Right Shoulder - Rotator Cuff Syndrome — example determination letter

Reference Determination Content

Suggested draft · fictitious patient

Right 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 18 February 2025;
• A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 February 2025;
• A renal medicine consultation by the renal physician, dated 12 February 2000;
• X-ray both shoulders by the radiologist, dated 5 December 2006;
• A transplant discharge summary by the transplant unit, dated 18 June 2007;
• An emergency record and orthopaedic referral by the base hospital, dated 22 March 2008;
• An operation report by the orthopaedic surgeon, dated 14 October 2008;
• An outpatient health record by the medical officer, RAAF base health centre, dated 9 March 2009;
• A rheumatology consultation and MRI right shoulder by the rheumatologist and radiologist, dated 20 September 2010;
• A pre-deployment medical examination by the medical officer, dated 14 January 2013;
• An ultrasound and bursal aspiration report by Role 3 hospital, dated 16 June 2013;
• An operation report by the orthopaedic surgeon, dated 10 March 2014;
• A deployed health record and ultrasound by Role 2 facility, dated 22 June 2017;
• An MRI right shoulder by the radiologist, dated 8 September 2017;
• An operation report by the orthopaedic surgeon, dated 4 December 2017.

Your service

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

20 January 1995 and 15 November 2019

Right Shoulder - Rotator Cuff Syndrome

You have stated that your condition was caused by:

• having an injury to the affected shoulder within the 3 months 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 80 hours within a period of 120 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 2,000 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 200 hours within the 10 years before the clinical onset of rotator cuff syndrome
• using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 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 acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome
• having smoked at least 20 pack-years of tobacco products before 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
• taking an aromatase inhibitor for at least 4 weeks within the 2 years 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 18 February 2025, and is supported by an ultrasound and bursal aspiration report by Role 3 hospital, dated 16 June 2013.

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 (Reasonable Hypothesis) (No. 109 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 3 months 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 80 hours within a period of 120 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 2,000 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 200 hours within the 10 years before the clinical onset of rotator cuff syndrome
• using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 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 acquired scapular dyskinesis of the affected side at the time of the clinical onset of rotator cuff syndrome
• having smoked at least 20 pack-years of tobacco products before 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
• taking an aromatase inhibitor for at least 4 weeks within the 2 years 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 sudden severe right shoulder pain with a painful arc between 70 and 120 degrees of abduction, night pain preventing you lying on your right side, swelling and warmth over the shoulder and weakness when working overhead on 14 June 2013.

The diagnosis was confirmed by ultrasound on 16 June 2013 showing a 7 mm partial-thickness bursal-surface supraspinatus tear with subacromial-subdeltoid bursitis, and by bursal aspiration the same day. Clinical examination showed a painful arc, positive Hawkins-Kennedy and Neer tests and pain on resisted abduction. These findings meet the Statement of Principles definition of rotator cuff 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 wartime service.

I have therefore accepted that this condition is related to your service with effect from 14 June 2013.

Right 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 18 February 2025;
• A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 February 2025;
• A renal medicine consultation by the renal physician, dated 12 February 2000;
• X-ray both shoulders by the radiologist, dated 5 December 2006;
• A transplant discharge summary by the transplant unit, dated 18 June 2007;
• An emergency record and orthopaedic referral by the base hospital, dated 22 March 2008;
• An operation report by the orthopaedic surgeon, dated 14 October 2008;
• An outpatient health record by the medical officer, RAAF base health centre, dated 9 March 2009;
• A rheumatology consultation and MRI right shoulder by the rheumatologist and radiologist, dated 20 September 2010;
• A pre-deployment medical examination by the medical officer, dated 14 January 2013;
• An ultrasound and bursal aspiration report by Role 3 hospital, dated 16 June 2013;
• An operation report by the orthopaedic surgeon, dated 10 March 2014;
• A deployed health record and ultrasound by Role 2 facility, dated 22 June 2017;
• An MRI right shoulder by the radiologist, dated 8 September 2017;
• An operation report by the orthopaedic surgeon, dated 4 December 2017.

