Diagnostic Assessment — Left Foot - Intermetatarsal Bursitis
Example 1 of 1 · fictitious patient (Veteran BP)
Diagnostic Assessment
Left Foot - Intermetatarsal Bursitis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran BP, date of birth 17 May 1984, Australian Army, Military Police, enlisted 06 February 2003, medically discharged 28 April 2020. Operational service: Solomon Islands, 10 July 2006 to 15 November 2006 (non-warlike); Afghanistan, 15 January 2011 to 30 August 2011 (warlike); Middle East Area of Operations (Iraq), 01 June 2015 to 10 December 2015 (warlike).
Occupational History
Military police conduct foot and vehicle patrols, man gates, entry control points and detention facilities, and stand for long periods on concrete, gravel and bitumen. The role involves daily running for fitness and response, loaded patrolling in body armour and combat boots, and ceremonial and garrison duties in narrow service dress shoes.
Deployed military police work long shifts in heat and dust, often standing at checkpoints for most of a shift, with vehicle and crush injuries to the feet a recognised hazard around vehicle checkpoints and loading ramps. Forefoot overload, blisters and stress injuries of the feet are common.
History
Veteran BP, a military police soldier in the Australian Army, developed left intermetatarsal bursitis between the third and fourth metatarsal heads on 12 May 2011 during warlike service in Afghanistan, after a crush fracture of the left forefoot, months of standing and running in narrow-fitting boots, and the early onset of rheumatoid arthritis. The bursitis was confirmed on ultrasound and worsened during her 2015 deployment to Iraq, when treatment was again unavailable.
Timeline
- 22 Sep 2010 — Pre-deployment medical examination. Feet examined and recorded as normal, with no forefoot tenderness, swelling or deformity. Weight 82 kg, height 1.64 m, BMI 30.5. She was issued women's combat boots in a size and width that the podiatry note later recorded as too narrow across the forefoot, as wide fittings were out of stock. "feet NAD, BMI 30.5"
- 18 Nov 2010 — During pre-deployment training a vehicle ramp was lowered onto her left forefoot. X-ray showed undisplaced fractures of the necks of the left third and fourth metatarsals. She was immobilised in a walking boot for six weeks and returned to full duties in January 2011 before deploying. "L 3rd, 4th MT fractures"
- 14 Mar 2011 — During warlike service in Afghanistan she reported morning stiffness of both hands lasting over an hour and swelling of the knuckles. The medical officer recorded synovitis of the second and third metacarpophalangeal joints of both hands and took blood, which showed a raised CRP, positive rheumatoid factor and strongly positive anti-CCP antibodies. Rheumatology referral was deferred until return to Australia. "MCP synovitis, anti-CCP positive"
- 16 May 2011 — Presented with four days of burning pain and swelling between the third and fourth toes of the left foot, worse when standing at the entry control point and when running. She was standing 10 to 12 hours a shift and running 30 to 35 kilometres a week. Examination showed fullness and tenderness of the third web space with splaying of the third and fourth toes and a positive lateral squeeze test. The forefoot was compressed in her narrow boots. Weight 86 kg, BMI 32.0. "L 3rd web space swelling"
- 20 May 2011 — Ultrasound at the role 2 facility showed a 9 mm by 6 mm compressible fluid-filled intermetatarsal bursa between the left third and fourth metatarsal heads, extending dorsal to the deep transverse metatarsal ligament, with Doppler hyperaemia. There was no neuroma. Intermetatarsal bursitis was diagnosed. Podiatry and orthoses were not available in theatre. "intermetatarsal bursa 9 x 6 mm"
- 27 Oct 2011 — A rheumatologist in Australia confirmed seropositive rheumatoid arthritis meeting the 2010 ACR/EULAR classification criteria, with involvement of the hands and left forefoot, and commenced methotrexate. Gout was excluded on aspiration. Custom orthoses with a metatarsal dome and wide-fitting boots were prescribed. "seropositive RA, methotrexate commenced"
- 19 Oct 2015 — During warlike service in Iraq she presented with severe left forefoot pain and swelling after six weeks of 12-hour checkpoint shifts and running 30 kilometres a week. Her orthoses had been lost in transit and wide-fitting boots were not available in theatre. Methotrexate had been interrupted for five weeks because pathology monitoring was not available. Ultrasound showed the bursa had enlarged to 16 mm by 10 mm, with adjacent synovitis of the fourth metatarsophalangeal joint. Weight 90 kg, BMI 33.5. "bursa 16 x 10 mm, RA flare"
- 08 Mar 2016 — Orthopaedic foot and ankle review in Australia. MRI confirmed chronic intermetatarsal bursitis of the left third web space with early erosions of the fourth metatarsal head. Ultrasound-guided corticosteroid injection was performed and biologic therapy added. She was medically downgraded from patrol and checkpoint duties. "chronic bursitis, early erosions"
Symptoms
At onset the veteran had burning pain and a sense of fullness between the left third and fourth toes, worse with standing, running and tight boots, with the toes spreading apart and occasional tingling into the toes. After onset the pain became daily and limited her ability to stand at checkpoints and run.
