M21-1 Manual / Part V, Subpart iii, Chapter 1, Section B

Musculoskeletal Disabilities of the Extremities and Spine

M21-1, Part V, Subpart iii, Chapter 1, Section B

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	Evaluating Musculoskeletal Disabilities of the Arms
2	Evaluating Musculoskeletal Disabilities of the Hands
3	Evaluating Musculoskeletal Disabilities of the Spine
4	Evaluating Musculoskeletal Disabilities of the Legs
5	Evaluating Musculoskeletal Disabilities of the Feet

1. Evaluating Musculoskeletal Disabilities of the Arms

Introduction

This topic contains information on evaluating musculoskeletal disabilities of the arms, including

considering separate evaluations for disabilities of the shoulder and arm
example of separate evaluations for disabilities of the shoulder and arm
assigning separate evaluations for disabilities of the elbow, forearm, and wrist
example of separate evaluations for multiple disabilities of the elbow, forearm, and wrist, and
considering impairment of supination and pronation of the forearm.

Change Date

April 13, 2018

V.iii.1.B.1.a. Considering Separate Evaluations for Disabilities of the Shoulder and Arm

Separate evaluations may be given for disabilities of the shoulder and arm under 38 CFR 4.71a diagnostic codes (DCs) 5201, 5202, or 5203 if the manifestations represent separate and distinct symptomatology that are neither duplicative nor overlapping.Reference: For more information concerning separate and distinct symptomatology, see
38 CFR 4.14, and
Esteban v. Brown, 6 Vet.App. 259 (1994)

V.iii.1.B.1.b. Example of Separate Evaluations for Disabilities of the Shoulder and Arm

Situation: A Veteran was involved in an automobile accident that resulted in multiple injuries to the upper extremities. The Veteran sustained the following injuries
a humeral fracture resulting in restriction of arm motion at shoulder level, and
a clavicular fracture resulting in malunion of the clavicle.
Result:
assign a 20-percent evaluation for the impairment of the humerus under 38 CFR 4.71a, DC 5202-5201, and
assign a separate 10-percent evaluation for malunion of the clavicle under 38 CFR 4.71a, DC 5203.
Notes:
The hyphenated evaluation DC is assigned under 38 CFR 4.71a, DC 5202-5201 because the humerus impairment affects range of motion (ROM).
The separate evaluation for the clavicle disability is warranted because this disability does not affect ROM.
Exception: Multiple evaluations cannot be assigned under 38 CFR 4.71a, DC 5201 for limited flexion and abduction of the shoulder. Reference: For more information on evaluating shoulder conditions, see Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013).

V.iii.1.B.1.c. Assigning Separate Evaluations for Disabilities of the Elbow, Forearm, and Wrist

Impairments of the elbow, forearm, and wrist will be assigned separate disability evaluations. The motions of these joints are all viewed as clinically separate and distinct. Assign separate evaluations for impairment under the following DCs:

elbow
- flexion under 38 CFR 4.71a, DC 5206, or
- extension under 38 CFR 4.71a, DC 5207
forearm supination and pronation under 38 CFR 4.71a, DC 5213, and
wrist flexion or ankylosis under 38 CFR 4.71a, DC 5214 or 38 CFR 4.71a, DC 5215.

Notes:
38 CFR 4.59 may be applied separately to the elbow, the forearm, and the wrist to result in potentially three separate evaluations for painful motion when the evidence otherwise supports such a finding. However, 38 CFR 4.59 may only be applied once to the elbow and may not be separately applied to both elbow flexion and elbow extension.
When examination or other evidence denotes pain present in the joint or periarticular region but does not delineate the specific motions in which pain is present and there is a potential for a separate evaluation under 38 CFR 4.59 as discussed in M21-1, Part V, Subpart iii, 1.A.1, obtain a medical opinion to determine which motions are painful. When the examiner cannot delineate which motions are associated with pain, resolve doubt in favor of the Veteran and consider painful motion to be present in the separate plane such as to allow assignment of the separate minimum compensable evaluation under 38 CFR 4.59.
Reference: For more information on assigning separate evaluations for elbow motion, see M21-1, Part V, Subpart iii, 1. A.3.c.

V.iii.1.B.1.d. Example of Separate Evaluations for Disabilities of the Elbow, Forearm, and Wrist

Situation: A Veteran sustained multiple injuries to the right upper extremity in a vehicle rollover accident. The following impairments are due to the service-connected (SC) injuries:
elbow flexion limited to 90 degrees
elbow extension limited to 45 degrees
full ROM on supination and pronation with painful supination, and
full ROM of the wrist with pain on dorsiflexion.
Result: Assign the following disability evaluations
20-percent for limited elbow flexion under 38 CFR 4.71a, DC 5206
10-percent for limited elbow extension under 38 CFR 4.71a, DC 5207
10-percent for painful forearm supination under 38 CFR 4.71a, DC 5213, and
10-percent for painful wrist motion under 38 CFR 4.71a, DC 5215.
Explanation:
Compensable limitation of motion (LOM) of elbow flexion and extension is present. Separate evaluations are warranted for elbow flexion and extension.
Motion of the forearm is separate and distinct from elbow motion. Therefore, a separate evaluation is warranted for painful supination.
Motion of the wrist is separate and distinct from forearm motion. Therefore, a separate evaluation is warranted for painful motion of the wrist.
Note: If elbow flexion is limited to 100 degrees and elbow extension is limited to 45 degrees, assign a single 20-percent disability evaluation under 38 CFR 4.71a, DC 5208.References: For more information on
separate evaluations for motion of a single joint, see
VAOPGCPREC 9-2004, and
M21-1, Part V, Subpart iii, 1.A.3.c, and
separate evaluations for the elbow, forearm, and wrist, see M21-1, Part V, Subpart iii, 1.B.1.c.

