Statement of Principles concerning plantar fibromatosis (Reasonable Hypothesis) (No. 21 of 2023)

The instrument relies on a small number of legal and medical concepts, each defined or used in a narrow technical sense in the text. The primary concepts are:

• Plantar fibromatosis: defined as a benign, progressive fibroproliferative disease of the plantar and digital fascia of the foot that causes puckering and thickening of plantar skin and nodule and cord formation in the fascia that may progress to contracture of the digits (s 6(2)(a)). The instrument explicitly excludes plantar fasciitis, plantar fascial tear, hyperplastic wound scarring and soft tissue neoplasia from this definition (s 6(2)(b)). The Note confirms alternative names (Ledderhose disease, morbus Ledderhose).
• Clinical onset and clinical worsening: the Statement distinguishes factors that must exist at the time of the clinical onset of plantar fibromatosis from those that must exist at the time of clinical worsening. The instrument uses those temporal markers repeatedly in s 8; the specific content and timing vary by factor.
• Reasonable hypothesis: the Statement is directed to the evidentiary threshold of a "reasonable hypothesis" that a condition is related to service. Section 8 states that at least one of the listed factors must, as a minimum, exist before it can be said that a reasonable hypothesis has been raised connecting plantar fibromatosis or death from plantar fibromatosis with the circumstances of a person's relevant service. The Statement therefore operationalises the "reasonable hypothesis" test for this condition by itemising qualifying factors and temporalities (s 8).
• Relevant service: defined broadly in Schedule 1 to cover operational service, peacekeeping, hazardous service, British nuclear test defence service under the VEA, and warlike and non‑warlike MRCA service (Schedule 1). Section 9 requires that any listed factor must be related to the person's relevant service.
• Terminal event and death from condition: the Statement treats death as included where a terminal event or condition was contributed to by plantar fibromatosis (s 6(3)). The Schedule defines terminal event to include proximate or ultimate causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function (Schedule 1).
• Trauma and its threshold: trauma is defined in Schedule 1 to mean a significant injury causing symptoms and signs lasting at least seven days, or that is severe enough to warrant medical attention. Examples include laceration, sprain, crush injury, fracture, surgery, and thermal, chemical or electrical burns.

Other central operative points include the drug‑exposure factors (phenobarbital, primidone and vemurafenib) with explicit exposure and cessation windows (s 8(5), (6), (12), (13)), and the final factor in s 8(15), "inability to obtain appropriate clinical management for plantar fibromatosis", which is included without a definition in the Schedule.

The Statement also contains a cross‑reference mechanism: if a factor refers to another injury or disease covered by another Statement of Principles, then the factors in that other Statement apply as in force from time to time (s 10). This constructs a mapped network of interdependent Statements for claim assessment.

This Statement affects claimants seeking a determination that plantar fibromatosis, or death from plantar fibromatosis, is connected to their relevant service for the purposes of entitlements under the VEA or MRCA. The instrument expressly applies to "a claim to which section 120A of the VEA or section 338 of the MRCA applies" (s 4). Those provisions (in the relevant Acts) are the points at which a Statement of Principles is invoked in claim processes; the Statement therefore affects veterans, members of Peacekeeping Forces and members of the Forces whose service falls within the Schedule 1 definition of "relevant service" (Schedule 1).

Stakeholders directly affected include:

• Claimants: veterans and former members who allege plantar fibromatosis or death from that disease is related to their service. Claimants must marshal evidence that at least one of the listed factors existed and was related to relevant service (s 8; s 9).
• Medical practitioners and treating clinicians: their diagnoses, treatment records and medication histories will be primary sources of evidence to establish factors such as alcohol use disorder, alcoholic liver cirrhosis, diabetes mellitus, epilepsy, trauma, medication use (phenobarbital, primidone, vemurafenib), and inability to obtain appropriate clinical management. The Statement prescribes the precise timing and durations that will be probative (s 8).
• Decision‑makers under the VEA and MRCA statutory schemes: while the Statement itself does not identify the decision‑maker in each claim, it is expressed to apply to claims to which s 120A VEA or s 338 MRCA applies (s 4). Those decision‑makers are the entities that will use this Statement as the Repatriation Medical Authority's scientific determination when assessing the reasonable hypothesis question. The Statement thus constrains the kinds of medical circumstances that, if proved and related to service, will raise that threshold.
• Parties preparing evidence for death claims: because death from plantar fibromatosis is included where death from a terminal event was contributed to by the condition (s 6(3) and Schedule 1), coronial reports, terminal event diagnoses and proximate cause evidence may be relevant.

