Diagnostic Assessment — Right Hip - CAM Type Femoroacetabular Impingement (FAI)
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Right Hip - CAM Type Femoroacetabular Impingement (FAI)
SOP - Femoroacetabular Impingement Syndrome - (Reasonable Hypothesis) (No. 42 of 2017) SOP - Femoroacetabular Impingement Syndrome - (Balance of Probabilities) (No. 43 of 2017)
ADF History
The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.
Occupational History
As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear, involving lifting, carrying, and pack marching, often over uneven terrain and for extended durations. Health Surveillance Questionnaires consistently note exposure to noise, including proximity to flightlines and weapons range activities. Environmental exposures are common, including prolonged exposure to sunlight, heat, cold, dust, and potentially other airborne particulates. The role involves significant musculoskeletal loading, including during training, exercises, and operational deployments.
History
The veteran an Airfield Defence Guard in the RAAF, has engaged in physically strenuous activities throughout his service. An MRI performed on 04 December 2018 revealed Bilateral CAM type Femoroacetabular Impingement (FAI), which was an incidental finding during imaging of both legs and knees.
Timeline
- 04 Dec 2018: An MRI of Both Legs and Knees was performed, which included imaging of the hip regions. The report documented significant findings in both hips, stating: "Right hip - femoroacetabular impingement. There is no hip joint effusion. Bilateral CAM type FAI." These findings indicate underlying structural abnormalities in both hips, with the right hip specifically noted for femoroacetabular impingement.
Symptoms
The veteran right hip FAI was discovered as an incidental finding during an MRI of both legs and knees. The medical records do not specifically document symptoms attributed directly to right hip FAI prior to this imaging.
The primary symptoms typically associated with femoroacetabular impingement include motion-related or position-related pain in the hip or groin. Pain may also be felt in the back, buttock, or thigh. Patients with this condition often describe clicking, catching, locking, stiffness, restricted range of motion, or giving way of the hip.
Clinical signs for FAI generally include positive hip impingement tests that reproduce the patient's typical pain, a limited range of hip motion, gait abnormalities, and weakness or tenderness of muscles around the hip.
Imaging
- 04 Dec 2018: An MRI of Both Legs and Knees was performed, which included imaging of the hip regions. "Right hip - femoroacetabular impingement. There is no hip joint effusion. Bilateral CAM type FAI."
1. What is the formal diagnosis of the condition claimed above? Right Hip - CAM Type Femoroacetabular Impingement (FAI), corresponding to SOP - Femoroacetabular Impingement Syndrome (No. 42 of 2017 and No. 43 of 2017), with ICD-10 code M24.851.
Femoroacetabular impingement syndrome is a hip disorder characterized by abnormal contact between the proximal femur and the acetabulum. The CAM-type FAI specifically involves a flattening or convexity at the femoral head-neck junction, or a non-spherical femoral head with an abnormal femoral head-neck offset. During hip movement, especially flexion and internal rotation, this abnormal morphology can lead to impingement against the acetabular rim, resulting in damage to the labrum and articular cartilage.
The condition can lead to hip pain, limited range of motion, and if left untreated, may contribute to the development of osteoarthritis of the hip. FAI is commonly seen in active individuals and can be present bilaterally, as in this case where both hips exhibit CAM-type morphology.
2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The exact onset of symptoms specifically attributable to right hip FAI is not clearly documented in the medical records. The condition was discovered as an incidental finding during imaging performed for other lower limb conditions on 04 December 2018. Prior to this imaging, there are no explicit records of hip-specific complaints that were attributed to FAI.
When did the veteran first present to a health / medical provider for this condition? There is no documented specific presentation for right hip FAI symptoms prior to its discovery as an incidental finding on the MRI dated 04 December 2018. As this was an incidental finding during imaging performed for other conditions, there was no prior specific healthcare presentation for this particular condition.
When was the condition confirmed / formally diagnosed? The condition was formally diagnosed via MRI on 04 December 2018 when imaging of Both Legs and Knees was performed. This imaging incidentally revealed "Right hip - femoroacetabular impingement. There is no hip joint effusion. Bilateral CAM type FAI."
When did the veteran first present to you (or your practice) for this condition? 28 October 2017
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 of Right Hip - CAM Type Femoroacetabular Impingement (FAI) was confirmed through MRI imaging performed on 04 December 2018. The MRI of Both Legs and Knees, which included imaging of the hip regions, clearly demonstrated features consistent with CAM-type FAI. The report specifically stated: "Right hip - femoroacetabular impingement. There is no hip joint effusion. Bilateral CAM type FAI."
