Reference Determination Content
Suggested draft · fictitious patient
Neck - Left Trapezius 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 5 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 5 August 2025;
- A pre-deployment medical examination by the medical officer, dated 15 January 2010;
- A deployed health record by the medical officer, role 1 facility, Afghanistan, dated 17 June 2010;
- An ultrasound report (role 2 facility) by the afghanistan, dated 22 June 2010;
- An outpatient health record and X-ray report by the medical officer, Garrison health centre, dated 14 February 2012;
- A physiotherapy assessment by the physiotherapist, dated 20 May 2016;
- A deployed health record by the medical officer, role 1 facility, Iraq, dated 9 October 2017;
- An ultrasound report by the iraq, dated 12 October 2017;
- An MRI report and sports medicine consultation by the sports physician, dated 2 January 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
23 January 2004 and 11 March 2020
Neck - Left Trapezius 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: Left Trapezius Strain
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 5 August 2025, and is supported by a deployed health record by the medical officer, role 1 facility, Afghanistan, dated 17 June 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 sharp pain and spasm in the left side of the neck and top of the left shoulder, pain on turning your head to the right and on shrugging and lifting the left arm, and tenderness over the acromioclavicular joint on 17 June 2010.
The diagnosis was made clinically by the medical officer on 17 June 2010 from the mechanism of injury and the findings of tenderness and spasm of the left upper trapezius, pain on resisted shoulder elevation and on passive stretch into right side flexion, and acromioclavicular joint tenderness. Ultrasound on 22 June 2010 showed oedema of the left upper trapezius without a tear and a grade I acromioclavicular joint sprain, confirming a muscle strain with an associated joint sprain.
This has then led to further investigations and the diagnosis of your condition of Left Trapezius Strain. I have accepted your condition of Left Trapezius 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 17 June 2010.
Neck - Left Trapezius 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 5 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 5 August 2025;
- A pre-deployment medical examination by the medical officer, dated 15 January 2010;
- A deployed health record by the medical officer, role 1 facility, Afghanistan, dated 17 June 2010;
- An ultrasound report (role 2 facility) by the afghanistan, dated 22 June 2010;
- An outpatient health record and X-ray report by the medical officer, Garrison health centre, dated 14 February 2012;
- A physiotherapy assessment by the physiotherapist, dated 20 May 2016;
- A deployed health record by the medical officer, role 1 facility, Iraq, dated 9 October 2017;
- An ultrasound report by the iraq, dated 12 October 2017;
- An MRI report and sports medicine consultation by the sports physician, dated 2 January 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
23 January 2004 and 11 March 2020
Neck - Left Trapezius 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: Left Trapezius Strain (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 5 August 2025, and is supported by a deployed health record by the medical officer, role 1 facility, Afghanistan, dated 17 June 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 sharp pain and spasm in the left side of the neck and top of the left shoulder, pain on turning your head to the right and on shrugging and lifting the left arm, and tenderness over the acromioclavicular joint on 17 June 2010.
The diagnosis was made clinically by the medical officer on 17 June 2010 from the mechanism of injury and the findings of tenderness and spasm of the left upper trapezius, pain on resisted shoulder elevation and on passive stretch into right side flexion, and acromioclavicular joint tenderness. Ultrasound on 22 June 2010 showed oedema of the left upper trapezius without a tear and a grade I acromioclavicular joint sprain, confirming a muscle strain with an associated joint sprain.
After the condition arose, it was worsened during your service. On warlike service in Iraq on 9 October 2017 you lifted a 40 kg ammunition box overhead in body armour, applying significant force through the left acromioclavicular joint, which was tender that day and showed oedema and capsular thickening on MRI on 2 January 2018. The same overhead lift on warlike service on 9 October 2017 required high-intensity contraction of the left upper trapezius, which tore at that moment; ultrasound on 12 October 2017 confirmed a 2 cm partial-thickness tear with haematoma. On warlike service in Iraq from October to December 2017 no physiotherapist was available for seven weeks, MRI was not available in theatre, and operational requirements kept you on armoured force protection duties with a torn muscle.
This has then led to further investigations and the diagnosis of your condition of Left Trapezius Strain (Worsening). I have accepted your condition of Left Trapezius 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 October 2017.