Indirectly affected are tribunals or courts that may review administrative decisions made using the Statement; however, the Statement itself does not contain judicial review or appeal procedures. It does, though, set the medical framework that such reviews will encounter.

The Statement also affects the interface between Statements of Principles, because if a listed factor refers to another injury or disease covered by a different Statement, that other Statement's factors apply as in force from time to time (s 10). That creates dependence where, for example, a factor referring to diabetes mellitus must also be assessed with reference to any Statement on diabetes where applicable.

This instrument does not create statutory entitlements, remedies, or penalties by itself. Instead it is a medical‑scientific determination given statutory force by being made under subsection 196B(2) of the VEA (s 3) and applied in claims under the VEA and MRCA (s 4). The operative legal effect is that the presence of one or more of the listed factors, related to the person's relevant service, constitutes the minimum factual foundation to raise a reasonable hypothesis that plantar fibromatosis or death from plantar fibromatosis is related to service (s 8; s 9). That construction generates the following practical duties and rights in claim handling terms:

• Duty to treat the Statement as the Repatriation Medical Authority's view: decision‑makers are required to take the Statement into account when addressing the reasonable hypothesis question in claims to which s 120A VEA or s 338 MRCA apply. The Statement sets out the relevant factors that, if present and linked to relevant service, are sufficient to raise the reasonable hypothesis threshold (s 8 and s 9).
• Claimant evidentiary right: a claimant has the right to rely on any of the listed factors in s 8 as the basis for raising a reasonable hypothesis, provided the factor is shown to exist and is linked to relevant service (s 8; s 9(1)). For factors that refer to another injury or disease, claimants may rely on the applicable other Statement of Principles (s 10).
• Temporal and causal constraints: the Statement imposes timing requirements. Some factors must exist "at the time of the clinical onset" (for example alcohol use disorder and alcoholic liver cirrhosis under s 8(1) and 8(2)), others must be present "before" clinical onset (for example diabetes mellitus under s 8(3)), and several apply to either onset or worsening with specific temporal windows (for example phenobarbital/primidone exposure and vemurafenib exposure in s 8(5), (6), (12), (13)). These temporal specifications function as thresholds claimants must document.
• Duty to connect the factor to relevant service: s 9(1) requires that the existence of any factor in s 8 be related to the relevant service rendered by the person. That imposes a causal or associational element in the claim assessment; the Statement does not treat listed factors as automatically service‑connected irrespective of relationship to service.
• Limitation on aggravation/material contribution factors: s 9(2) narrows the application of subsections 8(8) to 8(15) so that those factors apply only to material contribution to, or aggravation of, plantar fibromatosis where the person's condition was suffered or contracted before or during, but did not arise out of, relevant service. That creates a distinct class of claims (pre‑existing conditions aggravated by service) to which those factors are directed.
• Cross‑reference duty: where a listed factor refers to another injury or disease covered by another Statement of Principles, decision‑makers must apply the factors in that other Statement as in force from time to time (s 10). This integrates the Repatriation Medical Authority's determinations across conditions.

The Statement is framed as a set of minimum evidential criteria to raise a reasonable hypothesis. It does not specify how decision‑makers must resolve competing medical evidence once a reasonable hypothesis has been raised. It also does not set evidentiary standards for proving the existence of a factor or for proving its relationship to relevant service; those procedural and standard‑of‑proof matters are governed by the VEA, MRCA and decision‑maker practice and policy rather than by this Statement itself.

