Diagnostic Assessment — Bilateral Knees - Bursitis / Knee Pain
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
BILATERAL KNEES - BURSITIS / KNEE PAIN
Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
ADF History
Name: The veteran Date of Birth: [withheld] Occupation: Communications, SASR Enlistment Date: 17 Dec 1993 Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran duties involve significant lower extremity demands that place stress on the knee joints and surrounding structures. SASR operations require extensive load carriage with heavy equipment during prolonged marches over variable terrain, creating substantial compressive and shear forces across the knee joints. The role involves tactical movements including deep squatting, crawling, and kneeling on hard surfaces during equipment setup and maintenance, which places direct pressure on the anterior knee structures including the prepatellar and infrapatellar bursae. Physical training includes high-impact activities such as running, jumping, and landing maneuvers that create repetitive stress on the knee joints. These occupational activities represent significant risk factors for the development of knee bursitis and associated knee pain.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed bilateral anterior knee pain associated with swelling and tenderness over the prepatellar and infrapatellar regions. Clinical evaluation and diagnostic testing have confirmed bilateral knee bursitis affecting both the prepatellar and infrapatellar bursae.
Timeline
- 22 Jul 2017: Initial presentation with right anterior knee pain and swelling following extended kneeling during field exercise. Patient reports "painful swelling over the front of the knee after kneeling on hard ground".
- 29 Jul 2017: Assessment documented swelling and tenderness over the right prepatellar region with mild erythema. Clinical diagnosis of prepatellar bursitis (housemaid's knee).
- 05 Aug 2017: Development of similar symptoms in the left knee. "Now experiencing bilateral knee pain and swelling after kneeling".
- 12 Aug 2017: Physical examination noted fluctuant swelling over the prepatellar region bilaterally and tenderness at the infrapatellar region, more pronounced on the right. "Clinical findings consistent with bilateral prepatellar and infrapatellar bursitis".
- 19 Aug 2017: Ultrasound of bilateral knees performed. "Fluid distension of the prepatellar bursae bilaterally and to a lesser extent the infrapatellar bursae. No evidence of infection or crystalline disease."
- 26 Aug 2017: Sports medicine consultation confirming diagnoses. "Bilateral knee bursitis related to occupational activities requiring prolonged kneeling".
- 10 Sep 2017: Follow-up noting improvement with activity modification but recurrence with return to kneeling activities. "Symptoms directly related to occupational kneeling requirements".
Symptoms
The veteran initially presented with right anterior knee pain and visible swelling following extended periods of kneeling during a field exercise. The pain was described as a dull ache that worsened with direct pressure over the anterior knee, particularly when kneeling or with direct palpation. The swelling was visible as a fluid-filled mass over the prepatellar region that fluctuated with position and activity level. Similar symptoms subsequently developed in the left knee with continued occupational exposure to kneeling activities. Physical examination revealed fluctuant swelling over the prepatellar region bilaterally and tenderness at the infrapatellar region, more pronounced on the right. There was mild erythema without significant warmth or signs of infection. Range of motion was preserved but with discomfort at extremes of flexion. Current symptoms include recurrent episodes of anterior knee swelling and pain that directly correlate with occupational activities requiring kneeling, particularly during field operations involving communications equipment setup and maintenance. The symptoms typically improve with activity modification and anti-inflammatory measures but predictably recur with resumption of kneeling activities, creating functional limitations in his ability to perform certain aspects of his communications role that require prolonged or repeated kneeling on hard surfaces.
Imaging
19 Aug 2017 - ULTRASOUND BILATERAL KNEES: Right knee: There is significant fluid distension of the prepatellar bursa measuring approximately 2.3 x 1.8 x 0.9 cm. The fluid appears anechoic without internal debris or synovial thickening. The infrapatellar bursa also shows mild fluid distension. The patellar tendon appears normal without evidence of tendinopathy. No joint effusion identified. Left knee: Similar but less pronounced findings with prepatellar bursal fluid collection measuring approximately 1.8 x 1.5 x 0.7 cm. Minimal fluid noted in the infrapatellar bursa. The patellar tendon appears normal. No joint effusion identified. IMPRESSION: Bilateral prepatellar bursitis, more significant on the right. Mild infrapatellar bursitis, also more significant on the right. No evidence of infection or crystalline disease.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Knees Bursitis (ICD-10 Code: M70.4 for prepatellar bursitis, M70.5 for other knee bursitis). This diagnosis falls under the DVA Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
Bursitis refers to inflammation of a bursa, which is a fluid-filled sac that provides a cushion between bones and tendons or muscles around a joint. In the knee, there are multiple bursae, with the prepatellar bursa (located between the skin and the patella) and the infrapatellar bursa (located between the patellar tendon and the tibia) being commonly affected.
Prepatellar bursitis, often called "housemaid's knee" or "carpet layer's knee," typically presents with swelling and tenderness anterior to the patella and is commonly associated with activities requiring prolonged or repetitive kneeling. Infrapatellar bursitis affects the area below the patella and can cause pain and swelling in the region of the patellar tendon.
