Right Hip - Gluteal Tendinopathy — DVA claim example

Diagnostic Assessment — Right Hip - Gluteal Tendinopathy

Example 1 of 1 · fictitious patient (Veteran H)

Diagnostic Assessment

Right Hip - Gluteal Tendinopathy

BOP Code: 95 of 2023 (Gluteal Tendinopathy)
RH Code: 94 of 2023 (Gluteal Tendinopathy)

ADF History

Veteran H, date of birth 14 April 1985, Australian Army, Physical Training Instructor, enlisted 20 January 2004, medically discharged 15 March 2021. Operational service: Afghanistan, 05 February 2012 to 20 October 2012 (warlike); Middle East Area of Operations (Iraq), 12 January 2018 to 30 July 2018 (warlike).

Occupational History

As an Army physical training instructor the veteran led and took part in daily physical training: distance running, interval and hill running, pack marching with loads of 20 to 35 kilograms, stair and step circuits, obstacle courses and agility work. Instructors routinely run and march more than the soldiers they train, because they demonstrate, pace and supervise several groups each week, and they are expected to maintain a very high level of personal fitness.

On deployment the trade also involves dismounted patrolling and load carriage over rough, rocky ground, repeated climbing in and out of protected vehicles with equipment, and long periods of standing. These duties place sustained, repetitive load on the hip abductor tendons, and falls onto the lateral hip from vehicles and uneven ground are a recognised hazard. Field and deployed conditions also carry a risk of gastrointestinal infection, and access to physiotherapy, imaging and specialist care is limited.

History

Veteran H, an Army physical training instructor, developed right gluteal tendinopathy on 18 June 2012 during warlike service in Afghanistan, after a fall onto her right lateral hip, a period of very high running and load-carriage volume and a sudden increase in patrol duties. The condition worsened in October 2018 after her deployment to Iraq, where she developed reactive arthritis with an abnormal gait and could not obtain treatment, followed by weight gain and right hip arthroscopy.

Timeline

• 12 Jan 2012 — Pre-deployment medical examination before Afghanistan. The veteran reported no hip, groin or buttock pain. Examination of both hips was normal, with full range of movement and no tenderness over the greater trochanters. Weight 64 kg, height 1.67 m, BMI 22.9. She was fit for deployment as a physical training instructor attached to a task group headquarters. "hips NAD, fit to deploy"
• 31 May 2012 — At a patrol base in Afghanistan the veteran presented after falling from the rear step of a protected mobility vehicle onto rocky ground the previous evening, landing directly on her right lateral hip with her body armour and pack on. There was a 6 cm haematoma over the right greater trochanter, marked tenderness and painful, restricted hip abduction and internal rotation. The medical officer injected corticosteroid and local anaesthetic into the right peritrochanteric region of the hip. She resumed running two days later. "fall onto R lateral hip"
• 20 Jun 2012 — Presentation to the role 2 medical facility with two days of right lateral hip pain, worse lying on the right side, climbing into vehicles and on stairs. In the preceding four weeks she had averaged 64 km of running a week while running the task group fitness program and training for a base half-marathon, and from 11 June she had been tasked to daily dismounted patrols, increasing her load-carriage time from about 1.5 to 4.5 hours a day. There was tenderness over the right greater trochanter, a positive single-leg stance test and pain on resisted abduction. "R trochanteric pain, SLS positive"
• 05 Nov 2012 — After return to Australia, ultrasound of the right hip showed tendinosis of the gluteus medius tendon at its insertion. A sports physician confirmed right gluteal tendinopathy and prescribed a graded isometric loading program with load modification. She was restricted from running and pack marching for three months. Symptoms improved but did not resolve, and pain recurred with prolonged running. "gluteus medius tendinosis confirmed"
• 06 Mar 2018 — During warlike service in Iraq the veteran developed a painful swollen left knee and left ankle and left Achilles enthesitis three weeks after culture-proven Campylobacter gastroenteritis on 08 February 2018. The role 2 medical officer diagnosed reactive arthritis and prescribed naproxen. She walked with an antalgic left-sided limp and a right Trendelenburg sign, transferring her weight onto the right hip. No physiotherapy or imaging was available and her right hip loading program could not be continued. "reactive arthritis, antalgic gait"
• 14 Aug 2018 — After return to Australia a rheumatologist confirmed HLA-B27 positive reactive arthritis and commenced prednisolone 25 mg daily. Weight had risen to 85 kg. An MRI arthrogram of the right hip showed an anterosuperior labral tear, attributed to the 2012 fall, and an orthopaedic surgeon listed her for arthroscopy. Her gait remained antalgic and she continued to offload onto the right leg. "HLA-B27 positive, prednisolone 25 mg"
• 20 Sep 2018 — Right hip arthroscopy with labral repair under general anaesthetic. She was discharged on crutches, partial weight bearing for four weeks, with an altered, shuffling gait. Analgesia and prednisolone continued. "R hip arthroscopy, labral repair"
• 10 Oct 2018 — Review by the sports physician for markedly increased right lateral hip pain, night pain and inability to lie on the right side. The VISA-G score had fallen from 62 in 2017 to 31, and resting pain was 8 out of 10 compared with 4 out of 10 before deployment. Weight 87 kg, BMI 31.2. MRI the same day showed a partial-thickness tear of the gluteus medius tendon with tendinosis of gluteus minimus. Ultrasound-guided injection and a supervised rehabilitation program were arranged. "worse, partial GMed tear, BMI 31.2"

