Bilateral Legs - Chronic Exertional Compartment Syndrome — ICD-10 M79.A21, M79.A22

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Bilateral Legs - Chronic Exertional Compartment Syndrome

Example 1 of 1 · fictitious patient (Veteran T)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Bilateral Legs - Chronic Exertional Compartment Syndrome

BOP Code: 99 of 2023 (Chronic Exertional Compartment Syndrome Of The Lower Leg)
RH Code: 98 of 2023 (Chronic Exertional Compartment Syndrome Of The Lower Leg)

ADF History

Veteran T, date of birth 21 June 1990, Australian Army, Infantryman (Rifleman), enlisted 14 January 2009, medically discharged 06 March 2020. Operational service: Afghanistan, 10 February 2011 to 28 September 2011 (warlike); Iraq, Middle East Area of Operations, 14 November 2016 to 26 June 2017 (warlike).

Occupational History

As an infantryman the veteran undertook sustained foot patrolling, loaded marching and running as the core physical demands of his trade. Patrol loads of 35 to 45 kilograms, including body armour, weapon, ammunition, water and radio batteries, were routine on exercise and on operations, often over steep, rocky or soft ground and in high heat. Unit physical training included distance running, interval work, pack marches of 15 to 30 kilometres and battle fitness assessments.

Infantry training and operations place repetitive, high-volume, weight-bearing load through the lower legs, with abrupt increases in workload around field exercises, courses, selection preparation and operational surges. These are recognised risks for exertional lower leg conditions, including compartment syndrome, medial tibial stress syndrome and stress fractures. Access to physiotherapy and specialist assessment is limited in the field and on deployment.

History

Veteran T, an infantryman in the Australian Army, developed exertional pain and tightness in the front and outer parts of both lower legs on 18 June 2011 during a surge of daily foot patrols on warlike service in Afghanistan, on top of a sustained high-volume running programme. Chronic exertional compartment syndrome of both lower legs was confirmed on compartment pressure testing in February 2012, worsened during selection preparation in 2014 and again on warlike service in Iraq in 2017, and was treated with bilateral fasciotomy in September 2017.

Timeline

05 Jan 2011 — Pre-deployment medical examination at the garrison health centre. The veteran passed his basic fitness assessment and a 15 kilometre pack march with a 35 kilogram load without difficulty. No lower limb complaints were recorded, and examination of both legs was normal. He was assessed as fit for warlike service in Afghanistan. "fit to deploy, legs NAD"
22 Jun 2011 — Seen by the medical officer at a patrol base in Uruzgan Province, Afghanistan. He reported four days of tightness and aching in the front and outer aspects of both shins, starting about 15 minutes into each foot patrol and settling within 20 minutes of stopping. He had been running about 65 kilometres a week on the base perimeter track for two months and had moved from two to daily five-hour patrols on 11 June 2011. Examination at rest showed no bony tenderness. Rest from running was advised; patrols continued. "bilateral exertional shin tightness, settles rest"
14 Nov 2011 — Review by a sports and exercise physician on return to Australia. Symptoms persisted with any loaded march or run beyond 15 to 20 minutes, with a sensation of fullness in the anterior and lateral compartments and transient numbness over the dorsum of both feet. Examination after a provocative treadmill test showed firm, tender anterior compartments bilaterally. Compartment pressure testing and MRI were requested to confirm chronic exertional compartment syndrome and exclude stress fracture. "?CECS bilateral, for pressures"
20 Feb 2012 — Dynamic intracompartmental pressure testing of both legs. Resting anterior compartment pressures were 18 mmHg on the left and 17 mmHg on the right. One minute after symptom-limited treadmill exercise they were 36 and 34 mmHg, and at five minutes 28 and 26 mmHg. Lateral compartment pressures were similarly raised. The sports physician confirmed bilateral chronic exertional compartment syndrome and commenced a gait retraining and load management programme. "pressures diagnostic, CECS confirmed"
08 May 2014 — Review after a month of selection preparation in Australia, during which the veteran ran about 65 kilometres a week and had doubled his loaded marching to more than four hours a day in the week before 07 April 2014. Symptoms now began after five minutes of marching, with foot drop sensation and numbness lasting an hour. Repeat pressure testing showed resting pressures of 24 and 22 mmHg, rising to 48 and 45 mmHg at one minute. Fasciotomy was recommended, but surgery was not scheduled because of his posting cycle. "worse, pressures 48/45, fasciotomy advised"
09 May 2017 — Seen by the medical officer on warlike service in Iraq. He reported marked worsening of bilateral leg pain and numbness since 02 May 2017, after his training team doubled its daily range and patrol serials to more than two hours a day in temperatures above 40 degrees. He had been unable to complete a two kilometre loaded walk. No physiotherapy, imaging or surgical review was available in theatre, and he was placed on restricted duties until return to Australia. "CECS worse, no surgical access"
14 Sep 2017 — An orthopaedic surgeon performed bilateral anterior and lateral compartment fasciotomies. The fascia was thickened and tight, with muscle herniation through a fascial defect on the left. Recovery was complicated by a wound haematoma on the right. He returned to light duties after twelve weeks. "bilateral fasciotomy, fascia thickened"
18 Jun 2019 — Orthopaedic and sports medicine review. Exercise tolerance had improved but he still had aching in both legs after marching more than three kilometres or running more than two kilometres, and persisting patchy numbness over the dorsum of the left foot. He was unable to meet the infantry fitness standard and was referred for a medical employment classification review, leading to medical discharge in March 2020. "residual pain, unable to march"

