Statement of Principles concerning PES PLANUS (Reasonable Hypothesis) (No. 67 of 2021) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 21 May 2021 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Nicholas Saunders AO Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions 1 Name This is the Statement of Principles concerning pes planus (Reasonable Hypothesis) (No. 67 of 2021). 2 Commencement This instrument commences on 21 June 2021. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning pes planus No. 45 of 2012 (Federal Register of Legislation No. F2012L01361) made under subsection 196B(2) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about pes planus and death from pes planus. Meaning of pes planus (2) For the purposes of this Statement of Principles, pes planus: (a) means a substantial collapse of the medial longitudinal arch of the foot that results in either: (i) medical treatment; or (ii) symptoms of medial foot pain; and (b) includes congenital pes planus, developmental pes planus, acquired pes planus, flexible pes planus and rigid pes planus. Note 1: Pes planus is also known as flatfoot deformity and can occur with calcaneal valgus or forefoot abduction. Note 2: Medical treatment may include the use of orthotics. (3) While pes planus attracts ICD‑10‑AM code M21.4 or Q66.5, in applying this Statement of Principles the meaning of pes planus is that given in subsection (2). (4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from pes planus (5) For the purposes of this Statement of Principles, pes planus, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's pes planus. Note: terminal event is defined in the Schedule 1 - Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that pes planus and death from pes planus can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary. 9 Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting pes planus or death from pes planus with the circumstances of a person's relevant service: (1) having a fracture or osteonecrosis involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot before the clinical onset of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (2) having a dislocation of a joint or subluxation of a joint or joint instability involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot before the clinical onset of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (3) having a sprain, penetrating trauma or surgery to the ligaments involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot within the 3 months before the clinical onset of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (4) having a strain, penetrating trauma or surgery involving the muscles or tendons that support the medial longitudinal arch of the affected foot within the 3 months before the clinical onset of pes planus; (5) having rupture or division of the plantar fascia of the affected foot before the clinical onset of pes planus; (6) having weakness or paralysis of the supinators of the affected foot at the time of the clinical onset of pes planus; Note: Examples of conditions that can give rise to weakness or paralysis of the foot supinator muscles include central or peripheral nervous system pathology, myopathy and tendonitis. (7) having spasticity or shortening of the pronators of the affected foot at the time of the clinical onset of pes planus; Note: Examples of conditions that can give rise to spasticity or shortening of the foot pronator muscles include central or peripheral nervous system pathology and myopathy. (8) having posterior tibialis tendinopathy at the time of the clinical onset of pes planus; (9) having a space occupying lesion limiting the ability of the affected foot to supinate at the time of the clinical onset of pes planus; (10) having arthritis or other destructive lesion of one or more of the joints of the tarsal or metatarsal bones of the medial longitudinal arch of the affected foot at the time of the clinical onset of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (11) being obese at the time of the clinical onset of pes planus; Note: being obese is defined in the Schedule 1 - Dictionary. (12) being pregnant at the time of the clinical onset of pes planus; (13) having a fracture or osteonecrosis involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot before the clinical worsening of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (14) having a dislocation of a joint or subluxation of a joint or joint instability involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot before the clinical worsening of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (15) having a sprain, penetrating trauma or surgery to the ligaments involving one or more tarsal or metatarsal bones of the medial longitudinal arch of the affected foot within the 3 months before the clinical worsening of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (16) having a strain, penetrating trauma or surgery involving the muscles or tendons that support the medial longitudinal arch of the affected foot within the 3 months before the clinical worsening of pes planus; (17) having rupture or division of the plantar fascia of the affected foot before the clinical worsening of pes planus; (18) having weakness or paralysis of the supinators of the affected foot at the time of the clinical worsening of pes planus; Note: Examples of conditions that can give rise to weakness or paralysis of the foot supinator muscles include central or peripheral nervous system pathology, myopathy and tendonitis. (19) having spasticity or shortening of the pronators of the affected foot at the time of the clinical worsening of pes planus; Note: Examples of conditions that can give rise to spasticity or shortening of the foot pronator muscles include central or peripheral nervous system pathology and myopathy. (20) having posterior tibialis tendinopathy at the time of the clinical worsening of pes planus; (21) having a space occupying lesion limiting the ability of the affected foot to supinate at the time of the clinical worsening of pes planus; (22) having arthritis or other destructive lesion of one or more of the joints of the tarsal or metatarsal bones of the medial longitudinal arch of the affected foot at the time of the clinical worsening of pes planus; Note: tarsal or metatarsal bones of the medial longitudinal arch is defined in the Schedule 1 - Dictionary. (23) being obese at the time of the clinical worsening of pes planus; Note: being obese is defined in the Schedule 1 - Dictionary. (24) being pregnant at the time of the clinical worsening of pes planus; (25) running or jogging: (a) an average of at least 30 kilometres per week; and (b) for at least the 4 weeks before the clinical worsening of pes planus; (26) walking: (a) an average of at least 10 kilometres per week; and (b) while carrying loads of at least 15 kilograms; and (c) for at least the 4 weeks before the clinical worsening of pes planus; (27) inability to obtain appropriate clinical management for pes planus. 10 Relationship to service (1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 9(13) to 9(27) apply only to material contribution to, or aggravation of, pes planus where the person's pes planus was suffered or contracted before or during (but did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time. Schedule 1 - Dictionary Note: See Section 6 1 Definitions In this instrument: being obese means having a Body Mass Index (BMI) of 30 or greater. Note: BMI is also defined in the Schedule 1 - Dictionary. BMI means W/H2 where: (a) W is the person's weight in kilograms; and (b) H is the person's height in metres. MRCA means the Military Rehabilitation and Compensation Act 2004. pes planus—see subsection 7(2). relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. tarsal or metatarsal bones of the medial longitudinal arch means the calcaneus, talus, navicular, cuneiforms and the first, second and third metatarsals. terminal event means the proximate or ultimate cause of death and includes the following: (a) pneumonia; (b) respiratory failure; (c) cardiac arrest; (d) circulatory failure; or (e) cessation of brain function. VEA means the Veterans' Entitlements Act 1986.