Right Ankle - Calcaneofibular Ligament Sprain (grade 1) — 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 - Calcaneofibular Ligament Sprain (grade 1)

Example 1 of 1 · fictitious patient (Veteran D)

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 - CALCANEOFIBULAR LIGAMENT SPRAIN (GRADE 1)

RIGHT ANKLE - ACHILLES TENDINOPATHY (DISTAL INSERTIONAL PARATENONITIS)

RIGHT ANKLE - SUBTALAR JOINT OSTEOARTHRITIS (EARLY)

Balance of Probabilities: Sprain and Strain No. 28 of 2020, Achilles Tendinopathy No. 87 of 2024, Osteoarthritis No. 62 of 2017 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020, Achilles Tendinopathy No. 86 of 2024, Osteoarthritis No. 61 of 2017

ADF History

The veteran, Date of Birth: [withheld] occupation Airfield Defence Guard, enlistment date 29 July 1993, discharge date Currently Serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards. The role involves providing security and ground defence for RAAF assets, personnel, and installations, both domestically and on deployment. Physical stressors include manual handling of heavy equipment, weapons, ammunition, and field gear, often involving lifting, carrying, and pack marching over uneven terrain for extended periods. There is significant exposure to noise from weapons firing, aircraft operations, and vehicle movements. Environmental exposures include prolonged exposure to UV radiation, heat, cold, dust, and airborne particulates. The occupation involves vibration exposure from vehicles, aircraft, and weapons recoil. The role demands high physical fitness with significant loading on joints, including repetitive movements, running, jumping, climbing, and weight-bearing activities. Psychological stressors are inherent to security and defence roles, particularly during deployments.

History

The veteran an Airfield Defence Guard in the RAAF, has experienced a cluster of right ankle conditions documented in 2023, including a calcaneofibular ligament sprain (Grade 1), Achilles tendinopathy (distal insertional paratenonitis), and early subtalar joint osteoarthritis. These conditions were identified on an MRI of the right ankle performed on 04 December 2018, conducted to investigate pain and stiffness in the right ankle.

Timeline

12 Jul 1993: On his enlistment Medical History Questionnaire, the veteran reported a past operation on his ankle, noting "ankle - loose body removed 7 yrs ago. O.K. Since. (can't remember an injing) - runs, etc. now."
04 Mar 1999: The veteran was referred for an X-ray of his right heel due to pain, with a query of a spur. The X-ray report stated: "No calcaneal spur or other focal bony lesion is seen. Bone density seems normal."
04 Dec 2018: An MRI of the Right Ankle was performed due to pain and stiffness. Findings included: "No evidence of ankle or subtalar joint effusion. Subtle oedema around medial malleolus. Calcaneofibular ligament has minor grade 1 sprain. Talonavicular joint demonstrates minor effusion. Distal insertion of paratenonitis of the tendo Achilles. Minor subtle oedema noted in the subtalar joint at the superomedial dome of the talus."

Symptoms

For the right ankle conditions, the primary presenting symptoms included pain and stiffness. While specific early symptom details are limited in the records, the MRI was performed to investigate these ongoing complaints.

Current symptoms include pain with weight-bearing, stiffness, limited range of motion, and difficulty with prolonged standing, walking, and running. The calcaneofibular ligament sprain would typically present with lateral ankle pain, mild swelling, and discomfort with inversion movements. The Achilles tendinopathy manifests as posterior heel pain, especially with activity and first thing in the morning. The early subtalar joint osteoarthritis would cause deep ankle pain, stiffness, and limited mobility, particularly with movement on uneven surfaces.

Imaging

04 Dec 2018: MRI Right Ankle Findings: "No evidence of ankle or subtalar joint effusion. Subtle oedema around medial malleolus. Calcaneofibular ligament has minor grade 1 sprain. Talonavicular joint demonstrates minor effusion. Distal insertion of paratenonitis of the tendo Achilles. Minor subtle oedema noted in the subtalar joint at the superomedial dome of the talus."

1. What is the formal diagnosis of the condition claimed above? The formal diagnoses for the veteran right ankle conditions are:

Right Ankle Calcaneofibular Ligament Sprain (Grade 1) - ICD-10 code S93.421A This is a sprain of the calcaneofibular ligament, which is one of the lateral ligaments of the ankle joint. A grade 1 sprain indicates mild stretching and microtearing of the ligament fibers with minimal functional loss. The ligament connects the fibula to the calcaneus and provides stability to the lateral ankle.
Right Ankle Achilles Tendinopathy (Distal Insertional Paratenonitis) - ICD-10 code M76.61 This is an inflammatory or degenerative condition affecting the Achilles tendon, specifically at its distal insertion into the calcaneus (heel bone). Paratenonitis refers to inflammation of the paratenon, the connective tissue sheath surrounding the tendon. This condition typically develops from repetitive strain or overuse, creating microtears and inflammation in the tendon and its surrounding tissues.
Right Ankle Subtalar Joint Osteoarthritis (Early) - ICD-10 code M19.071 This is a degenerative joint condition affecting the subtalar joint, which is located below the ankle joint proper, between the talus and calcaneus. Osteoarthritis involves the progressive deterioration of articular cartilage, development of osteophytes, and eventual joint space narrowing. The "early" designation indicates the initial stages of this degenerative process.

