1. The Tribunal must decide whether Ms Edwards suffered an 'injury' giving rise to Comcare being liable for de Quervain's pursuant to s 14 of the SRC Act:

(a) Whether Ms Edwards suffered from an 'ailment' or an 'aggravation of an ailment' as defined in ss 4(1), 5A and 5B of the SRC Act.

(b) If so, whether the ailment (or aggravation of an ailment) was 'contributed to a significant degree' by her employment with DHA and therefore a 'disease' within the meaning of the SRC Act.

1. The SRC Act relevantly provides:
   1. 2. 3. 4. 5. 6. 7. 8.

(1) In this Act, unless the contrary intention appears:

aggravation includes acceleration or recurrence.

ailment means any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development).

that was contributed to, to a significant degree, by the employee's employment by the Commonwealth or a licensee.

(2) In determining whether an ailment or aggravation was contributed to, to a significant degree, by an employee's employment by the Commonwealth or a licensee, the following matters may be taken into account:

(b) the nature of, and particular tasks involved in, the employment;

(c) any predisposition of the employee to the ailment or aggravation;

(d) any activities of the employee not related to the employment;

(e) any other matters affecting the employee's health.

This subsection does not limit the matters that may be taken into account.

significant degree means a degree that is substantially more than material.

(1) Subject to this Part, Comcare is liable to pay compensation in accordance with this Act in respect of an injury suffered by an employee if the injury results in death, incapacity for work, or impairment.

(2) Compensation is not payable in respect of an injury that is intentionally self‑inflicted.

(3) Compensation is not payable in respect of an injury that is caused by the serious and wilful misconduct of the employee but is not intentionally self‑inflicted, unless the injury results in death, or serious and permanent impairment.

1. 10. 11. 12. 13. There is little in factual dispute in this matter. The evidence of Ms Edwards was not seriously contested at the hearing. Nor was the evidence of the DHA lay witness, Ms Hamer, of significant probative value other than to provide the policy framework for Ms Edwards' employment at DHA.
2. Insofar as there is a contradiction, it is in the medical evidence and even then, it is of narrow distinction as to the opinions of the medical experts relied upon by the parties as to the causation of Ms Edwards condition of de Quervain's.

1. Ms Edwards provided a 'statement of evidence', undated, that relevantly states[9]:

(a) Ms Edwards was employed with DHA as a Housing Contact Centre Consultant from 12 July 2021 to 12 December 2022. > > (b) The role involved significant periods of keyboard data entry and mouse work, both of which required repetitive wrist and thumb movement. > > (c) After a desk move in March 2022 she started having wrist pain. > > (d) Between April and August 2022, Ms Edwards sought to alleviate symptoms by purchasing and ergonomic mouse and mousepad, after unsuccessfully seeking to obtain these via DHA. > > (e) On 3 August 2022, Ms Edwards was in significant pain and unable to report to work, she reported the wrist pain to DHA. Ms Edwards sought medical treatment on 3 August 2022, including obtaining an ultrasound on the following day that had a diagnosis of de Quervain's. > > (f) On 11 August 2022, DHA approved treatment through the 'Early Intervention Support Subsidy', enabling immediate medical treatment of 2 general practitioner and 5 physiotherapist appointments. > > (g) On 15 August 2022, DHA provided a third party to conduct a workstation assessment. > > (h) On 7 December 2022, she lodged the Claim. > > (i) On 12 December 2022, she commenced employment with Defence Travel Services. > > (j) In December 2023, she recommenced wearing a wrist brace at work due to increased wrist pain and continued to wear the brace at night during the Christmas stand-down period. She experienced a decrease in symptoms during her absence from work. > > (k) She concludes:

It remains my strong belief that I suffered a work injury (de Quervain's tenosynovitis) as a result of my DHA work duties. I had never experienced the symptoms of wrist or thumb pain prior to commencing employment with DHA, and the symptoms gradually increased in nature, forcing me to seek treatment on 3rd August 2022. I believe that the timings of onset and gradual increase in my symptoms, together with the fact that these same symptoms would decrease during periods away from my work duties, is clear evidence of the work-related causation. Furthermore, this is supported by my treating Orthopaedic Surgeon, Dr Levi Morse, who in all his correspondence has confirmed the diagnosis of de Quervains tenosynovitis and attributed the condition to repeated actions within my work duties (i.e. mouse work and data entry).

1. Ms Edwards tendered a number of medical journal articles in support of her contention that de Quervain's was caused by her employment:

(a) First, an article titled 'The side of my wrist hurts'[10], that posits 'the exact cause of De Quervain's tenosynovitis is still debated, possible aetiologies include acute injuries (eg blunt trauma, biomechanical compression), forceful repetition of the wrist and thumb leading to increased frictional forces or microtrauma (eg workplace-related activity, actions performed by new mothers), inflammatory diseases, anatomical variations, abnormalities of the first dorsal compartment and, rarely pathogens.' > > (b) Second, an article from 'Physiopedia'[11] that posits that the most common cause of de Quervain's is 'chronic overuse' with 'activities such as golfing, playing the piano, fly fishing, carpentry, or activities by office workers and musicians can lead to chronic overuse injuries'. The 'classic patient population is mothers of newborns who are repeatedly lifting their baby with their thumbs radially abducted and wrists going from ulnar to radial deviation'. > > (c) Third, an article from the 'American Academy of Orthopaedic Surgeons'[12] that posits that de Quervain's is common and may be caused by the overuse of the thumb and wrist and is most common in people in their 40s and 50s and affects more women than men.

1. Ms De-Ahne Lee Hamer (Ms Hamer), an operations manager in DHA provided a written statement, dated 24 January 2024, that relevantly stated:[13]

11. The Contact Centre is a multi-channel service delivery centre where consultants perform a range of tasks such as answering phone calls, processing emails, and executing allocated tasks via our workflow system.

12. Consultants are rotated through a range of tasks according to skill set, priority of tasks, and peaks and troughs in workloads. Managers take these factors into consideration to help ensure a fair rotation and job variety for all employees where possible.

13. Alana was rotated through a combination of telephone-based work and processing work in accordance with the fair job rotation strategies implemented by the Resource Planning Manager. This is evidenced by IPFX data - Presence Reports

15. Any time logged as "Empower" or "Available (Desk)" denotes off-phone processing duties. Whilst this work does require keying in core systems, the consultant is not rostered in the phone queue, so there is flexibility for a consultant to move away from their desk should they require it for any reason

16. There is a range of other 'offline' activities that consultants are typically engaged in that are complementary to their immediate role when they are not processing or taking phone calls. These activities could include coaching sessions, one-on-ones, team meetings, learning and development activities, and other general activities.

17. Consultants are provided with a binaural headset, an adjustable workstation, and a chair. In addition to instructing consultants regarding correct ergonomic set up via ILS modules/induction programs, an independent ergonomic assessment is available for employees who indicate they require additional support to ensure their workstation set-up meets their individual needs and workplace ergonomic requirements.

22. Due to the sedentary nature of their work, consultants are provided with the opportunity to take a small break {approximately 5-minutes every hour) to enable them to stretch and move about on a regular basis.

23. Accessing health breaks on an hourly basis will not adversely affect a consultant's performance/scorecard results as the benchmark has been developed allowing for hourly breaks to be taken.

24. Consultants are required to log those breaks by using an exception code in the telephony system, 1PFX. The code to be used is "Gone Out". These breaks are also referred to as health breaks.

25. A review of Alana's call logs indicates that she did not take these breaks hourly though they were accessed on a reasonably regular basis.

27. Annexure D shows that Alana took 42 health breaks in addition to her normal scheduled breaks during the month of November 2021.

28. The fact that Alana did, on numerous occasions, use the correct presence code and taken a break that is of the correct duration for a break of this type, suggests that it is likely that the information contained in the presence code log is a reasonably accurate representation of her utilisation of health breaks.

29. One of the key performance indicators for a Housing Consultant is how well they adhere to their schedules. In determining the benchmark for this KPI, health breaks were taken into account.

30. In the area of Average Handling Time, Alana did not meet the required performance standard for any of the months, except October 2022.

1. During the hearing Ms Hamer gave evidence on the calculation of breaks taken by Ms Edwards from the data collected by the DHA in its 'presence reports'[14]. The Tribunal questioned the methodology used by Comcare in selecting a particular period of time to demonstrate that Ms Edwards had a number of short breaks per day that might be inconsistent with her evidence. When pressed, Comcare conceded that it was of 'peripheral relevance' and did not take the Tribunal to a consideration of the veracity of Ms Edwards evidence.

