Statement of Principles concerning plantar fibromatosis (Balance of Probabilities) (No. 22 of 2023)

This instrument is a Statement of Principles (No. 22 of 2023) concerning plantar fibromatosis made by the Repatriation Medical Authority under subsection 196B(3) of the Veterans' Entitlements Act 1986, and commenced on 23 May 2023 (see ss 1-3). It is an authoritative medical‑scientific determination setting out the disease that is covered, precise inclusions and exclusions, the medical and non‑medical factors that must be present for a finding that the condition is connected with a person’s relevant service, and how factors that refer to other Statements of Principles interact with those Statements (see ss 6-10 and Schedule 1).

Mechanically, the instrument does not itself create payments or benefits. It operates as an evidentiary and presumptive instrument to be applied in the assessment of claims that fall under section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004, because section 4 makes the instrument applicable to those claims. The Authority states its basis for the Statement as "sound medical‑scientific evidence" and records the threshold of causation it uses, namely balance of probabilities, in s 7. The Statement therefore supplies a fixed list of factors which adjudicators must look for when deciding whether plantar fibromatosis, or death from it, can be related to relevant service on the balance of probabilities. At least one factor in section 8 must exist before a causal connection is accepted (s 8).

The instrument defines plantar fibromatosis, including what the condition means clinically, and it expressly excludes a number of other foot conditions and tissue pathologies (s 6(2)(a)-(b)). It also defines death from the condition as death from a terminal event or condition to which the condition contributed, and provides a list of examples of terminal events (s 6(3); Schedule 1). The Statement lists seven discrete factors that can establish connection with service, including medical comorbidities at clinical onset or clinical worsening, and an inability to obtain appropriate clinical management (s 8). Section 9 sets the requirement that any factor relied on must be related to the person’s relevant service as defined in the Schedule, and clarifies limits on the operation of factors 4 to 7 where the condition preceded service but did not arise out of it.

In short, the instrument provides the medical rulebook that decision‑makers use when determining service connection for plantar fibromatosis under the stated provisions of the VEA and MRCA, by defining the condition narrowly, listing qualifying factors, and specifying how factors link to "relevant service".

The Statement frames a small set of core legal and medical concepts which govern how a claim for plantar fibromatosis is assessed. Those concepts are defined and used in particular ways in the text.

• Definition of the condition: Plantar fibromatosis is defined as "a benign, progressive fibroproliferative disease of the plantar fascia and the digital fascia of the foot" that may produce nodules and contractures (s 6(2)(a)). The instrument explicitly excludes plantar fasciitis, plantar fascial tear, hyperplastic wound scarring, and soft tissue benign or malignant neoplasia (s 6(2)(b)). The definition therefore narrows the class of pathologies that may be claimed under this Statement.

• Death from the condition: Death from plantar fibromatosis is treated as death from a terminal event or condition to which the disease contributed (s 6(3)). The Schedule supplies examples of terminal events, including pneumonia and circulatory failure (Schedule 1). The instrument thus recognises indirect fatal outcomes, provided the disease made a contribution.

• Causal threshold and evidentiary posture: The Authority states that, based on available medical science, it is "more probable than not" that the disease can be related to relevant service (s 7). The Statement therefore adopts the balance of probabilities test for connection, and the factors listed in s 8 are interpreted as the prima facie conditions that must be present to satisfy that threshold.

• Enumerated qualifying factors: Section 8 sets out seven alternative factors. These fall into two main groups. The first group consists of pre‑existing comorbidity at clinical onset or before clinical worsening, specifically alcohol use disorder, alcoholic liver cirrhosis, and diabetes mellitus (ss 8(1)-(3), (4)-(6)). The second group includes an inability to obtain appropriate clinical management for the condition (s 8(7)). The instrument therefore treats particular comorbidities and access to care as mechanisms by which relevant service can be linked to the disease.

• Temporal markers: The text uses clinical timing concepts such as "clinical onset" and "clinical worsening" without defining them in the Schedule. These temporal markers determine when a listed comorbidity must have been present for the factor to arise (s 8). Section 9(2) further delimits the application of factors 4 to 7, making them applicable only to material contribution or aggravation where the condition existed before or during relevant service but did not arise out of it.

