Reference Determination Content
Suggested draft · fictitious patient
Left Foot - Fifth Metatarsal Strain (Metatarsalgia)
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 9 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 9 April 2025;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 2 March 2009;
- A patrol base treatment record by the medical officer, Afghanistan, dated 18 July 2009;
- An X-ray left foot by Role 2 medical facility, Afghanistan, dated 19 July 2009;
- A patrol base treatment record by the medical officer, Afghanistan, dated 21 August 2009;
- An MRI left foot by the radiologist, dated 15 January 2010;
- A sports medicine consultation by the sports physician, dated 15 January 2010;
- A podiatry assessment by the podiatrist, dated 10 September 2010;
- A role 2 medical facility record and X-ray by the medical officer, Afghanistan, dated 22 June 2013;
- An MRI left foot by the radiologist, dated 30 July 2013;
- An operation report by the orthopaedic foot and ankle surgeon, dated 18 March 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
11 July 2005 and 19 February 2016
Left Foot - Fifth Metatarsal Strain (Metatarsalgia)
You have stated that your condition was caused by:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon
Diagnosis: Fifth Metatarsal Strain (Metatarsalgia)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 9 April 2025, and is supported by an MRI left foot by the radiologist, dated 15 January 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon
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 sudden tearing pain on the outer border of the left foot with swelling and bruising over the base of the fifth metatarsal, difficulty weight bearing and pain on turning the foot outwards on 18 July 2009.
The diagnosis was made by a sports physician on 15 January 2010 on the history of a forced inversion injury under load, immediate pain and tenderness at the fifth tarsometatarsal joint and the peroneus brevis insertion, pain on resisted eversion and passive inversion, and MRI showing a sprain of the fifth tarsometatarsal joint ligaments and thickening with partial tearing of the peroneus brevis tendon at its insertion. A fracture of the base of the fifth metatarsal was excluded on X-ray on 19 July 2009 and MRI. This meets the Statement of Principles definitions of strain and sprain: tearing or stretching of a tendon and of joint ligaments, with pain and tenderness at the site within 24 hours of the injury.
This has then led to further investigations and the diagnosis of your condition of Fifth Metatarsal Strain (Metatarsalgia). I have accepted your condition of Fifth Metatarsal Strain (Metatarsalgia).
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 18 July 2009.
Left Foot - Fifth Metatarsal Strain (Metatarsalgia) (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 9 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 9 April 2025;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 2 March 2009;
- A patrol base treatment record by the medical officer, Afghanistan, dated 18 July 2009;
- An X-ray left foot by Role 2 medical facility, Afghanistan, dated 19 July 2009;
- A patrol base treatment record by the medical officer, Afghanistan, dated 21 August 2009;
- An MRI left foot by the radiologist, dated 15 January 2010;
- A sports medicine consultation by the sports physician, dated 15 January 2010;
- A podiatry assessment by the podiatrist, dated 10 September 2010;
- A role 2 medical facility record and X-ray by the medical officer, Afghanistan, dated 22 June 2013;
- An MRI left foot by the radiologist, dated 30 July 2013;
- An operation report by the orthopaedic foot and ankle surgeon, dated 18 March 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
11 July 2005 and 19 February 2016
Left Foot - Fifth Metatarsal Strain (Metatarsalgia) (Worsening)
You have stated that the worsening of your condition was caused by:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon
- inability to obtain appropriate clinical management for sprain or strain
Diagnosis: Fifth Metatarsal Strain (Metatarsalgia) (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 9 April 2025, and is supported by an MRI left foot by the radiologist, dated 15 January 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon
- inability to obtain appropriate clinical management for sprain or strain
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 sudden tearing pain on the outer border of the left foot with swelling and bruising over the base of the fifth metatarsal, difficulty weight bearing and pain on turning the foot outwards on 18 July 2009.
The diagnosis was made by a sports physician on 15 January 2010 on the history of a forced inversion injury under load, immediate pain and tenderness at the fifth tarsometatarsal joint and the peroneus brevis insertion, pain on resisted eversion and passive inversion, and MRI showing a sprain of the fifth tarsometatarsal joint ligaments and thickening with partial tearing of the peroneus brevis tendon at its insertion. A fracture of the base of the fifth metatarsal was excluded on X-ray on 19 July 2009 and MRI. This meets the Statement of Principles definitions of strain and sprain: tearing or stretching of a tendon and of joint ligaments, with pain and tenderness at the site within 24 hours of the injury.
After the condition arose, it was worsened during your service. During warlike service in Afghanistan on 22 June 2013 your left foot was forced into inversion and plantarflexion in a concealed ditch as you ran under a 35 kg load to a helicopter, applying a significant force through the fifth tarsometatarsal joint and worsening the sprain, confirmed on MRI on 30 July 2013. In the same incident on warlike service on 22 June 2013 the peroneus brevis was contracting at high intensity during a loaded sprint and was forcefully stretched by the inversion, producing a split tear of the tendon that worsened the 2009 strain. During warlike service in Afghanistan from July to November 2009 there was no physiotherapy, imaging beyond plain X-ray or relief from patrolling, and you continued dismounted patrols under load on a taped, injured foot for four months before you could obtain rehabilitation.
This has then led to further investigations and the diagnosis of your condition of Fifth Metatarsal Strain (Metatarsalgia) (Worsening). I have accepted your condition of Fifth Metatarsal Strain (Metatarsalgia) (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 wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 22 June 2013.
