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Right Trapezius Strain And Right Shoulder Condition


I was sent for a comp and pen exam as part of an BVA remand. The judge had stated that all of the evidence on record was in my favor but wanted a more current diagonosis and and the relationship to the service. I'm still awaiting a decision but, I have a copy of the exam report, here is some of what is in the report. What exams did he use and what codes would be used to rate trapezius strain and a rotator cuff strain and impingement syndrome of the right shoulder? Any thoughts on possile sc % if any?

Some exam results are;

right shoulder condition-Range of motion right shoulder in degrees. flexion 0 to 135, abduction 0 to 134, internal and external rotation 0-90. There was evidence of pain during movement of the right shoulder. The was some clicking with internal and external rotation associated with pain. The motion was primarily noted during motion in the rotator cuff deltoid area but also extended to the superior trapezius areas as well. Additional loss of range of motion during flares is not likely. For comparison the range of motion of the left shoulder is all normal. Right shoulder pain with abduction and adduction between 45 and 90 degrees. This condition has moderate affects on the Veterans activitieshe Veterans chronic right shoulder rotator cuff strain with impingement syndrome is as least likely as not caused by or a result of the Veterans military service.

right scapular and trapezius area indicates tenderness to palpitation over the superior and mid right trapezius muscle area over the rhomboid area. Although the veteran is not claiming spinal pathology in and of itself. alteration in neck movement due to his trapezius strain, range of motion of the cervical spine was measured. Range of motion of the cervical spine are as follows; forward flexion 0 to 30 , extension 0 to 40, right and left lateral flexion 0 t 40, right and left rotation 0 to 60. with neck movements there was there was increased pain noted in the upper right trapezius muscle, especially movement that would stretch that muscle. Based on examinatiob it would be feasible for the veteran to lose an addition 5 to 10 degrees of right and left lateral flexion and right and left lateral rotation of the cervical spine during flare ups of the right trapezius strain when these occur due to pain and spasm. This condition has had significant affects on the veterans activities.The veterans right trapezius strain is as least likely as not caused by or a result of the Veterans military service.

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