Diagnostic Assessment — Left Elbow - Ulnar Neuropraxia
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Elbow — Ulnar Neuropraxia BOP Code: 66 of 2017 (Ulnar Neuropathy at the Elbow) RH Code: 65 of 2017 (Ulnar Neuropathy at the Elbow)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Combat Engineer from 25 November 1980 to 11 September 1987
Occupational History
As a Combat Engineer at a field engineer regiment, the veteran was required to participate in physical training activities including athletics events such as shotput throwing.
Shotput involves forceful throwing movements that can place significant traction and compressive forces on the ulnar nerve at the elbow, particularly in the cubital tunnel
History
The veteran sustained a left ulnar nerve neuropraxia at the elbow during training at a field engineer regiment about 24 June 1981, after putting the shot with his left (dominant) hand; weakness of the left hand began the following day.
The injury caused significant motor compromise with documented loss of flexion of digits 3, 4, and 5, loss of abductor digiti minimi, and loss of interossei and lumbricales 3, 4, and 5 — indicating a significant ulnar nerve motor deficit.
He was referred to the Physiotherapy Department at RGHH (Repatriation General Hospital Hollywood) from a field engineer regiment and was treated with a below-elbow splint with MCP joints in flexion and active stretching exercises.
Sensation had fully returned by 13 July 1981, but the medical officer recorded persisting weakness of the interossei that day; he was discharged from physiotherapy on 22 July 1981 because the Navy was transferring him interstate, and no recovery of motor function was recorded
Timeline
24 Jun 1981 — Combat Engineer the veteran, as a young adult, put the shot with his left (dominant) hand at a field engineer regiment; the following day he developed weakness of the left hand, followed by numbness and pins and needles over the medial (ulnar) half of the hand and forearm.
The Daily Medical Record of 1 July 1981 dates the shot put to one week earlier, and the physiotherapy referral of 3 July 1981 to nine days earlier. "Tingling and numbness" 03 Jul 1981 — Referred to the Physiotherapy Department at RGHH from a field engineer regiment.
Examination documented significant ulnar nerve motor deficit: loss of flexion of digits 3, 4, and 5, loss of abductor digiti minimi, and loss of interossei and lumbricales 3, 4, and 5.
A below-elbow splint with MCP joints in flexion was applied and active stretching exercises were commenced. "Ulnar nerve motor deficit" 07 Jul 1981 — The splint was rubbing and was reshaped.
Increasing sensation was noted in the previously affected area, indicating early nerve recovery. "Increasing sensation" 13 Jul 1981 — Full feeling had returned in the hand.
Active assisted exercises were continued. "Full feeling in hand" 22 Jul 1981 — Discharged from physiotherapy because of his transfer interstate by the Navy.
Sensation had fully returned, but persisting weakness of the interossei had been recorded on 13 July 1981 and no recovery of motor function was documented. "Transfer of Pt interstate by Navy" 18 May 2021 — Professor Panegyres' neurology examination documented mild weakness of ulnar innervated muscles of the left hand without atrophy.
Tinel sign was negative at the wrists and elbows.
This finding, 40 years after the original injury, may represent a late sequela of the in-service ulnar neuropraxia. "Mild weakness ulnar innervated muscles"
Symptoms
At the time of injury, the veteran experienced tingling, numbness, and pins and needles over the medial (ulnar) half of the left hand and forearm, with significant motor deficit affecting digit flexion and intrinsic hand muscle function.
Sensation recovered fully within about three weeks, but weakness of the interossei persisted on 13 July 1981.
Current examination by Professor Panegyres in May 2021 demonstrated mild persistent weakness of ulnar innervated muscles of the left hand without atrophy, which may represent incomplete recovery or a late sequela of the original neuropraxia
Imaging
30 Jun 1981 — X-ray right elbow and wrist for right ulnar nerve lesion (the request and report name the right side, although the clinical records describe a left ulnar nerve lesion).
No bone or joint injury demonstrated.
Ulna groove views or CT scanning suggested.
