June 5, 2025 • 61 mins
Former VA Compensation and Pension examiner Bethanie Spangenberg breaks down the complex process of VA knee disability claims, sharing insider knowledge on how veterans can better prepare for their exams and secure fair compensation.
• Knee DBQ is 14 pages long but typically one of the easiest musculoskeletal exams to complete
• Veterans should provide detailed evidence including when symptoms started, specifics of injuries, imaging reports, and surgical documentation
• Describing flare-ups accurately is crucial - veterans should know what triggers them and how they impact daily functioning
• Veterans should verbalize when pain begins during range of motion testing
• Examiners are no longer allowed to say they cannot determine limitations during flare-ups "without mere speculation"
• Secondary conditions from knee problems can affect other body parts - these connections should be documented and claimed
• Pre-existing conditions that didn't show symptoms before service can still qualify for service connection if symptoms developed during service
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
J Basser (00:02):
Welcome folks to another episode of the Exposed
Ed Productions recording.
This is a weekly show.
We discuss veterans' issues anddifferent things affecting
veterans anywhere from the VAnavigation to the VA claims
process, from stem to stern, ato B to A to Z.
We've been in the past fewmonths doing a little training
(00:22):
session as far as the DisabledBenefits Questionnaires
otherwise known as theworld-famous DBQs that the VA
uses and they do theirdisability exams, and we brought
in one of the people that knewexactly what to do with DBQs.
She used to do CMPs for the VA.
Her name is Bethany Spangenbergand she's our guest tonight and
(00:45):
our co-host today is Mr RayCobb, down in Tennessee.
Looking good, ray.
Ray Cobb (00:50):
Thank you, I appreciate that I'm feeling good
.
J Basser (00:53):
Bethany, how are you tonight?
Bethanie Spangenberg (00:55):
I'm doing great.
We've got a lot going on andlooking forward to a good show.
Got a lot to talk about.
J Basser (01:04):
Yes, we do.
I know we're going to discussthe old dreaded knees DBQ.
I know a lot of vets that gotknee issues and they kind of
walk like a hawk.
You know they don't really walk, they hobble.
Some of them have to go to IHOPand eat, you know.
But why don't you go ahead andget us started?
(01:26):
We'll go down the list on theDBQ and kind of give us a little
brief of what you know, whatwe're going to learn tonight.
Bethanie Spangenberg (01:34):
So definitely going to start with
an overview when it comes to themusculoskeletal DBQs.
These DBQs to talk aboutbetween a provider that's doing
them and a layman or somebodythat's not used to medical stuff
is actually very dry, so I'mgoing to try to make this as
smooth as possible andentertaining as possible.
(01:54):
When you look at the knee DBQitself, it's probably one of the
easiest DBQs to complete from adisability standpoint,
specifically pertaining tomusculoskeletal.
So the fingers are moredifficult wrists, elbows,
everything else is moredifficult except for the knee.
(02:14):
The knee is the easiest one.
It's usually pretty smooth inand out the door within 30
minutes, and I say that becauseit's 14 pages long.
Okay, so all these DBQs thatwe've talked about, they're not
as beefy as the musculoskeletalones, so I've kind of tried to
put these musculoskeletal oneson the back end because they are
(02:35):
difficult and dry to discuss.
So I'm going to hit on the mainpoints.
I'm not really going to hitevery section.
I do have a couple of storiesto tie with it that I like to
talk about, and then today is aspecial day for me and my life
that I'd like to talk about aswell.
So maybe we can end upsomewhere down that path talking
(02:58):
about it.
So why I want to talk about themusculoskeletal DBQs is because
a lot of veterans are seekingservice connection, especially
for the knees, and the knees isa good one, it's a common one
that we should be talking about.
To understand the DBQ meansthat you know what questions are
(03:22):
coming, means that you knowwhat questions are coming.
So, as a veteran, if you'reapplying for a service
connection for the knees, youneed to understand what you will
be asked and you need to knowhow to answer them.
I think one of the things whenI was doing these for the VA is
I would ask the veteran specificquestions about their knee and
things that would causeflare-ups or be bothersome for
(03:46):
their condition, and they wouldsay, well, I don't know.
Or they would tell me like, oh,I don't have flare-ups and I'm
like, well, if you havearthritis, you have flare-ups.
So it didn't leave me muchmaterial or understanding from
the clinical side of things.
So when we talk about thesequestions, I really just want
you to let those questions sinkin and ask yourself these same
(04:09):
questions as I go through here.
14 pages.
This DBQ was last updated inSeptember of 2024.
First section is your standardquestion on the veteran's
information and the relationshipthe clinician has to that
veteran and how the examinationwas conducted.
(04:30):
As always, there's an evidencereview section in there the
evidence.
I want the veteran to provide,a statement and supportive claim
and I want you to talk aboutwhen the condition started.
The examiner needs tounderstand when you started
having symptoms and it can be aslow progression.
(04:53):
You can talk about how wellwhen I was at work it would
start to bother me just everyonce in a while and then it
progressed and that'sparticularly important if you're
looking at secondary conditionsNow.
If you injured your knee inservice and you're tying it
direct to service, thatstatement needs to include
specifics of that injury.
(05:14):
So, for example, if you werejumping off the back of a truck
or a vehicle and your kneelocked up and you fell, you need
to talk about how far youjumped down, was the vehicle
moving, did you hit the groundand what kind of care or
symptoms did you have to follow?
A lot of times when I was doingexams, the veterans would talk
(05:35):
about yeah, I heard it inservice and they wouldn't give
me much details.
A big one is motor vehicleaccidents.
There is so much information tocollect from a motor vehicle
accident.
How fast were you going?
Were you the driver or thepassenger?
Were you wearing a seat belt?
How fast were you going?
What happened?
All of those details need to bein your statement supportive
(05:59):
claim for that clinician tounderstand how this condition
began and how it progressed, tounderstand how this condition
began and how it progressed.
Another very important piece ofevidence that the veterans
should have in there is imagingNot necessarily the pictures,
but I want the radiologist'sreport.
The radiologist will give animpression for their X-ray or an
(06:20):
MRI.
That MRI is going to give usdetails.
The X-ray is going to give usdetails to understand the
progression and that part of thestory.
So that's important to have inthere.
If you've had any type ofsurgery, that's important to
have in there.
The details that theorthopedist puts in there will
(06:41):
talk about what the internalparts of the knee look like.
You have a meniscus.
You have ligaments.
The cartilage is part of themeniscus.
You have protective cartilageunder the bones.
The surgeon's going to talkabout all of that in their
surgical report.
So we want to see that surgicalreport as well.
Okay, any questions aboutevidence?
(07:04):
Any comments that anybody wantsto chime in about evidence.
Ray Cobb (07:11):
No, I don't think so it was his evidence
Bethanie Spangenberg (07:20):
For page two.
It's a full list of diagnosedconditions.
We're not going to talk aboutit, there's a time.
Page three continues fordiagnosis and starts the medical
history.
The medical examiner is goingto talk about the onset and the
course of the claimed condition.
The onset and the course of theclaimed condition.
(07:44):
The next part of the medicalhistory is does the veteran
report flare-ups of the knee orlower leg?
So we're focusing on knee.
So does the veteran report aflare-up of the knee condition?
And the flare-up is not reallydefined good for the medical
examiner.
So the medical examinertypically has to put it in terms
(08:05):
for the veteran to understand.
And the way that I alwaysexplained it was a temporary
worsening or limitation due tothe symptoms of the knee
condition.
So I would always say you know,sometimes patients have a
baseline of pain and if theystart to walk for X amount of
distance that pain will getworse.
Sometimes it lasts a few days,sometimes it lasts a few minutes
(08:27):
, but then it kind of goes backto baseline.
That bump is a flare-up.
Some veterans who have backconditions.
They will tweak their back andthey will have a temporary
flare-up.
Typically flare-ups of the backare a lot longer lasting than a
flare up of the knee.
Our knees are a little bit moreforgiving in that aspect, where
(08:50):
our back isn't.
But we're looking at atemporary worsening of that knee
condition, whether it'sswelling, pain, fatigue,
weakness All of that could beincorporated into what a
flare-up can can include.
You should also know whattriggers a flare-up.
Okay, that's a question here onpage four.
(09:12):
What kind of activities is it?
Prolonged sitting, prolongedstanding, walking for a long
distance?
Do you have to warm up thatknee after you've sat for a
period of time?
That's another common one,because after you sit or you
stand for a long period, thatfluid shifts within the joint
and makes that knee stiff andharder to move.
(09:34):
So if you're experiencingflare-ups with those types of
activities, you need to knowthat, you need to be able to
talk about that, and if you havea flare-up, you want to talk
about how it impacts you.
So some people or some veteranswill say well, when I get a
(09:54):
flare-up, the pain's worse, okay.
So what else Do you have?
Swelling in the knee joint whenyou have a flare-up?
You know some veterans talkabout how they feel instability
during a flare-up.
The swelling gets bad and itjust makes me uncomfortable to
even walk on the leg.
You need to be able to talkabout those symptoms.
(10:16):
Okay, there is a question inhere that says does the veteran
report or have a history ofinstability or recurrent
subluxation of the knee?
Often that is a no.
The instability has to do withthe ligaments within the joint.
The subluxation means adislocation.
(10:38):
So you can actually dislocatethe kneecap and you can
dislocate the tibia, the mainbone and the lower leg.
So I've actually done examswhere the examiner is supposed
to put their hands behind theknee joint, they stabilize that
knee joint and then they pull onthat lower part of the knee and
(11:00):
I've completely dislocated aknee before.
So it is not a good feelingthat hearing that clunk is like,
uh, let's just, let's just putthis back Very uncomfortable.
And those with patellar issuesthey can get a common if you
(11:24):
dislocate that kneecap.
Unfortunately that's somethingthat starts to occur often
unless it's surgically repaired.
So those are the type of thingsthat that question is looking
for.
(11:48):
The dislocation that I that Idid on exam, that was because
the veteran had a poorly fittingum knee replacement.
They gave him a kneereplacement that wasn't
appropriate and I don't know howthat.
He was wearing a brace and hewasn't what he did.
Didn't want to go throughsurgery again because of his age
and the risk of complications.
So this man had to deal withthis instability that I don't
(12:09):
even know how he could functionday to day, especially if you're
going to dislocate that easy.
That was wild.
A question in here talks aboutfluid buildup or effusion in the
knee, so you want to be able totalk about that too.
Any questions about the history?
J Basser (12:32):
No, but I hope the guy got a good rating out of that
situation, because any time youpull a knee out, you dislocate
it and you put pressure on it,it pops out.
Bethanie Spangenberg (12:47):
Yeah, I don't know, what happened to
that?
That was like 10 years ago.
Actually, that was more than 10years, that was 2011.
