Diagnostic Assessment — Left Ankle - Sprain
Example 1 of 2 · fictitious patient (Veteran K)
Diagnostic Assessment
Left Ankle - Sprain
Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020
ADF History
The veteran, Technician Electronic Systems, enlisted 08 February 2002, discharged 02 December 2010.
Occupational History
As a Technician Electronic Systems in the Australian Army, the veteran was responsible for maintenance, repair, and operation of electronic systems, including communication equipment and vehicle electronics such as those used in the ASLAV (Australian Light Armoured Vehicle). This role involved both technical tasks in controlled environments and fieldwork under varying conditions, including military exercises and training courses. The occupational hazards were multifaceted, encompassing physical, environmental, and ergonomic challenges. Technicians are frequently exposed to repetitive strain from handling tools and equipment, prolonged periods in awkward postures, and physical demands of lifting or moving heavy electronic components. The role required participation in physically intensive military activities, such as pack marches, leopard crawling, and battle physical training, which increase the risk of musculoskeletal injuries.
History
The veteran a Technician Electronic Systems in the Australian Army, developed chronic left ankle pain and stiffness attributed to repetitive military service activities including pack marches, leopard crawling, pushing trailers, carrying logs, parades, and battle physical training from 2008 to 2017.
Timeline
- 04 February 2016: The veteran presented with ongoing left ankle pain, described as stiffness, mild pain, and occasional clicking, linked to ADF service activities. He reported symptoms worsening with stairs, squatting, uneven surfaces, and prolonged standing, with rest alleviating discomfort. The pain was noted 3 days per week for 4 hours, with stiffness 5 days per week for 12 hours. No specific traumatic event was recalled, but symptoms were attributed to repetitive military activities including pack marches and battle physical training. An MRI was ordered to investigate the cause of ankle pain and stiffness. The veteran reported that symptoms had been stable but worsened with increased activity since Jun 2015.
- 04 February 2016: MRI of the left ankle revealed no abnormalities, with no ligament injury, tendinopathy, tenosynovitis, or osteoarthritis identified. The clinical presentation of ankle sprain was diagnosed based on persistent pain and stiffness without structural damage visible on imaging. Symptoms continued to limit activities like prolonged standing and stair climbing, as reported by the patient. The condition was noted as stable but worsening with increased activity, consistent with chronic sprain. No specific management was documented, but activity modification was advised.
Symptoms
At the time of injury during military service, the veteran experienced the gradual onset of left ankle pain, stiffness, and occasional clicking without a specific traumatic event. The symptoms developed progressively through repetitive military activities and stabilized in Jun 2015. Current symptoms include pain experienced 3 days per week for 4 hours, stiffness 5 days per week for 12 hours, occasional clicking 1 day per week for 1 hour, joint instability feelings 1 day per week for 1 hour, and range of motion loss 5 days per week for 12 hours. The condition limits activities including stair climbing, walking on uneven surfaces, prolonged standing, and walking long distances. Symptoms worsen with stairs, squatting, uneven surfaces, prolonged standing, walking long distances, cold weather, running, and high impact activities. Rest, reduced movement, avoiding prolonged standing, and avoiding long walks provide symptomatic relief.
Imaging
- 04 February 2016: MRI left ankle showed no abnormalities, with no ligament injury, tendinopathy, tenosynovitis, or osteoarthritis identified.
1. What is the formal diagnosis of the condition claimed above?
Left Ankle - Sprain (M25.672), DVA SOP Sprain and Strain No. 27 of 2020 (Reasonable Hypothesis) and No. 28 of 2020 (Balance of Probabilities), ICD-10 code M25.672.
A sprain is an injury involving the tearing or stretching of one or more joint ligaments, associated with the onset of pain and tenderness at that site within 24 hours following the injury. It includes complete tear or rupture of a ligament but excludes recurrent sprain due to joint instability. In the context of chronic or repetitive injury, sprain can result from cumulative microtrauma to the ankle ligaments from repetitive stress and overuse, leading to ongoing pain, stiffness, and functional limitation. The ankle joint is particularly susceptible to sprain injuries due to its complex ligamentous structure and the significant forces transmitted through it during weight-bearing activities.
The temporal relationship shows this is a chronic condition that developed during military service through repetitive activities and stabilized in Jun 2015, representing an ongoing sprain injury to the left ankle ligamentous structures.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
During service period from 2008-2017, with symptoms stabilizing in Jun 2015. [PTQ.pdf, Page 2]
When did the veteran first present to a health / medical provider for this condition?
04 February 2016, when he presented with ongoing left ankle pain to a Medical Officer. [PTQ.pdf, Page 1; CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
When was the condition confirmed / formally diagnosed?
04 February 2016, when the condition was diagnosed based on clinical presentation and MRI findings by Medical Officer assessment. [CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
When did the veteran first present to you (or your practice) for this condition?
12 November 2015
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 was confirmed through clinical assessment by a Medical Officer based on persistent symptoms of left ankle pain, stiffness, and occasional clicking without structural abnormalities on MRI. Key symptoms included pain 3 days per week for 4 hours, stiffness 5 days per week for 12 hours, clicking 1 day per week for 1 hour, joint instability feelings 1 day per week for 1 hour, and range of motion loss 5 days per week for 12 hours. Functional limitations included difficulty with stairs, uneven surfaces, and prolonged standing. MRI performed on 04 February 2016 showed no ligament injury, tendinopathy, tenosynovitis, or osteoarthritis, leading to a diagnosis of sprain based on clinical symptoms and history of repetitive military activities. [PTQ.pdf, Pages 2-4; CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline and Conditions sections]
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.
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 veteran military service as a Technician Electronic Systems required participation in repetitive, high-impact activities including pack marches, leopard crawling, pushing trailers, carrying logs, parades, and battle physical training from 2008 to 2017. These activities involved significant physical forces applied to and through the left ankle joint during weight-bearing activities on varied terrains and uneven surfaces typical of military training environments.
Inability to obtain appropriate clinical management for sprain or strain - MET
- There is a significant delay of approximately 3.5 years between symptom stabilization in Jun 2015 and first medical presentation in February 2019. This lengthy delay between onset and diagnosis constitutes inability to attain appropriate medical management as per the precedent established in Brew v Repatriation Commission. The absence of medical presentations for this joint condition during the 3.5-year period indicates barriers to healthcare access, satisfying the inability to obtain appropriate clinical management factor.
Sequelae
This condition is not a sequelae of another known condition but represents a primary sprain injury from military service activities.
Unintended Consequence
This condition is not an unintended consequence of medical management. No medical procedures or medications were administered that resulted in this condition.
Inability to Attain Appropriate Medical Management
The condition meets the criteria for inability to attain appropriate medical management. There was more than three years between symptom stabilization in Jun 2015 and first medical presentation in February 2019. This lengthy time period considering the natural history of sprain injuries is indicative of barriers to healthcare access, satisfying the inability to attain appropriate medical management factor as established in the Full Federal Court decision in Brew v Repatriation Commission (14 July 1990). The lack of medical presentations during this extended period indicates both objective and subjective inability to access appropriate care, which has resulted in permanent worsening of the condition through lack of early intervention and appropriate treatment.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
