Statement of Principles concerning posterior adventitial heel bursitis (Reasonable Hypothesis) (No. 47 of 2019)

This instrument is a Statement of Principles (SOP) issued by the Repatriation Medical Authority under subsection 196B(2) of the Veterans' Entitlements Act 1986 (the VEA) that sets the medical and causal factors to be used in assessing claims for posterior adventitial heel bursitis and death from posterior adventitial heel bursitis (No. 47 of 2019). The instrument is dated 26 April 2019 and commenced on 27 May 2019 (see sections 1, 2 and the seal on the instrument). It expressly repeals the earlier Statement of Principles concerning heel bursitis No. 77 of 2010 (Federal Register No. F2010L02316) (section 4).

Mechanically, the instrument does three principal things, each stated in and constrained by its provisions:

• It defines the injury/disease subject to the SOP. Section 7(2) defines "posterior adventitial heel bursitis" as inflammation of the superficial retro‑Achilles bursa between the skin and the distal Achilles tendon, characterised by painful, tender swelling of the posterior heel, and expressly excludes retrocalcaneal bursitis and plantar calcaneal bursitis. Section 7(3) extends the meaning to include death from the condition when the bursitis contributed to a terminal event or condition.

• It prescribes the threshold factual factors that must exist to raise a reasonable hypothesis connecting the condition (or death from it) with relevant service. Section 9 requires that at least one of the listed factors exist as a minimum; those factors are specific and limited (wearing footwear causing friction or pressure at clinical onset, Haglund deformity at onset, footwear friction/pressure at clinical worsening, Haglund deformity at clinical worsening, and inability to obtain appropriate clinical management).

• It sets the relationship-to-service rules that determine how those factors link to relevant service. Section 10(1) requires that any factor in section 9 be related to the person’s relevant service, and section 10(2) limits the application of subsections 9(3) to 9(5) to material contribution to, or aggravation of, the condition where the bursitis existed before or during, but did not arise out of, relevant service.

The SOP applies to claims to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 (MRCA) applies (section 5). The instrument also contains a Schedule 1 dictionary that defines key technical terms used in the SOP, including Haglund deformity, plantar calcaneal bursitis, relevant service categories, terminal event and cross‑references to the MRCA and VEA (Schedule 1).

The Repatriation Medical Authority states that it is of the view that there is sound medical‑scientific evidence indicating that posterior adventitial heel bursitis and death from it can be related to relevant service (section 8). The SOP therefore provides the medical basis and the discrete causal links that administrative decision‑makers should use when addressing the "reasonable hypothesis" threshold in claims involving this condition (see section 9).

The instrument is built around a limited set of legal and medical concepts that determine whether a reasonable hypothesis connecting posterior adventitial heel bursitis to relevant service is raised. Those concepts are defined in the instrument or established by its structural rules.

Posterior adventitial heel bursitis: The SOP defines the condition in section 7(2). It is inflammation of the superficial retro‑Achilles bursa located between the skin and the distal Achilles tendon, and is characterised clinically by painful and tender swelling of the posterior aspect of the heel. The definition expressly excludes retrocalcaneal bursitis and plantar calcaneal bursitis. For death claims, section 7(3) extends the condition to include death from a terminal event or condition to which the bursitis contributed. The Schedule defines "posterior adventitial heel bursitis,see subsection 7(2)" and gives a definition for plantar calcaneal bursitis for differentiation.

Reasonable hypothesis threshold: Section 9 sets the evidential gate. It states that at least one of the enumerated factors must exist before it can be said that a reasonable hypothesis has been raised connecting the condition (or death from it) with relevant service. The SOP therefore operates as a list of minimal factual circumstances that, if established and related to service, satisfy the RMA’s test for a causal link at the threshold stage.

Enumerated factors: The SOP lists five discrete factors in section 9:

• 9(1) Wearing footwear that causes friction or pressure on the posterior aspect of the heel at the time of clinical onset.

• 9(2) Having a Haglund deformity at the time of clinical onset.

• 9(3) Wearing footwear that causes friction or pressure on the posterior aspect of the heel at the time of clinical worsening.

• 9(4) Having a Haglund deformity at the time of clinical worsening.

