Diagnostic Assessment — Right Elbow - Triceps Tendinopathy
Example 1 of 1 · fictitious patient (Veteran F)
Diagnostic Assessment
RIGHT ELBOW - TRICEPS TENDINOPATHY
Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
ADF History
Name: The veteran
Date of Birth: [withheld]
Occupation: Communications, SASR
Enlistment Date: 17 Dec 1993
Discharge Date: Still Serving
Occupational History
As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran duties involve significant upper extremity demands that place stress on the elbow tendons, including the triceps tendon. His role requires extensive pushing and pulling activities during equipment installation, carrying heavy loads often with the elbows in extension, and performing tactical movements that involve triceps loading. SASR physical training includes push-ups, dips, and other exercises that place repetitive strain on the triceps insertion. The communications specialty often requires working in confined spaces or overhead, positions that can create increased tension on the triceps tendon. These occupational activities represent significant risk factors for the development of triceps tendinopathy, particularly in the dominant arm which typically bears greater load during occupational tasks.
History
The veteran the veteran a Communications specialist with the Australian a specialist regiment, developed right posterior elbow pain localized to the triceps insertion on the olecranon. Clinical evaluation and diagnostic testing have confirmed right triceps tendinopathy.
Timeline
- 16 Mar 2016: Initial presentation with right posterior elbow pain following intensive physical training. Patient reports "pain at the back of the elbow, especially when straightening against resistance".
- 23 Mar 2016: Assessment documented tenderness over the triceps insertion on the olecranon with pain on resisted elbow extension. Clinical diagnosis of triceps tendinopathy.
- 30 Mar 2016: Physical therapy assessment noting posterior elbow pain reproduced with specific loading of the triceps tendon. "Symptoms consistent with triceps tendinopathy".
- 14 Apr 2016: Continued symptoms despite activity modification and initial therapy. "Pain persists with certain occupational activities".
- 28 Apr 2016: Ultrasound of right elbow performed. "Hypoechoic changes and thickening of the triceps tendon at its insertion on the olecranon. No tear identified."
- 11 May 2016: Sports medicine consultation confirming diagnosis. "Right triceps tendinopathy related to repetitive loading during occupational and training activities".
- 25 May 2016: Follow-up noting partial response to targeted eccentric strengthening program. "Improvement noted but symptoms persist with heavy loading".
Symptoms
The veteran presented with pain localized to the posterior aspect of the right elbow, specifically at the triceps insertion on the olecranon. The pain was described as a deep ache that became sharp with activities requiring forceful elbow extension, such as push-ups and certain lifting maneuvers. The pain was most notable during the "lockout" phase of elbow extension against resistance. Physical examination revealed tenderness to palpation directly over the triceps insertion on the olecranon, with pain reproduction during resisted elbow extension. There was no significant swelling, warmth, or crepitus noted. Current symptoms include activity-related pain that worsens with occupational activities involving forceful or repetitive elbow extension, particularly during equipment installation requiring overhead work and during physical training exercises that load the triceps. The symptoms are more severe during intensive field operations and training cycles that require increased upper body loading. Pain typically improves with rest but returns with resumption of aggravating activities, creating functional limitations in his ability to perform certain aspects of his communications role and physical training requirements.
Imaging
28 Apr 2016 - ULTRASOUND RIGHT ELBOW: The triceps tendon shows hypoechoic changes and mild thickening at its insertion on the olecranon process. Increased vascularity is noted on power Doppler imaging at the tendon insertion. No partial or complete tear identified. The olecranon bursa appears normal without significant fluid collection. The common extensor and flexor tendons also demonstrate mild hypoechoic changes consistent with tendinopathy as previously documented. The elbow joint space appears normal without significant effusion. IMPRESSION: Right triceps tendinopathy at the olecranon insertion. Previously documented lateral and medial epicondyle tendinopathy also noted.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Elbow Triceps Tendinopathy (ICD-10 Code: M77.8). This diagnosis falls under the DVA Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015 and Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015.
Triceps tendinopathy refers to a clinical condition characterized by pain and dysfunction at the triceps tendon insertion on the olecranon process of the ulna. Like other tendinopathies, it represents a degenerative process in the tendon rather than active inflammation, with pathological changes including disorganized collagen fibers, increased ground substance, and neovascularization.
The condition typically presents with pain at the posterior aspect of the elbow, particularly during activities that require forceful or repetitive elbow extension against resistance. The pain is usually localized to the triceps insertion on the olecranon and is exacerbated by specific loading of the triceps muscle-tendon unit.
Triceps tendinopathy is less common than lateral or medial epicondyle tendinopathy (tennis or golfer's elbow) but occurs in populations that perform activities requiring forceful or repetitive elbow extension, particularly in overhead positions. Military personnel, especially those in specialized units like SASR who perform extensive upper body loading during both occupational tasks and physical training, are at increased risk for developing this condition.
