Left Knee - Joint Instability — DVA claim example

Diagnostic Assessment — Left Knee - Joint Instability

Example 1 of 1 · fictitious patient (Veteran BE)

Diagnostic Assessment

Left Knee - Joint Instability

BOP Code: 58 of 2019 (Joint Instability)
RH Code: 57 of 2019 (Joint Instability)

ADF History

Veteran BE, date of birth 22 September 1984, Australian Army, Medical Assistant (Combat Medic), enlisted 12 July 2004, medically discharged 30 November 2018. Operational service: Afghanistan, 15 February 2008 to 14 July 2008 (warlike), aeromedically evacuated after injury.

Occupational History

As a combat medic the veteran carried a medical pack and personal equipment totalling 30 to 40 kilograms on foot patrols, dismounted repeatedly from armoured vehicles, knelt and crouched for long periods while treating casualties, and lifted and carried casualties on stretchers over rough ground. In garrison she worked in health centres and on field exercises, conducted physical training and took part in casualty evacuation drills.

Medics share the injury risks of the troops they support, including falls, jumps from vehicles, blast and twisting injuries to the knees and hips, and cumulative loading of the lower back from pack carriage. Operational injuries were commonly managed in the field so that the soldier could remain in theatre, and specialist review and surgery were often delayed by postings, waiting lists and operational tempo.

History

Veteran BE, a combat medic in the Australian Army, sprained her left knee in training in 2006 and dislocated the left patella with an osteochondral fracture and ligament damage when she jumped from a vehicle under fire in Afghanistan on 12 July 2008. Recurrent instability of the left knee began on 01 November 2011, five weeks after childbirth and while severely obese, and it worsened after a fall at work on 02 March 2015, four weeks after a second delivery.

Timeline

• 14 Mar 2006 — During a field exercise in Australia the veteran twisted her left knee when her foot caught in a vehicle rut while carrying a stretcher. The medical officer found medial joint line tenderness, laxity on valgus stress with a firm end point and an effusion, and diagnosed a grade 2 medial collateral ligament sprain. She was placed in a hinged brace and on light duties for six weeks. "grade 2 MCL sprain, brace"
• 12 Jul 2008 — On warlike service in Afghanistan her patrol came under fire and she jumped from the rear of an armoured vehicle carrying a 32 kg medical pack. She landed on her left leg with the knee twisting into valgus and fell on to her right side. The left patella dislocated laterally and was reduced in the field, and she could not bear weight on the right leg. At the role 3 hospital radiographs showed an osteochondral fragment from the lateral femoral condyle and a right subcapital femoral neck fracture, which was fixed with screws. She was aeromedically evacuated on 14 July 2008. "patellar dislocation, osteochondral fragment"
• 02 Sep 2008 — MRI of the left knee showed rupture of the medial patellofemoral ligament, a partial tear of the anterior cruciate ligament, a tear of the posterior horn of the medial meniscus and a 12 mm osteochondral defect of the lateral femoral condyle. An orthopaedic surgeon recommended reconstruction, but she was placed on a waiting list and managed with bracing and physiotherapy. She was commenced on olanzapine for posttraumatic stress disorder in 2009. "MPFL rupture, partial ACL tear"
• 28 Sep 2011 — The veteran delivered her first child at term. Her weight at the postnatal check was 112 kg at a height of 1.65 m, a BMI of 41.1, up from 66 kg in 2008, after olanzapine treatment, the inactivity imposed by her knee and hip injuries, and pregnancy. She had a right total hip replacement on 18 August 2010 for avascular necrosis after the 2008 femoral neck fracture. "term delivery, BMI 41.1"
• 01 Nov 2011 — At a Defence-arranged physiotherapy session for her left knee, the knee gave way during a loaded step-down exercise and the patella subluxed laterally, with immediate pain and swelling. Over the following five weeks she had three further episodes of the knee giving way and two patellar subluxations during ordinary walking and on stairs. "knee gave way, patella subluxed"
• 06 Dec 2011 — An orthopaedic surgeon diagnosed chronic instability of the left knee, with a positive Lachman test, a pivot shift, a positive patellar apprehension test and recurrent subluxation. MRI showed progression to a complete anterior cruciate ligament tear, medial patellofemoral ligament deficiency and grade 3 chondral loss of the lateral femoral condyle with early osteoarthritis. BMI 41.3. Reconstruction was again recommended. "chronic instability, complete ACL tear"
• 19 Jun 2013 — After a further 18 months on the waiting list, during which she was posted interstate and the referral lapsed, the veteran underwent anterior cruciate ligament reconstruction with a hamstring graft and medial patellofemoral ligament reconstruction. At anaesthetic induction for an earlier arthroscopy on 14 March 2012 her jaw had dislocated during laryngoscopy, and she has had recurrent temporomandibular joint subluxation since. "ACL and MPFL reconstruction"
• 02 Mar 2015 — Four weeks after delivering her second child on 03 February 2015, the veteran slipped on a wet stairwell at her unit lines and fell, twisting the left knee. MRI on 10 March 2015 showed rupture of the anterior cruciate ligament graft, a bucket-handle tear of the lateral meniscus and grade 4 chondral loss of the lateral compartment. The giving-way episodes increased from monthly to several times a week and her Lysholm score fell from 74 to 38. BMI 42.0. "graft rupture, Lysholm 38"
• 15 Oct 2018 — The veteran had a left total knee replacement on 11 July 2017 for end-stage post-traumatic osteoarthritis. Flexion instability of the prosthetic knee with recurrent giving way began on 20 February 2018 and worsened, and on 15 October 2018 she underwent revision to a thicker constrained polyethylene insert. BMI 43.1. She was medically discharged on 30 November 2018. "prosthetic instability, insert revision"

