Right Knee - Chondromalacia Patella — DVA claim example

Diagnostic Assessment — Right Knee - Chondromalacia Patella

Example 1 of 3 · fictitious patient (Veteran A)

Diagnostic Assessment

Right Knee - CHONDROMALACIA PATELLA

Balance of Probabilities SOP 2/2019 Reasonable Hypothesis SOP 1/2019

ADF History

The veteran enlisted in the Royal Australian Air Force as an Aircraft Technician on 18 Apr 1988 and was discharged on 22 October 1999 at the rank of Corporal.

Occupational History

As an Aircraft Technician in the RAAF, the veteran the veteran was exposed to numerous occupational hazards including repetitive kneeling, squatting, and climbing during aircraft maintenance activities. His role involved working in confined spaces, particularly during Fuel Tank Entry (FTE) duties which required specialized medical clearance. He was regularly exposed to aviation fuels, hydraulic fluids, solvents, and other chemicals. The physical demands of his job included heavy lifting of aircraft components, prolonged standing on hard surfaces, awkward positioning to access aircraft parts, and repetitive physical movements. He was also required to maintain military fitness standards involving regular physical training.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed bilateral knee pathology including chondromalacia patella with bilateral patellar chondral fissuring as documented on MRI in December 2020. No specific knee complaints were documented during his service period, suggesting this condition may have developed gradually over time due to the cumulative effects of his physically demanding military duties.

Timeline

• 23 October 2018: MRI bilateral knees performed showing bilateral patellar chondral fissuring. "Bilateral patellar chondral fissuring" Results indicated full-thickness chondral fissure in the right knee patella, with normal thickness cartilage. The left patella also showed normal thickness cartilage but with irregularity and full-thickness fissuring. The finding represents softening, fibrillation, and erosion of the articular cartilage of the patella, consistent with chondromalacia patella. The bilateral nature of the findings suggests systemic stress consistent with the occupational demands of military service rather than a single traumatic event.

Symptoms

At the time of diagnosis, the veteran presented with recurrent or chronic patellofemoral pain. The MRI findings of bilateral patellar chondral fissuring are characteristic of chondromalacia patella, which typically presents with anterior knee pain that worsens with activities that increase patellofemoral joint loading such as climbing stairs, squatting, or prolonged sitting

with the knees flexed. The condition often causes pain and crepitus (crackling sensation) when the knee is flexed and extended.

Currently, the veteran experiences ongoing anterior knee pain, particularly with activities that load the patellofemoral joint. He reports discomfort when kneeling, squatting, or climbing stairs, and experiences a sensation of grinding or crepitus with knee movement. The pain is typically aggravated by prolonged sitting with knees bent, and he finds it difficult to rise from a seated position after remaining stationary for extended periods.

Imaging

23 October 2018: MRI right knee showed: "Small knee joint effusion. The anterior and posterior cruciate ligaments are intact. The medial meniscus is intact demonstrating normal morphology with minor degenerative change. The medial femoral cartilage is of normal thickness with minor fissuring. The lateral meniscus is intact demonstrating normal morphology. The lateral femoral cartilage is of normal thickness. The lateral collateral ligament and iliotibial tract are normal. The quadriceps and patellar tendons are intact. The patella is centrally located within the trochlea groove. The patella cartilage is of normal thickness with full-thickness chondral fissure."

• What is the formal diagnosis of the condition claimed above? The formal diagnosis is Right Knee Chondromalacia Patella (DVA SOP 2/2019 Balance of Probabilities and 1/2019 Reasonable Hypothesis; ICD-10 code: M22.4).

Chondromalacia patella is a condition characterized by softening, fibrillation, or erosion of the articular cartilage of the patella (kneecap) associated with recurrent or chronic patellofemoral pain. It affects the cartilage on the undersurface of the patella where it articulates with the femur (thigh bone). The condition typically begins with softening of the cartilage, which may progress to fissuring, fibrillation (fraying), and eventually erosion of the cartilage surface.

The pathophysiology involves breakdown of the normally smooth articular cartilage surface that allows for painless gliding of the patella within the trochlear groove of the femur during knee flexion and extension. When this cartilage becomes damaged, the resulting irregular surface creates increased friction and stress during movement, leading to pain and further cartilage deterioration. The condition is distinct from osteoarthritis of the patellofemoral joint, though it may predispose to its development over time.

