Statement of Principles concerning fracture (Reasonable Hypothesis) (No. 62 of 2024)

The instrument revolves around a small set of tightly defined legal-medical concepts, each of which shapes how evidence will be evaluated in claims. Central concepts are “fracture”, “death from fracture”, “reasonable hypothesis” as operationalised by the list of factors, “relevant service”, and the temporal concept of “clinical worsening” such as fracture non-union.

Fracture. The instrument defines fracture in section 7(2). A fracture is an acquired break of bone caused by an applied force that ordinarily causes breakage in healthy bone. The definition lists inclusions and exclusions. Included are several fracture types and sequelae, for example avulsion, crush, comminuted, burst, blowout, closed and compound fractures, stress fractures of the fatigue type, fractures contiguous with implants, periosteal and soft tissue damage directly caused by displaced bone, torsion or spiral fractures, and wound infection from bony fragments (section 7(2)(b)(i)-(ix)). Excluded are pathological fractures, bone stress injuries/bone marrow oedema that are not stress fractures, insufficiency-type stress fractures, osteonecrosis, periostitis, dental and cartilage fractures, fracture of orthopaedic implants (screws, plates, prostheses), and spondylolysis (section 7(2)(c)(i)-(ix)). The instrument also includes the medical note that clinical worsening could include fracture non-union but not an additional fracture; an additional fracture would require invocation of the Statement again.

Death from fracture. The instrument includes death from a terminal event or condition contributed to by the fracture (section 7(3)). The Schedule defines “terminal event” to include pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function (Schedule 1).

Factors that must exist. Section 9 lists the discrete factors, any one of which, at minimum, must be present to raise a reasonable hypothesis connecting the fracture or death to relevant service. The factors are categorical and, in some cases, conditional on the fracture type or phase of healing. Examples: significant physical force applied to or through the affected bone at clinical onset (section 9(1)); for stress fracture only, significant repetitive loading stress prior to clinical onset or chronic abnormal force intensity or direction at onset (section 9(2)-(3)); factors tied to clinical worsening/fracture non-union such as smoking during treatment prior to non-union (section 9(4)), diabetes mellitus at the time of non-union (section 9(5)), osteoporosis at the time of non-union (section 9(6)), vitamin D deficiency defined as serum 25(OH)D < 50 nmol/L at the time of non-union (section 9(7)), BMI of 40 or greater at the time of non-union (section 9(8)), and inability to obtain appropriate clinical management prior to clinical worsening (section 9(9)). The instrument notes that one gram of tobacco equals one cigarette for smoking equivalence (Note under section 9(4)).

Temporal and relational rules. Section 10 requires that any listed factor must be related to the person’s relevant service. Section 10(2) restricts the “clinical worsening” aspects of factors in section 9 to situations where the fracture was suffered or contracted before or during, but did not arise out of, relevant service. That is, non-union and aggravation factors only operate where the original fracture pre-dated or coincided with service but was not caused by service.

Cross-reference to other Statements. Section 11 provides that where a section 9 factor refers to an injury or disease covered by another Statement of Principles, the factors in that other Statement apply in accordance with its terms as in force.

Definitions in the Schedule. The Schedule supplies operational definitions that matter for proof: BMI formula (Schedule 1), the meaning of relevant service including operational, peacekeeping, hazardous, British nuclear test defence (VEA), warlike or non-warlike service (MRCA) (Schedule 1), terminal event, and references to MRCA and VEA (Schedule 1). These definitions determine which personnel and what service categories are in scope (section 5).

Finally, the instrument positions itself as a product of the Repatriation Medical Authority’s view that there is sound medical-scientific evidence that fracture and death from fracture can be related to relevant service (section 8). That is a statement of evidentiary basis, not an adjudicative conclusion about any particular claim.

This Statement of Principles affects three principal groups directly and several stakeholders indirectly.

Primary affected group: claimants and potential claimants under the VEA and MRCA. The instrument applies to claims to which section 120A of the VEA or section 338 of the MRCA applies (section 5). The Schedule defines “relevant service” to include operational, peacekeeping, hazardous and British nuclear test defence service under the VEA, and warlike or non-warlike service under the MRCA (Schedule 1). Consequently, veterans, former members of the Forces and members of Peacekeeping Forces who have fractures and make claims under the referenced statutory provisions are directly affected because the Statement provides the medical threshold for a reasonable hypothesis of service connection.

