Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) (No. 3 of 2026)

The central concept is femoroacetabular impingement syndrome itself. The SoP defines it as a disorder of the hip due to abnormal contact between the proximal femur and the acetabulum, in the presence of (a) relevant symptoms and corresponding clinical signs, and (b) abnormal morphology at the hip joint that leads to impingement, such as cam morphology or pincer morphology (subsection 7(3)). Cam morphology is defined in the Schedule 1 Dictionary as a flattening or convexity at the femoral head neck junction, or a non-spherical femoral head with an abnormal femoral head neck offset. Pincer morphology is global or focal overcoverage of the femoral head by the acetabulum. This means that simple presence of cam or pincer on imaging is not enough; the morphology must lead to impingement, and the patient must have symptoms and clinical signs.

Another critical concept is clinical onset. The Dictionary defines it as “the point backwards in time from the first date of imaging findings of abnormal morphology at the hip joint, to the date at which the symptoms of femoroacetabular impingement syndrome were persistently present, as assessed by a registered medical practitioner.” This is a retrospective definition. The starting point is the date of the first imaging that shows abnormal morphology. From that date, you go backwards to the earliest time when symptoms were persistently present. That point is the clinical onset. This means clinical onset could be years before the imaging was performed. It creates a specific burden on claimants to show when symptoms became persistent, which may be difficult if medical records are limited. Note 1 under subsection 7(2) acknowledges that imaging findings will usually be after the date of clinical onset.

The factors revolve around the concept of METs (metabolic equivalents). The SoP uses a threshold of 8 METs. It does not define METs itself but gives examples of activities at that intensity: competitive soccer, competitive football, basketball, vigorous downhill skiing, hockey, vigorous calisthenics and martial arts. The note clarifies that MET is a unit of measure of the level of physical capability of the cardiorespiratory system. The factor requires the exercise to be weight-bearing and involve repeated activity of the hip on the affected side. For clinical onset, the cumulative period is at least 5 years before clinical onset; for clinical worsening, at least 1 year before clinical worsening.

The concept of relevant service is defined in the Dictionary to mean operational service, peacekeeping service, hazardous service, or British nuclear test defence service under the VEA, or warlike or non-warlike service under the MRCA. This covers a wide range of military service but excludes peacetime service that is not within those categories.

Finally, the instrument uses the concept of a “terminal event” for death claims. The Dictionary lists pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function as examples. Death from FAI includes death contributed to by FAI via one of these terminal events.

The primary group affected are veterans and members of the Australian Defence Force who have or had femoroacetabular impingement syndrome and who are claiming entitlement to compensation or medical treatment under the VEA or MRCA. This includes those who rendered operational service, peacekeeping service, hazardous service, or British nuclear test defence service under the VEA, and those who rendered warlike or non-warlike service under the MRCA. Dependants of deceased persons may also be affected if a death claim is based on FAI as a contributing cause.

The instrument directly binds the decision-makers who assess these claims: the Repatriation Commission, the Military Rehabilitation and Compensation Commission, delegates, and review tribunals (the Veterans’ Review Board and the Administrative Appeals Tribunal). They must apply the factors in section 9 strictly. If a claimant cannot satisfy at least one factor, the decision-maker must find that no reasonable hypothesis exists, and the claim must be refused (subject to the standard of proof under the relevant Act).

Medical practitioners are affected indirectly. The definition of FAI in the SoP requires a diagnosis based on “relevant symptoms and corresponding clinical signs” and imaging findings of abnormal morphology. The clinical onset definition also requires an assessment by a registered medical practitioner that symptoms were persistently present at a particular backwards point in time. So doctors who examine veterans and members need to understand the SoP’s diagnostic criteria to provide useful reports. Their notes from years earlier may be crucial for proving clinical onset.

Legal and advocacy professionals representing veterans and members will need to advise on the narrow pathways. The instrument effectively limits successful claims to those who can prove a history of high-intensity weight-bearing exercise over years before symptoms began. This will disproportionately affect those whose duties involved lower intensity activity (e.g., long marches, standing, ordinary running) that may not reach 8 METs consistently for 4 hours per week over 5 years. Veterans with congenital cam morphology may find no factor even if their FAI becomes symptomatic, unless they also had the required exercise history. The factor for inability to obtain appropriate clinical management is available only for clinical worsening, not for initial onset. Therefore, many claimants will have no path under this SoP.

This instrument does not create duties or rights in the ordinary sense; it prescribes the evidentiary requirements for a legislative threshold. The key “right” for a claimant is to have their FAI claim assessed under this SoP. If they can point to evidence satisfying at least one factor in section 9, and that factor is related to their relevant service, then a reasonable hypothesis must be taken to exist (subject to the overall standard of proof under VEA section 120 or MRCA section 338). That right is enforceable on review if the decision-maker fails to apply the SoP correctly.

