J Basser: 0:02

Welcome folks to another episode of the Exposed Ed Productions recording. This is a weekly show. We discuss veterans' issues and different things affecting veterans anywhere from the VA navigation to the VA claims process, from stem to stern, a to B to A to Z. We've been in the past few months doing a little training session as far as the Disabled Benefits Questionnaires otherwise known as the world-famous DBQs that the VA uses and they do their disability exams, and we brought in one of the people that knew exactly what to do with DBQs. She used to do CMPs for the VA. Her name is Bethany Spangenberg and she's our guest tonight and our co-host today is Mr Ray Cobb, down in Tennessee. Looking good, ray.

Ray Cobb: 0:50

Thank you, I appreciate that I'm feeling good.

J Basser: 0:53

Bethany, how are you tonight?

Bethanie Spangenberg: 0:55

I'm doing great. We've got a lot going on and looking forward to a good show. Got a lot to talk about.

J Basser: 1:04

Yes, we do. I know we're going to discuss the old dreaded knees DBQ. I know a lot of vets that got knee 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 IHOP and eat, you know. But why don't you go ahead and get us started? We'll go down the list on the DBQ and kind of give us a little brief of what you know, what we're going to learn tonight.

Bethanie Spangenberg: 1:34

So definitely going to start with an overview when it comes to the musculoskeletal DBQs. These DBQs to talk about between a provider that's doing them and a layman or somebody that's not used to medical stuff is actually very dry, so I'm going to try to make this as smooth as possible and entertaining as possible. When you look at the knee DBQ itself, it's probably one of the easiest DBQs to complete from a disability standpoint, specifically pertaining to musculoskeletal. So the fingers are more difficult wrists, elbows, everything else is more difficult except for the knee. The knee is the easiest one. It's usually pretty smooth in and out the door within 30 minutes, and I say that because it's 14 pages long. Okay, so all these DBQs that we've talked about, they're not as beefy as the musculoskeletal ones, so I've kind of tried to put these musculoskeletal ones on the back end because they are difficult and dry to discuss. So I'm going to hit on the main points. I'm not really going to hit every section. I do have a couple of stories to tie with it that I like to talk about, and then today is a special day for me and my life that I'd like to talk about as well. So maybe we can end up somewhere down that path talking about it. So why I want to talk about the musculoskeletal DBQs is because a lot of veterans are seeking service connection, especially for the knees, and the knees is a good one, it's a common one that we should be talking about. To understand the DBQ means that you know what questions are coming, means that you know what questions are coming. So, as a veteran, if you're applying for a service connection for the knees, you need to understand what you will be asked and you need to know how to answer them. I think one of the things when I was doing these for the VA is I would ask the veteran specific questions about their knee and things that would cause flare-ups or be bothersome for their condition, and they would say, 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 have arthritis, you have flare-ups. So it didn't leave me much material or understanding from the clinical side of things. So when we talk about these questions, I really just want you to let those questions sink in and ask yourself these same questions as I go through here. 14 pages. This DBQ was last updated in September of 2024.

Bethanie Spangenberg: 4:20

First section is your standard question on the veteran's information and the relationship the clinician has to that veteran and how the examination was conducted. As always, there's an evidence review section in there the evidence. I want the veteran to provide, a statement and supportive claim and I want you to talk about when the condition started. The examiner needs to understand when you started having symptoms and it can be a slow progression. You can talk about how well when I was at work it would start to bother me just every once in a while and then it progressed and that's particularly important if you're looking at secondary conditions Now.

Bethanie Spangenberg: 5:06

If you injured your knee in service and you're tying it direct to service, that statement needs to include specifics of that injury. So, for example, if you were jumping off the back of a truck or a vehicle and your knee locked up and you fell, you need to talk about how far you jumped down, was the vehicle moving, did you hit the ground and what kind of care or symptoms did you have to follow? A lot of times when I was doing exams, the veterans would talk about yeah, I heard it in service and they wouldn't give me much details. A big one is motor vehicle accidents. There is so much information to collect from a motor vehicle accident. How fast were you going? Were you the driver or the passenger? Were you wearing a seat belt? How fast were you going? What happened? All of those details need to be in your statement supportive claim for that clinician to understand how this condition began and how it progressed, to understand how this condition began and how it progressed.

