Statement of Principles concerning EPICONDYLITIS (Reasonable Hypothesis) (No. 5 of 2023) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 23 December 2022. The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Terence Campbell AM Chairperson Contents 1 Name....................................................3 2 Commencement.............................................3 3 Authority..................................................3 4 Repeal...................................................3 5 Application................................................3 6 Definitions................................................3 7 Kind of injury, disease or death to which this Statement of Principles relates.....3 8 Basis for determining the factors..................................4 9 Factors that must exist.........................................4 10 Relationship to service.........................................6 11 Factors referring to an injury or disease covered by another Statement of Principles.6 Schedule 1 - Dictionary...............................................7 1 Definitions................................................7 1 Name This is the Statement of Principles concerning epicondylitis (Reasonable Hypothesis) (No. 5 of 2023). 2 Commencement This instrument commences on 23 January 2023. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning epicondylitis No. 7 of 2015 (Federal Register of Legislation No. F2014L01784) made under subsection 196B(2) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004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 epicondylitis and death from epicondylitis. Meaning of epicondylitis (2) For the purposes of this Statement of Principles, epicondylitis: (a) means a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the medial or lateral epicondyle of the elbow; and (b) includes medial epicondylitis and lateral epicondylitis. Note 1: Epicondylitis typically presents with pain and tenderness over the medial or lateral epicondyle, with exacerbation of pain by the use of the muscles of the forearm, such as with wrist extension in lateral epicondylitis or with wrist flexion in medial epicondylitis. Note 2: Lateral epicondylitis is also known as tennis elbow. Medial epicondylitis is also known as golfer's elbow. Note 3: Epicondylitis is also known as elbow tendinopathy. (3) While epicondylitis attracts ICD‑10‑AM codes M77.0 or M77.1, in applying this Statement of Principles the meaning of epicondylitis 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 epicondylitis (5) For the purposes of this Statement of Principles, epicondylitis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's epicondylitis. 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 epicondylitis and death from epicondylitis 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 epicondylitis or death from epicondylitis with the circumstances of a person's relevant service: (1) performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained activities with the hand or forearm on the affected side; for at least 1 hour per day, on more days than not, over a period of at least the 4 weeks before the clinical onset of epicondylitis; Note: Performing forceful and repetitive or forceful and sustained activities with the hand or forearm can occur as compensation for disability in the contralateral upper limb (including epicondylitis or amputation), or with manual wheelchair use. Activities with the hand or forearm involve bending or straightening of the elbow; rotation, pronation, supination, twisting or screwing motion of the forearm; and flexion, extension or bending of the wrist or hand. (2) using a hand-held computer mouse on the affected side for at least 20 hours per week in the 6 months before the clinical onset of epicondylitis; (3) having a sudden alteration of loading pattern as specified for a continuous period of at least 1 hour, within the 3 days before the clinical onset of epicondylitis; Note: having a sudden alteration of loading pattern as specified is defined in the Schedule 1 - Dictionary. (4) taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis; Note: Examples of fluoroquinolone antibiotics include ciprofloxacin, moxifloxacin, norfloxacin and ofloxacin. (5) having spondyloarthritis at the time of the clinical onset of epicondylitis; Note: spondyloarthritis is defined in the Schedule 1 – Dictionary. (6) performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained activities with the hand or forearm on the affected side; for at least 1 hour per day, on more days than not, over a period of at least the 4 weeks before the clinical worsening of epicondylitis; Note: Performing forceful and repetitive or forceful and sustained activities with the hand or forearm can occur as compensation for disability in the contralateral upper limb (including epicondylitis or amputation), or with manual wheelchair use. Activities with the hand or forearm involve bending or straightening of the elbow; rotation, pronation, supination, twisting or screwing motion of the forearm; and flexion, extension or bending of the wrist or hand. (7) using a hand-held computer mouse on the affected side for at least 20 hours per week in the 6 months before the clinical worsening of epicondylitis; (8) having a sudden alteration of loading pattern as specified for a continuous period of at least 1 hour, within the 3 days before the clinical worsening of epicondylitis; Note: having a sudden alteration of loading pattern as specified is defined in the Schedule 1 - Dictionary. (9) taking a fluoroquinolone antibiotic within the 14 days before the clinical worsening of epicondylitis; Note: Examples of fluoroquinolone antibiotics include ciprofloxacin, moxifloxacin, norfloxacin and ofloxacin. (10) having spondyloarthritis at the time of the clinical worsening of epicondylitis; Note: spondyloarthritis is defined in the Schedule 1 – Dictionary. (11) inability to obtain appropriate clinical management for epicondylitis. 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(6) to 9(11) apply only to material contribution to, or aggravation of, epicondylitis where the person's epicondylitis 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: epicondylitis—see subsection 7(2). having a sudden alteration of loading pattern as specified means suddenly increasing the frequency, duration or intensity of forceful and repetitive or sustained activities with the hand or forearm on the affected side by at least 100 percent and to a minimum intensity of at least 5 METs. Examples of such activities include using a rowing machine, carrying objects of at least 10 kilograms, vigorous gardening, using heavy power tools or carpentry; Note: MET is defined in the Schedule 1 – Dictionary. 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. 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. spondyloarthritis means: (a) ankylosing spondylitis; (b) enteropathic spondyloarthropathy; (c) reactive arthritis; or (d) undifferentiated spondyloarthropathy. 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.