In the veteran case, ultrasound imaging has confirmed the presence of fluid distension in both the prepatellar and infrapatellar bursae bilaterally, more significant on the right than the left. The clinical presentation and imaging findings are consistent with occupational bursitis related to the kneeling requirements associated with his communications specialist role in SASR.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms of right knee bursitis on or before 22 July 2017, when he initially presented with right anterior knee pain and swelling following extended kneeling during a field exercise. Left knee symptoms developed around 05 August 2017, when he reported bilateral knee pain and swelling after kneeling activities.
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for right knee pain and swelling on 22 July 2017. He subsequently reported left knee symptoms during a follow-up visit on 05 August 2017.
When was the condition confirmed / formally diagnosed? The initial clinical diagnosis of right prepatellar bursitis was made on 29 July 2017. As symptoms progressed to involve both knees and both the prepatellar and infrapatellar bursae, comprehensive clinical assessment on 12 August 2017 documented findings consistent with bilateral prepatellar and infrapatellar bursitis. Definitive confirmation was provided by ultrasound on 19 August 2017, which demonstrated fluid distension of the prepatellar bursae bilaterally and to a lesser extent the infrapatellar bursae. The diagnosis was formally established by a sports medicine specialist on 26 August 2017, who characterized the condition as "bilateral knee bursitis related to occupational activities requiring prolonged kneeling."
When did the veteran first present to you (or your practice) for this condition? 17 December 2017.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis of Bilateral Knees Bursitis was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included: • Anterior knee pain and visible swelling following extended periods of kneeling • Dull ache worsening with direct pressure over the anterior knee • Visible fluid-filled mass over the prepatellar region • Symptoms directly correlated with kneeling activities • Recurrent episodes with resumption of aggravating activities
Clinical examination findings included: • Fluctuant swelling over the prepatellar region bilaterally • Tenderness at the infrapatellar region bilaterally, more pronounced on the right • Mild erythema without significant warmth or signs of infection • Preserved range of motion with discomfort at extremes of flexion • No signs of intra-articular pathology or ligamentous instability
Diagnostic imaging provided definitive confirmation: Ultrasound of Bilateral Knees (19 August 2017) demonstrated: • Significant fluid distension of the right prepatellar bursa (2.3 x 1.8 x 0.9 cm) • Less pronounced fluid collection in the left prepatellar bursa (1.8 x 1.5 x 0.7 cm) • Mild fluid distension of the infrapatellar bursae bilaterally, more significant on the right • Anechoic fluid without internal debris or synovial thickening • Normal patellar tendons without evidence of tendinopathy • No joint effusion identified
Specialist opinion from a sports medicine consultation on 26 August 2017 confirmed the diagnosis of bilateral knee bursitis, noting the relationship to occupational activities requiring prolonged kneeling associated with the veteran role in SASR.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Factors under Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015:
at the time of the clinical onset of bursitis, undertaking an activity or undergoing a medical procedure that involves kneeling on a hard surface, crawling with knee flexion, lifting, pushing or pulling loads greater than 20 kilograms, or carrying out activities requiring the application of repetitive or sustained friction directly at the site of the affected bursa: MET
- As a Communications specialist in SASR, the veteran duties routinely involve kneeling on hard surfaces during equipment setup and maintenance in field conditions. The temporal relationship between these kneeling activities and the onset of symptoms is clearly documented, with the initial presentation occurring "following extended kneeling during field exercise." The recurrent nature of the symptoms with resumption of kneeling activities further supports the direct causal relationship between the occupational kneeling requirements and the development of knee bursitis.
having trauma or surgery to the affected bursa within the three months before the clinical onset of bursitis: NOT MET
- No specific trauma or surgery to the affected bursae documented.
having a bacterial, fungal or parasitic infection of the affected bursa within the three months before the clinical onset of bursitis: NOT MET
- No evidence of infectious bursitis. Ultrasound specifically noted "no evidence of infection."
having a disease from specified list: NOT MET
- No evidence of diseases from the specified list.
inability to obtain appropriate clinical management for bursitis: NOT MET
- This is a clinical worsening factor. There is no evidence that appropriate management was unavailable once the condition developed.
Factors under Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015: The factors in the Reasonable Hypothesis SOP related to bursitis are identical to those in the Balance of Probabilities SOP, with the same MET status for activities involving kneeling on a hard surface and NOT MET status for all other factors.
Based on the available information and service history, the direct cause of bilateral knee bursitis in this veteran is clearly the occupational requirement for kneeling on hard surfaces during communications equipment setup and maintenance in field conditions. This causal relationship is supported by:
- The clear temporal association between kneeling activities and symptom onset
- The bilateral nature of the condition, consistent with bilateral knee loading during kneeling
- The anatomical distribution (prepatellar and infrapatellar bursae), which corresponds exactly with the areas that receive direct pressure during kneeling
- The recurrent pattern with symptom improvement during periods of activity modification and predictable recurrence with resumption of kneeling activities
Sequelae
There is no indication that the bilateral knee bursitis is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the bilateral knee bursitis resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his bilateral knee bursitis. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, anti-inflammatory treatment, and specialist consultation. The Full Federal Court in Brew v Repatriation Commission (22 July 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense, but in this case, appropriate management was readily available and obtained.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
