C&P Exam for Bursitis (DC 5019)

Diagnostic code: 5019Condition: BursitisRegulation: 38 CFR § 4.71aDBQ: DBQ MUSC Knee and Lower Leg; DBQ MUSC Ankle; DBQ MUSC Hip and Thigh; DBQ MUSC Shoulder and Arm; DBQ MUSC Hand and Finger; DBQ MUSC Wrist; DBQ MUSC Back (Thoracolumbar Spine); DBQ MUSC Neck (Cervical Spine); DBQ MUSC Foot Conditions Including Flatfoot (Pes Planus); DBQ RHEUM Arthritis

Which form the examiner uses

For bursitis (DC 5019), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQ MUSC Knee and Lower Leg (public PDF on VA.gov)
DBQ MUSC Ankle (public PDF on VA.gov)
DBQ MUSC Hip and Thigh (public PDF on VA.gov)
DBQ MUSC Shoulder and Arm (public PDF on VA.gov)
DBQ MUSC Hand and Finger (public PDF on VA.gov)
DBQ MUSC Wrist (public PDF on VA.gov)
DBQ MUSC Back (Thoracolumbar Spine) (public PDF on VA.gov)
DBQ MUSC Neck (Cervical Spine) (public PDF on VA.gov)
DBQ MUSC Foot Conditions Including Flatfoot (Pes Planus) (public PDF on VA.gov)
DBQ RHEUM Arthritis (public PDF on VA.gov)

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

DBQ MUSC Knee and Lower Leg

This DBQ evaluates knee and lower leg conditions including range of motion, ankylosis, joint stability, tibial/fibular impairment, meniscal conditions, and surgical procedures.

How DC 5019 maps to this DBQ: This diagnostic code applies to many joints. The C&P examiner uses whichever DBQ matches the affected joint and completes the standard exam sections (Diagnosis, Medical History, Range of Motion, etc.). Sections covering other joints on this form do not apply.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire
1B. Select diagnoses associated with the claimed condition(s) (check all that apply)
The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
Knee strain - Side affected / ICD Code / Date of diagnosis
Knee meniscal tear - Side affected / ICD Code / Date of diagnosis
Knee anterior cruciate ligament tear - Side affected / ICD Code / Date of diagnosis
Knee posterior cruciate ligament tear - Side affected / ICD Code / Date of diagnosis
Patellar or quadriceps tendon rupture - Side affected / ICD Code / Date of diagnosis
Knee joint osteoarthritis - Side affected / ICD Code / Date of diagnosis
Knee joint ankylosis - Side affected / ICD Code / Date of diagnosis
Knee fracture (including patellar fracture) - Side affected / ICD Code / Date of diagnosis
Stress fracture of tibia - Side affected / ICD Code / Date of diagnosis
Tibia and/or fibula fracture - Side affected / ICD Code / Date of diagnosis
Recurrent patellar dislocation - Side affected / ICD Code / Date of diagnosis
Recurrent subluxation - Side affected / ICD Code / Date of diagnosis
Knee instability - Side affected / ICD Code / Date of diagnosis
Patellar instability - Side affected / ICD Code / Date of diagnosis
Knee cartilage restoration surgery - Side affected / ICD Code / Date of diagnosis
Shin splints/medial tibial stress syndrome - MTSS (including post-surgery or treatment) - Side affected / ICD Code / Date of diagnosis
Patellofemoral pain syndrome - Side affected / ICD Code / Date of diagnosis
Degenerative arthritis, other than post traumatic - Side affected / ICD Code / Date of diagnosis
Arthritis, gonorrheal - Side affected / ICD Code / Date of diagnosis
Arthritis, pneumococcic - Side affected / ICD Code / Date of diagnosis
Arthritis, streptococcic - Side affected / ICD Code / Date of diagnosis
Arthritis, syphilitic - Side affected / ICD Code / Date of diagnosis
Arthritis, rheumatoid (multi-joints) - Side affected / ICD Code / Date of diagnosis
Post-traumatic arthritis - Side affected / ICD Code / Date of diagnosis
Arthritis, typhoid - Side affected / ICD Code / Date of diagnosis
Other specified forms of arthropathy (excluding gout) - Side affected / ICD Code / Date of diagnosis / Specify
Osteoporosis, residuals of - Side affected / ICD Code / Date of diagnosis
Osteomalacia, residuals of - Side affected / ICD Code / Date of diagnosis
Bones, neoplasm, benign - Side affected / ICD Code / Date of diagnosis
Osteitis deformans - Side affected / ICD Code / Date of diagnosis
Gout - Side affected / ICD Code / Date of diagnosis
Bursitis - Side affected / ICD Code / Date of diagnosis
Myositis - Side affected / ICD Code / Date of diagnosis
Heterotopic ossification - Side affected / ICD Code / Date of diagnosis
Tendinopathy (select one if known) - Tendinitis / Tendinosis / Tenosynovitis - Side affected / ICD Code / Date of diagnosis
Inflammatory other types - Side affected / ICD Code / Date of diagnosis / Specify
Other (specify) - Other diagnosis #1 / #2 / #3 - Side affected / ICD Code / Date of diagnosis
1C. If there are additional diagnoses that pertain to knee conditions, list using above format

MEDICAL HISTORY (Section II)

2A. Describe the history, including onset and course, of the Veteran's knee and/or lower leg condition(s). Brief summary
2B. Does the Veteran report flare-ups of the knee and/or lower leg?
If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms.
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.
2D. Does the Veteran report or have a history of instability or recurrent subluxation of the knee?
If yes, document the Veteran's description of instability/recurrent subluxation in his/her own words.
2E. Does the Veteran report or have a history of frequent effusion of the knee?
If yes, is the frequent effusion a result of a diagnosis in Section 1? Describe below

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements - All normal / Abnormal or outside of normal range / Unable to test / Not indicated
If 'Unable to test' or 'Not indicated' please explain
If ROM is outside of 'normal' range, but is normal for the Veteran (for reason other than a knee/lower leg condition, such as age, body habitus, neurologic disease), please describe
If abnormal, does the range of motion itself contribute to a functional loss? Yes / No - If yes, please explain
Can testing be performed? Yes / No - If no, provide an explanation
If this is the unclaimed joint, is it: Damaged / Undamaged
Active Range of Motion (ROM) - Flexion endpoint (140 degrees): degrees
Active Range of Motion (ROM) - Extension endpoint (0 degrees): degrees
If noted on examination, which ROM exhibited pain (select all that apply): Flexion / Extension
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe. Flexion degree endpoint (if different than above) / Extension degree endpoint (if different than above)
Passive Range of Motion - Flexion endpoint (140 degrees): degrees / Same as active ROM
Passive Range of Motion - Extension endpoint (0 degrees): degrees / Same as active ROM
If noted on examination, which passive ROM exhibited pain (select all that apply): Flexion / Extension
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe. Flexion degree endpoint (if different than above) / Extension degree endpoint (if different than above)
Is there evidence of pain? Yes / No - If yes, check all that apply: weight-bearing / nonweight-bearing / active motion / passive motion / on rest/non-movement / does not result in/cause functional loss / causes functional loss
Comments
Is there objective evidence of crepitus? Yes / No
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? Yes / No - If yes, please explain. Include location, severity, and relationship to condition(s).
3B. Observed repetitive use ROM - Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No - If no, please explain
Is there additional loss of function or range of motion after three repetitions? Yes / No
If yes - Flexion endpoint (140 degrees): degrees
If yes - Extension endpoint (0 degrees): degrees
Select factors that cause this functional loss. Check all that apply: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
3C. Repeated use over time - Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss. Check all that apply: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion in degrees for this joint immediately after repeated use over time - Flexion endpoint (140 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time - Extension endpoint (0 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3D. Flare-ups - Is the examination being conducted during a flare-up? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups? Yes / No
Select factors that cause this functional loss. Check all that apply: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion in degrees for this joint during flare-ups - Flexion endpoint (140 degrees): degrees
Estimate range of motion in degrees for this joint during flare-ups - Extension endpoint (0 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3E. Additional factors contributing to disability - None / Interference with sitting / Interference with standing / Swelling / Disturbance of locomotion / Deformity / Less movement than normal / More movement than normal / nonunion of fracture / Weakened movement / Atrophy of disuse / Instability of station / Other, describe
Please describe additional contributing factors of disability

MUSCLE ATROPHY (Section IV)

4A. Does the Veteran have muscle atrophy? Yes / No
4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No - If no, provide rationale
4C. For any muscle atrophy due to a diagnosis listed in Section I, indicate specific location of atrophy - Right lower extremity (specify location of measurement such as '10cm above or below knee')
Circumference of more normal side: cm
Circumference of atrophied side: cm
4C. For any muscle atrophy due to a diagnosis listed in Section I, indicate specific location of atrophy - Left lower extremity (specify location of measurement such as '10cm above or below knee')
Circumference of more normal side: cm
Circumference of atrophied side: cm

ANKYLOSIS (Section V)

5A. Is there ankylosis of the knee and/or lower leg? Yes / No
If yes, indicate the severity of ankylosis: 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
5B. Indicate angle of ankylosis in degrees. degrees / N/A no ankylosis of knee joint
5C. If ankylosed, is there involvement of Muscle Group XIII (posterior thigh group, hamstring complex of 2-joint muscles: (1) biceps femoris; (2) semimembranosus; (3) semitendinosus)? Yes / No

JOINT STABILITY (Section VI)

6A. Is there recurrent subluxation or persistent instability? Yes / No
6B. Is there or has there been a ligament tear (sprain)? Yes / No - If yes, select one of the following: Complete ligament tear / Incomplete/partial ligament tear
6C. Was the ligament tear repaired? Yes / No - If yes, select one of the following: Complete tear repair- successful / Complete tear repair- failed
6D. Does the Veteran require a prescription (by a medical provider) of any of the following for ambulation? Yes / No - If yes, check all that apply: Cane(s) / Walker / Crutches / Brace(s)
6E. Is there recurrent patellar instability? Yes / No
6F. Has the Veteran had surgical repair of the knee for patellar instability? Yes / No - If yes, please describe
6G. Does the Veteran require a prescription (by a medical provider) of any of the following for ambulation with patellar instability? Yes / No - If yes, check all that apply: Cane(s) / Walker / Crutches / Brace(s)

TIBIAL OR FIBULAR IMPAIRMENT (Section VII)

7A. Does the Veteran currently have or has the Veteran been diagnosed with a recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment? Yes / No
If yes, indicate condition: Stress fracture of the lower leg / Describe current symptoms
Acquired and/or traumatic genu recurvatum with objectively demonstrated weakness and insecurity in weight-bearing.
Recurrent patellar dislocation
'Shin Splints' (medial tibial stress syndrome - MTSS) - Indicate length of treatment: no treatment received / treatment for less than 12 consecutive months / requiring treatment for 12 consecutive months or more
If Veteran underwent treatment, indicate response to treatment: responsive to surgery and/or treatment / unresponsive to either shoe orthotics or other conservative treatment / unresponsive to surgery and either shoe orthotics or other conservative treatment
Leg length discrepancy (shortening of any bones of the lower extremity) - Measurements: Right leg cm / inch; Left leg cm / inch
For any leg length discrepancy, please describe the relationship to the conditions listed in the diagnosis section above

MENISCAL CONDITIONS (Section VIII)

8A. Does the Veteran currently have or has the Veteran been diagnosed with a meniscus (semilunar cartilage) condition? Yes / No
If yes, indicate severity and frequency of symptoms: No current symptoms / Meniscal dislocation / Meniscal tear / Frequent episodes of joint 'locking' / Frequent episodes of joint pain / Frequent episodes of joint effusion
For all checked boxes above, describe

SURGICAL PROCEDURES (Section IX)

9A. Indicate any surgical procedures that the Veteran has had performed (check all that apply): No surgery
Knee joint resurfacing - Date of surgery
Total knee joint replacement - Date of surgery
Total knee joint replacement residuals: None / Intermediate degrees of residual weakness, pain, or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other residuals, describe
Meniscectomy - Date of surgery
Arthroscopic ligament repair - Date of surgery
Other surgery not described (specify below) - Date of surgery / Type of surgery
Residual signs of symptoms due to meniscectomy, arthroscopic ligament repair or other knee surgery not described above - Describe residuals

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section X)

10A. 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 / No - If yes, describe (brief summary)
10B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section? Yes / No

ASSISTIVE DEVICES (Section XI)

