Right Knee - Pes Anserine Bursitis — DVA claim example

Diagnostic Assessment — Right Knee - Pes Anserine Bursitis

Example 1 of 1 · fictitious patient (Veteran BD)

Diagnostic Assessment

Right Knee - Pes Anserine Bursitis

BOP Code: 66 of 2018 (Knee Bursitis)
RH Code: 65 of 2018 (Knee Bursitis)

ADF History

Veteran BD, date of birth 03 September 1984, Australian Army, Combat Engineer (Sapper, later Combat Engineer Section Commander), enlisted 16 May 2003, medically discharged 30 March 2020. Operational service: Afghanistan, 15 February 2011 to 12 October 2011 (warlike); Middle East Area of Operations (Iraq), 05 May 2017 to 28 November 2017 (warlike).

Occupational History

As a combat engineer the veteran conducted route clearance and search for improvised explosive devices, kneeling and crawling for hours on rocky ground and hard surfaces, carried loads of 30 to 45 kilograms on foot, and rode trail motorcycles and all-terrain vehicles for route reconnaissance. Construction tasks involved kneeling on concrete, steel decking and vehicle ramps.

Engineers have high rates of knee injury, including meniscal tears, early osteoarthritis and bursitis, from kneeling, loaded marching, running and repeated knocks to the knee. Deployed engineers worked with limited specialist care, and skin wounds sustained in the field were at high risk of infection.

History

Veteran BD, a combat engineer in the Australian Army, developed septic and inflammatory bursitis of the right pes anserine bursa, with involvement of the prepatellar, medial collateral ligament and semimembranosus bursae, on warlike service in Afghanistan on 23 June 2011. It followed a surgically closed laceration over the knee, hours of kneeling search and motorcycle riding, high-volume running, and pre-existing medial compartment osteoarthritis, genu valgum, psoriasis, gout and methotrexate treatment, and it worsened in Iraq in August 2017.

Timeline

• 12 Mar 2007 — The veteran injured his right knee jumping from a vehicle on a field exercise. MRI showed a complex tear of the medial meniscus, and he underwent arthroscopic partial medial meniscectomy on 26 April 2007. He returned to full duties after three months. "right partial medial meniscectomy"
• 19 Aug 2009 — A podiatrist assessed recurrent medial knee pain under load and recorded right genu valgum of 12 degrees, bilateral pes planus with excessive subtalar pronation, and a functional leg length inequality of 1.5 cm. Custom orthoses were prescribed. A dermatologist was managing chronic plaque psoriasis, including plaques on the extensor surfaces of both knees, and commenced methotrexate 15 mg weekly in October 2009. "genu valgum, pronation, orthoses prescribed"
• 22 Nov 2010 — At his pre-deployment medical examination, X-ray of the right knee showed medial compartment joint space narrowing with marginal osteophytes, Kellgren-Lawrence grade 2, and the medical officer recorded medial compartment osteoarthritis. He had had two attacks of gout in the first metatarsophalangeal joint in 2010, with a serum urate of 0.58 mmol/L, and allopurinol had been commenced. There was no knee swelling or bursal tenderness. "medial compartment OA, gout"
• 30 May 2011 — During warlike service in Afghanistan he fell onto rocks and barbed wire while searching a culvert and sustained a 4 cm laceration over the right medial proximal tibia and abrasions over the patella. The surgeon at the role 2 facility debrided and closed the wound on the same day. Over the following weeks he continued route search, kneeling for about four hours a day, and rode a trail motorcycle on reconnaissance for about two hours a day, gripping the fuel tank with his knees. "laceration debrided and closed"
• 24 Jun 2011 — He presented to the role 1 facility with 24 hours of painful swelling, warmth and redness over the right medial proximal tibia below the joint line, fever of 38.4 degrees and swelling over the patella. He was training for the Army marathon team and had averaged 64 km a week of running in the preceding four weeks. Aspiration of the pes anserine bursa yielded turbid fluid that grew Staphylococcus aureus. "septic pes anserine bursitis"
• 28 Jun 2011 — Ultrasound at the role 3 hospital showed a distended pes anserine bursa with thickened walls and debris, and fluid in the prepatellar, medial collateral ligament and semimembranosus-tibial collateral ligament bursae. He received intravenous flucloxacillin for four days and then oral antibiotics, and methotrexate was withheld. He remained on deployment with intermittent medial knee pain. "multiple bursae, IV flucloxacillin"
• 15 Aug 2017 — During warlike service in Iraq he presented with recurrent painful swelling over the right pes anserine bursa, fever, and a discharging sinus. In the preceding four weeks he had run about 62 km a week, knelt for about five hours a day teaching search techniques, ridden a trail motorcycle for range reconnaissance, and on 25 July 2017 sustained a laceration over the medial knee from a steel vehicle ramp that was surgically closed. Aspiration grew Staphylococcus aureus. "recurrent septic bursitis, discharging sinus"
• 09 Oct 2017 — MRI after his return showed a thick-walled, septated pes anserine bursa measuring 46 mm, larger than on the 2011 ultrasound, with surrounding oedema and progression of medial compartment osteoarthritis. An orthopaedic surgeon diagnosed chronic recurrent pes anserine bursitis, performed open bursectomy on 30 October 2017 and later recommended medical discharge from field engineering. "chronic bursitis, bursectomy performed"

