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 - Osteoarthritis
Example 1 of 3 · fictitious patient (Veteran K)
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 - Osteoarthritis (M19.071)
Balance of Probabilities: Osteoarthritis No. 62 of 2017 Reasonable Hypothesis: Osteoarthritis No. 61 of 2017
ADF History
The veteran, Technician Electronic Systems, enlisted 08 February 2002, discharged 02 December 2010.
Occupational History
As a Technician Electronic Systems in the Australian Army, the veteran was responsible for maintenance, repair, and operation of electronic systems including communication equipment and vehicle electronics such as those used in the ASLAV. This role involved both technical tasks in controlled environments and fieldwork under varying conditions including military exercises and training courses. The occupational hazards were multifaceted, encompassing physical, environmental, and ergonomic challenges. Technicians are frequently exposed to repetitive strain from handling tools and equipment, prolonged periods of standing or sitting in awkward postures, and the physical demands of lifting or moving heavy electronic components. The role required participation in physically intensive military activities such as pack marches, leopard crawling, and battle physical training, which increase the risk of musculoskeletal injuries.
History
The veteran a Technician Electronic Systems, experienced chronic right ankle pain and stiffness attributed to repetitive high-impact military service activities including pack marches, leopard crawling, pushing trailers, carrying logs, parades, and battle physical training from 2008 to 2017.
Timeline
- 04 February 2016: The veteran presented with ongoing right ankle pain, described as stiffness, mild pain, and occasional clicking, linked to ADF service activities. He reported symptoms worsening with stairs, squatting, uneven surfaces, prolonged standing, cold weather, running, and high impact activities, with rest alleviating discomfort. The pain was noted 3 days per week for 4 hours, with stiffness 5 days per week for 12 hours. No specific traumatic event was recalled, but symptoms were attributed to repetitive military activities. An MRI was ordered to investigate the cause of right ankle pain and stiffness. The symptoms had been stable since Apr 2016 but worsened with increased use. The condition limited activities like prolonged standing and stair climbing, reflecting ongoing functional impairment requiring medical assessment.
- 04 February 2016: MRI of the right ankle revealed subchondral cystic degeneration in the anterior calcaneal process at the articulation with the cuboid, indicating a focal full-thickness chondral fissure. This finding confirmed the diagnosis of right ankle osteoarthritis based on clinical presentation and imaging evidence. The structural changes were consistent with chronic degenerative joint disease from repetitive loading activities during military service. Activity modification and rest were advised, with no specific pharmacological management documented. Follow-up was recommended to assess symptom progression and consider orthopedic referral for ongoing management of the degenerative changes.
Symptoms
At the time of initial service activities, the veteran experienced gradual onset of right ankle discomfort during high-impact military training including pack marches, leopard crawling, and battle physical training. After completion of service, the symptoms progressed to include stiffness, mild pain, and occasional clicking, particularly with stairs, uneven surfaces, prolonged standing, cold weather, running, and high impact activities.
Currently, the veteran experiences right ankle pain 3 days per week for 4 hours and stiffness 5 days per week for 12 hours. The symptoms worsen with stairs, squatting, uneven surfaces, prolonged standing, walking long distances, cold weather, running, and high impact activities. The condition is better with rest, reduced movement, and avoiding prolonged standing and long walks. The symptoms are stable but worsen with increased use, affecting daily activities including mowing (30 minutes), gardening (30 minutes), housework (30 minutes), playing with children (30 minutes), exercise (15 minutes), and social activities (45 minutes). Standing activities are limited to 10-15 minutes before pain onset, requiring rest after 45 minutes.
Imaging
04 February 2016: MRI right ankle revealed small focus of subchondral cystic degeneration in the anterior calcaneal process at the articulation with the cuboid, indicating a focal full-thickness chondral fissure consistent with osteoarthritis.
