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Electronic Code of Federal Regulations

e-CFR Data is current as of August 28, 2014

Title 38Chapter IPart 4Subpart B → Subject Group


Title 38: Pensions, Bonuses, and Veterans' Relief
PART 4—SCHEDULE FOR RATING DISABILITIES
Subpart B—Disability Ratings


The Musculoskeletal System

§4.40   Functional loss.

Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like.

§4.41   History of injury.

In considering the residuals of injury, it is essential to trace the medical-industrial history of the disabled person from the original injury, considering the nature of the injury and the attendant circumstances, and the requirements for, and the effect of, treatment over past periods, and the course of the recovery to date. The duration of the initial, and any subsequent, period of total incapacity, especially periods reflecting delayed union, inflammation, swelling, drainage, or operative intervention, should be given close attention. This consideration, or the absence of clear cut evidence of injury, may result in classifying the disability as not of traumatic origin, either reflecting congenital or developmental etiology, or the effects of healed disease.

§4.42   Complete medical examination of injury cases.

The importance of complete medical examination of injury cases at the time of first medical examination by the Department of Veterans Affairs cannot be overemphasized. When possible, this should include complete neurological and psychiatric examination, and other special examinations indicated by the physical condition, in addition to the required general and orthopedic or surgical examinations. When complete examinations are not conducted covering all systems of the body affected by disease or injury, it is impossible to visualize the nature and extent of the service connected disability. Incomplete examination is a common cause of incorrect diagnosis, especially in the neurological and psychiatric fields, and frequently leaves the Department of Veterans Affairs in doubt as to the presence or absence of disabling conditions at the time of the examination.

§4.43   Osteomyelitis.

Chronic, or recurring, suppurative osteomyelitis, once clinically identified, including chronic inflammation of bone marrow, cortex, or periosteum, should be considered as a continuously disabling process, whether or not an actively discharging sinus or other obvious evidence of infection is manifest from time to time, and unless the focus is entirely removed by amputation will entitle to a permanent rating to be combined with other ratings for residual conditions, however, not exceeding amputation ratings at the site of election.

§4.44   The bones.

The osseous abnormalities incident to trauma or disease, such as malunion with deformity throwing abnormal stress upon, and causing malalignment of joint surfaces, should be depicted from study and observation of all available data, beginning with inception of injury or disease, its nature, degree of prostration, treatment and duration of convalescence, and progress of recovery with development of permanent residuals. With shortening of a long bone, some degree of angulation is to be expected; the extent and direction should be brought out by X-ray and observation. The direction of angulation and extent of deformity should be carefully related to strain on the neighboring joints, especially those connected with weight-bearing.

§4.45   The joints.

As regards the joints the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations:

(a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.).

(b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.).

(c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.).

(d) Excess fatigability.

(e) Incoordination, impaired ability to execute skilled movements smoothly.

(f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions.

§4.46   Accurate measurement.

Accurate measurement of the length of stumps, excursion of joints, dimensions and location of scars with respect to landmarks, should be insisted on. The use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs. Muscle atrophy must also be accurately measured and reported.

[41 FR 11294, Mar. 18, 1976]

§§4.47-4.54   [Reserved]

§4.55   Principles of combined ratings for muscle injuries.

(a) A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions.

(b) For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions: 6 muscle groups for the shoulder girdle and arm (diagnostic codes 5301 through 5306); 3 muscle groups for the forearm and hand (diagnostic codes 5307 through 5309); 3 muscle groups for the foot and leg (diagnostic codes 5310 through 5312); 6 muscle groups for the pelvic girdle and thigh (diagnostic codes 5313 through 5318); and 5 muscle groups for the torso and neck (diagnostic codes 5319 through 5323).

(c) There will be no rating assigned for muscle groups which act upon an ankylosed joint, with the following exceptions:

(1) In the case of an ankylosed knee, if muscle group XIII is disabled, it will be rated, but at the next lower level than that which would otherwise be assigned.

(2) In the case of an ankylosed shoulder, if muscle groups I and II are severely disabled, the evaluation of the shoulder joint under diagnostic code 5200 will be elevated to the level for unfavorable ankylosis, if not already assigned, but the muscle groups themselves will not be rated.

(d) The combined evaluation of muscle groups acting upon a single unankylosed joint must be lower than the evaluation for unfavorable ankylosis of that joint, except in the case of muscle groups I and II acting upon the shoulder.

(e) For compensable muscle group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups.

(f) For muscle group injuries in different anatomical regions which do not act upon ankylosed joints, each muscle group injury shall be separately rated and the ratings combined under the provisions of §4.25.

(Authority: 38 U.S.C. 1155)

[62 FR 30237, June 3, 1997]

§4.56   Evaluation of muscle disabilities.

(a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal.

(b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged.

(c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.

(d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows:

(1) Slight disability of muscles—(i) Type of injury. Simple wound of muscle without debridement or infection.

(ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section.

(iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue.

(2) Moderate disability of muscles—(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection.

(ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles.

(iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side.

(3) Moderately severe disability of muscles—(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring.

(ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements.

(iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment.

(4) Severe disability of muscles—(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring.

(ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements.

(iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability:

(A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile.

(B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle.

(C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests.

(D) Visible or measurable atrophy.

(E) Adaptive contraction of an opposing group of muscles.

(F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle.

(G) Induration or atrophy of an entire muscle following simple piercing by a projectile.

(Authority: 38 U.S.C. 1155

[62 FR 30238, June 3, 1997]

§4.57   Static foot deformities.

It is essential to make an initial distinction between bilateral flatfoot as a congenital or as an acquired condition. The congenital condition, with depression of the arch, but no evidence of abnormal callosities, areas of pressure, strain or demonstrable tenderness, is a congenital abnormality which is not compensable or pensionable. In the acquired condition, it is to be remembered that depression of the longitudinal arch, or the degree of depression, is not the essential feature. The attention should be given to anatomical changes, as compared to normal, in the relationship of the foot and leg, particularly to the inward rotation of the superior portion of the os calcis, medial deviation of the insertion of the Achilles tendon, the medial tilting of the upper border of the astragalus. This is an unfavorable mechanical relationship of the parts. A plumb line dropped from the middle of the patella falls inside of the normal point. The forepart of the foot is abducted, and the foot everted. The plantar surface of the foot is painful and shows demonstrable tenderness, and manipulation of the foot produces spasm of the Achilles tendon, peroneal spasm due to adhesion about the peroneal sheaths, and other evidence of pain and limited motion. The symptoms should be apparent without regard to exercise. In severe cases there is gaping of bones on the inner border of the foot, and rigid valgus position with loss of the power of inversion and adduction. Exercise with undeveloped or unbalanced musculature, producing chronic irritation, can be an aggravating factor. In the absence of trauma or other definite evidence of aggravation, service connection is not in order for pes cavus which is a typically congenital or juvenile disease.

