Diagnostic Assessment — Right Ankle - Joint Instability
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
RIGHT ANKLE - JOINT INSTABILITY
Statement of Principles concerning joint instability (Reasonable Hypothesis) Instrument No. 26 of 2021 and Statement of Principles concerning joint instability (Balance of Probabilities) Instrument No. 27 of 2021.
ADF History
Name: The veteran
Date of Birth: [withheld]
Occupation: Communications, SASR
Enlistment Date: 17 Dec 1993
Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran has been exposed to significant occupational hazards affecting the ankle joint. SASR operations require movement over variable and unpredictable terrain, often while carrying heavy loads of communications equipment, weapons, and tactical gear. These activities place the ankle at high risk for traumatic injury including sprains that can lead to chronic instability. The role involves tactical movements including rapid changes in direction, jumping from heights, and navigating obstacles during both training and operational deployment. Night operations and limited visibility conditions increase the risk of misplacement of the foot and subsequent ankle trauma. These occupational exposures create substantial risk for both acute ankle injuries and the development of chronic instability over time.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, sustained a right ankle injury during a training exercise and subsequently developed chronic lateral ankle instability. Clinical evaluation and stress testing have confirmed persistent instability of the right ankle joint consistent with ligamentous insufficiency following the initial injury.
Timeline
- 29 Dec 2014: Initial injury during field training exercise. Patient reports "rolling" the right ankle while moving over uneven terrain with communications equipment.
- 30 Dec 2014: Initial assessment documented significant lateral ankle swelling, ecchymosis, and pain with weight-bearing. Clinical assessment of acute lateral ankle sprain, grade 2-3.
- 31 Dec 2014: X-rays of right ankle performed. "No evidence of fracture. Soft tissue swelling laterally."
- 06 Jan 2015: Follow-up assessment noting continued pain and instability with weight-bearing. "Unable to fully trust the ankle when walking".
- 20 Jan 2015: Physical therapy assessment and initiation of rehabilitation program. "Persistent laxity with anterior drawer and talar tilt testing".
- 27 Feb 2015: Progress evaluation noting improved strength but continued sensation of instability. "Reports frequent episodes of the ankle 'giving way' during routine activities".
- 24 Mar 2015: MRI Right Ankle performed. "Chronic tear of the anterior talofibular ligament with attenuation and scarring. Mild thickening of the calcaneofibular ligament consistent with prior sprain. No evidence of osteochondral lesion."
- 08 Apr 2015: Orthopedic consultation confirming diagnosis of chronic right ankle instability. "Mechanical instability with positive stress testing and corresponding MRI findings".
Symptoms
Following the initial injury on 29 December 2014, the veteran experienced significant pain, swelling, and ecchymosis of the right lateral ankle consistent with an acute ligamentous sprain. After the acute phase, he developed persistent symptoms of instability, including a sensation of the ankle "giving way" during routine activities, particularly when walking on uneven surfaces or during changes in direction. Physical examination demonstrated positive anterior drawer and talar tilt tests, indicating mechanical instability of the lateral ankle ligaments. Current symptoms include recurrent episodes of ankle instability during occupational activities, particularly when carrying equipment over variable terrain, persistent mild swelling after prolonged activity, and difficulty with certain tactical movements that require rapid direction changes or single-leg stability. These symptoms significantly impact his operational effectiveness in the field, requiring compensatory mechanisms and protective bracing during high-demand activities.
Imaging
31 Dec 2014 - X-RAY RIGHT ANKLE: AP, lateral, and mortise views demonstrate no evidence of fracture or dislocation. The ankle mortise is intact and well-aligned. There is significant soft tissue swelling over the lateral malleolus. No evidence of osteochondral lesions or degenerative changes. IMPRESSION: Soft tissue swelling consistent with lateral ankle sprain. No fracture identified.
24 Mar 2015 - MRI RIGHT ANKLE: The anterior talofibular ligament demonstrates abnormal morphology with thinning, elongation, and increased signal intensity consistent with a chronic tear and scarring. The calcaneofibular ligament shows mild thickening consistent with prior sprain but appears intact. The deltoid ligament complex appears intact. The posterior talofibular ligament is unremarkable. The Achilles tendon and peroneal tendons are intact. No evidence of osteochondral lesion of the talar dome. Mild joint effusion is present. IMPRESSION: Chronic tear of the anterior talofibular ligament consistent with lateral ankle instability. Evidence of prior calcaneofibular ligament sprain with healing.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Ankle Joint Instability (ICD-10 Code: M25.37). This diagnosis falls under the DVA Statement of Principles concerning joint instability (Reasonable Hypothesis) Instrument No. 26 of 2021 and Statement of Principles concerning joint instability (Balance of Probabilities) Instrument No. 27 of 2021.
Joint instability refers to abnormal excessive movement of a joint that results in symptoms and/or functional impairment. In the ankle, this commonly presents as lateral ankle instability following damage to the lateral ligament complex, particularly the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The condition is characterized by recurrent episodes of the ankle "giving way," persistent or recurrent symptoms of pain and swelling, and difficulty performing activities that challenge ankle stability.
