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  1. This is my latest C&P what am I looking at? Can anyone break this down? Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No Evidence Comments: BOARD REMAND 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: No diagnosis provided. Diagnosis #1: CERVICO-OCCIPITAL NEURALGIA ICD code: == Date of diagnosis: 9/28/2015 Diagnosis #2: CERVICAL RADICULOPATHY WITH BULGING DISC ICD code: == Date of diagnosis: 2016 Diagnosis #3: MECHANICAL CERVICAL PAIN SYNDROME ICD code: == Date of diagnosis: 4/29/2015 If there are additional diagnoses that pertain to cervical spine (neck) conditions, list using above format: CERVICAL VERTEBRAE(NECK MUSCLE SPASM), DATE OF DIAGNOSIS, 6/25/1996. CERVICAL HERNIATED AND BULGING DISC, MUSCLE SPASM, AND CORD CONTUSION WITH COMPRESSION MYELOMALACIA, 8/14/12 CERVICAL SPONDYLOSIS AND DEGENERATIVE DISC DISEASE, 9/25/2014. On today's C&P examination, 11/21/17, Veteran reports several incidents in 1992-1995 of blunt trauma including carrying 50 caliber machine gun barrels and ammunition. Involved in ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Also went to Bethesda for back school(approx. week). Currently, Veteran reports daily neck pain. Denies neck surgery. Denies no recent physical therapy. Uses Flexeril, Ibuprofen, Oxycodone, and Tens unit for pain relief. Last treated by chiropractor in 2016(Tampa Bay, Florida). b. Dominant hand: [ ] Right [ ] Left [X] Ambidextrous c. Does the Veteran report flare-ups of the cervical spine (neck)? [ ] Yes [X] No d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (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: Can't do much of any type of physical activity, that's really limited. Obviously a hindrance, job related stuff. Multiple days off from work(pain, stiffness). Can't do lawn activities. Can't wash dishes. Can't play with your kids like you want to. Sleeping is impossible-Sometimes you have to sleep sitting up in a chair. 3. Range of motion (ROM) and functional limitations --------------------------------------------------- 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 (0-45): 0 to 46 degrees Extension (0-45): 0 to 15 degrees Right Lateral Flexion (0-45): 0 to 23 degrees Left Lateral Flexion (0-45): 0 to 14 degrees Right Lateral Rotation (0-80): 0 to 48 degrees Left Lateral Rotation (0-80): 0 to 44 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Limited bending. 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)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, 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 joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Tenderness on palpation of the cervical spine. b. 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: Unable to perform due to severe pain. 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 nor 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: This examiner is unable to opine and would otherwise be speculating to state whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Therefore this examiner cannot describe any such additional limitation due to pain, weakness, fatigability or incoordination. Furthermore, such opinion is also not feasible to give degrees of additional ROM loss due to "pain on use or during flare-ups" without speculation. d. Flare-ups Not applicable e. Guarding and muscle spasm Does the Veteran have guarding, or muscle spasm of the cervical spine? [X] Yes [ ] No Muscle spasm [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Guarding [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: 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. Please describe: Decreased ROM. 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 Elbow 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 Elbow 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 Wrist flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Abduction Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [X] Yes [ ] No If muscle atrophy is present, indicate location: Upper Arm Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side: 37.5 cm. Atrophied side: 36 cm. 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 Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No If yes, complete the following section: a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of C8/T1 nerve roots (lower radicular group) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [X] Yes [ ] No b. If yes to question 10a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 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? [ ] 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. 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) 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.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. 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. 14. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a 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): 9/25/2014,MRI Cervical spine:Visibility of the central canal of the cord at the C5 level with diameter of 2mm, not considered to reflect significant syringohydromyelia and not associated with mass or abnormal enhancement. Spondylosis and degenerative disc disease of the cervical spine. Right-sided predominant disc osteophyte complex at C6-7 causes mild right central canal and moderate right neural foraminal stenosis at this level. No other central canal stenosis with milder areas of neural foraminal encroachment detailed above. C2-3:Focal shallow central to right paracentral disc protrusion. No central canal or neural foraminal stenosis. C3-4:Mild generalized disc bulge. Mild right than left neural foraminal stenosis with central canal patent. C6-7:Mild generalized disc bulge with more focal disc osteophyte complex in the right paracentral, right subarticular, and right lateral stations. C7-T1:Negative for disc herniation. 8/14/2012, MRI Cervical spine:Herniated disk C3/4, C5/6, and C6/7 levels. Bulging disk C2/3 and C4/5 levels. Diffuse spondylitic changes. Straightened alignment suggesting muscle spasm. Focal area of cord contusion or compression myelomalacia at C5 level. 15. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine (neck) conditions, providing one or more examples: Veteran is capable of limited lifting, carrying, and bending. 16. Remarks, if any: -------------------- NOTE:Veteran performed neck flexion repeition which reduced ROM to 32deg. Unable to perform any further repetition for other ROM maneuvers. ************************************************************************* Additional exam request information: For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non- weightbearing. In addition to the questions on the DBQ, please respond to the following questions: 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? YES **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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 Evidence Comments: BOARD REMAND MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: (a) Please state all diagnoses as to the Veteran's cervical spine, and address all diagnoses already of record: herniated disk and bulging disk of the cervical spine and spondylitic changes, muscle spasm and contusion/compression, spondylosis and degenerative disc disease of the cervical spine, mechanical cervical pain syndrome and radiculopathy. (b) Please provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed cervical spine disability was caused by or etiologically related to active duty. Please specifically address the back injuries and complaints of back pain noted in the STRs. (c) Please specifically address the Veteran's lay statements that he has suffered cervical spine pain since service, and that in service he suffered injury to his neck while carrying heavy equipment and continuous wear of duty gear. (d) Please address the conflicting evidence of record and offer a clarifying opinion, notably the February 2013 VA examination positing a negative nexus, and the April 2016 private opinion positing a positive nexus. b. Indicate type of exam for which opinion has been requested: NECK 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: Upon review of all available medical evidence, including eVBMS, virtual VA, and Board Remand, the following pertinent information is obtained and reported in 'Evidence Comments': Prior VA Examination, 6/25/96, reports Mr. served in the Marine Corps. he was inducted in 1990 and received separation with an honorable discharge in 1996. Medical History-In 1992, he had onset of pain in the neck area diagnosed at Quantico. Xrays were negative. Impression was muscle spasm and stress. Enlistment RME/RMH for national guard, 4/13/98, reported no neck problems and normal exam of the spine. Miami VAMC, Outpatient clinic, 5/6/2005:Assessment is chronic neck and low back pain-Will get plain films and MRI, does not want any meds. 2/28/2013, VA examination opines "Unable to find SMR evidence of significant neck injury or complaint in service. No evidence to support chronicity of problem for over 10 years post-discharge." THIS OPINION IS GIVEN LOW WEIGHT BECAUSE IT IS NEITHER SUPPORTED NOR CONSISTENT WITH THE RECORDS IN FILE THAT SHOW COMPLAINTS OF NECK PAIN INDICATING A CHRONIC CONDITION. 4/29/15, DBQ neck was completed providing a diagnosis of mechanical cervical pain syndrome and radiculopathy. As received 4/8/16, VA physician, , states that the Veteran suffers from cervico-occipital neuralgia and cervical radiculopathy with bulging disc "are as likely as not a direct result of blunt trauma received during the patient's military career. His conditions are a severe occupational impairment to the veteran and has been exacerbated by many years of continuous wear of duty gear related to his profession." On today's C&P examination, 11/21/17, Veteran is a credible historian and reports several incidents in 1992-1995 of blunt trauma, involving ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Veteran also reported chronic neck pain during service was due to carrying 50 caliber machine gun barrels and ammunition. He also went to Bethesda for back school(approx. week). In summary, the Veteran has been under chronic medical care for neck pain first reported during service(6/25/96) and the condition has progressed from cervical muscle spasm to mechanical cervical pain syndrome and radiculopathy, cervical herniated and bulging disc with muscle spasm, cord contusion/compression myelomalacia, cervical spondylosis and degenerative disc disease, cervico-occipital neuralgia, and cervical radiculopathy with bulging disc. A nexus has been established. Therefore, it is at least as likely as not that the claimed condition has direct service connection.
