Reference Determination Content
Suggested draft · fictitious patient
Left Foot - Exostosis
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 19 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 August 2025;
- An emergency record by the x-ray and CT reports, Base medical centre and Radiologist, dated 18 June 2003;
- An operation report by the orthopaedic surgeon, dated 20 June 2003;
- An MRI left foot report and infectious diseases consultation by the radiologist and infectious diseases physician, dated 22 July 2003;
- A specialist consultation by the dermatologist, dated 8 February 2006;
- An outpatient health record and X-ray report by the medical officer, Base medical centre, dated 12 March 2007;
- A periodic health examination by the medical officer, Base medical centre, dated 14 May 2007;
- An outpatient health record by the medical officer, Base medical centre, dated 10 September 2007;
- An X-ray left foot report by the radiologist, dated 12 September 2007;
- An outpatient health record by the medical officer, Afghanistan, dated 14 July 2008;
- An X-ray left foot report by the radiologist, dated 20 October 2008;
- An operation report by the orthopaedic surgeon, dated 18 March 2009;
- A medical discharge documentation by the medical employment classification review board, dated 30 September 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 March 2000 and 30 September 2015
Left Foot - Exostosis
You have stated that your condition was caused by:
- having a fracture or dislocation of the bones or joints of the affected site before the clinical onset of exostosis
- having a surgical procedure on the bones or joints of the affected site before the clinical onset of exostosis
- having infection of the bone or periosteum at the affected site before the clinical onset of exostosis
- having a crush injury or subperiosteal haematoma at the affected site within the 2 years before the clinical onset of exostosis
- having repeated external pressure or friction over the affected site from footwear for at least 30 hours per week for at least the 6 months before the clinical onset of exostosis
- undertaking repetitive impact loading of the affected foot, such as marching, running or jumping while carrying a load of at least 20 kilograms, on at least 3 days per week for at least the 6 months before the clinical onset of exostosis
- having osteoarthritis of a joint adjacent to the affected site at the time of the clinical onset of exostosis
- taking a systemic retinoid for a continuous period of at least 6 months within the 5 years before the clinical onset of exostosis
Diagnosis: Exostosis
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 August 2025, and is supported by an X-ray left foot report by the radiologist, dated 12 September 2007.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Balance of Probabilities (reasonable satisfaction) - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- having a fracture or dislocation of the bones or joints of the affected site before the clinical onset of exostosis
- having a surgical procedure on the bones or joints of the affected site before the clinical onset of exostosis
- having infection of the bone or periosteum at the affected site before the clinical onset of exostosis
- having a crush injury or subperiosteal haematoma at the affected site within the 2 years before the clinical onset of exostosis
- having repeated external pressure or friction over the affected site from footwear for at least 30 hours per week for at least the 6 months before the clinical onset of exostosis
- undertaking repetitive impact loading of the affected foot, such as marching, running or jumping while carrying a load of at least 20 kilograms, on at least 3 days per week for at least the 6 months before the clinical onset of exostosis
- having osteoarthritis of a joint adjacent to the affected site at the time of the clinical onset of exostosis
- taking a systemic retinoid for a continuous period of at least 6 months within the 5 years before the clinical onset of exostosis
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 a hard, tender lump on the top of the left midfoot that was painful under boot laces and after marching, with thickened skin over it on 10 September 2007.
The diagnosis was confirmed by X-ray on 12 September 2007, which showed a 6 mm dorsal osteophytic exostosis arising from the first and second tarsometatarsal joints with post-traumatic osteoarthritis of the second tarsometatarsal joint, corresponding to the hard, tender bony prominence found on examination on 10 September 2007.
This has then led to further investigations and the diagnosis of your condition of Exostosis. I have accepted your condition of Exostosis.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your peacetime service.
I have therefore accepted that this condition is related to your service with effect from 3 September 2007.
Left Foot - Exostosis (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 19 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 August 2025;
- An emergency record by the x-ray and CT reports, Base medical centre and Radiologist, dated 18 June 2003;
- An operation report by the orthopaedic surgeon, dated 20 June 2003;
- An MRI left foot report and infectious diseases consultation by the radiologist and infectious diseases physician, dated 22 July 2003;
- A specialist consultation by the dermatologist, dated 8 February 2006;
- An outpatient health record and X-ray report by the medical officer, Base medical centre, dated 12 March 2007;
- A periodic health examination by the medical officer, Base medical centre, dated 14 May 2007;
- An outpatient health record by the medical officer, Base medical centre, dated 10 September 2007;
- An X-ray left foot report by the radiologist, dated 12 September 2007;
- An outpatient health record by the medical officer, Afghanistan, dated 14 July 2008;
- An X-ray left foot report by the radiologist, dated 20 October 2008;
- An operation report by the orthopaedic surgeon, dated 18 March 2009;
- A medical discharge documentation by the medical employment classification review board, dated 30 September 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 March 2000 and 30 September 2015
Left Foot - Exostosis (Worsening)
You have stated that the worsening of your condition was caused by:
- having repeated external pressure or friction over the exostosis from footwear for at least 30 hours per week for at least the 6 months before the clinical worsening of exostosis
- undertaking repetitive impact loading of the affected foot, such as marching, running or jumping while carrying a load of at least 20 kilograms, on at least 3 days per week for at least the 6 months before the clinical worsening of exostosis
- having direct trauma to the exostosis before the clinical worsening of exostosis
- inability to obtain appropriate clinical management for exostosis
Diagnosis: Exostosis (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 August 2025, and is supported by an X-ray left foot report by the radiologist, dated 12 September 2007.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- having repeated external pressure or friction over the exostosis from footwear for at least 30 hours per week for at least the 6 months before the clinical worsening of exostosis
- undertaking repetitive impact loading of the affected foot, such as marching, running or jumping while carrying a load of at least 20 kilograms, on at least 3 days per week for at least the 6 months before the clinical worsening of exostosis
- having direct trauma to the exostosis before the clinical worsening of exostosis
- inability to obtain appropriate clinical management for exostosis
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 a hard, tender lump on the top of the left midfoot that was painful under boot laces and after marching, with thickened skin over it on 10 September 2007.
The diagnosis was confirmed by X-ray on 12 September 2007, which showed a 6 mm dorsal osteophytic exostosis arising from the first and second tarsometatarsal joints with post-traumatic osteoarthritis of the second tarsometatarsal joint, corresponding to the hard, tender bony prominence found on examination on 10 September 2007.
After the condition arose, it was worsened during your service. You wore laced combat boots over the exostosis for 12 to 16 hours a day throughout the 6 months before the worsening, from 14 January 2008 to 14 July 2008, in pre-deployment training and then on warlike service in Afghanistan from 1 February 2008. On warlike service in Afghanistan you patrolled on foot over rocky ground on most days carrying 30 to 40 kilograms of equipment and body armour, on far more than three days a week, throughout the 6 months before the worsening, from 14 January 2008 to 14 July 2008. On 10 July 2008, on warlike service in Afghanistan, you struck the exostosis on a rock while crossing a creek bed on patrol, and four days later presented with constant pain, swelling and an inability to lace your boot over the lump. In Afghanistan from July to September 2008 no podiatrist, boot modification or orthopaedic review was available, and you had to keep patrolling in laced boots with the laces loosened.
This has then led to further investigations and the diagnosis of your condition of Exostosis (Worsening). I have accepted your condition of Exostosis (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 14 July 2008.