• 9(5) Inability to obtain appropriate clinical management for posterior adventitial heel bursitis.

Timing and causation distinctions: The SOP distinguishes between clinical onset and clinical worsening. Sections 9(1) and 9(2) tie factors to the time of clinical onset. Sections 9(3) to 9(5) are expressly concerned with clinical worsening, and section 10(2) restricts their application to cases where the bursitis was suffered or contracted before or during, but did not arise out of, relevant service. That distinction draws a legal difference between conditions that arise out of service and pre‑existing conditions that are materially contributed to or aggravated by service.

This SOP directly affects persons who make claims under the statutory provisions specified in the instrument, and indirectly affects those who provide medical evidence and the administrators who decide those claims.

Primary claimants: Section 5 states the instrument applies to claims to which section 120A of the VEA or section 338 of the MRCA applies. The Schedule defines the scope of "relevant service" to include operational, peacekeeping, hazardous and British nuclear test defence service under the VEA, and warlike and non‑warlike service under the MRCA. Therefore, veterans, former service members and other persons whose service fits those categories who assert posterior adventitial heel bursitis or death from it as related to their service are directly affected. The person asserting the claim carries the practical burden of adducing evidence to show at least one of the section 9 factors existed and that it related to their relevant service (section 9 and section 10(1)).

Decision makers: Administrative decision makers who adjudicate claims under the VEA and MRCA must apply the SOP when assessing whether a reasonable hypothesis has been raised. The instrument does not itself set out administrative procedures, but section 5 makes this SOP applicable to specified claims, and section 11 provides cross‑application rules when factors invoke other SOPs. The Repatriation Medical Authority established the SOP under s196B(2) (section 3), so decision makers will treat the RMA’s determination and the enumerated factors as authoritative for the reasonable hypothesis test.

Medical practitioners and report writers: The list of factors is clinical or semi‑clinical in nature. Clinicians preparing reports for claimants will need to address, with reference to the claimant’s history and investigations, whether any of the section 9 factors existed at the relevant times (clinical onset or clinical worsening) and whether they relate to the claimant’s relevant service. The Schedule’s medical definitions, for example of Haglund deformity and of plantar calcaneal bursitis, will be used to frame clinical findings against the SOP’s language.

Family and estates in death claims: Where death is alleged to have been contributed to by posterior adventitial heel bursitis, the SOP affects estates or dependants making death claims because section 7(3) imports death from the condition into the SOP if the bursitis contributed to a "terminal event" as defined in the Schedule.

Other SOPs and related claims: Section 11 affects parties whose claims invoke injuries or diseases that are the subject of other SOPs. If a factor in section 9 refers to an injury or disease that has its own SOP, the other SOP’s factors apply in accordance with that SOP as in force. That will affect claims where posterior adventitial heel bursitis co‑exists with or is related to another recognised condition.

This SOP does not create novel criminal or civil duties; instead it prescribes the factual and medical criteria that must be met for a reasonable hypothesis linking posterior adventitial heel bursitis or death from it to relevant service. Rights and duties must therefore be read in the administrative context of claims under the VEA and MRCA.

What the SOP requires claimants to establish: Section 9 is the operative duty from the claimant’s perspective. As a minimum, a claimant must establish that at least one of the enumerated factors existed in the person before it can be said that a reasonable hypothesis has been raised connecting the condition to relevant service. The claimant therefore must assemble evidence that supports one or more of those factors, and evidence that relates the factor to relevant service per section 10(1).

Relation to relevant service: Section 10(1) requires that any factor relied upon be related to the person’s relevant service. The SOP does not define the precise evidential standard for establishing that relation; it simply requires it. This places on claimants an obligation to link the factual factor to the person’s service record or service circumstances. The Schedule’s definition of "relevant service" enumerates the categories of service that are the relevant legal context.

Onset versus worsening and material contribution: Section 10(2) affects how duties are structured depending on timing. If a claimant contends the condition was materially contributed to or aggravated by service, and the bursitis was present before or during (but did not arise out of) the service, then subsections 9(3) to 9(5) may be relied upon. This creates a duty to show material contribution or aggravation rather than initial causation, and to show the pre‑existence or presence of the condition before service or during service, but not arising out of service.

