What percentage should I expect based on this C&P exam

[X] Tendonitis(achilles/peroneal/posterior tibial)

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

[X] Arthritic conditions

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

c . Co m m e n t s ( i f a n y ) : N o r e s p o n s e p r o v i d e d

d. Was an opinion requested about this condition (Internal VA only)? [X]Yes []No []N/A

2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's

ankle
condition (brief summary): Veteran reports he strained both ankles repetitively in service. He was seen many times, and right was injured more frequently than left. He participated in physical therapy for both ankles. After separation, he has progressively worsening pain. Walking and standing are limited to 10 minutes. He has not had any treatment on ankles since separation. He has frequent clicking with weight bearing. He occasionally restrains them.

b. Does the Veteran report flare-ups of the ankle? [X]Yes []No

If yes, document the Veteran's description of the flare-ups in his or her

own words:
They click all the time and seem kind of weak.

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

If yes, document the Veteran's description of functional loss or f u n ct i o n al

impairment in his or her own words:
Walking and standing are limited to 10 minutes

3. Range of motion (ROM) and functional limitations ---------------------------------------------------
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 20 degrees

If abnormal, does the range of motion itself contribute to a functional loss?[X]Yes,(pleaseexplain) []No

If yes, please explain:
Walking and standing are limited to 10 minutes

Description of pain (select best response):
Pain noted on examination and causes functional loss

If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion

Isthereevidenceofpainwithweightbearing?[X]Yes []No

Is there objective evidence of localized tenderness or pain on palpation of thejointorassociatedsofttissue?[]Yes [X]No

Isthereobjectiveevidenceofcrepitus?[]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 15 degrees Plantar Flexion (0-45): 0 to 20 degrees

If abnormal, does the range of motion itself contribute to a functional loss?[X]Yes,(pleaseexplain) []No

If yes, please explain:
Walking and standing are limited to 10 minutes

Description of pain (select best response):
Pain noted on examination and causes functional loss

If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion

Isthereevidenceofpainwithweightbearing?[X]Yes []No
Is there objective evidence of localized tenderness or pain on palpation of

thejointorassociatedsofttissue?[]Yes [X]No Isthereobjectiveevidenceofcrepitus?[]Yes [X]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

describingfunctionallosswithrepetitiveuseovertime. Please

explain.
[X] The examination is neither medically consistent or inconsistent with

the
Veterans statements describing functional loss with repetitive use over t ime.

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?
[X]Yes []No []Unabletosayw/omerespeculation

Select all factors that cause this functional loss: Pain

Abletodescribeintermsofrangeofmotion?[]Yes [X]No

If no, please describe:
Limitations would be variable based on degree of repetitive use or

flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner.

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 w

iththeVeteransstatements describingfunctionallosswithrepetitiveuseovertime. Please explain.

[X] The examination is neither medically consistent or inconsistent with the

Veterans statements describing functional loss with repetitive use over t ime.

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?
[X]Yes []No []Unabletosayw/omerespeculation

Select all factors that cause this functional loss: Pain

Abletodescribeintermsofrangeofmotion?[]Yes [X]No

If no, please describe:
Limitations would be variable based on degree of repetitive use or

flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner.

d. Flare-ups

Right ankle
-----------
Istheexaminationbeingconductedduringaflare-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

describingfunctionallossduringflare-ups. Pleaseexplain.
[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?
[X]Yes []No []Unabletosayw/omerespeculation

Select all factors that cause this functional loss: Pain

Abletodescribeintermsorrangeofmotion?[]Yes [X]No

If no, please describe:
Limitations would be variable based on degree of repetitive use or

flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner.

Left ankle
----------
Istheexaminationbeingconductedduringaflare-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

describingfunctionallossduringflare-ups. Pleaseexplain.
[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?
[X]Yes []No []Unabletosayw/omerespeculation

Select all factors that cause this functional loss: Pain

Abletodescribeintermsofrangeofmotion?[]Yes [X]No

If no, please describe:
Limitations would be variable based on degree of repetitive use or

flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner.