So I don't know what ended uphappening, but that was before I
started Valor for Vet.
It was when I was on the darkside.
J Basser (13:05):
On the dark side.
Ray Cobb (13:08):
I like that.
So if we jump into section,three.
J Basser (13:14):
You can be in the hot now.
Bethanie Spangenberg (13:18):
Oh man.
Section three this is the rangeof motion testing and this is
where you're going to get yourrating, your disability rating.
For Now, the knees areinteresting when they actually
do a rating, because you don'talways get one rating for the
knee.
What I have seen morefrequently is that veterans are
getting two and three ratingsfor the knee and I actually
(13:41):
pulled a veteran that we workedwith his rating sheet because I
want to read it to you.
So he got a 0% rating for hisright knee meniscal tear.
He got a 0% rating for asemi-lunar cartilage tear, which
(14:04):
is actually part of themeniscus as well.
He got a 0% rating forosteoarthritis and limitation of
extension and he got a 10%rating for the right knee Sorry,
that's the right knee arthritisthat actually they give him 10%
(14:27):
for later.
So he had two for meniscal well, cartilage tears, two 0% for
cartilage tears and a 10% forarthritis and limitation of
extension, arthritis andlimitation of extension.
So I don't quite understand.
Like I do understand, becausethey're basing it off the
(14:49):
diagnostic codes.
If you go in the ratingschedule, it has limitation of
flexion of the leg for the knee.
You'll get a rating percentageif you have that, If you have
limitation of.
So that was limitation offlexion.
There's limitation of extensionthat you can get service
connection for, and then you canget service connection for
(15:14):
impairments of the lowerextremity as well, so like shin
splints, and those are allseparate because they're under
different diagnostic codes.
Yeah, so see, and here I can'tcount about zero.
I know.
So here, like, just like theone I read the cartilage a, five
(15:38):
, two, five, nine.
Diagnostic code the semi lunarcartilage removal.
If he's symptomatic he has a10%.
So they must have claimed thathe was asymptomatic.
So he got a zero.
And then a different code 5258,is another cartilage
dislocation with locking andpain.
Completely different code 20%code 20%.
(16:11):
So the needs are kind of.
You have to really look at yourDBQ and the rating schedule to
understand what is going to bemost appropriate for your
disability rating.
Okay, so part of thatdisability rating percentage
comes from the range of motionand functional limitation.
So for the knee DBQ, they wantthe examiner to schedule the
(16:32):
good knee or the conditionthat's not being examined.
So like, okay, you're claimingthe right knee.
They want the examiner toexamine the right knee and the
other knee in comparison.
Okay, and so when you gothrough your physical exam at
the C&P exam, they're going todo exams on both, and a lot of
(16:52):
times the veteran's like well, Ijust claimed my right knee, why
are you looking at my left knee?
And they want a comparison.
Now, I'm not sure why, becauseit really doesn't affect the
rating In my opinion.
It affects the medicalexaminer's opinion.
(17:13):
So whether they are going towrite in favor of your service
connection or not, this givesthem information where they can
look and see the differencebetween the two knees.
Now if a veteran has a rightknee condition related to injury
(17:34):
and service and a left kneecondition that happened after
service, that's not a reallygood story for that medical
examiner to learn and understandthe difference between the two
conditions.
So having a good knee and a badknee I don't think brings value
to that veteran when it comesto their rating disability.
(17:57):
In my opinion it basicallyprovides the examiner with
information that may skew theiropinion.
Initial range of motion.
The examiner is going to taketheir goniometer.
It's like a big protractor orrange of motion tester.
(18:19):
I should have one actually herein my office but they're going
to put it along the knee to lookat the initial range of motion
motion tester.
I should have one actually herein my office so, but it's
they're going to put it alongthe knee to look at the initial
range of motion.
So they're going to have yousay okay, I want you to fully
extend your knee one time, andso you'll extend your knee and
they'll capture the range ofmotion that is the initial range
of motion, and then they'regoing to document whether you
have um have normal range ofmotion or abnormal range of
(18:44):
motion, or whether or not youhave pain or functional loss
associated with that initialrange of motion.
Then they're going to have youcomment on the unaffected side
or the need that's not beingclaimed.
This didn't used to be in here,what we call the contralateral
side, the opposite side.
That didn't used to be in there.
(19:08):
If we look at the next page,which we're on page six, they
want specifically to know if anyof the motions are attributable
to pain, weakness, fatigabilityor incoordination, and so
they're to document that they'realso supposed to do range of
motion where they assist you inyour movement, and document that
(19:30):
.
Then they have you do range ofmotion on your own, okay.
Then because of the delucacriteria from the 90s, they're
going to have you repeat rangeof motion three times and then
measure that at the end of therating that for some reason is
supposed to capture, whether ornot fatigability is demonstrated
(19:54):
in the knee joints.
Um, that three range of motion.
I find it hysterical because Idon't see how you can truly
document fatigability in threemotions, right, and so I
actually looked that up and thatcame from a Social Security,
(20:20):
Disability and American Academyof Family Physicians opinion.
So they wanted to use that datafrom those disability and
brought it over to the VA andthat's where we get the DeLuca
criteria.
Is that three-repeatfatigability, which has really
(20:43):
no clinical application?
I don't know why they chose itfor that.
Any questions?
What I've talked about so far,no, sir, no.
Ray Cobb (20:59):
Okay okay, is there?
Excuse me, bethany, is there anumber?
I mean, when you were talkingabout the range of motion, I
remember when I went through myCMP and they used a little tool
is there like?
For I wish I could remember thenumbers I heard him say, but he
(21:22):
told me a certain degree ofmotion that I had.
When I ended up with mine.
I ended up with a 60%disability on my left knee knee.
(21:48):
Now, did that range of motionaffect that mostly or would that
be affected by the fatigue thatyou were just talking about?
What do they use?
What does the doctor when herecommends those things?
What would be considered thenormal move of motion, the
normal angle at which your kneecan go without hurting or
without completely stopping andlocking up?
Bethanie Spangenberg (22:12):
So there's a difference between clinical
application and what the VA hasokay and what the VA has Okay.
So in the VA paperwork, anormal extension so this is your
knee Okay, this is your kneejoint A normal extension should
(22:37):
be at zero.
If you are flexing, a normal isat 140.
So it's pretty far back there,okay.
When you tell me 60% for yourknee, I'm not thinking that's
range of motion, because rangeof motion doesn't get you, or
limitation in range of motiondoesn't get you, a whole lot of
bang for your buck.
So I just wonder if they'verated it differently In your
(22:59):
case.
Do you have any type ofreplacements?
Ray Cobb (23:04):
in your case, do you have any type of replacements?
No, no, mine is strictly um.
I got bone against bone due tothe diabetes eating away at the
uh, the cartilage and the padbetween my and my knee joints,
and normally I would havesurgery but due to the heart
(23:24):
condition they chose not to dothe surgery.
Bethanie Spangenberg (23:27):
Gotcha, so I'm not sure where they're
getting.
I'd have to look at your ratingschedule to see where they're
getting that 60%.
Is it 60% for just one knee?
Ray Cobb (23:42):
60% for one and 40% for the other.
Bethanie Spangenberg (23:47):
Yeah, I'd have to look at your rating
schedule Because when it comesto just looking at the range of
motion, if you have 60 degreesof flexion okay, so this is 90,
okay of flexion Okay, so this is, this is 90.
Okay, so if you have 60 degreesof range of motion, of excuse
(24:07):
me of flexion in that range ofmotion, you get a 0% rating.
So that means you're only doingthis, okay, and you're only
getting a 0% for that little bitof, I mean, to me that's
significantly limited.
You can't squat down, you'restruggling to pick stuff up off
the floor, so that's a 0%.
(24:29):
So you're not getting a wholelot there.
Now, the reason why this DBQ wasexpanded to the 14 pages is
because of the fatigabilityissue, is because of the
fatigability issue and they wantthe medical examiner to
document where pain starts orwhen they start to exhibit signs
of pain.
So when we do the DBQ, Irecommend that the veteran
(24:54):
verbalize when their pain starts.
Okay, because true disabilityincludes pain and you have to
capture when the pain startsduring your range of motion
testing.
But when you look at disabilityratings, when it comes to range
of motion, the limitation offlexion at 60 degrees is 0%.
(25:19):
Limitation of flexion to 45degrees is 10%.
Limitation to 30 degrees, whichis here's where you start,
limitation to 30,.
So if you can only move thatlittle bit, I should get my
goniometer for this.
Can we hold on?
So I get my goniometer, john Goahead.
(25:44):
Let's see.
J Basser (25:47):
Go ahead.
Bethanie Spangenberg (25:48):
Let's see if I can grab my goniometer.
I am in my office.
J Basser (25:57):
You got a goniometer Ray.
Ray Cobb (26:00):
No, I don't have one of those things.
I've seen a few of them, butI've had them hold them next to
my leg a few times.
J Basser (26:13):
I've had airplane measure with that sucker.
There it is.
Bethanie Spangenberg (26:17):
This is a large joint goniometer.
Okay, I actually have a digitalone, okay.
Okay, I like the digital onebecause it gives me exact
measures.
So I tend to um use my digitalone.
And then this is what isexpected of your cmp examiner.
Okay, so there's little numbershere, yeah that's the one they
(26:40):
used on me.
J Basser (26:42):
They can In all reality.
If your exam requires you to bemeasured with a goniometer and
the examiner doesn't do it, youcan ask for a new exam.
Bethanie Spangenberg (26:52):
Yep, yep.
So let me show you how muchlimited 30 degrees is okay.
So this is the knee fullyextended.
This is your knee joint.
This will be is your knee joint.
This will be your thigh andthis will be your lower leg, so
your foot's down here.
Okay, so a knee flexion of 30degrees is right there.
Okay, that's all you're getting, and you get.
(27:12):
You get 20 for that.
That.
That is significant,significant limitations to me.
So I don't know why they'resaying this is only a 20% rating
.
This is non-functional.
This is not independence, thisis that aid and attendance we
should be looking at.
Right.
So you get, if you have thismuch range of motion, you get a
(27:36):
0%, and normal range of motionis right there.
So visually, you can see thedifference Normal range of
motion, and this gets you zero,this gets you 10,.
This gets you 20, this gets you20.
(28:01):
This gets you 30.
That's wild, anyways.
Ray Cobb (28:08):
Any questions about that?
Bethanie Spangenberg (28:15):
No questions.
J Basser (28:18):
I guess it all depends on the examiner and what the
readings are.
Ray Cobb (28:25):
Well, I think Benedict pointed out a very good point.
There is that, yeah, I guess Ihad a good examiner when I went
through mine.
I've been through it twice.
Both times they asked me toidentify as soon as the pain
started, including standing.
So, like when they first had meto stand, as soon as I put
(28:47):
weight on my knees the painstarts.
