Statement of Principles concerning olecranon bursitis (Balance of Probabilities) (No. 64 of 2018)

The central concept is "olecranon bursitis" defined as inflammation or infection of the bursa overlying the olecranon process of the ulna. This is a mechanical, clinical definition that excludes bursitis elsewhere and focuses on the elbow. The dictionary defines "immunocompromised state as specified" as a condition of substantially lowered immune function from HIV, immunosuppressive drugs, haematological or solid organ malignancy, chronic renal failure, severe malnutrition, or organ/stem cell/bone marrow transplantation. This list is exhaustive for the purpose of factor 8(4) and 8(11). "Specified list of disorders" means diabetes mellitus, gout/pseudogout/other crystal-induced arthropathy, or rheumatoid arthritis. These are chronic systemic conditions that predispose to bursitis. "Crystal-induced arthropathy" is itself defined as arthropathy from monosodium urate, calcium pyrophosphate dihydrate, calcium hydroxyapatite, or calcium oxalate. "Chronic renal failure" means GFR <15 mL/min/1.73 m2 for three months, or need for dialysis/transplantation. "Immunosuppressive drug" is defined broadly as a drug that results in substantial suppression of immune responses, with a non-exhaustive list including corticosteroids (non-inhaled/topical), transplant rejection drugs, TNF-alpha inhibitors, and chemotherapeutic agents. "Trauma" is not defined but examples are given: cuts, abrasions, lacerations, repeated rubbing or knocking, needle aspiration, or corticosteroid injection. The instrument distinguishes between "clinical onset" (first manifestation) and "clinical worsening" (material contribution or aggravation after the condition was suffered before or during service but did not arise out of service). This distinction matters because factors 8(1) to 8(7) apply only to clinical onset, while factors 8(8) to 8(15) apply to clinical worsening. However, factor 8(15) (inability to obtain appropriate clinical management) can apply to either onset or worsening. The concept of "relevant service" is confined to eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA. Operational service and hazardous service are excluded because they use the higher standard of reasonable satisfaction in the VEA. The instrument uses the balance of probabilities standard only. The concept of "terminal event" is defined to include pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function, allowing death claims.

The primary affected group is veterans and members of the Australian Defence Force who have rendered "relevant service" as defined: eligible war service (non-operational), defence service (non-hazardous, non-British nuclear test), or peacetime service under the MRCA. Claimants with operational service or hazardous service cannot rely on this SOP; they must use the higher "reasonable satisfaction" standard instead. The instrument also affects their dependents for death claims. It directly binds decision-makers: the Repatriation Commission, the Military Rehabilitation and Compensation Commission, and the Veterans' Review Board and Administrative Appeals Tribunal when reviewing decisions. The Repatriation Medical Authority is the rule-maker, but it does not adjudicate claims. Medical practitioners who treat veterans may be indirectly affected because their clinical notes and diagnoses will be scrutinised against the SOP factors. For example, a doctor noting "repeated knocking of the elbow" within 30 days before onset becomes relevant. The instrument creates a compliance burden on veterans to prove the existence of a factor. It also affects legal and advocacy professionals who assist claimants, as they must be familiar with the specific definitions and time frames. The Commonwealth is affected through fiscal implications: acceptance of claims ties to compensation payments, medical treatment costs, and ongoing entitlements. The instrument may also affect private insurers if they cover veterans for similar conditions, though the Veterans' Affairs system is separate. By standardising criteria, the instrument reduces discretion for decision-makers, which limits the ability to accept claims that do not fit the precise factors, even if a doctor believes the condition is service-related. Conversely, it can make acceptance easier for claimants who can show a factor, as they do not need to prove causation by general medical evidence. The instrument does not directly affect non-veterans or civilian workers, unless their employer is the Commonwealth or they have a claim under another scheme that adopts this SOP by reference.