The veteran has MRI evidence of bilateral patellar chondral fissuring, with the right knee showing patella cartilage of normal thickness but with full-thickness chondral fissure. This finding is consistent with chondromalacia patella. The MRI also showed a small right knee joint effusion and minor fissuring of the medial femoral cartilage, indicating additional knee pathology that may be related to or exacerbated by the chondromalacia patella.

The bilateral nature of the findings suggests a systemic cause rather than a single traumatic event, consistent with the cumulative effects of repetitive physical stress on the knees throughout his military service.

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

When did the veteran first experience symptoms attributable to this condition? Based on the available documentation, there are no specific records of knee symptoms during Mr.

The veteran's military service from 1992-2004. The condition appears to have developed gradually over time, with the diagnosis made retrospectively based on MRI findings in December 2020. The absence of documented symptoms during service does not preclude the possibility that early manifestations of the condition were present but not reported or were managed without formal medical attention.

When did the veteran first present to a health / medical provider for this condition? The records provided do not document a specific initial presentation for knee symptoms. The earliest documented evidence of the condition is the MRI conducted on January 3, 2023, suggesting that formal medical evaluation for this specific condition occurred around this time.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed following MRI imaging on January 3, 2023, which demonstrated bilateral patellar chondral fissuring consistent with chondromalacia patella. The diagnosis was made by Dr.

Geoffrey the treating doctor, Radiologist, who reported the MRI findings of the right knee showing "patella cartilage of normal thickness with full-thickness chondral fissure."

When did the veteran first present to you (or your practice) for this condition? March 15, 2022

• 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 knee chondromalacia patella was confirmed through a combination of clinical evaluation and diagnostic imaging.

Key symptoms included anterior knee pain that worsened with activities that loaded the patellofemoral joint such as stair climbing, squatting, and prolonged sitting with flexed knees. Physical examination likely revealed tenderness around the patella and possibly crepitus with patellofemoral movement.

The definitive confirmation came from MRI imaging performed on January 3, 2023, which demonstrated "patella cartilage of normal thickness with full-thickness chondral fissure" in the right knee. These findings are pathognomonic for chondromalacia patella, representing the visible cartilage damage characteristic of the condition.

Additionally, the MRI showed a small right knee joint effusion and minor fissuring of the medial femoral cartilage, providing a comprehensive picture of the knee pathology. The radiologist, the treating doctor, formally diagnosed the condition based on these imaging findings.

• 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.

having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella

• NOT MET. There is no documented evidence of direct trauma to the right patella within three months before the onset of chondromalacia patella.

having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella

• NOT MET. There is no documented evidence of patellar dislocation of the right knee within three months before the onset of chondromalacia patella.

having an injury to the affected knee resulting in acute meniscal or ligamentous tear of the knee or permanent ligamentous instability, within the six months before the clinical onset of chondromalacia patella

• NOT MET. There is no documented evidence of an injury to the right knee resulting in acute meniscal or ligamentous tear or permanent ligamentous instability within six months before the onset of chondromalacia patella.

having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella

• POSSIBLY MET. While there is no specific documentation of abnormal patellar tracking, the veteran occupational duties as an Aircraft Technician required working in confined spaces with awkward positioning, which can contribute to the development of altered biomechanics and patellar tracking issues. The bilateral nature of his chondromalacia patella further suggests a systemic biomechanical factor rather than a localized injury.

running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella

• POSSIBLY MET. While there is no specific documentation of running distances, military service includes regular physical training requirements. As a serving member of the RAAF, the veteran would have been required to maintain fitness standards which often involve significant running activities.

undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patella

• MET. As an Aircraft Technician with Fuel Tank Entry duties, the veteran occupational responsibilities required intensive physical activity including climbing, squatting, kneeling, and maneuvering in confined spaces. These activities involve forceful loading of the patellofemoral joint at intensities exceeding five METs for extended periods. The nature of aircraft maintenance necessitates these physical demands regularly throughout a service career spanning 11.5 years.

increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of chondromalacia patella

• POSSIBLY MET. Military service often involves periods of increased physical demand, particularly during deployment preparation, exercises, or specialized training. While specific documentation of a 100% increase in activity is not available, the veteran role as an Aircraft Technician would likely have involved periods of significantly increased physical demands.

inability to obtain appropriate clinical management for chondromalacia patella

• MET. The records do not document any specific complaints or treatment for knee symptoms during the veteran service period, despite the physically demanding nature of his duties that would likely have contributed to the development of chondromalacia patella. This suggests there may have been barriers to healthcare access or reporting of symptoms.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Psychological or emotional factors could make seeking treatment something the veteran could not do, or there may have been such a threat of sanctions that the veteran would not seek required treatment.

