Did he just service connect me for RA?

Jessamine · February 3, 2019

Hey all. You guys were amazing and so helpful when I went through my last C&P exam so I figured I would try my luck again.

Short story is I was medboarded out in 2004 for a rather nastu ankle fracture that was misdiagnosed as a sprain for 2 months at Fort Gordon. So i was reading through my most recent c&p expecting it to be tanked again and he closed the report with

"Upon review of this case, it becomes apparent that the multiple joint complains while AD are consistent with Rheumatoid arthritis even though it wasn't diagnosed on active duty. This is conformed by records reviewed by DOCTOR DOCTOR dated 3/16/18.

Veteran has been seen and evaluated by an outside rheumatologist and hasbeen diagnosed. Treatment started in 2018"

He was only doing a knee and ankle c&p and he mentioned both hips, feet, ankles, knees, etc. So I'm shocked. Does this mean what I think it does?

Jessamine · February 3, 2019

Yikes, sorry for the spelling errors. my hands are really sore today with the cold

vetquest · February 3, 2019

It would be good if we could see the whole letter, redacted of course. If a C&P doctor wrote this it might mean that you would be eligible for benefits.

Jessamine · February 3, 2019

Sorry for the delay, dude wrote my name and my doctors name like everywhere. Hopefully I didn't miss anything with anonymizing it.

Foot Conditions, including Flatfoot (Pes Planus)
                       Disability Benefits Questionnaire


   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:

    Arthropathy of foot

b. Select diagnoses associated with the claimed condition(s):

    [X] Arthritic conditions

        [X] Arthritis, rheumatoid
            Side affected: Both
            Date of diagnosis: Right 2018
            Date of diagnosis: Left 2018

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 foot
    condition (brief summary):
    Medical History extracted from last Foot DBQ dated 9/13/2016:
    "STR's are silent for a left foot metatarsal fractures."

    Veteran claims on 9-24-2004 she was diagnosis with closed metatarsal
    fracture of the left 2nd and 3rd metatarsals. VBMS was silent for a left
    foot metatarsal condition. Veteran claims she has submitted the evidence
to
    PhilRO for consideration for her claim on 9-1-2016."

    INTERVAL HISTORY:
    Veteran has been diagnosed with Rheumatoid Arthritis (RA) (DOCTOR ,
DO
    of ANYTOWN, PA) and is currently undergoing treatment. Of note, veteran has
    musculoskeletal complaints consistent with pain in multiple bilateral
joints
    including her feet, ankles, knees, hips, back and TMJ joints. 6/10 for
    pain. DOCTOR has provided an opinion that states that the Veteran's
ankle
    trauma was more than likely the inital preciptating factor in the onset of
    her Rheumatoid Arthritis.

b. Does the Veteran report pain of the foot being evaluated on this DBQ?
    [X] Yes   [ ] No

        If yes, document the Veteran's description of pain in his or her own
        words:
        Pain as an "achiness" in the left and right foot (as well as in the
        ankles, knees, hips, back and TMJ joints).

c. Does the Veteran report that flare-ups impact the function of the foot?
    [X] Yes   [ ] No

        If yes, document the Veteran's description of flare-ups in his or her
        own words:
        Foot pain is like a throbbing ache.

d. Does the Veteran report having any functional loss or functional impairment
    of the foot being evaluated on this DBQ (regardless of repetitive use)?
    [ ] Yes   [X] No



3. Flatfoot (pes planus)
------------------------
No response provided

4. Morton's neuroma (Morton's disease) and metatarsalgia
--------------------------------------------------------
No response provided

5. Hammer toe
-------------
No response provided

6. Hallux valgus
----------------
No response provided

7. Hallux rigidus
-----------------
No response provided

8. Acquired pes cavus (clawfoot)
--------------------------------
No response provided

9. Malunion or nonunion of tarsal or metatarsal bones
-----------------------------------------------------
No response provided

10. Foot injuries and other conditions
--------------------------------------
a. Does the Veteran have any foot injuries or other foot conditions not
already
    described?
    [X] Yes   [ ] No

        If yes, describe the foot injury or other conditions (including
        frequency and physical exam findings) and complete question b.
(severity
        and side affected).
        Pain in the feet consistent with arthropathy with has been confirmed to
        be secondary to RA.

b. Indicate severity and side affected:
    [X] Moderately severe     [ ] Right [ ] Left [X] Both

c. Does the foot condition chronically compromise weight bearing?
    [ ] Yes   [X] No

d. Does the foot condition require arch supports, custom orthotic inserts or
    shoe modifications?
    [ ] Yes   [X] No

e. Comments: No comments provided

11. Surgical procedures
-----------------------
a. Has the Veteran had foot surgery (arthroscopic or open)?
    [ ] Yes   [X] No

b. Does the Veteran have any residual signs or symptoms due to arthroscopic or
    other foot surgery?
    No response provided

12. Pain
--------
RIGHT FOOT:

    Is there pain on physical exam?
    [X] Yes   [ ] No

        If yes, (there is pain on physical exam), does the pain contribute to
        functional loss?
        [X] Yes [ ] No

        (Further description of limitations requested in Section XIII below.)


LEFT FOOT:

    Is there pain on physical exam?
    [X] Yes   [ ] No

        If yes, (there is pain on physical exam), does the pain contribute to
        functional loss?
        [X] Yes [ ] No

        (Further description of limitations requested in Section XIII below.)


13. Functional loss and limitation of motion
--------------------------------------------
a. Contributing factors of disability (check all that apply and indicate side
    affected):

    [X] Pain on movement
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Pain on weight-bearing
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Pain on non weight-bearing
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Interference with standing
        Side affected: [ ] Right [ ] Left   [X] Both


Contributing factors of disability associated with limitation of motion:

b. Is there pain, weakness, fatigability, or incoordination that significantly
    limits functional ability during flare-ups or when the foot is used
    repeatedly over a period of time?