And then they saw theinstability of walking, which
also creates more pain, and myability.
I mean, they made me sit downafter I took about three steps,
because they grabbed me by theback of the pants and said sit
(29:07):
down, because they didn't wantto take a chance at me falling.
But I guess that part is all Idon't know.
If you fell right there infront of him, if your knees gave
out, you might get 100% ready,I don't know.
But in any case they wanted tomake sure that I sat down.
But it was mainly the pain Itold them.
(29:30):
I said it's mainly pain when Istand and walk.
You know, I was able toidentify exactly when it started
, how it started.
Bethanie Spangenberg (29:42):
I'd be interested in reading, your
reading.
There is times where I didn'tfeel comfortable doing the knee
exam because of the instabilitywith standing, your range of
motion of the knees.
You should be doing it.
You know if you're doing itactive.
I like to have the veteransstand on both legs and holding a
(30:04):
chair for stability and thenhave them bring their heel to
their butt If you, becausethat's against gravity.
That is the active range ofmotion.
You are going against gravity.
If you're sitting in a chairand you extend that leg out and
then drop your heel to the floor, that's with gravity.
So you're assisted by gravityin that testing.
(30:29):
If you're standing at a chairand bringing your heel to your
butt, that is against gravity.
That is shown true strengthwith, with function.
Does that make sense?
Ray Cobb (30:43):
well, it does.
Let me ask you a third way.
They actually it was the lastexaminer I had.
I actually he had me layingdown and he lifted my leg and he
actually moved the leg or hadme to move it, and he had his
hand behind my knee and I thinkbehind my calf and was holding
(31:04):
that little meter there with histhumb in place and adjusting it
.
So I was not sitting orstanding with that last one.
So I don't know what thepurpose of that was.
Does that make sense, that hedid it that way?
Bethanie Spangenberg (31:20):
Yeah, probably safety, and then
probably so like because he'strying to get it.
If you're sitting and you bendyour knees, your gravity is
helping you, so it's more of apassive movement than you
actively bending that knee.
So if he puts you on a table,you're now being forced to bring
(31:42):
your your heels up to your buttto try to bend that knee.
That that was with laying downis more safety, because if he's
worried about you falling oreven having issues with you,
your knee giving out the safetyreasons is why he's going to put
(32:03):
you on a flatbed.
Ray Cobb (32:06):
Yeah, well, I think I went in there riding my scooter,
you know.
I mean, I didn't walk in, Iwent in on the scooter.
J Basser (32:16):
That would be my first indication of why you're
sitting on the bed, okay, yep.
First of all, what's the gatecall when you're trying to, when
you fall down and you're tryingto cross the floor trying to
get up, is that a certain gatecalled the elbow gate or what,
and you crawl across the floortrying to get up?
Is that a certain gate?
Bethanie Spangenberg (32:37):
called the elbow gate or what.
While we're talking about this,okay, while we're talking about
the instability and stuff, if aveteran has instability and
their knee is giving out or forsome reason, your knee would
lock up and causes you to fall,veterans should be claiming any
(33:01):
injuries that occur from thatfall.
So if you fall because of yourknee and you hit your head and
get a brain bleed and a stroke,you need to be filing for that
fall.
Okay, I know that's not reallytalked a lot with VSOs or
veterans, but it is discussedvery heavily with attorneys and
(33:22):
they talk about, you know,fighting for those, their, their
secondary conditions.
They they occurred because ofthe veterans need condition.
So I want you guys to keep thatin mind, okay.
J Basser (33:37):
Any condition that caused you to fall, like if you
set a snooker for it and youfall, like me, you break bones,
tail bones and all kinds ofstuff.
You know of course it's notpainful, because you know when
you wake up it's painful, butyou know you don't feel it when
it happens.
But you can mess yourself up,paulie, especially when you hit
(34:03):
your metal and you're in trouble.
Bethanie Spangenberg (34:08):
So for.
Ray Cobb (34:09):
Just falling out of a wheelchair.
Count, yes, yes, yes.
Bethanie Spangenberg (34:18):
I laugh.
Ray Cobb (34:18):
That's what I did this weekend.
J Basser (34:22):
You can tell me about that, Ray.
Ray Cobb (34:26):
Well, on our driveway at a certain point there's about
a three-inch drop, and I'd gonedown to the mailbox.
It was coming back and therewas a car parked in the driveway
.
So I went beside the car and Igot a little further than I
meant to and the wheels went offand I just tumbled over and
(34:49):
went out.
And there's the result.
See, this looks a little faker,so I guess I got another claim
there, right?
Can you see that I can't getthat little finger in anymore?
J Basser (35:05):
Well, they can't pay you no more money right.
Ray Cobb (35:07):
Well, I know, I got all I got.
I got all I got.
Bethanie Spangenberg (35:10):
Let me see both your hands like this.
I'm having trouble seeing you.
It almost looked like you mighthave broken your finger.
J Basser (35:22):
He's got that big hand .
Ray Cobb (35:25):
Well that's yeah.
That's yeah.
Well, they can't do anythingabout it though, right, I mean I
can pull on it.
I've tried to straighten it out, but it goes back like it was.
That will get it extra.
Until we go from knees tofingers right, one joint to the
(35:52):
other right.
Bethanie Spangenberg (35:54):
Hey, it's relevant and that's the case.
Oh goodness.
Ray Cobb (35:59):
That's right.
J Basser (36:00):
This bone is connected to that bone.
Right.
Ray Cobb (36:02):
That's right.
Bethanie Spangenberg (36:07):
So when we look at the rest of the range
of motion testing, I brieflymentioned that the examiner is
going to have you do theextension and flexion three
times and then they're going tomeasure it to look at
fatigability.
So if you're not able to dothat, then the examiner is
actually supposed to estimatewhat they think it would be.
(36:28):
Then they're also supposed toestimate what your range of
motion will be during theflare-up.
Estimate what your range ofmotion will be during the
flare-up.
Now, a lot of the times amedical examiner likes to say,
oh, I can't say this withoutmere speculation, but now they
took that option out, so youcan't.
The examiner is not allowed tosay, oh, I can't decide because
of mere speculation.
(36:48):
And if you see that anywhere inyour rating decision or on your
DBQ and it affects a ratingrating decision or on your DBQ
and it affects a rating, youneed to appeal that because that
is not acceptable.
In my opinion, if a clinicianlistens to their veteran, does
their range of motion, theyshould be able to adequately
guesstimate a limitation due toa flare-up.
(37:13):
So if you have the examiner youknow say that they can't, you
just need to.
Often you need to find anotherexaminer.
But that can be difficult to dotoo.
But you need to find somewhereelse in your exam to fight that
appropriate rating.
(37:34):
They do ask about additionalfactors related or contributing
to disability interference withstanding, disturbance with your
gait, deformity, swelling,atrophy, which is where the
muscles start to shrink becauseyou're not using those muscles,
instability of movement,weakened movement those all play
(37:55):
a role in the disability.
Okay, section four looks atmuscle atrophy.
That's the um, where the muscleshrinks because it's not being
used.
It is more common to see thatatrophy and advanced arthritis
because you're not getting this,the range of motion.
You're only not getting therange of motion, you're only
(38:15):
getting that small range ofmotion and that affects the
muscle substance.
It's not as strong anymorebecause of that limited movement
.
So you normally see that inadvanced arthritis talks about
(38:39):
ankylosis.
Okay, sometimes the arthritiscan develop significantly where
there is a frozen joint.
We see frozen joints morecommon in the shoulder, but it
can happen in the knee and youwill actually start to get um
where the the bone.
So this is your femur bone andthis is your tibia at the bottom
, where the knees will actuallythe bones will start to curve so
(39:01):
you'll get bowing into theknees, you'll see somebody with
inward bowing when the arthritisis so advanced that can develop
into ankylosis because of howsevere the arthritis is, where
it's bone on bone and you haveno cushion.
And so there's that wholesection there talks about
ankylosis and they want theexaminer to document at what
(39:22):
degree that that ankylosis hasoccurred or that frozen joint
has occurred.
The joint stability looks at theligaments.
You have ligaments on the sideof the knee that keep the knee
from moving side to side.
Okay, your knee actually onlyhas one plane of movement.
Okay, it's not rotating incircles, it's not moving side to
(39:45):
side, it's moving forward andbackward.
It has one plane.
So if you have instability ofthe joint, the ligaments from
the side can be affected.
And inside the knee you have aligament in the front and a
ligament in the back that crossand they are to stabilize that
forward movement of the kneejoint.
(40:08):
So if you have instability,that means that one of those
four ligaments is affected.
Right, one of those fourligaments is affected.
Section 8 talks about meniscusconditions.
There's obviously a rating thatwe talked about for the
semilunar cartilage, that's themeniscus or part of the meniscus
(40:32):
area, and it asks about sectionfor locking swelling.
If there's any type of meniscaltear, you'll often have a
locking sensation duringmovement or during walking, or
it will swell prettysignificantly.
Talks about surgery, which,where I said surgery notes are
(40:53):
important.
Talks about assistive devices.
You use a brace cane, crutch,walker, wheelchair.
If you have a cane and thereare certain times that you pick
up that cane, you need to beable to tell the examiner when
and why.
So if you're going to thegrocery store and you don't like
to go to the grocery store butyour wife's dragging you along,
(41:16):
you'll take your cane becauseyou know you're going to walk a
long distance and it causes aflare up of the knee.
You need to be able toverbalize that and tell them
what assistive devices that youuse.
Okay, it talks about diagnostictesting.
I think diagnostic testing isabsolutely necessary for VA
(41:38):
claims and you should not begoing into the VA for your C&P
exam never having an x-ray ofthe knee.
If you're claiming a kneecondition, you should already
have one before you even go in.
They may or may not order onefor your C&P exam.
It's up to the examiner.
Then it talks about functionalimpact.
(41:59):
We've talked about itpreviously how you need to put
the functional impact in yourstatement in support of claim.
So you need to talk about howyour work duties are affected
due to the knee condition.
Then the last section is theremark section.
So that just leaves theexaminer area to free text.
(42:19):
Okay, so a lot in there.
I just mainly focused in onwhat kind of questions that you
should know how to answer.
Expect to hear that way you'reprepared on how to answer those
questions.
Any thoughts or opinions on theDBQ?
J Basser (42:45):
Yeah, there's not really necessarily the DBQ in
itself.
The main issue questions I haveis you know, if you are rated
for knee condition and say youare a jumper or you can pedal a
plane or helicopter or whateverand you lay it on your knee,
you've got issues with your kneestructure.
Eventually you're going tostart having secondary issues
(43:09):
other parts of your body likeyour hips and things like that
are going to start to go.
That's all secondary to yourknee too, but I've seen a lot of
denials in the VA on that andit's kind of weird how it
happens.
