Left Shoulder - Rotator Cuff Syndrome — example DVA determination letter

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Left Shoulder - Rotator Cuff Syndrome

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 17 March 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 March 2025;
A hospital admission record by the deployed hospital, East Timor, dated 8 January 2000;
An emergency department record and shoulder X-ray by the emergency physician, dated 14 July 2003;
An operation report by the orthopaedic surgeon, dated 21 September 2004;
A clinical record by the regimental medical officer, Afghanistan, dated 22 June 2007;
A trauma record and X-ray report by Role 3 hospital, Afghanistan, dated 6 November 2007;
An electromyography report by the neurologist, dated 12 February 2008;
A renal medicine consultation by the nephrologist, dated 3 March 2009;
A rheumatology consultation by the rheumatologist, dated 10 October 2011;
A pathology report by the medical officer, Garrison health centre, dated 14 August 2012;
An endocrinology consultation by the endocrinologist, dated 20 March 2013;
An operation report by the orthopaedic surgeon, dated 4 March 2015;
A histopathology report by the pathologist, dated 12 May 2015;
A periodic health examination by the medical officer, Garrison health centre, dated 18 February 2016;
An ultrasound report and aspirate microbiology by the radiologist and microbiologist, dated 10 June 2016;
An operation report by the orthopaedic surgeon, dated 14 June 2016;
An MRI report and aspirate microbiology by the radiologist and microbiologist, dated 22 August 2018;
An orthopaedic consultation by the orthopaedic surgeon, dated 3 September 2018.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

19 January 1995 and 30 June 2019

Left Shoulder - Rotator Cuff Syndrome

You have stated that your condition was caused by:

having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome
undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome
performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome
performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome
lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset of rotator cuff syndrome
having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome
regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome
having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome
having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome
having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome
having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome
having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome
having diabetes mellitus before the clinical onset of rotator cuff syndrome
having dyslipidaemia before the clinical onset of rotator cuff syndrome
taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome
taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome

Diagnosis: Rotator Cuff Syndrome

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 March 2025, and is supported by an operation report by the orthopaedic surgeon, dated 14 June 2016.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Rotator Cuff Syndrome (Balance of Probabilities) (No. 110 of 2022)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having an injury to the affected shoulder within the 30 days before the clinical onset of rotator cuff syndrome
undergoing a surgical procedure involving the affected shoulder joint before the clinical onset of rotator cuff syndrome
performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical onset of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical onset of rotator cuff syndrome
performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical onset of rotator cuff syndrome
lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical onset of rotator cuff syndrome
having dialysis-related amyloidosis before the clinical onset of rotator cuff syndrome
regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical onset of rotator cuff syndrome
having anatomical narrowing of the subacromial space on the affected side at the time of the clinical onset of rotator cuff syndrome
having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical onset of rotator cuff syndrome
having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical onset of rotator cuff syndrome
having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical onset of rotator cuff syndrome
having gout involving the affected shoulder at the time of the clinical onset of rotator cuff syndrome
having diabetes mellitus before the clinical onset of rotator cuff syndrome
having dyslipidaemia before the clinical onset of rotator cuff syndrome
taking a glucocorticoid drug as specified before the clinical onset of rotator cuff syndrome
taking a fluoroquinolone antibiotic within the 60 days before the clinical onset of rotator cuff syndrome

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 constant anterolateral left shoulder pain, worse at night and when lying on the left side, a painful arc between 70 and 120 degrees of abduction, weakness when lifting the arm and pushing up from the wheelchair, and fever with a hot, swollen shoulder.After the worsening in 2018 you could not lift the left arm above shoulder height, could not push up through the left arm for transfers without pain and needed help with dressing on 10 June 2016.

The diagnosis was confirmed by ultrasound on 10 June 2016, which showed a partial-thickness bursal-surface tear of supraspinatus with subacromial bursal effusion and dynamic impingement, and at arthroscopy on 14 June 2016, where an orthopaedic surgeon confirmed the tear and an inflamed, infected subacromial bursa. This meets the Statement of Principles definition of rotator cuff syndrome, which includes rotator cuff tear and subacromial impingement syndrome.

This has then led to further investigations and the diagnosis of your condition of Rotator Cuff Syndrome. I have accepted your condition of Rotator Cuff Syndrome.

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 peacetime service.

I have therefore accepted that this condition is related to your service with effect from 9 June 2016.

Left Shoulder - Rotator Cuff Syndrome (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 17 March 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 March 2025;
A hospital admission record by the deployed hospital, East Timor, dated 8 January 2000;
An emergency department record and shoulder X-ray by the emergency physician, dated 14 July 2003;
An operation report by the orthopaedic surgeon, dated 21 September 2004;
A clinical record by the regimental medical officer, Afghanistan, dated 22 June 2007;
A trauma record and X-ray report by Role 3 hospital, Afghanistan, dated 6 November 2007;
An electromyography report by the neurologist, dated 12 February 2008;
A renal medicine consultation by the nephrologist, dated 3 March 2009;
A rheumatology consultation by the rheumatologist, dated 10 October 2011;
A pathology report by the medical officer, Garrison health centre, dated 14 August 2012;
An endocrinology consultation by the endocrinologist, dated 20 March 2013;
An operation report by the orthopaedic surgeon, dated 4 March 2015;
A histopathology report by the pathologist, dated 12 May 2015;
A periodic health examination by the medical officer, Garrison health centre, dated 18 February 2016;
An ultrasound report and aspirate microbiology by the radiologist and microbiologist, dated 10 June 2016;
An operation report by the orthopaedic surgeon, dated 14 June 2016;
An MRI report and aspirate microbiology by the radiologist and microbiologist, dated 22 August 2018;
An orthopaedic consultation by the orthopaedic surgeon, dated 3 September 2018.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

