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Neede help with exam notes for Plantar and Bilateral Femoralpatello Pain syndrme

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DirtyBulk

Question

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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  • 1
11 minutes ago, DirtyBulk said:

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. 

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!

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