§4.58   Arthritis due to strain.

With service incurred lower extremity amputation or shortening, a disabling arthritis, developing in the same extremity, or in both lower extremities, with indications of earlier, or more severe, arthritis in the injured extremity, including also arthritis of the lumbosacral joints and lumbar spine, if associated with the leg amputation or shortening, will be considered as service incurred, provided, however, that arthritis affecting joints not directly subject to strain as a result of the service incurred amputation will not be granted service connection. This will generally require separate evaluation of the arthritis in the joints directly subject to strain. Amputation, or injury to an upper extremity, is not considered as a causative factor with subsequently developing arthritis, except in joints subject to direct strain or actually injured.

§4.59   Painful motion.

With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.

§4.60   [Reserved]

§4.61   Examination.

With any form of arthritis (except traumatic arthritis) it is essential that the examination for rating purposes cover all major joints, with especial reference to Heberden's or Haygarth's nodes.

§4.62   Circulatory disturbances.

The circulatory disturbances, especially of the lower extremity following injury in the popliteal space, must not be overlooked, and require rating generally as phlebitis.

§4.63   Loss of use of hand or foot.

Loss of use of a hand or a foot, for the purpose of special monthly compensation, will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of the hand or foot, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance and propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis.

(a) Extremely unfavorable complete ankylosis of the knee, or complete ankylosis of 2 major joints of an extremity, or shortening of the lower extremity of 312 inches (8.9 cms.) or more, will be taken as loss of use of the hand or foot involved.

(b) Complete paralysis of the external popliteal nerve (common peroneal) and consequent, footdrop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot.

[29 FR 6718, May 22, 1964, as amended at 43 FR 45349, Oct. 2, 1978]

§4.64   Loss of use of both buttocks.

Loss of use of both buttocks shall be deemed to exist when there is severe damage to muscle Group XVII, bilateral (diagnostic code number 5317) and additional disability rendering it impossible for the disabled person, without assistance, to rise from a seated position and from a stooped position (fingers to toes position) and to maintain postural stability (the pelvis upon head of femur). The assistance may be rendered by the person's own hands or arms, and, in the matter of postural stability, by a special appliance.

§4.65   [Reserved]

§4.66   Sacroiliac joint.

The common cause of disability in this region is arthritis, to be identified in the usual manner. The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes. X-ray changes from arthritis in this location are decrease or obliteration of the joint space, with the appearance of increased bone density of the sacrum and ilium and sharpening of the margins of the joint. Disability is manifest from erector spinae spasm (not accounted for by other pathology), tenderness on deep palpation and percussion over these joints, loss of normal quickness of motion and resiliency, and postural defects often accompanied by limitation of flexion and extension of the hip. Traumatism is a rare cause of disability in this connection, except when superimposed upon congenital defect or upon an existent arthritis; to permit assumption of pure traumatic origin, objective evidence of damage to the joint, and history of trauma sufficiently severe to injure this extremely strong and practically immovable joint is required. There should be careful consideration of lumbosacral sprain, and the various symptoms of pain and paralysis attributable to disease affecting the lumbar vertebrae and the intervertebral disc.

§4.67   Pelvic bones.

The variability of residuals following these fractures necessitates rating on specific residuals, faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifest by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion.

§4.68   Amputation rule.

The combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. For example, the combined evaluations for disabilities below the knee shall not exceed the 40 percent evaluation, diagnostic code 5165. This 40 percent rating may be further combined with evaluation for disabilities above the knee but not to exceed the above the knee amputation elective level. Painful neuroma of a stump after amputation shall be assigned the evaluation for the elective site of reamputation.

§4.69   Dominant hand.

Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes.

(Authority: 38 U.S.C. 1155)

[62 FR 30239, June 3, 1997]

§4.70   Inadequate examinations.

If the report of examination is inadequate as a basis for the required consideration of service connection and evaluation, the rating agency may request a supplementary report from the examiner giving further details as to the limitations of the disabled person's ordinary activity imposed by the disease, injury, or residual condition, the prognosis for return to, or continuance of, useful work. When the best interests of the service will be advanced by personal conference with the examiner, such conference may be arranged through channels.

§4.71   Measurement of ankylosis and joint motion.

Plates I and II provide a standardized description of ankylosis and joint motion measurement. The anatomical position is considered as 0°, with two major exceptions: (a) Shoulder rotation—arm abducted to 90°, elbow flexed to 90° with the position of the forearm reflecting the midpoint 0° between internal and external rotation of the shoulder; and (b) supination and pronation—the arm next to the body, elbow flexed to 90°, and the forearm in midposition 0° between supination and pronation. Motion of the thumb and fingers should be described by appropriate reference to the joints (See Plate III) whose movement is limited, with a statement as to how near, in centimeters, the tip of the thumb can approximate the fingers, or how near the tips of the fingers can approximate the proximal transverse crease of palm.

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[29 FR 6718, May 22, 1964, as amended at 43 FR 45349, Oct. 2, 1978; 67 FR 48785, July 26, 2002]

§4.71a   Schedule of ratings—musculoskeletal system.

