Newbie here!!!!! Thanks to fellow Veterans I finally filed a disability claim 15 years after I retired from USMC with 20 years of active duty service. Of course initial claim was denied(Jan 2015), not enough evidence to service connect. Thanks again to fellow veterans and this forum did some homework and filed an appeal Dec 2015. Opted into RAMP on July 2018, C&P exam a few weeks ago, still gathering evidence in Vets.gov
Did not post all of the C&P Exam just what seemed to be relevant; can someone with experience let me know their thoughts?
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
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
[X] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: DDD
ICD code: M51.36
Date of diagnosis: 2005
Diagnosis #2: IVDS
ICD code: M51
Date of diagnosis: 2005
Diagnosis #3: Disc Herniation
ICD code: M51.2
Date of diagnosis: 9/12/2016
2. Medical history
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a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary):
The veteran has years of chronic back pain and left leg radicular symptoms. The veterans initial back injury occured while
repelling and loosing control of the rope and landing quite hard, also injuring his shoulder and ribs in this fall. The veteran has reported
chronic back pain since that time. The veterans DDD has progressed and lead to bulging discs and radiculopathy. The veteran is currently experiencing a
flare-up, he reports that for the last month his back has been flared-up and the pain is severe. The veteran today has antalgic short strided gait,
if he takes a longer stride his left leg sciatica in unbearable. The veteran is clearly in significant pain due to his current flare-up.
3. Range of motion (ROM) and functional limitation
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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 5 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 10 degrees
Left Lateral Rotation (0 to 30): 0 to 10 degrees
Observed repetitive use
Is the Veteran able to perform repetitive use testing with at least three repetitions?
[ ] Yes [X] No
If no, please provide reason:
current flare-up prevents further ROM testing.
If the examination is not being conducted immediately
after repetitive
use over time:
[X] The examination is medically consistent with the
Veteran's statements describing functional loss with repetitive use over time.
Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
[X] Yes [ ] No
a. Indicate symptoms' location and severity (check all that
apply):
Constant pain (may be excruciating at times)
Right lower extremity: [X] None [ ] Mild [ ] Moderate
[ ] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate
Intermittent pain (usually dull)
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
Numbness
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service
injury, event or illness.
c. Rationale: The veterans STR's show complaints of back pain throughout service, including his retirement physical in which he reported
history of chronic recurrent back pain. The veterans back condition has progressed, his radiculopathy is the progression of the DDD and chronic pain.
The post service records clearly chow no other injuries, and they all show he's has chronic back pain since the military. The current symptoms are
reflective of the flare-up he was having during this appointment.