Left Knee - Iliotibial Band Syndrome — DVA claim example

Diagnostic Assessment — Left Knee - Iliotibial Band Syndrome

Example 1 of 1 · fictitious patient (Veteran I)

Diagnostic Assessment

Left Knee - Iliotibial Band Syndrome

BOP Code: 4 of 2019 (Iliotibial Band Syndrome)
RH Code: 3 of 2019 (Iliotibial Band Syndrome)

ADF History

Veteran I, date of birth 14 June 1986, Australian Army, Rifleman (Infantry), enlisted 21 February 2005, medically discharged 15 November 2016. Operational service: East Timor, 08 January 2007 to 19 July 2007 (non-warlike); Solomon Islands, 18 January 2010 to 27 April 2010 (non-warlike, returned early after injury); Afghanistan, 01 March 2011 to 31 October 2011 (warlike).

Occupational History

As an infantry rifleman the veteran patrolled on foot for long periods carrying body armour, weapon, ammunition, water and radio equipment totalling 30 to 45 kilograms, often over steep, terraced or broken ground and in extreme heat. Training involved section and platoon attacks, repeated crouching, kneeling, climbing and jumping from vehicles, route marches with full loads and compulsory running-based physical training.

Infantry soldiers have high rates of overuse injury of the knee, hip and lower limb from cumulative running and load carriage, and of acute ligament injury from falls, twisting on uneven ground and contact during training and operations. Access to physiotherapy and imaging on deployment is limited, and soldiers are commonly expected to continue patrolling with lower limb pain.

History

Veteran I, an infantry rifleman in the Australian Army, ruptured the anterior cruciate ligament of his left knee on non-warlike service in the Solomon Islands in April 2010 and underwent reconstruction in August 2010, leaving varus thrust and left hip abductor weakness. He developed left iliotibial band syndrome on warlike service in Afghanistan on 12 April 2011 during a period of very high running, cycling and patrol loads, and the condition worsened in July 2011 when he was returned to full patrolling without treatment.

Timeline

• 14 Jun 2007 — During non-warlike service in East Timor the veteran presented with left lateral hip pain after six weeks of daily foot patrols carrying about 35 kg in mountainous terrain. The medical officer found tenderness over the left greater trochanter and pain on resisted hip abduction. Ultrasound at the regional hospital showed left gluteus medius tendinopathy. He was managed with load modification and remained on deployment. "L gluteus medius tendinopathy, weak abduction"
• 15 Apr 2010 — On non-warlike service in the Solomon Islands the veteran fell down a steep embankment during a night patrol, landing with his left knee twisted into varus. He had immediate swelling and could not bear weight. Examination showed a positive Lachman test, increased varus laxity at 30 degrees of flexion and a positive dial test. He was aeromedically evacuated to Australia on 27 April 2010. "L knee ACL and PLC injury"
• 24 Aug 2010 — An orthopaedic surgeon performed a left anterior cruciate ligament reconstruction with a hamstring graft, fixed on the femoral side with a cross-pin implant in the distal lateral femur, together with posterolateral corner repair and partial medial meniscectomy. Rehabilitation was supervised at the garrison physiotherapy department and he returned to unrestricted duties on 31 January 2011. "L ACLR, femoral cross-pin fixation"
• 10 Feb 2011 — At his pre-deployment medical the left knee was stable with full range of movement and no lateral knee pain or tenderness. Physiotherapy dynamometry showed left hip abduction strength 32 per cent below the right, and gait assessment showed a left varus thrust in stance. A long-leg standing radiograph showed a mechanical axis of 5 degrees varus on the left. He was cleared to deploy with a home exercise program. "no lateral knee pain, varus thrust"
• 14 Apr 2011 — At a patrol base in Afghanistan the veteran presented with two days of sharp lateral left knee pain that began during a clearance patrol on 12 April 2011, worse descending terraces and running downhill. The regimental medical officer found point tenderness over the lateral femoral epicondyle, a positive Noble compression test and a positive Ober test. Over the preceding four weeks he had run 65 to 70 km per week, cycled 11 hours per week and patrolled 9 hours per week, and in the preceding seven days his patrol and cycling hours had more than doubled. "lateral epicondyle tender, Noble positive"
• 20 Apr 2011 — Ultrasound at the role 2 medical facility confirmed thickening of the distal iliotibial band to 4.2 mm with a small fluid collection deep to the band at the lateral femoral epicondyle. A diagnosis of left iliotibial band syndrome was made. Physiotherapy was not available at the patrol base and he was returned to patrolling with simple analgesia. "distal ITB thickened, fluid"
• 22 Jul 2011 — The veteran re-presented with constant lateral left knee pain at rest, inability to complete patrols and a limp, after four weeks of running 62 km per week, cycling 10 to 11 hours per week and patrolling 8 to 10 hours per week, with a doubling of patrol and cycling hours in the final week during a surge operation. Repeat ultrasound showed the distal iliotibial band thickened to 6.1 mm with a larger fluid collection and surrounding oedema. He was placed on restricted duties for the rest of the deployment. "ITB 6.1 mm, worsening, restricted"
• 15 Nov 2011 — After return to Australia an MRI of the left knee confirmed distal iliotibial band syndrome with oedema of the band and the lateral synovial recess, an intact reconstructed anterior cruciate ligament graft and the femoral cross-pin in the distal lateral femur. A sports physician commenced a structured hip abductor strengthening program and gave a corticosteroid injection deep to the band. Symptoms persisted and contributed to his medical discharge in 2016. "MRI confirms distal ITBS"