Acute, Subacute, or Chronic Diseases

   Rating
5000   Osteomyelitis, acute, subacute, or chronic:
Of the pelvis, vertebrae, or extending into major joints, or with multiple localization or with long history of intractability and debility, anemia, amyloid liver changes, or other continuous constitutional symptoms100
Frequent episodes, with constitutional symptoms60
With definite involucrum or sequestrum, with or without discharging sinus30
With discharging sinus or other evidence of active infection within the past 5 years20
Inactive, following repeated episodes, without evidence of active infection in past 5 years10
Note (1): A rating of 10 percent, as an exception to the amputation rule, is to be assigned in any case of active osteomyelitis where the amputation rating for the affected part is no percent. This 10 percent rating and the other partial ratings of 30 percent or less are to be combined with ratings for ankylosis, limited motion, nonunion or malunion, shortening, etc., subject, of course, to the amputation rule. The 60 percent rating, as it is based on constitutional symptoms, is not subject to the amputation rule. A rating for osteomyelitis will not be applied following cure by removal or radical resection of the affected bone.
Note (2): The 20 percent rating on the basis of activity within the past 5 years is not assignable following the initial infection of active osteomyelitis with no subsequent reactivation. The prerequisite for this historical rating is an established recurrent osteomyelitis. To qualify for the 10 percent rating, 2 or more episodes following the initial infection are required. This 20 percent rating or the 10 percent rating, when applicable, will be assigned once only to cover disability at all sites of previously active infection with a future ending date in the case of the 20 percent rating.
5001   Bones and joints, tuberculosis of, active or inactive:
Active100
Inactive: See §§4.88b and 4.89.   
5002   Arthritis rheumatoid (atrophic) As an active process:
With constitutional manifestations associated with active joint involvement, totally incapacitating100
Less than criteria for 100% but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods60
Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year40
One or two exacerbations a year in a well-established diagnosis20
For chronic residuals:
For residuals such as limitation of motion or ankylosis, favorable or unfavorable, rate under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.
Note: The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. Assign the higher evaluation.
5003   Arthritis, degenerative (hypertrophic or osteoarthritis):
Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below:
With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations20
With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups10
Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion.
Note (2): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive.
5004   Arthritis, gonorrheal.
5005   Arthritis, pneumococcic.
5006   Arthritis, typhoid.
5007   Arthritis, syphilitic.
5008   Arthritis, streptococcic.
5009   Arthritis, other types (specify).
With the types of arthritis, diagnostic codes 5004 through 5009, rate the disability as rheumatoid arthritis.
5010   Arthritis, due to trauma, substantiated by X-ray findings: Rate as arthritis, degenerative.
5011   Bones, caisson disease of: Rate as arthritis, cord involvement, or deafness, depending on the severity of disabling manifestations.
5012   Bones, new growths of, malignant100
Note: The 100 percent rating will be continued for 1 year following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. At this point, if there has been no local recurrence or metastases, the rating will be made on residuals.
5013   Osteoporosis, with joint manifestations.
5014   Osteomalacia.
5015   Bones, new growths of, benign.
5016   Osteitis deformans.
5017   Gout.
5018   Hydrarthrosis, intermittent.
5019   Bursitis.
5020   Synovitis.
5021   Myositis.
5022   Periostitis.
5023   Myositis ossificans.
5024   Tenosynovitis.
The diseases under diagnostic codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002.
5025   Fibromyalgia (fibrositis, primary fibromyalgia syndrome)
With widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms:
That are constant, or nearly so, and refractory to therapy40
That are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time20
That require continuous medication for control10
Note: Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities.

Prosthetic Implants

   Rating
MajorMinor
5051   Shoulder replacement (prosthesis).
Prosthetic replacement of the shoulder joint:
For 1 year following implantation of prosthesis100100
With chronic residuals consisting of severe, painful motion or weakness in the affected extremity6050
With intermediate degrees of residual weakness, pain or limitation of motion, rate by analogy to diagnostic codes 5200 and 5203.
Minimum rating3020
5052   Elbow replacement (prosthesis).
Prosthetic replacement of the elbow joint:
For 1 year following implantation of prosthesis100100
With chronic residuals consisting of severe painful motion or weakness in the affected extremity5040
With intermediate degrees of residual weakness, pain or limitation of motion rate by analogy to diagnostic codes 5205 through 5208.
Minimum evaluation3020
5053   Wrist replacement (prosthesis).
Prosthetic replacement of wrist joint:
For 1 year following implantation of prosthesis100100
With chronic residuals consisting of severe, painful motion or weakness in the affected extremity4030
With intermediate degrees of residual weakness, pain or limitation of motion, rate by analogy to diagnostic code 5214.
Minimum rating2020
Note: The 100 pct rating for 1 year following implantation of prosthesis will commence after initial grant of the 1-month total rating assigned under §4.30 following hospital discharge.
5054   Hip replacement (prosthesis).
Prosthetic replacement of the head of the femur or of the acetabulum:
For 1 year following implantation of prosthesis   100
Following implantation of prosthesis with painful motion or weakness such as to require the use of crutches   190
Markedly severe residual weakness, pain or limitation of motion following implantation of prosthesis   70
Moderately severe residuals of weakness, pain or limitation of motion   50
Minimum rating   30
5055   Knee replacement (prosthesis).
Prosthetic replacement of knee joint:
For 1 year following implantation of prosthesis   100
With chronic residuals consisting of severe painful motion or weakness in the affected extremity   60
With intermediate degrees of residual weakness, pain or limitation of motion rate by analogy to diagnostic codes 5256, 5261, or 5262.
Minimum rating   30
5056   Ankle replacement (prosthesis).
Prosthetic replacement of ankle joint:
For 1 year following implantation of prosthesis   100
With chronic residuals consisting of severe painful motion or weakness   40
With intermediate degrees of residual weakness, pain or limitation of motion rate by analogy to 5270 or 5271.
Minimum rating   20
Note (1): The 100 pct rating for 1 year following implantation of prosthesis will commence after initial grant of the 1-month total rating assigned under §4.30 following hospital discharge.
Note (2): Special monthly compensation is assignable during the 100 pct rating period the earliest date permanent use of crutches is established.
combinations of disabilities
5104   Anatomical loss of one hand and loss of use of one foot   1100
5105   Anatomical loss of one foot and loss of use of one hand   1100
5106   Anatomical loss of both hands   1100
5107   Anatomical loss of both feet   1100
5108   Anatomical loss of one hand and one foot   1100
5109   Loss of use of both hands   1100
5110   Loss of use of both feet   1100
5111   Loss of use of one hand and one foot   1100

1Also entitled to special monthly compensation.

