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Jeromy

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About Jeromy

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  1. Does anyone have a good NoD or a 'statement in support of claim' that wouldn't mind sharing regarding denial of clothing allowance. I received the clothing allowance last year, but was denied this year. Reason given on the letter was "No Device on Record." Per the flowchart to determine eligibility, if I can demonstrate how my knee brace for my service connected injury causes clothing damage, I can would be deemed eligible. Keep in mind that the new rules that came into effect in 2016 were a knee brace with hinges that is covered by cloth or tighten with Velcro are not "deemed as not being damage causing" braces. Seems odd to me because my pants and my shorts have frays and fringes worn and torn into them via such clothing safe braces not only by the Velcro but the plastic strappings, plus sweat and such transferring onto materials, regardless of how clean you keep items. Anyone have some examples? Thank you in advance.
  2. Thank you, we shall see what the rating person does and goes on the side of rounding up.
  3. Thanks, that is what I looked over and I meet all in the 30% section and in the 50% section I meet the "difficulty in establishing and maintaining effective work and social relationships." I wish you were my VSR, I would take your rating of 70%.
  4. Ok folks, I had my PTSD C&P last week and here is the short version of the results. My question is, am I at the 50% or 30% level? I meet the one aspect of 50% by the "Difficulty in establishing and maintaining effective work and social relationships" as checked in the DBQ by the C&P examiner. Just not sure what the rater will do as all my, "Symptoms are tagged extent as MILD." Thank you in advance for your feedback. Here is the short synopsis: This Veteran's self-report, the records reviewed on VBMS and CPRS, the test results, and my observations all are consistent with the diagnosis of PTSD. It is at least as likely as not (50% or higher probability) that the PTSD symptoms are associated with this Veteran's military experiences and the stressors reported. For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Difficulty in establishing and maintaining effective work and social relationships This Veteran currently meets diagnostic criteria for PTSD. His PTSD symptoms are directly related to his stressors in service. Therefore, it is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) deployment to XXXXXX during service.
  5. I have copies of the C&P's and attended all the exam. The one that throws me off is my hearing, in the exam notes it states by the audiologist, " "Therefore, it is my opinion, that it is as least as likely as not that the hearing loss found upon examination and the tinnitus reported during today's examination, are related to the noise exposures as associated with his MOS and his combat service, and as demonstrated by the bilateral STS's across all frequencies." I am already service connected for tinnitus, yet my eBenefts says, hearing loss, NOT SERVICE CONNECTED.... The orthopedic docs wrote in my exams at my already service connected knee has (severe arthritis or moderate/severe) plus a meniscus tear, I am 10% for mild arthritis only from 2006. C&P complie Ebenefits still shows no change and moderate is 20% and severe is 30%
  6. I don't know if I am being impatient, but here is my situation. My claim in eBenefits shows closed and complete as of 12 July 2018. Under my "Disabilities" section it shows that my current service connected percentage didn't change and the list of disabilities does show all the items I claimed from this current closed/complete claim states, "not service connected." Is it too early to freak out and to let the system catch up and wait for the formal benefits letter stating what the real deal is or should I just start getting my appeal ducks lined up as all my claim was canned? Anyone ran into this same situation and assumed the worst and was right based on this same scenario?
  7. You should get a questionnaire giving feedback for your exam either by email or regular mail. I did on mine about a month ago, can't wait to my next one on the current exam I had last week so I can tell my side of the story. I'd definitely get the ducks in a row and provide any new medical reports between now and the outcome of your claim. Then request a "reconsideration" based on "XYZ" evidence the examiner missed and new material associated with claim. It beats doing a full appeal.
  8. Does it look like that from the sentence of the doc's notes, "Rather, the Veteran's back condition is an independent finding sepatate in time and location from his knee condition", that I should claim the back condition solely by itself rather than as a secondary condition as I did in my current claim?
