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Question
maleboog
Hi to all,
Great site!!! I was hoping I could get some help deciphering the below C&P results. I am currently 10% on both knees for knee strain. I submitted to get an increase for the left knee, and to also get a secondary left hip Service connection from the bad knee....
Any help would be greatly apprciated!
Curt
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
[X] Other (please identify other evidence reviewed):
X-rays
1. Diagnosis ------------
a. List the claimed condition(s) that pertain to this DBQ: osteoarthritis
b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
[X] Osteoarthritis, hip
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: M16.0
Date of diagnosis: Right 2016
Date of diagnosis: Left 2016
c. Comments (if any): No response provided
d. Was an opinion requested about this condition (internal VA only)? Yes
2. Medical history ------------------
a. Describe the history (including onset and course) of the Veteran's hip or thigh condition:
Claims for secondary service connection for the veterans left hip secondary or proximally due to results of his chronic left knee strain has been requested. On close questioning the veteran reported he had insidious onset of mild bilateral hip pain for the past 15 years. Veteran's stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Due to traumatic injury of his left knee an escalation of left hip pain and stiffness has ccurred. September 30 2016 bilateral radiographs of the hips:
Early DJD arthritis of both hips.
Current complaints constant left hip pain with stiffness.
Treatment: No surgery or injections to date.
b. Does the Veteran report flare-ups of the hip or thigh? [ ] 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
(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:
See description of functional loss and impairment of work restrictions below
3. Range of motion (ROM) and functional limitations ---------------------------------------------------
a. Initial range of motion
Right hip
---------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0-125): 0 to 110 degrees
Extension (0-30): 0 to 20 degrees
Abduction (0-45): 0 to 40 degrees
Adduction (0-25): 0 to 20 degrees
Is adduction limited such that the Veteran cannot cross legs?
[ ] Yes [X] No
External Rotation (0-60): 0 to 40 degrees
Internal Rotation (0-40): 0 to 20 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
Loss of range of motion is a functional loss
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Flexion, Extension, Abduction, Adduction, External rotation,
Internal rotation
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? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s):
Slight to moderate tenderness anterior acetabular region
Is there objective evidence of crepitus? [ ] Yes [X] No
Left hip
--------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0-125): 0 to 105 degrees
Extension (0-30): 0 to 20 degrees
Abduction (0-45): 0 to 30 degrees
Adduction (0-25): 0 to 15 degrees
Is adduction limited such that the Veteran cannot cross legs?
[ ] Yes [X] No
External Rotation (0-60): 0 to 40 degrees
Internal Rotation (0-40): 0 to 20 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
Loss of range of motion is a functional loss
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Flexion, Extension, Abduction, Adduction, External rotation
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? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s):
Slight to moderate tenderness anterior acetabular region
s there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right hip
---------
Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No
Left hip
--------
Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No
c. Repeated use over time
Right hip ---------
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:
[X] 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.
[ ] 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:
Unable examine over a period of time
Left hip
--------
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:
[X] 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.
[ ] 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:
Unable examine over a period of time
d. Flare-ups: Not applicable
e. Additional factors contributing to disability
Right hip
---------
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:
Disturbance of locomotion
Left hip
--------
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:
Disturbance of locomotion
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 Hip
Rate Strength: Flexion: 5/5
Extension: 5/5
Abduction: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Hip
Rate Strength: Flexion: 5/5
Extension: 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 the hip.
