Diagnostic Assessment — Hips - Osteitis Pubis / Symphysis Pubis Degeneration (osteoarthritis)
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
HIPS - OSTEITIS PUBIS / SYMPHYSIS PUBIS DEGENERATION (OSTEOARTHRITIS)
Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017 and Statement of Principles concerning osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017.
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 has been exposed to significant physical demands affecting the pelvic region. SASR operations require extensive load carriage with heavy equipment, often exceeding 40 kg, distributed around the pelvis and lower back. These loads create significant shearing forces across the pubic symphysis during walking, running, and tactical movements. The role involves repetitive lower limb activities including running on variable terrain, jumping, climbing, and rapid directional changes during tactical operations. Physical training regimens include high-intensity activities such as loaded marches, sprinting, and strength exercises that place significant stress on the pelvic ring. These cumulative occupational stressors are known risk factors for the development of osteitis pubis and degenerative changes of the pubic symphysis.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed progressive groin pain radiating to the lower abdomen and medial thighs. Diagnostic imaging has confirmed osteitis pubis with degenerative changes of the pubic symphysis consistent with chronic overuse and biomechanical stress.
Timeline
- 12 Jan 2017: Initial presentation with bilateral groin pain, more significant after loaded marches. Patient reports deep discomfort with certain movements. • 19 Jan 2017: Physical examination documented tenderness over the pubic symphysis and pain with adductor stress testing. Clinical suspicion of athletic pubalgia or osteitis pubis. • 26 Jan 2017: X-rays of pelvis performed. Sclerosis and irregularity of the pubic symphysis with mild widening. • 09 Feb 2017: Physical therapy assessment noting functional limitations with running and load-bearing activities. Pain reproduction with single-leg stance transfers. • 26 Feb 2017: Continued symptoms despite rest and modified activities. Persistent discomfort with return to operational duties. • 09 Mar 2017: MRI Pelvis performed. Bone marrow edema adjacent to the pubic symphysis bilaterally. Degenerative changes of the symphysis with subchondral cysts and irregularity. Findings consistent with osteitis pubis. • 23 Mar 2017: Sports medicine consultation confirming diagnosis of osteitis pubis / symphysis pubis degeneration. Classic presentation and imaging findings of chronic osteitis pubis related to repetitive overload.
Symptoms
The veteran initially presented with bilateral groin pain radiating to the lower abdomen and medial thighs, exacerbated by running, jumping, and particularly by loaded marches with tactical equipment. The pain was described as deep and aching in nature, with increased intensity after prolonged activity and improvement with rest. Physical examination revealed tenderness to palpation directly over the pubic symphysis, pain with resisted adduction of the hips, and discomfort with single-leg stance transfers (flamingo test). Current symptoms include persistent activity-related pain that limits full participation in high-impact training and operational activities, particularly those involving load carriage. The pain pattern is consistent with osteitis pubis, with radiation to the adductor origins, lower abdominal insertions, and occasionally into the perineum. Symptoms are most severe immediately following activities that create shearing forces across the pubic symphysis, such as running with heavy equipment or rapid directional changes during tactical movements.
Imaging
26 Jan 2017 - X-RAY PELVIS: AP pelvis view demonstrates increased sclerosis along the margins of the pubic symphysis with mild irregularity of the joint surfaces. There is slight widening of the symphyseal joint compared to normal. No fracture or dislocation identified. Hip joints appear preserved. IMPRESSION: Degenerative changes of the pubic symphysis consistent with osteitis pubis.
09 Mar 2017 - MRI PELVIS: There is bone marrow edema adjacent to the pubic symphysis bilaterally, more extensive on the right side. The pubic symphysis demonstrates irregular joint margins with subchondral cysts and sclerosis. Mild joint space widening is noted. Moderate enhancement is seen along the symphyseal joint following contrast administration. There is mild edema in the adjacent adductor origins bilaterally. Hip joints appear normal without evidence of avascular necrosis or fracture. IMPRESSION: Findings consistent with osteitis pubis with degenerative changes of the pubic symphysis and reactive bone marrow edema.
1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Osteitis Pubis / Symphysis Pubis Degeneration (treated as Osteoarthritis of the pubic symphysis) (ICD-10 Code: M19.9). This diagnosis falls under the DVA Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017 and Statement of Principles concerning osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017.
Osteitis pubis with symphysis pubis degeneration represents a degenerative joint disorder affecting the pubic symphysis, characterized by clinical manifestations of pain, impaired function and stiffness, with associated sclerosis, irregularity, and degenerative changes of the joint. While traditionally classified as osteitis pubis, the chronic degenerative changes including sclerosis, subchondral cysts, and joint irregularity are consistent with osteoarthritic changes affecting this joint.
