Left Knee - Joint Instability — example DVA determination letter

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Left Knee - Joint Instability

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 7 May 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 7 May 2025;
An outpatient health record by the medical officer, Garrison health centre, dated 14 March 2006;
A trauma admission and X-ray report by Role 3 hospital, Afghanistan, dated 13 July 2008;
An MRI report and orthopaedic consultation by the orthopaedic surgeon, dated 2 September 2008;
An MRI lumbar spine report by the radiologist, dated 12 April 2010;
An operation report (right total hip replacement) by the orthopaedic surgeon, dated 18 August 2010;
An emergency department record (dislocated hip prosthesis) by the emergency physician, dated 5 January 2011;
An upper limb consultation by the orthopaedic surgeon, dated 20 June 2011;
A postnatal record by the obstetrician, dated 28 September 2011;
A physiotherapy record by the physiotherapist, dated 1 November 2011;
An MRI report and orthopaedic consultation by the orthopaedic surgeon, dated 6 December 2011;
An anaesthetic record by the anaesthetist, dated 14 March 2012;
An operation report by the ACL and MPFL reconstruction, Orthopaedic surgeon, dated 19 June 2013;
A dental treatment record by the dental officer, dated 22 July 2014;
An MRI report and orthopaedic review by the orthopaedic surgeon, dated 10 March 2015;
An operation report (revision hip arthroplasty) by the orthopaedic surgeon, dated 30 August 2016;
An operation report (left total knee replacement) by the orthopaedic surgeon, dated 11 July 2017;
An operation report (revision of knee insert) by the orthopaedic surgeon, dated 15 October 2018.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

12 July 2004 and 30 November 2018

Left Knee - Joint Instability

You have stated that your condition was caused by:

having physical trauma to the affected joint at the time of the clinical onset of joint instability
having a dislocation or subluxation of the affected joint before the clinical onset of joint instability
having a sprain of the affected joint before the clinical onset of joint instability
having damage to a soft tissue structure as specified before the clinical onset of joint instability
having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical onset of joint instability
having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of joint instability
for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of joint instability
for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of joint instability
for total hip joint prosthesis joint instability only, being obese at the time of the clinical onset of joint instability
for tibiofemoral joint instability only, having morbid obesity at the time of the clinical onset of joint instability

Diagnosis: Joint Instability

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 7 May 2025, and is supported by an MRI report and orthopaedic consultation by the orthopaedic surgeon, dated 6 December 2011.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Joint Instability (Balance of Probabilities) (No. 58 of 2019)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having physical trauma to the affected joint at the time of the clinical onset of joint instability
having a dislocation or subluxation of the affected joint before the clinical onset of joint instability
having a sprain of the affected joint before the clinical onset of joint instability
having damage to a soft tissue structure as specified before the clinical onset of joint instability
having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical onset of joint instability
having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of joint instability
for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of joint instability
for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of joint instability
for total hip joint prosthesis joint instability only, being obese at the time of the clinical onset of joint instability
for tibiofemoral joint instability only, having morbid obesity at the time of the clinical onset of joint instability

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with episodes of the left knee giving way during ordinary walking, on stairs and when turning, with the kneecap slipping out of place, followed each time by pain, swelling and several days of reduced weight bearing on 1 November 2011.

The diagnosis was made by an orthopaedic surgeon on 6 December 2011 on a history of repeated episodes of the knee giving way and patellar subluxation since 1 November 2011, with a positive Lachman test, a positive pivot shift and a positive patellar apprehension test. MRI on the same day showed a complete anterior cruciate ligament tear, a deficient medial patellofemoral ligament and chondral loss of the lateral femoral condyle. This meets the Statement of Principles definition of joint instability: an acquired lack of stability due to damage to the stabilising structures, manifesting as recurrent subluxation and recurrent sprain.

This has then led to further investigations and the diagnosis of your condition of Joint Instability. I have accepted your condition of Joint Instability.

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.

I have therefore accepted that this condition is related to your service with effect from 1 November 2011.