Decision makers and administrative bodies. The Statement is an instrument of the Repatriation Medical Authority made under subsection 196B(2) of the VEA (section 3). The authority’s determinations are used by decision makers in the relevant claims processes. While the Statement itself does not adjudicate claims, its presence constrains decision makers’ medical findings and helps standardise which factual or clinical circumstances may raise a reasonable hypothesis. Agencies administering VEA or MRCA claims, medical assessors, rehabilitation providers and case officers will rely on the Statement’s factors when assessing causation.

Medical practitioners and providers. Treating clinicians and forensic medical examiners will be asked to supply the clinical data that aligns with the instrument’s factors, for example documentation of the applied force, stress loading history, smoking during treatment, presence of diabetes or osteoporosis at the time of non-union, serum 25(OH)D results, BMI at the time of non-union, or the absence of appropriate clinical management. The instrument’s definitions and timing requirements will shape what tests and clinical notes are material.

Indirectly affected third parties. The Statement has implications for insurers, rehabilitation providers, and legal advisers who represent claimants or the Department. The instrument may alter evidentiary strategies and the types of records that are necessary to establish a reasonable hypothesis.

Who does not become affected by operation of this instrument. The instrument excludes certain presentations from being classed as “fracture” for this Statement (section 7(2)(c)), for example pathological fractures, insufficiency stress fractures, fracture of orthopaedic implants and dental fractures. Claims that rely solely on those excluded conditions will not raise the fracture Statement’s listed factors. Additionally, the Statement’s clinical worsening factors are confined by section 10(2) to fractures that were suffered or contracted before or during but did not arise out of relevant service; where a fracture arises out of service the temporal rule for worsening does not apply in the same way, and different causation logic will control.

In short, the instrument reshapes the evidentiary and medical thresholds for a subset of veterans’ entitlement claims involving fracture and death from fracture, and it assigns predictable documentary and clinical tasks to claimants, medical practitioners, and decision makers within the VEA and MRCA frameworks.

The Statement itself does not create statutory duties in the sense of criminal obligations; it defines the criteria that must be satisfied to raise a reasonable hypothesis that fracture or death from fracture is related to relevant service. However, the Statement imposes de facto duties on various actors in the claims process through evidentiary and temporal requirements.

Duty to establish a listed factor. For a reasonable hypothesis to be raised, at least one factor in section 9 must exist. That imposes on claimants and their representatives the duty to adduce evidence addressing one or more of the listed factors (section 9). The factors are specific and often temporally bounded, for example smoking during treatment prior to fracture non-union (section 9(4)), vitamin D deficiency with serum 25(OH)D < 50 nmol/L at the time of non-union (section 9(7)), or BMI of 40 or greater at the time of non-union (section 9(8)). These criteria require contemporaneous or retrospective medical evidence.

Duty to link factors to relevant service. Section 10(1) requires that the existence of any section 9 factor must be related to the person’s relevant service. This places an evidentiary obligation on claimants to show a connection between the factor and the service period defined as relevant service in the Schedule (Schedule 1), for example by demonstrating that the significant physical force or repetitive loading occurred in the course of the relevant service, or that the timing of clinical worsening coincided with service-related limitations on treatment access.

Temporal duty with respect to clinical worsening. Section 10(2) constrains the operation of the clinical worsening factors to cases where the fracture was suffered or contracted before or during, but did not arise out of, relevant service. This imposes a duty to establish timing: the claimant must demonstrate when the original fracture was sustained relative to service and whether it “arose out of” service.

Cross-statement obligations. Section 11 provides that if a section 9 factor refers to an injury or disease covered by another Statement of Principles, the factors in that other Statement apply. Practically, this creates a duty to identify and invoke the relevant additional Statement(s) where factors intersect, and to follow those Statements “as in force from time to time”.

Rights of claimants in the claims process. The instrument frames how a claimant may raise a reasonable hypothesis; it does not, in itself, change substantive entitlements granted under the VEA or MRCA. The practical right is procedural: if a claimant satisfies the minimal condition (such as establishing at least one factor and its relation to relevant service), the claims process must proceed on that basis. The Statement therefore defines the claimant’s right to have the claim considered where the prescribed factors and linkage are demonstrated.

