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 withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment — Bilateral Lower Limbs - Bilateral Lower Limb Strain
Example 1 of 2 · fictitious patient (Veteran P)
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 withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment
Bilateral Lower Limbs - Bilateral Lower Limb Strain
Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Warehouse Operator, enlisted 15 July 2010, discharged 16 May 2013.
Occupational History
As a Warehouse Operator in the Australian Army, the veteran was exposed to intensive military physical training requirements including regular running programs, high-impact exercises, and sustained weight-bearing activities. Military personnel routinely undertake activities that place significant stress on lower limb musculature including explosive movements, repetitive impact training, and progressive physical conditioning that can exceed normal physiological tolerance. The transition from civilian to military training levels represents a substantial increase in physical demands on the musculoskeletal system.
History
The veteran a Warehouse Operator with the Australian Army, developed bilateral lower limb strain during the early phase of his military service related to increased physical training demands, with the initial strain subsequently progressing to medial tibial stress syndrome as documented in his comprehensive medical timeline.
Timeline
- Mid-2013 - the veteran began experiencing bilateral lower limb strain symptoms associated with the transition to intensive military physical training demands. The initial strain injury developed as his musculoskeletal system adapted to the significantly increased training loads compared to civilian activity levels. The strain represented the acute phase of overuse injury affecting the lower limb musculature and supporting structures before progressing to the chronic bone stress reaction phase.
- Early 2013-2014 - The bilateral lower limb strain progressed from acute muscular strain to chronic overuse injury patterns as military training continued. The repetitive nature of military physical training created ongoing stress on the already strained lower limb structures, leading to the development of the documented medial tibial stress syndrome. This represents the natural progression from acute strain to chronic bone stress reaction in the context of continued high-demand training.
- 08 Dec 2011 - The progression from initial strain to medial tibial stress syndrome was formally documented when the veteran presented to physiotherapy services with "bilateral ant/medial pain along shins" that had been present for "6-12 months". The physiotherapy assessment noted he had "bi-lat shin splints since joining up to the army" indicating the condition originated from the early military training period as an initial strain injury.
- Management Period - The strain and its sequelae were managed through activity modification, biomechanical correction including orthotic intervention, and graduated return to military training activities. The comprehensive management addressed both the acute strain components and the chronic adaptations that had developed.
Symptoms
At the time of initial injury in mid-2013, the veteran experienced bilateral lower limb strain symptoms associated with the transition to intensive military physical training. The strain initially presented as muscular discomfort and pain in the lower limb structures associated with high-impact activities and repetitive loading from military training exercises.
The strain subsequently progressed to chronic medial tibial stress syndrome as documented in the comprehensive medical timeline, representing the natural progression from acute muscular strain to chronic bone stress reaction under continued training demands.
Imaging
No specific imaging was performed for the initial bilateral lower limb strain as this was a clinical diagnosis based on the pattern of symptoms and their relationship to military training activities. Subsequent imaging focused on ruling out stress fractures when the condition progressed to medial tibial stress syndrome.
1. What is the formal diagnosis of the condition claimed above?
Bilateral Lower Limb Strain (M79.3) - DVA SOP Code: Sprain and Strain No. 28 of 2020, ICD-10 Code: M79.3
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. In this case, the bilateral lower limb strain represents the initial musculoskeletal injury that occurred during the transition to intensive military physical training. The strain affected multiple muscle groups and supporting structures in both lower limbs as they adapted to the significantly increased training demands. This condition represents the acute phase of what subsequently developed into chronic medial tibial stress syndrome, demonstrating the progression from acute muscular injury to chronic bone stress reaction.
The temporal relationship shows this was the initial injury that occurred during early military training and subsequently progressed to the documented medial tibial stress syndrome, representing a continuum of overuse injury development.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Mid-2013 - during the transition to intensive military physical training in the first year of service
When did the veteran first present to a health / medical provider for this condition? The initial strain was managed through self-treatment and military training modifications. Formal presentation occurred 08 December 2011 when the condition had progressed to medial tibial stress syndrome requiring physiotherapy intervention.
When was the condition confirmed / formally diagnosed? 08 December 2011 - The progression from initial strain to medial tibial stress syndrome was confirmed by military physiotherapist who noted the condition had been present since joining the army, establishing the temporal relationship to the initial strain injury.
