Statement of Principles concerning retrocalcaneal heel bursitis (Balance of Probabilities) (No. 89 of 2024)

This instrument is a Statement of Principles made by the Repatriation Medical Authority (RMA) under subsection 196B(3) of the Veterans' Entitlements Act 1986 (VEA) (see Authority, section 3). It sets the medical and causal criteria the RMA considers sufficient, on the balance of probabilities, to connect retrocalcaneal heel bursitis and death from that condition with a person's relevant service. The instrument is titled "Statement of Principles concerning retrocalcaneal heel bursitis (Balance of Probabilities) (No. 89 of 2024)" (Name, section 1) and commences on 19 November 2024 (Commencement, section 2). It expressly repeals the earlier Statement of Principles entitled "Achilles tendinopathy and bursitis (Balance of Probabilities) (No. 97 of 2015)" (Repeal, section 4).

Mechanically, the instrument does the following things:

• Defines the covered condition as retrocalcaneal heel bursitis and excludes posterior adventitial heel bursitis (Kind of injury, disease or death to which this Statement of Principles relates, subsection 7(2)).
• States that death from the condition is included where the condition “contributed to” the person’s terminal event or condition, with “terminal event” given specific examples in the Schedule (see subsection 7(3) and Schedule 1 - Dictionary).
• Lists the specific factors that, if established, meet the RMA’s view that it is more probable than not the condition is related to relevant service; at least one factor must exist (Factors that must exist, section 9).
• Requires that any factor relied upon be related to the person’s relevant service, which is defined in the Schedule as particular categories of VEA or MRCA service (Relationship to service, section 10; Schedule 1 - Dictionary).
• Provides that where a factor refers to another injury or disease covered by a different Statement of Principles, the factors in that other Statement apply in accordance with its terms (Factors referring to an injury or disease covered by another Statement of Principles, section 11).

The instrument states the RMA’s evidentiary stance: on the available medical‑scientific evidence the RMA is of the view that it is more probable than not retrocalcaneal heel bursitis and death from it can be related to relevant service (Basis for determining the factors, section 8). It applies to claims to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 (MRCA) apply (Application, section 5). The Schedule supplies operational definitions for “relevant service”, “terminal event”, and the statutory abbreviations MRCA and VEA (Schedule 1 - Dictionary).

In short, the Statement provides a fixed set of causal and factual triggers the RMA considers sufficient to establish a service connection for retrocalcaneal heel bursitis on the balance of probabilities for the statutory claims identified.

The instrument rests around a few narrowly defined legal and medical concepts, each carrying a specific operational role in claim assessment.

Retrocalcaneal heel bursitis: The instrument defines the condition precisely as inflammation of the deep Achilles bursa located between the distal Achilles tendon and the calcaneus, and it excludes posterior adventitial heel bursitis (subsection 7(2)). This exclusion narrows the covered pathology to the deep bursa at the tendon-bone interface.

Death from the condition: The Statement treats death as included where retrocalcaneal heel bursitis “contributed to” the person’s terminal event or condition. The Schedule supplies examples of terminal events including pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (subsection 7(3); Schedule 1 - Dictionary). The instrument therefore contemplates both proximate and ultimate contribution to death, subject to ordinary evidentiary proof.

Relevant service: The causal connection must be related to "relevant service", a defined statutory concept. The Schedule defines relevant service to mean eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA (Schedule 1 - Dictionary). This determines the cohort of military service that can be the basis of a claim.

Causation standard: The RMA frames its view as applying on the balance of probabilities. The instrument states the RMA’s view that it is more probable than not that the condition can be related to relevant service (section 8). The Statement therefore provides the RMA’s medical-scientific thresholds for probable connection which claim decision‑makers will apply in statutory claims governed by the cited sections of the VEA and MRCA (Application, section 5).

