M21-1 Manual / Part V, Subpart iii, Chapter 1, Section A
Painful Motion and Functional Loss
M21-1, Part V, Subpart iii, Chapter 1, Section A
Overview
In This Section | This section contains the following topics:
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1. Principles for Evaluating Painful Motion
| Introduction | This topic contains principles for evaluating painful motion, including
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| Change Date | March 25, 2026 |
V.iii.1.A.1.a. Establishing the Minimum Compensable Evaluation Under 38 CFR 4.59 | An actually painful joint can be a basis for assignment of a compensable evaluation even though the specific criteria for a compensable evaluation listed in a diagnostic code (DC) for the joint are not met. The regulatory language at 38 CFR 4.59 provides that
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V.iii.1.A.1.b. Precedential Court Holdings Impacting 38 CFR 4.59 | Multiple precedential decisions have impacted the application of 38 CFR 4.59. Refer to the table below for a listing of impactful precedential court holdings, a brief description of the impact, and the applicability date (date of decision) for each. More detailed explanations for each holding and its impact on the application of 38 CFR 4.59 in claims processing can be found in M21-1, Part V, Subpart iii, 1.A.1.c-i.
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V.iii.1.A.1.c. Assessing Functional Loss Due to Pain Per Deluca v. Brown | DeLuca v. Brown, 8 Vet.App. 202 (1995), held that in examinations of musculoskeletal disabilities, the examiner must be asked to give an opinion on whether pain could significantly limit functional ability during flare-ups or with repeated use over a period of time. This information must be portrayed in terms of the degree of additional ROM lost due to pain on use or during flare-ups. Important:
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V.iii.1.A.1.e. Assessing Functional Loss Due to Pain Per Mitchell v. Shinseki | Mitchell v. Shinseki, 25 Vet.App. 32 (2011), held that pain alone does not constitute a functional loss under VA regulations that evaluate disability based upon ROM loss. Thus, when assigning a disability evaluation based on loss of ROM, painful motion is not considered the same as limited motion unless the pain actually causes a loss of motion. If pain is associated with movement,
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V.iii.1.A.1.g. Selecting a DC and Minimum Compensable Evaluation for 38 CFR 4.59 Per Sowers v. McDonald | Sowers v. McDonald, 27 Vet.App. 472 (2016), held that 38 CFR 4.59 is limited by the DC applicable to the claimant’s disability, and where that DC does not provide a compensable rating, 38 CFR 4.59 does not apply. Example: Painful motion of a right ring finger fracture that is rated under 38 CFR 4.71a, DC 5230 would not receive a compensable evaluation under 38 CFR 4.59 because this DC does not contain a compensable evaluation. Important: Sowers did not specifically hold that the minimum compensable evaluation must be assigned under the applicable DC for the disability involved. However, the holding did influence a subsequent policy determination that the minimum compensable evaluation under the DC must be assigned when painful motion is demonstrated under 38 CFR 4.59. This policy is effective May 23, 2016.
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V.iii.1.A.1.h. Assessing Joint Disabilities for Pain Per Correia v. McDonald | Correia v. McDonald, 28 Vet.App. 158 (2016), held that the final sentence of 38 CFR 4.59 requires that certain ROM testing be conducted to assess for pain whenever possible in evaluating joint disabilities. Particularly,
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V.iii.1.A.1.j. Assessing Medical Evidence for Functional Loss Due to Pain | Medical evidence used to evaluate functional impairment due to pain must account for
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V.iii.1.A.1.k. Considering DeLuca and Mitchell Results | In order to properly evaluate the functional impairment of a joint due to pain, use the
Important:
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V.iii.1.A.1.l. Evaluating Painful Motion of Minor Joints or Joint Groups Under 38 CFR 4.59 | The determining factor as to whether a minimum compensable evaluation may be assigned under 38 CFR 4.59 is whether the appropriate corresponding DC for the joint or periarticular region involved includes a compensable evaluation, as demonstrated in Sowers v. McDonald, 27 Vet.App. 472 (2016). 38 CFR 4.59 does not include a specific provision limiting application to major joints or provisions for how to consider groups of minor joints. Thus, major joint involvement or multiple minor joint involvement is not a factor in determining whether a minimum compensable evaluation may be assigned under 38 CFR 4.59. The following principles apply when evaluating painful motion of the minor joints of the hands and feet:
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V.iii.1.A.1.m. Steps for Applying 38 CFR 4.59 | Refer to the table below for procedures for assessing the applicability of and applying 38 CFR 4.59.