Symptoms

At onset the veteran had acute painful swelling, warmth and redness over the medial proximal tibia below the knee joint line, fever, swelling over the kneecap, pain on climbing stairs and pain at night when the knees touched. After onset he had recurrent medial knee pain and swelling after kneeling, running and riding, and in August 2017 recurrent infection with a discharging sinus.

He now reports persisting medial knee pain on stairs, kneeling and walking more than 2 kilometres, night pain when lying on his side, and stiffness after sitting. He cannot run or kneel and has a well-healed bursectomy scar with local tenderness.

Imaging

• 22 Nov 2010 — X-ray right knee: "Medial compartment joint space narrowing with marginal osteophytes, Kellgren-Lawrence grade 2. No effusion."
• 28 Jun 2011 — Ultrasound right knee: "Distended pes anserine bursa, 28 mm, with thickened hyperaemic walls and internal debris. Smaller fluid collections in the prepatellar bursa, the medial collateral ligament bursa and the semimembranosus-tibial collateral ligament bursa."
• 09 Oct 2017 — MRI right knee: "Thick-walled septated pes anserine bursa measuring 46 mm with surrounding soft tissue oedema. Progression of medial compartment osteoarthritis with full-thickness cartilage loss and a degenerate meniscal remnant."

Onset Date

The most likely date of onset of this condition is 23 Jun 2011.

At that date the veteran was on warlike service in Afghanistan with an engineer squadron, conducting route search and reconnaissance, and running in his own time to qualify for the Army marathon team. On 23 June 2011 painful swelling developed over the right medial proximal tibia, and he presented the next day with fever and a red, swollen pes anserine bursa.

This date is appropriate because his pre-deployment examination of 22 November 2010 and the wound review of 06 June 2011 recorded no bursal swelling or tenderness, and he first presented with the condition on 24 June 2011, the day after symptoms began. It falls within warlike service.

For the running factors, the four weeks before onset run from 26 May 2011 to 23 Jun 2011, during which he averaged 64 km a week. For the kneeling and pressing factors, the two months before onset run from 23 Apr 2011 to 23 Jun 2011, during which he knelt in route search for about four hours a day on more than 40 days and rode a trail motorcycle for about two hours a day on about 45 days. For the trauma and surgery factors, the 30 days before onset run from 24 May 2011 to 23 Jun 2011, and the laceration and its surgical closure occurred on 30 May 2011. Medial compartment osteoarthritis, psoriasis of the extensor knee, gout, the biomechanical abnormality and methotrexate treatment were each present on 23 Jun 2011, and the bursa was infected at onset.

For the worsening factors, the period after onset runs from 23 Jun 2011 to the documented worsening on 15 Aug 2017 in Iraq. The four weeks before the worsening run from 18 Jul 2017 to 15 Aug 2017, the 30 days before from 16 Jul 2017 to 15 Aug 2017, and the two months before from 15 Jun 2017 to 15 Aug 2017. In those periods he ran about 62 km a week, knelt for about five hours a day, rode a trail motorcycle, and had a laceration surgically closed on 25 Jul 2017, and the bursa was infected, with psoriasis, gout, medial compartment osteoarthritis, the biomechanical abnormality and methotrexate treatment all present on 15 Aug 2017.