11A. Does the Veteran use any assistive devices (other than those noted in Section VI) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? Yes / No
Wheelchair - Frequency of use: Occasional / Regular / Constant
Brace - Frequency of use: Occasional / Regular / Constant
Crutches - Frequency of use: Occasional / Regular / Constant
Cane(s) - Frequency of use: Occasional / Regular / Constant
Walker - Frequency of use: Occasional / Regular / Constant
Other, describe - Frequency of use: Occasional / Regular / Constant
11B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XII)

12A. Due to the Veterans knee 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 lower extremity include balance and propulsion, etc.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. / No
If yes, indicate extremities for which this applies: Right lower / Left lower
12B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary)

DIAGNOSTIC TESTING (Section XIII)

13A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination? Yes / No
13B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No - If yes, indicate side: Right / Left / Both
13C. If yes, provide type of test or procedure, date, and results (brief summary)
13D. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No - If yes, provide type of test or procedure, date, and results (brief summary)
13E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions

FUNCTIONAL IMPACT (Section XIV)

14A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples

REMARKS (Section XV)

15A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

DBQ MUSC Ankle

This DBQ evaluates ankle conditions including range of motion, ankylosis, joint stability, surgical procedures, and functional impact.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire
1B. Select diagnoses associated with the claimed condition(s) (check all that apply)
The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
Lateral collateral ligament sprain (chronic/recurrent) - Side affected / ICD code / Date of diagnosis
Deltoid ligament sprain (chronic/recurrent) - Side affected / ICD code / Date of diagnosis
Osteochondritis dissecans to include osteochondral fracture - Side affected / ICD code / Date of diagnosis
Impingement (anterior/posterior (or trigonum syndrome)/anterolateral) - Side affected / ICD code / Date of diagnosis
Tendonitis (Achilles/peroneal/posterior tibial) - Side affected / ICD code / Date of diagnosis
Retrocalcaneal bursitis - Side affected / ICD code / Date of diagnosis
Achilles' tendon rupture - Side affected / ICD code / Date of diagnosis
Avascular necrosis, talus - Side affected / ICD code / Date of diagnosis
Ankle joint replacement - Side affected / ICD code / Date of diagnosis
Ankylosis of ankle, subtalar or tarsal joint - Side affected / ICD code / Date of diagnosis
Shin splints/medial tibial stress syndrome - MTSS (including post-surgery or treatment) - Side affected / ICD code / Date of diagnosis
Degenerative arthritis, other than post-traumatic - Side affected / ICD code / Date of diagnosis
Arthritis, gonorrheal - Side affected / ICD code / Date of diagnosis
Arthritis, pneumococcic - Side affected / ICD code / Date of diagnosis
Arthritis, streptococcic - Side affected / ICD code / Date of diagnosis
Arthritis, syphilitic - Side affected / ICD code / Date of diagnosis
Arthritis, rheumatoid (multi-joints) - Side affected / ICD code / Date of diagnosis
Arthritis, post-traumatic - Side affected / ICD code / Date of diagnosis
Arthritis, typhoid - Side affected / ICD code / Date of diagnosis
Other specified forms of arthropathy (excluding gout) - Side affected / ICD code / Date of diagnosis
Osteoporosis, residuals of - Side affected / ICD code / Date of diagnosis
Osteomalacia, residuals of - Side affected / ICD code / Date of diagnosis
Bones, neoplasm, benign - Side affected / ICD code / Date of diagnosis
Bones, neoplasm, malignant, primary or secondary - Side affected / ICD code / Date of diagnosis
Osteitis deformans - Side affected / ICD code / Date of diagnosis
Gout - Side affected / ICD code / Date of diagnosis
Bursitis - Side affected / ICD code / Date of diagnosis
Myositis - Side affected / ICD code / Date of diagnosis
Heterotopic ossification - Side affected / ICD code / Date of diagnosis
Tendinopathy (select one if known): Tendinitis / Tendinosis / Tenosynovitis - Side affected / ICD code / Date of diagnosis
Other diagnosis #1 - Side affected / ICD code / Date of diagnosis
Other diagnosis #2 - Side affected / ICD code / Date of diagnosis
Other diagnosis #3 - Side affected / ICD code / Date of diagnosis
1C. If there are additional diagnoses that pertain to ankle conditions, list using above format

MEDICAL HISTORY (Section II)

2A. Describe the history, including onset and course, of the Veteran's ankle condition(s). Brief summary
2B. Does the Veteran report flare-ups of the ankle?
If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he/she experiences during a flare-up of symptoms
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words
2D. Does the Veteran report or have a history of instability of the ankle?
If yes, document the Veteran's description of instability in his/her own words

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements: All Normal / Abnormal or outside of normal range / Unable to test / Not indicated
If 'Unable to test' or 'Not indicated', please explain
If ROM is outside of 'normal' range, but is normal for the Veteran (for reasons other than an ankle condition, such as age, body habitus, neurologic disease), please describe
If abnormal, does the range of motion itself contribute to a functional loss?
Can testing be performed?
If this is the unclaimed joint, is it: Damaged / Undamaged
Active Range of Motion (ROM) - Plantar flexion endpoint (45 degrees): degrees
Active Range of Motion (ROM) - Dorsiflexion endpoint (20 degrees): degrees
If noted on examination, which ROM exhibited pain (select all that apply): Plantar flexion / Dorsiflexion
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe
Plantar flexion degree endpoint (if different than above)
Dorsiflexion degree endpoint (if different than above)
Passive Range of Motion - Plantar flexion endpoint (45 degrees): degrees / Same as active ROM
Passive Range of Motion - Dorsiflexion endpoint (20 degrees): degrees / Same as active ROM
If noted on examination, which passive ROM exhibited pain (select all that apply): Plantar flexion / Dorsiflexion
Is there evidence of pain? Weight-bearing / Nonweight-bearing / Active motion / Passive motion / On rest/nonmovement / Causes functional loss / Does not result in/cause functional loss
Comments
Is there objective evidence of crepitus?
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? If yes, please explain. Include location, severity, and relationship to condition(s).
3B. Observed repetitive use ROM - Is the Veteran able to perform repetitive-use testing with at least three repetitions?
Is there additional loss of function or range of motion after three repetitions?
After three repetitions - Plantar flexion endpoint (45 degrees): degrees
After three repetitions - Dorsiflexion endpoint (20 degrees): degrees
Select factors that cause this functional loss. Check all that apply: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
3C. Repeated use over time - Is the Veteran being examined immediately after repeated use over time?
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?
Select factors that cause this functional loss (repeated use over time): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimate range of motion in degrees for this joint immediately after repeated use over time - Plantar flexion endpoint (45 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time - Dorsiflexion endpoint (20 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3D. Flare-ups - Is the examination being conducted during a flare-up?
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?
Select factors that cause this functional loss (flare-ups): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimate range of motion in degrees for this joint during flare-ups - Plantar flexion endpoint (45 degrees): degrees
Estimate range of motion in degrees for this joint during flare-ups - Dorsiflexion endpoint (20 degrees): degrees
3E. Additional factors contributing to disability: None / Interference with sitting / Interference with standing / Swelling / Disturbance of locomotion / Deformity / Less movement than normal / More movement than normal / Weakened movement / Atrophy of disuse / Instability of station / Other
Please describe additional contributing factors of disability

MUSCLE ATROPHY (Section IV)

4A. Does the Veteran have muscle atrophy?
4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? If no, provide rationale
4C. Right lower extremity - specify location of measurement such as '1cm above or below ankle'
Circumference of more normal side: cm
Circumference of atrophied side: cm
4C. Left lower extremity - specify location of measurement such as '1cm above or below ankle'
Circumference of more normal side: cm (left)
Circumference of atrophied side: cm (left)

ANKYLOSIS (Section V)

5A. Is there ankylosis of the ankle?
If yes, indicate the severity of ankle ankylosis: In plantar flexion, less than 30 degrees / In plantar flexion, between 30 degrees and 40 degrees / In plantar flexion at more than 40 degrees / In dorsiflexion, between 0 degrees and 10 degree / In dorsiflexion at more than 10 degrees / With an abduction deformity / With an adduction deformity / With an inversion deformity / With an eversion deformity
5B. Indicate angle of ankle ankylosis in degrees: N/A no ankle ankylosis of joint / Plantar flexion / Dorsiflexion
5C. Is there ankylosis of the subastragalar or tarsal joint? If yes, indicate severity: In good weight-bearing position / In poor weight-bearing position

JOINT STABILITY (Section VI)

6A. Anterior Drawer Test: Is there absence of firm end point with asymmetric or excessive motion?
Talar Tilt Test: Is there asymmetric or excessive motion?
If unable to test, please explain why
6B. If unable to test, is ankle instability suspected? If yes, please describe

ADDITIONAL COMMENTS (Section VII)

7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?
Stress fracture of the lower leg - Describe current symptoms
Achilles tendonitis or Achilles tendon rupture - Describe current symptoms
Malunion of calcaneus (os calcis) or talus (astragalus) - Indicate severity: Moderate deformity / Marked deformity
'Shin Splints' (medial tibial stress syndrome - MTSS) - Indicate length of treatment: no treatment received / treatment for less than 12 consecutive months / requiring treatment for 12 consecutive months or more
If Veteran underwent treatment, indicate response to treatment: responsive to surgery and/or treatment / unresponsive to either shoe orthotics or other conservative treatment / unresponsive to surgery and either shoe orthotics or other conservative treatment
Does this condition affect ROM of knee?
Talectomy - Describe current symptoms

SURGICAL PROCEDURES (Section VIII)

8A. Indicate any surgical procedures that the Veteran has had performed: No surgery / Total ankle joint replacement / Arthroscopic or other ankle surgery
Total ankle joint replacement - Date of surgery
Total ankle joint replacement - Residuals: None / Intermediate degrees of residual weakness, pain or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other, describe
Arthroscopic or other ankle surgery - Type of surgery
Arthroscopic or other ankle surgery - Date of surgery
Residuals of arthroscopic or other ankle surgery - Describe residuals

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section IX)

9A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above? If yes, describe (brief summary)
9B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section?

ASSISTIVE DEVICES (Section X)

10A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
Wheelchair - Frequency of use: Occasional / Regular / Constant
Brace(s) - Frequency of use: Occasional / Regular / Constant
Crutch(es) - Frequency of use: Occasional / Regular / Constant
Cane(s) - Frequency of use: Occasional / Regular / Constant
Walker - Frequency of use: Occasional / Regular / Constant
Other - Frequency of use: Occasional / Regular / Constant
10B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XI)

11A. Due to the Veterans ankle 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?
If yes, indicate extremities for which this applies: Right lower / Left lower
11B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary)

DIAGNOSTIC TESTING (Section XII)

12A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination?
12B. If yes, is degenerative or post-traumatic arthritis documented? If yes, indicate side: Right / Left / Both
12C. If yes, provide type of test or procedure, date and results (brief summary)
12D. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? If yes, provide type of test or procedure, date and results (brief summary)
12E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions

FUNCTIONAL IMPACT (Section XIII)

13A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
If yes, describe the functional impact of each condition, providing one or more examples

REMARKS (Section XIV)

14A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

DBQ MUSC Hip and Thigh

This DBQ evaluates hip and thigh conditions including range of motion, ankylosis, femur impairment, and surgical procedures.