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2. Examples of Evaluating Painful Motion
Introduction | This topic contains examples of evaluating painful motion under 38 CFR 4.59, including
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Change Date | March 25, 2026 |
V.iii.1.A.2.a. Painful Motion of the Shoulder | The following examples demonstrate the proper procedures for considering 38 CFR 4.59 when evaluating shoulder disabilities.Example 1: Assume a shoulder strain with forward elevation and abduction limited to 145 degrees with credible evidence of pain while performing each motion, starting at 140 degrees. Assign a 20-percent evaluation under 38 CFR 4.71a, DC 5201. Under 38 CFR 4.59 there is actually painful motion and joint or periarticular pathology (a strain). Therefore, the intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for shoulder motion under the DC is 20 percent. Example 2: Assume the same facts as in Example 1 but the diagnosis is traumatic arthritis of the shoulder based on x-rays. Assign a 20-percent evaluation under 38 CFR 4.71a, DC 5010-5201 with application of 38 CFR 4.59. The ROM does not meet the criteria for a 20-percent evaluation under 38 CFR 4.71a, DC 5201 because arm motion is not limited at shoulder height. However, pursuant to 38 CFR 4.59 there is actually painful motion and joint or periarticular pathology (arthritis). Therefore, the intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for shoulder motion under 38 CFR 4.71a, DC 5201 is 20 percent. Example 3: Assume the same facts as in Example 2 except that there was no pain on motion and the arthritis is degenerative rather than traumatic. There was a minor amount of swelling of the shoulder. Assign a 10-percent evaluation under 38 CFR 4.71a, DC 5003. There is x-ray evidence of degenerative arthritis and motion that is noncompensable under the applicable DC. There is no indication of painful motion, so 38 CFR 4.59 is not applicable. Under 38 CFR 4.71a, DC 5003, LOM must be “objectively confirmed” by findings such as swelling, spasm, or satisfactory evidence of painful motion. In this case there was objective evidence supporting the LOM – namely the minor swelling of the shoulder. |
V.iii.1.A.2.b. Non-Objective Pain Under 38 CFR 4.59 | Example 1: On examination, a claimant reports current symptoms of regular pain of the right knee (particularly when fully straightening the knee) that is worsened with increased activity. The examiner finds normal ROM without pain on examination. Repetitive motion testing produces no evidence of pain or loss of motion. The assessment is right knee strain. Assign a 10-percent evaluation under 38 CFR 4.71a, DC 5261. The claimant’s reports of joint pain are found to be credible. There is no basis to reject the complaints of pain as lacking in credibility. 38 CFR 4.59 does not require objective evidence of painful motion. The claimant’s statement establishes that there is actually painful motion of the joint, even though it was not objectively verified on VA examination. Example 2: On examination, a claimant reports constant pain of the left elbow (particularly when bending the arm). The examiner finds normal ROM without pain on examination. Repetitive motion testing produces no evidence of pain or loss of motion. There is no swelling or spasm. The assessment is degenerative arthritis of the left elbow corroborated by x-rays. Assign a 10-percent evaluation under 38 CFR 4.71a, DC 5003-5206. The claimant’s reports of joint pain are found to be credible. There is no basis to reject the complaints of pain as lacking in credibility. Although 38 CFR 4.71a, DC 5003 requires noncompensable LOM and objective confirmation of LOM by spasm, swelling, or satisfactory evidence of painful motion, 38 CFR 4.59 provides an alternative basis for a compensable evaluation and does not require objective evidence of painful motion. The claimant’s statement establishes that there is actually painful motion of the joint, even though pain was not objectively verified on VA examination. Example 3: Start with the same facts as Example 2. However, in this example, claimant reports significant pain on elbow motion consistently for the last year and particularly in the last week. However, treatment records from the past year show normal, painless range of elbow motion and no history of pain at rest, or on motion. Notably, in a VA outpatient report from two days before the VA examination, the claimant told the treating doctor that the elbow was not painful and had not been painful at all in the last year. Continue the 0-percent evaluation. Review of all the evidence satisfactorily demonstrates that the complaints of painful motion were not credible. Elbow motion is not found to be actually painful. |
