C&p Exam For Achillies Tendonitis/ankle Sprain

[Shadow2b]

I recently had a C&P exam for achillies tendonitis, and as with my over claims, I tired to research a possible outcome, but to no avail. I was hoping someone could give me their opinion on what a possible rating would be. I figure 10 if I am lucky but 0 percent is just as well.

Date/Time: 30 Sep 2014 @ 0900

Note Title: C&P Examination 16255J

Date/Time Signed: 30 Sep 2014 @ 0946

Note

Ankle Conditions

Disability Benefits Questionnaire

Name of patient/Veteran:

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[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 an ankle condition?

[X] Yes [ ] No

If yes, provide only diagnoses that pertain to ankle condition(s):

Diagnosis #1: Left Achilles sprain

ICD code: 848.9

Date of diagnosis: 8-2008

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

Diagnosis #2: Chronic Achilles tendinitis

ICD code: 726.71

Date of diagnosis: 2014

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

2. Medical history

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

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

ankle

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

Claimed condition: left Achilles tendonitis

The veteran is claiming his current left Achilles tendonitis was incurred

in or caused by the rupture, Achilles tendon, left treated on 7/25/2008

(see tabbed STR in VBMS).

Opinion Requested #2: Direct service connection

Is the veteran's current left Achilles tendonitis at least as likely

as

not (50 percent or greater probability) incurred in or caused by the

rupture, Achilles tendon, left treated on 7/25/2008? Rationale must be

provided in the appropriate section below. Your review is not limited to

the evidence identified on this request form, or tabbed in the claims

folder. If an examination or additional testing is required, obtain them

prior to rendering your opinion.

Veteran submitted a statement in support of his claim, as follows:

"My

previous claim for Achilles tendinitis was denied because I did not

submit

proof that it was service connected. I now have an LOD statement, but

didn't receive it until after my claim was denied. I am currently

having

issues with my Achilles tendon, and am seeking treatment at the Mather

VA.

It was affecting me running and doing prolonged physical exercise, which

as a member of the national guard, I am required to do in order to pass

our physical fitness tests. This injury seriously affects my ability to

do my job in the Guard as I am an infantryman and we are required to

run/road march long distances."

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.

There is a sick leave slip from July 25, 2008 stating the left Achilles

tendon is swollen, with a profile and treatment. The note states he has a

grade I strain. He was also seen in f/u the next day for the same

condition.

Enclosed within the STR there is a memorandum dated Feb. 2, 2009, from

the

Dept. of the Army. Subject: Line of duty investigation for ,

John: "The enclosed line of duty investigation (LOD) for

has been reviewed for completeness and found to have been "In the Line

of Duty" for left Achilles tendon. injury occurred on

July 22,2008. There is a further "Statement of medical examination and duty

status" dated 8-11-2008 stating that the veteran incurred Achilles

tendinitis while on active duty.

There is a Pre-deployment Health Assessment dated 11-08-2011 in which the

Veteran annotated that he had pulled/strained his left Achilles tendon 3

weeks earlier during training. Was on profile for three weeks. Tendon

is still slightly sore. The examining clinician noted "Left Achilles strain.

treated. No issues". Veteran had an original C&P exam on 10-17-2009 at which time he

described his ankle injury as follows:

PROBLEM: left achiiles tendon

DATE OF ONSET: 8/2008

CIRCUMSTANCES AND INTIIAL MANIFESTATIONS: He was training before going

to Iraq and climbing up hills with heavy gear (60-70 pounds of backpack

material). He noticed gradually pain on his right achilles tendon and

was given rest/light duty due to

severity of pain. He still has pain if he goes up inclines and walks

alot. Pain is

2-3/10, lasts for 2 days and resolves with rest. Denies any trauma to

his achilles

tendon.

COURSE SINCE ONSET: Stable

CURRENT TREATMENTS: None

DESCRIPTION OF PAST TREATMENTS: motrin

Veteran was seen in orthopedics clinic at Mather on 6-11-2014 as follows:

CHIEF COMPLAINT:

Pain in left ankle and heel.

HISTORY OF PRESENT ILLNESS:

This 34-year-old gentleman was referred from Primary Care with complaints

of pain in his left ankle. The patient stated that he first noted pain

in

2008 just before deployment to Afghanistan. He eventually returned from

Afghanistan in November of 2013. The pains kind of waxed and waned over that 5-year period. After he returned from

Afghanistan in November of 2013, he had recurrent pain in the left ankle

area. He said the pain is a little better now with rest of the ankle.

