Statement of Principles concerning Achilles tendinopathy (Reasonable Hypothesis) (No. 86 of 2024) (Cth)

Statement of Principles concerning ACHILLES TENDINOPATHY (Reasonable Hypothesis) (No. 86 of 2024) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 18 October 2024.

Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority

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 Achilles tendinopathy (Reasonable Hypothesis) (No. 86 of 2024). 1. Commencement This instrument commences on 19 November 2024. 1. Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 1. Repeal The Statement of Principles concerning Achilles tendinopathy and bursitis (Reasonable Hypothesis) (No. 96 of 2015) (Federal Register of Legislation No. F2015L01336) made under subsection 196B(2) of the VEA is repealed. 1. 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. 1. Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 1. Kind of injury, disease or death to which this Statement of Principles relates 1. This Statement of Principles is about Achilles tendinopathy and death from Achilles tendinopathy. Meaning of Achilles tendinopathy 1. For the purposes of this Statement of Principles, Achilles tendinopathy: 1. means a symptomatic inflammatory or degenerative disease of the Achilles tendon or paratendon; and 2. includes: 1. insertional tendinopathy of the Achilles tendon; 2. mid portion tendinopathy of the Achilles tendon; 3. degenerative tears of the Achilles tendon; and 4. Achilles enthesopathy or enthesitis. Note: Achilles tendinopathy is also known as Achilles tendonitis or paratendonitis, Achilles tendinosis or paratendinosis. Insertional Achilles tendinopathy is less than 2 cm proximal to the calcaneus and is a separate disease from Achilles enthesopathy, and mid portion Achilles tendinopathy is 2-7 cm proximal to the calcaneal insertion. Death from Achilles tendinopathy 1. For the purposes of this Statement of Principles, Achilles tendinopathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's Achilles tendinopathy. Note: terminal event is defined in the Schedule 1 – Dictionary. 1. Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that Achilles tendinopathy and death from Achilles tendinopathy 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. 1. 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 Achilles tendinopathy or death from Achilles tendinopathy with the circumstances of a person's relevant service: 1. running or jogging an average of at least 30 kilometres per week for the 4 weeks before clinical onset or clinical worsening; 2. undertaking weight bearing exercise involving repeated activity of the ankle joint on the affected side for: 1. a minimum intensity of 5 METS; and 2. for at least 4 hours per week; and 3. for at least the 4 weeks before clinical onset or clinical worsening; Note 1: Examples of weight bearing exercise involving repeated activity of the ankle joint at a minimum intensity of 5 METS include marching, playing basketball, football, volleyball, and track and field (especially those activities that involve jumping). Note 2: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening. 1. increasing the frequency, duration or intensity of activity involving the ankle joint on the affected side: 1. by at least 100 percent; and 2. to a minimum intensity of 5 METs; and 3. for at least 2 hours per day; within the 1 week before the clinical onset or clinical worsening; Note: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening. 1. having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: 1. pes planus; 2. pes cavus; 3. decreased ankle or forefoot flexibility; 4. forefoot varus; 5. lateral ankle joint instability; 2. having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: 1. ankylosing spondylitis; 2. Behcet syndrome; 3. enteropathic spondyloarthropathy (arthritis associated with inflammatory bowel disease); 4. gout; 5. pseudogout (calcium pyrophosphate dihydrate) or crystal-induced arthropathy from the deposition of calcium hydroxyapatite or calcium oxalate; 6. psoriatic arthropathy 7. reactive arthritis; 8. rheumatoid arthritis; or 9. undifferentiated spondyloarthropathy; 3. having chronic renal failure within the 10 years before clinical onset or clinical worsening as indicated by: 1. a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or 2. undergoing chronic dialysis for renal failure; 4. being treated with a fluoroquinolone antibiotic within the 30 days before clinical onset or clinical worsening; Note: Examples of fluoroquinolone antibiotics include ciprofloxacin, moxifloxacin, norfloxacin and ofloxacin. 1. being treated with a glucocorticoid drug as specified before clinical onset or clinical worsening; Note: being treated with a glucocorticoid drug as specified is defined in the Schedule 1 - Dictionary. 1. having a glucocorticoid injection into the Achilles tendon, in the region of the Achilles tendon or in the retrocalcaneal bursa, before the rupture of the Achilles tendon; Note: rupture of the Achilles tendon can constitute clinical onset or clinical worsening of Achilles tendinopathy. 1. being treated with an aromatase inhibitor for at least 4 weeks within the 1 year before clinical onset or clinical worsening; Note: Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. 1. having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; Note: BMI is defined in the Schedule 1 – Dictionary. 1. having diabetes mellitus at the time of clinical onset or clinical worsening; 2. inability to obtain appropriate clinical management for Achilles tendinopathy before clinical worsening. 1. 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, Achilles tendinopathy where the person's Achilles tendinopathy was suffered or contracted before or during (but did not arise out of) the person's relevant service. 2. 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.