Diagnostic Assessment — Left Foot - First Metatarsophalangeal Joint Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran BO)
Diagnostic Assessment
Left Foot - First Metatarsophalangeal Joint Osteoarthritis
BOP Code: 62 of 2017 (Osteoarthritis)
RH Code: 61 of 2017 (Osteoarthritis)
ADF History
Veteran BO, date of birth 26 September 1979, Australian Army, Combat Engineer (Sapper, later Corporal and Search Team Commander), enlisted 13 July 1998, medically discharged 11 December 2020. Operational service: East Timor, 11 October 2000 to 25 April 2001 (warlike); Iraq, 14 January 2006 to 28 July 2006 (warlike); Afghanistan, 20 November 2009 to 15 June 2010 (warlike); Afghanistan, 02 February 2012 to 30 August 2012 (warlike).
Occupational History
As a combat engineer the veteran built and repaired field defences, roads, bridges and accommodation, handled steel, timber, concrete and stores, carried heavy packs and search equipment on foot, and conducted route and area searches for improvised explosive devices, much of it kneeling or crouching. He used compactors, jackhammers, rock drills and chainsaws, and from 2002 to 2008 worked in a construction squadron with daily scaffold and ladder access.
Engineers are exposed to crush and impact injuries of the feet, forced hyperextension of the toes when jumping from vehicles and structures, cold injury in mountainous theatres, foot infection from prolonged wet boots, blast injury, and heavy cumulative loading through the forefoot, particularly the first metatarsophalangeal joint during kneeling, squatting and push-off.
History
Veteran BO, a combat engineer in the Australian Army, developed osteoarthritis of the left first metatarsophalangeal joint (hallux rigidus) on 06 March 2015, after an intra-articular fracture of the first metatarsal head in East Timor in 2001, gout, psoriatic arthritis, frostbite and septic arthritis of the joint in Afghanistan in 2010, and a dislocation of the joint in Afghanistan in 2012. The osteoarthritis worsened in October 2021 after recommended surgery was delayed for 18 months.
Timeline
- 18 Jan 2001 — On warlike service in East Timor, two weeks after he and three other sappers had been detained by an armed militia group for four days from 02 January 2001 near the border, a 60-kilogram concrete block fell onto the veteran's left forefoot during construction of a vehicle checkpoint. Radiographs at the field hospital showed an intra-articular fracture of the left first metatarsal head. The joint was tense and 8 mL of blood was aspirated. He was immobilised in a below-knee cast for six weeks. "intra-articular fracture 1st MT head"
- 09 Mar 2006 — On warlike service in Iraq the veteran's vehicle rolled after an improvised explosive device strike. He sustained a comminuted fracture of the right calcaneus, treated by open reduction and internal fixation in Australia. He was left with a stiff right subtalar joint and an asymmetric, antalgic gait, documented by the physiotherapist and at every subsequent review, which shifted load to the left forefoot. "right calcaneal fracture, asymmetric gait"
- 14 Aug 2007 — A rheumatologist reviewed the veteran for a sausage-shaped swollen left great toe and plaque psoriasis that had flared during his 2006 deployment, and diagnosed psoriatic arthritis with dactylitis of the left hallux. He had also had recurrent acute gout of the left first metatarsophalangeal joint since November 2005, confirmed by urate crystals on aspiration and a serum urate of 0.58 mmol/L. Allopurinol and methotrexate were commenced. "psoriatic dactylitis; gout left MTPJ"
- 15 Feb 2010 — On warlike service in Afghanistan, three weeks after frostbite of the toes of the left foot, including the great toe, during 30 hours in a mountain observation post at minus 18 degrees in January 2010, the veteran developed a hot, swollen left first metatarsophalangeal joint with fever. Aspiration grew Staphylococcus aureus and he was evacuated and treated for septic arthritis with arthroscopic washout and six weeks of antibiotics. Numbness of the left great toe persisted after the frostbite. "frostbite; septic arthritis left MTPJ"