Table II—Ratings for Multiple Losses of Extremities With Dictator's Rating Code and 38 CFR Citation

Impairment of one extremityImpairment of other extremity
Anatomical loss or loss of use below elbowAnatomical loss or loss of use below kneeAnatomical loss or loss of use above elbow (preventing use of prosthesis)Anatomical loss or loss of use above knee (preventing use of prosthesis)Anatomical loss near shoulder (preventing use of prosthesis)Anatomical loss near hip (preventing use of prosthesis)
Anatomical loss or loss of use below elbowM Codes M-1 a, b, or c, 38 CFR 3.350 (c)(1)(i)L Codes L-1 d, e, f, or g, 38 CFR 3.350(b)M1/2 Code M-5, 38 CFR 3.350 (f)(1)(x)L1/2 Code L-2 c, 38 CFR 3.350 (f)(1)(vi)N Code N-3, 38 CFR 3.350 (f)(1)(xi)M Code M-3 c, 38 CFR 3.350 (f)(1)(viii)
Anatomical loss or loss of use below kneeL Codes L-1 a, b, or c, 38 CFR 3.350(b)L1/2 Code L-2 b, 38 CFR 3.350 (f)(1)(iii)L1/2 Code L-2 a, 38 CFR 3.350 (f)(1)(i)M Code M-3 b, 38 CFR 3.350 (f)(1)(iv)M Code M-3 a, 38 CFR 3.350 (f)(1)(ii)
Anatomical loss or loss of use above elbow (preventing use of prosthesis)N Code N-1, 38 CFR 3.350 (d)(1)M Code M-2 a, 38 CFR 3.350 (c)(1)(iii)N1/2 Code N-4, 38 CFR 3.350 (f)(1)(ix)M1/2 Code M-4 c, 38 CFR 3.350 (f)(1)(xi)
Anatomical loss or loss of use above knee (preventing use of prosthesis)M Code M-2 a, 38 CFR 3.350 (c)(1)(ii)M1/2 Code M-4 b, 38 CFR 3.350 (f)(1)(vii)M1/2 Code M-4 a, 38 CFR 3.350 (f)(1)(v)
Anatomical loss near shoulder (preventing use of prosthesis)O Code O-1, 38 CFR 3.350 (e)(1)(i)N Code N-2 b, 38 CFR 3.350 (d)(3)
Anatomical loss near hip (preventing use of prosthesis)N Code N-2 a, 38 CFR 3.350 (d)(2)

Note.—Need for aid attendance or permanently bedridden qualifies for subpar. L. Code L-1 h, i (38 CFR 3.350(b)). Paraplegia with loss of use of both lower extremities and loss of anal and bladder sphincter control qualifies for subpar. O. Code O-2 (38 CFR 3.350(e)(2)). Where there are additional disabilities rated 50% or 100%, or anatomical or loss of use of a third extremity see 38 CFR 3.350(f) (3), (4) or (5).

(Authority: 38 U.S.C. 1115)

Amputations: Upper Extremity

   Rating
MajorMinor
Arm, amputation of:
5120   Disarticulation190190
5121   Above insertion of deltoid190180
5122   Below insertion of deltoid180170
Forearm, amputation of:
5123   Above insertion of pronator teres180170
5124   Below insertion of pronator teres170160
5125   Hand, loss of use of170160
multiple finger amputations
5126   Five digits of one hand, amputation of170160
Four digits of one hand, amputation of:
5127   Thumb, index, long and ring170160
5128   Thumb, index, long and little170160
5129   Thumb, index, ring and little170160
5130   Thumb, long, ring and little170160
5131   Index, long, ring and little6050
Three digits of one hand, amputation of:
5132   Thumb, index and long6050
5133   Thumb, index and ring6050
5134   Thumb, index and little6050
5135   Thumb, long and ring6050
5136   Thumb, long and little6050
5137   Thumb, ring and little6050
5138   Index, long and ring5040
5139   Index, long and little5040
5140   Index, ring and little5040
5141   Long, ring and little4030
Two digits of one hand, amputation of:
5142   Thumb and index5040
5143   Thumb and long5040
5144   Thumb and ring5040
5145   Thumb and little5040
5146   Index and long4030
5147   Index and ring4030
5148   Index and little4030
5149   Long and ring3020
5150   Long and little3020
5151   Ring and little3020
(a) The ratings for multiple finger amputations apply to amputations at the proximal interphalangeal joints or through proximal phalanges.
(b) Amputation through middle phalanges will be rated as prescribed for unfavorable ankylosis of the fingers.
(c) Amputations at distal joints, or through distal phalanges, other than negligible losses, will be rated as prescribed for favorable ankylosis of the fingers.
(d) Amputation or resection of metacarpal bones (more than one-half the bone lost) in multiple fingers injuries will require a rating of 10 percent added to (not combined with) the ratings, multiple finger amputations, subject to the amputation rule applied to the forearm.
(e) Combinations of finger amputations at various levels, or finger amputations with ankylosis or limitation of motion of the fingers will be rated on the basis of the grade of disability; i.e., amputation, unfavorable ankylosis, most representative of the levels or combinations. With an even number of fingers involved, and adjacent grades of disability, select the higher of the two grades.
(f) Loss of use of the hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump with a suitable prosthetic applicance.
single finger amputations
5152   Thumb, amputation of:
With metacarpal resection4030
At metacarpophalangeal joint or through proximal phalanx3020
At distal joint or through distal phalanx2020
5153   Index finger, amputation of
With metacarpal resection (more than one-half the bone lost)3020
Without metacarpal resection, at proximal interphalangeal joint or proximal thereto2020
Through middle phalanx or at distal joint1010
5154   Long finger, amputation of:
With metacarpal resection (more than one-half the bone lost)2020
Without metacarpal resection, at proximal interphalangeal joint or proximal thereto1010
5155   Ring finger, amputation of:
With metacarpal resection (more than one-half the bone lost)2020
Without metacarpal resection, at proximal interphalangeal joint or proximal thereto1010
5156   Little finger, amputation of:
With metacarpal resection (more than one-half the bone lost)2020
Without metacarpal resection, at proximal interphalangeal joint or proximal thereto1010
Note: The single finger amputation ratings are the only applicable ratings for amputations of whole or part of single fingers.

1Entitled to special monthly compensation.