Bethanie Spangenberg: 6:05

Another very important piece of evidence that the veterans should have in there is imaging Not necessarily the pictures, but I want the radiologist's report. The radiologist will give an impression for their X-ray or an MRI. That MRI is going to give us details. The X-ray is going to give us details to understand the progression and that part of the story. So that's important to have in there. If you've had any type of surgery, that's important to have in there. The details that the orthopedist puts in there will talk about what the internal parts of the knee look like. You have a meniscus. You have ligaments. The cartilage is part of the meniscus. You have protective cartilage under the bones. The surgeon's going to talk about all of that in their surgical report. So we want to see that surgical report as well. Okay, any questions about evidence? Any comments that anybody wants to chime in about evidence.

Ray Cobb: 7:11

No, I don't think so it was his evidence

Bethanie Spangenberg: 7:20

For page two. It's a full list of diagnosed conditions. We're not going to talk about it, there's a time. Page three continues for diagnosis and starts the medical history. The medical examiner is going to talk about the onset and the course of the claimed condition. The onset and the course of the claimed condition. The next part of the medical history is does the veteran report flare-ups of the knee or lower leg? So we're focusing on knee. So does the veteran report a flare-up of the knee condition? And the flare-up is not really defined good for the medical examiner. So the medical examiner typically has to put it in terms for the veteran to understand.

Bethanie Spangenberg: 8:06

And the way that I always explained it was a temporary worsening or limitation due to the symptoms of the knee condition. So I would always say you know, sometimes patients have a baseline of pain and if they start to walk for X amount of distance that pain will get worse. Sometimes it lasts a few days, sometimes it lasts a few minutes, but then it kind of goes back to baseline. That bump is a flare-up. Some veterans who have back conditions. They will tweak their back and they will have a temporary flare-up. Typically flare-ups of the back are a lot longer lasting than a flare up of the knee. Our knees are a little bit more forgiving in that aspect, where our back isn't. But we're looking at a temporary worsening of that knee condition, whether it's swelling, pain, fatigue, weakness All of that could be incorporated into what a flare-up can can include.

Bethanie Spangenberg: 9:07

You should also know what triggers a flare-up. Okay, that's a question here on page four. What kind of activities is it? Prolonged sitting, prolonged standing, walking for a long distance? Do you have to warm up that knee 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, that fluid shifts within the joint and makes that knee stiff and harder to move. So if you're experiencing flare-ups with those types of activities, you need to know that, you need to be able to talk about that, and if you have a flare-up, you want to talk about how it impacts you.

Bethanie Spangenberg: 9:49

So some people or some veterans will say well, when I get a flare-up, the pain's worse, okay. So what else Do you have? Swelling in the knee joint when you have a flare-up? You know some veterans talk about how they feel instability during a flare-up. The swelling gets bad and it just makes me uncomfortable to even walk on the leg. You need to be able to talk about those symptoms.

Bethanie Spangenberg: 10:16

Okay, there is a question in here that says does the veteran report or have a history of instability or recurrent subluxation of the knee? Often that is a no. The instability has to do with the ligaments within the joint. The subluxation means a dislocation. So you can actually dislocate the kneecap and you can dislocate the tibia, the main bone and the lower leg. So I've actually done exams where the examiner is supposed to put their hands behind the knee joint, they stabilize that knee joint and then they pull on that lower part of the knee and I've completely dislocated a knee before. So it is not a good feeling that hearing that clunk is like, uh, let's just, let's just put this back Very uncomfortable. And those with patellar issues they can get a common if you dislocate that kneecap. Unfortunately that's something that starts to occur often unless it's surgically repaired. So those are the type of things that that question is looking for.

Bethanie Spangenberg: 11:48

The dislocation that I that I did on exam, that was because the veteran had a poorly fitting um knee replacement. They gave him a knee replacement that wasn't appropriate and I don't know how that. He was wearing a brace and he wasn't what he did. Didn't want to go through surgery again because of his age and the risk of complications. So this man had to deal with this instability that I don't even know how he could function day to day, especially if you're going to dislocate that easy. That was wild. A question in here talks about fluid buildup or effusion in the knee, so you want to be able to talk 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 you pull 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 10 years, that was 2011. So I don't know what ended up happening, but that was before I started Valor for Vet. It was when I was on the dark side.