V.iii.1.B.1.e. Considering Impairment of Supination and Pronation of the Forearm

When preparing ratings decisions involving impairment of supination and pronation of the forearm, consider the following facts:

Full pronation is the position of the hand flat on a table.
Full supination is the position of the hand palm up.
When examining limitation of pronation, the
- arc is from full supination to full pronation, and
- middle of the arc is the position of the hand, palm vertical to the table.

Assign the lowest, 20-percent evaluation when pronation cannot be accomplished through more than the first three-quarters of the arc from full supination.Do not assign a compensable evaluation for both limitation of pronation and limitation of supination of the same extremity.Reference: For more information on considering painful motion when assigning multiple LOM evaluations for a joint, see M21-1, Part V, Subpart iii, 1.A.3.e.

2. Evaluating Musculoskeletal Disabilities of the Hands

Introduction

This topic contains information on evaluating musculoskeletal disabilities of the hands, including

identifying digits of the hand
evaluating
- amputations of multiple fingers, and
- ankylosis of one or more fingers
compensable evaluations for the fingers, and
rating Dupuytren’s contracture of the hand.

Change Date

February 8, 2021

V.iii.1.B.2.a. Identifying Digits of the Hand

Follow the guidelines listed below to accurately specify the injured digits of the hand.

The digits of the hand are identified as
- thumb
- index
- long
- ring, or
- little.
Do not use numerical designations for either the fingers or the joints of the fingers.
Each digit, except the thumb, includes three phalanges
- the proximal phalanx (closest to the wrist)
- the middle phalanx, and
- the distal phalanx (closest to the tip of the finger).
The joint between the proximal and middle phalanges is called the proximal interphalangeal or PIP joint.
The joint between the middle and distal phalanges is called the distal interphalangeal or DIP joint.
The thumb has only two phalanges, the proximal phalanx and the distal phalanx. Therefore, each thumb has only a single joint, called the interphalangeal or IP joint.
The joints connecting the phalanges in the hands to the metacarpals are the metacarpophalangeal or MCP joints.
Designate either right or left for the digits of the hand.

Note: If the location of the injury is unclear, obtain x-rays to clarify the exact point of injury.References: For
more information on
determining dominant handedness, see 38 CFR 4.69, and
the normal anatomical position (also called position of function) of the hand and fingers and normal range of motion of the fingers, see Note 1 preceding 38 CFR 4.71a, DC 5216, and
an exhibit of the anatomy of the hand, see the illustration following 38 CFR 4.71a, DC 5156.

V.iii.1.B.2.b. Evaluating Amputations of Multiple Fingers

Consider and apply the following principles as applicable when evaluating amputations of multiple fingers:

Amputations other than at the PIP joints or through the proximal phalanges will be rated as ankylosis of the fingers.
- Amputations at distal joints, or through distal phalanges (other than negligible losses) will be rated as favorable ankylosis of the fingers.
- Amputation through middle phalanges will be rated as unfavorable ankylosis of the fingers.
If there is amputation or resection of metacarpal bones (where more than one-half the bone is lost) in multiple finger injuries, add (not combine) 10 percent to the specified evaluation for the finger amputations subject to the amputation rule (at the forearm level).
When an evaluation is assigned under 38 CFR 4.71a, DC 5126 to 5130 there will also be entitlement to special monthly compensation.
Loss of use of the hand exists when no effective function remains other than that which would be equally well served by an amputation stump with a suitable prosthetic appliance.

V.iii.1.B.2.c. Evaluating Ankylosis of One or More Fingers

When considering an evaluation for ankylosis of the index, long, ring or little finger, evaluate as:

favorable ankylosis if either the MCP or PIP joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible
unfavorable ankylosis if
- either the MCP or PIP joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, or
- both the MCP and PIP joints of a digit are ankylosed (even if each joint is individually fixed in a favorable position), or
amputation without metacarpal resection at the PIP joint or proximal thereto (38 CFR 4.71a, DC 5153 to 5156) if both the MCP and PIP joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone.

When considering an evaluation for ankylosis of the thumb, evaluate as:
favorable ankylosis if either the carpometacarpal or IP joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and fingers with the thumb attempting to oppose the fingers
unfavorable ankylosis if
either the carpometacarpal or IP joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the thumbpad and the fingers, with the thumb attempting to oppose the fingers, or
both the carpometacarpal and IP joints are ankylosed (even if each joint is individually fixed in a favorable position), or
amputation at the carpometacarpal joint or joints or through proximal phalange (38 CFR 4.71a, DC 5152) if both the carpometacarpal and IP joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone.
Note: Only joints ankylosed in normal anatomical position as defined in Note 1 preceding 38 CFR 4.71a, DC 5216 are considered favorably ankylosed. Reference: For more information on evaluation of ankylosis of the fingers, see the notes prior to 38 CFR 4.71a, DC 5216.

V.iii.1.B.2.d. Compensable Evaluations for the Fingers

When considering evaluations for the fingers based on LOM, a compensable evaluation can be assigned for any of the following:

LOM of the thumb as specified in 38 CFR 4.71a, DC 5228.
LOM of the index or long finger as specified in 38 CFR 4.71a, DC 5229.
X-ray evidence of arthritis or other condition rated under the criteria of 38 CFR 4.71a, DC 5003, affecting a group of minor joints of the fingers of one hand. There must be
- noncompensable LOM in more than one of the joints comprising the group of affected minor joints, and
- findings such as swelling, muscle spasm or satisfactory evidence of painful motion in the affected minor joints of the joint group.
X-ray-only evidence of arthritis (where there is no LOM) under the criteria of 38 CFR 4.71a, DC 5003, affecting two or moregroups of minor joints – namely the fingers of both hands or a group of minor joints in one hand in combination with another group of minor joints.
Painful motion of the thumb, index finger, or long finger as directed at M21-1, Part V, Subpart iii, 1.A.1.l.

