Right Ankle - Atfl Sprain — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Right Ankle - Atfl Sprain

Example 1 of 1 · fictitious patient (Veteran N)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Right Ankle - ATFL Sprain

SOP Codes: Balance of Probabilities - Sprain and Strain No. 28 of 2020; Reasonable Hypothesis - Sprain and Strain No. 27 of 2020

ADF History

The veteran, Chef (Army Catering Force), enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs are exposed to physical training activities including running, marching, and sports participation, walking on uneven surfaces in field kitchens and military exercises, prolonged standing on various surfaces during food preparation, participation in organized military recreational activities including football, and manual handling activities that may involve sudden movements and awkward positioning. These activities predispose to ankle ligament injuries through inversion mechanisms and traumatic episodes.

History

The veteran the veteran a military chef, sustained a right ankle ATFL sprain on 14 Mar 2015 during organized football practice at the base while serving in the Australian Defence Force, when he kicked his foot into the ground during soccer training.

Timeline

15 Mar 2015 - the veteran presented to the base Health Centre following foot injury the previous day during football practice. He kicked his foot into the ground during soccer training, resulting in pain with walking, plantar flexion, and fast movements. Examination revealed pain-limited dorsiflexion and plantar flexion with tenderness to palpate over the ankle joint line and overlying tendons. Clinical impression was anterior ankle joint sprain. Earlier assessment by military medical staff noted the member tried to kick a soccer ball and contacted the ground as well as the ball, experiencing 05/08 pain when trying to walk or apply pressure to the foot, with pain on both dorsiflexion and plantar flexion, and pain when trying to invert and evert the ankle.
05 January 2019 - MRI bilateral ankle revealed chronic changes from the original injury. There was mild asymmetric low signal thickening of the fibular attachment of the right ATFL suspicious for an old sprain injury and subsequent mature scar remodelling. The impression noted mild scarring of the fibular attachment of the right ATFL suggesting remote sprain injury. The imaging confirmed long-term structural consequences of the original service-related injury, demonstrating incomplete healing and permanent ligamentous changes.

Symptoms

Initial symptoms included acute ankle pain, difficulty weight-bearing, pain with dorsiflexion and plantar flexion, and pain with inversion and eversion movements. Current symptoms include chronic ankle instability and discomfort related to the residual ATFL scarring, with potential for recurrent ankle sprains due to ligamentous weakness.

Imaging

05 January 2019 - MRI bilateral ankle revealed mild asymmetric low signal thickening of the fibular attachment of the right ATFL suspicious for an old sprain injury and subsequent mature scar remodelling. The impression noted mild scarring of the fibular attachment of the right ATFL suggesting remote sprain injury.

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

Right Ankle Anterior Talofibular Ligament (ATFL) Sprain with Chronic Scarring and Mature Scar Remodelling. SOP: Sprain and Strain No. 28 of 2020. ICD-10: S93.4.

A sprain means an injury involving the tearing or stretching of one or more joint ligaments, associated with the onset of pain and tenderness at that site within the 24 hours following the injury. The anterior talofibular ligament is the most commonly injured ligament in ankle sprains, providing stability against excessive inversion and anterior translation of the talus. ATFL sprains typically result from inversion injuries when the foot is plantarflexed, causing stretching or tearing of the ligament with subsequent healing through scar tissue formation.

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

When did the veteran first experience symptoms attributable to this condition? 14 Mar 2015 during football practice at the base. [Chart Review Document, multiple pages documenting the injury during soccer training]

When did the veteran first present to a health / medical provider for this condition? 15 Mar 2015 to military medical staff at the base Health Centre. [Chart Review Document, multiple pages documenting initial presentation]

When was the condition confirmed / formally diagnosed? 15 Mar 2015 by Military Medical Officer who diagnosed anterior ankle joint sprain, with chronic changes confirmed 05 January 2019 by the treating doctor, Radiologist. [Chart Review Document and Imaging.pdf, page 1]

When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018

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

Initial diagnosis was confirmed by Military Medical Officer at the base Health Centre through clinical examination revealing pain-limited dorsiflexion and plantar flexion, tenderness to palpate over the ankle joint line and overlying tendons, 05/08 pain with walking and pressure application, and pain with inversion and eversion movements. Chronic structural damage was confirmed by MRI imaging conducted by Radiologist the treating doctor on 05 January 2019, revealing mild asymmetric low signal thickening of the fibular attachment of the right ATFL suspicious for old sprain injury and subsequent mature scar remodelling. [Chart Review Document, multiple pages and Imaging.pdf, page 1 - link to imaging report]

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET

The documented soccer injury on 14 Mar 2015 during organized military recreational activity involved significant physical force when the veteran kicked his foot into the ground while attempting to kick a soccer ball, resulting in inversion injury to the right ankle with subsequent ATFL sprain

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - NOT MET

This factor applies to muscle/tendon strain rather than ligament sprain

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament - MET

Ongoing military activities and occupational demands following the initial injury could have caused further stress to the healing ATFL, contributing to the permanent scarring and chronic changes evident on 2023 MRI

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon - NOT MET

This factor applies to muscle/tendon strain rather than ligament sprain

Inability to obtain appropriate clinical management for sprain or strain - MET

While initial assessment occurred, there is no documentation of comprehensive rehabilitation or follow-up care for the ATFL sprain, with the chronic scarring on 2023 MRI indicating inadequate healing, representing inability to obtain appropriate ongoing clinical management as per Brew v Repatriation Commission precedent

Sequelae

This condition is not a sequelae of another known condition but represents primary ligamentous injury from the documented sports injury during military service.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was inability to attain appropriate medical management. While the acute injury was assessed and diagnosed, there is no evidence of comprehensive rehabilitation, physiotherapy, or ongoing management of the ATFL sprain. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) establishes that "inability" encompasses both objective and subjective barriers to obtaining treatment. The presence of chronic scarring and mature scar remodelling on 2023 MRI indicates inadequate healing, suggesting that appropriate clinical management including structured rehabilitation, physiotherapy, and functional training was not provided. This failure to obtain appropriate ongoing management has caused permanent worsening of the condition, as early comprehensive rehabilitation could have prevented excessive scar tissue formation and maintained better ligamentous function.

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

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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