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Amputations: Lower Extremity

   Rating
Thigh, amputation of:
5160   Disarticulation, with loss of extrinsic pelvic girdle muscles290
5161   Upper third, one-third of the distance from perineum to knee joint measured from perineum280
5162   Middle or lower thirds260
Leg, amputation of:
5163   With defective stump, thigh amputation recommended260
5164   Amputation not improvable by prosthesis controlled by natural knee action260
5165   At a lower level, permitting prosthesis240
5166   Forefoot, amputation proximal to metatarsal bones (more than one-half of metatarsal loss)240
5167   Foot, loss of use of240
5170   Toes, all, amputation of, without metatarsal loss30
5171   Toe, great, amputation of:
With removal of metatarsal head30
Without metatarsal involvement10
5172   Toes, other than great, amputation of, with removal of metatarsal head:
One or two20
Without metatarsal involvement0
5173   Toes, three or four, amputation of, without metatarsal involvement:
Including great toe20
Not including great toe10

2Also entitled to special monthly compensation.

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The Shoulder and Arm

   Rating
MajorMinor
5200   Scapulohumeral articulation, ankylosis of:
Note: The scapula and humerus move as one piece.
Unfavorable, abduction limited to 25° from side5040
Intermediate between favorable and unfavorable4030
Favorable, abduction to 60°, can reach mouth and head3020
5201   Arm, limitation of motion of:
To 25° from side4030
Midway between side and shoulder level3020
At shoulder level2020
5202   Humerus, other impairment of:
Loss of head of (flail shoulder)8070
Nonunion of (false flail joint)6050
Fibrous union of5040
Recurrent dislocation of at scapulohumeral joint.
With frequent episodes and guarding of all arm movements3020
With infrequent episodes, and guarding of movement only at shoulder level2020
Malunion of:
Marked deformity3020
Moderate deformity2020
5203   Clavicle or scapula, impairment of:
Dislocation of2020
Nonunion of:
With loose movement2020
Without loose movement1010
Malunion of1010
Or rate on impairment of function of contiguous joint.

The Elbow and Forearm

   Rating
MajorMinor
5205   Elbow, ankylosis of:
Unfavorable, at an angle of less than 50° or with complete loss of supination or pronation6050
Intermediate, at an angle of more than 90°, or between 70° and 50°5040
Favorable, at an angle between 90° and 70°4030
5206   Forearm, limitation of flexion of:
Flexion limited to 45°5040
Flexion limited to 55°4030
Flexion limited to 70°3020
Flexion limited to 90°2020
Flexion limited to 100°1010
Flexion limited to 110°0   0
5207   Forearm, limitation of extension of:
Extension limited to 110°5040
Extension limited to 100°4030
Extension limited to 90°3020
Extension limited to 75°2020
Extension limited to 60°1010
Extension limited to 45°1010
5208   Forearm, flexion limited to 100° and extension to 45°2020
5209   Elbow, other impairment of Flail joint6050
Joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius2020
5210   Radius and ulna, nonunion of, with flail false joint5040
5211   Ulna, impairment of:
Nonunion in upper half, with false movement:
With loss of bone substance (1 inch (2.5 cms.) or more) and marked deformity4030
Without loss of bone substance or deformity3020
Nonunion in lower half2020
Malunion of, with bad alignment1010
5212   Radius, impairment of:
Nonunion in lower half, with false movement:
With loss of bone substance (1 inch (2.5 cms.) or more) and marked deformity4030
Without loss of bone substance or deformity3020
Nonunion in upper half2020
Malunion of, with bad alignment1010
5213   Supination and pronation, impairment of:
Loss of (bone fusion):
The hand fixed in supination or hyperpronation4030
The hand fixed in full pronation3020
The hand fixed near the middle of the arc or moderate pronation2020
Limitation of pronation:
Motion lost beyond middle of arc3020
Motion lost beyond last quarter of arc, the hand does not approach full pronation2020
Limitation of supination:
To 30° or less1010
Note: In all the forearm and wrist injuries, codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of hand.

The Wrist

   Rating
MajorMinor
5214   Wrist, ankylosis of:
Unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation5040
Any other position, except favorable4030
Favorable in 20° to 30° dorsiflexion3020
Note: Extremely unfavorable ankylosis will be rated as loss of use of hands under diagnostic code 5125.
5215   Wrist, limitation of motion of:
Dorsiflexion less than 15°1010
Palmar flexion limited in line with forearm1010

Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand

   Rating
Major Minor
(1) For the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion
(2) When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level
(3) Evaluation of ankylosis of the index, long, ring, and little fingers:
(i) If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto
(ii) If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position
(iii) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as unfavorable ankylosis
(iv) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as favorable ankylosis
(4) Evaluation of ankylosis of the thumb:
(i) If both the carpometacarpal and interphalangeal joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation at metacarpophalangeal joint or through proximal phalanx
(ii) If both the carpometacarpal and interphalangeal joints are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position
(iii) If only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as unfavorable ankylosis
(iv) If only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as favorable ankylosis
(5) If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations
I. Multiple Digits: Unfavorable Ankylosis
5216   Five digits of one hand, unfavorable ankylosis of6050
Note: Also consider whether evaluation as amputation is warranted.
5217   Four digits of one hand, unfavorable ankylosis of:
Thumb and any three fingers6050
Index, long, ring, and little fingers5040
Note: Also consider whether evaluation as amputation is warranted.
5218   Three digits of one hand, unfavorable ankylosis of:
Thumb and any two fingers5040
Index, long, and ring; index, long, and little; or index, ring, and little fingers4030
Long, ring, and little fingers3020
Note: Also consider whether evaluation as amputation is warranted.
5219 Two digits of one hand, unfavorable ankylosis of:
Thumb and any finger4030
Index and long; index and ring; or index and little fingers3020
Long and ring; long and little; or ring and little fingers2020
Note: Also consider whether evaluation as amputation is warranted.
II. Multiple Digits: Favorable Ankylosis
5220   Five digits of one hand, favorable ankylosis of5040
5221   Four digits of one hand, favorable ankylosis of:
Thumb and any three fingers5040
Index, long, ring, and little fingers4030
5222 Three digits of one hand, favorable ankylosis of:
Thumb and any two fingers4030
Index, long, and ring; index, long, and little; or index, ring, and little fingers3020
Long, ring and little fingers2020
5223   Two digits of one hand, favorable ankylosis of:
Thumb and any finger3020
Index and long; index and ring; or index and little fingers2020
Long and ring; long and little; or ring and little fingers1010
III. Ankylosis of Individual Digits
5224   Thumb, ankylosis of:
Unfavorable2020
Favorable1010
Note: Also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.
5225   Index finger, ankylosis of:
Unfavorable or favorable1010
Note: Also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.
5226   Long finger, ankylosis of:
Unfavorable or favorable1010
Note: Also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.
5227   Ring or little finger, ankylosis of:
Unfavorable or favorable00
Note: Also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.
IV. Limitation of Motion of Individual Digits
5228   Thumb, limitation of motion:
With a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers2020
With a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers1010
With a gap of less than one inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers00
5229   Index or long finger, limitation of motion:
With a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees1010
With a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees00
5230   Ring or little finger, limitation of motion:
Any limitation of motion00

