Diagnostic Assessment — Left Knee - External Bruise
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Knee — External Bruise BOP Code: 44 of 2024 (Traumatic Contusion or Haematoma) RH Code: 43 of 2024 (Traumatic Contusion or Haematoma)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as a Supply Operator from 9 April 1989 to 24 January 1996
Occupational History
As a Supply Operator aboard service vessels and at shore establishments, the veteran was exposed to the occupational hazards of wet and moving decks, heavy equipment, confined spaces, and physically demanding recruit training, including drill at the double; he also played organised rugby from late April 1989.
These activities carry a risk of contusion injuries to the lower limbs
History
The veteran sustained a bruise to the left knee during ADF service.
On 15 April 1989, six days after enlistment, he presented to the Medical Officer at a support squadron with a bruised left knee following a blow to the left knee two days earlier; the cause of the injury was not recorded.
The blow occurred in his first week of Supply Operator training, while he lived and trained at a support squadron, and walking and doubling aggravated the pain.
He also had a pre- enlistment left knee injury (direct blow to patella from a football tackle) documented on his enlistment medical history, indicating susceptibility of the left knee to further injury
Timeline
12 Feb 1989 — Pre-enlistment left knee arthroscopy performed by the treating doctor.
Under anaesthetic the knee was stable.
Arthroscopy showed only minimal chondral damage on the medial facet of the patella.
Ligaments intact, meniscii intact.
The knee was considered resolved and did not preclude enlistment.
The original injury was a direct blow to the patella from a football tackle, establishing that the left knee was susceptible to direct impact injuries. "Minimal chondral damage" 15 Apr 1989 — Supply Operator the veteran, as a young adult, presented to the Medical Officer at a support squadron with a bruised left knee following a blow to the left knee two days earlier, with pain when walking and doubling.
A past history of patellar cartilage damage was noted.
Examination demonstrated tenderness of the patellar tendon and medial ligament, with the ligaments intact, and pain along the lateral joint line on valgus strain.
He was treated with Brufen and placed on light duty for 3 days. "Bruised L knee"
Symptoms
At presentation on 15 April 1989, the veteran had pain when walking and doubling following a blow to the left knee two days earlier, with tenderness of the patellar tendon and medial ligament and pain along the lateral joint line on valgus strain.
A bruise (contusion) to the left knee typically presents with localised pain, swelling, and discolouration at the site of direct impact.
Given the pre-existing minimal chondral damage to the medial facet of the left patella (from the pre-enlistment arthroscopy), the blow struck a knee with minor pre-existing cartilage damage
Imaging
No specific imaging of the left knee related to a bruise was performed during service
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Knee External Bruise / Contusion (ICD-10: S80.02XA).
The relevant Statements of Principles are those concerning Traumatic Contusion or Haematoma (Balance of Probabilities No.
44 of 2024; Reasonable Hypothesis No.
43 of 2024), applied by analogy as this is a DRCA claim.
A contusion (bruise) is defined as an injury to soft tissue caused by direct impact without breaking the skin, resulting in damage to subcutaneous tissue, blood vessels, and potentially underlying structures such as bone (bone bruise)
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 13 April 1989, following a blow to the left knee two days before his presentation at a support squadron on 15 April 1989.
When did the veteran first present to a health / medical provider for this condition? 15 April 1989 (Medical Officer, a support squadron).
When was the condition confirmed / formally diagnosed? 15 April 1989, when the Medical Officer at a support squadron diagnosed a bruised left knee.
When did the veteran first present to you (or your practice) for this condition? 20 August 2020
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
A contusion to the left knee is a clinical diagnosis based on the mechanism of injury and physical examination findings.
The diagnosis was confirmed clinically on 15 April 1989 by the Medical Officer at a support squadron, who recorded a bruised left knee following a blow to the knee two days earlier, with pain when walking and doubling, tenderness of the patellar tendon and medial ligament, intact ligaments and pain along the lateral joint line on valgus strain.
The pre-enlistment history of a direct blow to the left patella from a football tackle, which required arthroscopy, demonstrates the vulnerability of this knee to impact injuries
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 7 July 2009 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(1): having trauma involving the affected site within the 24 hours before clinical onset — MET - The Daily Medical Record of 15 April 1989 from a support squadron records a 'blow to L knee 2/7 ago', that is on about 13 April 1989, and diagnoses a bruised left knee, with pain on walking and doubling and tenderness of the patellar tendon and medial ligament.
The blow was trauma involving the left knee, the affected site, and the bruise developed from it, so the trauma occurred within the 24 hours before the clinical onset of the contusion on about 13 April 1989.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having trauma involving the affected site within the 24 hours before clinical onset — MET - The blow to the left knee on about 13 April 1989, recorded at a support squadron on 15 April 1989 with a diagnosis of bruised left knee, was trauma involving the affected site at the onset of the contusion, and so within the 24 hours before clinical onset.
Other Plausible Links to Service The blow occurred on about 13 April 1989, four days after the veteran enlisted, in his first week as an adult Supply Operator at a support squadron, where he lived and trained far from his home in a support squadron.
The cause-of-injury field of the Daily Medical Record was left blank, but the absence of a recorded cause is not evidence that the injury arose outside service: at that stage his activities were those of recruit training and life on the establishment, and the pain was aggravated by walking and doubling, both recruit training activities.
The injury is therefore likely to have arisen out of, or in the course of, his service.
The blow struck a knee with minor pre-existing cartilage damage on the medial facet of the patella from a pre-enlistment football tackle (arthroscopy on 12 February 1989, reported as settled on 20 February 1989), which the medical officer noted on 15 April 1989.
Continuing recruit training on the injured knee for two days, with walking and doubling, aggravated its symptoms until light duties were given.
Conclusion the veteran's left knee bruise was caused by a blow to the knee on about 13 April 1989, diagnosed by the medical officer at a support squadron on 15 April 1989; the factor of trauma involving the affected site within the 24 hours before clinical onset is met under both Statements of Principles.
Although the cause of the blow was not recorded, it occurred in his first week of Supply Operator training, while he lived and trained on the establishment, and recruit training aggravated the pain, so the injury is attributable to his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the bruise of the veteran's left knee is found not to have arisen out of his service, the following factor addresses whether it was worsened after its clinical onset on about 13 April 1989.
He continued Supply Operator training at a support squadron, where walking and doubling aggravated the pain until he was placed on light duties for three days on 15 April 1989.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
44 of 2024) Factor 9(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, there was no inability: the veteran was examined by the medical officer at a support squadron within two days of the blow, prescribed Brufen and given three days' light duty, and the bruise resolved without further presentation.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Traumatic Contusion or Haematoma, No.
43 of 2024) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(2): inability to obtain appropriate clinical management for traumatic contusion or haematoma before clinical worsening — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no objective or subjective inability: the bruise was examined and treated within two days of the blow and resolved without further presentation
Sequelae
No specific sequelae documented
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
There was no inability to obtain appropriate clinical management.
The veteran was examined by the medical officer at a support squadron within two days of the blow, prescribed Brufen and given three days' light duty, and the bruise resolved without further presentation.
Assessed objectively and subjectively as required by Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this factor is NOT MET
Date of Clinical Onset
Left knee external bruise is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 13 April 1989 — blow to the left knee two days before his presentation at a support squadron on 15 April 1989 [CHART REVIEW document].
Date of clinical onset: approximately 13 April 1989.
This date falls within the veteran's ADF service (9 April 1989 24 January 1996).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
