Diagnostic Assessment — Bilateral Hip - Osteoarthritis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Bilateral Hip — Osteoarthritis BOP Code: 62 of 2017 (Osteoarthritis) RH Code: 61 of 2017 (Osteoarthritis)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Transport Driver from 19 November 1980 to 5 September 1987
Occupational History
As a Transport Driver in the Australian Army, the veteran performed physically demanding duties including heavy manual handling, lifting of survey equipment and steel cables, and operating aboard moving service vessels.
He was also required to participate in military sporting activities including rugby union, rugby league, and boxing.
These activities placed repetitive and high-impact loading through the hip joints over the course of several years of service.
Additionally, the veteran had documented obesity during service from at least October 1984 (BMI 32.3), which places increased mechanical loading on the weight-bearing hip joints
History
The veteran has bilateral hip osteoarthritis, right more prominent than left, first identified on bone scan in December 2013 with mild to moderate degenerative changes and right greater trochanteric enthesopathy/bursitis.
The condition was further characterised on bone scan in September 2020 showing bilateral hip OA more prominent on the right with subchondral bone cysts at the right acetabular roof.
Dedicated MRI of both hips in March 2022 confirmed mild to moderate osteoarthritis bilaterally with labral tears, cartilage loss, and associated soft tissue pathology
Timeline
27 December 2013 — Whole body bone scan demonstrated mild to moderate hip degenerative changes bilaterally and right greater trochanteric enthesopathy/bursitis with lower-grade changes on the left.
Arthropathy with tendinopathy was also identified in both shoulders. "Mild to moderate degenerative changes" 9 January 2014 — Ultrasound-guided injection of 3mL bupivacaine and 1mL Celestone into the right greater trochanteric bursa was performed by the treating doctor Ng for symptomatic relief of the right hip bursitis. "Greater trochanteric bursitis" 08 Sep 2020 — Localised bone scan with SPECT/CT confirmed bilateral hip osteoarthritis, more prominent on the right, with subchondral bone cysts at the right acetabular roof.
The degenerative changes had progressed since the 2014 scan. "Bilateral hip OA" 16 Feb 2022 — MRI right hip for bilateral hip pain.
Demonstrated mild to moderate degenerative changes with cartilage thinning involving multiple aspects of the acetabulum (anterosuperior, superolateral, superomedial, posterosuperior), which was full-thickness toward the acetabular margin.
Several subchondral cysts were present in the superolateral acetabular margin.
Cartilage thinning of the far lateral femoral head was noted.
A degenerative anterosuperior labral tear with a tiny paralabral cyst was identified.
Moderate hamstring origin tendinopathy with low-grade fissuring was also present.
Mild cam morphology of the anterosuperior femoral head and a suggestion of cranial acetabular retroversion were noted. "Mild to moderate hip OA" 20 Feb 2022 — MRI left hip for bilateral hip pain.
Demonstrated patchy high-grade chondral ulceration and fissuring of the acetabulum, most pronounced anterosuperiorly and superolaterally, with foci of subchondral cystic change and bone marrow oedema.
Mild chondral thinning of the femoral head superomedially.
Anterosuperior and posterosuperior acetabular labral tearing.
Small hip joint effusion with synovitis.
Moderate hamstring origin tendinopathy with partial thickness tearing predominantly involving semimembranosus.
Mild gluteus minimus and medius tendinopathy.
Greater trochanteric bursal oedema.
An aberrant sciatic nerve course was noted with the common peroneal component extending through the inferior fibres of piriformis. "Mild to moderate left hip OA"
Symptoms
The veteran reports bilateral hip pain.
The right hip has been symptomatic since at least 2014 when greater trochanteric bursitis required injection therapy.
Both hips now demonstrate pain with weight-bearing and functional limitation
Imaging
27 December 2013 — Bone scan: "Mild to moderate hip degenerative changes.
Right greater trochanteric enthesopathy/bursitis." 08 Sep 2020 — Bone scan: "Bilateral hip OA, more prominent on the right, with subchondral bone cysts at the right acetabular roof." 16 Feb 2022 — MRI right hip: "Mild to moderate hip OA.
Degenerative anterosuperior labral tear.
Moderate hamstring origin tendinopathy.
Mild cam morphology.
