Left Ankle - Osteoarthritis — DVA claim example

Diagnostic Assessment — Left Ankle - Osteoarthritis

Example 1 of 1 · fictitious patient (Veteran EB)

Diagnostic Assessment

Left Ankle - Osteoarthritis

BOP Code: 62 of 2017 (Osteoarthritis)
RH Code: 61 of 2017 (Osteoarthritis)

ADF History

Veteran EB, date of birth 12 April 1932, Australian Army, Rifleman (infantry soldier) and from 1958 Army Diver (Royal Australian Engineers), enlisted 18 August 1949, retired on reaching compulsory retirement age as a Warrant Officer Class 2 on 11 April 1987. Operational service: Korea, 28 September 1950 to 06 September 1953, including captivity as a prisoner of war from 24 April 1951 to 06 September 1953 (warlike); Malaya, 15 October 1955 to 20 October 1957 (operational, Malayan Emergency); Vietnam, 12 May 1966 to 10 May 1967 (warlike).

Occupational History

As an infantry soldier from 1949 to 1958 the veteran marched and patrolled carrying loads of 25 to 40 kilograms over mountainous and jungle terrain, in extremes of cold in Korea and heat in Malaya. As an Army diver from 1958 to 1974 he carried and lifted diving sets, weights, compressors, sandbags and stores of 20 to 45 kilograms, climbed dive ladders, wharf ladders and ship ladders many times a day, worked kneeling and squatting on barges and pontoons, and used pneumatic chipping hammers, rock drills and jackhammers above and below water.

Army divers of the period performed repeated deep and decompression dives without modern decompression tables or bone surveillance, and were at risk of dysbaric osteonecrosis, decompression illness and penetrating injuries from coral, piling and debris. Prisoners of war in Korea endured starvation, untreated dysentery and beriberi, forced marches and exposure to sub-zero temperatures without adequate clothing or footwear.

History

Veteran EB, an infantry soldier and later Army diver who was a prisoner of war in Korea from 1951 to 1953, where he suffered frostbite of the left foot and ankle, beriberi neuropathy, reactive arthritis and amputation of two right toes, sustained an intra-articular trimalleolar fracture of the left ankle in 1962 and septic arthritis of the left ankle on warlike service in Vietnam in 1966. Osteoarthritis of the left ankle began on 15 May 1976, after gout, dysbaric osteonecrosis of the talus, Paget's disease of the distal tibia, acromegaly and decades of heavy load carriage, and worsened to end-stage disease by 18 June 1985, requiring ankle arthrodesis.

Timeline

• 18 Aug 1949 — The veteran enlisted in the Australian Army aged 17 and was allotted to the infantry. The entry medical examination recorded normal feet and ankles, a normal gait and no previous injuries. Weight 76 kg, height 1.80 m. "fit, feet and ankles normal"
• 06 Sep 1953 — The veteran was repatriated after more than two years as a prisoner of war in Korea, having been captured on 24 April 1951. The repatriation medical examination recorded healed frostbite scarring over the left foot and ankle from the winter of 1951 to 1952, amputation of the right great and second toes at the metatarsophalangeal joints for frostbite gangrene in February 1952, a history of dysentery followed by swelling of the left ankle and both knees diagnosed as reactive arthritis, and beriberi with loss of vibration and position sense at both ankles. He walked with an asymmetric gait, offloading the right forefoot. "frostbite left ankle, toes amputated"
• 14 Mar 1962 — While serving as an Army diver in Australia he fell about three metres from a wharf ladder onto the deck of a barge, landing on his left foot. He sustained a trimalleolar fracture of the left ankle extending into the joint surface, with a tense haemarthrosis that was aspirated, and an osteochondral fragment from the talar dome found at open reduction and internal fixation. The fracture healed with 6 degrees of varus talar tilt and external rotation malalignment, and recurrent giving way of the ankle was recorded from 1963. Weight 88 kg, BMI 27.2. "trimalleolar fracture, haemarthrosis aspirated"
• 21 Sep 1966 — On warlike service in Vietnam, while clearing piling at a port, the veteran sustained a puncture wound over the front of the left ankle from a steel reinforcing bar. Three days later the ankle was hot, swollen and exquisitely painful, and he was febrile. Aspiration produced pus growing Staphylococcus aureus, and septic arthritis of the left ankle was treated with arthrotomy, washout and six weeks of antibiotics at a field hospital. "septic arthritis left ankle, S. aureus"
• 09 Jul 1969 — He had an acute attack of gout in the left ankle, with a serum urate of 0.58 mmol/L, confirmed by aspiration showing monosodium urate crystals. Further attacks in the left ankle followed in 1970, 1972 and 1974. His waist circumference was recorded as 106 cm and his weight as 95 kg, BMI 29.3. "gout left ankle, urate crystals"
• 17 Nov 1972 — An endocrinologist confirmed acromegaly, with raised growth hormone and a pituitary adenoma, and transsphenoidal surgery was performed. Single-photon absorptiometry showed bone mineral density 1.6 standard deviations above the young adult male mean. A long-bone survey for Army divers on the same day showed dysbaric osteonecrosis of the left talar dome. On 14 February 1973 X-ray and a raised alkaline phosphatase confirmed Paget's disease of the distal left tibia extending to the joint surface. "acromegaly, dysbaric osteonecrosis left talus"
• 02 Jun 1976 — The veteran presented with mechanical pain and stiffness of the left ankle since mid-May 1976, distinct from his gout, worse on ladders and uneven ground and after standing, with swelling and loss of movement. His periodic health examination of 20 October 1975 had recorded no mechanical ankle pain. X-ray showed joint space narrowing, osteophytes and subchondral sclerosis of the left ankle. An orthopaedic surgeon confirmed osteoarthritis of the left ankle on 10 August 1976 and recommended a brace and a sedentary posting. "left ankle OA, joint space narrowing"
• 18 Jun 1985 — The orthopaedic surgeon recorded end-stage osteoarthritis of the left ankle with pain at rest and at night, a fixed varus deformity and only 5 degrees of movement, and bone-on-bone contact on X-ray. Ankle arthrodesis had first been recommended in 1981 but was deferred for four years by postings and the waiting list. Dual-photon absorptiometry on 22 October 1984 had shown osteoporosis, T-score minus 2.6, attributed to hypopituitarism after the 1972 pituitary surgery. Arthrodesis of the left ankle was performed on 03 March 1986. "end-stage OA, arthrodesis recommended"

