Valgus vs varus Radiology Reference Article ...

I have the Grammarly extension for chrome and it keeps telling me I should be using "that" instead of "because." Here is an example of part of one of the sentences it wants me to correct:
"The reason the knee is flexed 30 degrees during varus or valgus stress testing is because the ACL and PCL are tight in the neutral position, and have more slack when the knee is slightly flexed, so in the flexed position only the MCL or LCL integrity is being tested when a medial or lateral force is applied."

Hey all, first case study I’m posting! I’m trying to make this slightly interactive, to encourage people to get involved and promote discussion. If people like this format let me know! More than happy to take suggestions / criticism, and adapt them moving forward.
Clinical Case Study 1
It’s 3:20pm on a Saturday in a quiet suburban neighbourhood, temperature is around 20C.
You are dispatched to an apartment block - non emergent “24yoM PT C/O L) lower leg pain for 1/24” - response time is 10 minutes.
On Arrival:
You find a 24YOM in obvious pain. Pt is 183cm and 84kg. Pt had been playing rugby earlier that day, and had taken a decent blow to the L) lower leg (anterior lower leg made contact with another player) - pt felt a slight pop/ odd sensation at the time. Although painful, after a few minutes he was able to return to play and continue the match. The pain continued, however was a dull ache around 3/10 - ice was applied following the game, pt had a few beers then returned home. It is now approximately 4 hours post injury - Pt states that over the past 1-2 hours, the pain has substantially increased, with the last 60 minutes being borderline unbearable (9/10). Pt reports weakness and difficulty moving the limb, with slight parasthesia distally. On basic inspection of the L) lower leg, there appears to be swelling generalised swelling, however more prominent over the anterior aspect - slight bruising noted. Patient is asking for pain relief at this point, and is obviously distressed.

• PMHx - Asthma, R) #Radius 5y ago - plates in place
• Medications - Salbutamol/Albuterol as needed
• Allergies - Morphine, hayfever
• Last oral intake - Lunch and beers 3-4 hours ago

VSS: - HR 106 - RR 22 - GCS 15 - BP 140/90 - SPO2 98%RA - ECG Sinus Tachycardia
EDIT / UPDATE WILL BE PROVIDED IN 12 HOURS WITH FURTHER INFORMATION
QUESTIONS:

1. List 3 differential diagnoses
2. What further information would you like? What additional assessments would you like to perform?
3. What are you currently concerned about (if anything)?

POST UPDATE: Sorry it’s a bit late, got recalled for a major incident!
A few of the main things asked for is a more detailed pain, neurovasuclar and musculoskeletal assessment.
Pain - I will be using the DOLORS acronym - Description: Generalised severe pain, alternating from deep burning pain to sharp stabbing pain upon movement. - Onset: Dull pain at time of injury, severity began increasing 2/24 ago - Location: Pain in left lower leg, spread throughout however particularly localised anteriorly. - Other Signs / Symptoms: Parasthesia/numbness in limb, slight nausea - Relieving / Provoking Factors: No relief, has attempted icing intermittently with no effect. Provoking factors include any movement or palpation of the affected limb. - Severity: Currently rated as a 9/10 on the pain scale. Pain seems out of proportion to injury.
Neurovascular Assessment: The 6 P’s! - Pain - Yes, severe and localised to lower L) leg - Pallor - Foot appears pale / dusky - Parasthesia - Present in limb distally, felt mainly in toes - Paralysis - Movement is present, however is limited and extremely painful. Weakness in L) limb. - Pulses - Unable to palpate a pedal pulse in the L) foot. - Poikilothermy - Left foot is cold to the touch
Musculoskeletal Assessment: Extremely painful to perform, but this is what you would find if you wished to assess. - Anterior & Posterior Drawer test of the L) knee is negative - Varus / Valgus stress tests are negative - Lower limb is grossly intact - tibia and fibula appear stable from what you can assess
QUESTIONS 1) What condition is now at the top of your differential? 2) Treatment? (Pre-hospital and in-hospital)
UPDATE WILL BE PROVIDED IN 6-8 HOURS

