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cavscout1967

BVA remand shoulder exam results

Question

Hi, I am currently rated at 20% for my shoulder. I went in for a CP exam recently and these were the results. This is a remand exam from the BVA. Am I looking at a decrease to 10 or even zero? I am not bending my shoulder so it may dislocate for any of these people or any examination and I think it may have hurt me. If you could take a look I'd appreciate it. Thanks for your time!

Shoulder and Arm Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: 
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination

Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
Strain with radicular sx
b. Select diagnoses associated with the claimed condition(s) (check all that
apply):
[X] Shoulder strain
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: S46.019A
Date of diagnosis: Left UNK- S/C
c. Comments, if any:
No response provided
d. Was an opinion requested about this condition?
[ ] Yes [X] No [ ] N/A
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
shoulder
or arm condition (brief summary):
*** Note - Veteran was notified that this evaluation is for Compensation
and
Pension purposes only and he/she is to return to his/her treating
clinician
for
regular medical care

===========================================================================
=====
Veteran served in the US Army as a Cav Scout E-5 from 1988-1996 - reports
that he
is s/c for L shoulder strain with radicular sx. Reports current condition
includes
the following sx-
L shoulder Pain- intermittent Daily lasting 10 minutes to hours 3-7/10
dull to sharp depending on activity
Dislocations - Last occurred was 3 years ago - has popping and clicking,
sensation of weakness
Reports constant L lateral 1st metatcarpal numbness
Has additional numbness from axillary region to the Lateral aspect of the
L
1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2 hours
Condition impacts Occupation/Recreation/Daily activities- Limits carrying,
lifting, pushing, pulling and overhead work
Current Tx
Type Duration Response to Medications
1. Medications
OTC ASA, Tylenol, Advil as directed PRN- fair results
2. Denies Physical therapy
Occupation since discharge- HVAC mechanic now on SSDI since 2013
2. DOMINANT HAND: right

3. POSTURE & GAIT: straight; gait stable, smooth, symmetric
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
c. Does the Veteran report flare-ups of the shoulder or arm?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his
or
her own words:
L shoulder Pain- intermittent Daily lasting 10 minutes to hours
3-7/10 dull to sharp depending on activity
Dislocations - Last occurred was 3 years ago - has popping and
clicking, sensation of weakness
Reports constant L lateral 1st metatcarpal numbness
Has additional numbness from axillary region to the Lateral aspect of
the L 1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2
hours
Condition impacts Occupation/Recreation/Daily activities- Limits
carrying, lifting, pushing, pulling and overhead work
Pain, weakness, fatigability, or incoordination could significantly
limit
functional ability during flare-ups, or when the joint is used
repeatedly over a
period of time. Veteran would have additional limitations in ROM but
unable to
quantify the degree of ROM loss as it would vary due to severity of
pain ,
weakness, fatigability and overuse.
d. 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)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:
L shoulder Pain- intermittent Daily lasting 10 minutes to hours
3-7/10 dull to sharp depending on activity
Dislocations - Last occurred was 3 years ago - has popping and
clicking, sensation of weakness

Reports constant L lateral 1st metatcarpal numbness
Has additional numbness from axillary region to the Lateral aspect of
the L 1st metacarpal- occurs 3-5 x weekly lasting 10 minutes to 2
hours
Condition impacts Occupation/Recreation/Daily activities- Limits
carrying, lifting, pushing, pulling and overhead work
Pain, weakness, fatigability, or incoordination could significantly
limit
functional ability during flare-ups, or when the joint is used
repeatedly over a
period of time. Veteran would have additional limitations in ROM but
unable to
quantify the degree of ROM loss as it would vary due to severity of
pain ,
weakness, fatigability and overuse.
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Left Shoulder
-------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 130 degrees
Abduction (0 to 180): 0 to 150 degrees
External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees
If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than a shoulder condition, such as age, body habitus,
neurologic disease), please describe:
Veteran refuses to move L shoulder beyond stated range due to fear of
pain and dislocation- poor effort
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
limits ROM

Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Flexion, Abduction
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
Left Shoulder
------
-------
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
Left Shoulder
-------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
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:
Pain, weakness, fatigability, or incoordination could significantly
limit
functional ability during flare-ups, or when the joint is used
repeatedly over a
period of time. Veteran would have additional limitations in ROM but
unable to
quantify the degree of ROM loss as it would vary due to severity of
pain
,
weakness, fatigability and overuse.

