ShuMan

Shoulder impingement syndrome C&P thoughts?

8 posts in this topic

Vets,

At what rating (if any) do you think the below C&P will be documented?

As always, thank you so much!!!!

 

1. Diagnosis

------------

a. List the claimed condition(s) that pertain to this DBQ:

R Shoulder

b. Select diagnoses associated with the claimed condition(s) (check all that

apply):

[X] Shoulder impingement syndrome

Side affected: [X] Right [ ] Left [ ] Both

ICD Code: M75.41

Date of diagnosis: Right 2009

[X] Other (specify):

Other diagnosis: Avulsion injury to superior aspect of the distal clavicle

Side affected: Right

ICD code: S52

Date of diagnosis (right side): 2009

********************************************************************

c. Comments, if any:

NA

d. Was an opinion requested about this condition?

[ ] Yes [X] No [ ] N/A

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

shoulder

or arm condition (brief summary):

The Veteran reports he developed some shoulder pain with lifting sand

bags.

b. Dominant hand:

[X] Right [ ] Left [ ] Ambidextrous

c. Does the Veteran report flare-ups of the shoulder or arm?

[X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his

or

her own words:

When I did any thing heavy like lift air compressors when I was in the

service, it would hurt. Now a days I feel it when I do yard work or

digging. Or if I hold it in one position for too long.

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d. Does the Veteran report having any functional loss or functional

impairment

of the joint or extremity being evaluated on this DBQ (regardless of

repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or

functional impairment in his or her own words:

Manual labor hurts it.

3. Range of motion (ROM) and functional limitation

--------------------------------------------------

a. Initial range of motion

Right Shoulder

--------------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 50 degrees

Abduction (0 to 180): 0 to 50 degrees

External rotation (0 to 90): 0 to 65 degrees

Internal rotation (0 to 90): 0 to 90 degrees

If ROM is outside of normal range, but is normal for the Veteran (for

reasons other than a shoulder condition, such as age, body habitus,

neurologic disease), please describe:

It is difficult to assess due to his level of anticipatory pain or

marginal effort.

If abnormal, does the range of motion itself contribute to functional

loss? [ ] Yes (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Flexion, Abduction, External rotation

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation of

the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

Anterior shoulder, not joint space or not able to localize

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Left Shoulder

-------------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 180 degrees

Abduction (0 to 180): 0 to 150 degrees

External rotation (0 to 90): 0 to 80 degrees

Internal rotation (0 to 90): 0 to 90 degrees

If abnormal, does the range of motion itself contribute to functional

loss? [ ] Yes (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Abduction, External rotation

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation of

the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

Anterior shoulder

b. Observed repetitive use

Right Shoulder

--------------

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional functional loss or range of motion after three

repetitions? [ ] Yes [X] No

Left Shoulder

-------------

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional functional loss or range of motion after three

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repetitions? [ ] Yes [X] No

c. Repeated use over time

Right Shoulder

--------------

Is the Veteran being examined immediately after repetitive use over time?

[X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

Left Shoulder

-------------

Is the Veteran being examined immediately after repetitive use over time?

[X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups

Right Shoulder

--------------

Is the exam being conducted during a flare-up? [ ] Yes [X] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-ups?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

Not currenlty in a flare up.

Left Shoulder

-------------

Is the exam being conducted during a flare-up? [ ] Yes [X] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-ups?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

e. Additional factors contributing to disability

Right Shoulder

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--------------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

Left Shoulder

-------------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

4. Muscle strength testing

--------------------------

a. Muscle strength - Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Right Shoulder: Rate Strength:

Forward flexion: 4/5

Abduction: 4/5

Is there a reduction in muscle strength? [X] Yes [ ] No

If yes, is the reduction entirely due to the claimed condition in the

Diagnosis Section? [ ] Yes [X] No

If no (the reduction is not entirely due to the claimed condition),

provide rationale:

Questionable effort

Left Shoulder: Rate Strength:

Forward flexion: 5/5

Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

c. Comments, if any:

NA

5. Ankylosis

------------

Complete this section if the Veteran has ankylosis of scapulohumeral

(glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus

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move as one piece).

a. Indicate severity of ankylosis and side affected (check all that apply):

Right side:

[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head

(Favorable ankylosis)

[ ] Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

[X] No ankylosis

Left side:

[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head

(Favorable ankylosis)

[ ] Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

[X] No ankylosis

b. Comments, if any:

NA

6. Rotator cuff conditions

--------------------------

Is rotator cuff condition suspected?

Right Shoulder: [X] Yes [ ] No

If "Yes" complete the following:

Hawkins' Impingement Test (Forward flex the arm to 90 degrees with

the

elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation

indicates a positive test; may signify rotator cuff tendinopathy or tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.

Patient turns thumbs down and resists downward force applied by the

examiner. Weakness indicates a positive test; may indicate rotator cuff

pathology, including supraspinatus tendinopathy or tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

External Rotation/ Infraspinatus Strength Test (Patient holds arms at

side

with elbow flexed 90 degrees. Patient externally rotates against

resistance. Weakness indicates a positive test; may be associated with

infraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

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Lift-off Subscapularis Test (Patient internally rotates arm behind lower

back, pushes against examiner's hand. Weakness indicates a positive

test;

may indicate subscapularis tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Left Shoulder: [ ] Yes [X] No

7. Shoulder instability, dislocation or labral pathology

--------------------------------------------------------

a. Is shoulder instability, dislocation or labral pathology suspected?

