Diagnostic Assessment — Right Ankle - Deltoid Ligament Sprain
Example 1 of 1 · fictitious patient (Veteran EC)
Diagnostic Assessment
Right Ankle - Deltoid Ligament Sprain
BOP Code: 28 of 2020 (Sprain and Strain)
RH Code: 27 of 2020 (Sprain and Strain)
ADF History
Veteran EC, date of birth 26 January 1990, Australian Army, Infantry Soldier (Paratrooper, later Lance Corporal), enlisted 09 June 2008, medically discharged 17 February 2022. Operational service: Afghanistan, 20 May 2011 to 28 December 2011 (warlike); Iraq, 15 January 2019 to 30 July 2019 (warlike).
Occupational History
As a paratrooper in an infantry battalion the veteran conducted static-line parachute descents with equipment of up to 50 kilograms, foot patrols and route marches carrying 35 to 45 kilograms, fast-roping and helicopter insertions, and jumping from vehicles, walls and compound features in full equipment. Night operations and rough, rocky or irrigated ground were routine.
Parachute landings, jumps from height under load and patrolling on uneven ground make ankle ligament injuries one of the most common injuries in infantry and airborne soldiers. On operations, injured soldiers usually continue patrolling with strapping, and imaging, physiotherapy and orthopaedic review are rarely available until return to Australia.
History
Veteran EC, a paratrooper in the Australian Army, sprained the deltoid ligament of the right ankle and strained the tibialis posterior tendon on 08 September 2011 during warlike service in Afghanistan, when he jumped about 2.5 metres from a compound wall carrying 38 kilograms and landed with his foot forced into eversion. The injury worsened on 14 April 2019 in Iraq, when he stepped down from a vehicle under load and fully ruptured the deep deltoid ligament and partially tore the tibialis posterior tendon.
Timeline
- 02 Mar 2011 — At his pre-deployment medical the veteran's ankles were examined and recorded as normal, with full range of movement and no instability or tenderness. He had completed 42 parachute descents without injury. No previous ankle injury was recorded. "ankles normal, no instability"
- 08 Sep 2011 — During a clearance patrol on warlike service in Afghanistan the veteran jumped about 2.5 metres from a compound wall carrying about 38 kilograms. He landed on uneven ground with his right foot forced outwards into eversion and external rotation, felt a pop on the inner ankle and had immediate pain and swelling. The patrol medic strapped the ankle, and he walked back to the patrol base, about four kilometres. "eversion landing, medial ankle pain"
- 09 Sep 2011 — The Regimental Medical Officer recorded swelling and bruising over the medial ankle, tenderness over the deltoid ligament and along the tibialis posterior tendon behind the medial malleolus, pain on resisted inversion and pain on eversion stress. Ottawa rules indicated an X-ray, which showed no fracture. A grade II deltoid ligament sprain and tibialis posterior strain were diagnosed. He continued patrolling in a brace because no relief was available. "deltoid sprain, tibialis posterior strain"
- 14 Feb 2012 — After return to Australia, MRI of the right ankle showed a partial-thickness tear of the deep deltoid ligament and a low-grade tear of the tibialis posterior tendon. An orthopaedic surgeon confirmed the diagnosis and arranged physiotherapy. He returned to full duties, including parachuting, in July 2012 with residual medial ankle ache after long marches. "MRI partial deep deltoid tear"
- 14 Apr 2019 — On warlike service in Iraq the veteran stepped down about 1.2 metres from the rear of a protected mobility vehicle carrying about 35 kilograms, landed on a rock with the right foot everting and felt a tearing sensation on the inner ankle. Severe pain, swelling and inability to bear weight followed. The deployed medical officer recorded marked medial tenderness, a widened gap on eversion stress and weak, painful resisted inversion. X-ray showed no fracture. "re-injury stepping down, unable to weight-bear"
- 28 May 2019 — Ultrasound at the coalition medical facility showed thickening and disruption of the deltoid ligament and fluid around the tibialis posterior tendon. MRI was not available in theatre, physiotherapy was available only once a fortnight, and he was managed in a walking boot until return to Australia. "deltoid disruption on ultrasound"
- 19 Aug 2019 — MRI showed a complete rupture of the deep deltoid ligament with medial clear space widening and a longitudinal split tear of the tibialis posterior tendon. An orthopaedic foot and ankle surgeon confirmed clinical worsening, with medial ankle instability and a flattening arch. Foot and Ankle Ability Measure sports score 31 per cent, compared with 78 per cent in 2012. "complete deep deltoid rupture"
- 11 Nov 2019 — The surgeon performed deltoid ligament repair with suture anchor augmentation and debridement and repair of the tibialis posterior tendon. He was medically downgraded from parachuting and field duties and was later medically discharged. "deltoid repair, tib post repair"
Symptoms
At onset the veteran had sudden pain on the inner side of the right ankle, swelling and bruising below the medial malleolus, pain on walking and turning the foot outwards, and weakness and pain on pushing up onto his toes. Medial ankle ache persisted after long marches and parachute descents until the worsening in 2019.
