Left Knee - Internal Derangement — ICD-10 M23.2

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Left Knee - Internal Derangement

Example 1 of 1 · fictitious patient (Veteran BC)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Left Knee - Internal Derangement

BOP Code: 8 of 2019 (Internal Derangement of the Knee)
RH Code: 7 of 2019 (Internal Derangement of the Knee)

ADF History

Veteran BC, date of birth 11 November 1983, Royal Australian Navy, Boatswain's Mate, enlisted 03 July 2002, medically discharged 19 January 2017. Operational service: Middle East Area of Operations (Persian Gulf, maritime security operations), 15 February 2008 to 20 August 2008 (warlike); Middle East Area of Operations (Arabian Sea, maritime security operations), 10 January 2013 to 25 July 2013 (warlike).

Occupational History

A boatswain's mate is responsible for seamanship on board a warship: mooring and anchoring, replenishment at sea, small boat operations, and the handling of heavy lines, wires and stores on a moving deck. On operational deployments boatswain's mates crew the rigid-hulled inflatable boats and form part of boarding parties that board dhows and merchant vessels at sea.

Boarding requires jumping from a pitching boat onto a vessel, climbing rope and pilot ladders in full body armour and equipment weighing 20 to 30 kilograms, and moving over cluttered, wet and uneven decks. Twisting and pivoting injuries of the knee, falls on ladders and in passageways, and repeated kneeling and squatting are common in the trade, and access to specialist care at sea is limited.

History

Veteran BC, a boatswain's mate in the Royal Australian Navy, sprained the ligaments and tore the medial meniscus of his left knee while boarding a dhow on warlike service in the Persian Gulf on 14 May 2008, and developed internal derangement of the left knee on 02 September 2008. The condition worsened in April 2013, when a second boarding injury on warlike service ruptured his anterior cruciate ligament and tore the lateral meniscus.

Timeline

14 May 2008 — During a boarding operation on warlike service in the Persian Gulf, the veteran jumped from a rigid-hulled inflatable boat onto the deck of a dhow in a heavy swell, landed on his left leg and twisted on the planted foot as the dhow rolled. He felt a pop and medial knee pain and could not continue. The ship's medical officer recorded a moderate effusion, medial joint line tenderness and laxity on valgus stress with a firm end point. He was diagnosed with a grade 2 medial collateral ligament sprain and a suspected meniscal injury, and was restricted from boarding duties for six weeks. "MCL sprain, joint line tender"
10 Jul 2008 — At discharge from shipboard physiotherapy the knee had a full range of movement, no effusion, stable ligaments on testing and no locking or giving way. He was returned to full duties, including boarding party duties, for the remainder of the deployment. "full range, ligaments stable"
05 Sep 2008 — After returning to Australia he presented to the base health centre with episodes of the left knee giving way on stairs and ladders and catching and locking, which began on 02 September 2008, with recurrent swelling after duties. Examination showed a small effusion, medial joint line tenderness, a positive McMurray test, a positive Lachman test with a soft end point and mild valgus laxity. He was referred for MRI and orthopaedic review. "giving way, locking, McMurray positive"
25 Sep 2008 — MRI showed a vertical longitudinal tear of the posterior horn of the medial meniscus, a partial tear of the anterior cruciate ligament and a thickened healing medial collateral ligament, with a joint effusion. An orthopaedic surgeon confirmed internal derangement of the left knee from the boarding injury and recommended arthroscopy. Surgery could not be scheduled until February 2009 because his ship's sea program required him on board. "medial meniscal tear, ACL partial"
12 Feb 2009 — Arthroscopy confirmed an unstable tear of the posterior horn of the medial meniscus and a partial anterior cruciate ligament tear with about 40 per cent of fibres intact. A partial medial meniscectomy was performed and the ligament managed conservatively with a hamstring strengthening program and a functional brace. He returned to sea duties in June 2009 with intermittent instability. "partial medial meniscectomy, ACL lax"
10 Apr 2013 — On warlike service in the Arabian Sea he presented to the ship's medical officer one week after his left knee gave way while climbing a pilot ladder onto a merchant vessel on 03 April 2013. He had twisted and fallen onto the deck with a large immediate effusion. The knee now locked at 20 degrees short of full extension and gave way with turning. The Lachman test was grossly positive. MRI and orthopaedic review were not available on deployment and he continued limited duties in a brace. "locked knee, Lachman grossly positive"
30 Jul 2013 — After the deployment MRI showed a complete rupture of the anterior cruciate ligament, a displaced bucket-handle tear of the lateral meniscus, the previous partial medial meniscectomy and bone bruising of the lateral femoral condyle and posterolateral tibial plateau. The orthopaedic surgeon recorded a Lysholm knee score of 41, down from 78 in 2010. "complete ACL rupture, bucket-handle tear"
15 Oct 2013 — He underwent anterior cruciate ligament reconstruction with a hamstring autograft and repair of the lateral meniscus. Rehabilitation was prolonged by recurrent effusions. He was unable to return to boarding or sea duties. "ACL reconstruction, lateral meniscal repair"
22 Jun 2016 — At orthopaedic review he reported ongoing pain, swelling after walking more than 2 kilometres, giving way on uneven ground and difficulty kneeling and squatting. Examination showed a small effusion, quadriceps wasting of 2 cm and a mildly positive pivot shift. The surgeon recorded permanent internal derangement of the left knee and he was referred to a medical employment classification review, which led to his discharge. "persisting instability, quadriceps wasting"

