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Back and Knees C&P
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Question
armyvet89
Sorry all. I previously started a thread but couldnt edit it to include my C&Ps. This claim was for an increase on my Left Knee and Back and Right Knee secondary to my left knee. Anyone care to give a guess at percentages? Im already at 10% for tinnitus and 0% for left knee.
Provide description and/or etiology:
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
limitation in terms of additional ROM loss as this cannot be
objectively quantified.
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
limitation in terms of additional ROM loss as this cannot be
objectively quantified.
Loss of normal lordotic curve
Guarding:
[ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
Provide description and/or etiology:
Loss of normal lordotic curve
f. Additional factors contributing to disability
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Disturbance of locomotion, Interference with sitting, Interference with
standing
4. Muscle strength testing
--------------------------
a. 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
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Page 30 of 109
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Great toe extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
5. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Page 31 of 109
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
7. Straight leg raising test
----------------------------
Provide straight leg raising test results:
Right: [X] Negative [ ] Positive [ ] Unable to perform
Left: [X] Negative [ ] Positive [ ] Unable to perform
8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[X] Yes [ ] No
a. Indicate symptoms' location and severity (check all that apply):
Constant pain (may be excruciating at times)
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No
c. Indicate nerve roots involved: (check all that apply)
[X] Involvement of L2/L3L/L4 nerve roots (femoral nerve)
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
9. Ankylosis
Page 32 of 109
------------
Is there ankylosis of the spine? [ ] Yes [X] No
10. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
12. 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?
[X] Yes [ ] No
If yes, identify assistive device(s) used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
----------------- -----------------
[X] Cane(s) [X] Occasional [ ] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
Cane is used for both knee pain and low back pain
13. Remaining effective function of the extremities
---------------------------------------------------
Due to a thoracolumbar spine (back) condition, 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.; functions of the
lower extremity include balance and propulsion, etc.)
[X] No
14. 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?
Page 33 of 109
[ ] 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
15. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are
the
results available?
[X] Yes [ ] No
If yes, is arthritis documented?
[X] Yes [ ] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or
her
ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's
thoracolumbar
spine (back) conditions providing one or more examples:
The veteran states the pain in both his RIGHT and LEFT knees
creates a functional limitation of inability to complete his
recurrent PT testing that may cause the veteran to lose his
employed postion as a police officer at DSCC.
17. Remarks, if any:
--------------------
The veteran's claim file was reviewed in VBMS, CPRS, Vista Web, and
Vista
Imaging. Previous C&P history and physical exam records from 9-21-2016
were
reviewed.
The veteran served active duty United States Army from 2008 - 2014. The
veteran earned a combat badge while serving on active duty. In January 2010
Knee and Lower Leg Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
RIGHT KNEE CONDITION SECONDARY TO LEFT KNEE
STATUS POST LEFT MEDIAL MENISCECTOMY AND CHONDROPLASTY, LEFT PATELLOFEMORAL
JOINT
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] Knee meniscal tear
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: M23
Date of diagnosis: Left SC
[X] Patellofemoral pain syndrome
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: M22
Date of diagnosis: Left SC
c. Comments (if any):
Page 36 of 109
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[X] Yes [ ] 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):
The veteran's claim file was reviewed in VBMS, CPRS, Vista Web, and
Vista
Imaging. Previous C&P history and physical exam records from 9-21-2016
were
reviewed and it was noted that the range of motion testing for the
veteran's
LEFT knee could not be completed during that C&P exam.
The veteran served active duty United States Army from 2008 - 2014. The
veteran earned a combat badge while serving on active duty. In January
2010
the veteran sustained an injury to his LEFT KNEE while taking mortar fire
during combat while serving in Iraq and this injury is documented in the
veteran's STRS as well as prior C&P exams.
Ultimately, the veteran was placed on light duty while still serving on
active duty several times due to LEFT knee pain and instability. The
veteran eventually underwent a second LEFT knee surgery to correct a
meniscus tear and also repair arthritic changes (the first LEFT knee
surgery
occurred prior to the veteran's active duty service).
