Right Ankle - Impingement Syndrome — DVA claim example

Diagnostic Assessment — Right Ankle - Impingement Syndrome

Example 1 of 1 · fictitious patient (Veteran BJ)

Diagnostic Assessment

Right Ankle - Impingement Syndrome

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran BJ, date of birth 17 February 1985, Australian Army, Infantry Soldier (Paratrooper, Corporal), enlisted 12 July 2004, medically discharged 03 March 2020. Operational service: East Timor, 08 June 2007 to 15 December 2007 (warlike); Afghanistan, 02 February 2009 to 01 August 2009 (warlike); Afghanistan, 10 May 2012 to 30 November 2012 (warlike).

Occupational History

As a parachute-qualified infantry soldier the veteran made repeated static-line parachute descents, often at night, onto uneven drop zones while carrying equipment containers of 30 to 50 kilograms, with a high rate of ankle inversion and impact injuries on landing. He conducted long foot patrols and route marches carrying 35 to 45 kilograms over rough, rocky and steep terrain.

Infantry duties require repeated forced ankle dorsiflexion when climbing slopes, ladders and compound walls, squatting and kneeling in fire positions, and running on uneven ground in combat boots. Lower limb fractures, sprains and the surgery used to treat them are common in the trade, and soldiers are frequently required to keep working on injured ankles during deployments and exercises.

History

Veteran BJ, a paratrooper in the Australian Army, sustained repeated right ankle inversion injuries and a fracture-dislocation of the right ankle with a posterior talar process fracture in Afghanistan in 2009, treated by internal fixation. He developed combined anterior and posterior impingement syndrome of the right ankle in September 2012 on a later Afghanistan deployment, which worsened after a parachute landing injury in July 2014.

Timeline

• 14 Oct 2007 — On warlike service in East Timor the veteran inverted his right ankle descending a steep, rocky track on patrol carrying about 40 kilograms. He had immediate lateral ankle swelling and bruising and could not bear weight. A medical officer diagnosed a grade 2 sprain of the anterior talofibular ligament, and he was on restricted duties for four weeks. "grade 2 ATFL sprain, right"
• 18 Jun 2009 — On warlike service in Afghanistan the veteran fell about two metres into an irrigation ditch during a night patrol, landing on a forcibly plantarflexed and twisted right ankle. X-ray and CT at the role 3 hospital showed a Weber B fracture of the distal fibula with syndesmotic disruption and a fracture of the posterior process of the talus. He underwent plate fixation of the fibula and syndesmotic screw insertion and was evacuated to Australia. "Weber B fracture, talar process fracture"
• 02 Mar 2011 — After returning to parachuting the veteran had two further inversion injuries of the right ankle on landing, in August 2010 and January 2011. An orthopaedic surgeon found a positive anterior drawer test and increased talar tilt and diagnosed chronic lateral ankle instability. CT showed non-union of the posterior talar process fragment. He was fitted with an ankle brace and continued full duties. "chronic lateral instability, non-union fragment"
• 30 Apr 2012 — At his pre-deployment medical examination the veteran reported occasional lateral ankle giving way but no ankle pain, and he had full painless dorsiflexion and plantarflexion. His parachute log recorded 132 descents since 2005. He had completed about 4,200 hours of foot patrolling and route marching with loads of at least 20 kilograms since enlistment. "ankle pain-free, full range"
• 10 Sep 2012 — On warlike service in Afghanistan the veteran presented to the role 2 facility with one week of constant pain at the front of the right ankle on climbing slopes and compound ladders and when kneeling, and pain at the back of the ankle when walking downhill. Forced dorsiflexion and forced plantarflexion both reproduced the pain. He was given anti-inflammatories and continued patrolling. "anterior and posterior ankle pain"
• 22 Feb 2013 — MRI of the right ankle showed anterior tibial and talar neck osteophytes, anterolateral gutter synovitis with a meniscoid lesion, a thickened distal fascicle of the anterior inferior tibiofibular ligament, and a non-united posterior talar process fragment with surrounding oedema and posterior synovitis. An orthopaedic surgeon diagnosed combined anterior, anterolateral and posterior impingement syndrome of the right ankle and placed him on a waiting list for arthroscopy. "anterior and posterior impingement, MRI"
• 15 Jul 2014 — Still awaiting surgery, the veteran landed heavily on a rocky drop zone during a parachute descent in Australia and inverted his right ankle. He developed constant pain, swelling and a block to dorsiflexion. Repeat MRI on 29 July 2014 showed enlarged anterior osteophytes, increased synovitis and a new osteochondral contusion of the talar dome. The surgeon recorded worsening of the impingement, with dorsiflexion reduced from 15 to 0 degrees. "parachute injury, dorsiflexion now 0"
• 05 May 2015 — Arthroscopic debridement of the right ankle with excision of the anterior osteophytes and anterolateral soft tissue, and posterior arthroscopic excision of the posterior talar fragment, was finally performed, 26 months after the diagnosis. Persistent pain and stiffness led to permanent restrictions and medical discharge in 2020. "arthroscopic debridement, delayed 26 months"