Interaction with other Statements of Principles: Section 11 creates a duty on decision makers to apply an alternative SOP if a factor in section 9 refers to an injury or disease covered by another SOP. In practice, this gives claimants and decision makers a right and duty to treat cross‑referenced diseases according to their own SOPs, and not to confine analysis to this instrument when overlap occurs.

Rights in death claims: Section 7(3) confers the right to have a death claim considered under this SOP where posterior adventitial heel bursitis contributed to a terminal event. The Schedule examples of terminal events identify possible medical mechanisms (for example pneumonia or cardiac arrest) but do not dictate a specific mode of proof. Claimants relying on death causation must show a contribution to those terminal events.

The instrument itself does not create criminal sanctions, civil penalties or independent enforcement mechanisms. Its legal effect is to set medical causation rules , specifically, the factual factors that must exist before a reasonable hypothesis may be said to be raised connecting posterior adventitial heel bursitis or death from it to relevant service.

Administrative enforcement through claims: The SOP is expressly made under subsection 196B(2) of the VEA (section 3) and is applicable to claims to which section 120A of the VEA or section 338 of the MRCA applies (section 5). That situates the SOP within the administrative framework used to determine entitlements and related benefits under those Acts. The enforcement mechanism, therefore, is the claims process within the VEA/MRCA regimes, which use the RMA’s SOPs as determinative guides to medical causation at the reasonable hypothesis stage. The SOP itself does not specify the mechanics of claims assessment, appeals, penalties for false claims or other procedural consequences; those are matters governed by the VEA, the MRCA and their administrative procedures.

No express disciplinary provisions or sanctions: There are no sections in the instrument prescribing fines, imprisonment, disciplinary measures or civil liability for non‑compliance. The absence of such provisions means the SOP’s role is evidentiary and normative for decision makers, not regulatory in the sense of imposing independent sanctions.

Relevance to entitlement outcomes: Although the SOP contains no penalties, its application in the claims process can produce consequential outcomes for claimants. If a claimant cannot show at least one of the factors in section 9 and cannot show the factor was related to relevant service per section 10(1), the claimant will not have raised the RMA’s standard for a reasonable hypothesis under this SOP, which can directly affect the success of the claim and any entitlements or benefits dependent on that link. Conversely, establishing a qualifying factor related to relevant service may be a necessary step toward entitlement. The SOP thus operates as an administrative filter that can determine entitlement outcomes, even though it does not itself prescribe enforcement measures.

Death claims and terminal events: Section 7(3) extends the SOP to death where posterior adventitial heel bursitis contributed to a terminal event as defined in the Schedule. In such cases the SOP will be used in the administrative determination of whether the death is related to service for the purposes of any VEA/MRCA entitlements that flow from death being service‑related. The SOP does not itself create a cause of action or specify compensation amounts.

The SOP is not a stand‑alone legislative instrument; it operates within the statutory frameworks of the VEA and the MRCA and is designed to be used by decision makers applying those Acts. The instrument contains a few explicit cross‑references and limits, and its interaction with other laws is mediated by those references and its function as an evidentiary tool.

Primary statutory context: The SOP is made under subsection 196B(2) of the VEA (section 3). Section 5 makes the SOP applicable to claims to which section 120A of the VEA or section 338 of the MRCA applies. The instrument therefore operates as an RMA determination under the VEA that is to be applied in the statutory claims processes of the VEA and the MRCA. Any procedural, substantive or remedial rules concerning claims, appeals, assessment standards, time limits or payment of benefits are those that exist under the VEA and MRCA; the SOP provides the medical causation framework for parts of that assessment.

Cross‑reference to other Statements of Principles: Section 11 provides the interaction rule where a factor in section 9 refers to an injury or disease covered by another SOP made under subsection 196B(2) of the VEA. In such cases, the factors in that other SOP apply in accordance with that SOP as in force from time to time. That mechanism ensures interoperability among SOPs and avoids inconsistent application where conditions overlap or where a factor is more precisely treated in another SOP.

