Diagnostic Assessment — Right Hip - Femoroacetabular Impingement Syndrome
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
RIGHT HIP - FEMOROACETABULAR IMPINGEMENT SYNDROME
Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) Instrument No. 70 of 2019 and Statement of Principles concerning femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019.
ADF History
Name: The veteran Date of Birth: [withheld] Occupation: Communications, SASR Enlistment Date: 17 Dec 1993 Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran has been exposed to significant physical demands affecting the hip joints bilaterally. SASR operations require tactical movements including deep squatting, repetitive climbing, crawling, and running with heavy loads over variable terrain. Communications specialists often work in confined spaces requiring sustained awkward hip positions during equipment setup and operation. Military physical training involves high-intensity activities including loaded marches, obstacle courses, and strength training that place repetitive stress on the hip joints. These occupational activities can exacerbate anatomical predispositions to femoroacetabular impingement and contribute to progressive symptoms over time.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed right hip pain during tactical training exercises and physical conditioning. While less symptomatic than his left hip, diagnostic imaging has confirmed bilateral femoroacetabular impingement syndrome, with the right hip demonstrating mixed cam and pincer-type morphology.
Timeline
- 05 Aug 2016: Initial mention of right hip discomfort during follow-up for more significant left hip symptoms. Patient reports occasional discomfort with similar movements as left hip. • 18 Aug 2016: Physical examination documented mild limitation in internal rotation of the right hip with subtle impingement signs. Less pronounced than left side but similar pattern. • 29 Aug 2016: X-rays of pelvis and bilateral hips performed. Bilateral cam morphology with additional mild pincer component on the right. • 14 Sep 2016: Increasing right hip symptoms noted during physical therapy for left hip. Patient reports progression of right hip discomfort with deep squatting. • 28 Sep 2016: Comparative examination noted similar but less pronounced impingement signs on the right compared to left. Positive FADIR test bilaterally, more painful on left. • 09 Oct 2016: MRI Arthrogram of the right hip performed. Mixed cam and pincer-type morphology. No definite labral tear but evidence of impingement. • 23 Oct 2016: Orthopedic consultation confirming bilateral femoroacetabular impingement syndrome. Symptomatic bilateral FAI, left greater than right.
Symptoms
The veteran initially reported mild right hip discomfort in the context of more significant left hip symptoms. The right hip pain was described as a dull ache in the groin and anterior hip region, particularly noticeable during deep squatting, prolonged sitting in tactical vehicles, and after intense physical training. While less severe than his left hip symptoms, the right hip demonstrated a similar pattern of impingement-related pain with certain movements. Physical examination revealed mild limitation in internal rotation with reproduction of symptoms during impingement testing (FADIR test). Current symptoms include intermittent activity-related discomfort that worsens with the same movements that aggravate the left hip, but at a lower intensity level. There are fewer mechanical symptoms in the right hip compared to the left, consistent with the absence of significant labral pathology on imaging.
Imaging
29 Aug 2016 - X-RAY PELVIS AND BILATERAL HIPS: AP pelvis and lateral hip views demonstrate bilateral cam-type morphology of the femoral head-neck junctions with alpha angles of 62 degrees on the left and 58 degrees on the right (normal <55 degrees). The right acetabulum shows mild retroversion with crossover sign, suggesting a mild pincer component not seen on the left. Joint spaces are preserved bilaterally. No fracture or dislocation identified. IMPRESSION: Bilateral femoroacetabular impingement morphology, cam-type bilaterally with additional mild pincer component on the right.
09 Oct 2016 - MRI ARTHROGRAM RIGHT HIP: Following intra-articular contrast injection, images demonstrate mixed cam and pincer-type morphology with alpha angle of 59 degrees and mild acetabular retroversion. There is no definite labral tear identified, but subtle signal changes at the anterosuperior labrum suggest early impingement. The articular cartilage appears intact. No stress fracture or avascular necrosis. Minimal joint effusion present. IMPRESSION: Mixed cam and pincer-type femoroacetabular impingement morphology of the right hip without definite labral tear.
1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Right Hip Femoroacetabular Impingement Syndrome (ICD-10 Code: M25.85). This diagnosis falls under the DVA Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) Instrument No. 70 of 2019 and Statement of Principles concerning femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019.
Femoroacetabular impingement (FAI) syndrome is a clinical disorder characterized by symptomatic premature contact between the femoral head-neck junction and the acetabular rim during hip motion, particularly flexion and internal rotation. This abnormal contact can lead to damage of the acetabular labrum and articular cartilage over time. There are two primary morphological types of FAI: cam-type (abnormal femoral head-neck junction contour) and pincer-type (acetabular overcoverage). The veteran has mixed morphology in his right hip, with both cam features (alpha angle of 58-59 degrees) and mild pincer features (acetabular retroversion with crossover sign).
