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lt4ds

Any Help With Interpetation Will Be Appreciated

Question

I had my first C & P exam in Aug of 08. I was rated in Oct 08 with a 10% rating on my back for:

Residuals, back surgery with degenerative arthritis

I submitted a Notice of Disagreement in Nov 08 and had a secondary C & P in Jan 09. I recently requested a copy of the C & P notes for both exams, (I had no idea I had a right to a copy). There are some big differences between the 2, and am curious what those differences translate into. Can someone tell me what the results of the second exam will mean in regards to my rating, or a best guess. Thanks in advance.

1st exam

Review of system:

no radiation of pain, gradual onset of pain, constant duration of pain, frequency of pain daily, flare-ups, 1-2 months, duration 3-7 day, severity mild, walking distance 1/4 mile.

no noted abnormalities of cervical or Thoracic spine.

Inspection of spine:

Posture normal, head position normal, symetric in appearance, normal gait

No abnormal curvatures

Motor exam

normal

Sonsory exam:

normal

Reflex exam:

normal

ROM:

normal except for presence of pain

2nd exam

Review of system:

Numbness, Leg and foot weakness, other symptoms decreased motion, stiffness, spaasms, pain, continuous pain, moderate severity, constant duration, radiation of pain through right buttock and leg, flare-ups 1-2 months, duration 2 - 4 weeks, walking distance 50 yards, Note ***no specific additional impairment other than increased pain with loss of excursion from about 45 degrees flexion at basline to 30 degrees with flare

Inspection of spine:

Posture: Pelvis titled to the left, head position normal, symetric in appearance, antalgic gait, abnormal curvature of spine:list, and lumbar flattening.

Muscles of the spine:

Spasms (right), guarding (right), Pain with motion (left/right), tenderness (left/right), abnormal gait due to pain, spasms, guarding, and tenderness

Motor exam

abnormal (4/5) right hip flexion (femoral nerve), right Hip extention (infirior gluteal nerve), Knee extention (femoral nerve), ankle dorsiflexion (deep peroneal nerve), ankle plantar flexion (tibial nerve), great toe extention (deep peroneal nerve)

Sonsory exam:

light touch 1/2 ***entire right leg with diminished light touch compared to left, no focal pattern detectable

Reflex exam:

Knee jerk left/right 1+

ankle jerk right 0

ROM: in degrees

flexion: 0 to 30

extention: 0 to 10

left lateral flexion: 0 to 10

left lateral rotation: 0 to 10

right laterial flexion: 0 to 5

right lateral rotation: 0 to 5

objective evidence of pain on active ROM, and repetitive motion

unable to test repetitive motion due to severe baseline pain and limited ROM

Diagnosis:

Traumatic arthritis lumbar spine secondary to surgery for lumbar disc disease

Paralysis, incomplete, moderate, right sciatic nerve, as likely as not secondary to service connected lumbar spine condition.

impacts:

decreased mobility, problems with lifting and carrying, pain

prevents: exercise, sports, recration

severe: chores

moderate: shopping, traveling, bathing, dressing,

mild: toileting, grooming

none: feeding

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3 answers to this question

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You need to file a seperate claim for sciatic neurapthy. It looks as if you have decreased range of motion, which should get an increase. Remember the back is based on range of motion, not pain. Pain is only worth 10%!

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The first exam that you list was not an acceptable exam.

No Goniometer measurements of ROM.......not even any "guesses" as to ROM.

If you went to a private MD and got a IMO that was worded like your 1st exam.......the VA would not even consider it.

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Thank you for the responses. From what I can gather, it should increase my rating to 52 rounded down to 50. I wasn't sure about the neuropathy, if it would be included as part of the exam, since it wasn't listed. I recieved a letter today from the VA, stating they are still evaluating my application for compensation. It's a form letter, but I recieved one like it about a week before I recieved my notification of rating. It could be notification of a scheduled C&P exam for the remaining 9 items that they screwed up on the 1st C&P. I figure I have at least 3 more coming up, but I was told they will break them out and rate one or two at a time, taking about 3 months for each exam. I have items unrelated to my back that I still have to resolve with the VA.

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