- 10 May 2012 — On warlike service in Afghanistan the veteran jumped from the rear of a vehicle with a 40-kilogram load and forcibly hyperextended the left great toe, which dislocated dorsally. It was reduced at the role 2 facility. MRI in Australia on 02 October 2012 showed a ruptured plantar plate, an acute articular cartilage tear of the first metatarsal head and early avascular necrosis of the subchondral bone. Radiographs on 05 March 2013 showed a preserved joint space with no osteophytes. "MTPJ dislocation, plantar plate rupture"
- 20 Jun 2013 — An endocrinologist confirmed acromegaly with a raised IGF-1 and a pituitary macroadenoma, removed by trans-sphenoidal surgery in August 2013. DXA showed increased bone mineral density, with a total hip T-score of +1.5. A bone scan performed for foot pain showed Paget's disease of bone of the left first metatarsal, confirmed with a raised alkaline phosphatase. His BMI was 30 and waist 106 cm. "acromegaly; Paget's left first metatarsal"
- 13 Mar 2015 — The veteran presented to the garrison health centre with a stiff, painful left great toe since 06 March 2015, worse on push-off, kneeling and running, with a tender dorsal bump. Radiographs showed joint space narrowing, a large dorsal osteophyte and subchondral sclerosis of the left first metatarsophalangeal joint. Dorsiflexion was limited to 25 degrees. A podiatrist and sports physician diagnosed hallux rigidus. "hallux rigidus, dorsal osteophyte"
- 18 Oct 2021 — An orthopaedic surgeon reviewed the veteran after an 18-month delay to the cheilectomy recommended in March 2020, which had been cancelled when elective surgery was suspended and was not rescheduled during his transition from the ADF. Dorsiflexion had reduced to 5 degrees, radiographs showed bone-on-bone narrowing with subchondral cysts, and DXA in 2020 had shown osteoporosis (femoral neck T-score -2.7) from hypopituitarism after his pituitary surgery. First metatarsophalangeal joint fusion was performed in February 2022. "end-stage MTPJ OA, fusion planned"
Symptoms
At onset the veteran had pain and stiffness of the left great toe, worse on push-off when walking and running, on kneeling during search drills and on climbing ladders, with a tender dorsal swelling and pain in tight boots.
Since the worsening he has had constant pain at the base of the left great toe, a markedly stiff toe, a lateral roll-off gait, painful callosities, difficulty walking more than 1 kilometre and inability to run, kneel or squat. After the fusion in 2022 the pain has reduced but walking on uneven ground and slopes remains limited.
Imaging
- 18 Jan 2001 — Left foot radiographs (field hospital): "Intra-articular fracture of the head of the first metatarsal with a minimally displaced dorsal fragment."
- 02 Oct 2012 — MRI left forefoot: "Rupture of the first metatarsophalangeal plantar plate. Acute articular cartilage tear of the first metatarsal head. Subchondral avascular necrosis of the first metatarsal head. Malunited old fracture with dorsal angulation of the articular surface."
- 05 Mar 2013 — Left foot radiographs: "First metatarsophalangeal joint space preserved. No osteophytes. Old healed fracture of the first metatarsal head with 12 degrees of dorsal angulation."
- 13 Mar 2015 — Left foot radiographs: "Narrowing of the first metatarsophalangeal joint space with a large dorsal osteophyte and subchondral sclerosis, consistent with osteoarthritis (hallux rigidus)."
- 18 Oct 2021 — Left foot radiographs: "Severe osteoarthritis of the first metatarsophalangeal joint with bone-on-bone narrowing, subchondral cysts and circumferential osteophytes."
Onset Date
The most likely date of onset of this condition is 06 Mar 2015.
At that date the veteran was a serving combat engineer corporal in a field engineer regiment in Australia, instructing search techniques that involved prolonged kneeling. From that date he had persistent mechanical pain and stiffness of the left great toe, distinct from his earlier episodes of gout and dactylitis.
This date is appropriate because radiographs on 05 March 2013 showed a preserved joint space with no osteophytes, and he first presented with the new symptoms on 13 March 2015, when radiographs showed a dorsal osteophyte and joint space narrowing. The onset falls within continuous full-time service.
