My C&P Ankle Conditions

[John.e.]

                                Ankle Conditions                        Disability Benefits Questionnaire

      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: No response provided    b. Select diagnoses associated with the claim condition(s) (Check all that     apply):       [X] Other (specify):      Other diagnosis: S/P Right Achilles tendon resection with anchor    reattachment and flexor hallucis tendon transfer with residual pain and loss    of mobility       ICD Code: sc  Side affected: Right      Date of diagnosis: Right:10/10/17      ********************************************************************          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 ankle     condition (brief summary): This veteran underwent rt achilles tendon

     debridement in january 2017 but developed much pain and difficulty walking     severe enough that it required a second corrective surgical procedure on     10/10/2017 resulting in resection of tendon because of severe tendinosis and     enthesopathy. The tendon was reattached via anchors and a transfer of the rt     flexor hallucis longus. The surgical procedure has significantly improved     the pain and ambulation but he has lost about 30 degrees of plantar flexion     on the big toe because of the hallucis longus tendon transfer. He is     undergoing weekly PT in order to improve this but there is not much     improvement as yet. He is still expeirencing daily recurrent posterior ankle     pain at about 5/10 level aggravated by prolonged walking and standing, he     needs to use a special foot drop brace for proper walking and there is daily     swelling over the scar area usually by day's end.     He is taking daily meloxicam 15mg, tramadol 50 bid, voltaren pain cream and     frequently has to take extra OTC aleve.       b. Does the Veteran report flare-ups of the ankle?     [X] Yes   [ ] No          If yes, document the Veteran's description of the flare-ups in his or her     own words:       Daily flare ups due to walking or prolonged standing with loss of function       due to pain and swelling.         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:       see above         3. Range of motion (ROM) and functional limitations  --------------------------------------------------  a. Initial range of motion       Right ankle     ----------     [ ] All Normal     [X] Abnormal or outside of normal range     [ ] Unable to test (please explain)     [ ] Not indicated (please explain)

         Dorsiflexion (0-20):    0 to 10 degrees         Plantar Flexion (0-45): 0 to 30 degrees

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

     Description of pain (select best response):       Pain noted on examination and causes functional loss            If noted on examination, which ROM exhibited pain (select all that apply)?  Dorsiflexion, Plantar 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):          Very tender over entire length of the achilles tendon

     Is there objective evidence of crepitus?  [ ] Yes   [X] No    

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

         Dorsiflexion (0-20):    0 to 20 degrees         Plantar Flexion (0-45): 0 to 45 degrees

     Description of pain (select best response):       No pain noted on exam            Is there evidence of pain with weight bearing? [ ] Yes   [X] No          Is there objective evidence of localized tenderness or pain on palpation of     the joint or associated soft tissue? [ ] Yes   [X] No

     Is there objective evidence of crepitus?  [ ] Yes   [X] No    

  b. Observed repetitive use       Right ankle     ----------     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 ankle     ---------     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 ankle     ----------     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 Veterans statements         describing functional loss with repetitive use over time.     [ ] The examination is medically inconsistent with the Veterans statements         describing functional loss with repetitive use over time.  Please         explain.     [X] The examination is neither medically consistent or inconsistent with the         Veterans 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: It would be speculative to provide accurate ROMs during a flare up or  after repetitive motion over time since this veteran is not having  a flare up at the time of this exam. I can't provide this information based on a hypothetical situation.               

     Left ankle     ---------     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 Veterans statements         describing functional loss with repetitive use over time.     [ ] The examination is medically inconsistent with the Veterans statements describing functional loss with repetitive use over time.  Please         explain.     [X] The examination is neither medically consistent or inconsistent with the Veterans 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: It would be speculative to provide accurate ROMs during a flare up or after repetitive motion over time since this veteran is not having a flare up at the time of this exam. I can't provide this information based on a hypothetical situation.              

  d. Flare-ups       Right ankle     ----------     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 Veterans statements         describing functional loss during flare-ups.     [ ] The examination is medically inconsistent with the Veterans statements         describing functional loss during flare-ups.  Please explain.     [X] The examination is neither medically consistent or inconsistent with the         Veterans statements describing functional loss during flare-ups.

     Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up?     [ ] Yes   [ ] No   [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: It would be speculative to provide accurate ROMs during a flare up or after repetitive motion over time since this veteran is not having  a flare up at the time of this exam. I can't provide this  information based on a hypothetical situation.              