1. On 4 August 2022, Dr Bilal, a radiologist, provided a report of an ultrasound of Ms Edwards's right wrist that opined:[15]

There is no compression of median nerve in the carpal tunnel. There is however thickening of the tendon sheath of exterior pollicis longus and extensor pollicis brevis with a trace of fluid, consistent with de Quervain's tenosynovitis. This would be relevant if the patient has ongoing tenderness as well. Mild arthritic changes are suspected along the 1st CMC joint.

1. On 14 November 2023, Dr Bilal, provided a report[16] of an MRI of Ms Edwards's right wrist and thumb that opined that mild de Quervain's tenosynovitis was seen, there was a tiny ganglion cyst present. He diagnosed mild de Quervain's tenosynovitis, dorsal intercarpal ligament sprain, mild tenosynovitis of extensor carpi ulnaris in the right wrist. In the right thumb he diagnosed mild osteoarthritis changes involving the 1st CMC articulation.

1. Dr Thompson, an occupational therapist, provided a letter to Ms Edwards's general practitioner (GP) Dr Garcia, dated 22 August 2022, that states:[17]

Alana self referred to our clinic reporting an approximate 2 week history of right wrist pain, which she reports coincides with a recent change in desk at work. Ultrasound imaging identifies right wrist "de Quervain's tenosynovitis".

Alana attended for initial review in our clinic on 12/08/2022. She reported symptoms of pain in the "top" of her wrist (over 4th dorsal compartment) with typing and pain at the thumb side of wrist (1st dorsal compartment) with mouse work. Clinic testing indicates 1st and 4th dorsal compartment tendonitis. I have fabricated a wrist and thumb immobilisation orthosis and advised Alana to wear this full time for a period of 4-6 weeks; following this we will assess readiness to wean from the orthosis and commence strengthening and work hardening.

1. On 20 December 2022, Dr Thompson provided a report that opined that clinical testing was positive for de Quervain's tendinosis and for intersection syndrome and 4th dorsal compartment tendinopathy. Dr Thompson believed that Ms Edwards employment duties of repetitive phone, keyboard and mouse use significantly contributed to her condition.[18]
2. Dr Thompson did not give evidence at the hearing.

1. Dr Simon White, an occupational physician provided a report, dated 24 January 2023, based on a telehealth consultation with the assistance of a physiotherapist under his supervision, that relevantly provides:[19]

De Quervain's disease or De Quervain's tendinopathy is a condition that affects two tendons (the abductor pollicis longus and extensor pollicis brevis) where they pass through the first dorsal compartment for the forearm into the wrist. It was previously thought to be an acute inflammatory condition of the tendon sheath however, histologically, the pathology appears more related to degeneration rather than acute inflammation. It is a condition which has been frequently attributed to repetitive activities (be they during work or away from work), particularly involving postures maintaining the thumb in extension and abduction. Prospective studies however have not demonstrated a convincing or definite relationship here.

The disease involves a non-inflammatory thickening of both the tendons and the tunnel or

sheath that they pass through. It is most common in middle-aged to older females and is also often seen in women in the post-partum period. It is associated with inflammatory arthropathy and may also be contributed to by conditions causing fluid retention. Occupational risk factors for De Quervain's disease for which there is some evidence include highly repetitive work alone or in combination with other factors such as forceful work and awkward postures. Proposed occupational risk factors for which there is insufficient evidence include vibration, keyboard activities, cold environment, length of employment shorter than three years, and dominant hand use.

There is observational data (as opposed to prospective studies), which suggest that physical activities involving a combination of high force and repetition or force and awkward posture involving the thumb in abduction and extension, or other highly repetitive tasks may be associated with exacerbating the symptoms. It is however also expected that if an individual has chronic De Quervain's disease then any regular use of the upper extremities (even light tasks which would not be associated in any causative sense) may result in the awareness of symptoms of the underlying pathology.

In my opinion her onset of the De Quervain's tenosynovitis is not related to her work duties,

on the balance of probabilities from the information provided and is constitutional in nature.

1. What is the specific diagnosis of the condition/s that Ms Edwards currently

suffers from? Please specify if the condition/s is an aggravation of another

2. The reported mechanism of injury as stated by Ms Edwards claims report indicates causation due to her normal duties of employment involving 'repetitive data entry over a period of time'. Based on your professional opinion is the reported mechanism consistent with the current symptoms.

The onset of right wrist symptoms was reported during her normal administrative office based duties whilst working in the Defence Housing Australia call centre in Townsville. In my opinion the onset of the De Quervain's tenosynovitis is not related to her work duties, on the balance of probabilities from the information provided and is constitutional in nature.

3. Does Ms Edwards have any pre-existing, congenital or underlying health

condition/s which may contribute to the injury sustained to her right wrist? If so

(a) If relevant, what is the significance of Ms Edwards pre-existing health condition(s) and the current presentation?

From the information available, there is no pre-existing congenital or underlying health conditions contributing to her right wrist apart from normal age-related constitutional factors.

4. Does Ms Edwards have any non-work-related factors which may have contributed or caused the diagnosis condition (i.e.: hobbies, sports, care tasks)

Ms Edwards does not have any significant contributing factors outside of work, apart from previous work in photography, editing photographs electronically, which she reports she has not done for many years. Apart from this she does gym work, which she is finding that certain poses and positions are increasing her symptoms temporarily.

5. Do you believe that her employment through Defence Housing Australia as a Housing Contact Centre Consultant, to be the significant contributing factor to her injury? Please detail your reasoning.

In my opinion from the information available, her call centre work with Defence Housing Australia is not a significant contributing factor to the development of the De Quervain's tenosynovitis, and in my opinion, it is constitutional in nature.

6. Is it probable that Ms Edwards current condition/s is attributable to factors other than her employment with Defence Housing Australia? In particular, please comment on the probable contribution of any non-employment related factors; these may include age, gender and non-work-related activities.

From the information available to me, her development of De Quervain's tenosynovitis is related to her constitutional factors (aged-related change).

7. When in your opinion, did Ms Edwards first suffer from a clinically identifiable diagnosis (not just symptoms) of the condition/s?

From the information available to me, Ms Edwards experienced her first symptoms of right wrist De Quervain's tenosynovitis in the months leading up to August 2022.

9. Has the injury resolved? If the injury has not resolved and requires ongoing treatment, please outline the best practice treatment including the frequency, type and duration?

Ms Edwards reports ongoing symptoms in her right wrist with certain activities including repetitive right mouse work and floor-based activities during yoga and sustained and repetitive gripping. I would recommend ongoing physiotherapy to help minimise or resolve these symptoms.

10. If the injury has not resolved, what is your current prognosis of Ms Edwards condition?

Her prognosis is good. De Quervain's tenosynovitis is a self-limiting condition and is managed symptomatically. While she may experience intermittent symptoms in the future, in my opinion these are constitutional in nature and will not preclude her from performing normal duties.

11. Can you please outline Ms Edwards current capacity for work including hours and any limitations or restrictions?

Ms Edwards has full capacity for work and can work within her symptoms in her current role.

1. Comcare tendered through Dr White a number of medical journal articles that provide:

(a) First, the 'AMA Guides to the Evaluation of Disease and Injury Causation' for 'de Quervain's Disease'[20] that states the occupational risk factor of keyboard activities and awkward postures is 'low risk evidence' with that defined 'as a potential risk factor that is possible if the individual had a major exposure but for which there is not enough scientific evidence'. Age and gender are risk factors with strong evidence. > > (b) Second, the 'MD Guidelines'[21] that state there is some evidence de Quervain's is caused by 'highly repetitive work alone or in combination with other factors such as forceful work and awkward postures'. > > (c) But insufficient evidence that de Quervain's is caused by 'vibration, keyboard activities, cold environment, length of employment shorter than 3 years, and dominant hand use'. > > (d) Further in the article, after the heading 'Work Relatedness' it states that 'Increasing hours of computer work has been associated with extensor compartment tenosynovitis, de Quervain's disease, and non-specific wrist and forearm pain' and 'Those risks may be due to contact stress at the wrist or sustained wrist postures. Split keyboards, which reduce awkward postures, have been associated with reduction in pain and disorders'. > > (e) Third, 'The Histopathology of De Quervain's Disease'[22] opined that 'highlighting degeneration in the absence of inflammation, suggests that the inflammatory components referred to in other pathological studies are merely superimposed on the basic pathological process of degeneration; the presence of inflammatory cells does not necessarily imply an inflammatory aetiology'. > > (f) Fourth, a literature review in 'UpToDate'[23] that states 'the etiology of de Quervain tendinopathy is not well-understood. In the past, it was frequently attributed to occupational or repetitive activities involving postures that maintain the thumb in extension and abduction'.