  2. Hi everyone, I already submitted an "intent to file" on e benefits with all the disabilities that I did not claim in the past, these include: flat foot, shin splints and plantar fasciitis. I get really bad shin splints just by walking around, I started noticing this during battalion hikes when I was in the marines. I get pain at the bottom of my feet most of the time because I do not have the arched area at all. There is a part in both my shins where I can see some tissue popping out (under the skin) when I move my feet around. My question is: Should I claim flat foot as a primary disability and shin splints, plantar fasciitis (pain in the heel section) as secondary to flat foot? Would this help me to get a greater rating? Any inputs welcomed, tiredmarine0331
  3. I tore both of my shoulders had surgery that is S/C already. At the time of me filing for VA claim I had no idea about secondary conditions (just learning bout it). Both Shoulders I have these Symptoms experience: Chronic PainPain Pain Diisorder (believe if I push or grab stuff) Cause Depression Cant Sleep (get well since suregery over 2 years ago) What is the best way to file the secondary injuries? Can I file for each shoulder all those symptoms I experience? Basically trying to understand the best way to file this so I dont get screwed by the VA.
  4. Hi, I am currently rated at 20% for my shoulder. I went in for a CP exam recently and these were the results. This is a remand exam from the BVA. Am I looking at a decrease to 10 or even zero? I am not bending my shoulder so it may dislocate for any of these people or any examination and I think it may have hurt me. If you could take a look I'd appreciate it. Thanks for your time! Shoulder and Arm 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] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Strain with radicular sx b. Select diagnoses associated with the claimed condition(s) (check all that apply): [X] Shoulder strain Side affected: [ ] Right [X] Left [ ] Both ICD Code: S46.019A Date of diagnosis: Left UNK- S/C c. Comments, if any: No response provided d. Was an opinion requested about this condition? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's shoulder or arm condition (brief summary): *** Note - Veteran was notified that this evaluation is for Compensation and Pension purposes only and he/she is to return to his/her treating clinician for regular medical care =========================================================================== ===== Veteran served in the US Army as a Cav Scout E-5 from 1988-1996 - reports that he is s/c for L shoulder strain with radicular sx. Reports current condition includes the following sx- L shoulder Pain- intermittent Daily lasting 10 minutes to hours 3-7/10 dull to sharp depending on activity Dislocations - Last occurred was 3 years ago - has popping and clicking, sensation of weakness Reports constant L lateral 1st metatcarpal numbness Has additional numbness from axillary region to the Lateral aspect of the L 1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2 hours Condition impacts Occupation/Recreation/Daily activities- Limits carrying, lifting, pushing, pulling and overhead work Current Tx Type Duration Response to Medications 1. Medications OTC ASA, Tylenol, Advil as directed PRN- fair results 2. Denies Physical therapy Occupation since discharge- HVAC mechanic now on SSDI since 2013 2. DOMINANT HAND: right 3. POSTURE & GAIT: straight; gait stable, smooth, symmetric b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report flare-ups of the shoulder or arm? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: L shoulder Pain- intermittent Daily lasting 10 minutes to hours 3-7/10 dull to sharp depending on activity Dislocations - Last occurred was 3 years ago - has popping and clicking, sensation of weakness Reports constant L lateral 1st metatcarpal numbness Has additional numbness from axillary region to the Lateral aspect of the L 1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2 hours Condition impacts Occupation/Recreation/Daily activities- Limits carrying, lifting, pushing, pulling and overhead work Pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Veteran would have additional limitations in ROM but unable to quantify the degree of ROM loss as it would vary due to severity of pain , weakness, fatigability and overuse. d. 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: L shoulder Pain- intermittent Daily lasting 10 minutes to hours 3-7/10 dull to sharp depending on activity Dislocations - Last occurred was 3 years ago - has popping and clicking, sensation of weakness Reports constant L lateral 1st metatcarpal numbness Has additional numbness from axillary region to the Lateral aspect of the L 1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2 hours Condition impacts Occupation/Recreation/Daily activities- Limits carrying, lifting, pushing, pulling and overhead work Pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Veteran would have additional limitations in ROM but unable to quantify the degree of ROM loss as it would vary due to severity of pain , weakness, fatigability and overuse. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Left Shoulder ------------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 130 degrees Abduction (0 to 180): 0 to 150 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees If ROM is outside of normal range, but is normal for the Veteran (for reasons other than a shoulder condition, such as age, body habitus, neurologic disease), please describe: Veteran refuses to move L shoulder beyond stated range due to fear of pain and dislocation- poor effort If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: limits ROM 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, Abduction 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 Left Shoulder ------ ------- 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 c. Repeated use over time Left Shoulder ------------- 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? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Veteran would have additional limitations in ROM but unable to quantify the degree of ROM loss as it would vary due to severity of pain , weakness, fatigability and overuse. d. Flare-ups Left Shoulder ------------- 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 If unable to say w/o mere speculation, please explain: Pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Veteran would have additional limitations in ROM but unable to quantify the degree of ROM loss as it would vary due to severity of pain , weakness, fatigability and overuse. e. Additional factors contributing to disability Left Shoulder ------------- 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., Other (please describe) Please describe additional contributing factors of disability: Condition impacts Occupation/Recreation/Daily activities- Limits carrying, lifting, pushing, pulling and overhead work 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 Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 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 the Veteran has ankylosis of scapulohumeral (glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus move as one piece). a. Indicate severity of ankylosis and side affected (check all that apply): Left side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis b. Comments, if any: No response provided 6. Rotator cuff conditions -------------------------- Is rotator cuff condition suspected? Right Shoulder: [ ] Yes [ ] No Left Shoulder: [X] Yes [ ] No If "Yes" complete the following: Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A External Rotation/ Infraspinatus Strength Test (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Lift-off Subscapularis Test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A 7. Shoulder instability, dislocation or labral pathology -------------------------------------------------------- a. Is shoulder instability, dislocation or labral pathology suspected? [X] Yes [ ] No If yes, complete questions 7b - 7d below: b. Is there a history of mechanical symptoms (clicking, catching, etc.)? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both c. Is there a history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? [X] Yes [ ] No If yes, indicate frequency, severity and side affected (check all that apply): [X] Infrequent episodes [ ] Right [X] Left [ ] Both [X] Guarding of movement only at [ ] Right [X] Left [ ] Both shoulder level d. Crank apprehension and relocation test (with patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of instability with further external rotation may indicate shoulder instability.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint conditions ------------------------------------------------------------------------------ a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? [X] Yes [ ] No If yes, complete questions 8b, 8d and 8e below: b. Does the Veteran have an AC joint condition or any other impairment of the clavicle or scapula? [ ] Yes [X] No c. Does the clavicle or scapula condition affect range of motion of the shoulder (glenohumeral) joint? No response provided d. Is there tenderness on palpation of the AC joint? [ ] Yes [X] No e. Cross-body adduction test (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 9. Conditions or impairments of the humerus ------------------------------------------- a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? [ ] Yes [X] No b. Does the Veteran have malunion of the humerus with moderate or marked deformity? [ ] Yes [X] No c. Does the humerus condition affect range of motion of the shoulder (glenohumeral) joint? No response provided d. Comments, if any: No response provided 10. Surgical procedures ----------------------- No response provided 11. 