Diagnostic Assessment — Thoracic - Intercostal Strain
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Thoracic - Intercostal Strain
SOP Codes: Balance of Probabilities: Sprain and Strain (No. 28 of 2020) Reasonable Hypothesis: Sprain and Strain (No. 27 of 2020)
ADF History
The veteran, Chef, enlisted 09 January 2009, discharged 27 Mar 2016.
Occupational History
Military chefs are exposed to significant occupational hazards including heavy lifting of large pots and equipment, repetitive bending and lifting activities, sustained forward posturing during cooking activities, carrying heavy field kitchen equipment, and physical training requirements. The role involves sustained intercostal muscle loading through respiratory demands during physical exertion, chest wall stress from heavy lifting activities, and repetitive thoracic movements during food preparation. Physical training activities including push-ups, carrying heavy packs, and cardiovascular exercises place additional stress on the intercostal musculature.
History
The veteran the veteran a military chef, developed intercostal strain during his military service through occupational activities involving heavy lifting, physical training, and sustained chest wall stress during his duties in the Australian Defence Force.
Timeline
- 10 August 2013 - the veteran presented with onset of right sided chest pain first noticed on waking that morning, worse with deep inspiration and movement. He denied shortness of breath, syncope or being otherwise unwell. Examination revealed pain with palpation over costochondral joints and pain with springing of chest wall, indicating intercostal muscle strain from recent physical activities.
- 12 August 2013 - the veteran returned from hospital following comprehensive cardiac workup with conclusion that costochondritis was a plausible differential diagnosis. Pain was evident with movement and relieved somewhat by sitting up, consistent with intercostal muscle strain affecting chest wall movement and respiratory function.
- 10 September 2013 - Clinical impression was costochondritis that was improving. Right upper chest wall was tender with pain reproducible on pectoralis activation. The ongoing chest wall tenderness and pain with muscle activation demonstrated persistent intercostal strain affecting the chest wall musculature.
- 31 September 2013 - During first day of physical training since 10 August 2013, the veteran started to get pain to right parasternal area within 200 meters of warm-up jogging. Examination revealed tenderness over right costochondral joint in parasternal location, indicating re-aggravation of intercostal strain with return to physical training activities.
- 17 January 2014 - the veteran was doing physical training that morning and started getting right sided chest pain identical to his previous costochondritis episodes. The pain increased with deep breathing and there was tenderness on palpation of sternum, demonstrating recurrent intercostal strain with physical exertion and respiratory movements.
Symptoms
The veteran experienced intercostal strain symptoms characterized by right-sided chest pain worse with deep inspiration and movement, tenderness over costochondral joints, and pain with chest wall springing. The symptoms were exacerbated by physical training activities and respiratory movements, indicating strain of the intercostal muscles affecting chest wall function. The pain was reproducible with pectoralis activation and chest wall palpation, demonstrating muscle strain affecting the intercostal musculature and associated chest wall structures.
The recurrent nature of symptoms with physical training activities (November 2015, February 2016) demonstrated ongoing intercostal strain related to military physical demands and training requirements.
Imaging
- 10 August 2013 - Chest X-ray was normal with no structural abnormalities. Multiple investigations including ECG showed no cardiac abnormalities, supporting the diagnosis of intercostal muscle strain rather than cardiac pathology.
1. What is the formal diagnosis of the condition claimed above?
Intercostal Strain, SOP Sprain and Strain (No. 28 of 2020), ICD-10 S23.3 (Sprain of ligaments of thoracic spine).
Intercostal strain is a soft tissue injury involving the tearing or stretching of the intercostal muscles located between the ribs, associated with the onset of pain and tenderness at the site within 24 hours following the injury. The intercostal muscles are essential for respiratory function and chest wall stability, and strain typically results from mechanical stress placed on these muscles through activities involving forceful breathing, heavy lifting, or sudden thoracic movements. The condition commonly presents with chest wall pain that worsens with deep inspiration, coughing, or movement, and may be associated with tenderness along the affected intercostal spaces. The pain is typically sharp and localized, and may be reproduced with chest wall palpation or respiratory movements.
The temporal relationship indicates episodic intercostal strain during military service (2017-2018) related to physical training activities and occupational demands, with recurrent episodes demonstrating ongoing strain of the intercostal musculature.
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 intercostal strain symptoms on 10 August 2013 with right-sided chest pain worse with deep inspiration and movement [Service Medical Record, Page 33].
When did the veteran first present to a health / medical provider for this condition? The veteran presented to military medical staff on 10 August 2013 for right-sided chest pain worse with deep inspiration [Service Medical Record, Page 33]. He was subsequently referred for emergency hospital assessment due to elevated troponin levels requiring comprehensive cardiac evaluation.
When was the condition confirmed / formally diagnosed? The condition was diagnosed following hospital discharge on 12 August 2013, with costochondritis noted as a plausible differential diagnosis by the treating cardiologist [Service Medical Record, Page 34]. Military medical staff confirmed the ongoing chest wall strain on 10 September 2013 [Service Medical Record, Page 35].
When did the veteran first present to you (or your practice) for this condition? 30 July 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 through clinical assessment by military medical staff and hospital specialists based on characteristic chest wall pain patterns and physical examination findings. Key symptoms included right-sided chest pain worse with deep inspiration and movement, tenderness over costochondral joints, and pain with chest wall springing [Service Medical Record, Page 33]. Comprehensive cardiac investigation including echocardiogram, cardiac MRI, chest X-ray, and multiple ECGs excluded cardiac pathology [Service Medical Record, Page 34]. The pain was reproducible with pectoralis activation and improved with positioning, supporting the diagnosis of intercostal muscle strain [Service Medical Record, Page 35].
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(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 military duties involved forceful stretching and high intensity use of intercostal muscles through physical training activities, heavy lifting of kitchen equipment, and respiratory demands during physical exertion that would place significant stress on the intercostal musculature.
Factor 9(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
- MET. The documented recurrence of symptoms during physical training activities in November 2015 and February 2016 demonstrates clinical worsening related to continued forceful stretching and high intensity use of intercostal muscles during military physical training and occupational demands.
Factor 9(5): Inability to obtain appropriate clinical management for sprain or strain
- MET. The recurrent episodes (September 2015, November 2015, February 2016) without evidence of comprehensive management strategies or modification of physical training to prevent re-injury suggests barriers to obtaining appropriate clinical management during military service, constituting inability to attain appropriate medical management as defined in Brew v Repatriation Commission.
Sequelae
This condition is not a sequelae of another known condition but represents a primary occupational injury related to military service duties and physical training requirements.
Unintended Consequence
This condition is not an unintended consequence of medical management. No medical procedures or medications contributed to the development of intercostal strain.
Inability to Attain Appropriate Medical Management
MET. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective sense. The recurrent presentations for intercostal strain (September 2015, November 2015, February 2016) that recurred with return to physical training activities indicates inadequate clinical management during military service. The failure to implement appropriate rehabilitation protocols or modify physical training to prevent re-injury demonstrates inability to attain appropriate medical management. This inadequate management contributed to ongoing episodes of intercostal strain throughout military service, representing a permanent worsening of the condition through failure to provide comprehensive clinical management that would prevent recurrence.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
