{"id":"F2022L00681","name":"Statement of Principles concerning thoracic outlet syndrome (Reasonable Hypothesis) (No. 47 of 2022)","slug":"statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":441376,"registerId":"F2022L00681-fast-fetch-1775956686362","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning thoracic outlet syndrome (Reasonable Hypothesis) (No. 47 of 2022)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 22.10.0\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nTHORACIC OUTLET SYNDROME (Reasonable Hypothesis)\n\n(No. 47 of 2022)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 29 April 2022\n\n \n\n \n\n \n\n \n\n \n\n| The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:
|\n| --- |\n|
Professor Terence Campbell AM
Chairperson
|\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Application\n\n5 Definitions\n\n6 Kind of injury, disease or death to which this Statement of Principles relates\n\n7 Basis for determining the factors\n\n8 Factors that must exist\n\n9 Relationship to service\n\n10 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning thoracic outlet syndrome (Reasonable Hypothesis) (No. 47 of 2022).\n\n2 Commencement\n\n This instrument commences on 30 May 2022.\n\n3 Authority\n\nThis instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n4 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n5 Definitions\n\nThe terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.\n\n6 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about thoracic outlet syndrome and death from thoracic outlet syndrome.\n\nMeaning of thoracic outlet syndrome\n\n(2) For the purposes of this Statement of Principles, thoracic outlet syndrome:\n\n(a) means a collection of symptoms and signs arising from compression of the subclavian artery, subclavian vein or the nerves of the brachial plexus which occurs as these structures exit the thoracic cavity above the first rib and pass through the anatomical spaces of the thoracic outlet; and\n\n(b) includes:\n\n(i) arterial thoracic outlet syndrome;\n\n(ii) neurogenic thoracic outlet syndrome; and\n\n(iii) venous thoracic outlet syndrome.\n\nNote 1: Symptoms and signs of arterial thoracic outlet syndrome typically include pain, pallor, paraesthesia, coldness and diminished pulses of the affected arm or hand. Symptoms may be recurrent (claudication), or occur suddenly due to acute arterial thromboembolism. Complications include development of mural thrombus in the subclavian artery or a subclavian artery aneurysm.\n\nNote 2: Symptoms and signs of neurogenic thoracic outlet syndrome typically include pain, dysesthesia, numbness and weakness involving the shoulder, arm or hand of the affected side. Symptoms may be aggravated by activities that require elevation or sustained use of the arms or hands.\n\nNote 3: Symptoms and signs of venous thoracic outlet syndrome typically include pain, cyanosis and swelling of the affected arm. Complications include recurrent venous thromboembolism and pulmonary thromboembolism.\n\nNote 4: The anatomical spaces within the thoracic outlet that can typically cause neurovascular compromise include the scalene triangle, the costoclavicular space and the pectoralis minor space.\n\nNote 5: arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome and venous thoracic outlet syndrome are defined in the Schedule 1 - Dictionary.\n\nDeath from thoracic outlet syndrome\n\n(3) For the purposes of this Statement of Principles, thoracic outlet syndrome, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's thoracic outlet syndrome.\n\nNote: terminal event is defined in the Schedule 1 – Dictionary.\n\n7 Basis for determining the factors\n\nThe Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that thoracic outlet syndrome and death from thoracic outlet syndrome can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.\n\n8 Factors that must exist\n\nAt least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting thoracic outlet syndrome or death from thoracic outlet syndrome with the circumstances of a person's relevant service:\n\n(1) performing repetitive and forceful activities involving the affected arm and shoulder:\n\n(a) for an average of at least 40 hours per month; and\n\n(b) for a cumulative period of at least 3 months before the clinical onset of thoracic outlet syndrome; and\n\nif those activities have ceased before the clinical onset of thoracic outlet syndrome, then that onset occurred within 2 months of cessation;\n\nNote: Examples of repetitive and forceful activities include lifting or carrying heavy loads, overhead throwing, swimming, rowing and playing musical instruments.\n\n(2) having trauma involving the upper chest, shoulder or neck of the affected side within the 1 year before the clinical onset of thoracic outlet syndrome;\n\nNote 1: Examples of types of trauma that can cause neurovascular compression in the thoracic outlet include fractures of the clavicle or the first rib and blows to the upper chest and shoulder. Delayed onset of thoracic outlet syndrome may occur as a result of the response to injury, including the formation of callus around fractures and the development of scar tissue.