The fracture, haemarthrosis and trauma of 18 Jan 2001, the gout from Nov 2005, the psoriatic arthritis from 2007, the frostbite of Jan 2010, the septic arthritis of 15 Feb 2010, the left knee meniscal tear of Sep 2009 and the dislocation and cartilage tear of 10 May 2012 all preceded onset, the dislocation by almost three years. The 25 years before onset run from 06 Mar 1990 to 06 Mar 2015 and cover his entire service. For the asymmetric gait and disordered mechanics factors, the 5 years before onset run from 06 Mar 2010 to 06 Mar 2015; the asymmetric gait was present from 09 Mar 2006 and the malunion of the first metatarsal head from 2001. For the overweight and waist factors, the 10 years before onset run from 06 Mar 2005 to 06 Mar 2015, and his BMI was above 25 and waist above 102 cm from his periodic health examination of 2004. Lifting of about 310,000 kilograms occurred from 1998 to 2008 and carrying of about 4,200 hours from 1999 to 2009, and the onset falls within 25 years of each period. Stair and ladder climbing of more than 150 a day occurred continuously from Feb 2002 to Feb 2008. Kneeling and squatting for more than an hour a day occurred continuously from 2009 to 2015.
For the worsening factors, the period after onset runs from 06 Mar 2015 to the documented worsening on 18 Oct 2021. The 25 years before the worsening run from 18 Oct 1996 to 18 Oct 2021. Osteoporosis was confirmed in 2020, and the recommended cheilectomy could not be obtained from Mar 2020 to Oct 2021.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Foot - First Metatarsophalangeal Joint Osteoarthritis (ICD-10-AM M19.17), post-traumatic osteoarthritis of the left first metatarsophalangeal joint (hallux rigidus), under the Statements of Principles concerning osteoarthritis, Balance of Probabilities No. 62 of 2017 and Reasonable Hypothesis No. 61 of 2017.
Osteoarthritis is a degenerative joint disorder with pain, stiffness and impaired function, and imaging evidence of loss of articular cartilage or osteophytes. At the first metatarsophalangeal joint it is known as hallux rigidus: a dorsal osteophyte blocks dorsiflexion, so that push-off in walking, running, kneeling and climbing becomes painful. It is accelerated by intra-articular fracture, dislocation, infection, gout, inflammatory arthritis, cold injury, abnormal joint mechanics and heavy loading of the forefoot.
The osteoarthritis began on 06 March 2015, was confirmed on radiographs on 13 March 2015 and worsened in October 2021, leading to fusion of the joint in February 2022.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
06 March 2015.
When did the veteran first present to a health / medical provider for this condition?
13 March 2015.
When was the condition confirmed / formally diagnosed?
13 March 2015.
When did the veteran first present to you (or your practice) for this condition?
22 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on weight-bearing radiographs of the left foot on 13 March 2015, which showed narrowing of the first metatarsophalangeal joint space, a large dorsal osteophyte and subchondral sclerosis, in a veteran with pain, stiffness and impaired function of the joint and dorsiflexion limited to 25 degrees. This meets the Statement of Principles definition of osteoarthritis. It is not an acute articular cartilage tear or osteochondritis dissecans.
A sports physician confirmed the diagnosis on 13 March 2015 and an orthopaedic surgeon on 03 March 2020. The worsening was confirmed on radiographs of 18 October 2021 showing bone-on-bone narrowing, subchondral cysts and circumferential osteophytes.
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.
Legislation: the clinical onset of this condition was on 06 March 2015, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, during which much of the cumulative lifting, carrying, ladder climbing and kneeling occurred. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 2000 and 2001, Iraq in 2006 and Afghanistan in 2009 and 2010 and in 2012, during which the detention, the fracture, the calcaneal injury, the frostbite and septic arthritis and the dislocation occurred.
Each factor must be related to the person's relevant 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.
