Diagnostic Assessment — Left Sacroiliac Joint - Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran AA)
Diagnostic Assessment
Left Sacroiliac Joint - Osteoarthritis
BOP Code: 62 of 2017 (Osteoarthritis)
RH Code: 61 of 2017 (Osteoarthritis)
ADF History
Veteran AA, date of birth 17 July 1972, Australian Army, Infantry Soldier, later Assault Pioneer (Sergeant), enlisted 05 February 1990, medically discharged 22 April 2016. Operational service: Somalia, 17 January 1993 to 21 May 1993 (warlike); East Timor, 20 September 1999 to 10 February 2000 (warlike); Iraq, 18 April 2005 to 30 October 2005 (warlike); Afghanistan, 08 January 2008 to 16 June 2008 (warlike, ended by aeromedical evacuation after a blast injury).
Occupational History
As an infantry soldier and assault pioneer the veteran carried loads of 30 to 50 kilograms on foot, filled and placed sandbags, built field defences and obstacles, cleared routes and demolished structures. Pioneer work involved jackhammers, rock drills, demolition saws and chainsaws, and long periods kneeling and squatting at fire positions, in trenches and while laying and clearing obstacles.
Infantry and pioneer duties carry a high cumulative load through the spine, pelvis and lower limbs, with risks of blast and vehicle injury, falls, cold injury in mountainous theatres and tropical infection. Accommodation and headquarters in barracks were in multi-storey buildings without lifts.
History
Veteran AA, an infantry soldier and assault pioneer, developed osteoarthritis of the left sacroiliac joint on 25 August 2014, six years after an improvised explosive device blast in Afghanistan caused a left transtibial amputation and a fracture-dislocation of the left sacroiliac joint, on a background of reactive sacroiliitis after captivity in Somalia, septic sacroiliitis in East Timor and decades of heavy load carriage. The osteoarthritis worsened in 2019, while he was without a properly fitting prosthesis and had developed osteoporosis.
Timeline
- 25 Mar 1993 — On warlike service in Somalia the veteran and two others were captured by an armed militia on 02 March 1993 after their vehicle broke down, and held for six days before release, with contaminated water and little food. He developed bloody diarrhoea and Shigella flexneri was cultured. Three weeks later he presented with left buttock pain, a swollen left knee and conjunctivitis. The medical officer diagnosed reactive arthritis with left sacroiliitis; HLA-B27 was positive and sulfasalazine was given until 1995. "captivity, Shigella, reactive left sacroiliitis"
- 09 Jan 2000 — On warlike service in East Timor the veteran developed fever and severe left buttock pain two weeks after an infected tropical ulcer of the leg. Blood cultures grew Staphylococcus aureus and CT-guided aspiration of the left sacroiliac joint grew the same organism. He was evacuated and treated for septic arthritis of the left sacroiliac joint with six weeks of antibiotics. "septic arthritis left SIJ, S. aureus"
- 14 Jun 2008 — On warlike service in Afghanistan, five months after frostbite of the skin over the left buttock and sacral region from 14 hours prone on frozen ground in an observation post in February 2008, the veteran was injured by an improvised explosive device. He sustained a traumatic left transtibial amputation, a vertical shear fracture of the pelvis with the fracture line through the articular surface of the left sacroiliac joint and complete disruption of that joint, haemarthrosis of the joint on CT, an injury to the left lumbosacral plexus, and tears of the left anterior cruciate ligament and medial meniscus. The sacroiliac joint was reduced and fixed with iliosacral screws. "transtibial amputation, SIJ fracture-dislocation"
- 20 Jul 2010 — MRI and CT of the pelvis showed malunion of the left hemipelvis with 8 degrees of rotation and 9 mm of cranial displacement, subchondral osteonecrosis of the iliac side of the left sacroiliac joint, and chondrocalcinosis of the joint. Aspiration confirmed calcium pyrophosphate crystals. A rehabilitation physician recorded an asymmetric gait with a prosthesis, loss of pain and position sense over the left buttock and posterior pelvis from the plexus injury, and an MRI-confirmed acute articular cartilage tear of the left sacroiliac joint from the 2008 injury. "malunion, osteonecrosis, CPPD, asymmetric gait"
