Statement of Principles concerning POSTERIOR TIBIALIS TENDINOPATHY (Balance of Probabilities) (No. 46 of 2021) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986. Dated 26 March 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 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 posterior tibialis tendinopathy (Balance of Probabilities) (No. 46 of 2021). 2 Commencement This instrument commences on 27 April 2021. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Application This instrument applies to a claim to which section 120B of the VEA or section 339 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 posterior tibialis tendinopathy and death from posterior tibialis tendinopathy. Meaning of posterior tibialis tendinopathy (2) For the purposes of this Statement of Principles, posterior tibialis tendinopathy means inflammation or degeneration of the posterior tibialis tendon that produces localised pain or tenderness or rupture of the posterior tibialis tendon. Death from posterior tibialis tendinopathy (3) For the purposes of this Statement of Principles, posterior tibialis tendinopathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's posterior tibialis tendinopathy. Note: terminal event is defined in the Schedule 1 – Dictionary. 7 Basis for determining the factors On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that posterior tibialis tendinopathy and death from posterior tibialis tendinopathy can be related to relevant service rendered by veterans 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 exist before it can be said that, on the balance of probabilities, posterior tibialis tendinopathy or death from posterior tibialis tendinopathy is connected with the circumstances of a person's relevant service: (1) running or jogging an average of at least 60 kilometres per week, for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; (2) undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least six hours per week; and for at least the four weeks before the clinical onset of posterior tibialis tendinopathy; Note: MET is defined in the Schedule 1 - Dictionary. (3) increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least four hours per day; and within the seven days before the clinical onset of posterior tibialis tendinopathy; Note: MET is defined in the Schedule 1 - Dictionary. (4) having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical onset of posterior tibialis tendinopathy; (5) having an infection of the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; (6) having gout involving the affected posterior tibialis tendon at the time of the clinical onset of posterior tibialis tendinopathy; (7) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of posterior tibialis tendinopathy; Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary. (8) running or jogging an average of at least 60 kilometres per week, for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; (9) undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg: (a) at a minimum intensity of five METs; and (b) for at least six hours per week; and for at least the four weeks before the clinical worsening of posterior tibialis tendinopathy; Note: MET is defined in the Schedule 1 - Dictionary. (10) increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg: (a) by at least 100 percent; and (b) to a minimum intensity of five METs; and (c) for at least four hours per day; and within the seven days before the clinical worsening of posterior tibialis tendinopathy; Note: MET is defined in the Schedule 1 - Dictionary. (11) having trauma or surgery involving the affected posterior tibialis tendon within the 30 days before the clinical worsening of posterior tibialis tendinopathy; (12) having an infection of the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; (13) having gout involving the affected posterior tibialis tendon at the time of the clinical worsening of posterior tibialis tendinopathy; (14) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of posterior tibialis tendinopathy; Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary. (15) inability to obtain appropriate clinical management for posterior tibialis tendinopathy. 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(8) to 8(15) apply only to material contribution to, or aggravation of, posterior tibialis tendinopathy where the person's posterior tibialis tendinopathy 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(3) 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: MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, or 1.0 kcal/kg of body weight per hour, or resting metabolic rate. MRCA means the Military Rehabilitation and Compensation Act 2004. posterior tibialis tendinopathy—see subsection 6(2). relevant service means: (a) eligible war service (other than operational service) under the VEA; (b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or (c) peacetime service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. specified list of autoimmune diseases means: (a) ankylosing spondylitis; (b) inflammatory bowel disease; (c) psoriatic arthritis; (d) reactive arthritis; (e) rheumatoid arthritis; or (f) undifferentiated spondyloarthritis. 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.