Odd C&P for my Knee

[lcurle]

So I went in for a C&P for my R Knee.  I laid down on a table, brought my knee as high up as I could to my chest, and then put it back down again.  Did that 3 times and I was done.  Seems like there was not a complete ROM evaluation done, your thoughts.

[lcurle]

Here is the complete report, they are blaming it on my BMI which they grossly estimate at 41% which way off base.  Regardless, all of this from making me lay on my back and bring my knee as high as I can go 3 times.

 LOCAL TITLE: WI-C&P STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: AUG 24, 2015@09:00 ENTRY DATE: AUG 26, 2015@09:48:35 AUTHOR: CREASSER,MARY J EXP COSIGNER: URGENCY: STATUS: COMPLETED Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Curle ACE and Evidence Review ----------------------- 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

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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: CPRS: VistaWeb

b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: CPRS; Vistaweb 1. Diagnosis ------------

a. List the claimed condition(s) that pertain to this DBQ: right knee condition

b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Other (specify): Other diagnosis: Old Osgood-Schlatter's, bil. Side affected: Both ICD code: 732.4 Date of diagnosis (right side): developmental Date of diagnosis (left side): developmental

 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): Claiming right knee condition. HX per Veteran: Onset: ~2002, notin pain with running a lot while in Korea. a little pain now and then. past treatment: Maybe seen once, Rx Naproxyn. testing: Xray? Since AD: Mentioned when went to VA ~2012. Xray done. Not really andy treatment in particular. Injury: ~believes 2003 may have hurt the knee when rolled down a mountainside.? does not recall any particular treatment or xrays at that time. Surgery: Denies. Current treatment: No Rx. Self treats when needed with 'DC powder OTC' (is a ASA type product he states). Current symptoms: gets pain on anterior aspect- esp under knee cap, notes with deep knee bending; prolonged sitting; when first gets up in morning can be there until starts getting around. sig flares (for MuscSkel): Denies. b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] 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, 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 Right 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 130 degrees Extension (140 to 0): 0 to 0 degrees If ROM is outside of normal range, but is normal for the Veteran (for reasons other than a knee condition, such as age, body habitus, neurologic disease), please describe: BMI 41

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

Flexion 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? [ ] Yes [X] No

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 132 degrees Extension (140 to 0): 0 to 0 degrees 

If ROM is outside of normal range, but is normal for the Veteran (for reasons other than a knee condition, such as age, body habitus, neurologic disease), please describe: BMI 41 If abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): No pain noted on exam 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? [ ] Yes [X] No b. Observed repetitive use Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee ---------- 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 is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with 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 [X] No [ ] Unable to say w/o mere speculation Left Knee --------- 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 is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with 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 [X] No [ ] Unable to say w/o mere speculation 

d. Flare-ups No response provided e. Additional factors contributing to disability Right Knee ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Knee --------- 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: 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 Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 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 the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing

Right Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? 

[ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No b. Comments, if any: No response provided 8. Meniscal conditions

 ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. 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? [X] Yes [ ] No If yes, describe (brief summary): Old Osgood- Schlatter's- bil. R>L. 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 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? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:

 No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), 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., 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 13. Diagnostic testing ---------------------- 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? [ ] Yes [X] No 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): KNEE (RIGHT) 4 OR MORE VIEWS Exm Date: MAY 21, 2012 Report Status: Verified Date Reported: MAY 21, 2012 Reason for Study: Knee pain Report: Four views of the right knee show no fracture or dislocation. Joint spaces are well preserved. Patella is well seated. There is bony fragmentation of the anterior tibial tuberosity likely from old os good Schlatter's. No significant joint 

effusion. Impression: Residue of old Osgood-Schlatter's. Otherwise negative right knee. Primary Interpreting Staff: MICHELLE R CALVERT, MD, RADIOLOGIST (Verifier, no e- sig)/MRC ----------------------------------------------------------- ------------- ------- KNEE (LEFT) 4 OR MORE VIEWS Exm Date: MAY 21, 2012@09:01 Reason for Study: Knee pain Report: Four views of the left knee show no fracture or dislocation. Joint spaces are well preserved. Patella is well seated. There is bony fragmentation of the anterior tibial tuberosity likely from old Osgood-Schlatter's. No significant joint effusion. Impression: Residue old Osgood-Schlatter's. Otherwise negative left knee. Primary Interpreting Staff: MICHELLE R CALVERT, MD, RADIOLOGIST (Verifier, no e- sig)/MRC =========================================================== ============= ======= 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.)? [ ] Yes [X] No 15. Remarks, if any: -------------------- Old Osgood-Schlatter's (developmental): not caused buy AD Service nor aggravated beyond natural progression. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Curle 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 reviewed? Yes If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file: CPRS: VistaWeb MEDICAL OPINION SUMMARY ----------------------- The following contentions need to be examined: Active duty service dates: Branch: Army EOD: 01/08/2002 - RAD: 01/07/2005 MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection ------------------------------------------------------ RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran have a diagnosis of (a)right knee condition that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) repated complaints of pain and subsequent treatment during service? b. Indicate type of exam for which opinion has been requested: Knee 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: Current Exam findings significant for Old developmental Osgood Schlatter disease. There is no evidence of a chronic knee condition caused by AD Military service. Aggravation of the developmental Osgood Schlatter disease beyond Natural History is also not warrented. Occupational HX since AD- mainly office type jobs. BMI 41 SMR's: Multiple records i.e. Marked 'No' by veteran: swollen, painful, or dislocated joint or fluid in a joint; Locking of the knee or other joint; 