Symptoms

At onset the veteran had mechanical pain in the left ankle on weight bearing, worse on ladders, stairs and uneven ground, morning stiffness of about 20 minutes, swelling after activity, loss of ankle movement and a worsening limp. By 1985 the pain was present at rest and at night, the ankle was stiff in fixed varus, and he could walk only short distances.

Since the arthrodesis of 1986 the ankle is fused. He reports ongoing pain in the hindfoot and midfoot from adjacent joint degeneration, a stiff, limping gait, difficulty with stairs, slopes and uneven ground, and reliance on a walking stick. The right forefoot amputation and peripheral neuropathy add to his instability.

Imaging

• 14 Mar 1962 — X-ray left ankle: "Trimalleolar fracture with intra-articular extension into the tibial plafond and an osteochondral fragment from the lateral talar dome. Soft tissue swelling consistent with haemarthrosis."
• 20 Sep 1962 — X-ray left ankle: "United trimalleolar fracture with internal fixation. 6 degrees of varus talar tilt and external rotation malalignment of the distal fibula."
• 17 Nov 1972 — Long-bone survey (Army diver surveillance): "Subchondral sclerosis and lucency of the left talar dome consistent with dysbaric osteonecrosis. Generalised increased bone density."
• 14 Feb 1973 — X-ray left tibia and ankle: "Paget's disease of the distal left tibia with cortical thickening and coarse trabeculae extending to the articular surface. Ankle joint space preserved."
• 02 Jun 1976 — X-ray left ankle (weight-bearing): "Joint space narrowing, marginal osteophytes and subchondral sclerosis of the tibiotalar joint. Retained fixation. Osteoarthritis."
• 22 Oct 1984 — Dual-photon absorptiometry: "Lumbar spine T-score minus 2.6. Osteoporosis."
• 18 Jun 1985 — X-ray left ankle (weight-bearing): "End-stage osteoarthritis with complete loss of joint space, subchondral cysts, large osteophytes and varus tilt of the talus."

Onset Date

The most likely date of onset of this condition is 15 May 1976.

At that date the veteran was serving full time as a Warrant Officer Class 2 instructor at an Army engineer training establishment in Australia, aged 44, two years after he ceased operational diving. From mid-May 1976 he developed mechanical pain and stiffness of the left ankle on weight bearing.

This date is appropriate because his periodic health examination of 20 October 1975 recorded no mechanical ankle pain, and the X-ray of 14 February 1973 showed a preserved ankle joint space. At his presentation on 02 June 1976 he dated the mechanical pain to mid-May 1976, and X-ray that day showed osteoarthritis.