No specific imaging of the left elbow was performed
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Ulnar Nerve Neuropraxia at the Elbow (ICD-10: G56.21).
The relevant Statements of Principles are those concerning Ulnar Neuropathy at the Elbow (Balance of Probabilities No.
66 of 2017; Reasonable Hypothesis No.
65 of 2017), applied by analogy as this is a DRCA claim.
Neuropraxia is the mildest form of peripheral nerve injury, characterised by a transient conduction block without axonal disruption.
Ulnar neuropraxia at the elbow (cubital tunnel syndrome) involves compression or stretching of the ulnar nerve as it passes through the cubital tunnel behind the medial epicondyle of the elbow.
Shotput throwing involves forceful extension and valgus loading of the elbow, which can stretch or compress the ulnar nerve in this anatomical location.
The clinical presentation with significant motor loss (flexor digitorum profundus to digits 3- 5, interossei, lumbricals 3-5, abductor digiti minimi) followed by full recovery of sensation within three weeks is consistent with a neuropraxic injury
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? About 24 June 1981 (one week before the Daily Medical Record of 1 July 1981 and nine days before the physiotherapy referral of 3 July 1981) [ [CHART REVIEW document], pages 87, 162] When did the veteran first present to a health / medical provider for this condition? 3 July 1981 When was the condition confirmed / formally diagnosed? 3 July 1981 When did the veteran first present to you (or your practice) for this condition? 7 April 2022
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the physiotherapy department at RGHH.
The key symptoms were tingling, numbness, and pins and needles over the ulnar distribution of the left hand and forearm following shotput throwing.
The key signs were documented loss of motor function in ulnar nerve-innervated muscles (flexion of digits 3, 4, and 5; abductor digiti minimi; interossei and lumbricales 3, 4, and 5).
The full return of sensation within three weeks with splinting and exercises supports the neuropraxic (rather than axonotmetic or neurotmetic) nature of the injury, although weakness of the interossei persisted on 13 July 1981 [ [CHART REVIEW document], pages 86, 87, 162].
No nerve conduction study was performed
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 22 February 2001 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The SOP definition requires electrodiagnostic evidence of impaired ulnar nerve conduction across the elbow; no nerve conduction study is recorded, and the diagnosis rests on the 1981 clinical findings of ulnar sensory loss and weakness of ulnar-innervated muscles including flexor carpi ulnaris, which localises the lesion to the elbow.
The SOP is therefore applied by analogy under the DRCA.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Ulnar Neuropathy at the Elbow, No.
66 of 2017) Factor 9(1): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No fracture of the left elbow is recorded at any time; the X-ray requested for the ulnar nerve lesion on 30 June 1981 was of the right elbow and wrist and showed no bone or joint injury, and the left elbow was not imaged.
Factor 9(2): having trauma to the affected elbow within the one year before the clinical onset of ulnar neuropathy at the elbow — MET - The shot put with the veteran's left (dominant) hand during recruit training at a field engineer regiment, dated in the Daily Medical Record of 1 July 1981 to about one week earlier, was a discrete event applying significant force through the left elbow.
Weakness of the left hand developed the next day and progressed to numbness and paraesthesia; the Navy medical officers diagnosed neuropraxia of the ulnar nerve at the elbow, with weakness including flexor carpi ulnaris, and the deficit lasted well beyond seven days, with splinting and physiotherapy to 22 July 1981.
Elbow pain, tenderness and movement were not specifically recorded because the notes addressed the nerve deficit; applied by analogy, this trauma occurred the day before the clinical onset, within one year.
Factor 9(3): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — MET - At the onset the veteran, as a young adult, was a full-time Combat Engineer at a field engineer regiment, where his recorded activities included doubling, parade, rugby (injuries on 29 April, about 7 July and 25 April 1981) and the shot put, thrown with his dominant left arm the day before onset.
Estimating conservatively from that training, physical training, contact sport, throwing and carrying kit and stores heavier than 10 kg involved repetitive and forceful flexion and extension of the left elbow for at least 1.5 hours on each of five training days a week, about 97 hours in the 13 weeks before onset.