\n\nNote 2: trauma involving the upper chest, shoulder or neck of the affected side is defined in the Schedule 1 – Dictionary.\n\n(3) having surgery involving the upper chest, shoulder or neck of the affected side within the 1 year before the clinical onset of thoracic outlet syndrome;\n\nNote: Examples of types of surgery that can cause neurovascular compression in the thoracic outlet include manipulation of fractures of the clavicle or the first rib, surgery involving the clavicle or the first rib, and surgery involving the chest wall.\n\n(4) having an acquired space-occupying lesion involving the affected thoracic outlet at the time of the clinical onset of thoracic outlet syndrome;\n\nNote: Examples of acquired space-occupying lesions that can involve the thoracic outlet include neoplasms, hypertrophied shoulder girdle muscles, fibrous scar tissue resulting from chronic inflammation, haematomas, cysts and bony callus.\n\n(5) for venous thoracic outlet syndrome or arterial thoracic outlet syndrome only, being at an altitude of at least 3,000 metres for a continuous period of at least 24 hours within the 30 days before the clinical onset of venous thoracic outlet syndrome or arterial thoracic outlet syndrome;\n\nNote: venous thoracic outlet syndrome and arterial thoracic outlet syndrome are defined in the Schedule 1 – Dictionary.\n\n(6) for venous thoracic outlet syndrome only, having creation of an arteriovenous fistula in the arm of the affected side within the 2 years before the clinical onset of venous thoracic outlet syndrome;\n\nNote: venous thoracic outlet syndrome is defined in the Schedule 1 – Dictionary.\n\n(7) performing repetitive and forceful activities involving the affected arm and shoulder:\n\n(a) for an average of at least 40 hours per month; and\n\n(b) for a cumulative period of at least 3 months before the clinical worsening of thoracic outlet syndrome; and\n\nif those activities have ceased before the clinical worsening of thoracic outlet syndrome, then that worsening occurred within 2 months of cessation;\n\nNote: Examples of repetitive and forceful activities include lifting or carrying heavy loads, overhead throwing, swimming, rowing and playing musical instruments.\n\n(8) having trauma involving the upper chest, shoulder or neck of the affected side within the 1 year before the clinical worsening of thoracic outlet syndrome;\n\nNote 1: Examples of types of trauma that can cause neurovascular compression in the thoracic outlet include fractures of the clavicle or the first rib and blows to the upper chest and shoulder. Delayed onset of thoracic outlet syndrome may occur as a result of the response to injury, including the formation of callus around fractures and the development of scar tissue.\n\nNote 2: trauma involving the upper chest, shoulder or neck of the affected side is defined in the Schedule 1 – Dictionary.\n\n(9) having surgery involving the upper chest, shoulder or neck of the affected side within the 1 year before the clinical worsening of thoracic outlet syndrome;\n\nNote: Examples of types of surgery that can cause neurovascular compression in the thoracic outlet include manipulation of fractures of the clavicle or the first rib, surgery involving the clavicle or the first rib, and surgery involving the chest wall.\n\n(10) having an acquired space-occupying lesion involving the affected thoracic outlet at the time of the clinical worsening of thoracic outlet syndrome;\n\nNote: Examples of acquired space-occupying lesions that can involve the thoracic outlet include neoplasms, hypertrophied shoulder girdle muscles, fibrous scar tissue resulting from chronic inflammation, haematomas, cysts and bony callus.\n\n(11) for venous thoracic outlet syndrome or arterial thoracic outlet syndrome only, being at an altitude of at least 3,000 metres for a continuous period of at least 24 hours within the 30 days before the clinical worsening of venous thoracic outlet syndrome or arterial thoracic outlet syndrome;\n\nNote: venous thoracic outlet syndrome and arterial thoracic outlet syndrome are defined in the Schedule 1 – Dictionary.\n\n(12) for venous thoracic outlet syndrome only, having creation of an arteriovenous fistula in the arm of the affected side within the 2 years before the clinical worsening of venous thoracic outlet syndrome;\n\nNote: venous thoracic outlet syndrome is defined in the Schedule 1 – Dictionary.\n\n(13) inability to obtain appropriate clinical management for thoracic outlet syndrome.\n\n9 Relationship to service\n\n(1) The existence in a person of any factor referred to in section 8, must be related to the relevant service rendered by the person.