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oldtimer88

C & P Exam

Question

Ok Experts help me out, I think this exam was not focused on my complaints. I have already been rated 10% bilateral for shin splints (which was only approved when NOD filed and X-rays showed degenarative (sp) arthiritis in both ankles and knees. So i filed a claim for Exertional Compartment syndrome as NEW claim and lower leg pain as secondary to EXTERIONAL COMPARTMENT. My exam was suppose to be focused on lower leg pain and knee pain. This is the exam, don't match with ALL complaints. So does this sound like a denial for new or increase, because they already rated me for shin splints?

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No

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: Exertional compartment syndrome as related to "shin splints"

b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Shin splints (including tibia and/or fibula stress fracture and/or exertional compartment syndrome) Side affected: [ ] Right [ ] Left [X] Both ICD Code: M79.A29 Date of diagnosis: Right SC Date of diagnosis: Left SC

c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] 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): The Veteran began having bilateral leg pain while in basic training with boot camp. She was diagnosed with "shin splints." She continues to have bilateral lower leg pain, now when walking for prolonged distances. She has some swelling of the knees with prolonged walking, statest that the knees become painful and and the lower legs are stiff and tight. She uses Capsaicin for comfort as well as Motrin. There is no locking or giving way of the knees. She walks presently with an antalgic gait, after coming from the parking lot. The right lower extremity is worse than the left.

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: "My knees hurt, they're stiff, they throb.

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? [X] Yes [ ] No

If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: "Can't walk long distances. My knees hurt walking from the parking lot."

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 115 degrees Extension (140 to 0): 115 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 If noted on exam, which ROM exhibited pain (select all that apply)?

Flexion 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? [ ] 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 115 degrees Extension (140 to 0): 115 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): 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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not witnessed 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 rep eated 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 witnessed d. Flare-ups Right Knee ---------- 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: As the veteran is not actively experiencing a flare-up at the time of the examination, and the examination is being conducted within a limited time frame, I am unable to determine if 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. Owing to the same causes, I am also unable to describe any such additional limitation that might be due to pain, weakness, fatigability or incoordination that might occur. Left Knee --------- 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: As the veteran is not actively experiencing a flare-up at the time of the examination, and the examination is being conducted within a limited time frame, I am unable to determine if 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. Owing to the same causes, I am also unable to describe any such additional limitation that might be due to pain, weakness, fatigability or incoordination that might occur. 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: Swelling, Other (please describe) Please describe additional contributing factors of disability: Difficulty maneuvering stairs and climbing ladders. Swelling of the knees with prolonged walking. Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Other (please describe) Please describe additional contributing factors of disability: Difficulty maneuvering stairs and climbing ladders. Swelling of the knees with prolonged walking.

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: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: 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? [X] Yes [ ] No If yes, describe: Veteran reports swelling of the knees with prolonged walking. 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? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below. [X] Chronic exertional compartment syndrome Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of ankle? [ ] Yes [X] No Describe current symptoms: stiffness, tightness 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

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? [ ] 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 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] Other: OTC compression sleeve [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: Veteran wears a compression sleeve occasionally when planning to walk for long distances. 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.,

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? [X] Yes [ ] No If yes, indicate knee: [ ] Right [ ] Left [X] Both

b. Are there any other significant diagnostic test findings and/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 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: Difficulty walking for prolonged distances. Unable to run. Difficulty maneuvering stairs. 15. Remarks, if any: -------------------- Letter dated 22 May 2002 from W. Clark Jernigan, MD, Piedmont Orthopaedics, Greenville, SC, states that Veteran had "exertional compartment syndrome, often diagnosed as 'shin splints.'" *********************************************************************

The Veteran's knee pain is not due to, not related to, not secondary to the exertional compartment syndrome which, as stated by the above orthopaedist, is the same as "shin splints." The exertional compartment syndrome is with the lower leg. 

 The Veteran's current exertional compartment syndrome has not progressed. She is now having knee pain, which, as stated above, is not related to, not due to, not secondary to her SC exertional compartment syndrome or "shin splints," (as called by Dr. Jernigan as one in the same). ********************************************************************* X-Rays, 9/23/2016, knees bilaterally: Mild degenerative changes. Age, according to medical literature, continues to be one of the highest risk factors for developing degenerative joint disease. Obesity is also one of the highest risk factors. The Veteran's mild degenerative changes of the knees are at least as likely as not the result of these two high risk factors.

 

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This exam probably wont be getting you additional benefits.  Reason:  It has those awful words, "can not state without resort to mere speculation".  

The doc says he does not know.  

You need this to get additional beneifts:

1.  Current diagnosis of condition claimed.

2.  Nexus, or link to another service connected condition.  (With secondary conditions, if you are claiming this secondary to shin splints, you dont need an "in service event", because that is already established with the primary shin splints)

 

     If you are seeking an increase, you need to show how the condition worsened since your C and P exam that awarded benefits.   That is, you need to show more symptoms.  Remember dont frustrate yourself trying to get more benefits for a condition when you are already at the maximum rating for that condition.  If the max for shin splints is 10%, then more symptoms wont increase it to 20%.  You will have to look up that diagnostic code for shin splints and see what the max is..

 

     Since this c and p exam did not give you the requiste nexus and stated instead "can not say without speculation", you will likely need an IMO/IME or additional medical evidence.  

     This doc is saying "exertional compartment syndrome" IS "shin splints".  Pyramiding prevents you from getting benefits twice from 2 diseases that mean the same thing.  For example, if you had PTSD and depression, you get compensated for the symptoms of one or the other, but not both.  

Edited by broncovet

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It doesn't sound good in the doctors MO at the end, but this is only one piece of the puzzle.  I would go back and talk to the ortho doctor that diagnosed you with shin splints and ask them to write a nexus letter connecting the dots for what you are requesting. 

Good luck.

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