For the factors with no time limit, each exposure occurred before 15 May 1976: captivity from 1951 to 1953, frostbite in the winter of 1951 to 1952, reactive arthritis in 1952 and 1960, the intra-articular fracture, haemarthrosis, trauma and cartilage tear of 14 March 1962, the meniscal tear of 1963, septic arthritis in September 1966, gout from 1969, dysbaric osteonecrosis, acromegaly and increased bone density by 1972, and Paget's disease by 1973. For the 25-year factors, the 25 years before onset run from 15 May 1951 to 15 May 1976. For disordered joint mechanics, the varus malunion was present from September 1962, so the three and five years before onset (15 May 1973 and 15 May 1971 to 15 May 1976) were filled. The amputation and asymmetric gait were present from February 1952, filling the three and five years before onset. The lifting and carrying periods relied on run from 1958 to 1968, within the 25 years before onset; the stair and ladder climbing and kneeling ran from 1958 to 1974; vibrating tools were used from 1958 to 1974; and the veteran was overweight from 1962 and had a waist above 102 cm from 1964, more than ten years before onset.

For the worsening factors, the period after onset runs from 15 May 1976 to the documented worsening on 18 Jun 1985. The 25 years before the worsening run from 18 Jun 1960 to 18 Jun 1985, which include the 1962 injury, the 1963 meniscal tear and the 1958 to 1974 exposures. A further fall from a ladder on 04 August 1983, when the unstable ankle gave way, caused a haemarthrosis and was treated by immobilisation. Osteoporosis was present from at least 22 October 1984.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Left Ankle - Osteoarthritis (ICD-10-AM M19.17, post-traumatic arthrosis of the ankle and foot), under the Statements of Principles concerning osteoarthritis, Balance of Probabilities No. 62 of 2017 and Reasonable Hypothesis No. 61 of 2017.

Osteoarthritis is a degenerative joint disease in which the articular cartilage is progressively lost, with remodelling of the underlying bone, osteophyte formation, subchondral sclerosis and cysts. It causes mechanical pain, stiffness, swelling and loss of movement. In the ankle it is most often secondary to fracture, cartilage injury, instability, malalignment, infection, inflammatory and crystal arthritis or osteonecrosis, and it progresses with load bearing. End-stage disease is treated by arthrodesis or replacement.

The condition followed frostbite and captivity in Korea, an intra-articular fracture of the left ankle in 1962, septic arthritis on warlike service in Vietnam in 1966 and many other joint insults. It began on 15 May 1976, was confirmed by X-ray on 02 June 1976 and worsened to end-stage disease by 18 June 1985.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

15 May 1976.

When did the veteran first present to a health / medical provider for this condition?

02 June 1976.

When was the condition confirmed / formally diagnosed?

10 August 1976.

When did the veteran first present to you (or your practice) for this condition?

03 November 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by weight-bearing X-ray of the left ankle on 02 June 1976, which showed joint space narrowing, marginal osteophytes and subchondral sclerosis of the tibiotalar joint, and by an orthopaedic surgeon on 10 August 1976. This meets the Statement of Principles definition of osteoarthritis, a degenerative joint disease characterised by loss of articular cartilage and new bone formation.

The clinical features were consistent: mechanical pain on weight bearing, short morning stiffness, crepitus, bony swelling and loss of movement, distinct from the episodic inflammatory attacks of gout. The worsening was confirmed by X-ray and specialist review on 18 June 1985, showing end-stage disease, and arthrodesis was performed on 03 March 1986.

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.

Legislation: the clinical onset of this condition was on 15 May 1976, before 1 July 2004, during peacetime service and not on warlike or non-warlike service. This is a Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA) claim, under which the Statements of Principles do not bind, but every factor is still analysed below as the best statement of the sound medical-scientific evidence. Because the veteran also rendered operational service in Korea, Malaya and Vietnam and defence service from 7 December 1972, a claim under the Veterans' Entitlements Act 1986 is also available, under which the Statements of Principles apply: the Reasonable Hypothesis instrument to his operational service, including his captivity in Korea and his diving in Vietnam, and the Balance of Probabilities instrument to his peacetime and defence service.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack. This applies particularly to his period of captivity, for which no contemporaneous medical records exist.

Balance of Probabilities — Statement of Principles concerning Osteoarthritis, No. 62 of 2017

Causative factors

Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Reactive arthritis of the left ankle followed dysentery in captivity in 1952 and recurred in the left ankle in March 1960 after Salmonella gastroenteritis contracted on a field exercise in Queensland, when a medical officer recorded a hot, swollen left ankle with sterile aspirate. Reactive arthritis is an inflammatory joint disease as specified, and it affected the left ankle before onset in 1976.

Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET

- On 21 September 1966 the veteran developed bacterial septic arthritis of the left ankle, with pus growing Staphylococcus aureus, after a puncture wound from a steel reinforcing bar while clearing piling. It was treated with arthrotomy and washout. This was a bacterial infection of the affected joint resulting in inflammation, ten years before onset.

Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- On 14 March 1962 the veteran fell from a wharf ladder onto a barge while serving as an Army diver in Australia and sustained a trimalleolar fracture of the left ankle extending into the tibial plafond, confirmed on X-ray. This intra-articular fracture occurred 14 years before onset.

Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- The 1962 fracture was accompanied by a tense haemarthrosis of the left ankle, which was aspirated in the emergency department on 14 March 1962. Blood in the joint damages articular cartilage. This occurred before onset.

Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Gout of the left ankle was confirmed on 09 July 1969 by aspiration showing monosodium urate crystals, with a serum urate of 0.58 mmol/L, and further attacks in the left ankle followed in 1970, 1972 and 1974. Gout is a depositional joint disease as specified, and it affected the left ankle before onset. It was promoted by heavy drinking in the mess culture of the period and by weight gain after his service injuries.

Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET

- The fall from the wharf ladder on 14 March 1962 applied significant force through the left ankle, caused a fracture and immediate pain, swelling and loss of movement, and was treated by immobilisation and surgery. It occurred within the 25 years before onset, which run from 15 May 1951 to 15 May 1976.

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; — MET

- At open reduction and internal fixation on 15 March 1962 the surgeon recorded an acute osteochondral fragment torn from the lateral talar dome, an acute articular cartilage tear of the left ankle. It occurred 14 years before onset, within the 25-year window.

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; — MET

- On 08 May 1963, while climbing a dive ladder with a 30 kg weight belt, the veteran twisted his left knee and sustained an acute tear of the medial meniscus, treated by open meniscectomy. This occurred within the 25 years before onset. The resulting knee stiffness and antalgic gait increased the varus loading of his already malunited left ankle.

Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- In the winter of 1951 to 1952, as a prisoner of war in Korea without adequate boots or clothing, the veteran suffered frostbite of the left foot and ankle, with blistering and later scarring over the ankle recorded on repatriation on 06 September 1953. Frostbite damages articular cartilage and subchondral bone. It occurred before onset, during his service.

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 1962 trimalleolar fracture healed with 6 degrees of varus talar tilt and external rotation malalignment of the distal fibula, shown on X-ray on 20 September 1962. This angulation and rotation deformity of the joint maldistributed load across the tibiotalar joint from 1962 onward, for more than five years before onset, from 15 May 1971 to 15 May 1976.

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; — MET

- The Army diver long-bone survey of 17 November 1972 showed dysbaric osteonecrosis of the left talar dome, after 14 years of repeated deep and decompression dives from 1958. This necrosis of the subchondral bone of the affected joint was present before onset and arose directly from his diving duties.

Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, 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; — MET

- From 1958 to 1974, a continuous period of 16 years, the veteran worked as an Army diver handling lines, shackles, tools and diving equipment with forceful hand grip for about 35 hours a week, a cumulative period of more than ten years before onset. The same heavy gripping work was performed standing and squatting on barges, with his left ankle braced and loaded throughout.

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; — MET

- From 1958 to 1974 the veteran used pneumatic chipping hammers, rock drills and jackhammers on more days than not, a cumulative period of about 14 years within the 25 years before onset. Operating these tools standing on pontoons and uneven rock transmitted repeated impact through his lower limbs, including the left ankle.

Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The right great and second toes were amputated in February 1952 for frostbite gangrene sustained in captivity, an amputation involving the right leg, and the veteran walked from then on with an asymmetric gait, offloading the right forefoot and loading the left ankle. Both were present for 24 years before onset, well over the five years required.

Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: 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; — MET

- From 1958 to 1968 the veteran manually lifted diving sets, weight belts, compressors, sandbags and stores of 20 to 45 kilograms, about 30 lifts a day on 200 days a year at an average of 25 kg, about 150 000 kg a year and about 1 500 000 kg over the ten years, standing and bearing weight through the left ankle. The onset in 1976 occurred within the 25 years following that period.

Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: 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; — MET

- From 1958 to 1968 the veteran carried diving equipment of 30 to 45 kilograms down wharves, across barges and up and down ladders for about 10 hours a week on 48 weeks a year, about 4 800 hours over the ten years. The onset in 1976 occurred within the 25 years following that period.

Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: 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; — MET

- As an Army diver from 1958 to 1974 the veteran climbed dive ladders, wharf ladders and ship ladders about 15 to 25 times a day, about 300 rungs a day, on more days than not. This continued for 16 years, within the 25 years before onset.

Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET

- Single-photon absorptiometry on 17 November 1972 showed bone mineral density 1.6 standard deviations above the mean for young adult males, attributed to acromegaly, and the long-bone survey of the same date showed generalised increased bone density. This was present before onset.

Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's BMI was 27.2 in March 1962 and 29.3 in July 1969, and remained above 25 from 1962 to onset, more than ten years. The weight gain followed reduced activity after his 1962 ankle fracture and the effects of acromegaly.

Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's waist circumference was recorded as 104 cm in 1964 and 106 cm on 09 July 1969, and it exceeded 102 cm from 1964 to onset in 1976, more than ten years.

Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's waist circumference exceeded 102 cm from 1964, and therefore also exceeded the 88 cm figure in this sub-factor, for more than ten years before onset. The central adiposity reflects the same overweight status recorded from 1962.

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; — MET

- From 1958 to 1974 the veteran knelt and squatted on barges and pontoons while dressing divers, tending lines and maintaining equipment for about two hours a day on more days than not, a continuous period of 16 years, and the onset occurred within the 25 years following. Deep squatting forces the left ankle into end-range dorsiflexion and loaded his malunited joint.

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; — MET

- The veteran had internal derangement of the left knee from the medial meniscal tear of 08 May 1963, treated by open meniscectomy, with persisting locking and effusions recorded in 1964 and 1968. The knee disorder altered his gait and increased load on the left ankle before onset.

Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET

- Chondromalacia patella of the left knee was diagnosed by an orthopaedic surgeon in 1964, after the meniscectomy, with anterior knee pain on ladders and squatting. It was present before onset and contributed to his altered left lower limb mechanics.

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; — MET

- Beriberi peripheral neuropathy acquired in captivity left the veteran with loss of vibration and position sense at both ankles, recorded on repatriation on 06 September 1953 and confirmed on neurological examination in 1974. Loss of proprioception at the left ankle exposed the joint to repeated unprotected loading before onset.

Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Paget's disease of the distal left tibia, extending to the articular surface of the ankle, was confirmed on 14 February 1973 by X-ray and a raised alkaline phosphatase. It was present at the affected joint before onset in 1976.

Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET

- Acromegaly was confirmed by an endocrinologist on 17 November 1972, with raised growth hormone and a pituitary adenoma, after years of coarsening features and enlarging hands and feet. It was present for years before onset, and growth hormone excess causes cartilage overgrowth and early joint degeneration.

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; — MET

- Recurrent giving way and lateral instability of the left ankle were recorded from 1963 after the 1962 fracture, with a positive anterior drawer and talar tilt on stress testing in 1965. The instability was present more than ten years before onset.

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; — MET

- A pelvic X-ray on 11 March 1974 for left groin pain showed a pistol-grip (cam-type) deformity of the left femoral head-neck junction with restricted internal rotation and impingement pain, identified on later orthopaedic review as femoroacetabular impingement syndrome of the left hip, present before onset. The painful hip altered the loading of his left lower limb.

Worsening factors

Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The reactive arthritis of the left ankle of 1952 and 1960 preceded the documented worsening on 18 June 1985.

Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET

- The Staphylococcus aureus septic arthritis of the left ankle of September 1966 preceded the worsening on 18 June 1985.

Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The intra-articular trimalleolar fracture of 14 March 1962 preceded the worsening on 18 June 1985.

Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The haemarthrosis of 1962 preceded the worsening, and a further haemarthrosis was aspirated after a fall from a ladder on 04 August 1983, during service.

Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- Gout of the left ankle continued after onset, with attacks in 1978, 1981 and 1984, before the worsening on 18 June 1985.

Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET

- The 1962 fracture and the fall from a ladder on 04 August 1983, which caused a haemarthrosis and was treated by immobilisation, both occurred within the 25 years before the worsening, from 18 June 1960 to 18 June 1985.

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; — MET

- The acute osteochondral tear of the talar dome of 14 March 1962 occurred 23 years before the worsening, within the 25-year window.

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; — MET

- The acute medial meniscal tear of the left knee of 08 May 1963 occurred within the 25 years before the worsening.

Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The frostbite of the left foot and ankle of 1951 to 1952 preceded the worsening.

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 varus and rotational malunion persisted and progressed to a fixed varus deformity, present throughout the five years before the worsening, from 18 June 1980 to 18 June 1985.

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; — MET

- The dysbaric osteonecrosis of the left talar dome, shown in 1972, preceded the worsening and was associated with collapse of the talar dome on the 1985 X-ray.

Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, 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; — MET

- The veteran's heavy gripping work as an Army diver for about 35 hours a week from 1958 to 1974 preceded the worsening.

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; — MET

- The veteran used pneumatic percussive tools on more days than not from 1960 to 1974, more than ten years within the 25 years before the worsening.

Factor 9(37)(a): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The right toe amputations and asymmetric gait, present since 1952, continued throughout the five years before the worsening.

Factor 9(37)(b): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The lifting of about 1 500 000 kg from 1958 to 1968 preceded the worsening, which occurred in 1985, within the 25 years following that period.

Factor 9(37)(c): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The carrying of about 4 800 hours from 1958 to 1968 preceded the worsening, which occurred within the 25 years following that period.