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:

None

Left ankle ----------

In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:

None

4. Muscle strength testing
--------------------------
a. Muscle strength - rate strength according to the following scale

0/ 5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement 2/ 5 Active movement with gravity eliminated 3/5Activemovement against gravity
4/ 5 Active movement against some resistance 5/5Normalstrength

Right ankle:
RateStrength: PlantarFlexion: 5/5

Dorsiflexion: 5/ 5 Isthereareductioninmusclestrength?[]Yes [X]No

Left ankle:
RateStrength: PlantarFlexion: 5/5

Dorsiflexion: 5/ 5 Isthereareductioninmusclestrength?[]Yes [X]No

b.DoestheVeteranhavemuscleatrophy?[]Yes [X]No

c. Comments, if any: No response provided

5. Ankylosis
------------
Co m p l e t e t h i s s e c t i o n i f V e t e r a n h a s a n k y l o s i s o f t h e a n k l e

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

Right side:
[ ] In plantar flexion
[ ] In dorsiflexion
[ ] With an abduction deformity
[ ] With an inversion deformity
[ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing

p o si t i o n
[ ] In poor weight-bearing position [ ] In poor weight-bearing

p o si t i o n

Left side:
[ ] In plantar flexion

[ ] In dorsiflexion
[ ] With an abduction deformity

[ ] With an inversion deformity [ ] With an eversion deformity

[X] No ankylosis

[X] No ankylosis

b. Comments, if any:
No response provided

6. Joint stability ------------------ Right ankle

Isankleinstabilityor dislocationsuspected?

[X]Yes []No If yes, complete the following:

Anterior Drawer Test Istherelaxitycompared withoppositeside?

Talar Tilt Test Istherelaxitycompared withoppositeside?

Left ankle Isankleinstabilityor dislocationsuspected?

[]Yes [X]No []Unabletotest

[X]Yes []No

[X]Yes []No If yes, complete the following:

Anterior Drawer Test Istherelaxitycompared withoppositeside?

Talar Tilt Test Istherelaxitycompared withoppositeside?

[]Yes [X]No []Unabletotest

[X]Yes []No

7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints",

st r ess
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 ----------------------

No response provided

9. Other pertinent physical findings, complications conditions, signs, sympt oms

and scars

-------------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,

conditions, signs or symptoms related to any conditions listed in the DiagnosisSectionabove?[]Yes [X]No

b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Sectionabove?[]Yes [X]No

c. Comments, if any:
No response provided

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

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

If yes, indicate ankle: [ ] 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): Pacemaker Type

Yr Manufactured
* ( So m e p a c e m a k e r s a r e M R Co n d i t i o n a l )

Does the patient have any RELATIVEcontraindications to MRI?

NOHeartvalveType:NOBrainAneurysmClip: Yearimplanted: NO
Ca r o t i d a r t e r y v a s c u l a r c l a m p I n f u s i o n p u m p N O M a y b e p r e g n a n t NO

Intravascular stents, filtersor coilsNOShunt (spinal or intraventricular) NO Any implant held in place by a magnet NO Any

metallic fragments or shrapnel NO Transdermal patch

The patient DOESNOT have absolute or relative co n t r ai n d i cat i o n s

for the requested MRexamination. Thepatient isnot claustrophobic.

EXTENSION or PAGERWHEREYOU CAN BEREACHED IN CASEOF ABNORM ALITY
^@@^

Report Status: Verified 2018
Date Verified: MAY29, 2018

Date Reported: MAY29,

Verifier E-Sig:/ ES/ MANU M. BHATTATIRY, MD

Re p o r t : DISCUSSION:

MRI right ankle
Comparison: Plain film series of 4/ 20/ 2018.
Clinical History: Right ankle pain.
Technique: Multiple spin echo, multiplanar images were obtained without contrast.

Bones: No acute fractures, dislocation or osseous lytic lesions.
Subtle nonspecific heterogeneous increased marrow signal probably

related to degenerative changes versus remote trauma, in the lateral malleolus, in the lateral aspect of the fibula. No

definite osteochondral defects involving the talar dome; subchondral cystic degenerative changes are noted involving the

medial aspect of the medial talar dome. Mild degenerative changes

of the tibiotalar joint with patchy foci of sclerosis of the apposing articular surfaces. The ankle mortise is preserved; the

medial and lateral clear spaces appear intact. No loose bodies are noted within the tibiotalar joint.

Tendons: The Achilles tendon appears unremarkable. Mild thickening with heterogeneous signal of the tibialis posterior

and flexor digitorum longus tendons consistent with tendinosis.

The flexor hallucis longus tendon appears unremarkable. Physiological amount of fluid is noted within the tibialis posterior tendon sheath. Mild to moderate amount of fluid is

noted within the flexor hallucis longus tendon sheath consist ent
with tenosynovitis; there is probable associated resultant t ar sal

tunnel syndrome. Mild diffuse heterogeneous signal with minimal thickening of the peroneal tendons consistent with tendinosis;

the peroneal tendon sheath appears unremarkable. The extensor tendonsappear intact.