- 15 Mar 2011 — An endocrinologist confirmed acromegaly, with a raised IGF-1, failure of growth hormone suppression and a 13 mm pituitary macroadenoma, and arranged trans-sphenoidal surgery. DXA showed increased bone mineral density, with a lumbar spine T-score of +1.6. On 08 August 2012 a bone scan and raised alkaline phosphatase confirmed Paget's disease of bone of the left ilium extending to the left sacroiliac joint, treated with zoledronic acid. "acromegaly; Paget's left ilium"
- 03 Sep 2014 — The veteran presented to the garrison health centre with increasing left sacroiliac and buttock pain, morning stiffness and pain on standing and walking with his prosthesis since 25 August 2014. CT of 10 September 2014 showed joint space narrowing, marginal osteophytes and subchondral sclerosis of the left sacroiliac joint. CT of 12 June 2013 had shown a united fracture with a preserved joint space and no osteophytes. His BMI was 31, waist 109 cm. "left SIJ OA, osteophytes on CT"
- 12 Nov 2019 — The veteran presented to an orthopaedic surgeon with severe left sacroiliac pain limiting walking to 200 metres. His prosthetic socket had been ill-fitting since September 2018 and a replacement had not been provided because approval was delayed for 14 months, so he had walked with a markedly abnormal gait. DXA in July 2019 showed osteoporosis with a femoral neck T-score of -2.6. CT showed bone-on-bone narrowing with large bridging osteophytes. Left sacroiliac fusion was performed in March 2020. "severe progression, ill-fitting socket"
Symptoms
At onset the veteran had deep aching pain over the left sacroiliac joint and buttock, morning stiffness of about 30 minutes, pain on prolonged standing, on walking with the prosthesis and on rolling in bed, and tenderness over the joint with positive provocation tests.
Since the worsening he has had constant left sacroiliac pain, walking tolerance of about 200 metres before the fusion and 500 metres after it, difficulty with stairs, slopes and uneven ground, and disturbed sleep. He requires regular analgesia and cannot sit for more than 30 minutes.
Imaging
- 14 Jun 2008 — CT pelvis (role 3 hospital): "Vertical shear fracture of the left hemipelvis with the fracture line through the articular surface of the left sacroiliac joint, widening and disruption of the joint, and high-density fluid within the joint consistent with haemarthrosis."
- 20 Jul 2010 — MRI and CT pelvis: "Malunion of the left hemipelvis with rotation and cranial displacement. Subchondral osteonecrosis of the iliac side of the left sacroiliac joint. Chondrocalcinosis. Focal full-thickness articular cartilage defect."
- 12 Jun 2013 — CT pelvis: "United fracture with retained iliosacral screws. Joint space preserved. No osteophytes."
- 10 Sep 2014 — CT pelvis: "Narrowing of the left sacroiliac joint space with marginal osteophytes and subchondral sclerosis, consistent with osteoarthritis."
- 12 Nov 2019 — CT pelvis: "Severe progression of left sacroiliac osteoarthritis with bone-on-bone narrowing, subchondral cysts and large bridging anterior osteophytes."
Onset Date
The most likely date of onset of this condition is 25 Aug 2014.
At that date the veteran was a serving assault pioneer sergeant in a non-deployable rehabilitation posting in Australia, walking with a left transtibial prosthesis. From that date he had persistent left sacroiliac pain and stiffness of a mechanical, degenerative pattern, distinct from his earlier inflammatory and infective episodes.
This date is appropriate because CT of 12 June 2013 showed a preserved joint space with no osteophytes, and he first presented with the new pain on 03 September 2014, with CT on 10 September 2014 showing osteophytes and joint space loss. The onset falls within continuous full-time service.
