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degenerative arthritis
C&p Notes, Guesses On Ratings?

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Hello everyone, I am finally able to see notes regarding my recent exams. I am hoping that someone can give me a guestimate of what my ratings might be. Seems odd that my neck issues are simply "cervical strain" when it has been called degenerative disc disease, spondylosis and spinal stenosis.

1st my neck, and this is why the MEB began.The ROM part bothers me so much because it was eyeballed and I did not turn my head left, right or up much at all, because I cant!

1. Diagnosis
‐‐‐‐‐‐‐‐‐‐‐‐
Does the Veteran now have or has he/she ever been diagnosed with a cervical
spine (neck) condition?
[X] Yes [ ] No
[ ] Ankylosing spondylitis
[X] Cervical strain
[ ] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Cervical spondylosis with radiculopathy
ICD code: 721.1
Date of diagnosis: 2010
2. Medical history
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
a. Describe the history (including onset and course) of the Veteran's
cervical spine (neck) condition (brief summary):
He developed neck pain in 2001 or so. He was deployed and was seen in
clinic for neck pain. His neck pain has continued through the years and
he has had multiple MRIs. He has had physical therapy, steroid and facet
injections and RFA. His radio frequency ablation was in 2014. His
symptoms
worsened after that and he is on daily narcotics and uses his TENs daily.
His neck pain is constant, aching/sharp and severe. About 2‐3 days a
week
he has more severe flare ups of pain. His pain is worse with
lifting/carrying, any movement of the head and cold weather. He has not
had surgery on the neck. His pain radiates into both shoulders as a
stabbing pain. It is worse on the right. It does not radiate into the
left
arm. It radiates as a sharp stabbing pain down the right arm to the
fingers. The stabbing pain will taper off when he goes back to his normal
positions. He takse narcotic pain medications, ice, TENs unit, and rest
daily. He does yoga stretches also to help. He also gets chiropractic
care and massage. He goes off base to get these and it is helpful.
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
c. Does the Veteran report flare‐ups of the cervical spine (neck)?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare‐ups in his or
her own words:
He has even more limited ROM with flare ups.4/23/2015 My HealtheVet
about:blank 25/101
d. Does the Veteran report having any functional loss or functional
impairment of the cervical spine (neck) (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:
He has limited ROM on a daily basis.
3. Range of motion (ROM) and functional limitations
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
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 (0‐45): 0 to 45 degrees
Extension (0‐45): 0 to 30 degrees
Right Lateral Flexion (0‐45): 0 to 45 degrees
Left Lateral Flexion (0‐45): 0 to 30 degrees
Right Lateral Rotation (0‐80): 0 to 45 degrees
Left Lateral Rotation (0‐80): 0 to 45 degrees
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
Pt is unable to have normal ROM. He is limited in turning his head
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, 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
Is there objective evidence of localized tenderness or pain on palpation
of the joint or associated soft tissue of the cervical spine (neck)?
[X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
Pain with palpation over the trapezius muscle. Pain with palpation
over
the cervical paraspinous processes.
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
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[X] Yes [ ] No
If yes, complete the following section:
a. Indicate location and severity of symptoms (check all that apply):
Constant pain (may be excruciating at times)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Intermittent pain (usually dull)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Paresthesias and/or dysesthesias
Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Numbness
Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [X] None [ ] 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 C5/C6 nerve roots (upper radicular group)
[X] Involvement of C7 nerve roots (middle radicular group)
[X] Involvement of C8/T1 nerve roots (lower radicular group)
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
8. Ankylosis
‐‐‐‐‐‐‐‐‐‐‐‐
Is there ankylosis of the spine? [ ] Yes [X] No
9. Other neurologic abnormalities
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Does the Veteran have any other neurologic abnormalities related to a
cervical spine (neck) condition (such as bowel or bladder problems due to
cervical myelopathy)?
[ ] Yes [X] No
10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
a. Does the Veteran have IVDS of the cervical spine?
[ ] Yes [X] No
11. 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
If yes, identify assistive device(s) used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant4/23/2015 My HealtheVet
about:blank 29/101
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
He uses a neck brace at home several days a week.
12. Remaining effective function of the extremities
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Due to a cervical spine (neck) 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.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
13. 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
14. Diagnostic testing
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No
b. Does the Veteran have a 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?
15. Functional impact
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Does the Veteran's cervical spine (neck) condition impact on his or her
ability to work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's cervical spine
(neck) conditions, providing one or more examples:
He has missed about 1/3 to 1/2 of his work days due to his neck and
back pain in the last year.
I have many other ailments that were reviewed, I can post those as well. However the DOD is only looking at my neck as unfitting.

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