  9. Yes it does. This examiner is going off of notes and information over a decade ago. How can it be comprehensible to think info from 2006 is comparable to 2018, 12 years ago. It sickens me to no end.
  10. All, I had my C&P for my back the other day, here is my DBQ. Looking at the examiners notes, he is basically saying, "Yeah, since there is not a noted limp or impaired gait, the fact your were overweight but lost 100lbs., you're knee isn't the cause of your back problems." The doctor puts some medical articles to back up his own theory and opinion do actually persuade a coming denial for my claim. Take a look for yourself, would love the communities thoughts: Note LOCAL TITLE: C&P EXAMINATION NOTE STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAY 17, 2018@08:00 ENTRY DATE: MAY 17, 2018@14:32:21 AUTHOR: DYE,JAMES C EXP COSIGNER: URGENCY: STATUS: COMPLETED Back (Thoracolumbar Spine) 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 ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: No response provided. Diagnosis #1: degenerative arthritis with facet arthropathy L4-L5, L5-S1 ICD code: M47.817 Date of diagnosis: 8/01/2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): The Veteran states he developed back pain while in the military prior to injuring his right knee. He provides a copy of his STR from 11/20/2003 which show acute onset of idiopathic (non-traumatic) low back pain. The note states he had decreased ROM of the back with mild parapsinal tenderness. He was treated medically and seen again on 12/01/2003, and the medical information provided shows full resolution of a thoracic muscle sprain which had occurred 10 days prior according to the records provided. A normal exam was noted and the note states he was returned to full duty with complete resolution of the injury. The Veteran then injured right knee in 2005 which lead to a medical discharge on 5/10/2006. The MEB does not mention a back condition at that time. A review of the C&P examination performed on 7/24/2006 near the time of discharge noted the history of a thoracic muscle sprain, but notes the spine was completely normal on exam and the veteran had NO complaint of back pain. Thoracic and lumboscaral xrays of the spine performed on 7/20/2006 were compltely normal at that time. The Veteran's knee condition was noted and his gait was noted to be normal. The Veteran states today he continued with low back pain which he self-treated and did not require addititonal medical attention until 2014. The Veteran sought medical attention for his lower back during his first PCP visit at the Hunter Holmes McGuire VAMC on 08/01/2014 stating the back pain worsened due to moving and lifting heavy boxes a few months prior. At that time the Veteran also weighed nearly 300 pounds and had a BMI of 40 on 8/01/2014. His gait was noted to be normal. Records multiple medical visits to the Castle Point VAMC for his ongoing right knee pain years earlier, but no mention of a back condition. An orthopedic evaluation on 2008 noted the ongoing right knee condition but a normal gait and no back condition was recorded. The Veteran had a BMI of 40 on 08/01/2014. He went on a diet and lost 100 pounds over 2-3 years. His current BMI in approximately 30. He is a non-smoker. He drinks alcohol about about 5-6 beers on about 3-4 times weekly. He currently works at Fort Lee as a academic counselor, which is a seated non-stenous job, although prolonged sitting will aggravate his lower back. Currently, he is having a flair of low back pain which started 5/3/2018 and he was evaluated on 5/04/2018 by his PCP at the Hunter Holmes McGuire VAMC. He had been physically acitve prior to the onset of worsening back pain without any specific injury or changes in the activity before the pain decveloped by his rpeort. The PCP noted he had been participating in kick boxing according to the PCP note, but the Veteran states the kick boxing is non-combative and does not involve hitting but is more of a movement exercise, but states he did not injure himself. The Veteran appears very stiff and guarded with his back and prefers to stand during the interview. he has difficulty moving about the exam table due to low back pain, however on exal the lumbosacral muscles are flaccid without spasm or tension, although it is painful to gently palpate the lower lumbar muscles. The thoracic muscles are neither tender not tight. 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: The Veteran is currently have a flair with increased pain and decreased movement of the lower back. He reports 2 such flairs over the last year and will typically last 7-10 days, although currenlty the symptoms have been present for 2 weeks. 