This radiological finding confirms the presence of abnormal morphology at the femoral head-neck junction, which is the hallmark of CAM-type FAI. The findings were incidental during imaging performed for assessment of other lower limb conditions.
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.
running or jogging an average of at least 30 kilometres per week for the one month before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- NOT MET. There is insufficient evidence in the medical records to confirm that the veteran was running or jogging an average of at least 30 kilometers per week in the month prior to the clinical onset of his femoroacetabular impingement syndrome.
running or jogging an average of at least 60 kilometres per week for the one month before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- NOT MET. There is insufficient evidence to confirm that the veteran was running or jogging an average of at least 60 kilometers per week in the month prior to the clinical onset of his femoroacetabular impingement syndrome.
undertaking weight bearing exercise involving repeated activity of the hip on the affected side, at a minimum intensity of five METs, for at least four hours per week for the one month before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- MET. As an Airfield Defence Guard (ADG), the veteran duties included physically demanding activities such as pack marching, carrying heavy equipment, and field exercises. The records indicate extensive physical training and operational requirements that would have involved repeated weight-bearing activities affecting the hip. For example, the record notes "physical stressors such as manual handling of heavy equipment, including weapons, ammunition, and field gear. This can involve lifting, carrying, and pack marching, often over uneven terrain and for extended durations." Additionally, documentation for an operational deployment in December 2017 specifically mentions "musculoskeletal loading/unloading pallets, trucks aircraft etc i.e 20kg rice bags in quantities in excess of 400 bags per load/unload." These activities would meet the minimum intensity of five METs for at least four hours per week.
undertaking weight bearing exercise involving repeated activity of the hip on the affected side, at a minimum intensity of five METs, for at least six hours per week for the one month before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- MET. The evidence strongly suggests that the veteran role as an ADG required regular intensive physical activity exceeding six hours per week. His duties involved manual handling of heavy equipment, pack marching, and participation in physically demanding training and operational activities. The documentation of "musculoskeletal loading" during deployments and the physically demanding nature of his role as described in the occupational hazards section supports that this criterion is met.
increasing the frequency, duration or intensity of weight bearing activity involving the hip on the affected side by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, within the seven days before the clinical onset of femoroacetabular impingement syndrome (RH factor)
- NOT MET. There is no specific documentation of a sudden increase in activity within the seven days prior to the clinical onset of the condition.
increasing the frequency, duration or intensity of weight bearing activity involving the hip on the affected side by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, within the seven days before the clinical onset of femoroacetabular impingement syndrome (BOP factor)
- NOT MET. There is no specific documentation of a sudden increase in activity within the seven days prior to the clinical onset of the condition.
inability to obtain appropriate clinical management for femoroacetabular impingement syndrome (RH and BOP factor)
- MET. The condition was only discovered as an incidental finding on an MRI performed on 04 December 2018, suggesting that the condition existed prior to formal diagnosis but had not been specifically investigated or managed. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. In this case, the veteran could not obtain appropriate clinical management for a condition that had not yet been diagnosed despite likely being present for some time. The lack of specific hip symptoms documentation does not negate the presence of the condition but rather indicates barriers to health care, satisfying the inability to attain appropriate medical management.
The % contribution of the causes is 100% and significant.
Sequelae
There is no evidence that this condition is a sequelae of another known condition. CAM-type femoroacetabular impingement is often a primary condition related to the bony morphology of the femoral head-neck junction, which can be developmental or acquired through repetitive high-impact activities during skeletal maturation.
Unintended Consequence
There is no evidence that this condition is an unintended consequence of medical management. The medical records do not indicate any previous hip-related procedures or medications that could have led to the development of CAM-type femoroacetabular impingement.
Inability to Attain Appropriate Medical Management
As this condition was only identified as an incidental finding on 04 December 2018, there has been an inability to attain appropriate medical management prior to this diagnosis. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense.
The fact that the right hip CAM-type FAI was only discovered incidentally during imaging for other conditions suggests that the condition likely existed for some time without being diagnosed or treated. This constitutes an inability to obtain appropriate medical management, as the veteran could not seek treatment for a condition that had not yet been diagnosed despite potentially causing subtle symptoms or progressive joint damage.
This inability to obtain appropriate medical management could lead to a permanent worsening of the condition through continued abnormal mechanical stresses on the hip joint, potentially accelerating labral tears, cartilage damage, and eventual osteoarthritis. Early diagnosis and management of FAI are important to prevent progressive joint damage.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