Balance of Probabilities — Statement of Principles concerning Osteoarthritis, No. 62 of 2017
Causative factors
Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Psoriatic arthropathy with dactylitis of the left hallux, involving the first metatarsophalangeal joint, was diagnosed by a rheumatologist on 14 August 2007 and treated with methotrexate, more than seven years before the onset on 06 March 2015. Psoriatic arthropathy is on the specified list.
Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- Septic arthritis of the left first metatarsophalangeal joint due to Staphylococcus aureus was confirmed on aspiration on 15 February 2010 and treated with arthroscopic washout and antibiotics, five years before the onset on 06 March 2015. It followed infected frostbite blisters sustained during service.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Radiographs on 18 January 2001 showed an intra-articular fracture of the left first metatarsal head after a concrete block fell on the foot during construction work in his service, 14 years before the onset on 06 March 2015.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- On 18 January 2001, 8 mL of blood was aspirated from the tense left first metatarsophalangeal joint after the service-related fracture, establishing haemarthrosis 14 years before the onset on 06 March 2015.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Gout of the left first metatarsophalangeal joint, with recurrent acute attacks from November 2005, was confirmed by urate crystals on aspiration and a serum urate of 0.58 mmol/L, almost ten years before the onset on 06 March 2015. Attacks were precipitated by dehydration in hot field conditions.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- The crush injury of 18 January 2001 and the forced hyperextension and dislocation of 10 May 2012 each applied significant force through the left first metatarsophalangeal joint, causing fracture or dislocation, pain, loss of movement and immobilisation or reduction. Both occurred within the 25 years before the onset on 06 March 2015.
Factor 9(7): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- MRI on 02 October 2012 showed an acute articular cartilage tear of the left first metatarsal head caused by the hyperextension injury of 10 May 2012, less than three years before the onset on 06 March 2015.
Factor 9(8): having an acute meniscal tear of the affected knee within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- In September 2009, during a mission rehearsal exercise, the veteran sustained an acute tear of the medial meniscus of the left knee when he twisted under load, confirmed on MRI and repaired arthroscopically, within the 25 years before the onset on 06 March 2015.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- In January 2010 the veteran sustained frostbite of the toes of the left foot, including the great toe and the skin over the first metatarsophalangeal joint, during 30 hours in a mountain observation post at minus 18 degrees, recorded with blistering by the medical officer, five years before the onset on 06 March 2015.
Factor 9(10): having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- The 2001 fracture healed with 12 degrees of dorsal angulation of the first metatarsal articular surface (radiographs of 05 March 2013 and MRI of 02 October 2012), an angulation deformity that maldistributes load across the joint. It was present from 2001, 14 years before the onset on 06 March 2015, exceeding five years.
Factor 9(11): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- MRI on 02 October 2012 showed avascular necrosis of the subchondral bone of the left first metatarsal head following the fracture and dislocation, more than two years before the onset on 06 March 2015.
Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- From 1999 to 2012 the veteran's engineer duties involved sustained power grip, operating jackhammers, compactors, chainsaws and hand tools and handling steel and timber, for an average of more than 30 hours a week, for more than ten years within that 15-year period before the onset on 06 March 2015.
Factor 9(13): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran used hand-held vibrating percussive tools, including jackhammers, rock drills and compactor plates, on more days than not from 1999 to 2011, a cumulative period of about 11 years within the 25 years before the onset on 06 March 2015.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- Since the right calcaneal fracture of 09 March 2006 the veteran has walked with an asymmetric, antalgic gait from a stiff right subtalar joint, documented by the physiotherapist and orthopaedic surgeon, for nine years before the onset on 06 March 2015, exceeding five years.
Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From July 1998 to July 2008 the veteran lifted steel, timber, concrete blocks, sandbags and stores of 20 to 50 kilograms while standing, about 310,000 kilograms in total, as calculated from his trade duties, and the onset occurred within 25 years of that period.
Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1999 to 2009 the veteran carried packs, search equipment and stores of 20 to 45 kilograms for about 4,200 hours, and the onset occurred within 25 years of that period.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- From February 2002 to February 2008 the veteran served in a construction squadron with daily scaffold and ladder access to structures, climbing more than 150 rungs and stairs a day on most days, for a continuous period of six years within the 25 years before the onset on 06 March 2015.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- DXA on 20 June 2013 showed increased bone mineral density, with a total hip T-score of +1.5, associated with acromegaly, almost two years before the onset on 06 March 2015.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's BMI was 27 at his periodic health examination in February 2004 and remained between 27 and 31 to onset, more than ten years before the onset on 06 March 2015.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist circumference was 103 cm in February 2004 and 103 to 108 cm thereafter, exceeding 102 cm for more than ten years before the onset on 06 March 2015.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist circumference exceeded 88 centimetres at every recorded measurement from February 2004 to onset, more than ten years before the onset on 06 March 2015.
Factor 9(16): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; and (b) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 2009 to 2015 the veteran knelt or squatted for more than an hour a day on most days during search training and operations, a continuous period of six years, and the onset occurred within 25 years of that period.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The twisting injury of September 2009 also ruptured the left anterior cruciate ligament, an internal derangement of the left knee confirmed on MRI, more than five years before the onset on 06 March 2015.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was diagnosed at the School of Military Engineering in October 1999 and recorded at later examinations, many years before the onset on 06 March 2015.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The frostbite of January 2010 left a cold-induced neuropathy with loss of pain and position sense in the left great toe and over the first metatarsophalangeal joint, recorded on monofilament and proprioception testing by the podiatrist, five years before the onset on 06 March 2015.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of bone of the left first metatarsal, adjacent to the affected joint, was shown on bone scan with a raised alkaline phosphatase on 20 June 2013, almost two years before the onset on 06 March 2015.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 20 June 2013 with a raised IGF-1 and a pituitary macroadenoma, almost two years before the onset on 06 March 2015.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The left first metatarsophalangeal joint dislocated dorsally on 10 May 2012 and was reduced, almost three years before the onset on 06 March 2015, and the plantar plate rupture left it unstable.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- MRI of the left hip in September 2014 for groin pain showed cam-type femoroacetabular impingement with a labral tear, and impingement syndrome was diagnosed by the sports physician, before onset.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Psoriatic arthropathy of the left hallux, diagnosed in 2007, was present before the worsening on 18 October 2021.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis of the left first metatarsophalangeal joint of February 2010 preceded the worsening.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The intra-articular fracture of the left first metatarsal head of January 2001 preceded the worsening.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The haemarthrosis of the left first metatarsophalangeal joint of January 2001 preceded the worsening.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Gout of the left first metatarsophalangeal joint, present since 2005, continued with attacks in 2019 and 2020, before the worsening on 18 October 2021.
Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The crush injury of 2001 and the dislocation of 2012 both occurred within the 25 years before the worsening on 18 October 2021.
Factor 9(30): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The acute articular cartilage tear of May 2012 occurred within the 25 years before the worsening on 18 October 2021.
Factor 9(31): having an acute meniscal tear of the affected knee within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The acute medial meniscal tear of the left knee of September 2009 occurred within the 25 years before the worsening on 18 October 2021.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite involving the left great toe of January 2010 preceded the worsening.
Factor 9(33): having disordered joint mechanics of the affected joint for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The dorsal angulation deformity of the first metatarsal head had been present for 20 years before the worsening on 18 October 2021.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- The avascular necrosis of the first metatarsal head shown in 2012 was present before the worsening on 18 October 2021.
Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The sustained power grip of his duties from 1999 to 2012 preceded the worsening.
Factor 9(36): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The use of vibrating percussive tools on most days from 1999 to 2011 occurred within the 25 years before the worsening on 18 October 2021.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The asymmetric gait from the right calcaneal fracture had been present for more than 15 years before the worsening on 18 October 2021.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The lifting of about 310,000 kilograms from 1998 to 2008 preceded the worsening, which occurred within 25 years of that period.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The carrying of about 4,200 hours from 1999 to 2009 preceded the worsening, which occurred within 25 years of that period.
Factor 9(37)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The ladder and stair climbing from 2002 to 2008, six continuous years, occurred within the 25 years before the worsening on 18 October 2021.