a. Indicate severity of ankylosis and side affected
Right side: Left side:
[ ] Favorable, in flexion at [ ] Favorable, in flexion at an angle between 20 and an angle between 20 and 40 degrees, and slight 40 degrees, and slight abduction or adduction abduction or adduction [ ] Intermediate, between [ ] Intermediate, between favorable and unfavorable favorable and unfavorable [ ] Unfavorable, extremely [ ] Unfavorable, extremely unfavorable ankylosis, unfavorable ankylosis, foot not reaching ground, foot not reaching ground, crutches needed crutches needed [X] No ankylosis [X] No ankylosis
b. Comments, if any: No response provided
6. Additional conditions
------------------------
a. Does the Veteran have malunion or nonunion of femur, flail hip joint or leg length discrepancy? [ ] Yes [X] No
b. Comments, if any: No response provided
7. Surgical procedures
----------------------
No response provided
8. 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
9. Assistive devices --------------------
a. Does the Veteran use any assistive devices 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
10. Remaining effective function of the extremities ---------------------------------------------------
Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain 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
11. Diagnostic testing ----------------------
a. Have imaging studies of the hip or thigh been performed and are the results available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate hip: [ ] 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):
HIPS BILATERAL 3-4 VIEWS (D) (RAD Detailed) CPT:73522
Reason for Study: pain
Clinical History:
Patient weight: 252.5 lb [114.8 kg] (04/29/2016 09:07)
Report Status: Verified Date Reported: SEP
30, 2016
Date Verified: SEP
30, 2016
Verifier E-Sig:
Report:
Bilateral hips and pelvis, 3 views
Comparison: None
FINDINGS: Bone density appears normal. There is satisfactory anatomic alignment of the hip joint. Both hip joints are mildly narrowed. Rest of the pelvis appears normal. Degenerative changes in the lumbar spine. Surgical clips in the left groin area. Periarticular soft tissues appear within normal limits.
Impression:
Early DJD arthritis of both hips.
c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided
12. 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:
Claimed limitations due to comorbidity of hip and knee:
Lift/carry: 10 pounds
Prolonged standing: 15 minutes
Prolonged sitting: 25-30 minutes
Walk on flat land: 200 feet but less than ? mile.
Avoid uneven terrain, no steep slopes, no hiking or camping
Cannot run/jump
Limited repetitive use activities: Stooping, squatting, pulling/pushing, sweeping/ mopping, but no digging, gardening, kneeling, crawling, or bike riding
Limited climbing stairs and 2-3 foot step stool but no ladders.
13. Remarks, if any: --------------------
Veteran claims subjective chronic constant pain involving the joint, therefore there is pain throughout the entire arc of movement whether active or passive motion was performed.
1. Is there evidence of pain on passive range of motion testing? Yes
2. Is there evidence of pain when the joint is used in nonweightbearing?
Yes
3. If yes is the opposite joint undamaged (i.e. no abnormalities)? No, radiographs report bilateral degenerative arthritis.
****************************************************************************
Knee and Lower Leg 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
[X] Other (please identify other evidence reviewed):
X-rays
1. Diagnosis ------------
a. List the claimed condition(s) that pertain to this DBQ:
Chronic knee strain
ORIF comminuted fracture left patella 2014
Degenerative joint disease bilateral knee
b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
[X] Knee strain
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: S 83.90
Date of diagnosis: Right 2003 Date of diagnosis: Left 2003
[X] Knee joint osteoarthritis
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: M 17.10
Date of diagnosis: Right 2006
Date of diagnosis: Left 2006
[X] Other (specify):
Other diagnosis: closed comminuted fracture patella
Side affected: Left
ICD code: S 82.00
Date of diagnosis (left side): 2016
********************************************************************
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):
Veteran has been service-connected bilateral knee strain. 2006 for bilateralxray reported bilaterial DJD. bilateral knee strain's. Veteran's
stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Escalation of pain and stiffness has occurred since the injury.
Current complaints: Constant pain, recurrent swelling, gives way with crepitance.
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?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or functional impairment in his or her own words:
See description of functional loss and impairment of work restrictions below.
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? [X] Yes (please explain) [ ] No
If yes, please explain:
Loss of range of motion is a functional loss
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, Extension
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? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s):
Mild anterior knee pain
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 100 degrees
Extension (140 to 0): 100 to 0 degrees
If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
See description of functional loss and impairment of work restrictions below.
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, Extension
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? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s):
Slight to moderate periarticular tenderness
Is there objective evidence of crepitus? [X] Yes [ ] 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:
[X] 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.
[ ] 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:
Unable to examine over a period of time
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:
[X] 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.
[ ] 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:
Unable to examine over a period of time
d. Flare-ups Not applicable
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:
Disturbance of locomotion
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: 4/5
Extension: 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 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: Recurrent swelling occurs
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
----------------------
Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply):
Left Side:
[X] Meniscectomy, arthroscopic or other knee surgery not described above
Type of surgery: arthrotomy with open reduction internal fixation comminuted fracture patella Date of surgery: June 10, 2014
[X] Residual signs or symptoms due to meniscectomy, arthroscopic or other knee surgery not described above:
Describe residuals: increasing pain and stiffness.
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?
