Statement of Principles concerning joint instability (Reasonable Hypothesis) (No. 57 of 2019) (Cth)

Statement of Principles concerning JOINT INSTABILITY (Reasonable Hypothesis) (No. 57 of 2019) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 26 April 2019

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 joint instability (Reasonable Hypothesis) (No. 57 of 2019). 2 Commencement This instrument commences on 27 May 2019. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning joint instability No. 32 of 2010 (Federal Register of Legislation No. F2010L01048) made under subsection 196B(2) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004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 joint instability and death from joint instability. Meaning of joint instability (2) For the purposes of this Statement of Principles, joint instability: (a) means an acquired lack of stability of a joint due to damage to or abnormality of the stabilising structures of that joint, manifesting as recurrent subluxation, recurrent dislocation or recurrent sprain; and (b) includes joints with an internal joint prosthesis; and (c) excludes spondylolisthesis, and the loosening or migration of the fixation component of an internal joint prosthesis. (3) While joint instability attracts ICD‑10‑AM code M22.0, M22.1, M23.5, M24.2, M24.4, M25.3, M43.3, M43.4, M43.5, M53.2 or T84.0, in applying this Statement of Principles the meaning of joint instability 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 joint instability (5) For the purposes of this Statement of Principles, joint instability, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's joint instability. 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 joint instability and death from joint instability 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 joint instability or death from joint instability with the circumstances of a person's relevant service: (1) having physical trauma to the affected joint at the time of the clinical onset of joint instability; Note: Examples of activities and circumstances involving trauma to the affected joint include, but are not limited to, falls, collisions, lifting weights, push ups, pull ups, throwing objects, seizure and electrical injury. (2) having a dislocation or subluxation of the affected joint before the clinical onset of joint instability; (3) having a sprain of the affected joint before the clinical onset of joint instability; (4) having damage to a soft tissue structure as specified before the clinical onset of joint instability; Note: soft tissue structure as specified is defined in the Schedule 1 – Dictionary. (5) having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical onset of joint instability; Note: Examples of conditions which can cause a bony abnormality include, but are not limited to, osteonecrosis, dysbaric osteonecrosis and femoroacetabular impingement. (6) having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of joint instability; Note: disease process as specified is defined in the Schedule 1 - Dictionary. (7) being pregnant within the six weeks before the clinical onset of joint instability; (8) for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of joint instability; Note 1: Examples of activities which may involve wide mouth opening include, but are not limited to, yawning, laughing, vomiting, coughing, and chewing large pieces of food. Note 2: Examples of medical procedures that involve wide mouth opening include, but are not limited to, dental procedures, direct laryngoscopy, and intravenous administration of medications which cause drug-induced yawning. (9) for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of joint instability; (10) for total hip joint prosthesis joint instability only, being obese at the time of the clinical onset of joint instability; Note: being obese is defined in the Schedule 1 - Dictionary. (11) for tibiofemoral joint instability only, being severely obese at the time of the clinical onset of joint instability; Note: being severely obese is defined in the Schedule 1 - Dictionary. (12) for total knee joint prosthesis joint instability only, having morbid obesity at the time of the clinical onset of joint instability; (13) for elbow joint instability only, having more than three local glucocorticoid injections for epicondylitis before the clinical onset of joint instability; (14) having physical trauma to the affected joint at the time of the clinical worsening of joint instability; Note: Examples of activities and circumstances involving trauma to the affected joint include, but are not limited to, falls, collisions, lifting weights, push ups, pull ups, throwing objects, seizure and electrical injury. (15) having damage to a soft tissue structure as specified before the clinical worsening of joint instability; Note: soft tissue structure as specified is defined in the Schedule 1 – Dictionary. (16) having a fracture or bony abnormality involving the articulating surfaces of the affected joint before the clinical worsening of joint instability; Note: Examples of conditions which can cause a bony abnormality include, but are not limited to, osteonecrosis, dysbaric osteonecrosis and femoroacetabular impingement. (17) having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical worsening of joint instability; Note: disease process as specified is defined in the Schedule 1 - Dictionary. (18) being pregnant within the six weeks before the clinical worsening of joint instability; (19) for temporomandibular joint instability only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical worsening of joint instability; Note 1: Examples of activities which may involve wide mouth opening include, but are not limited to, yawning, laughing, vomiting, coughing, and chewing large pieces of food. Note 2: Examples of medical procedures that involve wide mouth opening include, but are not limited to, dental procedures, direct laryngoscopy, and intravenous administration of medications which cause drug-induced yawning. (20) for total hip prosthesis joint instability only, having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical worsening of joint instability; (21) for total hip joint prosthesis joint instability only, being obese at the time of the clinical worsening of joint instability; Note: being obese is defined in the Schedule 1 - Dictionary. (22) for tibiofemoral joint instability only, being severely obese at the time of the clinical worsening of joint instability; Note: being severely obese is defined in the Schedule 1 - Dictionary. (23) for total knee joint prosthesis joint instability only, having morbid obesity at the time of the clinical worsening of joint instability; (24) for elbow joint instability only, having more than three local glucocorticoid injections for epicondylitis before the clinical worsening of joint instability; (25) inability to obtain appropriate clinical management for joint instability. 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(14) to 9(25) apply only to material contribution to, or aggravation of, joint instability where the person's joint instability 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.