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 12. Assistive devices --------------------- a. Does the Veteran use any assistive devices? [ ] 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 the Veteran's shoulder and/or arm conditions, 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 14. Diagnostic testing ---------------------- a. Have imaging studies of the shoulder been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [ ] 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 15. 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 impact of each of the Veteran's shoulder conditions providing one or more examples: Condition impacts Occupation/Recreation/Daily activities- Limits carrying, lifting, pushing, pulling and overhead work 16. Remarks, if any: -------------------- Impression- 1. L shoulder strain with residuals of radicular sx as noted- Veteran refused to move L shoulder beyond stated range due to fear of pain and dislocation
  5. I am 10% rated with arthritis of spine. Ive had 2 car accidents one in 2011 and the other last march. My lbp was exacerbated exponentially. My back pain/muscle spasm started in 1995 and personal injuries and car accident made it worse. I have applied for an increase, cause now I can hardly get out of bed. Any suggestions or encouragement is appreciated. Regards DQM
  6. Me again, bet some of you are getting tired of me, right? I know I sure am! Anyway, I have an appointment with pain management for consult and/or treatment for pain in my lower back. More specifically for the pain in the illiac crest region, Physiatrist referred me to them recommending injections in my lower back to treat the pain in my waist. My concern is this, will this impede any claim for pelvic region pain, if the injections work and eliminate the pain? I had a C&P exam back on October 30th, for this, but at the time it was filed as hip pain. During the exam I kept pointing everywhere I felt the pain, as examiner was moving my legs. As it turns out, it wasn't my hips, since I was pointing to what I now know as my illiac crest areas. The illiac crest is the bony plates in your waist area between hips and lower back. And the pain is coming from there, most likely where muscles are attached. And he was recording the ROM and it put me in 30% or higher rating block. Afterwards I couldn't sit up with out his help. I'm trying to get someone to tie it down to something, either lower extremity related, or back, for a secondary claim. The physiatrist was quite intrigued by the whole thing, since I already tried the physical therapy and lasted only 3 sessions. Therapist was disappointed at the lack of improvements and didn't want to make things worse. He's on my side! Lol. Physiatrist said this kind of pain is more common with patients who were in a head on crash where their knees were driven back into their waist. Or with major muscle injuries in the back like deep tissue lacerations or major blunt force trauma. But since I fell down some stairs, 23 years ago, and have had over 2 decades of knee, feet, ankle and back issues ever since. And this illiac crest related pain only showed up after my PCP took me off ibuprofen due to effects on bp, and switched me to tylenol. We all know what that means, right? No more anti-inflammatory benefits, since Tylenol is not an anti-inflammatory. I firmly believe that is when I first began enjoying this new pain sensation, and it was masked by the ibuprofen previously. Anyway, any thoughts, opinions, and suggestions are welcome. Thanks, Andy
  7. My claim back in 2014 it was found that my tongue scar was 7822-7800 rated at 10% due to the Characteristic of Disfigurement width measurement. My 2015 reconsideration claim to add a separate code of 7804 for the account that it is also painful was successful, but, they removed the 7800 code for head, face, or neck. The changed it to 7822-7802 so it's still 10% lol....those bastards. So my question is, does it still count as head, face, or neck 7800? It's my understanding that every conflict should be resolved in favor of the higher rating. I mean...it would be a CUE to not see that my tongue is inside my head lol! Thank you!
  8. Folks: Can male Vets make a claim for Hypogonadism and the prescribed use due to the long term use of pain meds for established service related conditions? As a result, I am now on testosterone treatments for the rest of my life and I really do not like the stuff. My testosterone levels were extremely low and I felt really weak. I also get the SMC for ED but don't know if the hypogonadism would be treated and viewed separately for disability purposes? I take the pain meds due to my SC for my Tank Related back, neck, and spine injuries during my ARMY service?