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. The Veteran reports limiting his lifting to less than 15 pounds. He does not sit longer than a few minutes before trying to change position. He limits bending forward to pick up objects from the floor. He states he limits his exercises to stretching and gentle movements 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 20 degrees Extension (0 to 30): 0 to 18 degrees Right Lateral Flexion (0 to 30): 0 to 14 degrees Left Lateral Flexion (0 to 30): 0 to 12 degrees Right Lateral Rotation (0 to 30): 0 to 24 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: limited forward motion of lower back inhibit usual movments like bending forward to pick up objects 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, Left Lateral Flexion, Left Lateral 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 join ts or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender lower lumbar muscle to light tough, but muscles without spasm 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? [X] Yes [ ] No Select all factors that cause this functional loss: Pain ROM after 3 repetitions: Forward Flexion (0 to 90): 0 to 15 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 10 degrees Right Lateral Rotation (0 to 30): 0 to 24 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: The Veteran states there is more pain and less function when the joint is used over times repeatedly or during flair, but since those conditions are not currently present to examine any further estimation of ROM other than what is documented would be pure estimation. d. Flare-ups Is the exam being conducted during a flare-up? [X] Yes [ ] No 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 Able to describe in terms of range of motion: [X] Yes [ ] No Forward Flexion (0 to 90): 0 to 15 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 10 degrees Right Lateral Rotation (0 to 30): 0 to 24 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees 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: Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting Please describe additional contributing factors of disability: prolonged sitting and walking will worsen lower back pain 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 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 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? [ ] 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? [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: veteran states occasionally uses walking stick to steady himself whenback pain flairs 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? [ ] 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? [ ] Yes [X] 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: In regards to functional impairment related to occupations, veteran cannot perform tasks that require prolonged standing or sitting without reasonable accommodation for change in position, repetitive bending or lifting, or any tasks that require lifting above his head, pulling, pushing, crawling, or stooping. These activities would aggravate his current back condition and veteran may not be able to do these activities safely. Veteran's back condition does affect his ability to perform basic activities of daily living without difficulty. Based on the physical exam and medical record, veteran remains independent with his basic ADLs but performs them with difficulty because of his back condition. Specifically, his back condition affects his ability to dress himself, perform personal hygiene, and ambulate without pain or impairment 17. Remarks, if any: -------------------- Minimal degenrative arthritic changes noted on lumbosacral xray 8/01/2014. Per the VA Form 21-2507 related to this claim, this examiner addressed the Correia questions listed. For any joint condition tested during this exam, this examiner tested the affected joint listed in this claim along with the contralateral joint, unless medically contraindicated, and this examiner addressed pain on both passive and active motion, and on both weightbearing and non-weightbearing. For all measurements listed on this exam, the goniometer was used by this examiner. The measurements listed on this DBQ reflect measured pain-free active movement using the goniometer. In addition to the questions on the DBQ, this examiner responded to the following questions: 1. Is there evidence of pain on passive range of motion testing? (Yes, in the lower back. 2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes, at times in the lower back. 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? There is no opposing joint to the thoracolumbar spine. **************************************************************************** Medical Opinion Disability Benefits Questionnaire 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 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is the Veteran's degenerative disc disease/arthritis lumbar spine at least as likely as not (50% or greater probability) proximately due to or the results of knee arthritis status post patellar dislocation and arthroscopic knee surgery? b. Indicate type of exam for which opinion has been requested: DBQ Musc Knee TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: The Veteran injured his knee playing basketball in 2005 which resulted in a patellar injury, subsequent surgery, ongoing pain and evenetaully osteoarthritis of the right knee which causes the Veteran a good deal of pain in the right knee. There is no current gait abnormality from the