The corresponding duty on the decision-maker is to apply the SoP as it stands, not to accept alternative causal pathways not listed. The SoP is binding: the Authority has determined that sound medical-scientific evidence indicates that FAI can be related to relevant service only through the specified factors. A decision-maker cannot substitute their own views about causation. This reduces discretion and creates a rule-like framework.

Claimants have no duty to prove the factor - the burden lies on them to raise the hypothesis, but the standard is low (reasonable hypothesis). However, the SoP means that unless the factor is raised, no hypothesis exists. So in practice, claimants must produce evidence of the factor, such as records of exercise during service, or medical evidence of inability to obtain clinical management. The clinical onset definition imposes a duty on the claimant to establish when symptoms were persistently present, with medical practitioner assessment. This can be difficult if symptoms were mild or intermittent.

The SoP also interacts with the concept of relationship to service: the factor must be related to relevant service. This imposes a further evidentiary duty on the claimant - not only must the exercise have occurred, but it must have occurred as a consequence of service (e.g., unit physical training, recreational sport during deployment). The clinical worsening factor (factor 2) only applies if the person’s FAI was suffered or contracted before or during (but did not arise out of) relevant service. This creates a classification issue: if the FAI arose out of service, then clinical worsening factor cannot be used because the condition already arose out of service. That is a subtle point that advocates must navigate.

The SoP itself does not create any criminal or civil penalties. It is a legislative instrument that sets rules for claim assessment. Enforcement comes through the review system: a decision that fails to apply the SoP may be set aside on review or appeal. If a delegate incorrectly ignores the SoP or applies it wrongly, the claimant may seek merits review at the Veterans’ Review Board or appeal to the Administrative Appeals Tribunal, and ultimately the Federal Court on a question of law. There is no specific penalty for non-compliance by decision-makers, but the consequence is that the decision is invalid or reviewable.

There is indirect enforcement through the requirement to give reasons. If a decision-maker rejects a claim, they must explain why the factor was not satisfied. That reasoning is judicially reviewable. If the Authority itself were to issue a SoP that did not comply with VEA subsection 196B (e.g., if the Authority did not have a genuine view that sound medical-scientific evidence exists), that could be challenged, but that is rare.

For claimants, there are penalties under the VEA and MRCA for making false or misleading statements in support of a claim. Those penalties are not in this SoP but apply generally. So if a claimant fabricates an exercise history or incorrectly claims a clinical onset date, they risk prosecution under the Criminal Code. The SoP itself does not increase those penalties.

Importantly, the narrowness of the factors may create an enforcement risk for the system: claimants may feel pressure to exaggerate their exercise history to meet the 8 METs and 4 hours per week thresholds. The only safeguard is that the onus is on the claimant, but the standard of proof for operational service is low (reasonable hypothesis). That low standard means that even weak evidence of the factor might suffice to raise the hypothesis, leaving the Commission to disprove it beyond reasonable doubt. So enforcement in practice relies on the decision-maker critically evaluating the plausibility of the claimed exercise history.

This SoP is made under subsection 196B(2) of the VEA and is therefore a legislative instrument that must be applied when determining a claim under VEA section 120A or MRCA section 338. It overrides any general medical opinion about the cause of FAI that does not fall within the specified factors. The VEA and MRCA themselves provide the overall framework for entitlement - for example, the standard of proof (beyond reasonable doubt for operational service; balance of probabilities for MRCA warlike service). The SoP interacts by defining what constitutes a “reasonable hypothesis” (VEA) or what relevant evidence must be considered (MRCA). If the SoP factor is met, the hypothesis is raised; the decision-maker then must determine whether the hypothesis is disproved (for VEA) or whether the claim is otherwise satisfied (for MRCA).

Section 11 of the SoP provides an important interaction with other SoPs. If a factor in section 9 refers to an injury or disease that is covered by another SoP, then that other SoP applies. For example, the factor “inability to obtain appropriate clinical management for femoroacetabular impingement syndrome” might involve a separate disease such as depression if the inability arose from a mental health condition. In that case, the depression SoP (if one exists) would apply to determine whether that factor itself is related to service. This creates a chain of causation that must be followed.

The SoP also interacts with the provisions of the VEA and MRCA concerning the date of effect of a claim. The clinical onset definition will affect when the condition is considered to have started, which could affect backdating of pension. The SoP does not change the general law on backdating, but it may make it harder to establish an earlier onset date.

There is no interaction with workers’ compensation laws of the states, because military compensation is exclusively federal under these Acts. However, if a veteran also has a claim with the Department of Veterans’ Affairs for a different condition, this SoP is only relevant if FAI is claimed. It does not affect other condition claims unless they involve factors referring to this SoP.

