Diagnostic Assessment — Right Hip - Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran DW)
Diagnostic Assessment
Right Hip - Osteoarthritis
BOP Code: 62 of 2017 (Osteoarthritis)
RH Code: 61 of 2017 (Osteoarthritis)
ADF History
Veteran DW, date of birth 08 November 1968, Royal Australian Navy, Clearance Diver (Able Seaman to Chief Petty Officer), enlisted 14 February 1987, discharged 30 November 2017. Operational service: Persian Gulf, 16 January 1991 to 30 May 1991 (warlike); East Timor, 21 September 1999 to 18 December 1999 (warlike); Iraq, 05 March 2003 to 02 June 2003 (warlike); Afghanistan, 05 November 2009 to 22 April 2010 (warlike, ended by aeromedical evacuation after a blast injury).
Occupational History
As a clearance diver the veteran conducted mine countermeasures, explosive ordnance disposal, ship hull searches and underwater demolition, made thousands of air and mixed-gas dives, and manually handled diving sets, demolition charges and equipment of 20 to 40 kilograms on boats, wharves and ships. Life at sea involved repeated climbing of ships' ladders and accommodation in multi-deck vessels, and land-based explosive ordnance disposal involved prolonged kneeling and squatting.
Clearance divers are exposed to decompression illness and dysbaric osteonecrosis of the hip and shoulder, coral and marine injuries with infection, cold injury, blast, and heavy cumulative loading of the hips and knees. On land-based counter-improvised explosive device tasks they share the blast risks of combat engineers.
History
Veteran DW, a Navy clearance diver, developed osteoarthritis of the right hip on 19 April 2016, six years after a fracture-dislocation of the right hip from an improvised explosive device blast in Afghanistan, on a background of dysbaric osteonecrosis of the femoral head, septic arthritis after a coral injury in East Timor, ankylosing spondylitis, haemochromatosis and decades of heavy lifting and ladder climbing. The osteoarthritis worsened in August 2021 while total hip replacement was delayed.
Timeline
- 02 Mar 1991 — On warlike service in the Persian Gulf the veteran's diving team boat broke down during a clearance task on 22 February 1991 and he and two team members were held as prisoners by enemy soldiers for six days before being released at the ceasefire. Post-release medical examination recorded dehydration, weight loss of 6 kilograms and bruising from rough handling. He returned to clearance diving duties in March 1991. "six days captivity, dehydration"
- 11 Jul 1995 — A rheumatologist diagnosed ankylosing spondylitis with bilateral sacroiliitis on MRI, HLA-B27 positive, and synovitis of the right hip on ultrasound, after two years of inflammatory back pain and right groin pain. Treatment was with NSAIDs and courses of oral prednisolone for flares. In June 1998 he had type II (spinal) decompression sickness after a deep dive, treated with recompression, which left reduced position and vibration sense in the right leg. "AS with right hip synovitis"
- 24 Nov 1999 — On warlike service in East Timor the veteran sustained a coral laceration of the right leg during a harbour clearance dive that became infected. Ten days later he developed fever and severe right hip pain. Aspiration of the right hip grew Staphylococcus aureus, and after evacuation he underwent arthrotomy and washout and six weeks of antibiotics for septic arthritis. "septic arthritis right hip"
- 14 Oct 2008 — MRI of the hips for right groin pain showed dysbaric osteonecrosis of the right femoral head, a juxta-articular subchondral lesion without collapse, and a cam deformity with an anterosuperior labral tear. Femoroacetabular impingement syndrome was diagnosed. Ferritin was 1,850 micrograms per litre and HFE testing confirmed haemochromatosis with arthropathy of the hips, treated with venesection. "dysbaric osteonecrosis, cam FAI"
- 18 Apr 2010 — On warlike service in Afghanistan, three months after frostbite of the skin over the right hip and buttock while lying in snow during a high-altitude clearance task in January 2010, the veteran was injured by an improvised explosive device. He sustained a posterior fracture-dislocation of the right hip with an acetabular posterior wall fracture, haemarthrosis, an acute labral and articular cartilage tear, a right sciatic nerve injury with foot drop, and tears of the right anterior cruciate ligament and medial meniscus. The hip was reduced and the acetabulum fixed with plates and screws. "right hip fracture-dislocation, sciatic palsy"