Factors that must exist: Section 9 lists five alternative categories of factor; at least one must be present. They are:

• Running/jogging an average of at least 60 km per week for the four weeks before clinical onset or clinical worsening (section 9(1)).
• Undertaking weight-bearing exercise involving repeated ankle activity on the affected side at a minimum intensity of 5 METs for at least 6 hours per week for at least the four weeks before clinical onset or clinical worsening, with examples and a note on METs included (section 9(2) and accompanying notes).
• Having one of a list of systemic arthritic diseases at the time of clinical onset or clinical worsening, with specified enumerated diagnoses (section 9(3)).

Primary affected individuals

• Veterans and former members of the Forces who lodge claims for retrocalcaneal heel bursitis, and claimants whose entitlement to benefits depends on whether their condition is connected to relevant service under the statutory schemes identified. The instrument expressly applies to claims to which section 120B of the VEA or section 339 of the MRCA apply (Application, section 5). The Schedule defines “relevant service,” thereby delimiting the types of service that make a claimant eligible to have this Statement applied (Schedule 1 - Dictionary).

Dependents and estates

• Where death from retrocalcaneal heel bursitis is alleged, the instrument affects claimants pursuing entitlements in respect of a deceased person because the Statement includes death from the condition if it contributed to the terminal event (subsection 7(3); Schedule 1 - Dictionary).

Medical and allied health practitioners

• Clinicians who provide diagnostic and opinion evidence to support claims. The Statement establishes specific medical criteria and temporal windows (for example, activity levels in the four weeks before clinical onset or clinical worsening) that practitioners must link to a claimant’s history to satisfy the listed factors (section 9). The instrument therefore shapes the content and granularity of medical reporting that will be decisive in administrative decisions.

Decision-makers and administrators

• Administrative decision-makers applying the VEA and MRCA statutory schemes will use the Statement as the RMA’s medical-scientific guide to causation. The instrument was made under subsection 196B(3) of the VEA which is the statutory power by which the RMA issues Statements of Principles; it is not itself the decision-maker but a binding guidance instrument that feeds into claim determinations (Authority, section 3).

Service records and rehabilitation providers

• Records of training, unit physical programmes, marching, marching logs, medical encounter notes, and primary care or specialist consultations documenting infections or attempts to obtain clinical care will be more relevant because the Statement turns on specific activity thresholds, diagnostic categories, and the presence or absence of appropriate clinical management (section 9).

Legal advisers, advocates and insurers

• Lawyers, advocates, and representatives preparing claims or appeals and conducting evidentiary strategies must build documentary and expert evidence mapped to the Statement’s factors and temporal requirements. The Statement will determine which factual narratives are legally relevant for a tribunal or administrative review.

Duties on claimants and medical evidence providers

• The instrument places an evidentiary duty on claimants to establish at least one of the factors in section 9 and to show that the factor is related to their relevant service (section 9; section 10(1)). The listed factors are concrete and require specific types of proof: patterns of physical activity (for example, running an average of at least 60 kilometres per week over a four week window, section 9(1)); measured or described exercise meeting a minimum intensity of 5 METs performed at least 6 hours per week for at least four weeks (section 9(2)); documented systemic arthritic disease at the time of onset or worsening (section 9(3)); documented bacterial infection of the affected bursa (section 9(4)); or evidence that the person could not obtain appropriate clinical management before clinical worsening (section 9(5)).

• Clinicians who supply evidence will need to connect clinical dates to the temporal windows specified, state diagnoses from the enumerated list where applicable, document infection where present and describe treatment access where relevant. The Statement provides examples and notes concerning METs and activity intensity that clinicians can use to map patient histories to the specified thresholds (Notes to section 9).

Duty to relate factors to relevant service

• Section 10(1) requires that any factor must be related to the person’s relevant service. The Schedule defines relevant service categories. This creates a duty to articulate how the factual factor arose from or was tied to the person’s service record, for example by linking periods of qualifying service to the timeframe of clinical onset or worsening.

Temporal duty and limitation on clinical worsening

• Section 10(2) limits the application of the “clinical worsening” concept to cases in which the bursitis was “suffered or contracted before or during (but did not arise out of) the person's relevant service.” Therefore, for claims that invoke clinical worsening, the duty includes demonstrating the preexistence of the condition prior to the relevant service and that relevant service materially contributed to or aggravated it, rather than being its original cause.

