Diagnostic Assessment — Left Foot - Exostosis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Foot — Exostosis BOP Code: N/A (there is no Statement of Principles for this condition) RH Code: N/A
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Boatswain's Mate from 15 August 1989 to 31 May 1996
Occupational History
As a naval serviceman, the veteran was required to wear military-issued boots and footwear.
He had bilateral hammer toes that were formally diagnosed during service on 30 October 1991 and caused significant difficulty wearing shoes due to the deformity and associated dorsal calluses
History
The veteran has a left foot exostosis (bony overgrowth) that is related to the bilateral hammer toe deformity and the multiple surgical interventions performed during ADF service.
The enlistment medical history form of 13 June 1989 records previous fractures of the toes playing football (" toes football") but no toe deformity; hammer toes were first diagnosed on 30 October 1991, with initial surgery by the treating doctor on 25 November 1991 (flexor to extensor tenotomies and tendon transfers of the right 2nd, 3rd and 4th toes and left 4th toe, and fusion of the distal joint of the left 3rd toe), removal of a K-wire from the 2nd toe of the left foot on 23 December 1991, and bilateral toe straightening surgery (IP joint fusion of right 2nd, 3rd, 4th toes and left 4th toe) performed on 24 February 1994.
X-ray of both feet reported on 17 March 1994 (requested pre-operatively on 22 February 1994) showed small exostoses on the lateral aspects of the shafts of the left fourth and third proximal phalanges.
The surgery was documented as "unsuccessful" by the treating podiatrist in 2024, with retained hammer toes and chronic pain.
X-ray in March 2019 confirmed bilateral forefoot ankylosis at multiple PIP and DIP joints.
Exostosis (dorsal bony prominence) is a recognised consequence of hammer toe deformity and the altered biomechanics following surgical fusion
Timeline
13 Jun 1989 — Enlistment medical history form records previous fractures of the toes playing football (pre-service); no toe deformity recorded. " toes football" 30 Oct 1991 — Bilateral hammer toes affecting toes II, III, and IV of both feet formally diagnosed by the treating doctor at a patrol boat.
Significant difficulty wearing shoes due to deformity and associated dorsal calluses.
Referred to the treating doctor, orthopaedic surgeon, for operative repair.
Signal NGB149 declared sailor unfit for sea service for two months. "Bilateral hammer toes" 25 Nov 1991 — Admitted from a patrol boat to Calvary Hospital a patrol boat (14 28 Nov 1991).
Operation by the treating doctor, consultant orthopaedic surgeon: flexor to extensor tenotomies and tendon transfers of the right 2nd, 3rd and 4th toes and the left 4th toe, and fusion of the distal joint of the left 3rd toe.
Convalescent leave to 09 Jan 1992, with 45 days ineffective for work in total. "Flexor to extensor tenotomies tendon transfers" 23 Dec 1991 — Day care operation for removal of K-wire from 2nd toe left foot at Calvary Private Hospital by the treating doctor. "Removal of K-wire" 25 Nov 1993 — Orthopaedic consultation with the treating doctor at a patrol boat.
Bilateral claw toes with fixed flexion and dorsal painful calluses affecting right 2, 3, 4 toes and left 4th toe.
Recommended IP joint fusion. "Dorsal painful calluses" 24 Feb 1994 — Interphalangeal joint fusion of the right 2nd, 3rd and 4th toes and left 4th toe (with re-fusion of the left thumb MCP joint); 36 days ineffective for work. "Fusion of hammer toes" 17 Mar 1994 — X-ray of both feet (film 1556), requested at a patrol boat on 22 Feb 1994 as pre-operative X-rays for the planned IP joint fusion of the right 2nd, 3rd and 4th toes and left 4th toe, reported by J.
Stackpool, consultant radiologist: small exostosis on the lateral aspects of the shaft of the left fourth proximal phalanx and the 3rd proximal phalanx, with no other abnormality detected. "a small exostosis is present" 16 Oct 2024 — Podiatry referral letter from Rachel Lange, Galleria Podiatry.
Surgery on both feet around 1992 was "unsuccessful." Retains hammer toes with chronic ingrown toenails.
DVA white card held. "Surgery was unsuccessful" 21 Mar 2019 — X-ray bilateral feet for forefoot pain with previous surgical intervention.