Symptoms

At onset the veteran had sharp, localised pain over the lateral aspect of the left knee that came on after a fixed distance of patrolling or running, was worst going downhill and down terraces, and forced him to walk with his knee held straight. After onset the pain came on earlier in each patrol and was accompanied by a clicking sensation over the lateral knee and tightness along the lateral thigh.

Since the worsening in July 2011 he has had lateral knee pain at rest and at night, cannot run more than one kilometre, and has pain on stairs, squatting and prolonged sitting with the knee flexed. He now walks with a mild limp after more than 30 minutes.

Imaging

• 20 Apr 2010 — MRI left knee: "Complete rupture of the anterior cruciate ligament. Grade 3 injury of the posterolateral corner. Tear of the posterior horn of the medial meniscus."
• 10 Feb 2011 — Long-leg standing radiograph: "Left mechanical axis 5 degrees varus, right 1 degree varus. Femoral and tibial tunnels of anterior cruciate ligament reconstruction with cross-pin in the distal lateral femur."
• 20 Apr 2011 — Ultrasound left lateral knee: "Distal iliotibial band thickened to 4.2 mm at the level of the lateral femoral epicondyle with a small fluid collection deep to the band."
• 22 Jul 2011 — Ultrasound left lateral knee: "Distal iliotibial band thickened to 6.1 mm with a larger fluid collection deep to the band and surrounding soft tissue oedema."
• 15 Nov 2011 — MRI left knee: "Oedema of the distal iliotibial band and lateral synovial recess at the lateral femoral epicondyle, consistent with iliotibial band syndrome. Intact anterior cruciate ligament graft."

Onset Date

The most likely date of onset of this condition is 12 Apr 2011.

At that date the veteran was on warlike service in Afghanistan, based at a patrol base and conducting a seven-day clearance operation through terraced farmland carrying about 38 kg. He was also running 65 to 70 km a week and cycling on a stationary bike as part of a conditioning program for a selection course, eight months after a left anterior cruciate ligament reconstruction with a femoral cross-pin.

This date is appropriate because his pre-deployment medical of 10 February 2011 recorded no lateral knee pain or tenderness, and he first presented on 14 April 2011 with pain that began two days earlier on patrol. It falls within his warlike service and within uninterrupted full-time service.

For the running, weight bearing exercise and cycling factors, the four weeks before onset run from 15 Mar 2011 to 12 Apr 2011, which he spent on warlike service in Afghanistan, running 65 to 70 km a week, cycling 11 hours a week and patrolling 9 hours a week. For the increased activity factors, the seven days before onset run from 05 Apr 2011 to 12 Apr 2011, during which his patrolling increased from 2 hours to 4.5 hours a day and his cycling from 1.5 hours to 4 hours a day. For the knee reconstruction factor, the one year before onset runs from 12 Apr 2010 to 12 Apr 2011 and contains the reconstruction of 24 Aug 2010. The left hip abductor weakness (documented from 2007) and the varus thrust and varus malalignment (documented 10 Feb 2011) were present before onset.