Ray Cobb (43:23):
Well, that's a good point, John, because in my case
mine is secondary to diabetes,because mine basically started
with the neuropathy in the kneeand foot drop and then, once I
developed foot drop, that's whenmy knees started going bad,
until I had foot drop.
(43:44):
You know my knees didn't botherme any at all, that I can
remember.
You know that became secondary,the third secondary route or
the third question mark, fromthe diabetes itself.
(44:05):
And you know, I'm not for sureif you know the diabetes caused
the neuropathy.
Neuropathy caused the foot drophas caused my knees to go bad
and protruding disc and I thinkit's C1 and C2 in the lower back
.
So all of that could be.
I've never gone for my back,I've never requested anything
(44:28):
for the back.
J Basser (44:31):
S1, S2, or L1, L2?
.
Ray Cobb (44:33):
I guess it's L1 and L2 , the lower part.
J Basser (44:36):
Lumbar, lower lumbar.
Yeah, c1, c2, you don't want tohave it, you wouldn't be having
a show right now.
Ray Cobb (44:42):
But that's a good point, john, because these
things when they go bad, theykind of connect.
Bethanie Spangenberg (44:51):
Let me see if I can show you my
presentation here.
See if it'll let me.
J Basser (44:58):
Okay, okay.
All right, you can see that,then right well so this is
Bethanie Spangenberg (45:23):
actually this is part of a presentation
that I did for a nova conference.
Um, and I had an attorney oncesay you know, secondary
conditions for musculoskeletalcan only go up and down, correct
?
And I'm like, no, it's not howthis works.
So I created this because Iwanted to show how the mechanics
(45:46):
can relate to other conditions.
Okay, so if we look at this youcan see my cursor here the knee
condition can cause a backcondition.
A ankle condition can cause afoot condition.
(46:06):
An ankle condition can cause anankle condition.
A foot and ankle condition cancause a knee condition.
A foot and ankle condition cancause an ankle condition.
A foot and ankle condition cancause a knee condition.
A foot and ankle condition cancause a back condition.
So this is the ankle, this isthe foot, this is the toes.
So if you have flat feet youcan get bunions.
(46:28):
Okay, so you should be claimingthe bunions along with your
flat feet.
But is very common.
So if we look at the green here, these are very common things
that occur.
Okay, this is mainly due togravity and how we walk and
ambulate.
Okay, so these are less lesscommon, but they do occur.
So we're looking at a left kneecondition causing causing a
(46:51):
right knee condition, or a rightknee condition causing a left
knee condition.
Those occur, okay.
So ankle causing knee, theyhappen.
A hip condition causing a lowback condition, vice versa,
those can happen, okay.
And then we're talking aboutknees causing hip issues and
feet conditions causing hipissues and feet conditions
(47:12):
causing hip issues.
So hopefully that's a littlebit of a visual that you know
how common secondary conditionscan develop.
It's all SI joint issues too,Kenneth.
J Basser (47:28):
Say that again.
Bethanie Spangenberg (47:31):
SI joints, si joints, si joints they're
not meant to move.
They can get painful.
They are very painful If youhave.
You can have SI, instabilityand movement.
They're not meant to move,they're a fixed joint but
because there's a little bit ofcartilage there, that little bit
(47:56):
of shifting can create a lot oftension and discomfort,
especially with the musclestructure down there and what.
What john's saying is the sijoint is actually where your
hips meet your back.
So when you, if you have littledips in your lower back, that's
, that's part of your si joint.
Okay, I say joint issues aremore common.
Females because of pregnancyand their hips widen and they're
(48:17):
supposed to retract back andsometimes they do, sometimes
they don't.
So did that visual help kind ofunderstand?
Like how?
Ray Cobb (48:29):
Yeah, yeah, it's good.
Bethanie Spangenberg (48:33):
So we actually I have a Nexus letter
here.
I'm not going to go over everydetail of the nexus, but I just
want to show that we also useconditions together to show how
they're affecting the veteran.
So for this particular nexusletter we talked about how the
service-connected let me see ifI can find where we talk about
(49:03):
it.
Here it is.
We talked about how theservice-connected right knee
meniscal tear with arthritis andinstability of the left ankle.
So we took bothservice-connected
musculoskeletal conditions andtalked how it created another
musculoskeletal condition.
And that just helps to furthersupport how these joint
(49:25):
conditions are related.
So if you're a veteran andyou're claiming a secondary
condition, you don't have to sayit's because of one
musculoskeletal condition.
You can pile those on there andtalk about how all those
musculoskeletal conditionsaffect your movement.
Okay, and then I have a reallygood case that we're working on
(49:51):
right now that I think isimportant to talk about.
Let me just dive in.
J Basser (49:59):
Go ahead Head.
First Make sure the water isdeep enough.
Bethanie Spangenberg (50:05):
All right.
So this veteran, before heentered service in 91, he was on
the diving board and he wasdiving when he landed on the
diving board with his right knee, okay, ouch, he broke his
kneecap.
Okay, this is before service.
(50:26):
Okay, so I have the servicetreatment records from 91.
Before he went into service.
The DOD collected it as part ofhis entrance examination.
Okay, so they collected theinformation.
It shows the x-ray has afracture of the kneecap without
displacement.
Okay, so he was braced, put ina brace and usually you mobilize
(50:51):
those to to keep, uh, pressureoff the kneecap.
And let's see, that was in julyand by september he was
released.
Okay, it shows the x-rays showconsolidation of the fracture,
meaning that it's healed, and itsays he's going to work
aggressively, arrange motionstrengthening program and
(51:15):
actually, um, this was theaugust note, but he was
discharged in september.
Okay, so he completed the, therange of motion had no issues.
He had a fractured patella okay, so then he goes into that.
He had this injury and in theentrance examination the doctor
(51:40):
put that he had a fracture ofthe patella in 91, treated with
bracing, no residual.
Okay, so he had no residuals athis entrance examination of
that knee fracture, his entranceexamination of that knee
fracture While in service.
(52:05):
There's service treatmentrecords that said that he is
complaining of knee pain.
For three weeks in that rightknee he had tenderness.
He had what they call crepitusor that crunchy feeling when you
put your hand on the kneecap.
J Basser (52:14):
You can sometimes hear it.
Bethanie Spangenberg (52:15):
He was diagnosed with tendinitis and he
was put on light duty.
He was prescribed Motrin and tofollow up.
So the veteran was dischargedfrom service six years later and
he claimed in 1997 that he hada knee condition as a result of
(52:39):
service.
So they said in their ratingdecision, they said that the
aggravation of a pre-existingfracture was not service
connected.
Okay, so now we start with.
The veteran had a fracturedkneecap while in service.
(53:03):
He was diagnosed withtendinitis, which are not the
same.
And then, during his claim,they said well, your knee, uh,
fracture, um, it wasn't shownthat it was aggravated, so it's
not.
Your knee condition is notservice related.
So they denied him.
So now he appeals it again in2004, or, excuse me, 2018.
(53:27):
And then he appeals it again in2024.
And at this last ratingdecision he got ahold of us.
Okay, so I'm I'm the one writingthe nexus letter on this and
this is what I'm going to say.
I'm going to say that theveteran had a condition of the
patella, which is the knee.
(53:48):
He had a fracture of the knee.
He did not demonstratetendinitis prior to service.
During military training,during active service, he
developed symptoms of tendinitis, was treated for tendinitis and
continued to have symptoms oftendinitis through service that
(54:09):
he applied for in 97.
Two different conditions thatfracture of the kneecap was
considered healed and he had noresiduals at his entrance exam.
Does that knee fracture makehim more predisposed to
developing tendinitis?
Yes, but he didn't havetendinitis prior to service.
(54:32):
He had tendinitis because ofservice.
So now I'm writing the nexusletter saying didn't have
tendinitis before service.
Service had tendonitis becauseof service.
And then he went on to developa progression of the disease as
a result of the tendonitis.
So not only did he apply in 97,but he continued to apply and
(54:54):
he has all the medical treatmentrecords that shows that
progression and the continuityof the condition, that
progression and the continuityof the condition.
So if you're a veteran andyou're listening to this and you
have a similar case, if youdidn't have tendonitis before
service and now they're tryingto say, well, you had a
preexisting condition thatwasn't aggravated, you need to
(55:15):
break that down and you need tooutline hey, this is what I had
in service.
I didn't have it before service, clearly diagnosed.
This is the progression.
And so sometimes that does takea medical expert to write the
nexus letter, but it has value,especially if you've been
fighting it that long.
J Basser (55:35):
Ed.
Ray Cobb (55:35):
Thank you.
J Basser (57:27):
Okay, thank you.
Any questions, because legalprecedent sets in situations
like that.
Because any military, anyperson that goes in the military
, if they accept you in themilitary and you go to boot camp
(57:49):
, you are presumed to be soundwhen you go in absolutely and
especially a legal precedentprecedent like that.
Yeah, yep, legal precedent setsin, and more at the BVA and the
(58:09):
court than it does at theregional office.
I guarantee you that Mm-hmm Goahead, betsy.
Bethanie Spangenberg (58:19):
That's that physician that did his exam
, specifically annotated on thatknee fracture and said he had
no residuals and reported anormal exam.
So for them to say that itwasn't aggravated or to deny him
for that was just them playingthe game again.
J Basser (58:41):
It's a game.
Bethanie Spangenberg (58:41):
I do want to mention really quickly two
things.
I know we're running out oftime, so I'll make it quick.
One is Valor for Vets team.
One of our providers gotactivated in orders and is
deployed as we speak, and so weare running one man down.
(59:03):
So we're about 10 days behindour normal schedule.
So if you're here and you'relistening, please be patient.
We're working double time totry to get everything turned
over.
But the other thing that Iwanted to mention is that
Michael and I met 16 years agotoday while he was in the Marine
Corps, all by happenstance andso just one of those things
(59:29):
where the stars aligned orwhatever right.
So he had just got done with adeployment and he either had to
go one or two ways.
He was either going to staywith the same unit or get
transferred.
Two ways.
He was either going to staywith the same unit or get
transferred.
At the last minute he decidedto get transferred and it put
him back in Ohio for about amonth.
We met on his third day on hisleave and we've been together
(59:53):
ever since 16 years 16 years ago.
J Basser (01:00:05):
Well, make him take you at the dinner.
Bethanie Spangenberg (01:00:09):
Not tonight.
We got our kids and we got this, so it'll be this weekend, yeah
.
J Basser (01:00:17):
That's a good thing.
You know, ain't love grand, asMarty used to say, marty
Brenneman.
So that's great, that is great,but, guys, it's right up, we're
about out of time.
So, matthew, thank you forcoming on.
You're a breath of fresh air.
We do appreciate.
(01:00:37):
Every time you do.
We learn something.
A lot of folks learn whenyou're on.