Symptoms

At onset the veteran had constant pain at the front and outer side of the right ankle on climbing, squatting and kneeling, and pain at the back of the ankle on walking downhill and pushing off, with swelling after patrols and a sense of blocking at the end of dorsiflexion.

After onset the pain increased with patrolling and parachuting and, after the July 2014 injury, he lost all dorsiflexion beyond neutral. He now reports daily right ankle pain and stiffness, inability to run, squat or walk on uneven ground, swelling after walking more than two kilometres and difficulty with stairs and ladders.

Imaging

• 18 Jun 2009 — X-ray and CT right ankle: "Weber B fracture of the distal fibula with widening of the syndesmosis. Displaced fracture of the posterior process of the talus."
• 02 Mar 2011 — CT right ankle: "United fibular fracture with plate in situ. Non-union of the posterior talar process fragment. Small anterior tibial osteophyte."
• 22 Feb 2013 — MRI right ankle: "Anterior tibial and talar neck osteophytes. Anterolateral gutter synovitis with meniscoid lesion. Thickened distal fascicle of the anterior inferior tibiofibular ligament. Non-united posterior talar process fragment with oedema and posterior synovitis. Attenuated anterior talofibular ligament."
• 29 Jul 2014 — MRI right ankle: "Enlarged anterior osteophytes with increased anterior and anterolateral synovitis. New osteochondral contusion of the anterior talar dome."

Onset Date

The most likely date of onset of this condition is 03 Sep 2012.

At that date the veteran was a serving Army corporal on warlike service in Afghanistan, conducting daily foot patrols over steep, rocky terrain carrying about 40 kilograms and repeatedly climbing compound walls and ladders. From that day he had constant anterior and posterior right ankle pain on dorsiflexion and plantarflexion.

This date is appropriate because his pre-deployment medical examination on 30 April 2012 recorded no ankle pain and full painless movement, and he first presented to the role 2 facility on 10 September 2012 reporting one week of constant pain. MRI on 22 February 2013 confirmed impingement. The date falls within continuous full-time service.

For the injury and surgery causes, the inversion injury of 14 October 2007, the fracture of 18 June 2009 and its fixation, and the inversion injuries of August 2010 and January 2011 all occurred more than 3 months before onset. For chronic instability and the non-united posterior fragment, both were documented on 02 March 2011 and present for at least the 6 months before onset, from 03 Mar 2012 to 03 Sep 2012. For parachuting, the 10 years before onset run from 03 Sep 2002 to 03 Sep 2012 and contain 132 descents. For load carriage, the same 10 years contain about 4,200 hours of marching and patrolling with loads of at least 20 kilograms. For repetitive forced dorsiflexion, the 3 months before onset run from 03 Jun 2012 to 03 Sep 2012, during which he climbed slopes, walls and ladders on patrol every day.

For the worsening causes, the documented worsening was on 29 Jul 2014. The inversion injury on landing occurred on 15 Jul 2014, two weeks before it. The 12 months before the worsening run from 29 Jul 2013 to 29 Jul 2014, during which he made 11 further parachute descents and continued loaded marching while awaiting surgery that had been recommended on 22 February 2013.

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

The formal diagnosis is Right Ankle - Impingement Syndrome, being combined anterior, anterolateral and posterior impingement syndrome of the right ankle (ICD-10-AM M25.87).

Ankle impingement syndrome is painful mechanical limitation of ankle movement caused by bony or soft tissue structures being compressed between the tibia and talus at the end of the range. In anterior impingement, osteophytes on the front of the tibia and talar neck abut in dorsiflexion; in anterolateral impingement, scarred and inflamed synovium, a meniscoid lesion or a thickened fascicle of the anterior inferior tibiofibular ligament is trapped in the lateral gutter after inversion and syndesmotic injury; in posterior impingement, a posterior talar process fragment or os trigonum and surrounding soft tissue are compressed in plantarflexion. It follows ankle sprains, fractures, instability and repeated forced dorsiflexion and plantarflexion loading, and is common in paratroopers, soldiers and athletes.