    RIGHT FOOT: [X] Yes [ ] No

         If yes, (there is a functional loss due to pain, during flare-ups
         and/or when the joint is used repeatedly over a period of time) please
         describe the functional loss:
         Pain from RA is severe and limits ability to stand and hence work

    LEFT FOOT: [X] Yes [ ] No

         If yes, (there is a functional loss due to pain, during flare-ups
         and/or when the joint is used repeatedly over a period of time) please
         describe the functional loss:
         Pain from RA is severe and limits ability to stand and hence work


c. Is there any other functional loss during flare-ups or when the foot is
used
    repeatedly over a period of time?

    RIGHT FOOT: [ ] Yes [X] No

    LEFT FOOT: [ ] Yes [X] No

14. 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):
        RA diagnosed and treatment started in 2018. Multiple other joints also
        affected. Veteran also diagnosed with comorbid fibromyalgia. Right
        ankle ORIF surgery in October 2004 (not SC'd), PTSD and depression.


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: No comments provided

15. 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.

16. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's foot condition, 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

17. Diagnostic testing
----------------------
a. Have imaging studies of the foot been performed and are the results
    available?
    [X] Yes   [ ] No

        If yes, is degenerative or traumatic arthritis documented?
        [X] Yes [ ] No

            If yes, indicate foot: [ ] 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):
        Positive imaging for RA and lab results positive for RA performed by
Dr.
        DOCTOR , RO of DOCTOR OFFICe Medical Center in ANYTOWN, PA from 3/2018.

c. If any test results are other than normal, indicate relationship of
abnormal
    findings to diagnosed condition:
    No response provided

18. 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:
     RA is severe in multiple joints including feet, ankles, knees, hips, back
     and jaw. Veteran remains limited in her daily activities and is unable to
     work on a sustained basis. Work recommended would be of a sedentary
     nature.

19. Remarks, if any:
--------------------
Not an ACE Exam.

Foot Correia Questions:
#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 non-weight bearing?
Yes
#3. Is the opposing joint undamaged? No

Arthropathy of foot: Level of Severity: Moderate

Veteran is currently pregnant and is due to deliver her 5th child in July
2019.

Upon review for this case, it becomes apparent that the multiple joint
complaints while AD are consistent with Rheumatoid Arthritis even though it
was
not diagnosed while active duty. This is confirmed by records reviewed by Dr.
DOCTOR , DO dated 3/16/2018.

Veteran has been seen and evalauted by an outside Rheumatolgist and has been
diagnosed and treatment started for Rheumatoid Arthritis in 2018.




****************************************************************************

                         Knee and Lower Leg Conditions
                       Disability Benefits

   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:
    Recurrent fracture right medial maleous tibia; right lateral collateral
    ligament sprain, left knee lateral collateral ligament sprain

b. Select diagnoses associated with the claimed condition(s) (Check all that
    apply):

[X] Knee strain
     Side affected: [ ] Right   [X] Left [ ] Both
     Date of diagnosis: Left 2004

[X] Knee meniscal tear

[X] Tibia and/or Fibula fracture
     Side affected: [X] Right   [ ] Left [ ] Both

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):
    Knee Medical History extracted from last Knee DBQ dated 9/13/2016.
    "STR's evident for a left knee contusion on 25Aug04 that was self
limiting."

    "Veteran claims left knee gives out intermittently (once a week). Veteran
    denies any medication for her knee condition. Veteran claims her knee is
    sore daily. Veteran clains on 9-24-2004 she did have a left knee sprain
and
    was seen by a DOCTOR, but there is no supporting documentation. Veteran
    reports since military discharge that she had a left knee meniscus disorder
    dated 6/15/2007 and was diagnosis with DJD left knee on 2/11/2010. No
    evidence noted for a recurrent medial mallelous fracture noted. Veteran
    claims documentation to support her left knee complaints were previously
    submitted on 9-1-2016."

    KNEE INTERVAL HISTORY:
    Left knee is painful daily. Pain 6/10. Veteran has been diagnosed with
    Rheumatoid Arthritis (RA) (DOCTOR , DO of ANYTOWN, PA) and is currently
    undergoing treatment. Of note, veteran has musculoskeletal complaints
    consistent with pain in multiple bilateral joints including her feet,
    ankles, knees, hips, back and TMJ joints.

    Ankle Medical History extracted from last Knee DBQ dated 9/13/2016.
    "STR's evident for right ankle sprain which was later diagnosis as a right
    ankle fracture. STR' radiograms for a right ankle fracture evident and
    Veteran was medically boarded out of the military for this condition."

    "Veteran claims right ankle always hurts and she is unable to wear flat
    shoes. Veteran claims it hurts when it rains. She notes it will
    intermittently lock up and sometimes she will fall. Veteran denies any
    medication use for her right ankle condition.   Veteran claims shortly
after
    military discharge she had an ORIF right ankle for Trimal ANYTOWNr repair on
    13Dec04. Please note, VBMS is silent for this documentatin and she reports

    it was submitted on 9-1-2016 to support the claim."

    RIGHT ANKLE INTERVAL HISTORY:
    Veteran has been diagnosed with Rheumatoid Arthritis (RA) (DOCTOR ,
DO
    of ANYTOWN, PA) and is currently undergoing treatment. Of note, veteran has
    musculoskeletal complaints consistent with pain in multiple bilateral
joints
    including her feet, ankles, knees, hips, back and TMJ joints. 6/10 for
    pain. DOCTOR has provided an opinion that states that the Veteran's
ankle
    trauma was more than likely the inital preciptating factor in the onset of
    her Rheumatoid Arthritis.

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:
        Pain in right and left ankles (as well as in the ankles, knees, hips,
        back and TMJ joints). Also, Veteran claims intermittent sharp pain and
        when it locks it feels like it is being pinched/squeezed.


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:
        Ankle pain is like a throbbing ache and it limits her ability to fully
        flexes her feet.