- 08 May 2012 — An endocrinologist confirmed acromegaly with a raised IGF-1 and a pituitary macroadenoma, treated surgically. DXA showed increased bone mineral density with a total hip T-score of +1.8. In 2013 a bone scan and raised alkaline phosphatase showed Paget's disease of the right hemipelvis and proximal femur involving the hip. The rehabilitation physician recorded a persistent asymmetric gait with an ankle-foot orthosis, malunion of the posterior acetabular wall with retroversion, and reduced pain and position sense around the right hip. "acromegaly; Paget's right hemipelvis"
- 26 Apr 2016 — The veteran presented to the base medical centre with right groin and buttock pain, stiffness and difficulty putting on socks since 19 April 2016. Radiographs showed superolateral joint space narrowing, femoral and acetabular osteophytes and subchondral sclerosis of the right hip. Radiographs on 10 June 2014 had shown a united acetabular fracture with a preserved joint space and no osteophytes. Internal rotation was 10 degrees. BMI 31, waist 110 cm. "right hip OA, joint space narrowing"
- 03 Aug 2021 — An orthopaedic surgeon recorded severe right hip pain at night and walking tolerance of 300 metres. Total hip replacement had been recommended in June 2019 but had not been performed after a 26-month delay while liability was disputed and he waited on a public list. DXA in 2020 showed osteoporosis with a lumbar T-score of -2.6 after repeated glucocorticoids and hypogonadism. Radiographs showed bone-on-bone narrowing, cysts and early femoral head collapse. Total hip replacement was performed in March 2022. "end-stage right hip OA"
Symptoms
At onset the veteran had right groin and buttock pain on walking and climbing ladders, morning stiffness, pain on prolonged sitting and difficulty with shoes and socks, with restricted internal rotation of the hip.
Since the worsening he has had constant right hip pain, night pain, a limp, walking tolerance of 300 metres before the replacement, and inability to run, kneel or climb ladders. After the hip replacement he remains limited on stairs and uneven ground and cannot return to diving.
Imaging
- 14 Oct 2008 — MRI hips: "Dysbaric osteonecrosis of the right femoral head, juxta-articular, without collapse. Cam deformity of the right femoral head-neck junction with anterosuperior labral tear."
- 18 Apr 2010 — CT pelvis and right hip (role 3 hospital): "Posterior dislocation of the right hip with a comminuted posterior wall acetabular fracture involving the articular surface. Haemarthrosis. Intra-articular osteochondral fragment."
- 10 Jun 2014 — Right hip radiographs: "United acetabular fracture with retained fixation. Joint space preserved. No osteophytes."
- 26 Apr 2016 — Right hip radiographs: "Superolateral joint space narrowing, femoral and acetabular osteophytes and subchondral sclerosis, consistent with osteoarthritis."
- 03 Aug 2021 — Right hip radiographs: "Severe osteoarthritis with bone-on-bone narrowing, subchondral cysts and early collapse of the superolateral femoral head."
Onset Date
The most likely date of onset of this condition is 19 Apr 2016.
At that date the veteran was a serving chief petty officer clearance diver in a shore-based training appointment in Australia, restricted from diving since his 2010 injuries. From that date he had persistent mechanical right hip pain and stiffness, distinct from his earlier inflammatory and infective episodes.
This date is appropriate because radiographs on 10 June 2014 showed a preserved joint space with no osteophytes, and he first presented with the new symptoms on 26 April 2016, when radiographs showed osteoarthritis. The onset falls within continuous full-time service.
The captivity of 1991, the ankylosing spondylitis from 1995, the septic arthritis of Nov 1999, the osteonecrosis, impingement and haemochromatosis of 2008, the frostbite of Jan 2010 and the fracture-dislocation, haemarthrosis, cartilage tear, nerve injury and knee injuries of 18 Apr 2010 all preceded onset, the dislocation by six years. The 25 years before onset run from 19 Apr 1991 to 19 Apr 2016. For the asymmetric gait and disordered mechanics factors, the 5 years before onset run from 19 Apr 2011 to 19 Apr 2016, and both were present from 18 Apr 2010. For the overweight and waist factors, the 10 years before onset run from 19 Apr 2006 to 19 Apr 2016, and his BMI was above 25 and waist above 102 cm from 2004. Lifting of about 340,000 kilograms occurred from 1992 to 2002 and carrying of about 3,900 hours from 1994 to 2004, and the onset falls within 25 years of each period. Ladder and stair climbing of more than 150 a day occurred continuously at sea from Jan 2000 to Dec 2005. Kneeling and squatting for more than an hour a day occurred continuously from 2004 to 2010.