\n\n(2) The factors set out in subsections 8(7) to 8(13) apply only to material contribution to, or aggravation of, thoracic outlet syndrome where the person's thoracic outlet syndrome was suffered or contracted before or during (but did not arise out of) the person's relevant service.\n\n10 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 8 applies in relation to a person; and\n\n(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;\n\nthen 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.\n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 5\n\n1 Definitions\n\nIn this instrument:\n\n arterial thoracic outlet syndrome means partial or complete impairment of blood flow to the upper limb due to compression of the subclavian artery as it passes through the thoracic outlet, including complications arising from this compression.\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n neurogenic thoracic outlet syndrome means compression of the nerves of the brachial plexus as they pass through the thoracic outlet, causing symptoms or signs of damage to the affected nerves.\n\n relevant service means:\n\n(a) operational service under the VEA;\n\n(b) peacekeeping service under the VEA;\n\n(c) hazardous service under the VEA;\n\n(d) British nuclear test defence service under the VEA;\n\n(e) warlike service under the MRCA; or\n\n(f) non-warlike service under the MRCA.\n\nNote: MRCA and VEA are also defined in the Schedule 1 - Dictionary.\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n thoracic outlet syndrome—see subsection 6(2).\n\n trauma involving the upper chest, shoulder or neck of the affected side means a discrete event involving the application of significant physical force to or through the affected upper chest, shoulder or neck region, that causes:\n\n(a) damage to the upper chest, shoulder or neck; and\n\n(b) the development, within 24 hours of the event occurring, of symptoms and signs of pain and tenderness, and either altered mobility or range of movement of the upper chest, shoulder or neck. In the case of sustained unconsciousness or the masking of pain by analgesic medication, these symptoms and signs must appear on return to consciousness or the withdrawal of the analgesic medication; and\n\n(c) the persistence of these symptoms and signs for a period of at least 7 days following their onset, save for where medical intervention for the trauma to the upper chest, shoulder or neck has occurred and that medical intervention involves one of the following:\n\n(i) immobilisation of the upper chest, shoulder or neck by splinting or similar external agent;\n\n(ii) injection of a corticosteroid or local anaesthetic into the upper chest, shoulder or neck; or\n\n(iii) surgery to the upper chest, shoulder or neck.\n\n VEA means the Veterans' Entitlements Act 1986.\n\n venous thoracic outlet syndrome means partial or complete impairment of blood flow from the upper limb due to compression of the subclavian vein as it passes through the thoracic outlet, including complications arising from this compression.\n\n \n\n \n\n \n","sortOrder":0}],"analysis":{"flash_summary":{"complexity_score":5,"scope_assessment":{"changed":false,"description":"This instrument follows the established SOP format under subsection 196B(2) of the VEA: it sets medical definitions and a limited set of exposure criteria tying thoracic outlet syndrome to relevant service. It does not expand coverage beyond the condition and service types already within the statutory scheme, nor does it introduce new categories of entitlement. The instrument remains narrowly focused on medical linking criteria for TOS and does not broaden the policy scope beyond that original purpose."},"complexity_factors":["13 discrete factors listed in section 8 (s8(1)–(13)), some applying to onset and some to clinical worsening","Numeric thresholds and time windows (e.g. 40 hours/month, 3 cumulative months, 2 months post-cessation) creating binary/conditional tests (s8(1)/(7))","Several distinct exposure types requiring different kinds of evidence (repetitive activity, trauma, surgery, space-occupying lesions, altitude exposure, arteriovenous fistula)","Conditional applicability: subsections 8(7)–(13) apply only to material contribution/aggravation where TOS pre-existed before/during service (s9(2))","Cross-reference and interaction with other SOPs where a factor refers to another injury/disease (s10)","Defined terms in Schedule 1 (arterial/neurogenic/venous TOS, trauma definition, terminal event, relevant service, MRCA/VEA etc.) — multiple technical definitions that affect scope and proof","Notes give examples (non‑exhaustive) which must be interpreted alongside the formal text (e.g. examples of repetitive activities, types of trauma)","Moderate number of temporal linking requirements (within 1 year, within 30 days, within 2 years, continuous periods), increasing evidentiary complexity"],"plain_english_summary":"**What this instrument does (mechanics)\n\n- Establishes a medical \"Statement of Principles\" (SOP) that sets out the medical facts and specific exposure criteria that, if met, are intended to raise a \"reasonable hypothesis\" that a person’s thoracic outlet syndrome (TOS) or death from TOS is connected to their Australian military service. (See sections 6, 7 and 8.)