Ligaments: The spring ligament appears intact. The
t ibiocalcaneal
and tibionavicular ligaments are mildly thickened consistent with

chronic strain. Diffuse thickening with heterogeneous signal of

the anterior tibiotalar ligament consistent with chronic strain

versus partial-thickness tear. Mild diffuse chronic strain of the

posterior tibiotalar ligament. Partial thickness interstitial

tear of the anterior talofibular ligament. The posterior talofibular ligament appears intact. Diffuse heterogeneous signal

of the calcaneofibular ligament consistent with chronic partial

thickness tear. The anterior and posterior tibiofibular ligament s

appear unremarkable. Within the sinus tarsi, there is heterogeneous increased signal within the cervical and interosseous talocalcaneal ligaments consistent with chronic

st r ai n .

Soft Tissues: Physiological amount of fluid is noted within the

tibiotalar joint; no evidence for retrocalcaneal bursitis. No soft tissue mass lesions or abnormal fluid collections. No edema

is noted within the sinus tarsi. The visualized portions of the plantar aponeurosis appear grossly intact.

Impression:

1. No acute osseous abnormalities of the right ankle. Mild degenerativechangesofthetibiotalarjoint. 2.Tendinosis

of
the tibialis posterior and flexor digitorum longus tendons. Mild

to moderate flexor hallucis longus tenosynovitis with probable associated result in tarsal tunnel syndrome. Peroneal
t e n d i n o si s

noted. 3.Chronicstrainofthetibiocalcaneal/tibionavicular ligamentsandtheposteriortibiotalarligament. 4.Chronic strain versus partial-thickness tear of the anterior

t ibiot alar
ligament and calcaneofibular ligament. 5. Mild chronic strain of
the cervical and interosseous talocalcaneal ligaments within the

sinus tarsi.
Signed by Manu Bhattatiry on 5/29/2018 3:17 PM CDT

Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED

Primary Interpreting Staff:
MANU M. BHATTATIRY, MD, RADIOLOGIST (Verifier)

/MB

MRI ANKLEWOCONTRAST

Exm Date: MAY26, 2018@12:55
Req Phys: PENUKONDA,ISM AIL SUHAIL Pat Loc: FTW PACT TRINITY11 (Req'g Loc)

Img Loc: FW THEPRAIRIEMRI Service: Unknown

(Case 8053 COMPLETE) MRI ANKLEWO CONTRAST (MRI Det ailed)

CPT:73721
Proc Modifiers : LEFT
Reason for Study: L ANKLEPAIN

Clinical History:
Some of the following may be hazardous to the patient's safety or

could interfere with the patient's examination.

I f c o n t r a i n d i c a t i o n s a r e p r e s e n t t h e M RI s t u d y M U ST b e PRE-APPROVED by a Radiologist.

Please answer all questions listed below.
Does the patient have any ABSOLUTEcontraindications to MRI?

NOMetal in eyesNOInfusion pump NONeurostimulator or bone g r o w t h s t i m u l a t o r N O T i s s u e e x p a n d e r N O Co c h l e a r i m p l a n t N O Pacemaker Type

Yr Manufactured
* ( So m e p a c e m a k e r s a r e M R Co n d i t i o n a l )

Does the patient have any RELATIVEcontraindications to MRI?

NOHeartvalveType:NOBrainAneurysmClip: Yearimplanted: NO
Ca r o t i d a r t e r y v a s c u l a r c l a m p I n f u s i o n p u m p N O M a y b e p r e g n a n t NO

Intravascular stents, filtersor coilsNOShunt (spinal or intraventricular) NO Any implant held in place by a magnet NO Any

metallic fragments or shrapnel NO Transdermal patch

The patient DOESNOT have absolute or relative co n t r ai n d i cat i o n s

for the requested MRexamination.
Thepatient isnot claustrophobic.
EXTENSION or PAGERWHEREYOU CAN BEREACHED IN CASEOF

ABNORM ALITY ^@@^

Report Status: Verified 2018
Date Verified: MAY29, 2018

Date Reported: MAY29,

Verifier E-Sig:/ ES/ MANU M. BHATTATIRY, MD

Re p o r t : DISCUSSION:

MRI left ankle
Comparison: Plain film seriesof both anklesof 4/20/2018. Clinical History: Left ankle pain
Technique: Multiple spin echo, multiplanar images were obtained without contrast.

Bones: Bone island noted in the distal fibula. Subtle

heterogeneous increased marrow signal in the distal fibular epiphysis laterally with a probable remote avulsion injury to the
lateral malleolus. The ankle mortise is preserved.