Symptoms

At onset the veteran had episodes of the left knee giving way on stairs, ladders and moving decks, catching and locking, medial knee pain and recurrent swelling after duties. Symptoms were worse with pivoting, kneeling and squatting.

Since the 2013 worsening he has had ongoing pain and swelling after activity, giving way on uneven ground, an inability to run, jump or kneel, and difficulty with stairs and prolonged standing. He uses a brace for long walks and has not returned to sport.

Imaging

25 Sep 2008 — MRI left knee: "Vertical longitudinal tear of the posterior horn of the medial meniscus. Partial tear of the anterior cruciate ligament. Thickened, healing medial collateral ligament consistent with a recent grade 2 sprain. Moderate joint effusion."
30 Jul 2013 — MRI left knee: "Complete rupture of the anterior cruciate ligament. Displaced bucket-handle tear of the lateral meniscus. Post-surgical changes of partial medial meniscectomy. Bone bruising of the lateral femoral condyle and posterolateral tibial plateau."
22 Jun 2016 — X-ray left knee: "Satisfactory position of tunnels and fixation of the anterior cruciate ligament graft. Mild medial joint space narrowing."

Onset Date

The most likely date of onset of this condition is 02 Sep 2008.

At that date the veteran was serving full time on a frigate based in Western Australia, having returned on 20 August 2008 from warlike service in the Persian Gulf. He was on normal seagoing duties, including ladder work and line handling.

This date is appropriate because his physiotherapy discharge on 10 Jul 2008 recorded a full range of movement, no effusion and stable ligaments with no locking or giving way, and he first presented with recurrent giving way and locking on 05 Sep 2008, reporting that it began three days earlier. The acute injury of 14 May 2008 had then progressed to a chronic disorder due to the torn meniscus and the stretched and torn ligaments, which is the condition defined in the Statement of Principles. It falls within continuous full-time service.

For the sprain and acute meniscal tear factors, the one year before onset runs from 02 Sep 2007 to 02 Sep 2008. The boarding injury of 14 May 2008, which caused a grade 2 medial collateral ligament sprain, a partial anterior cruciate ligament tear and an acute tear of the medial meniscus, falls within that year, 111 days before onset.

For the worsening factors, the condition began on 02 Sep 2008 and worsened as documented on 10 Apr 2013, with the Lysholm score falling from 78 to 41. The one year before the worsening runs from 10 Apr 2012 to 10 Apr 2013 and includes the second boarding injury of 03 Apr 2013, which caused a complete anterior cruciate ligament rupture and an acute bucket-handle tear of the lateral meniscus on warlike service in the Arabian Sea.

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

The formal diagnosis is Internal Derangement of the Left Knee (ICD-10 M23.2), due to a torn medial meniscus and torn and stretched anterior cruciate and medial collateral ligaments, worsened by a complete anterior cruciate ligament rupture and a lateral meniscal tear, under the Statements of Principles concerning internal derangement of the knee, Balance of Probabilities No. 8 of 2019 and Reasonable Hypothesis No. 7 of 2019.

Internal derangement of the knee is a chronic disorder of the knee caused by a torn meniscus or a torn or stretched collateral, cruciate or capsular ligament. It is characterised by ongoing or recurrent pain, swelling, instability, locking and altered mobility. It usually follows a twisting or pivoting injury in which the foot is planted and the body rotates over the knee, often combining a ligament sprain with a meniscal tear. A knee with a deficient ligament or meniscus is prone to further injury, and repeated episodes of giving way extend the damage to other structures and accelerate degenerative change.