Note: The Federal Circuit held in Spicer v. Shinseki, 752 F.3d 1367 (Fed. Cir. 2014) that when evaluating arthritis of the hand, the minor joint group of IP joints of a hand is compensably disabled only when two or more joints in the group are affected by LOM. Refer to M21-1, Part V, Subpart iii, 1.A.3.a and b for more information on the applicability of the Spicer holding. References: For more information on
use of the terms major and minor when evaluating joints, see M21-1, Part V, Subpart iii, 1.A.3.a
assigning evaluations under 38 CFR 4.71a, DC 5003 when a compensable rating based on LOM cannot be assigned under another DC, see M21-1, Part V, Subpart iii, 1.C.4.b, and
applying 38 CFR 4.59 to minor joints, see M21-1, Part V, Subpart iii, 1.A.1.l.

V.iii.1.B.2.e. Rating Dupuytren’s Contracture of the Hand

The rating schedule does not specifically list Dupuytren’s contracture as a disease entity; therefore, assign an evaluation on the basis of limitation of finger movement.

3. Evaluating Musculoskeletal Disabilities of the Spine

Introduction

This topic contains information on evaluating musculoskeletal disabilities of the spine, including

evaluating manifestations of spine diseases and injuries
variations in terminology for intervertebral disc syndrome (IVDS)
definition of incapacitating episode of IVDS
objective neurological impairment associated with spinal disabilities
examples addressing neurological impairments associated with spinal disabilities
disability benefits questionnaire (DBQ) selections for radiculopathy
example of evaluating IVDS, and
evaluating ankylosing spondylitis.

Change Date

February 27, 2025

V.iii.1.B.3.a. Evaluating Manifestations of Spine Diseases and Injuries

Evaluate diseases and injuries of the spine based on the criteria listed in the 38 CFR 4.71a, General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under these criteria, evaluate conditions based on chronic orthopedic manifestations (for example, painful muscle spasm or LOM) and any associated neurological manifestations (for example, footdrop, muscle atrophy, or sensory loss) by assigning separate evaluations for the orthopedic and neurological manifestations.Evaluate intervertebral disc syndrome (IVDS) under 38 CFR 4.71a, DC 5243, either based on the General Rating Formula or the Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episode Formula), whichever formula results in the higher evaluation when all disabilities are combined under 38 CFR 4.25.Notes:

Utilize 38 CFR 4.71a, DC 5243only when there is disc herniation with compression and/or irritation of the adjacent nerve root. Otherwise, assign 38 CFR 4.71a, DC 5242 for all other disc diagnoses.
Irritation of the adjacent nerve root is evidenced by back pain and sciatica (pain along the course of the sciatic nerve) in the case of lumbar disc diseases. For cervical disc disease, neck and arm or hand pain will be shown.
If an evaluation is assigned based on incapacitating episodes, a separate evaluation may not be assigned for LOM, radiculopathy, or any other associated objective neurological abnormality as doing so would constitute pyramiding under 38 CFR 4.14.
Spinal fusion is a type of fixation of the spine. Evaluation based on ankylosis of the spine due to fusion is only warranted when the fixation affects the entire thoracolumbar or cervical spine segment. Fusion of only a portion of the cervical or thoracolumbar spine segment should be evaluated based on range or motion or IVDS, as warranted by the evidence.
There is no presumption of service connection (SC) for degenerative disc disease (DDD). Desiccation of the disc or other degenerative changes without any radiographic evidence of arthritic changes is not indicative of arthritis and is not, consequently, subject to presumptive SC under 38 CFR 3.309(a).

References: For more information on

evaluating
- degenerative spinal disease, such as spondylosis, see
  - M21-1, Part V, Subpart ii, 2.E.1.e, and
  - Cousin v. Wilkie, 905 F.3d 1316 (Fed.Cir. 2018), and
- co-existing SC and NSC disabilities affecting separate spinal segments, see
  - M21-1, Part V, Subpart ii, 3.D.2.c, and
  - Langdon v. McDonough, 1 F.4th 1008 (Fed. Cir. 2021), and
the historical application of
- 38 CFR 4.40, and 38 CFR 4.45 to evaluations for IVDS, see VAOPGCPREC 36-1997, and
- 38 CFR 4.71a, DC 5285, for demonstrable deformity of a vertebral body, see VAOPGCPREC 3-2006.

V.iii.1.B.3.b. Variations in Terminology for IVDS

Variations of diagnostic terminology exist for IVDS. When used in the clinical setting, the following terminology is consistent with the general designation of IVDS:

slipped or herniated disc
ruptured disc
prolapsed disc
bulging or protruded disc
DDD
sciatica
discogenic pain syndrome
herniated nucleus pulposus, and
pinched nerve.

V.iii.1.B.3.c. Definition: Incapacitating Episode of IVDS

By definition, an incapacitating episode of IVDS requires bedrest prescribed by a physician. When evaluating IVDS based on incapacitating episodes, there must be evidence the associated symptoms required bedrest as prescribed by a physician. The medical evidence of prescribed bedrest must be

of record in the claims folder, or
reviewed and described by an examiner completing an examination or disability benefits questionnaire (DBQ).

Note: If the records do not adequately document prescribed bedrest, use the General Rating Formula to evaluate IVDS and advise the Veteran to submit medical evidence documenting the periods of incapacitating episodes requiring bedrest prescribed by a physician.

V.iii.1.B.3.d. Objective Neurological Impairment Associated With Spinal Disabilities