The instrument is addressed to claimants, decision‑makers and medical assessors operating under the VEA and the MRCA. It expressly applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s 4). Those statutory references thereby identify the procedural contexts in which the Statement is used, though the instrument itself does not include the text of those sections.

• Claimants: The immediate group affected are persons who assert a claim that plantar fibromatosis, or death from plantar fibromatosis, is connected with their "relevant service". To succeed on that claim under the applicable Acts, at least one factor in s 8 must be established on the balance of probabilities and the factor must be related to the person’s relevant service as defined in the Schedule (ss 8 and 9). Relevant service is defined in the Schedule to include eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service), and peacetime service under the MRCA.

• Decision‑makers and medical assessors: The Repatriation Medical Authority made the instrument under its statutory power (s 3). The instrument therefore guides the medical and legal assessments performed by the Authority’s medical officers and by the administrative decision‑makers who decide entitlement under the VEA and MRCA frameworks. Those officials will apply the specific factors and exclusions in forming opinions on service connection.

• Departments and agencies administering entitlements: Administrators who process claims under section 120B of the VEA or section 339 of the MRCA are affected because they must apply this Statement when deciding whether the requisite causal connection exists. While the Statement does not itself allocate funds, its use in entitlement decisions will determine which claims proceed to benefits and further rehabilitation under the respective Acts.

• Professionals advising claimants: Health professionals, treating clinicians, veterans’ advocates, lawyers and rehabilitation providers are affected because the Statement identifies the medical evidence and timing that will be determinative in a claim. For example, the requirement that certain comorbidities be present at clinical onset or prior to clinical worsening (s 8) directs advisers to focus on chronologies in medical records.

• Interacting technical regimes: Where a factor in s 8 refers to an injury or disease covered by another Statement, those other Statements apply as in force from time to time (s 10). This means claimants whose cases involve multiple medical conditions will be affected by the interaction between Statements. Administratively, the cross‑reference can shift evidential burdens across multiple Statements.

The Statement creates obligations for how adjudicators and medical assessors must treat claims for plantar fibromatosis, and it establishes the criteria claimants must meet to have a finding of service connection under the VEA and MRCA contexts.

• Duty to apply the Statement: The Authority’s instrument is made under subsection 196B(3) of the VEA (s 3). Where a claim falls under section 120B of the VEA or section 339 of the MRCA, the Statement applies to that claim (s 4). Decision‑makers administering those provisions are therefore bound to consider the Statement as the official medical view about the relationship between plantar fibromatosis and service. In practice, the Statement functions as the medical standard against which causal connection is measured.

• Requirement of at least one factor: The Statement requires that "at least one" of the factors in section 8 exist before it can be said, on the balance of probabilities, that plantar fibromatosis or death from it is connected with relevant service (s 8). This allocates a clear, thresholded evidentiary task to claimants: they must produce evidence that at least one listed factor obtained in their case and was related to their relevant service.

• Connection to relevant service: Section 9(1) imposes a further requirement that any factor relied upon for connection must itself be related to the person’s relevant service. The Statement therefore establishes a two‑stage requirement: the factual existence of a qualifying factor, and a separate factual link between that factor and the person’s relevant service.

• Temporal constraints on aggravation/material contribution: Section 9(2) specifies that the factors in ss 8(4) to 8(7) apply only to material contribution to, or aggravation of, plantar fibromatosis where the person’s plantar fibromatosis was "suffered or contracted before or during (but did not arise out of) the person's relevant service." That operates as a constraint on the use of certain factors to prove material contribution or aggravation, and imposes a duty on decision‑makers to examine the chronology of onset relative to service.

• Cross‑statement duties: Section 10 requires application of factors from other Statements where a factor in s 8 refers to a condition covered by another Statement. This creates a duty to consult and apply other Statements "as in force from time to time" when overlap arises.