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 range of motion testing and this is where you're going to get your rating, your disability rating. For Now, the knees are interesting when they actually do a rating, because you don't always get one rating for the knee. What I have seen more frequently is that veterans are getting two and three ratings for the knee and I actually pulled a veteran that we worked with his rating sheet because I want to read it to you. So he got a 0% rating for his right knee meniscal tear. He got a 0% rating for a semi-lunar cartilage tear, which is actually part of the meniscus as well. He got a 0% rating for osteoarthritis and limitation of extension and he got a 10% rating for the right knee Sorry, that's the right knee arthritis that actually they give him 10% for later. So he had two for meniscal well, cartilage tears, two 0% for cartilage tears and a 10% for arthritis and limitation of extension, arthritis and limitation of extension.

Bethanie Spangenberg: 14:41

So I don't quite understand. Like I do understand, because they're basing it off the diagnostic codes. If you go in the rating schedule, it has limitation of flexion of the leg for the knee. You'll get a rating percentage if you have that, If you have limitation of. So that was limitation of flexion. There's limitation of extension that you can get service connection for, and then you can get service connection for impairments of the lower extremity as well, so like shin splints, and those are all separate because they're under different diagnostic codes. Yeah, so see, and here I can't count about zero.

Bethanie Spangenberg: 15:31

I know. So here, like, just like the one I read the cartilage a, five, two, five, nine. Diagnostic code the semi lunar cartilage removal. If he's symptomatic he has a 10%. So they must have claimed that he was asymptomatic. So he got a zero. And then a different code 5258, is another cartilage dislocation with locking and pain. Completely different code 20% code 20%. So the needs are kind of.

Bethanie Spangenberg: 16:12

You have to really look at your DBQ and the rating schedule to understand what is going to be most appropriate for your disability rating. Okay, so part of that disability rating percentage comes from the range of motion and functional limitation. So for the knee DBQ, they want the examiner to schedule the good knee or the condition that's not being examined. So like, okay, you're claiming the right knee. They want the examiner to examine the right knee and the other knee in comparison. Okay, and so when you go through your physical exam at the C&P exam, they're going to do exams on both, and a lot of times the veteran's like well, I just claimed my right knee, why are you looking at my left knee? And they want a comparison. Now, I'm not sure why, because it really doesn't affect the rating In my opinion. It affects the medical examiner's opinion. So whether they are going to write in favor of your service connection or not, this gives them information where they can look and see the difference between the two knees. Now if a veteran has a right knee condition related to injury and service and a left knee condition that happened after service, that's not a really good story for that medical examiner to learn and understand the difference between the two conditions. So having a good knee and a bad knee I don't think brings value to that veteran when it comes to their rating disability. In my opinion it basically provides the examiner with information that may skew their opinion.

Bethanie Spangenberg: 18:10

Initial range of motion. The examiner is going to take their goniometer. It's like a big protractor or range of motion tester. I should have one actually here in my office but they're going to put it along the knee to look at the initial range of motion motion tester. I should have one actually here in my office so, but it's they're going to put it along the knee to look at the initial range of motion. So they're going to have you say okay, I want you to fully extend your knee one time, and so you'll extend your knee and they'll capture the range of motion that is the initial range of motion, and then they're going to document whether you have um have normal range of motion or abnormal range of motion, or whether or not you have pain or functional loss associated with that initial range of motion. Then they're going to have you comment on the unaffected side or the need that's not being claimed. 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.

Bethanie Spangenberg: 19:08

If we look at the next page, which we're on page six, they want specifically to know if any of the motions are attributable to pain, weakness, fatigability or incoordination, and so they're to document that they're also supposed to do range of motion where they assist you in your movement, and document that.