Factor 9(37)(d): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The ladder climbing of about 300 rungs a day from 1960 to 1974, a continuous period of 14 years within the 25 years before the worsening, preceded it.

Factor 9(38)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET

- The veteran's BMI remained above 25 from 1962 to the worsening in 1985, and was 30.2 in June 1985.

Factor 9(38)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET

- The veteran's waist exceeded 102 cm from 1964 to the worsening, and was 109 cm in June 1985.

Factor 9(38)(c): for osteoarthritis of a joint of the lower limb or hand joint only: 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's waist exceeded 102 cm, and therefore also 88 cm, for more than ten years before the worsening.

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; — MET

- The kneeling and squatting of about two hours a day from 1958 to 1974 preceded the worsening, which occurred within the 25 years following that period.

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; — MET

- The internal derangement of the left knee from 1963 persisted before the worsening.

Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET

- The left chondromalacia patella diagnosed in 1964 persisted before the worsening.

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; — MET

- The beriberi neuropathy with loss of proprioception at the left ankle persisted before the worsening.

Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- Paget's disease of the distal left tibia remained active, with a raised alkaline phosphatase in 1984, before the worsening.

Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET

- Acromegaly, treated surgically in 1972, preceded the worsening.

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; — MET

- Lateral instability of the left ankle persisted from 1963 to the worsening, including the giving way that caused the fall of 04 August 1983.

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; — MET

- The left hip femoroacetabular impingement shown in 1974 persisted before the worsening.

Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis. — MET

- An orthopaedic surgeon recommended a custom brace in 1976 and arthrodesis of the left ankle in 1981, but the brace was not supplied for two years and the arthrodesis was deferred for four years by postings and the military hospital waiting list, while he continued to climb ladders as an instructor. The osteoarthritis progressed to end-stage disease by 18 June 1985. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Osteoarthritis, No. 61 of 2017

Causative factors

Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis; — MET

- The veteran was captured in Korea on 24 April 1951 and held as a prisoner of war until 06 September 1953, during warlike service. He endured starvation, untreated dysentery and beriberi, forced marches and sub-zero exposure, all before the onset of osteoarthritis in 1976.

Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Reactive arthritis of the left ankle and both knees followed dysentery in captivity in Korea in 1952, as recorded on repatriation, and recurred in the left ankle in 1960. This preceded onset.

Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET

- On warlike service in Vietnam on 21 September 1966 the veteran developed Staphylococcus aureus septic arthritis of the left ankle after a puncture wound while clearing piling, treated with arthrotomy and washout at a field hospital. This preceded onset.

Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- The intra-articular trimalleolar fracture of 14 March 1962 preceded onset. Its effects were compounded by diving, load carriage and ladder work on warlike service in Vietnam in 1966 and 1967, and by the septic arthritis there.

Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- The left ankle haemarthrosis aspirated on 14 March 1962 preceded onset, and the septic arthritis in Vietnam in 1966 caused a further destructive effusion of the same joint.

Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Gout of the left ankle, confirmed by urate crystals on 09 July 1969 with recurrent attacks to 1974, preceded onset. The veteran's heavy drinking increased after his operational service in Vietnam.

Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- The 1962 fracture was trauma to the left ankle, and on warlike service in Vietnam the penetrating injury of 21 September 1966 was a further discrete injury to the joint, followed by surgery. Both preceded onset.

Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- The acute osteochondral tear of the left talar dome found at surgery on 15 March 1962 preceded onset.

Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint; — MET

- The veteran sustained an acute medial meniscal tear of the left knee on 08 May 1963, before onset. The knee disorder, aggravated by load carriage in Vietnam, altered his gait and loaded his left ankle.

Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- As a prisoner of war in Korea in the winter of 1951 to 1952, during warlike service, the veteran suffered frostbite of the left foot and ankle, recorded on repatriation. This preceded onset.

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 varus and rotational malunion of the left ankle from 1962 was present for 14 years before onset, filling the three years from 15 May 1973 to 15 May 1976, and the septic arthritis in Vietnam in 1966 worsened the joint incongruity.

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; — MET

- Dysbaric osteonecrosis of the left talar dome was shown on 17 November 1972 after 14 years of Army diving, including repeated deep decompression dives on warlike service in Vietnam in 1966 and 1967 under operational time pressure. It preceded onset.

Factor 9(13)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, 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; — MET

- From 1958 to 1974, including warlike service in Vietnam, the veteran performed heavy gripping work as an Army diver for about 35 hours a week, more than ten years within a continuous 15 years before onset, standing and squatting with the left ankle loaded.