Factor 9(38)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran was overweight from 2004 to 2021, seventeen years before the worsening on 18 October 2021.
Factor 9(38)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2004 to 2021, more than ten years before the worsening on 18 October 2021.
Factor 9(38)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres at every measurement from 2004 to 2021, more than ten years before the worsening on 18 October 2021.
Factor 9(39): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at two years before the clinical worsening of osteoarthritis in that joint; and (b) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The kneeling and squatting from 2009 to 2015 preceded the worsening, which occurred within 25 years of that period.
Factor 9(40): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The internal derangement of the left knee from 2009 was present before the worsening on 18 October 2021.
Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was present before the worsening on 18 October 2021.
Factor 9(42): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The loss of pain and position sense in the left great toe from the frostbite persisted before the worsening on 18 October 2021.
Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease of the left first metatarsal was present before the worsening on 18 October 2021.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, confirmed in 2013, preceded the worsening.
Factor 9(45): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The dislocation of the left first metatarsophalangeal joint of May 2012 was more than nine years before the worsening on 18 October 2021.
Factor 9(46): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- The femoroacetabular impingement syndrome diagnosed in 2014 was present before the worsening on 18 October 2021.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis. — MET
- The cheilectomy recommended on 03 March 2020 was cancelled when elective surgery was suspended and was not rescheduled during the veteran's transition, so it could not be obtained for 18 months. The joint progressed to end-stage disease by 18 October 2021. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Osteoarthritis, No. 61 of 2017
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis; — MET
- On warlike service in East Timor, from 02 to 05 January 2001, the veteran and three other sappers were detained as prisoners by an armed militia group near the border before being released through negotiation, recorded in his deployed health record and post-incident debrief, 14 years before onset.
Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The psoriasis flared during warlike service in Iraq in 2006, and psoriatic arthropathy with dactylitis of the left hallux followed, diagnosed on 14 August 2007, before onset.
Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- Septic arthritis of the left first metatarsophalangeal joint followed infected frostbite blisters on warlike service in Afghanistan and was confirmed on aspiration on 15 February 2010, five years before onset.
Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The intra-articular fracture of the left first metatarsal head was sustained on warlike service in East Timor on 18 January 2001 when a concrete block fell on the foot during construction of a vehicle checkpoint.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Haemarthrosis of the left first metatarsophalangeal joint was confirmed by aspiration of blood at the field hospital on warlike service in East Timor on 18 January 2001.
Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Gout of the left first metatarsophalangeal joint, with attacks from November 2005, recurred on warlike service in Iraq in 2006 and Afghanistan in 2010 with dehydration in extreme heat and cold, and was present before onset.
Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The crush fracture on warlike service in East Timor on 18 January 2001 and the forced dislocation on warlike service in Afghanistan on 10 May 2012 each applied significant force through the left first metatarsophalangeal joint, causing pain, loss of movement and immobilisation or reduction.
Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The acute articular cartilage tear of the left first metatarsal head was caused by the hyperextension injury on warlike service in Afghanistan on 10 May 2012, shown on MRI on 02 October 2012.
Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint; — MET
- An acute tear of the medial meniscus of the left knee was sustained in September 2009 during the mission rehearsal exercise for his warlike deployment to Afghanistan, confirmed on MRI and repaired before he deployed in November 2009, and it was symptomatic during that warlike service, before onset.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The frostbite involving the left great toe and first metatarsophalangeal joint occurred on warlike service in Afghanistan in January 2010, during 30 hours in a mountain observation post at minus 18 degrees.
Factor 9(11): having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- The dorsal angulation deformity of the first metatarsal head resulted from the fracture on warlike service in East Timor in 2001 and was present for 14 years before onset, exceeding three years.
Factor 9(12): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- Avascular necrosis of the subchondral bone of the left first metatarsal head followed the fracture and dislocation sustained on warlike service, shown on MRI on 02 October 2012.
Factor 9(13)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's engineer duties from 1999 to 2012, including construction work on warlike service in East Timor, Iraq and Afghanistan, involved sustained power grip for more than 30 hours a week for more than ten years within 15 years before onset.
