Diagnostic Assessment — Right Shoulder - Trapezius Strain
Example 1 of 1 · fictitious patient (Veteran O)
Diagnostic Assessment
Right Shoulder - Trapezius Strain
Sprain and Strain Statement of Principles Balance of Probabilities No.28 of 2020 and Reasonable Hypothesis No.29 of 2020
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 intensive physical training for Special Forces selection involving high-intensity muscle use, repetitive heavy load bearing during pack marching with military equipment exceeding 35kg, weapon handling requiring sustained muscle tension, and occupational demands of infantry role requiring forceful stretching and high-intensity use of muscles and tendons during tactical training and operational activities.
History
The veteran a Rifleman with the Australian Army, developed right trapezius strain during intensive Special Forces selection training in Mar 2016, with the injury occurring during high-intensity physical activities requiring forceful muscle use.
Timeline
- 30 Jan 2013 - During SAS Selection Course exit medical examination, the veteran presented with acute onset right trapezius strain following intensive selection training activities. Clinical presentation included mild pain right [SO]Trapezius with associated symptoms developing during the physically demanding selection course. Physical examination revealed the right shoulder was tender over the upper trapezius with tightness on palpation, consistent with muscle strain injury. Normal range of motion was maintained for shoulder flexion, abduction, and rotation movements despite the muscle injury. The condition was directly attributed to the intensive physical demands of Special Forces selection training involving forceful stretching and high-intensity use of the trapezius muscle.
- 05 May 2013 - Pre-separation health examination documented resolution of the acute trapezius strain, with focus shifting to chronic bilateral shoulder symptoms. The acute muscle strain had resolved by this time, though it may have contributed to ongoing shoulder dysfunction and altered biomechanics predisposing to chronic conditions.
- 22 October 2015 - DVA diagnosis form completed for Right Upper Limb - Pain as claimed condition for compensation assessment, potentially encompassing the historical trapezius strain as part of the broader right upper limb symptom complex.
Symptoms
At the time of injury in Mar 2016, the veteran experienced acute onset right trapezius pain and tenderness following intensive Special Forces selection activities. The muscle strain was characterized by mild pain localized to the upper trapezius region with associated muscle tightness on palpation. The injury caused functional limitation during the selection course but maintained normal shoulder range of motion. The acute symptoms resolved with time and conservative management, though the injury may have contributed to altered shoulder mechanics and subsequent development of chronic shoulder conditions.
Imaging
No specific imaging was performed for the acute trapezius strain, as muscle strains are typically diagnosed clinically based on mechanism of injury, symptoms, and physical examination findings.
1. What is the formal diagnosis of the condition claimed above?
Right Trapezius Strain - Sprain and Strain SOP No.28 of 2020, ICD-10 code M62.11
Trapezius strain represents an injury involving the tearing or stretching of the trapezius muscle fibers, associated with the onset of pain and tenderness at the site within 24 hours following the injury. The trapezius muscle is a large, triangular muscle extending from the skull and cervical vertebrae to the shoulder blade and clavicle, responsible for shoulder blade movement and stabilization. Strain injuries occur when the muscle is subjected to forceful stretching or high-intensity use beyond its capacity, resulting in muscle fiber damage and associated inflammatory response.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
30 Jan 2013 during SAS Selection Course activities.
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.
When was the condition confirmed / formally diagnosed?
30 Jan 2013 through clinical assessment by military medical officer during SAS Selection Course exit medical examination, diagnosed based on clinical presentation of muscle pain, tenderness, and mechanism of injury.
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 clinical assessment by military medical officer on 30 Jan 2013 during SAS Selection Course exit medical examination. Key symptoms included acute onset right trapezius pain following intensive physical training activities, with physical examination revealing tenderness over the upper trapezius muscle and muscle tightness on palpation. The mechanism of injury involved forceful stretching and high-intensity use of the trapezius muscle during demanding selection course activities. The diagnosis was based on clinical presentation consistent with muscle strain injury, including pain onset within 24 hours of the causative activity and localized muscle tenderness.
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.
Sprain and Strain Factors:
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 - MET
- The veteran experienced right trapezius strain during SAS Selection Course activities involving intensive physical training requiring forceful stretching and high-intensity use of the trapezius muscle. The selection course involved demanding physical activities including lifting, carrying, climbing, and other exercises requiring sustained and forceful trapezius muscle activation beyond normal capacity, directly causing the muscle strain injury.
Factor 5: inability to obtain appropriate clinical management for sprain or strain - NOT MET
- The acute trapezius strain was appropriately recognized and managed at the time of injury during the selection course exit medical examination, with appropriate clinical assessment and conservative management provided.
Sequelae
The right trapezius strain does not appear to be a sequelae of another known compensable condition, representing a primary acute injury related to intensive military training activities.
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
The acute trapezius strain was appropriately recognized and managed at the time of injury during the SAS Selection Course exit medical examination. Appropriate clinical assessment was provided with conservative management suitable for acute muscle strain injury. There was no delay in recognition or treatment, and the acute condition resolved appropriately with time. 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