Duty to follow cross-referenced Statements

• Where a factor refers to another injury or disease that itself has an RMA Statement, section 11 obliges that the factors in that other Statement apply. Practitioners and decision-makers must therefore consult and satisfy requirements in the other Statement as it stands at the relevant time.

No criminal or civil penalties are created by this instrument. The Statement of Principles is an administrative medical‑scientific instrument made under subsection 196B(3) of the VEA (Authority, section 3). It does not itself prescribe sanctions, fines, or criminal liability. The text contains no penalty provisions.

Enforcement in practice is administrative. The instrument will be used by statutory decision-makers charged with applying the VEA and MRCA provisions listed in the Application (section 5) to determine whether retrocalcaneal heel bursitis or death from it is connected with relevant service on the balance of probabilities. That determination affects entitlement assessments under those Acts, with the Statement serving as the RMA’s expert medical view of causal factors (Basis for determining the factors, section 8). The Statement therefore functions as a determinative evidentiary standard in administrative adjudication rather than as an enforcement instrument imposing direct penalties.

Discretion and assessment

• The Statement prescribes factual thresholds and medical categories which decision-makers will interpret and apply. Discretion arises in assessing whether the claimant’s evidence meets the listed factors, whether the factor is related to relevant service (section 10(1)), and whether the clinical worsening rules apply (section 10(2)). The instrument does not specify adjudicative standards beyond the balance of probabilities formulation, nor does it set procedural timelines or evidentiary burdens beyond the content of the factors.

Implications for claim outcomes

• Although no penalties are attached, the Statement’s content will materially affect benefit decisions: meeting a listed factor and showing the connection to relevant service are prerequisites the RMA has framed as sufficient to support finding connection on the balance of probabilities (section 8 and section 9). Conversely, failing to establish any listed factor tied to relevant service may result in an adverse entitlement decision. The Statement therefore influences the enforcement of statutory benefit schemes by shaping causation assessments.

No enforcement mechanism for compliance with clinical management recommendation

• The instrument includes an item (section 9(5)) where inability to obtain appropriate clinical management is itself one of the factors. There is no enforcement mechanism within the Statement obliging any third party to provide treatment; rather it treats lack of access as a factual circumstance that may be causally relevant.

Statutory context and scope

• The Statement is made under subsection 196B(3) of the VEA (Authority, section 3). It applies to claims to which section 120B of the VEA or section 339 of the MRCA apply (Application, section 5). The instrument is therefore an RMA medical standard that fits into the adjudicative framework of those two statutory provisions. The text itself does not reproduce the operative sections of the VEA or MRCA but expressly limits the Statement’s application to claims governed by those provisions.

Relationship with prior RMA instruments

• The instrument expressly repeals the RMA’s earlier Statement titled "Achilles tendinopathy and bursitis (Balance of Probabilities) (No. 97 of 2015)" (Repeal, section 4). This repeal removes the earlier set of medical criteria and replaces them with the present, condition‑specific Statement for retrocalcaneal heel bursitis. Where a claim was previously to be assessed under the repealed instrument, assessors will now apply this Statement for retrocalcaneal heel bursitis claims.

Cross-reference to other Statements of Principles

• Section 11 provides an explicit mechanism for interaction: if a section 9 factor refers to another injury or disease that itself is the subject of another Statement, then the factors in that other Statement apply in accordance with its terms as in force from time to time. This creates a legal link between Statements and means that causation for some listed factors may require satisfying the conditions set out in other RMA Statements.

Interpretive relationship with VEA and MRCA decision-making provisions

• The Statement functions as the RMA’s medical view on causal factors and will be used by the relevant decision-makers operating under the VEA and MRCA to determine service connection. The instrument’s balance of probabilities framing (section 8) is an evidentiary standard that aligns with how administrative determinations of causal connection are normally conducted, although the instrument does not itself describe the procedural operation of those statutory decision-making sections.

