Statement of Principles concerning KNEE BURSITIS (Reasonable Hypothesis) (No. 65 of 2018) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 22 June 2018 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 Application 5 Definitions 6 Kind of injury, disease or death to which this Statement of Principles relates 7 Basis for determining the factors 8 Factors that must exist 9 Relationship to service 10 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 knee bursitis (Reasonable Hypothesis) (No. 65 of 2018). 2 Commencement This instrument commences on 23 July 2018. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 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. 5 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 6 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about knee bursitis and death from knee bursitis. Meaning of knee bursitis (2) For the purposes of this Statement of Principles, knee bursitis: (a) means inflammation or infection of a bursa around the knee joint; and (b) excludes popliteal (Baker) cyst. Note: Knee bursitis is characterised by pain, tenderness, redness, swelling and thickening in the region of the knee. (3) While knee bursitis attracts ICD‑10‑AM code M70.4 or M70.5, in applying this Statement of Principles the meaning of knee bursitis 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 knee bursitis (5) For the purposes of this Statement of Principles, knee bursitis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's knee bursitis. Note: terminal event is defined in the Schedule 1 – Dictionary. 7 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that knee bursitis and death from knee bursitis 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. 8 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 knee bursitis or death from knee bursitis with the circumstances of a person's relevant service: (1) for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 30 kilometres per week for the four weeks before the clinical onset of knee bursitis; (2) for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; Note: Examples of pressing the anterior knee against a hard vertical surface include working whilst standing against a guard rail on a rolling and pitching ship. (3) for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical onset of knee bursitis; Note: Examples of pressing the medial knee against a hard surface include horseback riding or motorcycle riding. (4) having trauma to the affected knee bursa in the 30 days before the clinical onset of knee bursitis; Note: Examples of trauma include cuts, abrasions and lacerations of the affected knee bursa, repeated knocking or hitting the affected knee bursa, needle aspiration of the affected knee bursa and wearing a below knee amputation prosthesis. (5) having surgery to the knee of the affected side in the 30 days before the clinical onset of knee bursitis; (6) having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical onset of knee bursitis; (7) for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of knee bursitis; Note: immunocompromised state as specified is defined in the Schedule 1 - Dictionary. (8) for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical onset of knee bursitis; (9) having a disease from the specified list of diseases at the time of the clinical onset of knee bursitis; Note: specified list of diseases is defined in the Schedule 1 - Dictionary. (10) for medial compartment bursitis only, having medial compartment osteoarthritis at the time of the clinical onset of knee bursitis; Note: medial compartment bursitis is defined in the Schedule 1 - Dictionary. (11) for pes anserine bursitis only, having a significant biomechanical abnormality involving the affected knee at the time of the clinical onset of knee bursitis; Note: significant biomechanical abnormality is defined in the Schedule 1 - Dictionary. (12) for knee bursitis other than prepatellar and superficial infrapatellar bursitis, running or jogging an average of at least 30 kilometres per week for the four weeks before the clinical worsening of knee bursitis; (13) for prepatellar bursitis or superficial infrapatellar bursitis only, working whilst kneeling, crawling or pressing the anterior knee against a hard vertical surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; Note: Examples of pressing the anterior knee against a hard vertical surface include working whilst standing against a guard rail on a rolling and pitching ship. (14) for medial collateral ligament bursitis only, pressing the medial side of the knee against a hard surface for a cumulative period of at least 60 hours within the two months before the clinical worsening of knee bursitis; Note: Examples of pressing the medial knee against a hard surface include horseback riding or motorcycle riding. (15) having trauma to the affected knee bursa in the 30 days before the clinical worsening of knee bursitis; Note: Examples of trauma include cuts, abrasions and lacerations of the affected knee bursa, repeated knocking or hitting the affected knee bursa, needle aspiration of the affected knee bursa and wearing a below knee amputation prosthesis. (16) having surgery to the knee of the affected side in the 30 days before the clinical worsening of knee bursitis; (17) having a bacterial, fungal or algal infection of the affected knee bursa at the time of the clinical worsening of knee bursitis; (18) for septic knee bursitis only, being in an immunocompromised state as specified at the time of the clinical worsening of knee bursitis; Note: immunocompromised state as specified is defined in the Schedule 1 - Dictionary. (19) for prepatellar, superficial infrapatellar or pretibial bursitis only, having psoriasis, atopic dermatitis or other inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected knee, at the time of the clinical worsening of knee bursitis; (20) having a disease from the specified list of diseases at the time of the clinical worsening of knee bursitis; Note: specified list of diseases is defined in the Schedule 1 - Dictionary. (21) for medial compartment bursitis only, having medial compartment osteoarthritis at the time of the clinical worsening of knee bursitis; Note: medial compartment bursitis is defined in the Schedule 1 - Dictionary. (22) for pes anserine bursitis only, having a significant biomechanical abnormality involving the affected knee at the time of the clinical worsening of knee bursitis; Note: significant biomechanical abnormality is defined in the Schedule 1 - Dictionary. (23) inability to obtain appropriate clinical management for knee bursitis. 9 Relationship to service (1) The existence in a person of any factor referred to in section 8, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 8(12) to 8(23) apply only to material contribution to, or aggravation of, knee bursitis where the person's knee bursitis was suffered or contracted before or during (but did not arise out of) the person's relevant service. 10 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 8 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 5 1 Definitions In this instrument: chronic renal failure means: (a) having a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least three months; or (b) a need for renal replacement therapy (dialysis or transplantation) for treatment of complications of decreased glomerular filtration rate which would otherwise increase the risk of morbidity and mortality; or (c) undergoing chronic dialysis. crystal-induced arthropathy means arthropathy resulting from the deposition of monosodium urate, calcium pyrophosphate dehydrate, calcium hydroxyapatite or calcium oxalate. immunocompromised state as specified means a condition of substantially lowered immune function, such as would occur in the following conditions or circumstances: (a) being infected with human immunodeficiency virus; (b) being treated with an immunosuppressive drug; (c) having a haematological or solid organ malignancy; (d) having chronic renal failure; (e) having severe malnutrition; or (f) undergoing solid organ, stem cell or bone marrow transplantation. Note: chronic renal failure and immunosuppressive drug are also defined in the Schedule 1 - Dictionary. immunosuppressive drug means a drug or an agent which results in substantial suppression of immune responses. Note: Examples of an immunosuppressive drug include corticosteroids other than inhaled or topical corticosteroids, drugs used to prevent transplant rejection, tumor necrosis factor- inhibitors and chemotherapeutic agents used for the treatment of cancer. knee bursitis—see subsection 6(2). medial compartment bursitis means pes anserine bursitis, medial collateral ligament bursitis and semimembranosus-tibial collateral ligament bursitis. MRCA means the Military Rehabilitation and Compensation Act 2004. 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. significant biomechanical abnormality means an abnormality that causes a significant alteration of biomechanical forces through the knee, such as would occur with genu valgum or collateral ligament knee joint instability. specified list of diseases means: (a) ankylosing spondylitis; (b) enteropathic spondyloarthropathy; (c) gout, pseudogout, or other crystal-induced arthropathy; (d) pigmented villonodular proliferation; (e) polymyalgia rheumatica; (f) psoriatic arthropathy; (g) reactive arthritis; (h) rheumatoid arthritis; (i) sarcoidosis; or (j) undifferentiated spondyloarthropathy. Note: crystal-induced arthropathy is also defined in the Schedule 1 - Dictionary. 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.