Bethanie Spangenberg: 19:31

Then they have you do range of motion on your own, okay. Then because of the deluca criteria from the 90s, they're going to have you repeat range of motion three times and then measure that at the end of the rating that for some reason is supposed to capture, whether or not fatigability is demonstrated in the knee joints. Um, that three range of motion. I find it hysterical because I don't see how you can truly document fatigability in three motions, right, and so I actually looked that up and that came from a Social Security, Disability and American Academy of Family Physicians opinion. So they wanted to use that data from those disability and brought it over to the VA and that's where we get the DeLuca criteria. Is that three-repeat fatigability, which has really no clinical application? I don't know why they chose it for 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 a number? I mean, when you were talking about the range of motion, I remember when I went through my CMP and they used a little tool is there like? For I wish I could remember the numbers I heard him say, but he told me a certain degree of motion that I had. When I ended up with mine. I ended up with a 60% disability on my left knee knee. Now, did that range of motion affect that mostly or would that be affected by the fatigue that you were just talking about? What do they use? What does the doctor when he recommends those things? What would be considered the normal move of motion, the normal angle at which your knee can go without hurting or without completely stopping and locking up?

Bethanie Spangenberg: 22:12

So there's a difference between clinical application and what the VA has okay and what the VA has Okay. So in the VA paperwork, a normal extension so this is your knee Okay, this is your knee joint A normal extension should be at zero. If you are flexing, a normal is at 140. So it's pretty far back there, okay. When you tell me 60% for your knee, I'm not thinking that's range of motion, because range of motion doesn't get you, or limitation in range of motion doesn't get you, a whole lot of bang for your buck. So I just wonder if they've rated it differently In your case. Do you have any type of replacements?

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 to the diabetes eating away at the uh, the cartilage and the pad between my and my knee joints, and normally I would have surgery but due to the heart condition they chose not to do the surgery.

Bethanie Spangenberg: 23:27

Gotcha, so I'm not sure where they're getting. I'd have to look at your rating schedule 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 comes to just looking at the range of motion, if you have 60 degrees of flexion okay, so this is 90, okay of flexion Okay, so this is, this is 90. Okay, so if you have 60 degrees of range of motion, of excuse me of flexion in that range of motion, you get a 0% rating. So that means you're only doing this, okay, and you're only getting a 0% for that little bit of, I mean, to me that's significantly limited. You can't squat down, you're struggling to pick stuff up off the floor, so that's a 0%. So you're not getting a whole lot there.

Bethanie Spangenberg: 24:32

Now, the reason why this DBQ was expanded to the 14 pages is because of the fatigability issue, is because of the fatigability issue and they want the medical examiner to document where pain starts or when they start to exhibit signs of pain. So when we do the DBQ, I recommend that the veteran verbalize when their pain starts. Okay, because true disability includes pain and you have to capture when the pain starts during your range of motion testing. But when you look at disability ratings, when it comes to range of motion, the limitation of flexion at 60 degrees is 0%. Limitation of flexion to 45 degrees is 10%. Limitation to 30 degrees, which is here's where you start, limitation to 30,. So if you can only move that little bit, I should get my goniometer for this. Can we hold on? So I get my goniometer, john Go ahead.

Bethanie Spangenberg: 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, but I'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 digital one, okay. Okay, I like the digital one because it gives me exact measures. So I tend to um use my digital one. And then this is what is expected of your cmp examiner. Okay, so there's little numbers here, yeah that's the one they used on me.

J Basser: 26:42

They can In all reality. If your exam requires you to be measured with a goniometer and the examiner doesn't do it, you can ask for a new exam.