When did the veteran first present to you (or your practice) for this condition? 14 January 2021
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 of bilateral lower limb strain was confirmed through clinical assessment and the documented progression to medial tibial stress syndrome. Key evidence included the temporal relationship between commencement of intensive military training and symptom onset, the bilateral nature of the condition affecting both lower limbs simultaneously, and the documented progression from initial strain symptoms to chronic bone stress reaction. The physiotherapy assessment noted symptoms had been present since joining the army, confirming the initial strain occurred during early military training. The pattern of bilateral involvement and progression to medial tibial stress syndrome is consistent with strain injury affecting multiple muscle groups and supporting structures.
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 transition from civilian to intensive military physical training involved forceful stretching and high intensity use of lower limb muscles and tendons during running, jumping, marching, and other high-impact military training activities.
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 - NOT MET - This factor relates to sprain (ligament injury) rather than strain (muscle/tendon injury).
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 - MET - Continued intensive military training represented ongoing forceful stretching and high intensity use of the already strained lower limb structures, contributing to the progression from acute strain to chronic medial tibial stress syndrome.
inability to obtain appropriate clinical management for sprain or strain - NOT MET - Appropriate clinical management was eventually provided through military physiotherapy services, though the initial strain phase was managed through self-treatment and training modifications consistent with military training practices.
Sequelae
This bilateral lower limb strain is not a sequelae of another condition but represents the primary injury that subsequently led to the development of medial tibial stress syndrome. The strain is the causative condition for the later development of chronic bone stress reaction.
Unintended Consequence
This condition is not an unintended consequence of medical management as no prior medical procedures or treatments were performed that could have led to this strain injury.
Inability to Attain Appropriate Medical Management
The Full Federal Court in Brew v Repatriation Commission (12 July 1996) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. This factor is PARTIALLY MET. During the initial strain phase in mid-2013, there is evidence that the veteran managed the condition through self-treatment and training modifications rather than formal medical intervention. The military training environment may have created barriers to seeking immediate medical attention for what was initially perceived as normal adaptation to training. However, when symptoms progressed and became functionally limiting, appropriate physiotherapy services were accessed in January 2013, demonstrating the availability of medical care when formally sought. The delay between initial strain and formal medical assessment may represent practical barriers to healthcare access during the adaptation phase of military training.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
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 withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment — Bilateral Lower Limbs - Bilateral Lower Limb Strain
Example 2 of 2 · fictitious patient (Veteran P)
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 withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment
Bilateral Lower Limbs - Bilateral Lower Limb Strain
Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Warehouse Operator, enlisted 15 July 2010, discharged 16 May 2013.
Occupational History
As a Warehouse Operator in the Australian Army, the veteran was exposed to intensive military physical training requirements including regular running programs, high-impact exercises, and sustained weight-bearing activities. Military personnel routinely undertake activities that place significant stress on lower limb musculature including explosive movements, repetitive impact training, and progressive physical conditioning that can exceed normal physiological tolerance. The transition from civilian to military training levels represents a substantial increase in physical demands on the musculoskeletal system.
History
The veteran a Warehouse Operator with the Australian Army, developed bilateral lower limb strain during the early phase of his military service related to increased physical training demands, with the initial strain subsequently progressing to medial tibial stress syndrome as documented in his comprehensive medical timeline.
Timeline
- Mid-2013 - the veteran began experiencing bilateral lower limb strain symptoms associated with the transition to intensive military physical training demands. The initial strain injury developed as his musculoskeletal system adapted to the significantly increased training loads compared to civilian activity levels. The strain represented the acute phase of overuse injury affecting the lower limb musculature and supporting structures before progressing to the chronic bone stress reaction phase.
- Early 2013-2014 - The bilateral lower limb strain progressed from acute muscular strain to chronic overuse injury patterns as military training continued. The repetitive nature of military physical training created ongoing stress on the already strained lower limb structures, leading to the development of the documented medial tibial stress syndrome. This represents the natural progression from acute strain to chronic bone stress reaction in the context of continued high-demand training.
- 08 Dec 2011 - The progression from initial strain to medial tibial stress syndrome was formally documented when the veteran presented to physiotherapy services with "bilateral ant/medial pain along shins" that had been present for "6-12 months". The physiotherapy assessment noted he had "bi-lat shin splints since joining up to the army" indicating the condition originated from the early military training period as an initial strain injury.
- Management Period - The strain and its sequelae were managed through activity modification, biomechanical correction including orthotic intervention, and graduated return to military training activities. The comprehensive management addressed both the acute strain components and the chronic adaptations that had developed.