For the worsening factors, the period after onset runs from 19 Apr 2016 to the documented worsening on 03 Aug 2021. The 25 years before the worsening run from 03 Aug 1996 to 03 Aug 2021. Osteoporosis was confirmed in 2020, and the recommended hip replacement could not be obtained from Jun 2019 to Aug 2021.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Hip - Osteoarthritis (ICD-10-AM M16.5), post-traumatic osteoarthritis of the right hip, 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 evidence of loss of articular cartilage or osteophytes. In the hip it causes groin and buttock pain, loss of internal rotation and a limp, and it commonly progresses to the need for joint replacement. It is accelerated by acetabular fracture and dislocation, osteonecrosis of the femoral head, infection, inflammatory and depositional arthritis, femoroacetabular impingement, abnormal joint mechanics and heavy cumulative loading.
The osteoarthritis began on 19 April 2016, was confirmed on radiographs on 26 April 2016 and worsened in August 2021, leading to total hip replacement in March 2022.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
19 April 2016.
When did the veteran first present to a health / medical provider for this condition?
26 April 2016.
When was the condition confirmed / formally diagnosed?
26 April 2016.
When did the veteran first present to you (or your practice) for this condition?
03 October 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on radiographs of the right hip on 26 April 2016, which showed superolateral joint space narrowing, femoral and acetabular osteophytes and subchondral sclerosis, in a veteran with pain, stiffness and impaired function and internal rotation reduced to 10 degrees. This meets the Statement of Principles definition of osteoarthritis. It is not an acute articular cartilage tear or osteochondritis dissecans.
An orthopaedic surgeon confirmed the diagnosis on 17 May 2016. The worsening was confirmed on radiographs of 03 August 2021 showing bone-on-bone narrowing, subchondral cysts and early femoral head collapse.
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 19 April 2016, 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 diving, lifting, ladder climbing and kneeling occurred. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Persian Gulf in 1991, East Timor in 1999, Iraq in 2003 and Afghanistan in 2009 and 2010, during which the captivity, septic arthritis, frostbite and fracture-dislocation 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
- Ankylosing spondylitis with synovitis of the right hip was diagnosed by a rheumatologist on 11 July 1995 and treated thereafter, more than 20 years before the onset on 19 April 2016. Ankylosing spondylitis is on the specified list.
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 right hip due to Staphylococcus aureus, following an infected coral laceration sustained while diving, was confirmed on aspiration on 24 November 1999 and treated with arthrotomy, washout and antibiotics, 16 years before the onset on 19 April 2016.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- CT on 18 April 2010 showed a comminuted posterior wall acetabular fracture involving the articular surface of the right hip, sustained in a blast during service, six years before the onset on 19 April 2016.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- CT on 18 April 2010 showed haemarthrosis of the right hip, and blood was evacuated from the joint at open reduction, six years before the onset on 19 April 2016.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Haemochromatosis was confirmed on 14 October 2008 with a ferritin of 1,850 micrograms per litre and HFE genotyping, with arthropathy involving the hips, more than seven years before the onset on 19 April 2016.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- The blast of 18 April 2010 applied massive force through the right hip, causing fracture-dislocation, pain, loss of movement and surgery to the joint, six years before the onset on 19 April 2016, 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
- An acute tear of the articular cartilage of the right femoral head and acetabulum, with an intra-articular osteochondral fragment, was shown on CT and found at surgery on 18 April 2010, six years before the onset on 19 April 2016.
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 18 April 2010 caused an acute tear of the medial meniscus of the right knee, confirmed on MRI on 06 May 2010, six years before the onset on 19 April 2016.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- In January 2010 the veteran sustained frostbite of the skin and subcutaneous tissue over the right hip and buttock while lying in snow for 11 hours during a high-altitude clearance task, recorded with blistering by the medical officer, six years before the onset on 19 April 2016.
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 posterior acetabular wall healed with malunion and retroversion of the acetabulum, a rotation deformity of the joint that maldistributes load across the hip, recorded by the rehabilitation physician and present from 2010, six years before the onset on 19 April 2016, 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 on 14 October 2008 showed dysbaric osteonecrosis of the subchondral bone of the right femoral head, caused by his long career of air and mixed-gas diving, more than seven years before the onset on 19 April 2016.
