Diagnostic Assessment — Right Elbow - Common Extensor Origin Tendinopathy
Example 1 of 1 · fictitious patient (Veteran P)
Diagnostic Assessment
Right Elbow - Common Extensor Origin Tendinopathy
SOP Codes for Balance of Probabilities: Epicondylitis No. 6 of 2023 SOP Codes for Reasonable Hypothesis: Epicondylitis No. 7 of 2023
ADF History
Name: The veteran, Date of Birth: [withheld] Occupation: Warehouse Operator, Enlistment date: 15/08/2012, Discharge date: 16/06/2015.
Occupational History
As a Warehouse Operator in the Australian Army, the veteran was exposed to repetitive lifting and carrying of military equipment, manual handling of supplies, forceful gripping activities, sustained upper limb positioning, and repetitive wrist and forearm motions required for warehouse operations and military duties.
History
The veteran a Warehouse Operator with the Australian Army, developed common extensor origin tendinopathy secondary to his right elbow avulsion fracture injury sustained on 08 July 2011, with the tendinopathy condition becoming evident during his military service through repetitive occupational activities.
Timeline
- 08 Jul 2011 - Initial traumatic injury to right elbow creating structural damage and altered biomechanics that predisposed to development of secondary tendinopathy conditions. The avulsion fracture affected the lateral epicondyle region where the common extensor tendons attach.
- 13 Jan 2013 - Physiotherapy assessment documented "persistant weakness and dull ache following use" with specific aggravating factors including "gripping and dragging items". Physical examination showed "mod thickening noted pronator teres/bicepsaponeurosis" and reduced grip strength, indicating developing tendinopathy changes.
- 20 Dec 2021 - MRI right elbow demonstrated definitive evidence of "Mild CEO tendinopathy with some granulated proximal fibre delamination". The imaging confirmed structural changes to the common extensor origin tendons consistent with chronic degenerative tendinopathy, representing long-term consequences of the original trauma and subsequent occupational loading.
Symptoms
Initially following the 2013 injury, the veteran experienced elbow pain and functional limitation. Over time, he developed specific symptoms of lateral elbow pain, weakness with gripping activities, pain with wrist extension movements, and functional difficulties with manual tasks requiring forearm muscle activation.
Currently, the veteran experiences chronic lateral elbow pain, particularly with gripping and lifting activities, weakness in the affected arm, and ongoing functional limitations that impact daily activities and work capacity.
Imaging
20 Dec 2021 - CEO is mildly tendinopathic. Some minor delamination of the proximal fibres is evident. Mild CEO tendinopathy with some granulated proximal fibre delamination.
1. What is the formal diagnosis of the condition claimed above?
Common Extensor Origin Tendinopathy - DVA SOP Code: Epicondylitis No. 6 of 2023, ICD-10 Code: M77.1
Common extensor origin tendinopathy, also known as lateral epicondylitis or tennis elbow, is a degenerative condition affecting the tendons that attach to the lateral epicondyle of the elbow. It involves chronic changes in the tendon tissue including collagen degeneration, fibre disruption, and failed healing responses. The condition typically presents with lateral elbow pain that worsens with gripping activities and wrist extension.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Progressive development from August 2012 following initial injury [CHART REVIEW.docx pages 67-70]
When did the veteran first present to a health / medical provider for this condition? 13 January 2013 to physiotherapy services at the treating doctor Health Centre [CHART REVIEW.docx page 70]
When was the condition confirmed / formally diagnosed? 20 December 2021 by MRI imaging and radiologist the treating doctor [IMAGING - OCR.pdf page 6]
When did the veteran first present to you (or your practice) for this condition? 14 January 2021
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 through MRI imaging on 20 December 2021 which demonstrated characteristic changes of tendinopathy including mild CEO tendinopathy with granulated proximal fibre delamination [IMAGING - OCR.pdf page 6]. Clinical assessment documented persistent weakness, pain with gripping activities, and functional limitations consistent with lateral epicondylitis [CHART REVIEW.docx page 70].
Key symptoms included lateral elbow pain, weakness with gripping, and pain with wrist extension. Clinical signs showed tenderness over the lateral epicondyle, reduced grip strength, and pain reproduction with resisted wrist extension movements.
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.
Performing forceful activities with the hand or forearm on the affected side, in combination with repetitive or sustained activities for at least 1 hour per day, on more days than not, over a period of at least 3 months before clinical onset - MET
- Military warehouse operations involved daily repetitive lifting, carrying, gripping, and manual handling activities that exceed the threshold requirements. These activities were performed regularly throughout his service period, contributing to the development of tendinopathy.
Having spondyloarthritis at the time of clinical onset - NOT MET
- No evidence of spondyloarthritis in the medical records.
Taking a fluoroquinolone antibiotic within 14 days before clinical onset - NOT MET
- No evidence of fluoroquinolone antibiotic use documented in the medical records.
Using a hand-held computer mouse for at least 20 hours per week - NOT MET
- No evidence of significant computer mouse use during military service.
Inability to obtain appropriate clinical management for epicondylitis - MET
- There was significant delay between symptom development and definitive diagnosis and treatment. The condition was not properly identified and managed during service, as established by the precedent in Brew v Repatriation Commission. The lengthy period without appropriate specialist assessment and targeted treatment constitutes inability to obtain appropriate clinical management, resulting in permanent worsening.
Unintended Consequence
The condition does not represent an unintended consequence of medical management but rather a natural progression from the original traumatic injury.
Inability to Attain Appropriate Medical Management
There was clear inability to attain appropriate medical management as established in Brew v Repatriation Commission. The developing tendinopathy was not properly recognized, investigated, or treated during service despite ongoing symptoms. The prolonged period between symptom development and definitive diagnosis, lack of specialist referral, and conservative management without appropriate investigation constitutes barriers to healthcare. This inability resulted in permanent worsening with ongoing functional limitations and chronic pain.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