The Statement of Principles contains no penalty provisions and does not itself create enforcement mechanisms. It is a medical‑scientific instrument rather than a regulatory or penal instrument. The text contains no fines, sanctions, offences, or enforcement procedures. Its effect is evidentiary and definitional for claims under the VEA and MRCA. Specific points to note from the instrument are:

• No penal regime in the instrument: there are no criminal or civil penalties, disciplinary measures, or enforcement processes set out in the Statement. It is limited to describing the condition, listing factors relevant to a reasonable hypothesis of service connection, and setting definitions and temporal parameters (whole instrument).
• Effect on administrative outcomes: while not a penalty mechanism, the Statement has practical administrative consequences. Establishing a reasonable hypothesis under the VEA or MRCA can be the threshold for further investigation, for entitlement decisions, or for referral to entitlements processes governed by those Acts (s 4, s 8). The Statement therefore influences which claims proceed to further consideration under statutory entitlements, but it does so by defining qualifying factors rather than by penal sanction.
• Enforcement of compliance with the Statement is procedural: the instrument places an evidentiary framework in the hands of decision‑makers under the VEA and MRCA. Any enforcement or remedial action,such as granting an entitlement, referring to medical assessment, or rejecting a claim,would arise from the decision‑making powers and processes in the VEA and MRCA, not from the Statement itself (see s 4).
• No investigatory powers conferred: the Repatriation Medical Authority is the maker of the Statement under s 196B(2) VEA (s 3), but the Statement does not create or alter the Authority's powers to investigate, audit, compel records or enforce compliance in relation to claims. Those powers, if any, are found elsewhere in the VEA and MRCA.

Practically, the Statement shapes outcomes by setting the medical factors that must be shown to raise a reasonable hypothesis. The instrument therefore has downstream consequences for decision‑makers and claimants in the statutory claims processes, but it does not itself prescribe or enforce sanctions.

The Statement is made under the Veterans' Entitlements Act 1986 and is expressly designed to be used in conjunction with the VEA and the Military Rehabilitation and Compensation Act 2004 in the assessment of claims. The instrument sets out multiple explicit interaction points:

• Statutory source and application: the Statement is made under subsection 196B(2) of the VEA (s 3) and applies to claims to which section 120A of the VEA or section 338 of the MRCA applies (s 4). Those references locate the Statement within the statutory architecture for veterans' entitlements and compensation. The Statement therefore functions as the Repatriation Medical Authority's determination for the reasonable hypothesis question within those statutory claim frameworks.
• Definition cross‑references: Schedule 1 adopts terms such as MRCA, VEA, terminal event, trauma and relevant service, thereby aligning the Statement's definitions to the language used in the parent statutes (Schedule 1). For example, relevant service is defined in Schedule 1 by enumerating service categories drawn from the VEA and MRCA schemes.
• Cross‑Statement interaction: s 10 provides that where a factor in s 8 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 from time to time. This creates legal dependence and interoperability between distinct Statements of Principles. It means that the assessment of a factor that references another condition must be conducted using the current terms of that other Statement, not solely this instrument.
• Relationship to claim processes under the VEA/MRCA: although this Statement does not itself set procedural rules, it affects the evidentiary foundation for entitlement decisions under the VEA and MRCA by identifying which factual circumstances will raise a reasonable hypothesis. Decision‑makers applying the VEA and MRCA must therefore incorporate the Repatriation Medical Authority's findings when determining whether further investigation or acceptance of service connection is warranted (s 8; s 9).
• No conflict or override language: the Statement contains no provision attempting to displace or override other statutory rules beyond its function as the Repatriation Medical Authority's scientific determination under the VEA. It does not create derogations from the VEA or MRCA; rather, it supplies medical determinations that feed into those Acts' decision‑making processes.
• Interaction with other medical evidence and Statements: because the Statement specifies factors and temporal windows, medical evidence inconsistent with those factors may be less likely to raise a reasonable hypothesis. Conversely, evidence that matches the factors and timing set out will be treated as meeting the minimum factual foundation. Where a listed factor overlaps with another condition subject to a separate Statement, that other Statement governs the proper application for that factor (s 10).