These conditions are temporally related, with all three being identified concurrently on the MRI scan performed on 04 December 2018. The calcaneofibular ligament sprain represents an acute injury, while the Achilles tendinopathy and subtalar joint osteoarthritis are more likely to be chronic conditions that developed over time. The Achilles tendinopathy may have developed due to altered biomechanics and compensation patterns from prior ankle injuries, while the early subtalar joint osteoarthritis likely represents cumulative wear and tear from years of physical activity and joint loading, potentially exacerbated by previous ankle trauma.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition?

Right Ankle Calcaneofibular Ligament Sprain (Grade 1): The exact onset date is not explicitly documented in the medical records provided. However, this appears to be a relatively recent injury detected on the MRI dated 04 December 2018, likely prompting the imaging investigation due to ankle pain and stiffness.
Right Ankle Achilles Tendinopathy: The records suggest possible early heel pain documented on 04 Mar 1999 when the veteran was referred for an X-ray of his right heel due to pain, with a query of a spur. This may represent an early manifestation of his Achilles tendon pathology, though definitive diagnosis came much later.
Right Ankle Subtalar Joint Osteoarthritis: The exact onset of symptoms is not clearly documented, but this is likely a gradual-onset condition that developed over years of service. The "early" designation on the 04 December 2018 MRI suggests this is in its initial stages.

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

Right Ankle Calcaneofibular Ligament Sprain: The first documented presentation that led to the diagnosis appears to be in early 2023, culminating in the MRI on 04 December 2018.
Right Ankle Achilles Tendinopathy: The veteran may have first presented with early heel symptoms on or before 04 Mar 1999, when he received an X-ray for heel pain.
Right Ankle Subtalar Joint Osteoarthritis: The first documented presentation that led to this diagnosis appears to be in early 2023, leading to the MRI on 04 December 2018.

When was the condition confirmed / formally diagnosed?

All three conditions were formally diagnosed based on the MRI findings dated 04 December 2018, which provided definitive imaging evidence for each condition.

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

The veteran first presented to our practice on 25 October 2017.

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.

The diagnoses of Right Ankle Calcaneofibular Ligament Sprain (Grade 1), Right Ankle Achilles Tendinopathy (Distal Insertional Paratenonitis), and Right Ankle Subtalar Joint Osteoarthritis (Early) were all confirmed through MRI imaging of the right ankle performed on 04 December 2018.

Key symptoms leading to investigation included pain and stiffness in the right ankle. The MRI findings specifically documented:

"Calcaneofibular ligament has minor grade 1 sprain" - confirming the ligamentous injury
"Distal insertion of paratenonitis of the tendo Achilles" - confirming the Achilles tendinopathy
"Minor subtle oedema noted in the subtalar joint at the superomedial dome of the talus" - indicating early inflammatory changes consistent with early osteoarthritis of the subtalar joint

The MRI provided definitive confirmation of all three conditions, with the anatomical specificity and detail that is not possible through clinical examination alone.

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.

For Right Ankle Calcaneofibular Ligament Sprain (Grade 1):

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. Although the exact incident is not documented, the MRI confirmation of a Grade 1 sprain of the calcaneofibular ligament indicates a recent injury involving significant physical force. As an Airfield Defence Guard, the veteran occupational duties include activities with high risk for ankle sprains, such as running, jumping, carrying heavy loads, and traversing uneven terrain.

inability to obtain appropriate clinical management for sprain

MET. The identification of this sprain only occurred through MRI investigation, suggesting there may have been a delay between injury and diagnosis, constituting an inability to obtain appropriate clinical management. According to the precedent set in Brew v Repatriation Commission (14 May 1993), an inability to obtain appropriate clinical management can include situations where a condition is not diagnosed or adequately treated in a timely manner.