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 1992 to 2006 the veteran's diving and explosive ordnance duties involved sustained power grip, handling diving sets, lifting gear, tools and demolition equipment for an average of more than 30 hours a week, for more than ten years within that 15-year period before the onset on 19 April 2016.
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
- The veteran used hand-held vibrating percussive tools, including pneumatic and hydraulic underwater breakers and impact drills for hull and obstacle work, on more days than not from 1993 to 2004, about 11 years within the 25 years before the onset on 19 April 2016.
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
- Since the right sciatic nerve injury of 18 April 2010 the veteran has had foot drop requiring an ankle-foot orthosis and an asymmetric gait, documented by the rehabilitation physician, for six years before the onset on 19 April 2016, 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 1992 to 2002 the veteran lifted diving sets, weights, demolition charges and boat equipment of 20 to 40 kilograms while standing, about 340,000 kilograms in total, and the onset 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 1994 to 2004 the veteran carried diving and demolition equipment of 20 to 40 kilograms for about 3,900 hours, and the onset 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 2000 to December 2005, during continuous sea service on mine countermeasures vessels and an amphibious ship, the veteran climbed more than 150 ladder rungs and stairs a day on most days, a continuous period of six years within the 25 years before the onset on 19 April 2016.
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 08 May 2012 showed increased bone mineral density, with a total hip T-score of +1.8, associated with acromegaly, four years before the onset on 19 April 2016.
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 2004 and remained between 27 and 31 to onset, more than ten years before the onset on 19 April 2016.
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 2004 and 104 to 110 cm thereafter, exceeding 102 cm for more than ten years before the onset on 19 April 2016.
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 circumference exceeded 88 centimetres at every recorded measurement from February 2004 to onset, more than ten years before the onset on 19 April 2016.
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 2004 to 2010 the veteran knelt or squatted for more than an hour a day on most days during explosive ordnance disposal tasks, a continuous period of six years, and the onset 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 18 April 2010 also ruptured the right anterior cruciate ligament, an internal derangement of the right knee confirmed on MRI on 06 May 2010, six years before the onset on 19 April 2016.
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 right knee was diagnosed during initial diver training in January 1988 and recorded at subsequent examinations, many years before the onset on 19 April 2016.
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
- Type II decompression sickness in June 1998 and the right sciatic nerve injury of 18 April 2010 left reduced pain and position sense around the right hip and leg, recorded by the rehabilitation physician, six years before the onset on 19 April 2016.
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 right hemipelvis and proximal femur, involving the hip, was confirmed on bone scan with a raised alkaline phosphatase in 2013, three years before the onset on 19 April 2016.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 08 May 2012 with a raised IGF-1 and a pituitary macroadenoma, four years before the onset on 19 April 2016.
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 right hip dislocated posteriorly on 18 April 2010 and was reduced, six years before the onset on 19 April 2016, 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 on 14 October 2008 showed a cam deformity with an anterosuperior labral tear of the right hip, and femoroacetabular impingement syndrome was diagnosed, more than seven years before the onset on 19 April 2016.
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
- Ankylosing spondylitis involving the right hip, diagnosed in 1995, was active before the worsening on 03 August 2021, requiring prednisolone in 2018 and 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 right hip of November 1999 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 acetabular fracture of April 2010 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 the right hip of April 2010 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
- Haemochromatosis arthropathy, diagnosed in 2008 and treated by venesection, was present before the worsening on 03 August 2021.
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 April 2010 occurred eleven years before the worsening on 03 August 2021, 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 April 2010 occurred within the 25 years before the worsening on 03 August 2021.
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 meniscal tear of the right knee of April 2010 occurred within the 25 years before the worsening on 03 August 2021.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite over the right hip of January 2010 preceded the worsening.
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 acetabular malunion with retroversion had been present for eleven years before the worsening on 03 August 2021.
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 dysbaric osteonecrosis of the right femoral head, shown in 2008, was present before the worsening on 03 August 2021 and contributed to the early head collapse seen in 2021.
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 1992 to 2006 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 from 1993 to 2004 occurred within the 25 years before the worsening on 03 August 2021.
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 asymmetric gait from the sciatic nerve injury had been present for eleven years before the worsening on 03 August 2021.
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 340,000 kilograms from 1992 to 2002 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 3,900 hours from 1994 to 2004 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 ladder and stair climbing at sea from 2000 to 2005 occurred within the 25 years before the worsening on 03 August 2021.