[X] Yes [ ] No
If yes, is there objective evidence that any of these scars are painful,
unstable, have a total area equal to or greater than 39 square cm (6 square inches) or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: anterior midline left knee
Measurements: length 13cm X width 0.4cm
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?
[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):
KNEE LEFT 2 VIEW (RAD Detailed) CPT:73560
Proc Modifiers : LEFT
CPT Modifiers : LT LEFT SIDE (PROCEDURES DONE ON THE LEFT SIDE OF THE BODY)
Reason for Study: left knee pain
Clinical History:
The veteran continues to experience left knee pain since fracturing his patella on a fall in June 2015. 2 views left knee on 4/29/2016. Comparison none. Patellar fractures are again seen. 2 fixation devices are seen overlying the patella. Mild tricompartmental osteophytes are seen consistent with degenerative change. No significant joint effusion.
Surgical clips overlie the right thigh.
Impression:
Fractures across the patella are present. Fixation hardware is seen overlying the patella.
KNEES ROUTINE 3 VIEWS (RAD Inactive) CPT:73562
Proc Modifiers : BILATERAL EXAM
CPT Modifiers : 50 BILATERAL PROCEDURE
Clinical History:
(C&P) Hx of degenerative joint disease
Report:
REPORT: Four views of both knees, 01/30/2006.
Comparison is made with examination of 10/03/2003. On the lateral view, there is ossification which has the appearance of a
fabella, however, it was not present on the prior examination and could possibly represent either a fabella or a loose body. On the left there are also very small osteophytes at the proximal and distal tip of the patella. On the right there are also very small osteophytes at the superior and posterior aspect of the articular surface of the patella. There also is enthesophyte formation on the right at the proximal and distal tips of the patella. On the sunrise view, there are small concave defects of the medial aspect of the articular surface of the medial condyle of the distal femur bilaterally. These are not visualized on the lateral views or tunnel views, and may be developmental rather than small osteochondritis dissecans defects bilaterally. These are medial to the articular surface opposite the patella. There is a small osteophyte at the tip of the lateral most intercondylar eminence of the tibial plateau on the right.
Impression:
1. Minimal degenerative change bilaterally. I doubt loose body on the left.
2. I also doubt osteochondritis dissecans of the articular surface of the distal femur medial to the patellar articular surface.
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:
Claimed limitations due to comorbidity of hip and knee:
Lift/carry: 10 pounds
Prolonged standing: 15 minutes
Prolonged sitting: 25-30 minutes
Walk on flat land: 200 feet but less than ? mile.
Avoid uneven terrain, no steep slopes, no hiking or camping
Cannot run/jump
Limited repetitive use activities: Stooping, squatting, pulling/pushing, sweeping/ mopping, but no digging, gardening, kneeling, crawling, or bike riding
Limited climbing stairs and 2-3 foot step stool but no ladders.
15. Remarks, if any:
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Veteran claims subjective chronic constant pain involving the joint, therefore
there is pain throughout the entire arc of movement whether active or passive motion was performed.
1. Is there evidence of pain on passive range of motion testing? Yes
2. Is there evidence of pain when the joint is used in nonweightbearing? Yes 3. If yes is the opposite joint undamaged (i.e. no abnormalities)? No, radiographs report bilateral degenerative arthritis
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Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
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
[X] Other (please identify other evidence reviewed):
X-rays
MEDICAL OPINION SUMMARY
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RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Secondary service connection: Is the veterans left hip at least as likely as not (50% or greater probability) proximally due to or the results of chronic left knee strain?
b. Indicate type of exam for which opinion has been requested: left hip
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ]
a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition.
c. Rationale: Claims for secondary service connection for the veterans left hip secondary or proximally due to results of his chronic left knee strain has been requested. On close questioning the veteran reported he had insidious onset of mild bilateral hip pain for the past 15 years. Veteran's stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Due to traumatic injury of his left knee an escalation of left hip pain and stiffness has ccurred. September 30 2016 bilateral radiographs of the hips: Early DJD arthritis of both hips.
Veteran has developed chronic bilateral degenerative changes of the hips, his complaints of aggravation due to the injury of his left knee is substantiated by the current physical examination. Additionally the veteran has altered gait probably due to his bilateral service-connected knee conditions.
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broncovet
Its a fairly good exam, even real good, as the doc gave you the much needed Nexus. That is, he stated your condition is at least as likely as not related to your service connected conditions.
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