DIAGNOSIS (Section I)

List the claimed conditions that pertain to this questionnaire:
The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
Osteoarthritis, hip — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Hip joint replacement — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Hip joint resurfacing — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Trochanteric pain syndrome (includes trochanteric bursitis) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Femoral acetabular impingement syndrome (includes labral tears) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Iliopsoas tendinitis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Femoral neck stress fracture — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Avascular necrosis, hip — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Ankylosis of hip joint — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Degenerative arthritis, other than posttraumatic — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, gonorrheal — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, pneumococcic — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, streptococcic — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, syphilitic — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, rheumatoid (multi-joints) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Post-traumatic arthritis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Arthritis, typhoid — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Other specified forms of arthropathy (excluding gout) (specify) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Osteoporosis, residuals of — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Osteomalacia, residuals of — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Bones, neoplasm, benign — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Osteitis deformans — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Gout — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Bursitis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Myositis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Heterotopic ossification — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Tendinopathy (select one if known): Tendinitis / Tendinosis / Tenosynovitis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Inflammatory other types (specify) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
Other (specify) — Other diagnosis #1: Side affected, ICD Code, Date of diagnosis
Other diagnosis #2: Side affected, ICD Code, Date of diagnosis
Other diagnosis #3: Side affected, ICD Code, Date of diagnosis

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's hip or thigh condition (brief summary):
2B. Does the Veteran report flare-ups of the hip or thigh? Yes / No
If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms.
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time? Yes / No
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements — All normal / Abnormal or outside of normal range / Unable to test / Not indicated
If ROM is outside of 'normal' range, but is normal for the Veteran (for reason other than a hip/thigh condition, such as age, body habitus, neurologic disease), please describe:
If abnormal, does the range of motion itself contribute to a functional loss? Yes / No
Can testing be performed? Yes / No
If this is the unclaimed joint, is it: Damaged / Undamaged
Active ROM — Flexion endpoint (125 degrees): degrees
Active ROM — Extension endpoint (30 degrees): degrees
Active ROM — Abduction endpoint (45 degrees): degrees
Active ROM — Adduction endpoint (25 degrees): degrees
Active ROM — External rotation endpoint (60 degrees): degrees
Active ROM — Internal rotation endpoint (40 degrees): degrees
If noted on examination, which ROM exhibited pain (select all that apply): Flexion / Extension / Abduction / Adduction / External Rotation / Internal Rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe.
Flexion degree endpoint (if different than above)
Extension degree endpoint (if different than above)
Abduction degree endpoint (if different than above)
Adduction degree endpoint (if different than above)
External Rotation degree endpoint (if different than above)
Internal Rotation degree endpoint (if different than above)
Does a limitation in adduction prevent the Veteran from crossing his/her legs? Yes / No
Passive ROM — Flexion endpoint (125 degrees): degree / Same as active ROM
Passive ROM — Extension endpoint (30 degrees): degree / Same as active ROM
Passive ROM — Abduction endpoint (45 degrees): degree / Same as active ROM
Passive ROM — Adduction endpoint (25 degrees): degree / Same as active ROM
Passive ROM — External rotation endpoint (60 degrees): degree / Same as active ROM
Passive ROM — Internal rotation endpoint (40 degrees): degree / Same as active ROM
If noted on examination, which ROM exhibited pain (passive) (select all that apply): Flexion / Extension / Abduction / Adduction / External Rotation / Internal Rotation
Does a limitation in passive adduction prevent the Veteran from crossing his/her legs? Yes / No
Is there evidence of pain? Yes / No — weight-bearing / nonweight-bearing / active motion / passive motion / on rest/non-movement / causes functional loss / does not result in/cause functional loss
Is there objective evidence of crepitus? Yes / No
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? Yes / No
3B. Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No
Is there additional loss of function or range of motion after three repetitions? Yes / No
Flexion endpoint after three repetitions (125 degrees): degrees
Extension endpoint after three repetitions (30 degrees): degrees
Abduction endpoint after three repetitions (45 degrees): degrees
Adduction endpoint after three repetitions (25 degrees): degrees
External rotation endpoint after three repetitions (60 degrees): degrees
Internal rotation endpoint after three repetitions (40 degrees): degrees
Does limitation in adduction after observed repetitive use prevent the Veteran from crossing his/her legs? Yes / No
Select factors that cause this functional loss: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
3C. Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss (repeated use over time): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion — Flexion endpoint after repeated use over time (125 degrees): degrees
Estimate range of motion — Extension endpoint after repeated use over time (30 degrees): degrees
Estimate range of motion — Abduction endpoint after repeated use over time (45 degrees): degrees
Estimate range of motion — Adduction endpoint after repeated use over time (25 degrees): degrees
Estimate range of motion — External rotation endpoint after repeated use over time (60 degrees): degrees
Estimate range of motion — Internal rotation endpoint after repeated use over time (40 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
Does limitation in adduction after repeated use over time prevent the Veteran from crossing his/her legs? Yes / No
3D. Is the examination being conducted during a flare-up? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups? Yes / No
Select factors that cause this functional loss (flare-ups): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion during flare-ups — Flexion endpoint (125 degrees): degrees
Estimate range of motion during flare-ups — Extension endpoint (30 degrees): degrees
Estimate range of motion during flare-ups — Abduction endpoint (45 degrees): degrees
Estimate range of motion during flare-ups — Adduction endpoint (25 degrees): degrees
Estimate range of motion during flare-ups — External rotation endpoint (60 degrees): degrees
Estimate range of motion during flare-ups — Internal rotation endpoint (40 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
Does limitation in adduction during flare-ups prevent the Veteran from crossing his/her legs? Yes / No
3E. In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with standing / Disturbance of locomotion / Less movement than normal / Weakened movement / Instability of station / Interference with sitting / Swelling / Deformity / More movement than normal / Atrophy of disuse / Other, describe
Please describe additional contributing factors of disability:

MUSCLE ATROPHY (Section IV)

4A. Does the Veteran have muscle atrophy? Yes / No
4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No — If no, provide rationale:
4C. Specify location of atrophy (e.g. '10cm above or below the hip'):
Circumference of more normal side: cm
Circumference of atrophied side: cm

ANKYLOSIS (Section V)

5A. Is there ankylosis of the hip and/or thigh? Yes / No
If yes, indicate the severity of ankylosis: Unfavorable, extremely unfavorable ankylosis, foot not reaching ground, crutches needed / Intermediate, between favorable and unfavorable / Favorable, in flexion at an angle between 20 and 40 degrees, and slight abduction or adduction

FEMUR OR FLAIL HIP JOINT IMPAIRMENT (Section VI)

6A. Does the Veteran have malunion or non union of femur, flail hip joint or leg length discrepancy? Yes / No
Fracture of shaft or neck (anatomical), with nonunion with loose motion (spiral or oblique fracture)
Fracture of shaft or neck (anatomical), resulting in nonunion without loose motion; weight-bearing preserved with aid of brace
Fracture of surgical neck with false joint
Malunion of the femur
Flail hip joint
Leg length discrepancy (shortening of any bones of the lower extremity)
Measurements: Right leg: cm / inch
Measurements: Left leg: cm / inch
For any leg length discrepancy, please describe the relationship to the conditions listed in the diagnosis section above:

SURGICAL PROCEDURES (Section VII)

7A. Indicate any surgical procedures that the Veteran has had performed (check all that apply): No surgery
Hip joint resurfacing — Date of surgery:
Total hip joint replacement — Date of surgery:
Total hip joint replacement residuals: None / Moderately severe residuals of weakness, pain or limitation of motion / Markedly severe residuals of weakness, pain or limitation of motion following implantation of prosthesis / Following implantation of prosthesis with painful motion or weakness such as to require the use of crutches / Other, describe:
Arthroscopic ligament repair — Date of surgery:
Other surgery not described (specify below): Date of surgery / Type of surgery:
Residuals of arthroscopic or other hip surgery — Describe residuals:

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VIII)

8A. 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 / No — If yes, describe (brief summary)
8B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section above? Yes / No

ASSISTIVE DEVICES (Section IX)

9A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? Yes / No
Wheelchair — Frequency of use: Occasional / Regular / Constant
Brace for ambulation — Frequency of use: Occasional / Regular / Constant
Crutches — Frequency of use: Occasional / Regular / Constant
Cane(s) — Frequency of use: Occasional / Regular / Constant
Walker — Frequency of use: Occasional / Regular / Constant
Other, describe: — Frequency of use: Occasional / Regular / Constant
9B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section X)

10A. Due to the Veterans hip or thigh condition(s), is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis (functions of the lower extremity include balance and propulsion, etc.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran / No
If yes, indicate extremities for which this applies: Right lower / Left lower
10B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

DIAGNOSTIC TESTING (Section XI)

11A. Have imaging studies been performed in conjunction with this examination? Yes / No
11B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No — Indicate side: Right / Left / Both
11C. If yes provide type of test or procedure, date and results (brief summary):
11D. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No — If yes, provide type of test or procedure, date and results (brief summary):
11E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:

FUNCTIONAL IMPACT (Section XII)

12A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples:

REMARKS (Section XIII)

13A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

DBQ MUSC Shoulder and Arm

This DBQ evaluates shoulder and arm conditions including range of motion, ankylosis, rotator cuff, instability, clavicle/scapula and humerus impairment, and surgical procedures.

DIAGNOSIS (Section I)

List the claimed conditions that pertain to this questionnaire
The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
Shoulder strain – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Shoulder impingement syndrome – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Bicipital tendonitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Bicipital tendon tear – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Rotator cuff tendonitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Rotator cuff tear – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Labral tear, including SLAP (superior labral anterior-posterior lesion) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Subacromial/subdeltoid bursitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Glenohumeral joint osteoarthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Acromioclavicular joint osteoarthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Ankylosis of glenohumeral articulations (shoulder joint) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Glenohumeral joint instability – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Glenohumeral joint dislocation/recurrent dislocation – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Shoulder joint replacement (total shoulder arthroplasty/hemiarthroplasty) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Acromioclavicular joint separation – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Degenerative arthritis, other than posttraumatic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, gonorrheal – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, pneumococcic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, streptococcic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, syphilitic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, rheumatoid (multi-joints) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Post-traumatic arthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Arthritis, typhoid – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Other specified forms of arthropathy (excluding gout) (specify) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Osteoporosis, residuals of – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Osteomalacia, residuals of – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Bones, neoplasm, benign – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Osteitis deformans – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Gout – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Bursitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Myositis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Heterotopic ossification – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Tendinopathy (select one if known): Tendinitis / Tendinosis / Tenosynovitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Inflammatory other types (specify) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Other (specify) – Other diagnosis #1: Side affected (Right/Left/Both), ICD Code, Date of diagnosis
Other (specify) – Other diagnosis #2: Side affected (Right/Left/Both), ICD Code, Date of diagnosis
If there are additional diagnoses that pertain to shoulder and/or arm conditions, list using above format

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's shoulder and/or arm condition (brief summary)
2B. Does the Veteran report flare-ups of the shoulder and/or arm? Yes / No
If yes, document the Veteran's description of the flare-ups he or she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time? Yes / No
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements: All normal / Abnormal or outside of normal range / Unable to test / Not indicated
If 'Unable to test' or 'Not indicated' please explain
If ROM is outside of 'normal' range, but is normal for the Veteran (for reason other than a shoulder/arm condition, such as age, body habitus, neurologic disease), please describe
If abnormal, does the range of motion itself contribute to a functional loss? Yes / No (if yes, please explain)
Can testing be performed? Yes / No; If no, provide an explanation
If this is the unclaimed joint, is it: Damaged / Undamaged
Active Range of Motion – Flexion endpoint (180 degrees)
Active Range of Motion – Abduction endpoint (180 degrees)
Active Range of Motion – Internal rotation endpoint (90 degrees)
Active Range of Motion – External rotation endpoint (90 degrees)
If noted on examination, which ROM exhibited pain (select all that apply): Flexion / Abduction / Internal Rotation / External Rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe – Flexion degree endpoint (if different than above)
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – Abduction degree endpoint (if different than above)
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – Internal rotation degree endpoint (if different than above)
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – External rotation degree endpoint (if different than above)
Passive Range of Motion – Flexion endpoint (180 degrees) / Same as active ROM
Passive Range of Motion – Abduction endpoint (180 degrees) / Same as active ROM
Passive Range of Motion – Internal rotation endpoint (90 degrees) / Same as active ROM
Passive Range of Motion – External rotation endpoint (90 degrees) / Same as active ROM
If noted on examination, which ROM exhibited pain? (select all that apply): Flexion / Abduction / Internal Rotation / External Rotation
Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Flexion degree endpoint (if different than above)
Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Abduction degree endpoint (if different than above)
Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Internal Rotation degree endpoint (if different than above)
Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – External rotation degree endpoint (if different than above)
Is there evidence of pain? Yes / No; If yes check all that apply: weight-bearing / nonweight-bearing / active motion / passive motion / on rest/non-movement / causes functional loss / does not result in/cause functional loss
Comments
Is there objective evidence of crepitus? Yes / No
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, to include the glenohumeral joint, humerus, clavicle, scapula, acromioclavicular joint, or sternoclavicular joint? Yes / No; If yes, please explain. Include location, severity, and relationship to condition(s).
3B. Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No; If no, please explain
Is there additional loss of function or range of motion after three repetitions? Yes / No
After three repetitions – Flexion endpoint (180 degrees)
After three repetitions – Abduction endpoint (180 degrees)
After three repetitions – Internal rotation endpoint (90 degrees)
After three repetitions – External rotation endpoint (90 degrees)
Select factors that cause this functional loss: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
3C. Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss (repeated use over time): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion immediately after repeated use over time – Flexion endpoint (180 degrees)
Estimate range of motion immediately after repeated use over time – Abduction endpoint (180 degrees)
Estimate range of motion immediately after repeated use over time – Internal rotation endpoint (90 degrees)
Estimate range of motion immediately after repeated use over time – External rotation endpoint (90 degrees)
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3D. Is the examination being conducted during a flare-up? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups? Yes / No
Select factors that cause this functional loss (flare-ups): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
Estimate range of motion during flare-ups – Flexion endpoint (180 degrees)
Estimate range of motion during flare-ups – Abduction endpoint (180 degrees)
Estimate range of motion during flare-ups – Internal rotation endpoint (90 degrees)
Estimate range of motion during flare-ups – External rotation endpoint (90 degrees)
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3E. In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with standing / Disturbance of locomotion / Less movement than normal / Weakened movement / Instability of station / Interference with sitting / Swelling / Deformity / More movement than normal / Atrophy of disuse / Other, describe
Please describe additional contributing factors of disability

MUSCLE ATROPHY (Section IV)

4A. Does the Veteran have muscle atrophy? Yes / No
4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No; If no, provide rationale
4C. Right upper extremity – specify location of measurement
Circumference of more normal side (cm)
Circumference of atrophied side (cm)
4C. Left upper extremity – specify location of measurement
Circumference of more normal side (cm)
Circumference of atrophied side (cm)

ANKYLOSIS (Section V)

5A. Is there ankylosis of the scapulohumeral (glenohumeral) articulation (shoulder joint) - (i.e., the scapula and humerus move as one piece)? Yes / No
If yes, indicate the severity of ankylosis: Ankylosis in abduction up to 60 degrees; can reach mouth and head (favorable ankylosis)
Ankylosis in abduction between favorable and unfavorable (intermediate ankylosis)
Ankylosis in abduction at 25 degrees or less from side (unfavorable ankylosis)
5B. Indicate angle of ankylosis in degrees of abduction
5C. If ankylosed, is there involvement of Muscle Group I (trapezius, levator scapulae, serratus magnus) and II (pectoralis major II (costosternal), latissimus dorsi and teres major, pectoralis minor; rhomboid)? Yes / No; If yes, complete the Muscle Injuries questionnaire.