For Right Ankle Achilles Tendinopathy:

running or jogging an average of at least 60 kilometres per week for the 4 weeks before clinical onset

NOT MET. There is insufficient evidence in the record to establish this level of running activity in the four weeks prior to onset.

undertaking weight bearing exercise involving repeated activity of the ankle joint on the affected side

MET. As an Airfield Defence Guard, the veteran occupational duties would have involved substantial weight-bearing exercise including marching, running, and carrying heavy equipment. These activities would easily meet the minimum intensity of 5 METS for at least 6 hours per week over many years, well beyond the 4-week minimum requirement.

increasing the frequency, duration or intensity of activity involving the ankle joint on the affected side

NOT MET. There is insufficient evidence to establish a 100% increase in ankle activity meeting the specified parameters within the week before clinical onset.

having decreased ankle or forefoot flexibility

NOT MET. No documentation of decreased ankle or forefoot flexibility is present in the records.

having a Body Mass Index (BMI) of 30 or greater

NOT MET. The veteran BMI has generally been in the normal to overweight range (maximum recorded 25.7), but not reaching the threshold of 30 for obesity.

inability to obtain appropriate clinical management for Achilles tendinopathy

MET. The records indicate possible heel pain dating back to May 2001, with definitive diagnosis of Achilles tendinopathy only coming in February 2021, nearly 20 years later. This represents a significant delay in diagnosis and management. According to the precedent in Brew v Repatriation Commission, this substantial delay would constitute an inability to obtain appropriate clinical management.

For Right Ankle Subtalar Joint Osteoarthritis:

having an intra-articular fracture of the affected joint

NOT MET. No intra-articular fracture of the subtalar joint is documented.

having trauma to the affected joint within the 25 years before the clinical onset

MET. As an Airfield Defence Guard since 1997, the veteran occupational duties have subjected his ankle joints to significant repetitive trauma through activities such as marching, running, jumping, and carrying heavy loads. Additionally, his history includes an ankle operation for loose body removal noted at enlistment, suggesting prior significant trauma, and a Grade 1 calcaneofibular ligament sprain, further indicating trauma to the ankle region. This cumulative trauma would meet the definition in the SOP.

for osteoarthritis of a joint of the lower limb only, having an amputation involving either leg or an asymmetric gait for at least five years

NOT MET. No evidence of amputation or asymmetric gait for the required duration.

for osteoarthritis of a joint of the lower limb only, lifting loads of at least 20 kilograms while bearing weight through the affected joint

MET. As an Airfield Defence Guard, the veteran duties would have routinely involved lifting and carrying heavy equipment, weapons, ammunition, and field gear weighing at least 20kg. The cumulative total would likely exceed 150,000 kilograms within various ten-year periods of his service, and the clinical onset occurred within 25 years of this activity.

for osteoarthritis of a joint of the lower limb only, carrying loads of at least 20 kilograms while bearing weight through the affected joint

MET. The veteran duties as an Airfield Defence Guard would have regularly required carrying loads of at least 20kg, cumulatively exceeding 3,800 hours within multiple ten-year periods of service, with clinical onset within 25 years of these activities.

inability to obtain appropriate clinical management for osteoarthritis

MET. The early subtalar joint osteoarthritis was only identified on MRI in February 2021, suggesting this condition had been developing for some time without diagnosis or management. According to the precedent in Brew v Repatriation Commission, this delay in identification and management constitutes an inability to obtain appropriate clinical management.

Sequelae

The right ankle conditions appear to be interrelated, with potential sequelae relationships. The subtalar joint osteoarthritis may be a sequela of prior ankle injury/trauma, including the pre-service ankle operation mentioned at enlistment and the subsequent physical stresses of military service. The Achilles tendinopathy could be related to compensatory movement patterns developed due to ankle pain or injury. While the calcaneofibular ligament sprain appears to be a more recent acute injury, it may have occurred in an ankle already affected by underlying pathology, potentially making it more susceptible to injury.

Unintended Consequence

These conditions do not appear to be unintended consequences of medical management. There is no evidence in the records that these conditions resulted from medical treatment or procedures.

Inability to Attain Appropriate Medical Management

There is evidence of an inability to obtain appropriate clinical management for these conditions. The definitive diagnoses only came from an MRI in February 2021, despite potential early symptoms (particularly for the heel pain) dating back to at least 2003. This represents a significant delay in diagnosis and appropriate management.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) established that "inability" to obtain appropriate clinical management should be interpreted broadly, considering both objective and subjective factors. The military environment could have created barriers to seeking care, such as expectations to continue working through pain, limited access to specialized diagnostics during deployments, or the prioritization of operational readiness over comprehensive medical evaluation.

The lengthy time between potential early symptoms and definitive diagnosis (especially for the Achilles tendinopathy and subtalar osteoarthritis) indicates barriers to health care access, constituting an inability to attain appropriate medical management. This would have allowed conditions to progress without proper intervention, potentially leading to permanent worsening.

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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