Just got this back today, I had a pretty good idea that I was going to appeal this right after it happened just because of how the doctor did the exam, didn't measure, or do many physical exams etc. I am already service connected, was filing for an increase, here are the results from the C&P, basically looks like I won't get much from what the VA Doc wrote. My knees are pretty bad, can't do much with them. Anybody see anything I am missing:
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, right knee
b. Select diagnoses associated with the claimed condition(s)(Check all that apply):
[X] Other (specify):
Bilateral knee tendonitis with patellofemoral pain syndrome
ICD Code: M25.569
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):
36y Veteran w comp & pen appt, SC for bilateral knee condition(s)
(claimed
as left, right knee tendonitis with patellofemoral pain syndrome)
Veteran continues w bilateral knee pain, right greater than left -
attributed to knee condition incurred during military service.He does not
recall a specific injury, however had numerous episodes of severe knee
pains
related to ruck marches when deployed - estimated onset mid-2007.Pain
around knee caps and down shins.Reports sought medic care at FOB and
painful knee problems improved w rest Ibuprofen.Apparently a diagnosis
not
made; h/o fracture not identified
Progression in past several years - increased discomfort especially R knee
Treatment: ice, ibuprofen, activity reduction
Medication/Herbal/OTC:Ibuprofen prn
Symptom: sharp pains, may feel stiff or tight - 'locks'
Minutes up to 2 hours
Severity.Reports could get up to level #4
Military Service: Army
Infantry - 11 Bravo
2005 - 2009
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:
It was on Friday.I was on the elliptical.
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:
Every time on the elliptical, [when] I start riding it, I feel a sharp shooting pain under the knee cap
3. Range of motion (ROM) and functional limitation
b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above?
[ ] Yes[X] No
c. Comments, if any:
No response provided
11. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion,
although occasional locomotion by other methods may be possible?
[ ] Yes[X] No
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
No response provided
12. Remaining effective function of the extremities
Due to the Veteran's knee and/or lower leg condition(s), is there
functional
13. Diagnostic testing
----------------------
a. Have imaging studies of the knee been performed and are the results
available?
[X] Yes[ ] No
If yes, is degenerative or traumatic arthritis documented? [ ] Yes[X] No
b. Are there any other significant diagnostic test findings and/or results? [ ] 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:
Impact for strenuous weight bearing such as running or prolonged climbing activities
15. Remarks, if any:
--------------------
For any joint condition, examiners should test the contralateral joint unless medically contraindicated, and the examiner should address pain on both passive
and active motion, and on both weight bearing and non-weight bearing.In addition to the questions on the DBQ, please respond to the following questions:
1.Is there evidence of pain on passive range of motion testing? No
2.Is there evidence of pain when the joint is used in non-weight bearing?No
3.If yes, is the opposing joint undamaged (i.e. no abnormalities)? n/a
Question
lightfighter214
Just got this back today, I had a pretty good idea that I was going to appeal this right after it happened just because of how the doctor did the exam, didn't measure, or do many physical exams etc. I am already service connected, was filing for an increase, here are the results from the C&P, basically looks like I won't get much from what the VA Doc wrote. My knees are pretty bad, can't do much with them. Anybody see anything I am missing:
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, right knee
b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
[X] Other (specify):
Bilateral knee tendonitis with patellofemoral pain syndrome
ICD Code: M25.569
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):
36y Veteran w comp & pen appt, SC for bilateral knee condition(s)
(claimed
as left, right knee tendonitis with patellofemoral pain syndrome)
Veteran continues w bilateral knee pain, right greater than left -
attributed to knee condition incurred during military service. He does not
recall a specific injury, however had numerous episodes of severe knee
pains
related to ruck marches when deployed - estimated onset mid-2007. Pain
around knee caps and down shins. Reports sought medic care at FOB and
painful knee problems improved w rest Ibuprofen. Apparently a diagnosis
not
made; h/o fracture not identified
Progression in past several years - increased discomfort especially R knee
Treatment: ice, ibuprofen, activity reduction
Medication/Herbal/OTC: Ibuprofen prn
Symptom: sharp pains, may feel stiff or tight - 'locks'
Minutes up to 2 hours
Severity. Reports could get up to level #4
Military Service: Army
Infantry - 11 Bravo
2005 - 2009
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:
It was on Friday. I was on the elliptical.
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:
Every time on the elliptical, [when] I start riding it, I feel a sharp shooting pain under the knee cap
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 110 degrees
Extension (140 to 0): 110 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, 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
condition(s):
peri-patellar ttp
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 125 degrees
Extension (140 to 0): 125 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? [ ] Yes [X] 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):
infra-patellar ttp
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?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
Neither Veteran nor examiner is able to specify additional
limitation
of range of motion without resorting to mere speculation due to
constraints of discomfort limiting exam
Left Knee
---------
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 [X] No [ ] Unable to say w/o mere speculation
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: [X] 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.
[ ] 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
Left Knee
---------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
with
If the examination is not being conducted during a flare-up:
[X] 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.
[ ] The examination is neither medically consistent or inconsistent
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:
Neither Veteran nor examiner is able to specify additional limitation
without resorting to mere speculation
e. Additional factors contributing to disability
Right Knee
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
Left Knee
---------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
4. Muscle strength testing
--------------------------
a. Muscle strength - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right Knee: Rate Strength: 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?
[ ] Yes [X] No
d. Performance of joint stability testing
Right Knee:
Was joint stability testing performed? [X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability? [ ] Yes [X] No
If yes (joint stability testing was performed), complete the section below:
- Anterior instability (Lachman test) [X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
Left Knee:
Was joint stability testing performed? [X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability? [ ] Yes [X] No
If yes (joint stability testing was performed), complete the section below:
- Anterior instability (Lachman test) [X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
e. Comments, if any:
No response provided
7. Additional conditions
------------------------
a. Does the Veteran now have or has he or she ever had recurrent patellar
dislocation, "shin splints" (medial tibial stress syndrome),
stress
fractures, chronic exertional compartment syndrome or any other tibial
and/or fibular impairment?
[ ] Yes [X] No
b. Comments, if any:
No response provided
8. Meniscal conditions
----------------------
No response provided
9. Surgical procedures
----------------------
No response provided
10. Other pertinent physical findings, complications, conditions, signs, symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above?
[X] Yes [ ] No
If yes, describe (brief summary): BP: 135/80 (01/14/2019 07:51) Pulse: 70 (01/14/2019 07:51)
Resp: 16 (01/14/2019 07:51)
Temp: 97.4 F [36.3 C] (01/14/2019 07:51)
PULSE OXIMETRY: 96
BMI: 32.0
b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above?
[ ] Yes [X] No
c. Comments, if any:
No response provided
11. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion,
although occasional locomotion by other methods may be possible?
[ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
No response provided
12. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's knee and/or lower leg condition(s), is there
functional
13. Diagnostic testing
----------------------
a. Have imaging studies of the knee been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results? [ ] 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:
Impact for strenuous weight bearing such as running or prolonged climbing activities
15. Remarks, if any:
--------------------
For any joint condition, examiners should test the contralateral joint unless medically contraindicated, and the examiner should address pain on both passive
and active motion, and on both weight bearing and non-weight bearing. In addition to the questions on the DBQ, please respond to the following questions:
1.Is there evidence of pain on passive range of motion testing? No
2.Is there evidence of pain when the joint is used in non-weight bearing?No
3.If yes, is the opposing joint undamaged (i.e. no abnormalities)? n/a
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