• Rights of claimants: The Statement does not itself create statutory entitlements, but it creates a pathway by which claimants can establish service connection for the purposes of the VEA and MRCA adjudicative processes. If a claimant establishes one of the factors in s 8, and the factor is related to relevant service per s 9, that satisfies the Authority’s prescribed medical position that connection is "more probable than not" (s 7). The legal effect of that finding for benefits and rehabilitation depends on the operative provisions of the VEA and MRCA that apply to the particular claim.

The instrument itself contains no criminal or civil penalties, and it does not create enforcement mechanisms. It is a medical determination for use within statutory claims processes rather than a penal instrument.

• No penalties within the Statement: There are no provisions in the text that impose fines, imprisonment, administrative penalties, or private rights of action. The Statement is silent on sanctions and corrective orders. Its function is to define medical causation criteria and to guide administrative determinations under specified statutory provisions.

• Administrative enforcement context: Enforcement in practice takes place within the claim‑adjudication procedures of the VEA and the MRCA. Section 4 makes the Statement applicable to claims under section 120B of the VEA and section 339 of the MRCA, and those statutory frameworks supply the decision‑making, review and appeal processes in which the Statement will be applied. The instrument itself does not describe those processes.

• Decision‑maker obligation and review avenues: Because the Statement is made under subsection 196B(3) of the VEA (s 3), it is likely to be treated as the authoritative medical guidance used by decision‑makers when determining whether an accepted disease is connected with service. Where a claimant disagrees with a decision based on the Statement, the relevant appeal or review mechanisms are those contained in the operative Acts and associated administrative rules. The Statement does not modify appeal rights or create new administrative remedies within its text.

• Implementation and compliance oversight: The instrument imposes no compliance reporting requirements, audit obligations, or supervisory duties on third parties. Compliance is achieved by decision‑makers following the Statement when making medical causation determinations. The Statement does not set penalties for failure to follow it; any consequences for non‑application would arise through internal administrative processes, judicial review of administrative decisions, or internal governance of agencies administering the VEA and MRCA.

• Evidential weight versus conclusive proof: The Statement declares the Repatriation Medical Authority’s view that it is "more probable than not" that plantar fibromatosis can be related to relevant service given the factors listed (s 7). The Statement therefore carries administrative weight in claims determinations but does not itself impose sanctioning powers against persons who provide contrary medical opinions. Conflicting medical evidence must be reconciled within the administrative decision process governed by the VEA and MRCA.

The Statement is expressly statutory in character, made under the authority of subsection 196B(3) of the Veterans' Entitlements Act 1986, and it is designed to be used in the decision‑making apparatus of the VEA and the Military Rehabilitation and Compensation Act 2004 (MRCA). The instrument includes cross‑reference rules and definitional links to those Acts and to other Statements of Principles.

• Authority and application: The instrument records its authority as subsection 196B(3) of the VEA (s 3). Section 4 specifies that it "applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies." That language ties the Statement directly to particular claim types under the two Acts. The Statement therefore functions as an instrument for assessing causation within the statutory frameworks of those Acts.

• Cross‑statement interaction: Section 10 provides a mechanism for interaction with other Statements of Principles. If a factor in s 8 refers to an injury or disease covered by another Statement, then the factors in that other Statement apply "in accordance with the terms of that Statement as in force from time to time." The effect is to create hierarchical or sequential application where overlap exists, and to ensure that the operative factors in other Statements are brought into the assessment where relevant.

• Definitions and exclusions: The Schedule defines "relevant service" and the Act abbreviations MRCA and VEA. The definition of relevant service excludes operational service, hazardous service and British nuclear test defence service from certain VEA categories, which interacts with the scope of claims under the VEA and MRCA. The exclusions in s 6(2)(b) delineate plantar fibromatosis from other foot pathologies; where a claimant advances a diagnosis that falls within an excluded category, other legal or medical frameworks (and possibly other Statements) must be engaged.

• Relationship to statutory causation standards: The Statement expressly adopts the balance of probabilities standard and presents the medical community’s view that certain factors can connect the condition to service (s 7). The manner in which this interacts with statutory causation standards in VEA s 120B and MRCA s 339 depends on the wording of those statutory provisions, which is not reproduced in this instrument. Administratively, the Statement will be applied in conjunction with those statutory causation standards by decision‑makers.

