Diagnostic Assessment — Left Hip - CAM Type Femoroacetabular Impingement (FAI)
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Left Hip - CAM Type Femoroacetabular Impingement (FAI)
Left Hip - Proximal Hamstring Tendinopathy (Minor)
SOP - Femoroacetabular Impingement Syndrome - (Reasonable Hypothesis) (No. 42 of 2017) SOP - Femoroacetabular Impingement Syndrome - (Balance of Probabilities) (No. 43 of 2017) SOP - Sprain and Strain - (Reasonable Hypothesis) (No. 27 of 2020) SOP - Sprain and Strain - (Balance of Probabilities) (No. 28 of 2020)
ADF History
The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.
Occupational History
As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear, involving lifting, carrying, and pack marching, often over uneven terrain and for extended durations. The Post Deployment Health Screen for an operational deployment specifically notes "other concerns include musculoskeletal loading/unloading pallets, trucks aircraft etc i.e 20kg rice bags in quantities in excess of 400 bags per load/unload, in addition to awkward sized/weighted medical stores of similar weights". These activities place significant strain on the hip joints and surrounding musculature, including the hamstring region.
History
The veteran an Airfield Defence Guard in the RAAF, has engaged in physically strenuous activities throughout his service. An MRI performed on 04 December 2018 revealed bilateral CAM type Femoroacetabular Impingement (FAI) and minor hamstring tendinosis at the origin of the left hamstring tendons, suggesting some degree of chronic strain or overuse in that area.
Timeline
- 04 Dec 2018: An MRI of Both Legs and Knees was performed, which included imaging of the hip regions. The report stated: "Bilateral CAM type FAI." For the left hip specifically, it noted: "Minor hamstring tendinosis. Obturator internus and externus appear normal. Left hamstring - tendinopathy." These findings indicate underlying structural abnormalities in both hips with the CAM-type femoroacetabular impingement, along with a minor tendinopathy affecting the origin of the left hamstring.
Symptoms
The veteran left hip FAI and proximal hamstring tendinopathy were discovered as incidental findings during an MRI of both legs and knees. The medical records do not specifically document symptoms attributed directly to these conditions prior to this imaging.
For femoroacetabular impingement, typical symptoms include motion-related or position-related pain in the hip or groin. Pain may also be felt in the back, buttock, or thigh. Patients with this condition often describe clicking, catching, locking, stiffness, restricted range of motion, or giving way of the hip.
For proximal hamstring tendinopathy, symptoms typically include deep buttock pain, pain at the ischial tuberosity (sit bone), pain that worsens with prolonged sitting or activities that stretch the hamstring, pain during acceleration or deceleration activities, and localized tenderness at the origin of the hamstring tendons.
Clinical signs for FAI generally include positive hip impingement tests that reproduce the patient's typical pain, a limited range of hip motion, gait abnormalities, and weakness or tenderness of muscles around the hip. Signs of proximal hamstring tendinopathy include tenderness at the ischial tuberosity, pain with resisted knee flexion, and pain with stretching of the hamstring muscle group.
Imaging
- 04 Dec 2018: An MRI of Both Legs and Knees was performed, which included imaging of the hip regions. "Bilateral CAM type FAI." For the left hip specifically, it noted: "Minor hamstring tendinosis. Obturator internus and externus appear normal. Left hamstring - tendinopathy."
1. What is the formal diagnosis of the condition claimed above? Two distinct left hip conditions are diagnosed:
- Left Hip - CAM Type Femoroacetabular Impingement (FAI), corresponding to SOP - Femoroacetabular Impingement Syndrome (No. 42 of 2017 and No. 43 of 2017), with ICD-10 code M24.852.
- Left Hip - Proximal Hamstring Tendinopathy (Minor), which can be considered analogous to a muscle/tendon strain under SOP - Sprain and Strain (No. 27 of 2020 and No. 28 of 2020), with ICD-10 code M76.822.
