Reference Determination Content
Suggested draft · fictitious patient
Right Ankle - Impingement Syndrome
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 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A field medical record by the medical officer, East Timor, dated 14 October 2007;
- A trauma admission by the x-ray and CT, operation report, Role 3 hospital, Afghanistan, dated 18 June 2009;
- An orthopaedic consultation and CT right ankle by the orthopaedic surgeon, dated 2 March 2011;
- A pre-deployment medical examination by the medical officer, dated 30 April 2012;
- A role 2 treatment record by the medical officer, Afghanistan, dated 10 September 2012;
- An MRI right ankle and orthopaedic consultation by the orthopaedic surgeon, dated 22 February 2013;
- A drop zone injury report and outpatient record by the medical officer, dated 15 July 2014;
- An MRI right ankle by the radiologist, dated 29 July 2014;
- An arthroscopy operation report by the orthopaedic surgeon, dated 5 May 2015;
- A parachute log summary by the 2005 to 2014, Parachute training records;
- Recognised causes of ankle impingement syndrome (orthopaedic and sports medicine literature (no Statement of Principles)).
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 July 2004 and 3 March 2020
Right Ankle - Impingement Syndrome
You have stated that your condition was caused by:
- having an inversion injury of the affected ankle with sprain of the lateral ligament complex at least 3 months before the clinical onset of impingement syndrome of the ankle
- having a fracture of the affected ankle, including a fracture of the malleoli or the talus, at least 3 months before the clinical onset of impingement syndrome of the ankle
- having an injury to the distal tibiofibular syndesmosis of the affected ankle before the clinical onset of impingement syndrome of the ankle
- having undergone surgery to the affected ankle at least 3 months before the clinical onset of impingement syndrome of the ankle
- having chronic lateral instability of the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle
- having an os trigonum, a non-united fracture of the posterior process of the talus or an enlarged posterior talar process in the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle
- making at least 100 parachute descents within the 10 years before the clinical onset of impingement syndrome of the ankle
- marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 2,000 hours within the 10 years before the clinical onset of impingement syndrome of the ankle
- undertaking activities involving repeated forced dorsiflexion of the affected ankle, such as climbing steep slopes, ladders or walls, squatting or kneeling, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle
- undertaking activities involving repeated forced plantarflexion of the affected ankle, such as descending steep slopes or stairs or jumping and landing, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle
Diagnosis: Impingement Syndrome
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by an MRI right ankle and orthopaedic consultation by the orthopaedic surgeon, dated 22 February 2013.
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 an inversion injury of the affected ankle with sprain of the lateral ligament complex at least 3 months before the clinical onset of impingement syndrome of the ankle
- having a fracture of the affected ankle, including a fracture of the malleoli or the talus, at least 3 months before the clinical onset of impingement syndrome of the ankle
- having an injury to the distal tibiofibular syndesmosis of the affected ankle before the clinical onset of impingement syndrome of the ankle
- having undergone surgery to the affected ankle at least 3 months before the clinical onset of impingement syndrome of the ankle
- having chronic lateral instability of the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle
- having an os trigonum, a non-united fracture of the posterior process of the talus or an enlarged posterior talar process in the affected ankle for at least the 6 months before the clinical onset of impingement syndrome of the ankle
- making at least 100 parachute descents within the 10 years before the clinical onset of impingement syndrome of the ankle
- marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 2,000 hours within the 10 years before the clinical onset of impingement syndrome of the ankle
- undertaking activities involving repeated forced dorsiflexion of the affected ankle, such as climbing steep slopes, ladders or walls, squatting or kneeling, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle
- undertaking activities involving repeated forced plantarflexion of the affected ankle, such as descending steep slopes or stairs or jumping and landing, on most days for at least the 3 months before the clinical onset of impingement syndrome of the ankle
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 constant pain at the front and outer side of the right ankle on climbing, squatting and kneeling, and pain at the back of the ankle on walking downhill and pushing off, with swelling after patrols and a sense of blocking at the end of dorsiflexion.After onset the pain increased with patrolling and parachuting and, after the July 2014 injury, you lost all dorsiflexion beyond neutral on 10 September 2012.
The diagnosis was confirmed on MRI of 22 February 2013, which showed anterior tibial and talar neck osteophytes, anterolateral gutter synovitis with a meniscoid lesion and a thickened distal fascicle of the anterior inferior tibiofibular ligament, and a non-united posterior talar process fragment with surrounding oedema and synovitis. These are the recognised structural features of anterior, anterolateral and posterior impingement.
