Diagnostic Assessment — Right Knee - Patellar Tendinopathy
Example 1 of 1 · fictitious patient (Veteran T)
Diagnostic Assessment
Right Knee - Patellar Tendinopathy
Balance of Probabilities: Patellar Tendinopathy (No. 22 of 2020) Reasonable Hypothesis: Patellar Tendinopathy (No. 21 of 2020)
ADF History
The veteran, Air Force Fuel SME (Ground Support Equipment Manager), enlisted 26 Jun 1974, discharged 26 October 2020 (extension of CRA).
Occupational History
As an Air Force Fuel SME and Ground Support Equipment Manager, the veteran the veteran was exposed to various occupational hazards throughout his military career. His role involved physical demands including lifting, carrying fuel equipment, prolonged standing, walking on various terrains, and maintaining fuel systems. The nature of military service includes regular physical training, marching, running, and weight-bearing exercises. His deployment to an overseas area of operations from 04 Jun 2003 to 21 February 2004 would have involved increased physical demands in challenging environmental conditions.
History
The veteran the veteran an Air Force Fuel SME, sustained knee injuries during his military service which have progressed to chronic patellar tendinopathy affecting his right knee.
Timeline
- 10 Apr 1990 - Patient assessed with increasing pain over the right knee. Arthroscopy performed with arthroscopic lateral release of the lateral retinaculum. Evidence of lateral tracking of the patella with some chondromalacing changesidentified during the procedure.
- 28 Apr 1990 - Following arthroscopy and lateral release, patient developed increasing pressure over the patello-femoral joint causing little synovitis after returning to rehabilitation and performing strenuous knee bending exercises with weights.
- 23 Jun 2017 - Assessment revealed ongoing knee problems with clinical notes documenting knee pain, drug treatment and references to previous arthroscopic interventions.
- 17 July 2013 - Clinical review for health status certification documented patient's ongoing knee conditions alongside other musculoskeletal issues.
- 23 November 2018 - DVA diagnosis form completed for lower limb pain conditions including knee pathology requiring assessment and management.
Symptoms
At the time of initial injury in 1994, the patient experienced increasing pain over the right knee with evidence of lateral tracking of the patella and chondromalacing changes. Following surgical intervention, he developed synovitis due to aggressive rehabilitation activities.
From current assessment documentation, the patient reports right knee soreness with occasional swelling. Symptoms are exacerbated by activities including mowing lawn, kneeling down, and lengthy walking. Pain management includes physiotherapy and ice pack application. The patient experiences constant pain and stiffness, with joint instability when walking up and down stairs. He reports constantly reduced range of motion and occasional episodes where the joint gives way during stair navigation.
Imaging
Current imaging findings - Right Knee - Patellar Tendinopathy documented in imaging reports, confirming the diagnosis of patellar tendinopathy affecting the right knee.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Knee Patellar Tendinopathy. This condition is covered under DVA SOP code M76.5 with ICD-10 code M76.5.
Patellar tendinopathy is an acquired clinically symptomatic condition involving inflammation or degeneration of the patellar tendon. It represents a degenerative process affecting the tendon structure, often resulting from repetitive stress and overuse. The condition is characterized by pain and tenderness localized to the patellar tendon at the front of the knee, with worsening of symptoms during physical activity. The pathophysiology involves tendon degeneration rather than acute inflammation, with microscopic changes including fiber disorganization, increased cellularity, and neovascularization.
The temporal relationship shows progression from initial knee pathology with chondromalacia and lateral tracking issues in 1994, developing into chronic patellar tendinopathy over subsequent years of military service and ongoing physical demands.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms attributable to patellar tendinopathy in May 1992 when he presented with increasing pain over the right knee. [FILE REVIEW - CLAIMS.docx, Page 18]
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to Mr. M. the treating doctor, F.R.C.S., Orthopaedic Surgeon, on 10 Apr 1990 for assessment of his right knee pain. [FILE REVIEW - CLAIMS.docx, Page 18]
When was the condition confirmed / formally diagnosed?
The condition was confirmed during arthroscopy performed by Mr. M. the treating doctor, F.R.C.S., Orthopaedic Surgeon, on 10 Apr 1990, which revealed lateral tracking of the patella with chondromalacing changes. The specific diagnosis of patellar tendinopathy was documented in recent imaging reports. [FILE REVIEW - CLAIMS.docx, Page 18] [IMAGING.pdf]
When did the veteran first present to you (or your practice) for this condition?
19 January 2018
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed through clinical presentation of right knee pain, arthroscopic findings revealing lateral tracking of the patella with chondromalacing changes, and subsequent imaging documenting patellar tendinopathy. Key symptoms included increasing pain over the right knee, functional limitations, and ongoing symptoms despite surgical intervention. Specialist opinion from orthopaedic surgeon Mr. M. the treating doctor confirmed the structural abnormalities through arthroscopy. Recent imaging studies have specifically identified patellar tendinopathy. [FILE REVIEW - CLAIMS.docx, Page 18] [IMAGING.pdf]
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Running or jogging an average of at least 30 kilometres per week for at least the four weeks before the clinical onset of patellar tendinopathy - NOT MET
- Military physical training requirements would not have consistently met this specific threshold of 30km per week running.
Undertaking weight bearing exercise involving jumping or repeated flexion and extension of the affected knee, at a minimum intensity greater than six METs for at least four hours per week, for at least the four weeks before the clinical onset of patellar tendinopathy - MET
- Military physical training, including drill, marching, running, and general military activities would have involved significant weight-bearing exercise with jumping and repeated knee flexion/extension exceeding six METs for more than four hours per week during the period before clinical onset.
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, within the seven days before the clinical onset of patellar tendinopathy - MET
- Military training and operational requirements frequently involve rapid increases in physical activity intensity, particularly during exercises, deployments, or intensive training periods that would meet these criteria.
Having direct trauma to the patellar tendon of the affected knee at the time of the clinical onset of patellar tendinopathy - NOT MET
- No evidence of specific direct trauma documented at the time of clinical onset.
Inability to obtain appropriate clinical management for patellar tendinopathy - MET
- The patient developed synovitis following aggressive rehabilitation after initial surgery, indicating inappropriate clinical management during the recovery period. The progression from initial chondromalacia to chronic patellar tendinopathy suggests inadequate management of the underlying condition over time.
Sequelae
This condition may be considered a sequelae of the initial chondromalacia and lateral patellar tracking issues identified in 1994, representing progression of the underlying knee pathology to chronic patellar tendinopathy.
Unintended Consequence
Consider whether the condition represents an unintended consequence of the aggressive rehabilitation program implemented following the 1994 arthroscopic lateral release, which resulted in synovitis and may have contributed to the development of chronic patellar tendinopathy.
Inability to Attain Appropriate Medical Management
The factor of inability to attain appropriate medical management is MET. Following the 1994 arthroscopic lateral release, the patient was subjected to aggressive rehabilitation involving strenuous knee bending exercises with weights, which caused synovitis and likely contributed to the progression of his condition. This represents inappropriate clinical management that caused permanent worsening of the condition.
The Full Federal Court in Brew v Repatriation Commission (17 July 1993) establishes that "inability" encompasses both objective and subjective factors that prevent appropriate treatment. The aggressive rehabilitation protocol that caused synovitis represents a failure of appropriate clinical management that contributed to the permanent worsening of the patient's knee condition, satisfying this factor.
The progression from initial chondromalacia in 1994 to chronic patellar tendinopathy represents a permanent worsening directly related to the inappropriate clinical management during the post-operative period.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