These activities continued to the day before onset, so they had not ceased more than 30 days before it.
Factor 9(4): having a surgical procedure under general anaesthesia, within the one month before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No surgical procedure under general anaesthesia is recorded in the month before the onset; his only earlier operation, a left knee arthroscopy on 30 September 1980, was months before.
Factor 9(5): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran has never had surgery to the left elbow, including elbow arthroscopy.
Factor 9(6): being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No hospitalisation or confinement to bed is recorded in the weeks before the onset; his viral illness of 2 June 1981 was treated as an outpatient.
Factor 9(7): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record that the veteran has ever used a manual wheelchair, and nothing in his history suggests it.
Factor 9(8): having paraplegia at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of paraplegia; at the onset he was an adult recruit in full physical training.
Factor 9(9): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record that he used elbow or forearm crutches in the three months before the onset, and nothing in his recruit training history suggests it.
Factor 9(10): having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran was 16 at the onset, and no inflammatory or degenerative joint disease of the left elbow from the specified list has ever been recorded.
Factor 9(11): having amyloidosis at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of amyloidosis, and nothing in his history suggests it.
Factor 9(12): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran had no cerebrovascular accident or hemiplegia before the onset, when he was an adult recruit.
Factor 9(13): having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No burn to the left arm, and no burn requiring hospitalisation, is recorded in the two years before the onset; his recorded burns all came later.
Factor 9(14): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of an infection involving the left ulnar nerve, such as leprosy or tuberculosis, and nothing in his history suggests it.
Factor 9(15): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - No lesion compressing or displacing the left ulnar nerve at the elbow was recorded; the left elbow was not imaged, and the return of sensation within three weeks is against a compressive lesion.
Factor 9(16): having acromegaly before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of acromegaly, and nothing in his history suggests it.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Ulnar Neuropathy at the Elbow, No.
65 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No fracture of the left elbow is recorded; the X-ray of 30 June 1981, requested for the ulnar nerve lesion, was of the right elbow and wrist and showed no bone or joint injury.
Factor 9(2): having trauma to the affected elbow within the two years before the clinical onset of ulnar neuropathy at the elbow — MET - The shot put with the veteran's left (dominant) hand at a field engineer regiment, about one week before the Daily Medical Record of 1 July 1981, was a discrete event applying significant force through the left elbow.
Weakness followed the next day and progressed to ulnar sensory loss and weakness localised to the elbow, lasting well beyond seven days and treated with splinting and physiotherapy to 22 July 1981.
Elbow pain and movement were not specifically recorded, but applied by analogy this trauma occurred the day before the clinical onset, within two years.
Factor 9(3): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — MET - At the onset the veteran, as a young adult, was a full-time Combat Engineer at a field engineer regiment, where his recorded activities included rugby (injuries on 29 April, about 7 July and 25 April 1981) and the shot put with his dominant left arm the day before onset.
On a conservative estimate from that training, physical training, contact sport, throwing and carrying loads heavier than 10 kg involved repetitive and forceful flexion and extension of the left elbow for at least one hour on each of five training days a week, more than 110 hours in the six months before onset, continuing to the day before it.
Factor 9(4): holding a tool, device or instrument in position, with the wrist in an extended position and the affected elbow in a flexed position: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record, and no reasonable basis to infer, that his recruit training required him to hold a tool, device or instrument with the left wrist extended and the elbow flexed for 90 hours in the six months before onset.
Factor 9(5): using the affected elbow as a support in a posture that is required as part of the activity being performed: (a) with the forearm pronated on a hard surface, or holding the arm with the elbow flexed by 30° or more; and (b) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (c) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No duty requiring him to support himself on the left elbow is recorded before the onset; the possible leaning on the elbow during a three-hour telephone call, noted on 1 July 1981, was brief, personal and after the onset of weakness.
Factor 9(6): having a surgical procedure under general anaesthesia, within the two months before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No surgical procedure under general anaesthesia is recorded in the two months before the onset; his left knee arthroscopy on 30 September 1980 was months earlier.