Factor 9(13)(b): for osteoarthritis of a joint of the upper limb only: 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; — MET

- The veteran used pneumatic chipping hammers, rock drills and jackhammers on more days than not from 1958 to 1974, including port clearance in Vietnam, a cumulative period of about 14 years before onset.

Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The right great and second toes were amputated in February 1952 for frostbite gangrene sustained as a prisoner of war in Korea, and the veteran walked thereafter with an asymmetric gait that loaded the left ankle, for 24 years before onset.

Factor 9(14)(b): 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 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; — MET

- From 1958 to 1968, including warlike service in Vietnam, the veteran lifted about 1 500 000 kg of diving equipment and stores of 20 to 45 kilograms while bearing weight through the left ankle, far above 100 000 kg in ten years.

Factor 9(14)(c): 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 in that joint; — MET

- From 1958 to 1968, including warlike service in Vietnam, the veteran carried diving equipment of 30 to 45 kilograms for about 4 800 hours. Earlier, from 1950 to 1958, he carried infantry loads of 25 to 40 kilograms in Korea and Malaya.

Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: 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; — MET

- From 1958 to 1974, including warlike service in Vietnam, the veteran climbed about 300 ladder rungs a day on more days than not, a continuous period of 16 years before onset.

Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET

- Bone mineral density 1.6 standard deviations above the young adult male mean was shown on 17 November 1972, before onset.

Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's BMI was above 25 from 1962 to onset, more than ten years, with further weight gain after his return from Vietnam in 1967.

Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's waist circumference exceeded 102 cm from 1964 to onset, more than ten years.

Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET

- The veteran's waist exceeded 102 cm, and therefore also the 88 cm figure in this sub-factor, from 1964 to onset.

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; — MET

- From 1958 to 1974, including warlike service in Vietnam, the veteran knelt and squatted on barges for about two hours a day on more days than not, forcing the left ankle into end-range dorsiflexion.

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; — MET

- Internal derangement of the left knee after the 1963 meniscal tear persisted, with effusions after load carriage in Vietnam in 1966, before onset.

Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET

- Chondromalacia patella of the left knee, diagnosed in 1964, was present before onset and was aggravated by ladder work in Vietnam.

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; — MET

- Beriberi neuropathy acquired as a prisoner of war in Korea caused loss of position and vibration sense at both ankles, recorded on 06 September 1953 and present before onset.

Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET

- Paget's disease of the distal left tibia, extending to the ankle joint surface, was confirmed on 14 February 1973, before onset.

Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET

- Acromegaly was confirmed on 17 November 1972 and had been present for years, before onset.

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; — MET

- Lateral instability of the left ankle was recorded from 1963, and the ankle gave way repeatedly on ladders and wet decks in Vietnam in 1966 and 1967, more than one year before onset.

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; — MET

- Cam-type femoroacetabular impingement of the left hip was shown on X-ray on 11 March 1974, before onset.

Worsening factors

Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The reactive arthritis of the left ankle that followed dysentery in captivity in Korea preceded the worsening on 18 June 1985.

Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET

- The septic arthritis of the left ankle on warlike service in Vietnam in 1966 preceded the worsening.

Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The intra-articular fracture of 1962 preceded the worsening.

Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- Haemarthroses in 1962 and 1983 preceded the worsening.

Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- Recurrent gout of the left ankle, with attacks to 1984, preceded the worsening.

Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The 1962 fracture, the 1966 penetrating injury in Vietnam and the fall of 04 August 1983 preceded the worsening.

Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The 1962 osteochondral tear of the talar dome preceded the worsening.

Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint; — MET

- The 1963 left medial meniscal tear preceded the worsening.

Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- The frostbite of the left ankle suffered as a prisoner of war in Korea preceded the worsening.

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 varus malunion, progressing to fixed varus, was present throughout the three years before the worsening, from 18 June 1982 to 18 June 1985.

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; — MET

- The dysbaric osteonecrosis of the talar dome, contributed to by diving in Vietnam, preceded the worsening.

Factor 9(35)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, 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; — MET

- The heavy gripping work of about 35 hours a week from 1958 to 1974 preceded the worsening.

Factor 9(35)(b): for osteoarthritis of a joint of the upper limb only: 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; — MET

- The use of percussive tools on more days than not from 1958 to 1974 preceded the worsening.

Factor 9(36)(a): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The toe amputations and asymmetric gait from captivity in Korea continued throughout the three years before the worsening.

Factor 9(36)(b): 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 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET

- The lifting of about 1 500 000 kg from 1958 to 1968 preceded the worsening.

Factor 9(36)(c): 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 worsening of osteoarthritis in that joint; — MET

- The carrying of about 4 800 hours from 1958 to 1968 preceded the worsening.

Factor 9(36)(d): for osteoarthritis of a joint of the lower limb only: 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; — MET

- The ladder climbing of about 300 rungs a day from 1958 to 1974 preceded the worsening, and as an instructor he continued to climb training tower ladders daily until 1984.