The Spine

   Rating
General Rating Formula for Diseases and Injuries of the Spine
(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes):
With or without symptoms such as pain (whther or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease
Unfavorable ankylosis of the entire spine100
Unfavorable ankylosis of the entire thoracolumbar spine50
Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine40
Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine30
Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis20
Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height10
Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.
Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.
Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted.
Note (4): Round each range of motion measurement to the nearest five degrees.
Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.
Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.
   5235   Vertebral fracture or dislocation
   5236   Sacroiliac injury and weakness
   5237   Lumbosacral or cervical strain
   5238   Spinal stenosis
   5239   Spondylolisthesis or segmental instability
   5240   Ankylosing spondylitis
   5241   Spinal fusion
   5242   Degenerative arthritis of the spine (see also diagnostic code 5003)
   5243   Intervertebral disc syndrome
Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25.
Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes
With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months60
With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months40
With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months20
With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months10
Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.
Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.
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The Hip and Thigh

   Rating
5250   Hip, ankylosis of:
Unfavorable, extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated390
Intermediate70
Favorable, in flexion at an angle between 20° and 40°, and slight adduction or abduction60
5251   Thigh, limitation of extension of:
Extension limited to 5°10
5252   Thigh, limitation of flexion of:
Flexion limited to 10°40
Flexion limited to 20°30
Flexion limited to 30°20
Flexion limited to 45°10
5253   Thigh, impairment of:
Limitation of abduction of, motion lost beyond 10°20
Limitation of adduction of, cannot cross legs10
Limitation of rotation of, cannot toe-out more than 15°, affected leg10
5254   Hip, flail joint80
5255   Femur, impairment of:
Fracture of shaft or anatomical neck of:
With nonunion, with loose motion (spiral or oblique fracture)80
With nonunion, without loose motion, weightbearing preserved with aid of brace60
Fracture of surgical neck of, with false joint60
Malunion of:
With marked knee or hip disability30
With moderate knee or hip disability20
With slight knee or hip disability10

3Entitled to special monthly compensation.

The Knee and Leg

   Rating
5256   Knee, ankylosis of:
Extremely unfavorable, in flexion at an angle of 45° or more60
In flexion between 20° and 45°50
In flexion between 10° and 20°40
Favorable angle in full extension, or in slight flexion between 0° and 10°30
5257   Knee, other impairment of:
Recurrent subluxation or lateral instability:
Severe30
Moderate20
Slight10
5258   Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint20
5259   Cartilage, semilunar, removal of, symptomatic10
5260   Leg, limitation of flexion of:
Flexion limited to 15°30
Flexion limited to 30°20
Flexion limited to 45°10
Flexion limited to 60°0
5261   Leg, limitation of extension of:
Extension limited to 45°50
Extension limited to 30°40
Extension limited to 20°30
Extension limited to 15°20
Extension limited to 10°10
Extension limited to 5°0
5262   Tibia and fibula, impairment of:
Nonunion of, with loose motion, requiring brace40
Malunion of:
With marked knee or ankle disability30
With moderate knee or ankle disability20
With slight knee or ankle disability10
5263   Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated)10

The Ankle

   Rating
5270   Ankle, ankylosis of:
In plantar flexion at more than 40°, or in dorsiflexion at more than 10° or with abduction, adduction, inversion or eversion deformity40
In plantar flexion, between 30° and 40°, or in dorsiflexion, between 0° and 10°30
In plantar flexion, less than 30°20
5271   Ankle, limited motion of:
Marked20
Moderate10
5272   Subastragalar or tarsal joint, ankylosis of:
In poor weight-bearing position20
In good weight-bearing position10
5273   Os calcis or astragalus, malunion of:
Marked deformity20
Moderate deformity10
5274   Astragalectomy20

Shortening of the Lower Extremity

   Rating
5275   Bones, of the lower extremity, shortening of:
Over 4 inches (10.2 cms.)360
31/2 to 4 inches (8.9 cms. to 10.2 cms.)350
3 to 31/2 inches (7.6 cms. to 8.9 cms.)40
21/2 to 3 inches (6.4 cms. to 7.6 cms.)30
2 to 21/2 inches (5.1 cms. to 6.4 cms.)20
11/4 to 2 inches (3.2 cms. to 5.1 cms.)10
Note: Measure both lower extremities from anterior superior spine of the ilium to the internal malleolus of the tibia. Not to be combined with other ratings for fracture or faulty union in the same extremity.

3Also entitled to special monthly compensation.

The Foot

   Rating
5276   Flatfoot, acquired:
Pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances
Bilateral50
Unilateral30
Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities:
Bilateral30
Unilateral20
Moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral10
Mild; symptoms relieved by built-up shoe or arch support0
5277   Weak foot, bilateral:
A symptomatic condition secondary to many constitutional conditions, characterized by atrophy of the musculature, disturbed circulation, and weakness:
Rate the underlying condition, minimum rating10
5278   Claw foot (pes cavus), acquired:
Marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity:
Bilateral50
Unilateral30
All toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads:
Bilateral30
Unilateral20
Great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads:
Bilateral10
Unilateral10
Slight0
5279   Metatarsalgia, anterior (Morton's disease), unilateral, or bilateral10
5280   Hallux valgus, unilateral:
Operated with resection of metatarsal head10
Severe, if equivalent to amputation of great toe10
5281   Hallux rigidus, unilateral, severe:
Rate as hallux valgus, severe.
   Note: Not to be combined with claw foot ratings.
5282   Hammer toe:
All toes, unilateral without claw foot10
Single toes0
5283   Tarsal, or metatarsal bones, malunion of, or nonunion of:
Severe30
Moderately severe20
Moderate10
Note: With actual loss of use of the foot, rate 40 percent.
5284   Foot injuries, other:
Severe30
Moderately severe20
Moderate10
Note: With actual loss of use of the foot, rate 40 percent.

