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2NDMARDIVDOC

Please tell me what these results mean

Question

 
Hello. Below are the C&P exam results for on my shoulder claim. I'm having difficulty comparing the results to the rating criteria for shoulder conditions. Can you please tell me what these results equal in regards to the percentage assigned? By the way, this is for my non-dominate side. Thank you.
 
[X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 140 degrees Abduction (0 to 180): 0 to 110 degrees External rotation (0 to 90): 0 to 70 degrees Internal rotation (0 to 90): 0 to 60 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please

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More is always better than less!

Semper Fi

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I hope you had the examiner to stop at the beginning of the pain and not let him keep moving your arm  for ROM?

.. YOU need to have them STOP at the slightest of pain (STOP Dr I can't stand the pain) if they go over a certain % of ROM you will probably be denied or only get a low ball rating.

Read this BVA case below  and pay close attention to the last 3 or 4 paragraphs   its a long read but you may learn about how they actually check ROM  and the criteria for it.

https://www.va.gov/vetapp12/files5/1237359.txt

Edited by Buck52

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Ok..Here's report. Its a long one.... Thanks! Please note that this is for a SECONDARY claim condition and the examiner also offered an opinion that the condition is "as likely as not" to be related to my already SC right shoulder.

 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:
      Left shoulder condition
     
  b.  Select diagnoses associated with the claimed condition(s) (check all that
      apply):
     
  [X] Labral tear, including SLAP (Superior labral anterior-posterior lesion)
      Side affected: [ ] Right   [X] Left   [ ] Both
      ICD Code: M75.102
      Date of diagnosis: Left 9/14/2016

  [X] Acromioclavicular joint osteoarthritis
      Side affected: [ ] Right   [X] Left   [ ] Both
      ICD Code: M19.019
      Date of diagnosis: Left 8/23/2016

  c.  Comments, if any:
      No response provided
     
  d.  Was an opinion requested about this condition?
      [X] Yes   [ ] No   [ ] N/A
     

  2. Medical history
  ------------------
  a.  Describe the history (including onset and course) of the Veteran's
shoulder
      or arm condition (brief summary):
      This Veteran is a 42 y/o MALE with complaint of Left shoulder pain x 2
      years, severe for 8 months.  The Veteran states he is Right hand dominant.
      He states he believes the left shoulder pain was caused by overuse due to
      Right shoulder incapacity after injury in 1998. Right shoulder is service
      connected, had surgery distal clavicle resection on Right shoulder 1999,
no
      strength since and instability with pain. The Veteran states his Left
      shoulder pain begins anterior and superior on the point of the shoulder
      tends to radiate to the back of the shoulder radiates down the deltoid
      area.  He denies a specific in service injury.  He states he was a weight
      lifter and stopped lifting after he injured his right shoulder in 1998
      while doing 8-count body builders for physical training.  Currently he is
      on 10/325 mg hydrocodone APAP and Motrin 800 mg.  He states he has not
been
      able to begin physical therpay due to the  Left shoulder pain.  He
      currently works in an administration position.  He denies work requiring
      repetitive overhead activities.  He states he uses a TENS unit daily.
     
***************************************************************************
      ****

      At the time of this interview, documentation of history, severity and
      frequency of reported symptoms has been reviewed with the veteran for
      accuracy and verified by the veteran as correct prior to veteran's
      departure. The veteran was permitted as much time as he needed to include
      whatever additional information he wished, and he voiced any other
problems
      or concerns that were not addressed no concerns or complaints about the
      exam.  The veteran denied having any other problems or concerns that were
      not addressed in this evaluation.
     
  b.  Dominant hand:
      [X] Right   [ ] Left   [ ] Ambidextrous
     
  c.  Does the Veteran report flare-ups of the shoulder or arm?
      [ ] Yes   [X] No
     
  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:
          less motion, more pain
         

  3. Range of motion (ROM) and functional limitation
  --------------------------------------------------
  a. Initial range of motion
 
     Right Shoulder
     --------------
     [X] All Normal
     [ ] Abnormal or outside of normal range
     [ ] Unable to test (please explain)
     [ ] Not indicated (please explain)
    
         Flexion (0 to 180):           0 to 180 degrees
         Abduction (0 to 180):         0 to 180 degrees
         External rotation (0 to 90):  0 to 90 degrees
         Internal rotation (0 to 90):  0 to 90 degrees

     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
    
     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 140 degrees
         Abduction (0 to 180):         0 to 110 degrees
         External rotation (0 to 90):  0 to 70 degrees
         Internal rotation (0 to 90):  0 to 60 degrees

         If abnormal, does the range of motion itself contribute to functional
         loss?  [X] Yes (please explain)   [ ] No
            If yes, please explain:
            decreased 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, External rotation, Internal rotation
        
     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 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
       

     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
 
     Right Shoulder
     --------------
     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:
         As the joint is repeatedly used over a period of time, such an opinion
         is not feasible and cannot As for an opinion for Pain, weakness,
         fatigability, or incoordination when be provided without resorting to
         mere speculation. Any decrease in ROM with repeated use over time is
         merely speculative and highly subjective (on the veteran's word alone)
         as neither this medical provider nor any other medical provider is
         present to objectively and repetitively measure (with a goniometer) the
         change in ROM with repeated use over time. And the veteran denies
         objectively and repetitively measuring (with a goniometer) ROM with
         repeated use over time.
        
        

     Left Shoulder
     -------------
     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:
         As the joint is repeatedly used over a period of time, such an opinion
         is not feasible and cannot As for an opinion for Pain, weakness,
         fatigability, or incoordination when be provided without resorting to
         mere speculation. Any decrease in ROM with repeated use over time is
         merely speculative and highly subjective (on the veteran's word alone)
         as neither this medical provider nor any other medical provider is
         present to objectively and repetitively measure (with a goniometer) the
         change in ROM with repeated use over time. And the veteran denies
         objectively and repetitively measuring (with a goniometer) ROM with
         repeated use over time.
        