Non-creation of civil liabilities or modification of non‑statutory schemes

• The Statement does not purport to change civil law causes of action, workers’ compensation, or other non‑statutory schemes. Its operation is administrative and confined to the RMA’s statutory remit (Authority, section 3 and Application, section 5). It will not, by itself, alter common law liability or obligations outside the VEA/MRCA adjudicative context.

Dates, instrument number and repeal

• The instrument is titled as Statement No. 89 of 2024 and is dated 18 October 2024 (front matter). The commencement date is 19 November 2024 (Commencement, section 2). Section 4 expressly repeals the earlier RMA Statement "Achilles tendinopathy and bursitis (Balance of Probabilities) (No. 97 of 2015)" (Repeal, section 4), with the earlier Statement identified by Federal Register of Legislation number F2015L01337 in the instrument’s preamble.

No other amendments recorded in the instrument

• The text supplied contains no other amendment schedule, transitional provision, or savings clause. It does not list modifications to other legislation; its only express legislative interaction is the repeal of the 2015 Statement and its making under subsection 196B(3) of the VEA (Authority, section 3).

Authority and continuity

• The Statement is made under subsection 196B(3) of the VEA (Authority, section 3). The instrument therefore continues the RMA’s established practice of issuing Statements of Principles under that statutory power and replaces the prior instrument in the specific subject area.

Implication for prior claims

• The instrument does not include explicit transitional provisions concerning claims that were in progress under the repealed 2015 Statement. The repeal is stated simply in section 4. The absence of transitional text in the instrument itself means that decision-makers and practitioners must rely on the standard administrative approach to applying the new Statement to claims made on or after commencement, subject to any procedural rules in the VEA/MRCA or guidance from the department administering those Acts.

Frequency and practice of updates

• This instrument shows the RMA’s periodic updating practice: a 2015 instrument was replaced in 2024 with a new condition-focused Statement. Section 11’s reference to other Statements “as in force from time to time” indicates the RMA designs Statements to be dynamic documents that can be updated independently.

Document identification

• The instrument name, number and dates provide the archival trail for practitioners and administrators to locate prior versions and to confirm that the 2015 Statement is no longer in force for the matters covered by this instrument.

In summary, the only express amendment action recorded within the instrument is the repeal of the 2015 RMA Statement on Achilles tendinopathy and bursitis. No other amendments or transitional arrangements are set out in the supplied text.

No litigation, case law or tribunal decisions are cited within the text of the Statement. The instrument itself records the RMA’s medical‑scientific determination and does not reference any judicial or tribunal authority. The document supplied does not include any summary of challenges, judicial review proceedings, appeals or other litigation in connection with this Statement, nor does it list precedents.

Consequently, within the source text there is no recorded litigation history to summarise. Practitioners should therefore treat the instrument as a current administrative standard produced by the RMA, and should not rely on any court or tribunal interpretation in the absence of external research. Any challenge to the Statement’s content, application, or validity would be external to the text and is not described in the instrument.

Because the supplied instrument contains no litigation references, practitioners preparing evidence or representing claimants should:

• Not assume there is settled case law interpreting the Statement from the text alone.
• Anticipate that issues likely to attract contestation include the application of the temporal windows (for example proof of activity “for the 4 weeks before clinical onset or clinical worsening”), the measurement and proof of METs and hours of activity, the meaning and proof of “inability to obtain appropriate clinical management”, and the application of the clinical worsening limitation in section 10(2).
• Be prepared to develop factual and medical evidence to address those contestable issues, because the instrument itself sets thresholds but does not provide adjudicative interpretive guidance or examples resolving borderline cases.

If litigation has occurred or will occur regarding the meaning or application of these provisions, that material is not contained in this Statement and must be sourced from judicial or tribunal records outside the instrument.