For the worsening factors, the documented worsening was on 22 Jul 2011, confirmed by ultrasound showing the band thickened from 4.2 mm to 6.1 mm. The four weeks before the worsening run from 24 Jun 2011 to 22 Jul 2011 and the seven days before it from 15 Jul 2011 to 22 Jul 2011, all on warlike service in Afghanistan. The one year before the worsening runs from 22 Jul 2010 to 22 Jul 2011 and also contains the reconstruction of 24 Aug 2010.

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

The formal diagnosis is Left Knee - Iliotibial Band Syndrome (ICD-10-AM M76.3), under the Statements of Principles concerning iliotibial band syndrome, Balance of Probabilities No. 4 of 2019 and Reasonable Hypothesis No. 3 of 2019.

Iliotibial band syndrome is an overuse condition of the distal iliotibial tract where it passes over the lateral femoral epicondyle. Repeated flexion and extension of the knee, particularly around 20 to 30 degrees of flexion during running, descending slopes and cycling, compresses the highly innervated fat and connective tissue beneath the band against the epicondyle, causing inflammation and pain. It is characterised by pain and tenderness over the lateral aspect of the knee which worsens with activity. Weak hip abductors, varus alignment of the knee and altered mechanics after knee surgery all increase the load on the band.

The condition began on warlike service in Afghanistan on 12 April 2011, was confirmed on ultrasound on 20 April 2011, worsened in July 2011 and was confirmed again on MRI in November 2011.

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

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

12 April 2011.

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

14 April 2011.

When was the condition confirmed / formally diagnosed?

20 April 2011.

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

18 June 2025.

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

The diagnosis was made clinically on 14 April 2011 and confirmed by ultrasound on 20 April 2011. The veteran had activity-related pain over the lateral aspect of the left knee, point tenderness over the lateral femoral epicondyle, a positive Noble compression test reproducing his pain at about 30 degrees of flexion, and a positive Ober test indicating a tight iliotibial band. Ultrasound showed thickening of the distal iliotibial band with fluid deep to it at the epicondyle. This meets the Statement of Principles definition: a condition of the distal portion of the iliotibial tract where it courses over the lateral femoral epicondyle, characterised by lateral knee pain and tenderness that worsens with physical activity.

Proximal iliotibial band syndrome and insertional tendinosis at Gerdy's tubercle were excluded clinically and on imaging. The reconstructed ligament was intact and there was no lateral meniscal tear. Repeat ultrasound on 22 July 2011 and MRI on 15 November 2011 confirmed the diagnosis and the worsening, and a sports physician confirmed it on 15 November 2011.

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 12 April 2011, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's operational service: his non-warlike service in the Solomon Islands in 2010, where the knee injury that led to reconstruction occurred, and his warlike service in Afghanistan in 2011, where the condition began and worsened. The Balance of Probabilities instrument applies to peacetime service, including the reconstruction and rehabilitation in Australia from 2010 to 2011 and his training before deployment.

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.

Balance of Probabilities — Statement of Principles concerning Iliotibial Band Syndrome, No. 4 of 2019

Causative factors

Factor 9(1): running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- The physical training instructor's log records that the veteran ran an average of 65 to 70 km a week, on the base perimeter track and a treadmill, throughout the four weeks before onset, from 15 March 2011 to 12 April 2011. The running followed a mandatory conditioning program set by his unit for soldiers nominated for a selection course and continued the 60 km-plus weekly program he began in peacetime training in Australia in February 2011.

Factor 9(2): undertaking weight bearing exercise involving repeated flexion and extension of the affected knee, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- Throughout the four weeks before onset, from 15 March 2011 to 12 April 2011, the veteran patrolled on foot for about 9 hours a week carrying about 38 kg up and down terraced farmland, which involves continuous repeated flexion and extension of the left knee at an intensity of 6 to 8 METs. These were his ordered duties as a rifleman.

