Statement of Principles

concerning

ACHILLES TENDINOPATHY
(Balance of Probabilities)

(No. 87 of 2024)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 18 October 2024.

Professor Terence Campbell AM

Chairperson

by and on behalf of

The Repatriation Medical Authority

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1.                Name

This is the Statement of Principles concerning Achilles tendinopathy (Balance of Probabilities) (No. 87 of 2024).

1.                Commencement

              This instrument commences on 19 November 2024.

1.                Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

1.                Repeal

The Statement of Principles concerning Achilles tendinopathy and bursitis (Balance of Probabilities) (No. 97 of 2015) (Federal Register of Legislation No. F2015L01337) made under subsection 196B(3) of the VEA is repealed.

1.                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.

1.                Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

1.                Kind of injury, disease or death to which this Statement of Principles relates
   1.           This Statement of Principles is about Achilles tendinopathy and death from Achilles tendinopathy.

Meaning of Achilles tendinopathy

1.           For the purposes of this Statement of Principles, Achilles tendinopathy:
   1.           means a symptomatic inflammatory or degenerative disease of the Achilles tendon or paratendon; and
   2.           includes:
      1.             insertional tendinopathy of the Achilles tendon;
      2.          mid portion tendinopathy of the Achilles tendon;
      3.        degenerative tears of the Achilles tendon; and
      4.         Achilles enthesopathy or enthesitis.

Note: Achilles tendinopathy is also known as Achilles tendonitis or paratendonitis, Achilles tendinosis or paratendinosis. Insertional Achilles tendinopathy is less than 2 cm proximal to the calcaneus and is a separate disease from Achilles enthesopathy, and mid portion Achilles tendinopathy is 2-7 cm proximal to the calcaneal insertion.  

Death from Achilles tendinopathy

1.           For the purposes of this Statement of Principles, Achilles tendinopathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's Achilles tendinopathy.

Note: terminal event is defined in the Schedule 1 – Dictionary.

1.                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 and death from Achilles tendinopathy can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

1.                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 death from Achilles tendinopathy 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 4 weeks before clinical onset or clinical worsening;
2.           undertaking weight bearing exercise involving repeated activity of the ankle joint on the affected side for:
   1.           a minimum intensity of 5 METS; and
   2.           for at least 6 hours per week; and
   3.           for at least the 4 weeks before clinical onset or clinical worsening;

Note 1: Examples of weight bearing exercise involving repeated activity of the ankle joint at a minimum intensity of 5 METS include marching, playing basketball, football, volleyball, and track and field (especially those activities that involve jumping).

Note 2: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening.

1.           increasing the frequency, duration or intensity of activity involving the ankle joint on the affected side:
   1.           by at least 100 percent; and
   2.           to a minimum intensity of 5 METs; and
   3.           for at least 4 hours per day;

within the 1 week before the clinical onset or clinical worsening;

Note: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening.

1.           having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening:
   1.           decreased ankle or forefoot flexibility;
   2.           forefoot varus;
2.           having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening:
   1.           ankylosing spondylitis;
   2.           Behcet syndrome;
   3.           enteropathic spondyloarthropathy (arthritis associated with inflammatory bowel disease);
   4.           gout;
   5.           pseudogout (calcium pyrophosphate dihydrate) or crystal-induced arthropathy from the deposition of calcium hydroxyapatite or calcium oxalate;
   6.            psoriatic arthropathy
   7.           reactive arthritis;
   8.           rheumatoid arthritis; or
   9.             undifferentiated spondyloarthropathy;
3.           being treated with a fluoroquinolone antibiotic within the 30 days before clinical onset or clinical worsening;

Note: Examples of fluoroquinolone antibiotics include ciprofloxacin, moxifloxacin, norfloxacin and ofloxacin.

1.           being treated with a glucocorticoid drug as specified before clinical onset or clinical worsening;

Note: being treated with a glucocorticoid drug as specified is defined in the Schedule 1 - Dictionary.

1.           having a glucocorticoid injection into the Achilles tendon, in the region of the Achilles tendon or in the retrocalcaneal bursa, before the rupture of the Achilles tendon;

Note: rupture of the Achilles tendon can constitute clinical onset or clinical worsening of Achilles tendinopathy.

1.           being treated with an aromatase inhibitor for at least 4 weeks within the 1 year before clinical onset or clinical worsening;

Note: Examples of aromatase inhibitors include anastrozole, exemestane and letrozole.

1.       having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening;

Note: BMI is defined in the Schedule 1 – Dictionary.

1.       having diabetes mellitus at the time of clinical onset or clinical worsening;
2.       inability to obtain appropriate clinical management for Achilles tendinopathy before clinical worsening.

1.            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 clinical worsening aspects of factors set out in section 9 apply only to material contribution to, or aggravation of, Achilles tendinopathy where the person's Achilles tendinopathy was suffered or contracted before or during (but did not arise out of) the person's relevant service.
2.            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—see subsection 7(2).

                               being treated with a glucocorticoid drug as specified means:

(a)          being treated with prednisolone, in the combinations of mode of administration, dose, duration of treatment and proximity to the clinical onset or worsening of Achilles tendinopathy, as specified in Table 1 below; or

(b)          being treated as specified in Table 1 with a glucocorticoid drug other than prednisolone in doses having an efficacy equivalent to prednisolone, that being calculated for the drugs listed in accordance with Table 2 below.

Table 1

Abbreviations: IV = intravenous; IM = intramuscular; O = oral; NS = not specified.

Table 2

                               BMI means W/H2 where:

(a)          W is the person's weight in kilograms; and

(b)          H is the person's height in metres.

                             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.

Note: MRCA and VEA are 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.