Bethanie Spangenberg: 26:52

Yep, yep. So let me show you how much limited 30 degrees is okay. So this is the knee fully extended. This is your knee joint. This will be is your knee joint. This will be your thigh and this will be your lower leg, so your foot's down here. Okay, so a knee flexion of 30 degrees is right there. Okay, that's all you're getting, and you get. You get 20 for that. That. That is significant, significant limitations to me. So I don't know why they're saying this is only a 20% rating. This is non-functional. This is not independence, this is that aid and attendance we should be looking at. Right. So you get, if you have this much range of motion, you get a 0%, and normal range of motion is right there. So visually, you can see the difference Normal range of motion, and this gets you zero, this gets you 10,. This gets you 20, this gets you 20. 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 I had a good examiner when I went through mine. I've been through it twice. Both times they asked me to identify as soon as the pain started, including standing. So, like when they first had me to stand, as soon as I put weight on my knees the pain starts. And then they saw the instability of walking, which also creates more pain, and my ability. I mean, they made me sit down after I took about three steps, because they grabbed me by the back of the pants and said sit down, because they didn't want to take a chance at me falling. But I guess that part is all I don't know. If you fell right there in front of him, if your knees gave out, you might get 100% ready, I don't know. But in any case they wanted to make sure that I sat down. But it was mainly the pain I told them. I said it's mainly pain when I stand and walk. You know, I was able to identify exactly when it started, how it started.

Bethanie Spangenberg: 29:42

I'd be interested in reading, your reading.

Bethanie Spangenberg: 29:47

There is times where I didn't feel comfortable doing the knee exam because of the instability with standing, your range of motion of the knees. You should be doing it. You know if you're doing it active. I like to have the veterans stand on both legs and holding a chair for stability and then have them bring their heel to their butt If you, because that's against gravity. That is the active range of motion. You are going against gravity. If you're sitting in a chair and you extend that leg out and then drop your heel to the floor, that's with gravity. So you're assisted by gravity in that testing. If you're standing at a chair and bringing your heel to your butt, that is against gravity. That is shown true strength with, 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 last examiner I had. I actually he had me laying down and he lifted my leg and he actually moved the leg or had me to move it, and he had his hand behind my knee and I think behind my calf and was holding that little meter there with his thumb in place and adjusting it. So I was not sitting or standing with that last one. So I don't know what the purpose of that was. Does that make sense, that he did it that way?

Bethanie Spangenberg: 31:20

Yeah, probably safety, and then probably so like because he's trying to get it. If you're sitting and you bend your knees, your gravity is helping you, so it's more of a passive movement than you actively bending that knee.

Bethanie Spangenberg: 31:38

So if he puts you on a table, you're now being forced to bring your your heels up to your butt to try to bend that knee. That that was with laying down is more safety, because if he's worried about you falling or even having issues with you, your knee giving out the safety reasons is why he's going to put 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, I went 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 gate call when you're trying to, when you fall down and you're trying to cross the floor trying to get up, is that a certain gate called the elbow gate or what, and you crawl across the floor trying 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 a veteran has instability and their knee is giving out or for some reason, your knee would lock up and causes you to fall, veterans should be claiming any injuries that occur from that fall. So if you fall because of your knee 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 really talked a lot with VSOs or veterans, but it is discussed very heavily with attorneys and they talk about, you know, fighting for those, their, their secondary conditions. They they occurred because of the veterans need condition. So I want you guys to keep that in mind, okay.

J Basser: 33:37

Any condition that caused you to fall, like if you set a snooker for it and you fall, like me, you break bones, tail bones and all kinds of stuff. You know of course it's not painful, because you know when you wake up it's painful, but you know you don't feel it when it happens. But you can mess yourself up, paulie, especially when you hit 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 gone down to the mailbox. It was coming back and there was a car parked in the driveway. So I went beside the car and I got a little further than I meant to and the wheels went off and I just tumbled over and 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 get that 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 might have 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 anything about 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 to fingers right, one joint to the 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 briefly mentioned that the examiner is going to have you do the extension and flexion three times and then they're going to measure it to look at fatigability. So if you're not able to do that, then the examiner is actually supposed to estimate what they think it would be. Then they're also supposed to estimate what your range of motion will be during the flare-up. Estimate what your range of motion will be during the flare-up. Now, a lot of the times a medical examiner likes to say, oh, I can't say this without mere speculation, but now they took that option out, so you can't. The examiner is not allowed to say, oh, I can't decide because of mere speculation. And if you see that anywhere in your rating decision or on your DBQ and it affects a rating rating decision or on your DBQ and it affects a rating, you need to appeal that because that is not acceptable. In my opinion, if a clinician listens to their veteran, does their range of motion, they should be able to adequately guesstimate a limitation due to a flare-up. So if you have the examiner you know say that they can't, you just need to. Often you need to find another examiner. But that can be difficult to do too. But you need to find somewhere else in your exam to fight that appropriate rating.