And, ray, thanks for coming onto co-hosting buddy, we
appreciate you too.
And yeah, and this is John JBassler On behalf of the J
Bassler's Exposed VetProductions.
(01:00:58):
Bentley Spangenberg, valor forVet and Mr Ray Cobb.
We'll be signing off for now.
Astro Exposed Vet Productions.
Bentley Spangenberg, valor forVet and Mr Ray Cobb.
We'll be signing off for now.
Welcome folks to another episode of the Exposed
Ed Productions recording.
This is a weekly show.
We discuss veterans' issues anddifferent things affecting
veterans anywhere from the VAnavigation to the VA claims
process, from stem to stern, ato B to A to Z.
We've been in the past fewmonths doing a little training
(00:22):
session as far as the DisabledBenefits Questionnaires
otherwise known as theworld-famous DBQs that the VA
uses and they do theirdisability exams, and we brought
in one of the people that knewexactly what to do with DBQs.
She used to do CMPs for the VA.
Her name is Bethany Spangenbergand she's our guest tonight and
(00:45):
our co-host today is Mr RayCobb, down in Tennessee.
Looking good, ray.
Ray Cobb (00:50):
Thank you, I appreciate that I'm feeling good
.
J Basser (00:53):
Bethany, how are you tonight?
Bethanie Spangenberg (00:55):
I'm doing great.
We've got a lot going on andlooking forward to a good show.
Got a lot to talk about.
J Basser (01:04):
Yes, we do.
I know we're going to discussthe old dreaded knees DBQ.
I know a lot of vets that gotknee issues and they kind of
walk like a hawk.
You know they don't really walk, they hobble.
Some of them have to go to IHOPand eat, you know.
But why don't you go ahead andget us started?
(01:26):
We'll go down the list on theDBQ and kind of give us a little
brief of what you know, whatwe're going to learn tonight.
Bethanie Spangenberg (01:34):
So definitely going to start with
an overview when it comes to themusculoskeletal DBQs.
These DBQs to talk aboutbetween a provider that's doing
them and a layman or somebodythat's not used to medical stuff
is actually very dry, so I'mgoing to try to make this as
smooth as possible andentertaining as possible.
(01:54):
When you look at the knee DBQitself, it's probably one of the
easiest DBQs to complete from adisability standpoint,
specifically pertaining tomusculoskeletal.
So the fingers are moredifficult wrists, elbows,
everything else is moredifficult except for the knee.
(02:14):
The knee is the easiest one.
It's usually pretty smooth inand out the door within 30
minutes, and I say that becauseit's 14 pages long.
Okay, so all these DBQs thatwe've talked about, they're not
as beefy as the musculoskeletalones, so I've kind of tried to
put these musculoskeletal oneson the back end because they are
(02:35):
difficult and dry to discuss.
So I'm going to hit on the mainpoints.
I'm not really going to hitevery section.
I do have a couple of storiesto tie with it that I like to
talk about, and then today is aspecial day for me and my life
that I'd like to talk about aswell.
So maybe we can end upsomewhere down that path talking
(02:58):
about it.
So why I want to talk about themusculoskeletal DBQs is because
a lot of veterans are seekingservice connection, especially
for the knees, and the knees isa good one, it's a common one
that we should be talking about.
To understand the DBQ meansthat you know what questions are
(03:22):
coming, means that you knowwhat questions are coming.
So, as a veteran, if you'reapplying for a service
connection for the knees, youneed to understand what you will
be asked and you need to knowhow to answer them.
I think one of the things whenI was doing these for the VA is
I would ask the veteran specificquestions about their knee and
things that would causeflare-ups or be bothersome for
(03:46):
their condition, and they wouldsay, well, I don't know.
Or they would tell me like, oh,I don't have flare-ups and I'm
like, well, if you havearthritis, you have flare-ups.
So it didn't leave me muchmaterial or understanding from
the clinical side of things.
So when we talk about thesequestions, I really just want
you to let those questions sinkin and ask yourself these same
(04:09):
questions as I go through here.
14 pages.
This DBQ was last updated inSeptember of 2024.
First section is your standardquestion on the veteran's
information and the relationshipthe clinician has to that
veteran and how the examinationwas conducted.
(04:30):
As always, there's an evidencereview section in there the
evidence.
I want the veteran to provide,a statement and supportive claim
and I want you to talk aboutwhen the condition started.
The examiner needs tounderstand when you started
having symptoms and it can be aslow progression.
(04:53):
You can talk about how wellwhen I was at work it would
start to bother me just everyonce in a while and then it
progressed and that'sparticularly important if you're
looking at secondary conditionsNow.
If you injured your knee inservice and you're tying it
direct to service, thatstatement needs to include
specifics of that injury.
(05:14):
So, for example, if you werejumping off the back of a truck
or a vehicle and your kneelocked up and you fell, you need
to talk about how far youjumped down, was the vehicle
moving, did you hit the groundand what kind of care or
symptoms did you have to follow?
A lot of times when I was doingexams, the veterans would talk
(05:35):
about yeah, I heard it inservice and they wouldn't give
me much details.
A big one is motor vehicleaccidents.
There is so much information tocollect from a motor vehicle
accident.
How fast were you going?
Were you the driver or thepassenger?
Were you wearing a seat belt?
How fast were you going?
What happened?
All of those details need to bein your statement supportive
(05:59):
claim for that clinician tounderstand how this condition
began and how it progressed, tounderstand how this condition
began and how it progressed.
Another very important piece ofevidence that the veterans
should have in there is imagingNot necessarily the pictures,
but I want the radiologist'sreport.
The radiologist will give animpression for their X-ray or an
(06:20):
MRI.
That MRI is going to give usdetails.
The X-ray is going to give usdetails to understand the
progression and that part of thestory.
So that's important to have inthere.
If you've had any type ofsurgery, that's important to
have in there.
The details that theorthopedist puts in there will
(06:41):
talk about what the internalparts of the knee look like.
You have a meniscus.
You have ligaments.
The cartilage is part of themeniscus.
You have protective cartilageunder the bones.
The surgeon's going to talkabout all of that in their
surgical report.
So we want to see that surgicalreport as well.
Okay, any questions aboutevidence?
(07:04):
Any comments that anybody wantsto chime in about evidence.
Ray Cobb (07:11):
No, I don't think so it was his evidence
Bethanie Spangenberg (07:20):
For page two.
It's a full list of diagnosedconditions.
We're not going to talk aboutit, there's a time.
Page three continues fordiagnosis and starts the medical
history.
The medical examiner is goingto talk about the onset and the
course of the claimed condition.
The onset and the course of theclaimed condition.
(07:44):
The next part of the medicalhistory is does the veteran
report flare-ups of the knee orlower leg?
So we're focusing on knee.
So does the veteran report aflare-up of the knee condition?
And the flare-up is not reallydefined good for the medical
examiner.
So the medical examinertypically has to put it in terms
(08:05):
for the veteran to understand.
And the way that I alwaysexplained it was a temporary
worsening or limitation due tothe symptoms of the knee
condition.
So I would always say you know,sometimes patients have a
baseline of pain and if theystart to walk for X amount of
distance that pain will getworse.
Sometimes it lasts a few days,sometimes it lasts a few minutes
(08:27):
, but then it kind of goes backto baseline.
That bump is a flare-up.
Some veterans who have backconditions.
They will tweak their back andthey will have a temporary
flare-up.
Typically flare-ups of the backare a lot longer lasting than a
flare up of the knee.
Our knees are a little bit moreforgiving in that aspect, where
(08:50):
our back isn't.
But we're looking at atemporary worsening of that knee
condition, whether it'sswelling, pain, fatigue,
weakness All of that could beincorporated into what a
flare-up can can include.
You should also know whattriggers a flare-up.
Okay, that's a question here onpage four.
(09:12):
What kind of activities is it?
Prolonged sitting, prolongedstanding, walking for a long
distance?
Do you have to warm up thatknee after you've sat for a
period of time?
That's another common one,because after you sit or you
stand for a long period, thatfluid shifts within the joint
and makes that knee stiff andharder to move.
(09:34):
So if you're experiencingflare-ups with those types of
activities, you need to knowthat, you need to be able to
talk about that, and if you havea flare-up, you want to talk
about how it impacts you.
So some people or some veteranswill say well, when I get a
(09:54):
flare-up, the pain's worse, okay.
So what else Do you have?
Swelling in the knee joint whenyou have a flare-up?
You know some veterans talkabout how they feel instability
during a flare-up.
The swelling gets bad and itjust makes me uncomfortable to
even walk on the leg.
You need to be able to talkabout those symptoms.
(10:16):
Okay, there is a question inhere that says does the veteran
report or have a history ofinstability or recurrent
subluxation of the knee?
Often that is a no.
The instability has to do withthe ligaments within the joint.
The subluxation means adislocation.
(10:38):
So you can actually dislocatethe kneecap and you can
dislocate the tibia, the mainbone and the lower leg.
So I've actually done examswhere the examiner is supposed
to put their hands behind theknee joint, they stabilize that
knee joint and then they pull onthat lower part of the knee and
(11:00):
I've completely dislocated aknee before.
So it is not a good feelingthat hearing that clunk is like,
uh, let's just, let's just putthis back Very uncomfortable.
And those with patellar issuesthey can get a common if you
(11:24):
dislocate that kneecap.
Unfortunately that's somethingthat starts to occur often
unless it's surgically repaired.
So those are the type of thingsthat that question is looking
for.
(11:48):
The dislocation that I that Idid on exam, that was because
the veteran had a poorly fittingum knee replacement.
They gave him a kneereplacement that wasn't
appropriate and I don't know howthat.
He was wearing a brace and hewasn't what he did.
Didn't want to go throughsurgery again because of his age
and the risk of complications.
So this man had to deal withthis instability that I don't
(12:09):
even know how he could functionday to day, especially if you're
going to dislocate that easy.
That was wild.
A question in here talks aboutfluid buildup or effusion in the
knee, so you want to be able totalk about that too.
Any questions about the history?
J Basser (12:32):
No, but I hope the guy got a good rating out of that
situation, because any time youpull a knee out, you dislocate
it and you put pressure on it,it pops out.
Bethanie Spangenberg (12:47):
Yeah, I don't know, what happened to
that?
That was like 10 years ago.
Actually, that was more than 10years, that was 2011.
So I don't know what ended uphappening, but that was before I
started Valor for Vet.
It was when I was on the darkside.
J Basser (13:05):
On the dark side.
Ray Cobb (13:08):
I like that.
So if we jump into section,three.
J Basser (13:14):
You can be in the hot now.
Bethanie Spangenberg (13:18):
Oh man.
Section three this is the rangeof motion testing and this is
where you're going to get yourrating, your disability rating.