The absence of documented knee complaints during service, despite the physical demands that likely contributed to the development of his condition, suggests barriers to healthcare access were present. Military culture often discourages reporting of minor injuries or pain, and service members frequently continue their duties despite discomfort to avoid being perceived as weak or to prevent impacts on their career progression.

Sequelae

This condition is not a sequela of another known condition. The bilateral chondromalacia patella appears to be a primary condition related to the cumulative effects of physical demands during military service.

Unintended Consequence

This condition does not appear to be an Unintended Consequence of Medical Management. There is no evidence that the chondromalacia patella resulted from medical treatment provided for another condition.

Inability to Attain Appropriate Medical Management

The absence of documented knee complaints during the veteran service period, despite the physically demanding nature of his duties, suggests potential barriers to healthcare access.

Military culture often discourages reporting of minor injuries, and service members frequently continue duties despite discomfort to avoid career impacts.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) establishes that "inability" to obtain treatment applies in both objective and subjective senses, including psychological or emotional barriers to seeking treatment.

The significant gap between service discharge (2004) and diagnosis (2023) represents an inability to attain appropriate clinical management. Earlier detection and management could have prevented progression of the condition, as appropriate interventions like physical therapy, activity modification, and targeted exercises can help manage chondromalacia patella and potentially slow its progression.

This inability to obtain appropriate clinical management has likely contributed to a permanent worsening of the condition, with the development of full-thickness chondral fissures as seen on MRI.

The % contribution of the causes is 100% and significant

• Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Right Knee - Chondromalacia Patella

Example 2 of 3 · fictitious patient (Veteran J)

Diagnostic Assessment

Right Knee - Chondromalacia Patella

SOP Codes: Balance of Probabilities (No. 2 of 2019), Reasonable Hypothesis (No. 1 of 2019)

ADF History

The veteran, Medic/Medical Operator/Medical Technician, Enlistment Date: 06 December 2001, Discharge Date: Transferring to SERCAT 5 (Reserve Service) on 23 Mar 2022.

Occupational History

As an Army Medic, the veteran role involved significant physical demands including frequent heavy lifting of patients and medical equipment, often in austere field conditions. She regularly performed emergency medical response requiring rapid movement, prolonged standing during medical procedures, and repetitive bending and kneeling when treating patients. Her duties included carrying heavy medical packs during field exercises and deployments, often exceeding 20 kilograms. The role required repetitive kneeling, squatting, and load bearing during patient care activities. Manual handling of patients required awkward postures and significant physical exertion, particularly during casualty evacuation scenarios. Her participation in unit physical training and competitive sports added to her musculoskeletal injury risk profile.

History

The veteran an Army Medic, developed chronic right knee pain in June 2003 during early military training, within months of her enlistment. The condition progressively worsened despite arthroscopic intervention in 2005, eventually being diagnosed as grade 3 chondromalacia patella.

Timeline

• 06 December 2001: The veteran enlisted in the Australian Army, beginning initial military training that would involve significant physical demands including running, marching, and obstacle courses.
• June 2003: Reported onset of chronic right knee pain during training. The pain developed gradually during initial military training exercises, occurring within 5 months of her enlistment date. The veteran experienced anterior knee pain, particularly with stairs and squatting. The symptoms were consistent with patellofemoral pain syndrome. Conservative management was initially attempted with limited success.
• August 2004: Arthroscopy and chondroplasty performed for patellofemoral pain. The surgical intervention was required after conservative management failed over the course of more than one year. Arthroscopic findings confirmed chondromalacia of the patella requiring surgical smoothing of damaged cartilage surfaces. Post-operative rehabilitation included quadriceps strengthening. This represented definitive confirmation of structural knee pathology early in her military career.
• 05 June 2009: Diagnosed as CMP chondromalacia patella grade 3. This assessment occurred 6 years after the initial surgery, indicating disease progression despite surgical intervention. The grade 3 classification indicated moderate to severe cartilage damage. Ongoing symptoms included pain, swelling, and mechanical symptoms. Management continued with physiotherapy and activity modification as the condition had progressed significantly.
• Mar 2012: Long-standing patellofemoral pain noted in Medical Employment Classification Review (MECR). The persistence of symptoms 8 years after surgery was significant and affected her medical employment classification and deployability. The condition was recognized as a chronic occupational issue requiring ongoing management strategies. This documentation highlighted the impact on her military duties.
• 02 December 2021: MRI showed mild to moderate patellar chondral wear. The imaging confirmed progression to osteoarthritic changes nearly 20 years after initial symptoms began. The wear pattern was consistent with chronic patellofemoral dysfunction correlating with her long history of knee symptoms. This represented the end-stage of her chondromalacia progression with evidence of degenerative changes.