Giving way of knee or other joint. 08/03/2004: Hx MVA. seat belt worn. states struck by another vehical at 40 mph. Refused Tx at time of accident. cc: ... 2. right knee pain. S: History as above, Knee pain is located along anterior joint line. Pain is increased with ascending stairs and running, relieved with rest and knee flexed. O: Knee: No effusion, edema, erythema, or deformity observed; FAROM without pain, Strength: WNL increased pain, with I?nee extension No instabIlity or laxity with valgus/varus stress, anterior/posterior drawer No pain or click with McMurray's test. No TIP noted. Strength: knee/hip 5/5 without pain. A: Right knee pain, contusion. 09/17/2004: PT treatment knee. Improvement. Post-Deployment screen 04/17/2004: Marked 'No' for swollen, stiff or painful joints. Separation H&P 08/06/2004: On HX screen-Have you now of Ever had: Swollen or painful jointis); Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.): Marked 'Yes' by veteran. Described as Right knee when climbing stairs or road march. Initial VA Claim dated 10/25/2004: Right knee pain. Initial C&P Gen Med Exam 12/02/2004 Exam and Xray noted as Normal. Impression: Normal exam of the right knee. Post Military: No Private records found. Records are then silent for a knee condition until 2012. CPRS: 05/21/2012 note: ...He states that he has had knee pain ever since he was injured in Iraq. He states that he was hit by an IED at which time his knees flew up. When his knees flew up, he jammed the top of his knees. (*) ASSESSMENT AND PLAN: 1. Knee pain. At this point, I will set the patient up for x- rays and imaging. It may be secondary to his obesity. I am unable to get into the records from outside the VA for further workup. He declines having any medications or any 

 interventions. Xrays Report/Clinical note show: findings of Osgood Schlatter Disorder. (*)no such incident found in records). **************************************************************** ********* /es/ Mary J Creasser DNP, APRN-C Signed: 08/26/2015 09:48

[Vync]

Did you submit any non-VA records? The doc says he could not find any. It's not uncommon for the VA docs to deny based on 'not being able to get into non-VA records'. If you submitted any, they were supposed to be in your claims file, which is given directly to the C&P doc to validate. Either they were not there or they are in there and the doc could not find them for whatever reason.

I am unable to get into the records from outside the VA for further workup.

 

The x-ray show Osgood Schlatter disorder, but they state that there is no evidence in records. I would double-check your entrance exam and all of your records. The is not supposed to deny based on a preexisting condition unless there is hard evidence or obvious evidence showing otherwise.

Xrays Report/Clinical note show: findings of Osgood Schlatter Disorder. (*)no such incident found in records).

 

If you have, or can get, an IMO from another doc, that could help.

[lcurle]

I did not submit any other records other than what the VA had. There are no outside documentation on my knees.

[john999]

When the doctor touched you knees you should have screamed in pain and when you stood up you should have moaned and shown that standing up from prone position was very painful for you.  Do you have a cane or walker.  You should use it before, during and after the exam if possible. You should have lost your balance and crashed into the table and grabbed the doctor on the way down.   This reminds me of many half ass exams I have had in the past.  The VA did a heart exam by just looking at me and asking me if I could walk two blocks.  After that exam I went out and got many tests at VA expense to show that the C&P exam was totally inadequate and incompetent.    You need outside documentation on your knees.  You should go to IME doctor and get a report if you want to appeal and win something on your knees.  Did they do MRI, CT scan or even x-ray?

[lcurle]

X-ray 3 years ago, nothing else 

[lcurle]

Still no decision, they have been waiting on documents from somewhere for quite a while now.  All information was at the VA as I do not have an outside Dr at this time.  Odd