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

The formal diagnosis is Right Knee - Pes Anserine Bursitis (ICD-10 M70.5), septic at onset and later chronic and recurrent, with involvement of the prepatellar, medial collateral ligament and semimembranosus bursae, under the Statements of Principles concerning knee bursitis, Balance of Probabilities No. 66 of 2018 and Reasonable Hypothesis No. 65 of 2018.

The pes anserine bursa lies on the inner side of the upper shin, beneath the joined tendons of the sartorius, gracilis and semitendinosus muscles. Bursitis is inflammation or infection of the bursa, causing pain, swelling and tenderness below the inner knee joint line, worse on stairs and at night. It is caused by friction and overuse, including running, by direct trauma, by infection through a skin wound, and by abnormal mechanics such as knock-knee and flat feet. It is more common with knee osteoarthritis, gout and inflammatory skin disease, and septic bursitis is more likely when the immune system is suppressed.

The condition began on warlike service in Afghanistan on 23 June 2011, three weeks after a surgically closed laceration over the knee, and worsened on warlike service in Iraq on 15 August 2017.

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

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

23 June 2011.

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

24 June 2011.

When was the condition confirmed / formally diagnosed?

24 June 2011.

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

26 February 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 24 June 2011 by the clinical findings of localised painful swelling, warmth and tenderness over the right pes anserine bursa, and by aspiration of turbid fluid that grew Staphylococcus aureus. Ultrasound on 28 June 2011 showed a distended pes anserine bursa with thickened hyperaemic walls and debris, and smaller collections in the prepatellar, medial collateral ligament and semimembranosus-tibial collateral ligament bursae. This meets the Statement of Principles definition of knee bursitis as inflammation or infection of a bursa around the knee joint, and is not a popliteal cyst.

The recurrence on 15 August 2017 was confirmed by aspiration and culture, and MRI on 09 October 2017 showed a larger, thick-walled, septated pes anserine bursa. An orthopaedic surgeon confirmed chronic recurrent pes anserine bursitis and the diagnosis was confirmed histologically at bursectomy on 30 October 2017.

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 23 June 2011, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2011, where the condition began, and in Iraq in 2017, where it worsened. The Balance of Probabilities instrument applies to peacetime service, during which the meniscal injury, the osteoarthritis, the biomechanical abnormality, the psoriasis and its methotrexate treatment, and the gout were established.

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 Knee Bursitis, No. 66 of 2018

Causative factors

Factor 8(1): for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 60 kilometres per week for the four weeks before the clinical onset of knee bursitis; — MET

- The veteran's training log, reviewed at the role 1 facility on 24 June 2011, recorded weekly running distances of 72, 40, 70 and 75 km in the four weeks before onset, from 26 May to 23 June 2011, an average of 64 km a week. He was training for selection in the Army marathon team, an activity encouraged by his unit. The pes anserine bursa is not a prepatellar or superficial infrapatellar bursa.

Factor 8(2): for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; — MET

- Ultrasound on 28 June 2011 showed prepatellar bursitis of the right knee alongside the pes anserine bursitis. In the two months before onset, from 23 April to 23 June 2011, the veteran knelt on rock and gravel during route search for about four hours a day on more than 40 days, more than 160 hours in total, as recorded in his patrol reports and the role 1 history.

Factor 8(3): for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; — MET

- Ultrasound on 28 June 2011 also showed fluid in the medial collateral ligament bursa. In the two months before onset he rode a trail motorcycle on route reconnaissance for about two hours a day on about 45 days, gripping the fuel tank with the medial side of his knees, a cumulative period of about 90 hours.

Factor 8(4): having trauma to the affected knee bursa in the 30 days before the clinical onset of knee bursitis; — MET

- On 30 May 2011, 24 days before onset, he fell onto rocks and barbed wire and sustained a 4 cm laceration directly over the right pes anserine bursa and abrasions over the patella. He also repeatedly knocked the medial knee on the motorcycle frame in the following weeks.

Factor 8(5): having surgery to the knee of the affected side in the 30 days before the clinical onset of knee bursitis; — MET

- The surgeon at the role 2 facility debrided and closed the laceration over the right medial proximal tibia on 30 May 2011, 24 days before onset. Surgical debridement and closure is surgery to the right knee region.