Cranial acetabular retroversion." 20 Feb 2022 — MRI left hip: "Mild to moderate left hip joint osteoarthritis with small joint effusion and synovitis.
High-grade chondral ulceration.
Anterosuperior and posterosuperior labral tears.
Moderate hamstring tendinopathy with partial tearing.
Mild gluteal tendinopathy."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Hip Osteoarthritis (ICD-10: M16.0).
The relevant Statements of Principles are those concerning Osteoarthritis (Balance of Probabilities No.
62 of 2017; Reasonable Hypothesis No.
61 of 2017), applied by analogy as this is a DRCA claim.
Osteoarthritis is a chronic degenerative joint disease characterised by progressive loss of articular cartilage, subchondral bone remodelling, osteophyte formation, synovial inflammation, and associated soft tissue pathology including labral tears and bursitis.
Hip osteoarthritis is a major cause of pain and functional disability.
The right hip demonstrates more advanced degenerative change with full-thickness cartilage loss toward the acetabular margin, while the left hip shows more active disease with high- grade chondral ulceration, synovitis, and bone marrow oedema
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 27 December 2013 (first imaging evidence of bilateral hip degenerative changes).
The insidious onset of hip OA makes precise dating difficult, however the contributory factors of obesity, heavy occupational loading, and sporting activities were present from the mid-1980s during service.
When did the veteran first present to a health / medical provider for this condition? 27 December 2013 (bone scan demonstrating bilateral hip changes) When was the condition confirmed / formally diagnosed? 8 September 2020 (bone scan explicitly diagnosing bilateral hip OA) When did the veteran first present to you (or your practice) for this condition? 1 April 2022
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on imaging.
Whole body bone scan on 27 December 2013 first demonstrated mild to moderate hip degenerative changes bilaterally.
Bone scan on 8 September 2020 confirmed bilateral hip OA with subchondral bone cysts.
Dedicated MRI of both hips in March 2022 comprehensively characterised the osteoarthritis with cartilage loss, labral tears, and associated soft tissue pathology bilaterally
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 16 February 2001 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The imaging element of the definition is clearly met, with loss of articular cartilage in both hips and osteophytes in the left hip on the MRIs of 1 and 20 February 2022, as are pain and impaired function; stiffness, the remaining clinical element, is not separately recorded in the documents and should be confirmed on examination.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Osteoarthritis, No.
62 of 2017) Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - None of the specified inflammatory joint diseases (ankylosing spondylitis, arthritis with Crohn's disease or ulcerative colitis, psoriatic or reactive arthritis, or rheumatoid arthritis) is recorded, and imaging of his sacroiliac joints between 2017 and 2021 showed no sacroiliitis.
Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint — NOT MET - No bacterial, viral, fungal or parasitic infection of either hip joint is recorded at any time.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of either hip is recorded, and none was shown on the bone scans of 2014, 2018 and 2021 or the MRIs of March 2022.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No bleeding into either hip joint is recorded, and he has had no hip surgery, recorded hip joint injury or anticoagulant treatment.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - Gout, pseudogout, haemochromatosis, alkaptonuria and Wilson's disease are not recorded, and no imaging of his hips describes chondrocalcinosis or crystal arthropathy.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - None of the veteran's in-service falls is recorded as injuring a hip: the fall onto his back at work on 28 December 1982 bruised the right loin and irritated the right L4 nerve root, the wet-deck slip of 15 August 1984 sprained the right knee, and the fall onto a floor polisher on 20 September 1985 bruised his ribs and back; no hip pain, tenderness or restricted hip movement was recorded.
Factor 9(7): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - No acute articular cartilage tear of either hip is recorded before the estimated onset in 2001; the labral tears and chondral damage first shown on MRI in March 2022 were reported with the osteoarthritis, the right labral tear expressly as degenerative.
Factor 9(8): having an acute meniscal tear of the affected knee within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects both hips.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of frostbite or any cold injury; his service was in Australian ships and establishments in temperate and tropical climates.
Factor 9(10): having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint — MET - The MRIs of 1 and 20 February 2022 show minor cranial acetabular retroversion of the left hip and a suggestion of it on the right, with mild cam morphology of the right femoral head.