19 January 1995 and 30 June 2019

Left Shoulder - Rotator Cuff Syndrome (Worsening)

You have stated that the worsening of your condition was caused by:

having an injury to the affected shoulder within the 30 days before the clinical worsening of rotator cuff syndrome
undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome
performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome
performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome
lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical worsening of rotator cuff syndrome
having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome
regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome
having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome
having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome
having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome
having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome
having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome
having diabetes mellitus before the clinical worsening of rotator cuff syndrome
having dyslipidaemia before the clinical worsening of rotator cuff syndrome
taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome
taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome
inability to obtain appropriate clinical management for rotator cuff syndrome

Diagnosis: Rotator Cuff Syndrome (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Rotator Cuff Syndrome (Balance of Probabilities) (No. 110 of 2022)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having an injury to the affected shoulder within the 30 days before the clinical worsening of rotator cuff syndrome
undergoing a surgical procedure involving the affected shoulder joint before the clinical worsening of rotator cuff syndrome
performing any combination of: (a) repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees; or (b) forceful activities with the affected upper limb; for at least 160 hours within a period of 210 consecutive days before the clinical worsening of rotator cuff syndrome, and where the repetitive or sustained or forceful activities have not ceased more than 30 days before the clinical worsening of rotator cuff syndrome
performing repetitive or sustained activities of the affected shoulder when the shoulder on the affected side is abducted or flexed by at least 60 degrees for at least 4,000 hours within the 10 years before the clinical worsening of rotator cuff syndrome
lifting or carrying loads of at least 20 kilograms using the upper limb of the affected side for at least 400 hours within the 10 years before the clinical worsening of rotator cuff syndrome
having dialysis-related amyloidosis before the clinical worsening of rotator cuff syndrome
regularly using the upper limbs for weight-bearing for a continuous period of at least the 1 year before the clinical worsening of rotator cuff syndrome
having anatomical narrowing of the subacromial space on the affected side at the time of the clinical worsening of rotator cuff syndrome
having joint instability of the affected shoulder, or dislocation or subluxation of the affected shoulder joint before the clinical worsening of rotator cuff syndrome
having an infection of the subacromial bursa or subdeltoid bursa of the affected shoulder at the time of the clinical worsening of rotator cuff syndrome
having an autoimmune disease from the specified list of autoimmune diseases, involving the shoulder joint or associated bursae of the affected side, before the clinical worsening of rotator cuff syndrome
having gout involving the affected shoulder at the time of the clinical worsening of rotator cuff syndrome
having diabetes mellitus before the clinical worsening of rotator cuff syndrome
having dyslipidaemia before the clinical worsening of rotator cuff syndrome
taking a glucocorticoid drug as specified before the clinical worsening of rotator cuff syndrome
taking a fluoroquinolone antibiotic within the 60 days before the clinical worsening of rotator cuff syndrome
inability to obtain appropriate clinical management for rotator cuff syndrome

After the condition arose, it was worsened during your service. On 5 August 2018, transferring from your wheelchair into a Defence vehicle, your right crutch slipped and you fell against the door frame onto the point of your left shoulder. In addition to the 2004 stabilisation, on 14 June 2016 you underwent arthroscopic washout, subacromial bursectomy and acromioplasty of the left shoulder for the septic bursitis present at onset. After the 2016 surgery you resumed crutch walking and wheelchair propulsion at the same intensity from 12 July 2016. The 10 years before the worsening run from 22 August 2008 to 22 August 2018. Within the 10 years before the worsening, from 22 August 2008 to 22 August 2018, you carried loads of 20 kg or more with your left upper limb for about 520 hours, between August 2008 and March 2015. Haemodialysis continued after onset and the dialysis-related amyloidosis confirmed in 2015 remained present before the worsening on 22 August 2018. Crutch walking and transfers continued without interruption after onset and throughout the year before the worsening, from 22 August 2017 to 22 August 2018. Despite acromioplasty in 2016, MRI on 22 August 2018 showed regrowth of inferior acromioclavicular osteophytes and the angulated acromion, with an acromiohumeral interval of 5 mm, narrowing the subacromial space at the time of worsening. The dislocations of 2003 and 2004 and the subluxation of 2007 all preceded the worsening, and a positive apprehension sign was again recorded on 22 August 2018. Aspiration on 22 August 2018 again yielded purulent fluid growing Staphylococcus aureus, a recurrent infection of the subacromial bursa present at the time of the worsening. Rheumatoid arthritis remained active, with left shoulder synovitis on the MRI of 22 August 2018, before the worsening. The aspirate of 22 August 2018 again showed monosodium urate crystals, so gout involved the left shoulder at the time of the worsening. Diabetes mellitus persisted, with an HbA1c of 8.4 per cent in June 2018, before the worsening. Atorvastatin continued as regular drug therapy to normalise blood lipid levels before the worsening. Prednisolone continued, bringing the cumulative oral dose to about 25 grams before the worsening on 22 August 2018. Moxifloxacin 400 mg daily was taken from 10 July 2018 to 16 July 2018 for community-acquired pneumonia, within the 60 days before the worsening that run from 23 June 2018 to 22 August 2018. MET.

This has then led to further investigations and the diagnosis of your condition of Rotator Cuff Syndrome (Worsening). I have accepted your condition of Rotator Cuff Syndrome (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 peacetime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 22 August 2018.

Left Shoulder - Rotator Cuff Syndrome — example determination letter

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Reference Determination Content

Left Shoulder - Rotator Cuff Syndrome

Evidence

Your service

Left Shoulder - Rotator Cuff Syndrome

Left Shoulder - Rotator Cuff Syndrome (Worsening)

Evidence

Your service

Left Shoulder - Rotator Cuff Syndrome (Worsening)