The condition followed a boarding injury on warlike service in the Persian Gulf on 14 May 2008. It began on 02 September 2008, was confirmed on MRI on 25 September 2008 and at arthroscopy on 12 February 2009, and worsened after a second boarding injury on warlike service in April 2013.

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

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

02 September 2008.

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

05 September 2008.

When was the condition confirmed / formally diagnosed?

25 September 2008.

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

29 May 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 05 September 2008 from recurrent giving way, catching and locking with an effusion, medial joint line tenderness, a positive McMurray test and a positive Lachman test, and confirmed by MRI on 25 September 2008, which showed a vertical longitudinal tear of the posterior horn of the medial meniscus, a partial anterior cruciate ligament tear and a healing medial collateral ligament sprain. An orthopaedic surgeon confirmed internal derangement of the left knee, and arthroscopy on 12 February 2009 confirmed an unstable medial meniscal tear and partial anterior cruciate ligament tear. The tear was traumatic, with vertical longitudinal morphology in a 24-year-old, and not degenerative.

This meets the Statement of Principles definition: a chronic disorder of the knee due to a torn meniscus and torn or stretched cruciate and collateral ligaments, without patellar disorder, discoid meniscus, osteochondritis dissecans, meniscal cyst, degenerative tear or osteoarthritis as the cause. MRI on 30 July 2013 confirmed the worsening, with complete anterior cruciate ligament rupture and a displaced bucket-handle tear of the lateral meniscus.

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 02 September 2008, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Persian Gulf in 2008, where the causative injury occurred, and in the Arabian Sea in 2013, where the worsening injury occurred.

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 Internal Derangement of the Knee, No. 8 of 2019

Causative factors

Factor 9(1): having a sprain involving a ligament of the affected knee within the one year before the clinical onset of internal derangement of the knee; — MET

- On 14 May 2008, while performing boarding duties as a boatswain's mate, the veteran twisted his left knee on landing on the deck of a dhow. The ship's medical officer recorded valgus laxity with a firm end point and diagnosed a grade 2 sprain of the medial collateral ligament, and MRI on 25 September 2008 confirmed the healing sprain together with a partial tear of the anterior cruciate ligament. The injury occurred 111 days before onset, within the one year before onset, from 02 September 2007 to 02 September 2008.

Factor 9(2): having an acute meniscal tear of the affected knee within the one year before the clinical onset of internal derangement of the knee; — MET

- The same twisting injury on 14 May 2008 tore the medial meniscus, with medial joint line tenderness and effusion recorded at the time. MRI on 25 September 2008 showed a vertical longitudinal tear of the posterior horn of the medial meniscus, a traumatic pattern, and arthroscopy on 12 February 2009 confirmed an unstable tear without degenerative change. The tear occurred within the one year before onset on 02 September 2008.

Worsening factors

Factor 9(3): having a sprain involving a ligament of the affected knee within the one year before the clinical worsening of internal derangement of the knee; — MET

- On 03 April 2013, while climbing a pilot ladder onto a merchant vessel during boarding duties, the veteran's left knee gave way and he twisted and fell onto the deck. MRI on 30 July 2013 showed a complete rupture of the anterior cruciate ligament, a grade 3 sprain. This occurred within the one year before the documented worsening on 10 April 2013, from 10 April 2012 to 10 April 2013, and the Lysholm score fell from 78 to 41.

Factor 9(4): having an acute meniscal tear of the affected knee within the one year before the clinical worsening of internal derangement of the knee; — MET

- The injury of 03 April 2013 also caused a displaced bucket-handle tear of the lateral meniscus, which produced the locked knee recorded on 10 April 2013 and was confirmed on MRI on 30 July 2013 and repaired on 15 October 2013. The acute tear occurred one week before the worsening, within the one year before it.

Factor 9(5): inability to obtain appropriate clinical management for internal derangement of the knee. — MET

- After the 2008 diagnosis arthroscopy was delayed for five months, until 12 February 2009, because the ship's sea program required him on board, and he continued ladder and deck work with an unstable meniscal tear. After the April 2013 injury no MRI or orthopaedic care was available at sea for almost four months, and he continued limited duties on a locked, unstable knee until July 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Internal Derangement of the Knee, No. 7 of 2019

Causative factors

Factor 9(1): having a sprain involving a ligament of the affected knee within the one year before the clinical onset of internal derangement of the knee; — MET

- The grade 2 medial collateral ligament sprain and partial anterior cruciate ligament tear were sustained on 14 May 2008 while the veteran was boarding a dhow on warlike service in the Persian Gulf, as part of a maritime security boarding party. The injury was recorded by the ship's medical officer on the day and occurred within the one year before onset on 02 September 2008.