For Now, the knees areinteresting when they actually
do a rating, because you don'talways get one rating for the
knee.
What I have seen morefrequently is that veterans are
getting two and three ratingsfor the knee and I actually
(13:41):
pulled a veteran that we workedwith his rating sheet because I
want to read it to you.
So he got a 0% rating for hisright knee meniscal tear.
He got a 0% rating for asemi-lunar cartilage tear, which
(14:04):
is actually part of themeniscus as well.
He got a 0% rating forosteoarthritis and limitation of
extension and he got a 10%rating for the right knee Sorry,
that's the right knee arthritisthat actually they give him 10%
(14:27):
for later.
So he had two for meniscal well, cartilage tears, two 0% for
cartilage tears and a 10% forarthritis and limitation of
extension, arthritis andlimitation of extension.
So I don't quite understand.
Like I do understand, becausethey're basing it off the
(14:49):
diagnostic codes.
If you go in the ratingschedule, it has limitation of
flexion of the leg for the knee.
You'll get a rating percentageif you have that, If you have
limitation of.
So that was limitation offlexion.
There's limitation of extensionthat you can get service
connection for, and then you canget service connection for
(15:14):
impairments of the lowerextremity as well, so like shin
splints, and those are allseparate because they're under
different diagnostic codes.
Yeah, so see, and here I can'tcount about zero.
I know.
So here, like, just like theone I read the cartilage a, five
(15:38):
, two, five, nine.
Diagnostic code the semi lunarcartilage removal.
If he's symptomatic he has a10%.
So they must have claimed thathe was asymptomatic.
So he got a zero.
And then a different code 5258,is another cartilage
dislocation with locking andpain.
Completely different code 20%code 20%.
(16:11):
So the needs are kind of.
You have to really look at yourDBQ and the rating schedule to
understand what is going to bemost appropriate for your
disability rating.
Okay, so part of thatdisability rating percentage
comes from the range of motionand functional limitation.
So for the knee DBQ, they wantthe examiner to schedule the
(16:32):
good knee or the conditionthat's not being examined.
So like, okay, you're claimingthe right knee.
They want the examiner toexamine the right knee and the
other knee in comparison.
Okay, and so when you gothrough your physical exam at
the C&P exam, they're going todo exams on both, and a lot of
(16:52):
times the veteran's like well, Ijust claimed my right knee, why
are you looking at my left knee?
And they want a comparison.
Now, I'm not sure why, becauseit really doesn't affect the
rating In my opinion.
It affects the medicalexaminer's opinion.
(17:13):
So whether they are going towrite in favor of your service
connection or not, this givesthem information where they can
look and see the differencebetween the two knees.
Now if a veteran has a rightknee condition related to injury
(17:34):
and service and a left kneecondition that happened after
service, that's not a reallygood story for that medical
examiner to learn and understandthe difference between the two
conditions.
So having a good knee and a badknee I don't think brings value
to that veteran when it comesto their rating disability.
(17:57):
In my opinion it basicallyprovides the examiner with
information that may skew theiropinion.
Initial range of motion.
The examiner is going to taketheir goniometer.
It's like a big protractor orrange of motion tester.
(18:19):
I should have one actually herein my office but they're going
to put it along the knee to lookat the initial range of motion
motion tester.
I should have one actually herein my office so, but it's
they're going to put it alongthe knee to look at the initial
range of motion.
So they're going to have yousay okay, I want you to fully
extend your knee one time, andso you'll extend your knee and
they'll capture the range ofmotion that is the initial range
of motion, and then they'regoing to document whether you
have um have normal range ofmotion or abnormal range of
(18:44):
motion, or whether or not youhave pain or functional loss
associated with that initialrange of motion.
Then they're going to have youcomment on the unaffected side
or the need that's not beingclaimed.
This didn't used to be in here,what we call the contralateral
side, the opposite side.
That didn't used to be in there.
(19:08):
If we look at the next page,which we're on page six, they
want specifically to know if anyof the motions are attributable
to pain, weakness, fatigabilityor incoordination, and so
they're to document that they'realso supposed to do range of
motion where they assist you inyour movement, and document that
(19:30):
.
Then they have you do range ofmotion on your own, okay.
Then because of the delucacriteria from the 90s, they're
going to have you repeat rangeof motion three times and then
measure that at the end of therating that for some reason is
supposed to capture, whether ornot fatigability is demonstrated
(19:54):
in the knee joints.
Um, that three range of motion.
I find it hysterical because Idon't see how you can truly
document fatigability in threemotions, right, and so I
actually looked that up and thatcame from a Social Security,
(20:20):
Disability and American Academyof Family Physicians opinion.
So they wanted to use that datafrom those disability and
brought it over to the VA andthat's where we get the DeLuca
criteria.
Is that three-repeatfatigability, which has really
(20:43):
no clinical application?
I don't know why they chose itfor that.
Any questions?
What I've talked about so far,no, sir, no.
Ray Cobb (20:59):
Okay okay, is there?
Excuse me, bethany, is there anumber?
I mean, when you were talkingabout the range of motion, I
remember when I went through myCMP and they used a little tool
is there like?
For I wish I could remember thenumbers I heard him say, but he
(21:22):
told me a certain degree ofmotion that I had.
When I ended up with mine.
I ended up with a 60%disability on my left knee knee.
(21:48):
Now, did that range of motionaffect that mostly or would that
be affected by the fatigue thatyou were just talking about?
What do they use?
What does the doctor when herecommends those things?
What would be considered thenormal move of motion, the
normal angle at which your kneecan go without hurting or
without completely stopping andlocking up?
Bethanie Spangenberg (22:12):
So there's a difference between clinical
application and what the VA hasokay and what the VA has Okay.
So in the VA paperwork, anormal extension so this is your
knee Okay, this is your kneejoint A normal extension should
(22:37):
be at zero.
If you are flexing, a normal isat 140.
So it's pretty far back there,okay.
When you tell me 60% for yourknee, I'm not thinking that's
range of motion, because rangeof motion doesn't get you, or
limitation in range of motiondoesn't get you, a whole lot of
bang for your buck.
So I just wonder if they'verated it differently In your
(22:59):
case.
Do you have any type ofreplacements?
Ray Cobb (23:04):
in your case, do you have any type of replacements?
No, no, mine is strictly um.
I got bone against bone due tothe diabetes eating away at the
uh, the cartilage and the padbetween my and my knee joints,
and normally I would havesurgery but due to the heart
(23:24):
condition they chose not to dothe surgery.
Bethanie Spangenberg (23:27):
Gotcha, so I'm not sure where they're
getting.
I'd have to look at your ratingschedule to see where they're
getting that 60%.
Is it 60% for just one knee?
Ray Cobb (23:42):
60% for one and 40% for the other.
Bethanie Spangenberg (23:47):
Yeah, I'd have to look at your rating
schedule Because when it comesto just looking at the range of
motion, if you have 60 degreesof flexion okay, so this is 90,
okay of flexion Okay, so this is, this is 90.
Okay, so if you have 60 degreesof range of motion, of excuse
(24:07):
me of flexion in that range ofmotion, you get a 0% rating.
So that means you're only doingthis, okay, and you're only
getting a 0% for that little bitof, I mean, to me that's
significantly limited.
You can't squat down, you'restruggling to pick stuff up off
the floor, so that's a 0%.
(24:29):
So you're not getting a wholelot there.
Now, the reason why this DBQ wasexpanded to the 14 pages is
because of the fatigabilityissue, is because of the
fatigability issue and they wantthe medical examiner to
document where pain starts orwhen they start to exhibit signs
of pain.
So when we do the DBQ, Irecommend that the veteran
(24:54):
verbalize when their pain starts.
Okay, because true disabilityincludes pain and you have to
capture when the pain startsduring your range of motion
testing.
But when you look at disabilityratings, when it comes to range
of motion, the limitation offlexion at 60 degrees is 0%.
(25:19):
Limitation of flexion to 45degrees is 10%.
Limitation to 30 degrees, whichis here's where you start,
limitation to 30,.
So if you can only move thatlittle bit, I should get my
goniometer for this.
Can we hold on?
So I get my goniometer, john Goahead.
(25:44):
Let's see.
J Basser (25:47):
Go ahead.
Bethanie Spangenberg (25:48):
Let's see if I can grab my goniometer.
I am in my office.
J Basser (25:57):
You got a goniometer Ray.
Ray Cobb (26:00):
No, I don't have one of those things.
I've seen a few of them, butI've had them hold them next to
my leg a few times.
J Basser (26:13):
I've had airplane measure with that sucker.
There it is.
Bethanie Spangenberg (26:17):
This is a large joint goniometer.
Okay, I actually have a digitalone, okay.
Okay, I like the digital onebecause it gives me exact
measures.
So I tend to um use my digitalone.
And then this is what isexpected of your cmp examiner.
Okay, so there's little numbershere, yeah that's the one they
(26:40):
used on me.
J Basser (26:42):
They can In all reality.
If your exam requires you to bemeasured with a goniometer and
the examiner doesn't do it, youcan ask for a new exam.
Bethanie Spangenberg (26:52):
Yep, yep.
So let me show you how muchlimited 30 degrees is okay.
So this is the knee fullyextended.
This is your knee joint.
This will be is your knee joint.
This will be your thigh andthis will be your lower leg, so
your foot's down here.
Okay, so a knee flexion of 30degrees is right there.
Okay, that's all you're getting, and you get.
(27:12):
You get 20 for that.
That.
That is significant,significant limitations to me.
So I don't know why they'resaying this is only a 20% rating
.
This is non-functional.
This is not independence, thisis that aid and attendance we
should be looking at.
Right.
So you get, if you have thismuch range of motion, you get a
(27:36):
0%, and normal range of motionis right there.
So visually, you can see thedifference Normal range of
motion, and this gets you zero,this gets you 10,.
This gets you 20, this gets you20.
(28:01):
This gets you 30.
That's wild, anyways.
Ray Cobb (28:08):
Any questions about that?
Bethanie Spangenberg (28:15):
No questions.
J Basser (28:18):
I guess it all depends on the examiner and what the
readings are.
Ray Cobb (28:25):
Well, I think Benedict pointed out a very good point.
There is that, yeah, I guess Ihad a good examiner when I went
through mine.
I've been through it twice.
Both times they asked me toidentify as soon as the pain
started, including standing.
So, like when they first had meto stand, as soon as I put
(28:47):
weight on my knees the painstarts.
And then they saw theinstability of walking, which
also creates more pain, and myability.
I mean, they made me sit downafter I took about three steps,
because they grabbed me by theback of the pants and said sit
(29:07):
down, because they didn't wantto take a chance at me falling.
But I guess that part is all Idon't know.
If you fell right there infront of him, if your knees gave
out, you might get 100% ready,I don't know.
But in any case they wanted tomake sure that I sat down.
