Diagnostic Assessment — Right Knee - Sprain
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Knee — Sprain BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as an Artilleryman from 2 March 1980 to 17 December 1986
Occupational History
As an Artilleryman aboard service vessels, the veteran worked on moving decks that were frequently wet and slippery, posing an inherent risk of slipping, falling, and sustaining lower limb injuries.
He was also required to participate in military sporting activities including rugby and football
History
The veteran sustained a mild sprain of the right knee on approximately 27 November 1983 when he slipped on a wet deck and fell at an artillery regiment.
He had a pre-enlistment left knee complaint of a sore left knee from a football injury with clicking, aching, and grinding for four months, documented on the enlistment medical history form dated 30 December 1979
Timeline
30 Dec 1979 — Enlistment medical history form notes a sore left knee from a pre- enlistment football injury, with four months duration and symptoms of clicking, aching, and grinding.
No locking was noted.
This documents a pre-existing left knee complaint (treated by arthroscopy on 6 January 1980) that was considered acceptable for enlistment; it did not involve the right knee. "Sore (L) knee" 27 Nov 1983 (approx) — ABSR the veteran, as a young adult, slipped on a wet deck at an artillery regiment and fell, sustaining a mild sprain of the right knee.
Examination demonstrated slight swelling to the right knee.
Medial and lateral collateral ligaments were checked and found to be intact.
Cruciate ligaments were assessed as intact.
There was some pain on examination but full range of motion was preserved.
He was treated with mobilisation, full-range joint exercises and swimming.
He was returned to duty.
The injury was documented on both the Daily Injury Record and the PM 278 Compensation Supporting Report, the latter clearly dating the event to 29.12.87 with the member as a young adult and stationed at an artillery regiment. "Sprain, right knee (mild)"
Symptoms
At the time of injury, the veteran experienced pain and slight swelling of the right knee following the slip and fall on the wet deck.
Full range of motion was preserved and the ligaments were intact on examination, indicating a mild sprain without structural damage
Imaging
No imaging of the right knee was performed at the time of injury or subsequently in the available records
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Knee Sprain (ICD-10: S83.90XA).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim.
A knee sprain involves stretching or tearing of the ligaments of the knee joint.
In this case, the medial collateral, lateral collateral, and cruciate ligaments were all assessed as intact, indicating a mild sprain (Grade I) without significant structural ligamentous damage
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 27 November 1983 [ [CHART REVIEW document], pages 10 11; [CHART REVIEW document], Pages 14 15] When did the veteran first present to a health / medical provider for this condition? Approximately 27 November 1983 When was the condition confirmed / formally diagnosed? Approximately 27 November 1983 When did the veteran first present to you (or your practice) for this condition? 13 July 2021
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending medical officer at an artillery regiment.
The key symptoms were right knee pain following a slip on a wet deck.
The key signs were slight swelling of the right knee with intact collateral and cruciate ligaments and preserved range of motion.
The injury was documented on both the Daily Injury Record and the PM 278 Compensation Supporting Report [ [CHART REVIEW document], pages 10 11; [CHART REVIEW document], Pages 14 15]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 30 May 2000 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - On 27 November 1983, while on duty in an artillery regiment, the veteran slipped on a wet deck and fell onto both knees, jarring the right knee (Daily Injury Record and PM 278 Compensation Supporting Report of 27 November 1983).
A fall onto the knee by a man then weighing about 113 kg (his weight in September 1983 and January 1984) applies a significant physical force to and through the right knee joint.
The medical officer diagnosed a mild sprain of the right knee the same day, with slight swelling and some pain but intact collateral and cruciate ligaments and menisci, so the force was experienced at the time of the clinical onset of the sprain.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — NOT MET - This factor applies only to a strain of a muscle or tendon.
The injury of 27 November 1983 was diagnosed as a mild sprain of the right knee, a ligament injury, and no muscle or tendon injury was recorded.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - On 27 November 1983, on duty in an artillery regiment, the veteran slipped on a wet deck and fell onto both knees, jarring the right knee.
The fall of a man weighing about 113 kg applied a significant physical force to and through the right knee joint, and the medical officer diagnosed a mild sprain of that knee the same day, so the force coincided with the clinical onset of the sprain.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — NOT MET - This factor applies only to a strain of a muscle or tendon; the veteran's right knee injury of 27 November 1983 was a ligament sprain, and no muscle or tendon injury was recorded.
Other Plausible Links to Service The injury arose out of, and in the course of, the veteran's employment as a member.
The PM 278 injury report of 27 November 1983 records that he was on duty in an artillery regiment when he slipped on the wet deck and jarred his knee, and the Daily Injury Record of the same date records that he fell onto both knees.
Wet and slippery decks are a recognised hazard of shipboard service, and the injury was a direct result of his duties on board.
Conclusion the veteran's right knee sprain was caused by his slip and fall onto both knees on a wet deck in an artillery regiment on 27 November 1983, while he was on duty; the fall applied a significant physical force through the right knee at the onset of the sprain, meeting factor 9(1) of both Statements of Principles, and the injury arose out of and in the course of his service.
The pre- enlistment football injury noted on the enlistment medical history of 30 December 1979, and treated by arthroscopy on 6 January 1980, involved the left knee, not the right, and there is no record of any earlier injury or instability of the right knee, so no other cause is identified.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right knee sprain is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 27 November 1983 aggravated it or contributed to it in a material degree.
He served for a further three years after the injury, including in an artillery regiment until about June 1984.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - There is no record of any clinical worsening of the right knee sprain.
The veteran returned to duty on 27 November 1983 and made no further presentation with right knee symptoms in his remaining three years of service or in the available post-service records.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — NOT MET - This factor applies only to a strain of a muscle or tendon.
The veteran's right knee condition is a sprain of the knee ligaments, and no worsening of any muscle or tendon injury of the knee is recorded.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, there was no inability: the medical officer in an artillery regiment examined the knee on the day of injury, prescribed mobilisation, full-range joint exercises and swimming and returned him to duty, and the mild sprain resolved without further presentation.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - No clinical worsening of the right knee sprain is recorded; the veteran returned to duty on 27 November 1983 and did not present again with right knee symptoms during or after his service.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — NOT MET - This factor applies only to a strain of a muscle or tendon; the veteran's right knee condition is a ligament sprain, and no worsening of a muscle or tendon injury is recorded.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no objective or subjective inability: the knee was examined and treated by the medical officer on the day of injury, and the mild sprain resolved without further presentation
Sequelae
The right knee sprain is an isolated acute injury.
No subsequent knee pathology has been specifically documented in the available records, however the acute ligamentous injury may predispose to future degenerative change
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
There was no inability to obtain appropriate clinical management.
The medical officer in an artillery regiment examined the knee on the day of injury and prescribed mobilisation, full-range joint exercises and swimming, and the mild sprain resolved without further presentation.
Assessed objectively and subjectively as required by Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this factor is NOT MET
Date of Clinical Onset
Right knee sprain is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 27 November 1983 — mild sprain of the right knee after slipping on a wet deck [ [CHART REVIEW document], pages 10 11; [CHART REVIEW document], pages 14 15].
Date of clinical onset: 27 November 1983.
This date falls within the veteran's ADF service (2 March 1980 17 December 1986).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