Symptoms

At onset the veteran had right lateral hip pain radiating into the buttock and down the outer thigh, worse with running, stairs, climbing into vehicles, standing on the right leg and lying on the right side at night. There was tenderness over the greater trochanter and pain on resisted hip abduction.

After the 2018 worsening she developed constant lateral hip pain, night pain that woke her several times a night, a limp after walking more than 500 metres and difficulty with stairs and getting in and out of cars. She now walks with a stick on longer outings, cannot run and cannot lie on her right side.

Imaging

• 05 Nov 2012 — Ultrasound right hip: "Thickened, hypoechoic gluteus medius tendon at its insertion on the greater trochanter consistent with tendinosis. Small volume of fluid in the trochanteric bursa."
• 14 Aug 2018 — MRI arthrogram right hip: "Anterosuperior labral tear. Gluteus medius tendinosis. No hip osteoarthritis."
• 10 Oct 2018 — MRI right hip: "Partial-thickness undersurface tear of the gluteus medius tendon at the lateral facet of the greater trochanter with surrounding oedema. Tendinosis of gluteus minimus. Trochanteric bursitis. Post-arthroscopic changes."

Onset Date

The most likely date of onset of this condition is 18 Jun 2012.

At that date the veteran was serving on warlike service in Afghanistan as a physical training instructor with a task group headquarters. She was running the task group fitness program, training for a base half-marathon and, from 11 June 2012, conducting daily dismounted patrols with body armour and a pack. On 18 June 2012 she developed right lateral hip pain that did not settle overnight.

This date is appropriate because her pre-deployment medical examination of 12 January 2012 recorded normal hips with no lateral hip pain, and she first presented with the symptoms at the role 2 medical facility on 20 June 2012, two days after they began. It falls within uninterrupted full-time warlike service.

For the running factor and the weight bearing exercise factor, the 4 weeks before onset run from 21 May 2012 to 18 Jun 2012; during this period she averaged 64 km of running a week and more than 7 hours a week of pack marching, step circuits and brisk walking. For the direct trauma factor, the 4 weeks before onset run from the same 21 May 2012; she fell onto her right lateral hip on 30 May 2012 and received a corticosteroid and local anaesthetic injection into the hip on 31 May 2012. For the increased activity factor, the one week before onset runs from 11 Jun 2012 to 18 Jun 2012, during which her hip loading activity rose from about 1.5 to 4.5 hours a day of patrolling at 6 to 8 METs.