3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion

    Right Knee
    ----------
    [X] All normal
    [ ] Abnormal or outside of normal range
    [ ] Unable to test (please explain)
    [ ] Not indicated (please explain)

        Flexion (0 to 140):           0 to 140 degrees
        Extension (140 to 0):         140 to 0 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 Knee
    ---------
    [X] All normal
    [ ] Abnormal or outside of normal range
    [ ] Unable to test (please explain)
    [ ] Not indicated (please explain)

        Flexion (0 to 140):           0 to 140 degrees
        Extension (140 to 0):         140 to 0 degrees

    Description of pain (select best response):
      Pain noted on exam on rest/non-movement

      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):
       On the medial and lateral joint line.

    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

    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:
        May vary with activity


    Left Knee
    ---------
    Is the Veteran being examined immediately after repetitive use over time?
    [ ] Yes   [X] No

    Does pain, weakness, fatigability or incoordination significantly limit
    functional ability with repeated use over a period of time?
    [ ] Yes   [ ] No [X] Unable to say w/o mere speculation
        If unable to say w/o mere speculation, please explain:
        May vary with activity


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:
        May vary with activity


    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:
        May vary with activity


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:
      Interference with standing

       Please describe additional contributing factors of disability:
       Joint pain secondary to RA limit ability to stand for prolonged periods
       of time

    Left Knee
    ---------
    In addition to those addressed above, are there additional contributing
    factors of disability? Please select all that apply and describe:
      Interference with standing

       Please describe additional contributing factors of disability:
       Joint pain secondary to RA limit ability to stand for prolonged periods
       of time

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?
          [ ] Yes
          [ ] No
          [ ] Not indicated
          [X] Indicated, but not able to perform

       If joint stability is indicated, but unable to test, provide reason:
       Guarding prevented testing

    Left Knee:

       Was joint stability testing performed?
          [ ] Yes
          [ ] No
          [ ] Not indicated
          [X] Indicated, but not able to perform

       If joint stability is indicated, but unable to test, provide reason:
       Guarding prevented testing

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?
    No response provided


b. Comments, if any:
    Ankle(s) Information
    a. Initial range of motion

                   Right ankle
                   -----------
         [ ] All Normal
         [X] Abnormal or outside of normal range
         [ ] Unable to test (please explain)
         [ ] Not indicated (please explain)

             Dorsiflexion (0-20):    0 to 10 degrees
             Plantar Flexion (0-45): 0 to 45 degrees

    If ROM is outside of normal range, but is normal for the Veteran
    (for
             reasons other than an ankle condition, such as age, body habitus,
             neurologic disease), please describe:
               Normal for body habitus.

         If abnormal, does the range of motion itself contribute to a
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 examination, which ROM exhibited pain (select all that
    apply)?
           Dorsiflexion, Plantar 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? [X] Yes   [ ] No

            If yes, describe including location, severity and relationship to
            condition(s):
              Veteran expressed tenderness on palpation of right ankle.

         Is there objective evidence of crepitus? [ ] Yes [X] No


                   Left ankle
                   ----------
         [ ] All Normal
         [X] Abnormal or outside of normal range
         [ ] Unable to test (please explain)
         [ ] Not indicated (please explain)

             Dorsiflexion (0-20):    0 to 10 degrees
             Plantar Flexion (0-45): 0 to 45 degrees

    If ROM is outside of normal range, but is normal for the Veteran
    (for
             reasons other than an ankle condition, such as age, body habitus,
             neurologic disease), please describe:
               Normal for body habitus.

         If abnormal, does the range of motion itself contribute to a
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

         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):
             Veteran expressed tenderness on palpation of left ankle.

         Is there objective evidence of crepitus? [X] Yes [ ] No


      b. Observed repetitive use

                   Right ankle
                   -----------
    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 ankle
                   ----------
    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 ankle
                   -----------
    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 Veterans
    statements
             describing functional loss with repetitive use over time.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss with repetitive use over time. Please
             explain.
    [X] The examination is neither medically consistent or inconsistent
    with the

    Veterans 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:
                May vary with activity.


                   Left ankle
                   ----------
    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 Veterans
    statements
             describing functional loss with repetitive use over time.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss with repetitive use over time. Please
             explain.
    [X] The examination is neither medically consistent or inconsistent
    with the
    Veterans 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:
                May vary with activity.


      d. Flare-ups

                   Right ankle
                   -----------
    Is the examination being conducted during a flare-up?   [ ] Yes [X]
    No

         Does pain, weakness, fatigability or incoordination significantly
limit
         functional ability with flare-up?
         [ ] Yes [ ] No   [X] Unable to say w/o mere speculation

             If unable to say w/o mere speculation, please explain:
                May vary with activity.


                   Left ankle
                   ----------
    Is the examination 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 Veterans
    statements
             describing functional loss during flare-ups.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss during flare-ups. Please explain.
    [X] The examination is neither medically consistent or inconsistent
    with the
             Veterans statements describing functional loss during flare-ups.

         Does pain, weakness, fatigability or incoordination significantly
limit
         functional ability with flare-up?
         [ ] Yes [ ] No   [X] Unable to say w/o mere speculation

             If unable to say w/o mere speculation, please explain:
                May vary with activity.


      e. Additional factors contributing to disability

                   Right ankle
                   -----------
         In addition to those addressed above, are there additional
contributing
         factors of disability? Please select all that apply and describe:
    Yes, newly diagnosed RA which has MD has opined may have been the
    preciptating factor for her other multiple musculoskeletal complaints

                   Left ankle
                   ----------
         In addition to those addressed above, are there additional
contributing
         factors of disability? Please select all that apply and describe:
    Yes, newly diagnosed RA which has MD has opined may have been the
    preciptating factor for her other multiple musculoskeletal complaints

      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 ankle:
            Rate Strength:   Plantar Flexion: 4/5
                             Dorsiflexion: 4/5

            Is there a reduction in muscle strength? [X] Yes   [ ] No


          Left ankle:
            Rate Strength:   Plantar Flexion: 4/5
                             Dorsiflexion: 4/5

