Diagnostic Assessment — Thoracic Strain
Example 1 of 2 · fictitious patient (Veteran I)
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
Thoracic 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, Aircraft Technician (ATECH/AMECH), approximately June 1986, ongoing service indicated up to at least 2021.
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was responsible for the maintenance, repair, and servicing of aircraft and associated systems. This role involved working in high-risk environments such as flight lines, engine bays, and maintenance hangars, exposing him to significant physical demands including heavy lifting, repetitive movements, awkward postures, and prolonged standing. The occupation required frequent manual handling of aircraft components, tools, and equipment, creating substantial ergonomic stressors on the musculoskeletal system, particularly the spine and supporting structures.
History
The veteran an Aircraft Technician in the RAAF, sustained an acute thoracic back strain on 18 Apr 1991 while lifting furniture. The incident occurred during what was likely a service-related relocation or personal activity influenced by military lifestyle demands.
Timeline
- 18 Apr 1991: The veteran presented with acute thoracic back pain following lifting furniture, likely during a service-related move or personal activity. The pain was localized to the thoracic region, with no radiation or neurological symptoms noted. Clinical examination confirmed thoracic strain, managed with reassurance and urinalysis to exclude renal causes. The injury was attributed to improper lifting technique or overexertion, consistent with the physical demands of military life. This presentation reflects the occupational and lifestyle demands of service, where heavy lifting is common in both occupational duties and frequent military relocations. The condition resolved with conservative management, with no documented chronic sequelae.
Symptoms
At the time of injury, the veteran experienced acute localized thoracic back pain with no radiating symptoms or neurological deficits. The pain was mechanical in nature, exacerbated by movement and relieved by rest. No current symptoms are documented in relation to this acute thoracic strain, indicating complete resolution with conservative management.
Imaging
No imaging was documented for this acute thoracic strain episode.
1. What is the formal diagnosis of the condition claimed above?
Thoracic strain, DVA SOP Sprain and Strain (Instrument No. 27 & 28 of 2017/2020), ICD-10 code S23.3.
Thoracic strain is an injury involving the tearing or stretching of muscles or tendons in the thoracic (mid-back) region, associated with the onset of pain and tenderness at the injury site within 24 hours following the injury. This condition typically results from sudden forceful movements, lifting heavy objects with poor technique, or overexertion of the thoracic musculature. The thoracic spine is generally more stable than the cervical or lumbar regions due to rib cage support, making strains in this area often related to specific traumatic incidents or significant physical stress.
This represents a single acute episode with no evidence of chronic or recurrent thoracic conditions.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 Apr 1991 [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]
When did the veteran first present to a health / medical provider for this condition?
18 Apr 1991, presented to military medical officer [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]
When was the condition confirmed / formally diagnosed?
18 Apr 1991, diagnosed as thoracic strain by military medical officer through clinical examination [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]
When did the veteran first present to you (or your practice) for this condition?
08 November 2017
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 examination by military medical personnel on 18 Apr 1991. Key symptoms included acute onset thoracic back pain following a lifting incident, with localized tenderness and no neurological deficits. The pain was mechanical in nature, consistent with muscular strain. Urinalysis was performed to exclude renal causes of back pain, which was normal. No imaging was required given the acute nature and typical presentation of muscular strain. The condition responded appropriately to conservative management with rest and reassurance. [CHART REVIEW.docx; CR - GEMINI.docx, Page 42]
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.
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 sustained the thoracic strain while lifting furniture on 18 Apr 1991, which constitutes forceful use of thoracic muscles and tendons. This incident occurred during service when such physical activities were common due to frequent military relocations and the physical demands of military lifestyle.
Inability to obtain appropriate clinical management for sprain or strain - NOT MET
- The veteran received immediate and appropriate clinical management for the acute thoracic strain, including clinical assessment, conservative management with rest, and urinalysis to exclude other causes. The condition resolved completely with appropriate care.
Note: This condition occurred after 26 February 1998 during peacetime service, so MRCA factors apply.
Sequelae
This thoracic strain is not a sequelae of another known condition. It represents an acute, isolated injury related to a specific lifting incident.
Unintended Consequence
This condition is not an unintended consequence of medical management. No procedures or medications were administered that contributed to this condition.
Inability to Attain Appropriate Medical Management
This factor is NOT MET. The veteran received immediate and appropriate medical attention for the acute thoracic strain on 18 Apr 1991. Clinical assessment was performed, appropriate conservative management was provided, and investigations (urinalysis) were conducted to exclude other pathology. The condition resolved completely with appropriate care, indicating that medical management was both timely and effective. There were no barriers to healthcare access, and the Full Federal Court precedent in Brew v Repatriation Commission does not apply in this case as appropriate clinical 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
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.