d. Flare-ups
Left Shoulder
-------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
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:
Pain, weakness, fatigability, or incoordination could significantly
limit
functional ability during flare-ups, or when the joint is used
repeatedly over a
period of time. Veteran would have additional limitations in ROM but
unable to
quantify the degree of ROM loss as it would vary due to severity of
pain
,
weakness, fatigability and overuse.
e. Additional factors contributing to disability
Left Shoulder
-------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc., Other
(please
describe)
Please describe additional contributing factors of disability:
Condition impacts Occupation/Recreation/Daily activities- Limits
carrying, lifting, pushing, pulling and overhead work

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 Shoulder: Rate Strength:
Forward flexion: 5/5
Abduction: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Shoulder: Rate Strength:
Forward flexion: 5/5
Abduction: 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 scapulohumeral
(glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus
move as one piece).
a. Indicate severity of ankylosis and side affected (check all that apply):
Left side:
[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head
(Favorable ankylosis)
[ ] Ankylosis in abduction between favorable and unfavorable
(Intermediate ankylosis)
[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable
ankylosis)
[X] No ankylosis
b. Comments, if any:
No response provided

6. Rotator cuff conditions
--------------------------
Is rotator cuff condition suspected?
Right Shoulder: [ ] Yes [ ] No
Left Shoulder: [X] Yes [ ] No
If "Yes" complete the following:
Hawkins' Impingement Test (Forward flex the arm to 90 degrees with
the
elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
indicates a positive test; may signify rotator cuff tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.
Patient turns thumbs down and resists downward force applied by the
examiner. Weakness indicates a positive test; may indicate rotator cuff
pathology, including supraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
External Rotation/ Infraspinatus Strength Test (Patient holds arms at
side
with elbow flexed 90 degrees. Patient externally rotates against
resistance. Weakness indicates a positive test; may be associated with
infraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Lift-off Subscapularis Test (Patient internally rotates arm behind lower
back, pushes against examiner's hand. Weakness indicates a positive
test;
may indicate subscapularis tendinopathy or tear.)
[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A
7. Shoulder instability, dislocation or labral pathology
--------------------------------------------------------
a. Is shoulder instability, dislocation or labral pathology suspected?
[X] Yes [ ] No
If yes, complete questions 7b - 7d below:
b. Is there a history of mechanical symptoms (clicking, catching, etc.)?
[X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
c. Is there a history of recurrent dislocation (subluxation) of the
glenohumeral (scapulohumeral) joint?
[X] Yes [ ] No

If yes, indicate frequency, severity and side affected (check all that
apply):
[X] Infrequent episodes [ ] Right [X] Left [ ] Both
[X] Guarding of movement only at [ ] Right [X] Left [ ] Both
shoulder level
d. Crank apprehension and relocation test (with patient supine, abduct
patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense
of
instability with further external rotation may indicate shoulder
instability.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint
conditions
------------------------------------------------------------------------------
a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular
joint condition suspected?
[X] Yes [ ] No
If yes, complete questions 8b, 8d and 8e below:
b. Does the Veteran have an AC joint condition or any other impairment of the
clavicle or scapula?
[ ] Yes [X] No
c. Does the clavicle or scapula condition affect range of motion of the
shoulder (glenohumeral) joint?
No response provided
d. Is there tenderness on palpation of the AC joint?
[ ] Yes [X] No
e. Cross-body adduction test (Passively adduct arm across the patient's
body
toward the contralateral shoulder. Pain may indicate acromioclavicular
joint
pathology.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
9. Conditions or impairments of the humerus
-------------------------------------------
a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail
shoulder), or fibrous union of the humerus?
[ ] Yes [X] No
b. Does the Veteran have malunion of the humerus with moderate or marked

deformity?
[ ] Yes [X] No
c. Does the humerus condition affect range of motion of the shoulder
(glenohumeral) joint?
No response provided
d. Comments, if any:
No response provided
10. Surgical procedures
-----------------------
No response provided
11. 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
12. Assistive devices
---------------------
a. Does the Veteran use any assistive devices?
[ ] 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
13. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's shoulder and/or arm conditions, 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
14. Diagnostic testing
----------------------
a. Have imaging studies of the shoulder 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. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
15. 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 impact of each of the Veteran's shoulder
conditions
providing one or more examples:
Condition impacts Occupation/Recreation/Daily activities- Limits carrying,
lifting, pushing, pulling and overhead work
16. Remarks, if any:
--------------------
Impression-
1. L shoulder strain with residuals of radicular sx as noted- Veteran refused
to move L shoulder beyond stated range due to fear of pain and dislocation

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