This instrument, Statement of Principles concerning femoroacetabular impingement syndrome (Reasonable Hypothesis) (No. 3 of 2026), repeals and replaces the earlier instrument (No. 42 of 2017) that was made under the same subsection 196B(2). The earlier instrument was registered as F2017L00883. The new instrument commences on 19 January 2026, meaning the old one ceases to have effect from that date. Section 4 states the repeal explicitly.

The instrument itself does not disclose what changes were made from the 2017 version. As a general practice, the Repatriation Medical Authority reviews each SoP periodically to reflect updated medical-scientific evidence. The Authority must be of the view that there is sound medical-scientific evidence indicating a relationship to service (section 8). Therefore, any revision likely reflects new studies, changes in diagnostic criteria, or reconsideration of the factors. The 2017 version may have had different thresholds (e.g., lower METs, shorter duration, or additional factors). Without the old instrument, we cannot identify specific changes. However, the fact that this is “No. 3 of 2026” suggests there have been at least two previous SoPs on FAI under the Reasonable Hypothesis standard. No amendments have been made to this instrument since its making; it stands alone.

The instrument was dated 19 December 2025 by the Chairperson of the Repatriation Medical Authority, Professor Terence Campbell AM. It is a legislative instrument that automatically takes effect 28 days after registration (or on the specified date, 19 January 2026). There is no transitional provision in the instrument; claims made after commencement are governed by this SoP. Claims made before commencement but not yet determined may be affected depending on the date of decision and any transitional arrangements in the VEA.

This instrument itself has not been the subject of any reported litigation, as it is new (commenced 19 January 2026). However, litigation can arise under earlier SoPs and under the VEA framework generally. The source text does not mention any specific cases. As an analyst, I cannot invent cases. What can be said is that the Repatriation Medical Authority’s SoPs have been challenged in the past in the High Court (e.g., Repatriation Commission v Law [2000] HCA 17) regarding the meaning of “sound medical-scientific evidence” and the standard of review. The Authority’s decisions on factors have been challenged in the Federal Court and the Administrative Appeals Tribunal, often by veterans who argue that the factors are too narrow or not supported by evidence. Such challenges are rare and rarely succeed because the Authority has a broad discretion.

Future litigation on this SoP is likely to focus on the interpretation of “clinical onset” as defined backwards from first imaging, and on the meaning of “inability to obtain appropriate clinical management.” Claimants may argue that their lack of access to physiotherapy or surgery during service constitutes inability to obtain appropriate clinical management, but the factor requires that the inability occurred before clinical worsening. There may also be arguments about whether the MET threshold of 8 is too high, or about the cumulative period of 5 years being arbitrary. However, courts typically defer to the Authority’s determinations on medical-scientific matters unless they are manifestly unreasonable.

The instrument does not incorporate any litigation history, so we must note that no case specific to this SoP is recorded. The reader should be aware that the SoP is subject to judicial review, but as of the date of the instrument, no challenge has been brought.

Several features of this SoP can trap both claimants and decision-makers.

(a) Clinical onset definition is retrospective and may be earlier than expected. The date of clinical onset is determined by going backwards from the first imaging finding of abnormal morphology to the date when symptoms were persistently present. If a veteran had symptoms for years but no imaging until later, the clinical onset may be many years before the imaging date. That means the 5-year exercise factor (or 1-year for worsening) must be completed before that earlier clinical onset. Claimants may mistakenly assume clinical onset matches the date of diagnosis or first medical visit for hip pain. Proving early symptoms from decades ago is often difficult.

(b) The exercise factor is cumulative, not continuous. The factor requires a cumulative period of at least 5 years before clinical onset. This does not have to be every week for 5 years; it can be broken periods, provided the total time exceeds 5 years. But each week must involve at least 4 hours at 8 METs. This is a high bar. Someone who played soccer for three seasons (say 30 weeks per year) at 6 hours per week would have 180 hours per year, or 900 hours over 5 years = 900/4 = 225 weeks needed cumulatively. That works out to about 4.3 years of actual weeks if continuous. But if the person only did 4 hours/week for 20 weeks a year, over 10 years that would be only 800 hours (200 weeks of 4-hour blocks) - which is less than 5 years of cumulative 4-hour weeks (5 years x 52 weeks = 260 weeks). Many will not meet the 260-week threshold. The arithmetic is critical.

(c) Only weight-bearing exercise counts, and it must involve repeated hip activity on the affected side. Non-weight-bearing exercise (e.g., cycling, swimming) does not count. Walking at a slow pace (under 8 METs) does not count. Many military activities like running (which may be 8-10 METs) count, but only if done for at least 4 hours per week and cumulatively for 5 years. If the running was not documented, proving it is hard.