Factor 8(6): having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical onset of knee bursitis; — MET

- Aspiration of the pes anserine bursa on 24 June 2011 yielded turbid fluid that grew Staphylococcus aureus, a bacterial infection of the affected bursa present at onset, introduced through the laceration of 30 May 2011.

Factor 8(7): for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of knee bursitis; — MET

- The bursitis was septic. At onset the veteran had taken methotrexate 15 mg weekly since October 2009 for psoriasis, an immunosuppressive drug causing substantial suppression of immune responses, and had last taken it on 19 June 2011.

Factor 8(8): for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical onset of knee bursitis; — MET

- The prepatellar bursa was involved, as shown on ultrasound on 28 June 2011. Chronic plaque psoriasis involving the extensor surface of the right knee had been documented by a dermatologist since 2009 and was active at onset, with a fissured plaque over the patella recorded on 24 June 2011.

Factor 8(9): having a disease from the specified list of diseases at the time of the clinical onset of knee bursitis; — MET

- Gout was diagnosed in 2010 after two attacks in the first metatarsophalangeal joint, with a serum urate of 0.58 mmol/L, and was present and treated with allopurinol at onset on 23 June 2011. Gout is on the specified list of diseases.

Worsening factors

Factor 8(10): for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 60 kilometres per week for the four weeks before the clinical worsening of knee bursitis; — MET

- In the four weeks before the worsening, from 18 July to 15 August 2017, the veteran ran about 62 km a week on the base perimeter and treadmill while training for an Army endurance event, as recorded at the role 1 facility on 15 August 2017. The worsening, with recurrent septic bursitis, a discharging sinus and an enlarged bursa on MRI, was documented on 15 August 2017.

Factor 8(11): for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; — MET

- The prepatellar bursa remained involved. In the two months before the worsening, from 15 June to 15 August 2017, he knelt on concrete for about five hours a day teaching search techniques to partner-force engineers, more than 200 hours in total.

Factor 8(12): for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; — MET

- The medial collateral ligament bursa remained involved. In the two months before the worsening he rode a trail motorcycle on range reconnaissance for about 90 minutes a day on about 45 days, more than 65 hours, gripping the tank with his knees.

Factor 8(13): having trauma to the affected knee bursa in the 30 days before the clinical worsening of knee bursitis; — MET

- On 25 July 2017, 21 days before the worsening, he struck the medial right knee on the edge of a steel vehicle ramp, causing a laceration over the pes anserine bursa.

Factor 8(14): having surgery to the knee of the affected side in the 30 days before the clinical worsening of knee bursitis; — MET

- The laceration of 25 July 2017 was surgically debrided and closed at the role 2 facility the same day, 21 days before the worsening.

Factor 8(15): having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical worsening of knee bursitis; — MET

- Aspiration on 15 August 2017 grew Staphylococcus aureus from the pes anserine bursa, a bacterial infection present at the worsening.

Factor 8(16): for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical worsening of knee bursitis; — MET

- The recurrence was septic, and the veteran was taking methotrexate 15 mg weekly for psoriasis at the time of the worsening on 15 August 2017.

Factor 8(17): for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical worsening of knee bursitis; — MET

- Psoriatic plaques over the right patella, worsened by heat and sweating on deployment, were recorded on 15 August 2017, with the prepatellar bursa still involved.

Factor 8(18): having a disease from the specified list of diseases at the time of the clinical worsening of knee bursitis; — MET

- Gout persisted at the worsening, with a serum urate of 0.52 mmol/L in August 2017 and an acute attack in the right first metatarsophalangeal joint in July 2017 on deployment.

Factor 8(19): inability to obtain appropriate clinical management for knee bursitis. — MET

- In Afghanistan in 2011 the septic bursitis was treated with only four days of intravenous antibiotics and the veteran remained on route search duties, kneeling and riding, without rest, ultrasound review or surgical drainage. The bursitis became chronic and recurrent and in 2017 he again could not obtain imaging or orthopaedic review on deployment until his return. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Knee Bursitis, No. 65 of 2018

Causative factors

Factor 8(1): for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 30 kilometres per week for the four weeks before the clinical onset of knee bursitis; — MET

- On warlike service in Afghanistan the veteran averaged 64 km a week of running on the patrol base in the four weeks before onset, from 26 May to 23 June 2011, more than twice the required distance.