Scope exclusions and definitions: Section 7(2)(c) excludes retrocalcaneal bursitis and plantar calcaneal bursitis from the definition of posterior adventitial heel bursitis. The Schedule defines plantar calcaneal bursitis. These definitions and exclusions determine the boundary between this SOP and other medical conditions that may be the subject of other SOPs or statutory assessments. For example, if a claimant’s presentation is better described as plantar calcaneal bursitis, that condition is not covered by this SOP and decision makers will turn to the SOP, if any, that covers plantar calcaneal bursitis or to clinical evidence under the VEA/MRCA framework.

Interaction with MRCA: The Schedule defines MRCA as the Military Rehabilitation and Compensation Act 2004, and section 5 states the instrument applies to claims to which section 338 of the MRCA applies. The SOP therefore serves as an RMA determination that is imported into the MRCA claims process where relevant. The instrument, however, does not amend the MRCA; it simply applies within statutory claim considerations under the MRCA where section 338 is engaged.

The instrument contains a limited and explicit amendment history within its own text.

• Repeal of earlier Statement of Principles: Section 4 repeals the Statement of Principles concerning heel bursitis No. 77 of 2010 (Federal Register of Legislation No. F2010L02316). The repeal is total as stated in section 4; no savings or transition clauses are included in the instrument itself.

• Date and commencement: The instrument is dated 26 April 2019 (as shown on the instrument) and commences on 27 May 2019 (section 2). That gives a fixed effective date for application in claims under the VEA and MRCA per section 5.

• Authority under the VEA: The instrument records its statutory authority at section 3, being made under subsection 196B(2) of the VEA. That traces the power underpinning the SOP to the Repatriation Medical Authority’s statutory function to determine Statements of Principles.

• No other amendments recorded in this instrument: The text contains no amending schedule or subsequent variations. The Schedule 1 dictionary sets out the operative definitions in the instrument. If future amendments are made, they will need to be made under the RMA’s statutory powers and published in the Federal Register or otherwise communicated; no such amendments are contained in this instrument.

What the instrument does not include about amendments: The SOP does not include any clause describing how future amendments interact with existing claims, and it does not set out retrospective or transitional application rules. There is no express provision preserving decisions made under the repealed SOP or stating which SOP applies to claims lodged before commencement. Those matters are controlled by the VEA/MRCA procedures or subsequent administrative guidance outside the text of this instrument.

Practical consequence of the repeal and replacement: The replacement of the earlier SOP means that from 27 May 2019 decision makers and claimants must look to this instrument for the RMA’s contemporary view on the factors that raise a reasonable hypothesis. The precise practical effect on particular pending claims will depend on the procedural rules under the VEA and MRCA and any administrative practice notes, which are not contained in this instrument.

The instrument itself does not record any litigation history. It is a Repatriation Medical Authority determination of medical factors and definitions. The text contains no references to judicial decisions, challenges, appeals or litigation arising from this instrument or its predecessor. The only legal references in the instrument are to statutes (the VEA and the MRCA) and to the prior SOP that it repeals.

What the instrument provides on legal authority: Section 3 identifies subsection 196B(2) of the VEA as the statutory authority for the RMA to make Statements of Principles. Section 8 records the RMA’s view that sound medical‑scientific evidence supports the connection between the condition and relevant service. The SOP therefore sets RMA policy and medical‑scientific determinations used by decision makers; disputes about their application in particular claims would arise in appeals or judicial review processes under the VEA and MRCA frameworks, but none of that litigation is described in the instrument.

No named cases in the text: The instrument does not cite or rely upon case law. It contains no citations to judicial authorities or examples of prior administrative or judicial determinations. The Schedule provides only medical definitions and examples of terminal events; it does not reference legal precedent.

Implication for researchers: Because the instrument contains no litigation history, anyone researching case law where this SOP was applied will need to consult external sources , tribunal decisions, Federal Court or administrative appeals , to identify how courts or tribunals have interpreted or relied on this SOP in contested claims. The instrument itself provides the RMA’s determinations and definitions but not how those determinations have fared in litigation.

This SOP is compact and tightly worded. A number of practical and interpretive pitfalls follow directly from the instrument’s structure and language. Below are concrete issues that claimants, clinicians and decision makers should be aware of, with references to the relevant text.