ROTATOR CUFF CONDITIONS (Section VI)

Hawkins' Impingement Test: Positive / Negative / Unable to test / N/A
Empty Can Test: Positive / Negative / Unable to test / N/A
External rotation/infraspinatus strength test: Positive / Negative / Unable to test / N/A
Lift-off subscapularis test: Positive / Negative / Unable to test / N/A
6B. If unable to test, is a rotator cuff condition suspected? Yes / No; If yes, please describe

SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY (Section VII)

7A. Crank Apprehension and Relocation Test: Positive / Negative / Unable to test / N/A
7B. If unable to test, is shoulder instability, dislocation or labral pathology suspected? Yes / No; If yes, please describe
7C. Is there shoulder instability, dislocation or labral pathology? Yes / No
7D. Does the Veteran have mechanical symptoms (clicking, catching, etc.)? Yes / No
7E. Are there current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? Yes / No; If yes, check all that apply: Infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90°) / Frequent episodes and guarding of all arm movements
Affects range of motion? Yes / No

CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT AND STERNOCLAVICULAR JOINT CONDITIONS (Section VIII)

8A. Cross-body adduction test: Positive / Negative / Unable to test / N/A
8B. If unable to test, is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? Yes / No; If yes, please describe
8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment? Yes / No; If yes, indicate severity: Malunion of clavicle or scapula / Nonunion of clavicle or scapula without loose movement / Nonunion of clavicle or scapula with loose movement / Dislocation (acromioclavicular separation or sternoclavicular dislocation) / Other (describe)
8D. Does the clavicle or scapula condition affect range of motion of the shoulder (glenohumeral joint)? Yes / No

CONDITIONS OR IMPAIRMENTS OF THE HUMERUS (Section IX)

9A. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? Yes / No; If yes, check all that apply: Loss of head (flail shoulder) / Nonunion (false flail shoulder) / Fibrous union
9B. Does the Veteran have malunion of the humerus with moderate or marked deformity? Yes / No; If yes, indicate severity: Moderate deformity / Marked deformity
9C. Does the humerus condition affect range of motion of the shoulder (glenohumeral joint)? Yes / No

SURGICAL PROCEDURES (Section X)

10A. No surgery
Total shoulder joint replacement – Date of surgery
Residuals: None / Intermediate degrees of residual weakness, pain, or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other residuals, describe
Arthroscopic or other shoulder surgery – Date of Surgery / Type of Surgery
Describe residuals

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section XI)

11A. Does the Veteran have any other pertinent physical findings, complications, signs, or symptoms related to any conditions listed in the diagnosis section above? Yes / No; If yes, describe (brief summary)
11B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section? Yes / No; If yes, also complete the appropriate dermatological questionnaire.
11C. Comments, if any

ASSISTIVE DEVICES (Section XII)

12A. Does the Veteran use any assistive devices? Yes / No
Brace – Frequency of use: Occasional / Regular / Constant
Other, describe – Frequency of use: Occasional / Regular / Constant
12B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XIII)

13A. Due to the Veteran's shoulder or arm condition(s), is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well-served by an amputation with prosthesis (functions of the upper extremity include grasping, manipulation, etc.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran / No
If yes, indicate extremities for which this applies: Right upper / Left upper
13B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function, and provide specific examples (brief summary)

DIAGNOSTIC TESTING (Section XIV)

14A. Have imaging studies been performed in conjunction with this examination? Yes / No
14B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No; If yes, indicate side: Right / Left / Both
14C. If yes, provide type of test or procedure, date and results (brief summary)
14D. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No; If yes, provide type of test or procedure, date and results (brief summary)
14E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition(s)

FUNCTIONAL IMPACT (Section XV)

15A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples

REMARKS (Section XVI)

16A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

DBQ MUSC Hand and Finger

This DBQ evaluates hand and finger conditions including range of motion, ankylosis, muscle strength, and functional impact.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire
1B. Select diagnoses associated with the claimed condition(s) (check all that apply)
Side affected: Right / Left / Both
ICD Code
Date of diagnosis
The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Dupuytren's contracture
Trigger finger
Swan neck deformity
Boutonniare deformity
Mallet finger
Gamekeeper's thumb
Instability (chronic collateral ligament sprain)
Volar plate injury
MCP/PIP joint prosthetic replacement
Ankylosis of digit joint(s), specify joint(s)
Degenerative arthritis, other than posttraumatic
Arthritis, gonorrheal
Arthritis, pneumococcic
Arthritis, streptococcic
Arthritis, syphilitic
Arthritis, rheumatoid (multi-joint)
Post-traumatic arthritis
Arthritis, typhoid
Other specified forms of arthropathy (excluding gout) (specify)
Osteoporosis, residuals of
Osteomalacia, residuals of
Bones, neoplasm, benign
Osteitis deformans
Gout
Bursitis
Myositis
Heterotopic ossification
Tendinopathy (select one if known)
Tendinitis
Tendinosis
Tenosynovitis
Inflammatory other types (specify)
Other (specify)
Other diagnosis #1
Other diagnosis #2
1C. If there are additional diagnoses that pertain to hand and finger conditions, list using above format

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's hand, finger or thumb condition (brief summary)
2B. Does the Veteran report flare-ups of the hand, finger or thumb? Yes / No
If yes, document the Veteran's description of the flare-ups he or she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time? Yes / No
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements: All normal / Unable to test / Abnormal or outside of normal range / Not indicated
If 'Unable to test' or 'Not indicated', please explain
If ROM is outside of 'normal' range, but is normal for the Veteran (for reason other than a hand/fingers condition, such as age, body habitus, neurologic disease), please describe
If abnormal, does the range of motion itself contribute to a functional loss? Yes / No (if yes, please explain)
Can testing be performed? Yes / No
If this is the unclaimed joint, is it: Damaged / Undamaged
Active Range of Motion (ROM) - Index finger MCP Flexion endpoint
Active Range of Motion (ROM) - Index finger PIP Flexion endpoint
Active Range of Motion (ROM) - Index finger DIP Flexion endpoint
Active Range of Motion (ROM) - Index finger MCP Extension endpoint
Active Range of Motion (ROM) - Index finger PIP Extension endpoint
Active Range of Motion (ROM) - Index finger DIP Extension endpoint
Active Range of Motion (ROM) - Long finger MCP Flexion endpoint
Active Range of Motion (ROM) - Long finger PIP Flexion endpoint
Active Range of Motion (ROM) - Long finger DIP Flexion endpoint
Active Range of Motion (ROM) - Long finger MCP Extension endpoint
Active Range of Motion (ROM) - Long finger PIP Extension endpoint
Active Range of Motion (ROM) - Long finger DIP Extension endpoint
Active Range of Motion (ROM) - Ring finger MCP Flexion endpoint
Active Range of Motion (ROM) - Ring finger PIP Flexion endpoint
Active Range of Motion (ROM) - Ring finger DIP Flexion endpoint
Active Range of Motion (ROM) - Ring finger MCP Extension endpoint
Active Range of Motion (ROM) - Ring finger PIP Extension endpoint
Active Range of Motion (ROM) - Ring finger DIP Extension endpoint
Active Range of Motion (ROM) - Little finger MCP Flexion endpoint
Active Range of Motion (ROM) - Little finger PIP Flexion endpoint
Active Range of Motion (ROM) - Little finger DIP Flexion endpoint
Active Range of Motion (ROM) - Little finger MCP Extension endpoint
Active Range of Motion (ROM) - Little finger PIP Extension endpoint
Active Range of Motion (ROM) - Little finger DIP Extension endpoint
Active Range of Motion (ROM) - Thumb MCP Flexion endpoint
Active Range of Motion (ROM) - Thumb IP Flexion endpoint
Active Range of Motion (ROM) - Thumb MCP Extension endpoint
Active Range of Motion (ROM) - Thumb IP Extension endpoint
Is there a gap between the pad of the thumb and fingers? Yes / No / cm
Is there a gap between the finger and proximal transverse crease of the hand on maximal finger flexion? Yes / No
Index Finger cm / Long Finger cm
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? Yes / No
If yes, please explain. Include location, severity, and relationship to condition(s).
If noted on examination, which digit exhibited pain (select all that apply): Index finger / Long finger / Thumb / Ring finger / Little finger
If any limitation of motion or gap is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) (if different than above) in which limitation of motion or gap is specifically attributable to the factors identified and describe
Passive Range of Motion - Index finger MCP Flexion endpoint
Passive Range of Motion - Index finger PIP Flexion endpoint
Passive Range of Motion - Index finger DIP Flexion endpoint
Passive Range of Motion - Index finger MCP Extension endpoint
Passive Range of Motion - Index finger PIP Extension endpoint
Passive Range of Motion - Index finger DIP Extension endpoint
Passive Range of Motion - Index finger Flexion same as active ROM
Passive Range of Motion - Index finger Extension same as active ROM
Passive Range of Motion - Long finger MCP Flexion endpoint
Passive Range of Motion - Long finger PIP Flexion endpoint
Passive Range of Motion - Long finger DIP Flexion endpoint
Passive Range of Motion - Long finger MCP Extension endpoint
Passive Range of Motion - Long finger PIP Extension endpoint
Passive Range of Motion - Long finger DIP Extension endpoint
Passive Range of Motion - Long finger Flexion same as active ROM
Passive Range of Motion - Long finger Extension same as active ROM
Passive Range of Motion - Ring finger MCP Flexion endpoint
Passive Range of Motion - Ring finger PIP Flexion endpoint
Passive Range of Motion - Ring finger DIP Flexion endpoint
Passive Range of Motion - Ring finger MCP Extension endpoint
Passive Range of Motion - Ring finger PIP Extension endpoint
Passive Range of Motion - Ring finger DIP Extension endpoint
Passive Range of Motion - Ring finger Flexion same as active ROM
Passive Range of Motion - Ring finger Extension same as active ROM
Passive Range of Motion - Little finger MCP Flexion endpoint
Passive Range of Motion - Little finger PIP Flexion endpoint
Passive Range of Motion - Little finger DIP Flexion endpoint
Passive Range of Motion - Little finger MCP Extension endpoint
Passive Range of Motion - Little finger PIP Extension endpoint
Passive Range of Motion - Little finger DIP Extension endpoint
Passive Range of Motion - Little finger Flexion same as active ROM
Passive Range of Motion - Little finger Extension same as active ROM
Passive Range of Motion - Thumb MCP Flexion endpoint
Passive Range of Motion - Thumb IP Flexion endpoint
Passive Range of Motion - Thumb MCP Extension endpoint
Passive Range of Motion - Thumb IP Extension endpoint
Passive Range of Motion - Thumb Flexion same as active ROM
Passive Range of Motion - Thumb Extension same as active ROM
Is there a gap between the pad of the thumb and fingers on passive ROM? Yes / No / cm
Is there a gap between the finger and proximal transverse crease of the hand on maximal finger flexion on passive ROM? Yes / No
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue on passive ROM? Yes / No
If noted on examination, which digit on passive ROM exhibited pain (select all that apply): Index finger / Long finger / Thumb / Ring finger / Little finger
Is there evidence of pain? Yes / No
If yes check all that apply: weight-bearing / nonweight-bearing / active motion / passive motion / on rest/nonmovement / causes functional loss / does not result in/cause functional loss
Comments
3B. Observed repetitive use ROM - Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No
Is there additional loss of function or range of motion after three repetitions? Yes / No
ROM values after three repetitions - Index finger MCP/PIP/DIP Flexion endpoint
ROM values after three repetitions - Index finger MCP/PIP/DIP Extension endpoint
ROM values after three repetitions - Long finger MCP/PIP/DIP Flexion endpoint
ROM values after three repetitions - Long finger MCP/PIP/DIP Extension endpoint
ROM values after three repetitions - Ring finger MCP/PIP/DIP Flexion endpoint
ROM values after three repetitions - Ring finger MCP/PIP/DIP Extension endpoint
ROM values after three repetitions - Little finger MCP/PIP/DIP Flexion endpoint
ROM values after three repetitions - Little finger MCP/PIP/DIP Extension endpoint
ROM values after three repetitions - Thumb MCP/IP Flexion endpoint
ROM values after three repetitions - Thumb MCP/IP Extension endpoint
Is there a gap between the pad of the thumb and fingers after the completion of three repetitions? Yes / No / cm
Is there a gap between the finger and proximal transverse crease of the hand on maximal finger flexion after the completion of three repetitions? Yes / No
Select factors that cause this functional loss: (check all that apply) Pain / Fatigability / Weakness / Lack of endurance / Incoordination / N/A / Other
3C. Repeated use over time - Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss. (Check all that apply) Pain / Fatigability / Weakness / Lack of endurance / Incoordination / N/A / Other
Estimate range of motion in degrees for this joint immediately after repeated use over time - Index finger MCP/PIP/DIP Flexion/Extension endpoint
Estimate range of motion in degrees for this joint immediately after repeated use over time - Long finger MCP/PIP/DIP Flexion/Extension endpoint
Estimate range of motion in degrees for this joint immediately after repeated use over time - Ring finger MCP/PIP/DIP Flexion/Extension endpoint
Estimate range of motion in degrees for this joint immediately after repeated use over time - Little finger MCP/PIP/DIP Flexion/Extension endpoint
Estimate range of motion in degrees for this joint immediately after repeated use over time - Thumb MCP/IP Flexion/Extension endpoint
Estimate the gap between the pad of the thumb and fingers immediately after repeated use over time. cm
Estimate the gap between the finger and proximal transverse crease of the hand on maximal finger flexion immediately after repeated use over time. Index Finger cm / Long Finger cm
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3D. Flare-ups - Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss. (Check all that apply) Pain / Fatigability / Weakness / Lack of endurance / Incoordination / N/A / Other
Estimate range of motion in degrees for this joint immediately after repeated use over time - Index finger MCP/PIP/DIP Flexion/Extension endpoint (flare-ups)
Estimate range of motion in degrees for this joint immediately after repeated use over time - Long finger MCP/PIP/DIP Flexion/Extension endpoint (flare-ups)
Estimate range of motion in degrees for this joint immediately after repeated use over time - Ring finger MCP/PIP/DIP Flexion/Extension endpoint (flare-ups)
Estimate range of motion in degrees for this joint immediately after repeated use over time - Little finger MCP/PIP/DIP Flexion/Extension endpoint (flare-ups)
Estimate range of motion in degrees for this joint immediately after repeated use over time - Thumb MCP/IP Flexion/Extension endpoint (flare-ups)
Estimate the gap between the pad of the thumb and fingers immediately after repeated use over time. cm (flare-ups)
Estimate the gap between the finger and proximal transverse crease of the hand on maximal finger flexion immediately after repeated use over time. Index Finger cm / Long Finger cm (flare-ups)
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.) (flare-ups)
3E. Additional factors contributing to disability - In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with sitting / Interference with standing / Swelling / Disturbance of locomotion / Deformity / Less movement than normal / More movement than normal / Weakened movement / Atrophy of disuse / Instability of station / Other, describe
Please describe additional contributing factors of disability