This has then led to further investigations and the diagnosis of your condition of Impingement Syndrome. I have accepted your condition of Impingement Syndrome.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 3 September 2012.
Right Ankle - Impingement Syndrome (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 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A field medical record by the medical officer, East Timor, dated 14 October 2007;
- A trauma admission by the x-ray and CT, operation report, Role 3 hospital, Afghanistan, dated 18 June 2009;
- An orthopaedic consultation and CT right ankle by the orthopaedic surgeon, dated 2 March 2011;
- A pre-deployment medical examination by the medical officer, dated 30 April 2012;
- A role 2 treatment record by the medical officer, Afghanistan, dated 10 September 2012;
- An MRI right ankle and orthopaedic consultation by the orthopaedic surgeon, dated 22 February 2013;
- A drop zone injury report and outpatient record by the medical officer, dated 15 July 2014;
- An MRI right ankle by the radiologist, dated 29 July 2014;
- An arthroscopy operation report by the orthopaedic surgeon, dated 5 May 2015;
- A parachute log summary by the 2005 to 2014, Parachute training records;
- Recognised causes of ankle impingement syndrome (orthopaedic and sports medicine literature (no Statement of Principles)).
Your service
I have identified that you have the following service:
Australian Defence Force service between :
12 July 2004 and 3 March 2020
Right Ankle - Impingement Syndrome (Worsening)
You have stated that the worsening of your condition was caused by:
- having a further inversion or impact injury of the affected ankle within the 3 months before the clinical worsening of impingement syndrome of the ankle
- making parachute descents or undertaking activities involving repeated forced dorsiflexion or plantarflexion of the affected ankle within the 12 months before the clinical worsening of impingement syndrome of the ankle
- marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 200 hours within the 12 months before the clinical worsening of impingement syndrome of the ankle
- inability to obtain appropriate clinical management for impingement syndrome of the ankle
Diagnosis: Impingement Syndrome (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by an MRI right ankle and orthopaedic consultation by the orthopaedic surgeon, dated 22 February 2013.
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 further inversion or impact injury of the affected ankle within the 3 months before the clinical worsening of impingement syndrome of the ankle
- making parachute descents or undertaking activities involving repeated forced dorsiflexion or plantarflexion of the affected ankle within the 12 months before the clinical worsening of impingement syndrome of the ankle
- marching, patrolling or running while carrying loads of at least 20 kilograms for a cumulative total of at least 200 hours within the 12 months before the clinical worsening of impingement syndrome of the ankle
- inability to obtain appropriate clinical management for impingement syndrome of the ankle
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 constant pain at the front and outer side of the right ankle on climbing, squatting and kneeling, and pain at the back of the ankle on walking downhill and pushing off, with swelling after patrols and a sense of blocking at the end of dorsiflexion.After onset the pain increased with patrolling and parachuting and, after the July 2014 injury, you lost all dorsiflexion beyond neutral on 10 September 2012.
The diagnosis was confirmed on MRI of 22 February 2013, which showed anterior tibial and talar neck osteophytes, anterolateral gutter synovitis with a meniscoid lesion and a thickened distal fascicle of the anterior inferior tibiofibular ligament, and a non-united posterior talar process fragment with surrounding oedema and synovitis. These are the recognised structural features of anterior, anterolateral and posterior impingement.
After the condition arose, it was worsened during your service. On 15 July 2014 you inverted your right ankle on a heavy parachute landing on a rocky drop zone, two weeks before the worsening documented on MRI on 29 July 2014, which showed enlarged osteophytes, increased synovitis and a new talar dome contusion, with dorsiflexion lost to neutral. Between 29 July 2013 and 29 July 2014 you made 11 parachute descents and continued infantry training involving climbing, kneeling and jumping, as required by your employment while awaiting surgery. Unit records show about 260 hours of route marching and field exercises with loads of 30 to 40 kilograms in the 12 months before the worsening, from 29 July 2013 to 29 July 2014. Arthroscopic debridement was recommended on 22 February 2013 but not performed until 5 May 2015, 26 months later, and in the meantime you were not removed from parachuting.
This has then led to further investigations and the diagnosis of your condition of Impingement Syndrome (Worsening). I have accepted your condition of Impingement Syndrome (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 peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 29 July 2014.