Factor 9(7): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the one year before the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran has never had surgery to the left elbow, including elbow arthroscopy.
Factor 9(8): being hospitalised, or confined to bed in a supine position, for at least two days within the 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No hospitalisation or confinement to bed is recorded in the 30 days before the onset; his viral illness of 2 June 1981 was treated as an outpatient.
Factor 9(9): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record that the veteran has ever used a manual wheelchair, and nothing in his history suggests it.
Factor 9(10): having paraplegia at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of paraplegia; at the onset he was an adult recruit in full physical training.
Factor 9(11): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical onset of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record that he used elbow or forearm crutches in the six months before the onset, and nothing in his recruit training history suggests it.
Factor 9(12): having an inflammatory or degenerative joint disease from the specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran was 16 at the onset, and no inflammatory or degenerative joint disease of the left elbow from the specified list has been recorded.
Factor 9(13): having amyloidosis at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of amyloidosis, and nothing in his history suggests it.
Factor 9(14): having haemodialysis or peritoneal dialysis for at least the one year before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of renal disease, haemodialysis or peritoneal dialysis at any time.
Factor 9(15): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical onset of ulnar neuropathy at the elbow — NOT MET - the veteran had no cerebrovascular accident or hemiplegia before the onset, at the age of 16.
Factor 9(16): having an external burn to the affected arm requiring hospitalisation, within the five years before the clinical onset of ulnar neuropathy at the elbow — NOT MET - No burn to the left arm, and no burn requiring hospitalisation, is recorded in the five years before the onset; his recorded burns all came later.
Factor 9(17): being pregnant within the three months before the clinical onset of ulnar neuropathy at the elbow — NOT MET - This factor cannot apply to the veteran, who is male.
Factor 9(18): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of an infection involving the left ulnar nerve, such as leprosy or tuberculosis, and nothing in his history suggests it.
Factor 9(19): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ulnar neuropathy at the elbow, and: (a) smoking commenced at least five years before the clinical onset of ulnar neuropathy at the elbow; and (b) where smoking has ceased, the clinical onset of ulnar neuropathy at the elbow has occurred within five years of cessation — NOT MET - the veteran was 16 at the onset; ten pack-years with smoking begun at least five years earlier, by about the age of 11, is not supported by any record, his only in-service record being about five cigarettes a day in April 1987.
Factor 9(20): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - No lesion compressing or displacing the left ulnar nerve at the elbow was recorded; the left elbow was not imaged, and the return of sensation within three weeks is against a compressive lesion.
Factor 9(21): having diabetes mellitus at the time of the clinical onset of ulnar neuropathy at the elbow — NOT MET - His diabetes mellitus was diagnosed in 2017, about 36 years after the onset, and urinalysis during his service was normal.
Factor 9(22): having acromegaly before the clinical onset of ulnar neuropathy at the elbow — NOT MET - There is no record of acromegaly, and nothing in his history suggests it.
Other Plausible Links to Service Independently of the SOP, the neuropraxia arose out of, and in the course of, the veteran's employment as a member.
He was an adult Combat Engineer in full-time training at a field engineer regiment when he put the shot with his dominant left arm, about one week before the Daily Medical Record of 1 July 1981, and weakness of the left hand followed the next day.
The injury was diagnosed and managed by Navy medical officers, with light duties, splinting and physiotherapy at the Repatriation General Hospital Hollywood on Navy referral; under the DRCA it is an injury arising out of, or in the course of, his service, and liability does not depend on the SOP.
The deficit did not fully resolve under service care.
The medical officer recorded persisting weakness of the interossei on 13 July 1981, and physiotherapy ended on 22 July 1981 not on recovery of strength but because the Navy was transferring him interstate; there was no later follow-up, no nerve conduction study, and the only imaging, on 30 June 1981, was of the right elbow and wrist.
The mild weakness of the left ulnar-innervated muscles found on neurological examination on 18 May 2021 is consistent with a residual deficit, a sequela of the in-service injury.
