Diagnostic Assessment — Left Hip - Femoroacetabular Impingement Syndrome
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
LEFT HIP - FEMOROACETABULAR IMPINGEMENT SYNDROME
Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) Instrument No. 70 of 2019 and Statement of Principles concerning femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019.
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 hip joints. SASR operations require tactical movements including deep squatting, repetitive climbing, crawling, and running with heavy loads over variable terrain. Communications specialists often work in confined spaces requiring sustained awkward hip positions during equipment setup and operation. Military physical training involves high-intensity activities including loaded marches, obstacle courses, and strength training that place repetitive stress on the hip joints. These occupational activities can exacerbate anatomical predispositions to femoroacetabular impingement and contribute to labral injuries over time.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed progressive left hip pain associated with mechanical symptoms during tactical movements and physical training. Diagnostic imaging has confirmed femoroacetabular impingement syndrome with associated labral scarring in the left hip.
Timeline
- 24 Jun 2016: Initial presentation with left groin and lateral hip pain during and after physical training. Patient reports deep pain with squatting and rotational movements. • 31 Jun 2016: Physical examination documented limited internal rotation of the left hip with positive impingement testing. Pain reproduction with flexion, adduction, and internal rotation maneuver. • 14 Jul 2016: X-rays of pelvis and left hip performed. Cam-type morphology of the left femoral head-neck junction with alpha angle of 62 degrees. • 26 Jul 2016: Physical therapy assessment noting functional limitations with deep squatting and tactical movements. Pain with specific hip loading exercises. • 18 Aug 2016: Continued symptoms despite conservative management prompted referral for advanced imaging. Mechanical symptoms persist with occupational activities. • 29 Aug 2016: MRI Arthrogram of the left hip performed. Cam-type morphology with evidence of labral damage and scarring anterosuperiorly. No evidence of complete labral tear. • 16 Sep 2016: Orthopedic consultation confirming diagnosis of femoroacetabular impingement syndrome with labral pathology. Symptomatic FAI with evidence of labral scarring consistent with chronic impingement.
Symptoms
The veteran initially presented with deep pain in the left groin and lateral hip region, exacerbated by specific movements including deep squatting, tactical maneuvers, and rotational activities. The pain was characterized as sharp and mechanical in nature, with occasional catching sensations during certain movements. Physical examination revealed limited internal rotation of the left hip with pain at the extremes of motion, positive impingement testing with reproduction of symptoms during the flexion-adduction-internal rotation (FADIR) test, and discomfort with resisted hip flexion. Current symptoms include persistent activity-related pain that limits full participation in tactical training exercises, difficulty with prolonged sitting in tactical vehicles, and pain after extended periods of load carriage. The mechanical symptoms have been particularly problematic during operations requiring rapid changes in direction, climbing, and deep squatting positions needed for communications equipment setup in field conditions.
Imaging
14 Jul 2016 - X-RAY PELVIS AND LEFT HIP: AP pelvis and lateral left hip views demonstrate cam-type morphology of the left femoral head-neck junction with alpha angle measured at 62 degrees (normal <55 degrees). No significant acetabular overcoverage or retroversion noted. Joint space is preserved. No fracture or dislocation identified. IMPRESSION: Cam-type femoroacetabular morphology of the left hip.
29 Aug 2016 - MRI ARTHROGRAM LEFT HIP: Following intra-articular contrast injection, images demonstrate cam-type morphology of the femoral head-neck junction with alpha angle of 64 degrees. There is evidence of labral damage and scarring in the anterosuperior quadrant consistent with chronic impingement, but no complete labral tear identified. Mild synovitis is noted. The articular cartilage shows early degenerative changes anterosuperiorly at the site of impingement. No stress fracture or avascular necrosis. IMPRESSION: Cam-type femoroacetabular impingement with evidence of chronic labral damage and scarring anterosuperiorly. Early cartilage degeneration at the impingement site.
1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Hip Femoroacetabular Impingement Syndrome with Labral Scarring (ICD-10 Code: M25.85). This diagnosis falls under the DVA Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) Instrument No. 70 of 2019 and Statement of Principles concerning femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019.
