Reference Determination Content
Suggested draft · fictitious patient
Right Foot - Stress Fracture Third Metatarsal
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 trauma admission and operation report by the orthopaedic surgeon, dated 14 June 2009;
- A CT scanogram report by the radiologist, dated 9 March 2010;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 21 November 2011;
- A treatment record by the medic, Afghanistan, dated 18 March 2012;
- An outpatient record and X-ray report by the medical officer, Role 2 facility, Afghanistan, dated 24 March 2012;
- A hospital admission and bronchoscopy report by the physician, Role 3 hospital, Afghanistan, dated 10 April 2012;
- An X-ray right foot report by the radiologist, dated 30 May 2012;
- An outpatient health record and pathology by the medical officer, Garrison health centre, dated 20 September 2012;
- A bone densitometry report (pathology and endocrinology consultation) by the endocrinologist, dated 5 November 2012;
- A CT right foot report and orthopaedic consultation by the radiologist and orthopaedic surgeon, dated 20 November 2012;
- An operation report by the orthopaedic surgeon, dated 15 February 2013.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
7 February 2007 and 12 December 2014
Right Foot - Stress Fracture Third Metatarsal
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 Third Metatarsal
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 6 May 2025, and is supported by an outpatient record and X-ray report by the medical officer, Role 2 facility, Afghanistan, dated 24 March 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 a sudden crack and severe pain in the right forefoot on landing, with swelling and bruising over the dorsum of the third metatarsal and inability to bear weight on 24 March 2012.
The diagnosis was made on 24 March 2012 at the role 2 facility on the history of forefoot pain with activity followed by an acute crack on landing, with point tenderness and swelling over the third metatarsal neck, and confirmed on X-ray the same day, which showed a fracture through the neck of the third metatarsal with established periosteal new bone along the shaft. The periosteal reaction shows that bone stress had been present for some weeks before the fracture completed, which identifies it as a stress fracture. This meets the Statement of Principles definition of fracture, including stress fracture.
This has then led to further investigations and the diagnosis of your condition of Stress Fracture Third Metatarsal. I have accepted your condition of Stress Fracture Third Metatarsal.
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 24 March 2012.
Right Foot - Stress Fracture Third Metatarsal (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 trauma admission and operation report by the orthopaedic surgeon, dated 14 June 2009;
- A CT scanogram report by the radiologist, dated 9 March 2010;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 21 November 2011;
- A treatment record by the medic, Afghanistan, dated 18 March 2012;
- An outpatient record and X-ray report by the medical officer, Role 2 facility, Afghanistan, dated 24 March 2012;
- A hospital admission and bronchoscopy report by the physician, Role 3 hospital, Afghanistan, dated 10 April 2012;
- An X-ray right foot report by the radiologist, dated 30 May 2012;
- An outpatient health record and pathology by the medical officer, Garrison health centre, dated 20 September 2012;
- A bone densitometry report (pathology and endocrinology consultation) by the endocrinologist, dated 5 November 2012;
- A CT right foot report and orthopaedic consultation by the radiologist and orthopaedic surgeon, dated 20 November 2012;
- An operation report by the orthopaedic surgeon, dated 15 February 2013.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
7 February 2007 and 12 December 2014
Right Foot - Stress Fracture Third Metatarsal (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 Third Metatarsal (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 6 May 2025, and is supported by an outpatient record and X-ray report by the medical officer, Role 2 facility, Afghanistan, dated 24 March 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 a sudden crack and severe pain in the right forefoot on landing, with swelling and bruising over the dorsum of the third metatarsal and inability to bear weight on 24 March 2012.
The diagnosis was made on 24 March 2012 at the role 2 facility on the history of forefoot pain with activity followed by an acute crack on landing, with point tenderness and swelling over the third metatarsal neck, and confirmed on X-ray the same day, which showed a fracture through the neck of the third metatarsal with established periosteal new bone along the shaft. The periosteal reaction shows that bone stress had been present for some weeks before the fracture completed, which identifies it as a stress fracture. This meets the Statement of Principles definition of fracture, including stress fracture.
After the condition arose, it was worsened during your service. You started smoking in February 2012 on deployment and smoked 15 to 20 cigarettes a day throughout treatment of the fracture, from 24 March 2012 to the confirmation of non-union on 20 November 2012, as recorded on 18 March 2012 and 20 September 2012. Diabetes mellitus was diagnosed on 20 September 2012, with a fasting glucose of 9.1 mmol/L and an HbA1c of 7.6 per cent, caused by the high-dose prednisolone prescribed for acute eosinophilic pneumonia contracted on deployment. After the fracture on 24 March 2012 you remained on restricted duties in theatre in a walking boot, without orthopaedic review, CT, non-weight-bearing immobilisation or relief from walking on rough ground, and the delayed union on 30 May 2012 was not acted on until specialist review in Australia in September 2012.
This has then led to further investigations and the diagnosis of your condition of Stress Fracture Third Metatarsal (Worsening). I have accepted your condition of Stress Fracture Third Metatarsal (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 September 2012.