Conclusion the veteran's left ulnar neuropathy at the elbow was caused by the forceful shot put with his dominant left arm during full-time recruit training at a field engineer regiment in about late June 1981, against a background of repetitive and forceful upper-limb training; these meet the trauma and repetitive-activity onset factors by analogy, and the condition is an injury arising out of, and in the course of, his service.
Its management was cut short when physiotherapy ended with his interstate transfer despite persisting weakness, and the mild residual left ulnar weakness found in May 2021 is consistent with a sequela of that injury, to which his diabetes (diagnosed in 2017, a post-service factor) may have contributed in later life.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left ulnar neuropathy at the elbow is found not to have arisen out of his service, the following factors address whether events after its clinical onset (about 24 June 1981), including his remaining six years of naval service, aggravated it or contributed to it in a material degree.
The only documented worsening is the left-hand weakness he reported in 2021, when mild weakness of the left ulnar-innervated muscles was found on neurological examination.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Ulnar Neuropathy at the Elbow, No.
66 of 2017) Factor 9(17): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No fracture of the left elbow is recorded at any time after the onset, including before the only documented worsening, the left-hand weakness reported in 2021.
Factor 9(18): having trauma to the affected elbow within the one year before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No trauma to the left elbow is recorded after the onset or in the year before the left-hand weakness reported in 2021; his workplace injury of September 2013 involved his face and back.
Factor 9(19): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - His later seamanship and survey duties involved such activities, for example lifting steel cables and cable drums in March 1982, but no worsening of the left ulnar nerve was recorded in service, and the weakness reported in 2021 was not preceded by such work within three months, as he has not worked since 2014.
Factor 9(20): having a surgical procedure under general anaesthesia, within the one month before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - Operations under general anaesthesia after the onset, including those on his left thumb from 1983 to 1985, were not followed within one month by any recorded worsening of the left ulnar nerve, and none is recorded in the month before the weakness reported in 2021.
Factor 9(21): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the six months before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - the veteran has never had surgery to the left elbow, including elbow arthroscopy.
Factor 9(22): being hospitalised, or confined to bed in a supine position, for at least two days within the two weeks before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - He was hospitalised for two days or more several times in service, for example on 2 28 July 1983 and 14 8 November 1983, but no worsening of the left ulnar nerve followed within two weeks, and no hospitalisation is recorded before the weakness reported in 2021.
Factor 9(23): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record that the veteran has ever used a manual wheelchair; he walks normally.
Factor 9(24): having paraplegia at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of paraplegia; the self-reported 'spinal stroke' of 2006 resolved completely, and he walks normally.
Factor 9(25): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of three months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No use of elbow or forearm crutches is recorded after the onset, including after his foot operations of 1983 and 1985, or before the weakness reported in 2021.
Factor 9(26): having an inflammatory or degenerative joint disease from the specified list of specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No inflammatory or degenerative disease of the left elbow from the specified list, such as osteoarthritis or gout, has been recorded at any time, including when the left-hand weakness was reported in 2021.
Factor 9(27): having amyloidosis at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of amyloidosis, and nothing in his history suggests it.
Factor 9(28): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No cerebrovascular accident with hemiplegia is recorded; the self-reported 'spinal stroke' of 2006 was not a cerebrovascular accident with hemiplegia and resolved completely.
Factor 9(29): having an external burn to the affected arm requiring hospitalisation, within the two years before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No burn of the left arm requiring hospitalisation preceded a recorded worsening: the burn of 4 April 1983 was to the right hand, and the sunburn and sunstroke admission of 14 September 1984 was followed by no recorded worsening of the nerve within two years.
Factor 9(30): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of an infection involving the left ulnar nerve, such as leprosy or tuberculosis, at any time.
Factor 9(31): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No lesion compressing or displacing the left ulnar nerve at the elbow has been identified; Tinel's sign was negative at both elbows on 18 May 2021, and the left elbow has not been imaged.
Factor 9(32): having acromegaly before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of acromegaly, and nothing in his history suggests it.