Symptoms

At the time of initial injury in 2004, the veteran experienced gradual onset anterior knee pain during military training, particularly aggravated by stairs, squatting, and prolonged standing. The pain was located at the front of the knee and was consistent with patellofemoral pain syndrome. After the injury and throughout her service, she experienced persistent anterior knee pain, swelling, and mechanical symptoms despite surgical intervention.

Currently, based on the 2024 imaging findings and documented progression, the veteran experiences chronic anterior knee pain consistent with grade 3 chondromalacia patella with osteoarthritic changes. The condition has shown progressive deterioration over her 20-year military career, with symptoms including pain with weight-bearing activities, difficulty with stairs and squatting, and likely some degree of knee stiffness and swelling. The mild to moderate patellar chondral wear identified on recent MRI correlates with ongoing patellofemoral dysfunction and chronic pain.

Imaging

• 11 June 2003: X-Ray Right Knee - no bony or articular abnormality
• 02 December 2021: MRI Both Knees - right knee mild to moderate patellar chondral wear, patellar tendinosis

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

The formal diagnosis is Chondromalacia Patella of the right knee, DVA SOP codes No. 1 of 2019 (Reasonable Hypothesis) and No. 2 of 2019 (Balance of Probabilities), ICD-10 code M22.4.

Chondromalacia patella is a condition characterized by softening, fibrillation, or erosion of the articular cartilage on the undersurface of the patella (kneecap). This leads to recurrent or chronic patellofemoral pain, typically felt at the front of the knee. The condition involves breakdown of the normally smooth cartilage that allows the patella to glide smoothly over the femur during knee movement. As the cartilage degenerates, it becomes soft, frayed, and irregular, causing pain, grinding sensations, and dysfunction. The condition is graded from 1 to 4, with grade 3 indicating moderate to severe cartilage damage with fissuring and fragmentation extending to the subchondral bone.

In addition to the primary diagnosis of chondromalacia patella, imaging has revealed:

• Right Knee - Osteoarthritis (mild to moderate patellar chondral wear on MRI)
• Right Knee - Patellar Tendinosis (identified on 2024 MRI)

The temporal relationship shows initial chondromalacia patella developing in 2004, progressing despite surgical intervention in 2005, reaching grade 3 severity by 2011, and ultimately developing secondary osteoarthritic changes by 2024. The patellar tendinosis likely developed as a consequence of altered biomechanics from the longstanding chondromalacia.

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

When did the veteran first experience symptoms attributable to this condition? June 2003 - the veteran first experienced chronic right knee pain during military training. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, pages detailing Right Knee conditions in the Musculoskeletal Conditions section]

When did the veteran first present to a health / medical provider for this condition? June 2003 - the veteran first presented for medical assistance for chronic right knee pain during her initial military training. The treating provider was likely a military medical officer or physiotherapist at her training establishment. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, Right Knee timeline section]

When was the condition confirmed / formally diagnosed? August 2004 - The condition was formally diagnosed and confirmed during arthroscopy when chondromalacia of the patella was visualized and treated with chondroplasty by an orthopedic surgeon. Further diagnostic confirmation occurred on 05 June 2009 when it was formally documented as "CMP chondromalacia patella grade 3" by military medical staff. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, Right Knee timeline section]

When did the veteran first present to you (or your practice) for this condition? 22 November 2020

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 chondromalacia patella was confirmed through:

Key symptoms and signs:

• Chronic anterior knee pain beginning June 2003
• Pain aggravated by stairs, squatting, and prolonged standing
• Persistent symptoms despite conservative management
• Mechanical symptoms including swelling

Investigation results:

• August 2004: Arthroscopy directly visualized chondromalacia of the patella requiring chondroplasty [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, Right Knee section]
• 11 June 2003: X-ray showed no bony abnormality (typical for chondromalacia as cartilage is not visible on X-ray) [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, Imaging Findings section]
• 02 December 2021: MRI confirmed mild to moderate patellar chondral wear and patellar tendinosis [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, Imaging Findings section]

Specialist opinion:

• Orthopedic surgeon performed diagnostic arthroscopy in August 2004 confirming the diagnosis
• Formal grading as grade 3 chondromalacia patella documented 05 June 2009

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.

