Statement of Principles concerning GLUTEAL TENDINOPATHY (Balance of Probabilities) (No. 95 of 2023) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986. Dated 25 October 2023. 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 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 gluteal tendinopathy (Balance of Probabilities) (No. 95 of 2023). 2 Commencement This instrument commences on 28 November 2023. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning trochanteric bursitis and gluteal tendinopathy No. 46 of 2015 (Federal Register of Legislation No. F2015L00011) made under subsections 196B(3) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004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. 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 gluteal tendinopathy and death from gluteal tendinopathy. Meaning of gluteal tendinopathy (2) For the purposes of this Statement of Principles, gluteal tendinopathy means a symptomatic inflammatory or degenerative disease of the gluteus medius or gluteus minimus tendons at or near their insertion into the greater trochanter of the hip. Note: Clinical manifestations of gluteal tendinopathy typically include pain and tenderness in the region of the lateral hip or buttock that usually worsens with physical activity. Gluteal tendinopathy can be associated with degenerative tendon tears. (3) While gluteal tendinopathy attracts ICD‑10‑AM code M76.0, in applying this Statement of Principles the meaning of gluteal tendinopathy 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 gluteal tendinopathy (5) For the purposes of this Statement of Principles, gluteal tendinopathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's gluteal tendinopathy. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 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 gluteal tendinopathy and death from gluteal 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. 9 Factors that must exist At least one of the following factors must exist before it can be said that, on the balance of probabilities, gluteal tendinopathy or death from gluteal 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 the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; (2) undertaking weight bearing exercise involving repeated activity of the hip on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 6 hours per week; and for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; Note 1: Examples of weight bearing exercise involving repeated activity of the hip at a minimum intensity of 5 METS include marching, sustained brisk walking, climbing stairs, playing football, and dancing. Note 2: MET is defined in the Schedule 1 - Dictionary. (3) increasing the frequency, duration or intensity of activity involving the hip on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 4 hours per day; within the one week before the clinical onset or clinical worsening of gluteal tendinopathy; Note: MET is defined in the Schedule 1 - Dictionary. (4) having direct trauma to the affected tendon within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; Note: direct trauma to the affected tendon is defined in the Schedule 1 – Dictionary. (5) having surgery to the hip of the affected side within the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; (6) having a systemic inflammatory disease before the clinical onset or clinical worsening of gluteal tendinopathy; Note: systemic inflammatory disease is defined in the Schedule 1 - Dictionary. (7) having a significantly abnormal gait for at least the 4 weeks before the clinical onset or clinical worsening of gluteal tendinopathy; (8) being obese at the time of the clinical onset or clinical worsening of gluteal tendinopathy; Note: being obese is defined in the Schedule 1 – Dictionary. (9) inability to obtain appropriate clinical management for gluteal tendinopathy before the clinical worsening of gluteal tendinopathy. 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 clinical worsening aspects of factors set out in section 9 apply only to material contribution to, or aggravation of, gluteal tendinopathy where the person's gluteal tendinopathy 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(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 6 1 Definitions In this instrument: being obese means having a Body Mass Index (BMI) of 30 or greater. Note: BMI is defined in the Schedule 1 – Dictionary. BMI means W/H2 where: W is the person's weight in kilograms; and H is the person's height in metres. direct trauma to the affected tendon means a discrete event involving the application of significant physical force to the affected tendon, that causes: (a) the development of symptoms and signs of pain and tenderness, and either altered mobility or range of movement of the hip. In the case of sustained unconsciousness or the masking of pain by analgesic medication, these symptoms and signs must appear on return to consciousness or the withdrawal of the analgesic medication; and (b) the persistence of these symptoms and signs for a period of at least 7 days following their onset, save for where medical intervention for the trauma to the affected tendon has occurred and that medical intervention involves one of the following: (i) immobilisation of the hip by splinting or similar external agent; (ii) injection of a corticosteroid or local anaesthetic into the hip; or (iii) surgery to the hip. gluteal tendinopathy—see subsection 7(2). 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) 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. systemic inflammatory disease means: (a) rheumatoid arthritis; (b) polymyalgia rheumatica; (c) ankylosing spondylitis; (d) enteropathic spondyloarthropathy (arthritis associated with inflammatory bowel disease); (e) psoriatic arthropathy; (f) reactive arthritis; or (g) 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.