Left Ankle - Peroneal Tendinopathy — DVA claim example

Diagnostic Assessment — Left Ankle - Peroneal Tendinopathy

Example 1 of 1 · fictitious patient (Veteran BG)

Diagnostic Assessment

Left Ankle - Peroneal Tendinopathy

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran BG, date of birth 11 September 1990, Australian Army, Rifleman (Infantry), parachute qualified, enlisted 03 February 2009, medically discharged 18 September 2020. Operational service: Afghanistan, 15 October 2012 to 20 June 2013 (warlike); Iraq, Middle East Region, 10 November 2016 to 30 May 2017 (warlike).

Occupational History

As an infantry rifleman the veteran conducted foot patrols, field exercises and fitness training carrying loads of 30 to 45 kilograms over rough, uneven and steep ground, in issued combat boots, for many hours a week. Infantry soldiers have high rates of ankle sprain, lateral ankle instability, stress injury and tendinopathy of the foot and ankle. As a member of a parachute-capable battalion he also undertook static-line parachute descents, which carry a recognised risk of ankle, hindfoot and calcaneal injury on landing.

On operations, patrolling over rocky, irrigated and mountainous terrain is sustained and often intensified at short notice. Field hygiene is limited, with a high incidence of gastrointestinal infection, and replacement equipment and specialist medical care, including imaging and physiotherapy, may be unavailable for long periods.

History

Veteran BG, an infantry rifleman in the Australian Army, developed left peroneal tendinopathy on 02 April 2013 during warlike service in Afghanistan, after a calcaneal fracture from a parachute landing, recurrent ankle sprains with retinacular injury, a sudden increase in heavy patrolling, and treatment with ciprofloxacin and prednisolone for dysentery and reactive arthritis. The condition was confirmed on ultrasound and MRI in July 2013 and worsened during warlike service in Iraq in 2017, after a corticosteroid injection and a further inversion injury.

Timeline

• 09 May 2011 — During a static-line parachute descent on a training exercise the veteran landed heavily on uneven ground and sustained a left calcaneal fracture. CT showed an intra-articular fracture with lateral wall expansion. It was managed without surgery and he was non-weight-bearing for eight weeks. The orthopaedic surgeon recorded that it healed with a prominent lateral wall and mild hindfoot varus. "left calcaneal fracture, lateral wall"
• 14 Jan 2013 — On warlike service in Afghanistan he inverted his left ankle on rocky ground while patrolling with a 40 kg load. The role 1 medical officer diagnosed a grade 2 lateral ligament sprain, his third left ankle sprain since 2010, with a positive anterior drawer test and a painful click behind the lateral malleolus. He was rested for ten days and returned to patrolling with strapping. "grade 2 inversion sprain, clicking"
• 01 Mar 2013 — He developed bloody diarrhoea and fever at a remote patrol base and stool culture grew Shigella. He was treated with ciprofloxacin 500 mg twice daily from 01 to 05 March 2013. On 20 March 2013 he developed a swollen left knee, bilateral heel enthesitis and conjunctivitis, and reactive arthritis was diagnosed. Prednisolone 25 mg daily was given from 22 to 31 March 2013. "Shigella, ciprofloxacin, reactive arthritis"
• 05 Apr 2013 — He presented to the role 1 medical officer with pain and swelling behind and below the left lateral malleolus, worse on patrol, that had begun on 02 April 2013. Over the previous four weeks his company's patrol hours had doubled after relocation to a remote patrol base, and his worn-out boots, with lateral heel wear, had not been replaced for eight weeks. Resisted eversion was painful and the peroneal tendons were tender and thickened. A review on 11 February 2013 had recorded no peroneal tenderness. "painful resisted eversion, swelling"
• 22 Jul 2013 — After his return to Australia, a sports physician reviewed ultrasound of 15 July 2013 and MRI of 18 July 2013, which showed peroneus brevis tendinosis with a longitudinal split, tenosynovitis, stripping of the superior peroneal retinaculum and a prominent peroneal tubercle on the healed calcaneus. He diagnosed left peroneal tendinopathy and recommended rehabilitation and surgical review. HLA-B27 was positive. "peroneal tendinopathy, split tear"
• 10 Oct 2016 — To meet his deployment readiness date, a corticosteroid injection was given into the left peroneal tendon sheath under ultrasound guidance. The planned surgical review had not occurred because of repeated postponement for training and courses. "steroid injection peroneal sheath"
• 20 Feb 2017 — On warlike service in Iraq he inverted his left ankle on broken ground during a force protection patrol carrying about 30 kg. He continued patrolling about twelve hours a week, as no physiotherapy or imaging was available in theatre. "further inversion injury, patrolling"
• 15 Mar 2017 — The medical officer in Iraq recorded marked worsening of lateral ankle pain and swelling, giving way, and inability to complete patrols, and he was placed on restricted duties. MRI after his return, on 12 June 2017, showed progression to a full-thickness longitudinal split tear of peroneus brevis, a peroneus longus tear and subluxation of the tendons. "worsening, unable to patrol"

