I had about decided to not file a n o d on the R O denial on right knee injury, However I paid Dr. Bash for an IMO, so I took it to my rep today and filed. Here is the quest of his report.
FACTS.
PATIENT ENTERED SERVICE FIT FOR DUTY
PT HAD RT KNEE INJURY WHILE IN SERVICE.
1994 DR.----- X-RAY READING OF DEGENERATIVE CHANGES WITH POSTERIOR OSTEOPHYTE WITH SCOPE FINDINGS OF MEDICAL MENISCAL TEAR, PARTIAL ACL TEAR AND DEBRIDEMENT OF PATELLAFEMORAL DEFECT.
10 JULY "... UNABLE TO STAND FOR MORE THAN A FEW MINUTES... PAIN... WALKING UP AND DOWN HILLS....DOWN IS WORSE...SWELLING... TENDERNESS...CREPITUS... SYNOVITIS... RIGHT SLIGHTLY LARGER THAN LEFT.....MEDICAL, LATERAL JOINT LINE TENDERNESS.... RIGHT KNEE OSTEOARTHRITIS..." DR..(VA DR ASSISTANT).
IN SUMMARY IT IS MY OPINION THAT THIS PATIENT'S RT KNEE PATHOLOGY WAS LIKELY CAUSED BY HIS SERVICE TIME INJURY TO THIS JOINT FOR THE FOLLOWING REASONS:
1. HE ENTERED SERVICE FIT FOR DUTY.
2, HE HAD A SERIOUS FALL ON HIS RT KNEE IN SERVICE, WHICH REQUIRED MEDICAL CARE.
3, THE2006 EVALUATION BY DR.----( BOARD CERTIFIED ORTHRO) FOUND AN OSTEOPHYTE, WHICH CAN FORM IN A FEW MONTHS TO MANY YEARS WHICH, IS NOT INCONSISTANT WITH AN INJURY IN SERVICE AS THIS WAS ALSO NOTICED IN THE 1994 ARTHROSCOPY BY DR.----
4. HE HAD CONTINUOUS SWELLING OF THAT KNEE IN SERVICE AS PER 1966 NOTE ( ATTACHED) AND HAD IT ASPIRATED 10 TIMES DURING THE 1970'S ACCORDING TO HISTORY TAKEN BY DR.---.
5. 2006 SPOUSE ATTACHED LAY STATEMENT DOCUMENTS SWELLING AS EARLY AS 1968.
6. THE PATIENT HAS A DIAGNOSIS OF DEGENERATIVE ARTHRITIS AND HAS HAD ARTHROSCOPY FINDINGS OF INTERNAL DERANGEMENTS AS DOCUMENTED IN 1994 BY DR......ABOVE.
7. IT IS WELL KNOWN THAT INJURIES TO JOINTS EARLY IN LIFE LEAD TO ADVANCED DEGENERATIVE ARTHRITIS DUE TO LIGIMENT LAXITY. THIS CONCEPT IS WELL DESCRIBED IN THE FOLLOWING EXCERPT FROM TUREK AND THE SAME PATHOPHSIOLOGY ANALOGOUSLY APPLIES TO OTHER MAJOR JOINTS:
"At the onset, tearing of ligaments and subluxation are manifest by local symptoms of low back accentuated by the motion which stretches the ligaments... Eventually, symptoms of localized degenerative arthritis are supper imposed...: (Turik page 853)
8. This case is confusing because many non-xray-professional Physicians such as orthopedic surgeons or primary care Physicans have read many of this patient's early x-rays. (If all of the old films were made available to me I would be glad to review them for additional contexual information). The difference between non-union and bipartite for example is important in determining the precise time of this patient's knee injury. Futhermore, much of this patient'S current knee pathology is only visible on arthroscopy, which he did not have until 1994.
In the record, I found seemingly contrary opinions by the rater that stated that since no chronic disability was shown on discharge examination from service and that since the va examination of 7 june 2006 by dr.... stated that this patient's rt. knee degenerative joint diease was not related to service that this patient's right knee pathology is not due to his military service. It is well known that basic discharge Physicals would be falsely negative for this patient's type of injury of internal knee damage that early on was only identified on arthroscope. This patient had a positive, arthroscope, which clearly shoes his injuries. The opinion of Dr..... basically states that this patient's type of current knee pathology is known to happen with a fall on the knee with direct force applied to the patella but he feels that this patient's falls happened outside of service befor or after service due to Dr.... evaluation of osteophytes. This opinion does not incorporate the patient,s history of a fall in service, the 1966 note that states that the patient has had swelling in his knee for over a year ( attached) or the patient's history of service time swelling or the concept of old patella nonunion fracture diagnosed by Dr.... or the concept that osteophytes can form over several months or several years which would not be inconsistent with an injury in service because we know that this osteophyte was also noticed in 1994 arthroscopy by Dr... These opinions are seemingly contrary but if they were to be redone considering the context of the case (nonunion of frcture, false negative aspects of plain films, 1966 clinical note, osteophyte formation natural history, literature) they more than likely would be consistent with my opinion above.
In summerary, this patient's history of injury in service, non-union, negative discharge physical and current advanced degenerative right knee arthritis all follow consistant medical logic and his post service falls complicate his current knee pathology as they are likely to have contributed to his current knee derangements. It is impossiable to assign specific percentages of contribution of his service time injuries vs his post service injuries other than to say that they both contributed significantly to his current right knee problems,but it is likely that his current right knee problems, are due to his service falls documented on at least two medical visits during his service time.
