Help - Schedule Of Ratings—musculoskeletal System

[carlie]

Have hearing on Sept 18th.

Issue : Increased Rating for SC'd Bursitis DC 5019 -

The VARO granted SC at zero percent,for R shoulder Bursitis on Rating Decision dated 6/14/2002,

with an effective date of 8-26-1999.

Reasons and Bases:

SMR's reveal that the veteran was seen for treatment of right shoulder after injury

to her neck and shoulder area. X-rays revealed a normal shoulder.

VA examination dated 2-28-02 from VAMC finds that the veteran has chronic bursitis and that it is more likely than not due to her injury in service. X-rays done in conjunction with the exam shows bones and soft tissue are within normal limits, impression normal. The examiner finds that she has full range of motion: flexation of 180 degrees, extant rotation 90 degrees, internal rotation 90 degrees. The abduction is 180 degrees. She has normal development and no muscle wasting.

Normal distal pulses. She does have decreased sensation to the interior lateral aspects of her upper arm only. Lower arm has normal sensation to the soft and sharp and her hands are also normal. She has normal strength and range of motion. The range of motion is with consideration of pain, weakness, lack of endurance.

In the absence of limited or painful motion an evaluation of 0 % is assigned effective the original date of claim, 8-26-99.

I filed a timely NOD on this and requested a rating of 10 % for DC 5019 Bursitis.

I feel 10 % should be granted due to:

The diseases under diagnostic codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002. 5003 Arthritis, degenerative (hypertrophic or osteoarthritis):

Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below:

With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations20

With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups10

Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion.

Note (2): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive.

MY QUESTION:

I am understanding this to mean that DC 5019 is to be rated as

Arthritis - Degenerative and that,

When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,...

Should I be rated at 10 % for this or am I understanding this wrong ?

Thanks for your responses.

carlie

[LarryJ]

"The examiner finds that she has full range of motion"

Nope, Carlie. Nada.

sorry

[carlie]

"The examiner finds that she has full range of motion"

Nope, Carlie. Nada.

sorry

Larry,

Please explain, this is what I need to be able to understand.

When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,...

Thanks,

carlie

[pacmanx1]

Carlie, I am not an expert but here is my opinion. According to your post you were awarded 0% for pain. The examiner stated: "The examiner finds that she has full range of motion and She has normal strength and range of motion. The range of motion is with consideration of pain, weakness, lack of endurance." In other words you do have pain but you do not have limited or painful motion. Meaning there is pain there but there is no pain in motion or none that the examiner noted. The examiner also did not note any limitation of motion. If I am wrong or just totally confused I hope you or someone else would correct me.

Also sorry

Edited September 2, 2009 by pacmanx1 (see edit history)

[LarryJ]

Larry,

Please explain, this is what I need to be able to understand.

When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,...

Thanks,

carlie

Sometimes, not often, maybe once a year, I run across something that I can't make sense out of.........................but, suffice it to say, if you ain't got the pain, then you ain't got the $gain$ and if you ain't got the swing then you ain't gonna hear the CA-CHING!

"limited motion", that's where it's ALL at

[rentalguy1]

I concur with Larry. If you had limitation of motion that was greater than full, but less than that outlined in the ten percent criteria, then this rule would apply. The statement that you must overcome in your records is "full range of motion."

Edited September 2, 2009 by rentalguy1 (see edit history)

[cowgirl]

Carlie, Oh, I see the BVA. Just wondering do you have constant ROM issues or variable episodes? Is there anything in your SMRs that show other measurements of ROM? Have you been in traction lately for your neck, did that include a shoulder evaluation?

I too have shoulder bursitis, the rain reminds me and I don't have limitations everyday, just often, especially with putting on seatbelts, lifting laundry or hanging curtains.

Thinking the best for ya,

Cg'up2009!

Edited September 2, 2009 by cowgirl (see edit history)

[carlie]

After I filed my NOD and requested a higher percentage another C&P was done

for increase. This is from it. Shouldn't this at least gey me the 10 % ?

Please remember this is no longer just for a NOD - I am at BVA and I do

believe they are supposed to consider everything.

Thanks to all who are helping me prepare for this BVA Hearing.

carlie

C&P dated 7/15/2003

Examining provider: Hirschfield, Jan

Approved By: Dr. Sutton 07/29/2003

p.4

Her medical records and C-file that were in current medical records and CORS on the computer, were reviewed pertinent to the questions asked for this exam. She is also being treated for seizures. She also has a diagnosis of an organic brain syndrome.

She has been treated for seizures at XXX VAMC starting in 1978 at that time she had

X-rays of her neck showing dorsal straightening of her cervical spine and S-shaped

sclerosis to her dorsal spine. She also has been in traction for her upper neck problems and her headaches.