In the veteran case, the right hip demonstrates features of FAI syndrome that are similar to but less advanced than his left hip, with absence of significant labral pathology on imaging. This suggests an earlier stage of the condition or a less severe manifestation in the right hip compared to the left.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to right hip femoroacetabular impingement syndrome on or before 05 August 2016, when he initially reported right hip discomfort during a follow-up appointment for his more significant left hip symptoms.
When did the veteran first present to a health / medical provider for this condition? The veteran first mentioned right hip symptoms to a health provider on 05 August 2016, during an appointment primarily focused on his left hip condition.
When was the condition confirmed / formally diagnosed? The condition was initially suspected based on clinical examination and bilateral hip X-rays on 29 August 2016, which demonstrated mixed cam and pincer-type morphology in the right hip. Definitive confirmation was provided by MRI arthrogram on 09 October 2016. The diagnosis of bilateral femoroacetabular impingement syndrome was formally established by an orthopedic specialist on 23 October 2016.
When did the veteran first present to you (or your practice) for this condition? 26 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 of Right Hip Femoroacetabular Impingement Syndrome was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included: • Dull ache in the groin and anterior hip region • Pain exacerbated by deep squatting and prolonged sitting • Activity-related discomfort after intense physical training • Similar pattern of impingement-related pain as the left hip but less severe
Clinical examination findings included: • Mild limitation in internal rotation of the right hip • Positive femoroacetabular impingement testing (FADIR test), though less painful than the left side • Reproduction of symptoms with provocative maneuvers specific for FAI • Absence of significant mechanical symptoms such as catching or locking
Diagnostic imaging provided definitive confirmation:
- X-ray of the Pelvis and Bilateral Hips (29 August 2016) demonstrated cam-type morphology with alpha angle of 58 degrees and mild acetabular retroversion with crossover sign
- MRI Arthrogram of the Right Hip (09 October 2016) provided detailed assessment showing mixed cam and pincer-type morphology with alpha angle of 59 degrees
Specialist opinion from an orthopedic consultation on 23 October 2016 confirmed the diagnosis of bilateral femoroacetabular impingement syndrome, noting that both hips were symptomatic but the left was more significantly affected than the right.
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.
Factors under Statement of Principles concerning femoroacetabular impingement syndrome (Balance of Probabilities) Instrument No. 71 of 2019:
having cam-type femoroacetabular impingement morphology of the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: MET
- Imaging studies demonstrate cam-type morphology with an alpha angle of 58-59 degrees, which exceeds the normal threshold of 55 degrees. This morphological variant is one of the primary underlying anatomical factors for the development of the syndrome in the right hip.
having pincer-type femoroacetabular impingement morphology of the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: MET
- Imaging studies demonstrate mild acetabular retroversion with crossover sign on X-ray, consistent with pincer-type morphology. This represents the second morphological component contributing to the impingement syndrome in the right hip.
having slipped capital femoral epiphysis before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of slipped capital femoral epiphysis.
having Legg-Calvé-Perthes disease before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of Legg-Calvé-Perthes disease.
having trauma to the affected hip, including surgery, before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No documented specific hip trauma or surgery prior to symptom onset.
having acetabular dysplasia involving the affected hip at the time of the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No radiographic evidence of acetabular dysplasia.
having a malunited fracture of the proximal femur or pelvis before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No history or radiographic evidence of proximal femur or pelvic fracture.
having a disease from the specified list before the clinical onset of femoroacetabular impingement syndrome: NOT MET
- No evidence of conditions from the specified list.
inability to obtain appropriate clinical management for femoroacetabular impingement syndrome: NOT MET
- This is a clinical worsening factor. There is no evidence that appropriate management was unavailable once symptoms developed.
The bilateral nature of the veteran FAI syndrome, with similar morphological features but differing severity of symptoms and pathological changes, suggests that his underlying anatomy has been subjected to similar stressors on both sides. The occupational activities associated with SASR service contributed significantly to the progression from asymptomatic morphology to symptomatic syndrome in both hips, though to a lesser degree in the right hip compared to the left.
Sequelae
There is no indication that the right hip femoroacetabular impingement syndrome is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the right hip femoroacetabular impingement syndrome resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his right hip condition. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, specialist consultation, and implementation of a treatment plan.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