            Is there a reduction in muscle strength? [X] Yes   [ ] No


      b. Does the Veteran have muscle atrophy? [ ] Yes   [X] No


      c. Comments, if any:
    Newly diagnosed RA which has MD has opined may have been the
    preciptating factor for right and left ankle condition(s) as well as her
    other multiple musculoskeletal complaints

      5. Ankylosis
      ------------
      Complete this section if Veteran has ankylosis of the ankle

    a. Indicate severity of ankylosis and side affected (check all that
    apply):

            Right side:                       Left side:
              [ ] In plantar flexion              [ ] In plantar flexion
              [ ] In dorsiflexion                 [ ] In dorsiflexion
    [ ] With an abduction deformity     [ ] With an abduction
    deformity
    [ ] With an inversion deformity     [ ] With an inversion
    deformity
              [ ] With an eversion deformity      [ ] With an eversion
deformity
    [ ] In good weight-bearing position [ ] In good weight-bearing
    position
    [ ] In poor weight-bearing position [ ] In poor weight-bearing
    position
              [X] No ankylosis                    [X] No ankylosis

      b. Comments, if any:
          No response provided

      6. Joint stability
      ------------------
      Right ankle
        Is ankle instability or
        dislocation suspected?          [X] Yes [ ] No

        If yes, complete the following:

        Anterior Drawer Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding

        Talar Tilt Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding


      Left ankle
        Is ankle instability or
        dislocation suspected?          [X] Yes [ ] No

        If yes, complete the following:

        Anterior Drawer Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding

        Talar Tilt Test
          Is there laxity compared
    with opposite side?           [ ] Yes [X] No [X] Unable to test
    due to pain and guarding


      7. Additional comments
      ----------------------
      Does the Veteran now have or has he or she ever had "shin splints",
stress
    fractures, achilles tendonitis, achilles tendon rupture, malunion of
    calcaneus
      (os calcis) or talus (astragalus), or has the Veteran had a talectomy
      (astragalectomy)? [ ] Yes   [X] No

      8. 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 ankle surgery
              Type of surgery: ORIF
              Date of surgery: 2004

              [X] Residuals of arthroscopic or other ankle surgery
                  Describe residuals:
    pressure with unable to wear flat shoes due to positional
    pressure.

        Left side:
           [X] Arthroscopic or other ankle surgery
              Type of surgery:
              Date of surgery: 2004

              [X] Residuals of arthroscopic or other ankle surgery
                  Describe residuals:
    pressure with unable to wear flat shoes due to positional
    pressure.

    9. 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):
             Rheumatoid Arthritis, Fibromyalgia, PTSD and depression.

      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

      c. Comments, if any:
    9 CM x 0.2 cm on both medial and lateral aspect of left achilles
    region

      10. 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

      11. Remaining effective function of the extremities
      ---------------------------------------------------
      Due to the Veteran's ankle condition, 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


      12. Diagnostic testing
      ----------------------
      a. Have imaging studies of the ankle been performed and are the results
         available? [X] Yes   [ ] No


      b. Are there any other significant diagnostic test findings or results?
           [ ] Yes [X] No


    c. If any test results are other than normal, indicate relationship of
    abnormal
         findings to diagnosed conditions:
           No response provided


      13. 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
    Unable to stand for long periods of time. Would be best suited for
    sedentary work.

    Ankle Correia Questions:
    #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 non-weight bearing?
    Yes
    #3. Is the opposing joint undamaged? No

    Recurrent Tibal Fracture: Level of Severity: Moderate

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):   Recurrent right of right medial
        tibia addressed with ankle questions as covered in 7.b. Additional
        Conditions noted above.

        Rheumatoid Arthritis, Fibromyalgia, PTSD and depression

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] Brace(s)               [X] Occasional [ ] Regular   [ ] Constant

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?
    [ ] Yes   [X] No

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):
        Positive Rheumatoid Factor as part of work-up by DOCTOR , DO
        DOCTOR OFFICe Medical Center ANYTOWN, PA in 3/2018.

c. If any test results are other than normal, indicate relationship of
abnormal
    findings to diagnosed conditions:
    DOCTOR opined that the ankle condition(s) diagnosed in 2004 were the
    initial pressnting arthritic condition that was subsequently diagnsed as
    Rheumatoid Arthritis in 2018.

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:
     RA is severe in multiple joints including feet, ankles, knees, hips, back
     and jaw. Veteran remains limited in her daily activities and is unable to

     work on a sustained basis. Work recommended would be of a sedentary
     nature.

15. Remarks, if any:
--------------------
Not an ACE Exam.

Knee Correia Questions:
#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 non-weight bearing?
Yes
#3. Is the opposing joint undamaged? No

Lateral Collateral Ligament Sprain: Level of Severity: Moderate

Upon review for this case, it becomes apparent that the multiple joint
complaints while AD are consistent with Rheumatoid Arthritis even though it
was
not diagnosed while active duty. This is confirmed by records reviewed by Dr.
DOCTOR , DO dated 3/16/2018.

Veteran has been seen and evalauted by an outside Rheumatolgist and has been
diagnosed and treatment started for Rheumatoid Arthritis in 2018.

Jessamine · February 3, 2019

I can't tell if this was a good c&p or a bad one, to be honest. He did ignore the flat feet and apparently missed the knee xrays. That's okay though because I have a few IMO's and DBQ's there that are crazy strong since I've been being treated for years. It is concerning that he doesn't mention the over 300 pages of records, including surgical records, that DAV sent in. What surprised me was that it just kept referring to RA and how in the end of both it seems like he linked it to my various pains in service, which kind of make it look like a service connection to me.

Any insight? My meds are insanely expensive and VA does not cover 3 of them so if it does in fact end up SC, I can hopefully opt in to choice and get the right medications. The thing that concerns me is every answer seems secondary to the RA so if his statements do not indicate service connection, I will continue being out on my butt paying $1192,16 for my rxs

vetquest · February 3, 2019

I really appreciate how the VA is able to miss records that are in our favor. If your records that are referenced as missing are important I would get with your VSO and resubmit them. Even so, when your case is completed by the RO look to see if these records were included in evidence used to make decision. That could be the basis of a CUE. I know it is a little late but it is good to have these records available at a C&P incase the doctor says he does not have them.