2. During cross examination by Ms Edwards, Dr White answered questions relevantly as follows:[24]

Q. Can I just ask, are you saying that this is not causation of repetitive work? The injury? You're saying it's age and gender related. Is that what you're saying?

A. My opinion in the report was based around the aetiology of De Quervain's disease. It's a degenerative condition - myxoid degeneration, which was previously thought as an inflammatory disease. But certainly, as evidence in the histopathology paper. That's a degenerative condition when it's released in the first dorsal compartment. It's found to be thickened extensive (indistinct) and thickened mucoid tendons. So yes, I'm saying that it's a degenerative condition. It is the diagnosis. I agree that there is a diagnosis of De Quervain's disease from the information that I had. But what I am - my opinion is that it's not related to office-based activity. The - you know, a weight of medical evidence would suggest that it doesn't pass the test of balance of probabilities.

Q. That document there also stated - that lists 30- to 50-year-old women. Would you agree that 30 to 50 year old women mainly do administration duties, which is a repetitive action?

A. Well, I - there would be a percentage of them that are in those roles, but they're describing the non-occupational factors in which people are at higher risk. And it's described that women 5 to 1 or 10 to 1 are more likely to get De Quervain's disease than men. And certainly, that age group is at the higher risk end because of the mucoid degeneration in that stage of their life and their fourth to sixth decade.

Q. And on probabilities, there would be a 5 to 1 chance of females of that age doing clerical, repetitive duties, do you think?

A. I'd have to look up the statistics to see how many people of that gender are in a particular role. But the evidence is based around the age-related and gender-related risk factors around the development of De Quervain's.

Q. Thank you. And that report also says causation with postpartum which again, is the mothers as well, which are brought up in the other one. And then finally, your report, page 285 that was submitted. The histopathology of De Quervain's disease. That report there, am I correct in saying that this report was done via autopsy on people who had already had surgery for De Quervain's? Since it says postmortem, within 24 hours of death and they'd already had surgery?

A. Yes, so, I mean - they're very difficult. This is a landmark paper. They're difficult to do on live people because you need your tendons. Certainly, they're looking at the state of the tendons and 23 patients that had surgery for De Quervain's disease were described with 24 controls. So they're describing the histopathology of the tendons and described as myxoid degeneration - not seen in the normal controlled tendon sheaths. So this is why they've described it as a degenerative disease.

Q. Do you agree with Dr Morse or disagree with anything he's written there?

A. I agree with his diagnosis. I agree that it may benefit from surgical intervention. I disagree with the work-relatedness, as that's contrary to the weight of the medical evidence.

Q. What would be causing it if it's not work, and why would it be flaring up during work and getting better when off work, if you disagree with it?

A. Yes, so as I said before, people with De Quervain's will get symptoms in all sorts of activities. And that would be not unusual but like I said, the weight of medical evidence is that there's no relationship with respect to work and keyboard activities particularly. Certainly, as you alluded to before about the repetitive nature, but that's in heavy manual workers; in process workers; meat workers, et cetera. So certainly, that would be at odds with the weight of the medical evidence.

Q. That repetitive action is linked to De Quervain's?

A. Repetitive, forceful activities in manual workers, not in office workers.

1. Dr White answered questions from the Tribunal, relevantly as follows:[25]

Q. Thank you. Before I hand you back to Mr Nolan, can I take you to your report. I'd take you to page 39 of the bundle - page 10 of 13 of your report. And it's got the schedule of questions up at the top. And the first question there, Dr White, is what is the specific diagnosis of the condition that Ms Edwards currently suffers from and please specify if the condition is an aggravation of another condition. That diagnosis there - are you making any comment on whether it could be an aggravation?

A. No, I'm just saying what the diagnosis is. Like I said before, I agree with Dr Morse regarding his diagnosis. And I made the same diagnosis on the day of assessment.

Q. And you understand that under the Safety, Rehabilitation and Compensation Act for disease, it includes the definition of ailment or aggravation of an ailment. Given the history that's been presented to you in terms of the type of work that Ms Edwards did, is it possible that there has been an aggravation of that disease in your opinion?

Q. If it's not that, then what is the cause of the pain that Ms Edwards suffered as a response to her history? With respect to her ongoing symptoms?

A. It's well documented that people with De Quervain's disease will get symptoms with certain activities. They vary, but mainly with gripping; even light activities can cause it. The activities of daily living such as using the vacuum cleaner, cutting up vegetables - all of those type of normal activities of daily living can give them symptoms, but it's related to their underlying constitutional condition as described earlier.

Q. But isn't that a contradiction? You're saying that it's not an aggravation, but what you just described is exactly an aggravation of an underlying degenerative disease?

A. I would describe it as an exacerbation - temporary exacerbation of underlying symptoms, not a material change in the aggravation.

Q. Just so I understand what your evidence is, Dr White, you're saying there was an underlying degenerative disease, yes?

Q. And you're saying that your evidence has been so far that the symptomology related to that disease can flare up by doing a variety of types of activities, including household activities and in the workplace. Is that correct?

Q. You describe that as an exacerbation of the underlying degenerative disease. That's what your evidence was, wasn't it?

A. Yes. Temporary symptoms - I think I've detailed that in page 9 of my report.

Q. You understand an aggravation as defined in the Act? And just for completeness, so that we're all talking about the same thing - aggravation includes acceleration or recurrence. That's in the definition of section 4 of the Act. Knowing that definition, could it possible that the symptoms Ms Edwards showed in her workplace were an aggravation of her underlying degenerative disease, even if they were temporary?

A. I stand by what I've said in the report with respect to the symptoms can be experienced with even mild activities, and the awareness of the symptoms. And I'd use the word, I guess, 'exacerbation' because they're temporary symptoms that are experienced due to the underlying condition. So I wouldn't class it as an aggravation.

Q. Are you saying an aggravation by your definition is a permanent aggravation of an injury rather than a temporal aggravation?

A. I'm saying what symptoms people get from De Quervain's with respect to their underlying degenerative condition.

Q. No, you haven't answered my question. Can you answer the question of whether or not you define aggravation as a permanent increase in symptomology versus maybe a temporary increase in symptomology?

A. Yes, I was talking about an exacerbation as a temporary symptom, and aggravation as a material change in symptoms.

Q. I'm trying to understand what your definition of 'aggravation' is as against what I've said what it is in the Act, which includes acceleration or recurrence. It seems a pretty self-explanatory definition. I'm asking you whether or not it's a - symptomology is shown at the workplace, whether or not that could be a temporary aggravation of the underlying degenerative disease, and if your answer is no, just tell me. But I'm just trying to get to the bottom of that?

A. Yes, no worries. I just - no worries, sorry. I just wanted to understand so I was clear. In my opinion, it would be awareness of the symptoms from the underlying condition.

Q. May I just clarify this point in terms of the (indistinct). Doctor, you've referred to page 9 of your report. You've said 'However, it is also expected that an individual who has chronic De Quervain's disease that any regular use of the upper extremities, even light tasks which would not be associated in any causative sense, may result in awareness of the symptoms of the underlying pathology'. Do you see that?

Q. Do I understand that to mean that once you have the De Quervain's disease that it enlivens spontaneously or due to the degenerative process, any upper limb activities, whether you're at work or not, is going to create an awareness of the symptoms. Is that right?

Q. I appreciate it may not be completely analogous, but it is something that's in the cases. Let's just say you have someone who has fractured a leg outside of work, and the fractured leg is encased in plaster, and will be unable to put it on the ground at work without suffering pain and disability. Do you see that sort of analogy? Is that the type of situation you're talking about in terms of whether work act - the typing would cause the symptoms. Is that what you mean?

A. Yes, like you said, I guess not a completely perfect analogy, but yes. The same type of thing. It's an awareness of symptoms during quiet, menial tasks.