Ost eochondr al
defect measuring 4.3 mm with associated subtle marrow edema is

noted in the medial talar dome. The ankle mortise is preserved;

the medial and lateral clear spaces appear unremarkable. Mild to
moderate degenerative changes of the tibiotalar joint with
pat chy

foci of degenerative sclerosis and subchondral degenerative cystic changes involving the apposing articular surfaces. No loose bodies are noted within the tibiotalar joint space.

Tendons: The Achilles tendon appears grossly unremarkable. The

tibialis posterior tendon reveals mild diffuse heterogeneous signal consistent with mild tendinosis. The flexor digitorum longus and flexor hallucis longus tendons appear unremarkable.

Minimal tibialis posterior tenosynovitis; mild to moderate amount
of fluid is noted within the flexor hallucis longus tendon sheat h

consistent with tenosynovitis with probable resultant tarsal

tunnel syndrome. Subtle heterogeneous signal involving the peroneal tendons consistent with tendinosis; minimal amount of

fluid is noted within the peroneal tendon sheath. The extensor

tendons appear unremarkable.

Ligaments: Diffuse mild thickening of the spring ligament consistent with chronic strain. Thickening of the
t ibiocalcaneal

and tibionavicular portions of the deltoid ligament consistent

with chronic strain. Thickening with heterogeneous signal of the

anterior tibiotalar ligament consistent with partial-thickness

tear. The posterior tibiotalar ligament appears unremarkable.

Partial-thickness tear of the anterior talofibular ligament. The
posterior talofibular ligament appears intact. Diffuse
t hickening

with heterogeneous signal of the calcaneofibular ligament consistent with chronic strain versus partial-thickness interstitial tear. The anterior and posterior tibiofibular ligaments appear unremarkable. Mild chronic strain of the cervical and interosseous talocalcaneal ligaments within the sinus tarsi.

Soft Tissues: Physiological amount of fluid is noted within the

tibiotalar joint space; no retrocalcaneal bursitis. The sinus
tarsi appears grossly unremarkable. No soft tissue mass lesions

or abnormal fluid collections. The visualized portions of the plantar aponeurosis appear grossly intact.

Impression:

1 . N o a c u t e o s s e o u s a b n o r m a l i t i e s o f t h e l e f t a n k l e . Su b - c m osteochondral defect with associated subtle marrow edema involving the medial talar dome. Mild to moderate degenerative

changes of the tibiotalar joint. 2. Minimal tibialis p o st e r i o r

tenosynovitis. Mild to moderate flexor hallucis longus tenosynovitis with probable resultant tarsal tunnel syndrome. Mild peroneal tendinosis. Clinical correlation suggested. 3. Chronic strain of the spring ligament and the

tibiocalcaneal/tibionavicular ligaments. 4. Partial-thickness tear of the anterior tibiotalar ligament and anterior
t al o f i b u l ar

ligament. Chronic strain versus partial-thickness interstitial tear of the calcaneofibular ligament. 5. Mild chronic strain
of

theligamentswithinthesinustarsiasnoted.
Signed by Manu Bhattatiry on 5/29/2018 1:19 PM CDT

Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED

Primary Interpreting Staff:
MANU M. BHATTATIRY, MD, RADIOLOGIST (Verifier)

/MB

c. If any test results are other than normal, indicate relationship of abnormal

findings to diagnosed conditions: No response provided

13. Functional impact
---------------------
Re g a r d l e s s o f t h e V e t e r a n ' s c u r r e n t e m p l o y m e n t s t a t u s , d o t h e

condit ion(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:

Walking and standing are limited to 10 minutes

14. Remarks, if any -------------------

Pain present with non weight bearing and passive ROM. Active ROM same as passive.

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

Knee and Lower Leg Conditions Disability Benefits Questionnaire

Nameofpatient/Veteran: Braggs,DerickCryer

passive.

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

Medical Opinion
Disability Benefits Questionnaire

Nameofpatient/Veteran: Braggs,DerickCryer

ACEand 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 (VBMSor Virtual VA)
[X] CPRS
[X] Other (please identify other evidence reviewed):

Vi st a

MEDICAL OPINION SUMMARY -----------------------
RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Does the Veteran has a diagnosis of left ankle condition that is at least as likely as not incurred in or caused by service?

TYPEOFMEDICALOPINIONPROVIDED: [ MEDICALOPINIONFORDIRECTSERVICE CONNECTION ]

a. The condition claimed was at least as likely as not (50%or greater

probability) incurred in or caused by the claimed in-service injury, event or

illness.

c. Rationale: STR's and medical records reviewed. 20 Jan 1993 notes a bilateral ankle complaint. 21Aug1992 notes complaint of both ankles and diagnosis of bilateral achilles tenodontis. Enlistment is silent for ankle