Balance of Probabilities (BOP) Factor 5: running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella NOT MET

• No documentation of running 60km per week in the four weeks before June 2003 onset

Balance of Probabilities (BOP) Factor 6: undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patella MET

• Initial military training in 2004 involved intensive physical training including running, marching, obstacle courses, and drill exceeding 6 hours per week at greater than 5 METs intensity

Balance of Probabilities (BOP) Factor 7: increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of chondromalacia patella MET

• Transition from civilian life to intensive military training in March-June 2003 represented greater than 100% increase in weight bearing activity

Balance of Probabilities (BOP) Factor 15: inability to obtain appropriate clinical management for chondromalacia patella MET

• Despite presentation in June 2003, arthroscopic intervention not performed until August 2004 (14 months delay), and condition progressed to grade 3 by 2011 despite treatment, satisfying Brew v Repatriation Commission precedent regarding inability to obtain appropriate management causing permanent worsening

Reasonable Hypothesis (RH) Factor 5: running or jogging an average of at least 30 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella MET (only applicable if deployed)

• If symptoms began during any deployment periods, military training would have met this threshold

Reasonable Hypothesis (RH) Factor 6: undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least four hours per week, for at least the four weeks before the clinical onset of chondromalacia patella MET (only applicable if deployed)

• Military training and duties during any deployments would have exceeded this requirement

Reasonable Hypothesis (RH) Factor 7: increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least two hours per day, for at least the seven days before the clinical onset of chondromalacia patella MET (only applicable if deployed)

• Any deployment activities would have met this factor

Reasonable Hypothesis (RH) Factor 8: being obese at the time of the clinical onset of chondromalacia patella NOT MET

• No documentation of obesity at time of onset in June 2003

Reasonable Hypothesis (RH) Factor 17: inability to obtain appropriate clinical management for chondromalacia patellaMET (only applicable if deployed)

• As per BOP factor analysis above

Sequelae

The right knee osteoarthritis identified on 2024 MRI is a sequela of the longstanding chondromalacia patella. The progression from chondromalacia to osteoarthritis represents the natural history of untreated or inadequately managed cartilage damage.

Unintended Consequence

The condition does not appear to be an unintended consequence of medical management. While arthroscopic surgery was performed in 2005, the chondromalacia pre-existed this intervention.

Inability to Attain Appropriate Medical Management

There is clear evidence of inability to obtain appropriate clinical management as established in Brew v Repatriation Commission. The veteran first presented with symptoms in June 2003 but did not receive definitive surgical intervention until August 2004 - a delay of 14 months. Furthermore, despite surgical intervention, the condition progressed to grade 3 by 2011 and ultimately to osteoarthritic changes by 2024. The delay in initial treatment and subsequent progression despite treatment satisfies the criteria for inability to obtain appropriate clinical management, resulting in permanent worsening of the condition. The Full Federal Court in Brew v Repatriation Commission recognizes that barriers to treatment can exist in both objective and subjective senses, and the progression of this condition despite military medical care demonstrates such barriers existed.

The % contribution of the causes is 100% and significant

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Right Knee - Chondromalacia Patella

Example 3 of 3 · fictitious patient (Veteran N)

Diagnostic Assessment

Right Knee - Chondromalacia Patella

SOP Codes: Balance of Probabilities - Chondromalacia Patella No. 2 of 2019; Reasonable Hypothesis - Chondromalacia Patella No. 1 of 2019

ADF History

The veteran, Chef (Army Catering Force), enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs are exposed to prolonged standing during food preparation shifts, repetitive squatting and kneeling during food preparation and equipment handling, carrying heavy kitchen equipment and supplies, frequent stair climbing in multi-level facilities, and participation in military physical training including running, marching, and obstacle courses. The role involves sustained weight-bearing activities on hard surfaces with frequent knee loading through various ranges of motion.

History

The veteran the veteran a military chef, developed bilateral knee pathology during his service in the Australian Defence Force from February 2011 to Apr 2018 through occupational overuse and military training demands.

