Diagnostic Assessment — Right Knee - Patellofemoral Pain Syndrome
Example 1 of 1 · fictitious patient (Veteran Z)
Diagnostic Assessment
Right Knee - Patellofemoral Pain Syndrome
BOP Code: 2 of 2019 (Chondromalacia Patella)
RH Code: 1 of 2019 (Chondromalacia Patella)
ADF History
Veteran Z, date of birth 03 February 1990, Australian Army, Infantry Soldier (Rifleman), enlisted 14 July 2008, medically discharged 30 November 2020. Operational service: Afghanistan, 15 February 2011 to 20 October 2011 (warlike); Middle East Area of Operations (Iraq), 10 March 2016 to 25 October 2016 (warlike).
Occupational History
As an infantry rifleman the veteran conducted dismounted patrols carrying 35 to 45 kilograms of equipment, often for many hours a day over rocky, steep and irrigated ground. His duties involved repeated kneeling, squatting, crawling, climbing compound walls, jumping from vehicles and walls, and running under load, together with frequent fitness testing and endurance running.
These duties place high and repeated compressive loads on the patellofemoral joint and carry a high risk of direct blows to the knee, twisting injuries, ligament and meniscal tears and patellar dislocation. On operations, access to physiotherapy, imaging and orthopaedic care was limited.
History
Veteran Z, an infantry rifleman in the Australian Army, developed right patellofemoral pain syndrome with chondromalacia patella on 20 August 2011 while on warlike service in Afghanistan, after a medial ligament and meniscal tear, a direct blow to the kneecap, a patellar dislocation and a sharp increase in patrol and running load. The condition worsened on warlike service in Iraq in August 2016, after further injuries to the same knee, with progression to full-thickness cartilage loss on MRI.
Timeline
- 12 Mar 2011 — On warlike service in Afghanistan the veteran twisted his right knee jumping 1.5 m from a vehicle under load. The medical officer at the patrol base recorded medial joint line tenderness, valgus laxity and an effusion. He was managed with a hinged brace and returned to patrols after three weeks. On 30 Mar 2011 the physiotherapist recorded wasting of the vastus medialis and lateral patellar maltracking. "MCL sprain, medial meniscus suspected"
- 28 May 2011 — During a contact on patrol he dived onto rocky ground and struck the front of his right kneecap. He had immediate patellar pain, bruising and swelling, and pain persisted for five days. X-ray at the role 2 facility excluded a fracture. "direct blow R patella, no fracture"
- 04 Jun 2011 — While pivoting to cross an irrigation ditch his right patella dislocated laterally and was reduced by the patrol medic. The medical officer recorded a positive apprehension test and medial retinacular tenderness. He returned to patrols in a patellar stabilising brace after ten days. "lateral patellar dislocation, reduced"
- 23 Aug 2011 — He presented to the role 1 facility with three days of anterior right knee pain, worse with stairs, kneeling and squatting, and pain after sitting with his knee bent. In the preceding ten days his patrol hours had tripled, and he had been running about 65 km a week. Examination showed retropatellar crepitus, a positive patellar grind test, lateral patellar tilt and a J-sign. Weight 101 kg, height 1.82 m, BMI 30.5. "anterior knee pain, retropatellar crepitus"
- 15 Dec 2011 — After return to Australia, MRI of the right knee showed grade II to III chondromalacia of the patella with fibrillation and fissuring of the median ridge and lateral facet, a healed medial collateral ligament tear with residual laxity, a medial meniscal tear and scarring of the medial patellofemoral ligament. An orthopaedic surgeon diagnosed patellofemoral pain syndrome with chondromalacia patella and acquired patellar maltracking. Kujala score 68. "chondromalacia patella grade II-III"
- 10 Apr 2016 — On warlike service in Iraq he twisted the right knee stepping off a vehicle ramp. The medical officer recorded an acute lateral meniscal tear with locking, confirmed on ultrasound at the role 2 facility, and residual valgus laxity. On 20 Jun 2016 the patella dislocated again during a section attack drill, and on 02 Jul 2016 he struck the kneecap on a concrete step, with pain for three days. "lateral meniscal tear, patella redislocated"
- 18 Aug 2016 — He presented with marked worsening of anterior knee pain, swelling after every patrol and giving way on stairs, which had begun three days earlier, a week after his patrol and training hours had more than doubled. He had been running about 62 km a week for the preceding month. Physiotherapy was not available at his location and surgical review was deferred until the end of the deployment. BMI 31.6. "anterior knee pain markedly worse"
- 30 Nov 2016 — Repeat MRI showed progression to grade IV chondral loss over the lateral patellar facet with subchondral oedema, compared with grade II to III change in 2011. Kujala score had fallen to 41. An orthopaedic surgeon performed arthroscopic chondroplasty and lateral meniscal repair on 14 Feb 2017. He was medically downgraded and later discharged. "grade IV chondral loss, Kujala 41"
Symptoms
At onset the veteran had anterior right knee pain around and behind the kneecap, worse with stairs, kneeling, squatting and prolonged sitting, with grinding and swelling after patrols. After onset the pain persisted with all loaded activity, and from August 2016 it worsened with giving way, effusions and inability to run.