The reactive sacroiliitis of 1993, the septic arthritis of 2000, the frostbite of February 2008, and the fracture-dislocation, haemarthrosis, cartilage tear, plexus injury and amputation of 14 Jun 2008 all preceded onset. For the 25-year factors, the 25 years before onset run from 25 Aug 1989 to 25 Aug 2014 and cover his entire service. For the amputation, asymmetric gait and disordered joint mechanics factors, the 5 years before onset run from 25 Aug 2009 to 25 Aug 2014, and these were present continuously from 14 Jun 2008. For the instability factor, the joint disruption of 14 Jun 2008 was six years before onset. For the overweight and waist factors, the 10 years before onset run from 25 Aug 2004 to 25 Aug 2014; his BMI was above 25 and his waist above 102 cm from his periodic health examination of 2003. For lifting, the ten-year period from Feb 1990 to Feb 2000 contained about 260,000 kilograms of lifting, and for carrying, the period from 1995 to 2005 contained about 4,600 hours. For stairs, the continuous period from Jan 1994 to Sep 1999 exceeded five years. Kneeling and squatting of more than an hour a day continued from 1990 to 2008.
For the worsening factors, the period after onset runs from 25 Aug 2014 to the documented worsening on 12 Nov 2019. The 25 years before the worsening run from 12 Nov 1994 to 12 Nov 2019 and include the infection, frostbite and blast injuries. Osteoporosis was confirmed in Jul 2019, and the ill-fitting socket left him without appropriate prosthetic management from Sep 2018 to Nov 2019.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Sacroiliac Joint - Osteoarthritis (ICD-10-AM M19.15), post-traumatic osteoarthritis of the left sacroiliac joint, under the Statements of Principles concerning osteoarthritis, Balance of Probabilities No. 62 of 2017 and Reasonable Hypothesis No. 61 of 2017.
Osteoarthritis is a degenerative joint disorder with pain, stiffness and impaired function, and imaging or arthroscopic evidence of loss of articular cartilage or osteophytes. It is accelerated by previous inflammation, infection, fracture and dislocation of the joint, by abnormal joint mechanics, and by heavy cumulative loading. The sacroiliac joint transmits the load of the trunk to the lower limbs, and an amputation with an asymmetric prosthetic gait and a malunited pelvic fracture concentrate abnormal forces through it.
The osteoarthritis began on 25 August 2014, was confirmed on CT in September 2014 and worsened in November 2019, leading to fusion of the joint in March 2020.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
25 August 2014.
When did the veteran first present to a health / medical provider for this condition?
03 September 2014.
When was the condition confirmed / formally diagnosed?
10 September 2014.
When did the veteran first present to you (or your practice) for this condition?
14 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by CT of the pelvis on 10 September 2014, which showed narrowing of the left sacroiliac joint space, marginal osteophytes and subchondral sclerosis, in a veteran with pain, stiffness and impaired walking. This meets the Statement of Principles definition of osteoarthritis: a degenerative joint disorder with clinical manifestations of pain, impaired function and stiffness and radiological evidence of loss of articular cartilage and osteophytes. It is not an acute articular cartilage tear or osteochondritis dissecans.
A sports and exercise physician confirmed the diagnosis clinically on 18 September 2014. The worsening was confirmed on CT of 12 November 2019, which showed bone-on-bone narrowing, subchondral cysts and bridging osteophytes.
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 25 August 2014, 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, during which much of the cumulative lifting, carrying, stair climbing and kneeling occurred. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Somalia in 1993, East Timor in 1999 and 2000, Iraq in 2005 and Afghanistan in 2008, during which the captivity, reactive and septic sacroiliitis, frostbite and blast injuries 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 Osteoarthritis, No. 62 of 2017
Causative factors
Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Reactive arthritis with left sacroiliitis, HLA-B27 positive, was diagnosed on 25 March 1993 after Shigella dysentery contracted during service, and treated with sulfasalazine until 1995. Reactive arthritis is on the specified list and it affected the left sacroiliac joint 21 years before the onset on 25 August 2014.
Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- Septic arthritis of the left sacroiliac joint was confirmed on 09 January 2000, with Staphylococcus aureus grown from blood and joint aspirate, a bacterial infection causing inflammation within the joint. It occurred during service, 14 years before the onset on 25 August 2014.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- CT on 14 June 2008 showed the fracture line of a vertical shear pelvic fracture passing through the articular surface of the left sacroiliac joint, sustained in a blast during service, six years before the onset on 25 August 2014.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- CT on 14 June 2008 showed high-density fluid within the disrupted left sacroiliac joint consistent with haemarthrosis, bleeding into the joint from the service-related fracture, six years before the onset on 25 August 2014.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Chondrocalcinosis of the left sacroiliac joint was shown on CT of 20 July 2010 and calcium pyrophosphate crystals were confirmed on aspiration, establishing calcium pyrophosphate dihydrate deposition disease in that joint four years before the onset on 25 August 2014. It developed in the joint damaged by service injuries.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- On 14 June 2008 the blast applied massive force through the left sacroiliac joint, causing fracture-dislocation, immediate pain, tenderness and loss of movement, and surgery to the joint. This trauma was six years before the onset on 25 August 2014, well within 25 years.
