Statement of Principles concerning de Quervain tendinopathy (Balance of Probabilities) (No. 42 of 2019)

The central concept is “de Quervain tendinopathy” as defined in subsection 6(2). It is not a general term for tendon pain at the thumb base; it is a specific entrapment of one or both tendons in the first extensor compartment of the radial wrist. The definition is self-contained and does not incorporate the full ICD‑10‑AM descriptor for M65.4, which is broader. This means a medical diagnosis using the code M65.4 is not sufficient; the condition must meet the instrument’s own wording. A person may have a clinically diagnosed de Quervain tenosynovitis but still not satisfy the instrument if the tendons are not entrapped in that compartment.

Two key dichotomies are “clinical onset” and “clinical worsening”. Factors 1 through 5 relate to clinical onset (the first occurrence of the condition). Factors 6 through 11 relate to clinical worsening (the condition existing before or during service but not arising out of service; the factors then address aggravation). This distinction matters because for worsening the person must already have had the condition before the relevant service or during it (but not caused by it), and the factor must contribute materially to that worsening. The difference in causation periods also differs: onset factors require the activity or event to occur within a specified period before the clinical onset, while worsening factors use the same periods but measured from the clinical worsening.

The instrument defines “forceful activities” as tasks requiring hand force equivalent to lifting or carrying loads of more than three kilograms, or lifting or carrying an object greater than one kilogram more than ten times per hour. “Repetitive activities” means bending or twisting the hand or wrist at least 50 times per hour, or carrying out the same or similar hand or wrist movements at least 50 times per hour. Both definitions are quantitative and cumulative, requiring at least 500 hours in the six months before onset or worsening. The 500-hour threshold is a bright line: 499 hours in six months does not count. The instrument does not explain how hours are to be aggregated, nor does it address whether rest breaks or shifts affect the accumulation.

“Acute trauma” is illustrated by examples: laceration, puncture, heavy blow, fracture, crush injury. It must involve the affected wrist or tendon and occur within one year before onset or worsening. The instrument does not require that the trauma be the sole cause or even a direct anatomical insult; it just requires that an acute trauma event occurred in that window. The use of “involving” could be interpreted broadly, but the note implies a direct mechanical insult.

The drug factors cover growth hormone (within one year), fluoroquinolone antibiotics (within six months), and aromatase inhibitors (within one year). “Treated with or using” for growth hormone could include self‑administration or prescription use. Importantly, the factor for fluoroquinolones uses “being treated with” not “using”, which might exclude non‑prescription use if such use is possible. The factor for “inability to obtain appropriate clinical management” does not include a time limit, unlike the others. This factor applies to both onset and worsening but only where the inability itself is related to the person’s relevant service (e.g. service prevented access to surgery).

“Relevant service” is defined in the dictionary and comprises three categories: eligible war service (other than operational) under VEA, defence service (other than hazardous and British nuclear test) under VEA, and peacetime service under MRCA. This definition is central: the instrument cannot be used for operational service or hazardous service. For those, a different SoP (No. 41 of 2019, presumably) would apply. The instrument also defines “terminal event” narrowly: pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function, not including other causes like infection without respiratory failure.

This instrument primarily affects three groups: veterans and members of the Forces who have rendered “relevant service” as defined; the decision‑makers within the Department of Veterans’ Affairs and the Military Rehabilitation and Compensation Commission who assess claims; and medical practitioners who provide expert evidence in support of such claims. It does not affect civilians, reservists (unless on peacetime service), or veterans with operational service (for whom a different standard and SoP apply). For claimants with “relevant service”, this instrument determines whether their de Quervain tendinopathy is accepted as service‑related. If accepted, it may lead to compensation for incapacity, medical treatment, or other benefits under the VEA or MRCA. If rejected, the claimant has no right to benefits for that condition.

Decision‑makers must apply the instrument strictly. The instrument removes discretion: a claimant who meets at least one factor, with that factor related to service, must be found to have a service connection on the balance of probabilities. Conversely, a claimant who fails to meet any factor or cannot show the factor relates to service must be refused, regardless of other evidence that a doctor might describe as causal. The instrument binds the decision‑maker and the tribunal (Administrative Appeals Tribunal) in relation to claims under section 120B VEA or section 339 MRCA.