Warning: I wound up writing a novel here, but feel free to just look at the pics. The album contains some gross pictures, including what my knee looked like immediately after the injury as well as some pics of the inside of my knee during surgery. The surgery pics are actually so abstract that they're not that gross, but in case you don't have a strong stomach you've been warned. https://imgur.com/a/G97Dd7E
The Injury
I'm a 28 year old male (27 when the injury occurred). My initial injury happened in September of 2017. I was running towards a ball flying over my head during a soccer game, and mistimed my control of the ball - rather than get my foot under it, I stepped on the ball as it was landing. My right leg was planted when I did this, and since I was sprinting full speed I slipped, causing my whole body to move except my leg. It immediately twisted and dislocated, and I'm told people heard the pop from 40-50 yards away. An ambulance was called, but the refs were afraid to move me so the game was called off while we waited. I didn't have the guts to look down at my leg (and moving even slightly was unimaginably painful so I didn't wanna try) but I knew I would be curious about what it looked like so I had my girlfriend take pictures (pics #1 and 2 in the album).
Initial Treatment
Everyone was fascinated with my knee in the emergency department. It was a university hospital, so all sorts of residents and students came by to look at it and ask questions. Most knee dislocations reduce themselves, but mine was stuck. An orthopedic surgeon with decades of experience would later take a picture of the X-ray they took while it was still dislocated because of how bad it looked. I had to wait a couple hours for the orthopedics resident on call to make his way to me and get approval from a full doctor to reduce my knee, and during this time the adrenaline wore off. I could feel my bones pushing into the skin (I came very close to having an open dislocation, which results in amputation about 50% of the time because infections are difficult to manage), and this was probably the worst pain I've felt in my life. Some of the doctors were talking about emergency surgery to reduce my knee, since it didn't look like it would respond to manual reduction. At this point, my hero arrived - the orthopedics resident came in, looked at my knee, and said we were popping it back into place right now. They shot me up with some dilaudid and four doctors did the deed: one resident grabbed my leg around the knee and held it up while the other three grabbed around my ankle and twisted. When I say twisted, I mean three adults pulling as hard as they could. Four incredible pops later, my knee was back in alignment and the pain was immediately resolved.
They kept me in the hospital for two days for observation because they were concerned my popliteal artery might have been damaged (see Zach Miller's recent knee dislocation for what happens, emergency surgery is needed to save the leg). The artery was fine, so eventually they released me. They took MRIs while I was in the hospital, and based on the MRI and X-ray reports it initially looked like the following were torn: ACL, PCL, MCL, LCL, lateral and medial menisci, patellar tendon, knee capsule, and quadriceps, with avulsion fractures in the tibia and femur. It later turned out there was so much blood in my knee that some of the structures (mainly my menisci and LCL) looked damaged in the MRI but were actually fine. My patellar tendon was only partially torn. Everything else was completely torn (MCL off the bone, ACL and PCL in the middle), including my quad having been basically sliced by my kneecap.
I saw my sports medicine surgeon about a week after the injury (picture #3 in the album, the bruising actually got much worse after this and about 3/4 of my leg was purple) and he did the manual tests - Lachman, drawer, valgus, and varus. My ACL and PCL were definitely torn, and in the valgus test my knee was giving way like it was made of rubber. The varus test looked surprisingly stable though. I was scheduled for surgery just a few days later, and they would basically figure out how much they could do in that surgery (and whether my LCL and menisci were still in good shape) after cutting me open.
Surgery 1
The first surgery was in the end of September. There was so much edema, blood, and swelling that they were only able to repair my MCL, reattaching the original ligament to the bone. My LCL and menisci were confirmed to be healthy though, and they stitched my knee capsule and quad back together. My doctor showed me a picture (unfortunately I don't have a copy) immediately after the procedure of what the inside of my knee looked like - he described it as looking like a grenade had gone off inside my knee, and that the giant hole was not something they had done, but what my knee already looked like when they went in to look. A femoral nerve block meant that I felt absolutely no pain post-op, and I stopped taking my prescribed painkillers at the same time the nerve block wore off. The surgery also immediately cleared up a four day calf cramp I had been experiencing, which my surgeon theorized was being caused by blood flowing from the knee down my leg.
A week after, I saw my surgeon again (pic #4). The swelling had decreased significantly and I was cleared to start PT, but I was non-weight bearing for the first 4-6 weeks post-op. Surgeon wanted me to get to 120 degrees of flexion before he would operate on the ACL and PCL to avoid permanent stiffness - he seemed to think I'd get that back in about a month or so. My physical therapist was awesome, but flexion came very slowly. I was walking without crutches around December, but it wound up taking until January 2018 for me to hit 115 degrees, which my surgeon deemed good enough.
Surgery 2
Surgery #2 was in February 2018. I had been having back of knee pain so they looked at my lateral meniscus again just to verify, but it turned out to be healthy - the pain was probably just a hamstring strain. I received single bundle allografts (hamstring tissue) for both my ACL and PCL, affixed using a button rather than screw (as I understand it, the screw is more beneficial when using patellar grafts that include some bone, but for hamstring grafts the button allows the grafts to be tighter). Autografts were not an option since my knee was so damaged that the doctor didn't feel comfortable harvesting anything else. The nerve block this time was botched so it was only partially effective, but even then pain post-op was minimal. The images labeled 001-009 are of the surgery itself: 001-003 are my medial and lateral meniscus looking good, 004-005 are the drill creating the tunnel in my bones for the grafts, 006-008 are the new ACL and PCL grafts, and 009 is of where my kneecap meets the rest of my knee. After the surgery, I was told that my knee injury was part of an annual presentation by the residents at the university - a dubious honor, but pretty cool.
I was allowed to partially weight bear immediately this time, but I had some weird lumpy swelling (see pic #5) that felt pretty uncomfortable when I would put weight on the leg. I was also put on a CPM machine immediately after the surgery, and hit around 85 degrees of flexion (120 on the CPM, but it does not reflect real flexion very well) within a week. After a PCL reconstruction, however, you're not allowed to bend your own knee for the first four weeks - when the hamstring activates during flexion and pulls back the tibia, it puts stress on the PCL graft which can cause it to loosen. I was on strictly PT-assisted or CPM flexion for the first month, and after that I was given a custom-fit PCL brace made by Ossur that applied a force at my tibia during flexion to counteract the stress on the graft.
The hamstring strain actually got a lot worse during this period, and started to hurt incredibly while doing heel slides. Between lots of hamstring stretching and slowly working on heel slides, however, it eventually faded. The swelling went down, flexion improved, and I was told to drop the crutches as soon as my PCL brace arrived.
Present Day
I had my three month followup earlier this week, and my doctor said all of the repaired/reconstructed ligaments felt incredibly stable. I was expecting to be on the PCL brace for 6 months, but got the all-clear to drop the brace immediately. I was so happy to be done with the brace (which was the 5th knee brace I had gotten for this injury) that I went out and tried riding a real bike for the first time - I was a little shaky, but eventually I got comfortable riding. Stationary bikes are nice, but I had been so excited to finally feel the wind on my face while riding.
I'm not sure that I'll ever actually want to play soccer again, but my goal for PT is to recover to the point that I could play if I felt like it. Not there yet, but I'm told in 6 weeks I might be able to start jogging. Slow progress, but any progress is awesome considering 6 months ago it felt like I would never be close to normal again. Thanks for reading, and feel free to ask any questions!