Question
kkp
I had about decided to not file a n o d on the R O denial on right knee injury, However I paid Dr. Bash for an IMO, so I took it to my rep today and filed. Here is the quest of his report.
FACTS.
PATIENT ENTERED SERVICE FIT FOR DUTY
PT HAD RT KNEE INJURY WHILE IN SERVICE.
1994 DR.----- X-RAY READING OF DEGENERATIVE CHANGES WITH POSTERIOR OSTEOPHYTE WITH SCOPE FINDINGS OF MEDICAL MENISCAL TEAR, PARTIAL ACL TEAR AND DEBRIDEMENT OF PATELLAFEMORAL DEFECT.
10 JULY "... UNABLE TO STAND FOR MORE THAN A FEW MINUTES... PAIN... WALKING UP AND DOWN HILLS....DOWN IS WORSE...SWELLING... TENDERNESS...CREPITUS... SYNOVITIS... RIGHT SLIGHTLY LARGER THAN LEFT.....MEDICAL, LATERAL JOINT LINE TENDERNESS.... RIGHT KNEE OSTEOARTHRITIS..." DR..(VA DR ASSISTANT).
IN SUMMARY IT IS MY OPINION THAT THIS PATIENT'S RT KNEE PATHOLOGY WAS LIKELY CAUSED BY HIS SERVICE TIME INJURY TO THIS JOINT FOR THE FOLLOWING REASONS:
1. HE ENTERED SERVICE FIT FOR DUTY.
2, HE HAD A SERIOUS FALL ON HIS RT KNEE IN SERVICE, WHICH REQUIRED MEDICAL CARE.
3, THE2006 EVALUATION BY DR.----( BOARD CERTIFIED ORTHRO) FOUND AN OSTEOPHYTE, WHICH CAN FORM IN A FEW MONTHS TO MANY YEARS WHICH, IS NOT INCONSISTANT WITH AN INJURY IN SERVICE AS THIS WAS ALSO NOTICED IN THE 1994 ARTHROSCOPY BY DR.----
4. HE HAD CONTINUOUS SWELLING OF THAT KNEE IN SERVICE AS PER 1966 NOTE ( ATTACHED) AND HAD IT ASPIRATED 10 TIMES DURING THE 1970'S ACCORDING TO HISTORY TAKEN BY DR.---.
5. 2006 SPOUSE ATTACHED LAY STATEMENT DOCUMENTS SWELLING AS EARLY AS 1968.
6. THE PATIENT HAS A DIAGNOSIS OF DEGENERATIVE ARTHRITIS AND HAS HAD ARTHROSCOPY FINDINGS OF INTERNAL DERANGEMENTS AS DOCUMENTED IN 1994 BY DR......ABOVE.
7. IT IS WELL KNOWN THAT INJURIES TO JOINTS EARLY IN LIFE LEAD TO ADVANCED DEGENERATIVE ARTHRITIS DUE TO LIGIMENT LAXITY. THIS CONCEPT IS WELL DESCRIBED IN THE FOLLOWING EXCERPT FROM TUREK AND THE SAME PATHOPHSIOLOGY ANALOGOUSLY APPLIES TO OTHER MAJOR JOINTS:
"At the onset, tearing of ligaments and subluxation are manifest by local symptoms of low back accentuated by the motion which stretches the ligaments... Eventually, symptoms of localized degenerative arthritis are supper imposed...: (Turik page 853)
8. This case is confusing because many non-xray-professional Physicians such as orthopedic surgeons or primary care Physicans have read many of this patient's early x-rays. (If all of the old films were made available to me I would be glad to review them for additional contexual information). The difference between non-union and bipartite for example is important in determining the precise time of this patient's knee injury. Futhermore, much of this patient'S current knee pathology is only visible on arthroscopy, which he did not have until 1994.
In the record, I found seemingly contrary opinions by the rater that stated that since no chronic disability was shown on discharge examination from service and that since the va examination of 7 june 2006 by dr.... stated that this patient's rt. knee degenerative joint diease was not related to service that this patient's right knee pathology is not due to his military service. It is well known that basic discharge Physicals would be falsely negative for this patient's type of injury of internal knee damage that early on was only identified on arthroscope. This patient had a positive, arthroscope, which clearly shoes his injuries. The opinion of Dr..... basically states that this patient's type of current knee pathology is known to happen with a fall on the knee with direct force applied to the patella but he feels that this patient's falls happened outside of service befor or after service due to Dr.... evaluation of osteophytes. This opinion does not incorporate the patient,s history of a fall in service, the 1966 note that states that the patient has had swelling in his knee for over a year ( attached) or the patient's history of service time swelling or the concept of old patella nonunion fracture diagnosed by Dr.... or the concept that osteophytes can form over several months or several years which would not be inconsistent with an injury in service because we know that this osteophyte was also noticed in 1994 arthroscopy by Dr... These opinions are seemingly contrary but if they were to be redone considering the context of the case (nonunion of frcture, false negative aspects of plain films, 1966 clinical note, osteophyte formation natural history, literature) they more than likely would be consistent with my opinion above.
In summerary, this patient's history of injury in service, non-union, negative discharge physical and current advanced degenerative right knee arthritis all follow consistant medical logic and his post service falls complicate his current knee pathology as they are likely to have contributed to his current knee derangements. It is impossiable to assign specific percentages of contribution of his service time injuries vs his post service injuries other than to say that they both contributed significantly to his current right knee problems,but it is likely that his current right knee problems, are due to his service falls documented on at least two medical visits during his service time.
If anyone has an opinion, I would like to here it
kkp
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