He now reports medial ankle pain after walking more than two kilometres or standing for long periods, a feeling of the ankle giving way on uneven ground, swelling at the end of the day and stiffness in the mornings. He cannot run, jump or carry heavy loads and has given up hiking and touch football.
Imaging
- 09 Sep 2011 — X-ray right ankle: "No fracture. Soft tissue swelling over the medial malleolus. Ankle mortise congruent."
- 14 Feb 2012 — MRI right ankle: "Partial-thickness tear of the deep component of the deltoid ligament with surrounding oedema. Low-grade interstitial tear of the tibialis posterior tendon behind the medial malleolus. Lateral ligaments intact."
- 14 Apr 2019 — X-ray right ankle: "No fracture. Medial soft tissue swelling."
- 28 May 2019 — Ultrasound right ankle: "Thickened, disrupted deltoid ligament. Tenosynovial fluid around the tibialis posterior tendon."
- 19 Aug 2019 — MRI right ankle: "Complete rupture of the deep deltoid ligament with medial clear space widening of 6 mm. Longitudinal split tear of the tibialis posterior tendon. Interval progression compared with February 2012."
Onset Date
The most likely date of onset of this condition is 08 Sep 2011.
At that date the veteran was on warlike service in Afghanistan as a paratrooper in an infantry battalion, conducting clearance patrols in full equipment. He jumped about 2.5 metres from a compound wall carrying about 38 kilograms and landed with his right foot forced into eversion, with immediate pain and swelling on the inner ankle.
This date is appropriate because his pre-deployment medical on 02 March 2011 recorded normal ankles with no previous injury, and he presented to the Regimental Medical Officer on 09 September 2011, the day after the injury, with pain and tenderness that began within the 24 hours required by the definition. It falls within uninterrupted full-time service and within the deployment.
The sprain and strain factors relied on require the force or forceful stretching to occur at the time of onset; the jump and eversion landing of 08 Sep 2011 supplied both, with pain and tenderness at the deltoid ligament and tibialis posterior tendon within the following 24 hours.
For the worsening factors, the period after onset runs from 08 Sep 2011 to the documented worsening on 14 Apr 2019. The force and forceful stretching occurred at the time of the worsening, when he stepped down from a vehicle under load on 14 Apr 2019, and the worsening was confirmed on MRI on 19 Aug 2019. The inability to obtain appropriate clinical management covers 08 Sep 2011 to 28 Dec 2011 and 14 Apr 2019 to 30 Jul 2019, both periods of warlike service.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Ankle - Deltoid Ligament Sprain (ICD-10-AM S93.4), with an associated strain of the tibialis posterior tendon, under the Statements of Principles concerning sprain and strain, Balance of Probabilities No. 28 of 2020 and Reasonable Hypothesis No. 27 of 2020.
The deltoid ligament is the strong fan-shaped ligament on the inner side of the ankle that joins the medial malleolus of the tibia to the talus, calcaneus and navicular, and it resists the foot rolling outwards. It is injured by forceful eversion and external rotation, as in a landing from height with the foot turned out. The tibialis posterior tendon runs just behind it and supports the arch, and it is often strained in the same injury. Untreated or repeated deltoid injuries can lead to medial ankle instability, tibialis posterior dysfunction and a flattening arch.
The veteran's injury began on 08 September 2011 on warlike service in Afghanistan, when he landed from a 2.5 metre jump under load with the foot forced into eversion, and it worsened to a complete deep deltoid rupture with a tibialis posterior tear on warlike service in Iraq on 14 April 2019.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
08 September 2011.
When did the veteran first present to a health / medical provider for this condition?
09 September 2011.
When was the condition confirmed / formally diagnosed?
09 September 2011.
When did the veteran first present to you (or your practice) for this condition?
30 October 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by the Regimental Medical Officer on 09 September 2011, with medial ankle swelling and bruising, tenderness over the deltoid ligament, pain on eversion stress and pain on resisted inversion with tenderness along the tibialis posterior tendon, the day after a forceful eversion injury. X-ray excluded fracture. MRI on 14 February 2012 confirmed a partial-thickness tear of the deep deltoid ligament and a low-grade tear of the tibialis posterior tendon.
This is an injury involving tearing of a joint ligament, and tearing of a tendon, with pain and tenderness at the site within 24 hours, meeting the Statement of Principles definitions of sprain and strain. The ankle was stable before the 2019 injury, and the 2019 event was a fresh, high-force injury rather than a recurrent sprain due to joint instability, so the exclusion does not apply. The clinical worsening to a complete deep deltoid rupture with a tibialis posterior split tear was confirmed by MRI on 19 August 2019 and by the orthopaedic foot and ankle surgeon.
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 08 September 2011, 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. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2011, where the sprain and strain occurred, and in Iraq in 2019, where they worsened.
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 Sprain and Strain, No. 28 of 2020
Causative factors
Factor 9(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
- On 08 September 2011 the veteran jumped about 2.5 metres from a compound wall carrying about 38 kilograms and landed on uneven ground with the right foot forced into eversion and external rotation. The landing applied a significant force through the right ankle joint and tore the deep deltoid ligament, with medial pain and swelling immediately and tenderness recorded the next day.