MUSCLE STRENGTH TESTING (Section IV)

4A. Muscle strength - Hand grip: /5 (Right)
4A. Muscle strength - Hand grip: /5 (Left)
4B. If the Veteran has a reduction in muscle strength, is it due to the claimed condition in the diagnosis section? Yes / No
If no, provide rationale
4C. Does the Veteran have muscle atrophy? Yes / No
4D. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No
If no, provide rationale
4E. Right upper extremity (specify location of measurement)
Circumference of more normal side: cm
Circumference of atrophied side: cm
4E. Left upper extremity (specify location of measurement)
Circumference of more normal side: cm (left)
Circumference of atrophied side: cm (left)

ANKYLOSIS (Section V)

5A. Index finger - MCP joint: No ankylosis / MCP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Index MCP)
If ankylosed, is there angulation of a bone? Yes / No (Index MCP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Index MCP)
5A. Index finger - PIP joint: No ankylosis / PIP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Index PIP)
If ankylosed, is there angulation of a bone? Yes / No (Index PIP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Index PIP)
5A. Long finger - MCP joint: No ankylosis / MCP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Long MCP)
If ankylosed, is there angulation of a bone? Yes / No (Long MCP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Long MCP)
5A. Long finger - PIP joint: No ankylosis / PIP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Long PIP)
If ankylosed, is there angulation of a bone? Yes / No (Long PIP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Long PIP)
5A. Ring finger - MCP joint: No ankylosis / MCP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Ring MCP)
If ankylosed, is there angulation of a bone? Yes / No (Ring MCP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Ring MCP)
5A. Ring finger - PIP joint: No ankylosis / PIP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Ring PIP)
If ankylosed, is there angulation of a bone? Yes / No (Ring PIP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Ring PIP)
5A. Little finger - MCP joint: No ankylosis / MCP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Little MCP)
If ankylosed, is there angulation of a bone? Yes / No (Little MCP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Little MCP)
5A. Little finger - PIP joint: No ankylosis / PIP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Little PIP)
If ankylosed, is there angulation of a bone? Yes / No (Little PIP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Little PIP)
5A. Thumb - CMC joint: No ankylosis / CMC ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Thumb CMC)
If ankylosed, is there angulation of a bone? Yes / No (Thumb CMC)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Thumb CMC)
5A. Thumb - MCP joint: No ankylosis / MCP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Thumb MCP)
If ankylosed, is there angulation of a bone? Yes / No (Thumb MCP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Thumb MCP)
5A. Thumb - IP joint: No ankylosis / IP ankylosis
If ankylosed, is there rotation of a bone? Yes / No (Thumb IP)
If ankylosed, is there angulation of a bone? Yes / No (Thumb IP)
If ankylosed, what is the position of ankylosis? In extension / In full flexion / Other, degrees of flexion (Thumb IP)
5B. Does the ankylosis result in limitation of motion of other digits or interference with overall function of the hand? Yes / No
If no, provide rationale

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VI)

6A. 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 / No
If yes, describe (brief summary)
6B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section above? Yes / No

ASSISTIVE DEVICES (Section VII)

7A. Does the Veteran use any assistive devices? Yes / No
Brace - Frequency of use: Occasional / Regular / Constant
Other, describe - Frequency of use: Occasional / Regular / Constant
7B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section VIII)

8A. Due to the Veteran's hand, finger, or thumb condition(s), is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis (functions of the upper extremity include grasping, manipulation, etc.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran / No
If yes, indicate extremities for which this applies: Right upper / Left upper
8B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary)

DIAGNOSTIC TESTING (Section IX)

9A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination? Yes / No
9B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No
Indicate side: Right / Left / Both
9C. Is degenerative or post-traumatic arthritis documented in multiple joints of the same hand, including thumb and fingers? Yes / No
If yes, indicate side: Right / Left / Both
9D. If yes (to 9B and/or 9C), provide type of test or procedure, date, and results (brief summary)
9E. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No
If yes, provide type of test or procedure, date, and results (brief summary)
9F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions

FUNCTIONAL IMPACT (Section X)

10A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples

REMARKS (Section XI)

11A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

DBQ MUSC Wrist

This DBQ evaluates wrist conditions including range of motion, ankylosis, and surgical procedures.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire:
1B. Select diagnoses associated with the claimed condition(s) (check all that apply): [diagnosis name], Side affected: Right / Left / Both, ICD code, Date of diagnosis (Right / Left)
The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
1C. If there are additional diagnoses that pertain to wrist conditions, list using above format:

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's wrist condition (brief summary):
2B. Does the Veteran report flare-ups of the wrist? Yes / No
If yes, document the Veteran's description of the flare-ups he or she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms.
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time? Yes / No
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.

RANGE OF MOTION (Section III)

3A. Initial ROM measurements: All normal / Abnormal or outside of normal range / Unable to test / Not indicated
If "Unable to test" or "Not indicated", please explain:
If ROM is outside of "normal" range, but is normal for the Veteran (for reason other than a wrist condition, such as age, body habitus, neurologic disease), please describe:
If abnormal, does the range of motion itself contribute to a functional loss? Yes / No (if yes, please explain)
Can testing be performed? Yes / No
If this is the unclaimed joint, is it: Damaged / Undamaged
Active Range of Motion (ROM) - Dorsiflexion endpoint (70 degrees): degrees
Active Range of Motion (ROM) - Palmar flexion endpoint (80 degrees): degrees
Active Range of Motion (ROM) - Ulnar deviation endpoint (45 degrees): degrees
Active Range of Motion (ROM) - Radial deviation endpoint (20 degrees): degrees
If noted on examination, which ROM exhibited pain? (Select all that apply.) Dorsiflexion / Palmar flexion / Ulnar deviation / Radial deviation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other, please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe. Dorsiflexion degree endpoint (if different than above)
Palmar flexion degree endpoint (if different than above)
Ulnar deviation degree endpoint (if different than above)
Radial deviation degree endpoint (if different than above)
Describe:
Passive Range of Motion - Dorsiflexion endpoint (70 degrees): degrees / Same as active ROM
Passive Range of Motion - Palmar flexion endpoint (80 degrees): degrees / Same as active ROM
Passive Range of Motion - Ulnar deviation endpoint (45 degrees): degrees / Same as active ROM
Passive Range of Motion - Radial deviation endpoint (20 degrees): degrees / Same as active ROM
If noted on examination, which passive ROM exhibited pain? (select all that apply): Dorsiflexion / Palmar flexion / Ulnar deviation / Radial deviation
Is there evidence of pain? Yes / No
If yes, check all that apply: weight-bearing / nonweight-bearing / active motion / passive motion / on rest/non-movement / does not result in/cause functional loss / causes functional loss
Is there objective evidence of crepitus? Yes / No
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? Yes / No
If yes, please explain. Include location, severity, and relationship to condition(s).
3B. Observed repetitive use ROM - Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No
Is there additional loss of function or range of motion after three repetitions? Yes / No
After three repetitions - Dorsiflexion endpoint (70 degrees): degrees
After three repetitions - Palmar flexion endpoint (80 degrees): degrees
After three repetitions - Ulnar deviation endpoint (45 degrees): degrees
After three repetitions - Radial deviation endpoint (20 degrees): degrees
Select factors that cause this functional loss. (Check all that apply): N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
3C. Repeated use over time - Is the Veteran being examined immediately after repeated use over time? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss. (Check all that apply): N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimate range of motion in degrees for this joint immediately after repeated use over time - Dorsiflexion endpoint (70 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time - Palmar flexion endpoint (80 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time - Ulnar deviation endpoint (45 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time - Radial deviation endpoint (20 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
3D. Flare-ups - Is the examination being conducted during a flare-up? Yes / No
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
Select factors that cause this functional loss. (Check all that apply): N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimate range of motion in degrees for this joint immediately after repeated use over time [during flare-up] - Dorsiflexion endpoint (70 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time [during flare-up] - Palmar flexion endpoint (80 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time [during flare-up] - Ulnar deviation endpoint (45 degrees): degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time [during flare-up] - Radial deviation endpoint (20 degrees): degrees
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.) [flare-up]
3E. Additional factors contributing to disability: None / Interference with standing / Interference with sitting / Disturbance of locomotion / Swelling / Less movement than normal / Deformity / Weakened movement / More movement than normal / Instability of station / Atrophy of disuse / Other
Please describe additional contributing factors of disability:

MUSCLE ATROPHY (Section IV)