Left foot demonstrated ankylosis of 2nd PIP, 3rd DIP, 4th PIP, and 5th DIP joints.
No midfoot arthropathy. "Ankylosis"
Symptoms
The veteran reports chronic left forefoot pain following the unsuccessful surgical intervention.
The dorsal calluses and bony prominences cause difficulty with footwear and pain on weight- bearing
Imaging
17 Mar 1994 — X-ray both feet: "a small exostosis is present on the lateral aspects of the shaft of the (L) fourth proximal phalanx and the 3rd proximal phalanx N.O.A.D." 21 Mar 2019 — X-ray bilateral feet: "Left foot: ankylosis of the second PIP joint, third DIP joint, fourth PIP joint and fifth DIP joint.
No midfoot arthropathy."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Foot Exostosis (ICD-10: M89.37).
An exostosis is a bony overgrowth that projects outward from the surface of a bone.
In the context of the veteran's left foot, the exostosis is related to the hammer toe deformity (with dorsal bony prominences) and the subsequent surgical interventions (with post-surgical bony overgrowth at the fusion sites).
The condition is temporally related to the bilateral hammer toes (diagnosed during service) and the surgical interventions performed during service (K-wire fixation 1991, IP joint fusion 1993)
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 30 October 1991 (formal diagnosis of bilateral hammer toes with dorsal calluses and difficulty wearing shoes) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 30 October 1991 When was the condition confirmed / formally diagnosed? 17 March 1994 (X-ray of both feet reported by consultant radiologist J.
Stackpool: small exostosis on the lateral aspect of the shaft of the left fourth proximal phalanx) [CHART REVIEW document] When did the veteran first present to you (or your practice) for this condition? 26 December 2020
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 and radiological grounds.
Clinically, bilateral hammer toes with dorsal painful calluses were diagnosed during service (30 October 1991 and 25 November 1993), indicating bony prominences at the affected joints.
Radiologically, X-ray of both feet reported on 17 March 1994 by consultant radiologist J.
Stackpool showed a small exostosis on the lateral aspect of the shaft of the left fourth proximal phalanx [CHART REVIEW document], and X-ray of bilateral feet on 21 March 2019 confirmed multiple PIP and DIP joint ankylosis in the left foot, consistent with prior surgical fusion and associated bony remodelling
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 12 November 2009 (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.
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.
There is no Statement of Principles for an exostosis of a toe or for hammer toe deformity.
The question under the DRCA is therefore whether the veteran's left foot exostosis arose out of, or in the course of, his service, including as an unintended consequence of medical treatment paid for by the Commonwealth under section 6A of the DRCA, or was contributed to by his service to a significant degree.
Plausible Links to Service The exostoses arose in toes affected by hammer toe deformity.
The veteran's enlistment medical history of 13 June 1989 records previous fractures of the toes playing football (" toes football"), without stating which toes, but records no toe deformity, symptom or restriction, and he was accepted as fit for naval service.
On 30 October 1991, while he was serving in a patrol boat, the local medical officer, the treating doctor, diagnosed hammer toes of the second, third and fourth toes of both feet with calluses and difficulty wearing shoes, and a signal of the same date made him unfit for sea service for two months.
The orthopaedic surgeon, the treating doctor, wrote on 12 November 1991 that the deformities had been coming on for some time and were troubling him in tight footwear, "particularly when he is at sea".
Whether or not the deformity had begun before enlistment, it was in service footwear and during shipboard service that it became symptomatic and disabling.
The treating doctor on 25 November 1991, performing flexor-to-extensor tendon transfers of the right second to fourth toes and the left fourth toe and fusion of the distal joint of the left third toe; a K-wire was removed from a left toe on 23 December 1991, and he was ineffective for work for 45 days.
He was passed fit for sea duty on 23 September 1992 and from 28 December 1992 served in a patrol boat, including its deployment, with watchkeeping (nine hours of gangway duty on 2 June 1993), deck work and the stairs and ladders of a ship.
By 25 November 1993 the deformities had recurred as fixed flexion deformities with painful dorsal callosities of the right second to fourth toes and the left fourth toe, and the interphalangeal joints were fused on 24 February 1994, with a further 36 days ineffective for work.