Symptoms

At onset the veteran had tightness, cramping and aching in the anterior and lateral compartments of both lower legs, beginning about 15 minutes into a loaded foot patrol and resolving within 20 minutes of rest. Over the following months he developed transient numbness over the dorsum of both feet during exercise and a feeling that his feet were slapping when he marched.

After the 2014 and 2017 worsenings the symptoms began within five minutes of loaded walking and took an hour or more to settle. Since fasciotomy he reports aching in both legs after marching more than three kilometres or running more than two kilometres, patchy numbness over the dorsum of the left foot and tender surgical scars. He has stopped running and walks his dog only on flat ground.

Imaging

02 Feb 2012 — MRI both lower legs: "No stress fracture or bone marrow oedema of either tibia or fibula. No tendinopathy, muscle tear or mass. Mild oedema in the anterior compartment muscles bilaterally on post-exercise sequences."
02 Feb 2012 — Arterial duplex ultrasound with provocative manoeuvres, both legs: "Normal popliteal artery flow with no compression on active plantarflexion. No evidence of popliteal artery entrapment or peripheral vascular insufficiency. Ankle-brachial indices 1.1 bilaterally."
12 Mar 2012 — Nerve conduction studies, both lower limbs: "Normal superficial peroneal, deep peroneal and sural nerve conduction at rest. No evidence of nerve entrapment."
08 May 2014 — Repeat MRI both lower legs: "No stress fracture. Increased post-exercise signal in the anterior and lateral compartment muscles bilaterally, more marked than in 2012."

Onset Date

The most likely date of onset of this condition is 18 Jun 2011.

At that date the veteran was on warlike service in Uruzgan Province, Afghanistan, as a rifleman with an infantry battalion mentoring task group. He had been running about 65 kilometres a week on the base perimeter track and had moved from two to daily five-hour foot patrols with loads of 35 to 45 kilograms on 11 June 2011. On 18 June 2011 he first noticed tightness and aching in the front and outer parts of both shins during a patrol.

This date is appropriate because his pre-deployment medical examination of 05 January 2011 recorded no lower limb complaints and a normal examination, and he first presented with the symptoms on 22 June 2011, reporting four days of exertional pain. The diagnosis was later confirmed by compartment pressure testing on 20 February 2012, with stress fracture, tendinopathy, nerve entrapment, popliteal artery entrapment and vascular insufficiency excluded.