V.iii.1.A.2.c. Pain With Passive ROM Under 38 CFR 4.59 | Service connection (SC) is established for left rotator cuff impingement. The Veteran reports shoulder pain when lifting the left arm – particularly with repetitive motion of the arm at or above shoulder height. The Veteran reported a feeling of weakness with repeated over the head motions like painting. On examination, the Veteran had full active forward elevation, abduction, and external and internal rotation of the shoulder including on repeated motion. There was no report of pain with active motion. Passive ROM testing for impingement including the Hawkin’s Sign was positive and reproduced impingement with the guided movements at shoulder height. Assign a 20-percent evaluation under 38 CFR 4.71a, DC 5201. The Hawkin’s Sign is a test for pain on passive ROM. Under 38 CFR 4.59 the shoulder is actually painful to passive ROM and there is joint or periarticular pathology (rotator cuff impingement). The intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for limited ROM of the shoulder under the DC is 20 percent. Note: Medical Electronic Performance Support System (EPSS) provides that a rotator cuff tear should be rated by analogy to 38 CFR 4.71a, DC 5203 (clavicle or scapula, impingement of) because the rotator cuff holds the humeral head in the glenoid fossa of the scapula and consists of the muscles around the scapula. However, 38 CFR 4.71a, DC 5203 in turn provides that rather than rating impairment of the scapula by dislocation, nonunion, or malunion it may also be rated “on impairment of function of the contiguous joint.” Medical EPSS notes that rotator cuff impingement is characterized by pain and weakness with motions at or above shoulder height and advises that there may be LOM of the arm for the purposes of 38 CFR 4.71a, DC 5201 in cases of rotator cuff disease. |
V.iii.1.A.2.d. Painful Motion of Minor Joints | Example 1: Hallux valgus with painful motion of the first toe is most appropriately evaluated under 38 CFR 4.71a, DC 5280. The minimum compensable evaluation for this DC is 10 percent. Therefore, a 10-percent evaluation is warranted for painful motion of the first toe. This is applicable only when the disability evaluated is hallux valgus or another disability warranting analogous evaluation under this DC. Example 2: Residuals of fracture of the little finger with painful motion is most appropriately evaluated under 38 CFR 4.71a, DC 5230. The only possible evaluation under this DC is a 0 percent. Therefore, a compensable evaluation cannot be assigned for painful motion of the little finger. Example 3: Painful motion due to fracture of the index or long finger is most appropriately evaluated under 38 CFR 4.71a, DC 5229. The minimum compensable evaluation for this DC is 10 percent. Therefore, a 10-percent evaluation is available for painful motion of the index finger and an additional 10-percent evaluation is warranted for painful motion of the long finger, each under 38 CFR 4.71a, DC 5229. |
V.iii.1.A.2.e. Painful Motion Associated With Flatfoot | Situation: SC is warranted for flat feet under 38 CFR 4.71a, DC 5276. The clinical evidence shows complete relief of symptoms, including foot pain, with arch supports. However, the record also contains credible lay reports of pain. Outcome: Although no more than a 0-percent evaluation is warranted under 38 CFR 4.71a, DC 5276 on the basis of complete symptom relief due to an orthotic device, application of 38 CFR 4.59 warrants assignment of a 10-percent evaluation. Rationale:
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V.iii.1.A.2.f. Painful Motion Associated With Shin Splints | Situation: A Veteran has SC bilateral shin splints that have not required treatment, but which result in painful motion in both ankles. The Veteran is also SC for right ankle arthritis, currently evaluated as 10-percent disabling based on painful motion under 38 CFR 4.71a, DC 5271. Outcome: Assign a compensable evaluation under 38 CFR 4.71a, DC 5262, for bilateral shin splints based on the painful motion of the left ankle. Rationale: Even though the Veteran is receiving a compensable evaluation for painful motion of the right ankle under 38 CFR 4.59, the shin splints are also causing painful motion in the left ankle that is not being separately compensated.Reference: For more information on evaluating shin splints, see M21-1, Part V, Subpart iii, 1.B.3.h and i. |
3. Principles for Evaluating Joint Conditions and Functional Loss
Introduction | This topic contains information on evaluating joint conditions and functional loss, including
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Change Date | March 25, 2026 |
V.iii.1.A.3.a. Use of the Terms Major and Minor | The use of the terms major and minor joint in 38 CFR 4.45(f) applies solely to the evaluation of joint conditions affected by arthritis as discussed in Spicer v. Shinseki, 752 F.3d 1367 (2014). These terms are applicable when evaluating any form of arthritis using the evaluation criteria at 38 CFR 4.71a, DC 5003. Refer to the table below for more information on the use of the terms major and minor in joint evaluations.