Symptoms

At onset the veteran had episodes of the left knee giving way during ordinary walking, on stairs and when turning, with the kneecap slipping out of place, followed each time by pain, swelling and several days of reduced weight bearing. She lost confidence in the knee, could not run, kneel or carry loads, and needed a brace for all duties.

After the 2015 worsening the knee gave way several times a week, with locking from the meniscal tear, constant pain and swelling, and two falls. She now has a replaced left knee that remains unstable in flexion, uses a stick outdoors, cannot kneel, squat, run or climb ladders, and has difficulty with stairs and uneven ground.

Imaging

• 13 Jul 2008 — X-ray left knee and pelvis: "Reduced left patella with an osteochondral fragment from the lateral femoral condyle. Right subcapital femoral neck fracture."
• 02 Sep 2008 — MRI left knee: "Rupture of the medial patellofemoral ligament, partial tear of the anterior cruciate ligament, tear of the posterior horn of the medial meniscus, 12 mm osteochondral defect of the lateral femoral condyle."
• 12 Apr 2010 — MRI lumbar spine: "L4/5 disc prolapse with left paracentral extrusion. Early L4/5 and L5/S1 spondylosis."
• 06 Dec 2011 — MRI left knee: "Complete anterior cruciate ligament tear, deficient medial patellofemoral ligament, grade 3 chondral loss of the lateral femoral condyle, early osteoarthritis."
• 10 Mar 2015 — MRI left knee: "Ruptured anterior cruciate ligament graft, bucket-handle tear of the lateral meniscus, grade 4 chondral loss of the lateral compartment."
• 04 May 2017 — X-ray left knee: "Severe lateral compartment and patellofemoral osteoarthritis, Kellgren-Lawrence grade 4."

Onset Date

The most likely date of onset of this condition is 01 Nov 2011.

At that date the veteran was serving full time with a health company in Australia, on maternity leave from duty but attending Defence-arranged physiotherapy for the left knee injured in Afghanistan. During a loaded step-down exercise the knee gave way and the patella subluxed, and recurrent giving way and subluxation followed over the next five weeks.

This date is appropriate because joint instability is defined by recurrent subluxation, dislocation or sprain, and the first of the recurrent episodes occurred on 01 November 2011. Her physiotherapy review of 18 October 2011 recorded a stable knee in a brace with no episodes of giving way since 2008, and she presented to the physiotherapist on 01 November 2011 and to the orthopaedic surgeon on 06 December 2011 with recurrent episodes. It falls within full-time service.