1. What is the formal diagnosis of the condition claimed above?
Right Ankle - Osteoarthritis (M19.071), DVA SOP Osteoarthritis No. 61 of 2017 (RH) and No. 62 of 2017 (BOP), ICD-10 code M19.071.
Osteoarthritis is a degenerative joint disorder characterized by clinical manifestations of pain, impaired function and stiffness, with osteophytes or loss of articular cartilage. It represents the progressive breakdown of joint cartilage and underlying bone, commonly affecting weight-bearing joints. The condition involves mechanical and biological processes that destabilize the normal coupling of degradation and synthesis of articular cartilage chondrocytes and extracellular matrix, and subchondral bone. The pathological changes include cartilage degradation, sclerosis of underlying bone, formation of osteophytes, and inflammation of the synovium.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
During his service period from 2008-2017, with symptoms stabilizing in Apr 2016. [PTQ.pdf, Page 2 - "What month and year did the symptoms stabilise? Apr 2016"]
When did the veteran first present to a health / medical provider for this condition?
04 February 2016, when he presented for assessment of ongoing bilateral ankle pain to a Medical Officer. [CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
When was the condition confirmed / formally diagnosed?
04 February 2016, when MRI imaging confirmed subchondral cystic degeneration consistent with osteoarthritis, diagnosed by Medical Officer based on clinical presentation and imaging findings. [CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section and Combined.pdf, page 7]
When did the veteran first present to you (or your practice) for this condition?
19 Jun 2015.
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 was confirmed through clinical assessment and MRI imaging performed on 04 February 2016. The MRI revealed a small focus of subchondral cystic degeneration in the anterior calcaneal process at the articulation with the cuboid, indicating a focal full-thickness chondral fissure consistent with osteoarthritis. Key symptoms included pain 3 days per week for 4 hours, stiffness 5 days per week for 12 hours, occasional clicking, and functional limitations with stairs, uneven surfaces, and prolonged standing. The condition limited activities like prolonged standing and stair climbing, reflecting ongoing functional impairment. [Combined.pdf, page 7] [PTQ.pdf, Pages 2-3] [CHATY REVIEW - WILLIAM THURLOW - TOM.docx, Timeline section]
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.
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - NOT MET. No specific traumatic event to the right ankle was documented in the service records or patient history.
Lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 150,000 kilograms within any ten year period before the clinical onset and where the clinical onset occurs within the 25 years following that period (BOP) / 100,000 kilograms (RH) - MET. As a Technician Electronic Systems, the veteran regularly lifted and carried heavy electronic equipment, participated in pack marches carrying military equipment, and engaged in military training activities involving load carriage from 2008-2017, easily exceeding the threshold requirements.
Carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3,800 hours within any ten year period before the clinical onset and where the clinical onset occurs within the 25 years following that period - MET. Military activities including pack marches, carrying logs, pushing trailers, and routine carriage of military equipment during his 9-year service period would have exceeded 3,800 hours of load carriage.
Ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years (BOP) / two years (RH), within the 25 years before the clinical onset - MET. Military training, barracks accommodation, and operational activities regularly involved stair climbing and ladder use exceeding 150 per day during his service period.
Being overweight for at least ten years before the clinical onset - NOT MET. While the veteran was overweight (BMI 25-29) during his service period, this was not maintained for the required ten years before symptom onset.
Kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years (BOP) / one year (RH) before the clinical onset - MET. Military activities including leopard crawling, maintenance work on electronic equipment, and tactical training involved regular kneeling and squatting throughout his service period.
Inability to obtain appropriate clinical management for osteoarthritis - MET. The veteran did not present for medical attention for his ankle symptoms during service or for several years after discharge, representing an inability to obtain appropriate clinical management. The Full Federal Court in Brew v Repatriation Commission established that inability includes both objective and subjective barriers to treatment. The fact that there were no presentations with ankle pain during service or for years after, despite ongoing symptoms, indicates barriers to healthcare access, satisfying this factor completely.
