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Neede help with exam notes for Plantar and Bilateral Femoralpatello Pain syndrme
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DirtyBulk
Can any of the C&P exam experts help me try to hone in on what they think my rating will be based on these notes? There is a ton of stuff that I disagree with, but I will take on that issue after I get my rating. Any help is greatly appreciated.
Indicate method used to obtain medical information to complete this document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because the existing medical evidence provided sufficient information
on
which to prepare the DBQ and such an examination will likely provide no
additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using
the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
a. Evidence review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
bilateral patellofemoral pain syndrome
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] Patellofemoral pain syndrome
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: M22.2x1 and M22.2x2
Date of diagnosis: Right 2012
Date of diagnosis: Left 2012
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[ ] Yes [X] No [ ] N/A
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's knee
and/or lower leg condition (brief summary):
Bilateral patellofemoral pain syndrome diagonsed in the Marines following a
fall from a height when he landed on his knees. He has continued to have
pain in both anterior kneessince then. He has not had care for his knees
since discharge in 2013.
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[ ] Yes [X] No
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:
Pain with walking, climbing or decending stairs, and with prolonged
standing. He has pain with pressure on the anterior knees, so he
cannot
kneel down.
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Right Knee
----------
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 70 degrees
Extension (140 to 0): 70 to 0 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
pain with flexion of the knee joint and when walking.
Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Flexion
Is there evidence of pain with weight bearing? [X] Yes [ ] 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):
pain with palpation of the patella and the anterior joint line.
Is there objective evidence of crepitus? [ ] Yes [X] No
Left Knee
---------
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 70 degrees
Extension (140 to 0): 70 to 0 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
pain with flexion of the knee joint and when walking.
Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Flexion
Is there evidence of pain with weight bearing? [X] Yes [ ] 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):
pain with palpation of the patella and the anterior joint line.
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right Knee
----------
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 Knee
---------
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
c. Repeated use over time
Right Knee
----------
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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
Increased pain with ambulation and standing.
Left Knee
---------
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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
Increased pain with ambulation and standing.
d. Flare-ups
No response provided
e. Additional factors contributing to disability
Right Knee
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
Left Knee
---------
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 Knee: Rate Strength:
Forward flexion: 5/5
Extension: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Knee: Rate Strength:
Forward flexion: 5/5
Extension: 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:
No response provided
5. Ankylosis
------------
Complete this section if the Veteran has ankylosis of the knee and/or lower
leg.
a. Indicate severity of ankylosis and side affected (check all that apply):
Right Side:
[ ] Favorable angle in full extension or in slight flexion between 0 and
10 degrees
[ ] In flexion between 10 and 20 degrees
[ ] In flexion between 20 and 45 degrees
[ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more
[X] No ankylosis
Left Side:
[ ] Favorable angle in full extension or in slight flexion between 0 and
10 degrees
[ ] In flexion between 10 and 20 degrees
[ ] In flexion between 20 and 45 degrees
[ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more
[X] No ankylosis
b. Indicate angle of ankylosis in degrees:
No response provided
c. Comments, if any:
No response provided
6. Joint stability tests
------------------------
a. Is there a history of recurrent subluxation?
Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
b. Is there a history of lateral instability?
Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
c. Is there a history of recurrent effusion?
[ ] Yes [X] No
d. Performance of joint stability testing
Right Knee:
Was joint stability testing performed?
[X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability?
[ ] Yes [X] No
If yes (joint stability testing was performed), complete the section
below:
- Anterior instability (Lachman test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
Left Knee:
Was joint stability testing performed?
[X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability?
[ ] Yes [X] No
If yes (joint stability testing was performed), complete the section
below:
- Anterior instability (Lachman test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
e. Comments, if any:
No response provided
7. Additional conditions
------------------------
a. Does the Veteran now have or has he or she ever had recurrent patellar
dislocation, "shin splints" (medial tibial stress syndrome), stress
fractures, chronic exertional compartment syndrome or any other tibial
and/or fibular impairment?
[ ] Yes [X] No
b. Comments, if any:
No response provided
8. Meniscal conditions
----------------------
a. Does the Veteran now have or has he or she ever had a meniscus (semilunar
cartilage) condition?
[ ] Yes [X] No
b. For all checked boxes above, describe:
No response provided
9. Surgical procedures
----------------------
No response provided
10. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above?
[ ] Yes [X] No
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:
No response provided
11. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion,
although occasional locomotion by other methods may be possible?
[ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided
12. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's knee and/or lower leg condition(s), 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
13. Diagnostic testing
----------------------
a. Have imaging studies of the knee been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
14. 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
If yes, describe the functional impact of each condition, providing one or
more examples:
The Veteran has significant pain in both knees with walking, standing and
kneeling so that he would have a difficult time perorming duties which
would require those actions.
15. Remarks, if any:
--------------------
No response provided
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Navy4life
What is your current rating % from 2012?
DirtyBulk
I was SC'ed but rated at 0% because I missed my CP exam appointment due to a field ops I was required to go to.
Navy4life
Based on the C&P exam you provided I think the increase is eminent but I can't say for sure. I am sure others will come along with more expert advice!
4 answers to this question
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