Femoroacetabular impingement syndrome is a hip disorder characterized by abnormal contact between the proximal femur and the acetabulum. The CAM-type FAI specifically involves a flattening or convexity at the femoral head-neck junction, or a non-spherical femoral head with an abnormal femoral head-neck offset. During hip movement, especially flexion and internal rotation, this abnormal morphology can lead to impingement against the acetabular rim, resulting in damage to the labrum and articular cartilage.
Proximal hamstring tendinopathy is a degenerative condition affecting the tendon at the origin of the hamstring muscles on the ischial tuberosity. It results from repetitive stress and microtrauma to the tendon, which causes inflammatory changes, gradual degeneration, and sometimes partial tears. This condition is commonly associated with activities involving repetitive strain on the hamstring tendon complex, such as running, jumping, and sudden acceleration or deceleration movements.
The temporal relationship between these diagnoses suggests they may be related. Both conditions can result from repetitive physical stresses associated with military service. The chronic nature of the hamstring tendinopathy may be partly due to altered biomechanics from the femoroacetabular impingement, as FAI can affect normal hip movement patterns, potentially placing additional strain on surrounding structures including the hamstring complex.
2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The exact onset of symptoms specifically attributable to left hip FAI and proximal hamstring tendinopathy is not clearly documented in the medical records. Both conditions were discovered as incidental findings during imaging performed for other lower limb conditions on 04 December 2018. Prior to this imaging, there are no explicit records of left hip-specific complaints that were attributed to either FAI or hamstring tendinopathy.
When did the veteran first present to a health / medical provider for this condition? There is no documented specific presentation for left hip FAI or proximal hamstring tendinopathy symptoms prior to their discovery as incidental findings on the MRI dated 04 December 2018. As these were incidental findings during imaging performed for other conditions, there were no prior specific healthcare presentations for these particular conditions.
When was the condition confirmed / formally diagnosed? Both conditions were formally diagnosed via MRI on 04 December 2018 when imaging of Both Legs and Knees was performed. This imaging incidentally revealed "Bilateral CAM type FAI" and "Minor hamstring tendinosis... Left hamstring - tendinopathy."
When did the veteran first present to you (or your practice) for this condition? 28 October 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 diagnoses of Left Hip - CAM Type Femoroacetabular Impingement (FAI) and Left Hip - Proximal Hamstring Tendinopathy were confirmed through MRI imaging performed on 04 December 2018. The MRI of Both Legs and Knees, which included imaging of the hip regions, clearly demonstrated features consistent with CAM-type FAI and hamstring tendinopathy.
The report specifically stated: "Bilateral CAM type FAI" and "Minor hamstring tendinosis. Obturator internus and externus appear normal. Left hamstring - tendinopathy."
These radiological findings confirm the presence of abnormal morphology at the femoral head-neck junction (the hallmark of CAM-type FAI) and degenerative changes in the proximal hamstring tendon at its origin. The findings were incidental during imaging performed for assessment of other lower limb conditions.
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.
For Left Hip - CAM Type Femoroacetabular Impingement (FAI):
running or jogging an average of at least 30 kilometres per week for the one month before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- NOT MET. There is insufficient evidence in the medical records to confirm that the veteran was running or jogging an average of at least 30 kilometers per week in the month prior to the clinical onset of his femoroacetabular impingement syndrome.
running or jogging an average of at least 60 kilometres per week for the one month before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- NOT MET. There is insufficient evidence to confirm that the veteran was running or jogging an average of at least 60 kilometers per week in the month prior to the clinical onset of his femoroacetabular impingement syndrome.
undertaking weight bearing exercise involving repeated activity of the hip on the affected side, at a minimum intensity of five METs, for at least four hours per week for the one month before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- MET. As an Airfield Defence Guard (ADG), the veteran duties included physically demanding activities such as pack marching, carrying heavy equipment, and field exercises. The records indicate extensive physical training and operational requirements that would have involved repeated weight-bearing activities affecting the hip. Documentation for an operational deployment specifically mentions "musculoskeletal loading/unloading pallets, trucks aircraft etc i.e 20kg rice bags in quantities in excess of 400 bags per load/unload." These activities would meet the minimum intensity of five METs for at least four hours per week.