The recurrence of the deformity, and its progression to a fixed state, during sea service in service footwear with prolonged standing is consistent with aggravation of the hammer toes by his service, and it led directly to the second operation.
The small exostoses on the lateral aspects of the shafts of the left third and fourth proximal phalanges were first shown on the pre-operative X-ray of both feet requested on 22 February 1994 and reported on 17 March 1994, about two years after the operation of November 1991 on those same two toes.
A flexor-to-extensor transfer re-routes the long flexor tendon around the proximal phalanx, and surgical dissection and K-wire fixation close to bone can provoke a periosteal reaction with new bone formation, so a small bony outgrowth on the shaft of an operated phalanx is consistent with a consequence of that surgery.
Pressure and friction on the deformed toes in footwear is a further plausible contributor, and a contribution from the pre-service toe fractures cannot be excluded because their site is not recorded.
The civilian treatment was arranged by the Navy, which sought and was granted approval to pay the hospital, surgeon, anaesthetist and theatre fees (for example, in the signals of 11 and 24 December 1991).
An exostosis resulting from that surgery is therefore an unintended consequence of medical treatment paid for by the Commonwealth, and under section 6A of the DRCA it is taken to have arisen out of, or in the course of, his employment.
No injury to the feet after service is recorded, and the later course reflects the outcome of the treatment he received in service.
In October 2024 his podiatrist recorded that the surgery had been unsuccessful, that he still had a degree of hammer toes and that he suffered constant ingrown toenails; a further podiatry letter records ongoing pain in both forefeet following the surgery many years earlier and asks for an orthopaedic opinion; and the X-ray of 21 March 2019 showed ankylosis of the second and fourth proximal interphalangeal joints and the third and fifth distal interphalangeal joints of the left foot.
Conclusion The small exostoses of the veteran's left third and fourth proximal phalanges arose in toes with hammer toe deformity that became symptomatic and was aggravated during his naval service, making him unfit for sea in 1991 and recurring as fixed deformities by November 1993 after further sea service.
They were first shown two years after Commonwealth-funded surgery on those same toes and are consistent with a bony reaction to that surgery, an unintended consequence of medical treatment paid for by the Commonwealth under section 6A of the DRCA, with footwear pressure on the deformed toes a plausible further contributor.
The condition is therefore related to his service.
The % contribution of the causes is 100% and significant
Sequelae
The left foot exostosis arose in toes with hammer toe deformity that was aggravated during service and is consistent with a consequence of the surgery of 25 November 1991 on the left third and fourth toes; the persisting deformity, forefoot pain and ankylosis are sequelae of the hammer toes and of the surgery performed during ADF service
Unintended Consequence
The exostoses were first shown about two years after the operation of 25 November 1991 on the same two left toes, arranged and paid for by the Navy, and are consistent with a bony reaction to that surgery; the recurrence of the deformity after that operation required further Commonwealth-funded surgery on 24 February 1994.
An injury suffered as an unintended consequence of medical treatment paid for by the Commonwealth is taken, under section 6A of the DRCA, to have arisen out of, or in the course of, the member's employment — MET
Inability to Attain Appropriate Medical Management
The hammer toes were assessed and treated promptly during service, with specialist orthopaedic referral within two weeks of diagnosis in October 1991 and further specialist review and surgery in 1993, so there is no evidence that the veteran was unable to obtain appropriate clinical management for this condition during service — NOT MET
Date of Clinical Onset
Left foot exostosis is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with symptoms in the left foot and toes: 30 October 1991 — hammer toes with dorsal calluses causing difficulty wearing shoes, referred for operative repair (a patrol boat) [CHART REVIEW document].
End of ADF service: 31 May 1996.
First imaging / formal diagnosis (confirmation, not onset): 17 March 1994 (X-ray of both feet showing a small exostosis on the left fourth proximal phalanx [CHART REVIEW document]).
The precise date of clinical onset cannot be determined from the records.
It is therefore estimated as the midpoint between the first documented presentation with symptoms in the left foot and toes (30 October 1991) and the end of the veteran's ADF service (31 May 1996).
Estimated date of clinical onset: 13 February 1994.
This date falls within the veteran's ADF service (15 August 1989 31 May 1996).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