Factor 9(3): increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of iliotibial band syndrome; — MET

- For the seven days before onset, from 05 April 2011 to 12 April 2011, the veteran took part in a clearance operation in which his loaded foot patrolling increased from about 2 hours to 4.5 hours a day, an increase of 125 per cent, at 6 to 8 METs. The increase was ordered as part of the operation and is recorded in the patrol reports.

Factor 9(4): cycling at a minimum intensity of five METs for at least ten hours per week, for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- The conditioning program required daily stationary cycling at a heart rate zone corresponding to 7 to 9 METs, and the instructor's log records an average of 11 hours a week throughout the four weeks before onset, from 15 March 2011 to 12 April 2011. Cycling was prescribed as low-impact endurance training after his knee reconstruction.

Factor 9(5): increasing the frequency, duration or intensity of cycling by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of iliotibial band syndrome; — MET

- For the seven days before onset, from 05 April 2011 to 12 April 2011, the veteran's stationary cycling increased from about 1.5 hours to 4 hours a day, an increase of 167 per cent, at 7 to 9 METs, completed in two sessions while he was on quick reaction force standby at the patrol base between clearance patrols. The increase is recorded in the conditioning log.

Factor 9(6): undergoing knee reconstruction surgery with placement of an implant in the distal lateral femur within the one year before the clinical onset of iliotibial band syndrome; — MET

- On 24 August 2010 the veteran underwent left anterior cruciate ligament reconstruction with femoral fixation by a cross-pin implant placed in the distal lateral femur, confirmed on the radiograph of 10 February 2011. This was within the one year before onset, from 12 April 2010 to 12 April 2011. The surgery was performed and funded by Defence for an injury sustained on service, and the implant lies beneath the distal iliotibial band.

Worsening factors

Factor 9(7): running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- After a brief reduction in May 2011 the veteran was directed to resume the conditioning program, and the log records an average of 62 km a week throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011. Repeat ultrasound on 22 July 2011 showed the band had thickened from 4.2 mm to 6.1 mm.

Factor 9(8): undertaking weight bearing exercise involving repeated flexion and extension of the affected knee, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- Throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011, the veteran patrolled for 8 to 10 hours a week carrying about 38 kg over terraced ground at 6 to 8 METs, as ordered.

Factor 9(9): increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical worsening of iliotibial band syndrome; — MET

- During a surge operation from 15 July 2011 to 22 July 2011, the seven days before the worsening, his loaded patrolling increased from about 1.5 hours to 4 hours a day, an increase of 167 per cent, at 6 to 8 METs.

Factor 9(10): cycling at a minimum intensity of five METs for at least ten hours per week, for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- The conditioning log records 10 to 11 hours a week of stationary cycling at 7 to 9 METs throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011.

Factor 9(11): increasing the frequency, duration or intensity of cycling by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical worsening of iliotibial band syndrome; — MET

- From 15 July 2011 to 22 July 2011 his cycling increased from about 1.5 hours to 4 hours a day at 7 to 9 METs while he was on quick reaction force standby during the surge operation, as recorded in the log.

Factor 9(12): undergoing knee reconstruction surgery with placement of an implant in the distal lateral femur within the one year before the clinical worsening of iliotibial band syndrome; — MET

- The reconstruction with a distal lateral femoral cross-pin was performed on 24 August 2010, within the one year before the worsening, from 22 July 2010 to 22 July 2011.

Factor 9(13): inability to obtain appropriate clinical management for iliotibial band syndrome. — MET

- After diagnosis on 20 April 2011 no physiotherapy, activity modification or specialist review was available at the patrol base, and the veteran was returned to full patrolling and directed to resume the conditioning program with only simple analgesia. The condition worsened over the following three months, with the band thickening from 4.2 mm to 6.1 mm by 22 July 2011. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Iliotibial Band Syndrome, No. 3 of 2019

Causative factors

Factor 9(1): running or jogging an average of at least 30 kilometres per week for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- On warlike service in Afghanistan the veteran ran an average of 65 to 70 km a week throughout the four weeks before onset, from 15 March 2011 to 12 April 2011, under a unit conditioning program, more than twice the required average.