Since the 2015 worsening she has constant forefoot pain after standing for more than 30 minutes, cannot run, and needs wide, cushioned footwear with custom orthoses. She has intermittent swelling of the forefoot during flares of rheumatoid arthritis.
Imaging
- 18 Nov 2010 — X-ray left foot: "Undisplaced fractures of the necks of the third and fourth metatarsals."
- 20 May 2011 — Ultrasound left forefoot (role 2 facility): "9 mm by 6 mm compressible fluid-filled bursa in the third intermetatarsal space, dorsal to the deep transverse metatarsal ligament, with Doppler hyperaemia. Healing fractures of the third and fourth metatarsal necks with mild plantar angulation. No Morton's neuroma."
- 19 Oct 2015 — Ultrasound left forefoot (role 2 facility): "Enlarged third intermetatarsal bursa measuring 16 mm by 10 mm with synovitis of the fourth metatarsophalangeal joint."
- 08 Mar 2016 — MRI left forefoot: "Chronic intermetatarsal bursitis of the third web space with synovial thickening, and early marginal erosions of the fourth metatarsal head. Malunited fourth metatarsal neck with 10 degrees of plantar angulation."
Onset Date
The most likely date of onset of this condition is 12 May 2011.
At that date the veteran was on warlike service in Afghanistan as a military police soldier, standing 10 to 12 hours a shift at an entry control point and running 30 to 35 kilometres a week, in boots too narrow across the forefoot. She had healed but malunited fractures of the left third and fourth metatarsal necks from November 2010, and rheumatoid arthritis with positive anti-CCP antibodies documented in March 2011.
This date is appropriate because her pre-deployment examination of 22 September 2010 recorded normal feet, and she first presented with left third web space pain and swelling on 16 May 2011, reporting four days of symptoms. It falls within continuous full-time warlike service.
For the running and standing causes, the 4 weeks before onset run from 14 Apr 2011 to 12 May 2011 and the 3 months before onset run from 12 Feb 2011 to 12 May 2011, all within her deployment, during which she ran 30 to 35 kilometres a week and stood 10 to 12 hours a shift. For the forefoot trauma cause, the 12 months before onset run from 12 May 2010 to 12 May 2011 and contain the crush fracture of 18 Nov 2010. Rheumatoid arthritis, the forefoot malalignment, obesity and the narrow boots were each present at onset.
For the worsening causes, the period after onset runs from 12 May 2011 to the documented worsening on 19 Oct 2015, when ultrasound showed the bursa had enlarged from 9 mm by 6 mm to 16 mm by 10 mm. The 4 weeks before the worsening run from 21 Sep 2015 to 19 Oct 2015, during which she was on warlike service in Iraq standing 12 hours a shift and running about 30 kilometres a week in narrow boots without orthoses, with a flare of rheumatoid arthritis and a BMI of 33.5.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Foot - Intermetatarsal Bursitis (ICD-10 M71.87), of the third intermetatarsal space. No Statement of Principles has been determined for this condition, so it is assessed against the recognised causes on the sound medical-scientific evidence.
Intermetatarsal bursitis is inflammation and distension of the bursa that lies between adjacent metatarsal heads, dorsal to the deep transverse metatarsal ligament, most often in the second and third web spaces. It causes forefoot pain, swelling and splaying of the adjacent toes, and the enlarged bursa can compress the interdigital nerve and mimic a Morton's neuroma. It is caused by repetitive forefoot loading, compression from narrow footwear, forefoot trauma and malalignment, obesity, and inflammatory arthritis, particularly rheumatoid arthritis, of which it is a common early feature.
The diagnosis followed a crush fracture of the left forefoot, months of prolonged standing and running in narrow boots, and the onset of rheumatoid arthritis during warlike service in Afghanistan. It began on 12 May 2011, was confirmed on ultrasound on 20 May 2011, and worsened in Iraq in 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 May 2011.
When did the veteran first present to a health / medical provider for this condition?
16 May 2011.
When was the condition confirmed / formally diagnosed?
20 May 2011.
When did the veteran first present to you (or your practice) for this condition?
