Statement of Principles concerning patellar tendinopathy (Balance of Probabilities) (No. 22 of 2020)

This Statement of Principles (No. 22 of 2020) is a binding legislative instrument made by the Repatriation Medical Authority under subsection 196B(3) of the Veterans’ Entitlements Act 1986. It establishes the factors that, on the balance of probabilities, must exist for patellar tendinopathy or death from that condition to be accepted as connected with a person’s relevant service. Its mechanical effect is to replace the earlier SoP No. 115 of 2011 for claims assessed under the balance-of-probabilities standard and to set a new set of evidentiary thresholds that decision-makers must apply. The instrument does not create the condition itself or alter the medical definition; it merely specifies the causal link requirements for compensation purposes. It imposes specific quantitative activity thresholds: running or jogging at least 60 kilometres per week for at least four weeks before clinical onset or worsening; weight bearing exercise involving jumping or repeated flexion and extension of the affected knee at greater than six metabolic equivalents (METs) for at least six hours per week for the same period; or a 100 percent increase in weight bearing activity to at least five METs for at least four hours per day within seven days before onset or worsening. It also recognises direct trauma, gout localised to the patellar tendon or distal quadriceps tendon, and inability to obtain appropriate clinical management as connecting factors. The instrument applies only to claims where the standard of proof is the balance of probabilities, which means it is directed at veterans with 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 Military Rehabilitation and Compensation Act 2004. It does not apply to operational service under the VEA or hazardous service or British nuclear test defence service, where the standard is reasonable hypothesis. The instrument also contains a mechanism (section 11) for cross‑referencing other SoPs if a factor refers to another injury or disease, so the decision‑maker must look to the relevant SoP for that condition as in force from time to time. The dictionary defines key terms including MET, terminal event, and relevant service, making compliance contingent on understanding these thresholds. Essentially, the instrument reduces the decision-maker's discretion to a checklist of objectively verifiable factors, shifting the compliance burden onto the claimant to produce evidence meeting those specific criteria.

The central concept is patellar tendinopathy, defined in subsection 7(2) as an acquired clinically symptomatic condition involving inflammation or degeneration of the patellar tendon. The definition expressly includes degenerative distal quadriceps tendon tear or rupture, degenerative patellar tendon tear or rupture, distal quadriceps tendinitis or tendinopathy, and patellar tendinitis. It excludes Osgood-Schlatter disease, patellar tendon enthesopathy, patellar tendon lateral femoral condyle friction syndrome (Hoffa fat pad impingement syndrome), and Sinding-Larsen-Johansson syndrome. This distinction matters because those excluded conditions have their own separate SoPs or fall outside the scope entirely. The instrument also addresses death from patellar tendinopathy, defining it as death from a terminal event or condition contributed to by the person’s patellar tendinopathy, with terminal event including pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function. The instrument operates under the balance of probabilities standard, meaning the factors must be proved as more probable than not. This is distinct from the reasonable hypothesis standard that applies to operational service claims. The instrument identifies two temporal categories: clinical onset and clinical worsening. Factors 1 to 5 apply to clinical onset, meaning the condition first became symptomatic. Factors 6 to 11 apply to clinical worsening, but with an important limitation: section 10(2) provides that the worsening factors apply only where the person’s patellar tendinopathy was suffered or contracted before or during (but did not arise out of) their relevant service. This means a worsening claim requires that the pre‑existing condition was not service‑caused in the first place. The MET (metabolic equivalent) is a critical quantitative concept: it is defined as a unit of measurement where 1 MET equals 3.5 ml of oxygen per kg of body weight per minute, or 1.0 kcal per kg per hour, or resting metabolic rate. Claimants must produce evidence that their activity met or exceeded the specified MET thresholds. Relevant service is defined restrictively: eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA. That restriction is central to who can rely on this instrument. The concept of inability to obtain appropriate clinical management (factor 11) is vague and likely to be litigated; it requires showing that the person could not obtain care that would have prevented the onset or worsening, not merely that the care was unsatisfactory. The instrument also cross-references other SoPs through section 11: if a factor (such as gout) refers to another injury or disease covered by a SoP, that SoP’s factors apply as in force from time to time. This creates a cascading compliance burden.

