Diagnostic Assessment — Right Ankle - Posterior Tibialis Tendinopathy
Example 1 of 1 · fictitious patient (Veteran BH)
Diagnostic Assessment
Right Ankle - Posterior Tibialis Tendinopathy
BOP Code: 46 of 2021 (Posterior Tibialis Tendinopathy)
RH Code: 45 of 2021 (Posterior Tibialis Tendinopathy)
ADF History
Veteran BH, date of birth 03 September 1985, Royal Australian Air Force, Airfield Defence Guard, enlisted 20 July 2004, medically discharged 15 November 2021. Operational service: Afghanistan, 05 January 2010 to 30 July 2010 (warlike); Iraq, Middle East Area of Operations, 12 February 2015 to 20 September 2015 (warlike).
Occupational History
Airfield defence guards provide ground defence for air bases. The trade involves dismounted security patrols of airfield perimeters, often at night and over rough, uneven or flooded ground, with loads of 25 to 40 kilograms including body armour, weapon, ammunition and communications equipment. Physical training includes distance running, pack marching and obstacle courses, and fitness standards are tested regularly.
On operations, patrol tempo rises sharply in response to threat levels, and work is done in extreme heat with limited access to water, hygiene and fresh food. Shared accommodation and dining facilities make outbreaks of gastroenteritis common. Ankle and foot injuries, overuse tendinopathies and heat-related illness are recognised hazards of the trade.
History
Veteran BH, an airfield defence guard in the Royal Australian Air Force, developed pain and swelling along the right posterior tibialis tendon on 14 May 2010 on warlike service in Afghanistan, after high-volume running and patrolling, a sharp increase in patrol tempo, a laceration and contusion over the tendon, a gastroenteritis outbreak followed by reactive arthritis, and a first attack of gout. The tendinopathy, complicated by septic and gouty tenosynovitis, worsened with a partial tear on warlike service in Iraq in July 2015 and required surgical repair.
Timeline
- 18 Dec 2009 — Pre-deployment medical examination at an RAAF base health centre. The veteran passed his fitness assessment with a 2.4 kilometre run in 9 minutes 40 seconds. Examination of both ankles and feet was normal, with no tenderness along the posterior tibialis tendons and normal single-leg heel raises. Serum urate was 0.44 mmol/L and he was given dietary advice. "ankles NAD, urate 0.44"
- 12 Apr 2010 — Seen at the role 2 medical facility at Kandahar Airfield during a gastroenteritis outbreak affecting 40 personnel at the base. He had two days of bloody diarrhoea, fever and cramps. Stool culture grew Shigella flexneri. He was treated with oral rehydration and ciprofloxacin and returned to duty after five days. "Shigella gastroenteritis, outbreak"
- 22 Apr 2010 — During a night perimeter patrol the veteran fell into a concrete drainage culvert and struck the inside of his right ankle on its edge. He sustained a 3 centimetre laceration and contusion immediately behind the right medial malleolus. The wound was irrigated and sutured by the medic. He continued patrolling with strapping. "laceration behind R medial malleolus"
- 05 May 2010 — Review by the medical officer for a painful swollen left knee, pain at both heels and red, gritty eyes, three weeks after the Shigella infection. Examination showed a moderate left knee effusion, Achilles enthesitis and conjunctivitis. HLA-B27 was positive. Reactive arthritis was diagnosed and he was started on naproxen. He also reported a first attack of acute gout in the right big toe in March 2010. "reactive arthritis post Shigella"
- 17 May 2010 — Presented with three days of pain and swelling along the course of the right posterior tibialis tendon from behind the medial malleolus to its insertion, starting on 14 May 2010. Pain was worse with patrolling and running, and he could perform only three painful single-leg heel raises on the right. The region was warm and tender, and the healing laceration was red. He had been running about 65 kilometres a week and patrolling daily for six hours since 08 May 2010. "R tib post pain, warm, swollen"
- 20 May 2010 — At the role 3 hospital, ultrasound showed a thickened, hypoechoic right posterior tibialis tendon with a distended tendon sheath. Guided aspiration of the sheath yielded turbid fluid containing negatively birefringent monosodium urate crystals, and culture grew Staphylococcus aureus. An orthopaedic surgeon diagnosed posterior tibialis tendinopathy with septic and gouty tenosynovitis. He received intravenous flucloxacillin for seven days and colchicine, and returned to restricted duties. "septic and gouty tenosynovitis, MSU"
- 24 Jul 2015 — On warlike service in Iraq the veteran felt a sharp pain and giving way of the right medial ankle while running, ten days after striking the ankle on a vehicle step. The ankle was swollen and he could not perform a single-leg heel raise. A red, painful wound over the medial ankle, a flare of gout and an active flare of his inflammatory arthritis were recorded. No imaging or orthopaedic review was available in theatre and he was treated with antibiotics and restricted duties until return to Australia. "R tib post worse, no heel raise"
- 08 Dec 2015 — After MRI on 12 October 2015 showed a longitudinal split tear, an orthopaedic surgeon performed debridement and repair of the right posterior tibialis tendon with tenosynovectomy. Tophaceous urate deposits and chronic inflamed synovium were found within the tendon sheath. Histology confirmed tendinosis with urate deposits. He was immobilised for eight weeks. "split tear repaired, tophaceous deposits"
- 11 Mar 2020 — Orthopaedic review. The veteran had persisting medial ankle pain after standing or walking more than 30 minutes, early flattening of the right medial arch and could perform only five single-leg heel raises on the right. He was unable to meet the airfield defence guard fitness standard and was referred for medical employment classification review, leading to discharge in November 2021. "persisting pain, early flatfoot"
Symptoms
At onset the veteran had pain and swelling along the inside of the right ankle, behind the medial malleolus and towards the arch, which was worse with patrolling and running and eased with rest. The area was warm and tender, and he had difficulty rising onto his toes on the right.