The instrument imposes no duties on private individuals or businesses. It confers a right on a claimant: if at least one factor in section 8 is found to exist and is related to relevant service, then the decision-maker must accept that olecranon bursitis is connected to service on the balance of probabilities. This is a statutory presumption: the decision-maker cannot reject the claim based on contradictory medical opinion if the factor is established. The claimant's duty is to produce evidence that satisfies the factor. For example, for factor 8(1), the claimant must show a bacterial, fungal or algal infection involving the affected bursa at the time of clinical onset. This likely requires pathology results. For factor 8(2), trauma to the external elbow within 30 days before onset: the claimant must show evidence of such trauma (medical records, incident reports). For factor 8(4) (septic bursitis only), the claimant must show they were in an immunocompromised state as specified at the time of onset. The dictionary exhaustively defines that state, so the claimant cannot rely on other immune-compromising conditions. The instrument also imposes a duty on the decision-maker to consider "inability to obtain appropriate clinical management" (factor 8(15)) as a means of connecting the condition to service in the absence of a direct causal factor. This could arise when service prevents the person from getting timely treatment, leading to worsening. The instrument does not create a duty on medical practitioners to report factors, but practical compliance requires careful documentation. For multiple factors, only one needs to be satisfied. The claimant has the right to rely on any factor, but the burden of proof lies with them on the balance of probabilities. There is also a right to rely on another SOP if a factor refers to an injury or disease covered by that SOP (section 10). For example, factor 8(5) refers to having a disorder from the specified list, which includes diabetes mellitus. If the claimant has diabetes, they may need to also satisfy the SOP for diabetes mellitus to establish the diabetes itself is service-related if that is in issue. However, the instrument does not require that the underlying disorder itself be service-related unless the SOP says so; the factor is simply having the disorder at the time of onset or worsening.

This instrument does not create any criminal offences or civil penalties. It is a legislative instrument that sets out rules for administrative decision-making. Enforcement is through the appeals process: a claimant dissatisfied with a decision can seek review by the Veterans' Review Board and then the Administrative Appeals Tribunal. The instrument can be relied on in those proceedings. If a decision-maker fails to apply the instrument correctly, the decision may be set aside or remitted. There is no private right of action for breach of the SOP. However, there is a potential for administrative penalties under the VEA for fraudulent claims, but those would be based on the VEA itself, not this instrument. The instrument can be used as a shield by the Commonwealth: if no factor exists, the claim must be refused unless the decision-maker is satisfied to a higher degree (for operational service). For non-operational service, this instrument is effectively the gatekeeper. The Repatriation Medical Authority has no enforcement role after the instrument is made. Compliance by claimants is voluntary in the sense that they choose whether to claim; if they do claim, they must adduce evidence that meets the factors. The risk for claimants is that if they cannot satisfy a factor, their claim will be rejected, even if a doctor believes the condition is related to service. This creates an incentive to obtain early medical documentation of trauma, infection, or predisposing conditions. There is no penalty for a claimant who misstates facts, but that could be dealt with under the general law of fraud. For the Commonwealth, misapplication of the instrument could lead to successful appeals and payment of compensation plus arrears. The instrument therefore imposes an implicit cost on decision-makers to get it right.

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. That section gives the Repatriation Medical Authority power to determine Statements of Principles on the balance of probabilities. The VEA itself, particularly sections 120 and 120B, governs the standard of proof for different types of service. For operational service, the standard is "reasonable satisfaction" (a higher threshold), and the SOPs are not binding in the same way; the decision-maker must still have regard to them. This instrument applies only to non-operational service under the VEA (eligible war service and defence service excluding hazardous service) and peacetime service under the MRCA. The MRCA system is separate but the SOPs are adopted by reference under section 339 of the MRCA. The instrument interacts with other SOPs through section 10: if a factor (e.g., having a specified disorder) refers to an injury or disease that is itself covered by an SOP, then the factors of that other SOP apply in accordance with its terms. This prevents the need to re-prove the underlying condition's service connection separately, but it means the claimant may need to satisfy the other SOP entirely for that factor to be accepted. For example, factor 8(5) includes having rheumatoid arthritis at the time of onset of olecranon bursitis. If the rheumatoid arthritis is not already accepted as service-related, the claimant may need to rely on the SOP for rheumatoid arthritis to establish that connection. The instrument does not affect criminal law, tort law, or workers' compensation outside the military system. It may interact with the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 for certain veterans, but the MRCA now covers most post-2004 service. The instrument also interacts with the Administrative Decisions (Judicial Review) Act 1977 if a decision-maker misapplies it. It does not affect the common law or contract law. There is no interaction with state workers' compensation schemes because the Commonwealth has exclusive jurisdiction for veterans' entitlements. However, a veteran might also have a civil claim against a third party (e.g., a tortfeasor who caused the trauma), and any compensation from that source may be recoverable by the Commonwealth under the VEA.