For the running factors, the 4 weeks before onset run from 21 May 2011 to 18 Jun 2011. Throughout that period his fitness log recorded running of 60 to 70 kilometres a week, an average of about 65 kilometres a week. For the weight-bearing exercise factors, the same 4 weeks were filled by foot patrolling with loads of 35 to 45 kilograms, never less than 10 hours a week. For the increase factors, the one week before onset runs from 11 Jun 2011 to 18 Jun 2011, during which patrols rose from two of two and a half hours each week to daily patrols of about five hours, an increase of several hundred per cent.

For the first worsening, documented on 07 Apr 2014 during peacetime selection preparation, the 4 weeks before the worsening run from 10 Mar 2014 to 07 Apr 2014, when he ran about 65 kilometres a week, and the one week before runs from 31 Mar 2014 to 07 Apr 2014, when his loaded marching doubled to more than four hours a day. For the second worsening, on 02 May 2017 on warlike service in Iraq, the 4 weeks before run from 04 Apr 2017 to 02 May 2017 and the one week before runs from 25 Apr 2017 to 02 May 2017, when his daily range and patrol serials doubled to more than two hours a day. Fasciotomy, recommended in May 2014, was not performed until 14 Sep 2017.

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

The formal diagnosis is Chronic Exertional Compartment Syndrome of both lower legs (ICD-10 M79.A21 and M79.A22), affecting the anterior and lateral compartments bilaterally, under the Statements of Principles concerning chronic exertional compartment syndrome of the lower leg, Balance of Probabilities No. 99 of 2023 and Reasonable Hypothesis No. 98 of 2023.

Chronic exertional compartment syndrome is a condition in which the pressure within a closed fascial compartment of the leg rises abnormally during exercise, because the fascia cannot accommodate the normal increase in muscle volume and blood flow that comes with sustained effort. The raised pressure reduces tissue perfusion and causes predictable pain, tightness and sometimes numbness or weakness that starts at a consistent point in exercise and settles with rest. It is common in military recruits, infantry soldiers and runners, and is strongly associated with high-volume and rapidly increased weight-bearing activity such as running and loaded marching. Treatment is load modification and gait retraining, and fasciotomy where symptoms persist.

The condition began on 18 June 2011 on warlike service in Afghanistan, was confirmed on compartment pressure testing on 20 February 2012, worsened in April 2014 and again in May 2017, and was treated surgically in September 2017 with incomplete recovery.

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

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

18 June 2011.

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

22 June 2011.

When was the condition confirmed / formally diagnosed?

20 February 2012.

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

17 April 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by dynamic intracompartmental pressure testing on 20 February 2012, which showed resting anterior compartment pressures of 18 and 17 mmHg, rising to 36 and 34 mmHg one minute after exercise and remaining at 28 and 26 mmHg at five minutes. These values meet the accepted diagnostic criteria (resting pressure of 15 mmHg or more, one minute post-exercise pressure of 30 mmHg or more, or five minute pressure of 20 mmHg or more). Raised muscle compartment pressure manifesting with exercise-induced pain and tightness originating in the shin, which resolves with rest, meets the Statement of Principles definition.

The exclusions in the definition were addressed. MRI on 02 February 2012 and 08 May 2014 showed no fracture or stress fracture and no tendinopathy or bursitis. Nerve conduction studies on 12 March 2012 showed no sural or superficial peroneal nerve entrapment. Provocative arterial duplex ultrasound excluded popliteal artery entrapment syndrome and vascular insufficiency, and there was no history of acute sprain or strain. A sports and exercise physician made the diagnosis, repeat testing in May 2014 confirmed worsening, and the operative findings at fasciotomy on 14 September 2017 of thickened, tight fascia with muscle herniation were consistent.

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 18 June 2011, after 1 July 2004, during continuous full-time service. 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, including the selection preparation in Australia in 2014 that worsened the condition, and the activity levels at onset also exceeded its higher thresholds.

