C&p Exam For Ankles

[Airborne01]

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Airborne

Ankle Conditions

Disability Benefits Questionnaire

[X] In-person examination

1. Diagnosis

a. List the claimed condition(s) that pertain to this DBQ: Left ankle fractue

S/P bone graft, left ankle degenerative joint disesase

b. Select diagnoses associated with the claim condition(s) (Check all that

apply):

Summary of other diagnosis:

[X] Other

Other diagnosis: Left ankle fractue, bone graft

ICD Code: 824

Side affected: Left

Date of diagnosis: Left:1991

Other diagnosis: Right ankle avulsion fracture

ICD Code: 824

Side affected: Right

Date of diagnosis: Right:2011

c. Comments (if any): No response provided

2. Medical History

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

ankle condition (brief summary): The veteran has a history of bilateral ankle pain starting in 1991. His left ankle was originally injured during a bad landing from a parachute jump. He was diagnosed with a ankle fracture and underwent left ankle reconstruction with a bone graft that same year. Following the surgery the veteran had extensive physical therapy and continues to take pain medication as needed. The veteran reports that in 2008 his left ankle pain continued to increase he was found to have bone spurs in his left ankle and underwent a tarsal tunnel release with excision of ostomy in November 2008. Since the surgery the veteran continues to have limited range of motion in his left ankle along with some numbness around the incision sites. The veterans right ankle pain started in 2011. He reports he injured his ankle and was diagnosed with avulsion fracture of his right navicular bone. He was treated with a walking boot for weeks and physical therapy. The veteran continues to have bilateral ankle pain and popping that is worth walking. He takes Celebrex, Naprosyn and tramadol as needed for pain. The veteran reports that because of his continued pain he will be attending physical therapy again in the future for his ankles.

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

[ ] Yes [X] No

c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of

repetitive use)?

[ ] Yes [X] No

3. Range of motion (ROM) and functional limitations

a. Initial range of motion

Left ankle

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Dorsiflexion (0-20): 0 to 10 degrees

Plantar Flexion (0-45): 0 to 10 degrees

If abnormal, does the range of motion itself contribute to a functional

loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that apply)?

Plantar Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain on palpation of

the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s): There is mild tenderness of the medial and lateral malleolus

consistent with a previous ankle fracture.

Right ankle

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Dorsiflexion (0-20): 0 to 20 degrees

Plantar Flexion (0-45): 0 to 35 degrees

If abnormal, does the range of motion itself contribute to a functional

loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that apply)?

Dorsiflexion, Plantar Flexion

Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain on palpation of

the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

There is mild tenderness of the medial and lateral malleolus

Consistent with a previous ankle fracture.

b. Observed repetitive use

Left ankle

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three

repetitions? [ ] Yes [X] No

Right ankle

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three

repetitions? [ ] Yes [X] No

c. Repeated use over time

Left ankle

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

If the examination is not being conducted immediately after repetitive use

over time:

[ ] The examination supports the Veteran?s statements describing functional

loss with repetitive use over time.

[ ] The examination contradicts the Veteran?s statements describing

functional loss with repetitive use over time. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

This cannot be determined without an exam after repeated use over

time.

Right ankle

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

If the examination is not being conducted immediately after repetitive use

over time:

[ ] The examination supports the Veteran?s statements describing functional

loss with repetitive use over time.

[ ] The examination contradicts the Veteran?s statements describing

functional loss with repetitive use over time. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s

statements describing functional loss with repetitive use over time.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

This cannot be determined without an exam after repeated use over

time.

d. Flare-ups

Left ankle

Is the examination being conducted during a flare-up? [ ] Yes [X] No

If no, does the Veteran report flare-ups? [X] Yes [ ] No

Frequency: Daily

Severity: 10/10

Duration: Couple hours

If the examination is not being conducted during a flare-up:

[ ] The examination supports the Veteran?s statements describing functional

loss during flare-ups.

[ ] The examination contradicts the Veteran?s statements describing functional loss during flare-ups. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s statements describing functional loss during flare-ups.

Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

This cannot be determined without an exam during a flare up.

Right ankle

Is the examination being conducted during a flare-up? [ ] Yes [X] No

If no, does the Veteran report flare-ups? [X] Yes [ ] No

Frequency: Daily

Severity: 7/10

Duration: Couple of hours

If the examination is not being conducted during a flare-up:

[ ] The examination supports the Veteran?s statements describing functional

loss during flare-ups.

