C&P Exams for Back, Hips and Knees, could someone review and give me your thoughts?

soriol36 · June 11, 2017

Back (Thoracolumbar Spine) 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] CPRS

1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No

Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[ ] Lumbosacral strain
[X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome

[ ] Sacroiliac injury
[ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation [ ] Vertebral fracture

Diagnosis #1: osteoarthritis lumbaar spine Date of diagnosis: 2014

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):

Vet says he has dull lower back pain for about 2 yrs and shooting pain
electric like radiating to the rt upper leg with numbness and tingling to

the foot for several hours daily, precipitated by prolonged sitting or

laying or standing . The latter symptoms began 5 mos ago. He has flare up almost every day precipitated by bending or lack of sleep.
He stops what he is doing for a few minutes during the flare up.

He says naprosyn is not effective. He drinks etoh to relieved the pain.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?
[X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his or her
own words:

see above

c. Does the Veteran report having any functional loss or functional
impairment of the thoracolumbar spine (back) (regardless of repetitive use)?

[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words.

see in recliner most of the day

3. Range of motion (ROM) and functional limitation --------------------------------------------------
a. Initial range of motion

[ ] All normal
[X] Abnormal or outside of normal range [ ] Unable to test (please explain)
[ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 70 degrees Extension (0 to 30): 0 to 20 degrees

Right Lateral Flexion (0 to 30): Left Lateral Flexion (0 to 30): Right Lateral Rotation (0 to 30): Left Lateral Rotation (0 to 30):

0 to 25 degrees 0 to 25 degrees

0 to 30 degrees 0 to 30 degrees

Description of pain (select best response):
Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Forward Flexion, Extension, Right Lateral Flexion, Left Lateral
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 joints or associated soft tissue of the thoracolumbar spine (back)?
[ ] Yes [X] No

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No

c. Repeated use over time

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

d. Flare-ups

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

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [ ] Yes [X] No

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: None

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

5 [ ] 1/5
[ ] 0/5

Left: [X] 5/5 [ ] 0/5

[ ] 4/5 [ ] 4/5

[ ] 3/5 [ ] 3/5

[ ] 2/ [ ] 2/5

[ ] 1/5

Knee extension:

Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5

Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5

Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5

Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5

[ ] 3/5 [ ] 3/5

[ ] 2/5 [ ] 2/5

[ ] 1/5 [ ] 1/5

b. Does the Veteran have muscle atrophy? No response provided.

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 Left: [ ] 0

Ankle: Right: [ ] 0 Left: [ ] 0

[ ] 1+ [ ] 1+

[X] 2+ [X] 2+

[ ] 3+ [ ] 3+

[ ] 4+ [ ] 4+

6. Sensory exam
---------------
Provide results for sensation to light touch (dermatome) testing:

Upper anterior thigh (L2):
Right: [ ] Normal [ ] Decreased [X] Absent

Left: [ ] Normal [ ] Decreased [X] Absent

Thigh/knee (L3/4):
Right: [ ] Normal [ ] Decreased [X] Absent

Lower leg/ankle (L4/L5/S1):
Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent

Foot/toes (L5):
Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] 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?
[ ] Yes [X] No

9. Ankylosis
------------
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?

[ ] 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.

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?
No response provided

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

If yes, provide type of test or procedure, date and results (brief
summary):

mri lumbar spine 2014

1. Mild to moderate L4/L5, and mild L2/L3, and L3/L4 facet
joint

degenerative disease.

2. No degenerative disc disease of the lumbar spine. Mild
lumbar
spine scoliosis is stable.

16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?

[ ] Yes [X] No

17. Remarks, if any:
--------------------
The absent light touch on both lowwer extremities cnnot be explained by the
imaging of the lumbar spine. Vet had admitted chronically drinking a lot of
otoh but does not appear intoxicated this exam. This may explain the absent
sensation.

******************

1. Is there evidence of pain on passive range of motion
testing?
(Yes/No/Cannot be performed or is not medically appropriate) yes

2. Is there evidence of pain when the joint is used in non- weight
bearing? (Yes/No/Cannot be performed or is not medically

appropriate) yes

3. If yes, is the opposing joint undamaged (i.e. no abnormalities)?
(Yes/No)

If yes, conduct range of motion testing for the opposing joint and provide
ROM measurements.