(d) The clinical worsening factor (9(1)(b)) only applies if the FAI did not arise out of service. Section 10(2) limits clinical worsening to material contribution or aggravation where the condition was suffered or contracted before or during service but did not arise out of service. If the FAI originally arose out of service (e.g., from a specific injury), then claiming worsening due to further exercise is not possible under this factor. The claimant would need to rely on factor (1) for the original onset. This nuance is often missed.

(e) Factor 3 (inability to obtain appropriate clinical management) applies only before clinical worsening, not before clinical onset. So if a veteran could not get treatment soon after symptoms began, that does not help for the initial claim; it only helps for a claim of worsening. This severely limits its utility.

(f) The definition of FAI requires both symptoms/signs and abnormal morphology. If a veteran has symptoms and signs but no imaging (or imaging shows no cam or pincer), the SoP does not apply. Similarly, if imaging shows cam/pincer but no symptoms, no FAI.

(g) The note under section 7(2) says “It will usually be the case that the date of the imaging findings of abnormal morphology at the hip joint is after the date of clinical onset.” This is a useful but not binding statement. If a veteran had imaging before symptoms, the clinical onset could be after imaging, which may create unusual timing for the factor period.

(h) The section 11 incorporation of other SoPs is complex. For example, “inability to obtain appropriate clinical management” might involve a mental health condition. The other SoP must then be satisfied for that condition to be related to service. This creates layers of proof.

(i) The definition of “relevant service” excludes peacetime permanent forces service that is not operational, hazardous, or warlike. Many reservists may not have qualifying service.

For a claimant seeking to succeed in a claim for FAI under this SoP, the following steps are necessary.

Step 1: Secure a diagnosis that matches the SoP definition. The claimant must obtain a medical report from a registered medical practitioner that confirms (a) relevant symptoms (motion- or position-related hip/groin pain, clicking, locking, stiffness, giving way); (b) corresponding clinical signs (positive impingement test, limited range of motion, gait abnormalities); and (c) imaging findings (X-ray, CT, or MRI) showing cam morphology or pincer morphology that leads to impingement. The report should state that the imaging findings are consistent with abnormal morphology at the hip joint leading to impingement. The date of the first imaging showing such morphology is critical.

Step 2: Determine the clinical onset date. The first date of imaging (showing abnormal morphology) is the reference point. The claimant’s doctor must then assess, based on medical records and history, the earliest date at which symptoms were persistently present before that imaging. That date is the clinical onset. The doctor’s assessment must be documented as a clinical opinion. If records are sparse, contemporary notes of complaints to medical officers or physiotherapists will be crucial.

Step 3: Collect evidence of the factor. For factor (a) (clinical onset): gather records of weight-bearing exercise involving repeated hip activity at a minimum intensity of 8 METs for at least 4 hours per week, cumulatively for at least 5 years before the clinical onset date. This could include unit physical training schedules, personal fitness diaries, sports club memberships, competition records, service records of posted duties that involved such activity. The evidence must show the specific activity, its intensity (e.g., competitive soccer, hockey, martial arts), duration per week, and dates. For factor (b) (clinical worsening): produce evidence covering the 1 year before the clinical worsening date. For factor (c): produce medical evidence that appropriate clinical management (e.g., physiotherapy, activity modification, surgery) was not obtained before clinical worsening, and that this inability was related to service.

Step 4: Link the factor to relevant service. The claimant must show that the exercise (or the inability to obtain clinical management) occurred during, or as a consequence of, their relevant service (operational, peacekeeping, hazardous, warlike, or non-warlike). For example, if the exercise was part of unit fitness programs during deployment, or was recreational sport at a base during warlike service, that should be documented. If the exercise was entirely in civilian life before service, it cannot be used unless it was performed during a period of relevant service (e.g., the person was a reservist on active duty for 5 years and exercised on base). The SoP requires the factor to be related to relevant service - it does not require the exercise to be a duty requirement, but it must be connected.

Step 5: For death claims. Provide evidence that FAI contributed to a terminal event (pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function). This requires a medical opinion linking FAI to the cause of death.

For decision-makers, compliance means applying the SoP mechanically. They must obtain the claimant’s evidence of the factor, verify the clinical onset date, check the MET intensity and duration of exercise, and confirm the cumulative period. They must reject claims that rely on factors not in section 9. They should be alert to the nuances of the clinical onset definition and ensure that the exercise period precedes clinical onset, not vice versa. They must also apply section 10(2) correctly for clinical worsening claims. If the claimant has a pre-existing FAI that arose out of service, factor (b) cannot be used for worsening; the only path would be factor (c) if management was unavailable. The decision-maker should request the claimant’s doctor to clarify the clinical onset date if there is ambiguity. Records must be kept. The SoP is the complete statement of the factors; no other factors can be considered.