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V.iii.1.A.3.b. Importance of Accurate Measurements in Joint Cases | Accurate measurements are very important in joint cases. VA examinations must measure joint motion with a goniometer. A number of disability benefits questionnaires (DBQ) relating to joints require use of a goniometer. Important: There is a presumption that examiners will conduct examinations in line with examination standards. Accordingly, treat measurements on examinations that require a goniometer as having been taken using the device unless there is clear evidence that a goniometer was not used. Do not seek clarification of DBQs requiring goniometer use, or return the examination as insufficient, merely because the report does not explicitly refer to goniometer use.References: For more information on
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V.iii.1.A.3.c. Assigning Multiple LOM Evaluations for a Joint | In VAOPGCPREC 9-2004, the Office of General Counsel held that separate evaluations under 38 CFR 4.71a, DC 5260, (limitation of knee flexion) and 38 CFR 4.71a, DC 5261, (limitation of knee extension) can be assigned without pyramiding. Despite the fact that knee flexion and extension both occur in the same plane of motion, limitation of flexion (bending the knee) and limitation of extension (straightening the knee) represent distinct disabilities. Important:
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V.iii.1.A.3.d. Assigning a Separate Noncompensable Evaluation When Schedular 0-Percent Criteria Are Not Specified | When considering a separate evaluation for a motion of a joint specified in M21-1, Part V, Subpart iii, 1.A.3.c, where 0-percent evaluation criteria are not provided by the DC, any LOM for that specific movement falling short of criteria for a compensable level of evaluation will be assigned a separate 0-percent evaluation. 38 CFR 4.31 provides that in every instance where the schedule does not provide a 0-percent evaluation for a DC, a 0-percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. The motions include
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V.iii.1.A.3.e. Considering Pain When Assigning Multiple LOM Evaluations for a Joint | When considering the role of pain in evaluations for multiple motions of a single joint, the following guidelines apply.
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V.iii.1.A.3.f. Ankylosis of the Joints | Ankylosis is a condition of, or term used for the sign/symptom of, abnormal stiffness, immobility, or abnormal bending of a joint. It is a stiffness or immobility in a joint caused by bones fusing as a result of disease or injury or by intentional fusion through surgery. Favorable ankyloses is fixation of a joint in a neutral position (at 0 degrees). Unfavorable ankyloses is fixation of a joint in flexion or extension that results in significant functional impairment. Reference: For more information on spinal ankylosis, see the General Rating Formula for Diseases and Injuries of the Spine at 38 CFR 4.71a (affiliated with DCs 5235-5243), Notes 5 and 6. |
V.iii.1.A.3.g. Functional Equivalence of Ankylosis | 38 CFR 4.40 and 4.45 apply when considering whether LOM results in the functional equivalence of ankylosis of the joint. The functional equivalence of ankylosis arises when application of theeffect of pain or other factors identified under 38 CFR 4.40 or 4.45, to include during flare-ups and repetitive use over time, results in additional loss of motion to the joint that effectively results in functional impairment consistent with ankylosis. Reference: For more information on the functional equivalence of ankylosis, see Chavis v. McDonough, 34 Vet.App. 1 (2021). |
V.iii.1.A.3.h. Joint Replacement and Resurfacing | Joint replacement and resurfacing are evaluated under 38 CFR 4.71a, DCs 5051-5056.