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Diagnostic Assessment — Thoracic Strain
Example 2 of 2 · fictitious patient
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 Thoracic Strain BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as an Airfield Defence Guard from 12 February 1987 to 28 November 1993
Occupational History
As an Airfield Defence Guard in the Royal Australian Air Force, the veteran performed physically demanding duties including manual handling, heavy lifting, and participation in military sporting activities.
His duties aboard service vessels required repetitive use of the upper back and thoracic musculature
History
The veteran sustained a strain of the upper back musculature on approximately 8 May 1991, while serving in an airbase, three days before he presented on 11 May 1991 with tenderness over the left scapular region and upper back.
It was first treated with Brufen and local heat, the treatment prescribed on 8 May 1991 for the incident of 4 May 1991 in which a car slid off a jack and pinned him by the shoulders while he was changing a flat tyre on his way home from work, and it deteriorated especially when he went up and down stairs in ships
Timeline
04 May 1991 — ABSR the veteran, as a young adult, was repairing a flat tyre on his way home from work when the jack shifted and the car pinned him by the shoulders as he lay on the road beneath it; the injury was recorded as not on duty.
When treated on 8 May 1991 he had pain in the right shoulder, spine and lower back with pain down the left leg, and was given Brufen 400mg three times daily and local heat, with seven days' light duty. "Soft tissue injury (R) shoulder, lower back" 11 May 1991 — ABSR the veteran, as a young adult, presented having injured his left upper back three days prior.
He had initially been given Brufen 400mg and local heat treatment.
His condition had improved slightly but then started to deteriorate, particularly when going up and down stairs in ships.
Examination demonstrated tenderness over the left scapular region and upper back musculature with movements intact.
He was diagnosed with strain of the musculature and treated with Voltaren 50mg twice daily and Messal (methyl salicylate) cream for topical application.
He was excused from duty. "Strain musculature"
Symptoms
At the time of injury, the veteran experienced pain in the left upper back and scapular region that improved slightly and then deteriorated, especially when he went up and down stairs in ships.
Movements were recorded as full
Imaging
No imaging of the thoracic spine was performed at the time of the injury.
The earliest imaging of the thoracic spine was a X-ray of 11 August 2019, for lower thoracic spine pain, which showed minor degenerative disc disease and endplate changes; a X-ray of 19 January 2020 showed multilevel thoracic spondylosis
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Thoracic Strain (ICD-10: S29.012A).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim.
A strain is a stretching or tearing of muscle or tendon fibres.
Thoracic strains involve damage to the muscles and tendons of the upper back and are commonly caused by sudden or repetitive loading of the thoracic musculature
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 8 May 1991 (three days prior to presentation on 11 May 1991) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 11 May 1991 When was the condition confirmed / formally diagnosed? 11 May 1991 When did the veteran first present to you (or your practice) for this condition? 24 June 2018
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending Medical Officer (the treating doctor) on 11 May 1991.
The key symptoms were left upper back pain that had begun to deteriorate, especially when he went up and down stairs in ships.
The key signs were tenderness over the left scapular region and upper back musculature with movements intact [CHART REVIEW document]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 12 May 2007 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — NOT MET - The Outpatient Health Record of 11 May 1991 records a strain of the left scapular and upper back muscles with full movements; no sprain of a thoracic joint ligament was recorded, so this factor does not apply to this condition.
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 Outpatient Health Record of 11 May 1991 records an injury to the veteran's left upper back three days earlier, first treated with Brufen 400 mg and local heat, which is the treatment prescribed on 8 May 1991 for his injury of 4 May 1991, when a car slid off a jack and pinned him by the shoulders as he lay beneath it.
Being pinned by the shoulders under the weight of a car forcibly stretched and loaded the muscles of the shoulder girdle and upper back.
The Medical Officer found tenderness over the left scapular and upper back muscles and diagnosed a strain of the musculature, which began with that forceful stretching.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — NOT MET - The upper back injury of April 1991 was diagnosed as a muscle strain with full spinal movement, and no ligament sprain was recorded, so this sprain factor does not apply.
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's left upper back strain, diagnosed on 11 May 1991 with tenderness over the left scapular and upper back muscles, followed an incident in which a car slid off a jack and pinned him by the shoulders (4 May 1991, first treated on 8 May 1991 with the same Brufen and local heat noted on 30 June).
The weight of the car forcibly stretched and loaded these muscles at the time the strain began.
Other Plausible Links to Service The strain appears to have arisen from the incident of 4 May 1991, when a car slid off a jack and pinned the veteran by the shoulders, because the initial treatment recorded for the upper back (Brufen 400 mg and local heat) is the treatment prescribed for that incident on 8 May 1991.
The Daily Injury Record states that he was repairing a flat tyre 'on way home from work'; if that is accepted, the injury may fall within the journey provisions that applied to Commonwealth employees in 1991, although the same form ticks 'No' for duty and for travelling to or from duty.