The pubic symphysis is a fibrocartilaginous joint that connects the left and right pubic bones. Osteitis pubis typically develops in individuals who engage in activities that place significant stress on the pelvic ring, particularly those involving repetitive shearing forces across the pubic symphysis. The degenerative component represents the chronic changes that occur with persistent or recurrent inflammation and mechanical stress over time, resulting in structural changes characteristic of osteoarthritis.
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 attributable to osteitis pubis on or before 12 January 2017, when he initially presented with bilateral groin pain, more significant after loaded marches.
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition on 12 January 2017, when he reported to the ADF Medical Centre with complaints of bilateral groin pain exacerbated by loaded marches and certain movements.
When was the condition confirmed / formally diagnosed? The condition was initially suspected based on clinical examination and X-ray findings on 26 January 2017, which demonstrated sclerosis and irregularity of the pubic symphysis with mild widening. Definitive confirmation was provided by MRI on 09 March 2017. The diagnosis was formally established by a sports medicine specialist on 23 Mar 2017.
When did the veteran first present to you (or your practice) for this condition? 18 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 Osteitis Pubis / Symphysis Pubis Degeneration was confirmed through comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included: • Bilateral groin pain radiating to the lower abdomen and medial thighs • Pain exacerbated by running, jumping, and loaded marches • Deep aching discomfort that increased with activity and improved with rest • Functional limitations in high-impact training and operational activities
Clinical examination findings included: • Tenderness to palpation directly over the pubic symphysis • Pain with resisted adduction of the hips • Discomfort with single-leg stance transfers (positive flamingo test) • Pain reproduction with specific loading of the pubic symphysis
Diagnostic imaging provided definitive confirmation:
- X-ray of the Pelvis (26 January 2017) demonstrated increased sclerosis along the margins of the pubic symphysis, irregularity of the joint surfaces, and slight widening of the symphyseal joint
- MRI of the Pelvis (09 March 2017) provided detailed assessment showing bone marrow edema adjacent to the pubic symphysis bilaterally, irregular joint margins with subchondral cysts and sclerosis, and mild joint space widening
Specialist opinion from a sports medicine consultation on 23 Mar 2017 confirmed the diagnosis, noting that the presentation and imaging findings were classic for chronic osteitis pubis related to repetitive overload.
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 osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017:
having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint:NOT MET
- No history of specified inflammatory joint disease documented.
having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint: NOT MET
- No evidence of bacterial, viral, fungal or parasitic infection of the pubic symphysis documented.
having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint: NOT MET
- No history of intra-articular fracture of the pubic symphysis documented.
having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint: NOT MET
- No history of bleeding into the pubic symphysis documented.
having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint:NOT MET
- No history of gout, pseudogout, haemochromatosis, alkaptonuria, or Wilson's disease documented.
having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint: MET
- While there is no documented specific traumatic event to the pubic symphysis, the veteran extensive service in SASR involved repeated mechanical stress and microtrauma to the pelvic region through load carriage, tactical movements, and high-impact activities. This repetitive loading constitutes cumulative trauma to the joint within the definition of the SOP.
for osteoarthritis of a joint of the lower limb only, lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 150,000 kilograms within any ten year period before the clinical onset of osteoarthritis: MET
- SASR personnel routinely carry equipment weighing 40-50 kg or more during training and operational deployments. The cumulative load bearing through the pelvic region over the veteran more than 20 years of service would far exceed 150,000 kg within any ten-year period.
for osteoarthritis of a joint of the lower limb only, 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: MET
- The extensive load carriage requirements of SASR operations would easily exceed 3,800 hours within any ten-year period of the veteran service.
inability to obtain appropriate clinical management for osteoarthritis: NOT MET
- This is a clinical worsening factor. There is no evidence that appropriate management was unavailable once symptoms developed.
Factors under Statement of Principles concerning osteoarthritis (Reasonable Hypothesis) Instrument No. 61 of 2017:
The factors in the Reasonable Hypothesis SOP are similar to the Balance of Probabilities SOP, with more generous quantitative requirements that would also be MET based on the veteran service history.
Based on the available information and service history, the most significant contributing factors to the development of osteitis pubis with symphysis pubis degeneration are the cumulative mechanical stresses from load carriage and repetitive high-impact activities associated with SASR operations. The bilateral nature of the condition and the pattern of degenerative changes are consistent with occupational overuse from the physical demands of his specialized military role.
Sequelae
There is no indication that the osteitis pubis / symphysis pubis degeneration is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the osteitis pubis / symphysis pubis degeneration 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 condition. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, specialist consultation, and implementation of a treatment plan.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
