Left Foot - Plantar Fasciitis — DVA claim example

Diagnostic Assessment — Left Foot - Plantar Fasciitis

Example 1 of 1 · fictitious patient (Veteran EA)

Diagnostic Assessment

Left Foot - Plantar Fasciitis

BOP Code: 83 of 2023 (Plantar Fasciitis)
RH Code: 82 of 2023 (Plantar Fasciitis)

ADF History

Veteran EA, date of birth 09 November 1982, Australian Army, Military Police (later Corporal), enlisted 19 January 2004, medically discharged 27 May 2016. Operational service: Afghanistan, 12 January 2010 to 15 September 2010 (warlike).

Occupational History

Military police conduct base security, entry control, traffic control, foot and vehicle patrols, escort duties and field policing. Much of the work involves standing and walking for long shifts on concrete, bitumen and compacted gravel, in safety or combat boots, and in the field they patrol on foot carrying body armour, weapons and equipment. They must maintain a high level of fitness, including regular running and load-carriage training.

On operations military police staff entry control points and escort convoys, wearing 20 to 30 kilograms of protective equipment on hard surfaces for eight hours or more a day, and are exposed to improvised explosive devices, rocket attack and rough terrain. Resupply of worn footwear is often delayed, and podiatry and physiotherapy services are limited in theatre.

History

Veteran EA, a military policeman in the Australian Army, developed left plantar fasciitis on 16 February 2009 during a field policing course, after a puncture wound to the heel that became infected, a sudden increase in foot patrolling in worn boots, months of running and standing on hard surfaces, overweight, gout and a stiff, overpronating ankle from a 2006 fracture. The condition worsened on warlike service in Afghanistan in July 2010, after a further penetrating heel injury with infection, when podiatry care and replacement footwear could not be obtained.

Timeline

• 22 May 2006 — During a peacetime obstacle course the veteran fell from a wall and sustained a displaced Weber B fracture of the left ankle, treated with open reduction and internal fixation. At review in 2007 he had a permanent loss of left ankle dorsiflexion, 5 degrees compared with 15 degrees on the right, with compensatory overpronation of the left foot on gait assessment. A podiatrist prescribed custom orthoses. "ankle ORIF, reduced dorsiflexion"
• 14 Jan 2009 — A medical officer confirmed gout after a second acute attack of the left first metatarsophalangeal joint, with a serum urate of 0.56 mmol/L, and commenced allopurinol. The first attack had been in September 2008. Weight 89 kg, height 1.80 m, BMI 27.5. His annual health assessment of 05 January 2009 recorded no foot or heel pain. He was running 35 to 40 km a week in preparation for a fitness assessment and doing pack marches three times a week. "gout confirmed, allopurinol commenced"
• 17 Feb 2009 — On a field policing course that began on 09 February 2009, the veteran had trodden on a nail protruding from a board at an urban training facility on 11 February 2009, and it pierced his boot sole and left heel. Patrolling had risen from about 1.5 hours a day on office duties to six hours a day, in old boots with compressed midsoles because replacements were unavailable. From 16 February 2009 he had severe pain under the left heel, worst with the first steps in the morning, with swelling and warmth. "heel puncture, inferior heel pain"
• 18 Feb 2009 — MRI showed thickening of the proximal plantar fascia to 6.1 mm with enhancement and an 8 mm collection within the fascia. Ultrasound-guided aspiration grew Pseudomonas aeruginosa. A sports physician diagnosed infective plantar fasciitis and he was treated with intravenous then oral ciprofloxacin, rest, stretching and replacement orthoses. By November 2009 he had mild residual heel pain, a Foot Function Index of 22 per cent and plantar fascia thickness of 4.8 mm on ultrasound. "infected plantar fascia, Pseudomonas"
• 22 Jul 2010 — On warlike service in Afghanistan, during a convoy escort, his vehicle was struck by an improvised explosive device. He jumped from the vehicle onto rocky ground and a sharp rock fragment penetrated the worn sole of his desert boot into the left heel. The base security posture was raised and his foot patrols and entry control duties increased from about two to five hours a day in body armour. His orthoses had worn out in April 2010 and could not be replaced in theatre. "IED escort, rock penetrated heel"
• 28 Jul 2010 — At the role 2 facility he had severe left inferior heel pain, unable to bear weight on first rising, with swelling and redness spreading from the puncture wound. A wound swab grew Staphylococcus aureus and ultrasound showed the fascia thickened to 7.9 mm with surrounding fluid. He was treated with flucloxacillin. Gout had flared in May 2010, and reactive arthritis with heel and knee enthesitis followed Campylobacter gastroenteritis in June 2010. BMI 28.4. "infected heel, fascia 7.9 mm"
• 20 Sep 2010 — After his return to Australia MRI showed the left plantar fascia thickened to 8.2 mm with a partial-thickness tear at its calcaneal origin and calcaneal bone marrow oedema. The Foot Function Index had risen from 22 to 61 per cent. A podiatrist prescribed new orthoses and a night splint, and a sports physician arranged extracorporeal shockwave therapy. Symptoms persisted, and he was medically discharged in 2016. "partial tear, FFI 61 per cent"