Objective neurological abnormalities associated with spinal disabilities

are evaluated separately from the spinal disability (except, as noted in M21-1, Part V, Subpart iii, 1.B.3.a, when IVDS is evaluated based on incapacitating episodes), and
represent a medical progression or worsening of the spinal disease.
For that reason and because neurological complications of spinal disease are contemplated in the evaluation criteria for spinal conditions under 38 CFR 4.71a, a claim asserting new complications of spinal disease is considered a claim for increase rather than a claim for secondary SC.
When evaluating an expressly claimed spinal disability, decision makers must consider entitlement to compensation for any neurological complications as within scope of the claim in accordance with M21-1, Part V, Subpart ii, 3.A.2.c.
Likewise, a primary spinal condition responsible for an expressly claimed neurological complication is considered within the scope of the expressly claimed issue, as discussed in M21-1, Part V, Subpart ii, 3.A.1.c.
When assigning effective dates for neurological spinal complications, consider effective date provisions specifically for increases as specified in M21-1, Part V, Subpart ii, 4.A.5.e.
Notes:
When an SC thoracolumbar disability is present and objective neurological abnormalities or radiculopathy are diagnosed but the medical evidence does not identify a specific nerve root, rate the lower extremity radiculopathy under the sciatic nerve, 38 CFR 4.124a, DC 8520.
Additional examinations of other body systems may be required if there are neurological complications of the peripheral nerves, bladder, and/or impairment of sphincter control.
Apply the previous provisions of historical 38 CFR 3.157(b) when determining the effective date for neurological abnormalities of the spine that are identified by requisite records prior to March 24, 2015.
Example: Veteran has been SC for DDD since 2012. Upon review of a claim for increase received on June 2, 2015, it is noted in Department of Veterans Affairs (VA) medical records that the Veteran received treatment for bladder impairment secondary to DDD on July 7, 2014. Because the VA medical records constitute a claim for increase under rules in effect prior to March 24, 2015, it is permissible to apply previous rules from 38 CFR 3.157 (b) in adjudicating the bladder impairment issue. References: For more information on
assigning disability evaluations for
peripheral nerve disabilities, to include radiculopathy, see M21-1, Part V, Subpart iii, 12.A.2, and
progressive spinal muscular atrophy, see M21-1, Part V, Subpart iii, 12.A.1.c
issues within the scope of a claim, see
38 CFR 3.155(d)(2), and
M21-1, Part V, Subpart ii, 3.A.2
assigning effective dates for neurological spinal complications, see
38 CFR 3.400(o)
38 CFR 3.155, and
M21-1, Part V, Subpart ii, 4.A.5.e, and
procedural guidance on handling the effective dates and coding complications of an SC disability in Veterans Benefits Management System - Rating (VBMS-R), see M21-1, Part V, Subpart ii, 4.A.5.e.

V.iii.1.B.3.e. Examples Addressing Neurological Impairments Associated With Spinal Disabilities

Example 1: A Veteran files a claim for an increased evaluation for the SC condition of spinal stenosis. An intent to file (ITF) a claim was not received. The DBQ shows decreased ROM of the spine that is unchanged from the prior evaluation and a diagnosis of radiculopathy of the bilateral lower extremities. No other evidence indicates that radiculopathy was diagnosed prior to the date of this DBQ. The rating activity should evaluate the spinal stenosis and grant SC for bilateral radiculopathy with an effective date assigned based on the receipt of the claim for the increased evaluation in the spinal stenosis.Example 2: A Veteran submits a claim for SC of right leg pain and numbness, more than one year following discharge. An ITF is not associated with this claim. Development of the claim confirms a diagnosis of radiculopathy that is due to an unclaimed back injury. The back injury was sustained in service. Sufficient evidence to establish SC for the back disability is of record. Consider the unclaimed back disability within scope of the claimed radiculopathy and establish SC for both issues with an effective date assigned based on the date of the receipt of the claim for SC of radiculopathy.Example 3: The Veteran files a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, for an increased evaluation in an SC spinal disability. In conjunction with that claim, the Veteran submits private medical records showing a diagnosis of radiculopathy, related to the SC spinal disability, within the last year. An ITF is not associated with the claim. The private medical evidence is sufficient to evaluate the radiculopathy but does not contain ROM findings for the lumbosacral spine. The rating activity should grant SC for radiculopathy from the date of the diagnosis of radiculopathy (in accordance with 38 CFR 3.400(o)(2)) and defer the evaluation of the spinal disability for an increase evaluation examination.

V.iii.1.B.3.f. DBQ Selections for Radiculopathy

Radiculopathy is a common type of neurological impairment associated with spinal disabilities.Refer to the table below to determine which DBQ to request when the claimed disability is a thoracolumbar/cervical spine condition and/or lumbar/cervical radiculopathy.

If the claimed condition is a/an ...	Then, request the ...
thoracolumbar spine condition (initial SC or increased evaluation) with or without a claim for radiculopathy	Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire when otherwise necessary to decide the claim. *Important*: The DBQ contains a section for radiculopathy that must be completed by the examiner if there is an indication of radiculopathy. If the examiner fails to address radiculopathy, the examination must be returned as insufficient.
cervical spine condition (initial SC or increased evaluation) with or without a claim for radiculopathy	Neck (Cervical Spine) Conditions Disability Benefits Questionnaire when otherwise necessary to decide the claim. *Important*: The DBQ contains a section for radiculopathy that must be completed by the examiner if there is an indication of radiculopathy. If the examiner fails to address radiculopathy, the examination must be returned as insufficient.
increased evaluation of lower extremity or lumbar radiculopathy, or upper extremity or cervical radiculopathy	Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire.
upper extremity radiculopathy (initial SC) without a claim for cervical spine condition	Neck (Cervical Spine) Disability Benefits Questionnaire*Important*: If the examiner fails to address radiculopathy, the examination must be returned as insufficient.
lower extremity radiculopathy (initial SC) without a claim for thoracolumbar spine condition	Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire*Important*: If the examiner fails to address radiculopathy, the examination must be returned as insufficient.

Note: Do not routinely request an examination for an issue(s) for which the evidence of record is sufficient to make a decision. This includes DBQs completed by a private or VA provider that are deemed adequate for rating purposes.References: For more information on

determining when an examination is necessary to decide a claim, see M21-1, Part IV, Subpart i, 1.A
using medical evidence in lieu of an examination, see M21-1, Part IV, Subpart i, 1.B.1.a, and
sufficiency of examinations, see M21-1, Part IV, Subpart i, 3.A.