Factor 9(7): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- MRI of 20 July 2010 showed a focal full-thickness articular cartilage defect of the left sacroiliac joint that the radiologist and rehabilitation physician attributed to the acute injury of 14 June 2008, six years before the onset on 25 August 2014.
Factor 9(8): having an acute meniscal tear of the affected knee within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- The blast of 14 June 2008 caused an acute tear of the medial meniscus of the left knee, shown on MRI on 02 July 2008 and repaired arthroscopically, six years before the onset on 25 August 2014.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- In February 2008 the veteran lay prone for 14 hours on frozen ground in wet clothing and sustained frostbite of the skin and subcutaneous tissue over the left buttock and sacroiliac region, recorded by the medical officer with blistering and later skin loss, six years before the onset on 25 August 2014. It occurred in the course of his service.
Factor 9(10): having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- The pelvic fracture healed with malunion, the left hemipelvis rotated 8 degrees and displaced 9 mm cranially, a rotation deformity of the bones adjacent to the joint that maldistributes load across it (CT of 20 July 2010). The deformity was present from June 2008, more than six years before onset, exceeding five years.
Factor 9(11): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- MRI of 20 July 2010 showed subchondral osteonecrosis of the iliac side of the left sacroiliac joint, attributed to the vascular disruption of the 2008 fracture, four years before the onset on 25 August 2014.
Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- From 1993 to 2008 the veteran's duties involved sustained power grip for an average of more than 30 hours a week, operating jackhammers, rock drills, demolition saws, picks and shovels and handling weapons and stores, for more than ten years within that 15-year period before the onset on 25 August 2014.
Factor 9(13): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- As an assault pioneer from 1996 to 2008 the veteran used hand-held vibrating percussive tools, including jackhammers and rock drills, on more days than not for a cumulative period of about 11 years, all within the 25 years before the onset on 25 August 2014.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran has had a left transtibial amputation since 14 June 2008, with an asymmetric prosthetic gait documented by the rehabilitation physician on 20 July 2010. Both were present for more than six years before the onset on 25 August 2014, exceeding five years.
Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From February 1990 to February 2000 the veteran lifted sandbags, ammunition boxes, pickets, wire and pioneer stores of 20 to 40 kilograms while standing, about 260,000 kilograms in total, as calculated from his duty records. The onset in 2014 occurred within 25 years of that period.
Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1995 to 2005 the veteran carried packs, weapons and stores of 20 to 50 kilograms on foot for about 4,600 hours in total, and the onset in 2014 occurred within 25 years of that period.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- From January 1994 to September 1999 the veteran lived on the fourth floor of a barracks block and worked in a three-storey battalion headquarters without lifts, climbing about 180 stairs a day on most days for a continuous period of more than five years, within the 25 years before the onset on 25 August 2014.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- DXA on 15 March 2011 showed increased bone mineral density, with a lumbar spine T-score of +1.6, more than one standard deviation above the young adult mean, associated with acromegaly, three years before the onset on 25 August 2014.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's BMI was 27 at his periodic health examination in February 2003 and remained between 27 and 31 to onset, so he was overweight for more than ten years before the onset on 25 August 2014.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist circumference was 104 cm in February 2003 and between 104 and 109 cm thereafter, exceeding 102 cm for more than ten years before the onset on 25 August 2014.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's recorded waist circumference exceeded 88 centimetres at every measurement from February 2003 to onset, more than ten years, reaching 109 cm in September 2014.
