Statement of Principles
concerning
ACHILLES TENDINOPATHY AND BURSITIS
(Balance of Probabilities)
(No. 97 of 2015)
The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans’ Entitlements Act 1986.
 
Dated    21 August         2015
 
 
 
 
 
The Common Seal of the
Repatriation Medical Authority
was affixed to this instrument
at the direction of:
 
 
 
 
Professor Nicholas Saunders AO
Chairperson
 
 
 
  
Contents
1          Name........................................................................................................................................... 3
2          Commencement........................................................................................................................ 3
3          Authority..................................................................................................................................... 3
4          Revocation................................................................................................................................. 3
5          Application................................................................................................................................. 3
6          Definitions.................................................................................................................................. 3
7          Kind of injury, disease or death to which this Statement of Principles relates............... 3
8          Basis for determining the factors........................................................................................... 4
9          Factors that must exist............................................................................................................. 4
10        Relationship to service............................................................................................................. 6
11        Factors referring to an injury or disease covered by another Statement of Principles. 7
Schedule 1 - Dictionary............................................................................................. 8
1          Definitions.................................................................................................................................. 8
 
 
 
1               Name
This is the Statement of Principles concerning Achilles tendinopathy and bursitis (Balance of Probabilities) (No. 97 of 2015).
2               Commencement
This instrument commences on 21 September 2015.
3               Authority
This instrument is made under subsection 196B(3) of the Veterans’ Entitlements Act 1986.
4               Revocation
The Statement of Principles concerning Achilles tendinopathy and bursitis No. 38 of 2007 made under subsection 196B(3) of the VEA is revoked.
5               Application
This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.
6               Definitions
The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.
7               Kind of injury, disease or death to which this Statement of Principles relates
(1)          This Statement of Principles is about Achilles tendinopathy and bursitis and death from Achilles tendinopathy and bursitis.
Meaning of Achilles tendinopathy and bursitis
(2)          For the purposes of this Statement of Principles,
(a)           Achilles tendinopathy means a condition characterised by painful inflammation associated with degeneration in the Achilles tendon, including degenerative tears of the Achilles tendon, or inflammation of the paratendinous tissues; and
(b)          bursitis means inflammation and thickening of the deep retrocalcaneal bursa about the Achilles tendon; and
(c)           excludes posterior adventitial heel bursitis.
(3)          While Achilles tendinopathy and bursitis attracts ICD‑10‑AM code M76.6, in applying this Statement of Principles the meaning of Achilles tendinopathy and bursitis is that given in subsection (2).
(4)          For subsection (3), a reference to an ICD‑10‑AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM), Ninth Edition, effective date of 1 July 2015, copyrighted by the Independent Hospital Pricing Authority, ISBN 978‑1‑76007‑020‑5.
Death from Achilles tendinopathy and bursitis
(5)          For the purposes of this Statement of Principles, Achilles tendinopathy or bursitis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person’s Achilles tendinopathy or bursitis.
Note: terminal event is defined in the Schedule 1 – Dictionary.
8               Basis for determining the factors
On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that Achilles tendinopathy or bursitis and death from Achilles tendinopathy or bursitis can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.
Note: relevant service is defined in the Schedule 1 – Dictionary.
9               Factors that must exist
At least one of the following factors must exist before it can be said that, on the balance of probabilities, Achilles tendinopathy or bursitis or death from Achilles tendinopathy or bursitis is connected with the circumstances of a person’s relevant service:
(1)          running or jogging an average of at least 60 kilometres per week for the four weeks before the clinical onset of Achilles tendinopathy or bursitis;
(2)          undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg, at a minimum intensity of five METs, for at least six hours per week for the four weeks before the clinical onset of Achilles tendinopathy or bursitis;
Note: MET is defined in the Schedule 1 - Dictionary.
(3)          increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, within the seven days before the clinical onset of Achilles tendinopathy or bursitis;
Note: MET is defined in the Schedule 1 - Dictionary.
(4)          having a disease from the specified list of systemic arthritic diseases at the time of the clinical onset of Achilles tendinopathy or bursitis;
Note: specified list of systemic arthritic diseases is defined in the Schedule 1 - Dictionary.
(5)          having a significant biomechanical abnormality involving the affected foot or affected ankle at the time of the clinical onset of Achilles tendinopathy or bursitis;
Note: significant biomechanical abnormality is defined in the Schedule 1 – Dictionary.
(6)          for Achilles tendinopathy only, undergoing treatment with fluoroquinolone antibiotics within the seven days before the clinical onset of Achilles tendinopathy;
(7)          being treated with a glucocorticoid drug as specified before the clinical onset of Achilles tendinopathy or bursitis;
Note: glucocorticoid drug as specified is defined in the Schedule 1 - Dictionary.
(8)          being obese at the time of the clinical onset of Achilles tendinopathy or bursitis;
Note: being obese is defined in the Schedule 1 - Dictionary.
(9)          having diabetes mellitus at the time of the clinical onset of Achilles tendinopathy or bursitis;
(10)      being treated for at least four weeks with an aromatase inhibitor within the one year before the clinical onset of Achilles tendinopathy or bursitis;
(11)      running or jogging an average of at least 60 kilometres per week for the four weeks before the clinical worsening of Achilles tendinopathy or bursitis;
(12)      undertaking weight bearing exercise involving repeated activity of the ankle joint of the affected leg, at a minimum intensity of five METs, for at least six hours per week for the four weeks before the clinical worsening of Achilles tendinopathy or bursitis;
Note: MET is defined in the Schedule 1 - Dictionary.
(13)      increasing the frequency, duration or intensity of weight bearing activity involving the ankle joint of the affected leg by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, within the seven days before the clinical worsening of Achilles tendinopathy or bursitis;
Note: MET is defined in the Schedule 1 - Dictionary.
(14)      having a disease from the specified list of systemic arthritic diseases at the time of the clinical worsening of Achilles tendinopathy or bursitis;
Note: specified list of systemic arthritic diseases is defined in the Schedule 1 - Dictionary.
(15)      having a significant biomechanical abnormality involving the affected foot or affected ankle at the time of the clinical worsening of Achilles tendinopathy or bursitis;
Note: significant biomechanical abnormality is defined in the Schedule 1 – Dictionary.
(16)      for Achilles tendinopathy only, undergoing treatment with fluoroquinolone antibiotics within the seven days before the clinical worsening of Achilles tendinopathy;
(17)      being treated with a glucocorticoid drug as specified before the clinical worsening of Achilles tendinopathy or bursitis;
Note: glucocorticoid drug as specified is defined in the Schedule 1 - Dictionary.
(18)      having a glucocorticoid injection into the Achilles tendon or in the region of the Achilles tendon, before the clinical worsening of Achilles tendinopathy or bursitis;
(19)      being obese at the time of the clinical worsening of Achilles tendinopathy or bursitis;
Note: being obese is defined in the Schedule 1 - Dictionary.
(20)      having diabetes mellitus at the time of the clinical worsening of Achilles tendinopathy or bursitis;
(21)      being treated for at least four weeks with an aromatase inhibitor within the one year before the clinical worsening of Achilles tendinopathy or bursitis;
(22)      inability to obtain appropriate clinical management for Achilles tendinopathy or bursitis.
10           Relationship to service
(1)          The existence in a person of any factor referred to in section 9 must be related to the relevant service rendered by the person.
(2)          The factors set out in subsections 9(11) to 9(22) apply only to material contribution to, or aggravation of, Achilles tendinopathy or bursitis where the person’s Achilles tendinopathy or bursitis was suffered or contracted before or during (but did not arise out of) the person’s relevant service.
11           Factors referring to an injury or disease covered by another Statement of Principles
In this Statement of Principles:
(1)          if a factor referred to in section 9 applies in relation to a person; and
(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;
then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
 