4A. Does the Veteran have muscle atrophy? Yes / No
4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No
If no, provide rationale:
4C. Right upper extremity (specify location of measurement, such as "10 cm below anterior elbow crease"):
Circumference of more normal side: cm
Circumference of atrophied side: cm
4C. Left upper extremity (specify location of measurement, such as "10 cm below anterior elbow crease"):
Circumference of more normal side: cm
Circumference of atrophied side: cm

ANKYLOSIS (Section V)

5A. Is there ankylosis of the wrist? Yes / No
If yes, indicate severity of ankylosis: Extremely unfavorable
Unfavorable, in any degree of palmar flexion - If checked, provide degrees of palmar flexion:
Unfavorable, with ulnar deviation - If checked, provide degrees of ulnar deviation:
Unfavorable, with radial deviation - If checked, provide degrees of radial deviation:
Any other position except favorable - If checked, describe:
Favorable in 20 to 30 degrees dorsiflexion
5B: Comments if any:

SURGICAL PROCEDURES (Section VI)

6A. Indicate any surgical procedures that the Veteran has had performed (check all that apply): No surgery / Total wrist joint replacement / Arthroscopic or other wrist surgery
Total wrist joint replacement - Date of surgery:
Total wrist joint replacement - Residuals: None / Intermediate degrees of residual weakness, pain, or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other residuals, describe:
Arthroscopic or other wrist surgery - Type of surgery:
Arthroscopic or other wrist surgery - Date of surgery:
Arthroscopic or other wrist surgery - Describe residuals:

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VII)

7A. 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 / No
If yes, describe (brief summary):
7B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section? Yes / No

ASSISTIVE DEVICES (Section VIII)

8A. Does the Veteran use any assistive devices? Yes / No
Brace - Frequency of use: Occasional / Regular / Constant
Other, describe: - Frequency of use: Occasional / Regular / Constant
8B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section IX)

9A. Due to the Veteran's wrist 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.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. / No
If yes, indicate extremities for which this applies: Right upper / Left upper
9B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

DIAGNOSTIC TESTING (Section X)

10A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination? Yes / No
10B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No - Indicate side: Right / Left / Both
10C. If yes provide type of test or procedure, date and results (brief summary):
10D. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No
If yes, provide type of test or procedure, date and results (brief summary):
10E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:

FUNCTIONAL IMPACT (Section XI)

11A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples:

REMARKS (Section XII)

12A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

DBQ MUSC Back (Thoracolumbar Spine)

This DBQ evaluates thoracolumbar spine conditions including range of motion, muscle strength, neurologic findings, ankylosis, and IVDS.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire:
1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
Ankylosing spondylitis - ICD Code / Date of diagnosis
Degenerative arthritis - ICD Code / Date of diagnosis
Degenerative disc disease other than intervertebral disc syndrome (IVDS) - ICD Code / Date of diagnosis
Lumbosacral strain - ICD Code / Date of diagnosis
Intervertebral disc syndrome - ICD Code / Date of diagnosis
Sacroiliac injury - ICD Code / Date of diagnosis
Sacroiliac weakness - ICD Code / Date of diagnosis
Segmental instability - ICD Code / Date of diagnosis
Spinal fusion - ICD Code / Date of diagnosis
Spinal stenosis - ICD Code / Date of diagnosis
Spondylolisthesis - ICD Code / Date of diagnosis
Traumatic paralysis, complete - ICD Code / Date of diagnosis
Vertebral dislocation - ICD Code / Date of diagnosis
Vertebral fracture - ICD Code / Date of diagnosis
Other diagnosis #1 - ICD Code / Date of diagnosis
Other diagnosis #2 - ICD Code / Date of diagnosis
Other diagnosis #3 - ICD Code / Date of diagnosis
1C. If there are additional diagnoses pertaining to thoracolumbar spine conditions, list using above format:

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's thoracolumbar spine condition (brief summary):
2B. Does the Veteran report flare-ups of the thoracolumbar spine?
If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he/she experiences during a flare-up of symptoms:
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.

RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)

3A. Initial ROM measurements: All Normal / Abnormal or outside of normal range / Unable to test / Not indicated
If ROM is outside of 'normal' range, but is normal for the Veteran (for reasons other than a back condition, such as age, body habitus, neurologic disease), please describe:
If abnormal, does the range of motion itself contribute to a functional loss?
Can testing be performed?
Active ROM - Forward flexion endpoint (90 degrees): degrees
Active ROM - Extension endpoint (30 degrees): degrees
Active ROM - Right lateral flexion endpoint (30 degrees): degrees
Active ROM - Left lateral flexion endpoint (30 degrees): degrees
Active ROM - Right lateral rotation endpoint (30 degrees): degrees
Active ROM - Left lateral rotation endpoint (30 degrees): degrees
If noted on examination, which ROM exhibited pain (select all that apply): Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe. [Active - Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation degree endpoints]
Was passive range of motion testing performed?
Passive ROM - Forward flexion endpoint (90 degrees): degrees / Same as active ROM
Passive ROM - Extension endpoint (30 degrees): degrees / Same as active ROM
Passive ROM - Right lateral flexion endpoint (30 degrees): degrees / Same as active ROM
Passive ROM - Left lateral flexion endpoint (30 degrees): degrees / Same as active ROM
Passive ROM - Right lateral rotation endpoint (30 degrees): degrees / Same as active ROM
Passive ROM - Left lateral endpoint (30 degrees): degrees / Same as active ROM
If noted on examination, which passive ROM exhibited pain (select all that apply): Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) [Passive - Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation degree endpoints]
Is there evidence of pain? If yes check all that apply: Weight-bearing / Nonweight-bearing / Active motion / Passive motion / On rest/non-movement / Causes functional loss / Does not result in/cause functional loss
Is there objective evidence of crepitus?
Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue?
If yes, describe location, severity, and relationship to condition(s):
3B. Is the Veteran able to perform repetitive use testing with at least three repetitions?
Is there additional loss of function or range of motion after three repetitions?
After three repetitions - Forward flexion endpoint (90 degrees): degrees
After three repetitions - Extension endpoint (30 degrees): degrees
After three repetitions - Right lateral flexion endpoint (30 degrees): degrees
After three repetitions - Left lateral flexion endpoint (30 degrees): degrees
After three repetitions - Right lateral rotation endpoint (30 degrees): degrees
After three repetitions - Left lateral rotation endpoint (30 degrees): degrees
Select all factors that cause this functional loss: (check all that apply) N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
3C. Is the Veteran being examined immediately after repeated use over time?
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?
Select all factors that cause this functional loss [repeated use]: N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimated ROM immediately after repeated use over time - Forward flexion endpoint (90 degrees): degrees
Estimated ROM immediately after repeated use over time - Extension endpoint (30 degrees): degrees
Estimated ROM immediately after repeated use over time - Right lateral flexion endpoint (30 degrees): degrees
Estimated ROM immediately after repeated use over time - Left lateral flexion endpoint (30 degrees): degrees
Estimated ROM immediately after repeated use over time - Right lateral rotation endpoint (30 degrees): degrees
Estimated ROM immediately after repeated use over time - Left lateral rotation endpoint (30 degrees): degrees
Please cite and discuss evidence [repeated use over time]. (Must be specific to the case and based on all procurable evidence):
3D. Is the Veteran being examined during a flare-up?
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?
Select all factors that cause this functional loss [flare-ups]: N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
Estimated ROM during flare-ups - Forward flexion endpoint (90 degrees): degrees
Estimated ROM during flare-ups - Extension endpoint (30 degrees): degrees
Estimated ROM during flare-ups - Right lateral flexion endpoint (30 degrees): degrees
Estimated ROM during flare-ups - Left lateral flexion endpoint (30 degrees): degrees
Estimated ROM during flare-ups - Right lateral rotation endpoint (30 degrees): degrees
Estimated ROM during flare-ups - Left lateral rotation endpoint (30 degrees): degrees
Please cite and discuss evidence [flare-ups]. (Must be specific to the case and based on all procurable evidence):
3E. Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?
Localized tenderness: None / Not resulting in abnormal gait or abnormal spinal contour
Muscle spasm: None / Resulting in abnormal gait or abnormal spine contour / Not resulting in abnormal gait or abnormal spinal contour / Unable to evaluate
Guarding: None / Resulting in abnormal gait or abnormal spine contour / Not resulting in abnormal gait or abnormal spinal contour / Unable to evaluate
3F. In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with sitting / Interference with standing / Swelling / Deformity / Disturbance of locomotion / Less movement than normal / More movement than normal / Weakened movement / Atrophy of disuse / Instability of station / Other
Please describe additional contributing factors of disability:

MUSCLE STRENGTH TESTING (Section IV)

4A. Right Hip Flexion strength (/5)
4A. Right Knee Extension strength (/5)
4A. Right Ankle Plantar Flexion strength (/5)
4A. Right Ankle Dorsiflexion strength (/5)
4A. Right Great Toe Extension strength (/5)
4A. Left Hip Flexion strength (/5)
4A. Left Knee Extension strength (/5)
4A. Left Ankle Plantar Flexion strength (/5)
4A. Left Ankle Dorsiflexion strength (/5)
4A. Left Great Toe Extension strength (/5)
4B. Does the Veteran have muscle atrophy?
4C. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section?
4D. Circumference of normal side: cm
4D. Circumference of atrophied side: cm

REFLEX EXAM (Section V)

5A. Right Knee deep tendon reflex (+)
5A. Right Ankle deep tendon reflex (+)
5A. Left Knee deep tendon reflex (+)
5A. Left Ankle deep tendon reflex (+)

SENSORY EXAM (Section VI)

6A. Right Upper Anterior Thigh (L2): Normal / Decreased / Absent
6A. Right Thigh/Knee (L3/4): Normal / Decreased / Absent
6A. Right Lower Leg/Ankle (L4/L5/S1): Normal / Decreased / Absent
6A. Right Foot/Toes (L5): Normal / Decreased / Absent
6A. Left Upper Anterior Thigh (L2): Normal / Decreased / Absent
6A. Left Thigh/Knee (L3/4): Normal / Decreased / Absent
6A. Left Lower Leg/Ankle (L4/L5/S1): Normal / Decreased / Absent
6A. Left Foot/Toes (L5): Normal / Decreased / Absent
Other sensory findings, if any:

STRAIGHT LEG RAISING TEST (Section VII)

7A. Right straight leg raising test: Negative / Positive / Unable to perform
7A. Left straight leg raising test: Negative / Positive / Unable to perform
If 'Unable to perform,' please explain:

RADICULOPATHY (Section VIII)

Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
8A. Constant pain (may be excruciating at times): Right lower extremity: None / Mild / Moderate / Severe
8A. Constant pain (may be excruciating at times): Left lower extremity: None / Mild / Moderate / Severe
8A. Intermittent pain (usually dull): Right lower extremity: None / Mild / Moderate / Severe
8A. Intermittent pain (usually dull): Left lower extremity: None / Mild / Moderate / Severe
8A. Paresthesias and/or dysesthesias: Right lower extremity: None / Mild / Moderate / Severe
8A. Paresthesias and/or dysesthesias: Left lower extremity: None / Mild / Moderate / Severe
8A. Numbness: Right lower extremity: None / Mild / Moderate / Severe
8A. Numbness: Left lower extremity: None / Mild / Moderate / Severe
8B. Does the Veteran have any other signs or symptoms of radiculopathy?
8C. Involvement of L2/L3/L4 nerve roots (femoral nerve): Right / Left / Both
8C. Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve): Right / Left / Both
8C. Other nerves (specify nerve and side(s) affected): Right / Left / Both
8D. For any abnormal or positive identified neurological findings identified in Sections 4-8, explain the likely cause of those identified symptoms:

ANKYLOSIS (Section IX)

9A. Is there ankylosis of the spine?
If yes, indicate severity of ankylosis: Unfavorable ankylosis of the entire spine / Unfavorable ankylosis of the entire thoracolumbar spine / Favorable ankylosis of the entire thoracolumbar spine
9B. Comments, if any:

OTHER NEUROLOGIC ABNORMALITIES (Section X)

10A. Does the Veteran have any other neurologic abnormalities or findings (other than those identified in Sections 4 - 8) related to a thoracolumbar spine condition (such as bowel or bladder problems/pathologic reflexes)?
If yes, describe condition and how it is related:

INTERVERTEBRAL DISC SYNDROME (IVDS) AND EPISODES REQUIRING BED REST (Section XI)

11A. Does the Veteran have IVDS of the thoracolumbar spine?
11B. Has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months?
If yes, select the total duration over the past 12 months: With no episodes of bed rest / At least 1 week but less than 2 weeks / At least 2 weeks but less than 4 weeks / At least 4 weeks but less than 6 weeks / At least 6 weeks
11C. Medical history as described by the Veteran only, without documentation:
11C. Medical history as shown and documented in the Veteran's file - Individual date(s) of each treatment record(s) reviewed:
11C. Facility/provider:
11C. Describe treatment:

ASSISTIVE DEVICES (Section XII)

12A. Does the Veteran use any assistive devices as a normal mode of locomotion?
Wheelchair - Frequency of use: Occasional / Regular / Constant
Brace(s) - Frequency of use: Occasional / Regular / Constant
Crutch(es) - Frequency of use: Occasional / Regular / Constant
Cane(s) - Frequency of use: Occasional / Regular / Constant
Walker - Frequency of use: Occasional / Regular / Constant
Other - Frequency of use: Occasional / Regular / Constant
12B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XIII)

13A. Due to the Veteran's thoracolumbar spine condition, 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?
If yes, indicate extremities for which this applies: Right lower / Left lower / Right upper / Left upper
For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section XIV)

14A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above?
If yes, describe (brief summary):
14B. Does the Veteran have any scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section?
14C. Comments, if any:

DIAGNOSTIC TESTING (Section XV)

15A. Have imaging studies been performed in conjunction with this examination?
15B. If yes, is degenerative or post-traumatic arthritis documented?
15C. If yes, provide type of test or procedure, date and results (brief summary):
15D. Does the Veteran have imaging evidence of a thoracolumbar vertebral fracture?
If yes, is there loss of 50 percent or more of height?
15E. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination?
If yes, provide type of test or procedure, date and results (brief summary):
15F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:

FUNCTIONAL IMPACT (Section XVI)

16A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting etc.)?
If yes, describe the functional impact of each condition, providing one or more examples:

REMARKS (Section XVII)

17A. Remarks (if any – please identify the section to which the remark pertains when appropriate).