In short, the Statement integrates into the broader statutory apparatus by providing a condition‑specific list of qualifying factors and definitions which decision‑makers under the VEA and MRCA are required to consider when assessing whether a reasonable hypothesis exists that plantar fibromatosis or death from it is related to relevant service.

The instrument itself contains brief historical markers appearing in the published text. Key points in the amendment history as recorded in the instrument are:

• Instrument identification and date: the instrument is titled "Statement of Principles concerning PLANTAR FIBROMATOSIS (Reasonable Hypothesis) (No. 21 of 2023)". The instrument bears the Repatriation Medical Authority seal and is dated 24 April 2023 (heading material).
• Commencement: the Statement commences on 23 May 2023 (s 2).
• Authority clause: it is made under subsection 196B(2) of the Veterans' Entitlements Act 1986 (s 3).

The instrument contains no express amendment history beyond its own making and commencement. It does not list prior versions of a plantar fibromatosis Statement, nor does it record prior amendment dates or repeal provisions. There is also no transitional or savings provision contained in the text.

Because s 10 contemplates that other Statements of Principles may change "from time to time" and requires application of those Statements as in force, any future amendment of those other Statements will affect how referenced factors are treated when they refer to another injury or disease (s 10). Similarly, future amendments to the VEA or MRCA that alter the statutory claims framework or the operation of the reasonable hypothesis test could change the practical effect of this Statement, but such future changes are outside the instrument's text and therefore not recorded here.

If a practitioner needs an authoritative version history, they must consult the legislative instrument register, the Repatriation Medical Authority records, or consolidated legislative databases that record subsequent amendments or repeals. The Statement itself records only its making date and commencement date.

The Statement contains no information about litigation involving this instrument or the issues it addresses. The instrument does not cite any decisions, nor does it list any judicial or tribunal determinations that have considered this Statement. There is no litigation history, case law reference, or administrative appeals record included in the text.

Because the Statement operates as a medical‑scientific determination to be applied in statutory claims under the VEA and MRCA, decisions made using this Statement may be subject to administrative review, internal review, merits review or judicial review under the procedural and review mechanisms in the VEA, MRCA and general administrative law. However, the Statement itself provides no account of past litigation or precedent, and it does not identify any cases or tribunal decisions that have interpreted the Statement of Principles.

Practitioners seeking to understand how this Statement has been applied in contested cases will need to search tribunal and court decisions involving claims to which section 120A VEA or section 338 MRCA apply, and specifically those that reference this Statement of Principles (No. 21 of 2023). The instrument does not provide such references.

The text contains several features that may produce practical pitfalls for claimants, treating clinicians and decision‑makers. These are concrete textual features likely to affect evidence gathering and claim strategy:

• Narrow definition of the condition and specific exclusions: plantar fibromatosis is narrowly defined in s 6(2)(a) and expressly excludes plantar fasciitis, plantar fascial tear, hyperplastic wound scarring and soft tissue benign or malignant neoplasia (s 6(2)(b)). A claimant with a diagnosis labelled "plantar fasciitis" cannot rely on this Statement unless medical evidence establishes that the condition falls within the plantar fibromatosis definition.
• Distinct timing words produce different evidentiary windows: several factors use differing temporal language. For example, alcohol use disorder and alcoholic liver cirrhosis must be present "at the time of the clinical onset" (s 8(1)-(2)), diabetes mellitus must exist "before the clinical onset" (s 8(3)), and phenobarbital/primidone use requires a continuous two‑year period prior to onset and a one‑year window if treatment has ceased (s 8(5)). Practitioners must map clinical records precisely to the timing words in s 8 to decide which factors are available.
• Separate lists for onset and worsening: s 8 splits factors applicable to clinical onset (s 8(1)-(7)) and those applicable to clinical worsening (s 8(8)-(15)). Subsection 9(2) adds a critical restriction: subsections 8(8)-(15) 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 means these factors generally support claims of aggravation of a pre‑existing condition rather than primary causation arising from service. Practitioners must be careful which box the claim fits.
• Medication exposure windows are specific and unforgiving: for phenobarbital or primidone, the claimant must show regular treatment for a continuous period of at least two years before clinical onset, and if treatment ceased the onset must have occurred within one year of cessation (s 8(5)). A similar rule applies to clinical worsening (s 8(12)). For vemurafenib, exposure within two years before clinical onset (s 8(6)) or worsening (s 8(13)) is required. Missing or incomplete medication records could be decisive.
• Trauma is narrowly defined: Schedule 1 defines trauma as significant injury with symptoms and signs lasting at least seven days, or of sufficient severity to warrant medical attention, and includes specific examples (Schedule 1). Minor or transient injuries that do not meet this threshold will not qualify under the trauma factors in s 8(7) and s 8(14).
• "Inability to obtain appropriate clinical management" is undefined: s 8(15) lists inability to obtain appropriate clinical management for plantar fibromatosis as a qualifying factor for clinical worsening. The Schedule does not define "appropriate clinical management". That absence is likely to increase discretionary assessment and raise evidentiary questions about what attempts to obtain care are reasonable, and what constitutes adequacy of management. Practitioners should collect documentary evidence of attempts to obtain care, waiting lists, referrals, or other administrative barriers to create a record.
• Relationship to relevant service required: s 9(1) states any factor in s 8 must be related to the person's relevant service. The Statement does not state what degree of causal or associational link suffices, leaving that question to application in the VEA/MRCA claims process. Practitioners should expect decision‑makers to require some articulation or evidence of the relationship between the factor and the individual's service history.
• Cross‑Statement dependencies: where a factor refers to another disease covered by another Statement, the relevant provisions of that other Statement apply "as in force from time to time" (s 10). This can add complexity where factors intersect multiple conditions, because claimants must satisfy not only this Statement's requirements but also the current terms of the other Statement.
• Death claims require contribution to terminal event: s 6(3) includes death where a terminal event or condition was contributed to by plantar fibromatosis. The Schedule defines terminal events narrowly to include pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function. Establishing contribution to those terminal events will likely require proximate cause and medical evidence linking plantar fibromatosis to the terminal event.
• No procedural guidance or evidentiary thresholds: the Statement sets the substantive medical factors but does not provide procedural guidance about the standard of proof for establishing the existence of a factor or its relationship to service. Those procedural matters will be governed by the VEA/MRCA and administrative practice. Practitioners must therefore anticipate that the Statement supplies the minimum substantive requirements while other legal rules govern proof and procedure.

These textual features are not doctrinal judgments. They are direct readings of the instrument likely to affect case selection, evidence collection and presentation in claims.

The Statement of Principles supplies specific factual and temporal thresholds that a claimant must meet to raise a reasonable hypothesis that plantar fibromatosis or death from plantar fibromatosis is related to relevant service. Compliance in practice therefore means assembling medical and service evidence that corresponds to the listed factors and showing their relationship to relevant service. Practical steps, grounded in the instrument's contents, are:

1. Identify the correct claim framework

• Confirm the claim is one "to which section 120A of the VEA or section 338 of the MRCA applies" (s 4). If not, this Statement will not be operative. Ensure the claimant's service category matches the Schedule 1 definition of relevant service.

2. Establish the diagnosis and ensure it matches the Statement's definition

• Obtain definitive medical records and diagnostic reports documenting plantar fibromatosis as defined in s 6(2)(a). Because the Statement excludes plantar fasciitis, plantar fascial tear, hyperplastic wound scarring and soft tissue neoplasia (s 6(2)(b)), ensure pathology, imaging or specialist notes explicitly support the plantar fibromatosis diagnosis or show that other excluded diagnoses are not being relied upon.