Duties of medical and administrative actors. The Statement imposes an evidentiary duty on medical practitioners and administrative decision makers to apply the listed factors and definitions when determining whether a reasonable hypothesis exists. The Repatriation Medical Authority’s statement in section 8 that there is sound medical-scientific evidence underlying the Statement indicates that decision makers are to treat the Statement as the authoritative medical basis for the causation threshold.

No penalties or private rights created. The instrument does not create compensation entitlements, fines, or penalties. It is a criterion-setting instrument used within the statutory decision-making framework of the VEA and MRCA (sections 3 and 5). Any further rights or duties under the VEA or MRCA remain sourced in those Acts; this Statement affects how those rights are argued and established.

In practice the key duties are evidentiary: collect and present clinical data that align with the factors, and show timing and relation to relevant service. The key right is that if those duties are discharged to the standard of raising a reasonable hypothesis, the claimant has procedural entitlement to have their claim progressed under the relevant statutory process.

The Statement of Principles itself contains no provisions imposing criminal or civil penalties. It is not a sanctioning instrument. Its legal effect is definitional and evidentiary within the statutory claims system. The instrument was made under subsection 196B(2) of the VEA (section 3), and it applies to claims to which section 120A of the VEA or section 338 of the MRCA applies (section 5). Enforcement of any resulting benefit entitlements, sanctions for false claims, or administrative penalties would arise from the VEA, MRCA or other legislation and administrative procedures, not from this Statement directly.

Who enforces or applies the Statement. Decision makers within the claims administration process under the VEA and MRCA will apply the Statement when assessing whether a reasonable hypothesis that a fracture is related to relevant service has been raised. The instrument supplies the medical-scientific criteria those decision makers must use. The Repatriation Medical Authority is the statutory source of the instrument (section 3), but the instrument does not itself impose enforcement powers on the Authority beyond the power to issue the Statement under subsection 196B(2).

Consequences of non-compliance with evidence duties. The practical consequence for claimants who do not produce evidence addressing at least one of the factors in section 9, or who cannot show that a factor is related to relevant service as required by section 10(1), is that a reasonable hypothesis will not be raised and the claim may not proceed to the next stage of entitlements consideration. That is an administrative consequence under the VEA/MRCA claims process rather than a penalty enacted in this Statement.

No criminal or civil sanctions specified. The Statement contains no sections imposing fines, imprisonment or civil liability for failure to satisfy a factor. It does not establish monitoring or inspection regimes. Nor does it specify any sanction for inaccurate medical reporting; such issues would be governed by other legal and professional frameworks.

Interaction with other enforcement regimes. Section 11 requires that where a section 9 factor refers to another injury or disease covered by a different Statement of Principles, the factors of that other Statement apply “as in force from time to time”. That clause implicitly creates an enforcement chain: the standards and application rules in other Statements will inform decision makers, and those Statements may in turn be used by administrative or legal actors to reach determinations that have enforcement consequences under the VEA or MRCA.

Record-keeping and evidentiary implications. The lack of internal penalty provisions does not remove practical consequences: claimants and clinicians must provide contemporaneous, reliable documentation of the factors (for example, smoking history, serum 25(OH)D results, BMI at relevant times, evidence of inability to obtain appropriate clinical management), because absent such evidence, the administrative outcome is likely to be unfavourable for the claimant.

In summary, enforcement of the Statement is procedural and evidentiary within the claims framework. The Statement does not itself create new penalties; it supplies the causation criteria which decision makers use to decide entitlements that are governed and enforced under the VEA and MRCA.

This Statement sits within the statutory framework of the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004. It is made under subsection 196B(2) of the VEA (section 3) and applies to claims within the processes engaged by section 120A of the VEA or section 338 of the MRCA (section 5). Those cross-references are the primary statutory touchpoints.

Operational relationship to VEA and MRCA processes. The instrument is not a stand-alone law but a medical-technical instrument that supplies the criteria decision makers must use when applying the causation provisions of the VEA or MRCA. Section 5 makes the application dependent on those statutory claim-making provisions. The Statement therefore modifies the evidentiary landscape in which the substantive and procedural provisions of the VEA and MRCA are applied.

Interaction with other Statements of Principles. Section 11 provides direct interaction: where a section 9 factor refers to an injury or disease covered by another Statement of Principles issued under subsection 196B(2) of the VEA, then that other Statement’s factors apply in accordance with its terms as in force from time to time. This establishes a networked relationship among Statements, where cross-referenced conditions must be considered according to the prevailing versions of those other Statements.

