Diagnostic Assessment — Right Elbow - Lateral Epicondylitis
Example 1 of 1 · fictitious patient (Veteran ED)
Diagnostic Assessment
Right Elbow - Lateral Epicondylitis
BOP Code: 6 of 2023 (Epicondylitis)
RH Code: 5 of 2023 (Epicondylitis)
ADF History
Veteran ED, date of birth 23 July 1988, Australian Army, Electronics Technician (Corporal), enlisted 14 January 2008, medically discharged 03 March 2022. Operational service: Afghanistan, 05 February 2012 to 30 September 2012 (warlike); Middle East Area of Operations, 10 January 2016 to 15 July 2016 (warlike).
Occupational History
As an electronics technician the veteran installed, maintained and repaired radios, electronic countermeasure systems, antennas and vehicle electronic fit-outs. The work combines forceful use of hand tools, including torque wrenches, spanners, crimping tools, impact drivers and pry bars, with repeated gripping and twisting of the forearm while removing and refitting equipment mounts and connectors in cramped vehicle interiors, often with the arm held in awkward sustained positions.
Fault diagnosis, configuration and maintenance records are done on laptops and workstations with a hand-held mouse for several hours a day. On operations technicians work long shifts at short notice, re-fitting vehicles after damage, lifting equipment of 10 to 25 kilograms and dismantling antenna masts, with limited access to physiotherapy and specialist care.
History
Veteran ED, an electronics technician in the Australian Army, developed right lateral epicondylitis on 18 March 2012 during warlike service in Afghanistan, after weeks of forceful, repetitive tool work and heavy mouse use, an urgent vehicle re-fit, a course of ciprofloxacin and the onset of reactive arthritis. The condition worsened on further warlike service in the Middle East, documented on 22 April 2016, with a partial tear of the common extensor tendon on ultrasound.
Timeline
- 02 Dec 2011 — Pre-deployment medical examination recorded no elbow pain, full range of movement of both elbows and equal grip strength of 46 kg on the right and 43 kg on the left. He was right-hand dominant. From December 2011 he worked on the pre-deployment electronic fit-out of protected vehicles, removing and refitting mounts and torqueing bolts by hand for four to six hours a day, and spent at least four hours a day on diagnostic software with a hand-held mouse in his right hand. "elbows normal, grip 46 kg"
- 08 Mar 2012 — During warlike service in Afghanistan the veteran presented with bloody diarrhoea and fever two days after eating at a partner force facility. Stool culture grew Shigella flexneri. A medical officer prescribed ciprofloxacin 500 mg twice daily for three days, from 08 to 10 March 2012. "Shigella dysentery, ciprofloxacin 500 mg"
- 15 Mar 2012 — The veteran reported a painful swollen left knee and pain under the right heel, with gritty red eyes, one week after the dysentery. A medical officer diagnosed reactive arthritis with left knee synovitis and right Achilles enthesitis, and naproxen was commenced. HLA-B27 later returned positive. "reactive arthritis post-Shigella"
- 16 Mar 2012 — After an improvised explosive device damaged two vehicles, the veteran worked a continuous six-hour shift stripping and refitting electronic countermeasure equipment, carrying 15 kg units and using a heavy impact driver and pry bar with his right hand, about twice the intensity and duration of his usual tasks. His workshop log records the urgent re-fit. "urgent re-fit, six-hour shift"
- 18 Mar 2012 — The veteran presented with pain over the outer right elbow that had begun that morning, worse with gripping tools, turning a spanner and using the mouse. Examination showed tenderness over the right lateral epicondyle and pain on resisted wrist and middle finger extension, with grip strength reduced to 34 kg on the right. A medical officer diagnosed right lateral epicondylitis and advised rest from tool work, but no relief technician was available and physiotherapy was not available at the base. "R lateral epicondylitis, grip 34 kg"
- 15 Oct 2012 — After his return to Australia ultrasound showed thickening and hypoechoic change of the right common extensor tendon origin with neovascularity, consistent with lateral epicondylitis. A physiotherapist recorded a Patient-Rated Tennis Elbow Evaluation score of 38 and began an eccentric loading program. A rheumatologist diagnosed undifferentiated spondyloarthropathy in February 2013 after persisting heel and buttock pain, with sacroiliitis on MRI. "extensor tendinopathy, PRTEE 38"
- 22 Apr 2016 — On warlike service in the Middle East the veteran reported a marked increase in right elbow pain after three months of daily vehicle and antenna maintenance, a course of ciprofloxacin from 09 to 11 April 2016 for dysentery, and five hours dismantling and carrying 20 kg antenna mast sections on 20 April 2016. He could not hold a coffee cup or use a screwdriver. Grip strength was 18 kg on the right. The Patient-Rated Tennis Elbow Evaluation score was 71. "worse R elbow, PRTEE 71"
- 05 Aug 2016 — Ultrasound after his return to Australia showed a 6 mm partial-thickness tear of the right common extensor tendon origin, new since 2012, with increased thickening. A sports physician performed a platelet-rich plasma injection. The elbow did not recover sufficiently for technician duties, and he was medically discharged on 03 March 2022. "partial-thickness tear, 6 mm"
Symptoms
At onset the veteran had pain over the outer right elbow, worse with gripping, lifting, turning spanners and screwdrivers, and using a mouse, with tenderness over the bony point of the outer elbow and weakness of grip. In the months after onset the pain spread into the back of the forearm and persisted at rest after heavy days, with morning stiffness.