Factor 8(2): for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; — MET

- On warlike service in Afghanistan from 23 April to 23 June 2011 he knelt and crawled during route search for improvised explosive devices for more than 160 hours, and the prepatellar bursa was involved on ultrasound on 28 June 2011.

Factor 8(3): for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; — MET

- On warlike service in Afghanistan he rode a trail motorcycle on route reconnaissance for about 90 hours in the two months before onset, pressing the medial knees against the tank, and the medial collateral ligament bursa was involved on ultrasound.

Factor 8(4): having trauma to the affected knee bursa in the 30 days before the clinical onset of knee bursitis; — MET

- On warlike service in Afghanistan on 30 May 2011 he lacerated the skin over the right pes anserine bursa in a fall onto rocks and barbed wire while searching a culvert, 24 days before onset.

Factor 8(5): having surgery to the knee of the affected side in the 30 days before the clinical onset of knee bursitis; — MET

- The laceration was surgically debrided and closed at the role 2 facility in Afghanistan on 30 May 2011, 24 days before onset.

Factor 8(6): having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical onset of knee bursitis; — MET

- Staphylococcus aureus was grown from the pes anserine bursa aspirated on warlike service on 24 June 2011, the infection having entered through the laceration sustained on patrol.

Factor 8(7): for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of knee bursitis; — MET

- The veteran was taking methotrexate 15 mg weekly, an immunosuppressive drug, throughout his warlike service in Afghanistan, including at the onset of the septic bursitis on 23 June 2011.

Factor 8(8): for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical onset of knee bursitis; — MET

- Psoriasis over the extensor surface of the right knee flared in the heat and dust of Afghanistan and was recorded with a fissured plaque over the patella at onset, with the prepatellar bursa involved.

Factor 8(9): having a disease from the specified list of diseases at the time of the clinical onset of knee bursitis; — MET

- Gout, on the specified list of diseases, was present at onset on warlike service, with an attack of the first metatarsophalangeal joint in April 2011 attributed to dehydration in the heat of Afghanistan.

Factor 8(10): for medial compartment bursitis only, having medial compartment osteoarthritis at the time of the clinical onset of knee bursitis; — MET

- Ultrasound on 28 June 2011 showed bursitis of the semimembranosus-tibial collateral ligament bursa in the medial compartment of the knee. Medial compartment osteoarthritis of the right knee, Kellgren-Lawrence grade 2, had been shown on X-ray on 22 November 2010 after the 2007 meniscectomy, and was present at onset on warlike service.

Factor 8(11): for pes anserine bursitis only, having a significant biomechanical abnormality involving the affected knee at the time of the clinical onset of knee bursitis; — MET

- The veteran had right genu valgum of 12 degrees with excessive subtalar pronation and a 1.5 cm leg length inequality, documented by a podiatrist on 19 August 2009, which increase the load on the pes anserine insertion. His custom orthoses were not replaced when they wore out on warlike service in Afghanistan, and the abnormality was present at onset.

Worsening factors

Factor 8(12): for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 30 kilometres per week for the four weeks before the clinical worsening of knee bursitis; — MET

- On warlike service in Iraq he ran about 62 km a week in the four weeks before the worsening of 15 August 2017.

Factor 8(13): for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; — MET

- On warlike service in Iraq from 15 June to 15 August 2017 he knelt on concrete teaching search techniques for more than 200 hours, with the prepatellar bursa involved.

Factor 8(14): for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; — MET

- On warlike service in Iraq he rode a trail motorcycle on range reconnaissance for more than 65 hours in the two months before the worsening, with the medial collateral ligament bursa involved.

Factor 8(15): having trauma to the affected knee bursa in the 30 days before the clinical worsening of knee bursitis; — MET

- On warlike service in Iraq on 25 July 2017 he lacerated the skin over the pes anserine bursa on a steel vehicle ramp, 21 days before the worsening.

Factor 8(16): having surgery to the knee of the affected side in the 30 days before the clinical worsening of knee bursitis; — MET

- The laceration was surgically closed at the role 2 facility in Iraq on 25 July 2017, 21 days before the worsening.