Factor 9(16): for osteoarthritis of a hip or knee joint only: (a) 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; and (b) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1990 to 2008 the veteran knelt or squatted for more than an hour a day on most days at fire positions, in trenches, and while building obstacles and laying charges, a continuous period of far more than two years, and the onset in 2014 occurred within 25 years of that period.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The blast of 14 June 2008 tore the left anterior cruciate ligament and medial meniscus, an internal derangement of the left knee shown on MRI on 02 July 2008, six years before the onset on 25 August 2014.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was diagnosed during infantry training in October 1991 and recorded at subsequent examinations, many years before the onset on 25 August 2014.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The 2008 blast injured the left lumbosacral plexus, and the rehabilitation physician recorded loss of pain and position sense over the left buttock and posterior pelvis involving the region of the left sacroiliac joint on 20 July 2010, four years before the onset on 25 August 2014.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of bone of the left ilium extending to the left sacroiliac joint was confirmed on bone scan with a raised alkaline phosphatase on 08 August 2012, two years before the onset on 25 August 2014.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 15 March 2011, with a raised IGF-1, failure of growth hormone suppression and a 13 mm pituitary macroadenoma, three years before the onset on 25 August 2014.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The left sacroiliac joint was completely disrupted (dislocated) in the vertical shear injury of 14 June 2008, six years before the onset on 25 August 2014, more than one year.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- MRI of the pelvis on 20 July 2010 also showed cam-type femoroacetabular impingement with a labral tear, and impingement syndrome was diagnosed clinically by the rehabilitation physician, four years before the onset on 25 August 2014.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The reactive arthritis with left sacroiliitis of 1993 affected the joint 26 years before the worsening on 12 November 2019.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis of the left sacroiliac joint of January 2000 preceded the worsening by almost 20 years.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The intra-articular fracture of the left sacroiliac joint of 14 June 2008 preceded the worsening by 11 years.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The haemarthrosis of the left sacroiliac joint shown on 14 June 2008 preceded the worsening by 11 years.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Calcium pyrophosphate dihydrate deposition disease of the left sacroiliac joint, confirmed in July 2010, was present before the worsening on 12 November 2019.
Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The fracture-dislocation of 14 June 2008 occurred 11 years before the worsening on 12 November 2019, within 25 years.
Factor 9(30): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The acute articular cartilage tear of the left sacroiliac joint from 14 June 2008 occurred 11 years before the worsening on 12 November 2019, within 25 years.
Factor 9(31): having an acute meniscal tear of the affected knee within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The acute medial meniscal tear of the left knee of 14 June 2008 occurred 11 years before the worsening on 12 November 2019, within 25 years.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite over the left sacroiliac region of February 2008 preceded the worsening by 11 years.
Factor 9(33): having disordered joint mechanics of the affected joint for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The malunion with rotation of the left hemipelvis has been present since June 2008, more than eleven years before the worsening on 12 November 2019.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- The subchondral osteonecrosis adjacent to the left sacroiliac joint, shown in July 2010, was present before the worsening on 12 November 2019.
Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The sustained power grip of his duties from 1993 to 2008, averaging more than 30 hours a week for more than ten years within 15 years, preceded the worsening.
Factor 9(36): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The use of vibrating percussive tools on most days for about 11 years from 1996 to 2008 occurred within the 25 years before the worsening on 12 November 2019.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The left transtibial amputation and asymmetric gait had been present for more than eleven years before the worsening on 12 November 2019, and the gait was made worse by the ill-fitting socket from September 2018.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The lifting of about 260,000 kilograms from 1990 to 2000 preceded the worsening, which occurred within 25 years of that period.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The carrying of about 4,600 hours from 1995 to 2005 preceded the worsening, which occurred within 25 years of that period.
Factor 9(37)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The stair climbing of about 180 stairs a day from January 1994 to September 1999, more than five continuous years, occurred within the 25 years before the worsening on 12 November 2019.
Factor 9(38)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's BMI was above 25 from 2003 and was 32 in 2019, so he was overweight for 16 years before the worsening on 12 November 2019.
Factor 9(38)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2003 and measured 111 cm in 2019, more than ten years before the worsening on 12 November 2019.
Factor 9(38)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres at every measurement from 2003 to 2019, more than ten years before the worsening on 12 November 2019.
Factor 9(39): for osteoarthritis of a hip or knee joint only: (a) 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 two years before the clinical worsening of osteoarthritis in that joint; and (b) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The kneeling and squatting of more than an hour a day from 1990 to 2008 preceded the worsening, which occurred within 25 years of that period.