For the pregnancy factor, the six weeks before onset run from 20 Sep 2011 to 01 Nov 2011; she was pregnant until she delivered on 28 Sep 2011. The sprain of 14 March 2006, the dislocation, osteochondral fracture and ligament damage of 12 July 2008 and the meniscal tear on MRI of 02 September 2008 all occurred before onset. Post-traumatic osteoarthritis and morbid obesity, with a BMI of 41.1 on 28 September 2011 and 41.3 on 06 December 2011, were present on 01 November 2011.

For the worsening factors, the documented worsening is the fall of 02 Mar 2015, confirmed by MRI on 10 March 2015 and a fall in the Lysholm score from 74 to 38. The six weeks before the worsening run from 19 Jan 2015 to 02 Mar 2015; she was pregnant until she delivered on 03 February 2015. The graft rupture and meniscal tear, the osteochondral defect, the osteoarthritis and a BMI of 42.0 were present at the worsening. The coexisting instabilities of the right total hip prosthesis, the right elbow, the temporomandibular joint and, from 2018, the left total knee prosthesis are dated in the factors below.

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

The formal diagnosis is chronic instability of the left knee (ICD-10 M23.5), involving the tibiofemoral and patellofemoral joints, under the Statements of Principles concerning joint instability, Balance of Probabilities No. 58 of 2019 and Reasonable Hypothesis No. 57 of 2019.

Joint instability is an acquired lack of stability of a joint due to damage to, or abnormality of, its stabilising structures, manifesting as recurrent subluxation, recurrent dislocation or recurrent sprain. In the knee, stability depends on the cruciate and collateral ligaments, the menisci, the medial patellofemoral ligament, the joint capsule and the shape of the articular surfaces, supported by the quadriceps and hamstrings. Once these structures are damaged the knee gives way with pivoting and loading, and each episode causes further damage to the cartilage and menisci, leading to early osteoarthritis.

In this veteran the instability followed a sprain in training in 2006 and a patellar dislocation with an osteochondral fracture and ligament damage on warlike service in 2008. It began on 01 November 2011, was confirmed by an orthopaedic surgeon on 06 December 2011, and worsened after a fall on 02 March 2015.

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

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

01 November 2011.

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

01 November 2011.

When was the condition confirmed / formally diagnosed?

06 December 2011.

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

07 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 by an orthopaedic surgeon on 06 December 2011 on a history of repeated episodes of the knee giving way and patellar subluxation since 01 November 2011, with a positive Lachman test, a positive pivot shift and a positive patellar apprehension test. MRI on the same day showed a complete anterior cruciate ligament tear, a deficient medial patellofemoral ligament and chondral loss of the lateral femoral condyle. This meets the Statement of Principles definition of joint instability: an acquired lack of stability due to damage to the stabilising structures, manifesting as recurrent subluxation and recurrent sprain.

The worsening was confirmed by MRI on 10 March 2015, which showed rupture of the reconstructed ligament and a new bucket-handle meniscal tear, with an increase in giving-way episodes from monthly to several times a week and a fall in the Lysholm knee score from 74 to 38. Instability of the left total knee prosthesis, which the definition includes, was confirmed clinically and at revision surgery in 2018.

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 01 November 2011, 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, including the 2006 sprain, the onset in 2011 and the worsening in 2015. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2008, where the patellar dislocation, osteochondral fracture, ligament and meniscal damage, hip fracture and lumbar injury were sustained.

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 Joint Instability, No. 58 of 2019

Causative factors

Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of joint instability; — MET

- On 01 November 2011, at a Defence-arranged physiotherapy session for her service knee injury, the veteran's left knee gave way under load during a step-down exercise with a 10 kg weight, and the patella subluxed with immediate pain and an effusion. This loading trauma to the knee occurred at the moment the recurrent instability began.

Factor 9(2): having a dislocation or subluxation of the affected joint before the clinical onset of joint instability; — MET

- The left patella dislocated laterally on 12 July 2008 when the veteran jumped from an armoured vehicle under fire, and was reduced in the field. The dislocation was confirmed on radiographs at the role 3 hospital on 13 July 2008, more than three years before onset on 01 November 2011.