Precise thresholds that require precise proof

• The Statement requires discrete, time‑bounded activity thresholds. Running or jogging must average at least 60 kilometres per week for the four weeks before clinical onset or clinical worsening (section 9(1)). Weight‑bearing exercise must meet a minimum intensity of 5 METs, be performed at least 6 hours per week, and occur for at least the four weeks before the relevant clinical date (section 9(2)). These quantitative thresholds invite exacting evidentiary scrutiny, and the Statement supplies examples of activities and brief MET guidance (Notes to section 9). In practice, claimants will need contemporaneous records, training logs, unit orders, fitness app data, or clinician history that explicitly maps to these numerical limits to meet the RMA criteria.

Ambiguity in clinical terms

• The instrument uses terms such as “clinical onset” and “clinical worsening” but does not define them in the Schedule (sections 9 and 10). That omission creates room for dispute about the starting point of the relevant four‑week windows and about what constitutes worsening. Evidence providers must therefore define and justify how they identify the clinical onset/worsening dates in each case.

“Appropriate clinical management” is unqualified

• One of the listed factors is “inability to obtain appropriate clinical management for retrocalcaneal heel bursitis before clinical worsening” (section 9(5)). The instrument does not define “appropriate”, nor does it set what kinds of attempts at access by the claimant will be sufficient. This invites contested factual inquiry: was the care sought reasonable, were the avenues available, and what standard of “appropriate” should be applied? Decision-makers will need to decide whether to adopt a standard based on locality, available services during the relevant period, or professional norms.

Clinical worsening limitation can narrow claims

• The clinical worsening rule in section 10(2) applies only where the bursitis was suffered or contracted before or during relevant service but did not arise out of that service. Thus, if a claimant’s condition first arose out of relevant service, clinical worsening provisions do not operate as the route to connection. That restriction affects claims narratives and requires clear proof of the condition’s chronology.

Cross-reference dependencies

• Section 11 requires that where a factor invokes another disease covered by a separate Statement of Principles, that other Statement’s factors apply “as in force from time to time”. This means that satisfying a listed factor may also require meeting another Statement’s evolving criteria. Practitioners must therefore check the current version of any referenced Statement, as its terms may have changed since the instant instrument’s publication.

For claimants and their advisers

• Map the claim to the correct statutory pathway. Confirm that the claim falls within the instrument’s application: it must be a claim to which section 120B of the VEA or section 339 of the MRCA applies (Application, section 5). Verify that the claimant’s service qualifies as “relevant service” under the Schedule definition (Schedule 1 - Dictionary).

• Identify which section 9 factor(s) will be relied upon. At least one factor must be established (section 9). Prepare evidence tailored to that factor. For example, if relying on running 60 km per week, assemble contemporaneous records such as training logs, unit fitness records, GPS/fitness app data, or corroborative witness statements that specify weekly distances and the four-week window before clinical onset or worsening (section 9(1)).

• If relying on weight‑bearing exercise (section 9(2)), provide objective or contemporaneous evidence that the activity reached a minimum intensity of 5 METs, was performed for at least 6 hours per week, and occurred for at least four weeks before the clinical date. The Statement gives activity examples and an explanatory note on METs; clinicians should quantify activity intensity where possible and explain how the described activities map onto the 5 MET threshold (Notes to section 9).

• For systemic arthritic disease factors (section 9(3)), ensure the medical record contains a contemporaneous diagnosis from the enumerated list, supported by relevant laboratory or imaging findings as applicable, and that the diagnosis was present at the time of clinical onset or worsening.

• For infection factors (section 9(4)), produce microbiological, operative, or clinical documentation of bacterial infection of the affected retrocalcaneal bursa at the relevant time.

• If relying on the inability to obtain appropriate clinical management (section 9(5)), document attempts to obtain care, the nature of the services sought, any administrative or geographic barriers encountered and contemporaneous correspondence or notes illustrating that the subject could not obtain "appropriate" care before clinical worsening. Because the instrument does not define “appropriate”, provide clinical justification for why the sought treatments qualified as appropriate and why denial or lack of access materially affected the outcome.

For medical experts and treating clinicians