After the 2016 worsening he could not hold a cup or a screwdriver without pain and had night pain. He now reports daily right elbow pain, weak grip, difficulty carrying shopping bags, opening jars and using tools, and pain after more than 30 minutes of keyboard and mouse use.
Imaging
- 18 Mar 2012 — X-ray right elbow: "No fracture, calcification or joint abnormality."
- 15 Oct 2012 — Ultrasound right elbow: "Thickened hypoechoic common extensor tendon origin with neovascularity at the lateral epicondyle. No tear."
- 05 Aug 2016 — Ultrasound right elbow: "6 mm partial-thickness tear of the deep fibres of the common extensor tendon origin, with increased tendon thickening and neovascularity compared with 15 October 2012."
Onset Date
The most likely date of onset of this condition is 18 Mar 2012.
At that date the veteran was on warlike service in Afghanistan as an electronics technician maintaining electronic countermeasure systems on protected vehicles. Two days earlier he had worked a six-hour urgent re-fit after an improvised explosive device strike, he had finished a course of ciprofloxacin eight days earlier, and he had developed reactive arthritis three days earlier. Pain over the outer right elbow began on the morning of 18 March 2012.
This date is appropriate because his pre-deployment examination of 02 Dec 2011 recorded normal elbows and equal grip strength, and he presented on 18 Mar 2012 with lateral epicondylar tenderness, pain on resisted wrist extension and reduced grip strength, with the diagnosis confirmed on ultrasound on 15 Oct 2012.
For the forceful activity factors, the 4 weeks before onset run from 19 Feb 2012 to 18 Mar 2012, and the 3 months before onset run from 18 Dec 2011 to 18 Mar 2012. Throughout both periods he performed forceful, repetitive and sustained tool work with his right hand for four to six hours a day, in Australia on pre-deployment vehicle fit-outs until early February 2012 and then in Afghanistan. For the mouse factors, the 6 months before onset run from 18 Sep 2011 to 18 Mar 2012 and the 1 year before onset from 18 Mar 2011 to 18 Mar 2012; in each period he used a hand-held mouse in his right hand for at least 20 hours a week. The sudden alteration of loading occurred on 16 Mar 2012, within the 3 days before onset (15 Mar to 18 Mar 2012). The ciprofloxacin course of 08 to 10 Mar 2012 fell within the 14 days before onset (04 Mar to 18 Mar 2012). Reactive arthritis, diagnosed on 15 Mar 2012, was present on 18 Mar 2012.
For the worsening factors, the documented worsening was on 22 Apr 2016 in the Middle East. The 4 weeks before the worsening run from 25 Mar 2016 to 22 Apr 2016 and the 3 months before from 22 Jan 2016 to 22 Apr 2016, during which he performed daily forceful tool work. The 6 months before the worsening run from 22 Oct 2015 to 22 Apr 2016 and the 1 year before from 22 Apr 2015 to 22 Apr 2016, with mouse use of at least 20 hours a week throughout. The antenna mast dismantling on 20 Apr 2016 fell within the 3 days before the worsening, the ciprofloxacin of 09 to 11 Apr 2016 within the 14 days before (08 Apr to 22 Apr 2016), and the undifferentiated spondyloarthropathy diagnosed in February 2013 was present at the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Elbow - Lateral Epicondylitis (ICD-10-AM M77.1), with a partial-thickness tear of the common extensor tendon origin from 2016, under the Statements of Principles concerning epicondylitis, Balance of Probabilities No. 6 of 2023 and Reasonable Hypothesis No. 5 of 2023.