Physical Examination:

Reveals a well developed, well nourished white female.

Neck revealed no submandibular or cervical, or lateralnodes. Examination of the cervical spine revealed a tight right paravertebral muscle compared to left and a tenderness trigger point at the posterior occiput at the insertion of that muscle. There is some tenderness over the cervical spine.

Her cervical range of motion shows a flexation of 25 degrees, extension of 15 degrees, lateral flexation of 25 to the left, and 25 degrees to the right. Her rotation to the right is 30 degrees

and 30 degrees on the left. Her motor strength is normal upper and lower body.

Her gait is normal.

Diagnostic Impression:

1. Chronic recurrent Otitis Media with significant blockage of external right ear canal and chronic purulent discharge.

2. Chronic headaches with radiation of frontal down to across superior temporal

to occiput area.

3. Seizures

4. Organic Brain Syndrome.

5. Cervical neck strain with suspected cervical degeneration disc disease,

traumatic in origin, with chronic pain and decreased range of motion.

As stated she has been sent for cervical spine films today.

6.Endocardial fibroelastosis

7. Extrinsic asthma

REMARKS:

It's my medical opinion that her chronic ear infection otitis media is definitely to the Otitis Media acute that she has in the military, which has continued to be a chronic condition, requiring

tympanoplasty and nasal septal deviation and chronic antibiotic treatment.

It is my medical opinion that her chronic recurrent headaches are more likely than not,

secondary to the trauma she suffered in the military on three different accident's to

the front of her head, causing a mild whiplash type injury, then a second direct head trauma,

and also a frontal injury to the front of the head, causing a whiplash type injury.

It is my medical opinion that her cervical neck symptoms of pain and discomfort,

and an upper neck, upper shoulder scapula trapezius Rhomboid area is definitely related to the three traumatic events from her military experience.

It is my medical opinion that the headaches are not comorbid with her seizures but

are directly related to the same injury in which began her seizures of which she is service connected for.

As stated, her C-file and medical records were reviewed and referenced to the questions asked for this exam.

The veteran was told to discuss any aspect of this exam with her primary care provider.

X-RAY RESULTS:

Minimal DJD most marked at the C6-7 level .

[rentalguy1]

It is my medical opinion that her cervical neck symptoms of pain and discomfort,

and an upper neck, upper shoulder scapula trapezius Rhomboid area is definitely related to the three traumatic events from her military experience.

unfortunately, this is just a nexus statement. You still need to overcome the "full range of motion" statement from your C&P. You need a IMO that states that you have limitations in range of motion that are less than the 10% compensable degree.

[carlie]

unfortunately, this is just a nexus statement. You still need to overcome the "full range of motion" statement from your C&P. You need a IMO that states that you have limitations in range of motion that are less than the 10% compensable degree.

I guess it would also help if I were add that there are more issues at BVA

two of them are:

1. SC for cervical neck strain

2. SC for osteophytosis - I have MRI documentation for this that the forminal narrowing

from osteophytytes effect the spinal cord.

So does that mean that this does not count,

"Her cervical range of motion shows a flexation of 25 degrees, extension of 15 degrees, lateral flexation of 25 to the left, and 25 degrees to the right. Her rotation to the right is 30 degrees

and 30 degrees on the left. Her motor strength is normal upper and lower body.

Her gait is normal."

Going by the chart for muscle-skeletal doesn't this show limited motion ?

So if the first C&P says full range of motion and the second C&P shows

limited motion then that should open up the benefit of the doubt that goes to the

veteran ?

and

It is my medical opinion that her cervical neck symptoms of pain and discomfort,

and an upper neck, upper shoulder scapula trapezius Rhomboid area is definitely related to the three traumatic events from her military experience.

I feel like this shows that there is PAIN in my shoulder and the X-Rays show

Minimal DJD at C6-7 ?????

And of course this goes back to the question of Arthritis, degenerative,

When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,...

carlie

Edited September 2, 2009 by carlie (see edit history)

[sharon]

The rating is based on range of motion. Since you have a hearing be prepared to show them your range of motion. Especially since you can't raise your arm high enough to comb your hair B)

[LarryJ]

In the absence of limitation of motion, rate as

below:

With X-ray evidence of involvement of 2 or more major joints 20

or 2 or more minor joint groups, with occasional

incapacitating exacerbations...............................

With X-ray evidence of involvement of 2 or more major joints 10

or 2 or more minor joint groups............................

Note (1): The 20 pct and 10 pct ratings based on X-ray

findings, above, will not be combined with ratings based on

limitation of motion.

Note (2): The 20 pct and 10 pct ratings based on X-ray

findings, above, will not be utilized in rating conditions

listed under diagnostic codes 5013 to 5024, inclusive.