Factor 9(40): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The internal derangement of the left knee from 14 June 2008 was present before the worsening on 12 November 2019.
Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee, diagnosed in 1991, was present before the worsening on 12 November 2019.
Factor 9(42): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The loss of pain and position sense around the left sacroiliac joint from the 2008 plexus injury persisted before the worsening on 12 November 2019.
Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease of the left ilium and sacroiliac joint, diagnosed in 2012, was present before the worsening on 12 November 2019.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, diagnosed in 2011, preceded the worsening, and the joint changes it caused persisted after surgical treatment.
Factor 9(45): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The disruption of the left sacroiliac joint on 14 June 2008 was eleven years before the worsening on 12 November 2019.
Factor 9(46): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- Cam-type femoroacetabular impingement syndrome, diagnosed in 2010, was present before the worsening on 12 November 2019.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis. — MET
- From September 2018 to November 2019 the veteran could not obtain a replacement for his ill-fitting prosthetic socket because approval was delayed for 14 months, and walked with a markedly abnormal gait that overloaded the left sacroiliac joint. CT on 12 November 2019 showed severe progression. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Osteoarthritis, No. 61 of 2017
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis; — MET
- On warlike service in Somalia on 02 March 1993 the veteran and two other soldiers were captured by an armed militia after their vehicle broke down and were held as prisoners for six days, with poor food and contaminated water, before release. The captivity is recorded in his deployed health record and post-operational debrief, 21 years before onset.
Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Reactive arthritis with left sacroiliitis followed Shigella dysentery contracted during captivity on warlike service in Somalia, diagnosed on 25 March 1993, 21 years before onset.
Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- Septic arthritis of the left sacroiliac joint due to Staphylococcus aureus followed an infected tropical ulcer on warlike service in East Timor, confirmed on aspiration on 09 January 2000, 14 years before onset.
Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The intra-articular fracture of the left sacroiliac joint was sustained in an improvised explosive device blast on warlike service in Afghanistan on 14 June 2008, six years before onset.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Haemarthrosis of the left sacroiliac joint was shown on CT on 14 June 2008, from the fracture sustained on warlike service in Afghanistan.
Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Calcium pyrophosphate dihydrate deposition disease developed in the left sacroiliac joint damaged on warlike service, confirmed by chondrocalcinosis on CT and crystals on aspiration on 20 July 2010, before onset.
Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The blast on warlike service in Afghanistan on 14 June 2008 applied massive force through the left sacroiliac joint, causing fracture-dislocation, pain, loss of movement and surgery to the joint, six years before onset.
Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The acute articular cartilage tear of the left sacroiliac joint, shown on MRI in July 2010, was caused by the blast on warlike service in Afghanistan on 14 June 2008.
Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint; — MET
- An acute tear of the medial meniscus of the left knee was caused by the blast on warlike service in Afghanistan on 14 June 2008, shown on MRI on 02 July 2008, six years before onset.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- In February 2008, on warlike service in Afghanistan, the veteran lay prone for 14 hours on frozen ground in an observation post and sustained frostbite over the left buttock and sacroiliac region, six years before onset.
Factor 9(11): having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- The malunion of the pelvic fracture sustained on warlike service in Afghanistan left a rotation deformity of the left hemipelvis from June 2008, more than six years before onset, exceeding three years.
Factor 9(12): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- Subchondral osteonecrosis adjacent to the left sacroiliac joint, shown on MRI on 20 July 2010, resulted from the vascular disruption of the fracture sustained on warlike service in Afghanistan.
Factor 9(13)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's infantry and pioneer duties from 1993 to 2008, including heavy tool and weapon handling throughout his warlike service in Somalia, East Timor, Iraq and Afghanistan, involved sustained power grip for more than 30 hours a week for more than ten years within 15 years before onset.
Factor 9(13)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical onset of osteoarthritis in that joint; — MET
- The veteran used jackhammers and rock drills on more days than not from 1996 to 2008, a cumulative period of about 11 years, including construction of field defences on warlike service in East Timor and Iraq.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- The left transtibial amputation, with an asymmetric prosthetic gait, resulted from the blast on warlike service in Afghanistan on 14 June 2008 and was present for six years before onset, exceeding three years.