Whatever its precise origin, the strain was aggravated in the course of his service: the Outpatient Health Record of 11 May 1991 records that it deteriorated especially when he went up and down stairs in ships, and treatment had to be escalated and he was excused duty.
Under the DRCA, an aggravation that arises out of, or in the course of, employment is itself an injury, so this shipboard aggravation provides a direct link to service.
The strain involved the same left scapular region that was tender after the rugby scrum collapse at an airbase on 13 July 1987, and the veteran later developed moderate multilevel thoracic spondylosis (MRI of 27 January 2017).
The recurrent in-service injuries to the upper back are a plausible contributor to that degeneration, although the MRI also shows the sequelae of Scheuermann's disorder, a developmental condition.
Conclusion the veteran's strain of the left scapular and upper back muscles, diagnosed on 11 May 1991, probably resulted from the incident of 4 May 1991 in which a car slid off a jack and pinned him by the shoulders, which on his account occurred on his way home from work.
After onset, the strain was aggravated by high-intensity use of the injured muscles in climbing stairs in ships, requiring escalation of treatment and time off duty, and the thoracic spine was never investigated in service.
The strain was aggravated by his service and, if the journey home from work is accepted, also arose in the course of it.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's thoracic strain is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (about 8 May 1991, three days before the Outpatient Health Record of 11 May 1991) aggravated it or contributed to it in a material degree.
He served for about two and a half years after that date.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - This factor concerns the worsening of a ligament sprain; the veteran's thoracic condition was a strain of the left scapular and upper back muscles, and no later sprain of the thoracic joints at that site was recorded.
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 Outpatient Health Record of 11 May 1991 records that the veteran's upper back had 'improved slightly' after the injury and had then 'started to deteriorate', especially 'when he goes up & down stairs in ships'.
Climbing the steep stairs of a ship, hauling up a body weight of about 114 kilograms (recorded on 23 March 1991), is a high-intensity use of the shoulder girdle and upper back muscles, and it took place while the strain was recovering.
The deterioration was measurable: treatment was escalated from Brufen and heat to Voltaren 50 mg twice daily and Messal cream, and he was excused duty.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - the veteran's upper back strain, which followed a car falling onto him and was deteriorating on 11 May 1991, was managed with anti-inflammatory medication and cream, without thoracic imaging or recorded follow-up.
His thoracic region was injured again in a fall on duty on 14 December 1991, but the thoracic spine was never X-rayed in service; it was first imaged in July 2019, showing established multilevel degenerative disc disease.
Sea service, a command signal of 4 April 1990 suspecting him of malingering and the loss of his medical record in December 1992 were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions, so this factor is met.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - The thoracic condition was a strain of the left upper back muscles, not a ligament sprain, and no later sprain of the thoracic joints at that site was recorded.
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 - On 11 May 1991 the Medical Officer recorded that the veteran's upper back strain had begun to deteriorate, especially when he went up and down stairs in ships, a high-intensity use of the injured shoulder girdle and upper back muscles during shipboard service.
The worsening was measurable, as treatment was escalated from Brufen and heat to Voltaren and Messal cream and he was excused duty.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - The upper back strain of April 1991, which followed a car falling onto the veteran and was deteriorating, was managed with medication alone, and his thoracic spine was not imaged in service or until July 2019.
With sea service, the 1990 malingering signal and the loss of his medical record in 1993, this amounts to an inability to obtain appropriate clinical management under Brew v Repatriation Commission (Full Federal Court, 10 September 1999)
Sequelae
The thoracic strain was one of several in-service injuries to the upper back, with the rugby scrum collapse of 13 July 1987, which left the same left scapular region tender, and the car-jack incident of 4 May 1991.
These injuries are a plausible contributor to the moderate multilevel thoracic spondylosis later shown on imaging (MRI of 27 January 2017), although that imaging also shows the sequelae of Scheuermann's disorder, a developmental condition, so any sequela of the strain is likely to be partial
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
The upper back strain, which followed the car-jack incident of 4 May 1991 and was deteriorating when the veteran was seen on 11 May 1991, was managed with anti-inflammatory medication and cream, without imaging of the thoracic spine or any recorded follow-up; the thoracic spine was never X-rayed in service and was first imaged in July 2019.
Sea service, a command signal of 4 April 1990 suspecting him of malingering and the loss of his medical record in December 1992 were further barriers.
As held by the Full Federal Court in Brew v Repatriation Commission (10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions — MET
Date of Clinical Onset
Thoracic strain is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 8 May 1991 — injury to the left upper back about three days before his presentation on 11 May 1991, a week after the car-jack incident of 4 May 1991 [CHART REVIEW document].
The later records, including later thoracic imaging, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: approximately 8 May 1991.
This date falls within the veteran's ADF service (12 February 1987 28 November 1993).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