[ ] Yes [X] No

8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint

conditions

------------------------------------------------------------------------------

a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular

joint condition suspected?

[ ] Yes [X] No

9. Conditions or impairments of the humerus

-------------------------------------------

a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail

shoulder), or fibrous union of the humerus?

[ ] Yes [X] No

b. Does the Veteran have malunion of the humerus with moderate or marked

deformity?

[ ] Yes [X] No

c. Does the humerus condition affect range of motion of the shoulder

(glenohumeral) joint?

No response provided

d. Comments, if any:

NA

10. Surgical procedures

-----------------------

No response provided

11. Other pertinent physical findings, complications, conditions, signs,

symptoms and scars

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a. Does the Veteran have any other pertinent physical findings,

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complications,

conditions, signs or symptoms related to any conditions listed in the

Diagnosis Section above?

[X] Yes [ ] No

If yes, describe (brief summary):

Pain anterior and not in proximity of R distal clavicular

injury/avulsion or impingement.

b. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

Section above?

[ ] Yes [X] No

c. Comments, if any:

NA

12. Assistive devices

---------------------

a. Does the Veteran use any assistive devices?

[ ] Yes [X] No

b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

NA

13. Remaining effective function of the extremities

---------------------------------------------------

Due to the Veteran's shoulder and/or arm conditions, is there functional

impairment of an extremity such that no effective function remains other than

that which would be equally well served by an amputation with prosthesis?

(Functions of the upper extremity include grasping, manipulation, etc., while

functions for the lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

14. Diagnostic testing

----------------------

a. Have imaging studies of the shoulder been performed and are the results

available?

[X] Yes [ ] No

If yes, is degenerative or traumatic arthritis documented?

[ ] Yes [X] No

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b. Are there any other significant diagnostic test findings or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief

summary):

10/30/ 2009 R shoulder showed evidence of R chronic changes suggestive

of old injury.

c. If any test results are other than normal, indicate relationship of

abnormal

findings to diagnosed conditions:

The Veteran's current report of pain does not correlated anatomically

to the

area of past injury or impingement.

15. Functional impact

---------------------

Regardless of the Veteran's current employment status, do the

condition(s)

listed in the Diagnosis Section impact his or her ability to perform any type

of occupational task (such as standing, walking, lifting, sitting, etc.)?

[X] Yes [ ] No

16. Remarks, if any:

--------------------

Vista Imaging R shoulder films 10/30/2009 were interpreted by the radiologist

as: A small well-corticated diaphram and the superior aspect of the distal

clavicle, likely chronic injury. Previous films on 04/23/2009 were interpreted

by the radiologist as "AC joint hypertrophy, which can contribute to

impingement.

No additional remarks.

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Sorry, I forgot to include that I am currently service connected for my Right shoulder at 0%. 

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Flexion (0 to 180): 0 to 50 degrees
Abduction (0 to 180): 0 to 50 degrees
External rotation (0 to 90): 0 to 65 degrees
Internal rotation (0 to 90): 0 to 90 degrees

It looks possible that you might be able to get a 20% rating for your right shoulder due to limited ROM. The values I highlighted above show significantly limited ROM. It appears that the impingement in your joint is causing this. Even though you were positive for a couple of the tests, those tests are likely used to help identify the specific body parts causing the problem. However, the rating criteria will most likely be based on ROM.

Here's the link to the shoulder rating criteria: http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=38:1.0.1.1.5

The Shoulder and Arm

  Rating
MajorMinor
5200   Scapulohumeral articulation, ankylosis of:  
Note: The scapula and humerus move as one piece.  
Unfavorable, abduction limited to 25° from side5040
Intermediate between favorable and unfavorable4030
Favorable, abduction to 60°, can reach mouth and head3020
5201   Arm, limitation of motion of:  
To 25° from side4030
Midway between side and shoulder level3020
At shoulder level2020
5202   Humerus, other impairment of:  
Loss of head of (flail shoulder)8070
Nonunion of (false flail joint)6050
Fibrous union of5040
Recurrent dislocation of at scapulohumeral joint.  
With frequent episodes and guarding of all arm movements3020
With infrequent episodes, and guarding of movement only at shoulder level2020
Malunion of:  
Marked deformity3020
Moderate deformity2020
5203   Clavicle or scapula, impairment of:  
Dislocation of2020
Nonunion of:  
With loose movement2020
Without loose movement1010
Malunion of1010
Or rate on impairment of function of contiguous joint.  
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Thanks Vync,

I was hoping to get in the 10 - 20 % rating with this.

When I find out I'll be sure to update this thread so others can see.

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Good luck!

Remember, there are three components to direct SC claims:
1. Proof of an injury/diagnosis in service
2. Proof you have it now
3. Doctor's IMO/nexus "least as likely as not" or "50%/50%" (or higher) caused by in service

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Apparently this is an application for increase, since I did not see a nexus so it must have been elsewhere.  The 20% sounds reasonable considering the loss of ROM.  

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