He now reports daily anterior knee pain, inability to kneel, squat or run, pain on stairs and after sitting more than 30 minutes, and episodes of the knee giving way.
Imaging
- 28 May 2011 — X-ray right knee (role 2 facility, Afghanistan): "No fracture. Soft tissue swelling anterior to the patella. Lateral patellar tilt on the skyline view."
- 15 Dec 2011 — MRI right knee: "Grade II to III chondromalacia of the patella with fibrillation and fissuring of the median ridge and lateral facet. Healed medial collateral ligament tear. Horizontal tear of the posterior horn of the medial meniscus. Scarring of the medial patellofemoral ligament with lateral patellar tilt."
- 10 Apr 2016 — Ultrasound right knee (role 2 facility, Iraq): "Displaced tear of the lateral meniscus with parameniscal fluid and a moderate effusion."
- 30 Nov 2016 — MRI right knee: "Progression to grade IV full-thickness chondral loss over the lateral patellar facet with subchondral bone oedema. Lateral meniscal tear. Persisting lateral patellar tilt and subluxation. No osteoarthritic osteophytes."
Onset Date
The most likely date of onset of this condition is 20 Aug 2011.
At that date the veteran was on warlike service in Afghanistan with an infantry battalion, conducting long dismounted patrols from a forward patrol base. His patrol hours had tripled from 10 August 2011 during a clearance operation, and he was running about 65 km a week in his own time.
This date is appropriate because the physiotherapy review of 08 Aug 2011 recorded no anterior knee pain, and he first presented with the symptoms on 23 Aug 2011, three days after they began. It falls within continuous full-time service.
For the direct trauma and patellar dislocation factors, the three months before onset run from 20 May 2011 to 20 Aug 2011; the blow to the kneecap on 28 May 2011 and the dislocation on 04 Jun 2011 fall within it. For the ligamentous and meniscal tear, the six months before onset run from 20 Feb 2011 to 20 Aug 2011, and the injury of 12 Mar 2011 falls within it. For the abnormal tracking factor, the maltracking recorded from 30 Mar 2011 was present throughout the three months from 20 May 2011 to 20 Aug 2011. For the running and weight bearing factors, the four weeks before onset run from 23 Jul 2011 to 20 Aug 2011, filled by running about 65 km a week and patrolling more than 15 hours a week. For the increase in activity, the seven days before onset run from 13 Aug 2011 to 20 Aug 2011, within the surge in patrol hours from 10 Aug 2011. His BMI was 30.5 at onset.
