degenerative arthritis What % Will Be Granted For Lower Back?

[Navy04]

Below is C&P results for back exam. Can you please help me with figuring on what % I might get. Thanks so much and God Bless!!!

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

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 (hard copy paper C-file)

reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not

included in the

Veteran's VA claims file:

VA medical records.

1. Diagnosis

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

Does the Veteran now have or has he/she ever been diagnosed with

a

thoracolumbar spine (back) condition?

[X] Yes [ ] No

Thoracolumbar Common Diagnoses:

[ ] Ankylosing spondylitis

[X] Lumbosacral strain

[ ] Degenerative arthritis of the spine

] Intervertebral disc syndrome

[ ] Sacroiliac injury

[ ] Sacroiliac weakness

[ ] Segmental instability

[ ] Spinal fusion

[ ] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: LS strain

Date of diagnosis: 2000s

2. Medical history

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

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

Veteran's

thoracolumbar spine (back) condition (brief summary):

The Veteran states that he initially injured his lower back

during

military service in 2005 secondary to heavy liftingl then it

was

re-injured in 2007 and 2010.

He was treated conservatively at those times.

Since military service discharge in early 2013, the Veteran

states that he

has experienced daily lower back pain, along with RLE

radiuclar symptoms.

He has been seeing a chiropractor of late, which has helped

somewhat.

He has a TENS unit which he uses as needed.

He denies bowel or bladder dysfunction secondary to his lower

back.

He also has ED, for which he is prescribed Viagra, and for

which he is

service connected as well, secondary to his chronic

epididymitis and

varicocele surgery.

He also ambulates with a cane for lower back and bilateral

knee support

and stabilization.

X-rays of his lower back in October 2013 were read as normal.

MRI of the LS spine on 2/15/2014 at Red River Regional

Hospital revealed

the following:

L2-3: Mild facet DJD

L3-4: Mild facet DJD

L4-5: Bulging annulus

L5-S1: Mild facet DJD

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

the

thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of

flare-ups in

his or her own words:

Stiffness/weakness

c. Does the Veteran report having any functional loss or

functional

impairment of the thoracolumbar spine (back) (regardless of

repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional

loss or

functional impairment in his or her own words.

See (b) above

3. Range

of motion (ROM) and functional limitation

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

a. Initial range of motion

[ ] All normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 55 degrees

Extension (0 to 30): 0 to 20 degrees

Right Lateral Flexion (0 to 30): 0 to 20 degrees

Left Lateral Flexion (0 to 30): 0 to 20 degrees

Right Lateral Rotation (0 to 30): 0 to 30 degrees

Left Lateral Rotation (0 to 30): 0 to 30 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 on rest/non-movement

If noted on exam, which ROM exhibited pain (select all that

apply)?

Forward Flexion, Extension, Right Lateral Flexion, Left

Lateral

Flexion, Right Lateral Rotation, Left Lateral Rotation

Is there evidence of pain with weight bearing? [X] Yes [ ]

No

Does the Veteran have localized tenderness or pain on

palpation of joints

and/or soft tissue of the thoracolumbar spine (back)? [X] Yes

[ ] No

If yes, describe including location, severity and

relationship to

condition(s):

There is localized tenderness over the bilateral

paralumbar muscles and

SI joints, as well as the right mid buttock and right

sciatic notch.

b. Observed repetitive use

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

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:

Not currently flared up.

d. Flare-ups

Is the exam being conducted during a flare-up? [ ] Yes [X]

No

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

No

Frequency: Weekly

Severity: Moderate

Duration: 1-2 days

If the examination is not being conducted during a flareup:

[ ] 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

Does pain, weakness, fatigability or incoordination

significantly limit

functional ability with flare-ups?

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

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

Not currently flared up.

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the

thoracolumbar spine

(back)? [X] Yes [ ] No

Muscle spasm:

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal

contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology:

Diffuse spasm on the right side

Localized tenderness:

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal

contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology:

See above.

Guarding:

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal

contour

[ ] Unable to evaluate, describe below:

f. Additional factors contributing to disability

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. 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

Hip flexion:

Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Knee extension:

Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Ankle plantar flexion:

Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Ankle dorsiflexion:

Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Great toe extension:

Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

5.

Reflex exam

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

Rate deep tendon reflexes (DTRs) according to the following

scale:

0 Absent

1+ Hypoactive

2+ Normal

3+ Hyperactive without clonus

4+ Hyperactive with clonus

Knee:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Ankle:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

6. Sensory exam

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

Provide results for sensation to light touch (dermatome)

testing:

Upper anterior thigh (L2):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Thigh/knee (L3/4):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Lower leg/ankle (L4/L5/S1):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Foot/toes (L5):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Other sensory findings, if any: There is normal perianal

sensation and

normal anal sphincter tone.

7. Straight leg raising test

Provide straight leg raising test results:

Right: [ ] Negative [X] Positive [ ] Unable to perform

Left: [X] Negative [ ] Positive [ ] Unable to perform

8. Radiculopathy

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

Does the Veteran have radicular pain or any other signs or

symptoms due to

radiculopathy?