Bethanie Spangenberg: 37:34

They do ask about additional factors related or contributing to disability interference with standing, disturbance with your gait, deformity, swelling, atrophy, which is where the muscles start to shrink because you're not using those muscles, instability of movement, weakened movement those all play a role in the disability. Okay, section four looks at muscle atrophy. That's the um, where the muscle shrinks because it's not being used. It is more common to see that atrophy and advanced arthritis because you're not getting this, the range of motion. You're only not getting the range of motion, you're only getting that small range of motion and that affects the muscle substance. It's not as strong anymore because of that limited movement. So you normally see that in advanced arthritis talks about ankylosis. Okay, sometimes the arthritis can develop significantly where there is a frozen joint. We see frozen joints more common in the shoulder, but it can happen in the knee and you will actually start to get um where the the bone. So this is your femur bone and this is your tibia at the bottom, where the knees will actually the bones will start to curve so you'll get bowing into the knees, you'll see somebody with inward bowing when the arthritis is so advanced that can develop into ankylosis because of how severe the arthritis is, where it's bone on bone and you have no cushion. And so there's that whole section there talks about ankylosis and they want the examiner to document at what degree that that ankylosis has occurred or that frozen joint has occurred.

Bethanie Spangenberg: 39:29

The joint stability looks at the ligaments. You have ligaments on the side of the knee that keep the knee from moving side to side. Okay, your knee actually only has one plane of movement. Okay, it's not rotating in circles, it's not moving side to side, it's moving forward and backward. It has one plane. So if you have instability of the joint, the ligaments from the side can be affected. And inside the knee you have a ligament in the front and a ligament in the back that cross and they are to stabilize that forward movement of the knee joint. So if you have instability, that means that one of those four ligaments is affected. Right, one of those four ligaments is affected.

Bethanie Spangenberg: 40:22

Section 8 talks about meniscus conditions. There's obviously a rating that we talked about for the semilunar cartilage, that's the meniscus or part of the meniscus area, and it asks about section for locking swelling. If there's any type of meniscal tear, you'll often have a locking sensation during movement or during walking, or it will swell pretty significantly. Talks about surgery, which, where I said surgery notes are important. Talks about assistive devices. You use a brace cane, crutch, walker, wheelchair. If you have a cane and there are certain times that you pick up that cane, you need to be able to tell the examiner when and why. So if you're going to the grocery store and you don't like to go to the grocery store but your wife's dragging you along, you'll take your cane because you know you're going to walk a long distance and it causes a flare up of the knee. You need to be able to verbalize that and tell them what assistive devices that you use. Okay, it talks about diagnostic testing.

Bethanie Spangenberg: 41:33

I think diagnostic testing is absolutely necessary for VA claims and you should not be going into the VA for your C&P exam never having an x-ray of the knee. If you're claiming a knee condition, you should already have one before you even go in. They may or may not order one for your C&P exam. It's up to the examiner. Then it talks about functional impact. We've talked about it previously how you need to put the functional impact in your statement in support of claim. So you need to talk about how your work duties are affected due to the knee condition. Then the last section is the remark section. So that just leaves the examiner area to free text. Okay, so a lot in there. I just mainly focused in on what kind of questions that you should know how to answer. Expect to hear that way you're prepared on how to answer those questions. Any thoughts or opinions on the DBQ?

J Basser: 42:45

Yeah, there's not really necessarily the DBQ in itself. The main issue questions I have is you know, if you are rated for knee condition and say you are a jumper or you can pedal a plane or helicopter or whatever and you lay it on your knee, you've got issues with your knee structure. Eventually you're going to start having secondary issues other parts of your body like your hips and things like that are going to start to go.