knee injury noted on examination today and review of the Veteran's medical records do not show any abberation in the Veteran's gait despite ongoing knee pain in medical information available fom 5/28/2005, 07/24/2006, 11/03/2008, 08/01/2014, 03/21/2018, 4/26/2018 and 05/04/2018, which includes exams by orthopedic (2008 and 3/21/2018) and PMR (04/26/2018) specialists. The idea that an injury in one part of the body, espescially a lower limb, will cause a condition to develop in another part of the body - such as the low back, is a popular notion with little basis in fact. A discussion paper, "Limping and Back Pain" in the The Workplace Safety and Insurance Appeals Tribunal, March 2004 and Revised: August 2013 prepared by: Dr. Ian J. Harrington, B.A.Sc., P. Eng., M.D., F.R.C.S.(C), M.S., MSc. (Strath.) examines the possible connection between limping from a number of causes and the development of back pain. The article states that in general only persons with a limp with an abnormal gait caused by the lower leg condition MAY be at risk for developing a condition in the lower back from excess torque or angulation of the lower back with walking. According to the article, "it would probably be necessary for the limp to be severe and prolonged, meaning years, for it to have a significant impact on the initiation or aggravation of arthritis of the spine. As well, it would also be necessary for the Trendelenburg gait pattern to have been severe and present for an extended period of time, probably years, to have any permanent effect on the spine. Even then, the article states such evidence is limited and inconclusive. However, most importantly, the Veteran has no such limp today, nor is a gait abnormality or significant back angulation with movement ever noted in the Veteran's medical records dating from 2005 until the present. Thus this lack of connecting physical findings and possible biomechanics makes it extremely unlikely pain in the knee would then cause the Veteran to develop a back condition in an anatomically separate area. Rather, the Veteran's back condition is an independent finding sepatate in time and location from his knee condition. Low back pain is an extremely common problem in working-age people. Risk factors associated with back pain complaints include smoking, obesity, age, female gender, physically strenuous work, sedentary work, psychologically strenuous work, low educational attainment, Workers' Compensation insurance, job dissatisfaction, and psychologic factors such as somatization disorder, anxiety, and depression. Transient exposure to a number of modifiable physical and psychosocial triggers substantially increases risk for a new episode of lower back pain making one causal event difficult to pinpoint. (Steffens, D., Ferreira, M. L., Latimer, J., Ferreira, P. H., Koes, B. W., Blyth, F., Li, Q. and Maher, C. G. (2015), What Triggers an Episode of Acute Low Back Pain? A Case-Crossover Study. Arthritis Care & Research, 67: 403-410. doi:10.1002/acr.22533.) Based on this examiner's review of current peer-reviewed literature along with a Cochrane Database Systemic Review, the systemic review of multiple studies support that there is a causal association between obesity and low back pain. Several possible mechanisms explain this association. First, obesity could increase the mechanical load on the spine by causing a higher compressive force or increased shear on the lumbar spine structures during various activities. Obese people may also be more liable to incur accidental injuries. Second, obesity may cause low back pain through systemic chronic inflammation. Obesity is associated with increased production of cytokines and acute-phase reactants and with activation of proinflammatory pathways, which, in turn, may lead to pain. Third, population-based studies have shown a stronger association of abdominal obesity than generalized obesity with low back pain. Other studies have reported that obesity is associated with disc degeneration and vertebral endplate changes. Spinal mobility decreases with increasing body weight, which may interfere with disc nutrition. Atherosclerosis could cause malnutrition of the disc cells, which may predispose to disc degeneration (The Association Between Obesity and Low Back Pain: A Meta-Analysis. Am J Epidemiol (2009) 171 (2): 135-154.) The Veteran was nearly 300 pounds with a BMI of 40 at the point the Veteran sought medical attention for back pain. While obesity was not likely the sole causal factor either, it more likely than not a combination of factors such as obesity, sedentary work and others were the root of the Veteran's onset of his current back condition. ************************************************************************* TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR AGGRAVATION OF A NONSERVICE CONNECTED CONDITION BY A SERVICE CONNECTED CONDITI0N ] a. Can you determine a baseline level of severity of (claimed condition/diagnosis) based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by (service connected condition)? Yes i. Describe the baseline level of severity of (claimed