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 of right triceps tendinopathy on or before 16 Mar 2016, when he initially presented with right posterior elbow pain following intensive physical training. He specifically reported "pain at the back of the elbow, especially when straightening against resistance," which is characteristic of triceps tendinopathy.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented to a health provider for right posterior elbow pain on 16 Mar 2016, when he reported to the ADF Medical Centre following intensive physical training.
When was the condition confirmed / formally diagnosed?
The initial clinical diagnosis of triceps tendinopathy was made on 23 Mar 2016, based on physical examination findings of tenderness over the triceps insertion on the olecranon and pain with resisted elbow extension. Definitive confirmation was provided by ultrasound on 28 Apr 2016, which demonstrated hypoechoic changes and thickening of the triceps tendon at its insertion on the olecranon. The diagnosis was formally established by a sports medicine specialist on 11 May 2016.
When did the veteran first present to you (or your practice) for this condition?
09 December 2017.
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 of Right Elbow Triceps Tendinopathy was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation:
Key symptoms included pain localized to the posterior aspect of the right elbow at the triceps insertion, pain exacerbated by activities requiring forceful elbow extension against resistance, deep ache becoming sharp pain during the "lockout" phase of elbow extension, and activity-related pain that improved with rest but returned with resumption of aggravating activities.
Clinical examination findings included tenderness to palpation directly over the triceps insertion on the olecranon, pain reproduction with resisted elbow extension, absence of significant swelling, warmth, or crepitus, and preserved elbow range of motion.
Diagnostic imaging provided definitive confirmation with Ultrasound of Right Elbow demonstrating hypoechoic changes and mild thickening of the triceps tendon at its insertion on the olecranon, increased vascularity on power Doppler imaging at the tendon insertion, no partial or complete tear identified, normal olecranon bursa without significant fluid collection, and normal elbow joint space without significant effusion.
Specialist opinion from a sports medicine consultation confirmed the diagnosis of right triceps tendinopathy, noting the relationship to repetitive loading during occupational and training activities associated with the veteran role in SASR.
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.
Factors under Statement of Principles concerning tendinopathy and bursitis (Balance of Probabilities) Instrument No. 98 of 2015:
performing repetitive activities, or carrying out activities requiring the application of sustained or repetitive force against resistance, involving the elbow or wrist of the affected side, for an average of at least 20 hours per week for a continuous period of at least the six months before the clinical onset of tendinopathy: MET
- As a Communications specialist in SASR, the veteran duties would routinely involve repetitive activities and application of force against resistance involving the elbows. Specific to triceps tendinopathy, activities would include pushing and pulling during equipment installation, carrying heavy loads with extended arms, performing push-ups and other exercises during physical training, and various tactical movements requiring triceps loading. Given his full-time role and the intensive nature of SASR operations, these activities would easily exceed the minimum requirement of 20 hours per week for at least six months before symptom onset.
having trauma or surgery to the affected tendon or bursa within the three months before the clinical onset of tendinopathy: NOT MET
- No specific trauma or surgery to the triceps tendon documented.
maintaining a specific posture, that has produced symptoms, for at least four hours per day on more days than not, for a continuous period of at least the six months before the clinical onset of tendinopathy: MET
- The communications specialist role often requires prolonged periods working in positions that may load the triceps tendon, such as overhead work or extended arm positions during equipment installation and maintenance. This would likely exceed the four hours per day requirement.
having a disease from specified list: NOT MET
- No evidence of diseases from the specified list.
being treated with fluoroquinolone antibiotics within the 30 days before the clinical onset of tendinopathy: NOT MET
- No documented treatment with fluoroquinolone antibiotics.
having diabetes mellitus at the time of the clinical onset of tendinopathy: NOT MET
- No diagnosis of diabetes mellitus.
inability to obtain appropriate clinical management for tendinopathy: NOT MET
- There is no evidence that appropriate management was unavailable once the condition developed.
Factors under Statement of Principles concerning tendinopathy and bursitis (Reasonable Hypothesis) Instrument No. 97 of 2015:
The factors in the Reasonable Hypothesis SOP are similar to those in the Balance of Probabilities SOP, with some differences in quantitative requirements. For repetitive activities, the RH SOP requires 15 hours per week rather than 20 hours, which would also be MET based on the veteran occupational duties.
The most significant contributing factor to the development of right triceps tendinopathy in this veteran is the repetitive nature of his occupational activities as a Communications specialist in SASR, particularly those involving forceful or sustained elbow extension against resistance. The development of triceps tendinopathy in the right (dominant) arm is consistent with occupational overuse from activities requiring forceful and repetitive elbow extension, with the dominant arm typically bearing greater load during occupational tasks.
Sequelae
There is no indication that the right triceps tendinopathy is a sequela of another condition.
Unintended Consequence
There is no evidence to suggest that the right triceps tendinopathy resulted as an unintended consequence of medical treatment provided by the Commonwealth.
Inability to Attain Appropriate Medical Management
There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his right triceps tendinopathy. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, physical therapy intervention including a targeted eccentric strengthening program, and specialist consultation.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