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 Chronic Exertional Compartment Syndrome Of The Lower Leg, No. 99 of 2023

Causative factors

Factor 9(1): running or jogging an average of at least 60 kilometres per week for the 4 weeks before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- The veteran's unit fitness log recorded running of 60 to 70 kilometres a week, an average of about 65 kilometres a week, throughout the 4 weeks before onset, from 21 May 2011 to 18 June 2011. He ran six days a week on the patrol base perimeter track as part of a structured programme set by his platoon to prepare him for special forces selection. Running at this volume is the leading recognised cause of exertional compartment syndrome.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the lower leg on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 6 hours per week; and for at least the 4 weeks before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- From 21 May 2011 to 18 June 2011 the veteran conducted dismounted foot patrols carrying 35 to 45 kilograms over broken ground, never less than 10 hours a week, as recorded in the platoon patrol reports. Loaded marching of this kind is well above 5 METs and involves repeated activity of both lower legs, which are both affected. This exceeded 6 hours a week for the whole of the 4 weeks before onset.

Factor 9(3): increasing the frequency, duration or intensity of weight bearing activity involving the lower leg on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 4 hours per day; within the one week before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- On 11 June 2011 his platoon moved from two patrols of about two and a half hours a week to daily clearance patrols of about five hours for a task group operation. In the one week before onset, from 11 June 2011 to 18 June 2011, his loaded patrolling rose from about 5 hours a week to about 35 hours a week, an increase of about 600 per cent, at an intensity above 5 METs and for at least 4 hours on each day. Both legs were involved and both became symptomatic.

Worsening factors

- During peacetime selection preparation in Australia the veteran ran an average of about 65 kilometres a week in the 4 weeks before the first worsening, from 10 March 2014 to 07 April 2014, following a programme set by his unit's physical training instructor. Repeat pressure testing on 08 May 2014 showed the resting pressures had risen from 18 and 17 mmHg to 24 and 22 mmHg, and post-exercise pressures from 36 and 34 mmHg to 48 and 45 mmHg.

- From 10 March 2014 to 07 April 2014 the veteran completed pack marches of 15 to 30 kilometres with loads of 30 to 40 kilograms on at least four days a week, about 12 hours a week, as part of selection preparation. This loaded marching was above 5 METs, involved both legs and was sustained for the whole 4 weeks before the documented worsening.

- In the week from 31 March 2014 to 07 April 2014 the veteran's selection preparation moved into a simulated test week, with daily loaded navigation marches of four and a half to six hours, doubling his loaded marching from about 12 to about 30 hours a week. The intensity exceeded 5 METs on every day and both legs were involved. His symptoms then started within five minutes of marching, compared with 15 minutes previously.

Factor 9(4): inability to obtain appropriate clinical management for chronic exertional compartment syndrome of the lower leg before the clinical worsening of chronic exertional compartment syndrome of the lower leg. — MET

- Bilateral fasciotomy was recommended on 08 May 2014 but was not scheduled for more than three years because of the veteran's posting and deployment cycle, and he continued full infantry duties in the interim. In Iraq from November 2016 he had no access to physiotherapy, pressure testing or surgical review, and the condition worsened further on 02 May 2017. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Chronic Exertional Compartment Syndrome Of The Lower Leg, No. 98 of 2023

Causative factors

Factor 9(1): running or jogging an average of at least 30 kilometres per week for the 4 weeks before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- While on warlike service in Afghanistan, the veteran ran an average of about 65 kilometres a week on the patrol base perimeter track throughout the 4 weeks before onset, from 21 May 2011 to 18 June 2011, as recorded in his fitness log. This was more than twice the 30 kilometres a week required.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the lower leg on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 4 hours per week; and for at least the 4 weeks before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- On warlike service in Uruzgan Province, the veteran conducted loaded dismounted patrols carrying 35 to 45 kilograms for at least 10 hours a week throughout the 4 weeks before onset, from 21 May 2011 to 18 June 2011. This weight-bearing exercise was well above 5 METs and involved repeated activity of both lower legs.

Factor 9(3): increasing the frequency, duration or intensity of weight bearing activity involving the lower leg on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; within the one week before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- During a task group operation on warlike service in Afghanistan, the veteran's loaded patrolling rose from about 5 hours a week to daily patrols of about five hours from 11 June 2011, within the one week before onset on 18 June 2011. The increase was about 600 per cent, at an intensity above 5 METs and for well over 2 hours a day, involving both legs.