Symptoms

At onset the veteran had pain and swelling behind and below the left lateral malleolus, worse with patrolling and on uneven ground, a painful click and stiffness in the morning. After onset he developed a sensation of the tendons slipping and recurrent giving way of the ankle.

He now reports persistent lateral ankle pain with walking more than one kilometre, instability on uneven ground, swelling after activity and difficulty with running, ladders and carrying loads. He underwent peroneal tendon repair and superior peroneal retinaculum reconstruction in 2018 and still wears an ankle brace for outdoor activity.

He reports that he can no longer run, hike or play team sport, and that he avoids uneven ground and ladders. He has had to modify his civilian employment to avoid prolonged standing and walking.

Imaging

• 09 May 2011 — CT left hindfoot: "Intra-articular fracture of the left calcaneus with lateral wall expansion and mild depression of the posterior facet."
• 15 Jul 2013 — Ultrasound left ankle: "Thickened, hypoechoic peroneus brevis tendon with a longitudinal split and fluid in the common peroneal tendon sheath, consistent with tendinopathy and tenosynovitis."
• 18 Jul 2013 — MRI left ankle: "Peroneus brevis tendinosis with a partial longitudinal split tear and tenosynovitis. Stripping of the superior peroneal retinaculum. Healed calcaneal fracture with lateral wall prominence and an enlarged peroneal tubercle. Chronic anterior talofibular ligament thickening."
• 12 Jun 2017 — MRI left ankle: "Progression to a full-thickness longitudinal split tear of peroneus brevis and a partial tear of peroneus longus, with lateral subluxation of the tendons over the fibula and increased tenosynovitis."

Onset Date

The most likely date of onset of this condition is 02 Apr 2013.

At that date the veteran was on warlike service in Afghanistan, patrolling from a remote patrol base with a 40 kg load over rocky terrain. He was recovering from a grade 2 inversion sprain of the left ankle, had chronic lateral ankle instability and a healed calcaneal fracture with lateral wall prominence, and had recently completed courses of ciprofloxacin and prednisolone for Shigella dysentery and reactive arthritis.

This date is appropriate because the role 1 review of 11 February 2013 recorded no peroneal tenderness after his January sprain, and he first presented with pain behind the lateral malleolus on 05 April 2013, three days after it began. It falls within uninterrupted full-time service.

For the inversion injury cause, the 1 year before onset runs from 02 Apr 2012 to 02 Apr 2013, and the sprain occurred on 14 Jan 2013. For the load-bearing cause, the 3 months before onset run from 02 Jan 2013 to 02 Apr 2013, during which he patrolled at least 15 hours a week with a 40 kg load. For the sudden increase in load and the footwear causes, the 4 weeks before onset run from 05 Mar 2013 to 02 Apr 2013, when patrol hours doubled and his worn boots had not been replaced since early February 2013. For the fluoroquinolone cause, the 30 days before onset run from 03 Mar 2013 to 02 Apr 2013, which include the last three days of ciprofloxacin, 03 to 05 Mar 2013. For the corticosteroid cause, the 3 months before onset run from 02 Jan 2013 to 02 Apr 2013, which include prednisolone from 22 to 31 Mar 2013. The calcaneal fracture, retinacular tear, chronic instability and reactive arthritis were each present on 02 Apr 2013.