Factor 9(13)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical onset of osteoarthritis in that joint; — MET
- The veteran used jackhammers, rock drills and compactors on more days than not from 1999 to 2011, about 11 years, including construction tasks on warlike service in East Timor and Iraq.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- The asymmetric gait from the right calcaneal fracture sustained on warlike service in Iraq on 09 March 2006 was present for nine years before onset, exceeding three years.
Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; — MET
- The veteran lifted loads of 20 to 50 kilograms to a total of about 310,000 kilograms between 1998 and 2008, including construction on warlike service in East Timor and Iraq.
Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; — MET
- The veteran carried loads of 20 to 45 kilograms for about 4,200 hours between 1999 and 2009, including foot patrols and searches on warlike service in East Timor and Iraq.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; — MET
- From February 2002 to February 2008 the veteran climbed more than 150 rungs and stairs a day on most days, continuing on warlike service in Iraq in 2006 where he built and maintained elevated guard towers, a continuous period of six years.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- Increased bone mineral density, a total hip T-score of +1.5, was shown on DXA on 20 June 2013, before onset.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran was overweight from 2004 to onset, more than ten years, his weight increasing during and after his warlike service.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2004 to onset, more than ten years.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres at every measurement from 2004 to onset, more than ten years.
Factor 9(16): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The veteran knelt or squatted for more than an hour a day on most days from 2009 to 2015, including route and area searches on warlike service in Afghanistan in 2009 and 2010 and in 2012, much longer than one year before onset.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The left anterior cruciate ligament rupture sustained in September 2009 on the mission rehearsal exercise for warlike service in Afghanistan was an internal derangement of the left knee, present during that warlike service and before onset.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was diagnosed in 1999 and was symptomatic on warlike service in East Timor, before onset.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The cold-induced neuropathy from frostbite on warlike service in Afghanistan caused loss of pain and position sense in the left great toe and first metatarsophalangeal joint, before onset.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of the left first metatarsal was confirmed on 20 June 2013, before onset.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was confirmed on 20 June 2013, before onset.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The left first metatarsophalangeal joint dislocated on warlike service in Afghanistan on 10 May 2012, almost three years before onset.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- Cam-type femoroacetabular impingement syndrome of the left hip was diagnosed in September 2014, before onset.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Psoriatic arthropathy of the left hallux, which followed the psoriasis flare on warlike service in Iraq, was present before the worsening.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis from warlike service in Afghanistan in 2010 preceded the worsening.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The intra-articular fracture from warlike service in East Timor in 2001 preceded the worsening.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The haemarthrosis from warlike service in East Timor in 2001 preceded the worsening.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Gout of the left first metatarsophalangeal joint, aggravated on warlike service, was present before the worsening.
Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The crush and dislocation injuries from warlike service in 2001 and 2012 preceded the worsening.
Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The acute cartilage tear from warlike service in Afghanistan in 2012 preceded the worsening.
Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint; — MET
- The acute meniscal tear of the left knee of 2009 preceded the worsening.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite from warlike service in Afghanistan in 2010 preceded the worsening.
Factor 9(33): having disordered joint mechanics of the affected joint for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The angulation deformity from the warlike service fracture had been present for 20 years before the worsening.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- The avascular necrosis of the first metatarsal head from the warlike service injuries was present before the worsening.
Factor 9(35)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The sustained power grip of his duties, including on warlike service, preceded the worsening.
Factor 9(35)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical worsening of osteoarthritis in that joint; — MET
- The use of vibrating percussive tools for about 11 years, including on warlike service, preceded the worsening.
Factor 9(36)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The asymmetric gait from the warlike service calcaneal fracture had been present for more than 15 years before the worsening.
Factor 9(36)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET
- The lifting of about 310,000 kilograms, including on warlike service, preceded the worsening.
Factor 9(36)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET
- The carrying of about 4,200 hours, including on warlike service, preceded the worsening.
Factor 9(36)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years, before the clinical worsening of osteoarthritis in that joint; — MET
- The stair and ladder climbing from 2002 to 2008, including on warlike service in Iraq, preceded the worsening.