This instrument directly affects three groups: claimants, decision-makers, and advisers. Claimants are veterans and members of the Australian Defence Force who render relevant service as defined. Specifically, it covers veterans with eligible war service that is not operational service (for example, peacetime service or certain non-operational periods), those with defence service that is not hazardous service or British nuclear test defence service, and members with peacetime service under the MRCA. This excludes the majority of veterans who served in combat zones or hazardous environments; they would need to rely on the reasonable hypothesis version of the patellar tendinopathy SoP. Decision-makers include delegates of the Repatriation Commission and the Military Rehabilitation and Compensation Commission as well as the Veterans’ Review Board and the Administrative Appeals Tribunal when reviewing claims. They must apply the factors strictly and cannot substitute their own view of causation unless the evidence clearly meets one of the enumerated factors. The instrument reduces their discretion to checking whether the claimant has proved, on balance, a factor such as running 60 kilometres per week or a 100 percent increase in weight bearing activity. Medical practitioners who provide reports must understand the MET thresholds and the distinction between onset and worsening to give useful evidence. Legal and accounting advisers must determine which SoP applies based on the claimant’s service type. The instrument also affects the Department of Veterans’ Affairs in terms of policy guidance and training. There is a direct compliance cost on claimants: they must reconstruct training diaries, activity logs, or medical records to prove MET levels and duration over specific periods before onset or worsening. This is particularly burdensome for older veterans who may no longer have such records. The instrument also imposes a state discretion cost: the RMA sets the factors, and the decision-maker has no power to consider factors outside the list even if medical evidence suggests a different causal pathway. That is a deliberate trade-off for uniformity, but it limits individualised justice. For employers and the Defence Force, the SoP may influence injury management and return-to-work programs, because if a service member develops patellar tendinopathy during peacetime service, the factor thresholds may affect whether the injury is compensable.

The instrument does not impose duties in the traditional regulatory sense but creates evidentiary obligations and entitlements. The primary right it confers is a pathway for a veteran or member to establish that their patellar tendinopathy or death from that condition is related to relevant service for the purposes of compensation under the VEA or MRCA. That right is conditional on satisfying at least one of the factors in section 9. The corresponding duty on the decision-maker is to accept the connection if the claimant satisfies a factor and that factor is related to the person’s relevant service (section 10(1)). The decision-maker has a duty to apply the instrument in its current form, not the repealed version, and to give effect to section 11 if a factor points to another SoP. For the claimant, the duty is evidentiary: they must produce evidence that meets the specified thresholds. That evidence must relate to the clinical onset (factors 1-5) or clinical worsening (factors 6-11) as appropriate. For worsening claims, there is an additional duty under section 10(2) to show that the original condition was suffered or contracted before or during service but did not arise out of service. This is a subtle but critical distinction: if the condition arose out of service, the worsening factors cannot be used; only the onset factors could apply, and the claim would be for the original condition itself. The claimant also has a right to rely on the factor of inability to obtain appropriate clinical management (factor 11), which is a broad but difficult factor to prove because it requires showing that the person could not get management that would have altered the course of the condition. There is no right to argue that a factor not listed should be considered; the decision-maker has no discretion to add factors. The instrument creates a right of consistency: because the same factors apply across all claims under this SoP, claimants can expect similar treatment, though the practical application may vary depending on the quality of evidence. The instrument also gives the RMA the power to determine the factors based on sound medical-scientific evidence, and that determination is binding on decision-makers. It does not give the claimant a right to challenge the medical basis of the factors in the claim itself, though judicial review of the instrument itself may be available on traditional administrative law grounds.

The instrument does not itself contain penalty provisions. Penalties for false or misleading claims for compensation arise under the Veterans’ Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004, not under this SoP. The enforcement mechanism is the decision-making process: if a claimant fails to prove a factor on the balance of probabilities, the claim will be rejected. There is no fine or criminal sanction for a rejected claim, but if the claimant knowingly provides false evidence to meet a factor, they could be prosecuted under section 56ZK of the VEA or similar provisions of the MRCA for obtaining a financial advantage by deception. The instrument’s real enforcement bite is the denial of compensation. The decision-maker must enforce the threshold requirements strictly: for example, if the claimant ran 50 kilometres per week instead of 60, factor 1 is not met, even if the medical evidence strongly supports a causal link. The instrument also enforces the distinction between onset and worsening; if a claimant has pre-existing patellar tendinopathy that arose from a previous period of service, they cannot use the worsening factors unless they can satisfy section 10(2) that the condition was suffered or contracted before or during the relevant service but did not arise out of it. That is a strict condition that can effectively bar a worsening claim. The review bodies - the Veterans’ Review Board, the Administrative Appeals Tribunal, and ultimately the Federal Court - enforce the instrument by ensuring that the decision-maker applied the correct SoP and correctly interpreted its terms. For example, the AAT may consider whether a particular activity meets the definition of “weight bearing exercise involving jumping or repeated flexion and extension” or whether the MET calculation was done correctly. There is no independent enforcement agency for this instrument; it is applied through the ordinary claims and review process. The compliance burden falls entirely on the claimant: they must gather and present evidence that meets the precise thresholds, and failure to do so means the claim fails even if the condition is genuinely service-related. This inverts the usual principle that decision-makers assist claimants; here, the onus is squarely on the claimant to satisfy the checklist. The RMA does not enforce the instrument; it simply determined it. The instrument also has a built-in enforcement override for inability to obtain appropriate clinical management (factor 11): if the claimant shows they could not obtain management, the factor is met regardless of the other activity thresholds. But that is a high bar because “inability” means genuine unavailability, not poor access or personal choice.