29 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 by ultrasound on 20 May 2011, which showed a 9 mm by 6 mm compressible fluid-filled bursa in the third intermetatarsal space, dorsal to the deep transverse metatarsal ligament, with Doppler hyperaemia and no neuroma. The clinical findings were consistent: fullness and tenderness of the third web space, splaying of the third and fourth toes and a positive lateral squeeze test. A bursa larger than about 3 mm in transverse diameter, symptomatic and hyperaemic, is diagnostic of intermetatarsal bursitis.
The worsening was documented on ultrasound on 19 October 2015, with enlargement of the bursa to 16 mm by 10 mm, and confirmed by MRI on 08 March 2016 showing chronic synovial thickening of the bursa with early erosions of the adjacent fourth metatarsal head.
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 by the Repatriation Medical Authority for intermetatarsal bursitis. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the musculoskeletal, podiatric and rheumatological literature and are each applied to the veteran's service.
Legislation: the clinical onset of this condition was on 12 May 2011, after 1 July 2004, during continuous full-time warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The more generous reasonable hypothesis standard applies to the veteran's warlike service in Afghanistan in 2011 and Iraq in 2015, and the balance of probabilities standard to her peacetime service, including the crush injury in pre-deployment training. Each cause must be related to the person's 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 rheumatoid arthritis or another inflammatory arthritis affecting the forefoot at the time of the clinical onset of intermetatarsal bursitis; — MET
- On 14 March 2011, two months before onset, the veteran had synovitis of the metacarpophalangeal joints with positive rheumatoid factor and strongly positive anti-CCP antibodies. A rheumatologist confirmed seropositive rheumatoid arthritis involving the hands and left forefoot on 27 October 2011, dating its onset to early 2011. It was present at onset on 12 May 2011. Intermetatarsal bursitis is a frequent, often presenting, feature of rheumatoid arthritis, because the bursa communicates with the inflamed metatarsophalangeal joint synovium.
Cause 2: running or marching an average of at least 25 kilometres per week for at least the 4 weeks before the clinical onset of intermetatarsal bursitis; — MET
- During warlike service in Afghanistan the veteran ran 30 to 35 kilometres a week for fitness and response training, as recorded in her fitness log and the presentation note of 16 May 2011. This continued throughout the 4 weeks before onset, from 14 April 2011 to 12 May 2011. Running repeatedly loads and compresses the forefoot between the metatarsal heads.
Cause 3: standing or walking on hard surfaces for an average of at least 6 hours per day, on more days than not, for at least the 3 months before the clinical onset of intermetatarsal bursitis; — MET
- From her arrival in Afghanistan on 15 January 2011 the veteran stood 10 to 12 hours a shift on concrete and gravel at an entry control point, on six or seven days a week. This covered the whole of the 3 months before onset, from 12 February 2011 to 12 May 2011. Prolonged static standing overloads the forefoot.
Cause 4: wearing footwear that compresses the forefoot, including footwear with a narrow toe box, for an average of at least 6 hours per day at the time of the clinical onset of intermetatarsal bursitis; — MET
- The veteran was issued women's combat boots in a width the podiatry note recorded as too narrow across the forefoot, because wide fittings were out of stock, and wore them 10 to 12 hours a day throughout her deployment. The examining medical officer recorded on 16 May 2011 that the forefoot was compressed in her boots. Lateral compression of the metatarsal heads squeezes and irritates the intermetatarsal bursa.
Cause 5: having a fracture, crush injury or other significant trauma to the affected forefoot within the 12 months before the clinical onset of intermetatarsal bursitis; — MET
- On 18 November 2010, during pre-deployment training, a vehicle ramp was lowered onto the veteran's left forefoot, fracturing the necks of the third and fourth metatarsals, the two metatarsals that bound the affected bursa. This was within the 12 months before onset, a window from 12 May 2010 to 12 May 2011.
Cause 6: having a deformity or malalignment of the affected forefoot, including malunion of a metatarsal, splay foot or hallux valgus, at the time of the clinical onset of intermetatarsal bursitis; — MET
- The metatarsal fractures of November 2010 healed with plantar angulation of the third and fourth metatarsal necks, shown on ultrasound on 20 May 2011 and measured at 10 degrees on MRI in 2016. This malalignment altered load sharing between the metatarsal heads and was present at onset on 12 May 2011.
Cause 7: having a Body Mass Index (BMI) of 30 or greater at the time of the clinical onset of intermetatarsal bursitis; — MET
- The veteran's BMI was 30.5 on 22 September 2010 and 32.0 on 16 May 2011, at a height of 1.64 m, after weight gain during six weeks of immobilisation for the service-related metatarsal fractures and on deployed rations. Obesity increases forefoot plantar pressure.