But it was mainly the pain Itold them.
(29:30):
I said it's mainly pain when Istand and walk.
You know, I was able toidentify exactly when it started
, how it started.
Bethanie Spangenberg (29:42):
I'd be interested in reading, your
reading.
There is times where I didn'tfeel comfortable doing the knee
exam because of the instabilitywith standing, your range of
motion of the knees.
You should be doing it.
You know if you're doing itactive.
I like to have the veteransstand on both legs and holding a
(30:04):
chair for stability and thenhave them bring their heel to
their butt If you, becausethat's against gravity.
That is the active range ofmotion.
You are going against gravity.
If you're sitting in a chairand you extend that leg out and
then drop your heel to the floor, that's with gravity.
So you're assisted by gravityin that testing.
(30:29):
If you're standing at a chairand bringing your heel to your
butt, that is against gravity.
That is shown true strengthwith, with function.
Does that make sense?
Ray Cobb (30:43):
well, it does.
Let me ask you a third way.
They actually it was the lastexaminer I had.
I actually he had me layingdown and he lifted my leg and he
actually moved the leg or hadme to move it, and he had his
hand behind my knee and I thinkbehind my calf and was holding
(31:04):
that little meter there with histhumb in place and adjusting it
.
So I was not sitting orstanding with that last one.
So I don't know what thepurpose of that was.
Does that make sense, that hedid it that way?
Bethanie Spangenberg (31:20):
Yeah, probably safety, and then
probably so like because he'strying to get it.
If you're sitting and you bendyour knees, your gravity is
helping you, so it's more of apassive movement than you
actively bending that knee.
So if he puts you on a table,you're now being forced to bring
(31:42):
your your heels up to your buttto try to bend that knee.
That that was with laying downis more safety, because if he's
worried about you falling oreven having issues with you,
your knee giving out the safetyreasons is why he's going to put
(32:03):
you on a flatbed.
Ray Cobb (32:06):
Yeah, well, I think I went in there riding my scooter,
you know.
I mean, I didn't walk in, Iwent in on the scooter.
J Basser (32:16):
That would be my first indication of why you're
sitting on the bed, okay, yep.
First of all, what's the gatecall when you're trying to, when
you fall down and you're tryingto cross the floor trying to
get up, is that a certain gatecalled the elbow gate or what,
and you crawl across the floortrying to get up?
Is that a certain gate?
Bethanie Spangenberg (32:37):
called the elbow gate or what.
While we're talking about this,okay, while we're talking about
the instability and stuff, if aveteran has instability and
their knee is giving out or forsome reason, your knee would
lock up and causes you to fall,veterans should be claiming any
(33:01):
injuries that occur from thatfall.
So if you fall because of yourknee and you hit your head and
get a brain bleed and a stroke,you need to be filing for that
fall.
Okay, I know that's not reallytalked a lot with VSOs or
veterans, but it is discussedvery heavily with attorneys and
(33:22):
they talk about, you know,fighting for those, their, their
secondary conditions.
They they occurred because ofthe veterans need condition.
So I want you guys to keep thatin mind, okay.
J Basser (33:37):
Any condition that caused you to fall, like if you
set a snooker for it and youfall, like me, you break bones,
tail bones and all kinds ofstuff.
You know of course it's notpainful, because you know when
you wake up it's painful, butyou know you don't feel it when
it happens.
But you can mess yourself up,paulie, especially when you hit
(34:03):
your metal and you're in trouble.
Bethanie Spangenberg (34:08):
So for.
Ray Cobb (34:09):
Just falling out of a wheelchair.
Count, yes, yes, yes.
Bethanie Spangenberg (34:18):
I laugh.
Ray Cobb (34:18):
That's what I did this weekend.
J Basser (34:22):
You can tell me about that, Ray.
Ray Cobb (34:26):
Well, on our driveway at a certain point there's about
a three-inch drop, and I'd gonedown to the mailbox.
It was coming back and therewas a car parked in the driveway
.
So I went beside the car and Igot a little further than I
meant to and the wheels went offand I just tumbled over and
(34:49):
went out.
And there's the result.
See, this looks a little faker,so I guess I got another claim
there, right?
Can you see that I can't getthat little finger in anymore?
J Basser (35:05):
Well, they can't pay you no more money right.
Ray Cobb (35:07):
Well, I know, I got all I got.
I got all I got.
Bethanie Spangenberg (35:10):
Let me see both your hands like this.
I'm having trouble seeing you.
It almost looked like you mighthave broken your finger.
J Basser (35:22):
He's got that big hand .
Ray Cobb (35:25):
Well that's yeah.
That's yeah.
Well, they can't do anythingabout it though, right, I mean I
can pull on it.
I've tried to straighten it out, but it goes back like it was.
That will get it extra.
Until we go from knees tofingers right, one joint to the
(35:52):
other right.
Bethanie Spangenberg (35:54):
Hey, it's relevant and that's the case.
Oh goodness.
Ray Cobb (35:59):
That's right.
J Basser (36:00):
This bone is connected to that bone.
Right.
Ray Cobb (36:02):
That's right.
Bethanie Spangenberg (36:07):
So when we look at the rest of the range
of motion testing, I brieflymentioned that the examiner is
going to have you do theextension and flexion three
times and then they're going tomeasure it to look at
fatigability.
So if you're not able to dothat, then the examiner is
actually supposed to estimatewhat they think it would be.
(36:28):
Then they're also supposed toestimate what your range of
motion will be during theflare-up.
Estimate what your range ofmotion will be during the
flare-up.
Now, a lot of the times amedical examiner likes to say,
oh, I can't say this withoutmere speculation, but now they
took that option out, so youcan't.
The examiner is not allowed tosay, oh, I can't decide because
of mere speculation.
(36:48):
And if you see that anywhere inyour rating decision or on your
DBQ and it affects a ratingrating decision or on your DBQ
and it affects a rating, youneed to appeal that because that
is not acceptable.
In my opinion, if a clinicianlistens to their veteran, does
their range of motion, theyshould be able to adequately
guesstimate a limitation due toa flare-up.
(37:13):
So if you have the examiner youknow say that they can't, you
just need to.
Often you need to find anotherexaminer.
But that can be difficult to dotoo.
But you need to find somewhereelse in your exam to fight that
appropriate rating.
(37:34):
They do ask about additionalfactors related or contributing
to disability interference withstanding, disturbance with your
gait, deformity, swelling,atrophy, which is where the
muscles start to shrink becauseyou're not using those muscles,
instability of movement,weakened movement those all play
(37:55):
a role in the disability.
Okay, section four looks atmuscle atrophy.
That's the um, where the muscleshrinks because it's not being
used.
It is more common to see thatatrophy and advanced arthritis
because you're not getting this,the range of motion.
You're only not getting therange of motion, you're only
(38:15):
getting that small range ofmotion and that affects the
muscle substance.
It's not as strong anymorebecause of that limited movement
.
So you normally see that inadvanced arthritis talks about
(38:39):
ankylosis.
Okay, sometimes the arthritiscan develop significantly where
there is a frozen joint.
We see frozen joints morecommon in the shoulder, but it
can happen in the knee and youwill actually start to get um
where the the bone.
So this is your femur bone andthis is your tibia at the bottom
, where the knees will actuallythe bones will start to curve so
(39:01):
you'll get bowing into theknees, you'll see somebody with
inward bowing when the arthritisis so advanced that can develop
into ankylosis because of howsevere the arthritis is, where
it's bone on bone and you haveno cushion.
And so there's that wholesection there talks about
ankylosis and they want theexaminer to document at what
(39:22):
degree that that ankylosis hasoccurred or that frozen joint
has occurred.
The joint stability looks at theligaments.
You have ligaments on the sideof the knee that keep the knee
from moving side to side.
Okay, your knee actually onlyhas one plane of movement.
Okay, it's not rotating incircles, it's not moving side to
(39:45):
side, it's moving forward andbackward.
It has one plane.
So if you have instability ofthe joint, the ligaments from
the side can be affected.
And inside the knee you have aligament in the front and a
ligament in the back that crossand they are to stabilize that
forward movement of the kneejoint.
(40:08):
So if you have instability,that means that one of those
four ligaments is affected.
Right, one of those fourligaments is affected.
Section 8 talks about meniscusconditions.
There's obviously a rating thatwe talked about for the
semilunar cartilage, that's themeniscus or part of the meniscus
(40:32):
area, and it asks about sectionfor locking swelling.
If there's any type of meniscaltear, you'll often have a
locking sensation duringmovement or during walking, or
it will swell prettysignificantly.
Talks about surgery, which,where I said surgery notes are
(40:53):
important.
Talks about assistive devices.
You use a brace cane, crutch,walker, wheelchair.
If you have a cane and thereare certain times that you pick
up that cane, you need to beable to tell the examiner when
and why.
So if you're going to thegrocery store and you don't like
to go to the grocery store butyour wife's dragging you along,
(41:16):
you'll take your cane becauseyou know you're going to walk a
long distance and it causes aflare up of the knee.
You need to be able toverbalize that and tell them
what assistive devices that youuse.
Okay, it talks about diagnostictesting.
I think diagnostic testing isabsolutely necessary for VA
(41:38):
claims and you should not begoing into the VA for your C&P
exam never having an x-ray ofthe knee.
If you're claiming a kneecondition, you should already
have one before you even go in.
They may or may not order onefor your C&P exam.
It's up to the examiner.
Then it talks about functionalimpact.
(41:59):
We've talked about itpreviously how you need to put
the functional impact in yourstatement in support of claim.
So you need to talk about howyour work duties are affected
due to the knee condition.
Then the last section is theremark section.
So that just leaves theexaminer area to free text.
(42:19):
Okay, so a lot in there.
I just mainly focused in onwhat kind of questions that you
should know how to answer.
Expect to hear that way you'reprepared on how to answer those
questions.
Any thoughts or opinions on theDBQ?
J Basser (42:45):
Yeah, there's not really necessarily the DBQ in
itself.
The main issue questions I haveis you know, if you are rated
for knee condition and say youare a jumper or you can pedal a
plane or helicopter or whateverand you lay it on your knee,
you've got issues with your kneestructure.
Eventually you're going tostart having secondary issues
(43:09):
other parts of your body likeyour hips and things like that
are going to start to go.
That's all secondary to yourknee too, but I've seen a lot of
denials in the VA on that andit's kind of weird how it
happens.
Ray Cobb (43:23):
Well, that's a good point, John, because in my case
mine is secondary to diabetes,because mine basically started
with the neuropathy in the kneeand foot drop and then, once I
developed foot drop, that's whenmy knees started going bad,
until I had foot drop.
(43:44):
You know my knees didn't botherme any at all, that I can
remember.
You know that became secondary,the third secondary route or
the third question mark, fromthe diabetes itself.