[ ] The examination contradicts the Veteran?s statements describing

functional loss during flare-ups. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s

statements describing functional loss during flare-ups.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-up?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

This cannot be determined without an exam during a flare up.

e. Additional factors contributing to disability

Left ankle

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe:

None

Right ankle In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe:

None

4. Muscle strength testing

a. Muscle strength - rate strength according to the following scale

Right ankle:

Strength Evaluation Plantar Flexion: 5/5

Dorsiflexion: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

Left ankle:

Strength Evaluation Plantar Flexion: 5/5

Dorsiflexion: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

b. Does the Veteran have muscle atrophy? [ ] Yes [X] No

c. Comments, if any:

No response provided

5. Ankylosis

Complete this section if Veteran has anklosis of the ankle

a. Indicate severity of ankylosis and side affected

Right side: Left side:

[ ] In plantar flexion [ ] In plantar flexion

[ ] In dorsiflexion [ ] In dorsiflexion

[ ] With an abduction deformity [ ] With an abduction deformity

[ ] With an inversion deformity [ ] With an inversion deformity

[ ] With an eversion deformity [ ] With an eversion deformity

[ ] In good weight-bearing position [ ] In good weight-bearing

position

[ ] In poor weight-bearing position [ ] In poor weight-bearing

position

[X] No ankylosis [X] No ankylosis

b. Comments, if any:

No response provided

6. Joint stability

Right ankle

Is ankle instability or

dislocation suspected? [ ] Yes [X] No

Left ankle

Is ankle instability or

dislocation suspected? [ ] Yes [X] No

7. Additional comments

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:

[X] Stress fracture of the lower leg

Indicate side affected: [ ] Right [X] Left [ ] Both

Describe current symptoms: The Veteran has a history of a stress

fractue of the left distal tibia with no current symptoms.

8. Surgical procedures

Indicate any surgical procedures that the Veteran has had performed and

Provide the additional information as requested (check all that apply):

Right side:

No response provided

Left side:

[X] Arthroscopic or other ankle surgery

Type of surgery: Left ankle reconstruction with bone graft 1991,

Tarsal tunnel release and excision of ostectomy Date of surgery: 1991/2008

[X] Residuals of arthroscopic or other ankle surgery

Limited ROM left ankle and pain

9. Other pertinent physical findings, complications conditions, signs,

symptoms and scars

a. Does the Veteran have any other pertinent physical findings, complication,

conditions, signs or symptoms related to any conditions listed in the

diagnosis section above? [ ] Yes [X] No

b. 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? [X] Yes [ ] No

If yes, are any of these scars painful or unstable, have a total area

equal to or greater than 39 square cm (6 square inches) or are located on

the head, face or neck? [X] Yes [ ] No

If yes, also complete VA Form 21-0960F-1, Scars/Disfigurement

c. Comments, if any:

No response provided

10. Assistive devices

a. Does the Veteran use any assistive devices as a normal mode of locomotion,

although occasional locomotion by other methods may be possible?

[X] Yes [ ] No

If yes, idenitify assistive devices used (check all that apply and

indicate

frequency):

[ ] Wheelchair

Frequency of use: [ ] Occasional [ ] Regular [ ] Constant

[X] Brace

Frequency of use: [X] Occasional [ ] Regular [ ] Constant

[ ] Crutches

Frequency of use: [ ] Occasional [ ] Regular [ ] Constant

[ ] Cane

Frequency of use: [ ] Occasional [ ] Regular [ ] Constant

[ ] Walker

Frequency of use: [ ] Occasional [ ] Regular [ ] Constant

[ ] Other:

Frequency of use: [ ] Occasional [ ] Regular [ ] Constant

b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

The Veteran uses a prescription ankle brace 2-3 times a week for

residuals

of his left ankle fracture.

11. Remaining effective function of the extremities

Due to the Veteran's ankle condition, is there functional impairment of

An extremity such that no effective functions 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

12. Diagnostic testing

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

available? [X] Yes [ ] No

If yes, is degenerative or traumatic arthritis documented?

[ ] Yes [X] No

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

[ ] Yes [X] No

c. Is there objective evidence of crepitus? [X] Yes [ ] No

If yes, indicate ankle: [ ] Right [ ] Left [X] Both

d. If any test results are other than normal, indicate relationship of

abnormal findings to diagnosed conditions:

No response provided

13. Functional impact

Regardless of the Veteran's current employment status. Do the

condition(s) listed in the diagnosis section impact his or her ability to perform any type

of occupational task (such as standing, walking, lifting, sitting, etc.)?

[ ] Yes [X] No

14. Remarks, if any

VBMS was reviewed.

Claimed condition: Left ankle degenerative joint disease, left ankle

fracture

S/P bone graft

Diagnosis: Left ankle fracture with bone graft, right Ankle avulsion fracture

Prognosis: These are chronic conditions that will continue to cause pain.

Evidence: STRs, clinical history, physical exam.

Edited January 24, 2015 by Airborne01