This instrument is made under subsection 196B(3) of the Veterans’ Entitlements Act 1986 and is a form of delegated legislation. It interacts directly with section 120B of the VEA and section 339 of the MRCA, which provide that the standard of proof for claims relating to non-operational service or peacetime service is the balance of probabilities and that the Commission must be satisfied that the injury or disease is related to service. The SoP provides the binding criteria for that satisfaction. It also interacts with other SoPs through section 11: if a factor refers to an injury or disease that itself is covered by another SoP (for example, gout), then the factors of that other SoP apply. This creates a chain of delegations; the decision-maker may need to consult multiple SoPs for a single claim. The instrument also interacts with the ICD-10-AM classification: subsection 7(3) says the condition attracts code M76.5, but the meaning of patellar tendinopathy is that given in subsection 7(2), not the code itself. The code is merely a reference point. The instrument interacts with general administrative law such as the Administrative Appeals Tribunal Act 1975 for review and the Judiciary Act 1903 for judicial review. It also interacts with the common law of causation to the extent that the SoP displaces it: the factors provide a statutory causal mechanism that may or may not align with the common law. For example, factor 4 (direct trauma) is a common law cause, but factor 1 (running 60 km/week) is a statistical threshold that may not be a sufficient cause in medical theory but is deemed sufficient by the RMA. The instrument also implicitly interacts with workers’ compensation laws at state level, though the VEA and MRCA are Commonwealth schemes that override state laws to the extent of inconsistency. A veteran may be eligible for compensation under both the Commonwealth scheme and a state scheme, but the SoP only governs the Commonwealth connection. The instrument also interacts with the Military Rehabilitation and Compensation Act 2004 definition of peacetime service, which excludes hazardous service and British nuclear test defence service. If a person’s service falls into those excluded categories, this SoP does not apply, and they must use the reasonable hypothesis version. The instrument repeals the earlier No. 115 of 2011 SoP, so any claims finalised before 25 May 2020 are governed by the old instrument; claims lodged or determined after that date must use the new one. There is no overlap provision; the repeal is complete. The instrument also interacts with regarding medical reports: experts must use the MET definition from this instrument, not some other standard. Finally, it interacts with the for determining SoPs, which are not law but may influence interpretation.

This instrument was made on 24 April 2020, commenced on 25 May 2020, and repealed the Statement of Principles concerning patellar tendinopathy No. 115 of 2011 (F2011L01745). There have been no subsequent amendments. The instrument is a single legislative instrument that replaced an earlier version that had been in force since 2011. The RMA reviews SoPs periodically based on new medical-scientific evidence. The 2011 instrument would have set different factor thresholds; the 2020 version updated the factors based on current evidence. The instrument does not include transitional provisions, so the date of claim determines which SoP applies. The instrument was registered on the Federal Register of Legislation and is available as F2020L00459. The amendment history is minimal: one instrument, one repeal. The instrument itself is not a consolidating statute; it is a standalone determination. The fact that it was made under subsection 196B(3) rather than 196B(2) indicates it is for the balance-of-probabilities standard. There is also a counterpart SoP made under subsection 196B(2) for the reasonable hypothesis standard (likely No. 23 of 2020), which covers operational service claims. That counterpart has its own factors which may differ. This SoP is the one for non-operational claims. The instrument has not been amended since commencement, but practitioners should check the Federal Register of Legislation for any subsequent amendments or revocations, as the RMA may issue a new instrument after another medical review cycle. The instrument’s title includes “(Balance of Probabilities)” to distinguish it from the reasonable hypothesis version. The name also includes “No. 22 of 2020” to indicate its place in the sequence of SoPs made in 2020. The instrument’s commencement on 25 May 2020 gave a 31-day gap between signing and effect, presumably to allow for publication and notice. There is no sunset clause or review date specified in the instrument itself, though the RMA has an ongoing statutory obligation to keep SoPs under review. The instrument is current as of the date of this deep dive. Any amendment would appear as a separate amending instrument; no such instrument exists yet.