Factor 9(33): inability to obtain appropriate clinical management for ulnar neuropathy at the elbow — MET - the veteran did not obtain complete management of the neuropathy: no nerve conduction study was done, the only imaging (30 June 1981) was of the right elbow and wrist rather than the affected left side, and the radiologist's suggested ulnar groove views or CT were not obtained.
The medical officer recorded persisting weakness of the interossei on 13 July 1981, yet physiotherapy ended on 22 July 1981 because the Navy was transferring him interstate, with no later follow-up, and mild left ulnar weakness was found in May 2021.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic; objectively, an adult recruit posted interstate mid-treatment could not secure continuing care.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Ulnar Neuropathy at the Elbow, No.
65 of 2017) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(23): having a fracture of the bones of the affected elbow, including fracture of the medial epicondyle of the humerus, before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No fracture of the left elbow is recorded at any time after the onset, including before the left-hand weakness reported in 2021.
Factor 9(24): having trauma to the affected elbow within the two years before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No trauma to the left elbow is recorded after the onset or in the two years before the left- hand weakness reported in 2021; his workplace injury of September 2013 involved his face and back.
Factor 9(25): performing repetitive and forceful activities involving flexion and extension of the affected elbow: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where the repetitive and forceful activities have not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - His later seamanship and survey duties involved such activities, such as lifting steel cables and cable drums in March 1982, but no worsening of the left ulnar nerve was recorded in service, and no such work preceded the weakness reported in 2021 within six months, as he has not worked since 2014.
Factor 9(26): holding a tool, device or instrument in position, with the wrist in an extended position and the affected elbow in a flexed position: (a) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - His later survey duties involved operating survey equipment and instruments, but no worsening of the left ulnar nerve was recorded in service, and no such activity preceded the weakness reported in 2021, as he has not worked since 2014.
Factor 9(27): using the affected elbow as a support in a posture that is required as part of the activity being performed: (a) with the forearm pronated on a hard surface, or holding the arm with the elbow flexed by 30° or more; and (b) for a cumulative period of at least 90 hours, within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (c) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - The only recorded episode, possible leaning on the elbow during a three-hour personal telephone call noted on 1 July 1981, fell far short of 90 hours and was not a posture required by his duties; no such posture is recorded before the weakness reported in 2021.
Factor 9(28): having a surgical procedure under general anaesthesia, within the two months before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - Operations under general anaesthesia after the onset, including those on his left thumb from 1983 to 1985, were not followed within two months by any recorded worsening of the left ulnar nerve, and none is recorded in the two months before the weakness reported in 2021.
Factor 9(29): having a surgical procedure to the affected elbow, including elbow arthroscopy, within the one year before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - the veteran has never had surgery to the left elbow, including elbow arthroscopy.
Factor 9(30): being hospitalised, or confined to bed in a supine position, for at least two days within the 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - His in-service admissions of two days or more, such as 2 28 July 1983 and 14 8 November 1983, were not followed within 30 days by any recorded worsening of the left ulnar nerve, and no hospitalisation is recorded before the weakness reported in 2021.
Factor 9(31): daily self-propulsion of a manual wheelchair: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record that the veteran has ever used a manual wheelchair; he walks normally.
Factor 9(32): having paraplegia at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of paraplegia; the self-reported 'spinal stroke' of 2006 resolved completely, and he walks normally.
Factor 9(33): using elbow or forearm crutches: (a) for a cumulative period of at least 60 hours within a continuous period of six months before the clinical worsening of ulnar neuropathy at the elbow; and (b) where this activity has not ceased more than 30 days before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No use of elbow or forearm crutches is recorded after the onset, including after his foot operations of 1983 and 1985, or before the weakness reported in 2021.
Factor 9(34): having an inflammatory or degenerative joint disease from the specified list of inflammatory and degenerative joint diseases, involving the affected elbow, at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No inflammatory or degenerative disease of the left elbow from the specified list has been recorded at any time, including when the left-hand weakness was reported in 2021.
Factor 9(35): having amyloidosis at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of amyloidosis, and nothing in his history suggests it.
