Here are the results for my C&P Exam.I appealed the last denial because,I was told that the VA did not have my service records.I cut some of the wording down.
[X] In-person examination
a. Evidence Review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other: vbms
a. List the claimed condition(s) that pertain to this DBQ:
plantar fasciitis
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus)
ICD code: 000
Side affected: Both
[X] Plantar fasciitis
ICD Code: 000
Side affected: Both
Date of diagnosis: Right May 1, 2015
Date of diagnosis: Left May 1, 2015
[X] Arthritic conditions
[X] Arthritis, degenerative
ICD Code: 716.93. May 1, 2015
Side affected: Both
Date of diagnosis: Right May 1, 2015
Date of diagnosis: Left May 1, 2015
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[X] Yes [ ] No [ ] N/A
If yes, document the Veteran's description of flare-ups in his or
her
own words:
Severe 8 out of 10
d. Does the Veteran report having any functional loss or functional impairment
of the foot being evaluated on this DBQ (regardless of repetitive use)?
[ ] Yes [X] No
3. Flatfoot (pes planus)
------------------------
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
c. Is there indication of swelling on use? [ ] Yes [X] No
d. Does the Veteran have characteristic callouses? [ ] Yes [X] No
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic
Device Side Not Relieved:
[X] Orthotics [ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both
feet?
No response provided
g. Does the Veteran have decreased longitudinal arch height of one or both
feet
on weight-bearing? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
h. Is there objective evidence of marked deformity of one or both feet
(pronation, abduction etc.)? [ ] Yes [X] No
i. Is there marked pronation of one or both feet? [ ] Yes [X] No
j. For one or both feet, does the weight-bearing line fall over or medial to
the great toe? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
a. Does the Veteran have symptoms due to a hallux valgus condition?
[X] Yes [ ] No
If yes, indicate severity:
[X] Mild or moderate symptoms
Side affected: [ ] Right [ ] Left [X] Both
RIGHT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
LEFT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ]
13. Functional loss and limitation of motion
a. Contributing factors of disability (check all that apply and indicate side
affected):
[X] Pain on movement
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on non weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
17. Diagnostic testing
a. Have imaging studies of the foot been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate foot: [ ] Right [ ] Left [X] Both
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
October 10, 2012 x-ray show bunions with arthritis first MTP's. May
1,
2015 x-rays of the feet showed mild to moderate bunions with minimal
arthritis of the first MTPs bilaterally
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed condition:
18. 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.)?
[X] Yes [ ] No
If yes, describe the functional impact of each condition, providing one or
more examples:
Walking up to 100 yards standing up to 20 minutes
[X] In-person examination
a. Evidence review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other:
vbms
a. List the claimed condition(s) that pertain to this DBQ:
Left knee
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] Arthritic conditions
[X] Arthritis, degenerative
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: 716.93
Date of diagnosis: Left May 1, 2015
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[X] Yes [ ] No [ ] N/A
2. Medical history
a. Describe the history (including onset and course) of the Veteran's
knee
and/or lower leg condition (brief summary):
He is claiming direct service connection for his left knee arthritis which
she strained while on active duty and also injured playing football. He
endorses continuation progression of the left knee now with constant
moderate 5 out of 10 pain
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his
or
her own words:
Severe 8 out of 10
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
a. Initial range of motion
Left Knee
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 90 degrees
Extension (140 to 0): 90 to 0 degrees
If abnormal, does the range of motion itself contribute to 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
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
Is there objective evidence of crepitus? [X] Yes [ ] No
If the examination is not being conducted immediately after repetitive
use over time:
[X] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
symptoms and scars
a. Have imaging studies of the knee been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate knee: [ ] Right [ ] Left [X] Both
b. 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):
March 9, 2013 MRI shows arthritis.
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
14. 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.)?
[X] Yes [ ] No
If yes, describe the functional impact of each condition, providing one or
more examples:
One flight of stairs at a time standing up to 20 minutes lifting up to 20
pounds
[ ] 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
Was the Veteran's VA claims file reviewed? No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other:
vbms
MEDICAL OPINION SUMMARY
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Is the condition of his feet related to
treatment in service
b. Indicate type of exam for which opinion has been requested: feet
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The plantar fasciitis found on active duty is a progression of
his pes planus due to service
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR AGGRAVATION OF A
CONDITION THAT EXISTED PRIOR TO SERVICE ]
a. The claimed condition, which clearly and unmistakably existed prior to
service, was aggravated beyond its natural progression by an in-service
event, injury or illness.
c. Rationale: The pre-existing pes planus that was not symptomatic exam
aggravated beyond its natural progression due to service as evidence by the
diagnosis of plantar fasciitis, and now bunions with arthritis of the first
MTPs
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Is the arthritis of the left knee incurred
in or caused by pain strain tendinitis of the left knee during service
b. Indicate type of exam for which opinion has been requested: left knee
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: I found evidence in his service treatment records of ongoing
left leg soreness diagnosis of left knee strain on August 9, 1989 ; injuries
chronic strain playing football August 21, 1989 and May 4, 1991 over use
injury along with orthopedic evaluation showing ongoing tendinitis in
September 11, 1989 patella laxity. The arthritis is natural progression of
Question
maine2000
Here are the results for my C&P Exam.I appealed the last denial because,I was told that the VA did not have my service records.I cut some of the wording down.