Medical practitioners who provide reports for claimants need to understand the specific definitions. A report that says a veteran did repetitive work for three months but does not quantify the hours per week or the hourly repetitions will be insufficient. The thresholds are quantitative, so a practitioner must be prepared to record the actual frequency and force demands or rely on the veteran’s description. The instrument also means that a practitioner’s opinion on causation that does not align with one of the listed factors will not carry weight; the decision‑maker must refer to the factor and the evidence for it.

The instrument also indirectly affects the Department’s internal systems and the distribution of resources. A new SoP may reduce claims entirely if the factors are hard to prove, or may increase claims if the factors are easier to satisfy. Over time, the instrument influences the pattern of allowed and disallowed claims and therefore the allocation of taxpayer‑funded compensation. While the stated purpose is to apply sound medical‑scientific evidence, the bright‑line rules create a system that is administratively efficient for the Department but may be costly for claimants who must gather detailed evidence of tasks performed years or decades earlier.

The instrument does not impose duties on individuals. Its legal effect is on decision‑makers: they have a duty to apply the factors when determining whether de Quervain tendinopathy is connected to relevant service. Specifically, under section 120B of the VEA, the Commission must be satisfied, on the balance of probabilities, that the condition is related to service, and the Commission must take into account any Statement of Principles determined by the Repatriation Medical Authority. This instrument is such a Statement, and it prescribes the only factors that can positively establish that relationship. The decision‑maker cannot find that an alternative factor (not listed in section 8) establishes the connection, unless that factor falls within section 10 (where it refers to another injury or disease covered by its own SoP). So the duty is to apply the instrument strictly.

Claimants have a right to have their claim assessed in accordance with the instrument. If they can prove the existence of a factor and that it relates to service, they are entitled to a favourable determination. The instrument does not create a right to be paid; it creates a prescribed method of proving the causal link. Claimants also have a right to request a review or appeal a decision, but the review will apply the same instrument unless the SoP is later revoked or replaced.

Claimants have an evidentiary burden. They must produce evidence of the factor: for example, sworn statements or contemporaneous records of the tasks performed, medical records of the trauma or prescriptions, or evidence that appropriate clinical management was unavailable because of service. The instrument’s terms define what counts as “forceful activities” and “repetitive activities”, so claimants must structure their evidence accordingly. A simple claim that “my job involved heavy manual work” is unlikely to suffice unless it can be broken down into force equivalents and repetition counts. This creates a compliance burden, particularly for older veterans whose service records may not contain such detail.

There is no right in the instrument to have a factor relaxed; the 500‑hour threshold is absolute. There is also no right to rely on a factor that is not listed, even if medical science later advances. Therefore the instrument restricts rights as much as it confers them. It is also noteworthy that factor 11, inability to obtain appropriate clinical management, is not time‑limited, so a veteran whose condition worsened because service prevented surgery during peacetime service may have a claim, but they must show that the inability was related to service and that the worsening was material.

This instrument creates no penalties itself. It is not a penal instrument; it does not make anything unlawful or impose fines or imprisonment. Enforcement is relevant only in the sense that a decision‑maker who fails to apply the instrument may have their decision set aside on review. The enforcement mechanism is administrative and judicial. A claimant whose claim is refused because the decision‑maker misapplied the instrument can seek review by the Veterans’ Review Board and then the Administrative Appeals Tribunal, and ultimately the Federal Court on a question of law. Conversely, a refusal that correctly applies the instrument stands, even if the decision appears harsh.

Fraudulent claims for service‑related de Quervain tendinopathy could attract penalties under the VEA or MRCA, including prosecution for making false statements to obtain benefits (section 210 VEA provides for offences), but those penalties are not in this SoP. The instrument merely defines the circumstances under which a claim can succeed; if a claimant fabricates the existence of a factor, the general law against fraud applies.

The Repatriation Medical Authority has no enforcement role under this instrument. Its function ended when it determined the Statement. The Authority can later revoke or replace the SoP, but it does not monitor compliance. Compliance with the instrument is monitored only through the claims and review process. In practice, the greatest enforcement cost is borne by claimants who must satisfy the evidence requirements, not by any regulator.

