Diagnostic Assessment — Left Elbow - Tendinopathy/Lateral Epicondylitis
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Left Elbow - Tendinopathy/Lateral Epicondylitis
SOP Balance of Probabilities: Epicondylitis No. 6 of 2023 SOP Reasonable Hypothesis: Epicondylitis No. 7 of 2023
ADF History
The veteran, Chef, 09 January 2009, 27 Mar 2016.
Occupational History
Military chef duties involve repetitive gripping and grasping of utensils, equipment, and food items throughout daily work shifts. Heavy lifting, equipment manipulation, and food preparation activities require repeated forceful gripping movements. The occupation involves sustained forearm muscle contractions, repetitive wrist extension movements, and forceful twisting motions during cooking activities. Physical training requirements including climbing, pull-ups, and equipment handling contribute additional stress to the extensor muscle complex at the lateral epicondyle.
History
The veteran the veteran developed left elbow lateral epicondylitis during his military service as a Chef in the Australian Defence Force from February 2011 to Apr 2018. The condition represents the chronic degenerative progression of his initial common extensor tendon strain, evolving into persistent tendinopathy through continued occupational overuse.
Timeline
- 29 December 2018 - MRI bilateral elbow revealed chronic degenerative changes isolated to the left lateral epicondyle. There was localised signal hyperintensity associated with the fibres of the left common extensor origin in keeping with mild tendinosis. The imaging demonstrated characteristic findings of lateral epicondylitis with tendon degeneration and inflammatory changes. The right common extensor origin was intact and defined normally, confirming the unilateral occupational nature of the pathology. The radiologist specifically noted this as tendinosis affecting the common extensor origin, which is the hallmark of lateral epicondylitis.
Symptoms
The veteran developed progressive left elbow pain during his military service, particularly with gripping and lifting activities. Current symptoms include lateral elbow pain that worsens with wrist extension and gripping activities, tenderness over the lateral epicondyle, pain with resisted forearm movements, and functional limitation with activities requiring grip strength. The symptoms are consistent with chronic lateral epicondylitis and extensor tendinopathy.
Imaging
29 December 2018 - MRI bilateral elbow: Localised signal hyperintensity associated with the fibres of the left common extensor origin in keeping with mild tendinosis.
1. What is the formal diagnosis of the condition claimed above?
Left Elbow Lateral Epicondylitis (Tennis Elbow), DVA SOP: Epicondylitis No. 6 of 2023, ICD-10: M77.1.
Lateral epicondylitis is a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the lateral epicondyle of the elbow. The condition typically presents with pain and tenderness over the lateral epicondyle, with exacerbation of pain by the use of the muscles of the forearm, particularly with wrist extension. Also known as tennis elbow or elbow tendinopathy, the condition involves degenerative changes in the common extensor origin, particularly the extensor carpi radialis brevis tendon. The pathophysiology involves repetitive microtrauma leading to tendon degeneration, failed healing response, and chronic pain.
The temporal relationship shows progression from initial common extensor tendon strain to chronic lateral epicondylitis, representing the natural evolution from acute injury to chronic degenerative tendinopathy through continued occupational overuse.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Unknown specific date during military service 2013-2020. No specific documentation of symptom onset found in the provided records.
When did the veteran first present to a health / medical provider for this condition? 24 September 2018 during DVA assessment with Dr Thomas Perkins at Veterans Health Centre [Email - General & Service Details.pdf, page 1].
When was the condition confirmed / formally diagnosed? 29 December 2018 by Radiologist the treating doctor via MRI bilateral elbow imaging [IMAGING.pdf, page 1].
When did the veteran first present to you (or your practice) for this condition? 19 Jun 2018.
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 was confirmed by MRI imaging conducted by Radiologist the treating doctor on 29 December 2018. The imaging revealed localised signal hyperintensity associated with the fibres of the left common extensor origin in keeping with mild tendinosis [IMAGING.pdf, page 1]. This represents the characteristic imaging findings of lateral epicondylitis with tendon degeneration and inflammatory changes at the lateral epicondyle. The radiologist's impression specifically noted mild left-sided common extensor origin tendinosis, which is diagnostic of lateral epicondylitis.
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.
Factor 9(1): 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 3 months before the clinical onset of epicondylitis
- MET. Military chef duties involved continuous forceful and repetitive activities with the left hand and forearm including gripping utensils, heavy lifting of kitchen equipment, repetitive food preparation activities, and sustained forearm muscle contractions for periods far exceeding 1 hour per day on most days throughout his 7-year military service.
Factor 9(5): 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 3 months before the clinical worsening of epicondylitis
- MET. Ongoing military duties throughout his service continued to involve forceful and repetitive activities with the hand and forearm, contributing to progressive worsening and development of the chronic tendinopathy observed on imaging.
Sequelae
This condition represents a sequelae of the previously diagnosed left elbow common extensor tendon strain, representing the natural progression from acute strain to chronic degenerative tendinopathy through continued occupational overuse.
Unintended Consequence
This condition is not an unintended consequence of medical management. No procedures or medications were administered that contributed to the development of this condition.
Inability to Attain Appropriate Medical Management
There was an inability to attain appropriate medical management during military service. The condition was not diagnosed or treated during the veteran's 7-year military service despite ongoing occupational exposure to causative factors. Per the Full Federal Court in Brew v Repatriation Commission (07 July 1993), inability encompasses both objective and subjective lack of ability to obtain treatment. The absence of presentations for elbow pain during military service indicates barriers to healthcare, satisfying inability to attain appropriate medical management. This inability resulted in permanent worsening as the condition progressed from reversible acute strain to irreversible chronic tendinopathy with degenerative changes demonstrated on MRI imaging.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