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his
or
her own words:
The veteran states he has continued to have pain since the LEFT KNEE
injury on active duty occurred. The veteran states he has at least
DAILY
flare-ups of pain in his LEFT knee which he describes as a "sharp
pain"
that severely limits his range of motion.
The veteran ALSO states he has at least WEEKLY flare-ups of pain in his
RIGHT knee which he describes as a "sharp and throbbing pain in
two
different spots" that limits his range of motion.
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
Page 37 of 109
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:
The veteran states the flare-ups in both his RIGHT and LEFT knee make
it
difficult to stand for long periods and walking for long distances
becomes difficult.
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 130 degrees
Extension (140 to 0): 130 to 0 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
Limited ROM as described above
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, Extension
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):
Mild soft tissue tenderness to palpation diffusely over knee joint but
no
redness or warmth
Is there objective evidence of crepitus? [X] Yes [ ] No
Left Knee
---------
[ ] All normal
Page 38 of 109
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 15 to 110 degrees
Extension (140 to 0): 110 to 15 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
Limited ROM as described above
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, Extension
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):
Mild soft tissue tenderness to palpation diffusely over knee joint but
no
redness or warmth
Is there objective evidence of crepitus? [X] Yes [ ] 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?
Page 39 of 109
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with
repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
limitation in terms of additional ROM loss during repeated use over
time
as this cannot be objectively quantified.
Left Knee
---------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[X] The examination is neither medically consistent or inconsistent
Page 40 of 109
with
the Veteran's statements describing functional loss with
repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
limitation in terms of additional ROM loss during repeated use over
time
as this cannot be objectively quantified.
d. Flare-ups
Right Knee
----------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
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:
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
Page 41 of 109
limitation in terms of additional ROM loss as this cannot be
objectively
quantified.
Left Knee
---------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
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:
Pain is the functional limitation impacting the veteran's
abilities
during flare-ups.
The exam today WAS NOT DURING A FLARE-UP and the veteran was able to
perform repetitive range of motion maneuvers.
In summary, it is not practical or feasible to express additional
limitation in terms of additional ROM loss as this cannot be
objectively
quantified.
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:
Disturbance of locomotion, Interference with sitting, Interference with
standing
Left Knee
---------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Page 42 of 109
Disturbance of locomotion, Interference with sitting, Interference with
standing
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:
Flexion: 5/5
Extension: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Knee: Rate Strength:
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: [ ] None [X] Slight [ ] Moderate [ ] Severe
Left: [ ] None [ ] Slight [X] 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)
Page 44 of 109
[ ] 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)
Page 45 of 109
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?
[X] Yes [ ] No
If yes, indicate severity and frequency of symptoms, and side affected:
Left Side:
[X] Meniscal tear
b. For all checked boxes above, describe:
Surgery x 3 for left knee meniscus tears
9. Surgical procedures
----------------------
Indicate any surgical procedures that the Veteran has had performed and
provide
the additional information as requested (check all that apply):
Left Side:
[X] Meniscectomy, arthroscopic or other knee surgery not described above
Type of surgery: MENISCUS REPAIR
Date of surgery: 2011
[X] Residual signs or symptoms due to meniscectomy, arthroscopic or
other knee surgery not described above:
Describe residuals: Chronic pain with daily flare ups and limitied
range of motion
10. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
Page 46 of 109
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?
[X] Yes [ ] No
If yes, is there objective evidence that any of these scars are
painful,
unstable, have a total area equal to or greater than 39 square cm (6
square inches) or are located on the head, face or neck? (An
"unstable
scar" is one where, for any reason, there is frequent loss of
covering
of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: LEFT KNEE POST OP X 3
Measurements: length 1cm X width 0.5cm
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?
[X] Yes [ ] No
If yes, identify assistive device(s) used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
----------------- -----------------
[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant
[X] Cane(s) [X] Occasional [ ] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
Brace and cane are both used for chronic and pain and flare ups in the
veteran's RIGHT and LEFT knee.
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?
Page 47 of 109
(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
sorry for the length i couldnt figure out how to shorten it without removing information. Any and all help or guidance is appreciated. Thanks!
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