V.iii.1.B.3.g. Example of Evaluating IVDS

Situation: A Veteran’s IVDS is being evaluated.
LOM warrants a 20-percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine
mild radiculopathy of the left lower extremity warrants a 10-percent evaluation as a neurological complication (evidence of irritation of the adjacent nerve root) under 38 CFR 4.124a, DC 8520, and
medical evidence shows incapacitating episodes requiring bedrest prescribed by a physician of four weeks duration over the past 12 months which would result in a 40-percent evaluation based on the incapacitating episode formula.
Result: Assign a 40-percent evaluation under 38 CFR 4.71a, DC 5243 based on incapacitating episodes. Explanation:
Evaluating IVDS using incapacitating episodes results in the highest evaluation.
Since incapacitating episodes are used to evaluate IVDS, the associated LOM and neurological signs and symptoms will not be assigned a separate evaluation.

V.iii.1.B.3.h. Evaluating Ankylosing Spondylitis

Ankylosing spondylitis may be evaluated as an active disease process or based upon LOM of the spine. The table below describes appropriate action for evaluating ankylosing spondylitis.

If ankylosing spondylitis is ...	Then ...
an active process	evaluate under 38 CFR 4.71a, DC 5009(using the criteria in 38 CFR 4.71a, DC 5002 for the acute phase).
inactive	evaluate based on chronic residuals affecting the spine under 38 CFR 4.71a, DC 5003 or DC 5240, and separately evaluate other affected joints or body systems under the appropriate DC.

4. Evaluating Musculoskeletal Disabilities of the Legs

Introduction

This topic contains information on evaluating musculoskeletal disabilities of the lower extremities (not including the feet), including

evaluating noncompensable knee conditions
definition of instability and subluxation of the knee
evaluating instability of the knee
separate evaluations
- for knee instability and LOM, and
- of meniscal disabilities
examples of evaluating meniscal disabilities
separate evaluations – genu recurvatum
evaluating impairment of the tibia and fibula
evaluating pain associated with shin splints, and
ankle instability.

Change Date

March 25, 2026

V.iii.1.B.4.a. Evaluating Noncompensable Knee Conditions

Evaluate a noncompensable knee condition by analogy to 38 CFR 4.71a, DC 5257 if

there is no associated arthritis

the schedular criteria for a noncompensable evaluation under 38 CFR 4.71a, DC 5260 or DC 5261 are not met, and
the condition cannot be appropriately evaluated under 38 CFR 4.71a, DC 5258, 5259, 5262, or 5263.

References: For more information on

using analogous DCs, see 38 CFR 4.20, and
when to assign a 0-percent evaluation, see 38 CFR 4.31.

V.iii.1.B.4.b. Definitions: Instability and Subluxation of the Knee

Instability, as referred to in 38 CFR 4.71a, DC 5257, includes
patellar instability due to recurrent patellar subluxation or patellar dislocation, and/or
any other instability or laxity of the knee that involves other stabilizing structure of the knee such as the collateral or cruciate ligaments.
Subluxation refers to partial or incomplete dislocation of the knee joint (tibiofemoral dislocation/subluxation) or tendency for the patella to dislocate from its track (patellar dislocation/subluxation). Evaluations under 38 CFR 4.71a, DC 5257 may be assigned based on the requirement for assistive device(s) and/or bracing. The assistive device or bracing must be prescribed by a medical provider and there must be objective evidence of the prescription in the evidentiary record.

V.iii.1.B.4.c. Evaluating Instability of the Knee

Evaluations for instability of the knee are assigned based on whether the instability arises from

sprain or a ligament tear, or
patellar instability.

When there is persistent instability but the medical evidence and/or examination report does not identify the instability as related to either a ligament tear/sprain or a diagnosed condition involving the patellofemoral complex (such as instability due to osteoarthritis or osteoarthrosis), then evaluate it using the patellar instability criteria under 38 CFR 4.71a, DC 5257.Note: The presence of persistent instability is sufficient to satisfy the requirement of recurrent symptoms for the 10-percent evaluation.

V.iii.1.B.4.d. Separate Evaluations for Knee Instability and LOM

A separate evaluation for knee instability may be assigned in addition to any evaluation(s) assigned based on limitation of knee motion. The Office of General Counsel has issued precedent opinions that an evaluation under 38 CFR 4.71a, DC 5257, does not pyramid with evaluations based on LOM. References: For more information on

pyramiding and separating individual findings in a rating decision, see M21-1, Part V, Subpart ii, 3.D.2.b
separate evaluation of knee instability, see
- VAOPGCPREC 23-1997, and
- VAOPGCPREC 9-1998, and
evaluation of joint replacement or resurfacing, see M21-1, Part V, Subpart iii, 1.A.3.h-l.

V.iii.1.B.4.e. Separate Evaluation of Meniscal Disabilities

Evaluation of a knee disability under 38 CFR 4.71a, DC 5257, DC 5260, or 5261 does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under

38 CFR 4.71a, DC 5258 (dislocated semilunar cartilage), or
38 CFR 4.71a, DC 5259 (symptomatic removal of semilunar cartilage).

A meniscal disability may be rated separately under 38 CFR 4.71a, DC 5258/5259 apart from

38 CFR 4.71a, DC 5257 for manifestations of the knee disability other than recurrent subluxation and instability, and/or
38 CFR 4.71a, DC 5260/5261 if a manifestation of the meniscal disability did not result in an elevation of the disability evaluation warranted under 38 CFR 4.71a, DC 5260/5261 via application of 38 CFR 4.40 and 38 CFR 4.45 pursuant to DeLuca v. Brown, 8 Vet.App. 202 (1995).