Factor 9(3): having a sprain of the affected joint before the clinical onset of joint instability; — MET

- On 14 March 2006, during a field exercise in Australia, the veteran sustained a grade 2 sprain of the medial collateral ligament of the left knee while carrying a stretcher, with laxity on valgus stress and an effusion. She wore a hinged brace for six weeks. The sprain occurred during peacetime service, five years before onset.

Factor 9(4): having damage to a soft tissue structure as specified before the clinical onset of joint instability; — MET

- MRI on 02 September 2008 showed rupture of the medial patellofemoral ligament, a partial tear of the anterior cruciate ligament and a tear of the posterior horn of the medial meniscus of the left knee. Each is a ligament or fibrocartilaginous structure that contributes to stability of the knee. The damage was present before onset on 01 November 2011.

Factor 9(5): having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical onset of joint instability; — MET

- The patellar dislocation of 12 July 2008 sheared an osteochondral fragment from the articular surface of the lateral femoral condyle, shown on radiographs on 13 July 2008 and as a 12 mm osteochondral defect on MRI on 02 September 2008. The fracture involved the articulating surface of the knee and was present before onset.

Factor 9(6): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of joint instability; — MET

- Post-traumatic osteoarthritis of the lateral compartment of the left knee, a degenerative condition of the affected joint, developed from the 2008 osteochondral fracture. Grade 3 chondral loss with early osteoarthritis was shown on MRI on 06 December 2011 and was present at onset on 01 November 2011, altering the congruity and load sharing of the articular surfaces.

Factor 9(7): for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of joint instability; — MET

- The veteran also has instability of the temporomandibular joint. Its clinical onset was on 14 March 2012, when her jaw dislocated during direct laryngoscopy at anaesthetic induction for arthroscopy of her left knee at a Defence-funded hospital. Recurrent jaw subluxation has followed since. The wide mouth opening was imposed by the medical procedure at the moment of onset.

Factor 9(8): for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of joint instability; — MET

- The veteran also has instability of her right total hip prosthesis, inserted on 18 August 2010 for avascular necrosis after the femoral neck fracture of 12 July 2008. The prosthesis first dislocated on 05 January 2011 and dislocated twice more in 2011. MRI on 12 April 2010 had shown an L4/5 disc prolapse with lumbar spondylosis from years of pack carriage, and both were present at the onset of the prosthetic instability on 05 January 2011.

Factor 9(9): for total hip joint prosthesis joint instability only, being obese at the time of the clinical onset of joint instability; — MET

- At the first dislocation of the right total hip prosthesis on 05 January 2011 the veteran weighed 98 kg at a height of 1.65 m, a BMI of 36.0. Her obesity followed olanzapine treatment for service-related posttraumatic stress disorder and inactivity from her service injuries.

Factor 9(10): for tibiofemoral joint instability only, having morbid obesity at the time of the clinical onset of joint instability; — MET

- The left knee instability involves the tibiofemoral joint, with anterior cruciate ligament deficiency and a positive pivot shift. The veteran's BMI was 41.1 on 28 September 2011 and 41.3 on 06 December 2011, morbid obesity, and it was present at onset on 01 November 2011.

Worsening factors

Factor 9(11): having physical trauma to the affected joint at the time of the clinical worsening of joint instability; — MET

- On 02 March 2015 the veteran slipped on a wet stairwell at her unit lines and fell, twisting the left knee. MRI on 10 March 2015 showed rupture of the reconstructed anterior cruciate ligament and a new bucket-handle tear of the lateral meniscus, and the giving-way episodes increased from monthly to several times a week.

Factor 9(12): having damage to a soft tissue structure as specified before the clinical worsening of joint instability; — MET

- The medial patellofemoral ligament and anterior cruciate ligament damage of 2008, the medial meniscal tear and the reconstructed grafts of 19 June 2013 were all present before the worsening on 02 March 2015. The graft rupture and lateral meniscal tear shown on MRI on 10 March 2015 added further damage to stabilising structures.

Factor 9(13): having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical worsening of joint instability; — MET

- The osteochondral defect of the lateral femoral condyle from the 2008 fracture persisted and was present before the worsening on 02 March 2015, progressing to grade 4 chondral loss on MRI on 10 March 2015.