(44:05):
And you know, I'm not for sureif you know the diabetes caused
the neuropathy.
Neuropathy caused the foot drophas caused my knees to go bad
and protruding disc and I thinkit's C1 and C2 in the lower back
.
So all of that could be.
I've never gone for my back,I've never requested anything
(44:28):
for the back.
J Basser (44:31):
S1, S2, or L1, L2?
.
Ray Cobb (44:33):
I guess it's L1 and L2 , the lower part.
J Basser (44:36):
Lumbar, lower lumbar.
Yeah, c1, c2, you don't want tohave it, you wouldn't be having
a show right now.
Ray Cobb (44:42):
But that's a good point, john, because these
things when they go bad, theykind of connect.
Bethanie Spangenberg (44:51):
Let me see if I can show you my
presentation here.
See if it'll let me.
J Basser (44:58):
Okay, okay.
All right, you can see that,then right well so this is
Bethanie Spangenberg (45:23):
actually this is part of a presentation
that I did for a nova conference.
Um, and I had an attorney oncesay you know, secondary
conditions for musculoskeletalcan only go up and down, correct
?
And I'm like, no, it's not howthis works.
So I created this because Iwanted to show how the mechanics
(45:46):
can relate to other conditions.
Okay, so if we look at this youcan see my cursor here the knee
condition can cause a backcondition.
A ankle condition can cause afoot condition.
(46:06):
An ankle condition can cause anankle condition.
A foot and ankle condition cancause a knee condition.
A foot and ankle condition cancause an ankle condition.
A foot and ankle condition cancause a knee condition.
A foot and ankle condition cancause a back condition.
So this is the ankle, this isthe foot, this is the toes.
So if you have flat feet youcan get bunions.
(46:28):
Okay, so you should be claimingthe bunions along with your
flat feet.
But is very common.
So if we look at the green here, these are very common things
that occur.
Okay, this is mainly due togravity and how we walk and
ambulate.
Okay, so these are less lesscommon, but they do occur.
So we're looking at a left kneecondition causing causing a
(46:51):
right knee condition, or a rightknee condition causing a left
knee condition.
Those occur, okay.
So ankle causing knee, theyhappen.
A hip condition causing a lowback condition, vice versa,
those can happen, okay.
And then we're talking aboutknees causing hip issues and
feet conditions causing hipissues and feet conditions
(47:12):
causing hip issues.
So hopefully that's a littlebit of a visual that you know
how common secondary conditionscan develop.
It's all SI joint issues too,Kenneth.
J Basser (47:28):
Say that again.
Bethanie Spangenberg (47:31):
SI joints, si joints, si joints they're
not meant to move.
They can get painful.
They are very painful If youhave.
You can have SI, instabilityand movement.
They're not meant to move,they're a fixed joint but
because there's a little bit ofcartilage there, that little bit
(47:56):
of shifting can create a lot oftension and discomfort,
especially with the musclestructure down there and what.
What john's saying is the sijoint is actually where your
hips meet your back.
So when you, if you have littledips in your lower back, that's
, that's part of your si joint.
Okay, I say joint issues aremore common.
Females because of pregnancyand their hips widen and they're
(48:17):
supposed to retract back andsometimes they do, sometimes
they don't.
So did that visual help kind ofunderstand?
Like how?
Ray Cobb (48:29):
Yeah, yeah, it's good.
Bethanie Spangenberg (48:33):
So we actually I have a Nexus letter
here.
I'm not going to go over everydetail of the nexus, but I just
want to show that we also useconditions together to show how
they're affecting the veteran.
So for this particular nexusletter we talked about how the
service-connected let me see ifI can find where we talk about
(49:03):
it.
Here it is.
We talked about how theservice-connected right knee
meniscal tear with arthritis andinstability of the left ankle.
So we took bothservice-connected
musculoskeletal conditions andtalked how it created another
musculoskeletal condition.
And that just helps to furthersupport how these joint
(49:25):
conditions are related.
So if you're a veteran andyou're claiming a secondary
condition, you don't have to sayit's because of one
musculoskeletal condition.
You can pile those on there andtalk about how all those
musculoskeletal conditionsaffect your movement.
Okay, and then I have a reallygood case that we're working on
(49:51):
right now that I think isimportant to talk about.
Let me just dive in.
J Basser (49:59):
Go ahead Head.
First Make sure the water isdeep enough.
Bethanie Spangenberg (50:05):
All right.
So this veteran, before heentered service in 91, he was on
the diving board and he wasdiving when he landed on the
diving board with his right knee, okay, ouch, he broke his
kneecap.
Okay, this is before service.
(50:26):
Okay, so I have the servicetreatment records from 91.
Before he went into service.
The DOD collected it as part ofhis entrance examination.
Okay, so they collected theinformation.
It shows the x-ray has afracture of the kneecap without
displacement.
Okay, so he was braced, put ina brace and usually you mobilize
(50:51):
those to to keep, uh, pressureoff the kneecap.
And let's see, that was in julyand by september he was
released.
Okay, it shows the x-rays showconsolidation of the fracture,
meaning that it's healed, and itsays he's going to work
aggressively, arrange motionstrengthening program and
(51:15):
actually, um, this was theaugust note, but he was
discharged in september.
Okay, so he completed the, therange of motion had no issues.
He had a fractured patella okay, so then he goes into that.
He had this injury and in theentrance examination the doctor
(51:40):
put that he had a fracture ofthe patella in 91, treated with
bracing, no residual.
Okay, so he had no residuals athis entrance examination of
that knee fracture, his entranceexamination of that knee
fracture While in service.
(52:05):
There's service treatmentrecords that said that he is
complaining of knee pain.
For three weeks in that rightknee he had tenderness.
He had what they call crepitusor that crunchy feeling when you
put your hand on the kneecap.
J Basser (52:14):
You can sometimes hear it.
Bethanie Spangenberg (52:15):
He was diagnosed with tendinitis and he
was put on light duty.
He was prescribed Motrin and tofollow up.
So the veteran was dischargedfrom service six years later and
he claimed in 1997 that he hada knee condition as a result of
(52:39):
service.
So they said in their ratingdecision, they said that the
aggravation of a pre-existingfracture was not service
connected.
Okay, so now we start with.
The veteran had a fracturedkneecap while in service.
(53:03):
He was diagnosed withtendinitis, which are not the
same.
And then, during his claim,they said well, your knee, uh,
fracture, um, it wasn't shownthat it was aggravated, so it's
not.
Your knee condition is notservice related.
So they denied him.
So now he appeals it again in2004, or, excuse me, 2018.
(53:27):
And then he appeals it again in2024.
And at this last ratingdecision he got ahold of us.
Okay, so I'm I'm the one writingthe nexus letter on this and
this is what I'm going to say.
I'm going to say that theveteran had a condition of the
patella, which is the knee.
(53:48):
He had a fracture of the knee.
He did not demonstratetendinitis prior to service.
During military training,during active service, he
developed symptoms of tendinitis, was treated for tendinitis and
continued to have symptoms oftendinitis through service that
(54:09):
he applied for in 97.
Two different conditions thatfracture of the kneecap was
considered healed and he had noresiduals at his entrance exam.
Does that knee fracture makehim more predisposed to
developing tendinitis?
Yes, but he didn't havetendinitis prior to service.
(54:32):
He had tendinitis because ofservice.
So now I'm writing the nexusletter saying didn't have
tendinitis before service.
Service had tendonitis becauseof service.
And then he went on to developa progression of the disease as
a result of the tendonitis.
So not only did he apply in 97,but he continued to apply and
(54:54):
he has all the medical treatmentrecords that shows that
progression and the continuityof the condition, that
progression and the continuityof the condition.
So if you're a veteran andyou're listening to this and you
have a similar case, if youdidn't have tendonitis before
service and now they're tryingto say, well, you had a
preexisting condition thatwasn't aggravated, you need to
(55:15):
break that down and you need tooutline hey, this is what I had
in service.
I didn't have it before service, clearly diagnosed.
This is the progression.
And so sometimes that does takea medical expert to write the
nexus letter, but it has value,especially if you've been
fighting it that long.
J Basser (55:35):
Ed.
Ray Cobb (55:35):
Thank you.
J Basser (57:27):
Okay, thank you.
Any questions, because legalprecedent sets in situations
like that.
Because any military, anyperson that goes in the military
, if they accept you in themilitary and you go to boot camp
(57:49):
, you are presumed to be soundwhen you go in absolutely and
especially a legal precedentprecedent like that.
Yeah, yep, legal precedent setsin, and more at the BVA and the
(58:09):
court than it does at theregional office.
I guarantee you that Mm-hmm Goahead, betsy.
Bethanie Spangenberg (58:19):
That's that physician that did his exam
, specifically annotated on thatknee fracture and said he had
no residuals and reported anormal exam.
So for them to say that itwasn't aggravated or to deny him
for that was just them playingthe game again.
J Basser (58:41):
It's a game.
Bethanie Spangenberg (58:41):
I do want to mention really quickly two
things.
I know we're running out oftime, so I'll make it quick.
One is Valor for Vets team.
One of our providers gotactivated in orders and is
deployed as we speak, and so weare running one man down.
(59:03):
So we're about 10 days behindour normal schedule.
So if you're here and you'relistening, please be patient.
We're working double time totry to get everything turned
over.
But the other thing that Iwanted to mention is that
Michael and I met 16 years agotoday while he was in the Marine
Corps, all by happenstance andso just one of those things
(59:29):
where the stars aligned orwhatever right.
So he had just got done with adeployment and he either had to
go one or two ways.
He was either going to staywith the same unit or get
transferred.
Two ways.
He was either going to staywith the same unit or get
transferred.
At the last minute he decidedto get transferred and it put
him back in Ohio for about amonth.
We met on his third day on hisleave and we've been together
(59:53):
ever since 16 years 16 years ago.
J Basser (01:00:05):
Well, make him take you at the dinner.
Bethanie Spangenberg (01:00:09):
Not tonight.
We got our kids and we got this, so it'll be this weekend, yeah
.
J Basser (01:00:17):
That's a good thing.
You know, ain't love grand, asMarty used to say, marty
Brenneman.
So that's great, that is great,but, guys, it's right up, we're
about out of time.
So, matthew, thank you forcoming on.
You're a breath of fresh air.
We do appreciate.
(01:00:37):
Every time you do.
We learn something.
A lot of folks learn whenyou're on.
And, ray, thanks for coming onto co-hosting buddy, we
appreciate you too.
And yeah, and this is John JBassler On behalf of the J
Bassler's Exposed VetProductions.
(01:00:58):
Bentley Spangenberg, valor forVet and Mr Ray Cobb.
We'll be signing off for now.
Astro Exposed Vet Productions.
Bentley Spangenberg, valor forVet and Mr Ray Cobb.
We'll be signing off for now.
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