Important:
A repaired meniscal tear (s/p partial meniscectomy) is not directly synonymous with either 38 CFR 4.71a, DC 5258 or 38 CFR 4.71a, DC 5259. Therefore, it is most appropriate to rate the disability analogous to whichever code most closely approximates the current symptoms.
Entitlement to a separate evaluation for the meniscal disability depends on whether the manifestations are utilized to assign an evaluation under a different DC. Evaluation of the same manifestation under multiple diagnoses is prohibited under 38 CFR 4.14. Thus, when all the symptoms of the meniscal disability are used to support elevation of an evaluation under 38 CFR 4.71a, DC 5260/5261 or assignment of an evaluation under 38 CFR 4.71a, DC 5257, a separate evaluation cannot be assigned under 38 CFR 4.71a, DC 5258/5259.
When considering applicability of 38 CFR 4.59 for meniscal disabilities,
when only a meniscal disability is present, utilize the procedures at M21-1, Part V, Subpart iii, 1.A.1.m, and
when multiple knee disabilities are present and the painful motion is attributable to a knee disability other than the meniscal condition, assign separate evaluations when otherwise warranted under 38 CFR 4.14.
The policy and procedures identified in this block reflect a change in policy resulting from the holding in Lyles v. Shulkin, 29 Vet.App. 107 (2017), effective November 29, 2017. Prior to the Lyles holding, separate evaluations for meniscal disabilities under 38 CFR 4.71a, DC 5258 or DC 5259 and other knee evaluations under 38 CFR 4.71a, DC 5257, 5260, or DC 5261 were prohibited. This is not considered a liberalizing change.
References: For more information on
evaluation of meniscal disabilities, see Lyles v. Shulkin, 29 Vet.App. 107 (2017), and
examples of evaluation of meniscal disabilities, see M21-1, Part V, Subpart iii, 1.B.4.f.

V.iii.1.B.4.f. Examples-- Evaluating Meniscal Disabilities

Example 1: A Veteran’s left knee disability, which includes a meniscal condition, is evaluated as 30-percent disabling on the basis of limitation of extension under 38 CFR 4.71a, DC 5261. The knee also manifests pain, swelling, popping, locking, and grinding due to the meniscus disability. These symptoms, which are consistent with the manifestations identified under 38 CFR 4.40 and 38 CFR 4.45, were considered and did not result in a higher evaluation under 38 CFR 4.71a, DC 5261. Therefore, they may be considered for assignment of a separate evaluation under 38 CFR 4.71a, DC 5258/5259. Example 2: The evaluations and fact pattern for Example 1 are the same except that the VA examiner indicates that the pain, swelling, popping, locking, and grinding of the knee, which results from the meniscal disability, result in additional limitation of extension to 30 degrees during flare-ups or with repeated use over a period of time, which warrants an elevation of the rating to 40-percent under 38 CFR 4.71a, DC 5261. A separate evaluation under 38 CFR 4.71a, DC 5258/5259 is not warranted for the symptoms of pain, swelling, popping, locking, and grinding since these symptoms were considered under 38 CFR 4.40 and 38 CFR 4.45 in accordance with the DeLuca holding to elevate the evaluation to 40-percent under 38 CFR 4.71a, DC 5261. Assignment of a separate evaluation under 38 CFR 4.71a, DC 5258/5259 would constitute pyramiding. Example 3: A Veteran’s left knee disability, which includes meniscal impairment, is evaluated as 30-percent disabling on the basis of limitation of extension under 38 CFR 4.71a, DC 5261. Pain is present due to the meniscus disability. A VA examiner indicated that pain during repetitive motion testing as well as functional loss due to pain during flare-ups additionally limit extension to 30 degrees, which results in elevation of the 30-percent evaluation under 38 CFR 4.71a, DC 5261 to 40-percent. A separate evaluation under 38 CFR 4.71a, DC 5258/5259 is not warranted for the symptoms of pain since it was considered under 38 CFR 4.40 and 38 CFR 4.45 in accordance with the DeLuca holding to elevate the evaluation to 40-percent under 38 CFR 4.71a, DC 5261. Assignment of a separate evaluation under 38 CFR 4.71a, DC 5258/5259 would constitute pyramiding. Example 4: A Veteran’s right knee disability is evaluated as 20-percent disabling on the basis of limitation of extension. This disability includes arthritis of the joint and a post-operative meniscal condition. The knee also manifests pain, swelling, popping, locking, and grinding due to both arthritis and the meniscal condition. A VA examiner found that repetitive motion testing additionally limited extension by five degrees, from 15 to 20 degrees, due to pain. The consideration of pain on motion, which is a manifestation identified under 38 CFR 4.40 and 38 CFR 4.45, results in elevation of the evaluation under 38 CFR 4.71a, DC 5261 to 30-percent. Since the swelling, popping, locking, and grinding, which were at least in part due to the meniscal condition, were not considered in awarding a higher evaluation under 38 CFR 4.71a, DC 5261 with application of 38 CFR 4.40 and 38 CFR 4.45, a separate evaluation may be awarded for the meniscus removal. Example 5: Examination of the left knee disability reveals an unrepaired incomplete ligament tear that results in persistent instability. The Veteran’s physician has prescribed a brace and a cane for ambulation. Additionally, the Veteran has a history of meniscectomy with residual symptoms of stiffness, crepitus, and pain without effusion or locking. ROM is full with no additional functional impairment following repeated ROM testing. Since the stiffness, crepitus, and pain are separate symptoms and not used to support an evaluation under 38 CFR 4.71a, DC 5257/5260/5261 and the persistent instability is not used to support an evaluation for the meniscal symptoms, a 20-percent evaluation is warranted under 38 CFR 4.71a, DC 5257 with a separate 10-percent evaluation assigned under 38 CFR 4.71a, DC 5259.

V.iii.1.B.4.g. Separate Evaluations – Genu Recurvatum

When evaluating genu recurvatum, which involves hyperextension of the knee beyond 0 degrees of extension, under 38 CFR 4.71a, DC 5263

do not also evaluate separately under 38 CFR 4.71a, DC 5261, but
do evaluate separately under other evaluations if manifestations that are not overlapping, such as limitation of flexion under 38 CFR 4.71a, DC 5260, are attributed to genu recurvatum, and
do not evaluate separately under 38 CFR 4.71a, DC 5257; however, if instability is manifested from genu recurvatum evaluate based on the criteria that will provide the highest evaluation.

