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Thoughts/opinions On C&p Exam For Knee Sprain


Shadow2b

Question

Can someone please help me understand this C&P exam? I tried to research on how the flexion and extension limits affect the rating, but I had a hard time understanding it. I know my ROM is limited after the repetition tests, but I wasn't sure if it was that or something else that were the major contributing factors to the rating. Any help would be much appreciated. Thanks.

Knee and Lower Leg Conditions

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this document:

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:CPRS

If no, check all records reviewed:

[ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

1. Diagnosis

Does the Veteran now have or has he/she ever had a knee and/or lower leg

condition?

[X] Yes [ ] No

Diagnosis #1: Left knee sprain (chronic) ICD code: 848.9

Date of diagnosis: 2001

Side affected: [ ] Right [X] Left [ ] Both

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

knee and/or lower leg condition (brief summary):

Veteran is a 35 year old male with multiple periods of active duty in

the Army:

8-12-1997 to 4-13-2001

8-16-2008 to 9-02-2009

8-01-2010 to 2-17-2012

5-03-2013 to 12-23-2013

The veteran is claiming an increase in his service connected:

- Left knee sprain: Currently evaluated as 0% disabling.

Veteran had an original enlistment exam on 7-16-1996. At that time he denied any prior history or arthritis, rheumatism, or bursitis; bone,

joint, or deformity; lameness; "trick" or locked knee; or foot trouble.The exam of his lower extremities and feet was reported to be normal and there was no identification of a pre-existing knee or ankle problem.The medical history is excerpted from the veteran's C&Pexam on 10-17-2009 as follows:

PROBLEM: left knee pain

DATE OF ONSET: 2001

CIRCUMSTANCES AND INTIIAL MANIFESTATIONS: Reports pain was noticible

particularly

when he was in the service getting in/out of vehicles and jumping and

placing stress

on the knee (ex, running more than 1 mile, standing for porlonged

periods of time).

Pain has especially gotten worse recently since getting back from

Iraq. Pain is

4/10, constant, worsens with activity and improves with rest. Reports

he had an

episode when he banged his knee on the front of his car. His knee was

visibly swollen and the doctor gave him rest, and motrin. This injury worsened his knee pain

in the sense that pain went from occuring 1-2 per month to weekly and it took less activity to aggravate the pain.

COURSE SINCE ONSET: Progressively worse

CURRENT TREATMENTS: None

DESCRIPTION OF PAST TREATMENTS: motrin .

 

I did find an entry in the STR consisting of a referral (May 2010) to orthopedics in which the referral note states: "30 year old male

2 months s/p left posterior cruciate ligament reconstruction on limited

duty during rehab period. Vet denies that he ever had arthroscopy or

knee surgery, on either knee.

Left knee x-ray normal on 9-04-2009. 

Vet states that his left knee is sore when he awakens; he hears it "pop" a lot. He tries to exercise regularly (couple times a week) low impact; can't run like he used to as it bothers his knee. He is still in the National Guard. He states that he can run about 2.5 miles before his knee starts to bother him; plus he'll feel it afterwards.

Doing squats will aggravate his knee. Aggravating factors: running; squats; stairs; sitting in one position at work, when he gets up it will pop and kind of hurt until he moves around a bit. Mitigating factors: Ibuprofen; elevation. He has intermittent pain in the left knee...2-3 times a month. Especially when he does his drills. Pain

level is 4-5/10. The highest has been 8/10 after having been on his feet all day with all his gear on. Pain lasts 1-2 hours.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the knee

and/or lower leg?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-up in his or her own words

He has intermittent pain in the left knee...2-3 times a month. Especially when he does his drills. Pain level is 4-5/10. The

highest has been 8/10 after having been on his feet all day with

all his gear on. Pain lasts 1-2 hours.