Factor 9(36): having haemodialysis or peritoneal dialysis for at least the one year before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of renal disease, haemodialysis or peritoneal dialysis at any time.
Factor 9(37): having a cerebrovascular accident with hemiplegia, excluding transient ischaemic attack or transient symptoms with infarction, before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No cerebrovascular accident with hemiplegia is recorded; the self-reported 'spinal stroke' of 2006 was not such an event and resolved completely.
Factor 9(38): having an external burn to the affected arm requiring hospitalisation, within the five years before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No burn of the left arm requiring hospitalisation preceded a recorded worsening: the burn of 4 April 1983 was to the right hand, and the sunburn and sunstroke admission of 14 September 1984 was followed by no recorded worsening of the nerve within five years.
Factor 9(39): being pregnant within the three months before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - This factor cannot apply to the veteran, who is male.
Factor 9(40): having an infection involving the affected ulnar nerve in the region of the elbow at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of an infection involving the left ulnar nerve, such as leprosy or tuberculosis, at any time.
Factor 9(41): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ulnar neuropathy at the elbow, and: (a) smoking commenced at least five years before the clinical worsening of ulnar neuropathy at the elbow; and (b) where smoking has ceased, the clinical worsening of ulnar neuropathy at the elbow has occurred within five years of cessation — NOT MET - Although his self-reported smoking, about 50 cigarettes a day until 2006, exceeds ten pack- years, the only documented worsening, the left-hand weakness reported in 2021, occurred about 15 years after he stopped, outside the five-year limit.
Factor 9(42): having a lesion as specified at the elbow that compresses or displaces the affected ulnar nerve at the time of the clinical worsening of ulnar neuropathy at the elbow — NOT MET - No lesion compressing or displacing the left ulnar nerve at the elbow has been identified; Tinel's sign was negative at both elbows on 18 May 2021, and the left elbow has not been imaged.
Factor 9(43): having diabetes mellitus at the time of the clinical worsening of ulnar neuropathy at the elbow — MET - the veteran's diabetes mellitus, diagnosed in 2017 and treated with Diaformin, was present when he reported weakness of the left hand in the months before the neurological examination of 18 May 2021, which found mild weakness of the left ulnar-innervated muscles without atrophy.
Diabetes is a recognised contributor to ulnar nerve dysfunction, so this factor is met for the later worsening, but on post-service facts that the records do not relate to his service.
Factor 9(44): having acromegaly before the clinical worsening of ulnar neuropathy at the elbow — NOT MET - There is no record of acromegaly, and nothing in his history suggests it.
Factor 9(45): inability to obtain appropriate clinical management for ulnar neuropathy at the elbow — MET - After the injury the veteran did not obtain complete management: no nerve conduction study was done, the only imaging (30 June 1981) was of the right elbow and wrist, not the affected left side, and physiotherapy ended on 22 July 1981 because the Navy was transferring him interstate, although persisting weakness of the interossei had been recorded on 13 July 1981; there was no later follow-up, and mild left ulnar weakness was found in May 2021.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Sequelae
The mild weakness of the ulnar-innervated muscles of the left hand found by Professor Panegyres on 18 May 2021 is consistent with a residual deficit, a sequela of the in- service neuropraxia, which had not fully recovered when physiotherapy ended on 22 July 1981
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
MET.
Physiotherapy ended on 22 July 1981 because the Navy was transferring the veteran interstate, although persisting weakness of the interossei had been recorded on 13 July 1981, and there was no later follow-up.
No nerve conduction study was performed, and the only imaging was of the right elbow and wrist rather than the affected left side.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic
Date of Clinical Onset
Left elbow ulnar neuropraxia is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 24 June 1981 — shotput injury at a field engineer regiment, after which he developed weakness and numbness in the ulnar distribution of the left hand; neuropraxia of the left ulnar nerve was recorded at a field engineer regiment and treated by physiotherapy from 3 July 1981 [ [CHART REVIEW document], pages 87, 162].
The later records, including the neurology review of 18 May 2021, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: approximately 24 June 1981.
This date falls within the veteran's ADF service (25 November 1980 11 September 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