Factor 9(14): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical worsening of joint instability; — MET

- Post-traumatic osteoarthritis of the left knee was present at the worsening on 02 March 2015, with grade 4 chondral loss of the lateral compartment on MRI on 10 March 2015, and progressed to Kellgren-Lawrence grade 4 by 04 May 2017.

Factor 9(15): for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical worsening of joint instability; — MET

- The temporomandibular joint instability worsened on 22 July 2014, when the jaw dislocated during extraction of an impacted lower wisdom tooth by a Defence dentist, requiring manual reduction. The frequency of jaw subluxation increased from every few months to weekly after the procedure.

Factor 9(16): for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical worsening of joint instability; — MET

- The instability of the right total hip prosthesis worsened in 2016, with three dislocations between February and June 2016 requiring revision to a dual-mobility bearing on 30 August 2016. The L4/5 disc prolapse and lumbar spondylosis were present at that worsening, confirmed on repeat MRI on 14 March 2016.

Factor 9(17): for total hip joint prosthesis joint instability only, being obese at the time of the clinical worsening of joint instability; — MET

- The veteran's BMI was 42.3 in June 2016, when the right total hip prosthesis instability worsened.

Factor 9(18): for tibiofemoral joint instability only, having morbid obesity at the time of the clinical worsening of joint instability; — MET

- The veteran's BMI was 42.0 on 02 March 2015, when the tibiofemoral instability of the left knee worsened. Morbid obesity increases the shear and rotational loads on a ligament-deficient knee.

Factor 9(19): inability to obtain appropriate clinical management for joint instability. — MET

- Reconstruction of the left knee was recommended on 02 September 2008 but was not performed until 19 June 2013, almost five years later, because the veteran remained on a waiting list, was posted interstate and the referral lapsed. Throughout that period the knee remained ligament-deficient, and the instability began and progressed with further chondral and meniscal damage. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Joint Instability, No. 57 of 2019

Causative factors

Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of joint instability; — MET

- The loading trauma at onset on 01 November 2011 occurred during physiotherapy provided by Defence to rehabilitate the knee injured on warlike service in Afghanistan, so the trauma at onset arose from treatment of the operational injury.

Factor 9(2): having a dislocation or subluxation of the affected joint before the clinical onset of joint instability; — MET

- The left patella dislocated on warlike service in Afghanistan on 12 July 2008, when the veteran jumped from an armoured vehicle under fire with a 32 kg medical pack, and was reduced in the field.

Factor 9(3): having a sprain of the affected joint before the clinical onset of joint instability; — MET

- In the same incident on warlike service on 12 July 2008 the left knee twisted into valgus on landing, spraining the medial patellofemoral and anterior cruciate ligaments, as shown on MRI on 02 September 2008, before onset on 01 November 2011.

Factor 9(4): having damage to a soft tissue structure as specified before the clinical onset of joint instability; — MET

- The rupture of the medial patellofemoral ligament, the partial anterior cruciate ligament tear and the medial meniscal tear were sustained on warlike service in Afghanistan on 12 July 2008 and confirmed on MRI on 02 September 2008.

Factor 9(5): having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical onset of joint instability; — MET

- The osteochondral fracture of the lateral femoral condyle was sustained with the patellar dislocation on warlike service on 12 July 2008 and was shown on radiographs at the role 3 hospital in Afghanistan on 13 July 2008.

Factor 9(6): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of joint instability; — MET

- The post-traumatic osteoarthritis present at onset developed from the osteochondral fracture sustained on warlike service in Afghanistan in 2008, and was shown on MRI on 06 December 2011.

Factor 9(7): being pregnant within the six weeks before the clinical onset of joint instability; — MET

- The veteran was pregnant until she delivered her first child on 28 September 2011, within the six weeks before onset, from 20 September 2011 to 01 November 2011. The ligamentous laxity of late pregnancy and the post-partum period acted on a knee already made deficient by the injuries sustained on warlike service in 2008.

Factor 9(8): for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of joint instability; — MET

- The temporomandibular joint instability began on 14 March 2012 when the jaw dislocated during direct laryngoscopy for arthroscopy of the left knee, surgery required for the injury sustained on warlike service in Afghanistan.

