Ok, here it goes, I just had a c&p done. My case started in 2003 when I was ADSEP'd from the Navy, been fighting the VA since. Here is the modified copy of my latest C&P.
I got copies of my complete C-file from the VA. The c&p exam I had in 2004, the doctor stated that my back pain was more likely than not related to my service in the Navy. But I was denied service connection because there was not an official diagnosis, just stated back pain.
I also had a C&P exam on 16 Mar 2012, where the Dr. states that my Ankylosing Spondylitis is more likely than not related to my service. The following is a breakdown of the dr notes from the recent C&P:
Bilateral Hip Condition:
R hip flexion : 20
R hip extension: 5
L hip flexion : 20
L hip extension : 5
Painful motion begins at 5 on both
Abduction lost beyond 10 degrees yes (Both)
Adduction limited - can not cross legs yes (Both)
Rotation limited - Veteran cant toe-out more than 15 degrees yes (Both)
Patient in severe pain, repetitive use ROM not completed
Functional loss of hip and thigh - yes (Both)
Less movement than normal, Weakened movement, Excess fatigability, pain on movement, instability of station, disturbance of locomotion, interference with sitting, standing, and or weight-bearing these are all marked for both Hips.
localized tenderness or pain to palpitation for joints/soft tissue of either hip (yes - Both)
Muscle strength test -
Hip Flexion 4/5 on both
Hip abduction and hip extension 3/5 on both
Images were taken, degenerative arthritis is documented in both hips, and Ankylosing Spondylitis seen on x-ray results.
Cervical spine condition:
ROM:
forward flexion ends: 20
painful motion: 15
extension ends : 5
painful : 5
right and left lateral flexion ends : 5
painful motion : 5
right and left lateral rotation ends: 10
painful : 10
did not do repetitive ROM test, too much pain
Functional loss:
less movement than normal, weakened movement, excess fatigability, pain on movement, interference with sitting, standing, weight bearing
localized tenderness - yes
reflex exams:
biceps : 1+ (both)
triceps : 0 (both)
brachioradials : 1+ (both)
sensory all normal
x-rays show Ankylosing Spondylitis
Thoracolumbar spine condition:
forward flexion : 10 - ends with pain
extension - 10 - ends with pain
right lateral / left lateral flexion : 5 - ends with pain
right / left lateral rotation : 10 - with pain
did not complete repetitions
Functional loss: yes
less movement than normal, excess fatigability, instability of station, disturbance of locomotion, interference with sitting, standing, and/or weight bearing
Localized tenderness ; yes
guarding / muscle spasm of thoraculumbar spine (
yes, abnormal gait
Muscle strength : Hip flexion; knee extension;ankle plantar flexion; ankle dorsiflexion ; great toe extension - all 4/5 on both
reflexes : knee and ankle ; 0 - both sides
all sensory normal
Radiculopathy yes: l/r lower extremity ; moderate (both) paresthesias and or dysesthesias ; moderate (both)
nerve roots involved: L2/L3/L4 (both)(femoral nerve) ; L4/L5/S1/S2/S3 (sciatic nerve) (both)
severity of radiculopathy and side affected : Moderate - Both
Intervertebral disc syndrome and incapacitating episodes, yes to both
Images: Ankylosing Spondylitis and Scoliosis noted on thoracic and lumbar spine x-ray results
Pain and decreased ROM affect the veterans ability to work
Medical opinion of VA Examiner:
patient was diagnosed with Ankylosing Spondylitis in April 2011, However, symptoms began in 2001, during his enlistment. This is clearly supported when reviewing his medical records. The veteran was seen on multiple occasions for his ongoing back pain, but never officially diagnosed until recently.
The veteran's condition (back, bilateral hip) is at least as likely as not incurred in or caused by his military service.
Sorry this is so long, but I wanted to get an accurate opinion, and to do so, I have to give the full picture.
Do you have an opinion on what I may get as far as service connection goes? A best case scenario will be fine.