4. Initial range of motion (ROM) measurements

 

a. Right knee flexion

Select where flexion ends (normal endpoint is 140 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [X] 135 [ ] 140 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [X] 135 [ ] 140 or greater

b. Right knee extension

Select where extension ends:

 

[X] 0 or any degree of hyperextension (check this box if there is no limitation of extension)

Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion

 

c. Left knee flexion

Select where flexion ends (normal endpoint is 140 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [X] 125 [ ] 130 [ ] 135 [ ] 140 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [X] 125 [ ] 130 [ ] 135 [ ] 140 or greater

d. Left knee extension

Select where extension ends:

 

[X] 0 or any degree of hyperextension (check this box if there is no

Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion

e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a knee and/or leg condition, such as age, body habitus, neurologic disease), explain: No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Right knee post-test ROM

Select where post-test flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [X] 125 [ ] 130 [ ] 135 [ ] 140 or greater

Select where post-test extension ends:

 

[X] 0 or any degree of hyperextension (check this box if there is no limitation of extension)

 

c. Left knee post-test ROM

Select where post-test flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[X] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 or greater

Select where post-test extension ends:

 

[X] 0 or any degree of hyperextension (check this box if there is no limitation of extension)

 

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the knee and lower

leg following repetitive-use testing?

[X] Yes [ ] No

b. Does the Veteran have any functional loss and/or functional impairment of the knee and lower leg?

 

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment or additional limitation of ROM of the knee and lower leg after repetitive use,

indicate the contributing factors of disability below (check all that apply and indicate side affected):

[X] Less movement than normal [ ] Right [ ] Left [X] Both

[X] Pain on movement [ ] Right [X] Left [ ] Both

7. Pain (pain on palpation)

---------------------------

Does the Veteran have tenderness or pain to palpation for joint line or soft

tissues of either knee?

[X] Yes [ ] No

If yes, side affected: [ ] Right [ ] Left [X] Both

8. Muscle strength testing

--------------------------

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

Knee 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

9. Joint stability tests

------------------------

a. Anterior instability (Lachman test):

Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

b. Posterior instability (Posterior drawer test): Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

 

 

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

c. Medial-lateral instability (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion):

Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

10. Patellar subluxation/dislocation

------------------------------------

Is there evidence or history of recurrent patellar subluxation/dislocation?

[ ] Yes [X] No

11. Additional conditions

-------------------------

Does the Veteran now have or has he or she ever had "shin splints"

(medial tibial stress syndrome), stress fractures, chronic exertional compartment

syndrome or any other tibial and/or fibular impairment?

[ ] Yes [X] No

12. Meniscal conditions and meniscal surgery

--------------------------------------------

Has the Veteran had any meniscal conditions or surgical procedures for a

meniscal condition?

[ ] Yes [X] No

13. Joint replacement and other surgical procedures

---------------------------------------------------

a. Has the Veteran had a total knee joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other knee surgery not described above?

[ ] Yes [X] No

c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other knee surgery not described above?

[ ] Yes [X] No

14. Other pertinent physical findings, complications, conditions, signs and/or symptoms

-----------------------------------------------------------------------

a. 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

b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any

conditions listed in the Diagnosis section above?

[X] Yes [ ] No

If yes, describe (brief summary):Minimal patellar crepitance on the left side. Gait is normal

15. 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.

16. 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.)

[X] No

17. 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? [ ] Yes [X] No

b. Does the Veteran have x-ray evidence of patellar subluxation? [ ] Yes [X] No

c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No

18. Functional impact

---------------------

Does the Veteran's knee and/or lower leg condition(s) impact his or her

ability to work?

[ ] Yes [X] No

19. Remarks

-----------

a. Remarks, if any: No response provided

b. Mitchell criteria: Regarding Mitchell v. Shinseki: Pain (but not weakness, fatigability or

incoordination) could significantly limit functional ability during

flare-ups, or when the joint is used repeatedly over a period of time.

However, it would be mere speculation to express any additional

functional limitation in degrees of additional loss of ROM because the

veteran was not examined during flare-ups or when the joint was used

repeatedly over a period of time.

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