Reference Determination Content
Suggested draft · fictitious patient
Cervical Spine - Strain
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
- A pre-deployment medical examination by the medical officer, dated 3 March 2010;
- A patrol base medical record by the regimental medical officer, Afghanistan, dated 16 September 2010;
- An X-ray cervical spine by Role 2 facility, Afghanistan, dated 17 September 2010;
- A physiotherapy assessment by the physiotherapist, Garrison health centre, dated 22 March 2011;
- An MRI cervical spine by the radiologist, dated 4 April 2011;
- A deployed medical record by the medical officer, Iraq, dated 9 May 2016;
- An MRI and flexion-extension X-ray cervical spine by the radiologist, dated 30 August 2016;
- A specialist consultation by the sports and exercise physician, dated 11 February 2019.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
19 January 2004 and 14 June 2019
Cervical Spine - Strain
You have stated that your condition was caused by:
- 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
- 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
Diagnosis: Strain
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 6 May 2025, and is supported by an X-ray cervical spine by Role 2 facility, Afghanistan, dated 17 September 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- 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
- 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
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with sudden severe pain in the neck and left trapezius, muscle spasm and inability to turn your head to the left on 16 September 2010.
The diagnosis was made clinically by the regimental medical officer on 16 September 2010 and confirmed the next day, when X-ray excluded fracture: there was acute neck pain and tenderness beginning immediately after a defined injury, with paraspinal and trapezius spasm, tenderness over the left C4/5 and C5/6 facet joints and restricted rotation. This meets the Statement of Principles definitions of sprain (tearing or stretching of joint ligaments with pain and tenderness within 24 hours) and strain (tearing or stretching of a muscle or tendon with pain and tenderness within 24 hours).
This has then led to further investigations and the diagnosis of your condition of Strain. I have accepted your condition of Strain.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 16 September 2010.
Cervical Spine - Strain (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
- A pre-deployment medical examination by the medical officer, dated 3 March 2010;
- A patrol base medical record by the regimental medical officer, Afghanistan, dated 16 September 2010;
- An X-ray cervical spine by Role 2 facility, Afghanistan, dated 17 September 2010;
- A physiotherapy assessment by the physiotherapist, Garrison health centre, dated 22 March 2011;
- An MRI cervical spine by the radiologist, dated 4 April 2011;
- A deployed medical record by the medical officer, Iraq, dated 9 May 2016;
- An MRI and flexion-extension X-ray cervical spine by the radiologist, dated 30 August 2016;
- A specialist consultation by the sports and exercise physician, dated 11 February 2019.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
19 January 2004 and 14 June 2019
Cervical Spine - Strain (Worsening)
You have stated that the worsening of your condition was caused by:
- 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
- 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
- inability to obtain appropriate clinical management for sprain or strain
Diagnosis: Strain (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 6 May 2025, and is supported by an X-ray cervical spine by Role 2 facility, Afghanistan, dated 17 September 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- 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
- 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
- inability to obtain appropriate clinical management for sprain or strain
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with sudden severe pain in the neck and left trapezius, muscle spasm and inability to turn your head to the left on 16 September 2010.
The diagnosis was made clinically by the regimental medical officer on 16 September 2010 and confirmed the next day, when X-ray excluded fracture: there was acute neck pain and tenderness beginning immediately after a defined injury, with paraspinal and trapezius spasm, tenderness over the left C4/5 and C5/6 facet joints and restricted rotation. This meets the Statement of Principles definitions of sprain (tearing or stretching of joint ligaments with pain and tenderness within 24 hours) and strain (tearing or stretching of a muscle or tendon with pain and tenderness within 24 hours).
After the condition arose, it was worsened during your service. The sudden drop of the 32 kilogram ammunition container on 9 May 2016 occurred while loading a protected vehicle during warlike service in Iraq. In the same incident on warlike service in Iraq on 9 May 2016 the neck and shoulder muscles were forcefully stretched under high load as the dropped container's weight came onto them, at the time of the clinical worsening of the strain, shown by new muscle signal on MRI and the rise in Neck Disability Index from 16 to 34 per cent. On warlike service in Afghanistan from September 2010 to January 2011 no physiotherapy was available at your forward patrol base, and operational needs returned you to turret duties after three weeks despite persisting pain.
This has then led to further investigations and the diagnosis of your condition of Strain (Worsening). I have accepted your condition of Strain (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 9 May 2016.