Acetabular retroversion is a rotation deformity of the acetabulum that concentrates load on its anterosuperior rim, and both hips show anterosuperior labral tearing with cartilage loss at or near the rim, consistent with maldistribution of loading forces.
These deformities are developmental and were established by skeletal maturity in about 1983, some 18 years before the estimated onset on 31 October 2000, well over the five years required.
The factor is met for the left hip and, on the suggested retroversion and cam morphology, for the right.
Factor 9(11): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint — NOT MET - There is no evidence of osteonecrosis: the MRI of 16 February 2022 excluded avascular necrosis of the right femoral head, the left hip MRI showed subchondral cystic change and marrow oedema beneath damaged cartilage rather than necrosis, and no decompression illness is recorded from his diving in 1982.
Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing: (a) forceful or repetitive activities involving the affected joint; or (b) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of a joint of the upper limb; the veteran's osteoarthritis affects both hips, which are joints of the lower limb.
Factor 9(13): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand- held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the hand, wrist or elbow; the veteran's osteoarthritis affects both hips.
Factor 9(14): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical onset of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical onset of osteoarthritis in that joint; or (e) having increased bone mineral density before the clinical onset of osteoarthritis in that joint — MET - Limb (b) is met for both hips.
The veteran's Transport Driver and survey duties involved repeated lifting while standing: he strained his back at sea in a logistics unit on 26 February 1982 lifting steel cables and cable drums, his surgeon expected him back at 'heavy manual work' in 1984, and he was doing heavy lifting at a logistics unit in March 1987.
A conservative estimate of 15 lifts of loads of at least 20 kg (averaging 25 kg) on 150 working days a year over about five years of effective duty (mid-1982 to September 1987) gives about 280,000 kg, well above 150,000 kg within a ten-year period, and the onset in October 2000 falls within 25 years after it.
Limbs (a), (c), (d) and (e) are not shown (no amputation or recorded asymmetric gait, insufficient carrying, no continuous five years of 150 stairs or rungs a day, no bone densitometry).
Factor 9(15): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint — MET - Limb (a) is met for both hips.
The veteran's BMI was 32.9 on 5 January 1984 (115 kg, 187 cm), between 29.2 and 32.9 at every weight-surveillance reading in 1984 and 1985, and 35.7 at discharge on 5 September 1987, and a medical board on 7 December 1984 recorded that despite his thickset build he looked obese.
No weights are recorded from 1988 to 2014, but his body habitus made ultrasound technically very difficult in October 2013 and he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2016, with no record of any fall below a BMI of 25.
He was therefore overweight from at least December 1983 to the estimated onset on 31 October 2000, nearly 17 years.
Factor 9(16): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; and (b) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period — NOT MET - Kneeling and squatting are not recorded.
His deck scrubbing, rope work, survey and ship- husbandry duties would have involved intermittent kneeling, but there is no basis for estimating at least a hour a day on more days than not over a continuous two years, his seagoing service having been broken by shore postings, surgery and periods of incapacity.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the knee; the veteran's osteoarthritis affects both hips.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the patello-femoral joint; the veteran's osteoarthritis affects both hips.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception in either hip is recorded before 2001; the lumbar nerve-root irritation of 1983 and 1986 caused pain and paraesthesiae, not loss of joint sensation, and his diabetes was diagnosed only in 2017.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 27 December 2013 and later bone scans of the pelvis and hips did not show it.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint — NOT MET - Although the veteran was described in service as a large, thickset man, there is no record of acromegaly or any clinical feature of growth hormone excess.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of instability or dislocation of either hip; the familial recurrent dislocations in his history affected the thumbs, not the hips.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint — NOT MET - Femoroacetabular impingement syndrome has never been diagnosed, and no hip or groin symptoms or examination findings suggesting it are recorded before the estimated onset in 2001; the impingement morphology (mild cam morphology of the right hip and minor acetabular retroversion) was first noted on MRI in March 2022.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Osteoarthritis, No.
61 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis — NOT MET - the veteran was never a prisoner of war; he had no operational service.
Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - None of the specified inflammatory joint diseases (ankylosing spondylitis, arthritis with Crohn's disease or ulcerative colitis, psoriatic or reactive arthritis, or rheumatoid arthritis) is recorded, and imaging of his sacroiliac joints between 2017 and 2021 showed no sacroiliitis.
Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint — NOT MET - No bacterial, viral, fungal or parasitic infection of either hip joint is recorded at any time.
Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No fracture involving the articular surface of either hip is recorded, and none was shown on the bone scans of 2014, 2018 and 2021 or the MRIs of March 2022.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No bleeding into either hip joint is recorded, and he has had no hip surgery, recorded hip joint injury or anticoagulant treatment.
Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - Gout, pseudogout, haemochromatosis, alkaptonuria and Wilson's disease are not recorded, and no imaging of his hips describes chondrocalcinosis or crystal arthropathy.
Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No trauma to either hip meeting the definition is recorded before the estimated onset in 2001: the in-service falls of 28 December 1982 (onto his back, with right L4 nerve-root irritation), 15 August 1984 (right knee sprain) and 20 September 1985 (bruised ribs and back) produced no recorded hip pain, tenderness or restricted hip movement.
Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No acute articular cartilage tear of either hip is recorded before the estimated onset in 2001; the labral tears and chondral damage first shown on MRI in March 2022 were reported with the osteoarthritis, the right labral tear expressly as degenerative.
Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects both hips.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of frostbite or any cold injury; his service was in Australian ships and establishments in temperate and tropical climates.
Factor 9(11): having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint — MET - The MRIs of 1 and 20 February 2022 show minor cranial acetabular retroversion of the left hip and a suggestion of it on the right, with mild cam morphology of the right femoral head; acetabular retroversion is a rotation deformity that concentrates load on the anterosuperior acetabular rim, where both hips show labral tearing and cartilage loss.
Being developmental, these deformities were established by skeletal maturity in about 1983, some 18 years before the estimated onset on 31 October 2000, well over the three years required.
The factor is met for the left hip and, on the suggested retroversion and cam morphology, for the right.
Factor 9(12): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint — NOT MET - There is no evidence of osteonecrosis: the MRI of 16 February 2022 excluded avascular necrosis of the right femoral head, the left hip MRI showed subchondral cystic change and marrow oedema beneath damaged cartilage rather than necrosis, and no decompression illness is recorded from his diving in 1982.
Factor 9(13): for osteoarthritis of a joint of the upper limb only: (a) performing: (i) forceful or repetitive activities involving the affected joint; or (ii) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; or (b) using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical onset of osteoarthritis in that joint — NOT MET - This factor, including its vibrating-tool limb, applies only to osteoarthritis of a joint of the upper limb; the veteran's osteoarthritis affects both hips, which are joints of the lower limb.
Factor 9(14): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical onset of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; or (e) having increased bone mineral density before the clinical onset of osteoarthritis in that joint — MET - Limb (b) is met for both hips.
The veteran's Transport Driver and survey duties involved repeated lifting while standing, documented when he strained his back at sea in a logistics unit on 26 February 1982 lifting steel cables and cable drums and when he was doing heavy lifting at a logistics unit in March 1987.
A conservative estimate from these duties, 15 lifts of loads of at least 20 kg (averaging 25 kg) on 150 working days a year over about five years of effective duty (mid-1982 to September 1987), gives about 280,000 kg, well above the 100,000 kg required within a ten-year period before the onset in October 2000.
Limbs (a), (c), (d) and (e) are not shown (no amputation or recorded asymmetric gait, insufficient carrying, no continuous two years of 150 stairs or rungs a day, no bone densitometry).
Factor 9(15): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint — MET - Limb (a) is met for both hips.
The veteran's BMI was 32.9 on 5 January 1984, at least 29.2 at every later in-service reading and 35.7 at discharge on 5 September 1987; his body habitus made ultrasound technically very difficult in October 2013 and he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2016, with no record of any fall below a BMI of 25.
He was therefore overweight from at least December 1983 to the estimated onset on 31 October 2000, nearly 17 years, well over the ten years required.
Factor 9(16): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - Kneeling and squatting are not recorded.