1. Dr Levi Morse, an orthopaedic surgeon, provided a report dated 21 April 2023 that relevantly states:[26]

Alana reports progressive onset of radial sided wrist pain with repetitive use at work since August of last year. She denies any significant similar symptoms of the same previously. She had imaging that confirmed de Quervain's tenosynovitis and treatment has included physiotherapy along with recent steroid/local injection. The injection has proved beneficial which is pleasing. I understand that she has been seeing for an independent medical examination that has deemed her condition to be age-related or constitutional in nature. I disagree with this strongly. De Quervain's tenosynovitis is typically an overuse condition with onset due to repetitive use and I feel that it is completely reasonable to assume in her case it is work-related. If her symptoms do not settle after the recent steroid injection, then it would be reasonable to consider a de Quervain's release in the future.

1. On 17 May 2024, Dr Morse provided a letter to Dr Garcia that relevantly states:[27]

Alana was again seen back through my rooms today regarding her right wrist. She was seen about a year ago in my clinic and at that time I diagnosed right wrist de Quervain's tenosynovitis. She has had the onset of right-sided wrist pain due to repetitive use at work and in my opinion I feel this is very much work-related. She has had an MRI that shows some mild arthritis in the base of her thumb, however this is certainly not the cause of her pain. I am confident with the diagnosis of de Quervain's tenosynovitis due to the following factors:

2. Clinical features consistent with de Quervain's tenosynovitis (Finkelstein's test positive).

3. Complete relief of pain for a period following a steroid/local injection to the first dorsal compartment.

I believe that Alana has been struggling to get much support through her insurance claim. To clarify, I feel her condition is that of de Quervain's tenosynovitis and not anything else, and I feel that it is work-related.

Dr Simon Journeaux - Consultant Orthopaedic Surgeon

1. Dr Simon Journeaux, an orthopaedic surgeon, provided a report dated 17 November 2023 that relevantly states:[28]

In respect of the right wrist, she has a diagnosis of a dorsal intercarpal ligament sprain. It is my view that the MRI findings noted in the recent MRI scan pertaining to de Quervain's tenosynovitis and tenosynovitis of extensor carpi ulnaris, represent incidental findings. The MRI scan of the right thumb demonstrates evidence of mild osteoarthritic changes involving the 1st CMC articulation. This condition is relatively asymptomatic currently, and when she was examined by me she did not exhibit any tenderness referrable to that joint.

6. Your diagnosis of Ms Edwards' current physical condition(s) and the aetiology.

The above diagnoses in my view represent constitutional findings which have no work-relatedness. The intercarpal ligament sprain is somewhat difficult to interpret as to whether it represents real pathology or is an incidental finding of the MRI scan. I note no history either at work or out of work that would give rise to this condition. Examination findings however are consistent with an "injury/abnormality" to this area.

7. In respect of your answer to 6, please advise which (if any) of the conditions diagnosed are related to the Ms Edwards' employment with Defence Housing Australia having particular regard to:

(a) The information provided by Ms Edwards' employer that on average every 4 months staff move desks and swap locations to enable different people to work with each other. Ms Edwards moved desks twice and had a workstation assessment conducted by an Exercise Physiologist from Konekt Workcare which recommended a Microsoft Natural Ergonomic Keyboard Wave and Rockstick Vertical Mouse which were purchased and supplied.

(b) The information provided by Ms Edwards' employer that when changing desks, the employee is only required to relocate their personal possessions such as keyboard, mouse, pens and notebooks.

(c) The statement provided by Ms Dee Hamer (Operations Manager for Service Operations and Contact Centres) dated 18 August 2023 which indicates that:

(i) Ms Edwards was provided with a binaural headset, an adjustable workstation and chair.

(ii) Ms Edwards was instructed as to the correct ergonomic set up via ILS modules and induction programs.

(iii) An independent ergonomic assessment was available for any employee who indicated they required additional support setting up their workstation to meet their individual needs (and that Ms Edwards accessed this option).

(iv) Consultants are provided with the opportunity to take a small break (approximately 5 minutes each hour) to enable them to stretch and move about. Those breaks are logged by consultants using the "Gone Out" code. A review of Ms Edwards' Presence Reports shows that she took these breaks although not hourly, but on a regular basis.

(v) Ms Edwards was rotated through a combination of telephone based work and processing work based on the fair job rotation strategies that the Resource Planning Manager implements. This is recorded in the Presence Reports as "Empower" or "Available (Desk)" denoting off-phone processing duties. Whilst this work does require keying, the consultant is not rostered in the phone queue, so there is flexibility for a consultant to move away from their desk should they require it for any reason (in consultation with their Team Leader).

(vi) There is a range of other 'offline' activities that consultants are typically engaged in that are complementary to their immediate role where they are not processing or taking phone calls. These include activities such as coaching sessions, one on one meetings, team meetings and learning and development activities.

I am not of the view that any of the above conditions relate to Ms Edwards' employment with Defence Housing Australia. This view is in terms of causation and the likely aetiology. It is certainly possible that there would be a non-significant contribution in symptomatic terms in terms of work activities where use of the upper limb is more prevalent.

10. If you consider that Ms Edwards is suffering from a pre-existing condition, please describe:

(a) the nature of that pre-existing condition;

(b) the effect that the incident had on that pre-existing condition;

(c) whether Ms Edwards would have the same symptoms and incapacity she has now, even if there had been no recurrence, aggravation or acceleration of a pre-existing condition?

(d) whether, in your opinion, Ms Edwards has made a recovery from the recurrence, aggravation or acceleration caused by the incident?

Answered above. It is my view that Ms Edwards does have basal thumb osteoarthritis which is a degenerative condition common in women with ageing. The de Quervain tenosynovitis noted on the MRI scan is asymptomatic. The intercarpal ligament sprain I am unable to explain based on the history available to me.

14. Do you consider Ms Edwards has a physical capacity for her pre-injury hours and duties? If not, what is specifically preventing her from undertaking her preincident hours and duties?

Ms Edwards has full capacity to work in her usual occupation without restriction with appropriate self-modifications.

1. In a supplementary report, dated 20 December 2023, Dr Journeaux clarified that the reference on page 4 of his first report to 'Mr Duncan' was an error and should have been a reference to Ms Edwards.[29] This mistake was put to Dr Journeaux in cross-examination by Mr Edwards in the context of the number of reports Dr Journeaux wrote per year and was satisfactorily explained as an administrative error.
2. During cross examination by Ms Edwards, Dr Journeaux answered questions relevantly as follows:[30]

Q. Yet when we go over to page 398, which is page 14 of your report, it says that: 'There is no' - 'there's no symptoms'. You're saying that there is currently no symptoms. Are you able to explain that? How there's still symptoms but then you're saying that I'm not suffering symptoms and they're asymptomatic? Are you able to explain the contradictions between those statements?

A. Well, I don't believe it is a contradiction because I'm referring to the, 'alleged', in inverted commas, to De Quervain tenosynovitis noted on the MRI scan. So the findings on the MRI scan are, in my view, incidental and do not correlate or are discordant with the symptoms you are complaining of when I assessed you. So it's to do with that particular condition or diagnosis.

Q. Okay. So are you disagreeing that it's De Quervain's tenosynovitis?

A. Well, I think originally that was the diagnosis, but for the time I assessed you, I did not believe you had that diagnosis.

Q. Okay. So what was it that you were saying that it is, sorry?

A. Well, at the time you presented to me, you had evidence of an intercarpal ligament sprain on the dorsum of the wrist. And I believe there was some evidence of what we call basal thumb osteoarthritis.

1. Ms Edwards asked Dr Journeaux questions in respect of his difference of opinion as an 'independent medical examiner' and the opinion of Dr Morse as a treating physician. Dr Journeaux said 'I certainly respect her opinion on Dr Morse. He has an excellent reputation, but he's not an independent medical examiner. He's not independent of Ms Edwards' care. I, as an independent examiner - I'm completely independent. So I weigh up the history, the examination, the radiological findings, the medical brief. But also, I have an understanding of the aetiology of the condition because it's my duty to do that when I perform independent medical examinations based on my personal experience and my understanding of the literature which is well-documented in this condition'[31].
2. Dr Journeaux answered questions from the Tribunal, relevantly as follows:[32]

Q. Just perhaps if you can make some observations about the difference between it being constitutional and as a result of her workplace. Because that seems to be one of the key differences in the evidence. First, whether there is a diagnosis; because as I understand it, you are not as sure that - it might have been at a time, but not at the time that you saw her. If you could explain that difference first, and then the difference between?

