Reference Determination Content
Suggested draft · fictitious patient
Cervical Sprain
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 18 March 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 March 2025;
- A pre-deployment medical examination by the medical officer, dated 9 November 2011;
- A role 2 and role 3 treatment record and CT report by the afghanistan, dated 14 June 2012;
- An outpatient health record by the regimental medical officer, dated 2 July 2012;
- A specialist consultation and MRI report by the sports physician and radiologist, dated 18 December 2012;
- An incident report and treatment record by the medical officer, Iraq, dated 14 September 2015;
- A specialist consultation and MRI report by the sports physician and radiologist, dated 20 January 2016;
- A sports injury report and radiograph report by the medical officer, dated 12 May 2018;
- A medical board and discharge medical examination by the senior medical officer, dated 30 June 2021.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 January 2009 and 30 June 2021
Cervical Sprain
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: Cervical Sprain
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 18 March 2025, and is supported by an outpatient health record by the regimental medical officer, dated 2 July 2012.
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 severe neck pain centred on the lower cervical spine and the left side of the neck, muscle spasm and an inability to rotate or flex your head, made worse by wearing a helmet on 14 June 2012.
The diagnosis was made clinically by the regimental medical officer on 2 July 2012 and confirmed by a sports physician on 18 December 2012. The injury followed a clearly described mechanism of forced flexion and lateral bending under load, with immediate pain, spasm and loss of movement. Examination showed facet joint tenderness at C4 to C6, spasm of the left trapezius and levator scapulae and restricted rotation and flexion, with a normal upper limb neurological examination.
This has then led to further investigations and the diagnosis of your condition of Cervical Sprain. I have accepted your condition of Cervical Sprain.
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 14 June 2012.
Cervical Sprain (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 18 March 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 March 2025;
- A pre-deployment medical examination by the medical officer, dated 9 November 2011;
- A role 2 and role 3 treatment record and CT report by the afghanistan, dated 14 June 2012;
- An outpatient health record by the regimental medical officer, dated 2 July 2012;
- A specialist consultation and MRI report by the sports physician and radiologist, dated 18 December 2012;
- An incident report and treatment record by the medical officer, Iraq, dated 14 September 2015;
- A specialist consultation and MRI report by the sports physician and radiologist, dated 20 January 2016;
- A sports injury report and radiograph report by the medical officer, dated 12 May 2018;
- A medical board and discharge medical examination by the senior medical officer, dated 30 June 2021.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 January 2009 and 30 June 2021
Cervical Sprain (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: Cervical Sprain (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 18 March 2025, and is supported by an outpatient health record by the regimental medical officer, dated 2 July 2012.
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 severe neck pain centred on the lower cervical spine and the left side of the neck, muscle spasm and an inability to rotate or flex your head, made worse by wearing a helmet on 14 June 2012.
The diagnosis was made clinically by the regimental medical officer on 2 July 2012 and confirmed by a sports physician on 18 December 2012. The injury followed a clearly described mechanism of forced flexion and lateral bending under load, with immediate pain, spasm and loss of movement. Examination showed facet joint tenderness at C4 to C6, spasm of the left trapezius and levator scapulae and restricted rotation and flexion, with a normal upper limb neurological examination.
After the condition arose, it was worsened during your service. On warlike service in Iraq on 14 September 2015 the protected vehicle in which you were a passenger was struck from behind by a heavy truck, throwing your helmeted head back and then forward. On 14 September 2015, on warlike service in Iraq, you loaded about 60 boxes of ammunition, high-intensity use of the neck and shoulder girdle muscles, and later that day the rear-impact collision forcibly stretched the left trapezius and levator scapulae. On warlike service in Afghanistan in 2012 and in Iraq in 2015 you had no access to physiotherapy or a graded rehabilitation program after each injury and continued carrying combat loads.
This has then led to further investigations and the diagnosis of your condition of Cervical Sprain (Worsening). I have accepted your condition of Cervical Sprain (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 20 January 2016.