His deck scrubbing, rope work, survey and ship- husbandry duties would have involved intermittent kneeling, but there is no basis for estimating at least a hour a day of kneeling or squatting on more days than not over a continuous year.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the knee; the veteran's osteoarthritis affects both hips.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the patello-femoral joint; the veteran's osteoarthritis affects both hips.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception in either hip is recorded before 2001; the lumbar nerve-root irritation of 1983 and 1986 caused pain and paraesthesiae, not loss of joint sensation, and his diabetes was diagnosed only in 2017.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 27 December 2013 and later bone scans of the pelvis and hips did not show it.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint — NOT MET - Although the veteran was described in service as a large, thickset man, there is no record of acromegaly or any clinical feature of growth hormone excess.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint — NOT MET - There is no record of instability or dislocation of either hip; the familial recurrent dislocations in his history affected the thumbs, not the hips.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint — NOT MET - Femoroacetabular impingement syndrome has never been diagnosed, and no hip or groin symptoms or examination findings suggesting it are recorded before the estimated onset in 2001; the impingement morphology (mild cam morphology of the right hip and minor acetabular retroversion) was first noted on MRI in March 2022.
Other Plausible Links to Service the veteran's obesity began during his naval service.
He was above the weight for his height by 5 January 1984 (BMI 32.9), was placed on the Weight Surveillance Programme, was placed by a medical board on 7 December 1984 in a medical category that made him unfit for sea because of his weight, and weighed 125 kg (BMI 35.7) at discharge.
The obesity has persisted and progressed since, to about 168 kg before bariatric surgery in 2016 and 143.6 kg in May 2021.
Obesity is claimed as a separate condition; if it is accepted as related to service, his bilateral hip osteoarthritis is also related to service as a consequence of it, because excess body weight increases the load borne by the hips with every step and is a recognised cause of hip osteoarthritis.
The mild cam morphology of the right femoral head shown on the MRI of 16 February 2022 is recognised to develop during the final years of skeletal growth, particularly in adolescents undertaking intensive high-impact sport before the growth plate of the femoral head closes.
The veteran enlisted as a Transport Driver as a young adult on 19 November 1980 and, at an age when that growth plate is usually still open, undertook recruit physical training (including doubling) and played rugby as organised service sport, the scrum collapse of 19 April 1981 being recorded as on duty.
Service sport and training at that age may therefore have contributed to the cam morphology that now predisposes his right hip to impingement-type loading and osteoarthritis.
Conclusion the veteran's bilateral hip osteoarthritis is multifactorial.
Its principal causes are obesity, which began during his naval service (BMI 32.9 by December 1983 and 35.7 at discharge) and persisted for about 17 years before the estimated onset in October 2000, and the cumulative heavy lifting of his seagoing, survey and ship-husbandry duties, estimated at about 280,000 kg; a developmental impingement morphology of both hips (acetabular retroversion and, on the right, mild cam morphology) predisposed the joints, and the cam morphology may itself reflect the organised service sport and training he undertook from the age of 16.
The heavy lifting occurred entirely in service and the obesity began in service, so his service contributed to the condition to a significant degree, and the delay of nearly seven years in diagnosing it after 2014, together with his continuing obesity, contributed to its progression.
The % contribution of the causes is 100% and significant.
Worsening Factors the veteran's bilateral hip osteoarthritis is estimated to have had its clinical onset on 31 October 2000, more than 13 years after his discharge on 5 September 1987, so no ADF service was rendered after onset and service could not have aggravated the established condition.
The worsening factors are nevertheless addressed below; some are met on post-service facts, notably his continuing obesity and the long delay in diagnosis, during which the disease progressed from mild to moderate degenerative change in December 2013 to full-thickness acetabular cartilage loss and high-grade chondral ulceration by March 2022.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Osteoarthritis, No.
62 of 2017) Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No specified inflammatory joint disease has been diagnosed at any time; the small effusion and synovitis in the left hip on 20 February 2022 were reported as part of the osteoarthritis, and imaging showed no sacroiliitis between 2017 and 2021.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint — NOT MET - No bacterial, viral, fungal or parasitic infection of either hip joint is recorded before or during the worsening of his osteoarthritis.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No intra-articular fracture of either hip is recorded; the bone scans of 2014, 2018 and 2021 and the MRIs of March 2022 showed none, the right hip MRI expressly excluding a femoral neck fracture.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No bleeding into either hip joint is recorded, and he has had no hip surgery, recorded hip joint injury or anticoagulant treatment.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - Gout, pseudogout, haemochromatosis, alkaptonuria and Wilson's disease are not recorded at any time, and the hip imaging of 2014 to 2022 describes degenerative, not crystal, arthropathy.
Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - The fall at work on 24 August 2013, when a falling strut struck the veteran's face and he landed on his buttocks, followed the onset, but its records describe back, thoracic spine and right leg nerve symptoms, not hip joint pain, tenderness or restricted movement, and the steroid injection of 9 January 2014 was into the trochanteric bursa, outside the joint; trauma to the affected joint as defined is not established.
Factor 9(30): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - No acute articular cartilage tear of either hip is recorded; the labral tears and chondral ulceration shown in March 2022 were reported with the osteoarthritis, the right labral tear expressly as degenerative.
Factor 9(31): having an acute meniscal tear of the affected knee within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects both hips.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of frostbite or any cold injury at any time before the worsening of his osteoarthritis.
Factor 9(33): having disordered joint mechanics of the affected joint for at least five years before the clinical worsening of osteoarthritis in that joint — MET - The cranial acetabular retroversion of the veteran's hips (minor on the left, suggested on the right), a developmental rotation deformity that concentrates load on the anterosuperior acetabular rim, together with mild cam morphology of the right femoral head, persisted after the estimated onset in 2001 and had been present for decades, far more than five years, before the clinical worsening documented between December 2013 and March 2022.
By March 2022 the MRIs showed anterosuperior labral tearing in both hips, full-thickness acetabular cartilage loss on the right and high-grade chondral ulceration on the left, the pattern expected from rim loading.
The factor is met for both hips on non-service facts.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint — NOT MET - No osteonecrosis of either hip has been shown: the MRI of 16 February 2022 found no avascular necrosis of the right femoral head, and the left hip MRI showed subchondral cystic change and marrow oedema beneath damaged cartilage, not necrosis.
Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing: (a) forceful or repetitive activities involving the affected joint; or (b) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of a joint of the upper limb; the veteran's osteoarthritis affects both hips, which are joints of the lower limb.
Factor 9(36): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand- held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the hand, wrist or elbow; the veteran's osteoarthritis affects both hips.
Factor 9(37): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical worsening of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; or (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical worsening of osteoarthritis in that joint — NOT MET - After the estimated onset in 2001 the veteran's recorded work was office work in the transport sector and running car yards; the only heavy handling recorded, helping to load a truck in September 2013, falls far short of 150,000 kg, and no amputation, asymmetric gait, heavy carrying or stair climbing of the required extent is recorded.
His in-service lifting preceded the onset and so could not aggravate the condition.
Factor 9(38): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint — MET - the veteran remained obese after the estimated onset on 31 October 2000: his body habitus made ultrasound technically very difficult in October 2013, and he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2016; he then fell to 76 kg but regained weight, to 143.6 kg (BMI 41.5) on 12 May 2021.
He was thus overweight for more than ten years before the clinical worsening, in which mild to moderate degenerative change in December 2013 progressed to subchondral cysts in September 2020 and to full-thickness acetabular cartilage loss (right) and high-grade chondral ulceration (left) by March 2022.
The factor is met for both hips on post-service facts, although the obesity began during service.
Factor 9(39): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at two years before the clinical worsening of osteoarthritis in that joint; and (b) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period — NOT MET - No kneeling or squatting of this extent is recorded after the estimated onset in 2001; his recorded post-service work was office work in the transport sector and running car yards.
Factor 9(40): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the knee; the veteran's osteoarthritis affects both hips.
Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the patello-femoral joint; the veteran's osteoarthritis affects both hips.
Factor 9(42): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception in either hip is recorded: his diabetes (2017) has no recorded neuropathy, the 2014 neuropathy of the lateral cutaneous nerve of the thigh affected skin sensation, not the hip joint, and he recovered completely from a 'spinal stroke' in 2006.
Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and the bone scans of 2014, 2018 and 2021 did not show it.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of acromegaly or any clinical feature of growth hormone excess before the worsening of his osteoarthritis.
Factor 9(45): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of instability or dislocation of either hip at any time; the familial recurrent dislocations in his history affected the thumbs.