A. I do believe that Ms Edwards did have the diagnosis of De Quervain's tenosynovitis because there's enough evidence in the brief and the history and so on to support that. The key difference between Dr Morse and I is that I'm an independent medical examiner trained in causation. Dr Morse, to my knowledge, has not had those qualifications. And I've never seen him do an actual medical report, performing an independent assessment. And I certainly respect his opinion as a clinician. So there's a difference between a treating doctor and assessing doctor in that regard. The other thing to note that is that De Quervain's tenosynovitis as I've alluded to is a degenerative condition affecting the tendons. And you get secondary effects with swelling and so on. In a sense, assuming that a job does carry a lot of repetitive activities and so on, you can certainly experience worsening of symptoms while the condition is present.

Q. And is that condition, once you've got it, a continuing condition or is it something that can resolve itself?

A. Most conditions of this type are generally - are self-limiting. They typically last for certainly a number of months, maybe six to 12, depending. But with appropriate management, particularly, you know - activity modification, rest, anti-inflammatories and so on - most of the conditions don't need interventional treatment of any great degree. Some of them are helped by having injections and so on, but it's relatively rare that you'd need to operate on one.

Q. Once you have this diagnosis, is it a condition that will be with you for the rest of your life? It might flair up from time to time, but is it a condition that you will then have permanently?

A. Generally, no. It would be very rare for that to happen.

Q. Can you then go on to describe the difference between being constitutional and work related?

A. So I think we're - in this sense, we're referring to what's called the aetiology of conditions. What causes the conditions. So typically, it arises as a result of what's called tendinosis, which is a degenerative, if you like, micro-tears in the tendon and so on, and you get inflammation associated back with thickening. And then, particularly in De Quervain's where you have a tunnel of about 2 centimetres where the tendons (indistinct) up and down, you get thickening of the tendon sheath, and the tendon sheath is lined by what's called a synovium or tenosynovium because it's in the tendon, and that's why you get the inflammation and pain and so on.

Q. I'm trying to understand whether the diagnosed condition is a disease or is an injury?

A. In this case, it's a disease. I would not consider it an injury.

Q. And therefore, is it possible if it is an underlying disease that the workplace aggravated that disease?

A. Generically, a workplace could aggravate the condition, but it's heavily dependent on the actual use of the wrist at the time. So just because one undertakes repetitive movements does not necessarily mean that the condition will be aggravated by the work event. Normally, you need a combination of repetition with force and certain postures.

Q. But with the evidence that's before us in Ms Edward's case, there's no symptomology before the presentation in her evidence before the event which she went to get medical treatment?

Q. And the evidence is pretty clear that there is repetitive data entry for extended periods of time. With that background and context, is it possible that there was an aggravation of an underlying disease?

A. It is possible, depending on the actual level of repetitious work combined with force and posture.

Q. And what type of repetition and what type of work in an administrative data entry employment would you consider necessary to have that connection?

A. Well, if you look at the medical evidence in the literature, there's actually no evidence to support administrative workers as having an incident of De Quervain's tenosynovitis over and above that of a general female or male population.

Q. Dr Morse - disagrees strongly that it is constitutional. He says it's typically an overuse condition with onset due to repetitive use. And he says he feels that it's completely reasonable to assume in her case it is work related. Can you comment on that please?

A. Well, I respectfully disagree with his opinion, because that's not based on a causation analysis of the aetiology of the condition of based on a review of the medical literature.

Q. This is a subsequent letter from Dr Morse dated 17 May 2024. There's about a gap of a year between these two consultations. You would agree with that?

Q. And he has continued to keep the same diagnosis of De Quervain's?

Q. And your consultation for your independent medical report was in between those two, I think. Is that correct?

Q. Can you just comment, then - in circumstances where your previous evidence was that it could have resolved itself, whether or not you would concede that in May 2024 that it may have come back. Is that possible?

A. Yes, I think - well, that certainly seems to be the case, according to that letter.

Q. Are there any other aspects of that letter that you would want to comment on or disagree with?

A. Let's have a look. Only that again, it's to do with this legal causation threshold as per the Comcare Act and so on. So Dr Morse feels it is work related, but I do not believe it relieves - it reaches that legal threshold of causation.

Q. If it was either the ailment of an aggravation of the ailment, are you able to provide an opinion about whether or not the work that Ms Edwards undertook would have contributed to a significant degree?

A. Well, I hold that view because of my understanding and my explanation of the aetiology that I've given to the tribunal. Also the medical evidence does not support a higher incidence of this condition in administrative workers who clearly do repetitious work. So I don't believe it reaches that legal threshold for that reason.

1. Ms Edwards contended as follows:[33]

1. The Applicant has been consistent in her version of events throughout the history of this matter and complied with every request from the Respondent.

2. The approval for the Applicant to receive medical treatment under the EISS program, (when the Employer, DHA's own document confirms this program is only available for work-related conditions) illustrates that the Employer has already admitted liability for this condition. If the Employee and the Employer both acknowledge work causation, why is the Respondent (Insurer) fighting so hard to decline the Applicant's claim?

3. The weight of medical opinion from every treating clinician involved in this matter should be considered when reaching the above decision. It is only the IME doctors, who work directly for the Respondent (insurance company), who disagree with the degree of work causation. One of these doctors making his decision after undertaking a remote examination of the Applicant via video link, which was incomplete due to the lack of available equipment and the other after an approximate 15/20-minute consult. It should be noted that even the Employer-funded Allied Health professionals support work causation in their reports.

4. The Applicant asks the Tribunal to consider the decision-making of the Respondent's decision-maker in the Comcare Reconsideration of Determination document. The decision maker notes the Applicant's employment length (DHA for 18 months and Services Australia for 14 months) and then notes the Applicant's long time in admin roles in the Interior Design industry. We assert the grounds for his decision to be incorrect, as the Applicant was the Owner/Manager of her own floor coverings business for over 15 years (2003 - 2019) and this role was not strictly administrative, rather it was a management role. This inaccurate description of the Applicants work history and associated duties in previous private sector roles gives the impression that there is an increased likelihood of pre-existing pathology that may have affected the outcome of the initial application and subsequent Reconsideration. Furthermore, the Decision makers' choice to place great weight on Dr White's inclusion of references to medical literature is debatable, as there are also many reputable sources that state there to be a link between De Quervains Tenosynovitis and repetitive work duties. Some of these include an RACGP Info sheet on De Quevains Tenosynovitis (Attachment M), the PhysioPedia website (Attachment N) and the American Academy of Orthopaedic Surgeons website (Attachment O).

The decision as to whether the injury has been caused by the repetitive nature of duties of the Applicant's role should be based on the balance of probabilities, not based on who can quote the most medical references. The fact that other State based Insurers, such as Workcover Queensland, regularly accept the work causation link between repetitive computer work and de Quervains tenosynovitis, should be sufficient for Comcare, yet they continue to engage Independent Doctors and Lawyers in an attempt to deny a Commonwealth public servant their reasonable entitlement to treatment under worker's compensation.

1. In her closing submission, Ms Edwards contended that:[34]

3. Dr Morse is a highly qualified Orthopaedic Surgeon. Dr Levi Morse's sub-speciality interests include arthroplasty (hip, knee and shoulder) and upper limb surgery (surgery of the shoulder, elbow, wrist and hand). Dr Morse has advanced fellowship training in upper limb surgery and has published extensively in this field. Dr Morse is also a co-director of the Orthopaedic Research Institute of Queensland (ORIQL), a non-profit organisation that conducts scientific and clinical research in Orthopaedic Surgery. He is also the Director of Training for the Australian Orthopaedic Association at the Townsville University Hospital. Dr Morse regularly teaches and lectures nationally and internationally and hosts visiting Orthopaedic Surgeons within his operating theatre. The Applicant asserts that the above is evidence of the clinical expertise and professional integrity of Dr Morse and should be taken into consideration when placing appropriate weight on their opinion.