For the worsening factors, the documented clinical worsening is on 15 Aug 2016, confirmed by repeat MRI on 30 Nov 2016. The three months before it run from 15 May 2016 to 15 Aug 2016, containing the redislocation of 20 Jun 2016, the blow of 02 Jul 2016 and continuous maltracking. The six months before it run from 15 Feb 2016 to 15 Aug 2016, containing the lateral meniscal tear of 10 Apr 2016. The four weeks before it run from 18 Jul 2016 to 15 Aug 2016, and the seven days before it from 08 Aug 2016 to 15 Aug 2016.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Patellofemoral Pain Syndrome with Chondromalacia Patella (ICD-10-AM M22.4), under the Statements of Principles concerning chondromalacia patella, Balance of Probabilities No. 2 of 2019 and Reasonable Hypothesis No. 1 of 2019.
Patellofemoral pain syndrome is pain arising from the joint between the kneecap and the femur, typically felt around or behind the kneecap and provoked by stairs, squatting, kneeling, running and prolonged sitting. When the articular cartilage of the patella softens, fibrillates or erodes, the condition is chondromalacia patella. It results from excessive or abnormal loading of the patellofemoral joint, including direct trauma, patellar instability, maltracking and high training loads, and it can progress to full-thickness cartilage loss.
The condition followed a ligament and meniscal injury, a direct blow to the kneecap, a patellar dislocation and acquired maltracking, together with heavy patrol and running loads on warlike service in Afghanistan. It began on 20 August 2011, was confirmed on MRI on 15 December 2011 and worsened in Iraq in August 2016.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 August 2011.
When did the veteran first present to a health / medical provider for this condition?
23 August 2011.
When was the condition confirmed / formally diagnosed?
15 December 2011.
When did the veteran first present to you (or your practice) for this condition?
07 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by MRI on 15 December 2011, which showed grade II to III chondromalacia of the patella with fibrillation and fissuring of the median ridge and lateral facet, without osteoarthritic change. This meets the Statement of Principles definition of chondromalacia patella: softening, fibrillation or erosion of the articular cartilage of the patella associated with recurrent or chronic patellofemoral pain, excluding osteoarthritis.
The clinical picture was consistent: anterior knee pain with stairs, squatting and sitting, retropatellar crepitus, a positive patellar grind test, lateral patellar tilt and a J-sign. An orthopaedic surgeon confirmed the diagnosis on 15 December 2011. Repeat MRI on 30 November 2016 confirmed worsening to grade IV chondral loss, and arthroscopy on 14 February 2017 confirmed the cartilage damage.
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 20 August 2011, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2011, where the injuries occurred and the condition began, and in Iraq in 2016, where it worsened.
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 Chondromalacia Patella, No. 2 of 2019
Causative factors
Factor 9(1): having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella; — MET
- On 28 May 2011 the veteran dived onto rocky ground during a contact and struck the front of his right kneecap, with immediate patellar pain that persisted for five days and bruising recorded by the medical officer. This direct trauma to the patella occurred within the three months before onset, from 20 May 2011 to 20 August 2011.
Factor 9(2): having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella; — MET
- On 04 June 2011 his right patella dislocated laterally while he was pivoting to cross an irrigation ditch on patrol, and it was reduced by the patrol medic. This was within the three months before onset.
Factor 9(3): 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; — MET
- On 12 March 2011 he twisted his right knee jumping from a vehicle under load, tearing the medial collateral ligament and the medial meniscus, with residual valgus laxity confirmed on MRI in December 2011. This injury fell within the six months before onset, from 20 February 2011 to 20 August 2011.
Factor 9(4): having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella; — MET
- After the March 2011 injury the physiotherapist recorded wasting of the vastus medialis and lateral patellar maltracking on 30 March 2011, made worse by the dislocation of 04 June 2011. The maltracking, with lateral tilt and a J-sign, was acquired in service and was present throughout the three months before onset.
Factor 9(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; — MET
- The veteran ran an average of about 65 kilometres a week in the four weeks before onset, from 23 July 2011 to 20 August 2011, on the patrol base perimeter and treadmill while preparing for a special forces selection course.
Factor 9(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
- In the four weeks before onset he patrolled more than 15 hours a week on foot carrying about 40 kilograms over steep and rocky ground, with repeated climbing of compound walls, kneeling and squatting, forceful loading of the right patellofemoral joint at well over five METs.