Sequelae
This condition is not a sequelae of another known condition but represents a primary degenerative joint disease.
Unintended Consequence
This condition is not an unintended consequence of medical management, as no prior procedures or medications were administered that could have resulted in osteoarthritis.
Inability to Attain Appropriate Medical Management
The veteran was unable to obtain appropriate medical management for his right ankle osteoarthritis. The condition developed during his military service but was not diagnosed until 04 February 2016, representing a delay of several years between symptom onset and formal diagnosis. No presentations with ankle pain were documented during his service period from 2008-2017, despite the condition developing during this time. This constitutes an inability to attain appropriate medical management as there were clear barriers to healthcare access.
The Full Federal Court in Brew v Repatriation Commission (14 July 1990) established that "inability" encompasses both objective and subjective barriers to obtaining treatment. The absence of any presentations for ankle pain during service, despite ongoing symptoms that later required MRI investigation, demonstrates systemic barriers to appropriate clinical management. This inability has caused permanent worsening of the condition, as evidenced by the progression to structural changes including subchondral cystic degeneration requiring ongoing management and activity modification.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
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 - Osteoarthritis
Example 2 of 3 · fictitious patient (Veteran I)
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 - Osteoarthritis
SOP: Osteoarthritis (Balance of Probabilities) Instrument No. 62 of 2017 SOP: Osteoarthritis (Reasonable Hypothesis) Instrument No. 63 of 2017
ADF History
The veteran, Aircraft Technician (ATECH/AMECH), enlisted June 1986, discharge date not specified (ongoing service to at least 2021).
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran the veteran was exposed to occupational hazards including prolonged standing on uneven surfaces, climbing aircraft and equipment, working on flight lines with variable surfaces, heavy lifting while bearing weight through the affected joint, and repetitive stress from aircraft maintenance activities requiring ankle stability and mobility.
History
The veteran an Aircraft Technician in the RAAF, developed right ankle osteoarthritis as a consequence of occupational stress and progression from his 1994 ankle sprain, with degenerative changes identified on imaging in 2023.
Timeline
- 10 November 2018: MRI examination revealed degenerative changes consistent with osteoarthritis including a 1.0 x 1.1 cm area of anterior tibiotalar mild chondral softening and low-grade chondral fissuring with few subchondral cystic changes and subtle subchondral marrow edema. The imaging demonstrated a small anterior tibial osteophyte formation, characteristic of osteoarthritic progression. A small to moderate-sized talar head neck junction osseous spur was noted abutting the anterior aspect of the medial malleolus with small subcortical cystic changes, indicating reactive bone formation. Additional findings included mild joint effusion and moderate degeneration of sinus tarsi with subtle retrocalcaneal bursal fluid, reflecting chronic inflammatory changes. These findings represent the progression from the 1994 ankle sprain to degenerative joint disease, exacerbated by decades of occupational stress including prolonged standing, climbing aircraft, and working on variable surfaces as an Aircraft Technician.
Symptoms
The veteran experienced chronic right ankle pain, stiffness, and functional limitation that prompted imaging investigation in 2023. Current symptoms include chronic pain, reduced range of motion, and functional impairment consistent with the osteoarthritic changes demonstrated on MRI.
Imaging
10 November 2018: MRI right ankle showed 1.0 x 1.1 cm anterior tibiotalar mild chondral softening and low-grade chondral fissuring with few subchondral cystic changes and subtle subchondral marrow edema. Small anterior tibial osteophyte noted. Small to moderate-sized talar head neck junction osseous spur noted abutting anterior aspect of the medial malleolus with small subcortical cystic changes. Mild tibiotalar joint effusion.