Ankle joint instability is typically classified as mechanical (demonstrable excessive joint movement on clinical examination or stress radiography) and/or functional (subjective feeling of instability without demonstrable excessive joint movement). The veteran demonstrates both mechanical instability, confirmed by positive stress testing and MRI findings of ligamentous damage, and functional instability with subjective reports of the ankle "giving way" during activities.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced acute injury to the right ankle on 29 December 2014, when he "rolled" the ankle during a field training exercise while carrying communications equipment over uneven terrain. Symptoms of chronic instability developed in the weeks following the initial injury, with specific documentation of instability symptoms by 06 January 2015.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a health provider for the acute ankle injury on 30 December 2014, the day after the initial trauma. He subsequently reported symptoms of chronic instability during follow-up assessment on 06 January 2015.
When was the condition confirmed / formally diagnosed?
The condition of chronic right ankle instability was initially documented during physical therapy assessment on 20 January 2015. Objective confirmation was provided by MRI on 24 Mar 2015, which demonstrated chronic tear of the anterior talofibular ligament consistent with lateral ankle instability. The diagnosis was formally established by an orthopedic specialist on 08 Apr 2015.
When did the veteran first present to you (or your practice) for this condition?
24 February 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.
The diagnosis of Right Ankle Joint Instability was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included sensation of the ankle "giving way" during routine activities, difficulty walking on uneven surfaces, instability with changes in direction, persistent mild swelling after prolonged activity, and decreased confidence in the right ankle during operational activities.
Clinical examination findings included positive anterior drawer test (indicating anterior talofibular ligament laxity), positive talar tilt test (indicating calcaneofibular ligament laxity), mild persistent swelling in the lateral ankle region, decreased proprioception on single-leg balance testing, and normal range of motion but with apprehension at extremes.
Diagnostic imaging provided confirmation of underlying pathology with MRI of the Right Ankle demonstrating chronic tear of the anterior talofibular ligament with thinning, elongation, and increased signal intensity, mild thickening of the calcaneofibular ligament consistent with prior sprain, mild joint effusion, and absence of osteochondral lesions.
Specialist opinion from orthopedic consultation confirmed the diagnosis of chronic right ankle instability, noting both mechanical instability demonstrated on stress testing and corresponding MRI findings of ligamentous damage.
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.
Factors under Statement of Principles concerning joint instability (Balance of Probabilities) Instrument No. 27 of 2021:
having a significant physical force applied to the affected joint at the time of the clinical onset of joint instability: MET
- The veteran sustained a documented right ankle injury on 29 December 2014 during a field training exercise, when he "rolled" the ankle while carrying communications equipment over uneven terrain. This mechanism is consistent with an inversion injury applying significant force to the lateral ankle structures, particularly the anterior talofibular and calcaneofibular ligaments. The subsequent development of chronic instability is directly related to this initial traumatic event.
having damage to a joint stabilising structure of the affected joint at the time of the clinical onset of joint instability: MET
- The initial ankle injury resulted in damage to the lateral ligament complex of the right ankle, specifically the anterior talofibular ligament and calcaneofibular ligament, as confirmed by subsequent MRI findings. These structures are primary stabilizers of the ankle joint, and their damage directly led to the development of chronic instability.
having a disease process affecting the integrity of a joint stabilising structure of the affected joint at the time of the clinical onset of joint instability: NOT MET
- No underlying disease process affecting joint structures documented.
having an inflammatory or degenerative joint disease of the affected joint at the time of the clinical onset of joint instability: NOT MET
- No inflammatory or degenerative joint disease documented.
having a neurological condition affecting the stability of the affected joint at the time of the clinical onset of joint instability: NOT MET
- No neurological condition affecting joint stability documented.
inability to obtain appropriate clinical management for joint instability: NOT MET
- There is no evidence that appropriate management was unavailable once the condition developed.
Factors under Statement of Principles concerning joint instability (Reasonable Hypothesis) Instrument No. 26 of 2021:
The factors in the Reasonable Hypothesis SOP are identical to those in the Balance of Probabilities SOP, with the same MET status for physical force and damage to joint stabilizing structures, and NOT MET status for all other factors.
The right ankle joint instability in the veteran has a clear causal relationship to his documented ankle injury sustained during a field training exercise on 29 December 2014. The mechanism of injury—rolling the ankle while carrying equipment over uneven terrain—is typical for lateral ankle sprains that damage the anterior talofibular and calcaneofibular ligaments. The MRI findings of chronic ATFL tear and evidence of prior CFL sprain provide objective confirmation of the pathological basis for his chronic instability.
Sequelae
There is no indication that the right ankle joint instability is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the right ankle joint instability resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his right ankle condition. Upon sustaining the initial injury, he received timely assessment, appropriate diagnostic imaging, physical therapy rehabilitation, and specialist consultation when symptoms of chronic instability persisted.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
