Reference Determination Content
Suggested draft · fictitious patient
Right Shoulder - 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 10 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 10 June 2025;
- A pre-deployment medical examination by the medical officer, dated 10 June 2008;
- An incident report and casualty record by the detachment commander and combat medic, dated 22 October 2008;
- A deployed health record and ultrasound by Role 2 facility, dated 24 October 2008;
- A deployed health record by the medical officer, Patrol base, dated 2 December 2008;
- A physiotherapy assessment by the MRI and sports medicine consultation, Physiotherapist, radiologist and sports physician, dated 17 March 2009;
- A casualty record by the combat medic, Iraq, dated 11 April 2017;
- An ultrasound right shoulder by the coalition role 2 facility, dated 19 April 2017;
- An MRI right shoulder and sports medicine review by the radiologist and sports physician, dated 5 December 2017.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
22 August 2001 and 13 March 2022
Right Shoulder - 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: Trapezius Strain
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 10 June 2025, and is supported by a deployed health record and ultrasound by Role 2 facility, dated 24 October 2008.
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 tearing pain along the top of the right shoulder and the side of the neck, bruising, spasm, painful shoulder shrugging and turning of the head, and pain over the acromioclavicular joint on 22 October 2008.
The diagnosis was made clinically at the role 2 facility on 24 October 2008 on the basis of the mechanism of injury, immediate tearing pain, bruising, spasm and tenderness of the right upper trapezius with pain on shoulder elevation and neck side flexion, and acromioclavicular joint tenderness with a positive cross-body adduction test. Ultrasound that day confirmed a partial trapezius tear with haematoma and acromioclavicular joint effusion. This meets the Statement of Principles definition of a strain, with a sprain of the acromioclavicular joint.
This has then led to further investigations and the diagnosis of your condition of Trapezius Strain. I have accepted your condition of 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 22 October 2008.
Right Shoulder - 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 10 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 10 June 2025;
- A pre-deployment medical examination by the medical officer, dated 10 June 2008;
- An incident report and casualty record by the detachment commander and combat medic, dated 22 October 2008;
- A deployed health record and ultrasound by Role 2 facility, dated 24 October 2008;
- A deployed health record by the medical officer, Patrol base, dated 2 December 2008;
- A physiotherapy assessment by the MRI and sports medicine consultation, Physiotherapist, radiologist and sports physician, dated 17 March 2009;
- A casualty record by the combat medic, Iraq, dated 11 April 2017;
- An ultrasound right shoulder by the coalition role 2 facility, dated 19 April 2017;
- An MRI right shoulder and sports medicine review by the radiologist and sports physician, dated 5 December 2017.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
22 August 2001 and 13 March 2022
Right Shoulder - 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: Trapezius Strain (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 10 June 2025, and is supported by a deployed health record and ultrasound by Role 2 facility, dated 24 October 2008.
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 tearing pain along the top of the right shoulder and the side of the neck, bruising, spasm, painful shoulder shrugging and turning of the head, and pain over the acromioclavicular joint on 22 October 2008.
The diagnosis was made clinically at the role 2 facility on 24 October 2008 on the basis of the mechanism of injury, immediate tearing pain, bruising, spasm and tenderness of the right upper trapezius with pain on shoulder elevation and neck side flexion, and acromioclavicular joint tenderness with a positive cross-body adduction test. Ultrasound that day confirmed a partial trapezius tear with haematoma and acromioclavicular joint effusion. This meets the Statement of Principles definition of a strain, with a sprain of the acromioclavicular joint.
After the condition arose, it was worsened during your service. On warlike service in Iraq on 11 April 2017 the dropped trail of a towed howitzer applied a significant traction force through the right acromioclavicular joint, with a new effusion on ultrasound on 19 April 2017, at the time of the worsening. The same incident on warlike service in Iraq on 11 April 2017 forcefully stretched the contracting right upper trapezius, producing the new 3 cm partial-thickness tear confirmed on ultrasound on 19 April 2017, at the time of the worsening. On warlike service in Afghanistan in 2008 you had no physiotherapy and was returned to the gun line after ten days for operational reasons, and on warlike service in Iraq in 2017 physiotherapy and MRI were unavailable at your location for the rest of your tour.
This has then led to further investigations and the diagnosis of your condition of Trapezius Strain (Worsening). I have accepted your condition of 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 11 April 2017.