Factor 9(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
- From 10 August 2011, during a clearance operation, his dismounted patrol time rose from about 3 hours to about 9 hours a day under load, an increase of more than 100 percent at well over five METs, and this continued for the ten days before onset on 20 August 2011.
Worsening factors
Factor 9(8): having direct trauma to the patella of the affected knee within the three months before the clinical worsening of chondromalacia patella; — MET
- On 02 July 2016 the veteran struck his right kneecap on a concrete step on deployment, with immediate pain persisting for three days, within the three months before the worsening on 15 August 2016.
Factor 9(9): having patellar dislocation of the affected knee within the three months before the clinical worsening of chondromalacia patella; — MET
- On 20 June 2016 his right patella dislocated again during a section attack drill, within the three months before the worsening.
Factor 9(10): 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 worsening of chondromalacia patella; — MET
- On 10 April 2016 he sustained an acute lateral meniscal tear of the right knee stepping off a vehicle ramp, confirmed on ultrasound, within the six months before the worsening, from 15 February 2016 to 15 August 2016.
Factor 9(11): having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical worsening of chondromalacia patella; — MET
- Acquired lateral patellar maltracking persisted from 2011 and was recorded again after the June 2016 redislocation, present throughout the three months before the worsening, from 15 May 2016 to 15 August 2016.
Factor 9(12): running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical worsening of chondromalacia patella; — MET
- He ran about 62 kilometres a week in the four weeks before the worsening, from 18 July 2016 to 15 August 2016, training for a unit endurance event.
Factor 9(13): 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 worsening of chondromalacia patella; — MET
- In the four weeks before the worsening he patrolled and trained more than 12 hours a week carrying about 35 kilograms, with repeated kneeling, climbing and stair work.
Factor 9(14): 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 worsening of chondromalacia patella; — MET
- From 08 August 2016 his daily patrol and training time rose from about 3.5 hours to about 8 hours a day, an increase of more than 100 percent at well over five METs, for the seven days before the worsening on 15 August 2016.
Factor 9(15): inability to obtain appropriate clinical management for chondromalacia patella. — MET
- From February 2016 the veteran was waitlisted for orthopaedic review of his known chondromalacia, and on deployment to Iraq from March to October 2016 no physiotherapy, imaging follow-up or surgical review was available. He continued full patrol duties without modification, and the condition worsened to grade IV chondral loss. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Chondromalacia Patella, No. 1 of 2019
Causative factors
Factor 9(1): having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella; — MET
- The blow to the right kneecap on 28 May 2011 occurred during a contact on warlike service in Afghanistan, with patellar pain persisting for five days, within the three months before onset.
Factor 9(2): having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella; — MET
- The lateral patellar dislocation on 04 June 2011 occurred on patrol on warlike service in Afghanistan, within the three months before onset.
Factor 9(3): 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; — MET
- The medial collateral ligament and medial meniscal tear of 12 March 2011 occurred jumping from a vehicle on warlike service in Afghanistan, within the six months before onset, and left permanent valgus laxity.
Factor 9(4): having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella; — MET
- Lateral patellar maltracking was acquired after the March 2011 injury and the June 2011 dislocation on warlike service in Afghanistan, and was present throughout the three months before onset.
Factor 9(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
- On warlike service in Afghanistan the veteran ran about 65 kilometres a week in the four weeks before onset, well above 30 kilometres.
Factor 9(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
- On warlike service in Afghanistan he patrolled more than 15 hours a week under a 40 kilogram load, forcefully loading the patellofemoral joint, in the four weeks before onset.
Factor 9(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
- On warlike service in Afghanistan his patrol time rose from about 3 to 9 hours a day from 10 August 2011, more than 100 percent, for the ten days before onset.
Factor 9(8): being obese at the time of the clinical onset of chondromalacia patella; — MET
- The veteran weighed 101 kg at a height of 1.82 m on 23 August 2011, a BMI of 30.5, at onset on warlike service in Afghanistan.