Factor 9(36)(e): for osteoarthritis of a joint of the lower limb only: having osteoporosis before the clinical worsening of osteoarthritis in that joint; — MET

- Dual-photon absorptiometry on 22 October 1984 showed osteoporosis, T-score minus 2.6, from untreated hypogonadism after the 1972 pituitary surgery for acromegaly. This preceded the worsening on 18 June 1985 and was associated with subchondral collapse.

Factor 9(37)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET

- The veteran was overweight from 1962 to the worsening in 1985, with a BMI of 30.2 in June 1985.

Factor 9(37)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET

- The veteran's waist exceeded 102 cm from 1964 to the worsening.

Factor 9(37)(c): for osteoarthritis of a joint of the lower limb or hand joint only: 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's waist exceeded 102 cm, and therefore 88 cm, for more than ten years before the worsening.

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; — MET

- The kneeling and squatting of about two hours a day from 1958 to 1974 preceded the worsening.

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; — MET

- The left knee internal derangement from 1963 persisted before the worsening.

Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET

- The left chondromalacia patella persisted before the worsening.

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; — MET

- The beriberi neuropathy from captivity in Korea persisted before the worsening.

Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET

- Paget's disease of the distal left tibia remained active before the worsening.

Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET

- Acromegaly preceded the worsening.

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; — MET

- The left ankle instability persisted from 1963 to the worsening, including the fall of 04 August 1983.

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; — MET

- The left hip femoroacetabular impingement persisted before the worsening.

Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis. — MET

- A custom brace recommended in 1976 was not supplied for two years and the arthrodesis recommended in 1981 was deferred for four years by postings and the waiting list, and the osteoarthritis progressed to end-stage disease by 18 June 1985. The joint had been damaged by his captivity in Korea and his warlike service in Vietnam, and the delay amounts to an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

The osteoarthritis led to arthrodesis of the left ankle on 03 March 1986, which has been followed by degeneration of the adjacent subtalar and midfoot joints, chronic hindfoot pain and a stiff, limping gait. The altered gait has also contributed to pain in the right knee and lower back. These are sequelae of the left ankle osteoarthritis.

Unintended Consequence

Met. The pituitary surgery of 1972 for acromegaly, provided by the Commonwealth during service, caused hypopituitarism with untreated hypogonadism, which led to the osteoporosis shown in 1984 that contributed to subchondral collapse and the worsening of the osteoarthritis. The retained internal fixation from 1962 also caused local irritation. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA).

Inability to Attain Appropriate Medical Management

MET. An orthopaedic surgeon recommended a custom ankle brace and a sedentary posting in 1976 and arthrodesis in 1981. The brace was not supplied for two years, he remained in an instructor role that required daily ladder climbing, and the arthrodesis was deferred for four years by postings and the military hospital waiting list. The osteoarthritis progressed from moderate to end-stage disease, documented on 18 June 1985. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), service postings and waiting lists that prevented the recommended treatment amount to an inability to obtain appropriate clinical management, and this contributed to the worsening.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 18 Aug 1949, Entry medical examination, Army recruiting medical officer
2. 06 Sep 1953, Repatriation medical examination of returned prisoner of war, Medical officer
3. 14 Mar 1962, X-ray left ankle, emergency record and operation report, Radiologist and orthopaedic surgeon
4. 08 May 1963, Operation report, left knee meniscectomy, Orthopaedic surgeon
5. 21 Sep 1966, Field hospital admission and operation report, Surgeon, Vietnam
6. 09 Jul 1969, Outpatient health record and pathology, Medical Officer
7. 17 Nov 1972, Endocrinology report, absorptiometry and long-bone survey, Endocrinologist and radiologist
8. 14 Feb 1973, X-ray left tibia and pathology, Radiologist
9. 11 Mar 1974, X-ray pelvis, Radiologist
10. 20 Oct 1975, Periodic health examination, Medical Officer
11. 02 Jun 1976, Outpatient health record and X-ray left ankle, Medical Officer and radiologist
12. 10 Aug 1976, Specialist report, Orthopaedic surgeon
13. 22 Oct 1984, Dual-photon absorptiometry report, Radiologist
14. 18 Jun 1985, Specialist report and X-ray left ankle, Orthopaedic surgeon and radiologist
15. 03 Mar 1986, Operation report, left ankle arthrodesis, Orthopaedic surgeon
16. Statement of Principles concerning Osteoarthritis (Balance of Probabilities) No. 62 of 2017, Repatriation Medical Authority
17. Statement of Principles concerning Osteoarthritis (Reasonable Hypothesis) No. 61 of 2017, Repatriation Medical Authority