Symptoms
At the time of initial injury in mid-2013, the veteran experienced bilateral lower limb strain symptoms associated with the transition to intensive military physical training. The strain initially presented as muscular discomfort and pain in the lower limb structures associated with high-impact activities and repetitive loading from military training exercises.
The strain subsequently progressed to chronic medial tibial stress syndrome as documented in the comprehensive medical timeline, representing the natural progression from acute muscular strain to chronic bone stress reaction under continued training demands.
Imaging
No specific imaging was performed for the initial bilateral lower limb strain as this was a clinical diagnosis based on the pattern of symptoms and their relationship to military training activities. Subsequent imaging focused on ruling out stress fractures when the condition progressed to medial tibial stress syndrome.
1. What is the formal diagnosis of the condition claimed above?
Bilateral Lower Limb Strain (M79.3) - DVA SOP Code: Sprain and Strain No. 28 of 2020, ICD-10 Code: M79.3
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. In this case, the bilateral lower limb strain represents the initial musculoskeletal injury that occurred during the transition to intensive military physical training. The strain affected multiple muscle groups and supporting structures in both lower limbs as they adapted to the significantly increased training demands. This condition represents the acute phase of what subsequently developed into chronic medial tibial stress syndrome, demonstrating the progression from acute muscular injury to chronic bone stress reaction.
The temporal relationship shows this was the initial injury that occurred during early military training and subsequently progressed to the documented medial tibial stress syndrome, representing a continuum of overuse injury development.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Mid-2013 - during the transition to intensive military physical training in the first year of service
When did the veteran first present to a health / medical provider for this condition? The initial strain was managed through self-treatment and military training modifications. Formal presentation occurred 08 December 2011 when the condition had progressed to medial tibial stress syndrome requiring physiotherapy intervention.
When was the condition confirmed / formally diagnosed? 08 December 2011 - The progression from initial strain to medial tibial stress syndrome was confirmed by military physiotherapist who noted the condition had been present since joining the army, establishing the temporal relationship to the initial strain injury.
When did the veteran first present to you (or your practice) for this condition? 14 January 2021
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 of bilateral lower limb strain was confirmed through clinical assessment and the documented progression to medial tibial stress syndrome. Key evidence included the temporal relationship between commencement of intensive military training and symptom onset, the bilateral nature of the condition affecting both lower limbs simultaneously, and the documented progression from initial strain symptoms to chronic bone stress reaction. The physiotherapy assessment noted symptoms had been present since joining the army, confirming the initial strain occurred during early military training. The pattern of bilateral involvement and progression to medial tibial stress syndrome is consistent with strain injury affecting multiple muscle groups and supporting structures.
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 transition from civilian to intensive military physical training involved forceful stretching and high intensity use of lower limb muscles and tendons during running, jumping, marching, and other high-impact military training activities.
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 - NOT MET - This factor relates to sprain (ligament injury) rather than strain (muscle/tendon injury).
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 - MET - Continued intensive military training represented ongoing forceful stretching and high intensity use of the already strained lower limb structures, contributing to the progression from acute strain to chronic medial tibial stress syndrome.
inability to obtain appropriate clinical management for sprain or strain - NOT MET - Appropriate clinical management was eventually provided through military physiotherapy services, though the initial strain phase was managed through self-treatment and training modifications consistent with military training practices.
Sequelae
This bilateral lower limb strain is not a sequelae of another condition but represents the primary injury that subsequently led to the development of medial tibial stress syndrome. The strain is the causative condition for the later development of chronic bone stress reaction.
Unintended Consequence
This condition is not an unintended consequence of medical management as no prior medical procedures or treatments were performed that could have led to this strain injury.
Inability to Attain Appropriate Medical Management
The Full Federal Court in Brew v Repatriation Commission (12 July 1996) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. This factor is PARTIALLY MET. During the initial strain phase in mid-2013, there is evidence that the veteran managed the condition through self-treatment and training modifications rather than formal medical intervention. The military training environment may have created barriers to seeking immediate medical attention for what was initially perceived as normal adaptation to training. However, when symptoms progressed and became functionally limiting, appropriate physiotherapy services were accessed in January 2013, demonstrating the availability of medical care when formally sought. The delay between initial strain and formal medical assessment may represent practical barriers to healthcare access during the adaptation phase of military training.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
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 withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
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