Factor 9(2): 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; — MET
- In the same eversion landing on 08 September 2011 the tibialis posterior muscle contracted forcefully against the outward rotation of the foot while being stretched, straining the tendon. Tenderness along the tendon and pain on resisted inversion were recorded on 09 September 2011, and MRI on 14 February 2012 showed a low-grade tendon tear.
Worsening factors
Factor 9(3): 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
- On 14 April 2019 the veteran stepped down about 1.2 metres from the rear of a protected mobility vehicle carrying about 35 kilograms and landed on a rock with the right foot everting. The force through the ankle completed the rupture of the deep deltoid ligament, with medial clear space widening on MRI on 19 August 2019.
Factor 9(4): 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; — MET
- In the same landing on 14 April 2019 the tibialis posterior tendon was forcefully stretched as the foot everted under load, producing weak, painful resisted inversion and a longitudinal split tear on MRI on 19 August 2019, a worsening from the low-grade tear of 2012.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain. — MET
- After the injury of 08 September 2011 the veteran was required to keep patrolling in a brace for nearly four months without imaging, physiotherapy or orthopaedic review, which were not available until he returned to Australia, and MRI was not obtained until 14 February 2012. After the 2019 injury he again had no MRI, fortnightly physiotherapy at best and no surgical opinion for over three months. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Sprain and Strain, No. 27 of 2020
Causative factors
Factor 9(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
- During a clearance patrol on warlike service in Afghanistan on 08 September 2011 the veteran jumped about 2.5 metres from a compound wall under a load of about 38 kilograms and landed with the right foot forced into eversion, applying significant force through the ankle and tearing the deep deltoid ligament.
Factor 9(2): 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; — MET
- In the eversion landing on warlike service in Afghanistan on 08 September 2011 the tibialis posterior tendon was forcefully stretched while contracting to resist the outward rotation of the foot, straining the tendon, with tenderness recorded on 09 September 2011.
Worsening factors
Factor 9(3): 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
- On warlike service in Iraq on 14 April 2019 the veteran stepped down about 1.2 metres from a protected mobility vehicle under a load of about 35 kilograms and landed on a rock with the foot everting, applying significant force through the right ankle and rupturing the deep deltoid ligament completely.
Factor 9(4): 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; — MET
- In the same landing on warlike service in Iraq on 14 April 2019 the tibialis posterior tendon was forcefully stretched under load, worsening the strain to a longitudinal split tear confirmed on MRI on 19 August 2019.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain. — MET
- On warlike service in Afghanistan from September to December 2011, and in Iraq from April to July 2019, the veteran could not obtain MRI, regular physiotherapy or orthopaedic review for his ankle and was required to continue operational duties in a brace or walking boot. The injury progressed from a partial deep deltoid tear to a complete rupture with a tibialis posterior split tear. 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 right ankle deltoid ligament sprain and the associated tibialis posterior strain are accepted injuries arising from warlike service. Medial ankle instability, tibialis posterior tendon dysfunction with early flattening of the arch, and post-traumatic osteoarthritis risk of the ankle are sequelae of the sprain and strain and of their worsening in 2019.
Unintended Consequence
Not met as a separate pathway. The worsening is attributable to a further service injury and to the lack of access to treatment on deployment rather than to an adverse effect of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the injury of 08 September 2011 on warlike service in Afghanistan the veteran was required to continue patrolling in a brace for nearly four months, with no MRI, physiotherapy or orthopaedic review until he returned to Australia. After the injury of 14 April 2019 in Iraq he again had no MRI, physiotherapy only once a fortnight and no surgical opinion for over three months. The partial deep deltoid tear progressed to a complete rupture with a tibialis posterior split tear, and his Foot and Ankle Ability Measure sports score fell from 78 to 31 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 timely imaging, rehabilitation and specialist care amount to an inability to obtain appropriate clinical management. The return to parachuting in 2012 with persisting medial ankle symptoms is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 02 Mar 2011, Pre-deployment medical, Medical Officer
- 08 Sep 2011, Patrol casualty record, Combat medic, Afghanistan
- 09 Sep 2011, Deployed health record and X-ray report, Regimental Medical Officer, Afghanistan
- 14 Feb 2012, MRI right ankle report and orthopaedic consultation, Orthopaedic surgeon
- 14 Apr 2019, Deployed health record and X-ray report, Medical Officer, Iraq
- 28 May 2019, Ultrasound report, Coalition medical facility, Iraq
- 19 Aug 2019, MRI right ankle report and specialist consultation, Orthopaedic foot and ankle surgeon
- 11 Nov 2019, Operation report, Orthopaedic foot and ankle surgeon
- Statement of Principles concerning Sprain and Strain (Balance of Probabilities) No. 28 of 2020, Repatriation Medical Authority
- Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) No. 27 of 2020, Repatriation Medical Authority