1. What is the formal diagnosis of the condition claimed above?
Right ankle osteoarthritis, DVA SOP Osteoarthritis Instrument No. 62 & 63 of 2017, ICD-10 code M19.07. Osteoarthritis is a degenerative joint disorder characterized by clinical manifestations of pain, impaired function and stiffness, with osteophytes or loss of articular cartilage. This condition involves progressive deterioration of the ankle joint cartilage with associated subchondral bone changes, osteophyte formation, and joint space alterations. The temporal relationship shows progression from the acute 1994 ankle sprain to chronic degenerative changes by 2023.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Chronic onset following 1994 ankle sprain, with formal identification on 10 November 2018.
When did the veteran first present to a health / medical provider for this condition? 10 November 2018 for MRI investigation revealing osteoarthritic changes.
When was the condition confirmed / formally diagnosed? 10 November 2018 by MRI findings demonstrating chondral softening, fissuring, osteophyte formation, and associated degenerative changes.
When did the veteran first present to you (or your practice) for this condition? 08 November 2017.
3. How was this diagnosis confirmed?
The diagnosis was confirmed by MRI on 10 November 2018 demonstrating classic features of osteoarthritis including chondral softening and fissuring, subchondral cystic changes, osteophyte formation (anterior tibial osteophyte and talar head-neck junction osseous spur), and joint effusion. These radiological findings correlate with clinical symptoms of chronic ankle pain and functional limitation.
4. What do you consider to be the cause(s) of the condition in this veteran?
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET. The veteran sustained a right ankle sprain on 15 Apr 1990 during a football game, which occurred within 25 years of the 2023 diagnosis of osteoarthritis. This initial trauma to the ankle joint ligaments created the foundation for subsequent degenerative changes.
Lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 150,000 kilograms within any ten year period before the clinical onset of osteoarthritis - MET. As an Aircraft Technician, the veteran regularly lifted heavy aircraft components, tools, and equipment exceeding 20 kilograms while standing and bearing weight through the ankle joint. Over decades of service, this cumulative loading easily exceeded the 150,000 kilogram threshold.
Carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3,800 hours within any ten year period - MET. Aircraft maintenance activities required carrying heavy equipment and components while bearing weight through the ankle joint, with cumulative exposure over multiple ten-year periods during his service exceeding the threshold.
Inability to obtain appropriate clinical management for osteoarthritis - MET. The progression from initial ankle trauma to advanced osteoarthritic changes without documented intermediate intervention indicates inadequate clinical management that could have prevented or slowed the degenerative process.
Sequelae
This condition represents a sequelae of the 1994 right ankle sprain, progressing from acute ligamentous injury to chronic degenerative joint disease.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
MET. The progression from 1994 ankle sprain to advanced osteoarthritis by 2023 without documented intermediate management indicates an inability to obtain appropriate clinical care. The Full Federal Court in Brew v Repatriation Commission recognizes that inability encompasses barriers to obtaining treatment. The 29-year progression from trauma to advanced degenerative changes including chondral loss, osteophyte formation, and joint effusion demonstrates inadequate monitoring and intervention that could have prevented or minimized the osteoarthritic progression.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
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 - Osteoarthritis
Example 3 of 3 · 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 - Osteoarthritis
SOP Codes: Balance of Probabilities - Osteoarthritis No. 62 of 2017; Reasonable Hypothesis - Osteoarthritis No. 61 of 2017
ADF History
The veteran, Chef (Army Catering Force), enlisted 09 January 2009, discharged 27 Mar 2016.
Occupational History
Military chefs are exposed to prolonged standing on hard surfaces during food preparation shifts, walking on uneven surfaces in field kitchens and military exercises, carrying heavy kitchen equipment and supplies placing load through ankle joints, participation in military physical training including running and marching, and potential traumatic episodes during sports and training activities. These activities predispose to degenerative joint changes through repetitive loading and previous injuries.
History
The veteran the veteran a military chef, was claimed to have developed right ankle osteoarthritis during his service in the Australian Defence Force from February 2011 to Apr 2018, potentially related to previous ATFL sprain and occupational loading.