After the 2015 worsening he could not rise onto his toes on the right, and his ankle gave way on uneven ground. Since surgery he reports ongoing medial ankle and arch pain after standing or walking for more than 30 minutes, swelling at the end of the day, a gradual flattening of the right arch and difficulty with stairs and slopes. He uses an orthotic and has stopped running.
Imaging
- 20 May 2010 — Ultrasound right ankle: "Thickened, hypoechoic right posterior tibialis tendon behind the medial malleolus with a distended tendon sheath containing echogenic fluid and increased Doppler flow, consistent with tendinopathy and tenosynovitis."
- 05 Oct 2010 — MRI right ankle: "Posterior tibialis tendinosis with intrasubstance thickening and increased signal from the medial malleolus to the navicular insertion. Residual tenosynovitis. No tear. Intact spring ligament."
- 12 Oct 2015 — MRI right ankle: "Longitudinal split tear of the posterior tibialis tendon over 4 centimetres behind the medial malleolus, with marked tendinosis and tenosynovitis. Intermediate signal deposits within the sheath, consistent with tophi. Early spring ligament strain."
- 11 Mar 2020 — Weight-bearing X-ray right foot: "Early loss of the medial longitudinal arch with reduced calcaneal pitch. No arthritis of the hindfoot."
Onset Date
The most likely date of onset of this condition is 14 May 2010.
At that date the veteran was on warlike service at Kandahar Airfield in Afghanistan as an airfield defence guard. He was running about 65 kilometres a week, had been patrolling the airfield perimeter for about six hours a day since 08 May 2010 under a raised threat state, was recovering from a laceration and contusion behind the right medial malleolus sustained on 22 April 2010, and had active reactive arthritis following a Shigella infection. On 14 May 2010 he first noticed pain and swelling along the inside of the right ankle.
This date is appropriate because his pre-deployment medical examination of 18 December 2009 found normal ankles with no posterior tibialis tenderness, and the medical officer's review of 05 May 2010 recorded no right ankle tendon pain. He first presented with the symptoms on 17 May 2010, reporting three days of pain, and the diagnosis was confirmed on ultrasound and aspiration on 20 May 2010.
For the running factors, the four weeks before onset run from 16 Apr 2010 to 14 May 2010; his fitness log recorded about 65 kilometres a week throughout. For the weight-bearing factors, the same four weeks were filled by loaded perimeter patrols of at least 10 hours a week. For the increase factors, the seven days before onset run from 07 May 2010 to 14 May 2010, during which patrolling rose from about 10 hours a week to about six hours a day. For the trauma factor, the 30 days before onset run from 14 Apr 2010 to 14 May 2010, and the injury to the tendon on 22 Apr 2010 fell 22 days before onset. The tendon sheath infection, the gout and the reactive arthritis were each present on 14 May 2010.
