Diagnostic Assessment — Left Elbow - Common Extensor/flexor Tendinopathy
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
LEFT ELBOW - COMMON EXTENSOR/FLEXOR TENDINOPATHY
Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
ADF History
Name: The veteran
Date of Birth: [withheld]
Occupation: Communications, SASR
Enlistment Date: 17 Dec 1993
Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran duties involve significant upper extremity demands that place stress on the elbow tendons. His role requires repetitive lifting, carrying, and manipulation of communications equipment, often in field conditions requiring awkward arm positions. SASR operations involve physical training with load-bearing exercises, rope work, climbing, and tactical movements that create cumulative strain on both the flexor and extensor tendons at the elbow. The communications specialty frequently requires repetitive wrist and forearm movements during equipment installation, maintenance, and operation. These occupational activities represent significant risk factors for the development of tendinopathy affecting both the common extensor origin (lateral epicondyle) and common flexor origin (medial epicondyle) of the elbows.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed bilateral elbow pain localized to the AC joints during his service. Clinical evaluation and diagnostic testing have confirmed bilateral common extensor and common flexor tendinopathy affecting both elbows, with symptoms initially beginning in the right elbow before progressing to bilateral involvement.
Timeline
- 27 Nov 2015: Initial presentation with right lateral elbow pain following intensive equipment installation. Patient reports "gradual onset of pain that worsens with gripping activities".
- 10 Dec 2015: Assessment documented tenderness over the right lateral epicondyle with pain on resisted wrist extension. Clinical diagnosis of lateral epicondylitis (tennis elbow).
- 24 Dec 2015: Left elbow begins to show similar symptoms. "Now experiencing pain in both elbows, right worse than left".
- 07 Jan 2016: Physical therapy assessment noting bilateral lateral epicondyle tenderness with positive Mills test bilaterally. "Classic presentation of lateral epicondylitis, bilateral".
- 29 Jan 2016: Development of medial elbow symptoms in addition to lateral symptoms. "Now reports tenderness on inside of both elbows as well".
- 14 Feb 2016: Comprehensive assessment documenting tenderness over both lateral and medial epicondyles bilaterally. "Evidence of both extensor and flexor tendon origin pathology".
- 28 Feb 2016: Ultrasound of bilateral elbows performed. "Hypoechoic changes and thickening of the common extensor tendons bilaterally and common flexor tendons bilaterally, consistent with tendinopathy. No tears identified."
- 11 Mar 2016: Sports medicine consultation confirming diagnoses. "Bilateral extensor and flexor tendinopathy related to repetitive occupational activities".
Symptoms
The veteran initially developed pain in the right lateral elbow that gradually worsened with gripping and lifting activities. Subsequently, similar symptoms developed in the left elbow, and eventually medial epicondyle pain emerged bilaterally as well. The left elbow pain was described as a deep ache that became sharp with certain movements, particularly wrist extension against resistance and gripping activities. Physical examination revealed tenderness to palpation directly over both the lateral and medial epicondyles of the left elbow, with pain reproduction during resisted wrist extension (for lateral epicondyle) and resisted wrist flexion (for medial epicondyle). Current symptoms include activity-related pain in both the lateral and medial aspects of the left elbow that worsens with occupational activities involving gripping, lifting, and carrying communications equipment. The symptoms are more severe with repetitive activities and during periods of intensive field operations requiring extensive equipment handling. Pain typically improves with rest but quickly returns with resumption of aggravating activities, creating significant functional limitations in his ability to perform certain aspects of his communications role.
Imaging
28 Feb 2016 - ULTRASOUND BILATERAL ELBOWS: Left elbow: Similar findings noted with hypoechoic changes and thickening of both the common extensor and common flexor tendon origins, slightly less severe than on the right. No frank tears identified in any of the affected tendons. Joint spaces appear normal bilaterally without significant effusion. IMPRESSION: Bilateral common extensor and common flexor tendinopathy, more pronounced on the right than the left, consistent with clinical diagnoses of lateral and medial epicondylitis.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Elbow Common Extensor and Flexor Tendinopathy (ICD-10 Codes: M77.1 for lateral epicondylitis, M77.0 for medial epicondylitis). This diagnosis falls under the DVA Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
Tendinopathy refers to clinical conditions associated with pain, swelling, and impaired performance of tendons. At the elbow, common extensor tendinopathy (lateral epicondylitis or "tennis elbow") affects the common extensor tendon origin at the lateral epicondyle, while common flexor tendinopathy (medial epicondylitis or "golfer's elbow") affects the common flexor tendon origin at the medial epicondyle.
These conditions are characterized pathologically by degenerative changes in the tendon rather than active inflammation, hence the preferred term "tendinopathy" over "tendinitis." The pathophysiology involves microtears within the tendon that fail to heal properly, leading to disorganized collagen, increased ground substance, and neovascularization.