Factor 9(2): undertaking weight bearing exercise involving repeated flexion and extension of the affected knee, at a minimum intensity of five METs for at least four hours per week, for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- Throughout the four weeks before onset, from 15 March 2011 to 12 April 2011, the veteran conducted loaded foot patrols of about 9 hours a week over terraced ground on warlike service in Afghanistan, at 6 to 8 METs with repeated flexion and extension of the left knee.

Factor 9(3): increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, for at least the seven days before the clinical onset of iliotibial band syndrome; — MET

- During a clearance operation on warlike service from 05 April 2011 to 12 April 2011, the seven days before onset, his loaded patrolling increased from about 2 hours to 4.5 hours a day at 6 to 8 METs.

Factor 9(4): cycling at a minimum intensity of five METs for at least five hours per week, for at least the four weeks before the clinical onset of iliotibial band syndrome; — MET

- The veteran cycled on a stationary bike at 7 to 9 METs for an average of 11 hours a week at the patrol base in Afghanistan throughout the four weeks before onset, from 15 March 2011 to 12 April 2011, as part of his directed conditioning program.

Factor 9(5): increasing the frequency, duration or intensity of cycling by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, for at least the seven days before the clinical onset of iliotibial band syndrome; — MET

- From 05 April 2011 to 12 April 2011, on warlike service, his cycling increased from about 1.5 hours to 4 hours a day at 7 to 9 METs while on quick reaction force standby.

Factor 9(6): undergoing knee reconstruction surgery with placement of an implant in the distal lateral femur within the one year before the clinical onset of iliotibial band syndrome; — MET

- The anterior cruciate ligament reconstruction of 24 August 2010, with a cross-pin implant in the distal lateral femur, treated a knee injury sustained in a fall on a night patrol on non-warlike service in the Solomon Islands on 15 April 2010. It was within the one year before onset, from 12 April 2010 to 12 April 2011.

Factor 9(7): having weakness or paralysis of an abductor muscle of the hip before the clinical onset of iliotibial band syndrome; — MET

- Left gluteus medius tendinopathy with weakness of resisted hip abduction was diagnosed on non-warlike service in East Timor on 14 June 2007 after six weeks of loaded patrolling in mountainous terrain. The weakness was compounded by post-operative deconditioning after the Solomon Islands knee injury, and dynamometry on 10 February 2011 showed left hip abduction 32 per cent weaker than the right, before onset on 12 April 2011.

Factor 9(8): having varus malalignment of the knee or varus thrust of the knee before the clinical onset of iliotibial band syndrome; — MET

- The posterolateral corner injury and partial medial meniscectomy that followed the fall on non-warlike service in the Solomon Islands left a dynamic varus thrust of the left knee in stance, recorded on gait assessment on 10 February 2011, and a left mechanical axis of 5 degrees varus on the long-leg radiograph of the same date, before onset on 12 April 2011.

Worsening factors

Factor 9(9): running or jogging an average of at least 30 kilometres per week for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- On warlike service in Afghanistan the veteran ran an average of 62 km a week throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011.

Factor 9(10): undertaking weight bearing exercise involving repeated flexion and extension of the affected knee, at a minimum intensity of five METs for at least four hours per week, for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- He patrolled for 8 to 10 hours a week with about 38 kg over terraced ground on warlike service throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011.

Factor 9(11): increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, for at least the seven days before the clinical worsening of iliotibial band syndrome; — MET

- During a surge operation on warlike service from 15 July 2011 to 22 July 2011, his loaded patrolling increased from about 1.5 hours to 4 hours a day at 6 to 8 METs.

Factor 9(12): cycling at a minimum intensity of five METs for at least five hours per week, for at least the four weeks before the clinical worsening of iliotibial band syndrome; — MET

- He cycled 10 to 11 hours a week at 7 to 9 METs at the patrol base in Afghanistan throughout the four weeks before the worsening, from 24 June 2011 to 22 July 2011.