Narrow enumerated factors as threshold gate: Section 9 requires that at least one of the five listed factors exist before a reasonable hypothesis is raised. If a claimant’s factual circumstances do not match those factors, the SOP provides no alternative pathway to establish the reasonable hypothesis for posterior adventitial heel bursitis. The factors are specific and clinical in form (footwear friction or pressure, Haglund deformity, inability to obtain appropriate clinical management), so cases that hinge on different mechanisms (for example, unusual trauma not captured by "wearing footwear that causes friction or pressure") are not covered by the SOP’s enumerated list.

Onset versus worsening distinction creates proof burdens: Sections 9 and 10 draw a legal distinction between clinical onset and clinical worsening. Sections 9(1) and 9(2) apply to the time of clinical onset. Sections 9(3) to 9(5) apply to clinical worsening but, per section 10(2), only where the bursitis was suffered or contracted before or during, but did not arise out of, relevant service. That means a claimant alleging onset during service should focus on 9(1) and 9(2), while a claimant alleging aggravation of a pre‑existing condition must demonstrate the pre‑existence and use 9(3) to 9(5), and must show material contribution or aggravation rather than initial causation. This timing distinction imposes evidentiary burdens as to when clinical onset and worsening occurred and whether the condition pre‑existed service.

Ambiguity in key terms: The SOP uses phrases that are clinically meaningful but not precisely defined in the instrument itself. Examples:

• "Wearing footwear that causes friction or pressure on the posterior aspect of the heel" (sections 9(1) and 9(3)). The instrument does not define what degree of friction or pressure is required, what types of footwear qualify, or how contemporaneous evidence of footwear must be documented.

• "Haglund deformity" is defined in the Schedule as an abnormality of the posterosuperior part of the calcaneus, a bony enlargement at the Achilles attachment. The practical proof will typically require imaging or clinical notation, but the SOP does not specify diagnostic criteria or which investigations are required.

The SOP prescribes a narrow evidential pathway. Compliance is therefore a matter of assembling and presenting documentary and clinical evidence that establishes at least one of the section 9 factors and shows its relation to the person’s relevant service per section 10(1). The following practical steps flow directly from the instrument itself.

1. Establish the diagnosis and clinical timeline

• Obtain contemporaneous clinical records that record the diagnosis of posterior adventitial heel bursitis, and identify the dates of clinical onset and any dates of clinical worsening. The SOP distinguishes between onset and worsening (sections 9 and 10(2)); decision makers will require clarity on timing.

• Ensure clinical records document the signs described in section 7(2): inflammation of the superficial retro‑Achilles bursa located between the skin and the distal Achilles tendon with painful and tender swelling of the posterior heel. Where the diagnosis is ambiguous, obtain specialist reports that address whether the presentation is posterior adventitial heel bursitis rather than retrocalcaneal or plantar calcaneal bursitis, which are excluded (section 7(2)(c) and Schedule).

2. Prove one or more of the enumerated factors in section 9

• For footwear factors (sections 9(1) and 9(3)): provide contemporaneous descriptions or evidence that the claimant was wearing specific footwear that caused friction or pressure at the time of clinical onset or clinical worsening. Documentary evidence might include service uniform/boot issue records, statements from the claimant and witnesses describing footwear and fit, or medical records noting footwear as a contributing factor. The SOP does not prescribe which evidence suffices, so be explicit and contemporaneous where possible.

• For Haglund deformity (sections 9(2) and 9(4)): secure imaging reports (x‑ray, MRI) or specialist orthopaedic documentation that identify a Haglund deformity as defined in the Schedule: a bony enlargement at the posterosuperior calcaneus at the Achilles attachment. The clinician should state whether the deformity was present at the time of onset or worsening and whether it is plausibly causative or contributory to the bursitis.

• For inability to obtain appropriate clinical management (section 9(5)): collect evidence showing attempts to obtain treatment and reasons for inability. This may include referral letters, appointment records showing declined or delayed care, correspondence with health services, records of service health provisioning during deployment, and contemporaneous notes from treating clinicians indicating management was unavailable. Because the SOP does not define "appropriate clinical management", supply corroborating detail about standards of care and the clinical needs that went unmet.