For the worsening causes, the documented worsening was on 15 Mar 2017 on warlike service in Iraq. The 6 months before the worsening run from 15 Sep 2016 to 15 Mar 2017 and include the corticosteroid injection of 10 Oct 2016. The 3 months before the worsening run from 15 Dec 2016 to 15 Mar 2017, during which he patrolled about twelve hours a week, and the further inversion injury occurred on 20 Feb 2017.

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

The formal diagnosis is Left Peroneal Tendinopathy (ICD-10-AM M76.7), with peroneus brevis split tear and tenosynovitis. No Statement of Principles has been determined for peroneal tendinopathy.

Peroneal tendinopathy is a degenerative and inflammatory disorder of the peroneus longus and peroneus brevis tendons, which run behind the lateral malleolus and evert and stabilise the ankle and foot. Repetitive loading, ankle inversion injuries, instability and abnormal hindfoot anatomy cause tendinosis, tenosynovitis and longitudinal split tears, particularly of peroneus brevis where it is compressed against the fibula. It causes lateral ankle pain, swelling and weakness, and is commonly associated with chronic lateral ankle instability and tendon subluxation. Advanced disease often requires surgical repair.

The diagnosis followed the 2011 calcaneal fracture, recurrent sprains and retinacular injury, and the heavy patrolling, fluoroquinolone and corticosteroid treatment and reactive arthritis of his 2013 deployment. It began on 02 April 2013, was confirmed on imaging in July 2013 and worsened on deployment in 2017.

In this veteran the tendinopathy developed on a background of a calcaneal malunion and chronic lateral instability, both of which are recognised to increase the load on the peroneal tendons, and the split tear pattern is typical of mechanical compression of peroneus brevis against the fibula.

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

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

02 April 2013.

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

05 April 2013.

When was the condition confirmed / formally diagnosed?

22 July 2013.

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

23 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 a sports physician on 22 July 2013 on the clinical findings of posterolateral ankle pain, swelling and tenderness along the peroneal tendons with pain on resisted eversion, together with ultrasound of 15 July 2013 and MRI of 18 July 2013 showing peroneus brevis tendinosis with a longitudinal split tear and tenosynovitis.

MRI also showed stripping of the superior peroneal retinaculum and the healed calcaneal fracture with lateral wall prominence and an enlarged peroneal tubercle. Repeat MRI on 12 June 2017 confirmed progression to a full-thickness split tear of peroneus brevis, a partial peroneus longus tear and tendon subluxation, and the tendon pathology was directly confirmed at surgery in 2018.

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.

No Statement of Principles has been determined for peroneal tendinopathy. The claim is therefore decided on the sound medical-scientific evidence of what causes the condition, without the limits a Statement of Principles would impose, and the recognised causes below are drawn from the orthopaedic and sports medicine literature.

Legislation: the clinical onset of this condition was on 02 April 2013, after 1 July 2004, during continuous full-time service and on warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The reasonable hypothesis standard applies to his warlike service in Afghanistan in 2012 to 2013, where the condition arose, and in Iraq in 2016 to 2017, where it worsened, and the balance of probabilities standard applies to his peacetime service, including the 2011 parachute injury and the 2016 injection. Each cause must be related to 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.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: having an inversion injury of the affected ankle within the 1 year before the clinical onset of peroneal tendinopathy; — MET

- On 14 January 2013, on warlike service in Afghanistan, the veteran inverted his left ankle on rocky ground while patrolling with a 40 kg load, and the role 1 medical officer diagnosed a grade 2 lateral ligament sprain. This was within the 1 year before onset, from 02 April 2012 to 02 April 2013. Inversion loads the peroneal tendons eccentrically and can tear them against the fibula.

