Reference Determination Content
Suggested draft · fictitious patient
Left Tibia - Stress Fracture (fredericson Type 1)
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 17 March 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 March 2025;
- An emergency and orthopaedic admission record by the regional hospital, dated 11 August 2010;
- A CT scanogram report by the radiologist, dated 14 June 2011;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 12 January 2012;
- An outpatient health record by the medical officer, Role 1 facility, Afghanistan, dated 18 June 2012;
- An X-ray report by Role 2 facility, Afghanistan, dated 19 June 2012;
- An MRI report by the radiologist, dated 8 October 2012;
- A CT report and sports medicine consultation by the sports physician, dated 15 October 2012;
- A respiratory medicine consultation by the respiratory physician, dated 10 December 2012;
- Pathology results and outpatient record by the medical officer, Garrison health centre, dated 4 April 2013;
- A DXA report and sports medicine review by the sports physician, dated 10 May 2013;
- A CT report and orthopaedic consultation by the orthopaedic surgeon, dated 20 June 2013;
- An operation report by the orthopaedic surgeon, dated 15 August 2013;
- A medical employment classification review and discharge medical by the medical officer, dated 12 December 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
21 January 2008 and 12 December 2014
Left Tibia - Stress Fracture (fredericson Type 1)
You have stated that your condition was caused by:
- having significant physical force applied to or through the affected bone at the time of clinical onset
- for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset
- 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
Diagnosis: Stress Fracture (fredericson Type 1)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 March 2025, and is supported by an MRI report by the radiologist, dated 8 October 2012.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Fracture (Reasonable Hypothesis) (No. 62 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 significant physical force applied to or through the affected bone at the time of clinical onset
- for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset
- 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
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, sharp pain in the left shin on landing, then aching pain at the junction of the middle and distal thirds of the tibia on every patrol, worse with load and on jumping, with focal bony tenderness and pain at night after long patrols on 18 June 2012.
The diagnosis is based on the typical history of focal shin pain arising under heavy repetitive load and becoming acute on landing from a jump, focal bony tenderness at the posteromedial tibia, a positive single-leg hop test and, after a normal initial X-ray, MRI on 8 October 2012 showing a linear cortical fracture line with Fredericson type 1 periosteal oedema, confirmed by CT on 15 October 2012. The fracture occurred in previously healthy bone in a 24-year-old soldier under training and operational load, so it is a stress fracture of the fatigue type, which is included in the Statement of Principles definition of fracture, and not an insufficiency fracture or a bone stress injury without a fracture line.
This has then led to further investigations and the diagnosis of your condition of Stress Fracture (fredericson Type 1). I have accepted your condition of Stress Fracture (fredericson Type 1).
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 June 2012.
Left Tibia - Stress Fracture (fredericson Type 1) (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 17 March 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 March 2025;
- An emergency and orthopaedic admission record by the regional hospital, dated 11 August 2010;
- A CT scanogram report by the radiologist, dated 14 June 2011;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 12 January 2012;
- An outpatient health record by the medical officer, Role 1 facility, Afghanistan, dated 18 June 2012;
- An X-ray report by Role 2 facility, Afghanistan, dated 19 June 2012;
- An MRI report by the radiologist, dated 8 October 2012;
- A CT report and sports medicine consultation by the sports physician, dated 15 October 2012;
- A respiratory medicine consultation by the respiratory physician, dated 10 December 2012;
- Pathology results and outpatient record by the medical officer, Garrison health centre, dated 4 April 2013;
- A DXA report and sports medicine review by the sports physician, dated 10 May 2013;
- A CT report and orthopaedic consultation by the orthopaedic surgeon, dated 20 June 2013;
- An operation report by the orthopaedic surgeon, dated 15 August 2013;
- A medical employment classification review and discharge medical by the medical officer, dated 12 December 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
21 January 2008 and 12 December 2014
Left Tibia - Stress Fracture (fredericson Type 1) (Worsening)
You have stated that the worsening of your condition was caused by:
- smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union
- having diabetes mellitus at the time of the fracture non-union
- inability to obtain appropriate clinical management for fracture before clinical worsening
Diagnosis: Stress Fracture (fredericson Type 1) (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 March 2025, and is supported by an MRI report by the radiologist, dated 8 October 2012.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Fracture (Balance of Probabilities) (No. 63 of 2024)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union
- having diabetes mellitus at the time of the fracture non-union
- inability to obtain appropriate clinical management for fracture 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 sudden, sharp pain in the left shin on landing, then aching pain at the junction of the middle and distal thirds of the tibia on every patrol, worse with load and on jumping, with focal bony tenderness and pain at night after long patrols on 18 June 2012.
The diagnosis is based on the typical history of focal shin pain arising under heavy repetitive load and becoming acute on landing from a jump, focal bony tenderness at the posteromedial tibia, a positive single-leg hop test and, after a normal initial X-ray, MRI on 8 October 2012 showing a linear cortical fracture line with Fredericson type 1 periosteal oedema, confirmed by CT on 15 October 2012. The fracture occurred in previously healthy bone in a 24-year-old soldier under training and operational load, so it is a stress fracture of the fatigue type, which is included in the Statement of Principles definition of fracture, and not an insufficiency fracture or a bone stress injury without a fracture line.
After the condition arose, it was worsened during your service. You started smoking during your deployment in March 2012 and was smoking 15 to 20 cigarettes a day when treatment for the fracture began on 8 October 2012. Diabetes mellitus was diagnosed on 4 April 2013, with an HbA1c of 7.6 per cent and a fasting glucose of 9.2 mmol/L, caused by high-dose prednisolone prescribed from 10 December 2012 for asthma. After the onset on 18 June 2012 no MRI or bone scan was available at the deployed role 1 and role 2 facilities, and the plain X-ray of 19 June 2012 did not show the fracture.
This has then led to further investigations and the diagnosis of your condition of Stress Fracture (fredericson Type 1) (Worsening). I have accepted your condition of Stress Fracture (fredericson Type 1) (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 20 June 2013.
