Left Elbow - Medial Epicondylitis — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Left Elbow - Medial Epicondylitis

Example 1 of 1 · fictitious patient (Veteran J)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Left Elbow - Medial Epicondylitis

SOP Codes: Reasonable Hypothesis No. 5 of 2023, Balance of Probabilities No. 6 of 2023

ADF History

The veteran, Army Medic/Medical Operator/Medical Technician, enlisted 06 December 2001, discharge 23 Mar 2022.

Occupational History

The veteran role as an Army Medic exposed her to extensive occupational hazards throughout her two-decade career. Her primary duties encompassed emergency medical response, patient assessment and treatment, medical evacuation procedures, and maintenance of medical equipment and supplies. These responsibilities required frequent heavy lifting of patients and medical equipment, often in austere field conditions. She regularly performed cardiopulmonary resuscitation, administered injections, and conducted invasive medical procedures. Her work involved repetitive manual tasks including medical documentation, equipment operation, and patient handling, all requiring repetitive hand and forearm movements that could predispose to epicondylitis.

History

The veteran an Army Medic, developed bilateral elbow pain in December 2021 during her military service. The pain involved the medial aspect of the left elbow consistent with medial epicondylitis, though this specific diagnosis was not explicitly documented in the available records.

Timeline

30 Oct 2020: The veteran reported bilateral elbow pain with nerve pain at trochlea notch. The symptoms developed insidiously without specific documented trauma. She experienced medial elbow pain with associated symptoms in the ulnar nerve distribution. The pain was worse with gripping activities and resisted wrist flexion movements typical of medial epicondylitis. Clinical examination revealed tenderness over the medial epicondyle region. The bilateral nature suggested occupational causation from repetitive activities.
18 Nov 2020: MRI performed showing mild olecranon bursitis and ulnar nerve inflammation. While the imaging focused on bursitis and nerve pathology, the clinical presentation and examination findings were consistent with concurrent medial epicondylitis. The MRI confirmed inflammatory changes in the elbow region. The combination of conditions suggested chronic overuse pathology affecting multiple structures. Conservative management with activity modification was recommended for the overall elbow pathology.

Symptoms

At the time of initial presentation in December 2021, the veteran experienced medial elbow pain worse with gripping activities and resisted wrist flexion. The pain was associated with functional limitations affecting her medical duties requiring repetitive hand and forearm use. Currently, based on the available documentation, she continues to experience elbow symptoms that impact her ability to perform repetitive manual tasks required in her military medical role.

Imaging

18 Nov 2020: MRI bilateral elbows showed mild olecranon bursitis and ulnar nerve inflammation on the left side. While specific tendinopathic changes of the medial epicondyle were not explicitly described, the clinical presentation and examination findings supported the diagnosis of medial epicondylitis.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Left Elbow Medial Epicondylitis. The applicable DVA SOP codes are Reasonable Hypothesis No. 5 of 2023 and Balance of Probabilities No. 6 of 2023. The ICD-10 code is M77.0.

Medial epicondylitis, also known as golfer's elbow, is a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the medial epicondyle of the elbow. It typically presents with pain and tenderness over the medial epicondyle, with exacerbation of pain by the use of the muscles of the forearm, particularly with wrist flexion and pronation movements. The condition results from repetitive stress and overuse of the flexor-pronator muscle group that originates from the medial epicondyle.

The temporal relationship shows that this condition developed concurrently with other left elbow pathology including olecranon bursitis and ulnar nerve inflammation, suggesting a pattern of chronic overuse affecting multiple elbow structures.

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 attributable to medial epicondylitis in December 2021, though the exact onset date within that month is not specified in the available documentation.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to military medical staff on 30 October 2020 with bilateral elbow pain including symptoms consistent with medial epicondylitis.

When was the condition confirmed / formally diagnosed? While the specific diagnosis of medial epicondylitis was not explicitly documented, the clinical presentation and examination findings consistent with this condition were noted on 30 October 2020. Formal imaging confirmation of elbow pathology occurred on 18 November 2020 with MRI.

When did the veteran first present to you (or your practice) for this condition? 24 Apr 2021.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed based on clinical presentation of medial elbow pain worse with gripping activities and resisted wrist flexion, examination findings of tenderness over the medial epicondyle region, and MRI imaging on 18 November 2020 showing inflammatory changes in the elbow. The key symptoms included medial elbow pain, functional limitations with gripping, and pain exacerbated by forearm muscle use consistent with medial epicondylitis.

4. What do you consider to be the cause(s) of the condition in this veteran?

Performing forceful activities with the hand or forearm on the affected side, in combination with repetitive 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 (RH) / 3 months (BOP)

MET. The veteran duties as an Army Medic involved extensive forceful and repetitive activities including patient lifting, medical equipment handling, documentation, and equipment operation requiring sustained hand and forearm use well exceeding the threshold requirements.

Using a hand-held computer mouse on the affected side for at least 20 hours per week in the 6 months (RH) / 1 year (BOP) before the clinical onset of epicondylitis

NOT MET. No evidence of extensive computer mouse use meeting the threshold requirements.

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

NOT MET. No documented sudden alteration of loading pattern within the specified timeframe.

Taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis

NOT MET. No documented fluoroquinolone use within the specified timeframe.

Having spondyloarthritis at the time of the clinical onset of epicondylitis

NOT MET. No documented spondyloarthritis.

Inability to obtain appropriate clinical management for epicondylitis

MET. The condition was not specifically diagnosed or offered targeted treatment for medial epicondylitis, constituting an inability to obtain appropriate clinical management. This has led to persistent symptoms and functional limitations.

Sequelae

This condition is not a sequelae of another known condition but rather represents primary pathology from occupational overuse.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

MET. The specific condition of medial epicondylitis was not diagnosed or offered appropriate targeted management despite clinical presentation consistent with this diagnosis. The Full Federal Court in Brew v Repatriation Commission (20 May 1996) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective senses. The failure to diagnose and provide specific treatment for medial epicondylitis despite suggestive clinical findings represents barriers to appropriate healthcare, satisfying the inability to attain appropriate medical management factor. This has caused permanent worsening through ongoing occupational activities without proper treatment or activity modification.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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