The instrument itself records a narrow, explicit administrative provenance and timeline. It is Statement of Principles concerning plantar fibromatosis (Balance of Probabilities), numbered No. 22 of 2023, dated 24 April 2023, and commenced on 23 May 2023 (ss 1-2; front matter). The Repatriation Medical Authority’s Common Seal was affixed under the direction of the Chairperson, Professor Terence Campbell AM, as recorded on the instrument.

• Date and commencement: The instrument is dated 24 April 2023 and the commencement date is 23 May 2023 (s 2 and front matter). These dates establish when the Authority adopted the Statement and when it began to operate for relevant claims.

• Numbering and instrument identity: The front matter identifies the instrument as No. 22 of 2023. That identifier can be used to track the instrument within the Authority’s series of Statements for that year.

• Authority of making: The instrument states the statutory power under which it was made, subsection 196B(3) of the VEA (s 3). That locates the Statement within the Authority’s powers to issue Statements of Principles.

• Absence of prior versions in the instrument: The text contains no express history of prior Statements dealing with plantar fibromatosis. The instrument does not record amendments to earlier Statements, revocations of previous instruments, or transitional provisions. From the instrument alone, this is the operative Statement commencing on the stated date.

• Dynamic incorporation of other Statements: Section 10 contemplates that other Statements of Principles may be relied upon and that the factors in those Statements apply "as in force from time to time." This language means that the Statement anticipates future amendments to other Statements, and that those amendments will automatically be incorporated in the interaction where a factor references another disease. That creates an indirect amendment linkage between this Statement and future changes to other Statements, but it does not itself amend those other Statements.

• No amending mechanism recorded within the instrument: The Statement does not include a mechanism for amendment of its own terms within the text. Any amendment would be by the Authority exercising its statutory power under subsection 196B(3) of the VEA, and such amendments would be recorded in subsequent instruments.

• Record‑keeping inference: Practitioners should treat the instrument as a living administrative instrument subject to replacement or amendment by later Statements issued by the Repatriation Medical Authority. The instrument’s cross‑reference to other Statements "as in force from time to time" underscores that medical evidence bases and Statements change over time, and claim evaluations will require checking the current version of any referenced Statement.

This Statement contains no litigation history, judicial citations, or references to contested decisions. The instrument is an administrative medical determination and does not record court cases or tribunal rulings.

• Absence of case references: Nowhere in the text are previous decisions, judicial interpretations, or tribunal authorities cited. The Statement presents the Repatriation Medical Authority’s view of the medical‑scientific evidence and its legal application under the balance of probabilities standard, but it does not mention litigation that has tested or interpreted its provisions.

• Practical implications for disputes: Although the instrument does not record litigation, Statements of Principles routinely become central to contested claims under the VEA and MRCA regimes. Disagreements about whether a listed factor exists, the interpretation of temporal markers such as "clinical onset" or "clinical worsening", and the application of s 9(2) in cases where the condition preceded service are likely to be the subjects of dispute. Those disputes, if litigated, would arise under the VEA and MRCA procedural frameworks rather than under the Statement itself.

• No precedent recorded: Because the instrument provides neither judicial decisions nor precedent, it does not itself bind courts. The Statement represents the Authority’s medical position. Where courts or tribunals are required to decide questions of law or the application of a Statement to facts, their reasoning and any legal tests would be recorded in judicial or tribunal decisions outside this instrument.

• Evidence contextualisation: Absent a litigation record in the Statement, practitioners must bring to bear the general administrative review and merits review pathways in the VEA and MRCA frameworks when disputes arise. The Statement itself will be an important piece of expert and administrative evidence in any contested decision, but the instrument does not provide guidance on how courts or tribunals have treated similar Statements.

For research into litigation over Statements of Principles generally, or over plantar fibromatosis in particular, users must consult external judicial and tribunal records because this instrument does not contain or summarise such material.