This Statement of Principles is made under subsection 196B(3) of the VEA and applies to claims under both the VEA and the MRCA (via section 339 of that Act). It does not replace the underlying Acts; it fits within their framework as a delegated legislative instrument. The interaction with the VEA is direct: section 120B requires the Commission to take into account the SoP when deciding claims where the standard is balance of probabilities. Section 196B(3) authorises the Repatriation Medical Authority to determine this SoP for claims where the reasonableness of hypothesis is not in issue (i.e. non‑operational service). For claims involving operational service, the relevant SoP is made under subsection 196B(2) and uses a reasonable hypothesis standard. Therefore a veteran with both operational and non‑operational service must be careful: this SoP applies only to the non‑operational component if the claim is for an injury during peacetime service.

Section 10 of this instrument provides an important interaction: if a factor refers to an injury or disease that has its own SoP, the factors in that other SoP apply as in force from time to time. For example, factor 3 (growth hormone treatment) might involve acromegaly; if acromegaly has a separate SoP, the factors for connecting acromegaly to service would need to be established before the growth hormone treatment itself can be considered as a factor for de Quervain tendinopathy. This creates a chain of causation that could be complex. The instrument also references ICD‑10‑AM, Tenth Edition (2017), but only to indicate the code it attracts; the definition of the condition is independent of that code. If a later edition of ICD‑10‑AM changes the coding, this SoP still uses the 2017 edition as a reference point, but the condition definition remains the instrument’s own.

The dictionary explicitly defines “relevant service” in terms that exclude operational service, hazardous service, and British nuclear test defence service. This means the instrument does not apply to claims under the Veterans’ Entitlements Act for operational service (which are under section 120, not 120B) or to members under MRCA who had hazardous service. Those claims use a different standard and a different SoP. The instrument also does not apply to claims under the Safety, Rehabilitation and Compensation Act 1988 (Commonwealth) for civilian employees, as that Act is not mentioned.

There is no mention of state workers’ compensation laws, but the instrument would not ordinarily apply to state claims. Its effect is limited to Commonwealth veterans’ and defence compensation. However, a state tribunal might refer to it as evidence of medical causation, but not as binding.

The instrument on its face shows no amendment history. It is numbered No. 42 of 2019, made on 1 March 2019 and commenced on 25 March 2019. It is a standalone instrument; there is no indication that it has been amended since commencement. Repatriation Medical Authority Statements of Principles are frequently revoked and replaced as medical knowledge evolves, but this particular version has no amendment record within its text. The instrument states that it was made under subsection 196B(3) and that it applies to claims after its commencement. There is no schedule of amendments or list of superseded provisions. This suggests that as of its publication, it has not been altered. That said, the Authority typically reviews SoPs every five years or earlier if new evidence emerges. Users should check the Federal Register of Legislation for later instruments that revoke or replace this SoP, but as of the instrument’s date, no amendments exist.

This instrument does not refer to any litigation. SoPs are frequently the subject of judicial review and tribunal decisions, but this document does not list or incorporate any case law. The Repatriation Medical Authority states at section 7 that it is of the view, on the sound medical‑scientific evidence, that the condition can be related to relevant service on the balance of probabilities. That statement is not itself litigated. However, the instrument can be challenged in the courts on grounds such as procedural fairness, jurisdictional error, or inconsistency with the VEA. For example, a claimant may argue that the definition of “repetitive activities” is ultra vires the VEA or that the factors do not cover all known causes. But no such litigation is recorded in this document.

In practice, the Administrative Appeals Tribunal and the Federal Court have considered many SoPs, and they often interpret the terms. For instance, the definition of “repetitive activities” has been considered in other SoP contexts. This instrument may attract similar interpretive challenges. A key potential issue is whether the 500‑hour threshold is arbitrary or unsupported by medical‑scientific evidence, but that would be an argument about the validity of the SoP, not about its application. The instrument itself offers no guidance on how to count hours, which might lead to disputes. The Repatriation Medical Authority may have internal guidelines, but they are not in this instrument.

Several traps await unwary claimants and their advisers. First, the definition of de Quervain tendinopathy in subsection 6(2) is specific to entrapment of tendons in the first extensor compartment. A diagnosis of “de Quervain’s tenosynovitis” from a general practitioner that does not specify tendon entrapment may not meet the definition. Similarly, if the pain is localised elsewhere in the wrist, the condition is not captured. Claimants must ensure their medical evidence uses the exact wording of the instrument.