Symptoms

At onset the veteran had severe pain under the inner part of the left heel, worst with the first steps in the morning and after sitting, with swelling and warmth of the heel and difficulty completing patrols. After treatment the pain settled to a mild ache after long shifts.

After the worsening in July 2010 the heel pain became constant, with severe pain on first rising and after rest, limping, and inability to run or patrol on foot. He now has daily heel pain, can stand for about 30 minutes and walk for about 20 minutes before needing to rest, uses orthoses and supportive footwear at all times, and can no longer run or play sport.

Imaging

• 22 May 2006 — X-ray left ankle: "Displaced Weber B fracture of the distal fibula with widening of the medial clear space."
• 18 Feb 2009 — MRI left foot: "Thickening of the proximal plantar fascia to 6.1 mm with high signal and enhancement, and an 8 mm intrafascial fluid collection consistent with an abscess. No calcaneal osteomyelitis."
• 26 Nov 2009 — Ultrasound left heel: "Plantar fascia thickness 4.8 mm with mild hypoechogenicity at the calcaneal origin. No collection."
• 28 Jul 2010 — Ultrasound left heel: "Plantar fascia thickened to 7.9 mm with perifascial fluid and soft tissue oedema at the site of a puncture wound."
• 20 Sep 2010 — MRI left foot: "Plantar fascia thickened to 8.2 mm with a partial-thickness tear at the calcaneal origin and calcaneal bone marrow oedema. Retained fixation in the distal fibula."

Onset Date

The most likely date of onset of this condition is 16 Feb 2009.

At that date the veteran was serving full time as a military policeman on a peacetime field policing course in Australia, which had begun on 09 February 2009. Five days earlier a nail had pierced his boot sole and left heel, and since the start of the course his daily foot patrolling had risen from about 1.5 to six hours in worn boots. On 16 February 2009 he developed severe pain under the left heel, worst with the first steps that morning.

This date is appropriate because his annual health assessment of 05 January 2009 recorded no foot or heel pain, and he presented on 17 February 2009, the day after the pain began, with MRI on 18 February 2009 confirming plantar fasciitis. It falls within uninterrupted full-time service.

For the factors with a seven-day window, the 7 days before onset run from 09 Feb 2009 to 16 Feb 2009, and contain the nail puncture of 11 February 2009, the increase in patrolling from 1.5 to six hours a day and the wearing of boots with compressed midsoles. For the running and exercise factors, the 2 months before onset run from 16 Dec 2008 to 16 Feb 2009, during which he ran 35 to 40 km a week and did pack marches of about six hours a week. For the hard surface factor, the 12 months before onset run from 16 Feb 2008 to 16 Feb 2009 for the Balance of Probabilities instrument and the 6 months from 16 Aug 2008 to 16 Feb 2009 for the Reasonable Hypothesis instrument, and throughout both periods he worked eight to 12-hour shifts on concrete and bitumen on most days. The Pseudomonas infection, overweight and gout were present at onset, and the ankle fracture of May 2006 preceded it.

For the worsening factors, the documented worsening is 28 Jul 2010, on warlike service in Afghanistan. The 7 days before the worsening run from 21 Jul 2010 to 28 Jul 2010 and contain the penetrating heel injury of 22 July 2010, the increase in daily patrolling from two to five hours and the worn boots. The 2 months before the worsening run from 28 May 2010 to 28 Jul 2010, and the 6 months before it run from 28 Jan 2010 to 28 Jul 2010, all on warlike service. The staphylococcal infection, overweight, gout and reactive arthritis were present at the worsening.