Factor 9(14)(b): 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 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; — MET
- The veteran lifted loads of 20 to 40 kilograms, including sandbags and stores for field defences on warlike service in Somalia and East Timor, to a total of about 260,000 kilograms between 1990 and 2000.
Factor 9(14)(c): 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
- The veteran carried loads of 20 to 50 kilograms for about 4,600 hours between 1995 and 2005, including foot patrols on warlike service in East Timor and Iraq.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder 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
- From January 1994 to September 1999 the veteran climbed about 180 stairs a day in his barracks and headquarters, and on warlike service in East Timor from September 1999 his unit operated from a multi-storey building in Dili, continuing the stair climbing, a continuous period of more than two years.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- Increased bone mineral density, a lumbar T-score of +1.6, was shown on DXA on 15 March 2011, three years before onset.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran was overweight, with a BMI of 27 to 31, from 2003 to onset, more than ten years, the weight gain following reduced activity after his warlike service and the 2008 amputation.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2003 to onset, more than ten years.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres at every measurement from 2003 to onset, more than ten years.
Factor 9(16): 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 one year before the clinical onset of osteoarthritis in that joint; — MET
- The veteran knelt or squatted for more than an hour a day on most days from 1990 to 2008, including at fire positions and while building obstacles on warlike service in Somalia, East Timor, Iraq and Afghanistan, for much longer than one year before onset.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The left anterior cruciate ligament and medial meniscus were torn in the blast on warlike service in Afghanistan on 14 June 2008, an internal derangement of the left knee.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was diagnosed in 1991 and was symptomatic throughout his warlike service in Somalia in 1993, many years before onset.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The left lumbosacral plexus injury from the blast on warlike service in Afghanistan caused loss of pain and position sense around the left sacroiliac joint, recorded on 20 July 2010.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of bone of the left ilium involving the left sacroiliac joint was confirmed on 08 August 2012, two years before onset.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 15 March 2011, three years before onset.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The left sacroiliac joint was dislocated in the vertical shear injury on warlike service in Afghanistan on 14 June 2008, six years before onset.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- Cam-type femoroacetabular impingement syndrome was diagnosed on 20 July 2010, after the injuries sustained on warlike service, before onset.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The reactive left sacroiliitis from warlike service in Somalia in 1993 preceded the worsening on 12 November 2019.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis of the left sacroiliac joint from warlike service in East Timor in 2000 preceded the worsening.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The intra-articular fracture from warlike service in Afghanistan in 2008 preceded the worsening.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The haemarthrosis of 14 June 2008 from warlike service in Afghanistan preceded the worsening.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Calcium pyrophosphate dihydrate deposition disease of the left sacroiliac joint was present before the worsening.
Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The fracture-dislocation from warlike service in Afghanistan in 2008 preceded the worsening.
Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The acute cartilage tear of the left sacroiliac joint from warlike service in 2008 preceded the worsening.
Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint; — MET
- The acute meniscal tear of the left knee from warlike service in 2008 preceded the worsening.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite over the left sacroiliac region from warlike service in Afghanistan in February 2008 preceded the worsening.
Factor 9(33): having disordered joint mechanics of the affected joint for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The pelvic malunion from the warlike service injury had been present for more than eleven years before the worsening.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- The subchondral osteonecrosis from the warlike service fracture was present before the worsening.
Factor 9(35)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The sustained power grip of his duties from 1993 to 2008, including on warlike service, preceded the worsening.
Factor 9(35)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical worsening of osteoarthritis in that joint; — MET
- The use of vibrating percussive tools on most days for about 11 years, including on warlike service, preceded the worsening.
Factor 9(36)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The amputation and asymmetric gait from warlike service in Afghanistan had been present for more than eleven years before the worsening, aggravated by the ill-fitting socket from September 2018.
Factor 9(36)(b): 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 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET
- The lifting of about 260,000 kilograms between 1990 and 2000, including on warlike service, preceded the worsening.
Factor 9(36)(c): 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 worsening of osteoarthritis in that joint; — MET
- The carrying of about 4,600 hours between 1995 and 2005, including on warlike service, preceded the worsening.
Factor 9(36)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years, before the clinical worsening of osteoarthritis in that joint; — MET
- The stair climbing from 1994 to 2000, continuing on warlike service in East Timor, preceded the worsening.