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V.iii.1.A.3.i. Evaluating Joint Replacement and Resurfacing | Refer to the table below for a comparison of policies and procedures applicable to evaluating joint replacements and resurfacing.
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V.iii.1.A.3.j. Evaluating Residuals of Joint Resurfacing | Unlike a joint replacement, there is no minimum schedular evaluation after a joint resurfacing procedure. Therefore, following the temporary 100-percent evaluation for joint resurfacing,
Note: When evaluating residuals of joint resurfacing,
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V.iii.1.A.3.k. Partial Knee Replacement Regulatory History | VA published an interpretative rule effective July 16, 2015, revising 38 CFR 4.71a to add a note stating that the term “prosthetic replacement” as used in 38 CFR 4.71a, DCs 5051-5056 means “total replacement of the named joint” except that in 38 CFR 4.71a, DC 5054 it means “total replacement of the head of the femur or of the acetabulum.” Effective February 7, 2021, after proposed rule and comment period, a final rule was issued updating rating schedule provisions pertaining to the musculoskeletal system, and explicitly stating that a minimum evaluation is assignable only for total joint replacement, not partial knee joint replacement. In a September 20, 2022, decision, NOVA v. Secretary of Veterans Affairs, 48 F.4th 1307 (2022) concluded that prior to February 7, 2021, 38 CFR 4.71a, DC 5055, as then written, did not exclude a partial knee replacement. The court vacated the rule change that was effective from July 15, 2015, to February 6, 2021.When deciding any claim involving evaluation of a partial knee joint replacement that was pending and not finally adjudicated on September 20, 2022, rate as follows:
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V.iii.1.A.3.l. Severe Painful Motion Following Joint Replacement | Severe painful motion and LOM, as utilized to evaluate residuals of joint replacements, are distinct concepts.
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V.iii.1.A.3.m. Use of Active ROM Findings | Active ROM testing is required to measure functional loss as is utilized in DCs based on LOM.Note: Passive ROM is for consideration in evaluating painful motion, as described in 38 CFR 4.59 and M21-1, Part V, Subpart iii, 1.A.1. |
4. Examples of Evaluating Joint Conditions and Functional Loss
Introduction | This topic contains examples of evaluating joint conditions and functional loss, including
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Change Date | September 15, 2021 |
V.iii.1.A.4.a. Compensable Limitation of Two Joint Motions | Situation: Evaluation of chronic knee strain with the following examination findings:
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V.iii.1.A.4.b. Compensable Limitation of One Motion With Pain in Another Motion | Situation: Evaluation of knee tenosynovitis with the following examination findings:
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V.iii.1.A.4.c. Noncompensable Limitation of Two Motions With Pain | Situation: Evaluation of knee degenerative arthritis shown on x-ray with the following examination findings:
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V.iii.1.A.4.d. Evaluating a Joint With Full ROM and Functional Loss Due to Pain | Situation: Evaluation of a knee condition with normal initial ROM and additional functional loss indicated on DeLuca and Mitchell assessments.
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V.iii.1.A.4.e. Evaluating a Joint With LOM and Functional Loss Due to Pain | Situation: Evaluation of a knee condition with limited initial ROM and additional functional loss indicated on DeLuca and Mitchell assessments.
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V.iii.1.A.4.f. Evaluating Joints With Arthritis by X-Ray Evidence Only With Other Joint(s) Affected by a Non-Arthritic Condition | Example: A Veteran is rated 10 percent for bilateral degenerative arthritis of the elbows confirmed by x-ray evidence, without limited or painful motion or incapacitating exacerbations. The Veteran subsequently files a claim for SC for chondromalacia of the right knee and is awarded a 20-percent evaluation based on VA examination, which revealed limitation of flexion of the right knee to 30 degrees. Analysis: A 10-percent evaluation for bilateral arthritis of the elbows and a separate 20-percent evaluation for right knee chondromalacia is justified. In this case, the rating does not violate Note (1) under 38 CFR 4.71a, DC 5003, because the knee condition is not an arthritic condition. Reference: For additional information on the principle in 38 CFR 4.71a, DC 5003, Note 1, see
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Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 1, Section A (U.S. government work, reproduced for reference). Browse all sections →