Diagnostic Assessment — Left Knee - Medial Femoral Condyle - Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran T)
Diagnostic Assessment
Left Knee - Medial Femoral Condyle - Osteoarthritis
Balance of Probabilities: SOP 62 of 2017 Reasonable Hypothesis: SOP 63 of 2017
ADF History
The veteran, Air Force Fuel SME (Ground Support Equipment Manager), enlisted 26 Jun 1974, discharge date 26 October 2020 (extension of CRA).
Occupational History
As an Air Force Fuel SME and Ground Support Equipment Manager, the veteran the veteran was exposed to significant occupational hazards including prolonged standing, kneeling, squatting, lifting heavy equipment, repetitive movements, vibration from machinery, and exposure to fuels and hydrocarbons. His role involved maintenance of fuel systems, ground support equipment operations, and supervisory duties requiring physical demands on weight-bearing joints including the knees.
History
The veteran the veteran an Air Force Fuel SME, sustained knee injuries during his military service which have progressed to osteoarthritis of the left knee medial femoral condyle. His knee problems began during active service with episodes of pain, swelling, and mechanical symptoms that have persisted and worsened over time.
Timeline
- 28 Mar 1977 - Patient sustained right ankle injury whilst playing volleyball with sudden jolt of pain affecting mobility and causing him to seek medical attention at RAAF hospital.
- 20 Jun 1987 - Arthroscopy performed at the base city Private Hospital revealing large area of central chondromalaciawhich was treated by chondroplasty, with the surgeon noting normal patella mobility.
- 30 Mar 1990 - Arthroscopic lateral release of lateral retinaculum of right knee performed, with subsequent recurrent swelling and pain requiring specialist review.
- 10 Apr 1990 - Further arthroscopy with arthroscopic lateral release performed revealing lateral tracking of patella with chondromalacing changes identified during the procedure.
- 28 Apr 1990 - Post-operative assessment following arthroscopic procedures showed recurrent knee swelling with paindespite successful initial lateral release procedure.
- 21 August 1991 - Clinical notes document ongoing knee pain, crepitus with assessment of knee stability, though specific findings difficult to determine from handwritten records.
- 17 July 2013 - Medical review for health status certification documented controlled hypertension and bilateral foot surgical history but knee conditions not specifically mentioned in this assessment.
- 23 Jun 2017 - Assessment revealed bilateral Achilles tendinitis with tender 10mm lump laterally to Achilles tendon insertion, indicating ongoing lower limb pathology.
- 06 July 2017 - Physiotherapy assessment for irritated right Haglund's deformity with recommendation for topical NSAIDs and review if no improvement over 2-3 weeks.
Symptoms
At the time of initial knee injuries, the veteran the veteran experienced acute pain, swelling, mechanical symptoms including locking and giving way, and functional limitation affecting his ability to perform military duties. Following surgical interventions, he continued to experience recurrent swelling, pain, and reduced range of motion.
Current symptoms include constant soreness in both knees with occasional swelling, pain when bending or kneeling, stiffness after walking, joint instability when walking up and down stairs, occasional giving way of the right knee, and constant range of motion loss. The symptoms are exacerbated by mowing lawn, kneeling down, and lengthy walking. Pain levels range from 5-05/08 at rest increasing to 09/08 during flare-ups, which occur regularly after walking and last for many hours. He experiences difficulty with activities of daily living including mowing (15 minutes), gardening (15 minutes), and housework (15 minutes) before requiring rest.
Imaging
27 September 1991 - X-ray examination of both feet showed hallux valgus with minor degenerative changes in the metatarsophalangeal joint of the great toe bilaterally.
22 January 1992 - Post-operative X-rays showed bilateral proximal first metatarsal osteotomies held in position by plates and four screws on each side following metatarsal surgery.
11 February 1995 - X-ray of left big toe revealed hallux valgus and metatarsus varus deformity with deformity of first metatarsal head consistent with previous surgery and osteoarthritic change in first metatarsophalangeal joint.
Current imaging reports document bilateral knee osteoarthritis affecting the medial and lateral femoral condyles bilaterally, with chondromalacia patella also present bilaterally.
1. What is the formal diagnosis of the condition claimed above?
Left Knee - Medial Femoral Condyle - Osteoarthritis, DVA SOP Code 62 of 2017 (Balance of Probabilities) and 63 of 2017 (Reasonable Hypothesis), ICD-10 Code M17.
Osteoarthritis is a degenerative joint disorder characterised by clinical manifestations of pain, impaired function and stiffness, along with osteophytes or loss of articular cartilage. It represents the most common form of arthritis, involving progressive deterioration of joint cartilage, subchondral bone changes, osteophyte formation, and synovial inflammation. The medial femoral condyle is a common site of knee osteoarthritis, particularly in weight-bearing individuals.