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 was overweight from 2004 to 2021, seventeen years before the worsening on 03 August 2021.
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 2004 to 2021, more than ten years before the worsening on 03 August 2021.
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 2004 to 2021, more than ten years before the worsening on 03 August 2021.
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 from 2004 to 2010 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 right knee from April 2010 was present before the worsening on 03 August 2021.
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 right knee was present before the worsening on 03 August 2021.
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 reduced pain and position sense around the right hip and leg persisted before the worsening on 03 August 2021.
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 right hemipelvis and proximal femur was present before the worsening on 03 August 2021.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, confirmed in 2012, preceded the worsening.
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 dislocation of the right hip of April 2010 was eleven years before the worsening on 03 August 2021.
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 of the right hip, diagnosed in 2008, was present before the worsening on 03 August 2021.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis. — MET
- Total hip replacement was recommended in June 2019 but could not be obtained for 26 months while liability was disputed and the veteran waited on a public list. The hip progressed to end-stage disease with early head collapse by 03 August 2021. 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 the Persian Gulf the veteran and two team members were captured by enemy soldiers on 22 February 1991 after their boat broke down during a clearance task, and were held as prisoners for six days until released at the ceasefire, recorded in his post-release medical examination of 02 March 1991, 25 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
- Ankylosing spondylitis with right hip involvement was diagnosed in 1995 and flared on warlike service in East Timor in 1999 and Iraq in 2003, requiring prednisolone on deployment, 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 right hip followed an infected coral laceration during a harbour clearance dive on warlike service in East Timor, confirmed on aspiration on 24 November 1999, 16 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 posterior wall acetabular fracture of the right hip was sustained in an improvised explosive device blast on warlike service in Afghanistan on 18 April 2010.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Haemarthrosis of the right hip was shown on CT on 18 April 2010, 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
- Haemochromatosis arthropathy of the hips was confirmed on 14 October 2008, before onset, and was symptomatic during warlike service in Afghanistan in 2009 and 2010.
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 18 April 2010 applied massive force through the right hip, causing fracture-dislocation, pain, loss of movement and surgery, 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 right hip, with an intra-articular osteochondral fragment, was caused by the blast on warlike service in Afghanistan on 18 April 2010.
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 right knee was caused by the blast on warlike service in Afghanistan on 18 April 2010, confirmed on MRI on 06 May 2010.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The frostbite over the right hip and buttock occurred on warlike service in Afghanistan in January 2010, while lying in snow for 11 hours during a high-altitude clearance task.
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 acetabular malunion with retroversion resulted from the fracture sustained on warlike service in Afghanistan and was present for 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
- The dysbaric osteonecrosis of the right femoral head shown on MRI in 2008 followed a diving career that included intensive clearance diving on warlike service in the Persian Gulf in 1991, East Timor in 1999 and Iraq in 2003.
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 diving and explosive ordnance duties from 1992 to 2006, including clearance operations on warlike service in East Timor and Iraq, 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 vibrating underwater breakers and impact drills on more days than not from 1993 to 2004, about 11 years, including obstacle and hull work 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 asymmetric gait from the right sciatic nerve injury sustained on warlike service in Afghanistan on 18 April 2010 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 to a total of about 340,000 kilograms between 1992 and 2002, including clearance operations on warlike service in East Timor.
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 40 kilograms for about 3,900 hours between 1994 and 2004, including 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 2000 to December 2005 the veteran climbed more than 150 ladder rungs and stairs a day at sea, including on warlike service in Iraq in 2003 aboard an amphibious ship, a continuous period of six 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 total hip T-score of +1.8, was shown on DXA on 08 May 2012, 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 from 2004 to onset, more than ten years, his weight increasing after his warlike service in Iraq and his injuries in Afghanistan.
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 2004 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 2004 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 2004 to 2010, including counter-improvised explosive device tasks on warlike service in Afghanistan in 2009 and 2010, 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 right anterior cruciate ligament and medial meniscus were torn in the blast on warlike service in Afghanistan on 18 April 2010, an internal derangement of the right 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 right knee, diagnosed in 1988, was symptomatic during warlike service in the Persian Gulf in 1991, 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 right sciatic nerve injury from the blast on warlike service in Afghanistan caused reduced pain and position sense around the right hip and leg, before onset.