Definitions rooted in the instrument that have statutory effect. The Schedule supplies definitions that are used internally for application of this Statement. For example, “relevant service” is defined to include specific categories under the VEA and MRCA (Schedule 1). While those Schedule definitions do not rewrite the VEA or MRCA, they determine how the Statement’s criteria are applied within the statutory frameworks.

No explicit transitional rule in this instrument. The instrument repeals the earlier fracture Statement No. 94 of 2015 (section 4) and commences on 24 September 2024 (section 2). The text does not provide express transitional provisions about claims in flight or the interplay with determinations made under the repealed Statement. That absence means decision makers and advisers will need to consult the VEA/MRCA frameworks and administrative practice to determine whether a claim started before commencement is to be assessed under the old or new Statement; the instrument itself does not resolve that question.

Evidence and professional regulatory interplay. The Statement’s requirements , for example the need for serum 25(OH)D levels at the time of fracture non-union, or BMI at that time, or smoking during treatment , interact with clinical practice standards and professional record-keeping obligations. Medical practitioners who provide reports will need to ensure that their assessments address the discrete criteria in the Statement if they are to be useful in VEA/MRCA claims processes. This creates an indirect interaction with professional regulatory standards concerning medical records, informed consent and clinical testing.

No interaction with criminal statutes in the Statement. The instrument is confined to the claims context and does not reference criminal or civil penalty statutes. Any allegations of false claims or fraud would continue to be governed by other laws.

In short, the Statement interfaces with the VEA and MRCA by providing the medical threshold that decision makers use when applying those statutes. It also links to and depends upon other Statements of Principles where factors overlap. It does not, on its face, displace or amend substantive entitlements in the VEA or MRCA; it is an evidentiary instrument within their application.

The instrument records a single explicit amendment action: repeal of the previous Statement of Principles concerning fracture No. 94 of 2015 (Federal Register of Legislation No. F2015L01340) (section 4). The current Statement is dated 20 August 2024 and commences on 24 September 2024 (sections 1 and 2). It was made under subsection 196B(2) of the VEA (section 3).

No other amendments, savings or transitional provisions are contained in the text. The Schedule contains definitions that replace or stand in for previous wording for the purposes of this instrument. The instrument does not itself state whether or how claims lodged or decided under the repealed 2015 Statement will be treated after commencement. The absence of express transitional clauses in the instrument means that administrators and practitioners must look to the VEA, MRCA and any accompanying administrative guidance issued by the Department or the Repatriation Medical Authority for directions on how to handle claims in progress, retrospective claims, or appeals that straddle the commencement date.

The Schedule’s definitions are integral to the Statement and form part of the operative text from commencement. Notable definitional insertions include the BMI formula (Schedule 1), the list of service types comprising “relevant service” (Schedule 1), and the specific list of terminal events that qualify for inclusion when death is contributed to by a fracture (Schedule 1).

Because the Statement is framed as “as in force from time to time” in section 11, the instrument anticipates future amendments via replacement of the whole Statement or variations issued under the same statutory power. Any future amendment would similarly be executed under subsection 196B(2) of the VEA. The Statement does not itself create an amendment schedule or specify consultation requirements for future changes.

In practice, administrative practice will likely record this document as the operative Statement for fracture from 24 September 2024 onwards, replacing the 2015 instrument. The repeal clause is unqualified, so, on its face, the 2015 Statement ceases to be in force from the commencement date. However, the instrument contains no saving or clarifying language regarding existing determinations that relied on the 2015 Statement. For that reason practitioners should seek administrative guidance or check the VEA/MRCA for any procedural rules about claims spanning the repeal and commencement dates.

The instrument itself is a Statement of Principles and does not record any litigation. There are no cases, judgments or appeals included in or referred to by the text. The instrument makes no reference to previous judicial or administrative determinations relating to the 2015 Statement or to fracture claims generally.

If litigation arises that challenges the medical-scientific basis of the Statement or its application in a particular claim, that litigation record will not be reflected in this instrument and must be sought from court or tribunal records. The Statement’s section 8 records the Repatriation Medical Authority’s view that “there is sound medical-scientific evidence” supporting the connection between fracture/death from fracture and relevant service; the instrument does not provide the evidence or references it relied upon. If a claimant or the Department wishes to challenge the Statement’s medical-scientific bases or their application, the route would be to litigate under the VEA/MRCA review and appeal processes, drawing on medical expert evidence that either supports or disputes the Authority’s stated view.