Reading the exams the doctor states "Upon review for this case, it becomes apparent that the multiple joint complaints while AD are consistent with Rheumatoid Arthritis even though it was not diagnosed while active duty." This sounds like a good exam where the doctor is trying to say you had RA in service. I think the doctor is new to the VA and how they do things though. A really good statement would be something like "it is more likely then not". They are trying to relate your RA to service in my opinion but we do not know if the raters know how to read when it is not in their preferred format. The second issue I see with your C&P is that the examiner notes that pain is your most prevalent feature. The VA is supposed to take this into consideration but they do not recognize pain a lot of times. If you have strong civilian evidence that is a good thing. Does your civilian doctor state you had RA in service? If they do it would be nice to see if they are willing to state "it is more likely then not that the Veteran had RA in service" in a DBQ or IMO.

Buck, Broncovet?

Edited February 3, 2019 by vetquest

doc25 · February 4, 2019

7 hours ago, Jessamine said:

Sorry for the delay, dude wrote my name and my doctors name like everywhere. Hopefully I didn't miss anything with anonymizing it.


Foot Conditions, including Flatfoot (Pes Planus)
                       Disability Benefits Questionnaire


   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:

    Arthropathy of foot

b. Select diagnoses associated with the claimed condition(s):

    [X] Arthritic conditions

        [X] Arthritis, rheumatoid
            Side affected: Both
            Date of diagnosis: Right 2018
            Date of diagnosis: Left 2018

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 foot
    condition (brief summary):
    Medical History extracted from last Foot DBQ dated 9/13/2016:
    "STR's are silent for a left foot metatarsal fractures."

    Veteran claims on 9-24-2004 she was diagnosis with closed metatarsal
    fracture of the left 2nd and 3rd metatarsals. VBMS was silent for a left
    foot metatarsal condition. Veteran claims she has submitted the evidence
to
    PhilRO for consideration for her claim on 9-1-2016."

    INTERVAL HISTORY:
    Veteran has been diagnosed with Rheumatoid Arthritis (RA) (DOCTOR ,
DO
    of ANYTOWN, PA) and is currently undergoing treatment. Of note, veteran has
    musculoskeletal complaints consistent with pain in multiple bilateral
joints
    including her feet, ankles, knees, hips, back and TMJ joints. 6/10 for
    pain. DOCTOR has provided an opinion that states that the Veteran's
ankle
    trauma was more than likely the inital preciptating factor in the onset of
    her Rheumatoid Arthritis.

b. Does the Veteran report pain of the foot being evaluated on this DBQ?
    [X] Yes   [ ] No

        If yes, document the Veteran's description of pain in his or her own
        words:
        Pain as an "achiness" in the left and right foot (as well as in the
        ankles, knees, hips, back and TMJ joints).

c. Does the Veteran report that flare-ups impact the function of the foot?
    [X] Yes   [ ] No

        If yes, document the Veteran's description of flare-ups in his or her
        own words:
        Foot pain is like a throbbing ache.

d. Does the Veteran report having any functional loss or functional impairment
    of the foot being evaluated on this DBQ (regardless of repetitive use)?
    [ ] Yes   [X] No



3. Flatfoot (pes planus)
------------------------
No response provided

4. Morton's neuroma (Morton's disease) and metatarsalgia
--------------------------------------------------------
No response provided

5. Hammer toe
-------------
No response provided

6. Hallux valgus
----------------
No response provided

7. Hallux rigidus
-----------------
No response provided

8. Acquired pes cavus (clawfoot)
--------------------------------
No response provided

9. Malunion or nonunion of tarsal or metatarsal bones
-----------------------------------------------------
No response provided

10. Foot injuries and other conditions
--------------------------------------
a. Does the Veteran have any foot injuries or other foot conditions not
already
    described?
    [X] Yes   [ ] No

        If yes, describe the foot injury or other conditions (including
        frequency and physical exam findings) and complete question b.
(severity
        and side affected).
        Pain in the feet consistent with arthropathy with has been confirmed to
        be secondary to RA.

b. Indicate severity and side affected:
    [X] Moderately severe     [ ] Right [ ] Left [X] Both

c. Does the foot condition chronically compromise weight bearing?
    [ ] Yes   [X] No

d. Does the foot condition require arch supports, custom orthotic inserts or
    shoe modifications?
    [ ] Yes   [X] No

e. Comments: No comments provided

11. Surgical procedures
-----------------------
a. Has the Veteran had foot surgery (arthroscopic or open)?
    [ ] Yes   [X] No

b. Does the Veteran have any residual signs or symptoms due to arthroscopic or
    other foot surgery?
    No response provided

12. Pain
--------
RIGHT FOOT:

    Is there pain on physical exam?
    [X] Yes   [ ] No

        If yes, (there is pain on physical exam), does the pain contribute to
        functional loss?
        [X] Yes [ ] No

        (Further description of limitations requested in Section XIII below.)


LEFT FOOT:

    Is there pain on physical exam?
    [X] Yes   [ ] No

        If yes, (there is pain on physical exam), does the pain contribute to
        functional loss?
        [X] Yes [ ] No

        (Further description of limitations requested in Section XIII below.)


13. Functional loss and limitation of motion
--------------------------------------------
a. Contributing factors of disability (check all that apply and indicate side
    affected):

    [X] Pain on movement
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Pain on weight-bearing
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Pain on non weight-bearing
        Side affected: [ ] Right [ ] Left   [X] Both

    [X] Interference with standing
        Side affected: [ ] Right [ ] Left   [X] Both


Contributing factors of disability associated with limitation of motion:

b. Is there pain, weakness, fatigability, or incoordination that significantly
    limits functional ability during flare-ups or when the foot is used
    repeatedly over a period of time?