If no, the examiner is requested to state whether it is medically feasible
to test the joint and if not to please state why the examiner cannot test
the range of motion of the opposing joint.

****************************************************************************

Hip and Thigh 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] CPRS

1. Diagnosis

------------
a. List the claimed condition(s) that pertain to this DBQ: No response

provided

b. Select diagnoses associated with the claimed condition(s) (Check all that

apply):
c. Comments (if any): No response provided

d. Was an opinion requested about this condition (internal VA only)? Yes

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's hip or

thigh condition:
Vet complains of bilateral hip pain, the right worse than the left. This
pain is the same as described with the back pain radiating to the legs.
There is a keloid on the right anterior upper leg which he says was
noted during service. He cannot recall injury to the thigh. Vet has not complained of the hip pain to his provider.

b. Does the Veteran report flare-ups of the hip or thigh? [X] Yes [ ] No

If yes, document the Veteran's description of the of flare- ups in his or
her own words:

same as the back flare up

c. Does the Veteran report having any functional loss or functional

impairment of the joint or extremity being evaluated on this DBQ
(regardless of repetitive use)? [X] Yes [ ] No

If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:

he says he has to sit most of the time. ( Vet is not employed)

3. Range of motion (ROM) and functional limitations

--------------------------------------------------- a. Initial range of motion

Right hip
---------
[ ] All Normal
[X] Abnormal or outside of normal range [ ] Unable to test (please explain)
[ ] Not indicated (please explain)

Flexion (0-125): Extension (0-30): Abduction (0-45): Adduction (0-25):

0 to 100 degrees 0 to 30 degrees

0 to 30 degrees 0 to 25 degrees

Is adduction limited such that the Veteran cannot cross legs?
[ ] Yes [X] No

External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees

If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than an hip condition, such as age, body habitus,

neurologic disease), please describe:
body habitus contributes to decreased rom

If abnormal, does the range of motion itself contribute to a functional
loss? [ ] Yes, (please explain) [X] No
Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that
apply)?

Flexion, Adduction, External rotation, Internal rotation

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):

vet verbalizing pzin onlateral thigh and anterior joint

Is there objective evidence of crepitus? [ ] Yes

Left hip
--------
[ ] All Normal
[X] Abnormal or outside of normal range [ ] Unable to test (please explain)
[ ] Not indicated (please explain)

[X] No

Flexion (0-125): Extension (0-30): Abduction (0-45): Adduction (0-25):

0 to 100 degrees 0 to 30 degrees

0 to 30 degrees 0 to 25 degrees

Is adduction limited such that the Veteran cannot cross legs?
[ ] Yes [X] No

External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees

If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than an hip condition, such as age, body habitus,

neurologic disease), please describe: body habitus contributes to decreased

If abnormal, does the range of motion itself contribute to a functional
loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response):
Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that
apply)?

Flexion, Adduction, External rotation, Internal rotation

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):

vet verbalizing pzin onlateral thigh and anterior joint Is there objective evidence of crepitus? [ ] Yes [X] No

b. Observed repetitive use

Right hip
---------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No

Left hip
--------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No

c. Repeated use over time

Right hip
---------
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 inconsisten
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: not obsersved

Left hip

--------
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: not observed

d. Flare-ups Right hip

---------
Is the examination 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: not observed

Left hip
--------
Is the examination 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: not observed

e. Additional factors contributing to disability

Right hip
---------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:

None

Left hip
--------
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 Hip
Rate Strength: Flexion: 5/5

Extension: 5/5 Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes

Left Hip
Rate Strength: Flexion: 5/5

Extension: 5/5 Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes b. Does the Veteran have muscle atrophy? [ ] Yes

[X] No

[X] No [X] No

c. Comments, if any: No response provided

5. Ankylosis
------------
No response provided

6. Additional conditions
------------------------
a. Does the Veteran have malunion or nonunion of femur, flail hip joint or

leg length discrepancy? [ ] Yes [X] No
b. Comments, if any: No response provided

7. Surgical procedures ----------------------
No response provided

8. 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

9. Assistive devices
--------------------
a. Does the Veteran use any assistive devices 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

10. Remaining effective function of the extremities ---------------------------------------------------
Due to the Veteran's hip or thigh conditions, is there functional impairment

of an extremity such that no effective functions remain 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

11. Diagnostic testing
----------------------
a. Have imaging studies of the hip or thigh been performed and are the

results available? [ ] Yes [X] No

b. Are there any other significant diagnostic test findings 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

12. 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.)?

