Reference Determination Content
Suggested draft · fictitious patient
Bilateral Great Toes - Ingrown Toenail
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 June 2025;
- An entry medical examination by the army recruiting medical officer, dated 12 March 1991;
- A podiatry assessment and X-ray both feet by the defence podiatrist and radiologist, dated 14 August 1998;
- A specialist letter by the dermatologist, dated 10 July 1999;
- A role 2 treatment record and post-exposure prophylaxis plan by the medical officer, East Timor, dated 16 October 1999;
- A pathology report (nail microscopy and culture) dated 8 November 1999;
- A regimental aid post record and X-ray both feet by the regimental medical officer, dated 2 December 1999;
- A regimental aid post record by the regimental medical officer, East Timor, dated 13 January 2000;
- A specialist letter and pathology by the dermatologist and medical officer, dated 14 June 2005;
- An oncology treatment plan by the medical oncologist and radiation oncologist, dated 10 October 2005;
- A hospital discharge summary by the medical officer, dated 30 November 2005;
- An operation report by the podiatric surgeon, dated 5 December 2005.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 March 1991 and 15 August 2007
Bilateral Great Toes - Ingrown Toenail
You have stated that your condition was caused by:
- having an acquired deformity of the affected digit which causes the nail to be pushed into the proximate soft tissue at the time of clinical onset
- having an injury to the affected nail or the affected nail bed, within the 6 months before clinical onset or clinical worsening
- being treated with; (a) an oral retinoid; within the 6 months before clinical onset or clinical worsening
- being treated with; (b) indinavir; within the 6 months before clinical onset or clinical worsening
- being treated with; (c) an epidermal growth factor inhibitor; within the 6 months before clinical onset or clinical worsening
- being treated with; (d) cyclosporine (cyclosporin); within the 6 months before clinical onset or clinical worsening
- having excessive trimming of the affected toenail or rounding the corners of the affected toenail rather than cutting the nail straight across the top within 14 days before clinical onset or clinical worsening
- wearing footwear that causes compression of the toes or pressure on the affected toenail. This includes but is not limited to footwear that is too narrow or too short, or has inadequate depth in the toe box on the affected foot, for at least 8 hours within the 4 weeks before clinical onset or clinical worsening
- having hyperhidrosis affecting the feet within the 7 days before the clinical onset or clinical worsening
- having diabetes mellitus at the time of clinical onset or clinical worsening
- having a fungal infection involving the affected nail within the 1 year before clinical onset or clinical worsening
Diagnosis: Ingrown Toenail
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 June 2025, and is supported by a regimental aid post record by the regimental medical officer, East Timor, dated 13 January 2000.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Ingrown Nail (Reasonable Hypothesis) (No. 72 of 2024)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having an acquired deformity of the affected digit which causes the nail to be pushed into the proximate soft tissue at the time of clinical onset
- having an injury to the affected nail or the affected nail bed, within the 6 months before clinical onset or clinical worsening
- being treated with; (a) an oral retinoid; within the 6 months before clinical onset or clinical worsening
- being treated with; (b) indinavir; within the 6 months before clinical onset or clinical worsening
- being treated with; (c) an epidermal growth factor inhibitor; within the 6 months before clinical onset or clinical worsening
- being treated with; (d) cyclosporine (cyclosporin); within the 6 months before clinical onset or clinical worsening
- having excessive trimming of the affected toenail or rounding the corners of the affected toenail rather than cutting the nail straight across the top within 14 days before clinical onset or clinical worsening
- wearing footwear that causes compression of the toes or pressure on the affected toenail. This includes but is not limited to footwear that is too narrow or too short, or has inadequate depth in the toe box on the affected foot, for at least 8 hours within the 4 weeks before clinical onset or clinical worsening
- having hyperhidrosis affecting the feet within the 7 days before the clinical onset or clinical worsening
- having diabetes mellitus at the time of clinical onset or clinical worsening
- having a fungal infection involving the affected nail within the 1 year before clinical onset or clinical worsening
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with pain, redness, swelling and tenderness along the medial and lateral nail folds of both great toes, worse with boots on and with walking, and discharge from the nail folds on 13 January 2000.
The diagnosis was made clinically by the regimental medical officer on 13 January 2000, who recorded the edges of both great toenails embedded in the medial and lateral nail folds, with inflammation, pain, paronychia and early granulation tissue. This meets the Statement of Principles definition of ingrown nail: the nail plate penetrating the soft tissue of the adjacent nail fold, resulting in inflammation and pain.
This has then led to further investigations and the diagnosis of your condition of Ingrown Toenail. I have accepted your condition of Ingrown Toenail.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 10 January 2000.