Worsening factors
Worsening 1: running or marching an average of at least 25 kilometres per week, or standing on hard surfaces for an average of at least 6 hours per day, for at least the 4 weeks before the clinical worsening of intermetatarsal bursitis; — MET
- During warlike service in Iraq the veteran stood 12 hours a shift at a checkpoint and ran about 30 kilometres a week throughout the 4 weeks before the worsening, from 21 September 2015 to 19 October 2015, when ultrasound showed the bursa had enlarged from 9 mm by 6 mm to 16 mm by 10 mm.
Worsening 2: wearing footwear that compresses the forefoot, including footwear with a narrow toe box, at the time of the clinical worsening of intermetatarsal bursitis; — MET
- In Iraq wide-fitting boots were not available in theatre and her prescribed wide boots and orthoses were lost in transit, so she wore standard narrow-fitting issue boots for 12-hour shifts at the time of the worsening on 19 October 2015.
Worsening 3: having rheumatoid arthritis or another inflammatory arthritis affecting the forefoot at the time of the clinical worsening of intermetatarsal bursitis; — MET
- At the worsening on 19 October 2015 the veteran had a flare of seropositive rheumatoid arthritis, with synovitis of the left fourth metatarsophalangeal joint on ultrasound, after methotrexate was interrupted for five weeks because pathology monitoring was not available in theatre.
Worsening 4: having a deformity or malalignment of the affected forefoot, including malunion of a metatarsal, splay foot or hallux valgus, at the time of the clinical worsening of intermetatarsal bursitis; — MET
- The malunited third and fourth metatarsal necks from the service crush injury of 2010 were present at the worsening in October 2015, with 10 degrees of plantar angulation of the fourth metatarsal confirmed on MRI on 08 March 2016.
Worsening 5: having a Body Mass Index (BMI) of 30 or greater at the time of the clinical worsening of intermetatarsal bursitis; — MET
- The veteran's BMI was 33.5 on 19 October 2015, at the time of the worsening, after reduced activity from her forefoot pain and rheumatoid arthritis.
Worsening 6: inability to obtain appropriate clinical management for intermetatarsal bursitis. — MET
- Podiatry, orthoses and wide-fitting boots were not available during warlike service in Afghanistan in 2011, and rheumatology referral for the rheumatoid arthritis underlying the bursitis was deferred until her return. In Iraq in 2015 replacement orthoses and wide boots could not be obtained and methotrexate monitoring was unavailable. The bursitis enlarged and became chronic with erosions. 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 intermetatarsal bursitis is in part a sequela of the veteran's accepted left metatarsal fractures and their malunion, and of her rheumatoid arthritis. It has in turn contributed to erosive change of the left fourth metatarsal head and chronic forefoot pain, and led to her medical downgrading from patrol and checkpoint duties in 2016.
Unintended Consequence
Met. The interruption of methotrexate in Iraq in 2015, because Defence could not provide the required pathology monitoring in theatre, caused a flare of rheumatoid arthritis that contributed to the worsening of the bursitis. This is an unintended consequence of the treatment arrangements provided 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. During warlike service in Afghanistan in 2011 no podiatry, orthoses or wide-fitting boots were available and rheumatology referral was deferred for more than seven months after positive anti-CCP antibodies were found. In Iraq in 2015 lost orthoses and boots could not be replaced and methotrexate had to be stopped for five weeks for lack of monitoring. The bursa enlarged from 9 mm by 6 mm to 16 mm by 10 mm and erosions developed. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), these operational and service health constraints amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 22 Sep 2010, Pre-deployment medical examination, Medical Officer, Garrison health centre
- 18 Nov 2010, X-ray left foot and outpatient record, Medical Officer, Garrison health centre
- 14 Mar 2011, Outpatient health record and pathology, Medical Officer, Role 1 health facility, Afghanistan
- 16 May 2011, Outpatient health record, Medical Officer, Role 1 health facility, Afghanistan
- 20 May 2011, Ultrasound left forefoot, Role 2 facility, Afghanistan
- 27 Oct 2011, Rheumatology consultation, Rheumatologist
- 27 Oct 2011, Podiatry assessment and orthotic prescription, Podiatrist
- 19 Oct 2015, Outpatient health record and ultrasound left forefoot, Role 2 facility, Iraq
- 08 Mar 2016, Orthopaedic consultation and MRI left forefoot, Orthopaedic foot and ankle surgeon