Left Knee - Joint Instability (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 7 May 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 7 May 2025;
An outpatient health record by the medical officer, Garrison health centre, dated 14 March 2006;
A trauma admission and X-ray report by Role 3 hospital, Afghanistan, dated 13 July 2008;
An MRI report and orthopaedic consultation by the orthopaedic surgeon, dated 2 September 2008;
An MRI lumbar spine report by the radiologist, dated 12 April 2010;
An operation report (right total hip replacement) by the orthopaedic surgeon, dated 18 August 2010;
An emergency department record (dislocated hip prosthesis) by the emergency physician, dated 5 January 2011;
An upper limb consultation by the orthopaedic surgeon, dated 20 June 2011;
A postnatal record by the obstetrician, dated 28 September 2011;
A physiotherapy record by the physiotherapist, dated 1 November 2011;
An MRI report and orthopaedic consultation by the orthopaedic surgeon, dated 6 December 2011;
An anaesthetic record by the anaesthetist, dated 14 March 2012;
An operation report by the ACL and MPFL reconstruction, Orthopaedic surgeon, dated 19 June 2013;
A dental treatment record by the dental officer, dated 22 July 2014;
An MRI report and orthopaedic review by the orthopaedic surgeon, dated 10 March 2015;
An operation report (revision hip arthroplasty) by the orthopaedic surgeon, dated 30 August 2016;
An operation report (left total knee replacement) by the orthopaedic surgeon, dated 11 July 2017;
An operation report (revision of knee insert) by the orthopaedic surgeon, dated 15 October 2018.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

12 July 2004 and 30 November 2018

Left Knee - Joint Instability (Worsening)

You have stated that the worsening of your condition was caused by:

having physical trauma to the affected joint at the time of the clinical worsening of joint instability
having damage to a soft tissue structure as specified before the clinical worsening of joint instability
having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical worsening of joint instability
having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical worsening of joint instability
for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical worsening of joint instability
for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical worsening of joint instability
for total hip joint prosthesis joint instability only, being obese at the time of the clinical worsening of joint instability
for tibiofemoral joint instability only, having morbid obesity at the time of the clinical worsening of joint instability
inability to obtain appropriate clinical management for joint instability

Diagnosis: Joint Instability (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Joint Instability (Balance of Probabilities) (No. 58 of 2019)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having physical trauma to the affected joint at the time of the clinical worsening of joint instability
having damage to a soft tissue structure as specified before the clinical worsening of joint instability
having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical worsening of joint instability
having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical worsening of joint instability
for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical worsening of joint instability
for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical worsening of joint instability
for total hip joint prosthesis joint instability only, being obese at the time of the clinical worsening of joint instability
for tibiofemoral joint instability only, having morbid obesity at the time of the clinical worsening of joint instability
inability to obtain appropriate clinical management for joint instability

After the condition arose, it was worsened during your service. On 2 March 2015 you slipped on a wet stairwell at your unit lines and fell, twisting the left knee. The medial patellofemoral ligament and anterior cruciate ligament damage of 2008, the medial meniscal tear and the reconstructed grafts of 19 June 2013 were all present before the worsening on 2 March 2015. The osteochondral defect of the lateral femoral condyle from the 2008 fracture persisted and was present before the worsening on 2 March 2015, progressing to grade 4 chondral loss on MRI on 10 March 2015. Post-traumatic osteoarthritis of the left knee was present at the worsening on 2 March 2015, with grade 4 chondral loss of the lateral compartment on MRI on 10 March 2015, and progressed to Kellgren-Lawrence grade 4 by 4 May 2017. The temporomandibular joint instability worsened on 22 July 2014, when the jaw dislocated during extraction of an impacted lower wisdom tooth by a Defence dentist, requiring manual reduction. The instability of the right total hip prosthesis worsened in 2016, with three dislocations between February and June 2016 requiring revision to a dual-mobility bearing on 30 August 2016. Your BMI was 42.3 in June 2016, when the right total hip prosthesis instability worsened. Your BMI was 42.0 on 2 March 2015, when the tibiofemoral instability of the left knee worsened. Reconstruction of the left knee was recommended on 2 September 2008 but was not performed until 19 June 2013, almost five years later, because you remained on a waiting list, was posted interstate and the referral lapsed.

This has then led to further investigations and the diagnosis of your condition of Joint Instability (Worsening). I have accepted your condition of Joint Instability (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 2 March 2015.

Left Knee - Joint Instability — example determination letter

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Reference Determination Content

Left Knee - Joint Instability

Evidence

Your service

Left Knee - Joint Instability

Left Knee - Joint Instability (Worsening)

Evidence

Your service

Left Knee - Joint Instability (Worsening)