        

  d. Flare-ups: Not applicable
 
  e. Additional factors contributing to disability
 
     Right Shoulder
     --------------
     In addition to those addressed above, are there additional contributing
     factors of disability?  Please select all that apply and describe: None
    
     Left Shoulder
     -------------
     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 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:           4/5
        Abduction:                 4/5
        Is there a reduction in muscle strength?   [X] Yes   [ ] No
       
        If yes, is the reduction entirely due to the claimed condition in the
        Diagnosis Section?   [X] Yes   [ ] 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):
 
     Right 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

     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   [X] 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.)
      [X] Positive   [ ] 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.)
      [X] Positive   [ ] 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.)
      [X] Positive   [ ] 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.)?
     [ ] Yes   [X] No
    
  c. Is there a history of recurrent dislocation (subluxation) of the
     glenohumeral (scapulohumeral) joint?
     [ ] Yes   [X] No
    
  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.)


     [X] Positive   [ ] Negative   [ ] Unable to perform   [ ] N/A
    
         If positive, indicate side affected:  [ ] Right   [X] Left   [ ] Both
        

  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?
     [X] Yes   [ ] No
    
         If yes, indicate side:  [ ] Right   [X] Left   [ ] Both
        
  e. Cross-body adduction test (Passively adduct arm across the patient's body
     toward the contralateral shoulder. Pain may indicate acromioclavicular
joint
     pathology.)
     [X] Positive   [ ] Negative   [ ] Unable to perform   [ ] N/A
    
         If positive, side affected:  [ ] Right   [X] Left   [ ] Both
        

  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
  -----------------------
  Indicate any surgical procedures that the Veteran has had performed and
provide
  the additional information as requested (check all that apply):
 
  Right side:
 
     [X] Arthroscopic or other shoulder surgery
         Type of surgery:  Distal clavicle resection
         Date of surgery:   1999

  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?
         [X] Yes   [ ] No
        
             If yes, indicate shoulder: [ ] Right   [X] Left   [ ] 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):
         08/23/2016 SHOULDER (LEFT) 2 OR MORE VIEWS
         Impression:
         Mild degenerative arthritis of the a.c. joint. The shoulder joint
         appears normal. The soft tissues are unremarkable.   


         09/14/2016 MRI SHOULDER W/O CONTRAST
         Impression:
         Suspect a small partial-thickness articular surface tear of the
         infraspinatus
         tendon at the footplate with an associated small
         interstitial/intrasubstance
         tear extending into the myotendinous junction. 
        
         Inferior and posterior inferior labral tear. Abnormal signal within
         the
         superior labrum which may be related to degeneration or possibly a
         tear. 
        
         Moderate a.c. joint degenerative changes which mildly narrows the
         supraspinatus outlet. 
        

        

        
        
  c. If any test results are other than normal, indicate relationship of
abnormal
     findings to diagnosed conditions:
     Left shoulder pain with osteoarthritis and suprspinatous tear.
    

  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:
      Difficulty with overhead activities or prolonged use of the left
      arm/shoulder.
      No sedentary restrictions.
     

  16. Remarks, if any:
  --------------------
  The purpose of Passive ROM (aided by another) is to help maintain flexibility
  and mobility at the joint being evaluated to reduce stiffness. Passive ROM
  involves no muscle work and the extent of the stretch is determined by how
much
  the muscles involved will elongate. It is the medical examiner and not the
  Veteran performing this motion and the potential for harm to the joint and
  surrounding soft tissue far outweighs the benefits of passively manipulating
  the joint to its maximum point merely for the purpose of measuring movement of
  the joint for non-therapeutic or treatment purposes. The medical provider may
  inadvertently move the joint past the tolerable point of pain and could
  potentially cause harm to said joint. Per current medical literature (DORLANDS
  MEDICAL DICTIONARY, NETTERS ATLAS OF HUMAN ANATOMY, WHEELESS' TEXTBOOK OF
  ORTHOPAEDICS), the function of one human joint is unequivocally independent of
  the identical contralateral joint in respects to muscular, skeletal and
  neurologic anatomy. Comparing one joint to its identical contralateral side is
  of little relevance and the potential for harm/injury far outweighs the
  benefits.  Therefore b/l Passive ROM is not performed on today's examination.

  Weight Bearing ROM of a joint has known inherent risks that could potentially
  cause harm/injury to an individual. For instance, many aspects of balance
  (including but not limited to structural, mechanical, neurological,
  psychological, age and medication use) need to be taken into consideration to
  assess for and prevent risk of fall, and these risks do not solely rely on the
  function of any individual joint. Per current medical literature (DORLANDS


  MEDICAL DICTIONARY, NETTERS ATLAS OF HUMAN ANATOMY, WHEELESS' TEXTBOOK OF
  ORTHOPAEDICS), the function of one human joint is unequivocally independent of
  the identical contralateral joint in respects to muscular, skeletal and
  neurologic anatomy. Comparing one joint to its identical contralateral side
has
  varying outcomes (e.g. surgical intervention, underlying defects or prior
  injury to the contralateral side) which may influence ROM outcome in respect
to
  Passive vs Wt Bearing vs Active and the potential for harm/injury to the
  individual far outweighs the benefits. Therefore b/l Weight Bearing ROM is not
  performed on today's examination.
 

 

 

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its hard to say without just guessing..they will probably give you a low rating for the left shoulder.

this Exam don't look like the examiner gave you a very favorable report  but this can still be rated  but in my opinion it will be a low rating maybe 10% to 30%

Just have to wait and see.

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