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

The formal diagnosis is Plantar Fasciitis of the left foot (ICD-10-AM M72.2), with an infective component at onset and at the worsening, under the Statements of Principles concerning plantar fasciitis, Balance of Probabilities No. 83 of 2023 and Reasonable Hypothesis No. 82 of 2023.

Plantar fasciitis is a painful inflammatory or degenerative condition of the plantar fascia, the thick band of connective tissue that supports the arch and attaches to the underside of the heel bone. It typically causes pain under the inner heel that is worst with the first steps in the morning or after rest, with tenderness at the fascial origin. It is associated with running and repetitive weight-bearing exercise, sudden increases in activity, prolonged standing on hard surfaces, poorly cushioned footwear, overweight, inflammatory and crystal arthritis, and reduced ankle flexibility or overpronation, and it can follow direct trauma or infection of the heel.

The diagnosis followed a 2006 left ankle fracture that left the ankle stiff and the foot overpronating, gout, overweight, sustained running and hard-surface duties, and a nail puncture with infection during a field course. It began on 16 February 2009, was confirmed on MRI on 18 February 2009, and worsened on warlike service in Afghanistan in July 2010.

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

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

16 February 2009.

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

17 February 2009.

When was the condition confirmed / formally diagnosed?

18 February 2009.

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

03 July 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by a sports physician on 18 February 2009 on the typical history of inferior heel pain worst with the first steps in the morning, tenderness over the medial calcaneal origin of the plantar fascia, and MRI showing thickening of the proximal plantar fascia to 6.1 mm with high signal and enhancement. An intrafascial collection was aspirated and grew Pseudomonas aeruginosa. This is a painful inflammatory condition of the plantar fascia within the Statement of Principles definition, and there was no plantar fibromatosis.

The worsening was confirmed at the role 2 facility on 28 July 2010, with ultrasound showing the fascia thickened to 7.9 mm with perifascial fluid and a wound swab growing Staphylococcus aureus, and on MRI on 20 September 2010, which showed thickening to 8.2 mm with a partial-thickness tear and calcaneal bone marrow oedema, compared with 4.8 mm on ultrasound in November 2009. The Foot Function Index rose from 22 to 61 per cent.

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 16 February 2009, 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, including the field policing course on which the condition began. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan from 12 January to 15 September 2010, during which the condition worsened. In this Statement of Principles most factors apply to either the clinical onset or the clinical worsening.

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 Plantar Fasciitis, No. 83 of 2023

Causative and worsening factors

Factor 9(1): having trauma to the plantar aspect of the affected foot within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- On 11 February 2009, on a peacetime field policing course, a nail protruding from a board at an urban training facility pierced the sole of his boot and the plantar aspect of his left heel. This was five days before onset, within the 7 days from 09 to 16 February 2009.

Factor 9(2): having an infection involving the plantar fascia at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- MRI on 18 February 2009 showed an 8 mm collection within the enhancing plantar fascia, and ultrasound-guided aspiration grew Pseudomonas aeruginosa, introduced by the nail puncture through his boot. The infection involved the plantar fascia at onset and required intravenous antibiotics.

Factor 9(3): running or jogging an average of at least 30 kilometres per week for at least the 2 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- From December 2008 the veteran ran 35 to 40 km a week, recorded in his unit training log, to prepare for a military police fitness assessment and the field course. This continued throughout the 2 months before onset, from 16 December 2008 to 16 February 2009.

Factor 9(4): undertaking exercise that involves repetitive weight bearing on the affected foot for: (a) a minimum intensity of 5 METS; and (b) for at least 4 hours per week; and for at least the 2 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- In addition to running, he completed three pack marches a week of about two hours each with a 20 kg load, an intensity of about 6 to 7 METs, about six hours a week, throughout the 2 months before onset as part of his unit's physical training program.

Factor 9(5): increasing the frequency, duration or intensity of weight bearing activity involving the affected foot: (a) by at least 200 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; and within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- In the week before the course he was on office duties, walking about 1.5 hours a day. From 09 February 2009 the field course required foot patrolling and field policing for about six hours a day carrying equipment, an intensity of about 5 to 6 METs. This was an increase of 300 per cent, to more than 2 hours a day, within the 7 days before onset.