[ ] Yes [X] No
13. Remarks, if any:

--------------------
1. Is there evidence of pain on passive range of motion
testing?
(Yes/No/Cannot be performed or is not medically appropriate) yes

2. Is there evidence of pain when the joint is used in non- weight
bearing? (Yes/No/Cannot be performed or is not medically appropriate) yes

3. If yes, is the opposing joint undamaged (i.e. no abnormalities)?
(Yes/No)

If yes, conduct range of motion testing for the opposing joint and provide
ROM measurements.

If no, the examiner is requested to state whether it is medically feasible
to test the joint and if not to please state why the examiner cannot test
the range of motion of the opposing joint. rom done bil

****************************************************************************

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] CPRS

1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:

bil knees

b. Select diagnoses associated with the claimed condition(s) (Check all that

apply):

[X] Patellofemoral pain syndrome
Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 1997
Date of diagnosis: Left 1997

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):
Vet is sc for bil retropatellar pain syndome with chondoromalacia. He has sx
since 1997. He was treated with physicla therapy and cortison injection to
the right knee x 3 in 2014. He says this was not effective.
The knees hurt daily, flares up after accidental trauma. The joints swell,
buckle frequently, wears brace when he leaves the house. During flare up he says he can't move, stays in a recliner for hours. Today
knee pain is worse because he has been on his feet earlier today. ( he came
in walking independently but with antalgic gait. The swelling lasts several
hours improves with leg elevation.

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:
see above

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?
[ ] Yes [X] No

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 100 degrees Extension (140 to 0): 100 to 0 degrees

If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No

If yes, please explain:
vet walking with anlagic gait

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 on palpation patella, supereior , inferior, and medial

lateral

border, jt lines
Is there objective evidence of crepitus? [ ] Yes

Left Knee
---------
[ ] All normal
[X] Abnormal or outside of normal range

[X] No

[ ] Unable to test (please explain) [ ] Not indicated (please explain)

Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees

If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No

If yes, please explain:
et walking with anlagic gait

Description of pain (select best response):
Pain noted on exam but does not result in/cause 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 on palpation patella, supereior , inferior, and medial

lateral

border, jt lines
Is there objective evidence of crepitus? [ ] Yes

b. Observed repetitive use

[X] No

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

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

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

d. Flare-ups

Right Knee
----------
Is the exam being conducted during a flare-up? [X] Yes

Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation

Select all factors that cause this functional loss: Pain

[] No

Able to describe in terms of range of motion: [X] Yes [] No
Flexion (0 to 140): 0 to 100 degrees
Extension (140 to 0): 100 to 0 degrees

Left Knee
---------
Is the exam being conducted during a flare-up? [X] Yes

Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation

Select all factors that cause this functional loss: Pain

[] No

Able to describe in terms of range of motion: [X] Yes [] No
Flexion (0 to 140): 0 to 100 degrees
Extension (140 to 0): 100 to 0 degrees

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:
Flexion:
Extension:
Is there a reduction in muscle strength?

Left Knee:
Flexion:
Extension:
Is there a reduction in muscle strength?

b. Does the Veteran have muscle atrophy? [ ] Yes [X] No

c. Comments, if any: No response provided

5. Ankylosis
------------
No response provided

Rate Strength: 5/5

6. Joint stability tests
------------------------
a. Is there a history of recurrent subluxation?

Right: [X] None [ ] Slight [ ] Moderate

Left: [X] None [ ] Slight [ ] Moderate b. Is there a history of lateral instability?

[ ] Severe [ ] Severe

Right: [X] None [ ] Slight [ ] Moderate

[ ] Severe

5/5

Rate Strength: 5/5

[ ] Yes

[X] No

5/5

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