J Basser: 43:14

That's all secondary to your knee too, but I've seen a lot of denials in the VA on that and it'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 knee and foot drop and then, once I developed foot drop, that's when my knees started going bad, until I had foot drop. You know my knees didn't bother me any at all, that I can remember. You know that became secondary, the third secondary route or the third question mark, from the diabetes itself. And you know, I'm not for sure if you know the diabetes caused the neuropathy. Neuropathy caused the foot drop has caused my knees to go bad and protruding disc and I think it'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 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 to have 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, they kind 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 once say you know, secondary conditions for musculoskeletal can only go up and down, correct? And I'm like, no, it's not how this works. So I created this because I wanted to show how the mechanics can relate to other conditions. Okay, so if we look at this you can see my cursor here the knee condition can cause a back condition. A ankle condition can cause a foot condition. An ankle condition can cause an ankle condition. A foot and ankle condition can cause a knee condition. A foot and ankle condition can cause an ankle condition. A foot and ankle condition can cause a knee condition. A foot and ankle condition can cause a back condition.

Bethanie Spangenberg: 46:22

So this is the ankle, this is the foot, this is the toes. So if you have flat feet you can get bunions. Okay, so you should be claiming the 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 to gravity and how we walk and ambulate. Okay, so these are less less common, but they do occur. So we're looking at a left knee condition causing causing a right knee condition, or a right knee condition causing a left knee condition. Those occur, okay. So ankle causing knee, they happen. A hip condition causing a low back condition, vice versa, those can happen, okay. And then we're talking about knees causing hip issues and feet conditions causing hip issues and feet conditions causing hip issues. So hopefully that's a little bit of a visual that you know how common secondary conditions can develop.

Bethanie Spangenberg: 47:25

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 you have. You can have SI, instability and movement. They're not meant to move, they're a fixed joint but because there's a little bit of cartilage there, that little bit of shifting can create a lot of tension and discomfort, especially with the muscle structure down there and what.

Bethanie Spangenberg: 47:59

What john's saying is the si joint is actually where your hips meet your back. So when you, if you have little dips in your lower back, that's, that's part of your si joint. Okay, I say joint issues are more common. Females because of pregnancy and their hips widen and they're supposed to retract back and sometimes they do, sometimes they don't. So did that visual help kind of understand? Like how?

Ray Cobb: 48:29

Yeah, yeah, it's good.

Bethanie Spangenberg: 48:33

So we actually I have a Nexus letter here.

Bethanie Spangenberg: 48:37

I'm not going to go over every detail of the nexus, but I just want to show that we also use conditions together to show how they're affecting the veteran. So for this particular nexus letter we talked about how the service-connected let me see if I can find where we talk about it. Here it is. We talked about how the service-connected right knee meniscal tear with arthritis and instability of the left ankle. So we took both service-connected musculoskeletal conditions and talked how it created another musculoskeletal condition. And that just helps to further support how these joint conditions are related. So if you're a veteran and you're claiming a secondary condition, you don't have to say it's because of one musculoskeletal condition. You can pile those on there and talk about how all those musculoskeletal conditions affect your movement. Okay, and then I have a really good case that we're working on right now that I think is important to talk about. Let me just dive in.

J Basser: 49:59

Go ahead Head. First Make sure the water is deep enough.

Bethanie Spangenberg: 50:05

All right. So this veteran, before he entered service in 91, he was on the diving board and he was diving when he landed on the diving board with his right knee, okay, ouch, he broke his kneecap. Okay, this is before service. Okay, so I have the service treatment records from 91. Before he went into service. The DOD collected it as part of his entrance examination.

Bethanie Spangenberg: 50:39

Okay, so they collected the information. It shows the x-ray has a fracture of the kneecap without displacement. Okay, so he was braced, put in a brace and usually you mobilize those to to keep, uh, pressure off the kneecap. And let's see, that was in july and by september he was released. Okay, it shows the x-rays show consolidation of the fracture, meaning that it's healed, and it says he's going to work aggressively, arrange motion strengthening program and actually, um, this was the august note, but he was discharged in september.