     Left ankle

     ---------     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 Veterans statements         describing functional loss during flare-ups.     [ ] The examination is medically inconsistent with the Veterans statements         describing functional loss during flare-ups.  Please explain.     [X] The examination is neither medically consistent or inconsistent with the         Veterans statements describing functional loss during flare-ups.

     Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up?     [ ] Yes   [ ] No   [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: It would be speculative to provide accurate ROMs during a flare up or after repetitive motion over time since this veteran is not having a flare up at the time of this exam. I can't provide this               information based on a hypothetical situation.              

  e. Additional factors contributing to disability       Right ankle     ----------     In addition to those addressed above, are there additional contributing     factors of disability?  Please select all that apply and describe:  Less movement than normal due to ankylosis, adhesions, etc., Swelling,       Disturbance of locomotion, Interference with standing   Left ankle     ---------     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 ankle

        Rate Strength:   Plantar Flexion:  4/5                         Dorsiflexion:     4/5

        Is there a reduction in muscle strength? [X] Yes   [ ] No       

      Left ankle:        Rate Strength:   Plantar Flexion:  5/5                         Dorsiflexion:     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 Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: Left side: [ ] In plantar flexion [ ] In plantar flexion [ ] In dorsiflexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an inversion deformity [ ] With an eversion deformity[ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis  [X] No ankylosis

  b. Comments, if any:      No response provided        6. Joint stability  -----------------  Right ankle    Is ankle instability or    dislocation suspected?          [ ] Yes   [X] No   

  Left ankle    Is ankle instability or    dislocation suspected?          [ ] Yes   [X] No   

  7. Additional comments  ---------Does the Veteran now have or has he or she ever had "shin splints", stress  fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus  (os calcis) or talus (astragalus), or has the Veteran had a talectomy  (astragalectomy)? [ ] Yes   [X] No    8. Surgical procedures  -----Indicate any surgical procedures that the Veteran has had performed and provide  the additional information as requested (check all that apply): Right side: [X] Arthroscopic or other ankle surgery. Type of surgery: achilles tendon resection with reattachment. Date of surgery: 10/10/2017

[X] Residuals of arthroscopic or other ankle surgery Describe residuals: pain, swelling reduced mobility of rt hallux

    Left side:   No response provided  9. 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 "unstablescar" 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: distal posterior rt leg

 Measurements: length 12 cm X width 1 cm. c. Comments, if any: No response provided 10. 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? [X] Yes   [ ] No If yes, identify assistive devices used (check all that apply and indicate frequency): [ ] Wheelchair Frequency of use:  [ ] Occasional   [ ] Regular   [ ] Constant [X] Brace(s) Frequency of use:  [ ] Occasional   [ ] Regular [X] Constant [ ] Crutches Frequency of use:    [ ] Occasional   [ ] Regular [ ] Constant [ ] Cane(s) Frequency of use:    [ ] Occasional   [ ] Regular [ ] Constant [ ] Walker  Frequency of use: [ ] Occasional   [ ] Regular  [ ] Constant [ ] Other: Frequency of use:  [ ] Occasional   [ ] Regular   [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 11. Remaining effective function of the extremities --- Due to the Veteran's ankle condition, 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 

  12. Diagnostic testing  ---------------------  a. Have imaging studies of the ankle been performed and are the results

     available? [X] Yes   [ ] No            If yes, is degenerative or traumatic arthritis documented?       [X] Yes   [ ] No                  If yes, indicate ankle: [X] Right   [ ] Left   [ ] Both

  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      

  13. 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:        This condition will impact any job requiring prolonged walking or        standing.

  14. Remarks, if any  ------------------    Correia:    1) There was pain on passive ROMs on right but not left ankle.    2) There was not pain on non weight bearing b/l.    3) The left ankle is normal on physical exam.

[Buck52]

You may want to check out some of these 38 CFR's

4.46   Accurate Measurement

4.57 static foot deformities

4.59 painful motion 

4.61 examination

4.63 loss of use of hand or foot

 

[Buck52]

Or check with hadit  elder member James Cripps  

if you have loss of use or ''drop foot''  on your ankle  James is the loss of use expert.

I can't speculate on your DBQ.  SORRY.

Other member can chime in.

Edited March 6, 2018 by Buck52

[Berta]

I didn't see any nexus statement in the DBQ.

Is this a claim for a condition that is secondary to an already established SC disability?

It doesn';t seem to be, per the DBQ.

The nexus is the documented inservice cause of or proof of treatment for this type of condition.