Cause 2: having chronic lateral ankle instability of the affected ankle at the time of the clinical onset of peroneal tendinopathy; — MET

- The veteran sprained his left ankle on field exercises in 2010 and 2011 and again in Afghanistan in January 2013. The medical officer recorded a positive anterior drawer test and recurrent giving way, and MRI on 18 July 2013 showed chronic anterior talofibular ligament thickening. Chronic lateral instability was present at onset on 02 April 2013, placing the peroneal tendons under constant load as dynamic stabilisers.

Cause 3: undertaking weight-bearing activity involving marching, patrolling or running on uneven ground while carrying a load of at least 20 kilograms, for at least 10 hours per week for at least the 3 months before the clinical onset of peroneal tendinopathy; — MET

- From October 2012 the veteran patrolled on foot over rocky and mountainous ground in Afghanistan four to six days a week, carrying about 40 kg, at least 15 hours a week. This continued throughout the 3 months before onset, from 02 January 2013 to 02 April 2013, apart from ten days of rest after his sprain.

Cause 4: undergoing an increase of at least 50 per cent in the duration or intensity of weight-bearing activity within the 4 weeks before the clinical onset of peroneal tendinopathy; — MET

- In early March 2013 his company relocated to a remote patrol base and his patrol hours rose from about 15 to about 30 hours a week, an increase of 100 per cent, as recorded by the platoon commander and the role 1 medical officer. This increase occurred within the 4 weeks before onset, from 05 March 2013 to 02 April 2013.

Cause 5: having a fracture of the calcaneus of the affected foot, which has healed with lateral wall expansion, peroneal tubercle prominence or hindfoot varus, before the clinical onset of peroneal tendinopathy; — MET

- On 09 May 2011 the veteran sustained a left intra-articular calcaneal fracture landing from a static-line parachute descent on a training exercise. It healed with lateral wall expansion and mild hindfoot varus, and MRI on 18 July 2013 showed a prominent lateral wall and enlarged peroneal tubercle narrowing the space for the peroneal tendons. This was established well before onset on 02 April 2013.

Cause 6: having a tear or stripping of the superior peroneal retinaculum of the affected ankle before the clinical onset of peroneal tendinopathy; — MET

- The inversion injury of 14 January 2013 in Afghanistan produced a painful click behind the lateral malleolus, and MRI on 18 July 2013 confirmed stripping of the superior peroneal retinaculum. Loss of the retinaculum allowed the tendons to sublux and abrade against the fibula before onset on 02 April 2013.

Cause 7: taking a fluoroquinolone antibiotic within the 30 days before the clinical onset of peroneal tendinopathy; — MET

- The veteran took ciprofloxacin 500 mg twice daily from 01 to 05 March 2013 for Shigella dysentery acquired at a remote patrol base in Afghanistan, prescribed by the role 1 medical officer. The last doses, from 03 to 05 March 2013, fell within the 30 days before onset, from 03 March 2013 to 02 April 2013. Fluoroquinolones are a recognised cause of tendinopathy and tendon rupture.

Cause 8: taking a systemic corticosteroid within the 3 months before the clinical onset of peroneal tendinopathy; — MET

- Prednisolone 25 mg daily was prescribed from 22 to 31 March 2013 for reactive arthritis, within the 3 months before onset, from 02 January 2013 to 02 April 2013. Combined fluoroquinolone and corticosteroid treatment substantially increases the risk of tendon injury.

Cause 9: having a seronegative inflammatory arthritis, including reactive arthritis, at the time of the clinical onset of peroneal tendinopathy; — MET

- Reactive arthritis followed the Shigella dysentery acquired on warlike service in Afghanistan and was diagnosed on 20 March 2013, with knee synovitis, heel enthesitis and conjunctivitis, and HLA-B27 was later positive. It was active at onset on 02 April 2013, and tenosynovitis is a typical feature of this condition.

Cause 10: wearing worn or inappropriate footwear during weight-bearing activity for at least the 4 weeks before the clinical onset of peroneal tendinopathy; — MET

- His issued combat boots had marked lateral heel wear from early February 2013, and no replacement pair could be supplied to the remote patrol base for eight weeks, as recorded on 05 April 2013. He wore them on patrol throughout the 4 weeks before onset, from 05 March 2013 to 02 April 2013, which increased hindfoot inversion and peroneal loading.