Worsening factors

- On warlike service in Iraq with a training team, the veteran ran an average of about 35 kilometres a week, in early morning sessions to maintain the unit fitness standard, throughout the 4 weeks before the second worsening, from 04 April 2017 to 02 May 2017. The worsening was documented by the medical officer on 09 May 2017.

- From 04 April 2017 to 02 May 2017, on warlike service in Iraq, the veteran conducted range practices and dismounted security patrols in body armour with loads of about 30 kilograms for at least 8 hours a week. This activity exceeded 5 METs, involved both legs and filled the 4 weeks before the worsening.

Factor 9(3): increasing the frequency, duration or intensity of weight bearing activity involving the lower leg on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; within the one week before the clinical onset or clinical worsening of chronic exertional compartment syndrome of the lower leg; — MET

- From 25 April 2017 his training team doubled its daily range and patrol serials ahead of an Iraqi army graduation, so that his loaded activity rose from about 8 hours a week to more than two and a half hours every day, an increase of more than 100 per cent, within the one week before the worsening on 02 May 2017. The activity was above 5 METs and involved both legs, and afterwards he could not complete a two kilometre loaded walk.

- On warlike service in Afghanistan in 2011 no compartment pressure testing or specialist review was available and he continued patrolling. On warlike service in Iraq from November 2016 to June 2017 he had no access to physiotherapy, imaging or surgical review, and the fasciotomy recommended in May 2014 had still not been performed when the condition worsened on 02 May 2017.

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

Sequelae

The veteran developed secondary conditions as a result of the chronic exertional compartment syndrome and its surgical treatment: persisting numbness over the dorsum of the left foot from superficial peroneal nerve irritation at the fasciotomy site, and painful hypertrophic scars over both lateral legs. Reduced exercise tolerance since 2014 has contributed to weight gain of 11 kilograms and low mood, which have been recorded by his general practitioner.

Unintended Consequence

Met. The persisting superficial peroneal nerve numbness on the left and the right wound haematoma are unintended consequences of the bilateral fasciotomy performed on 14 September 2017, which was provided and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. Bilateral fasciotomy was recommended by a sports physician on 08 May 2014 after repeat pressure testing confirmed worsening, but surgery was not performed until 14 September 2017, a delay of more than three years caused by the veteran's posting and deployment cycle. During that period he continued full infantry duties, deployed to Iraq where no physiotherapy, imaging or surgical review was available, and suffered a further documented worsening on 02 May 2017. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational and administrative constraints that prevent recommended treatment amount to an inability to obtain appropriate clinical management. The absence of any pressure testing or specialist review while he was symptomatic in Afghanistan in 2011 is a further example.

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

See attached report.

References

05 Jan 2011, Pre-deployment medical examination, Medical Officer, Garrison health centre
22 Jun 2011, Outpatient health record, Medical Officer, Patrol base, Afghanistan
14 Nov 2011, Specialist consultation, Sports and exercise physician
02 Feb 2012, MRI both lower legs and arterial duplex ultrasound, Radiologist
20 Feb 2012, Intracompartmental pressure testing report, Sports and exercise physician
12 Mar 2012, Nerve conduction studies, Neurophysiologist
08 May 2014, Repeat pressure testing and MRI, Sports and exercise physician and Radiologist
09 May 2017, Outpatient health record, Medical Officer, Iraq
14 Sep 2017, Operation report, Orthopaedic surgeon
18 Jun 2019, Specialist review, Orthopaedic surgeon and Sports and exercise physician
Statement of Principles concerning Chronic Exertional Compartment Syndrome Of The Lower Leg (Balance of Probabilities) No. 99 of 2023, Repatriation Medical Authority
Statement of Principles concerning Chronic Exertional Compartment Syndrome Of The Lower Leg (Reasonable Hypothesis) No. 98 of 2023, Repatriation Medical Authority

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Bilateral Legs - Chronic Exertional Compartment Syndrome — DVA claim example