For the worsening factors, the condition was established and documented in Afghanistan in June 2012 and confirmed on ultrasound in November 2012. The worsening is documented on 10 Oct 2018 by a fall in the VISA-G score from 62 to 31 and a new partial-thickness gluteus medius tear on MRI. The 4 weeks before the worsening run from 12 Sep 2018 to 10 Oct 2018; during this period she had right hip arthroscopy on 20 September 2018 and walked with a significantly abnormal gait from reactive arthritis and crutches. Reactive arthritis was diagnosed on 06 March 2018, before the worsening, and she was obese, with a BMI of 31.2, at the worsening. From February to July 2018 she could not obtain appropriate clinical management for the tendinopathy in Iraq.

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

The formal diagnosis is Right Hip - Gluteal Tendinopathy (ICD-10-AM M76.0), under the Statements of Principles concerning gluteal tendinopathy, Balance of Probabilities No. 95 of 2023 and Reasonable Hypothesis No. 94 of 2023.

Gluteal tendinopathy is a symptomatic inflammatory or degenerative disease of the gluteus medius and gluteus minimus tendons at or near their insertion into the greater trochanter of the femur. It was previously grouped under the term greater trochanteric pain syndrome or trochanteric bursitis. It is caused by excessive or poorly tolerated tensile and compressive load on the abductor tendons, for example from high-volume running, load carriage, sudden increases in activity, direct trauma and altered hip mechanics. It causes lateral hip pain, pain lying on the affected side and difficulty with stairs and single-leg loading, and it can progress to degenerative partial or full-thickness tendon tears.

The condition began on 18 June 2012 during warlike service in Afghanistan, was confirmed on ultrasound in November 2012, and worsened in October 2018 with a partial-thickness gluteus medius tear.

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

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

18 June 2012.

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

20 June 2012.

When was the condition confirmed / formally diagnosed?

05 November 2012.

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

18 June 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis is clinical, supported by imaging. On 20 June 2012 the veteran had right lateral hip pain with focal tenderness over the greater trochanter, a positive 30-second single-leg stance test and pain on resisted hip abduction, the recognised clinical features of gluteal tendinopathy. Ultrasound on 05 November 2012 showed tendinosis of the gluteus medius tendon at its insertion, and a sports physician confirmed the diagnosis. This meets the Statement of Principles definition: a symptomatic degenerative disease of the gluteus medius tendon at its insertion into the greater trochanter.

MRI on 10 October 2018 confirmed progression to a partial-thickness undersurface tear of gluteus medius with tendinosis of gluteus minimus, together with a fall in the VISA-G functional score from 62 to 31. The hip joint itself showed no osteoarthritis, and the lumbar spine was not the source of the lateral hip pain.

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 18 June 2012, 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. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2012, where the condition began, and in Iraq in 2018, where the reactive arthritis, abnormal gait and lack of treatment that led to the worsening arose.

In both instruments each factor applies to either the clinical onset or the clinical worsening of the condition, except the final factor, which applies to worsening only. The factors that were met at onset are grouped as causative factors and those met at the 2018 worsening are grouped as worsening factors. 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 Gluteal Tendinopathy, No. 95 of 2023

Causative factors

Factor 9(1): running or jogging an average of at least 60 kilometres per week for the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- In the 4 weeks before onset, from 21 May 2012 to 18 June 2012, the veteran ran an average of 64 km a week, recorded in her training log and in the role 2 notes of 20 June 2012. As the task group's physical training instructor she ran with each of several training groups during the week, led interval and hill sessions and was preparing for a base half-marathon. This running was part of her duties in full-time service.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the hip on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 6 hours per week; and for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- In addition to running, throughout the 4 weeks before onset, from 21 May 2012 to 18 June 2012, the veteran completed more than 7 hours a week of pack marching with 25 to 30 kg, step and stair circuits and sustained brisk walking in supervised physical training sessions, each at 6 to 8 METs. These activities involve repeated loading of the right hip and were required by her duties as a physical training instructor.

Factor 9(3): increasing the frequency, duration or intensity of activity involving the hip on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 4 hours per day; within the one week before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- On 11 June 2012, one week before onset, the veteran was tasked to daily dismounted patrols over rocky ground carrying body armour and a 30 kg pack. Her daily load-carriage time rose from about 1.5 hours to 4.5 hours, an increase of 200 per cent, at an intensity of 6 to 8 METs, every day from 11 June 2012 to 18 June 2012. The increase was directed by her chain of command.