Factor 9(13): increasing the frequency, duration or intensity of cycling by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, for at least the seven days before the clinical worsening of iliotibial band syndrome; — MET

- From 15 July 2011 to 22 July 2011, on warlike service, his cycling increased from about 1.5 hours to 4 hours a day at 7 to 9 METs.

Factor 9(14): undergoing knee reconstruction surgery with placement of an implant in the distal lateral femur within the one year before the clinical worsening of iliotibial band syndrome; — MET

- The reconstruction of 24 August 2010 for the injury sustained on non-warlike service in the Solomon Islands was within the one year before the worsening, from 22 July 2010 to 22 July 2011.

Factor 9(15): having weakness or paralysis of an abductor muscle of the hip before the clinical worsening of iliotibial band syndrome; — MET

- Left hip abductor weakness from the gluteus medius tendinopathy that arose in East Timor persisted, and repeat dynamometry on 22 July 2011 showed a 35 per cent deficit, before the documented worsening.

Factor 9(16): having varus malalignment of the knee or varus thrust of the knee before the clinical worsening of iliotibial band syndrome; — MET

- The left varus thrust and 5 degree varus mechanical axis that followed the Solomon Islands injury persisted and were recorded again on 22 July 2011, before the worsening.

Factor 9(17): inability to obtain appropriate clinical management for iliotibial band syndrome. — MET

- On warlike service in Afghanistan from April to July 2011 no physiotherapy, load modification or specialist review was available at the patrol base and the veteran was returned to full patrolling and conditioning with analgesia only. The condition worsened, with the band thickening from 4.2 mm to 6.1 mm by 22 July 2011.

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

Sequelae

The left iliotibial band syndrome is a sequela of the veteran's accepted left knee anterior cruciate ligament and posterolateral corner injury, through the reconstruction implant in the distal lateral femur, the resulting varus thrust, and the left hip abductor weakness that followed his gluteus medius tendinopathy and post-operative deconditioning.

Unintended Consequence

Met. The cross-pin implant in the distal lateral femur, placed during the Defence-funded anterior cruciate ligament reconstruction of 24 August 2010, created a prominence beneath the distal iliotibial band and is an unintended consequence of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA). The conditioning program, including high-volume cycling prescribed as part of his post-operative rehabilitation, also loaded the band.

Inability to Attain Appropriate Medical Management

MET. After the diagnosis on 20 April 2011 the veteran remained at a patrol base on warlike service with no physiotherapy, no structured rehabilitation and no option to reduce his patrol or conditioning load. He was returned to full duties with simple analgesia and the condition worsened, with the band thickening from 4.2 mm to 6.1 mm and pain at rest by 22 July 2011. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent recognised treatment amount to an inability to obtain appropriate clinical management. The delay of almost seven months between diagnosis and specialist sports medicine treatment in November 2011 is further evidence of barriers to care.

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

See attached report.

References

1. 14 Jun 2007, Outpatient health record and ultrasound report, Medical Officer, East Timor
2. 15 Apr 2010, Field medical record and aeromedical evacuation summary, Medical Officer, Solomon Islands
3. 20 Apr 2010, MRI left knee, Radiologist
4. 24 Aug 2010, Operation report, Orthopaedic surgeon
5. 10 Feb 2011, Pre-deployment medical and physiotherapy assessment, Medical Officer and Physiotherapist
6. 10 Feb 2011, Long-leg standing radiograph, Radiologist
7. 15 Mar 2011 to 22 Jul 2011, Physical conditioning log, Physical training instructor
8. 14 Apr 2011, Outpatient health record, Regimental Medical Officer, Afghanistan
9. 20 Apr 2011, Ultrasound left knee, Role 2 medical facility
10. 22 Jul 2011, Outpatient health record and repeat ultrasound, Regimental Medical Officer, Afghanistan
11. 15 Nov 2011, MRI left knee and sports medicine consultation, Sports physician
12. Statement of Principles concerning Iliotibial Band Syndrome (Balance of Probabilities) No. 4 of 2019, Repatriation Medical Authority
13. Statement of Principles concerning Iliotibial Band Syndrome (Reasonable Hypothesis) No. 3 of 2019, Repatriation Medical Authority