Factor 9(46): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint — NOT MET - Femoroacetabular impingement syndrome has not been diagnosed: the impingement morphology (mild cam morphology of the right hip and minor acetabular retroversion) was noted only on the MRIs of March 2022, which reported the hips as osteoarthritic, and the syndrome also requires characteristic clinical signs, none of which are recorded.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis — MET - Although the osteoarthritis is estimated to have been present from 2001, no assessment of the veteran's hips is recorded until the bone scan of 27 December 2013 showed degenerative change in both.
Management was then limited to a steroid injection of the right greater trochanteric bursa, investigation of his pain was directed to the lumbar spine, and hip osteoarthritis was not diagnosed until 8 September 2020, nearly seven years later, or imaged by MRI until March 2022, when both hips had advanced acetabular cartilage damage.
He had PTSD, depression and anxiety through much of this period.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity; the delay of more than five years from first presentation to diagnosis, while the disease progressed, satisfies the factor for both hips.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Osteoarthritis, No.
61 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No specified inflammatory joint disease has been diagnosed at any time; the small effusion and synovitis in the left hip on 20 February 2022 were reported as part of the osteoarthritis, and imaging showed no sacroiliitis between 2017 and 2021.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint — NOT MET - No bacterial, viral, fungal or parasitic infection of either hip joint is recorded before or during the worsening of his osteoarthritis.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No intra-articular fracture of either hip is recorded; the bone scans of 2014, 2018 and 2021 and the MRIs of March 2022 showed none, the right hip MRI expressly excluding a femoral neck fracture.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No bleeding into either hip joint is recorded, and he has had no hip surgery, recorded hip joint injury or anticoagulant treatment.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - Gout, pseudogout, haemochromatosis, alkaptonuria and Wilson's disease are not recorded at any time, and the hip imaging of 2014 to 2022 describes degenerative, not crystal, arthropathy.
Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - Neither the in-service falls of 1983 to 1986 nor the fall at work on 24 August 2013 (struck in the face, landing on his buttocks) is recorded as causing hip joint pain, tenderness or restricted movement, and the steroid injection of 9 January 2014 was into the trochanteric bursa, outside the joint, so trauma to the affected joint as defined is not established.
Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No acute articular cartilage tear of either hip is recorded; the labral tears and chondral ulceration shown in March 2022 were reported with the osteoarthritis, the right labral tear expressly as degenerative.
Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to the knee; the veteran's osteoarthritis affects both hips.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of frostbite or any cold injury at any time before the worsening of his osteoarthritis.
Factor 9(33): having disordered joint mechanics of the affected joint for at least three years before the clinical worsening of osteoarthritis in that joint — MET - The cranial acetabular retroversion of the veteran's hips (minor on the left, suggested on the right), a developmental rotation deformity that concentrates load on the anterosuperior acetabular rim, together with mild cam morphology of the right femoral head, had been present for decades, far more than three years, before the clinical worsening documented between December 2013 and March 2022, when the MRIs showed anterosuperior labral tearing, full- thickness acetabular cartilage loss on the right and high-grade chondral ulceration on the left.
The factor is met for both hips on non-service facts.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint — NOT MET - No osteonecrosis of either hip has been shown: the MRI of 16 February 2022 found no avascular necrosis of the right femoral head, and the left hip MRI showed subchondral cystic change and marrow oedema beneath damaged cartilage, not necrosis.
Factor 9(35): for osteoarthritis of a joint of the upper limb only: (a) performing: (i) forceful or repetitive activities involving the affected joint; or (ii) tasks involving repeated or sustained pinch grip or hand/power grip; for an average of at least 100 hours per month, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; or (b) using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor, including its vibrating-tool limb, applies only to osteoarthritis of a joint of the upper limb; the veteran's osteoarthritis affects both hips, which are joints of the lower limb.
Factor 9(36): for osteoarthritis of a joint of the lower limb only: (a) having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical worsening of osteoarthritis in that joint; (b) lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; (c) carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; (d) ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years, before the clinical worsening of osteoarthritis in that joint; or (e) having osteoporosis before the clinical worsening of osteoarthritis in that joint — NOT MET - After the estimated onset in 2001 no lifting, carrying or stair climbing of the required extent is recorded (his post-service work was office work in the transport sector, running car yards and, in September 2013, helping to load a truck), there was no amputation or recorded asymmetric gait, and osteoporosis is not recorded.
His in-service lifting preceded the onset and so could not aggravate the condition.