Worsening factors

Worsening 1: having a corticosteroid injection into or around the affected peroneal tendons within the 6 months before the clinical worsening of peroneal tendinopathy; — MET

- A corticosteroid injection was given into the left peroneal tendon sheath on 10 October 2016 so that he could meet his deployment readiness date, within the 6 months before the worsening, from 15 September 2016 to 15 March 2017. Local corticosteroid weakens tendon collagen and predisposes to tear progression.

Worsening 2: having a further inversion injury of the affected ankle before the clinical worsening of peroneal tendinopathy; — MET

- On 20 February 2017, on warlike service in Iraq, he inverted his left ankle on broken ground while patrolling with a 30 kg load, three weeks before the documented worsening on 15 March 2017.

Worsening 3: undertaking weight-bearing activity on uneven ground while carrying a load of at least 20 kilograms for at least 10 hours per week within the 3 months before the clinical worsening of peroneal tendinopathy; — MET

- On warlike service in Iraq he conducted force protection patrols and training carrying about 30 kg for about twelve hours a week throughout the 3 months before the worsening, from 15 December 2016 to 15 March 2017, and continued after the inversion injury because no alternative duties or treatment were available.

Worsening 4: inability to obtain appropriate clinical management for peroneal tendinopathy. — MET

- Surgical review recommended on 22 July 2013 was postponed for more than three years because of training commitments and courses, and he was given a corticosteroid injection in its place to deploy. In Iraq no physiotherapy, imaging or orthopaedic care was available after his further injury and he continued patrolling. The tendinopathy progressed to full-thickness tears, confirmed on MRI on 12 June 2017. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

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

Sequelae

The peroneal tendinopathy is a sequela of the veteran's accepted conditions: the left calcaneal fracture from the 2011 parachute landing, chronic left lateral ankle instability from recurrent service sprains, and reactive arthritis following dysentery on deployment. The tendinopathy has in turn led to peroneal tendon subluxation, tendon repair and retinacular reconstruction surgery, and altered gait with secondary pain in the left knee.

Unintended Consequence

Met. The tendinopathy is in part an unintended consequence of ciprofloxacin and prednisolone prescribed on deployment, and its worsening is in part an unintended consequence of the corticosteroid injection given to make him deployable, all 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. The surgical review recommended on 22 July 2013 was postponed for more than three years because of service commitments, and a corticosteroid injection was substituted to meet a deployment date. On warlike service in Iraq no physiotherapy, imaging or orthopaedic care was available after his further inversion injury, and he continued patrolling until the tendons tore through. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), service demands and operational constraints that prevent recommended specialist treatment amount to an inability to obtain appropriate clinical management. The lack of replacement boots at the patrol base in 2013 is also indicative of barriers to care.

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

See attached report.

References

1. 09 May 2011, Emergency attendance, CT report and orthopaedic follow-up, Orthopaedic surgeon
2. 14 Jan 2013, Deployed health record, Medical Officer, role 1 facility, Afghanistan
3. 11 Feb 2013, Deployed health record, Medical Officer, Afghanistan
4. 01 Mar 2013, Deployed health record and stool culture report, Medical Officer, Afghanistan
5. 20 Mar 2013, Deployed health record, Medical Officer, Afghanistan
6. 05 Apr 2013, Deployed health record, Medical Officer, Afghanistan
7. 15 Jul 2013, Ultrasound left ankle, Radiologist
8. 18 Jul 2013, MRI left ankle, Radiologist
9. 22 Jul 2013, Sports medicine consultation, Sports physician
10. 10 Oct 2016, Ultrasound-guided injection report, Radiologist
11. 15 Mar 2017, Deployed health record, Medical Officer, Iraq
12. 12 Jun 2017, MRI left ankle, Radiologist
13. 2018, Operation report, Orthopaedic foot and ankle surgeon