Bethanie Spangenberg: 51:20

Okay, so he completed the, the range of motion had no issues. He had a fractured patella okay, so then he goes into that. He had this injury and in the entrance examination the doctor put that he had a fracture of the patella in 91, treated with bracing, no residual. Okay, so he had no residuals at his entrance examination of that knee fracture, his entrance examination of that knee fracture While in service. There's service treatment records that said that he is complaining of knee pain. For three weeks in that right knee he had tenderness. He had what they call crepitus or 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 to follow up. So the veteran was discharged from service six years later and he claimed in 1997 that he had a knee condition as a result of service. So they said in their rating decision, they said that the aggravation of a pre-existing fracture was not service connected. Okay, so now we start with. The veteran had a fractured kneecap while in service. He was diagnosed with tendinitis, which are not the same. And then, during his claim, they said well, your knee, uh, fracture, um, it wasn't shown that it was aggravated, so it's not. Your knee condition is not service related. So they denied him. So now he appeals it again in 2004, or, excuse me, 2018. And then he appeals it again in 2024. And at this last rating decision he got ahold of us.

Bethanie Spangenberg: 53:37

Okay, so I'm I'm the one writing the nexus letter on this and this is what I'm going to say. I'm going to say that the veteran had a condition of the patella, which is the knee. He had a fracture of the knee. He did not demonstrate tendinitis prior to service. During military training, during active service, he developed symptoms of tendinitis, was treated for tendinitis and continued to have symptoms of tendinitis through service that he applied for in 97. Two different conditions that fracture of the kneecap was considered healed and he had no residuals at his entrance exam. Does that knee fracture make him more predisposed to developing tendinitis? Yes, but he didn't have tendinitis prior to service. He had tendinitis because of service.

Bethanie Spangenberg: 54:35

So now I'm writing the nexus letter saying didn't have tendinitis before service. Service had tendonitis because of service. And then he went on to develop a progression of the disease as a result of the tendonitis. So not only did he apply in 97, but he continued to apply and he has all the medical treatment records that shows that progression and the continuity of the condition, that progression and the continuity of the condition. So if you're a veteran and you're listening to this and you have a similar case, if you didn't have tendonitis before service and now they're trying to say, well, you had a preexisting condition that wasn't aggravated, you need to break that down and you need to outline 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 take a 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 legal precedent sets in situations like that. Because any military, any person that goes in the military, if they accept you in the military and you go to boot camp, you are presumed to be sound when you go in absolutely and especially a legal precedent precedent like that. Yeah, yep, legal precedent sets in, and more at the BVA and the court than it does at the regional office. I guarantee you that Mm-hmm Go ahead, betsy.

Bethanie Spangenberg: 58:19

That's that physician that did his exam, specifically annotated on that knee fracture and said he had no residuals and reported a normal exam. So for them to say that it wasn't aggravated or to deny him for that was just them playing the 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 of time, so I'll make it quick.

Bethanie Spangenberg: 58:49

One is Valor for Vets team. One of our providers got activated in orders and is deployed as we speak, and so we are running one man down. So we're about 10 days behind our normal schedule. So if you're here and you're listening, please be patient. We're working double time to try to get everything turned over. But the other thing that I wanted to mention is that Michael and I met 16 years ago today while he was in the Marine Corps, all by happenstance and so just one of those things where the stars aligned or whatever right. So he had just got done with a deployment and he either had to go one or two ways. He was either going to stay with the same unit or get transferred. Two ways. He was either going to stay with the same unit or get transferred. At the last minute he decided to get transferred and it put him back in Ohio for about a month. We met on his third day on his leave and we've been together ever since 16 years 16 years ago.

J Basser: 1:00:05

Well, make him take you at the dinner.

Bethanie Spangenberg: 1:00:09

Not tonight. We got our kids and we got this, so it'll be this weekend, yeah.

J Basser: 1:00:17

That's a good thing. You know, ain't love grand, as Marty 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 for coming on. You're a breath of fresh air. We do appreciate. Every time you do. We learn something. A lot of folks learn when you're on. And, ray, thanks for coming on to co-hosting buddy, we appreciate you too. And yeah, and this is John J Bassler On behalf of the J Bassler's Exposed Vet Productions. Bentley Spangenberg, valor for Vet and Mr Ray Cobb. We'll be signing off for now. Astro Exposed Vet Productions. Bentley Spangenberg, valor for Vet and Mr Ray Cobb. We'll be signing off for now.