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Statement fi‘0m_Dr. M1chael T. Lee, dated October 16,
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izt 2 11>· X} VA exarmnauon .d¤t¤d.N<>v¢mb¢r.11..2000. fr¤m.1h¢..§{A M€d1°&l.C¢¤t€I
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-<~1 -1:» » T..._...... _REASONS FOR DECISION
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1e-= 1. Evaluation of chondromalacia patella, left knee currently evaluated as 0 percent
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_Q l1‘· 1 T; FACTS: The statement from Dr. Lee indieatééthe vetéiéii ié§6i>¢§ ?¢§m~£eht1§rgb1éms tr. {A- ‘·‘·‘ 2;%-fj`
; ztn .. `. ·4;1 f with his knees. The veteran reports he can no longer participate in any activities that he 111; 1:
A I i.°t` ?Y*{T-J1? *1 ¤ likes} He is unable to bike ride, play basketball, jump or even_ do_any _kind of running.
ii§f~`l·j'·` A __, j ,._ 1Mr. Jung reportschronic aching and stiffness when hewakes in the imomingl He Q_-,1 jr,j_{Q*°1_
-- -»-·-_ _¤· 1 ’i·~ 1f piil ’ problems sitting through a movie or at an extended dinner] i_He has pain where he points ____ , 1
, ~j-- 1 ~ -‘‘··A _·1 >· -;_ to the interior aspect of his knees and refers to the lateral region. The veteran denies any-i —e`— i11‘ i fg ~V»'‘ 21 1_1i. I _°_vVk , JQ _..l. A
· . ; ; _ , _ sharp pain along the joint lines although he occasionally has a catch. He denies any gross »?SI1'; -__i‘ j ._..k‘ ; ‘°’‘e, 3 jg _‘,1
. A j_ T instability otherwiseQ There is no locking. _There isno obvious giving way but more gif .=1-1 1; l"1;`Y1·{1· 1 »‘’»·<‘_-._·
he v_ 1 i_ 11 I often chronic pain and some grinding. Thisrecord showsthe veteran has afull mgcpsr y 1k 1 1 ,_“` -
‘ iV.‘ if _i·: k_:_.p _ motion with some crepitation and lateral tightness. The examiner states the veteran . i_‘‘ _‘ _i‘. ix "‘'-· Qi
.. g I appears to have some slight lateral subluxation. 1 He has pain under the lateral facet to i’_a Ig}-1 tli. _1.k. il .,__ .’1V ; 1 .;;V _ 3;- ~;
1 — Eg t1“‘ · 5, » Q palpation butnot on the medial side; He has a negative pivot shift. His drawer signs are --;,2?;.jF1¥’ c.—- X
11 E - 11 1 [ - within normal limits. The examiner states a review of his Xgrays, AP, lateral and sunrise, __ ° T .1 QQ
f 1111.; 1 Q show a slightly increased patellarheight. lt appears to be islightlyinvthe ALTA position.1\;-4* if * 1 1. _ 1 1f.i{j.
, L ’.r_ 1 _ .21 — He also appears to have a definite lateral tilt compression, j_He_has_ subchondral sclerosis - »_p. i_. ~.·k 1
i-‘1 rvpr 1.} E? .11i » . - noted ofthe facetsbilaterally, but minimal osteophytic changes, The assessmentwas Y ;_; -,.., . .-1, ject V
. iikla _bilateral_ anterior knee painwithkunderlying_1ikelykchondromalaciaVsecondary to longe _..”y-,, 1'
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‘-.__ 1 ..»;._ 1 V`,.1 ._». _ The VA examination shows,_the,veteran,_1s well—a earm well-develo ed _ff‘`‘‘ . _1‘_ T ’1·
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.,1. ¤1f’ nourished, 8l€1't,"V cooperative and in no acute distress. ].,The,veterakn has -.,1.·.1 _ .-v·_ -*,—1 1% . 1`· if y
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hisjleit knee is _-6 toi 140Z There is1tenderiiess,laterall$ZQwith`°fYairTonQin5ti6n; '__. ,_Thei€é 'i·‘
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~ 2-;:331-4 ·... negatiye patellar grind, apprehension, gand Lachman's. ,_ There is _a positive McMurray's;T.;-;1e¢-rg-=.; 3;-;;;:;;-;;; ·-,.,
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ANALYSIS; The evaluation of chondromalacia patellajileii kne_ef_isQ increasedto ,10
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Case 2:04-cv-00429-MHM

Document 60-3

Filed 04/14/2006

Page 1 of 3

Case 2:04-cv-00429-MHM

Document 60-3

Filed 04/14/2006

Page 2 of 3

Case 2:04-cv-00429-MHM

Document 60-3

Filed 04/14/2006

Page 3 of 3