\n\n- Defines the condition. TOS is described as compression of the subclavian artery, subclavian vein or the brachial plexus nerves as they exit the chest above the first rib, and the SOP expressly covers arterial, neurogenic and venous types and death where TOS contributed to a terminal event. (See s6(2)–(3) and Schedule 1 definitions.)\n\n- Lists the specific factual factors that must exist to meet the medical threshold for a reasonable hypothesis linking TOS (or death from TOS) with relevant service. These are discrete, testable items such as repetitive and forceful use of the affected arm (numerical thresholds apply), recent trauma or surgery to the upper chest/shoulder/neck, presence of an acquired space‑occupying lesion, certain high‑altitude exposures, or creation of an arteriovenous fistula in the affected arm. There are separate but parallel factors for first clinical onset and for clinical worsening. (See s8(1)–(13).)\n\n- Requires that any factor relied on must be related to the person’s relevant service (the sorts of service covered are defined in the Dictionary). Some factors (those in s8(7)–(13)) apply only to claims of material contribution or aggravation where the TOS existed before or during service. (See s9(1)–(2).)\n\n- Provides that if a listed factor actually refers to an injury or disease that itself is covered by another SOP, then that other SOP’s factors apply according to its terms. (See s10.)\n\n\n**Who this affects\n\n- Veterans and former and current members of the Australian Defence Force who lodge claims where the Veterans' Entitlements Act 1986 (VEA) section 120A or the Military Rehabilitation and Compensation Act 2004 (MRCA) section 338 apply. In practice that means people seeking entitlements or compensation where relevant service is alleged to have caused or aggravated TOS. (See s4 and Schedule 1 definition of \"relevant service\".)\n\n\n**Why it matters (official rationale and practical effect)\n\n- Officially: the Repatriation Medical Authority (RMA) states there is sound medical‑scientific evidence that TOS and death from TOS can be related to relevant military service, and it sets this SOP under its statutory power to provide the medical threshold for administrative decision‑making. (See s7.)\n\n- Practically: this SOP provides the medical gateway used by decision makers (Department of Veterans' Affairs or claims decision bodies) to determine whether a claimant has reached the statutory \"reasonable hypothesis\" standard linking TOS with service. If a claimant can show one or more of the listed factors (and tie them to relevant service), the claim progresses on that medical link rather than being rejected on medical causation alone.\n\n\n**How the SOP operates in practice — costs, incentives, trade‑offs and implementation issues\n\n- Who pays / who benefits: If the SOP leads to acceptance of a claim, financial and medical entitlements are paid from government veterans’ programs (i.e. costs fall on public budgets). The concentrated beneficiaries are claimants whose medical and service histories match the listed factors (s8). Administrative and medical assessment costs are borne by the agencies that process claims.\n\n- Evidence and compliance burden: claimants must supply service records and medical evidence proving the presence and timing of listed factors (for example, records showing average exposure of at least 40 hours per month for 3 cumulative months for repetitive and forceful activity — s8(1) and s8(7)). Other factors require documentation of trauma/surgery dates within one year (s8(2)/(3)/(8)/(9)), evidence of altitude exposure (continuous ≥3,000 metres for ≥24 hours within 30 days — s8(5)/(11)), or proof of arteriovenous fistula creation (within 2 years — s8(6)/(12)).\n\n- Administrative discretion and predictability: the RMA supplies an objective list of factors to reduce medical dispute, but decision makers still exercise judgment in applying the SOP to real‑world evidence (e.g. interpreting whether an activity was \"repetitive and forceful\" in practice). The SOP limits medical discretion by setting numeric thresholds and time windows, but factual disputes about timing, intensity and causation remain.\n\n- Interaction with other SOPs (overlap risk): section 10 requires cross‑application where a listed factor refers to an injury/disease that is covered by another SOP. That produces potential complexity where multiple SOPs might apply and requires administrators to reconcile competing or overlapping medical statements.