Worsening factors
Factor 9(9): having direct trauma to the patella of the affected knee within the three months before the clinical worsening of chondromalacia patella; — MET
- The blow to the right kneecap on 02 July 2016 occurred on warlike service in Iraq, within the three months before the worsening.
Factor 9(10): having patellar dislocation of the affected knee within the three months before the clinical worsening of chondromalacia patella; — MET
- The redislocation of 20 June 2016 occurred during a drill on warlike service in Iraq, within the three months before the worsening.
Factor 9(11): 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 worsening of chondromalacia patella; — MET
- The lateral meniscal tear of 10 April 2016 occurred on warlike service in Iraq, within the six months before the worsening.
Factor 9(12): having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical worsening of chondromalacia patella; — MET
- Acquired maltracking was present throughout the three months before the worsening on warlike service in Iraq.
Factor 9(13): running or jogging an average of at least 30 kilometres per week for at least the four weeks before the clinical worsening of chondromalacia patella; — MET
- On warlike service in Iraq he ran about 62 kilometres a week in the four weeks before the worsening.
Factor 9(14): 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 worsening of chondromalacia patella; — MET
- On warlike service in Iraq he patrolled and trained more than 12 hours a week under load in the four weeks before the worsening.
Factor 9(15): 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 worsening of chondromalacia patella; — MET
- On warlike service in Iraq his daily activity rose from about 3.5 to 8 hours from 08 August 2016, for the seven days before the worsening.
Factor 9(16): being obese at the time of the clinical worsening of chondromalacia patella; — MET
- His BMI was 31.6 on 18 August 2016, at the worsening on warlike service in Iraq.
Factor 9(17): inability to obtain appropriate clinical management for chondromalacia patella. — MET
- On warlike service in Iraq from March to October 2016 no physiotherapy, imaging or orthopaedic review was available for his diagnosed chondromalacia, and the condition worsened while he continued full duties.
The % contribution of the causes is 100% and significant.
Sequelae
The right patellofemoral pain syndrome is a sequela of the veteran's accepted right knee injuries: the medial collateral ligament and meniscal tear of March 2011, the patellar dislocation of June 2011 and the resulting patellar instability and maltracking, all sustained on warlike service.
Unintended Consequence
Not applicable on the present evidence. No treatment provided by the Commonwealth caused or worsened the condition; the worsening arose from the absence of treatment rather than from treatment given.
Inability to Attain Appropriate Medical Management
MET. From February 2016 the veteran was awaiting orthopaedic review of his known chondromalacia, and on warlike service in Iraq from March to October 2016 there was no physiotherapy, imaging follow-up or surgical review, so he continued full patrol and training duties without modification. Repeat MRI on 30 November 2016 showed progression from grade II to III to grade IV chondral loss, and the Kujala score fell from 68 to 41. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent appropriate treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Mar 2011, Outpatient health record, Medical Officer, Patrol base, Afghanistan
- 30 Mar 2011, Physiotherapy assessment, Physiotherapist
- 28 May 2011, X-ray right knee, Role 2 facility, Afghanistan
- 04 Jun 2011, Outpatient health record, Medical Officer, Afghanistan
- 08 Aug 2011, Physiotherapy review, Physiotherapist
- 23 Aug 2011, Outpatient health record, Medical Officer, Role 1 facility, Afghanistan
- 15 Dec 2011, MRI right knee and orthopaedic consultation, Orthopaedic surgeon
- 10 Apr 2016, Ultrasound right knee, Role 2 facility, Iraq
- 18 Aug 2016, Outpatient health record, Medical Officer, Iraq
- 30 Nov 2016, MRI right knee, Radiologist
- 14 Feb 2017, Operation report, Orthopaedic surgeon
- Statement of Principles concerning Chondromalacia Patella (Balance of Probabilities) No. 2 of 2019, Repatriation Medical Authority
- Statement of Principles concerning Chondromalacia Patella (Reasonable Hypothesis) No. 1 of 2019, Repatriation Medical Authority