Factor 9(9): for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of joint instability; — MET

- The right total hip prosthesis was required because of the femoral neck fracture sustained on warlike service on 12 July 2008. The L4/5 disc prolapse and lumbar spondylosis, from pack carriage including on warlike service in Afghanistan, were present when the prosthesis first dislocated on 05 January 2011.

Factor 9(10): for total hip joint prosthesis joint instability only, being obese at the time of the clinical onset of joint instability; — MET

- The veteran's BMI was 36.0 when the right total hip prosthesis first dislocated on 05 January 2011. The weight gain followed olanzapine for posttraumatic stress disorder arising from the incident on warlike service in 2008.

Factor 9(11): for tibiofemoral joint instability only, being severely obese at the time of the clinical onset of joint instability; — MET

- The veteran's BMI was 41.1 on 28 September 2011 and 41.3 on 06 December 2011, above the threshold of 35 for severe obesity, at the onset of the tibiofemoral instability on 01 November 2011. Her weight rose from 66 kg after the injuries and posttraumatic stress disorder that followed warlike service.

Factor 9(12): for total knee joint prosthesis joint instability only, having morbid obesity at the time of the clinical onset of joint instability; — MET

- The left knee was replaced on 11 July 2017 for end-stage osteoarthritis following the injuries sustained on warlike service. Flexion instability of the total knee prosthesis began on 20 February 2018, when the veteran's BMI was 42.5, morbid obesity.

Factor 9(13): for elbow joint instability only, having more than three local glucocorticoid injections for epicondylitis before the clinical onset of joint instability; — MET

- The veteran also has instability of the right elbow. She developed right lateral epicondylitis from carrying her medical pack and stretchers, including on warlike service in Afghanistan in 2008, and received four local glucocorticoid injections on 09 February 2010, 15 June 2010, 23 November 2010 and 29 March 2011. Posterolateral rotatory instability of the right elbow, with recurrent clunking subluxation, began on 20 June 2011, after the fourth injection.

Worsening factors

Factor 9(14): having physical trauma to the affected joint at the time of the clinical worsening of joint instability; — MET

- The fall on a wet stairwell on 02 March 2015 twisted the left knee and ruptured the graft that had reconstructed ligaments first damaged on warlike service in Afghanistan, and the instability measurably worsened.

Factor 9(15): having damage to a soft tissue structure as specified before the clinical worsening of joint instability; — MET

- The ligament and meniscal damage sustained on warlike service on 12 July 2008 was present before the worsening on 02 March 2015, as was the reconstruction it required.

Factor 9(16): having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical worsening of joint instability; — MET

- The osteochondral defect from the fracture sustained on warlike service in 2008 was present before the worsening on 02 March 2015.

Factor 9(17): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical worsening of joint instability; — MET

- Post-traumatic osteoarthritis arising from the 2008 operational injury was present at the worsening, with grade 4 chondral loss on MRI on 10 March 2015.

Factor 9(18): being pregnant within the six weeks before the clinical worsening of joint instability; — MET

- The veteran was pregnant until she delivered her second child on 03 February 2015, within the six weeks before the worsening, from 19 January 2015 to 02 March 2015. Pregnancy-related ligamentous laxity acted on the knee damaged on warlike service in 2008.

Factor 9(19): for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical worsening of joint instability; — MET

- The temporomandibular joint instability, which began during laryngoscopy for surgery to the operationally injured knee, worsened on 22 July 2014 when the jaw dislocated during a wisdom tooth extraction by a Defence dentist.

Factor 9(20): for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical worsening of joint instability; — MET

- The L4/5 disc prolapse and lumbar spondylosis were present when the instability of the right total hip prosthesis, required after the femoral neck fracture on warlike service, worsened in February to June 2016.

Factor 9(21): for total hip joint prosthesis joint instability only, being obese at the time of the clinical worsening of joint instability; — MET

- The veteran's BMI was 42.3 when the right total hip prosthesis instability worsened in June 2016.

Factor 9(22): for tibiofemoral joint instability only, being severely obese at the time of the clinical worsening of joint instability; — MET

- The veteran's BMI was 42.0 at the worsening of the tibiofemoral instability on 02 March 2015.