condition/diagnosis) based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by (service connected condition): The Veteran was noted to have a normal spinal exam and no reported pain in the lower back on 7/24/2006 during a C&P examination shortly after his discharge. ii. Provide the date and nature of the medical evidence used to provide the baseline: C&P examination examined all claimed conditions at that time in 2006 which included the right knee, which was noted to have a debility, and the spine which was noted to be normal by the examining provider. iii. Is the current severity of the (claimed condition/diagnosis) greater than the baseline? Yes If yes, was the Veteran's (claimed condition/diagnosis) at least as likely as not aggravated beyond its natural progression by (insert "service connected condition")? No b. Provide rationale: There is no medical doucmentation to link the level of debility or dysfunction of the Veteran's service-connected knee condition and his claimed condition of the lumboscaral back. There is currently no gait abnormality from the knee injury noted on examination today and review of the Veteran's medical records do not show any abberation in the Veteran's gait despite ongoing knee pain in medical information available fom 5/28/2005, 07/24/2006, 11/03/2008, 08/01/2014, 03/21/2018, 4/26/2018 and 05/04/2018, which includes exams by orthopedic (2008 and 3/21/2018) and PMR (04/26/2018) specialists. As noted in prior opinion, the idea that an injury in one part of the body, espescially a lower limb, will cause a condition to develop in another part of the body - such as the low back, is a popular notion with little basis in fact. A discussion paper, "Limping and Back Pain" in the The Workplace Safety and Insurance Appeals Tribunal, March 2004 and Revised: August 2013 prepared by: Dr. Ian J. Harrington, B.A.Sc., P. Eng., M.D., F.R.C.S.(C), M.S., MSc. (Strath.) examines the possible connection between limping from a number of causes and the development of back pain. The article states that in general only persons with a limp of abnormal gait caused by the lower leg condition MAY be at risk for developing a condition in the lower back from excess torque or angulation of the lower back with walking. According to the article, "it would probably be necessary for the limp to be severe and prolonged, meaning years, for it to have a significant impact on the initiation or aggravation of arthritis of the spine. As well, it would also be necessary for the Trendelenburg gait pattern to have been severe and present for an extended period of time, probably years, to have any permanent effect on the spine. Even then, the article states such evidence is limited and inconclusive. However, most importantly, the Veteran has no such limp today, nor is a Gait abnormality or significant back angulation with movement ever noted in the Veteran's medical records dating from 2005 until the present. Thus this lack of connecting physical findings and possible biomechanics makes it extremely unlikely pain in the knee would then cause the Veteran to develop a back condition or aggravate an existing back problem in an anatomically separate area. Rather, the Veteran's back condition is an independent finding sepatate in time and location from his knee condition. ************************************************************************* /es/ JAMES C DYE, M.D. PRIMARY CARE ATTENDING Signed: 05/17/2018 14:32
  11. I have no idea whatmy original Rom was, my initial c&p was in summer 2006. If I get 30 on Rom and my arthritis up to 20 and get 10% for atrophy that works
  12. Just looking for some feedback on possible outcomes of results of my C&P for my knee. I am service connected for my right knee (10% for the scar and 10% for the arthritis). Here are the Nurse Practitioners notes who did my exam: 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Right Knee Arthritis b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Arthritic conditions [X] Arthritis, traumatic Side affected: [X] Right [ ] Left [ ] Both ICD Code: M17.10 Date of diagnosis: Right 8/2017 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. D escribe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Veteran is service connected for knee arthritis status post post right patellar dislocation and arthroscopic knee surgery. Veteran had surgery to the knee in 2005. Since the last compensation exam he reports stability issues and pain to the right knee. He states knee gives out and he has fallen upstairs and down stairs. He states he has a permanent limp. Locates pain to lateral knee and below the knee cap. He states the pain is constant, aggravated by prolonged sitting and standing, ascending/descending stairs. He was seen by Orthopedic in July 2017 and given a Synvasc injection. He uses a knee knee brace. He reports loss of sensation to the top of the knee cap. b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No 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: I try to maintain with cycling and swimming. I can only hike a mile before I get pain and tired in the knee - it seizes and locks up. 