For the worsening factors, the documented worsening was on 24 Jul 2015 on warlike service in Iraq, when a partial tear occurred. The four weeks before the worsening run from 26 Jun 2015 to 24 Jul 2015, when he ran about 62 kilometres a week and patrolled at least 8 hours a week. The seven days before run from 17 Jul 2015 to 24 Jul 2015, when patrolling doubled to more than four hours a day. The 30 days before run from 24 Jun 2015 to 24 Jul 2015, and the blow to the tendon on 14 Jul 2015 fell ten days before the worsening. The recurrent tendon sheath infection, gout flare and active inflammatory arthritis were each present on 24 Jul 2015.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Posterior Tibialis Tendinopathy of the right ankle (ICD-10 M76.81), with septic and gouty tenosynovitis at onset and a longitudinal split tear from July 2015, under the Statements of Principles concerning posterior tibialis tendinopathy, Balance of Probabilities No. 46 of 2021 and Reasonable Hypothesis No. 45 of 2021.
The posterior tibialis tendon runs behind the medial malleolus and inserts mainly into the navicular bone, supporting the medial arch of the foot and inverting the foot during walking and running. Tendinopathy is inflammation or degeneration of the tendon, causing pain and tenderness behind the medial malleolus and along the arch, swelling and weakness of heel raise. It is associated with high-volume and rapidly increased weight-bearing activity, direct trauma, inflammatory and crystal arthritis and infection. Progressive tendinopathy can lead to tearing and to adult acquired flatfoot deformity.
The condition began on 14 May 2010 on warlike service in Afghanistan, was confirmed by ultrasound and aspiration on 20 May 2010, worsened with a partial tear on 24 July 2015 on warlike service in Iraq and was repaired surgically on 08 December 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 May 2010.
When did the veteran first present to a health / medical provider for this condition?
17 May 2010.
When was the condition confirmed / formally diagnosed?
20 May 2010.
When did the veteran first present to you (or your practice) for this condition?
06 May 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 on 17 May 2010, with pain, swelling and tenderness along the course of the right posterior tibialis tendon and weak, painful single-leg heel raises, and confirmed on 20 May 2010 by ultrasound showing a thickened, hypoechoic tendon with tenosynovitis. Aspiration of the tendon sheath showed monosodium urate crystals and a culture of Staphylococcus aureus. Inflammation and degeneration of the posterior tibialis tendon producing localised pain and tenderness meets the Statement of Principles definition.
MRI on 05 October 2010 confirmed tendinosis with intrasubstance thickening, and MRI on 12 October 2015 showed a longitudinal split tear, which also falls within the definition. An orthopaedic surgeon confirmed the diagnosis at the role 3 hospital and again at surgery on 08 December 2015, when histology showed tendinosis with urate deposits.
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 14 May 2010, 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 Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2010, where the condition began, and in Iraq in 2015, where it worsened. The Balance of Probabilities instrument applies to peacetime service; the activity levels documented at onset and at worsening also exceeded its higher thresholds.
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 Posterior Tibialis Tendinopathy, No. 46 of 2021
Causative factors
Factor 8(1): running or jogging an average of at least 60 kilometres per week, for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; — MET
- The veteran's fitness log recorded an average of about 65 kilometres of running a week throughout the four weeks before onset, from 16 April 2010 to 14 May 2010. He ran six days a week on the airfield perimeter road to maintain the trade fitness standard and prepare for a promotion course.
Factor 8(2): undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least six hours per week; and for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; — MET
- From 16 April 2010 to 14 May 2010 the veteran conducted loaded dismounted patrols of the airfield perimeter, carrying about 35 kilograms over rough ground, for at least 10 hours a week, as recorded in the flight's patrol logs. This exercise was well above five METs and involved repeated loading of the right ankle.
Factor 8(3): increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least four hours per day; and within the seven days before the clinical onset of posterior tibialis tendinopathy; — MET
- After a rocket attack on 07 May 2010 the base threat state was raised, and from 08 May 2010 the veteran patrolled about six hours every day. In the seven days before onset his loaded patrolling rose from about 10 hours a week to about 42 hours a week, an increase of more than 300 per cent, at an intensity above five METs and for more than four hours a day.
Factor 8(4): having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical onset of posterior tibialis tendinopathy; — MET
- On 22 April 2010, during a night patrol, the veteran fell into a concrete culvert and struck the inside of his right ankle, sustaining a 3 centimetre laceration and contusion directly over the posterior tibialis tendon behind the medial malleolus. This was 22 days before onset on 14 May 2010.
Factor 8(5): having an infection of the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- Aspiration of the right posterior tibialis tendon sheath on 20 May 2010 grew Staphylococcus aureus, introduced through the culvert laceration of 22 April 2010. The infection was present at onset on 14 May 2010, when the healing wound was already red and the tendon warm, and it was treated with intravenous flucloxacillin.