The Skull

   Rating
5296   Skull, loss of part of, both inner and outer tables:
With brain hernia80
Without brain hernia:
Area larger than size of a 50-cent piece or 1.140 in2 (7.355 cm2)50
Area intermediate30
Area smaller than the size of a 25-cent piece or 0.716 in2 (4.619 cm2)10
Note: Rate separately for intracranial complications.

The Ribs

   Rating
5297   Ribs, removal of:
More than six50
Five or six40
Three or four30
Two20
One or resection of two or more ribs without regeneration10
Note (1): The rating for rib resection or removal is not to be applied with ratings for purrulent pleurisy, lobectomy, pneumonectomy or injuries of pleural cavity.
Note (2): However, rib resection will be considered as rib removal in thoracoplasty performed for collapse therapy or to accomplish obliteration of space and will be combined with the rating for lung collapse, or with the rating for lobectomy, pneumonectomy or the graduated ratings for pulmonary tuberculosis.

The Coccyx

   Rating
5298   Coccyx, removal of:
Partial or complete, with painful residuals10
Without painful residuals0

(Authority: 38 U.S.C. 1155)

[29 FR 6718, May 22, 1964, as amended at 34 FR 5062, Mar. 11, 1969; 40 FR 42536, Sept. 15, 1975; 41 FR 11294, Mar. 18, 1976; 43 FR 45350, Oct. 2, 1978; 51 FR 6411, Feb. 24, 1986; 61 FR 20439, May 7, 1996; 67 FR 48785, July 26, 2002; 67 FR 54349, Aug. 22, 2002; 68 FR 51456, Aug. 27, 2003; 69 FR 32450, June 10, 2004]

§4.72   [Reserved]

§4.73   Schedule of ratings—muscle injuries.

Note: When evaluating any claim involving muscle injuries resulting in loss of use of any extremity or loss of use of both buttocks (diagnostic code 5317, Muscle Group XVII), refer to §3.350 of this chapter to determine whether the veteran may be entitled to special monthly compensation.

The Shoulder Girdle and Arm

   Rating
DominantNondominant
5301   Group I. Function: Upward rotation of scapula; elevation of arm above shoulder level. Extrinsic muscles of shoulder girdle: (1) Trapezius; (2) levator scapulae; (3) serratus magnus
Severe4030
Moderately Severe3020
Moderate1010
Slight00
5302   Group II. Function: Depression of arm from vertical overhead to hanging at side (1, 2); downward rotation of scapula (3, 4); 1 and 2 act with Group III in forward and backward swing of arm. Extrinsic muscles of shoulder girdle: (1) Pectoralis major II (costosternal); (2) latissimus dorsi and teres major (teres major, although technically an intrinsic muscle, is included with latissimus dorsi); (3) pectoralis minor; (4) rhomboid
Severe4030
Moderately Severe3020
Moderate2020
Slight00
5303   Group III. Function: Elevation and abduction of arm to level of shoulder; act with 1 and 2 of Group II in forward and backward swing of arm. Intrinsic muscles of shoulder girdle: (1) Pectoralis major I (clavicular); (2) deltoid
Severe4030
Moderately Severe3020
Moderate2020
Slight00
5304   Group IV. Function: Stabilization of shoulder against injury in strong movements, holding head of humerus in socket; abduction; outward rotation and inward rotation of arm. Intrinsic muscles of shoulder girdle: (1) Supraspinatus; (2) infraspinatus and teres minor; (3) subscapularis; (4) coracobrachialis
Severe3020
Moderately Severe2020
Moderate1010
Slight00
5305   Group V. Function: Elbow supination (1) (long head of biceps is stabilizer of shoulder joint); flexion of elbow (1, 2, 3). Flexor muscles of elbow: (1) Biceps; (2) brachialis; (3) brachioradialis
Severe4030
Moderately Severe3020
Moderate1010
Slight00
5306   Group VI. Function: Extension of elbow (long head of triceps is stabilizer of shoulder joint). Extensor muscles of the elbow: (1) Triceps; (2) anconeus.
Severe4030
Moderately Severe3020
Moderate1010
Slight00

The Forearm and Hand

   Rating
Dominant Nondominant
5307   Group VII. Function: Flexion of wrist and fingers. Muscles arising from internal condyle of humerus: Flexors of the carpus and long flexors of fingers and thumb; pronator
Severe4030
Moderately Severe3020
Moderate1010
Slight00
5308   Group VIII. Function: Extension of wrist, fingers, and thumb; abduction of thumb. Muscles arising mainly from external condyle of humerus: Extensors of carpus, fingers, and thumb; supinator
Severe3020
Moderately Severe2020
Moderate1010
Slight00
5309   Group IX. Function: The forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. Intrinsic muscles of hand: Thenar eminence; short flexor, opponens, abductor and adductor of thumb; hypothenar eminence; short flexor, opponens and abductor of little finger; 4 lumbricales; 4 dorsal and 3 palmar interossei
Note: The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Rate on limitation of motion, minimum 10 percent.