Lateral epicondylitis, also called tennis elbow or lateral elbow tendinopathy, is a painful degenerative and inflammatory disorder of the tendons that attach the wrist and finger extensor muscles to the lateral epicondyle, the bony point on the outer side of the elbow. It is caused mainly by forceful and repetitive or sustained gripping, twisting and wrist extension, such as using hand tools, and is also associated with prolonged mouse use, sudden increases in hand-intensive work, fluoroquinolone antibiotics and inflammatory spondyloarthritis affecting tendon attachments. It presents with pain over the outer elbow, worse with gripping and lifting, tenderness over the epicondyle, pain on resisted wrist extension and weak grip. Continued loading can lead to tendon tearing and chronic pain.
The condition began on warlike service in Afghanistan on 18 March 2012 after forceful tool work, heavy mouse use, an urgent re-fit, ciprofloxacin and reactive arthritis, and worsened with a partial tendon tear after similar exposures on warlike service in the Middle East in 2016.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 March 2012.
When did the veteran first present to a health / medical provider for this condition?
18 March 2012.
When was the condition confirmed / formally diagnosed?
18 March 2012.
When did the veteran first present to you (or your practice) for this condition?
14 October 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by a medical officer on 18 March 2012 on the basis of pain over the right lateral epicondyle, local tenderness, pain on resisted wrist and middle finger extension and reduced grip strength, with a normal elbow radiograph. This meets the Statement of Principles definition of epicondylitis: a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the lateral epicondyle of the elbow. Ultrasound on 15 October 2012 confirmed thickening, hypoechoic change and neovascularity of the common extensor tendon origin.
The worsening was documented clinically on 22 April 2016, with grip strength falling from 34 kg to 18 kg and the Patient-Rated Tennis Elbow Evaluation score rising from 38 to 71, and was confirmed by ultrasound on 05 August 2016, which showed a new 6 mm partial-thickness tear of the common extensor tendon origin.
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.
Legislation: the clinical onset of this condition was on 18 March 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2012, where the condition began, and in the Middle East in 2016, where it worsened. The Balance of Probabilities instrument applies to peacetime service, including his pre-deployment fit-out work and mouse use in Australia in the months before onset and before the worsening.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Epicondylitis, No. 6 of 2023
Causative factors
Factor 9(1): performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained 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
- From December 2011 the veteran worked on the pre-deployment electronic fit-out of protected vehicles in Australia, and then from February 2012 on the same work in Afghanistan, removing and refitting equipment mounts, torqueing bolts and crimping connectors with his right hand for four to six hours a day on most days. This forceful work combined repetitive twisting of the forearm with sustained gripping in awkward positions. It continued throughout the 3 months before onset, from 18 December 2011 to 18 March 2012, as a requirement of his duties.
Factor 9(2): using a hand-held computer mouse on the affected side for at least 20 hours per week in the 1 year before the clinical onset of epicondylitis; — MET
- From his posting to a technical workshop in January 2011 the veteran spent at least four to five hours a working day on diagnostic and configuration software and maintenance records with a hand-held mouse in his right hand, at least 20 to 25 hours a week. This continued throughout the year before onset, from 18 March 2011 to 18 March 2012, as part of his duties.
Factor 9(3): taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis; — MET
- A Defence medical officer prescribed ciprofloxacin 500 mg twice daily from 08 to 10 March 2012 for Shigella dysentery contracted on service, eight to ten days before onset on 18 March 2012 and within the 14 days before onset, from 04 March to 18 March 2012.
Factor 9(4): having spondyloarthritis at the time of the clinical onset of epicondylitis; — MET
- Reactive arthritis, one of the forms of spondyloarthritis in the Statement of Principles definition, was diagnosed on 15 March 2012 following Shigella dysentery contracted on service, with left knee synovitis, right Achilles enthesitis and conjunctivitis, and HLA-B27 was positive. It was present at onset on 18 March 2012, and inflammation at tendon attachments is a feature of the disorder.