Factor 8(6): having gout involving the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- The same aspirate contained negatively birefringent monosodium urate crystals, confirming gout involving the right posterior tibialis tendon sheath at onset. His first attack of gout, in the right big toe in March 2010, followed sustained dehydration in heat and a high-protein ration diet on deployment.
Factor 8(7): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- Reactive arthritis, which is on the specified list, was diagnosed on 05 May 2010, three weeks after Shigella flexneri gastroenteritis acquired in a base outbreak, with knee effusion, Achilles enthesitis, conjunctivitis and positive HLA-B27. It was active at onset on 14 May 2010 and contributed to the tenosynovitis.
Worsening factors
Factor 8(8): running or jogging an average of at least 60 kilometres per week, for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; — MET
- In the four weeks before the worsening, from 26 June 2015 to 24 July 2015, the veteran ran an average of about 62 kilometres a week on deployment to meet a fitness test, as recorded in his training log. The worsening was a longitudinal split tear, confirmed on MRI on 12 October 2015.
Factor 8(9): undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least six hours per week; and for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; — MET
- From 26 June 2015 to 24 July 2015 the veteran patrolled the base perimeter in body armour with loads of about 30 kilograms for at least 8 hours a week, above five METs and with repeated loading of the right ankle.
Factor 8(10): increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least four hours per day; and within the seven days before the clinical worsening of posterior tibialis tendinopathy; — MET
- From 17 July 2015 a security surge raised his patrolling from about 8 hours a week to more than four and a half hours a day, an increase of about 300 per cent, at an intensity above five METs, within the seven days before the worsening on 24 July 2015.
Factor 8(11): having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical worsening of posterior tibialis tendinopathy; — MET
- On 14 July 2015 the veteran slipped while dismounting a protected vehicle and struck the inside of his right ankle on the metal step, causing a laceration and bruising over the posterior tibialis tendon. This was ten days before the worsening on 24 July 2015.
Factor 8(12): having an infection of the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- The step laceration became infected, with spreading redness along the tendon sheath recorded on 24 July 2015, and he was treated with oral antibiotics in theatre. Inflamed, infected synovium was later confirmed at surgery on 08 December 2015.
Factor 8(13): having gout involving the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- A gout flare at the medial ankle was recorded on 24 July 2015, with a serum urate of 0.52 mmol/L, after weeks of dehydration in temperatures above 45 degrees. Tophaceous urate deposits within the tendon sheath were seen on MRI and confirmed at surgery.
Factor 8(14): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- The reactive arthritis that began in 2010 had become chronic, and in 2014 a rheumatologist reclassified it as undifferentiated spondyloarthritis, which is on the specified list. It was active, with heel enthesitis and a raised CRP, when the tendinopathy worsened on 24 July 2015.
Factor 8(15): inability to obtain appropriate clinical management for posterior tibialis tendinopathy. — MET
- When the tendon worsened on 24 July 2015 in Iraq, no ultrasound, MRI or orthopaedic review was available in theatre, and the partial tear was not imaged until 12 October 2015 or repaired until 08 December 2015. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Posterior Tibialis Tendinopathy, No. 45 of 2021
Causative factors
Factor 8(1): running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; — MET
- On warlike service at Kandahar Airfield the veteran ran an average of about 65 kilometres a week throughout the four weeks before onset, from 16 April 2010 to 14 May 2010, more than twice the 30 kilometres required.
Factor 8(2): undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; — MET
- On warlike service in Afghanistan he conducted loaded airfield perimeter patrols of at least 10 hours a week, above five METs and repeatedly loading the right ankle, throughout the four weeks before onset, from 16 April 2010 to 14 May 2010.
Factor 8(3): increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical onset of posterior tibialis tendinopathy; — MET
- After a rocket attack on the airfield on warlike service, his patrolling rose from about 10 hours a week to about six hours a day from 08 May 2010, within the seven days before onset on 14 May 2010. The increase was more than 300 per cent, above five METs and for more than two hours a day.
Factor 8(4): having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical onset of posterior tibialis tendinopathy; — MET
- The laceration and contusion over the right posterior tibialis tendon from the culvert fall on a night patrol on warlike service on 22 April 2010 occurred 22 days before onset.
Factor 8(5): having an infection of the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- Staphylococcus aureus infection of the tendon sheath, introduced through the patrol laceration sustained on warlike service, was present at onset and confirmed on aspiration on 20 May 2010.
Factor 8(6): having gout involving the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- Monosodium urate crystals were found in the tendon sheath aspirate on 20 May 2010. The gout began in March 2010 on warlike service, precipitated by dehydration in heat and a high-protein ration diet, and involved the tendon at onset.