The instrument is No. 64 of 2018, determined on 22 June 2018 and commencing on 23 July 2018. According to the text provided, it is a standalone instrument with no amendment history listed. The instrument itself was not amended by later instruments (or if it was, that is not disclosed in the source). Typically, SOPs are replaced rather than amended: a new SOP revokes the old one. The VEA contains a mechanism under s 196B(11) for revocation. Since the source does not provide any previous SOP on olecranon bursitis, we must assume this is the first or a replacement. The instrument states it applies to claims to which s 120B of the VEA or s 339 of the MRCA applies, meaning it is the current version for claims lodged after commencement. No transitional provisions are included. The reader should check the Federal Register of Legislation for any later amendments or a more recent SOP (e.g., No. 96 of 2024 or similar). The instrument has a "Balance of Probabilities" designation, meaning there is likely a counterpart "Reasonable Satisfaction" SOP for operational service (e.g., No. 63 of 2018). That counterpart would have the same factors but different application. The absence of amendment history in the source suggests the instrument has not been amended; but in practice, the Repatriation Medical Authority revises SOPs periodically, often every few years. The reader should verify the current status before relying on this instrument for a claim.

The source text does not mention any case law. However, the SOP system is frequently litigated in the Administrative Appeals Tribunal and the Federal Court. Key recurring issues include: whether a factor is "related to" relevant service; the meaning of "trauma" and whether it includes minor incidents; the interpretation of "immunocompromised state as specified" and whether the definition is exhaustive; the timing requirements (within 30 days before clinical onset); and the distinction between clinical onset and clinical worsening. Cases on other SOPs have held that the terms must be given their ordinary meaning unless defined, and that the list in the dictionary is exhaustive. For example, in a different SOP, the federal court has held that "having" a disorder means the disorder must be present at the relevant time, not just a history. The tribunal has held that "trauma" does not require a specific incident; it can include repeated rubbing. Claimants have challenged the validity of SOPs on the ground that the Repatriation Medical Authority did not consider sound medical-scientific evidence, but such challenges rarely succeed. There are likely no reported decisions specifically on this 2018 olecranon bursitis SOP because it is a relatively straightforward condition. However, general principles from cases on other SOPs apply. The instrument's factor 8(15) (inability to obtain appropriate clinical management) is a common catch-all factor that attracts litigation on what constitutes "appropriate clinical management" and how inability relates to service. The reader should search for "M70.2" and "olecranon bursitis" in AustLII and the AAT decisions. Likely, the instrument has been applied without controversy. Given the lack of specific case references in the source, one must be cautious not to invent authorities.