Your service

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

20 January 1995 and 15 November 2019

Right 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 3 months 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 80 hours within a period of 120 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 2,000 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 200 hours within the 10 years before the clinical worsening of rotator cuff syndrome
• using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 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 acquired scapular dyskinesis of the affected side at the time of the clinical worsening of rotator cuff syndrome
• having smoked at least 20 pack-years of tobacco products before 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
• taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical worsening of rotator cuff syndrome
• inability to obtain appropriate clinical management for rotator cuff syndrome

Diagnosis: Rotator Cuff Syndrome (Worsening)

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 18 February 2025, and is supported by an ultrasound and bursal aspiration report by Role 3 hospital, dated 16 June 2013.

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 (Reasonable Hypothesis) (No. 109 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 3 months 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 80 hours within a period of 120 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 2,000 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 200 hours within the 10 years before the clinical worsening of rotator cuff syndrome
• using a hand-held, vibrating, percussive, heavy industrial tool with the affected upper limb, for at least 2,000 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 acquired scapular dyskinesis of the affected side at the time of the clinical worsening of rotator cuff syndrome
• having smoked at least 20 pack-years of tobacco products before 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
• taking an aromatase inhibitor for at least 4 weeks within the 2 years before the clinical worsening of rotator cuff syndrome
• inability to obtain appropriate clinical management for 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 sudden severe right shoulder pain with a painful arc between 70 and 120 degrees of abduction, night pain preventing you lying on your right side, swelling and warmth over the shoulder and weakness when working overhead on 14 June 2013.

The diagnosis was confirmed by ultrasound on 16 June 2013 showing a 7 mm partial-thickness bursal-surface supraspinatus tear with subacromial-subdeltoid bursitis, and by bursal aspiration the same day. Clinical examination showed a painful arc, positive Hawkins-Kennedy and Neer tests and pain on resisted abduction. These findings meet the Statement of Principles definition of rotator cuff syndrome.

After the condition arose, it was worsened during your service. The aileron injury of 8 June 2017 occurred on warlike service in the Middle East, 14 days before the worsening on 22 June 2017. The 2008 Bankart repair and the 2014 bursectomy and debridement preceded the worsening on warlike service in June 2017. From 22 February 2017 to 22 June 2017 you were on warlike service in the Middle East performing overhead and forceful right arm work for about three hours each shift, more than 80 hours, up to the worsening. About 4,500 hours of overhead work were performed in the 10 years before the worsening, including your 2010, 2013 and 2017 warlike deployments. More than 600 hours of lifting 20 kilograms or more with the right arm were performed in the 10 years before the worsening, including on warlike service in 2017. In the 10 years before the worsening you used pneumatic rivet guns and air tools with your right hand for more than 2,000 hours, including on warlike service in 2013 and 2017. Dialysis-related amyloidosis persisted and was present before the worsening on warlike service in 2017. Prone work in wing bays with upper limb weight-bearing continued throughout the year before the worsening, including on warlike service from February 2017. The acromioclavicular osteophyte and type III acromion were present at the worsening on warlike service, confirmed on MRI of 8 September 2017. The 2008 dislocation and subluxations preceded the worsening in 2017. Recurrent Staphylococcus aureus bursitis was confirmed by aspiration on warlike service on 22 June 2017, at the time of the worsening. Rheumatoid arthritis involving the right shoulder was present before the worsening on warlike service in 2017. Urate crystals in the aspirate of 22 June 2017, on warlike service, confirmed gout of the right shoulder at the worsening. Right scapular winging from long thoracic nerve palsy persisted, recorded at the role 2 facility on 22 June 2017, at the time of the worsening. By 2017 you had smoked about 30 pack-years, continuing on warlike service. Diabetes mellitus was present before the worsening on warlike service in 2017. Dyslipidaemia was present before the worsening on warlike service in 2017. More than 20 grams of oral prednisolone had been taken before the worsening, with no proximity limit at that dose. Ciprofloxacin was taken from 6 May 2017 to 13 May 2017 on warlike service, within the 60 days before the worsening. A second course of anastrozole 1 mg daily was taken from 16 November 2015 to 21 March 2016 for recurrent gynaecomastia, more than 4 weeks within the 2 years before the worsening, from 22 June 2015 to 22 June 2017. On warlike service in the Middle East after 22 June 2017 no shoulder surgeon or MRI was available and early repatriation was declined, so the full-thickness tear went unrepaired for five months and retracted.

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 wartime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 22 June 2017.