Hello DubNation!
As Steph's injury seems to have caused all sorts of heartache, stress, nervous tension, anxiety, and the like, to this community, I wanted to address this diagnosis to help further our understanding and hopefully enlighten a few individuals into our beloved leader's current situation. I am not an MD. I am a doctor of physical therapy that enjoys all sports and loves the Dubs.
I will cover the anatomy, diagnosis, assessment, common symptoms, and recovery expectations with a TL;DR at the bottom!.
Anatomy
First let's define the MCL (medial collateral ligament) - The MCL is the broad fan-like ligament that provides the stability to the medial (or inside part) of your knee joint . It prevents "valgus" forces (forces pressing from the outside of the knee inward) from completely bending your knee inward.
Diagnosis
What is the difference between the grades?
Here's a nice picture explained in massive block of words below.
Grade 1: most mild injury, likely due to slight over-stretching of MCL such as with a rapid valgus movement. At WORST there are minor tears to the MCL, but again, very minimal. It is possible for this to be a contact OR non-contact injury (as with Steph). Note the valgus alignment of Steph's knee in this picture (not terribly gruesome, but if you're squeamish... maybe just leave that link blue...).
Grade 2: wide range of moderate to severe injury that includes an over-stretched MCL as well as incomplete tearing of the MCL (or a "partial tear). This is the grade is by far the hardest to predict recovery time as this depends greatly on the extent of the tear.
Grade 3: severe injury due to large valgus force at the knee that leads to a complete rupture/tear of the MCL. In a professional athlete this would likely require surgery.
Assessment
The obvious gold standard for this assessment is an MRI that would be able to show the extend of the damage to the MCL. Within an outpatient clinic or with the trainer prior to the MRI they would also conduct a series of "special tests" to check the stability of the knee ligaments and structures. Here are some of those tests that would be done:

• Lachman's test for ACL
• Anterior drawer test for ACL
• Posterior drawer test for PCL
• Varus stress test (Left) for LCL
• Valgus stress test (Right) for MCL
• McMurray's test for medial and lateral menisci