Second, the 500‑hour cumulative threshold for repetitive or forceful activities is a bright line. Even if a veteran performed very intense work for 499 hours over six months, it does not count. The instrument does not define a “cumulative period” - does it mean the total time spent on those activities (e.g. 500 hours of actual work with the hand) or 500 hours of exposure including breaks? It says “cumulative period of at least 500 hours within the six months before the clinical onset”. If the work schedule is 8‑hour days, 10 repetitions per minute, that could be 480 hours over six months of 20‑day months (assuming 8 hours per day x 20 days per month = 160 hours per month; 160 x 6 = 960 hours). But if the veteran only did that work on some days, the calculation becomes messy. There is no formula for partial hours. This creates uncertainty.

Third, the definition of “forceful activities” uses an objective threshold: lifting or carrying loads over 3 kg, or lifting/carrying objects over 1 kg more than ten times per hour. The phrasing “equivalent to” allows some interpretive flexibility, but a biomechanical expert may be needed. The “repetitive activities” threshold (50 times per hour) requires counting bends, twists, or similar movements. A veteran who performed grip‑and‑release actions but not wrist movement may not qualify if the wrist did not bend. Medical evidence of the specific movements is necessary.

Fourth, the drug factors require careful attention to timing. Being treated with a fluoroquinolone antibiotic within six months before onset. The instrument does not specify whether a single dose counts; it likely does. The term “treated with” for fluoroquinolones may exclude self‑medication if the veteran obtained the antibiotic without a prescription. For growth hormone, the language is “treated with or using”, which arguably covers illicit use. Also note that aromatase inhibitors are typically prescribed for breast cancer; their list is not exhaustive but includes only named examples. If a veteran took a different aromatase inhibitor not listed, it may still be caught if it is an aromatase inhibitor per se, as the factor says “an aromatase inhibitor”. But the note may mislead some into thinking only those three drugs count.

Fifth, factor 11: “inability to obtain appropriate clinical management for de Quervain tendinopathy”. This factor does not have a time limit. But it requires that the inability is related to service (per section 9(1)). The condition could be a delay in surgery due to service posting or lack of medical facilities on base. However, “inability” is not defined; does a refusal of treatment count? The factor requires an actual inability, not a choice.

Sixth, the instrument applies only to “relevant service” as defined. If a veteran has both operational service (during war) and peacetime service, and the de Quervain’s began during peacetime service, this SoP applies. But if they claim that the condition was aggravated by later operational service, this SoP does not apply. The correct SoP for operational service would be under subsection 196B(2) with a lower evidentiary standard. Using the wrong SoP could prejudice the claim.

Seventh, the note under factor 8(2) gives examples of acute trauma including laceration, puncture, heavy blow, fracture, crush injury. This is non‑exhaustive, but decision‑makers may be conservative. If a veteran has a fall onto an outstretched hand with no fracture, it may not count as acute trauma unless it can be characterised as a heavy blow. The instrument does not define “heavy blow”.

Eighth, for clinical worsening factors (6‑11), the condition must have been suffered or contracted before or during (but not arising out of) the person’s relevant service. This means the person must have had de Quervain tendinopathy prior to the service or develop it during service from non‑service causes. Then the factor must have caused a material worsening. This is a higher bar than for onset, because the condition must already exist independently.

Ninth, the instrument incorporates other SoPs by reference under section 10. If factor 3 (growth hormone) leads to scrutiny of the underlying condition that required growth hormone, that condition’s SoP must be satisfied. This can create a cascade of evidentiary requirements. For example, if the growth hormone was prescribed for a childhood growth hormone deficiency, and that deficiency is not accepted as service‑related, then the growth hormone factor cannot be used because it must be related to service. But wait: section 9 requires that the factor (being treated with growth hormone) must be related to relevant service. If the treatment itself was prescribed due to a non‑service condition, how can the factor be related to service? It could be that the veteran was treated with growth hormone while in service for a pre‑existing condition, and the prescription was an ordinary medical intervention. The instrument does not say that the condition requiring the drug must be service‑related; it says the factor must be related to service. So if the veteran received the growth hormone during service as part of a military medical centre’s treatment, that likely relates to service. But the difficulty arises if the growth hormone was prescribed before service and continued during service. Then the factor of “being treated” may be said to have commenced before service. The instrument does not say the factor must first occur during service; it says the factor must be related to relevant service. That relationship could be established if the treatment continued during service at a military facility. This is a subtle but important point.

