Right Foot - Stress Fracture Third Metatarsal — DVA claim example (Diagnostic Assessment)

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 Foot - Stress Fracture Third Metatarsal

Example 1 of 1 · fictitious patient (Veteran P)

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 Foot - Stress Fracture Third Metatarsal

Balance of Probabilities: Fracture No. 63 of 2024 Reasonable Hypothesis: Fracture No. 62 of 2024

ADF History

The veteran, Warehouse Operator, enlisted 15 July 2010, discharged 16 May 2013.

Occupational History

As a Warehouse Operator in the Australian Army, the veteran was exposed to intensive military physical training including pack marching activities with additional load carriage, running programs, and weight-bearing exercises on various terrain surfaces. Military training involves repetitive loading stress to the foot structures through marching with military equipment, sustained weight-bearing activities, and progressive physical conditioning that significantly exceeds civilian activity levels. The role required participation in regular pack marches as part of routine military training at the treating doctor base.

History

The veteran a Warehouse Operator with the Australian Army, developed a high-grade stress fracture of the right foot third metatarsal in November 2011, early in his military service, occurring approximately 10 days following pack marching activities as part of military training requirements.

Timeline

November 2011 - the veteran developed pain in the right fourth metatarsal region according to clinical documentation for imaging referral. The mechanism involved repetitive loading stress from military pack marching activities, representing typical patterns of stress fracture development in military personnel. Initial symptom onset was characterized by localized metatarsal pain following specific training activities. The temporal relationship between pack marching exposure and symptom development was clearly established in the clinical history with onset "since pack march 10 days ago".
11 Oct 2010 - Initial X-ray right foot showed "No evidence of periosteal reaction or stress fracture" with recommendation that "Early radiographs may not demonstrate stress reaction" and "MRI is recommended if there is continuing clinical concern". The normal initial imaging was consistent with early stress fracture pathology before radiographic changes become apparent. Clinical suspicion remained high based on mechanism of injury and symptom pattern. Advanced imaging was recommended for definitive diagnosis given the high clinical probability of stress fracture.
22 Nov 2010 - MRI right foot confirmed "High grade stress fracture at the base" with detailed pathological findings. The imaging showed "Bone marrow oedema in the base of the third metatarsal" and "linear low T1/T2 abnormality extending from the medial dorsal side" into the cancellous bone. The radiologist confirmed the fracture was "not reaching the cortex of the other side" consistent with an incomplete high grade stress fracture. No other bone or joint abnormalities were identified, confirming the isolated nature of the stress fracture injury.
Management Period - the veteran underwent graduated return to military training activities with monitoring for symptom resolution and bone healing. The stress fracture required modification of weight-bearing activities and implementation of biomechanical interventions to prevent recurrence. Recovery involved progressive loading protocols and assessment of contributing factors including foot biomechanics and training load management.

Symptoms

At the time of injury onset in November 2011, the veteran experienced localized pain in the fourth metatarsal region of his right foot following pack marching activities. The pain was activity-related and developed approximately 10 days after intensive pack marching training. The symptoms were sufficient to warrant medical assessment and imaging investigation.

The comprehensive medical documentation indicates successful healing of the stress fracture with graduated return to military training activities following appropriate activity modification and progressive loading protocols.

Imaging

11 Oct 2010 - X-ray Right Foot: "No evidence of periosteal reaction or stress fracture line is identified. Early radiographs may not demonstrate stress reaction and MRI is recommended if there is continuing clinical concern"
22 Nov 2010 - MRI Right Foot: "High grade stress fracture at the base of the third metatarsal as described. Bone marrow oedema in the base of the third metatarsal with corresponding slight decrease in T1 signal and linear low T1/T2 abnormality extending from the medial dorsal side of the base of the third metatarsal into the cancellous bone but not reaching the cortex of the other side consistent with an incomplete high grade stress fracture"

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

Stress Fracture of Third Metatarsal, Right Foot (M84.376A) - DVA SOP Code: Fracture No. 63 of 2024, ICD-10 Code: M84.376A

A stress fracture is a type of fracture that results from repetitive loading stress applied to bone over time, causing microscopic damage that accumulates faster than the bone can repair itself. Stress fractures of the fatigue type occur when normal bone is subjected to abnormal or repetitive stress, which is common in military personnel and athletes. The third metatarsal is a common site for stress fractures in individuals engaged in weight-bearing activities such as marching and running. MRI is the gold standard for early detection of stress fractures, particularly when plain radiographs are normal, as occurred in this case.

This represents a single episode of stress fracture that developed during early military training, was appropriately diagnosed through advanced imaging, and healed with conservative management.

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

When did the veteran first experience symptoms attributable to this condition? November 2011 - approximately 10 days following pack marching activities

When did the veteran first present to a health / medical provider for this condition? 11 October 2010 - presented to military medical services for assessment of right foot pain and subsequent imaging referral.

When was the condition confirmed / formally diagnosed? 22 November 2010 - confirmed by MRI imaging demonstrating high-grade stress fracture at the base of the third metatarsal, interpreted by radiologist the treating doctor.

When did the veteran first present to you (or your practice) for this condition? 14 January 2021

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 advanced imaging techniques following initial normal radiographic findings. Key symptoms included localized right foot pain in the metatarsal region developing approximately 10 days after pack marching activities. Initial X-ray on 11 October 2010 was normal, consistent with early stress fracture pathology before radiographic changes become apparent. MRI imaging on 22 November 2010 provided definitive diagnosis, demonstrating bone marrow edema in the base of the third metatarsal with characteristic signal changes and linear abnormality extending into cancellous bone consistent with incomplete high-grade stress fracture. The diagnosis was confirmed by radiologist interpretation establishing the specific location, extent, and grade of the stress fracture injury.

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 significant physical force applied to or through the affected bone at the time of clinical onset - NOT MET - This was a stress fracture caused by repetitive loading rather than acute trauma.

for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset - MET - Military pack marching activities involving repetitive loading stress to the foot structures with additional weight from military equipment clearly constituted significant repetitive loading stress to the metatarsal bones during routine military training.

for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset - MET - The intensive military training represented abnormal force intensity compared to civilian activity levels, with pack marching creating repetitive loading stress exceeding normal physiological tolerance.

inability to obtain appropriate clinical management for fracture before clinical worsening - NOT MET - Appropriate clinical management was provided with timely diagnosis and conservative treatment allowing successful healing.

Sequelae

This condition is not a sequelae of another known condition but represents a primary stress fracture injury related to military training activities.

Unintended Consequence

This condition is not an unintended consequence of medical management as no prior medical procedures or treatments were performed that could have led to this stress fracture.

Inability to Attain Appropriate Medical Management

The Full Federal Court in Brew v Repatriation Commission (12 July 1996) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. This factor is NOT MET as the veteran received appropriate medical assessment and imaging investigation when he presented with foot pain in November 2011. The military medical system provided timely X-ray imaging followed by appropriate MRI when clinical suspicion remained high despite normal initial imaging, leading to accurate diagnosis and successful conservative management.

The % contribution of the causes is 100% and significant.

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

-see attached report

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