  9. Hey everyone. Ive been in the army for 5 years and im getting out in 197 days exactly and im just down right terrified. I wana cry at night cause im scared but my body wont let me shed one tear. Im here partly to get help to understand what i should do to get va disability, personal stories and partly for emotional support. Im going to behavior health for suicidal ideation, depression and anxiety currently. Ive been speaking to my ex girlfriend shes studying to be a shrink and she thinks i have paranoid schizophrenia and i was speaking to my mother the other day she said my sister has said for the last 4 years that she thought i have it as well, they both have never met in their life. However i did abuse cough syrup a few times. And im afraid they might blame the schizophrenia on that. But i was seeing behavior health before that even. Military found out. Never got introuble for it. Dark history in my life, but i have overcome that thanks to my asap class. Thank you God. I just got a psychiatric evaluation done, but im still waiting on the tests to come back to know whats really happening i dont even know who i am and worst of all for service connection, i have no clue at all what to make of this. I just had surgery for my shoulder impingement syndrome 2 weeks ago, they removed a bursa, did clavicular excision, and bicep tenesis. And ive healed well but still have a limited range of motion. (That much is all i know of va disability) I was told i have occipital nuralgia which causes me not only to have emence neck pain but to have incredible migranges daily i just walk around the motorpool acting like im busy but the pain is so bad i massage my neck and scalp to ease the pain and take naproxen like crazy, and when im off work not only do i stay home for fear of social interaction, i stay to nurse my headaches. I drink caffeine to help it and take more pain medication. I have lower back problems that came out of no where. 4 years ago my chiropractor said its facet syndrome but i stopped going to him for the last few years cause it wasnt helping and i went to see my primary care provider again for it he said its para spinal myalgia. Gave me some muscle relaxers and said have a good day after I asked for a referal back to the chiropractor. He just blew me off i feel. But i have social anxiety im scared to be a bother..... And i know im just screwing myself over but i cant help how i am. And i have to schedule appointments for anything and hes always a month backed up. Idk what to do about anything ladies and gentleman. Im begging for your help here. Im bugging my family so much about my anxieties they are ignoring my phone calls even... I want 100% disability not because it gets me out of work. I LOVE WORKING. It makes me feel accomplished and like I deserve to live and breath Gods air. But mentally im not right in the head.... If you all ask i can even show you all a text i sent to my mother when i was having a really bad episode, and even that doesnt cover all of me. (You all dont know me so i feel a ok sharing this if it helps the advice i would be given.) i mean its 0308. My mind is just racing itself i cant sleep at all!! PLEASE HELP.
  10. I have currently have a diagnosis for bilateral patella phemorial syndrome I am rated at 20 %for that and 20 % for bilateral Achilles tendinitis .I have in my medical files after falling off a obstical course it says add back therapy to treatment and for months after that date continuation of back pain and therapy. In my civilian records in more recent times i have been diagnosed with 2 herniated disks in my lower back. in the same area where the back pain was at in service. I have had pain in my back sense service .I was informed that the disk issue could be caused by the fall. 1) how do i connect the 2 in the VA's eyes ? 2) Other then the doctor's current notes and x rays showing the herniated disk what current medical evidence do i need? The pain has Progressively been getting worse with age and weight gain 3)Other then getting an IMO what are the KEY WORDS they are looking for in a fully developed claim ? ​During service I was basically given Motrin for all pain and told to suck it up.Now I realize there could have been a real underlying issue thank you for all you do i would appreciated any help you can be
  11. Good morning. This is my first post here. This site has been very helpful since I started reading it. I applied for PTSD starting back in June 2013. I was in Sadr City, Iraq in 2004-2005. I waited 8 years to claim, but my wife and parents were pushing me to claim it. I was awarded last month 50% for MDD. While I was applying for compensation, I was fixated on just getting the PTSD/MDD taken care of. Now that is over with, I am considering filing for the patellar femoral syndrome that I was diagnosed with back in 2008. At that time, I was called up to re-activate from IRR. I was released from that due to my patellar femoral syndrome, which I believe is service connected. It is intermittent pain and causes me difficulty walking at times. I'm not sure how much success I will have though, considering I was never treated for it while I was active duty, and it comes and goes, so I'm not sure how a C&P exam would go. I do have medical records however from my civilian primary care giver and orthopedic specialist showing that I have PFS. Any thoughts or advice? I don't want to waste my time if I don't have a chance of getting a rating. Thanks