Because there is no litigation history embedded in the text, practitioners should treat the instrument as an administrative medical standard to be applied until and unless it is modified by the Authority or successfully challenged through the statutory review processes applicable to decisions made under the VEA and MRCA. Any known litigation challenging earlier Statements or particular applications would need to be reported separately; it is not present in this document.

This Statement has several drafting features and evidentiary thresholds that generate practical hazards for claimants, advisers and decision makers.

At least one factor only, and specificity of factors. Section 9 requires at least one of the enumerated factors to exist to raise a reasonable hypothesis. Factors are narrowly phrased and often temporally bounded. For example, smoking must be “during treatment for fracture prior to fracture non-union” (section 9(4)), vitamin D deficiency is measured at the time of fracture non-union with a specific threshold of serum 25(OH)D < 50 nmol/L (section 9(7)), and BMI is to be calculated at the time of non-union and must be 40 or greater (section 9(8)). Absent precise clinical documentation at those times, claimants risk failing to meet the criterion.

“Significant” is undefined. Sections 9(1)-(3) use the term “significant” to describe force or repetitive loading stress. The instrument does not define “significant” in quantitative terms. That leaves room for interpretive disputes about what force or loading constitutes the required threshold. Practitioners should plan for expert evidence to bridge that gap.

Clinical worsening limited to particular temporal situations. Section 10(2) confines the “clinical worsening” aspects of the section 9 factors to fractures “suffered or contracted before or during (but did not arise out of) the person’s relevant service.” This means that if the fracture arose out of service, the clinical worsening factors linked to non-union may not be applicable in the same way. The distinction between “suffered or contracted” and “arose out of” relevant service is a precise timing-causation concept that will require careful factual analysis.

Excluded conditions. The instrument excludes pathological fractures, insufficiency-type stress fractures, osteonecrosis, periostitis, fracture of orthopaedic implants, dental and cartilage fractures, and spondylolysis (section 7(2)(c)(i)-(ix)). If a claim is based on one of these excluded conditions, the fracture Statement will not assist; claimants must instead consider other Statements or medical pathways.

Evidence timing challenges. Several factors hinge on measurements at the time of “fracture non-union”, for example vitamin D level and BMI (sections 9(7)-(8)). If the relevant tests were not performed at that precise time, reconstructing those values retrospectively may be difficult and subject to challenge. The instrument’s Note that fracture non-union is a “clinical worsening” emphasises that the non-union time point is legally significant.

“Ability to obtain appropriate clinical management” is open-textured. Section 9(9) grants a factor where there was an inability to obtain appropriate clinical management for fracture before clinical worsening. The instrument provides no definition of “appropriate” or metrics for assessing inability, which can lead to contested findings about access to care, alternative local options, and standard-of-care thresholds.

Cross-reference traps. Section 11 requires that if a section 9 factor refers to an injury or disease covered by another Statement, the other Statement applies “as in force from time to time”. Practitioners must check current versions of other Statements and ensure consistency. Failure to do so may result in misapplied medical criteria.

Repeal and commencement timing. The instrument repeals the 2015 Statement (section 4) and commences on 24 September 2024 (section 2) but contains no express transitional provisions. It is unclear from the instrument alone how claims that began under the old Statement are to be managed. Practitioners should seek guidance on transitional practice to avoid missed opportunities or procedural disadvantage.

“Death from fracture” includes terminal events. Section 7(3) includes death from a terminal event that was “contributed to by the person’s fracture”. The Schedule defines terminal event to include pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function. Establishing contribution to such terminal events will require medical evidence linking the fracture to those conditions; a mere temporal coincidence will not suffice.

In sum, the main gotchas are precise timing rules, narrow and sometimes unspecified thresholds, exclusions, the need to link factors to relevant service, and the absence of transitional guidance after repeal of the prior Statement. These features create evidentiary and strategic risks that require anticipatory collection of specific clinical and service records.

Compliance, read practically for claimants and their advisers, means assembling the discrete evidence necessary to establish at least one section 9 factor and to link that factor to relevant service as required by section 10(1). The Statement prescribes specific data points, and compliance requires active record-gathering and specific clinical testing where feasible.

1. Establish the timing and nature of the fracture.

• Obtain the initial clinical records describing the fracture, including date, mechanism, anatomical site, and whether the fracture was closed or compound (section 7(2)(b)). These records establish whether the injury falls within the Statement’s definition of fracture and whether any explicit exclusions apply (section 7(2)(c)).