He points to the Achilles tendon as the location for the pain.

Primary Care's note here indicates that the patient presented to the

Primary Clinic on March 21 stating that he had left posterior ankle pain

in the context of running up to 5 miles, 3-4 times a week. Conservative

treatment, NSAID, ice, and rest were all recommended to the patient, and

to restrict running and jogging activities. However, he was continuing

to have significant ankle and heel pain. X-ray of the ankle was normal. He

was referred for orthopedic evaluation of the posterior ankle pain. He

had not responded to NSAID medication activity modification. There was

concern he might have a partial Achilles tendon tear.

The patient does say the pain is better now. He works at a civilian job

with the State of California. It is a desk job. However, he works out

4-5 days per week doing squats, lunges, box jumping, jumping rope, and a

lot of running. Pains tend to wax and wane.

Pain localized to the posterior left ankle and heel area around Achilles

tendon. No significant radiation of pain.

PHYSICAL EXAMINATION:

VITAL SIGNS: Height given 5' 6", weight 165 pounds. LEFT ANKLE

AND FEET:

I had him stand without shoes on. He has a moderate arch and tends to

have bilateral calcaneal varus, left more than right. He walks normally

without favoring either foot or leg. He can heel and

toe-walk okay with both legs. In the seated position, heels do appear to

be in slight varus. Shoe wear on his current shoes is normal on the

heel.

Deep tendon reflexes, knee jerks are 2+ and brisk bilateral. Ankle jerks

2+ and brisk bilateral with about a 2 or 3 beat clonus of both ankles. Ankle dorsiflexion passively right 35 and

left 15 degrees. Ankle plantar flexion passive right 60 degrees, left 50

degrees. Left midfoot and forefoot are nontender. Rotation of the midfoot joints is not painful locking the heel bone. With the knee

extended, briskly dorsiflexing the ankles, he has about a 2-4 beat clonus,

a little worrisome on the left more than the right. Calves are soft and

nontender.

Further physical examination of the left Achilles tendon shows tenderness

in the mid tendon at the musculotendinous junction of the left Achilles.

He is nontender distal Achilles at insertion onto calcaneus. I do not

feel any nodules in the Achilles tendon.

IMPRESSION:

1. Chronic, intermittent, recurring left Achilles tendinitis related to

over activity.

2. Possible neurologic chronic issue related to clonus in the ankles.

3. Chronic low back pain

DISCUSSION:

Using pictures, diagrams, and drawings, I had a long discussion with the

patient about nature of Achilles tendinitis. Basically, he has to back

off the activity. When the ankle is hurting, go to activities with lower

impact such as walking, bicycle, swimming and/or

weightlifting. Stretching of the Achilles is a hallmark. Initially, he

declined referral to Physical Therapy, but later he decided he would

accept Physical Therapy referral for some instruction and education about

home exercises that he can do with a recurrent left

Achilles tendinitis. I mentioned that he could have arch supports and

heel lifts put in his shoes that would elevate the heels and might give

him some relief. However, there is a risk that the Achilles tendon would

tighten up in that spot also.

For now, conservative care. I mentioned an MRI x-ray of the Achilles

tendon, but do not think it is necessary at this time. If he is having

more trouble in the future, MRI might be appropriate. Patient initially

declined, but later accepted referral to Physical therapy. Return to

Orthopedics p.r.n. Conservative care for now with limiting impact

activity, stretching and strengthening of both Achilles tendons and calf

muscles.

D: 06/11/2014

/es/ Dale R. Butler, MD

Orthopaedic Surgery

Signed: 07/02/2014 17:31

Left ankle x-ray normal from 3-27-2014

No history of ankle surgery. The Vet has had recurring left

Achilles'

tendon problems since 2008; at times he has had minimal symptoms, but

generally that is when he is physically inactive. He remains in the

National Guard and in that role he continues to train and that seems to

aggravate the condition. He says that he has had intermittent pain for

the last year. When it is sore the pain level is a 4-5/10. He then

limits his mobility. Pain may last 2-3 days at atime. In a month's

time he may have pain 2 days in general. Aggravating factors: walking around

a lot; doing exercises; any kind of extended activity where he is on his

feet and moving a lot; Mitigating factors: ibuprofen; rest. In the

mornings when he first awakens, the left ankle feels stiff and sore.