Factor 9(2): having an acute meniscal tear of the affected knee within the one year before the clinical onset of internal derangement of the knee; — MET

- The acute tear of the posterior horn of the medial meniscus was sustained in the same boarding injury on warlike service in the Persian Gulf on 14 May 2008, and confirmed on MRI and at arthroscopy. It occurred within the one year before onset, from 02 September 2007 to 02 September 2008.

Worsening factors

Factor 9(3): having a sprain involving a ligament of the affected knee within the one year before the clinical worsening of internal derangement of the knee; — MET

- The complete anterior cruciate ligament rupture was sustained on 03 April 2013 while the veteran climbed a pilot ladder in body armour and boarding equipment during maritime security operations on warlike service in the Arabian Sea. It occurred within the one year before the worsening documented on 10 April 2013.

Factor 9(4): having an acute meniscal tear of the affected knee within the one year before the clinical worsening of internal derangement of the knee; — MET

- The displaced bucket-handle tear of the lateral meniscus was sustained in the same fall on warlike service in the Arabian Sea on 03 April 2013, causing the locking recorded by the ship's medical officer on 10 April 2013, within the one year before the worsening.

Factor 9(5): inability to obtain appropriate clinical management for internal derangement of the knee. — MET

- On warlike service in the Arabian Sea from April to July 2013 there was no access to MRI, an orthopaedic surgeon or arthroscopy, and the veteran remained on board with a locked, unstable knee for almost four months. The displaced meniscal tear and ligament deficiency went untreated during that time and the knee worsened.

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

Sequelae

The internal derangement of the left knee is a sequela of the boarding injury of 14 May 2008 on warlike service. The resulting ligament deficiency and partial meniscectomy predisposed the knee to the second injury on 03 April 2013, which is itself a consequence of the accepted instability. The veteran is now at increased risk of post-traumatic osteoarthritis of the left knee, and early medial joint space narrowing was already present in 2016. His altered gait has also caused right knee and low back pain.

Unintended Consequence

Met. The partial medial meniscectomy of 12 February 2009, performed as Defence-funded treatment of the service injury, removed part of the shock-absorbing meniscus and contributed to the persisting symptoms and the early medial joint space narrowing. The decision to manage the partial anterior cruciate ligament tear conservatively and return him to sea duties left the knee vulnerable to the 2013 rupture (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. After diagnosis in September 2008, arthroscopy was delayed for five months because the ship's sea program required the veteran on board, and he continued ladder and deck work with an unstable meniscal tear. After the April 2013 boarding injury on warlike service no MRI, orthopaedic assessment or surgery was available for almost four months, and he continued limited duties on a locked, unstable knee. The displaced bucket-handle tear and complete anterior cruciate ligament rupture were not confirmed until 30 July 2013 or treated until 15 October 2013. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely investigation and surgery amount to an inability to obtain appropriate clinical management, and the delay contributed to the worsening of the condition.

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

See attached report.

References

14 May 2008, Ship's medical record, Medical Officer, Persian Gulf
10 Jul 2008, Physiotherapy discharge summary, Physiotherapist
05 Sep 2008, Outpatient health record, Medical Officer, Base health centre
25 Sep 2008, MRI left knee, Radiologist
25 Sep 2008, Orthopaedic consultation, Orthopaedic surgeon
12 Feb 2009, Arthroscopy operation report, Orthopaedic surgeon
10 Apr 2013, Ship's medical record, Medical Officer, Arabian Sea
30 Jul 2013, MRI left knee and orthopaedic consultation, Orthopaedic surgeon
15 Oct 2013, Operation report, anterior cruciate ligament reconstruction, Orthopaedic surgeon
22 Jun 2016, X-ray left knee and orthopaedic review, Orthopaedic surgeon
Statement of Principles concerning Internal Derangement of the Knee (Balance of Probabilities) No. 8 of 2019, Repatriation Medical Authority
Statement of Principles concerning Internal Derangement of the Knee (Reasonable Hypothesis) No. 7 of 2019, Repatriation Medical Authority

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Left Knee - Internal Derangement — DVA claim example