Bilateral Great Toes - Ingrown Toenail (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 June 2025;
- An entry medical examination by the army recruiting medical officer, dated 12 March 1991;
- A podiatry assessment and X-ray both feet by the defence podiatrist and radiologist, dated 14 August 1998;
- A specialist letter by the dermatologist, dated 10 July 1999;
- A role 2 treatment record and post-exposure prophylaxis plan by the medical officer, East Timor, dated 16 October 1999;
- A pathology report (nail microscopy and culture) dated 8 November 1999;
- A regimental aid post record and X-ray both feet by the regimental medical officer, dated 2 December 1999;
- A regimental aid post record by the regimental medical officer, East Timor, dated 13 January 2000;
- A specialist letter and pathology by the dermatologist and medical officer, dated 14 June 2005;
- An oncology treatment plan by the medical oncologist and radiation oncologist, dated 10 October 2005;
- A hospital discharge summary by the medical officer, dated 30 November 2005;
- An operation report by the podiatric surgeon, dated 5 December 2005.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 March 1991 and 15 August 2007
Bilateral Great Toes - Ingrown Toenail (Worsening)
You have stated that the worsening of your condition was caused by:
- having an injury to the affected nail or the affected nail bed, within the 6 months before the clinical onset or clinical worsening
- Being treated with; (a) an oral retinoid; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (b) indinavir; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (c) an epidermal growth factor inhibitor; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (d) cyclosporine (cyclosporin); Within the 6 months before clinical onset or clinical worsening
- having excessive trimming of the affected toenail or rounding the corners of the affected toenail rather than cutting the nail straight across the top within 14 days before clinical onset or clinical worsening
- wearing footwear that causes compression of the toes or pressure on the affected toenail. This includes but is not limited to footwear that is too narrow or too short, or has inadequate depth in the toe box on the affected foot, for at least 8 hours within the 4 weeks before clinical onset or clinical worsening
- having hyperhidrosis affecting the feet within the 7 days before the clinical onset or clinical worsening
- having diabetes mellitus at the time of clinical onset or clinical worsening
- having a fungal infection involving the affected nail within the one year before clinical onset or clinical worsening
- inability to obtain appropriate clinical management for ingrown nail before clinical worsening
Diagnosis: Ingrown Toenail (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 June 2025, and is supported by a regimental aid post record by the regimental medical officer, East Timor, dated 13 January 2000.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Ingrown Nail (Balance of Probabilities) (No. 73 of 2024)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having an injury to the affected nail or the affected nail bed, within the 6 months before the clinical onset or clinical worsening
- Being treated with; (a) an oral retinoid; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (b) indinavir; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (c) an epidermal growth factor inhibitor; Within the 6 months before clinical onset or clinical worsening
- Being treated with; (d) cyclosporine (cyclosporin); Within the 6 months before clinical onset or clinical worsening
- having excessive trimming of the affected toenail or rounding the corners of the affected toenail rather than cutting the nail straight across the top within 14 days before clinical onset or clinical worsening
- wearing footwear that causes compression of the toes or pressure on the affected toenail. This includes but is not limited to footwear that is too narrow or too short, or has inadequate depth in the toe box on the affected foot, for at least 8 hours within the 4 weeks before clinical onset or clinical worsening
- having hyperhidrosis affecting the feet within the 7 days before the clinical onset or clinical worsening
- having diabetes mellitus at the time of clinical onset or clinical worsening
- having a fungal infection involving the affected nail within the one year before clinical onset or clinical worsening
- inability to obtain appropriate clinical management for ingrown nail before clinical worsening
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with pain, redness, swelling and tenderness along the medial and lateral nail folds of both great toes, worse with boots on and with walking, and discharge from the nail folds on 13 January 2000.
The diagnosis was made clinically by the regimental medical officer on 13 January 2000, who recorded the edges of both great toenails embedded in the medial and lateral nail folds, with inflammation, pain, paronychia and early granulation tissue. This meets the Statement of Principles definition of ingrown nail: the nail plate penetrating the soft tissue of the adjacent nail fold, resulting in inflammation and pain.
After the condition arose, it was worsened during your service. On 2 December 1999 a bundle of steel pickets fell across both forefeet while you were unloading a truck, crushing both great toenails, causing subungual haematomas and partially lifting both nail plates. You took isotretinoin, an oral retinoid, 40 mg daily from 10 July 1999 to 5 September 1999, prescribed by a Defence-funded dermatologist for nodulocystic acne aggravated by webbing and pack straps. You took indinavir from 16 October 1999 to 13 November 1999 as part of post-exposure prophylaxis after a needle-stick injury sustained while giving first aid in the course of your duties. You received weekly cetuximab, an epidermal growth factor receptor inhibitor, from 10 October 2005 to 28 November 2005 with radiotherapy for a squamous cell carcinoma of the scalp attributed to solar exposure on service. A dermatologist treated your chronic plaque psoriasis with cyclosporine 3 mg/kg/day from 5 April 2005 to 30 September 2005. On 1 January 2000, nine days before onset, you cut both great toenails short and rounded the corners with a knife to relieve pressure from the undersized boots, as no nail clippers were available at the forward base. From 20 December 1999 you wore resupply combat boots one size too small, because your size was unavailable, for 14 to 18 hours a day on patrol. Plantar hyperhidrosis was recorded by a Defence podiatrist on 14 August 1998, and on 13 January 2000 the medical officer recorded wet, macerated feet. Type 2 diabetes mellitus was diagnosed on 14 June 2005 with an HbA1c of 7.4 per cent and treated with metformin. Onychomycosis of both great toenails, with positive microscopy and culture of Trichophyton rubrum, was diagnosed on 8 November 1999, 63 days before onset and within the one year from 10 January 1999 to 10 January 2000. When the condition was diagnosed on 13 January 2000 you were returned to patrol the next day, could not carry out the prescribed foot soaks, and wedge resection was deferred because no podiatry or minor surgical service was available forward.
This has then led to further investigations and the diagnosis of your condition of Ingrown Toenail (Worsening). I have accepted your condition of Ingrown Toenail (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 30 November 2005.