Femoroacetabular impingement (FAI) syndrome is a clinical disorder characterized by symptomatic premature contact between the femoral head-neck junction and the acetabular rim during hip motion, particularly flexion and internal rotation. This abnormal contact leads to damage of the acetabular labrum and articular cartilage. There are two primary morphological types of FAI: cam-type (abnormal femoral head-neck junction contour) and pincer-type (acetabular overcoverage). The veteran has cam-type morphology, characterized by an increased alpha angle of 62-64 degrees on imaging studies.
The labral scarring represents evidence of chronic impingement and repetitive microtrauma to the labrum, which is the fibrocartilaginous ring surrounding the acetabulum. While there is no complete labral tear, the scarring indicates tissue damage and attempted healing in response to the abnormal mechanical forces produced by the impingement.
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 left hip femoroacetabular impingement syndrome on or before 24 Jun 2016, when he initially presented with left groin and lateral hip pain during and after physical training.
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 24 Jun 2016, when he reported to the ADF Medical Centre with complaints of left groin and lateral hip pain during and after physical training.
When was the condition confirmed / formally diagnosed? The condition was initially suspected based on clinical examination and X-ray findings on 14 July 2016, which demonstrated cam-type morphology consistent with femoroacetabular impingement. Definitive confirmation of both the impingement syndrome and the associated labral scarring was provided by MRI arthrogram on 29 August 2016. The diagnosis was formally established by an orthopedic specialist on 16 September 2016.
When did the veteran first present to you (or your practice) for this condition? 26 January 2018.
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 Left Hip Femoroacetabular Impingement Syndrome with Labral Scarring was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included: • Deep groin and lateral hip pain exacerbated by specific movements • Pain with deep squatting and rotational activities • Mechanical symptoms including catching sensations during certain movements • Activity-related pain affecting occupational performance
Clinical examination findings included: • Limited internal rotation of the left hip with pain at end range • Positive femoroacetabular impingement testing (FADIR test) • Discomfort with resisted hip flexion • Reproduction of symptoms with provocative maneuvers
Diagnostic imaging provided definitive confirmation:
- X-ray of the Pelvis and Left Hip (14 July 2016) demonstrated cam-type morphology with alpha angle of 62 degrees
- MRI Arthrogram of the Left Hip (29 August 2016) provided detailed assessment showing cam-type morphology with alpha angle of 64 degrees and evidence of labral damage and scarring
Specialist opinion from an orthopedic consultation on 16 September 2016 confirmed the diagnosis, noting that the findings were consistent with chronic impingement and the patient's clinical presentation.
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 femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019:
having cam-type femoroacetabular impingement morphology of the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: MET
- Imaging studies definitively demonstrate cam-type morphology with an alpha angle of 62-64 degrees, which exceeds the normal threshold of 55 degrees. This morphological variant is the primary underlying anatomical factor for the development of the syndrome.
having pincer-type femoroacetabular impingement morphology of the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: NOT MET
- Imaging studies do not demonstrate significant acetabular retroversion or overcoverage consistent with pincer-type morphology.
having slipped capital femoral epiphysis before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of slipped capital femoral epiphysis.
having Legg-Calvé-Perthes disease before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of Legg-Calvé-Perthes disease.
having trauma to the affected hip, including surgery, before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No documented specific hip trauma or surgery prior to symptom onset.
having acetabular dysplasia involving the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No radiographic evidence of acetabular dysplasia.
having a malunited fracture of the proximal femur or pelvis before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of proximal femur or pelvic fracture.
having a disease from the specified list before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No evidence of conditions from the specified list.
inability to obtain appropriate clinical management for femoroacetabular impingement syndrome: NOT MET
- This is a clinical worsening factor. There is no evidence that appropriate management was unavailable once symptoms developed.
The occupational activities associated with SASR service contributed significantly to the progression from asymptomatic morphology to symptomatic syndrome with labral pathology through activities involving deep squatting, repetitive hip flexion and rotation, loaded running and marching, and tactical maneuvers that place the hip in positions of impingement.
Sequelae
There is no indication that the left hip femoroacetabular impingement syndrome with labral scarring is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the left hip femoroacetabular impingement syndrome with labral scarring 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 left hip 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