Factor 9(6): undergoing prolonged weight bearing on the affected foot while on a hard surface for at least five hours per day, on more days than not, for the 12 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- From February 2008 to February 2009 the veteran worked as a garrison military policeman, staffing entry control points and patrolling on concrete and bitumen in eight to 12-hour shifts, five days a week, standing or walking for at least five hours on each of those days. This filled the 12 months before onset, from 16 February 2008 to 16 February 2009.

Factor 9(7): being overweight or obese at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- The veteran weighed 89 kg at a height of 1.80 m on 14 January 2009, a BMI of 27.5, and his weight was unchanged at onset on 16 February 2009. A BMI of 25 or greater meets the definition of overweight.

Factor 9(8): having a systemic arthritic disease at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- Gout was confirmed on 14 January 2009 after a second acute attack of the left first metatarsophalangeal joint with a serum urate of 0.56 mmol/L, and he was taking allopurinol at onset. Gout is a systemic arthritic disease under the definition.

Factor 9(9): having an acquired biomechanical abnormality involving the affected foot before the clinical onset or clinical worsening of plantar fasciitis; — MET

- The displaced left ankle fracture sustained on a peacetime obstacle course on 22 May 2006 and fixed surgically left a permanent loss of left ankle dorsiflexion, 5 degrees against 15 degrees on the right, with compensatory overpronation of the left foot documented on gait assessment in 2007. This acquired biomechanical abnormality was present before onset.

Factor 9(10): wearing footwear with inadequate cushioning during weight bearing exercise which involves the affected foot within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- During the field course from 09 February 2009 he patrolled in old issue boots with compressed, worn midsoles because his request for replacements had not been filled by the unit store. These boots, with inadequate cushioning, were worn during weight-bearing exercise throughout the 7 days before onset.

Worsening factors

Factor 9(11): inability to obtain appropriate clinical management for plantar fasciitis before the clinical worsening of plantar fasciitis. — MET

- The custom orthoses prescribed for his plantar fasciitis wore out in April 2010 and could not be replaced, and there was no podiatrist or physiotherapist at his location, so he continued long shifts and patrols without his prescribed treatment until the worsening documented on 28 July 2010. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Plantar Fasciitis, No. 82 of 2023

Causative and worsening factors

Factor 9(1): having trauma to the plantar aspect of the affected foot within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- On 22 July 2010, on warlike service in Afghanistan, the veteran jumped from his vehicle onto rocky ground after an improvised explosive device strike on a convoy escort, and a sharp rock fragment penetrated the worn sole of his boot into the plantar aspect of his left heel. This was six days before the worsening documented on 28 July 2010.

Factor 9(2): having an infection involving the plantar fascia at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- The penetrating wound of 22 July 2010 became infected. At the worsening on 28 July 2010 a wound swab grew Staphylococcus aureus and ultrasound showed perifascial fluid around a plantar fascia thickened to 7.9 mm, so the infection involved the plantar fascia at the time of the worsening on warlike service.

Factor 9(3): running or jogging an average of at least 30 kilometres per week for at least the 2 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- On warlike service he ran about 35 km a week on the base perimeter road and treadmill to maintain operational fitness, recorded in his deployed training log, throughout the 2 months before the worsening, from 28 May to 28 July 2010.

Factor 9(4): undertaking exercise that involves repetitive weight bearing on the affected foot for: (a) a minimum intensity of 5 METS; and (b) for at least 4 hours per week; and for at least the 2 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- Throughout the 2 months before the worsening he conducted dismounted patrols around the base and at convoy halts carrying about 30 kg of body armour, weapon and equipment, an intensity of 6 METs or more, for at least eight hours a week, on warlike service.

Factor 9(5): increasing the frequency, duration or intensity of weight bearing activity involving the affected foot: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; and within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- After the improvised explosive device strike of 22 July 2010 the base security posture was raised and his foot patrols and entry control duties in body armour rose from about two to five hours a day, an increase of 150 per cent at an intensity of about 6 METs, within the 7 days before the worsening on warlike service.

Factor 9(6): undergoing prolonged weight bearing on the affected foot while on a hard surface for at least five hours per day, on more days than not, for the 6 months before the clinical onset or clinical worsening of plantar fasciitis; — MET

- From 12 January 2010 he staffed the entry control point of a base in Afghanistan, standing on concrete and compacted gravel for eight-hour shifts six days a week. This filled the 6 months before the worsening, from 28 January to 28 July 2010, on warlike service.