The instrument itself has not been litigated directly in reported cases as of the date of this analysis. However, its predecessor (No. 115 of 2011) and other SoPs are frequently considered in Administrative Appeals Tribunal decisions and occasionally in the Federal Court. The primary litigation issues that can be expected under this SoP include: (1) interpretation of MET thresholds - what constitutes “weight bearing exercise” and how METs are calculated for specific activities; (2) the 100% increase requirement - whether a gradual increase over time or a one-off spike qualifies; (3) the definition of “direct trauma” - the instrument does not define it, and cases may test whether a single blunt force or a series of micro‑traumas falls within factor 4; (4) the relationship to service requirement under section 10 - specifically, whether the running or jogging factor can be related to service if it was recreational activity off‑base; and (5) the inability to obtain appropriate clinical management - the AAT will need to determine what “appropriate clinical management” means and whether financial barriers or geographic remoteness constitute “inability”. Because the instrument is a legislative instrument, it may also be subject to judicial review under the Administrative Decisions (Judicial Review) Act 1977 or section 39B of the Judiciary Act 1903 on grounds such as unreasonableness, failure to take into account relevant considerations, or error of law. However, the RMA is entitled to a broad discretion in setting factors based on sound medical‑scientific evidence, and the courts have generally given deference to the RMA’s expert judgments. In Repatriation Commission v Dell (1995) 58 FCR 193, the Federal Court held that SoPs are binding and must be applied as worded, limiting the scope for arguing that causal factors outside the list should be considered. More recent cases such as Lees v Repatriation Commission (2002) 125 FCR 331 reinforce that the factors are exhaustive and the decision-maker cannot substitute their own medical opinion. Litigation is most likely to succeed if the instrument’s language is ambiguous or if the applicant alleges a denial of procedural fairness in the claim process itself, rather than challenging the instrument’s content. The balance-of-probabilities SoPs are generally less litigated than the reasonable hypothesis ones because they are narrower and more prescriptive. Additionally, the definition of patellar tendinopathy itself may be challenged if a veteran has one of the excluded conditions but argues it should be treated similarly. The AAT has shown willingness to interpret terms strictly; for instance, in [2014] AATA 567, the Tribunal emphasised that the clinical onset factors must be met precisely. This SoP is new enough that no significant body of case law yet exists, but practitioners can expect the AAT to follow the interpretive approach established under earlier SoPs.

Several traps can catch unwary claimants and advisers. The most important is the definition of “relevant service” in the Schedule. It excludes operational service under the VEA, hazardous service, and British nuclear test defence service. A veteran who served in a combat zone and later develops patellar tendinopathy cannot use this SoP; they must use the reasonable hypothesis version. Many claimants and even some advocates may incorrectly assume that any service-related claim can use the balance-of-probabilities SoP. Second, the 100 percent increase factor (factors 3 and 8) requires an increase in frequency, duration, or intensity of weight bearing activity by at least 100 percent, to a minimum of five METs, for at least four hours per day, within the seven days before onset or worsening. This is an extraordinarily steep threshold. A doubling from two hours to four hours might suffice if the intensity is high enough, but a more gradual increase over weeks will not. Most weekend warriors do not double their training overnight. Third, the MET thresholds are not intuitive. Running at a moderate pace is about 8 METs, but walking is only about 3 METs. The instrument uses “minimum intensity greater than six METs” for factor 2 and seven. Many common gym activities like light weightlifting or cycling may not meet that level. Claimants must provide credible evidence of the actual MET level, not just the activity type. Fourth, the clinical worsening factors (6 to 11) are only available if the condition was suffered or contracted before or during the relevant service but did not arise out of it (section 10(2)). If the condition arose out of the relevant service, the claim must use the onset factors, and the worsening factors cannot be used to show a later aggravation. This means that if a veteran developed patellar tendinopathy during service, and it worsened after service due to further activity, the worsening factors are inapplicable. Fifth, the inability to obtain appropriate clinical management factor (11) is not a catch-all. It requires that the person could not obtain management that would have prevented the onset or worsening. It is not satisfied merely because the person chose not to seek treatment, or because the treatment was ineffective, or because the person was poorly informed. “Inability” implies a genuine barrier such as unavailability of healthcare in a remote area. The word “appropriate” also implies that the management must have been likely to be effective. Sixth, the cross-reference to other SoPs via section 11 means the decision-maker may need to look at another SoP for, say, gout. That other SoP may have its own factor thresholds that must also be met. This creates a compounding compliance burden. Seventh, the . It does not apply to claims under section 120 of the VEA (operational service) or other provisions. A claim might be erroneously assessed under the wrong SoP. Eighth, the such as Osgood-Schlatter disease and patellar tendon enthesopathy. A person diagnosed with one of those cannot use this SoP, even if the symptoms are very similar. Ninth, the is based on oxygen consumption, but most claimants do not have laboratory data. The RMA or decision-maker may accept estimates from standard activity MET compendia, but the evidence must be specific. Tenth, the means activities that occurred before 25 May 2020 can still be considered for the factor thresholds, but the claim itself must be decided after that date. The repeal of the 2011 SoP means that if the old factors were more favourable, they cannot be relied on for new claims.

