Diagnostic Assessment — Right Knee - Strain
Example 1 of 2 · fictitious patient (Veteran K)
Diagnostic Assessment
Right Knee - Strain
Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Technician Electronic Systems, enlisted 08 February 2002, discharged 02 December 2010.
Occupational History
As a Technician Electronic Systems in the Australian Army, the veteran was responsible for maintenance, repair, and operation of electronic systems, including communication equipment and vehicle electronics such as those used in the ASLAV (Australian Light Armoured Vehicle). This role involved both technical tasks in controlled environments and fieldwork under varying conditions, including military exercises and training courses. The occupational hazards were multifaceted, encompassing physical, environmental, and ergonomic challenges. Technicians are frequently exposed to repetitive strain from handling tools and equipment, prolonged periods in awkward postures, and physical demands of lifting or moving heavy electronic components. The role required participation in physically intensive military activities, such as pack marches, leopard crawling, and battle physical training, which increase the risk of musculoskeletal injuries.
History
The veteran a Technician Electronic Systems in the Australian Army, developed chronic right knee pain and stiffness attributed to repetitive military service activities including pack marches, leopard crawling, pushing trailers, carrying logs, parades, and battle physical training from 2008 to 2017.
Timeline
- 04 February 2016: The veteran presented with ongoing right knee pain, described as stiffness, mild pain, and occasional clicking, linked to ADF service activities. He reported symptoms worsening with stairs, squatting, and prolonged standing, with rest alleviating discomfort. The pain was noted 3 days per week for 4 hours, with stiffness 5 days per week for 12 hours. No specific traumatic event was recalled, but symptoms were attributed to repetitive military activities. An MRI was ordered to investigate the cause of knee pain and stiffness. The veteran reported that symptoms had been stable but worsened with increased activity since Jun 2014.
- 06 February 2016: MRI of the right knee revealed no abnormalities, with intact menisci, ligaments, and cartilage, and no evidence of osteoarthritis or effusion. The clinical presentation of knee strain was diagnosed based on persistent pain and stiffness without structural damage. Symptoms continued to limit activities like squatting and prolonged walking, as reported by the patient. The condition was noted as stable but worsening with increased activity, consistent with chronic strain. No specific management was documented, but activity modification was advised.
Symptoms
At the time of injury during military service, the veteran experienced the gradual onset of right knee pain, stiffness, and occasional clicking without a specific traumatic event. The symptoms developed progressively through repetitive military activities and stabilized in Jun 2014. Current symptoms include pain experienced 3 days per week for 4 hours, stiffness 5 days per week for 12 hours, occasional clicking 1 day per week for 1 hour, joint instability feelings 1 day per week for 1 hour, and range of motion loss 5 days per week for 12 hours. The condition limits activities including squatting, stair climbing, prolonged standing, and walking long distances. Symptoms worsen with stairs, squatting, uneven surfaces, prolonged standing, walking long distances, cold weather, running, and high impact activities. Rest, reduced movement, avoiding prolonged standing, and avoiding long walks provide symptomatic relief.
Imaging
- 06 February 2016: MRI bilateral knee showed no abnormalities in the right knee, with intact menisci, ligaments, and cartilage, and no evidence of osteoarthritis or effusion.
1. What is the formal diagnosis of the condition claimed above?
Right Knee - Strain (M25.661), DVA SOP Sprain and Strain No. 27 of 2020 (Reasonable Hypothesis) and No. 28 of 2020 (Balance of Probabilities), ICD-10 code M25.661.
A strain is an injury involving the tearing or stretching of a muscle or tendon, associated with the onset of pain and tenderness at that site within 24 hours following the injury. It includes complete tear or rupture of a muscle or tendon but excludes drug-induced disease of tendons or muscles. In the context of the knee, strain typically affects the muscles and tendons surrounding the knee joint, including the quadriceps, hamstrings, and other supporting musculature. Chronic strain can result from repetitive stress and overuse, leading to ongoing pain, stiffness, and functional limitation without structural joint damage visible on imaging.
The temporal relationship shows this is a chronic condition that developed during military service through repetitive activities and stabilized in Jun 2014, representing an ongoing strain injury to the right knee musculature and supporting structures.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
During service period from 2008-2017, with symptoms stabilizing in Jun 2014. [PTQ.pdf, Page 2]
When did the veteran first present to a health / medical provider for this condition?
04 February 2016, when he presented with ongoing right knee pain to a Medical Officer. [PTQ.pdf, Page 1; CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
When was the condition confirmed / formally diagnosed?
06 February 2016, when the condition was diagnosed based on clinical presentation and MRI findings by Medical Officer assessment. [CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
When did the veteran first present to you (or your practice) for this condition?
18 August 2015
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 assessment by a Medical Officer based on persistent symptoms of right knee pain, stiffness, and occasional clicking without structural abnormalities on MRI. Key symptoms included pain 3 days per week for 4 hours, stiffness 5 days per week for 12 hours, clicking 1 day per week for 1 hour, joint instability feelings 1 day per week for 1 hour, and range of motion loss 5 days per week for 12 hours. Functional limitations included difficulty with stairs, squatting, and prolonged standing. MRI performed on 06 February 2016 showed no meniscus, ligament, or chondral injury, leading to a diagnosis of strain based on clinical symptoms rather than structural damage. [PTQ.pdf, Pages 2-4; CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline and Conditions sections]
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.
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 - MET
- The veteran military service as a Technician Electronic Systems required participation in repetitive, high-impact activities including pack marches, leopard crawling, pushing trailers, carrying logs, parades, and battle physical training from 2008 to 2017. These activities involved forceful stretching and high intensity use of the muscles and tendons surrounding the right knee joint through repetitive loading and stress.
Inability to obtain appropriate clinical management for sprain or strain - MET
- There is a significant delay of approximately 5 years between symptom stabilization in Jun 2014 and first medical presentation in February 2019. This lengthy delay between onset and diagnosis constitutes inability to attain appropriate medical management as per the precedent established in Brew v Repatriation Commission. The absence of medical presentations for this joint condition during the 5-year period indicates barriers to healthcare access, satisfying the inability to obtain appropriate clinical management factor.
Sequelae
This condition is not a sequelae of another known condition but represents a primary strain injury from military service activities.
Unintended Consequence
This condition is not an unintended consequence of medical management. No medical procedures or medications were administered that resulted in this condition.
Inability to Attain Appropriate Medical Management
The condition meets the criteria for inability to attain appropriate medical management. There was more than five years between symptom stabilization in Jun 2014 and first medical presentation in February 2019. This lengthy time period considering the natural history of strain injuries is indicative of barriers to healthcare access, satisfying the inability to attain appropriate medical management factor as established in the Full Federal Court decision in Brew v Repatriation Commission (14 July 1990). The lack of medical presentations during this extended period indicates both objective and subjective inability to access appropriate care, which has resulted in permanent worsening of the condition through lack of early intervention and appropriate treatment.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