Factor 9(36)(e): for osteoarthritis of a joint of the lower limb only: having osteoporosis before the clinical worsening of osteoarthritis in that joint; — MET
- DXA in July 2019 showed osteoporosis, with a femoral neck T-score of -2.6, caused by disuse after the warlike service amputation and opioid-induced hypogonadism, before the worsening on 12 November 2019.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran was overweight from 2003 to 2019, sixteen years before the worsening.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2003 to 2019, more than ten years before the worsening.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres from 2003 to 2019, more than ten years before the worsening.
Factor 9(38): 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 one year before the clinical worsening of osteoarthritis in that joint; — MET
- The kneeling and squatting of more than an hour a day, including on warlike service, preceded the worsening.
Factor 9(39): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The internal derangement of the left knee from warlike service in 2008 was present before the worsening.
Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was present before the worsening.
Factor 9(41): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The loss of pain and position sense from the warlike service plexus injury persisted before the worsening.
Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease of the left ilium and sacroiliac joint was present before the worsening.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, confirmed in 2011, preceded the worsening.
Factor 9(44): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The dislocation of the left sacroiliac joint on warlike service in 2008 was eleven years before the worsening.
Factor 9(45): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- Femoroacetabular impingement syndrome, diagnosed in 2010, was present before the worsening.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis. — MET
- From September 2018 to November 2019 the veteran could not obtain a replacement prosthetic socket for the amputation sustained on warlike service, because approval was delayed for 14 months. The resulting abnormal gait overloaded the left sacroiliac joint and the osteoarthritis worsened, documented on CT on 12 November 2019.
The % contribution of the causes is 100% and significant.
Sequelae
The left sacroiliac osteoarthritis is a sequela of the veteran's accepted conditions: the fracture-dislocation of the left sacroiliac joint and left transtibial amputation from the blast in Afghanistan, the reactive arthritis following captivity in Somalia and the septic arthritis contracted in East Timor. The sacroiliac fusion and its consequences, chronic pain and reduced mobility are sequelae of the osteoarthritis.
Unintended Consequence
Met. The iliosacral screw fixation of 2008 left a malunion that altered the mechanics of the joint, and the opioid analgesia prescribed for his injuries caused hypogonadism contributing to the osteoporosis present before the worsening; both treatments were provided and paid for by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From September 2018 to November 2019 the veteran's prosthetic socket no longer fitted his residual limb, and a replacement could not be obtained because approval was delayed for 14 months. He walked throughout that period with a markedly asymmetric gait that overloaded the left sacroiliac joint, and CT on 12 November 2019 showed severe progression to bone-on-bone narrowing. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a prolonged administrative delay to essential prosthetic care amounts to an inability to obtain appropriate clinical management, and it materially contributed to the worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- Oct 1991, Outpatient health record, Medical Officer, Infantry training centre
- 25 Mar 1993, Deployed health record and pathology, Medical Officer, Somalia
- 09 Jan 2000, Deployed health record, CT-guided aspiration and microbiology, East Timor
- Feb 2003, Periodic health examination, Medical Officer, Garrison health centre
- Feb 2008, Deployed health record, Medical Officer, Afghanistan
- 14 Jun 2008, Trauma admission, CT and operation report, Role 3 hospital, Afghanistan
- 20 Jul 2010, MRI and CT pelvis and rehabilitation medicine consultation, Rehabilitation physician
- 15 Mar 2011, Endocrinology consultation and DXA, Endocrinologist
- 08 Aug 2012, Bone scan and specialist review, Endocrinologist
- 12 Jun 2013, CT pelvis, Radiologist
- 03 Sep 2014, Outpatient health record, Medical Officer, Garrison health centre
- 10 Sep 2014, CT pelvis, Radiologist
- 18 Sep 2014, Specialist consultation, Sports and exercise physician
- Jul 2019, DXA report, Radiologist
- 12 Nov 2019, Orthopaedic consultation and CT pelvis, Orthopaedic surgeon
- Statement of Principles concerning Osteoarthritis (Balance of Probabilities) No. 62 of 2017, Repatriation Medical Authority
- Statement of Principles concerning Osteoarthritis (Reasonable Hypothesis) No. 61 of 2017, Repatriation Medical Authority