4. The Applicant's and Respondent's medical evidence confirm the diagnosis of de Quervain's tenosynovitis (DQT).

5. The Respondent places emphasis on the timeline presented in the Applicant's evidence. The increases in the Applicant's symptoms are quite clearly associated with the periods of their role where there was significant data entry and mouse usage duties. The evidence presented on the first day of the hearing clearly supports the repetitive nature of the Applicant's duties whilst employed by the Employer. The Employer's data provided by the Respondent shows the Applicant had minimal breaks and higher allocation to the 'Queue' task than what would reasonably be expected. The Employer's adherence to schedule metric was policed to ensure the Applicant reached a minimum key performance indicator (KPI) percentage. It was not a tool to promote workplace health and safety.

6. The Applicant's increase in symptoms occurred during busy work periods and decreased during leave periods. Treatment from a team made up of General Practitioner, Sports Physician, Occupational Therapist and Orthopaedic Surgeon (including anti-inflammatory injections), along with a job change, resulted in a decrease in symptoms by December 2022. The Applicant commenced a new role with Defence Travel Services (DTS) on 12 December 2022. The initial months at DTS involved training by way of job shadowing; therefore, the Applicant did not experience repetitive mousing and keyboarding during the December 2022 peak travel workload period. The increase in symptoms in December 2023, sustained during the peak travel workload period for DTS, supports the work causation.

7. Dr Journeaux's examination was undertaken on 1 November 2023, 18 months after the onset of the DQT symptoms. In the previous 18 months, the Applicant had undertaken treatment with their treating GP, Accredited Hand Therapist, Orthopaedic Surgeon (Specialist in the conditions of the upper limbs) and a Sports Physician, who all agreed the condition they were treating was DQT. Such treatments would be expected to temporarily decrease the symptoms of DQT and provide a plausible explanation as to why Dr Journeaux did not believe the Applicant's symptoms, at the time of examination, were DQT and relied on the intercarpal ligament sprain imaging findings. Dr. Journeaux was unable to explain the diagnosis of intercarpal ligament sprain or confirm that the findings were not incidental. This information was presented in their written report and oral evidence. Dr Journeaux initially stated in oral evidence that they disagreed that the Applicant's work contributed to the ailment or an aggravation of the ailment. However, during cross examination, they agreed that exposure to repetitive action for 6 hours/day would be more likely to cause inflammation in the condition than anything else not done repetitively. During oral evidence, Dr. Journeaux appeared to be unfamiliar with the term 'Mother's Thumb', a common name for a type of DQT that affects many young mothers due to frequently picking up and holding a newborn. A simple internet search of reputable medical sites supports this. It is surprising that Dr Journeaux was unfamiliar with this well-known term and its accepted causation. This should be considered when evaluating Dr Journeaux's evidence/opinion supporting the Respondent. Following the Applicant's attendance at Dr Journeaux's IME, the Applicant continued to work full-time in their role at DTS and noticed the subsequent re-emergence of symptoms as workload spiked during the peak travel workload periods (Easter and Christmas). The Applicant again saw Dr Morse in May 2024. During oral evidence, Dr Journeaux stated it certainly seemed the DQT 'may have come back'. This follows the expected pattern of an increase in symptoms following the high-tempo Easter period.

8. Dr White's IME assessment was undertaken via remote video-link. They did not undertake the medical examination themself and noted a lack of equipment to undertake certain tests. Dr White has relied solely on literature of opinions and studies, not on the medical evidence. Dr White states that repetitive action performed by manual workers is a cause of DQT, but they indicate there is low-risk evidence of office-based activities. Dr White acknowledges the evidence linking repetitive lifting of newborn babies to DQT and agrees fluid in compartments can be a symptom of overuse. This conflicts with Dr White's previous assertion that DQT is a degenerative condition rather than from repetitive actions or overuse. Dr White states it would not be unusual for work to cause an increase in symptoms and agrees that 30-50 year old women, who are at higher risk of DQT, make up a large percentage of those who undertake administration duties. It should also be noted that Dr White failed to suitably clarify whether it was their opinion that the Applicant is suffering from an exacerbation or an aggravation of their condition (DQT), when questioned by the Senior Member. This should be a relatively straightforward question for Dr White because it relates to a condition being either permanently made worse or having a temporary increase in symptoms. For these reasons, the Applicant asserts that less weight should be placed on the evidence of Dr White.

9. The Respondent relied on the evidence/opinions of two independent doctors at the Hearing. These opinions are provided by doctors who spent minimal time examining the patient and whose presence at the Tribunal was funded by the Respondent. One of these independent doctors said that they provide over a thousand independent opinions annually and the other did not personally perform a physical assessment. This raises concerns about the quality of such evaluations in this case. The Applicant should not be disadvantaged by their financial inability to fund the presence of the treating doctors at a Hearing, a cost which could run into thousands of dollars. If Comcare had accepted this claim for workers compensation at the beginning and provided the appropriate and timely treatment for a work injury, as is their purpose, then we would not have the Commonwealth funding highly paid 'independent' specialists and barristers at a Hearing. The Applicant would have obtained the appropriate treatment required in a timely manner and would have gotten on with their life. It is not an exaggeration to suggest that the costs of defending this claim are far more than what would have been spent providing timely and clinically appropriate treatment.

10. The Applicant asserts that this is an example of an Insurer trying to avoid its responsibilities. The Applicant was employed in a role that required extended periods of repetitive hand and wrist movements (including gripping) for more than 7 hours out of every 8 hours at work per day. The Employer did not monitor their alleged system of breaks, preferring to concentrate on productivity ahead of safety. Furthermore, the data around rostering and breaks clearly shows the Applicant's exposure to the known causative activity was significant. There has been no evidence submitted to suggest that there was any other activity undertaken by the Applicant during the agreed period for such long periods of time, which could reasonably be attributed to causation. During periods where the Applicant was not exposed to the causative factor, their symptoms improved. When they were again undertaking extended periods of data entry and mousing, their symptoms returned.

11. The Respondent's own data did not support their argument. They then sought to obtain medical opinions to support their viewpoint. Their first IME provider agreed with the treating Surgeon's diagnosis. The Respondent then sought another IME Provider who undertook over 1,000 paid IME consultations per year and this doctor identified an alternate diagnosis, despite every other examining doctor agreeing with the DQT diagnosis. The Respondent has now revised their stance, concurring with the treating medical specialists' diagnosis of DQT. However, they have determined that the condition is not work-related, citing various articles from the Internet as the basis for this conclusion. A simple internet search of reputable medical websites will find just as many articles that state the causal connection exists between repetitive occupational exposure and DQT.

1. The crux of Ms Edwards's submissions is to ask the Tribunal to prefer the evidence of Dr Morse in respect to his opinion about the causation of Ms Edwards's Quervain's arising from her employment with DHA.

(a) Preference should be given to the opinion of Dr Journeaux that the diagnosis of de Quervain's is 'incidental', and the correct diagnosis is 'dorsal intercarpal ligament sprain'. > > (b) De Quervain's is appropriately characterised as a 'disease', based on the medical evidence of Dr Monteagudo, Dr Morse, Dr White and Dr Journeaux. > > (c) Employment with DHA did not contribute to a 'significant degree' to de Quervain's as required by s 5B of the SRC Act, relying on the opinions of Dr White and Dr Journeaux that de Quervain's developed 'due to normal age-related constitutional factors'.

2. Comcare in its closing submissions contends:[36]

(a) Based on the medical evidence, Ms Edwards had the progressive onset of de Quervain's in March/April to August 2022, which then abated in around December 2022 and then re-emerged in around December 2023. > > (b) The sole basis of Ms Edwards claim is that her de Quervain's was caused or aggravated by her work activities, not that they caused or aggravated intercarpal ligament strain or basal thumb osteoarthritis as diagnosed by Dr Journeaux. > > (c) Citing Military Rehabilitation and Compensation Commission v May [2016] HCA 19; (2016) 257 CLR 468 (May) as authority for the proposition that:

If the evidence amounts to something that can be described as an "ailment", being a physical or mental ailment, disorder, defect or morbid condition, it would be more appropriately characterised as a "disease", whereas if the evidence amounts to something that can be described as a sudden and ascertainable or dramatic physiological change or disturbance of the normal physiological state, then it should be more appropriately characterised as an "injury (other than a disease).

(d) That de Quervain's should be characterised as a 'disease' as defined in the SRC Act.