2. Prove a listed factor exists.

• Significant physical force: Collect incident reports, service records, witness statements, or contemporaneous entries documenting the force applied to the bone at clinical onset (section 9(1)). For example, training incident logs or accident reports from operational or peacekeeping activities that describe the applied force will be relevant.
• Stress fracture or repetitive loading: For stress fractures, obtain training records, duty rosters, exercise logs, and medical notes showing repetitive loading before onset, and medical assessments linking the fracture to fatigue-type stress (section 9(2)-(3)). If abnormal biomechanics are alleged (leg length inequality, valgus/varus malalignment), obtain orthopaedic assessments.
• Clinical worsening / non-union factors: If progression to non-union is alleged, assemble treatment records showing the course of management and the point of non-union diagnosis. For smoking, secure contemporaneous clinical notes showing smoking at least five cigarettes per day or equivalent during treatment prior to non-union, noting the instrument’s equivalence metric of one gram of tobacco per cigarette (section 9(4)). For diabetes or osteoporosis, provide diagnostic records or specialist letters showing those diagnoses at the time of non-union (sections 9(5)-(6)). For vitamin D deficiency, provide laboratory results showing serum 25(OH)D < 50 nmol/L at the time of non-union (section 9(7)). For BMI, calculate BMI = W/H2 with contemporaneous height and weight records at the time of non-union, and show BMI ≥ 40 (section 9(8) and Schedule 1).
• Inability to obtain appropriate clinical management: Document refusal, delay or lack of service provision during the treatment period, including appointment records, referral correspondence, waitlist evidence, and contemporaneous complaints or administrative logs showing access problems prior to clinical worsening (section 9(9)).

3. Link the factor to relevant service.

• Demonstrate that the factor occurred in the period of relevant service as defined in the Schedule. Tie service records to the clinical record to show the factor was related to operational, peacekeeping, hazardous, British nuclear test defence (VEA), or warlike/non-warlike service under the MRCA (section 10(1) and Schedule 1).

4. Address exclusions and definitions.

• Confirm that the fracture is not one of the excluded conditions listed in section 7(2)(c). If the injury is a stress fracture, specify whether it is a fatigue-type stress fracture rather than an insufficiency type, because insufficiency stress fractures are excluded (section 7(2)(b)(vii) and 7(2)(c)(iii)).

5. Cross-reference other Statements where applicable.

• If a factor refers to another injury or disease covered by a separate Statement of Principles, obtain the current version of that Statement and the evidence it requires, per section 11. For example, an osteoporosis factor might engage an osteoporosis Statement if in force.

6. Prepare expert evidence on ambiguous thresholds.

• Because the instrument uses qualitative terms such as “significant”, have qualified medical or biomechanical experts prepared to explain why the described force or loading meets the Statement’s threshold in the claimant’s circumstances (sections 9(1)-(3)).

7. Address temporal constraints for clinical worsening.

• If alleging non-union or other clinical worsening, be prepared to show that the fracture was suffered or contracted before or during, but did not arise out of, relevant service (section 10(2)). Create a clear chronology tying the original fracture, the service timeframe, subsequent treatment, and the non-union.

8. Check commencement and repeal dates.

• The Statement commences 24 September 2024 and repeals the 2015 Statement (sections 2 and 4). For claims or decision processes that span the repeal date, seek administrative guidance about whether the new or old Statement applies, because the instrument contains no transitional clause.

9. Use precise laboratory and anthropometric data.

• For vitamin D and BMI criteria, ensure tests and measurements are contemporaneous with the non-union diagnosis. Retrospective approximations are weaker evidentiary positions.

10. Keep comprehensive contemporaneous records.

• Because the Statement’s factors are narrowly framed and temporally sensitive, comprehensive service, clinical and administrative record-keeping is the most effective compliance strategy. Contemporaneous notes, imaging, lab results, and service documentation will materially assist in satisfying the reasonable hypothesis threshold.

In short, compliance requires targeted evidence gathering that addresses discrete, often time-specific requirements in the Statement. Practitioners should anticipate the need for medical expert formulations of “significance” and obtain cross-statement materials where overlaps exist. If necessary tests were not performed at relevant times, practitioners should explore whether secondary evidence or credible contemporaneous statements can meet the threshold in a particular case.