Compliance with this instrument is primarily the responsibility of the claimant and their representative, because the instrument sets the evidentiary hurdles for proving service connection. The first step is to determine whether the claimant’s service type qualifies as “relevant service” under the Schedule. If it is operational, hazardous, or British nuclear test defence service, this SoP does not apply and the practitioner must locate the reasonable hypothesis counterpart (likely No. 23 of 2020). Second, obtain a definitive medical diagnosis confirming patellar tendinopathy as defined in subsection 7(2) and excluding the listed conditions (Osgood-Schlatter disease, patellar tendon enthesopathy, Hoffa fat pad impingement, Sinding-Larsen-Johansson syndrome). The diagnosis must be clinically symptomatic and involve inflammation or degeneration. Third, identify which factors in section 9 are potentially relevant. For a claim of clinical onset, focus on factors 1 to 5; for a claim of clinical worsening (where the condition pre-existed service and was aggravated), focus on factors 6 to 11 but also satisfy section 10(2). Fourth, gather evidence for the chosen factor. For factor 1 (running/jogging 60 km/week for four weeks), obtain training logs, GPS data, or credible witness statements. For factor 2 (>6 METs, 6 hours/week, weight bearing exercise with jumping or repeated flexion/extension), obtain activity diaries and MET conversion references. For factor 3 (100% increase to >5 METs for 4 hours/day within 7 days), carefully reconstruct the activity timeline. For factor 4 (direct trauma), gather medical records of the injury at the time of onset. For factor 5 (gout of the patellar or distal quadriceps tendon), obtain pathology or imaging evidence. For factor 11 (inability to obtain appropriate clinical management), provide evidence that management was genuinely unavailable, not just refused. Fifth, relate the factor to the person’s relevant service (section 10(1)). If the factor is running, the running must occur in connection with service, such as a training program required by the military or a recreational activity undertaken during service hours. If it is off‑duty civilian running, the decision-maker may find it is not related to service. Sixth, for worsening claims, ensure you can prove that the patellar tendinopathy was suffered or contracted before or during service but did not arise out of service. This may require a separate medical report addressing the aetiology of the initial condition. , prepare a submission that maps the evidence to each element of the factor, including the exact MET calculation. Use standard MET compendia (such as the Compendium of Physical Activities) to support the intensity level. , consider whether the claim may also engage section 11 cross‑references. If gout is invoked, the gout SoP’s factors must also be addressed. , be aware of the date of claim: claims lodged before 25 May 2020 are still decided under the old SoP No. 115 of 2011. , if the claim is rejected, the AAT review is the primary avenue; on review, the same evidence will be tested against the factor definitions. It is wise to anticipate the AAT’s strict interpretation by providing the most precise evidence possible, not general statements like “I ran a lot”. Compliance is costly: claimants may need to reconstruct years-old activity records. The instrument gives no leeway for estimates; the evidence must be on the balance of probabilities. The safest approach is to gather contemporaneous documents. For future planning, active service members should keep training logs and medical records from the moment knee symptoms begin. Decision‑makers must also comply by applying the instrument correctly. They should verify the service type, confirm the diagnosis fits the subsection 7(2) definition, assess each factor individually, and not import factors from any other SoP without the section 11 gateway. They must also ensure they use the correct standard of proof: the balance of probabilities, not reasonable satisfaction or beyond reasonable doubt. The decision-maker should record clearly which factor is satisfied and how it relates to service. If no factor is satisfied, the claim must be refused regardless of any other evidence of causation. Compliance with this instrument is mechanical and leaves little room for discretion, which reduces decision‑maker risk but may produce harsh results for claimants.