The Foot and Leg

   Rating
5310   Group X. Function: Movements of forefoot and toes; propulsion thrust in walking. Intrinsic muscles of the foot: Plantar: (1) Flexor digitorum brevis; (2) abductor hallucis; (3) abductor digiti minimi; (4) quadratus plantae; (5) lumbricales; (6) flexor hallucis brevis; (7) adductor hallucis; (8) flexor digiti minimi brevis; (9) dorsal and plantar interossei. Other important plantar structures: Plantar aponeurosis, long plantar and calcaneonavicular ligament, tendons of posterior tibial, peroneus longus, and long flexors of great and little toes
Severe30
Moderately Severe20
Moderate10
Slight0
Dorsal: (1) Extensor hallucis brevis; (2) extensor digitorum brevis. Other important dorsal structures: cruciate, crural, deltoid, and other ligaments; tendons of long extensors of toes and peronei muscles
Severe20
Moderately Severe10
Moderate10
Slight0
Note: Minimum rating for through-and-through wounds of the foot—10.
5311   Group XI. Function: Propulsion, plantar flexion of foot (1); stabilization of arch (2, 3); flexion of toes (4, 5); Flexion of knee (6). Posterior and lateral crural muscles, and muscles of the calf: (1) Triceps surae (gastrocnemius and soleus); (2) tibialis posterior; (3) peroneus longus; (4) peroneus brevis; (5) flexor hallucis longus; (6) flexor digitorum longus; (7) popliteus; (8) plantaris
Severe30
Moderately Severe20
Moderate10
Slight0
5312   Group XII. Function: Dorsiflexion (1); extension of toes (2); stabilization of arch (3). Anterior muscles of the leg: (1) Tibialis anterior; (2) extensor digitorum longus; (3) extensor hallucis longus; (4) peroneus tertius
Severe30
Moderately Severe20
Moderate10
Slight0

The Pelvic Girdle and Thigh

   Rating
5313   Group XIII. Function: Extension of hip and flexion of knee; outward and inward rotation of flexed knee; acting with rectus femoris and sartorius (see XIV, 1, 2) synchronizing simultaneous flexion of hip and knee and extension of hip and knee by belt-over-pulley action at knee joint. Posterior thigh group, Hamstring complex of 2-joint muscles: (1) Biceps femoris; (2) semimembranosus; (3) semitendinosus
Severe40
Moderately Severe30
Moderate10
Slight0
5314   Group XIV. Function: Extension of knee (2, 3, 4, 5); simultaneous flexion of hip and flexion of knee (1); tension of fascia lata and iliotibial (Maissiat's) band, acting with XVII (1) in postural support of body (6); acting with hamstrings in synchronizing hip and knee (1, 2). Anterior thigh group: (1) Sartorius; (2) rectus femoris; (3) vastus externus; (4) vastus intermedius; (5) vastus internus; (6) tensor vaginae femoris
Severe40
Moderately Severe30
Moderate10
Slight0
5315   Group XV. Function: Adduction of hip (1, 2, 3, 4); flexion of hip (1, 2); flexion of knee (4). Mesial thigh group: (1) Adductor longus; (2) adductor brevis; (3) adductor magnus; (4) gracilis
Severe30
Moderately Severe20
Moderate10
Slight0
5316   Group XVI. Function: Flexion of hip (1, 2, 3). Pelvic girdle group 1: (1) Psoas; (2) iliacus; (3) pectineus
Severe40
Moderately Severe30
Moderate10
Slight0
5317   Group XVII. Function: Extension of hip (1); abduction of thigh; elevation of opposite side of pelvis (2, 3); tension of fascia lata and iliotibial (Maissiat's) band, acting with XIV (6) in postural support of body steadying pelvis upon head of femur and condyles of femur on tibia (1). Pelvic girdle group 2: (1) Gluteus maximus; (2) gluteus medius; (3) gluteus minimus
Severe*50
Moderately Severe40
Moderate20
Slight0
5318   Group XVIII. Function: Outward rotation of thigh and stabilization of hip joint. Pelvic girdle group 3: (1) Pyriformis; (2) gemellus (superior or inferior); (3) obturator (external or internal); (4) quadratus femoris
Severe30
Moderately Severe20
Moderate10
Slight0

*If bilateral, see §3.350(a)(3) of this chapter to determine whether the veteran may be entitled to special monthly compensation.

The Torso and Neck

   Rating
5319   Group XIX. Function: Support and compression of abdominal wall and lower thorax; flexion and lateral motions of spine; synergists in strong downward movements of arm (1). Muscles of the abdominal wall: (1) Rectus abdominis; (2) external oblique; (3) internal oblique; (4) transversalis; (5) quadratus lumborum
Severe50
Moderately Severe30
Moderate10
Slight0
5320   Group XX. Function: Postural support of body; extension and lateral movements of spine. Spinal muscles: Sacrospinalis (erector spinae and its prolongations in thoracic and cervical regions)
Cervical and thoracic region:
Severe40
Moderately Severe20
Moderate10
Slight0
Lumbar region:
Severe60
Moderately Severe40
Moderate20
Slight0
5321   Group XXI. Function: Respiration. Muscles of respiration: Thoracic muscle group
Severe or Moderately Severe20
Moderate10
Slight0
5322   Group XXII. Function: Rotary and forward movements of the head; respiration; deglutition. Muscles of the front of the neck: (Lateral, supra-, and infrahyoid group.) (1) Trapezius I (clavicular insertion); (2) sternocleidomastoid; (3) the “hyoid” muscles; (4) sternothyroid; (5) digastric
Severe30
Moderately Severe20
Moderate10
Slight0
5323   Group XXIII. Function: Movements of the head; fixation of shoulder movements. Muscles of the side and back of the neck: Suboccipital; lateral vertebral and anterior vertebral muscles
Severe30
Moderately Severe20
Moderate10
Slight0

Miscellaneous

   Rating
5324   Diaphragm, rupture of, with herniation. Rate under diagnostic code 7346
5325   Muscle injury, facial muscles. Evaluate functional impairment as seventh (facial) cranial nerve neuropathy (diagnostic code 8207), disfiguring scar (diagnostic code 7800), etc. Minimum, if interfering to any extent with mastication—10
5326   Muscle hernia, extensive. Without other injury to the muscle—10
5327   Muscle, neoplasm of, malignant (excluding soft tissue sarcoma)—100
Note: A rating of 100 percent shall continue beyond the cessation of any surgery, radiation treatment, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of §3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residual impairment of function.
5328   Muscle, neoplasm of, benign, postoperative. Rate on impairment of function, i.e., limitation of motion, or scars, diagnostic code 7805, etc
5329   Sarcoma, soft tissue (of muscle, fat, or fibrous connective tissue)—100
Note: A rating of 100 percent shall continue beyond the cessation of any surgery, radiation treatment, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of §3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residual impairment of function.

(Authority: 38 U.S.C. 1155)

[62 FR 30239, June 3, 1997]



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