    RIGHT FOOT: [X] Yes [ ] No

         If yes, (there is a functional loss due to pain, during flare-ups
         and/or when the joint is used repeatedly over a period of time) please
         describe the functional loss:
         Pain from RA is severe and limits ability to stand and hence work

    LEFT FOOT: [X] Yes [ ] No

         If yes, (there is a functional loss due to pain, during flare-ups
         and/or when the joint is used repeatedly over a period of time) please
         describe the functional loss:
         Pain from RA is severe and limits ability to stand and hence work


c. Is there any other functional loss during flare-ups or when the foot is
used
    repeatedly over a period of time?

    RIGHT FOOT: [ ] Yes [X] No

    LEFT FOOT: [ ] Yes [X] No

14. 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):
        RA diagnosed and treatment started in 2018. Multiple other joints also
        affected. Veteran also diagnosed with comorbid fibromyalgia. Right
        ankle ORIF surgery in October 2004 (not SC'd), PTSD and depression.


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: No comments provided

15. 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.

16. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's foot condition, 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

17. Diagnostic testing
----------------------
a. Have imaging studies of the foot been performed and are the results
    available?
    [X] Yes   [ ] No

        If yes, is degenerative or traumatic arthritis documented?
        [X] Yes [ ] No

            If yes, indicate foot: [ ] 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):
        Positive imaging for RA and lab results positive for RA performed by
Dr.
        DOCTOR , RO of DOCTOR OFFICe Medical Center in ANYTOWN, PA from 3/2018.

c. If any test results are other than normal, indicate relationship of
abnormal
    findings to diagnosed condition:
    No response provided

18. 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:
     RA is severe in multiple joints including feet, ankles, knees, hips, back
     and jaw. Veteran remains limited in her daily activities and is unable to
     work on a sustained basis. Work recommended would be of a sedentary
     nature.

19. Remarks, if any:
--------------------
Not an ACE Exam.

Foot Correia Questions:
#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 non-weight bearing?
Yes
#3. Is the opposing joint undamaged? No

Arthropathy of foot: Level of Severity: Moderate

Veteran is currently pregnant and is due to deliver her 5th child in July
2019.

Upon review for this case, it becomes apparent that the multiple joint
complaints while AD are consistent with Rheumatoid Arthritis even though it
was
not diagnosed while active duty. This is confirmed by records reviewed by Dr.
DOCTOR , DO dated 3/16/2018.

Veteran has been seen and evalauted by an outside Rheumatolgist and has been
diagnosed and treatment started for Rheumatoid Arthritis in 2018.




****************************************************************************

                         Knee and Lower Leg Conditions
                       Disability Benefits

   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:
    Recurrent fracture right medial maleous tibia; right lateral collateral
    ligament sprain, left knee lateral collateral ligament sprain

b. Select diagnoses associated with the claimed condition(s) (Check all that
    apply):

[X] Knee strain
     Side affected: [ ] Right   [X] Left [ ] Both
     Date of diagnosis: Left 2004

[X] Knee meniscal tear

[X] Tibia and/or Fibula fracture
     Side affected: [X] Right   [ ] Left [ ] Both

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):
    Knee Medical History extracted from last Knee DBQ dated 9/13/2016.
    "STR's evident for a left knee contusion on 25Aug04 that was self
limiting."

    "Veteran claims left knee gives out intermittently (once a week). Veteran
    denies any medication for her knee condition. Veteran claims her knee is
    sore daily. Veteran clains on 9-24-2004 she did have a left knee sprain
and
    was seen by a DOCTOR, but there is no supporting documentation. Veteran
    reports since military discharge that she had a left knee meniscus disorder
    dated 6/15/2007 and was diagnosis with DJD left knee on 2/11/2010. No
    evidence noted for a recurrent medial mallelous fracture noted. Veteran
    claims documentation to support her left knee complaints were previously
    submitted on 9-1-2016."

    KNEE INTERVAL HISTORY:
    Left knee is painful daily. Pain 6/10. Veteran has been diagnosed with
    Rheumatoid Arthritis (RA) (DOCTOR , DO of ANYTOWN, PA) and is currently
    undergoing treatment. Of note, veteran has musculoskeletal complaints
    consistent with pain in multiple bilateral joints including her feet,
    ankles, knees, hips, back and TMJ joints.

    Ankle Medical History extracted from last Knee DBQ dated 9/13/2016.
    "STR's evident for right ankle sprain which was later diagnosis as a right
    ankle fracture. STR' radiograms for a right ankle fracture evident and
    Veteran was medically boarded out of the military for this condition."

    "Veteran claims right ankle always hurts and she is unable to wear flat
    shoes. Veteran claims it hurts when it rains. She notes it will
    intermittently lock up and sometimes she will fall. Veteran denies any
    medication use for her right ankle condition.   Veteran claims shortly
after
    military discharge she had an ORIF right ankle for Trimal ANYTOWNr repair on
    13Dec04. Please note, VBMS is silent for this documentatin and she reports

    it was submitted on 9-1-2016 to support the claim."

    RIGHT ANKLE INTERVAL HISTORY:
    Veteran has been diagnosed with Rheumatoid Arthritis (RA) (DOCTOR ,
DO
    of ANYTOWN, PA) and is currently undergoing treatment. Of note, veteran has
    musculoskeletal complaints consistent with pain in multiple bilateral
joints
    including her feet, ankles, knees, hips, back and TMJ joints. 6/10 for
    pain. DOCTOR has provided an opinion that states that the Veteran's
ankle
    trauma was more than likely the inital preciptating factor in the onset of
    her Rheumatoid Arthritis.

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:
        Pain in right and left ankles (as well as in the ankles, knees, hips,
        back and TMJ joints). Also, Veteran claims intermittent sharp pain and
        when it locks it feels like it is being pinched/squeezed.


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:
        Ankle pain is like a throbbing ache and it limits her ability to fully
        flexes her feet.