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 90 degrees Extension (140 to 0): 90 to 0 degrees If abnormal, does the range of motion itself contribute to 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 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): Tender to palpation over lateral knee and infrapatellar region Is there objective evidence of crepitus? [ ] Yes [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? [X] Yes [ ] No Select all factors that cause this functional loss: Pain ROM after three repetitions: Flexion (0 to 140): 0 to 85 degrees Extension (140 to 0): 85 to 0 degrees Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms of range of motion: [X] Yes [ ] No Flexion (0 to 140): 0 to 85 degrees Extension (140 to 0): 85 to 0 degrees Right Knee ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling Please describe additional contributing factors of disability: Mild medial swelling noted 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 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? [X] Yes [ ] No If yes, is the muscle atrophy due to the claimed condition in the Diagnosis Section? [X] Yes [ ] No For any muscle atrophy due to a diagnosis listed in Section 1., indicate side and specific location of atrophy, providing measurements in centimeters of normal side and corresponding atrophied side, measured at maximum muscle bulk. [X] Right lower extremity (specify location of measurement such as "10cm above or below the knee"): Location: No location specified Circumference of more normal side: 47cm Circumference of atrophied side: 45cm 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 ankyloses 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 [ ] Slight [X] Moderate [ ] Severe 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: 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) 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? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. 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] Meniscectomy, arthroscopic or other knee surgery not described above Type of surgery: Arthroscopic Lysis of Adhesions, Medial Patellofemoral Ligament Repair Date of surgery: 2 February 2005 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: Anterior Right Knee Measurements: length 10.0cm 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 b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: Veteran uses a knee brace to support the knee for the right knee condition. 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 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate knee: [X] Right [ ] Left [ ] Both b. 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): Exm Date: AUG 10, 2017@16 Report: Right knee MRI There are susceptibility artifacts related to tendon anchor is within the medial aspect of the patella which correlates with findings on prior radiographs. This is likely related to prior medial retinacular repair. This makes evaluation of the medial facet of the patella very difficult. The patellar cartilage along the lateral facet of the patella appears largely intact. There is mild degenerative change of the patellofemoral joint with spurring off the articular surfaces. The quadriceps tendon and patellar tendon are intact. There is advanced degenerative chondrosis of the articular cartilage of the lateral femoral condyle. There is reactive subchondral edema within the lateral femoral condyle. There are reactive subchondral changes within the lateral tibial plateau as well. There is degeneration of the lateral meniscus and partial extrusion of the meniscus from the joint without definitive tear the medial meniscus is intact. The anterior cruciate ligament and the posterior cruciate ligament are intact. The medial collateral ligament and lateral collateral ligamentous complex are intact. Impression: There are postoperative changes of the patella without visible complication related to surgery however there is susceptibility artifact. There is relatively advanced degenerative arthritis of the lateral compartment of the knee without definitive meniscal tear. c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 14. 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: In regards to functional impairment related to occupations caused by knee condition, veteran cannot perform tasks that require prolonged standing, prolonged walking, any degree of running or any tasks that require crawling, squatting, or stooping. These activities would aggravate their current knee condition and veteran may not be able to do these activities safely. 15. Remarks, if any: -------------------- 1. Is there evidence of pain on passive range of motion testing? Yes 2. Is there evidence of pain when the joint is used in non-weight bearing? t be performed Yes 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? Yes See Exam above. A goniometer was used for range of motion measurements. **************************************************************************** Scars/Disfigurement Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No
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