Knee C&P help please

[armyvet89]

Can someone please help me out here. I asked for an increase on my left knee and claimed right knee secondary to already service connected left knee. This appears to a pretty favorable C&P. I received an award letter saying my left knee was increased to 20% from 0% and my right knee was deferred because the doc didnt provide a diagnosis for it during the C&P. So just this Monday he added an addendum that provided a diagnosis of "Right knee strain". Im just curious as to what percentage I can get from this because if I can at least get 10% it would be enough to round my overall percentage to 60%. From what I've read on here and other cites it looks like I should get 10% for the "slight instability" that he checked under DC 5257. I may be wrong all together. Please, any advice or help will be appreciated!

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):

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

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

[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?

[ ] 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

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

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:

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)

[ ] 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

Page 45 of 76

[ ] 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?

[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,

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?

(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

[Buck52]

Looks like a 10% for the right knee...not sure on the left?

 you need to attach that addendum and send it in as evidence !

if you don't have a decision yet?

[Buck52]

This may help you a little? or you may already know all this  but thoughtI'd put it on here incase you didn't.

http://www.militarydisabilitymadeeasy.com/kneeandleg.html#limo

 

[armyvet89]

Buck,

Sorry for the tardiness of my reply. I have yet to receive a decision yet. During the C&P the doc didnt provide a diagnosis for the right knee. So they just recently (31 January) went back and got one from him of "right knee strain". Over 30 days for that response! This was only part of the claim. They went ahead and finished the rest of it and deferred my right knee. I went from 10% to 50% but if I get at least 10% for my right knee ill bump to 60% overall. I felt that 10% was warranted for the right knee but now we are playing the waiting game with the VA... Thanks for the reply. I hope to hear back soon.

[Buck52]

Roger That armyvet89

it depends how much range of motion you showed at the C&P as for as how much they will rate, if you got 10%then 50% for your  right knee, if you showed the same ROM they should rate it the same bilaterally.

Maybe your left knee is not as bad as your right?

but like you said  if you get the 10% that will put you up more,but look at the ROM Report on your C&P Exam and see what the examiner said it was?...you can look up the ratings  for your knees  or your left knee and make sure they don't low ball you.

I'll try to research the ROM Ratings for knees.

§4.46   Accurate measurement.

Accurate measurement of the length of stumps, excursion of joints, dimensions and location of scars with respect to landmarks, should be insisted on. The use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs. Muscle atrophy must also be accurately measured and reported.

if it was me and they just gave me a 10%   and I felt like it should be more after I check the ROM Ratings schedule..I'd NOD it

fight them on it if you have a less ROM.

good luck buddy

 

Edited February 13, 2017 by Buck52