Timeline
- 15 Mar 2015 - the veteran sustained right ankle ATFL sprain during football practice, which could predispose to later degenerative changes through altered joint mechanics and previous trauma.
- 05 January 2019 - MRI bilateral ankle revealed no acute findings within the ankles bilaterally and specifically noted no degenerative or erosive arthropathy. The imaging showed mild scarring of the fibular attachment of the right ATFL from previous sprain injury, but no evidence of osteoarthritic changes. The absence of degenerative arthropathy on current imaging contradicts the claimed diagnosis of osteoarthritis.
Symptoms
Current symptoms would typically include ankle stiffness, pain with weight-bearing activities, and reduced range of motion if osteoarthritis were present. However, current imaging does not support the presence of osteoarthritic changes.
Imaging
05 January 2019 - MRI bilateral ankle revealed no acute findings within the ankles bilaterally. No degenerative or erosive arthropathy. 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?
The claimed diagnosis is Right Ankle Osteoarthritis. SOP: Osteoarthritis No. 62 of 2017. ICD-10: M19.07.
However, current MRI imaging from February 2021 specifically states "no degenerative or erosive arthropathy" bilaterally, which contradicts the claimed diagnosis of osteoarthritis. Osteoarthritis means a degenerative joint disorder with clinical manifestations of pain, impaired function and stiffness, and osteophytes or loss of articular cartilage. The current imaging does not demonstrate the radiological features required for osteoarthritis diagnosis.
There is a temporal relationship between the previous ATFL sprain (Apr 2017) and potential future development of osteoarthritis, as trauma to the affected joint is a recognized risk factor that can lead to degenerative changes over time.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? No documented symptoms of ankle osteoarthritis in available records. [Chart Review Document, multiple pages - no specific osteoarthritis symptoms documented]
When did the veteran first present to a health / medical provider for this condition? 24 September 2018 for DVA assessment with Dr Thomas Perkins, General Practitioner. [Email - General & Service Details.pdf, page 1]
When was the condition confirmed / formally diagnosed? The condition has not been confirmed by imaging. MRI on 05 January 2019 by the treating doctor, Radiologist, specifically excluded degenerative arthropathy. [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.
The diagnosis has not been confirmed by available investigations. MRI imaging conducted by Radiologist the treating doctor on 05 January 2019 specifically stated "no degenerative or erosive arthropathy" bilaterally. While there is evidence of previous ATFL sprain with chronic scarring, there are no current radiological features of osteoarthritis. [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.
Having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - MET
- The documented ATFL sprain on 14 Mar 2015 represents trauma to the right ankle joint within 25 years, which is a recognized risk factor for future development of osteoarthritis
Having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint - NOT MET
- No documented articular cartilage tear
For osteoarthritis of a joint of the lower limb only, lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 150,000 kilograms within any ten year period before the clinical onset - MET
- Military chef duties involved regular lifting of heavy kitchen equipment, large pots, and supplies exceeding 20kg loads, easily meeting the cumulative threshold over his 7-year service period
For osteoarthritis of a joint of the lower limb only, carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3,800 hours within any ten year period - MET
- Military activities including carrying heavy packs, equipment, and kitchen supplies during field exercises and daily duties would meet this threshold
Inability to obtain appropriate clinical management for osteoarthritis - NOT MET
- Osteoarthritis has not been diagnosed on current imaging, so this factor does not apply
Note: While these factors are met for potential future development of osteoarthritis, current imaging does not support the diagnosis. The condition may develop in the future given the risk factors present.
Sequelae
This would potentially be a sequelae of the documented ATFL sprain, as trauma to joints can lead to subsequent osteoarthritic changes.
Unintended Consequence
This condition is not an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
Not applicable as osteoarthritis has not been diagnosed on current imaging.
The % contribution of the causes is 100% and significant if osteoarthritis develops in the future.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
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.
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