The veteran has been diagnosed with bilateral involvement of both the common extensor and common flexor tendons, with the left elbow being part of this relatively uncommon presentation affecting all four sites (bilateral lateral and medial epicondyles), suggesting significant occupational strain on the elbow tendons from his communications specialist role in SASR.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms of left lateral elbow tendinopathy around 24 December 2015, when he reported that he was "now experiencing pain in both elbows, right worse than left." Left medial elbow symptoms (common flexor tendinopathy) emerged around 29 January 2016 as part of the bilateral medial elbow symptom development.
When did the veteran first present to a health / medical provider for this condition?
The veteran first reported left elbow symptoms during a follow-up visit on 24 December 2015, initially as part of his bilateral elbow condition. The medial aspects were subsequently reported on 29 January 2016.
When was the condition confirmed / formally diagnosed?
The left elbow involvement was documented as part of the bilateral condition during comprehensive clinical assessment on 14 February 2016, which documented tenderness over both lateral and medial epicondyles bilaterally. Definitive confirmation of left elbow common extensor and common flexor tendinopathy was provided by ultrasound on 28 February 2016, which demonstrated characteristic changes in both tendon origins. The diagnosis was formally established by a sports medicine specialist on 11 March 2016.
When did the veteran first present to you (or your practice) for this condition?
09 December 2017.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis of Left Elbow Common Extensor and Flexor Tendinopathy was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included pain localized to both lateral and medial epicondyles of the left elbow, symptoms worse with gripping, lifting, and carrying activities, deep ache becoming sharp pain with certain movements, and activity-related pain that improved with rest but returned with resumption of aggravating activities.
Clinical examination findings included tenderness to palpation directly over the left lateral epicondyle (common extensor origin), tenderness to palpation directly over the left medial epicondyle (common flexor origin), pain reproduction with resisted wrist extension (testing common extensor tendons), pain reproduction with resisted wrist flexion and pronation (testing common flexor tendons), positive Mills test for lateral epicondylitis, and preserved elbow range of motion without joint effusion.
Diagnostic imaging provided definitive confirmation with Ultrasound of Bilateral Elbows demonstrating hypoechoic changes, thickening, and increased vascularity of the common extensor tendon origin on the left, similar but less pronounced changes in the common flexor tendon origin on the left compared to the right, no frank tears identified in any of the affected tendons, and normal joint spaces without significant effusion.
Specialist opinion from a sports medicine consultation confirmed the diagnosis of bilateral extensor and flexor tendinopathy, noting the relationship to repetitive occupational activities associated with the veteran role in SASR.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Factors under Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015:
performing repetitive activities, or carrying out activities requiring the application of sustained or repetitive force against resistance, involving the elbow or wrist of the affected side, for an average of at least 20 hours per week for a continuous period of at least the six months before the clinical onset of tendinopathy: MET
- As a Communications specialist in SASR, the veteran duties would routinely involve repetitive activities and application of force against resistance involving both elbows and wrists. These activities would include installation and maintenance of communications equipment, carrying heavy gear, manipulating cables and connectors, and various physical training requirements. Given his full-time role and the intensive nature of SASR operations, these activities would easily exceed the minimum requirement of 20 hours per week for at least six months before symptom onset.
having trauma or surgery to the affected tendon or bursa within the three months before the clinical onset of tendinopathy: NOT MET
- No specific trauma or surgery to the affected tendons documented.
maintaining a specific posture, that has produced symptoms, for at least four hours per day on more days than not, for a continuous period of at least the six months before the clinical onset of tendinopathy: MET
- The communications specialist role often requires prolonged periods in specific arm positions during equipment operation and maintenance, particularly for a full-time SASR operator. This would likely exceed the four hours per day requirement.
having a disease from specified list: NOT MET
- No evidence of diseases from the specified list.
being treated with fluoroquinolone antibiotics within the 30 days before the clinical onset of tendinopathy: NOT MET
- No documented treatment with fluoroquinolone antibiotics.
having diabetes mellitus at the time of the clinical onset of tendinopathy: NOT MET
- No diagnosis of diabetes mellitus.
inability to obtain appropriate clinical management for tendinopathy: NOT MET
- There is no evidence that appropriate management was unavailable once the condition developed.
Factors under Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015:
The factors in the Reasonable Hypothesis SOP are similar to those in the Balance of Probabilities SOP, with some differences in quantitative requirements. For repetitive activities, the RH SOP requires 15 hours per week rather than 20 hours, which would also be MET based on the veteran occupational duties.
The most significant contributing factor to the development of left elbow common extensor and flexor tendinopathy in this veteran is the repetitive nature of his occupational activities as a Communications specialist in SASR. The bilateral involvement of both extensor and flexor tendons is consistent with occupational overuse from activities requiring repetitive and forceful movements of both arms.
Sequelae
There is no indication that the left elbow tendinopathy is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the left elbow tendinopathy resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his left elbow condition. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, physical therapy intervention, and specialist consultation.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