DBQ MUSC Foot Conditions Including Flatfoot (Pes Planus)

This DBQ evaluates foot conditions including flatfoot (pes planus), plantar fasciitis, hallux valgus, hallux rigidus, claw foot, hammer toe, Morton's neuroma, and foot injuries.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire:
1B. Select diagnoses associated with the claimed condition(s) (check all that apply): Flat foot (pes planus) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Plantar fasciitis — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Morton's neuroma — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Metatarsalgia — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Hammer toes — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Hallux valgus — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Hallux rigidus — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Acquired pes cavus (claw foot) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Malunion/nonunion of tarsal/ metatarsal bones — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Foot injury(ies), specify — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Arthritic conditions (degenerative, gonorrheal, pneumococcic, streptococcic, syphilitic, multi-joint, post-traumatic, typhoid, other) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Inflammatory conditions (Osteoporosis residuals, Osteomalacia residuals, Bones neoplasm benign, Bones neoplasm malignant, Osteitis deformans, Gout, Bursitis, Myositis, Myositis ossificans, Other specified forms) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Tendinopathy (Tendinitis, Tendinosis, Tenosynovitis) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1B. Other, specify (Diagnosis #1, #2, #3) — Side affected: Right / Left / Both; ICD Code; Date of diagnosis
1C. If there are additional diagnoses that pertain to foot conditions, list using above format:

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's foot condition (brief summary):
2B. Does the Veteran report pain of the foot being evaluated on this questionnaire? Yes / No
If yes, document the Veteran's description of pain in his or her own words:
2C. Does the Veteran report that flare-ups impact the function of the foot? Yes / No
If so, ask the Veteran to describe the flare-ups he or she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms.
2D. Does the Veteran report having any functional loss, or functional impairment, of the joint or extremity being evaluated on this questionnaire, including but not limited to repeated use over time? Yes / No
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words:

FLATFOOT (PES PLANUS) (Section III)

3A. Does the Veteran have pain on use of the feet? Yes / No; If yes, indicate side affected: Right / Left / Both; If yes, is the pain accentuated on use? Yes / No; If yes, indicate side affected: Right / Left / Both
3B. Does the Veteran have pain on manipulation of the feet? Yes / No; If yes, indicate side affected: Right / Left / Both; If yes, is the pain accentuated on manipulation? Yes / No; If yes, indicate side affected: Right / Left / Both
3C. Is there indication of swelling on use? Yes / No; If yes, indicate side affected: Right / Left / Both
3D. Does the Veteran have characteristic calluses? Yes / No; If yes, indicate side affected: Right / Left / Both
3E. Effects of use of arch supports or built-up shoes — Effecting Complete Relief of Symptoms: Arch Supports (Side Relieved: Right / Left / Both); Built-up Shoes (Side Relieved: Right / Left / Both); Tried But Remains Symptomatic: Arch Supports (Side Not Relieved: Right / Left / Both); Built-up Shoes (Side Not Relieved: Right / Left / Both)
3F. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? Yes / No; If yes, indicate side affected: Right / Left / Both; Is the tenderness improved by orthopedic shoes or appliances? Right: Yes / No / N/A; Left: Yes / No / N/A
3G. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? Yes / No; If yes, indicate side affected: Right / Left / Both
3H. Is there objective evidence of marked deformity of one or both feet (pronation, abduction, etc.)? Yes / No; If yes, indicate side affected: Right / Left / Both
3I. Is there marked pronation of one foot or both feet? Yes / No; If yes, indicate side affected: Right / Left / Both; Is the condition improved by orthopedic shoes or appliances? Right: Yes / No / N/A; Left: Yes / No / N/A
3J. For one or both feet, is the weight-bearing line over or medial to the great toe? Yes / No; If yes, indicate side affected: Right / Left / Both
3K. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? Yes / No; If yes, indicate side affected: Right / Left / Both; Describe lower extremity deformity other than pes planus causing alteration of the weight-bearing line:
3L. Does the Veteran have "inward" bowing of the Achilles' tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet? Yes / No; If yes, indicate side affected: Right / Left / Both
3M. Does the Veteran have marked inward displacement and severe spasm of the Achilles' tendon (rigid hindfoot) on manipulation of one or both feet? Yes / No; If yes, indicate side affected: Right / Left / Both; Is the marked inward displacement and severe spasm of the Achilles' tendon improved by orthopedic shoes or appliances? Right: Yes / No / N/A; Left: Yes / No / N/A
3N. Comments, if any:

PLANTAR FASCIITIS (Section IV)

4A. Has the Veteran undergone non-surgical treatment for plantar fasciitis? Yes / No; If yes, indicate side: Right / Left / Both
4B. If yes, did the non-surgical treatment relieve the symptoms? Yes / No; If no, indicate side not relieved: Right / Left / Both
4C. Has the Veteran undergone surgical treatment for plantar fasciitis? Yes / No; If yes, indicate side: Right / Left / Both
4D. If yes, did the surgical treatment relieve the symptoms? Yes / No; If no, indicate side not relieved: Right / Left / Both
4E. If the Veteran has not undergone surgical treatment, was the Veteran recommended for surgical intervention, but was not a surgical candidate? Yes / No; If yes, indicate side: Right / Left / Both
4F. Does the Veteran have any functional loss of the foot/feet due to plantar fasciitis? Yes / No; If yes, indicate side affected: Right / Left / Both; Describe the functional loss of the foot/feet due to plantar fasciitis:
4G. Comments, if any:

MORTON'S NEUROMA (MORTON'S DISEASE) AND METATARSALGIA (Section V)

5A. Does the Veteran have Morton's neuroma? Yes / No; If yes, indicate side affected: Right / Left / Both
5B. Does the Veteran have metatarsalgia? Yes / No; If yes, indicate side affected: Right / Left / Both
5C. Comments, if any:

HAMMER TOE (Section VI)

6A. If the Veteran has hammer toes, which toes are affected? Right: None / Great toe / Second toe / Third toe / Fourth toe / Little toe
6A. Left: None / Great toe / Second toe / Third toe / Fourth toe / Little toe
6B. Comments, if any:

HALLUX VALGUS (Section VII)

7A. Does the Veteran have symptoms due to a hallux valgus condition? Yes / No
If yes, indicate severity: Mild or moderate symptoms — Side affected: Right / Left / Both
If yes, indicate severity: Severe symptoms, with function equivalent to amputation of great toe — Side affected: Right / Left / Both
7B. Has the Veteran had surgery for hallux valgus? Yes / No
If yes: Resection of metatarsal head — Date of surgery; Side affected: Right / Left / Both
If yes: Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection) — Date of surgery; Side affected: Right / Left / Both
If yes: Other surgery for hallux valgus, describe — Date of surgery; Side affected: Right / Left / Both
7C. Comments, if any:

HALLUX RIGIDUS (Section VIII)

8A. Does the Veteran have symptoms due to hallux rigidus? Yes / No
If yes, indicate severity: Mild or moderate symptoms — Side affected: Right / Left / Both
If yes, indicate severity: Severe symptoms, with function equivalent to amputation of great toe — Side affected: Right / Left / Both
8B. Comments, if any:

ACQUIRED PES CAVUS (CLAW FOOT) (Section IX)

9A. Effect on toes due to pes cavus (check all that apply): None / Great toe dorsiflexed / All toes tending to dorsiflexion / All toes hammer toes / Other, describe — Side affected: Right / Left / Both
9B. Pain and tenderness due to pes cavus (check all that apply): None / Definite tenderness under metatarsal heads / Marked tenderness under metatarsal heads / Very painful callosities / Other, describe — Side affected: Right / Left / Both
9C. Effect on plantar fascia due to pes cavus (check all that apply): None / Shortened plantar fascia / Marked contraction of plantar fascia with dropped forefoot / Other, describe — Side affected: Right / Left / Both
9D. Dorsiflexion and varus deformity due to pes cavus (check all that apply): None / Some limitation of dorsiflexion at ankle / Limitation of dorsiflexion at ankle to right angle / Marked varus deformity / Other, describe — Side affected: Right / Left / Both
9E. Comments, if any:

MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES (Section X)

10A. Indicate severity and side affected for malunion or nonunion of tarsal or metatarsal bones: Moderate — Right / Left / Both
10A. Moderately severe — Right / Left / Both
10A. Severe — Right / Left / Both
10B. Comments, if any:

FOOT INJURIES AND OTHER CONDITIONS (Section XI)

11A. Does the Veteran have any foot injuries or other foot conditions not already described? Yes / No; If yes, describe the foot injury or other foot conditions (including frequency and physical exam findings):
11B. Indicate severity and side affected: Not affected / Mild / Moderate / Moderately severe / Severe — Right / Left / Both
11C. Does the foot condition chronically compromise weight-bearing? Yes / No
11D. Does the foot condition require arch supports, custom orthotic inserts or shoe modifications? Yes / No
11E. Comments, if any:

SURGICAL PROCEDURES (Section XII)

12A. Has the Veteran had foot surgery (arthroscopic or open)? Yes / No; If yes, indicate side affected, type of procedure and date of surgery: Right foot procedure; Date of surgery
12A. Left foot procedure; Date of surgery
12B. Does the Veteran have any residual signs or symptoms due to arthroscopic or other foot surgery? Yes / No; If yes, describe residuals:

PAIN (Section XIII)

Right Foot — Is there pain on physical exam? Yes / No
Right Foot — If no, but the Veteran reported pain in his/her medical history, please provide rationale below.
Right Foot — If yes (there is pain on physical exam), does the pain contribute to functional loss? Yes / No; If no, explain why:
Left Foot — Is there pain on physical exam? Yes / No
Left Foot — If no, but the Veteran reported pain in his/her medical history, please provide rationale below.
Left Foot — If yes (there is pain on physical exam), does the pain contribute to functional loss? Yes / No; If no, explain why:

FUNCTIONAL LOSS (Section XIV)

14A. Contributing factors of disability (check all that apply and indicate side affected): No functional loss for left lower extremity attributable to claimed condition
14A. No functional loss for right lower extremity attributable to claimed condition
14A. Less movement than normal — Right / Left / Both
14A. More movement than normal — Right / Left / Both
14A. Weakened movement — Right / Left / Both
14A. Swelling — Right / Left / Both
14A. Deformity — Right / Left / Both
14A. Atrophy of disuse — Right / Left / Both
14A. Instability of station — Right / Left / Both
14A. Disturbance of locomotion — Right / Left / Both
14A. Interference with sitting — Right / Left / Both
14A. Interference with standing — Right / Left / Both
14A. Pain — Right / Left / Both
14A. Fatigue — Right / Left / Both
14A. Weakness — Right / Left / Both
14A. Lack of endurance — Right / Left / Both
14A. Incoordination — Right / Left / Both
14A. Other, describe — Right / Left / Both
14B. Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability during flare-ups and/or after repeated use over time? Yes / No; If yes, indicate side affected: Right / Left / Both; If yes, please describe the functional loss as well as cite and discuss evidence:
14C. Is there any other functional loss during flare-ups and/or after repeated use over time? Yes / No; If yes, indicate side affected: Right / Left / Both; If yes, describe:
14D. Is there evidence of pain on any of the following? Passive motion — Right / Left / Both
14D. Active motion — Right / Left / Both
14D. Weight-bearing — Right / Left / Both
14D. Nonweight-bearing — Right / Left / Both
14D. On rest/non-movement — Right / Left / Both
If yes, describe:
If unable to assess, a rationale is required:

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS (Section XV)

15A. 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 / No; If yes, describe (brief summary):
15B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section? Yes / No

ASSISTIVE DEVICES (Section XVI)

16A. Does the Veteran use any assistive devices (other than those identified above) as a normal mode of locomotion? Yes / No
Wheelchair — Frequency of use: Occasional / Regular / Constant
Brace — Frequency of use: Occasional / Regular / Constant
Crutches — Frequency of use: Occasional / Regular / Constant
Cane — Frequency of use: Occasional / Regular / Constant
Walker — Frequency of use: Occasional / Regular / Constant
Other — Frequency of use: Occasional / Regular / Constant
16B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition:

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XVII)

17A. Due to the Veteran's foot condition(s), is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. / No
If yes, indicate extremities for which this applies: Right lower / Left lower
For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

DIAGNOSTIC TESTING (Section XVIII)

18A. Have imaging studies been performed in conjunction with this examination? Yes / No
18B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No; If yes, indicate foot: Right / Left / Both
18C. If yes, provide type of test or procedure, date and results (brief summary):
18D. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No; If yes, provide type of test or procedure, date and results (brief summary):
18E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:

FUNCTIONAL IMPACT (Section XIX)

19A. 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.)? Yes / No
If yes, describe the functional impact of each condition, providing one or more examples:

REMARKS (Section XX)

20A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

DBQ RHEUM Arthritis

This DBQ evaluates non-degenerative arthritis conditions (including inflammatory and autoimmune arthritides), documenting joint involvement, systemic involvement, and exacerbations.

DIAGNOSIS (Section I)

1A. List the claimed condition(s) that pertain to this questionnaire:
1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process - ICD Code:
Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process - Date of Diagnosis:
Please specify diagnosis(es):
Arthritis, gonorrheal - ICD Code:
Arthritis, gonorrheal - Date of Diagnosis:
Arthritis, pneumococcic - ICD Code:
Arthritis, pneumococcic - Date of Diagnosis:
Arthritis, typhoid - ICD Code:
Arthritis, typhoid - Date of Diagnosis:
Arthritis, syphilitic - ICD Code:
Arthritis, syphilitic - Date of Diagnosis:
Arthritis, streptococcic - ICD Code:
Arthritis, streptococcic - Date of Diagnosis:
Decompression illness (previously dysbaric osteocrenosis/caisson disease) - ICD Code:
Decompression illness (previously dysbaric osteocrenosis/caisson disease) - Date of Diagnosis:
Other specified forms of arthropathy (excluding gout) - ICD Code:
Other specified forms of arthropathy (excluding gout) - Date of Diagnosis:
Please specify diagnosis:
Other diagnosis #1 - ICD Code:
Other diagnosis #1 - Date of Diagnosis:
Other diagnosis #2 - ICD Code:
Other diagnosis #2 - Date of Diagnosis:
Other diagnosis #3 - ICD Code:
Other diagnosis #3 - Date of Diagnosis:
If there are additional diagnoses that pertain to non-degenerative arthritis conditions, list using above format:

MEDICAL HISTORY (Section II)

2A. Describe the history (including onset and course) of the Veteran's inflammatory, autoimmune, crystalline or infectious arthritis, or decompression illness (brief summary):
2B. Does the Veteran require continuous use of medication for the arthritis condition?
If yes, list only those medications used for this arthritis condition:
2C. Has the Veteran lost weight due to the arthritis condition?
If yes, provide baseline weight (average weight for 2-year period preceding onset of disease):
and current weight:
If yes, does the Veteran's weight loss (attributable to the arthritis condition) cause impairment of health?
If yes, describe the impairment:
2D. Does the Veteran have anemia due to the arthritis condition?
If yes, does the Veteran's anemia (which is attributable to the arthritis condition) cause impairment of health?
If yes, describe the impairment, and also provide Complete Blood Count (CBC) under Section IX - Diagnostic Testing:

JOINT INVOLVEMENT (Section III)

3A. Does the Veteran have any joint involvement (e.g., pain, limitation of motion, joint deformity) attributable to the arthritis condition?
If yes, indicate affected joints. Check all that apply: Cervical spine
Thoracolumbar spine
Sacroiliac joints
Right: Shoulder
Right: Elbow
Right: Wrist
Right: Hand/fingers
Right: Hip
Right: Knee
Right: Ankle
Right: Foot/toes
Left: Shoulder
Left: Elbow
Left: Wrist
Left: Hand/fingers
Left: Hip
Left: Knee
Left: Ankle
Left: Foot/toes
For all checked joints, describe involvement (brief summary):

SYSTEMIC INVOLVEMENT OTHER THAN JOINTS (Section IV)

4A. Does the Veteran have any involvement of any body systems, other than joints, attributable to the arthritis condition?
If yes, indicate systems involved. Check all that apply: Opthalmological
Skin and mucous membranes
Hematological
Pulmonary
Cardiac
Neurological
Renal
Gastrointestinal
Vascular
Other
For all checked systems, describe involvement (brief summary). Also complete the appropriate questionnaire for each affected body system, if indicated.
4B. Comments (if any):

INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS (Section V)

5A. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating?
If yes, indicate frequency of non-incapacitating exacerbations per year (on average): 0 / 1 / 2 / 3 / 4 or more
Date of most recent non-incapacitating exacerbation:
Duration of most recent non-incapacitating exacerbation:
Describe non-incapacitating exacerbation:
5B. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating?
If yes, indicate frequency of incapacitating exacerbations per year (on average): 0 / 1 / 2 / 3 / 4 or more
Indicate the total duration of incapacitation over the past 12 months: < 1 week / 1 week to < 2 weeks / 2 weeks to < 4 weeks / 4 weeks to < 6 weeks / 6 weeks or more
Date of most recent incapacitating exacerbation:
Duration of most recent incapacitating exacerbation:
Describe incapacitating exacerbation:
5C. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating?
5D. Is the Veteran's arthritis manifested by weight loss and anemia productive of severe impairment of health?
5E. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring four or more times a year, or a lesser number over prolonged periods?
5F. Is the Veteran's arthritis manifested by symptom combinations productive of definite impairment of health, objectively supported by examination findings?

OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VI)

6A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section above?
If yes, describe (brief summary):
6B. Does the Veteran have any scars or other disfigurement of the skin related to any conditions, or to the treatment of any conditions, listed in the diagnosis section?

ASSISTIVE DEVICES (Section VII)

7A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occassional locomotion by other methods may be possible?
Wheelchair - Frequency of use: Occasional / Regular / Constant
Brace(s) - Frequency of use: Occasional / Regular / Constant
Crutch(es) - Frequency of use: Occasional / Regular / Constant
Cane(s) - Frequency of use: Occasional / Regular / Constant
Walker - Frequency of use: Occasional / Regular / Constant
Other: - Frequency of use: Occasional / Regular / Constant
7B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition:

REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section VIII)

8A. Due to the Veteran's arthritis condition, 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?
If yes, indicate extremities for which this applies: Right upper
Left upper
Right lower
Left lower
8B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

DIAGNOSTIC TESTING (Section IX)

9A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination?
Was arthritis documented?
X-ray - Area(s) imaged:
X-ray - Date:
X-ray - Results:
Other, specify: - Area(s) imaged:
Other, specify: - Date:
Other, specify: - Results:
9B. Has clinically relevant laboratory testing been performed or reviewed in conjunction with this examination?
Erythrocyte sedimentation rate (ESR) - Date of test:
Erythrocyte sedimentation rate (ESR) - Results:
C-reaction protein - Date of test:
C-reaction protein - Results:
Rheumatoid factor (RF) - Date of test:
Rheumatoid factor (RF) - Results:
Anti-DNA antibodies - Date of test:
Anti-DNA antibodies - Results:
Antinuclear antibodies (ANA) - Date of test:
Antinuclear antibodies (ANA) - Results:
Anti-cyclic citrullinated peptide (ANTI - CCP) antibodies - Date of test:
Anti-cyclic citrullinated peptide (ANTI - CCP) antibodies - Results:
CBC - Date of test:
CBC - Results:
Hemoglobin:
Hematocrit:
White Blood cell count:
Platelets:
Uric acid test - Date of test:
Uric acid test - Results:
Other, specify: - Date of test:
Other, specify: - Results:
If any test results in this section are other than normal, include normal reference ranges for your facility.
9C. Has the Veteran had a joint aspiration or synovial fluid analysis?
If yes, indicate joint aspirated, date and results:
9D. Has the Veteran had a biopsy?
If yes, indicate area biopsied, date and results:
9E. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination?
If yes, provide type of test or procedure, date, and results (brief summary):
9F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition(s):

FUNCTIONAL IMPACT (Section X)

10A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
If yes, describe the functional impact of each condition, providing one or more examples:

REMARKS (Section XI)

11A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

Rating Levels for DC 5019

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

DC 5003

Evidence cited in published BVA decisions for DC 5019

The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code. Each row reports how often a given evidence type was discussed in the decision text, broken down by outcome. This is a factual aggregate of the public record, not a prediction or recommendation about any specific claim.

Private medical opinion: appeared in 4 granted decisions (0 denied, 2 remanded; 6 total)
Medical literature: appeared in 4 granted decisions (1 denied, 0 remanded; 5 total)
VA examination: appeared in 4 granted decisions (5 denied, 14 remanded; 23 total)
Buddy / lay statements: appeared in 2 granted decisions (1 denied, 1 remanded; 4 total)
Service treatment records: appeared in 1 granted decision (0 denied, 1 remanded; 2 total)

What the Board discussed in granted decisions for DC 5019

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

35% Benefit of doubt doctrine stated or applied generally
The Board cited, restated, or applied the statutory benefit-of-the-doubt doctrine, noting that when evidence is in approximate balance the claimant prevails.
175 of 500 sample sentences
18% VA or private examiner nexus opinion cited as at least as likely as not
A VA or private examiner opined that a claimed disability was at least as likely as not incurred in, caused by, or related to active military service or a service-connected condition.
91 of 500 sample sentences
16% Evidence found in equipoise on service connection
The Board found the lay and medical evidence at least in relative equipoise on whether a specific disability was incurred in or related to active service, warranting a grant of service connection.
82 of 500 sample sentences
14% Preponderance of evidence against claim; benefit of doubt inapplicable
The Board found the weight of evidence persuasively against the claim and therefore held that the benefit-of-the-doubt doctrine did not apply and the claim must be denied.
71 of 500 sample sentences
8% Equipoise on rating level; higher disability rating awarded
The Board found the evidence in equipoise or affording the Veteran the benefit of the doubt on whether a higher disability rating percentage was warranted, and assigned the increased rating.
38 of 500 sample sentences
4% Secondary service connection nexus documented by examiner
An examiner opined that a disability was caused or aggravated by an already service-connected condition, supporting a grant of secondary service connection.
20 of 500 sample sentences
4% Bursitis or related musculoskeletal condition linked to service
Medical evidence or examiner opinion specifically documented bursitis (trochanteric, prepatellar, elbow, shoulder, or knee) as at least as likely as not related to service or a service-connected disability.
18 of 500 sample sentences
1% Continuity of symptomatology noted as basis for service connection
The Board noted the Veteran's credible reports of continuous symptoms from service through the present as supporting a finding of service incurrence.
5 of 500 sample sentences

Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.

C&P Exam for Bursitis (DC 5019)

Which form the examiner uses

What the examiner records

DBQ MUSC Knee and Lower Leg

DBQ MUSC Ankle

DBQ MUSC Hip and Thigh

DBQ MUSC Shoulder and Arm

DBQ MUSC Hand and Finger

DBQ MUSC Wrist

DBQ MUSC Back (Thoracolumbar Spine)

DBQ MUSC Foot Conditions Including Flatfoot (Pes Planus)

DBQ RHEUM Arthritis

Rating Levels for DC 5019

Related diagnostic codes

Evidence cited in published BVA decisions for DC 5019

What the Board discussed in granted decisions for DC 5019