Reference Determination Content
Suggested draft · fictitious patient
Left Elbow - Medial Epicondylitis
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A gastroenterology and rheumatology consultations by the MRI sacroiliac joints report, Gastroenterologist and Rheumatologist, dated 12 November 2010;
- A pre-deployment health assessment by the medical officer, RAAF base health centre, dated 10 January 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 20 June 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 3 July 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 18 July 2011;
- An ultrasound left elbow report and sports medicine consultation by the sports physician, dated 2 September 2011;
- A rheumatology consultation by the rheumatologist, dated 15 March 2016;
- An outpatient health record by the medical officer, Role 2 facility, Middle East, dated 28 April 2017;
- An outpatient health record and ultrasound report by the medical officer, Role 2 facility, Middle East, dated 9 May 2017;
- An outpatient health record by the medical officer, Role 2 facility, Middle East, dated 22 May 2017;
- An MRI left elbow report and orthopaedic consultation by the orthopaedic surgeon, dated 25 September 2017;
- An operation note by the orthopaedic surgeon, dated 6 March 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
8 January 2008 and 27 September 2022
Left Elbow - Medial Epicondylitis
You have stated that your condition was caused by:
- 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
- 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
- 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
- taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis
- having spondyloarthritis at the time of the clinical onset of epicondylitis
Diagnosis: Medial Epicondylitis
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by an ultrasound left elbow report and sports medicine consultation by the sports physician, dated 2 September 2011.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Epicondylitis (Reasonable Hypothesis) (No. 5 of 2023)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- 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
- 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
- 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
- taking a fluoroquinolone antibiotic within the 14 days before the clinical onset of epicondylitis
- having spondyloarthritis at the time of the clinical onset of epicondylitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with aching and sharp pain over the inner side of the left elbow, radiating into the forearm, worse with gripping, riveting, drilling and using the mouse, with weakness of grip and stiffness after rest.After the 2017 worsening the pain became constant and severe, with night pain and marked loss of grip strength on 18 July 2011.
The diagnosis was confirmed by a sports physician on 2 September 2011 on the clinical findings of tenderness over the left medial epicondyle, pain on resisted wrist flexion and pronation and reduced grip strength, supported by ultrasound showing a thickened, hypoechoic common flexor origin with neovascularity and a normal extensor origin and ulnar nerve. This meets the Statement of Principles definition of epicondylitis as a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the medial or lateral epicondyle of the elbow, which expressly includes medial epicondylitis.
This has then led to further investigations and the diagnosis of your condition of Medial Epicondylitis. I have accepted your condition of Medial Epicondylitis.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 14 July 2011.
Left Elbow - Medial Epicondylitis (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 3 April 2025;
- A gastroenterology and rheumatology consultations by the MRI sacroiliac joints report, Gastroenterologist and Rheumatologist, dated 12 November 2010;
- A pre-deployment health assessment by the medical officer, RAAF base health centre, dated 10 January 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 20 June 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 3 July 2011;
- An outpatient health record by the medical officer, Role 1 health facility, Afghanistan, dated 18 July 2011;
- An ultrasound left elbow report and sports medicine consultation by the sports physician, dated 2 September 2011;
- A rheumatology consultation by the rheumatologist, dated 15 March 2016;
- An outpatient health record by the medical officer, Role 2 facility, Middle East, dated 28 April 2017;
- An outpatient health record and ultrasound report by the medical officer, Role 2 facility, Middle East, dated 9 May 2017;
- An outpatient health record by the medical officer, Role 2 facility, Middle East, dated 22 May 2017;
- An MRI left elbow report and orthopaedic consultation by the orthopaedic surgeon, dated 25 September 2017;
- An operation note by the orthopaedic surgeon, dated 6 March 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
8 January 2008 and 27 September 2022
Left Elbow - Medial Epicondylitis (Worsening)
You have stated that the worsening of your condition was caused by:
- 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
- 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
- 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
- taking a fluoroquinolone antibiotic within the 14 days before the clinical worsening of epicondylitis
- having spondyloarthritis at the time of the clinical worsening of epicondylitis
- inability to obtain appropriate clinical management for epicondylitis
Diagnosis: Medial Epicondylitis (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 3 April 2025, and is supported by an ultrasound left elbow report and sports medicine consultation by the sports physician, dated 2 September 2011.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Epicondylitis (Reasonable Hypothesis) (No. 5 of 2023)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- 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
- 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
- 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
- taking a fluoroquinolone antibiotic within the 14 days before the clinical worsening of epicondylitis
- having spondyloarthritis at the time of the clinical worsening of epicondylitis
- inability to obtain appropriate clinical management for epicondylitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with aching and sharp pain over the inner side of the left elbow, radiating into the forearm, worse with gripping, riveting, drilling and using the mouse, with weakness of grip and stiffness after rest.After the 2017 worsening the pain became constant and severe, with night pain and marked loss of grip strength on 18 July 2011.
The diagnosis was confirmed by a sports physician on 2 September 2011 on the clinical findings of tenderness over the left medial epicondyle, pain on resisted wrist flexion and pronation and reduced grip strength, supported by ultrasound showing a thickened, hypoechoic common flexor origin with neovascularity and a normal extensor origin and ulnar nerve. This meets the Statement of Principles definition of epicondylitis as a clinically symptomatic inflammatory or degenerative disorder of the tendons that attach to the medial or lateral epicondyle of the elbow, which expressly includes medial epicondylitis.
After the condition arose, it was worsened during your service. During warlike service in the Middle East you performed at least an hour a day of forceful, repetitive and sustained left-handed riveting and drilling on more days than not throughout the 4 weeks before the worsening, from 11 April 2017 to 9 May 2017. You used a mouse with your left hand for about 30 hours a week at your home base from November 2016 and about 25 hours a week on warlike service in the Middle East from 5 January 2017, throughout the 6 months before the worsening, from 9 November 2016 to 9 May 2017. On 6 May 2017, during warlike service in the Middle East, you spent seven continuous hours drilling out and re-riveting a damaged wing panel to return an aircraft to operations, more than doubling your usual heavy hand work at well above 5 METs, three days before the worsening. During warlike service in the Middle East you took moxifloxacin from 28 April to 4 May 2017 for pneumonia, within the 14 days before the worsening on 9 May 2017. Enteropathic spondyloarthropathy was present at the worsening on 9 May 2017 during warlike service in the Middle East. On warlike service in Afghanistan in 2011 and in the Middle East in 2017 physiotherapy, injection and specialist care were not available, and operational demands for aircraft repair meant you could not be relieved of riveting and planning work, so the tendon progressed to a partial tear before treatment.
This has then led to further investigations and the diagnosis of your condition of Medial Epicondylitis (Worsening). I have accepted your condition of Medial Epicondylitis (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 9 May 2017.