\n\n- Incentives and behaviour: the SOP creates an incentive for claimants to characterise their exposure in terms that match the listed factors (for example, documenting cumulative hours or obtaining medical records that record trauma/surgery). There is a potential for claims to be framed as worsening (aggravation) rather than new onset where s8(7)–(13) and s9(2) apply.\n\n- Opportunity costs and substitution effects: the instrument targets a narrow medical linkage rather than prescribing treatments. It may shift claimant resources to evidencing qualifying exposures (service records, occupational histories, medical reports) instead of other lines of argument.\n\n- Implementation risk: proving some factors is straightforward (documented surgery or fractures), but other factors are harder to establish objectively (self‑reported repetitive activity hours, or proving continuous altitude exposure). Time windows (e.g. onset within 2 months of cessation of activity, or trauma within 1 year) may be decisive and create borderline cases.\n\n\n**Key specific mechanical details to note (with section pointers)\n\n- Numeric thresholds: \"repetitive and forceful\" exposure requires an average of at least 40 hours per month for a cumulative period of at least 3 months prior to onset (s8(1)/(7)). If exposure ceased before clinical onset/worsening, the onset/worsening must be within 2 months of cessation (s8(1) note).\n\n- Trauma/surgery windows: trauma or surgery to the upper chest/shoulder/neck of the affected side must be within 1 year before clinical onset or clinical worsening (s8(2)/(3)/(8)/(9)); the SOP gives a detailed definition of qualifying trauma in the Dictionary (Schedule 1).\n\n- Altitude and fistula: arterial/venous TOS requires recent high altitude exposure (≥3,000 metres, continuous ≥24 hours within 30 days before onset/worsening — s8(5)/(11)); venous TOS can be related to creation of an arteriovenous fistula in the affected arm within 2 years before onset/worsening (s8(6)/(12)).\n\n- Death is covered where TOS contributed to a terminal event (s6(3) and Dictionary definition of \"terminal event\").\n\n\n**Bottom line\n\nThis is a focused medical‑criteria instrument that sets out the factual and temporal circumstances that, if established and related to a person’s defined \"relevant service\", will satisfy the RMA’s medical threshold of a \"reasonable hypothesis\" connecting thoracic outlet syndrome (or death from it) with service. It standardises the kinds of evidence decision makers should look for, while leaving factual assessment and entitlement decisions to the claims administrators who apply these criteria."},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This instrument maintains the standard scope for Repatriation Medical Authority Statements of Principles. It addresses a single medical condition (thoracic outlet syndrome) with the typical structure: definition, causal factors for onset and worsening, service connection requirements, and dictionary. There is no evidence of scope creep beyond the established pattern for determining service-related disability under the veterans' compensation schemes."},"complexity_factors":["13 distinct factual scenarios with multiple sub-conditions (hours per month, cumulative periods, cessation windows)","Type-specific limitations — factors 5, 6, 11 and 12 apply only to specific TOS subtypes (arterial/venous)","Dual temporal frameworks — separate factor sets for 'clinical onset' (factors 1-6) versus 'clinical worsening' (factors 7-12)","Nested definitions with cross-references — 'trauma' definition spans 150+ words with three cumulative elements and an exception clause","Cross-instrument dependencies — section 10 incorporates other Statements of Principles by reference, creating interlocking obligations","6 defined terms in Schedule 1, including recursive definitions ('thoracic outlet syndrome—see subsection 6(2)')","Conditional logic in section 9(2) restricting factors 7-13 to aggravation cases only"],"plain_english_summary":"This Statement of Principles sets the medical tests for deciding whether thoracic outlet syndrome (TOS) is linked to military service, affecting veterans and current/former defence members claiming under the Veterans’ Entitlements Act 1986 or the Military Rehabilitation and Compensation Act 2004. Using a \"reasonable hypothesis\" standard, it identifies service-related scenarios (e.g., repetitive heavy activity, trauma, surgery, space-occupying lesions) that, if met, strengthen entitlement to disability or death benefits. It covers arterial, neurogenic, and venous TOS."},"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022","history":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022/history","analysis":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022/analysis","conflicts":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022/important-cases","documents":"/api/acts/statement-of-principles-concerning-thoracic-outlet-syndrome-reasonable-hypothesis-no-47-of-2022/documents"}}