Several traps exist. First, the instrument applies only to claims where the standard is "balance of probabilities" - that means for eligible war service (non-operational), defence service (non-hazardous), and peacetime service under the MRCA. A claimant with operational service (e.g., deployment to a war zone) cannot rely on this instrument; a separate "Reasonable Satisfaction" SOP exists. Second, the time limits are strict: trauma or surgery must occur within 30 days before clinical onset (factors 8(2), 8(3), 8(9), 8(10)). This is a very short window. Traumatic events that occur earlier, even if they cause chronic changes, do not satisfy the factor unless they lead to immediate clinical onset. Third, the definitions in the dictionary are exhaustive. For example, "immunocompromised state as specified" is limited to six specific conditions. A person with a mild congenital immune deficiency or who is taking long-term antibiotics will not qualify. Fourth, "having a bacterial, fungal or algal infection involving the affected bursa" (factors 8(1) and 8(8)) requires that the infection be present at the time of clinical onset/worsening. A prior infection that has resolved but left damage does not count. Fifth, for septic olecranon bursitis only, the immunocompromised state factor (8(4) and 8(11)) cannot be used for non-septic bursitis. Sixth, factor 8(5) and 8(12) require having a disorder from the specified list at the time of onset/worsening. The specified list includes only diabetes, gout/pseudogout/crystal arthropathy, and rheumatoid arthritis. Other inflammatory arthritides (e.g., psoriatic arthritis, ankylosing spondylitis) are not included, even though they may predispose to bursitis. Seventh, factor 8(6) and 8(13) require the skin disorder to involve the skin of the extensor surface of the affected elbow. A skin condition elsewhere on the body does not count. Eighth, the "tyrosine kinase inhibitor" factor (8(7) and 8(14)) is specific to that drug class; other biologics or DMARDs are not covered unless they also fall within the definition of immunosuppressive drug. Ninth, the instrument distinguishes between clinical onset and clinical worsening. If a person had pre-existing olecranon bursitis before service and it worsened during service, they must use factors 8(8) to 8(15), not 8(1) to 8(7). This matters because the trauma window for worsening is also 30 days before worsening, not 30 days before onset. Tenth, factor 8(15) (inability to obtain appropriate clinical management) is available for both onset and worsening, but the burden is on the claimant to show that service caused the inability (e.g., remote posting, lack of medical facilities). Eleventh, the relationship to service requirement in section 9 means the claimant must not only show the factor exists but also that the factor itself is related to their relevant service. For example, having rheumatoid arthritis might satisfy factor 8(5), but if the rheumatoid arthritis is not service-related, the claim may fail unless the SOP for rheumatoid arthritis connects it. Finally, note that the instrument does not cover death from olecranon bursitis via sepsis or other causes unless the bursitis contributed to the terminal event. The terminal event definitions are broad but require a chain of causation.

For a claimant seeking to rely on this instrument, compliance means gathering evidence that fits neatly within one or more of the 15 factors. The first step is to obtain a clear diagnosis of olecranon bursitis (ICD-10-AM M70.2) from a medical practitioner, ideally with an explicit definitional statement that it is inflammation or infection of the bursa overlying the olecranon process. Second, determine whether the claim is for clinical onset (first appearance) or clinical worsening. If onset, document any infection, trauma, surgery, immunocompromised state, specified disorder, skin condition, or tyrosine kinase inhibitor use that occurred at or before onset. The critical time point is the date of clinical onset: the doctor should record exactly when symptoms began. For trauma, obtain evidence of a specific incident (e.g., accident report, medical record of a cut/abrasion) within the 30 days prior. "Repeated rubbing or knocking" is more subjective; a worker who performed tasks involving repeated elbow pressure (e.g., carpet laying) should have contemporaneous records or a statement describing the nature and timing of the activity. For infection, pathology results confirming bacteria, fungus, or algae in the bursa fluid are required. For immunocompromised state, provide lab results (HIV test, GFR, HIV viral load, cancer diagnosis, transplant status). For specified disorders, supply evidence of diabetes (HbA1c or diagnosis codes), gout (urate crystals or clinical diagnosis), pseudogout, or rheumatoid arthritis. For skin disorders, a dermatology note showing psoriasis, localised sclerosis, atopic dermatitis or other inflammatory skin disorder specifically on the extensor surface of the affected elbow. For tyrosine kinase inhibitors, a medication list and prescription history. For factor 8(15), document a barrier to clinical management: e.g., was the person deployed where no medical care was available? Was there a delay in treatment due to service requirements? The Department of Veterans' Affairs will request all relevant medical reports. The claimant's representative should prepare a statement explaining how each factor is related to service. For example, if trauma occurred during a workplace injury during defence service, link it to the service duties. If the claimant has an immunocompromised state from a condition that is itself accepted as service-related, provide that acceptance. If multiple factors apply, choose the strongest. For death claims, provide evidence that olecranon bursitis contributed to the terminal event (e.g., sepsis leading to respiratory failure). The claimant should be aware that the decision-maker may require the underlying disorder (e.g., rheumatoid arthritis) to also meet its own SOP. Therefore, it may be prudent to also file claims for those conditions. The instrument has no self-certification requirement; compliance is about proof. The Department often uses standard forms that ask for details matching the SOP factors. Finally, if the claim is refused, the claimant can seek review and argue that the evidence meets the factor. The instrument should be cited in submissions. For non-claimants (e.g., doctors), compliance means ensuring clinical notes include the precise date of onset, description of trauma, and identification of predisposing conditions, as these will be scrutinised by the Department.