V.iii.1.B.4.h. Evaluating Impairment of the Tibia and Fibula

Utilize 38 CFR 4.71a, DC 5262 for evaluating impairment of the tibia and fibula including nonunion, malunion (evaluated under the corresponding knee or ankle codes based on associated impairment), medial tibial stress syndrome (MTSS) , or shin splints. Evaluations for shin splints may be based on the use of conservative treatment. For this purpose, conservative treatment includes but is not limited to treatment of symptoms using the following:

rest
ice
elevation
medication
compression socks, and/or
massage.

Notes:

MTSS is synonymous with shin splints. Related assessments, such as compartment syndrome and/or stress fractures, may also appear in treatment records. When compartment syndrome is the predominant diagnosis, however, assign an evaluation under 38 CFR 4.73, DC 5331.
When evaluating shin splints, assign a single evaluation under 38 CFR 4.71a, DC 5262, whether the shin splints affect one or both legs.

V.iii.1.B.4.i. Evaluating Pain Associated With Shin Splints

MTSS, or shin splints, is a type of joint or periarticular pathology. When evaluating shin splints, apply 38 CFR 4.59 and assign the minimum compensable evaluation under 38 CFR 4.71a, DC 5262 when painful motion is shown and shin splints are otherwise noncompensable. The following principles apply:

Shin splints with pain that is not associated with motion, such as pain on palpation, are noncompensable under 38 CFR 4.59.
The minimum compensable evaluation is warranted when painful motion due to shin splints occurs in nearby affected joints such as the ankle or knee or when shin pain or other similar pain occurs with motion. However, when a separate knee or ankle disability exists and has been compensably evaluated, do not assign a compensable evaluation under 38 CFR 4.59 for shin splints causing painful motion in an already-compensable SC knee or ankle joint as this would be in violation of the pyramiding rules in 38 CFR 4.14.

Use the table below to determine if a compensable evaluation can be assigned for shin splints based on painful motion under 38 CFR 4.59.

Step

Action

Do the symptoms qualify for a compensable evaluation based on the criteria in 38 CFR 4.71a, DC 5262?

If yes,
- assign the appropriate compensable evaluation based on the criteria listed in 38 CFR 4.71a, DC 5262, and
- disregard the remaining steps of this table.
If no, go to the next step.

Are the shin splints associated with painful motion of the shin, ankle, or knee?

If yes, use the table below to determine the next step.
If no,
- do not apply 38 CFR 4.59, and
- assign a noncompensable evaluation for the shin splints under 38 CFR 4.71a, DC 5262.

If the shin splints are associated with painful motion of the …	Then …
shin	assign a compensable evaluation based on 38 CFR 4.59.
ankle or knee	go to Step 3.

Is the same joint(s) already compensably evaluated?

If yes,
- do not apply 38 CFR 4.59, and
- assign a noncompensable evaluation for the shin splints under 38 CFR 4.71a, DC 5262.
If no, assign a compensable evaluation based on 38 CFR 4.59.

Note: When evaluating shin splints, assign a single evaluation under 38 CFR 4.71a, DC 5262, whether the shin splints affect one or both legs, as noted in M21-1, Part V, Subpart iii, 1.B.4.h.Reference: For more information on the applicability of 38 CFR 4.59 to ratings for shin splints, see
M21-1, Part V, Subpart iii, 1.A.1.i, and
Southall-Norman v. McDonald, 28 Vet.App. 346 (2016).

V.iii.1.B.4.j. Ankle Instability

Do not assign separate evaluations for LOM and instability of the ankle. The intent of the ankle DCs, including 38 CFR 4.71a, DC 5271, is to address the overall ankle disability without limiting the focus to one specific type of ankle symptomatology. Although 38 CFR 4.71a, DC 5271 is titled, Ankle, limited motion of and utilizes objective ROM measurements to guide the decision maker as to the meaning of marked and moderate in evaluating symptoms, this DC may also be used to rate instability of the ankle with or without associated LOM. Note: 38 CFR 4.20 provides that when a condition is not listed in the rating schedule, an analogous rating is to be assigned. Based on the facts found, the DC most appropriate to the findings and that results in the highest evaluation should be selected. Reference: For more information on analogous ratings, see

5. Evaluating Musculoskeletal Disabilities of the Feet

Introduction

This topic contains information on evaluating musculoskeletal disabilities of the feet, including

selecting a DC for foot disabilities
identifying the digits of the foot
assigning separate evaluations for multiple foot disabilities
evaluating
- arthritis of the minor joints of the toes, and
- plantar fasciitis
definition of metatarsalgia or Morton’s disease, and
evaluating
- metatarsalgia or Morton’s disease, and
- metatarsalgia and
  - plantar fasciitis, and
  - pes planus.

Change Date

February 8, 2021

V.iii.1.B.5.a. Selecting a DC for Foot Disabilities

Foot injuries are rated under 38 CFR 4.71a, DC 5284. The application of this DC is limited to disabilities resulting from actual injuries to the foot, as opposed to disabilities caused by, for example, degenerative conditions. However, conditions that are not specifically listed under 38 CFR 4.71a, DC 5284 may be rated by analogy under DC 5284. 38 CFR 4.71a, DC 5284 does not apply to the other conditions of the foot specifically listed under 38 CFR 4.71a, DCs 5276 through 5283 and 5269. The listed conditions must be rated under the specified DCs and cannot be rated by analogy under 38 CFR 4.71a, DC 5284.In cases where a foot injury and either arthritis or another foot disability is involved
consider functional impairment, and
determine whether, depending on the nature of the disability and history of injury, it is more advantageous to evaluate the condition under 38 CFR 4.71a, DC 5284 or another DC.
Reminder: Consider the guidance in M21-1, Part V, Subpart iv, 1.C.4.b concerning applicability of the bilateral factor when a DC provides one evaluation for a bilateral condition.References: For more information on
limited applicability of 38 CFR 4.71a, DC 5284 to foot injuries, see Yancy v. McDonald, 27 Vet.App. 484 (2016)
prohibition of evaluating specific foot disabilities otherwise listed in 38 CFR 4.71a analogously under 38 CFR 4.71a, DC 5284, see Copeland v. McDonald, 27 Vet.App. 333 (2015), and
applying 38 CFR 4.59 to disabilities of minor joints, see M21-1, Part V, Subpart iii, 1.A.1.l.