Factor 9(37): for osteoarthritis of a joint of the lower limb or hand joint only: (a) being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; (b) for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; or (c) for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint — MET - the veteran remained obese after the estimated onset on 31 October 2000: his body habitus made ultrasound technically very difficult in October 2013, he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2016, and after regaining weight he was 143.6 kg (BMI 41.5) on 12 May 2021.
He was overweight for well over ten years before the clinical worsening, in which mild to moderate degenerative change in December 2013 progressed to full-thickness acetabular cartilage loss (right) and high-grade chondral ulceration (left) by March 2022.
The factor is met for both hips on post-service facts, although the obesity began during service.
Factor 9(38): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - No kneeling or squatting of this extent is recorded after the estimated onset in 2001; his recorded post-service work was office work in the transport sector and running car yards.
Factor 9(39): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the knee; the veteran's osteoarthritis affects both hips.
Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint — NOT MET - This factor applies only to osteoarthritis of the patello-femoral joint; the veteran's osteoarthritis affects both hips.
Factor 9(41): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - No disorder causing loss of pain sensation or proprioception in either hip is recorded: his diabetes (2017) has no recorded neuropathy, the 2014 neuropathy of the lateral cutaneous nerve of the thigh affected skin sensation, not the hip joint, and he recovered completely from a 'spinal stroke' in 2006.
Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of Paget's disease of bone, and the bone scans of 2014, 2018 and 2021 did not show it.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of acromegaly or any clinical feature of growth hormone excess before the worsening of his osteoarthritis.
Factor 9(44): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint — NOT MET - There is no record of instability or dislocation of either hip at any time; the familial recurrent dislocations in his history affected the thumbs.
Factor 9(45): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint — NOT MET - Femoroacetabular impingement syndrome has not been diagnosed: the impingement morphology (mild cam morphology of the right hip and minor acetabular retroversion) was noted only on the MRIs of March 2022, which reported the hips as osteoarthritic, and the syndrome also requires characteristic clinical signs, none of which are recorded.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis — MET - No assessment of the veteran's hips is recorded between the estimated onset in 2001 and the bone scan of 27 December 2013, which showed degenerative change in both; management was then limited to a steroid injection of the right greater trochanteric bursa, and hip osteoarthritis was not diagnosed until 8 September 2020 or imaged by MRI until March 2022, by which time both hips had advanced acetabular cartilage damage.
He also had PTSD, depression and anxiety during this period.
Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), which assesses inability objectively and subjectively and includes psychological incapacity, the delay of more than five years from first presentation to diagnosis satisfies the factor for both hips
Sequelae
Bilateral hip osteoarthritis may be considered a sequela of the in-service obesity (which commenced during service and has persisted), the cumulative occupational loading, and the repetitive sporting activities during ADF service
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — Although the osteoarthritis is estimated to have been present from 2001, no assessment of the veteran's hips is recorded until the bone scan of 27 December 2013 showed degenerative change in both.
Management was then limited to a steroid injection of the right greater trochanteric bursa, investigation of his pain was directed to the lumbar spine, and hip osteoarthritis was not diagnosed until 8 September 2020, nearly seven years later, or imaged by MRI until March 2022, when both hips had advanced acetabular cartilage damage.
He had PTSD, depression and anxiety through much of this period.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity; the delay of more than five years from first presentation to diagnosis, while the disease progressed, satisfies the factor for both hips
Date of Clinical Onset
Bilateral hip osteoarthritis is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with symptoms in the hips: 27 December 2013 — whole body bone scan performed for his symptoms, demonstrating bilateral hip changes [CHART REVIEW document].
End of ADF service: 5 September 1987.
First imaging / formal diagnosis (confirmation, not onset): 8 September 2020 (bone scan reporting bilateral hip osteoarthritis), with MRI of the hips on 1 and 20 February 2022.
The precise date of clinical onset cannot be determined from the records.
The condition was present, and symptomatic, before it was first documented, so its clinical onset is estimated as the midpoint between the end of the veteran's ADF service (5 September 1987) and the first documented presentation with symptoms in the hips (27 December 2013).
Estimated date of clinical onset: 31 October 2000.
This date falls after the veteran's ADF service (19 November 1980 5 September 1987), so the in- service events and exposures described in this report all preceded clinical onset