Factor 9(23): for total knee joint prosthesis joint instability only, having morbid obesity at the time of the clinical worsening of joint instability; — MET

- The flexion instability of the left total knee prosthesis worsened through 2018, requiring revision to a constrained polyethylene insert on 15 October 2018, when the veteran's BMI was 43.1.

Factor 9(24): for elbow joint instability only, having more than three local glucocorticoid injections for epicondylitis before the clinical worsening of joint instability; — MET

- After the four injections given before onset, the veteran received two further glucocorticoid injections to the right lateral epicondyle on 11 February 2014 and 05 August 2014. The right elbow instability worsened, with weekly subluxation and a positive lateral pivot-shift test under anaesthesia, and she underwent lateral ulnar collateral ligament reconstruction on 19 November 2014.

Factor 9(25): inability to obtain appropriate clinical management for joint instability. — MET

- After the injuries sustained on warlike service in Afghanistan in 2008, reconstruction of the left knee was recommended on 02 September 2008 but not performed until 19 June 2013 because of waiting lists, postings and a lapsed referral, and the knee remained ligament-deficient while the instability began and progressed.

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

Sequelae

Met. The instability of the left knee is a sequela of the medial collateral ligament sprain of 2006 and of the patellar dislocation, osteochondral fracture and ligament and meniscal damage sustained on warlike service in 2008. Its repeated giving way has in turn caused post-traumatic osteoarthritis of the left knee, which led to total knee replacement in 2017 and should be considered for a separate claim.

Unintended Consequence

Met. The trauma at onset occurred during Defence-arranged physiotherapy, and the temporomandibular joint dislocation of 14 March 2012 occurred during laryngoscopy for Defence-funded knee surgery, both unintended consequences of treatment provided by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA). The weight gain from olanzapine prescribed for service-related posttraumatic stress disorder also contributed.

Inability to Attain Appropriate Medical Management

MET. An orthopaedic surgeon recommended reconstruction of the veteran's ligament-deficient left knee on 02 September 2008, but she remained on a waiting list, was posted interstate and the referral lapsed, and the surgery was not performed until 19 June 2013. During those almost five years the knee remained unstable, the instability began on 01 November 2011 and the anterior cruciate ligament tear progressed from partial to complete with further chondral damage. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), delays imposed by the military health system and postings amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 14 Mar 2006, Outpatient health record, Medical Officer, Garrison health centre
2. 13 Jul 2008, Trauma admission and X-ray report, Role 3 hospital, Afghanistan
3. 02 Sep 2008, MRI report and orthopaedic consultation, Orthopaedic surgeon
4. 12 Apr 2010, MRI lumbar spine report, Radiologist
5. 18 Aug 2010, Operation report, right total hip replacement, Orthopaedic surgeon
6. 05 Jan 2011, Emergency department record, dislocated hip prosthesis, Emergency physician
7. 20 Jun 2011, Upper limb consultation, Orthopaedic surgeon
8. 28 Sep 2011, Postnatal record, Obstetrician
9. 01 Nov 2011, Physiotherapy record, Physiotherapist
10. 06 Dec 2011, MRI report and orthopaedic consultation, Orthopaedic surgeon
11. 14 Mar 2012, Anaesthetic record, Anaesthetist
12. 19 Jun 2013, Operation report, ACL and MPFL reconstruction, Orthopaedic surgeon
13. 22 Jul 2014, Dental treatment record, Dental Officer
14. 10 Mar 2015, MRI report and orthopaedic review, Orthopaedic surgeon
15. 30 Aug 2016, Operation report, revision hip arthroplasty, Orthopaedic surgeon
16. 11 Jul 2017, Operation report, left total knee replacement, Orthopaedic surgeon
17. 15 Oct 2018, Operation report, revision of knee insert, Orthopaedic surgeon
18. Statement of Principles concerning Joint Instability (Balance of Probabilities) No. 58 of 2019, Repatriation Medical Authority
19. Statement of Principles concerning Joint Instability (Reasonable Hypothesis) No. 57 of 2019, Repatriation Medical Authority