For a veteran or defence member seeking to establish a service connection for de Quervain tendinopathy under this SoP, the first step is to obtain a medical diagnosis that precisely matches the subsection 6(2) definition. The diagnosis should confirm entrapment of one or both tendons in the first extensor compartment, with localised pain and tenderness exacerbated by thumb or wrist movement. The medical report should use the exact wording to avoid interpretive challenge. If the diagnosis uses the ICD‑10‑AM code M65.4 but does not specify the compartment, additional clarification is needed.

Second, identify which factor(s) from section 8 might apply. For clinical onset, consider factors 1-5. For clinical worsening, factors 6-11. The factor must be related to relevant service (section 9). For factor 1 (repetitive/forceful activities), gather evidence of the specific tasks performed, the frequency (at least 50 per hour for repetitive, or force thresholds for forceful), and the cumulative hours over the six months before onset. Ideally, this evidence should be contemporaneous: personnel records, duty statements, eyewitness accounts, or sworn statements from the veteran. If the veteran cannot recall exact hour counts, an ergonomic assessment may help reconstruct likely exposure. A simple statement that the veteran “worked as a mechanic” is insufficient without quantification.

For factor 2 (acute trauma within one year before onset), obtain medical records showing the trauma to the affected wrist or tendon. The records should identify the nature of the trauma (e.g., blunt force, crush) and its date. If the trauma occurred during service, show that in the record. For factors 3-5 (drugs), obtain prescription records or hospital charts showing the drug, dosage, and dates. Ensure the timing window (one year or six months before onset/worsening) is respected. For factor 11 (inability to obtain appropriate clinical management), show that appropriate management (e.g., splinting, NSAIDs, corticosteroid injection, surgery) was unavailable or inaccessible because of service circumstances, and that the unavailability contributed to the onset or worsening.

Third, ensure that the factor is related to relevant service. For example, if the repetitive activities were part of a civilian job before service, they do not count unless they also occurred during service. The relationship means that the factor itself must have arisen from the person’s service (section 9(1)). For factors 6-11 (worsening), the condition must have existed before or during service but not from service, and the factor must contribute materially to the worsening. That means the baseline condition must be established clinically.

Fourth, compile the evidence into a claim and submit it to the Department of Veterans’ Affairs or the Military Rehabilitation and Compensation Commission, referencing this SoP. The decision‑maker will assess whether at least one factor exists and is related to service. If the claim is accepted, compensation flows. If rejected, the veteran can seek review, and the reviewing body will apply the same SoP.

For decision‑makers, compliance means applying the definitions strictly. Do not relax the 500‑hour threshold; do not accept a diagnosis that does not meet subsection 6(2) unless it can be clarified. Use the dictionary definitions for “forceful activities”, “repetitive activities”, and “acute trauma”. For drug factors, verify the drug class and timing. For factor 11, require evidence of inability and its service connection. For operations where standard the social, legislative or procedural elements are involved, note that this SoP does not apply to operational service. The decision‑maker should also check whether any factor refers to another condition with its own SoP (section 10) and apply that SoP if relevant. Maintaining a record of the evidence considered and the factor relied on will assist in defending any review.

For legal practitioners and advocates, the best strategy is to identify all possible factors early. If one factor is weak, build another. The cumulative nature of factor 1 (hours) can be supported by a job analysis expert. The drug factors are straightforward if records exist. Keep in mind that the SoP is binding and exhaustive. Do not argue that a factor not listed is sufficient on its own; that will not succeed. Instead, argue that the evidence meets the terms of a listed factor, or challenge the validity of the SoP itself (a rare strategy). The note to factor 8 says examples of acute trauma are not limited; use that to argue that other acute events (e.g., a twisting injury) might qualify if they involve the wrist or tendon. But be prepared for a decision‑maker to read “acute trauma” narrowly as a sudden mechanical insult.

Finally, monitor whether this SoP is revoked or replaced. The Repatriation Medical Authority revokes and issues new SoPs periodically. A more recent SoP might have different factors, lower thresholds, or broader definitions. The Veterans’ Entitlements Act allows the Minister to request a review. Staying current on the legislation is a compliance imperative.