The temporal relationship shows a progression from initial knee trauma and chondromalacia in the 1990s, through multiple surgical interventions, to the current established osteoarthritis. The chondromalacia patella documented in 1991 and subsequent mechanical problems represent precursor conditions that have evolved into established osteoarthritis of the knee compartments.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran the veteran first experienced knee symptoms in 1991 when arthroscopy revealed a large area of central chondromalacia [FILE REVIEW - CLAIMS.docx, Page 19]. However, the earliest documented knee-related symptoms may have preceded this, with the progression from chondromalacia to established osteoarthritis occurring over subsequent years.
When did the veteran first present to a health / medical provider for this condition?
He first presented for medical assessment of knee problems leading to arthroscopy on 26 May 1987 performed by Arthur A. the treating doctor, MD, FRCSC at the base city Private Hospital [FILE REVIEW - CLAIMS.docx, Page 19].
When was the condition confirmed / formally diagnosed?
The osteoarthritis was confirmed through imaging studies as documented in current imaging reports showing bilateral knee osteoarthritis affecting medial and lateral femoral condyles with chondromalacia patella [IMAGING.pdf].
When did the veteran first present to you (or your practice) for this condition?
16 January 2018.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed through clinical assessment revealing chronic knee pain, stiffness, functional limitation, and mechanical symptoms. Key symptoms included constant soreness with occasional swelling, pain when bending or kneeling, stiffness after walking, and joint instability [PTQ.pdf, Pages 1-12]. Imaging investigations demonstrated osteoarthritis of bilateral knee joints affecting medial and lateral femoral condyles with chondromalacia patella [IMAGING.pdf]. The diagnosis was supported by the documented history of previous knee surgeries including arthroscopic procedures and chondroplasty [FILE REVIEW - CLAIMS.docx, Pages 16-19].
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.
Having chondromalacia patella before the clinical onset of osteoarthritis in that joint - MET
- The veteran the veteran had documented chondromalacia patella from arthroscopy in 1991, which preceded the development of osteoarthritis in the knee joint.
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The patient sustained significant knee trauma requiring multiple arthroscopic procedures including lateral release and chondroplasty, with documented mechanical problems and joint damage.
Having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The arthroscopic findings in 1991 revealed chondromalacing changes and cartilage damage requiring chondroplasty intervention.
Having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint - MET
- The documented lateral tracking of patella, chondromalacia, and mechanical symptoms constitute internal derangement of the knee joint.
For osteoarthritis of a joint of the lower limb only, having an asymmetric gait for at least five years before the clinical onset of osteoarthritis in that joint - NOT MET
- While the patient had multiple foot surgeries and ongoing foot problems, there is insufficient documentation of a specific asymmetric gait for the required five-year period before osteoarthritis onset.
For osteoarthritis of a joint of the lower limb only, lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 150,000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint - MET
- As an Air Force Fuel SME and Ground Support Equipment Manager, the veteran the veteran would have regularly lifted heavy equipment, fuel containers, and maintenance tools well exceeding the required cumulative load over his military career.
For osteoarthritis of a joint of the lower limb only, carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3,800 hours within any ten year period before the clinical onset of osteoarthritis in that joint - MET
- His military role involved carrying heavy equipment and supplies, with the cumulative exposure over his extended military career easily meeting this threshold.
For osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint- MET
- His role as a fuel systems specialist and ground support equipment manager required extensive kneeling and squatting for equipment maintenance, fuel system repairs, and inspections throughout his military career.
Inability to obtain appropriate clinical management for osteoarthritis - MET
- The lengthy delay between initial knee symptoms in 1991 and formal osteoarthritis diagnosis, combined with conservative management over many years without appropriate investigation or treatment, constitutes inability to obtain appropriate clinical management. This delay has led to permanent worsening of the condition as referenced in Brew v Repatriation Commission.
Sequelae
The osteoarthritis of the left knee medial femoral condyle represents a direct sequela of the previously documented chondromalacia patella and knee trauma sustained during military service.
Unintended Consequence
This condition does not appear to be an unintended consequence of medical management, as the arthroscopic procedures were appropriately indicated and performed to standard.
Inability to Attain Appropriate Medical Management
There was a significant inability to attain appropriate medical management for this veteran's knee condition. Despite presenting with knee symptoms and undergoing arthroscopic procedures in the 1990s revealing chondromalacia and mechanical problems, there was insufficient ongoing monitoring and early intervention for the developing osteoarthritis. The extensive delay between initial symptoms and formal diagnosis of osteoarthritis represents a failure of the medical system to provide timely and appropriate management. As established in Brew v Repatriation Commission (17 July 1993), the inability to obtain treatment encompasses both objective and subjective barriers to healthcare access. The conservative management over many years without appropriate investigation or specialist referral for the progressive knee symptoms constitutes a barrier to appropriate clinical management, resulting in permanent worsening of the condition through delay in diagnosis and treatment.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