Factor 9(4): having direct trauma to the affected tendon within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- On 30 May 2012, 19 days before onset, the veteran fell from the rear step of a protected mobility vehicle onto rocky ground, landing directly on her right greater trochanter while carrying body armour and a pack. She had a 6 cm haematoma, pain, tenderness and restricted hip abduction and internal rotation. On 31 May 2012 the medical officer injected corticosteroid and local anaesthetic into the right hip, which satisfies the dictionary definition of direct trauma to the affected tendon. The fall occurred while she was performing her duties.

Worsening factors

Factor 9(5): having surgery to the hip of the affected side within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- The veteran had right hip arthroscopy with labral repair on 20 September 2018, 20 days before the documented worsening on 10 October 2018. The labral tear was attributed to the fall from a vehicle during service in 2012, and the surgery was performed and funded by Defence while she was serving.

Factor 9(6): having a systemic inflammatory disease before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- The veteran developed reactive arthritis on 06 March 2018 after culture-proven Campylobacter gastroenteritis on 08 February 2018, confirmed as HLA-B27 positive reactive arthritis by a rheumatologist on 14 August 2018. Reactive arthritis is a systemic inflammatory disease in the dictionary. It was established before the worsening on 10 October 2018 and was contracted while she was serving.

Factor 9(7): having a significantly abnormal gait for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- From 06 March 2018 the veteran walked with an antalgic left-sided limp from reactive arthritis of the left knee and ankle, with a right Trendelenburg sign and her weight shifted onto the right hip. After arthroscopy on 20 September 2018 she was on crutches, partial weight bearing. Her gait was significantly abnormal throughout the 4 weeks before the worsening, from 12 September 2018 to 10 October 2018, as recorded by the rheumatologist, surgeon and physiotherapist.

Factor 9(8): being obese at the time of the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- At the worsening on 10 October 2018 the veteran weighed 87 kg at a height of 1.67 m, a BMI of 31.2. Her weight had risen from 64 kg in 2012 after she was restricted from running and pack marching because of the tendinopathy, and then with inactivity from reactive arthritis and prednisolone 25 mg daily from August 2018, all during service.

Factor 9(9): inability to obtain appropriate clinical management for gluteal tendinopathy before the clinical worsening of gluteal tendinopathy. — MET

- From February to July 2018, while deployed, the veteran had no access to physiotherapy, imaging or image-guided injection, and her prescribed tendon loading program could not be continued alongside the reactive arthritis. On return to Australia she waited eight weeks for specialist review and imaging. The tendinopathy went without appropriate management for about seven months before the worsening on 10 October 2018. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Gluteal Tendinopathy, No. 94 of 2023

Causative factors

Factor 9(1): running or jogging an average of at least 30 kilometres per week for the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- During warlike service in Afghanistan, in the 4 weeks before onset from 21 May 2012 to 18 June 2012, the veteran ran an average of 64 km a week running the task group fitness program and training for a base half-marathon, more than twice the 30 km threshold.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the hip on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 4 hours per week; and for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- During warlike service in Afghanistan, throughout the 4 weeks before onset from 21 May 2012 to 18 June 2012, the veteran completed more than 7 hours a week of pack marching, step circuits and sustained brisk walking at 6 to 8 METs, all involving repeated loading of the right hip.

Factor 9(3): increasing the frequency, duration or intensity of activity involving the hip on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; within the one week before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- From 11 June 2012, one week before onset, the veteran's daily dismounted patrolling with body armour and a 30 kg pack in Afghanistan rose from about 1.5 to 4.5 hours a day, an increase of 200 per cent, at 6 to 8 METs. This tasking was part of her warlike service.

Factor 9(4): having direct trauma to the affected tendon within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- On 30 May 2012, during warlike service in Afghanistan, the veteran fell from a protected mobility vehicle directly onto her right greater trochanter, with haematoma, pain, tenderness and restricted hip movement, and was treated with a corticosteroid and local anaesthetic injection into the right hip on 31 May 2012, 18 days before onset.