[X] In-person examination
a. Evidence Review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other: vbms
a. List the claimed condition(s) that pertain to this DBQ:
plantar fasciitis
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus)
ICD code: 000
Side affected: Both
[X] Plantar fasciitis
ICD Code: 000
Side affected: Both
Date of diagnosis: Right May 1, 2015
Date of diagnosis: Left May 1, 2015
[X] Arthritic conditions
[X] Arthritis, degenerative
ICD Code: 716.93. May 1, 2015
Side affected: Both
Date of diagnosis: Right May 1, 2015
Date of diagnosis: Left May 1, 2015
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[X] Yes [ ] No [ ] N/A
If yes, document the Veteran's description of flare-ups in his or
her
own words:
Severe 8 out of 10
d. Does the Veteran report having any functional loss or functional impairment
of the foot being evaluated on this DBQ (regardless of repetitive use)?
[ ] Yes [X] No
3. Flatfoot (pes planus)
------------------------
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
c. Is there indication of swelling on use? [ ] Yes [X] No
d. Does the Veteran have characteristic callouses? [ ] Yes [X] No
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic
Device Side Not Relieved:
[X] Orthotics [ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both
feet?
No response provided
g. Does the Veteran have decreased longitudinal arch height of one or both
feet
on weight-bearing? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
h. Is there objective evidence of marked deformity of one or both feet
(pronation, abduction etc.)? [ ] Yes [X] No
i. Is there marked pronation of one or both feet? [ ] Yes [X] No
j. For one or both feet, does the weight-bearing line fall over or medial to
the great toe? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
a. Does the Veteran have symptoms due to a hallux valgus condition?
[X] Yes [ ] No
If yes, indicate severity:
[X] Mild or moderate symptoms
Side affected: [ ] Right [ ] Left [X] Both
RIGHT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
LEFT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ]
13. Functional loss and limitation of motion
a. Contributing factors of disability (check all that apply and indicate side
affected):
[X] Pain on movement
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on non weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
17. Diagnostic testing
a. Have imaging studies of the foot been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate foot: [ ] Right [ ] Left [X] Both
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
October 10, 2012 x-ray show bunions with arthritis first MTP's. May
1,
2015 x-rays of the feet showed mild to moderate bunions with minimal
arthritis of the first MTPs bilaterally
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed condition:
18. 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.)?
[X] Yes [ ] No
If yes, describe the functional impact of each condition, providing one or
more examples:
Walking up to 100 yards standing up to 20 minutes
[X] In-person examination
a. Evidence review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other:
vbms
a. List the claimed condition(s) that pertain to this DBQ:
Left knee
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] Arthritic conditions
[X] Arthritis, degenerative
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: 716.93
Date of diagnosis: Left May 1, 2015
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[X] Yes [ ] No [ ] N/A
2. Medical history
a. Describe the history (including onset and course) of the Veteran's
knee
and/or lower leg condition (brief summary):
He is claiming direct service connection for his left knee arthritis which
she strained while on active duty and also injured playing football. He
endorses continuation progression of the left knee now with constant
moderate 5 out of 10 pain
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his
or
her own words:
Severe 8 out of 10
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
a. Initial range of motion
Left Knee
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 90 degrees
Extension (140 to 0): 90 to 0 degrees
If abnormal, does the range of motion itself contribute to 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
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
Is there objective evidence of crepitus? [X] Yes [ ] No
If the examination is not being conducted immediately after repetitive
use over time:
[X] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
symptoms and scars
a. Have imaging studies of the knee been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate knee: [ ] Right [ ] Left [X] Both
b. 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):
March 9, 2013 MRI shows arthritis.
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
14. 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.)?
[X] Yes [ ] No
If yes, describe the functional impact of each condition, providing one or
more examples:
One flight of stairs at a time standing up to 20 minutes lifting up to 20
pounds
[ ] 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
Was the Veteran's VA claims file reviewed? No
If no, check all records reviewed:
[X] Military service treatment records
[X] Other:
vbms
MEDICAL OPINION SUMMARY
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Is the condition of his feet related to
treatment in service
b. Indicate type of exam for which opinion has been requested: feet
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The plantar fasciitis found on active duty is a progression of
his pes planus due to service
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR AGGRAVATION OF A
CONDITION THAT EXISTED PRIOR TO SERVICE ]
a. The claimed condition, which clearly and unmistakably existed prior to
service, was aggravated beyond its natural progression by an in-service
event, injury or illness.
c. Rationale: The pre-existing pes planus that was not symptomatic exam
aggravated beyond its natural progression due to service as evidence by the
diagnosis of plantar fasciitis, and now bunions with arthritis of the first
MTPs
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Is the arthritis of the left knee incurred
in or caused by pain strain tendinitis of the left knee during service
b. Indicate type of exam for which opinion has been requested: left knee
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: I found evidence in his service treatment records of ongoing
left leg soreness diagnosis of left knee strain on August 9, 1989 ; injuries
chronic strain playing football August 21, 1989 and May 4, 1991 over use
injury along with orthopedic evaluation showing ongoing tendinitis in
September 11, 1989 patella laxity. The arthritis is natural progression of
these chronic conditions.
Link to comment
Share on other sites
Top Posters For This Question
3
2
1
Popular Days
May 19
6
Top Posters For This Question
maine2000 3 posts
Berta 2 posts
Buck52 1 post
Popular Days
May 19 2015
6 posts
5 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now