3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion

    Right Knee
    ----------
    [X] All normal
    [ ] Abnormal or outside of normal range
    [ ] Unable to test (please explain)
    [ ] Not indicated (please explain)

        Flexion (0 to 140):           0 to 140 degrees
        Extension (140 to 0):         140 to 0 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 Knee
    ---------
    [X] All normal
    [ ] Abnormal or outside of normal range
    [ ] Unable to test (please explain)
    [ ] Not indicated (please explain)

        Flexion (0 to 140):           0 to 140 degrees
        Extension (140 to 0):         140 to 0 degrees

    Description of pain (select best response):
      Pain noted on exam on rest/non-movement

      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):
       On the medial and lateral joint line.

    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

    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:
        May vary with activity


    Left Knee
    ---------
    Is the Veteran being examined immediately after repetitive use over time?
    [ ] Yes   [X] No

    Does pain, weakness, fatigability or incoordination significantly limit
    functional ability with repeated use over a period of time?
    [ ] Yes   [ ] No [X] Unable to say w/o mere speculation
        If unable to say w/o mere speculation, please explain:
        May vary with activity


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:
        May vary with activity


    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:
        May vary with activity


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:
      Interference with standing

       Please describe additional contributing factors of disability:
       Joint pain secondary to RA limit ability to stand for prolonged periods
       of time

    Left Knee
    ---------
    In addition to those addressed above, are there additional contributing
    factors of disability? Please select all that apply and describe:
      Interference with standing

       Please describe additional contributing factors of disability:
       Joint pain secondary to RA limit ability to stand for prolonged periods
       of time

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?
          [ ] Yes
          [ ] No
          [ ] Not indicated
          [X] Indicated, but not able to perform

       If joint stability is indicated, but unable to test, provide reason:
       Guarding prevented testing

    Left Knee:

       Was joint stability testing performed?
          [ ] Yes
          [ ] No
          [ ] Not indicated
          [X] Indicated, but not able to perform

       If joint stability is indicated, but unable to test, provide reason:
       Guarding prevented testing

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?
    No response provided


b. Comments, if any:
    Ankle(s) Information
    a. Initial range of motion

                   Right ankle
                   -----------
         [ ] All Normal
         [X] Abnormal or outside of normal range
         [ ] Unable to test (please explain)
         [ ] Not indicated (please explain)

             Dorsiflexion (0-20):    0 to 10 degrees
             Plantar Flexion (0-45): 0 to 45 degrees

    If ROM is outside of normal range, but is normal for the Veteran
    (for
             reasons other than an ankle condition, such as age, body habitus,
             neurologic disease), please describe:
               Normal for body habitus.

         If abnormal, does the range of motion itself contribute to a
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 examination, which ROM exhibited pain (select all that
    apply)?
           Dorsiflexion, Plantar 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? [X] Yes   [ ] No

            If yes, describe including location, severity and relationship to
            condition(s):
              Veteran expressed tenderness on palpation of right ankle.

         Is there objective evidence of crepitus? [ ] Yes [X] No


                   Left ankle
                   ----------
         [ ] All Normal
         [X] Abnormal or outside of normal range
         [ ] Unable to test (please explain)
         [ ] Not indicated (please explain)

             Dorsiflexion (0-20):    0 to 10 degrees
             Plantar Flexion (0-45): 0 to 45 degrees

    If ROM is outside of normal range, but is normal for the Veteran
    (for
             reasons other than an ankle condition, such as age, body habitus,
             neurologic disease), please describe:
               Normal for body habitus.

         If abnormal, does the range of motion itself contribute to a
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

         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):
             Veteran expressed tenderness on palpation of left ankle.

         Is there objective evidence of crepitus? [X] Yes [ ] No


      b. Observed repetitive use

                   Right ankle
                   -----------
    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 ankle
                   ----------
    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 ankle
                   -----------
    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 Veterans
    statements
             describing functional loss with repetitive use over time.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss with repetitive use over time. Please
             explain.
    [X] The examination is neither medically consistent or inconsistent
    with the

    Veterans 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:
                May vary with activity.


                   Left ankle
                   ----------
    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 Veterans
    statements
             describing functional loss with repetitive use over time.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss with repetitive use over time. Please
             explain.
    [X] The examination is neither medically consistent or inconsistent
    with the
    Veterans 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:
                May vary with activity.


      d. Flare-ups

                   Right ankle
                   -----------
    Is the examination being conducted during a flare-up?   [ ] Yes [X]
    No

         Does pain, weakness, fatigability or incoordination significantly
limit
         functional ability with flare-up?
         [ ] Yes [ ] No   [X] Unable to say w/o mere speculation

             If unable to say w/o mere speculation, please explain:
                May vary with activity.


                   Left ankle
                   ----------
    Is the examination 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 Veterans
    statements
             describing functional loss during flare-ups.
    [ ] The examination is medically inconsistent with the Veterans
    statements
             describing functional loss during flare-ups. Please explain.
    [X] The examination is neither medically consistent or inconsistent
    with the
             Veterans statements describing functional loss during flare-ups.

         Does pain, weakness, fatigability or incoordination significantly
limit
         functional ability with flare-up?
         [ ] Yes [ ] No   [X] Unable to say w/o mere speculation

             If unable to say w/o mere speculation, please explain:
                May vary with activity.


      e. Additional factors contributing to disability

                   Right ankle
                   -----------
         In addition to those addressed above, are there additional
contributing
         factors of disability? Please select all that apply and describe:
    Yes, newly diagnosed RA which has MD has opined may have been the
    preciptating factor for her other multiple musculoskeletal complaints

                   Left ankle
                   ----------
         In addition to those addressed above, are there additional
contributing
         factors of disability? Please select all that apply and describe:
    Yes, newly diagnosed RA which has MD has opined may have been the
    preciptating factor for her other multiple musculoskeletal complaints

      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 ankle:
            Rate Strength:   Plantar Flexion: 4/5
                             Dorsiflexion: 4/5

