Right Ankle - Posterior Tibialis Tendinopathy — example DVA determination letter

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Right Ankle - Posterior Tibialis Tendinopathy

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 6 May 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
A pre-deployment medical examination by the medical officer, RAAF base health centre, dated 18 December 2009;
An outpatient health record and stool culture by Role 2 medical facility, Afghanistan, dated 12 April 2010;
A wound treatment record by the medic, Afghanistan, dated 22 April 2010;
An outpatient health record by the medical officer, Afghanistan, dated 5 May 2010;
An outpatient health record by the medical officer, Afghanistan, dated 17 May 2010;
An ultrasound (aspiration and orthopaedic consultation) by Role 3 hospital, Afghanistan, dated 20 May 2010;
An MRI right ankle by the radiologist, dated 5 October 2010;
A rheumatology consultation by the rheumatologist, dated 18 August 2014;
An outpatient health record by the medical officer, Iraq, dated 24 July 2015;
An MRI right ankle by the radiologist, dated 12 October 2015;
An operation report and histology by the orthopaedic surgeon and pathologist, dated 8 December 2015;
An orthopaedic review and weight-bearing X-ray by the orthopaedic surgeon, dated 11 March 2020.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

20 July 2004 and 15 November 2021

Right Ankle - Posterior Tibialis Tendinopathy

You have stated that your condition was caused by:

running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical onset of posterior tibialis tendinopathy
undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical onset of posterior tibialis tendinopathy
increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical onset of posterior tibialis tendinopathy
having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical onset of posterior tibialis tendinopathy
having an infection of the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy
having gout involving the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy
having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of posterior tibialis tendinopathy

Diagnosis: Posterior Tibialis Tendinopathy

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 6 May 2025, and is supported by an ultrasound (aspiration and orthopaedic consultation) by Role 3 hospital, Afghanistan, dated 20 May 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 Posterior Tibialis Tendinopathy (Reasonable Hypothesis) (No. 45 of 2021)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical onset of posterior tibialis tendinopathy
undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical onset of posterior tibialis tendinopathy
increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical onset of posterior tibialis tendinopathy
having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical onset of posterior tibialis tendinopathy
having an infection of the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy
having gout involving the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy
having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of posterior tibialis tendinopathy

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 and swelling along the inside of the right ankle, behind the medial malleolus and towards the arch, which was worse with patrolling and running and eased with rest on 17 May 2010.

The diagnosis was made clinically on 17 May 2010, with pain, swelling and tenderness along the course of the right posterior tibialis tendon and weak, painful single-leg heel raises, and confirmed on 20 May 2010 by ultrasound showing a thickened, hypoechoic tendon with tenosynovitis. Aspiration of the tendon sheath showed monosodium urate crystals and a culture of Staphylococcus aureus. Inflammation and degeneration of the posterior tibialis tendon producing localised pain and tenderness meets the Statement of Principles definition.

This has then led to further investigations and the diagnosis of your condition of Posterior Tibialis Tendinopathy. I have accepted your condition of Posterior Tibialis Tendinopathy.

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 14 May 2010.

Right Ankle - Posterior Tibialis Tendinopathy (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 6 May 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 6 May 2025;
A pre-deployment medical examination by the medical officer, RAAF base health centre, dated 18 December 2009;
An outpatient health record and stool culture by Role 2 medical facility, Afghanistan, dated 12 April 2010;
A wound treatment record by the medic, Afghanistan, dated 22 April 2010;
An outpatient health record by the medical officer, Afghanistan, dated 5 May 2010;
An outpatient health record by the medical officer, Afghanistan, dated 17 May 2010;
An ultrasound (aspiration and orthopaedic consultation) by Role 3 hospital, Afghanistan, dated 20 May 2010;
An MRI right ankle by the radiologist, dated 5 October 2010;
A rheumatology consultation by the rheumatologist, dated 18 August 2014;
An outpatient health record by the medical officer, Iraq, dated 24 July 2015;
An MRI right ankle by the radiologist, dated 12 October 2015;
An operation report and histology by the orthopaedic surgeon and pathologist, dated 8 December 2015;
An orthopaedic review and weight-bearing X-ray by the orthopaedic surgeon, dated 11 March 2020.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

20 July 2004 and 15 November 2021

Right Ankle - Posterior Tibialis Tendinopathy (Worsening)

You have stated that the worsening of your condition was caused by:

running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy
undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy
increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical worsening of posterior tibialis tendinopathy
having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical worsening of posterior tibialis tendinopathy
having an infection of the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy
having gout involving the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy
having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of posterior tibialis tendinopathy
inability to obtain appropriate clinical management for posterior tibialis tendinopathy

Diagnosis: Posterior Tibialis Tendinopathy (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Posterior Tibialis Tendinopathy (Reasonable Hypothesis) (No. 45 of 2021)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

running or jogging an average of at least 30 kilometres per week, for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy
undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least four hours per week; and for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy
increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least two hours per day; and within the seven days before the clinical worsening of posterior tibialis tendinopathy
having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical worsening of posterior tibialis tendinopathy
having an infection of the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy
having gout involving the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy
having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of posterior tibialis tendinopathy
inability to obtain appropriate clinical management for posterior tibialis tendinopathy

After the condition arose, it was worsened during your service. On warlike service in Iraq you ran an average of about 62 kilometres a week from 26 June 2015 to 24 July 2015, the four weeks before the worsening. On warlike service in Iraq you patrolled with about 30 kilograms for at least 8 hours a week throughout the four weeks before the worsening, from 26 June 2015 to 24 July 2015, above five METs. A security surge on warlike service in Iraq raised your patrolling from about 8 hours a week to more than four and a half hours a day from 17 July 2015, within the seven days before the worsening on 24 July 2015. The blow to the right medial ankle from a protected vehicle step on warlike service in Iraq on 14 July 2015 occurred ten days before the worsening. The infected step laceration tracked along the tendon sheath and was present at the worsening on 24 July 2015 on warlike service in Iraq. A medial ankle gout flare, precipitated by dehydration on warlike service in Iraq, was present at the worsening, and tophi in the tendon sheath were confirmed at surgery. Undifferentiated spondyloarthritis, which evolved from the reactive arthritis that followed Shigella infection on warlike service in Afghanistan, was active at the worsening on 24 July 2015. On warlike service in Iraq no imaging or orthopaedic review was available when the tendon tore, and imaging and repair were delayed until October and December 2015.

This has then led to further investigations and the diagnosis of your condition of Posterior Tibialis Tendinopathy (Worsening). I have accepted your condition of Posterior Tibialis Tendinopathy (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 24 July 2015.

Right Ankle - Posterior Tibialis Tendinopathy — example determination letter

See the letter exactly as it is delivered

Reference Determination Content

Right Ankle - Posterior Tibialis Tendinopathy

Evidence

Your service

Right Ankle - Posterior Tibialis Tendinopathy

Right Ankle - Posterior Tibialis Tendinopathy (Worsening)

Evidence

Your service

Right Ankle - Posterior Tibialis Tendinopathy (Worsening)