(e) Citing Comcare and Power (2015) FCR 187 (Power), 'This test of contribution requires an evaluative exercise of the matter in s 5B(2) of the SRC Act' and the requirement for a 'significant' connection between Ms Edwards work activities and her condition.

(f) That a predominant aspect of Ms Edward's role at DHA involved the use of a keyboard and mouse, but that does not mean that the symptoms she developed in her wrist are a consequence of that activity.

(g) The evidence of Dr Journeaux and Dr White, together, provides the Tribunal with an independent view that lead to 'the correct and preferable conclusion that the Applicant's typing and mousing activities did not contribute to the claimed condition in any way'.

(h) Aggravation of de Quervain's required a combination of repetition with force and certain postures that was not present in the circumstances of Ms Edwards. Further, citing Commonwealth v Beattie [1981] FCA 88, that 'it is not to say that a worker with a pre-existing injury, who carries out work and as a result suffers pain, will have suffered a compensable aggravation' and it followed from the evidence that there had not been any symptomatic aggravation of her condition.

(i) Because Dr Morse did not give evidence at the hearing, the Tribunal should give little weight to his opinion on causation.

(j) The reliance by Ms Edwards on the 'Statement of Principles concerning De Quervain Tendinopathy (no. 41 of 2019)' was relevant to a claim under the Veterans' Entitlement Act 1986 (Cth) and the Military Rehabilitation and Compensation Act 2004 (Cth) and had no evidentiary effect to claims under the SRC Act. Comcare cited the authority of Vivian and Military Rehabilitation and Compensation Commission [2005] AATA 875 for that contention.

Did Ms Edwards suffer an 'ailment or an aggravation of such an ailment'?

1. The High Court in May at [49] explained that the first task the Tribunal must undertake under the SRC Act is to consider the facts to determine if the employee is suffering a 'disease' or an 'injury'.
2. The question posed of whether Ms Edwards suffered an 'ailment or an aggravation of such an ailment' presupposes a factual finding that de Quervain's is a 'disease' as defined in the SRC Act. The parties did not contend otherwise but it is necessary for the Tribunal to be satisfied as to the distinction between 'injury' and 'disease' for the purposes of the SRC Act.
3. The definition of 'injury' under ss 5A(1) of the SRC Act includes 'a disease suffered by an employee'. Subsection 5B(1) of the SRC Act defines 'disease' to mean either 'an ailment suffered by an employee' or 'an aggravation of such an ailment', that was 'contributed to, to a significant degree, by the employee's employment by the Commonwealth or a licensee'.

1. The diagnosis of 'de Quervain's tenosynovitis' subject of the Claim is derived from the available medical imaging. The opinion of Dr Journeaux that de Quervain's was incidental, and the correct diagnosis was 'dorsal intercarpal ligament sprain' was subject to questions by the Tribunal where Dr Journeaux appropriately conceded that Dr Morse had diagnosed Ms Edwards as having de Quervain's at a time after his clinical examination of Ms Edwards and the provision of his report. Dr White agreed with Dr Morse's diagnosis of de Quervain's and had come to the same diagnosis on his own.
2. As to whether there was an aggravation of a pre-existing degenerative condition, the medical evidence was unequivocal that was not the case. Ms Edwards had no symptomology prior to her employment with DHA that would indicate that the clinical onset of her diagnosis of de Quervain's was earlier than her commencement with DHA.

1. The Tribunal is reasonably satisfied that the correct diagnosis of Ms Edwards condition is 'de Quervain's tenosynovitis' because the opinions of all the medical experts is consistent with the diagnosis and with the available medical imaging.
2. In the context of the medical evidence before the Tribunal, Ms Edwards's condition of 'de Quervain's tenosynovitis' satisfies the definition in 5A(a) of the SRC Act of 'a disease suffered by an employee' and therefore requires application of s 5B of the SRC Act to determine liability.

Was Ms Edwards's ailment contributed to, to a significant degree, by her employment so as to constitute a 'disease'?

1. The application of the term 'contributed to a significant degree by the employee's employment by the Commonwealth or a licensee' in s 5B of the SRC Act was considered by Katzmann J in Power[37]:
   1. There is no room for doubt that the purpose of the 2007 amendments was to strengthen the connection necessary between the employment and the contraction or aggravation of a disease. Including a definition of "significant" as "substantially more than material" makes this abundantly clear. In other words, it is insufficient that the contribution of the employment be "more than trivial"; it had to be substantially more than trivial. The Tribunal did not recognise this, despite its reference to the definition. The error the Tribunal made is similar to the one made by the Tribunal in Sahu-Khan. In a valiant attempt to save the decision Ms Robinson drew attention to the fact that Dr Lewin had said "certainly more than trivial", but this was no more than an emphatic way of saying "more than trivial". It did not satisfy the statutory test and the Tribunal was mistaken in thinking otherwise.
   2. Moreover, the current test of contribution also requires an evaluative exercise to be undertaken. That is apparent both from the words used in subs (1) of s 5B and also the matters to which subs (2) draws attention. The Tribunal did not engage with any of them. Indeed, it did not mention subs (2) at all. While the chapeau to the subsection states that those matters "may" (not "shall") be taken into account, a word which is generally permissive, properly construed it is at least arguable that in this context it is directory; in other words that "may" means "shall": see Julius v Lord Bishop of Oxford (1880) 5 App Cas 214 at 222-223 (Earl Cairns LC); North Australian Aboriginal Justice Agency Ltd v Northern Territory [2015] HCA 41 at [209] (Nettle and Gordon JJ). In the absence of argument on this question I refrain from expressing a concluded view. Nevertheless, there is nothing in the Tribunal's reasons to indicate that it carried out the kind of evaluative exercise required by the statute.
2. On one hand Dr Morse opines that the causation of Ms Edwards condition of de Quervain's is a direct consequence of her employment with the DHA and on the other Dr Journeaux and Dr White opine that it is constitutional.
3. As to Ms Edwards contention that the evidence of Dr Morse should be given greater weight than that of the 'independent medical experts' Dr Journeaux and Dr White, the Tribunal must carefully consider all of the evidence before it and make findings to its reasonable satisfaction. That does not mean the Tribunal must, in a binary fashion, accept one expert opinion over another unless contradictory opinions on a relevant issue are unable to be reconciled.
4. It is true that the Tribunal had the opportunity to hear Dr Journeaux and Dr White give their evidence at the hearing and be subject to cross examination and questions from the Tribunal which may be considered an advantage to Comcare, but a contrary view could also be taken depending on how a witness presented at a hearing.
5. Dr Journeaux and Dr White expressed their confidence in Dr Morse's diagnosis and his clinical skills. This was borne out by Dr Journeaux's concession that he accepted Dr Morse's continuing diagnosis of de Quervain's after Ms Edwards had been subject to clinical examination by him where he had not made that as a primary diagnosis. This finding is consistent with Ms Edward's evidence and submissions that at the time of her examination by Dr Journeaux, her symptomology of de Quervain's had abated due to her changing her employer and the medical treatment she had received since diagnosis.
6. Dr Journeaux differentiated his opinion from Dr Morse on the basis of his expertise in providing 'independent' medical opinions and the specific training and experience he had in that respect. Comcare relied on the decision of HNGN and Military Rehabilitation and Compensation Commission [2018] AATA 4096 (HNGN) for the proposition that independent medical examiners may form a more objective view than treating practitioners who have an ongoing relationship.
7. The Tribunal does not give weight to the distinction between an 'independent medical expert' and a 'treating specialist', rather preferring to weight their respective opinions by reference to all the available evidence and for them to be scrutinised by the Tribunal to make a judgment on their reliability. This approach is consistent with the reasoning in HNGN and the authorities referred to at [92] and [93] that any expert medical opinion to be of value must be founded on proven facts, comprehensible and rationally based.
8. The Tribunal accepts that Dr Journeaux and Dr White were credible expert witnesses who when pressed on their opinions, appropriately conceded or reasonably explained why their opinion was different to Dr Morse.
9. De Quervain's is not a condition with clear cut clinical evidence as to its causation as borne out by the reliance by the parties on various medical journal articles. None of the tendered journal articles were definitive to support Ms Edwards contention, or Dr Morse's opinion, that there was a direct link between Ms Edwards work conditions and the causation of de Quervain's.
10. In fact, the medical journal articles pointed to age, gender and specific occupational and environmental factors as having different degrees of connection with the condition. There was a possibility that Ms Edwards type of occupational conditions might contribute to de Quervain's, but the Tribunal is not reasonably satisfied they rose to the level that the Tribunal can accept that the type of work undertaken by Ms Edwards can be said to cause de Quervain's, or more importantly in the context of s 5B of the SRC Act, significantly contributed to her condition.
11. Ms Edwards contended that the Tribunal should have regard to the Repatriation Medical Authority, 'Statement of Principles concerning De Quervain's Tendinopathy'[38] (the SoP) that applies to the determination of liability for veterans under the Veterans' Entitlement Act 1986 (Cth) and the Military Rehabilitation and Compensation Act 2004 (Cth).
12. Ms Edwards is not a veteran and not entitled to bring a claim under any act that the SoP has legal effect. Consistent with the decision of Deputy President Muller in Vivian and Military Rehabilitation and Compensation Commission [2005] AATA 875, the Tribunal is satisfied that the SoP has no evidentiary basis in Ms Edwards claim under the SRC Act and gives it no consideration in determining the present application.
13. In deciding whether Ms Edwards's de Quervain's was contributed to a 'significant degree' (substantially more than material) by her employment with DHA, the SRC Act expressly provides by reference to s 5B(2) matters for the Tribunal to consider including the duration of her employment; the nature of, and particular tasks involved in her employment; any predisposition of the employee to de Quervain's; and activities of the employee not related to her employment; and any other matters affecting the employee's health.
14. The list is non-exhaustive, and s 5B(2) specifically provides that the matters listed do 'not limit the matters that may be taken into account'.