            Is there a reduction in muscle strength? [X] Yes   [ ] No


          Left ankle:
            Rate Strength:   Plantar Flexion: 4/5
                             Dorsiflexion: 4/5

            Is there a reduction in muscle strength? [X] Yes   [ ] No


      b. Does the Veteran have muscle atrophy? [ ] Yes   [X] No


      c. Comments, if any:
    Newly diagnosed RA which has MD has opined may have been the
    preciptating factor for right and left ankle condition(s) as well as her
    other multiple musculoskeletal complaints

      5. Ankylosis
      ------------
      Complete this section if Veteran has ankylosis of the ankle

    a. Indicate severity of ankylosis and side affected (check all that
    apply):

            Right side:                       Left side:
              [ ] In plantar flexion              [ ] In plantar flexion
              [ ] In dorsiflexion                 [ ] In dorsiflexion
    [ ] With an abduction deformity     [ ] With an abduction
    deformity
    [ ] With an inversion deformity     [ ] With an inversion
    deformity
              [ ] With an eversion deformity      [ ] With an eversion
deformity
    [ ] In good weight-bearing position [ ] In good weight-bearing
    position
    [ ] In poor weight-bearing position [ ] In poor weight-bearing
    position
              [X] No ankylosis                    [X] No ankylosis

      b. Comments, if any:
          No response provided

      6. Joint stability
      ------------------
      Right ankle
        Is ankle instability or
        dislocation suspected?          [X] Yes [ ] No

        If yes, complete the following:

        Anterior Drawer Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding

        Talar Tilt Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding


      Left ankle
        Is ankle instability or
        dislocation suspected?          [X] Yes [ ] No

        If yes, complete the following:

        Anterior Drawer Test
          Is there laxity compared
    with opposite side?           [ ] Yes [ ] No [X] Unable to test
    due to pain and guarding

        Talar Tilt Test
          Is there laxity compared
    with opposite side?           [ ] Yes [X] No [X] Unable to test
    due to pain and guarding


      7. Additional comments
      ----------------------
      Does the Veteran now have or has he or she ever had "shin splints",
stress
    fractures, achilles tendonitis, achilles tendon rupture, malunion of
    calcaneus
      (os calcis) or talus (astragalus), or has the Veteran had a talectomy
      (astragalectomy)? [ ] Yes   [X] No

      8. 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 ankle surgery
              Type of surgery: ORIF
              Date of surgery: 2004

              [X] Residuals of arthroscopic or other ankle surgery
                  Describe residuals:
    pressure with unable to wear flat shoes due to positional
    pressure.

        Left side:
           [X] Arthroscopic or other ankle surgery
              Type of surgery:
              Date of surgery: 2004

              [X] Residuals of arthroscopic or other ankle surgery
                  Describe residuals:
    pressure with unable to wear flat shoes due to positional
    pressure.

    9. 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):
             Rheumatoid Arthritis, Fibromyalgia, PTSD and depression.

      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

      c. Comments, if any:
    9 CM x 0.2 cm on both medial and lateral aspect of left achilles
    region

      10. 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

      11. Remaining effective function of the extremities
      ---------------------------------------------------
      Due to the Veteran's ankle condition, 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


      12. Diagnostic testing
      ----------------------
      a. Have imaging studies of the ankle been performed and are the results
         available? [X] Yes   [ ] No


      b. Are there any other significant diagnostic test findings or results?
           [ ] Yes [X] No


    c. If any test results are other than normal, indicate relationship of
    abnormal
         findings to diagnosed conditions:
           No response provided


      13. 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
    Unable to stand for long periods of time. Would be best suited for
    sedentary work.

    Ankle Correia Questions:
    #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 non-weight bearing?
    Yes
    #3. Is the opposing joint undamaged? No

    Recurrent Tibal Fracture: Level of Severity: Moderate

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):   Recurrent right of right medial
        tibia addressed with ankle questions as covered in 7.b. Additional
        Conditions noted above.

        Rheumatoid Arthritis, Fibromyalgia, PTSD and depression

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] Brace(s)               [X] Occasional [ ] Regular   [ ] Constant

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?
    [ ] Yes   [X] No

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):
        Positive Rheumatoid Factor as part of work-up by DOCTOR , DO
        DOCTOR OFFICe Medical Center ANYTOWN, PA in 3/2018.

c. If any test results are other than normal, indicate relationship of
abnormal
    findings to diagnosed conditions:
    DOCTOR opined that the ankle condition(s) diagnosed in 2004 were the
    initial pressnting arthritic condition that was subsequently diagnsed as
    Rheumatoid Arthritis in 2018.

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:
     RA is severe in multiple joints including feet, ankles, knees, hips, back
     and jaw. Veteran remains limited in her daily activities and is unable to

     work on a sustained basis. Work recommended would be of a sedentary
     nature.

15. Remarks, if any:
--------------------
Not an ACE Exam.

Knee Correia Questions:
#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 non-weight bearing?
Yes
#3. Is the opposing joint undamaged? No

Lateral Collateral Ligament Sprain: Level of Severity: Moderate

Upon review for this case, it becomes apparent that the multiple joint
complaints while AD are consistent with Rheumatoid Arthritis even though it
was
not diagnosed while active duty. This is confirmed by records reviewed by Dr.
DOCTOR , DO dated 3/16/2018.

Veteran has been seen and evalauted by an outside Rheumatolgist and has been
diagnosed and treatment started for Rheumatoid Arthritis in 2018.

It looks to me like an inadequate C&P exam. The examiner clearly and unmistakably fails to use the legal terminology to substantiate your claim.

I don't see the minimum threshold of "at least as likely as not" the veteran's condition is due to or the result of military service/SC condition. The rationale is insufficient.

This will most likely delay the process and will get sent back to the examiner for clarification. It's not a granted or denied claim. That's the good news.

If it does get denied. You'll need to appeal immeadiately on the basis that the examiner failed to provide the legal terminology to substantiate your claim.

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Did he just service connect me for RA?

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