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 the right hemipelvis and proximal femur, involving the hip, was confirmed in 2013, before onset.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 08 May 2012, 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 right hip dislocated in the blast on warlike service in Afghanistan on 18 April 2010, 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 of the right hip was diagnosed on 14 October 2008 and was symptomatic during warlike service in Afghanistan, 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
- Ankylosing spondylitis involving the right hip, which flared on warlike service, was active before the worsening.
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 from warlike service in East Timor in 1999 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 2010 preceded the worsening.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The haemarthrosis from warlike service in Afghanistan in 2010 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
- Haemochromatosis arthropathy of the hips 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 2010 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 from warlike service in 2010 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 right knee from warlike service in 2010 preceded the worsening.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite from warlike service in Afghanistan in January 2010 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 acetabular malunion from the warlike service fracture had been present for 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 dysbaric osteonecrosis of the right femoral head was present before the worsening and contributed to the femoral head collapse.
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, 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 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 asymmetric gait from the warlike service sciatic nerve injury had been present for eleven years before the worsening.
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 340,000 kilograms, 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 3,900 hours, 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 ladder and stair climbing at sea from 2000 to 2005, including on warlike service in Iraq, 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 2020 showed osteoporosis, with a lumbar T-score of -2.6, from repeated glucocorticoids for ankylosing spondylitis and hypogonadism, before the worsening on 03 August 2021.
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 2004 to 2021, seventeen 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 2004 to 2021, 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 2004 to 2021, 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 from 2004 to 2010, including on warlike service in Afghanistan, 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 right knee from warlike service in 2010 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 right 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 reduced pain and position sense from the warlike service nerve 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 right hemipelvis and proximal femur was present before the worsening.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, confirmed in 2012, 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 right hip on warlike service in 2010 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 of the right hip was present before the worsening.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis. — MET
- From June 2019 to August 2021 the veteran could not obtain the recommended total hip replacement for the osteoarthritis that arose from his warlike service injuries, and the hip progressed to end-stage disease with early head collapse, documented on 03 August 2021.
The % contribution of the causes is 100% and significant.
Sequelae
The right hip osteoarthritis is a sequela of the veteran's accepted conditions: the fracture-dislocation of the right hip sustained on warlike service in Afghanistan, the dysbaric osteonecrosis of the femoral head from clearance diving, the septic arthritis contracted in East Timor and the right sciatic nerve injury with an asymmetric gait. The total hip replacement and its consequences, chronic pain and reduced mobility are sequelae of the osteoarthritis.
Unintended Consequence
Met. The osteoporosis present before the worsening resulted in part from repeated courses of prednisolone prescribed for ankylosing spondylitis, and the posterior acetabular fixation of 2010 healed with retroversion that altered the mechanics of the hip; 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. An orthopaedic surgeon recommended total right hip replacement in June 2019. The operation was not performed for 26 months while liability was disputed and the veteran waited on a public hospital list. During that period his walking tolerance fell to 300 metres, he developed night pain, and radiographs on 03 August 2021 showed bone-on-bone narrowing, cysts and early femoral head collapse. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this delay 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
- Jan 1988, Outpatient health record, Medical Officer, Naval training establishment
- 02 Mar 1991, Post-release medical examination, Medical Officer, Persian Gulf
- 11 Jul 1995, Specialist consultation and MRI, Rheumatologist
- Jun 1998, Hyperbaric medicine records, Diving medical officer
- 24 Nov 1999, Deployed health record, aspiration and operation report, East Timor
- Feb 2004, Periodic health examination, Medical Officer, Naval health centre
- 14 Oct 2008, MRI hips and haematology consultation, Haematologist
- Jan 2010, Deployed health record, Medical Officer, Afghanistan
- 18 Apr 2010, Trauma admission, CT and operation report, Role 3 hospital, Afghanistan
- 08 May 2012, Endocrinology consultation and DXA, Endocrinologist
- 2013, Bone scan and rehabilitation medicine review, Rehabilitation physician
- 10 Jun 2014, Right hip radiographs, Radiologist
- 26 Apr 2016, Outpatient health record and radiographs, Medical Officer, Naval health centre
- 17 May 2016, Orthopaedic consultation, Orthopaedic surgeon
- Jun 2019, Orthopaedic consultation, Orthopaedic surgeon
- 2020, DXA report, Radiologist
- 03 Aug 2021, Orthopaedic consultation and radiographs, 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