1. Ms Edwards worked at DHA for approximately 18 months in the same role. The onset of her symptoms started approximately 7 months after she commenced.
2. Her employment history did not include a role commensurate with the type of role she had at DHA.
3. The Tribunal is not reasonably satisfied that her duration of employment with DHA significantly contributed to her de Quervain's.

Nature of tasks involved in employment with DHA

1. The Tribunal accepts Ms Edwards evidence in respect to the sustained and repetitive nature of her data entry, keyboard and mouse usage at DHA. The detailed evidence provided by DHA recording her performance and activity in her call centre role corroborated her evidence. The Tribunal is also satisfied that DHA did not enforce its policies in respect to breaks and failed to properly monitor Ms Edwards through a workplace health and safety focus rather than compliance with key performance indicators.
2. However, whilst Ms Edwards duties at DHA were repetitive and sustained, they were not the type of occupational factors that the medical journals relied upon by the parties, namely the use of significant force and awkward postures in the wrist that are connected with de Quervain's.
3. The Tribunal is not reasonably satisfied that the nature of Ms Edwards's role with DHA over the relatively short period of approximately 18 months has materially contributed to her de Quervain's.

Any predisposition of Ms Edwards to Quervain's

1. Ms Edwards is 51. The Tribunal is reasonably satisfied that the medical evidence shows that Ms Edwards had by her age and gender a predisposition to de Quervain's.
2. Her work history prior to DHA has been in other administrative roles where she used keyboards and a mouse, albeit not to the same intensity and duration as in her role at the DHA and are not likely to have contributed to her de Quervain's.

Any activities of Ms Edwards not related to her employment with the DHA

1. The Tribunal was not satisfied that any other activities undertaken by Ms Edwards, including her gym workouts, during her employment with DHA, had any adverse impact on the path of her de Quervain's.

Any other matters affecting Ms Edwards's health

1. Ms Edwards had no significant comorbidities that would contribute to her condition.

1. The Tribunal is reasonably satisfied that Ms Edwards condition of de Quervain's was not contributed to a significant degree by her employment with DHA, because:

(a) The Tribunal finds that de Quervain's is a degenerative disease of the tendon sheaths in the wrist that is more prevalent in women over 30. > > (b) The Tribunal accepts the opinions of Dr Journeaux and Dr White, insofar as they differ from Dr Morse, in respect to Ms Edwards condition of de Quervain's not being caused by her employment with DHA, as that is consistent with the medical articles relied upon by Ms Edwards and Comcare that do not provide the occupational factor supporting her contention. > > (c) Even if Ms Edwards employment with the DHA contributed to her condition of de Quervain's it was not to the standard required by s 5B of the SRC Act, because the weight of evidence does not support that conclusion, particularly the requirement of force and awkward postures in the use of her wrist. > > (d) Based on the medical evidence, Ms Edwards age and gender made her predisposed to de Quervain's. > > (e) The duration of Ms Edwards employment with DHA was for a relatively short period of approximately 18 months. > > (f) There was no medical evidence of aggravation of a pre-existing condition of de Quervain's and in any event, consistent with the reasoning by the Full Court in Commonwealth v Beattie[39], it is not enough that if her de Quervain's had been a pre-condition that her role with DHA caused an aggravation. > > (g) The Tribunal is reasonably satisfied that it is more likely that Ms Edwards condition of de Quervain's was caused by 'constitutional' factors as opined by Dr Journeaux and Dr White.

1. The Tribunal decides to affirm the decision under review.

Douglas Family Medical Practice records (HB, p531).

Dr Amanda Thompson, Arm to Palm Upper Limb Clinic records (HB, p548-558).

Section 71 response by Ms Kylie Savage, dated 25 August 2023 (HB, p315).

Witness statement of Ms De-Ahne Lee Hamer, dated 24 January 2024 (HB, p410).

Witness statement of Ms De-Ahne Lee Hamer, dated 24 January 2024 (HB, p417).

Presence Report for period 1-31 March 2022 (HB, p248-261).

Report of Dr Simon Journeaux, dated 17 November 2023 (HB, p385-401).

Supplementary report of Dr Simon Journeaux, dated 20 December 2023 (HB, p407-408).

Report of Dr Simon White, dated 24 January 2023 (HB p301).

Extract from AMA Guides to the Evaluation of Disease and Injury Causation (HB, p275).

MD Guidelines: Tenosynovitis, Radial Styloid (HB, p276).

The Histopathology of De Quervain's Disease by M.T. Clarke et al (HB, p285).

De Quervain Tendinopathy literature review by Rohit Aggarwal and David Ring, 2 November 2022 (HB, p291).

Application for Review, dated 3 July 2023 (T1).

Section 37 Statement, dated 7 August 2023 (T2).

Claim for Workers' Compensation, dated 7 December 2022 (T3).

Request for Reconsideration, dated 2 May 2023 (T16).

Ultrasound right wrist, dated 4 August 2022 (T5).

Report of Dr Amanda Thompson, dated 22 August 2022 (T7).

Report of Dr Amanda Thompson, dated 20 December 2022 (T9).

Referral from Dr Garcia-Monteagudo to Dr Levi Morse, dated 18 February 2023 (T13).

Report of Dr Garcia-Monteagudo, dated1 March 2023 (T14).

Report of Dr Levi Morse, dated 21 April 2023 (T15).

Ergonomic assessment report, dated 15 August 2022 (T19, p84-89).

Email from Ms Melanie Mears, dated 11 August 2022 (HB, p121).

Early intervention and return to work document, undated (HB, p122-125).

Emails from and to Ms Melanie Mears and Ms Alana Edwards, dated 1-2 December 2022 (HB, p126-127).

'The side of my wrist hurts' by V Allbrook, dated 11 November 2019 (HB, p131-134).

De Quervain's Tenosynovitis from American Academy of Orthopaedic Surgeons, February 2022 (HB, p136-140).

Incident Report, dated 9 August 2022 (HB, p288-290).

[2] On 14 October 2024, the AAT became the Administrative Review Tribunal (the Tribunal). Under the transitional provisions in the Administrative Review Tribunal (Consequential and Transitional Provisions No. 1) Act 2024 (the Transitional Act), applications for review to the AAT that were not finalised before 14 October 2024 are taken to be an application for review to the Tribunal. The Transitional Act gives the Tribunal the authority to continue and finalise any aspect of the review not already completed by the AAT. This decision and statement of reasons is made by the Tribunal.

[33] Applicant's Statement of Facts, Issues and Contentions (SOFIC) dated 15 December 2023.

[34] Applicant's closing submissions undated.

[35] Respondent's SOFIC dated 14 February 2025.

[36] Respondent's closing submissions dated 8 April 2025.

[37] [2015] FCA 1502 at [93]- [94].

[39] [1981] FCA 88; (1981) 35 ALR 369 at 378.