Schedule 1 - Dictionary  
Note: See Section 6
1               Definitions
 In this instrument:
                             Achilles tendinopathy and bursitis—see subsection 7(2).
                             being obese means having a Body Mass Index (BMI) of 30 or greater.
                             BMI = W/H2 and where:
                             W is the person's weight in kilograms; and
                             H is the person's height in metres.
                              crystal-induced arthropathy means arthropathy resulting from the deposition of monosodium urate, calcium pyrophosphate dihydrate, calcium hydroxyapatite or calcium oxalate.
                              glucocorticoid drug as specified means any of the corticosteroid drugs listed in the following table, in the specified combinations of administration, dose level and duration of treatment:

Drug or Class of Drugs
Mode*
Dose
Minimum Duration of Treatment
Duration

prednisolone or
pharmacologically equivalent glucocorticoid
IV, IM, O
 
 
³ 0.5 grams over 6 months
6 months
 
within the 3 years

³ 3 grams
NS
within the 5 years

³ 10 grams
 
NS
 
 
NS

Abbreviations: IV = intravenous; IM = intramuscular; O = oral; NS = not specified.
                             MET means a unit of measurement of the level of physical exertion.  1 MET = 3.5 ml of oxygen/kg of body weight per minute, or 1.0 kcal/kg of body weight per hour, or resting metabolic rate.
                             MRCA means the Military Rehabilitation and Compensation Act 2004.
                             relevant service means:
(a)           eligible war service (other than operational service) under the VEA;
(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or
(c)           peacetime service under the MRCA.
 
                              significant biomechanical abnormality means an abnormality that causes significant alteration of biomechanical forces through the ankle, such as would occur with pes planus or underpronation, decreased ankle or forefoot flexibility, forefoot varus, pes cavus or lateral ankle joint instability.
                              specified list of systemic arthritic diseases means:
(a)           ankylosing spondylitis;
(b)          Behcet syndrome;
(c)           gout, or another crystal-induced arthropathy;
(d)          enteropathic spondyloarthropathy;  
(e)           psoriatic arthropathy; 
(f)           reactive arthritis;
(g)          rheumatoid arthritis; or
(h)          undifferentiated spondyloarthropathy.
Note: crystal-induced arthropathy is also defined in the Schedule 1 - Dictionary.
                             terminal event means the proximate or ultimate cause of death and includes the following:
(a)           pneumonia;
(b)          respiratory failure;
(c)           cardiac arrest;
(d)          circulatory failure; or
(e)           cessation of brain function.
                             VEA means the Veterans' Entitlements Act 1986.