Factor 8(17): having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical worsening of knee bursitis; — MET

- Staphylococcus aureus was grown from the bursa on warlike service in Iraq on 15 August 2017, the date of the worsening.

Factor 8(18): for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical worsening of knee bursitis; — MET

- Methotrexate 15 mg weekly was continued on warlike service in Iraq and was being taken at the septic worsening on 15 August 2017.

Factor 8(19): for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical worsening of knee bursitis; — MET

- Active psoriasis over the right patella was recorded in Iraq on 15 August 2017, with the prepatellar bursa involved.

Factor 8(20): having a disease from the specified list of diseases at the time of the clinical worsening of knee bursitis; — MET

- Gout was present at the worsening, with an acute attack on warlike service in Iraq in July 2017 and a serum urate of 0.52 mmol/L.

Factor 8(21): for medial compartment bursitis only, having medial compartment osteoarthritis at the time of the clinical worsening of knee bursitis; — MET

- MRI on 09 October 2017 showed progression of medial compartment osteoarthritis to full-thickness cartilage loss, and the semimembranosus bursa remained involved at the worsening in Iraq.

Factor 8(22): for pes anserine bursitis only, having a significant biomechanical abnormality involving the affected knee at the time of the clinical worsening of knee bursitis; — MET

- Right genu valgum with excessive pronation and leg length inequality persisted at the worsening on warlike service in Iraq, where he again had no replacement orthoses.

Factor 8(23): inability to obtain appropriate clinical management for knee bursitis. — MET

- On warlike service in Afghanistan in 2011 the septic bursitis received only four days of intravenous antibiotics without rest, surgical drainage or imaging follow-up, and on warlike service in Iraq in 2017 no ultrasound or orthopaedic review was available until his return, after which the chronic bursa required excision.

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

Sequelae

The chronic recurrent pes anserine bursitis has altered the veteran's gait and limited his activity, contributing to the progression of medial compartment osteoarthritis of the right knee seen on MRI on 09 October 2017, and has left a tender bursectomy scar. These should be considered for acceptance as sequelae.

Unintended Consequence

Met. Methotrexate prescribed and paid for by the Commonwealth for the veteran's psoriasis caused the immunosuppression that allowed the bursa to become infected in 2011 and again in 2017. The infections followed lacerations that were surgically closed by Defence surgeons on deployment. Both are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. On warlike service in Afghanistan in June 2011 the septic pes anserine bursitis was treated with only four days of intravenous antibiotics, and the veteran returned to route search duties that required kneeling and motorcycle riding, without rest, follow-up ultrasound or surgical drainage. The bursitis became chronic and recurred. On warlike service in Iraq in August 2017 no ultrasound or orthopaedic review was available, and definitive bursectomy was delayed until 30 October 2017. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent rest, imaging and specialist treatment amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 12 Mar 2007, Outpatient health record and MRI right knee report, Medical Officer and Radiologist
2. 26 Apr 2007, Operation report, arthroscopic partial medial meniscectomy, Orthopaedic surgeon
3. 19 Aug 2009, Podiatry assessment, Podiatrist
4. 14 Oct 2009, Dermatology consultation, Dermatologist
5. 22 Nov 2010, Pre-deployment medical examination and X-ray right knee report, Medical Officer and Radiologist
6. 30 May 2011, Wound management record, Surgeon, Role 2 facility, Afghanistan
7. 06 Jun 2011, Wound review, Medical Officer, Role 1 facility, Afghanistan
8. 24 Jun 2011, Outpatient health record and microbiology report, Medical Officer, Role 1 facility, Afghanistan
9. 28 Jun 2011, Ultrasound right knee report and inpatient record, Role 3 hospital, Afghanistan
10. 25 Jul 2017, Wound management record, Surgeon, Role 2 facility, Iraq
11. 15 Aug 2017, Outpatient health record and microbiology report, Medical Officer, Role 1 facility, Iraq
12. 09 Oct 2017, MRI right knee report, Radiologist
13. 30 Oct 2017, Operation report and histopathology, bursectomy, Orthopaedic surgeon
14. Statement of Principles concerning Knee Bursitis (Balance of Probabilities) No. 66 of 2018, Repatriation Medical Authority
15. Statement of Principles concerning Knee Bursitis (Reasonable Hypothesis) No. 65 of 2018, Repatriation Medical Authority