Common Symptoms
Steph would most likely experience pain. Duh. Other than this, he may have some slight instability and discomfort with any tasks that would put (here's that buzzword again) a valgus stress on his right knee. This would include pushing off from his right leg in a defensive slide, trying to maintain a right pivot foot with someone (looking at you Beverley) leaning into his leg/knee, or even happening to take the wrong jab-step with his right leg.
So why was he limping to the bus in that video o0blarson0o!?!? Well... when your knee hurts you limp. Also, when you have a ligamentous injury such as this, the knee wants to inherently be in its "loose-packed" position (the position that all the joint's surrounding ligaments are most lax) and avoid the "close-packed" position (ligaments are most taut). For the knee, loose-packed = ~25 degrees of bend (which is about where Steph was) and close-packed = full knee extension (which is what a limp avoids).
Recovery Expectation
As stated millions of times from every Reddit doctor available, MCL injuries are difficult to judge. Grade 3 is easy: out for the season (likely at least 6-8 weeks or possible surgery with appropriate rehab). Grade 2 has slightly more gray area, but still most likely out for the season (probably around the 6-8 weeks guideline, but possibly sooner). Grade 1 is tough as a lot will depend on how painful it is, how long the tissues take to heal, but can range anywhere from as little as 1 week to as long as about 6 weeks (if instability and pain remain with sharp cuts). Important to also note is that this injury possesses a definite possibility of getting worse if Steph is rushed to return to play.
Complicating Factors
A couple notes: the MCL is very closely tied into the medial meniscus and even has some connecting fibers. It is entirely possible that an MCL injury could have a slight complication of meniscus involvement, but unlikely in Steph's case. Also, there was contact with Steph's medial knee onto the court along with the valgus stretch. This would be comparable to taking a rubber band (his MCL), stretching it to maximum length (valgus stretch), putting it over the sharp corner of a table (his tibia and femur), and then hitting it with a hammer (the court). Probably not fun.
So there ya have it... A breakdown of the medical side of things...
TL;DR There's a lot of stuff goin' on in Steph's knee. It probably hurts. Possibility of it worsening if rushed, but likely back in 2-4 weeks. I'm sure he's in good hands.

Can someone with a lot of experience in C&P exams help me out this and tell me based on the notes what my rating would be? Thanks, I greatly appreciate it!
Indicate method used to obtain medical information to complete this document:

 [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information 

on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

 [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using 

the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

 [ ] Examination via approved video telehealth [X] In-person examination 

a. Evidence review

 Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment 

records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other:
b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No

1. Diagnosis

   a. List the claimed condition(s) that pertain to this DBQ: bilateral patellofemoral pain syndrome
   b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
   [X] Patellofemoral pain syndrome Side affected: [ ] Right [ ] Left [X] Both ICD Code: M22.2x1 and M22.2x2 Date of diagnosis: Right 2012 Date of diagnosis: Left 2012
   c. Comments (if any): No response provided
   d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
   

2. Medical history

   a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Bilateral patellofemoral pain syndrome diagonsed in the Marines following a fall from a height when he landed on his knees. He has continued to have pain in both anterior kneessince then. He has not had care for his knees since discharge in 2013.
   b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No
   c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No
   

    If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Pain with walking, climbing or decending stairs, and with prolonged standing. He has pain with pressure on the anterior knees, so he 

   cannot kneel down.
   

3. Range of motion (ROM) and functional limitation

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

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   Left Knee
   [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
   

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   b. Observed repetitive use
   Right Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   Left Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   c. Repeated use over time
   Right Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   Left Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   d. Flare-ups No response provided
   e. Additional factors contributing to disability
   Right Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   Left Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   

4. Muscle strength testing

   a. Muscle strength - Rate strength according to the following scale:
   0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength
   Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
   c. Comments, if any: No response provided
   

5. Ankylosis

   Complete this section if the Veteran has ankylosis of the knee and/or lower leg.
   a. Indicate severity of ankylosis and side affected (check all that apply):
   Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   b. Indicate angle of ankylosis in degrees: No response provided
   c. Comments, if any: No response provided
   

6. Joint stability tests

   a. Is there a history of recurrent subluxation?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   b. Is there a history of lateral instability?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   c. Is there a history of recurrent effusion?
   [ ] Yes [X] No
   d. Performance of joint stability testing
   Right Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   Left Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   e. Comments, if any: No response provided
   

7. Additional conditions

   a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No
   b. Comments, if any: No response provided
   

8. Meniscal conditions

   a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No
   b. For all checked boxes above, describe: No response provided
   

9. Surgical procedures

   No response provided
   
10. Other pertinent physical findings, complications, conditions, signs,
    

    symptoms and scars

    a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    c. Comments, if any: No response provided
    

11. Assistive devices

    a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No
    b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided
    

12. Remaining effective function of the extremities

    Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
    [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No
    

13. Diagnostic testing

    a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No
    

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

    b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No
    c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided
    

14. Functional impact

    Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No
    If yes, describe the functional impact of each condition, providing one or more examples: The Veteran has significant pain in both knees with walking, standing and kneeling so that he would have a difficult time perorming duties which would require those actions.
    

15. Remarks, if any:

    No response provided