Worsening factors
Factor 9(5): performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained 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
- From 22 January 2016 to 22 April 2016 the veteran performed daily vehicle electronic maintenance and antenna installation, using spanners, torque wrenches and crimping tools with his right hand for at least three to five hours a day on most days, combining forceful work with repetitive and sustained forearm activity. This continued throughout the 3 months before the documented worsening on 22 April 2016.
Factor 9(6): using a hand-held computer mouse on the affected side for at least 20 hours per week in the 1 year before the clinical worsening of epicondylitis; — MET
- From 22 April 2015 to 22 April 2016, in his garrison workshop and then on deployment, the veteran used a hand-held mouse in his right hand for at least 20 hours a week on diagnostic software and maintenance records. He did not have access to an alternative mouse or a left-handed workstation.
Factor 9(7): taking a fluoroquinolone antibiotic within the 14 days before the clinical worsening of epicondylitis; — MET
- The veteran took ciprofloxacin 750 mg twice daily from 09 to 11 April 2016, prescribed by a Defence medical officer for dysentery, within the 14 days before the worsening on 22 April 2016, from 08 April to 22 April 2016.
Factor 9(8): having spondyloarthritis at the time of the clinical worsening of epicondylitis; — MET
- A rheumatologist diagnosed undifferentiated spondyloarthropathy in February 2013, after the reactive arthritis of March 2012 failed to resolve, with sacroiliitis on MRI and recurrent heel enthesitis. It was active, with raised inflammatory markers, at the worsening on 22 April 2016.
Factor 9(9): inability to obtain appropriate clinical management for epicondylitis. — MET
- After onset the medical officer advised rest from tool work, but no relief technician was available and physiotherapy was not available at his base in Afghanistan, so he continued forceful tool work and mouse use for six months without treatment. Physiotherapy did not begin until October 2012. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management, and his condition became established and later worsened with a tendon tear.
Reasonable Hypothesis — Statement of Principles concerning Epicondylitis, No. 5 of 2023
Causative factors
Factor 9(1): performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained 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; — MET
- On warlike service in Afghanistan from 05 February 2012 the veteran fitted and repaired electronic countermeasure equipment on protected vehicles for four to six hours a day, every day, gripping and twisting spanners, torque wrenches and pry bars with his right hand and holding equipment in sustained awkward positions. This continued throughout the 4 weeks before onset, from 19 February 2012 to 18 March 2012.
Factor 9(2): using a hand-held computer mouse on the affected side for at least 20 hours per week in the 6 months before the clinical onset of epicondylitis; — MET
- Throughout the 6 months before onset, from 18 September 2011 to 18 March 2012, the veteran used a hand-held mouse in his right hand for at least 20 hours a week, in Australia and then on warlike service in Afghanistan, where he logged faults and configured equipment on a laptop in the workshop at the end of each shift.
Factor 9(3): 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; — MET
- On 16 March 2012, two days before onset, the veteran worked a continuous six-hour shift on warlike service in Afghanistan stripping and refitting electronic countermeasure equipment on two vehicles damaged by an improvised explosive device, carrying 15 kg units and using a heavy impact driver and pry bar with his right hand. This more than doubled the intensity and duration of his forceful hand activity, at an exertion of well over 5 METs, as recorded in his workshop log.
Factor 9(4): taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis; — MET
- On warlike service in Afghanistan the veteran took ciprofloxacin 500 mg twice daily from 08 to 10 March 2012 for Shigella dysentery acquired from food at a partner force facility, within the 14 days before onset on 18 March 2012.
Factor 9(5): having spondyloarthritis at the time of the clinical onset of epicondylitis; — MET
- Reactive arthritis following Shigella dysentery contracted on warlike service in Afghanistan was diagnosed on 15 March 2012, with knee synovitis and heel enthesitis, and was present at onset on 18 March 2012.
Worsening factors
Factor 9(6): performing forceful activities with the hand or forearm on the affected side, in combination with: (a) repetitive activities with the hand or forearm on the affected side; or (b) sustained 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 worsening of epicondylitis; — MET
- On warlike service in the Middle East the veteran performed forceful, repetitive and sustained tool work with his right hand for three to five hours a day on most days, maintaining vehicle electronics and antennas, throughout the 4 weeks before the worsening, from 25 March 2016 to 22 April 2016.