The diagnosis followed an inversion injury in 2007, a fracture of the fibula and posterior talar process with internal fixation in 2009, chronic lateral instability and years of parachuting and loaded patrolling. It began on 03 September 2012, was confirmed on MRI on 22 February 2013 and worsened in July 2014.

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

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

03 September 2012.

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

10 September 2012.

When was the condition confirmed / formally diagnosed?

22 February 2013.

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

26 February 2025.

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

The diagnosis was confirmed on MRI of 22 February 2013, which showed anterior tibial and talar neck osteophytes, anterolateral gutter synovitis with a meniscoid lesion and a thickened distal fascicle of the anterior inferior tibiofibular ligament, and a non-united posterior talar process fragment with surrounding oedema and synovitis. These are the recognised structural features of anterior, anterolateral and posterior impingement.

The clinical picture was consistent: anterior and anterolateral ankle pain reproduced by forced dorsiflexion, posterior pain reproduced by forced plantarflexion, tenderness over the anterolateral gutter and behind the lateral malleolus, and a block to end-range dorsiflexion. An orthopaedic surgeon confirmed the diagnosis, and arthroscopy on 05 May 2015 confirmed impinging osteophytes, anterolateral scar tissue and the posterior fragment. The worsening was confirmed on 29 July 2014 by MRI showing enlarged osteophytes, increased synovitis and a talar contusion, with dorsiflexion reduced from 15 degrees to neutral.

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 impingement syndrome of the ankle. 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 orthopaedic and sports medicine literature.

Legislation: the clinical onset of this condition was on 03 September 2012, after 1 July 2004, during continuous full-time service and while on warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The veteran's warlike service in East Timor in 2007 and Afghanistan in 2009 and 2012, where the inversion injury, the fracture and the onset occurred, is operational service, and his parachuting and training in Australia is peacetime service. Each cause must be related to 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 an inversion injury of the affected ankle with sprain of the lateral ligament complex at least 3 months before the clinical onset of impingement syndrome of the ankle; — MET

- On warlike service in East Timor on 14 October 2007 the veteran sustained a grade 2 anterior talofibular ligament sprain of the right ankle on patrol, and further inversion injuries on parachute landings in August 2010 and January 2011. All occurred well over 3 months before onset on 03 September 2012. Scarring and synovitis in the anterolateral gutter after lateral ligament injury is the classic cause of anterolateral impingement.

Cause 2: having a fracture of the affected ankle, including a fracture of the malleoli or the talus, at least 3 months before the clinical onset of impingement syndrome of the ankle; — MET

- On warlike service in Afghanistan on 18 June 2009 the veteran sustained a Weber B fracture of the right distal fibula and a fracture of the posterior process of the talus in a fall into an irrigation ditch, confirmed on CT, more than three years before onset.

Cause 3: having an injury to the distal tibiofibular syndesmosis of the affected ankle before the clinical onset of impingement syndrome of the ankle; — MET

- The 2009 fracture was accompanied by syndesmotic disruption requiring a syndesmotic screw. The thickened distal fascicle of the anterior inferior tibiofibular ligament shown on MRI on 22 February 2013 is a direct consequence of that injury and a recognised cause of anterolateral impingement.

Cause 4: having undergone surgery to the affected ankle at least 3 months before the clinical onset of impingement syndrome of the ankle; — MET

- On 18 June 2009 the veteran underwent open reduction and plate fixation of the fibula and syndesmotic screw insertion. Post-surgical arthrofibrosis and synovial scarring contribute to impingement, and the surgery was more than three years before onset.

Cause 5: having chronic lateral instability of the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle; — MET

- An orthopaedic surgeon diagnosed chronic lateral ankle instability on 02 March 2011, with a positive anterior drawer test and increased talar tilt, after recurrent service inversion injuries. It persisted throughout the 6 months before onset, from 03 March 2012 to 03 September 2012, and repeated abnormal talar movement promotes anterior osteophytes and synovitis.

Cause 6: having an os trigonum, a non-united fracture of the posterior process of the talus or an enlarged posterior talar process in the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle; — MET

- CT on 02 March 2011 showed non-union of the posterior talar process fragment from the 2009 service fracture. The fragment was present throughout the 6 months before onset and caused the posterior component of the impingement, compressed between the tibia and calcaneus in plantarflexion.

Cause 7: making at least 100 parachute descents within the 10 years before the clinical onset of impingement syndrome of the ankle; — MET

- The veteran's parachute log records 132 static-line descents between 2005 and April 2012, within the 10 years before onset, from 03 September 2002 to 03 September 2012, many at night and with heavy equipment containers. Parachute landings impose repeated forced dorsiflexion and inversion loads on the ankle.