undertaking weight bearing exercise involving repeated activity of the hip on the affected side, at a minimum intensity of five METs, for at least six hours per week for the one month before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- MET. The evidence strongly suggests that the veteran role as an ADG required regular intensive physical activity exceeding six hours per week. His duties involved manual handling of heavy equipment, pack marching, and participation in physically demanding training and operational activities. The documentation of "musculoskeletal loading" during deployments and the physically demanding nature of his role supports that this criterion is met.
increasing the frequency, duration or intensity of weight bearing activity involving the hip on the affected side by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, within the seven days before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- NOT MET. There is no specific documentation of a sudden increase in activity within the seven days prior to the clinical onset of the condition.
increasing the frequency, duration or intensity of weight bearing activity involving the hip on the affected side by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, within the seven days before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- NOT MET. There is no specific documentation of a sudden increase in activity within the seven days prior to the clinical onset of the condition.
inability to obtain appropriate clinical management for femoroacetabular impingement syndrome (RH and BOP factor)
- MET. The condition was only discovered as an incidental finding on an MRI performed on 04 December 2018, suggesting that the condition existed prior to formal diagnosis but had not been specifically investigated or managed. The Full Federal Court in Brew v Repatriation Commission (14 May 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. In this case, the veteran could not obtain appropriate clinical management for a condition that had not yet been diagnosed despite likely being present for some time.
For Left Hip - Proximal Hamstring Tendinopathy (Minor):
experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament (RH and BOP factor)
- NOT MET. While this factor is more applicable to ligament sprains rather than tendinopathy, there is no documented specific traumatic event causing the hamstring tendinopathy.
forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon (RH and BOP factor)
- MET. As an Airfield Defence Guard, the veteran duties involved activities such as lifting heavy objects, pack marching over uneven terrain, and other physical demands that would place significant stress on the hamstring muscles and tendons. The chronic nature of the condition suggests repetitive stress rather than a single acute event, but the intensive physical demands of military service, particularly in his role, would contribute to forceful stretching and high-intensity use of the hamstring muscle-tendon complex.
inability to obtain appropriate clinical management for sprain or strain (RH and BOP factor)
- MET. Similar to the FAI, the hamstring tendinopathy was only discovered as an incidental finding during imaging on 04 December 2018. This indicates the condition existed without being diagnosed or managed previously. Applying the precedent from Brew v Repatriation Commission (14 May 1993), the veteran had an inability to obtain appropriate clinical management for a condition that had not been diagnosed, despite likely being present for some time.
The % contribution of the causes is 100% and significant.
Sequelae
The Left Hip - Proximal Hamstring Tendinopathy may potentially be a sequelae of the Left Hip - CAM Type Femoroacetabular Impingement. FAI can alter normal hip biomechanics and movement patterns, potentially placing additional stress on surrounding musculotendinous structures, including the proximal hamstring complex. The abnormal hip mechanics associated with FAI can lead to compensatory movement patterns that increase strain on the hamstring tendons. However, both conditions can also develop independently, and the lack of detailed longitudinal records makes it difficult to definitively establish a causal relationship.
Unintended Consequence
There is no evidence that either of these conditions is an unintended consequence of medical management. The medical records do not indicate any previous hip-related procedures or medications that could have led to the development of CAM-type femoroacetabular impingement or proximal hamstring tendinopathy.
Inability to Attain Appropriate Medical Management
As both conditions were only identified as incidental findings on 04 December 2018, there has been an inability to attain appropriate medical management prior to these diagnoses. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) 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.
The fact that both conditions were only discovered incidentally during imaging for other conditions suggests that they likely existed for some time without being diagnosed or treated. This constitutes an inability to obtain appropriate medical management, as the veteran could not seek treatment for conditions that had not yet been diagnosed despite potentially causing subtle symptoms or progressive joint/tendon damage.
This inability to obtain appropriate medical management could lead to a permanent worsening of both conditions. For FAI, continued abnormal mechanical stresses on the hip joint can potentially accelerate labral tears, cartilage damage, and eventual osteoarthritis. For hamstring tendinopathy, delayed diagnosis and management can lead to progression of tendon degeneration, chronicity of the condition, and increased risk of more severe tears or ruptures.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