Factor 9(7): using a hand-held computer mouse on the affected side for at least 20 hours per week in the 6 months before the clinical worsening of epicondylitis; — MET
- From 22 October 2015 to 22 April 2016, including his warlike service in the Middle East from 10 January 2016, the veteran used a hand-held mouse in his right hand for at least 20 hours a week on diagnostic software and maintenance records.
Factor 9(8): 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 worsening of epicondylitis; — MET
- On 20 April 2016, two days before the worsening, the veteran spent five continuous hours on warlike service dismantling antenna masts for a site relocation, undoing seized fittings with large spanners and carrying 20 kg mast sections, more than doubling his usual forceful hand activity at an intensity above 5 METs.
Factor 9(9): taking a fluoroquinolone antibiotic within the 14 days before the clinical worsening of epicondylitis; — MET
- On warlike service in the Middle East the veteran took ciprofloxacin 750 mg twice daily from 09 to 11 April 2016 for dysentery, within the 14 days before the worsening on 22 April 2016.
Factor 9(10): having spondyloarthritis at the time of the clinical worsening of epicondylitis; — MET
- Undifferentiated spondyloarthropathy, which evolved from the reactive arthritis that followed dysentery on warlike service in Afghanistan in 2012, was active at the worsening on 22 April 2016.
Factor 9(11): inability to obtain appropriate clinical management for epicondylitis. — MET
- On warlike service in Afghanistan in 2012 no physiotherapy was available and no relief technician could be provided, so the veteran continued forceful tool work after diagnosis. On warlike service in the Middle East in 2016, after the worsening of 22 April 2016, ultrasound and specialist care were not available until his return in July 2016, and he continued maintenance duties for almost three months. Under Brew v Repatriation Commission (1999), these operational circumstances amount to an inability to obtain appropriate clinical management, and the 6 mm partial-thickness tear found on 05 August 2016 developed during this period.
The % contribution of the causes is 100% and significant.
Sequelae
The lateral epicondylitis has progressed to a partial-thickness tear of the common extensor tendon origin, with chronic right elbow pain and reduced grip strength. The veteran has also developed overuse pain in the left forearm from compensating with his non-dominant hand. Each of these is a sequela of the accepted condition and may be claimed in its own right.
Unintended Consequence
Met. The ciprofloxacin prescribed by Defence medical officers in March 2012 and April 2016 is recognised to cause tendinopathy and contributed to the onset and worsening of the epicondylitis. This is an unintended consequence of treatment provided by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After diagnosis on warlike service in Afghanistan on 18 March 2012, the veteran was advised to rest from tool work, but no relief technician was available and there was no physiotherapy at his base, so he continued forceful tool work and heavy mouse use for six months untreated. After the worsening on warlike service in the Middle East on 22 April 2016, ultrasound and specialist care were not available until his return in July 2016, and a partial-thickness tendon tear was found on 05 August 2016. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his operational service prevented him from obtaining the rest and treatment that were clinically appropriate, and that inability contributed to the persistence and worsening of his lateral epicondylitis.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 02 Dec 2011, Pre-deployment medical examination, Medical Officer
- 08 Mar 2012, Treatment record and stool culture report, Medical Officer, Afghanistan
- 15 Mar 2012, Treatment record, reactive arthritis, Medical Officer, Afghanistan
- 16 Mar 2012, Workshop log, urgent vehicle re-fit, Technical workshop, Afghanistan
- 18 Mar 2012, Treatment record and X-ray report, Medical Officer, Afghanistan
- 15 Oct 2012, Ultrasound report and physiotherapy assessment, Radiologist and Physiotherapist
- 14 Feb 2013, Specialist consultation and MRI sacroiliac joints, Rheumatologist
- 09 Apr 2016, Treatment record, dysentery, Medical Officer, Middle East
- 22 Apr 2016, Treatment record, worsening right elbow, Medical Officer, Middle East
- 05 Aug 2016, Ultrasound report and specialist consultation, Radiologist and Sports physician
- Statement of Principles concerning Epicondylitis (Balance of Probabilities) No. 6 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Epicondylitis (Reasonable Hypothesis) No. 5 of 2023, Repatriation Medical Authority
