outstretched arm or forceful pulling on the arm) or repetitive overhead activities that place stress on the superior labrum and biceps anchor. They are common in military personnel, particularly those in combat roles or roles requiring significant physical exertion involving the upper extremities.
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 the right shoulder SLAP tear on or around 26 Apr 2017, when he reported right shoulder pain and mechanical symptoms during training exercises. [DIA1- text tho incomplete.pdf, page 1]
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 26 Apr 2017, when he reported to the ADF Medical Centre with complaints of right shoulder pain and mechanical symptoms. [DIA1- text tho incomplete.pdf, page 1]
When was the condition confirmed / formally diagnosed?
The condition was formally diagnosed on 29 May 2017 via MRI imaging, which confirmed a Type II SLAP tear of the right shoulder. This diagnosis was subsequently reviewed and confirmed by an orthopedic specialist on 14 Jun 2017. [DIA1- text tho incomplete.pdf, page 1] [IMAGING.pdf, page 1]
When did the veteran first present to you (or your practice) for this condition?
24 January 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 of Right Shoulder SLAP Tear was confirmed through a combination of clinical assessment and diagnostic imaging:
Key symptoms included: • Pain localized to the superior aspect of the right shoulder • Mechanical symptoms including catching and clicking during certain movements • Pain exacerbated by overhead activities and resistance training • Functional limitations with tasks requiring shoulder stability
Clinical examination findings included: • Positive O'Brien's test (sensitive for SLAP tears) • Positive Speed's test (suggesting biceps tendon involvement) • Positive active compression test • Pain with resisted supination of the forearm
The definitive diagnosis was established by MRI imaging performed on 29 May 2017, which demonstrated a Type II SLAP tear affecting the superior labrum from approximately the 11 o'clock to 1 o'clock position with minimal paralabral cyst formation. The MRI showed detachment of the labrum from the glenoid rim while the biceps tendon remained anchored to the superior labrum. [DIA1- text tho incomplete.pdf, page 2] [IMAGING.pdf, page 1]
This diagnosis was subsequently confirmed by an orthopedic specialist on 14 Jun 2017, who correlated the imaging findings with the clinical presentation and symptoms.
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.
Factors under Statement of Principles concerning labral tear (Balance of Probabilities) Instrument No. 37 of 2017:
having a significant physical force applied to or through the affected shoulder joint or the affected hip joint at the time of the clinical onset of labral tear: NOT MET
- There is no documented specific traumatic event to the right shoulder at the time of clinical onset of symptoms on 26 Apr 2017.
performing forceful and repetitive motions of the affected shoulder joint or the affected hip joint, involving extremes of the normal range of motion, for at least four hours per week for the one month before the clinical onset of labral tear: MET
- As a Communications specialist in the SASR, the veteran routinely performed duties requiring overhead activities such as equipment installation, maintenance, and operation. These activities would reasonably exceed four hours per week during his operational and training duties in the month before symptom onset.
for labral tear of the hip joint only, being in the third trimester of pregnancy within the one week before the clinical onset of labral tear: NOT APPLICABLE
- This factor applies only to hip labral tears, not shoulder labral tears.
inability to obtain appropriate clinical management for labral tear: NOT MET
- This is a clinical worsening factor. The veteran received appropriate and timely clinical management following the onset of symptoms.
Factors under Statement of Principles concerning labral tear (Reasonable Hypothesis) Instrument No. 36 of 2017:
having a significant physical force applied to or through the affected shoulder joint or the affected hip joint at the time of the clinical onset of labral tear: NOT MET
- As above, no specific trauma documented.
performing forceful and repetitive motions of the affected shoulder joint or the affected hip joint, involving extremes of the normal range of motion, for at least four hours per week for the one month before the clinical onset of labral tear: MET
- The RH SOP has the same criteria as the BOP SOP for this factor, which would be met given the nature of SASR duties.
for labral tear of the hip joint only, being in the third trimester of pregnancy within the one week before the clinical onset of labral tear: NOT APPLICABLE
- This factor applies only to hip labral tears.
inability to obtain appropriate clinical management for labral tear: NOT MET
- As above, appropriate management was obtained.
Based on the veteran's occupational duties in the SASR, the most significant contributing factor to the development of his right shoulder SLAP tear was the repeated performance of forceful and repetitive motions involving extremes of normal range of motion, which meets the criteria specified in the relevant SOPs. These activities are inherent to the role of a Communications specialist in the SASR, where regular installation, maintenance, and operation of communication equipment, along with general physical training and tactical exercises, place repetitive stress on the shoulder labrum.
Sequelae
There is no indication that the right shoulder SLAP tear is a sequelae of another condition.
Unintended Consequence
There is no evidence to suggest that the right shoulder SLAP tear resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his right shoulder SLAP tear. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, specialist consultation, and implementation of a treatment plan. The Full Federal Court in Brew v Repatriation Commission (22 July 1993) provides guidance on the meaning of "inability" in both objective and subjective senses, but this factor is not applicable in this case as appropriate medical management was readily available and provided.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