Worsening factors

Factor 9(5): having surgery to the hip of the affected side within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- Right hip arthroscopy with labral repair on 20 September 2018 was performed 20 days before the worsening on 10 October 2018. The labral tear arose from the fall from a vehicle on warlike service in Afghanistan on 30 May 2012.

Factor 9(6): having a systemic inflammatory disease before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- Reactive arthritis followed Campylobacter gastroenteritis contracted during warlike service in Iraq on 08 February 2018, was diagnosed on 06 March 2018 in Iraq and was present before the worsening on 10 October 2018.

Factor 9(7): having a significantly abnormal gait for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- The antalgic gait with a right Trendelenburg sign began on 06 March 2018 with reactive arthritis contracted on warlike service in Iraq, and continued, with crutch walking after the arthroscopy for the Afghanistan injury, throughout the 4 weeks from 12 September 2018 to 10 October 2018.

Factor 9(8): being obese at the time of the clinical onset or clinical worsening of gluteal tendinopathy; — MET

- The veteran's BMI was 31.2 at the worsening on 10 October 2018. The weight gain followed activity restriction from the tendinopathy that began on warlike service in Afghanistan, and inactivity and prednisolone treatment for reactive arthritis contracted on warlike service in Iraq.

Factor 9(9): inability to obtain appropriate clinical management for gluteal tendinopathy before the clinical worsening of gluteal tendinopathy. — MET

- During warlike service in Iraq from February to July 2018 there was no physiotherapy, imaging or image-guided injection available, and her tendon rehabilitation program stopped. The condition went untreated for about seven months before the worsening on 10 October 2018.

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

Sequelae

The right gluteal tendinopathy has led to a chronic antalgic gait and reduced walking tolerance, which load the lumbar spine and the left hip. Disturbed sleep from night pain and the loss of her ability to exercise contributed to further weight gain. These are sequelae of the accepted condition and should be considered in any related claim.

Unintended Consequence

Met. The worsening of the tendinopathy followed right hip arthroscopy on 20 September 2018 and the period of crutch walking that followed, and was compounded by weight gain from prednisolone prescribed for reactive arthritis. Both treatments were provided and paid for by Defence while the veteran was serving, and the worsening is an unintended consequence of that treatment under the MRCA.

Inability to Attain Appropriate Medical Management

MET. From February to July 2018, during warlike service in Iraq, the veteran's diagnosed gluteal tendinopathy could not be managed: no physiotherapist was available, there was no ultrasound for diagnosis or guided injection, and the loading program prescribed in Australia could not be continued once she developed reactive arthritis. On return she waited a further eight weeks for imaging and specialist review. Over that period her VISA-G score fell from 62 to 31 and MRI showed a new partial-thickness tear. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent prescribed treatment amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 12 Jan 2012, Pre-deployment medical examination, Medical Officer, Garrison health centre
2. 31 May 2012, Patrol base treatment record, Medical Officer, Afghanistan
3. 20 Jun 2012, Role 2 medical facility record, Medical Officer, Afghanistan
4. 05 Nov 2012, Ultrasound right hip, Radiologist
5. 05 Nov 2012, Sports medicine consultation, Sports physician
6. 06 Mar 2018, Role 2 medical facility record, Medical Officer, Iraq
7. 14 Aug 2018, Rheumatology consultation, Rheumatologist
8. 14 Aug 2018, MRI arthrogram right hip, Radiologist
9. 20 Sep 2018, Operation report, Orthopaedic surgeon
10. 10 Oct 2018, MRI right hip, Radiologist
11. 10 Oct 2018, Sports medicine review, Sports physician
12. Statement of Principles concerning Gluteal Tendinopathy (Balance of Probabilities) No. 95 of 2023, Repatriation Medical Authority
13. Statement of Principles concerning Gluteal Tendinopathy (Reasonable Hypothesis) No. 94 of 2023, Repatriation Medical Authority