Factor 8(7): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of posterior tibialis tendinopathy; — MET
- Reactive arthritis followed Shigella gastroenteritis acquired in an outbreak at the base on warlike service in April 2010, was diagnosed on 05 May 2010 and was active at onset on 14 May 2010.
Worsening factors
Factor 8(8): running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; — MET
- On warlike service in Iraq the veteran ran an average of about 62 kilometres a week from 26 June 2015 to 24 July 2015, the four weeks before the worsening.
Factor 8(9): undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; — MET
- On warlike service in Iraq he patrolled with about 30 kilograms for at least 8 hours a week throughout the four weeks before the worsening, from 26 June 2015 to 24 July 2015, above five METs.
Factor 8(10): increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical worsening of posterior tibialis tendinopathy; — MET
- A security surge on warlike service in Iraq raised his patrolling from about 8 hours a week to more than four and a half hours a day from 17 July 2015, within the seven days before the worsening on 24 July 2015.
Factor 8(11): having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical worsening of posterior tibialis tendinopathy; — MET
- The blow to the right medial ankle from a protected vehicle step on warlike service in Iraq on 14 July 2015 occurred ten days before the worsening.
Factor 8(12): having an infection of the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- The infected step laceration tracked along the tendon sheath and was present at the worsening on 24 July 2015 on warlike service in Iraq.
Factor 8(13): having gout involving the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- A medial ankle gout flare, precipitated by dehydration on warlike service in Iraq, was present at the worsening, and tophi in the tendon sheath were confirmed at surgery.
Factor 8(14): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of posterior tibialis tendinopathy; — MET
- Undifferentiated spondyloarthritis, which evolved from the reactive arthritis that followed Shigella infection on warlike service in Afghanistan, was active at the worsening on 24 July 2015.
Factor 8(15): inability to obtain appropriate clinical management for posterior tibialis tendinopathy. — MET
- On warlike service in Iraq no imaging or orthopaedic review was available when the tendon tore, and imaging and repair were delayed until October and December 2015.
The % contribution of the causes is 100% and significant.
Sequelae
The veteran has developed early adult acquired flatfoot deformity on the right, shown on weight-bearing X-ray on 11 March 2020, as a sequela of the posterior tibialis tendinopathy and tear. Altered gait from the right ankle has also been recorded as aggravating pain in the right knee and lower back.
Unintended Consequence
Met. Post-operative stiffness of the right ankle and a tender surgical scar along the medial ankle are unintended consequences of the tendon debridement and repair performed on 08 December 2015, and gastrointestinal upset from colchicine prescribed for the gout involving the tendon was recorded; this treatment was provided and paid for 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. When the right posterior tibialis tendon tore on 24 July 2015 on warlike service in Iraq, no ultrasound, MRI or orthopaedic review was available in theatre. The veteran was managed with antibiotics and restricted duties for two months, and the tear was not imaged until 12 October 2015 or repaired until 08 December 2015, by which time tophaceous deposits and early arch collapse had developed. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely imaging and specialist treatment amount to an inability to obtain appropriate clinical management. At onset in Afghanistan in 2010 he also continued patrolling for six days before ultrasound and aspiration were available.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 Dec 2009, Pre-deployment medical examination, Medical Officer, RAAF base health centre
- 12 Apr 2010, Outpatient health record and stool culture, Role 2 medical facility, Afghanistan
- 22 Apr 2010, Wound treatment record, Medic, Afghanistan
- 05 May 2010, Outpatient health record, Medical Officer, Afghanistan
- 17 May 2010, Outpatient health record, Medical Officer, Afghanistan
- 20 May 2010, Ultrasound, aspiration and orthopaedic consultation, Role 3 hospital, Afghanistan
- 05 Oct 2010, MRI right ankle, Radiologist
- 18 Aug 2014, Rheumatology consultation, Rheumatologist
- 24 Jul 2015, Outpatient health record, Medical Officer, Iraq
- 12 Oct 2015, MRI right ankle, Radiologist
- 08 Dec 2015, Operation report and histology, Orthopaedic surgeon and Pathologist
- 11 Mar 2020, Orthopaedic review and weight-bearing X-ray, Orthopaedic surgeon
- Statement of Principles concerning Posterior Tibialis Tendinopathy (Balance of Probabilities) No. 46 of 2021, Repatriation Medical Authority
- Statement of Principles concerning Posterior Tibialis Tendinopathy (Reasonable Hypothesis) No. 45 of 2021, Repatriation Medical Authority
