Diagnostic Assessment — Left Ankle - Anterior Ligament Strain
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Ankle — Anterior Ligament Strain BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Rifleman from 1 October 1981 to 17 July 1988
Occupational History
As a naval serviceman, the veteran was required to participate in military sporting activities including football training.
Military sport is conducted as a component of physical fitness training and team-building within the Australian Defence Force
History
The veteran sustained a strain of the anterior ligaments of the left ankle on 26 March 1988 during football training at an infantry battalion, approximately four months prior to his discharge from the Navy on 17 July 1988
Timeline
26 Mar 1988 — ABSR the veteran, as a young adult, strained the anterior ligaments of the left ankle during football training at an infantry battalion.
Examination demonstrated tender swelling over the anterior lateral aspect of the left ankle.
Joint movement was intact.
There was no malleolar swelling or tenderness, which clinically excluded a fracture.
He was prescribed Paracetamol (Paradol) for pain relief.
Review by the medical officer, with a possible X-ray, was arranged for 27 March 1988. "Strain anterior ligaments"
Symptoms
At the time of injury, the veteran experienced pain and swelling over the anterior lateral aspect of the left ankle.
Joint movement was preserved but the area was tender and swollen.
The injury was significant enough to warrant analgesia and medical officer review with a possible X-ray
Imaging
X-ray was requested for 27 March 1988 to exclude fracture.
The result is not documented in the available records
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Ankle Anterior Ligament Strain (ICD-10: S93.402A).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim.
A ligament strain of the ankle involves stretching or partial tearing of the ligaments that stabilise the ankle joint.
The anterior talofibular ligament is the most commonly injured ligament in ankle sprains and is located on the anterior lateral aspect of the ankle, consistent with the documented examination findings
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 26 March 1988 [ [CHART REVIEW document], pages 3 4] When did the veteran first present to a health / medical provider for this condition? 26 March 1988 When was the condition confirmed / formally diagnosed? 26 March 1988 When did the veteran first present to you (or your practice) for this condition? 11 February 2023
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending medical officer at an infantry battalion.
The key symptoms were ankle pain following a football training injury.
The key signs were tender swelling over the anterior lateral aspect of the left ankle with intact joint movement and no malleolar involvement, consistent with a ligamentous strain rather than a fracture [ [CHART REVIEW document], pages 3 4]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 29 December 2001 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The medical officer recorded a 'strain' of the anterior ligament of the left ankle; because the injured structure is a ligament (on the examination findings, the anterior talofibular ligament), the injury is a sprain within the meaning of subsection 7(2) of the Statements of Principles and is assessed as such.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): 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 — MET - On 26 March 1988 the veteran injured his left ankle during football training at an infantry battalion (Daily Injury Record of 26 March 1988).
The mechanism is not described, but tender swelling over the anterolateral aspect of the ankle, with no malleolar swelling or tenderness, is the pattern of a sprain of the anterior talofibular ligament, which results from forced inversion and plantar flexion of the ankle under body weight while running or turning.
For a man of his size (125 kg at discharge less than four months later), that is a significant physical force applied through the ankle joint, experienced at the time of the clinical onset of the sprain diagnosed that day.
Factor 9(2): 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 — NOT MET - This factor applies only to a strain of a muscle or tendon.
Although the record uses the word 'strain', the injury of 26 March 1988 was to the anterior ligament of the left ankle, which is a sprain, and no muscle or tendon injury was recorded.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): 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 — MET - The left ankle injury during football training at an infantry battalion on 26 March 1988, with tender anterolateral swelling typical of an anterior talofibular ligament sprain, resulted from forced twisting of the ankle under the body weight of a heavy man, a significant physical force through the joint at the time of the clinical onset of the sprain diagnosed that day.
Factor 9(2): 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 — NOT MET - This factor applies only to a strain of a muscle or tendon; the left ankle injury of 26 March 1988 affected the anterior ligament, which is a sprain, and no muscle or tendon injury was recorded.
Other Plausible Links to Service The injury occurred during football training and was recorded by the service medical record staff at an infantry battalion on the Navy's Daily Injury Record, at 12.30 pm on a working day, Thursday 26 March 1988.
Football training at a service establishment during working hours is consistent with organised service sport or physical training undertaken as part of his service and to maintain the fitness his duties required, and nothing in the record suggests private sport.
On that basis the injury arose in the course of his employment as a member.
Conclusion the veteran's left ankle condition is a sprain of the anterior (talofibular) ligament, recorded as an anterior ligament 'strain', caused by the injury during football training at an infantry battalion on 26 March 1988, which applied a significant physical force through the ankle at the onset of the sprain and meets factor 9(1) of both Statements of Principles.
The training is consistent with organised service sport or physical training, so the injury arose in the course of his service, and no other cause is identified.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the sprain of the veteran's left ankle is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 26 March 1988 aggravated it or contributed to it in a material degree.
He served at an infantry battalion for almost four months after the injury, until his discharge on 17 July 1988.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - There is no record of any clinical worsening of the left ankle sprain.
A review by the medical officer was arranged for 27 March 1988, and no further ankle presentation appears in the remaining months of his service or in the available post-service records.
Factor 9(4): 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 — NOT MET - This factor applies only to a strain of a muscle or tendon.
The left ankle injury was a ligament sprain, and no worsening of any muscle or tendon injury of the ankle is recorded.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, there was no inability: the ankle was examined on the day of injury, fracture was clinically unlikely with no malleolar tenderness, analgesia was given, and a medical officer review with a possible x-ray was arranged for the next day.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — NOT MET - No clinical worsening of the left ankle sprain is recorded after 26 March 1988, either in the remaining months of the veteran's service or afterwards.
Factor 9(4): 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 — NOT MET - This factor applies only to a strain of a muscle or tendon; the left ankle injury was a ligament sprain, and no worsening of a muscle or tendon injury is recorded.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no objective or subjective inability: the ankle was assessed and treated on the day of injury, a review was arranged for the next day, and no later ankle problem is recorded
Sequelae
The left ankle ligament strain may predispose to future ankle instability and degenerative change, however no specific ankle imaging is documented in the available records to assess for long-term sequelae
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
There was no inability to obtain appropriate clinical management.
The ankle was examined on the day of injury, fracture was clinically unlikely with no malleolar tenderness, analgesia was given, and a medical officer review with a possible X-ray was arranged for the next day; no later ankle problem is recorded.
Assessed objectively and subjectively as required by Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this factor is NOT MET
Date of Clinical Onset
Left ankle anterior ligament strain is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 26 March 1988 — strain of the anterior ligaments of the left ankle during football training at an infantry battalion [ [CHART REVIEW document], pages 3 4].
Date of clinical onset: 26 March 1988.
This date falls within the veteran's ADF service (1 October 1981 17 July 1988).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