Cause 8: marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 2,000 hours within the 10 years before the clinical onset of impingement syndrome of the ankle; — MET

- Unit training and deployment records show about 4,200 hours of route marching and foot patrolling with loads of 35 to 45 kilograms from 2004 to 2012, including warlike service in East Timor and Afghanistan, all within the 10 years before onset.

Cause 9: undertaking activities involving repeated forced dorsiflexion of the affected ankle, such as climbing steep slopes, ladders or walls, squatting or kneeling, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle; — MET

- On warlike service in Afghanistan from May 2012 the veteran patrolled steep terrain, climbed compound walls and ladders and knelt in fire positions every day carrying about 40 kilograms. This continued throughout the 3 months before onset, from 03 June 2012 to 03 September 2012. Repeated forced dorsiflexion causes the anterior tibial and talar neck osteophytes of anterior impingement.

Cause 10: undertaking activities involving repeated forced plantarflexion of the affected ankle, such as descending steep slopes or stairs or jumping and landing, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle; — MET

- The same patrols involved long descents down steep, loose slopes and repeated jumping down from compound walls and irrigation banks under load, every day throughout the 3 months before onset. Forced plantarflexion compresses the posterior talar fragment and soft tissue and is the recognised mechanism of posterior impingement.

Worsening factors

Worsening 1: having a further inversion or impact injury of the affected ankle within the 3 months before the clinical worsening of impingement syndrome of the ankle; — MET

- On 15 July 2014 the veteran inverted his right ankle on a heavy parachute landing on a rocky drop zone, two weeks before the worsening documented on MRI on 29 July 2014, which showed enlarged osteophytes, increased synovitis and a new talar dome contusion, with dorsiflexion lost to neutral.

Worsening 2: making parachute descents or undertaking activities involving repeated forced dorsiflexion or plantarflexion of the affected ankle within the 12 months before the clinical worsening of impingement syndrome of the ankle; — MET

- Between 29 July 2013 and 29 July 2014 the veteran made 11 parachute descents and continued infantry training involving climbing, kneeling and jumping, as required by his employment while awaiting surgery.

Worsening 3: marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 200 hours within the 12 months before the clinical worsening of impingement syndrome of the ankle; — MET

- Unit records show about 260 hours of route marching and field exercises with loads of 30 to 40 kilograms in the 12 months before the worsening, from 29 July 2013 to 29 July 2014.

Worsening 4: inability to obtain appropriate clinical management for impingement syndrome of the ankle. — MET

- Arthroscopic debridement was recommended on 22 February 2013 but not performed until 05 May 2015, 26 months later, and in the meantime he was not removed from parachuting. The impingement worsened during that delay after the July 2014 parachute injury. 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 impingement syndrome is a sequela of the veteran's accepted right ankle injuries: the lateral ligament sprain of 2007, the fracture of the fibula and posterior talar process with syndesmotic disruption in 2009, and the resulting chronic lateral ankle instability. The impingement has in turn contributed to post-traumatic arthritis of the right ankle and an altered gait, which should be considered as sequelae.

Unintended Consequence

Met. Part of the anterolateral scarring and stiffness is an unintended consequence of the open reduction, internal fixation and syndesmotic screw insertion of 18 June 2009, 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. An orthopaedic surgeon recommended arthroscopic debridement on 22 February 2013, but the operation did not take place until 05 May 2015, 26 months later, and in the meantime the veteran remained on parachuting and field duties. During that delay he sustained a further parachute injury and the impingement worsened, with dorsiflexion lost to neutral. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a delay of this length in providing recommended treatment, in circumstances outside his control, amounts to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 14 Oct 2007, Field medical record, Medical Officer, East Timor
2. 18 Jun 2009, Trauma admission, X-ray and CT, operation report, Role 3 hospital, Afghanistan
3. 02 Mar 2011, Orthopaedic consultation and CT right ankle, Orthopaedic surgeon
4. 30 Apr 2012, Pre-deployment medical examination, Medical Officer
5. 10 Sep 2012, Role 2 treatment record, Medical Officer, Afghanistan
6. 22 Feb 2013, MRI right ankle and orthopaedic consultation, Orthopaedic surgeon
7. 15 Jul 2014, Drop zone injury report and outpatient record, Medical Officer
8. 29 Jul 2014, MRI right ankle, Radiologist
9. 05 May 2015, Arthroscopy operation report, Orthopaedic surgeon
10. Parachute log summary, 2005 to 2014, Parachute training records
11. Recognised causes of ankle impingement syndrome, orthopaedic and sports medicine literature (no Statement of Principles)