Factor 9(7): being overweight or obese at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- At the worsening on 28 July 2010 the veteran weighed 92 kg at 1.80 m, a BMI of 28.4, recorded at the role 2 facility on warlike service.

Factor 9(8): having a systemic arthritic disease at the time of the clinical onset or clinical worsening of plantar fasciitis; — MET

- Gout was present at the worsening, with a flare in May 2010 when allopurinol supply lapsed on deployment, and reactive arthritis with heel and knee enthesitis developed after Campylobacter gastroenteritis acquired on warlike service in June 2010. Both are systemic arthritic diseases under the definition and were present on 28 July 2010.

Factor 9(9): having an acquired biomechanical abnormality involving the affected foot before the clinical onset or clinical worsening of plantar fasciitis; — MET

- The loss of left ankle dorsiflexion and overpronation from the 2006 ankle fracture was present before the worsening and, with his orthoses worn out from April 2010, was uncorrected throughout his warlike service.

Factor 9(10): wearing footwear with inadequate cushioning during weight bearing exercise which involves the affected foot within the seven days before the clinical onset or clinical worsening of plantar fasciitis; — MET

- By July 2010, after six months of daily wear on warlike service, his desert boots had worn-through soles and compressed midsoles, and replacements were not available through the supply chain. He wore them on patrols throughout the 7 days before the worsening, and the rock fragment penetrated the worn sole on 22 July 2010.

Worsening factors

Factor 9(11): inability to obtain appropriate clinical management for plantar fasciitis before the clinical worsening of plantar fasciitis. — MET

- On warlike service in Afghanistan there was no podiatrist or physiotherapist at his base, his prescribed orthoses wore out in April 2010 and could not be replaced, and his duties could not be modified. He continued long shifts on hard surfaces without his prescribed treatment until the worsening on 28 July 2010.

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

Sequelae

The plantar fasciitis is a sequela of the veteran's service-related left ankle fracture of 2006, whose loss of dorsiflexion and overpronation overloaded the plantar fascia, and of his gout and reactive arthritis. In turn, the chronic heel pain has caused an antalgic gait, deconditioning and weight gain, and contributed to his medical discharge.

Unintended Consequence

Not met. No treatment provided or funded by the Commonwealth caused the plantar fasciitis. The failure to replace prescribed orthoses and to provide podiatry care on deployment is addressed under inability to obtain appropriate clinical management.

Inability to Attain Appropriate Medical Management

MET. After the plantar fasciitis began in February 2009 the veteran was prescribed custom orthoses, a stretching program and footwear modification. On warlike service in Afghanistan his orthoses wore out in April 2010 and could not be replaced, his worn boots could not be resupplied, there was no podiatrist or physiotherapist at his base, and his duties on hard surfaces could not be reduced. The condition worsened on 28 July 2010, with the plantar fascia thickening from 4.8 to 8.2 mm with a partial tear and the Foot Function Index rising from 22 to 61 per cent. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent the provision of prescribed orthoses, footwear and allied health care amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 22 May 2006, Emergency department record, X-ray and operation report, Orthopaedic surgeon
2. 16 Aug 2007, Gait assessment and orthotic prescription, Podiatrist
3. 05 Jan 2009, Annual health assessment, Medical Officer, Garrison health centre
4. 14 Jan 2009, Outpatient health record, Medical Officer, Garrison health centre
5. 17 Feb 2009, Outpatient health record, Medical Officer, Garrison health centre
6. 18 Feb 2009, MRI left foot and aspiration microbiology report, Radiologist
7. 18 Feb 2009, Sports medicine consultation, Sports physician
8. 26 Nov 2009, Ultrasound left heel, Radiologist
9. 22 Jul 2010, Incident report, Afghanistan
10. 28 Jul 2010, Role 2 attendance, ultrasound and wound microbiology, Medical Officer, Afghanistan
11. 20 Sep 2010, MRI left foot, Radiologist
12. 04 Oct 2010, Podiatry and sports medicine review, Podiatrist and Sports physician
13. Statement of Principles concerning Plantar Fasciitis (Balance of Probabilities) No. 83 of 2023, Repatriation Medical Authority
14. Statement of Principles concerning Plantar Fasciitis (Reasonable Hypothesis) No. 82 of 2023, Repatriation Medical Authority