Factor 9(36)(e): for osteoarthritis of a joint of the lower limb only: having osteoporosis before the clinical worsening of osteoarthritis in that joint; — MET
- DXA in 2020 showed osteoporosis, with a femoral neck T-score of -2.7, caused by hypopituitarism after pituitary surgery, before the worsening on 18 October 2021.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran was overweight from 2004 to 2021, seventeen years before the worsening.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 102 cm from 2004 to 2021, more than ten years before the worsening.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's waist exceeded 88 centimetres from 2004 to 2021, more than ten years before the worsening.
Factor 9(38): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The kneeling and squatting from 2009 to 2015, including on warlike service, preceded the worsening.
Factor 9(39): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The internal derangement of the left knee was present before the worsening.
Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of the left knee was present before the worsening.
Factor 9(41): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The loss of pain and position sense from the warlike service frostbite persisted before the worsening.
Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease of the left first metatarsal was present before the worsening.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly, confirmed in 2013, preceded the worsening.
Factor 9(44): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The dislocation of the joint on warlike service in 2012 was more than nine years before the worsening.
Factor 9(45): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- Femoroacetabular impingement syndrome of the left hip was present before the worsening.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis. — MET
- From March 2020 to October 2021 the veteran could not obtain the recommended cheilectomy for the osteoarthritis that arose from his warlike service injuries, and the joint progressed to end-stage disease, documented on 18 October 2021.
The % contribution of the causes is 100% and significant.
Sequelae
The left first metatarsophalangeal osteoarthritis is a sequela of the veteran's accepted conditions: the intra-articular fracture and dislocation of the joint, the frostbite and septic arthritis sustained on warlike service, gout and psoriatic arthritis, and the asymmetric gait from the right calcaneal fracture. The fusion of the joint, the altered gait and the painful callosities are sequelae of the osteoarthritis.
Unintended Consequence
Met. The osteoporosis present before the worsening resulted from hypopituitarism after the trans-sphenoidal surgery for acromegaly, and the methotrexate prescribed for psoriatic arthritis delayed healing after the 2012 injury; both treatments were provided and paid for by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. An orthopaedic surgeon recommended cheilectomy of the left first metatarsophalangeal joint on 03 March 2020. The operation was cancelled when elective surgery was suspended, and it was not rescheduled during the veteran's discharge and transition, so it could not be obtained for 18 months. During that time dorsiflexion fell from 25 to 5 degrees and the joint progressed to end-stage disease, so that fusion became necessary. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this delay amounts to an inability to obtain appropriate clinical management, and it materially contributed to the worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- Oct 1999, Outpatient health record, Medical Officer, School of Military Engineering
- 18 Jan 2001, Deployed health record, radiographs and joint aspiration, Field hospital, East Timor
- Feb 2004, Periodic health examination, Medical Officer, Garrison health centre
- 09 Mar 2006, Trauma admission and operation report, Orthopaedic surgeon
- 14 Aug 2007, Specialist consultation, Rheumatologist
- Sep 2009, MRI left knee and orthopaedic consultation, Orthopaedic surgeon
- 15 Feb 2010, Deployed health record, aspiration and operation report, Afghanistan
- 10 May 2012, Deployed health record, Role 2 facility, Afghanistan
- 02 Oct 2012, MRI left forefoot, Radiologist
- 20 Jun 2013, Endocrinology consultation, DXA and bone scan, Endocrinologist
- 13 Mar 2015, Outpatient health record and radiographs, Medical Officer and Sports physician
- 03 Mar 2020, Orthopaedic consultation, Orthopaedic surgeon
- 2020, DXA report, Radiologist
- 18 Oct 2021, Orthopaedic consultation and radiographs, Orthopaedic surgeon
- Statement of Principles concerning Osteoarthritis (Balance of Probabilities) No. 62 of 2017, Repatriation Medical Authority
- Statement of Principles concerning Osteoarthritis (Reasonable Hypothesis) No. 61 of 2017, Repatriation Medical Authority