The Statement is concise and technical. Several features of its drafting and operative scope can create pitfalls for claimants, advisers and decision‑makers. These are factual and procedural hazards grounded in the text.

• Narrow diagnostic definition and explicit exclusions: The instrument’s definition of plantar fibromatosis is medically specific and excludes several common foot pathologies, including plantar fasciitis and plantar fascial tear (s 6(2)(a)-(b)). A claimant whose diagnosis is recorded as plantar fasciitis or another excluded condition will not meet this Statement’s definitional threshold. Advisers should not assume that generic "heel pain" or "plantar fasciitis" diagnoses qualify under this Statement.

• Temporal language left undefined: The instrument relies on "clinical onset" and "clinical worsening" for the timing of qualifying comorbidities (s 8). Those terms are not defined in the Schedule. Practically, this means adjudicators must determine when onset and worsening occurred using clinical records or expert interpretation. That can produce disputes over whether a comorbidity was present at the precise clinical moment required.

• Burden of proving "inability to obtain appropriate clinical management": Section 8(7) recognises inability to obtain appropriate clinical management as a factor, but the Statement does not define "appropriate", nor does it specify how inability is proved. Establishing this factor will typically require evidence showing both lack of access to recommended care and a causal link between that lack and the disease course. The text leaves the standard of proof and the evidentiary means to decision‑makers and treating clinicians.

• Interaction with other Statements: Section 10 brings in other Statements "as in force from time to time" where a factor refers to another disease. This can complicate proof when a factor such as diabetes mellitus is covered by its own Statement. Advisers must identify the current version of any referenced Statement and ensure that evidence satisfies both the plantar fibromatosis Statement and any secondary Statement.

• Relevance of "relevant service" definition: The Schedule’s definition of relevant service excludes operational service and hazardous categories in certain VEA contexts. A claimant who served in excluded service types may not find this Statement applicable to their claim. The label "relevant service" is therefore a legal gatekeeper; practitioners must map a claimant’s service classification to the Schedule to determine applicability.

Compliance, for claimants and advising professionals, means assembling and presenting the evidence necessary to show that at least one factor listed in section 8 existed, and that the factor was related to the person’s relevant service as defined in the Schedule. The Statement supplies the substantive criteria; compliance requires aligning medical and service records to those criteria.

• Establish the correct diagnosis under the Statement: The first step is to ensure that the claimant’s diagnosis fits the instrument’s definition of plantar fibromatosis (s 6(2)(a)) and is not one of the express exclusions (s 6(2)(b)). Treating clinicians should provide records and, if necessary, expert reports that explicitly diagnose plantar fibromatosis and describe the clinical features that match the Statement’s definition, such as fibroproliferative nodules and contracture potential.

• Document timing of clinical onset and clinical worsening: Because several factors require presence of a comorbidity "at the time of the clinical onset" or "before the clinical worsening" (ss 8(1)-(6)), contemporaneous medical records that timestamp symptom emergence, clinical assessments, and diagnostic tests are essential. Where the dates are uncertain, obtain treating clinician statements or expert opinion to fix the clinical chronology.

• Prove the listed comorbidities with medical records: The Statement lists alcohol use disorder, alcoholic liver cirrhosis, and diabetes mellitus as qualifying comorbidities (s 8). Compliance requires documented diagnosis, diagnostic test results, hospital records, or specialist notes that establish those conditions and their timing relative to clinical onset or worsening.

• Address "inability to obtain appropriate clinical management": For s 8(7), assemble records that show attempts to access recommended or accepted clinical management, contemporaneous evidence of denial, lack of access, or limited availability of treatment, and explanation of how lack of management materially affected disease progression. Statements from treating physicians, referral letters, appointment records, and correspondence with health services can be relevant. Where appropriate, obtain expert evidence linking lack of access to progression or worsening.

• Map service history to "relevant service": Use service records to demonstrate that the claimant’s service falls within the Schedule’s definition of relevant service. The Schedule defines "relevant service" as eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service), and peacetime service under the MRCA. Accurate service classification is fundamental to establishing that the Statement applies to the claim.