3. Match evidence to the listed factors and timing requirements

• For factors at clinical onset (s 8(1)-(7)), provide contemporaneous records showing the presence of the factor at the time of clinical onset. For example:

  • Alcohol use disorder or alcoholic liver cirrhosis: show diagnoses, hospital records or specialist notes at or before clinical onset (s 8(1)-(2)).
  • Diabetes mellitus: show diagnosis records indicating diabetes was present before clinical onset (s 8(3)).
  • Epilepsy: chart the presence of epilepsy at the time of onset (s 8(4)).
  • Phenobarbital or primidone: provide medication records confirming regular treatment for at least two continuous years before clinical onset, and if ceased, evidence of cessation date and onset within one year of cessation (s 8(5)).
  • Vemurafenib: produce oncology prescription or dispensing records showing vemurafenib use within two years before onset (s 8(6)).
  • Trauma to the affected foot: document the injury, its severity, duration of symptoms (at least seven days) or records that medical attention was sought, and that the trauma occurred within one year before onset (s 8(7); Schedule 1).

• For factors at clinical worsening (s 8(8)-(15)), provide similar time‑mapped records showing the factor's existence at the time of clinical worsening, and ensure that the condition was suffered or contracted before or during, but did not arise out of, relevant service where required by s 9(2).

4. Document relationship to relevant service

• For any factor relied on, compile service records, deployment records, medical assessments during service, and contemporaneous complaints or treatment in service that link the factor to the person's relevant service, as s 9(1) requires that the factor be related to relevant service. The Statement does not prescribe the precise form of this connection, so produce any material that supports a causal or associative link.

5. Address cross‑referenced Statements

• If a factor refers to another injury or disease that has its own Statement of Principles (s 10), identify that other Statement and ensure the evidence also meets its current terms. For example, if relying on diabetes mellitus, check whether a separate Statement on diabetes exists and follow its factors "as in force from time to time" (s 10).

6. For death claims, show contribution to terminal event

• If claiming death from plantar fibromatosis, obtain the death certificate, medical cause of death documentation, coronial findings where applicable, and clinical evidence showing that plantar fibromatosis contributed to a listed terminal event or condition (s 6(3); Schedule 1).

7. For the "inability to obtain appropriate clinical management" factor

• Because s 8(15) lists this as a factor without definition, document attempts to access care: referral letters, waiting lists, denial letters, correspondence with health providers, reasons for inability (cost, availability, geographic barriers), and contemporaneous clinical notes showing deterioration coinciding with lack of management. The Statement does not define "appropriate clinical management", so detailed records of the claimant’s interactions with healthcare providers are prudent.

8. Address medication exposure specifics carefully

• For phenobarbital/primidone and vemurafenib, ensure pharmacy dispensing records, prescription histories, and specialist letters provide continuous exposure dates and cessation dates, as the Statement imposes strict windowing (s 8(5), (6), (12), (13)).

9. Use specialist opinions to link factors to clinical onset/worsening and to service

• Obtain specialist medical opinions that expressly address whether the listed factors were present at the relevant time and whether, on medical grounds, those factors could raise a reasonable hypothesis of a link to service. While the Statement is the Repatriation Medical Authority's determination of relevant factors, claimant medical opinions that map clinical facts to the Statement’s requirements will assist decision‑makers.

10. Anticipate need to prove temporal thresholds

• Because many factors require precise temporal alignment with clinical onset or worsening, create a chronology showing dates of onset, dates of trauma, dates of diagnosis, dates of medication exposure and cessation, and service timeline. The Statement’s bifurcation between onset and worsening, and s 9(2)'s limitation on aggravation factors, make a clear chronology essential.

11. Maintain records for appeals and cross‑statement interactions

• Given s 10’s cross‑reference mechanism and the lack of procedural detail in the Statement, maintain full records of evidence and any decisions for possible internal reviews, merits review or judicial review in accordance with the VEA/MRCA frameworks.

In short, compliance requires mapping medical evidence to the precise factors and temporal conditions listed in s 8, demonstrating the relationship to relevant service as required by s 9, and attending to cross‑statement dependencies under s 10. The Statement provides the substantive checklist; the claimant and their advisers must provide the documentary and clinical evidence to meet those items.