3. Flare-ups

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

Does the Veteran report that flare-ups impact the function of the ankle?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups

in his or her own words:

He says that he has had intermittent pain for the last year. When it is

sore the pain level is a 4-5/10. He then limits his mobility. Pain may

last 2-3 days at a time. In a month's time he may have pain 2 days

in general. Climbing a hill may aggravate the ankle.

4. Initial range of motion (ROM) measurements:

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

a. Right ankle plantar flexion

Plantar flexion ends (normal endpoint is 45 degrees): 45

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

b. Right ankle dorsiflexion (extension)

Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 20

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 or greater

c. Left ankle plantar flexion

Plantar flexion ends (normal endpoint is 45 degrees): 45

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

d. Left ankle plantar dorsiflexion (extension)

Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 20

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 or greater

e. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than an ankle condition,

such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

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

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

[X] Yes [ ] No

a. Right ankle post-test ROM

Post-test plantar flexion ends: 45

Post-test dorsiflexion (extension) ends: 20

b. Left ankle post-test ROM

Post-test plantar flexion ends: 45

Post-test dorsiflexion (extension) ends: 20

6. Functional loss and additional limitation in ROM

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

a. Does the Veteran have additional limitation in ROM of the ankle following

repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the ankle?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the ankle after repetitive use, indicate

the contributing factors of disability below (check all that apply and

indicate side affected):

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

7. Pain (pain on palpation)

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

Does the Veteran have localized tenderness or pain on palpation of

joints/soft tissue of either ankle?

[ ] Yes [X] No

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

Ankle plantar 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

Ankle dorsiflexion:

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

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

a. Anterior drawer test

Is there laxity compared with opposite side?

[ ] Yes [X] No [ ] Unable to test

b. Talar tilt test (inversion/eversion stress)

Is there laxity compared with opposite side?

[ ] Yes [X] No [ ] Unable to test

10. Ankylosis

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

Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint?

[ ] Yes [X] No

11. Additional conditions

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

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

splints", stress

fractures, Achilles tendonitis, Achilles tendon rupture, malunion of

calcaneus (os calcis) or talus (astragalus), or has the Veteran had a

talectomy (astragalectomy)?

[X] Yes [ ] No

If yes, indicate condition and complete the appropriate sections below:

[ ] a. "Shin splints" (medial tibial stress syndrome)

[ ] b. Stress fracture of the lower extremity

[X] c. Achilles tendonitis or Achilles tendon rupture

If checked, indicate side affected: [ ] Right [X] Left [ ]

Both

Describe current symptoms:

See medical history.

[ ] d. Malunion of calcaneous (os calcis) or talus (astragalus)

[ ] e. Talectomy

12. Joint replacement and other surgical procedures

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

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

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other ankle surgery?

[ ] Yes [X] No

c. Does the Veteran have any residual signs and/or symptoms due to

arthroscopic or other ankle surgery?

[ ] Yes [X] No

13. 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?

[ ] Yes [X] No

14. 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

15. Remaining effective function of the extremities

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

Due to the Veteran's ankle 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.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

16. Diagnostic Testing

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

a. Have imaging studies of the ankle been performed and are the results

available?

[X] Yes [ ] No

If yes, are there abnormal findings?

[ ] Yes [X] No

b. Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

17. Functional impact

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

Does the Veteran's ankle condition impact his or her ability to work?

[ ] Yes [X] No

18. REMARKS

-----------

a. Remarks, if any:

Right ankle inversion (0-30 degrees): 30 degrees no pain

Left ankle inversion (0-30 degrees): 30 degrees no pain

Right ankle eversion (0-20 degrees): 20 degrees no pain

Left ankle eversion (0-20 degrees): 20 degrees no pain

Circumduction right ankle: able to perform

Circumduction left ankle: able to perform

Additional range of motion after repetitive use:

Right ankle inversion (0-30 degrees): 30 degrees

Left ankle inversion (0-30 degrees): 30 degrees

Right ankle eversion (0-20 degrees): 20 degrees

Left ankle eversion (0-20 degrees): 20 degrees

Circumduction right ankle: able to perform

Circumduction left ankle: able to perform

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.

Vet is not having a flare up today. He states that if he were, he would

be able to plantar flex and dorsiflex the left ankle at about 50% OF THE

RANGE-OF-MOTION THAT HE CAN DO TODAY.