5004 Arthritis, gonorrheal.

5005 Arthritis, pneumococcic.

5006 Arthritis, typhoid.

5007 Arthritis, syphilitic.

5008 Arthritis, streptococcic.

5009 Arthritis, other types (specify).

With the types of arthritis, diagnostic codes 5004 through

5009, rate the disability as rheumatoid arthritis.

5010 Arthritis, due to trauma, substantiated by X-ray findings:

Rate as arthritis, degenerative.

5011 Bones, caisson disease of: Rate as arthritis, cord

involvement, or deafness, depending on the severity of

disabling manifestations.

5012 Bones, new growths of, malignant 100

Note: The 100 percent rating will be continued for 1 year

following the cessation of surgical, X-ray, antineoplastic

chemotherapy or other therapeutic procedure. At this point,

if there has been no local recurrence or metastases, the

rating will be made on residuals.

5013 Osteoporosis, with joint manifestations.

5014 Osteomalacia.

5015 Bones, new growths of, benign.

5016 Osteitis deformans.

5017 Gout.

5018 Hydrarthrosis, intermittent.

5019 Bursitis.

5020 Synovitis.

5021 Myositis.

5022 Periostitis.

5023 Myositis ossificans.

5024 Tenosynovitis.

The diseases under diagnostic codes 5013 through 5024 will be

rated on limitation of motion of affected parts, as

arthritis, degenerative, except gout which will be rated

under diagnostic code 5002.

Carlie, it reads as though you MUST have some sort of limitation in your range of motion for you to be able to get even 10%. Othewise, your bursitis has been, essentially service-connected, but, unfortunately, at a compensable level of 0%.

It is a shame, that, when you had your C&P, that you did not at least flop around on the exam table like a fish out of water and moan something like "OMG, that hurts like hell, yah, that, that right there.......please don't hurt me no mo, no no mo!

I know what you did, you were the good soldier and bore the pain of the exam with a stiff upper lip.........and, now they've screwed ya one more time thru the drive-thru.......and you didn't even get the fries that you ordered.

Let this be a lesson to some of you other folks out there that are facting muscle and joint C&P exams. IF IT HURTS, before they get thru makin a pretzel outta ya, LET THEM KNOW, because PAIN must be considered as if, when the pain occurs, that at that point, your range of motion has been reached, even though the examiner may be able to push the affected joint even further. When it reaches the painful point, that is when the exam needs to stop and that is where the degree of range-of-motion should be measured from.

Carlie, I'm sorry, but from what I read........they gonna hold you to the ROM deal, unless you can convince them that you were allowing the examiner to see how far they could extend your ROM past the point of it being excrutiatingly painful.

[Ricky]

Carlie what it is saying - for example (example only) lets say you are to be rated under 5200. Under 5200 the lowest rating is Favorable Abduction to 60 degrees which will get you a 30 percent rating. Now lets say you had favorable abduction of 70 degrees. IAW the rating schedule you would not even be rated but the rule as it is says they must give you a 10 percent rating because you did display some limited range of motion.

However, in your case, the C&P states that you have normal range of motion. So without any loss of range of motion the rule does not apply to you. However, they still gave you a 0 percent rating.

hope this helps you to understand.

Edited September 3, 2009 by Clown Man (see edit history)

[Berta]

Carlie- I sure have no excpertise in these types of claims but what I understand is this:

"When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,..."..... if there is more than one joint affected-

this seems to tie in with what you still seem to have on appeal...

but I agree that the ROM would have to be affected as well as accounting for pain.

Did they use a goinometer when they determined your ROM status?

They are basing this all on the 2002 C & P exam?

[JamesBreckenridge]

I'd give her 10 percent for her shoulder due to painful motion under 38 CFR 4.59.

4.59 Painful motion.

With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint./i]

That's not how we USED to interpret 4.59, so I don't know how much retro she could get. But if her claim crossed my desk today, my analysis would be this: "Hrm, injury in service, so defintely service connected. Hrm, C&P shows articular pathology (bursitis) with painful motion, but full range of motion. So, I can't grant schedular, but I can still giver her a dime under 4.59."

It's a major joint, with a diagnosed problem, and painful motion. It gets ten percent, period end of statement. That's how it is in my office, anyway.

Carlie- I sure have no excpertise in these types of claims but what I understand is this:

"When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion,..."..... if there is more than one joint affected-

this seems to tie in with what you still seem to have on appeal...

but I agree that the ROM would have to be affected as well as accounting for pain.

Did they use a goinometer when they determined your ROM status?

They are basing this all on the 2002 C & P exam?

[carlie]

I sure do send a shout out of thanks to each person

that has helped me by providing their opinions in this thread.

carlie