[X] Yes [ ] No

a. Indicate symptoms' location and severity (check all that

apply):

Constant pain (may be excruciating at times)

Right lower extremity: [X] None [ ] Mild [ ] Moderate

[ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate

[ ] Severe

Intermittent pain (usually dull)

Right lower extremity: [ ] None [X] Mild [ ] Moderate

[ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate

[ ] Severe

Paresthesias and/or dysesthesias

Right lower extremity: [ ] None [X] Mild [ ] Moderate

[ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate

[ ] Severe

Numbness

Right lower extremity: [ ] None [X] Mild [ ] Moderate

[ ] Severe

b. Does the Veteran have any other signs or symptoms of

radiculopathy?

[ ] Yes [X] No

c. Indicate nerve roots involved: (check all that apply)

[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)

If checked, indicate: [X] Right [ ] Left [ ] Both

d. Indicate severity of radiculopathy and side affected:

Right: [ ] Not affected [X] Mild [ ] Moderate [ ]

Severe

Left: [X] Not affected [ ] Mild [ ] Moderate [ ]

Severe

9. Ankylosis

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

Is

there ankylosis of the spine? [ ] Yes [X] No

10. Other neurologic abnormalities

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

Does the Veteran have any other neurologic abnormalities or

findings related

to a thoracolumbar spine (back) condition (such as bowel or

bladder

problems/pathologic reflexes)?

[ ] Yes [X] No

11. Intervertebral disc syndrome (IVDS) and episodes requiring

bed rest

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

-------

a. Does the Veteran have IVDS of the thoracolumbar spine?

[ ] Yes [X] No

12. 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?

[X] Yes [ ] No

Identify assistive device(s) used

Assistive Device: Frequency of use:

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

[X] Cane(s) [ ] Occasional [X] Regular [ ]

Constant

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

condition and

identify the assistive device used for each condition:

See above.

13. Remaining effective function of the extremities

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

Due to a thoracolumbar spine (back) condition, 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.;

functions of the

lower extremity include balance and propulsion, etc.)

[X] No

14. Other pertinent physical findings, complications,

conditions, signs,

symptoms and scars

a. Does the Veteran have any other pertinent physical findings

complications, 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?

[ ] Yes [X] No

c. Comments, if any:

No response provided

15. Diagnostic testing

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

a. Have imaging studies of the thoracolumbar spine been

performed and are the

results available?

[X] Yes [ ] No

If yes, is arthritis documented?

[ ] Yes [X] No

b. Does the Veteran have a thoracic

vertebral fracture with loss

of 50

percent or more of height?

[ ] Yes [X] No

c. Are there any other significant diagnostic test findings

and/or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and

results (brief

summary):

Lumbar MRI has been ordered and is currently pending;

when

completed and reported, I will review it and add any

additional

comments as indicated.

Labs today: Testosterone 3.1 ng/ml (normal; this is

therefore not

the cause of his ED problem.)

16. Functional impact

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

Does the Veteran's thoracolumbar spine (back) condition impact

on his or her

ability to work?

[X] Yes [ ] No

If yes describe the impact of each of the Veteran's

thoracolumbar

spine (back) conditions providing one or more examples:

The Veteran's current lower back condition would limit

his ability

to perform repetitive heavy lifting, pushing or

pulling.

17. Remarks, if any:

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

The Veteran is claiming service connection for a lower back

condition.

Opinion: It is as least as likely as not that the Veteran's

current lower

back condition is proximately due to or caused by military

service.

Rationale: The C file was reviewed.

The STRs do contain documentation with regard to treatment for

the lower back

beginning in 2005, and again in 2007 as well.

Separation exam also comments on the lower back problems.

VA chiropractor notes in 2014 also describe chronic low back

pain since 2007.

****************************************************************************

[TiredCoastie]

Hey Shipmate! Looks like you made it to your C&Ps. Seems from your postings that you got some reasonable outcomes but you're in a better position to know if the docs got it right.

I'm a lot less severe and have 10%, so you're going to exceed that percentage.

[Navy04]

Thanks for the support bud. I have to do a few tests along with a brain scan but I made it thru thanks to you guys on Hadit.

[TiredCoastie]

PTL! Keep up the fight, Navy!

[iceturkee]

Hey Shipmate! Looks like you made it to your C&Ps. Seems from your postings that you got some reasonable outcomes but you're in a better position to know if the docs got it right.

I'm a lot less severe and have 10%, so you're going to exceed that percentage.

i disagree. compared to my lumbar mri, his is a cake walk. my guess is maybe 20 percent but probably 10. for the record, i have 5 herniated discs, spinal and foraminal stenosis, a slipped vertabrae, arthritis and 2 torn discs. i'm 40 percent for my back.

[Navy04]

I forgot to mention that due to the VA waiting to long to refer to Ortho Surgeon I developed a whole in the spine near L3 Plate caused by the pressure of the spine compression. That is what brought this claim to light when the VA back Dr caught this severe issue, but too late for surgery in my case. The C&P doc ordered another MRI of the Neck as it appears that the back issues brought on problems with the Neck and nerve damage. I guess we will see. I am 100% already just want it all documented. Heck I have a ton of other issues that I have not even submitted for, one being Sleep Apnea which is an automatic 50%. Just too much going on for now. I have multiple procedures over the next month to include Colonoscopy, Endoscopy, Brain Scan, Chest xrays and some kind of other Neuro Test. Thanks again