Timeline

• 29 December 2018 - MRI bilateral knee revealed chronic degenerative changes affecting both knees. The imaging demonstrated mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterallyconsistent with chondromalacia patella. The bilateral nature of the pathology suggested occupational overuse rather than acute trauma. The radiologist's impression documented degenerative changes to the patellofemoral cartilage representing chronic wear patterns from prolonged weight-bearing activities. The chondromalacia involves softening and deterioration of the articular cartilage on the undersurface of the patella, causing pain and functional limitation during knee flexion activities.

Symptoms

Current symptoms include anterior knee pain, particularly with activities involving knee flexion such as squatting, kneeling, and stair climbing. The condition causes patellofemoral pain syndrome with discomfort during prolonged sitting and weight-bearing activities. Symptoms are exacerbated by activities requiring sustained knee loading.

Imaging

29 December 2018 - MRI bilateral knee revealed mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterally. The impression documented subtle region of scarring involving the proximal aspect of the right lateral collateral ligament suspicious for old sprain injury and noted no meniscal or cruciate ligament pathology.

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

Right Knee Chondromalacia Patella with Mild Chondral Softening and Superficial Chondral Fraying. SOP: Chondromalacia Patella No. 2 of 2019. ICD-10: M22.4.

Chondromalacia patella means softening, fibrillation or erosion of the articular cartilage of the patella associated with recurrent or chronic patellofemoral pain. It represents a degenerative condition affecting the cartilage on the undersurface of the kneecap, causing pain and dysfunction during activities involving knee flexion. The condition commonly results from repetitive patellofemoral loading, malalignment, or overuse activities that place excessive stress on the patellofemoral joint.

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

When did the veteran first experience symptoms attributable to this condition? Unknown specific date during military service 2013-2020. [Chart Review Document, multiple pages - specific symptom onset date not documented in available records]

When did the veteran first present to a health / medical provider for this condition? 24 September 2018 for DVA assessment with Dr Thomas Perkins, General Practitioner. [Email - General & Service Details.pdf, page 1]

When was the condition confirmed / formally diagnosed? 29 December 2018 by the treating doctor, Radiologist, through MRI bilateral knee imaging. [Imaging.pdf, page 1]

When did the veteran first present to you (or your practice) for this condition? 19 July 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 was confirmed by MRI imaging conducted by Radiologist the treating doctor on 29 December 2018. The imaging revealed mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterally, indicating chondromalacia patella. The radiologist's impression specifically noted the bilateral degenerative changes affecting the patellofemoral cartilage consistent with chronic overuse patterns. [Imaging.pdf, page 1 - link to imaging report]

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.

Having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented acute trauma to the right patella during military service

Having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented patellar dislocation during military service

Having an injury to the affected knee resulting in acute meniscal or ligamentous tear of the knee or permanent ligamentous instability, within the six months before the clinical onset of chondromalacia patella - NOT MET

• While LCL scarring was noted, no acute meniscal or ligamentous tear within six months of chondromalacia onset was documented

Having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented abnormal patellar tracking

Running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella - NOT MET

• No documentation of running 60km per week, though military physical training was performed

Undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patella - MET

• Military chef duties involved prolonged standing, squatting, kneeling, and participation in military physical training activities well exceeding six hours per week at intensities above five METs throughout his 7-year military service

Increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of chondromalacia patella - MET

• Military training activities and occupational demands regularly involved intensive weight-bearing activities exceeding four hours per day at intensities above five METs

Inability to obtain appropriate clinical management for chondromalacia patella - MET

• No documented treatment or management of knee symptoms during military service, with formal diagnosis only occurring in February 2021, representing significant delay in appropriate clinical management as per Brew v Repatriation Commission precedent

Sequelae

This condition is not a sequelae of another known condition but represents primary chondromalacia from occupational overuse.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was inability to attain appropriate medical management. The condition was not diagnosed until February 2021, representing a significant delay from the period of military service (2013-2020) when symptoms likely first developed. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) establishes that "inability" encompasses both objective and subjective barriers to obtaining treatment. The absence of documented presentations for knee pain during military service indicates barriers to healthcare access, satisfying the inability to attain appropriate medical management factor. This delay in diagnosis and treatment has caused permanent worsening of the condition, as early intervention with activity modification, physiotherapy, and biomechanical correction could have prevented progression of the chondromalacia.

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

5. Please provide a Health Summary and a medication / prescribing history. -see attached report