V.iii.1.B.5.b. Identifying the Digits of the Foot

Follow the guidelines listed below to accurately specify the injured digits of the foot.

Refer to the digits of the foot as
- first or great toe
- second
- third
- fourth, or
- fifth.
Each digit, except the great toe, includes three phalanges
- the proximal phalanx (closest to the ankle)
- the middle phalanx, and
- the distal phalanx (closest to the tip of the toe).
The joint between the proximal and middle phalanges is called the proximal interphalangeal (PIP) joint.
The joint between the middle and distal phalanges is called the distal interphalangeal (DIP) joint.
The great toes each have only two phalanges, the proximal phalanx and the distal phalanx. Therefore, each great toe has only a single joint, called the interphalangeal (IP) joint.
The joints connecting the phalanges in the feet to the metatarsals are the metatarsophalangeal (MTP) joints.
Designate either right or left for the digits of the foot.

Note: If the location of the injury is unclear, obtain x-rays to clarify the exact point of injury.

V.iii.1.B.5.c. Assigning Separate Evaluations for Multiple Foot Disabilities

38 CFR 4.14 requires that the evaluation of the same disability and/or the same manifestation under various diagnoses is to be avoided. The compact anatomical structure of the foot as well as the inter-related physiological functioning may make it difficult to differentiate the etiology of certain disability symptoms. When multiple SC foot disabilities are present but the etiology of the symptoms cannot be separated, assign a single disability evaluation for the predominant symptoms. If, however, the etiology of the symptoms can be delineated, separate disability evaluations may be assigned under multiple DCs for foot disabilities provided that the principles of 38 CFR 4.14 have not been violated. Reference: For more information on evaluating SC and non-service-connected (NSC) symptoms that cannot be separated, see M21-1, Part V, Subpart ii, 3.D.2.c.

V.iii.1.B.5.d. Evaluating Arthritis of the Minor Joints of the Toes

For guidance on evaluating arthritis of a group of minor joints of the toes refer to the table below.

If arthritis ...	Then ...
is degenerative affects a group of minor joints in one foot is documented by x-ray evidence results in LOM, *and* is confirmed by satisfactory evidence of painful motion, pain on use or other findings such as swelling	assign a 10-percent evaluation under 38 CFR 4.71a, DC 5003.
is degenerative affects minor joint groups in both feet, *and* is documented by x-ray evidence, *but* does not result in LOM	assign a 10-percent evaluation under 38 CFR 4.71a, DC 5003. *Exception*: Assign a 20-percent evaluation if there are occasional incapacitating exacerbations).
is post-traumatic	evaluate under 38 CFR 4.71a, DC 5010-5284 with consideration given to 38 CFR 4.59 when warranted.

References: For more information on

assigning evaluations under 38 CFR 4.71a, DC 5003 when a compensable rating cannot be assigned under a DC for LOM of a joint, see M21-1, Part V, Subpart iii, 1.C.4.b, and
considering painful motion when evaluating functional loss for purpose of applying 38 CFR 4.71a, DC 5003, pursuant to the holding in Mitchell v. Shinseki, 25 Vet.App. 32 (2011), see M21-1, Part V, Subpart iii, 1.A.1.e.

V.iii.1.B.5.e. Evaluating Plantar Fasciitis

Evaluate plantar fasciitis under 38 CFR 4.71a, DC 5269. The most common symptom seen with plantar fasciitis is heel pain. The following considerations apply when evaluating the heel pain.

When painful motion with joint or periarticular pathology is present and is a symptom of the plantar fasciitis, 38 CFR 4.59 is applicable. However, at least a 10-percent evaluation would most often be warranted under 38 CFR 4.71a, DC 5269 without consideration of 38 CFR 4.59.
When SC is established for pes planus and plantar fasciitis, evaluate the symptoms of both conditions together under the DC warranting the highest evaluation for the combined impairment.
- Pes planus is characterized by pain on manipulation and use of the feet or other foot pain as included in the higher evaluation criteria. The evaluation criteria for pes planus and plantar fasciitis are similar enough that providing separate evaluations will compensate the same facet of disability, foot pain, violating the prohibition against pyramiding in 38 CFR 4.14.
- If, however, one or both conditions resulted from an injury to the foot, an evaluation for the combined conditions under 38 CFR 4.71a, DC 5284 may be assigned in lieu of evaluation under either the pes planus or plantar fasciitis criteria when doing so is more advantageous.

Reference: For more information on rating by analogy, see

V.iii.1.B.5.f. Definition of Metatarsalgia or Morton’s Disease

Metatarsalgia means pain in the forefoot – under the metatarsal heads. Morton’s Disease or Morton’s Neuroma refers to a painful lesion of a plantar interdigital nerve.

V.iii.1.B.5.g. Evaluating Metatarsalgia or Morton’s Disease

Anterior metatarsalgia of any type, to include cases due to Morton’s Disease, will be evaluated under 38 CFR 4.71a, DC 5279. The DC provides for an evaluation of 10 percent regardless of whether the condition is unilateral or bilateral.

V.iii.1.B.5.h. Evaluating Metatarsalgia and Plantar Fasciitis

Since metatarsalgia refers to pain in the forefoot while plantar fasciitis is associated with pain in the heel, the symptoms should generally not overlap and separate evaluations may be assigned unless assessment of the evidence reveals that separate evaluation would be in violation of the pyramiding rules at 38 CFR 4.14.

V.iii.1.B.5.i. Evaluating Metatarsalgia and Pes Planus

Do not assign separate evaluations for pes planus and metatarsalgia.

Pes planus is accompanied by pain on manipulation and use of the feet or other foot pain, as included in the higher evaluation criteria. The evaluation criteria are similar enough that providing separate evaluations will compensate the same facet of disability, foot pain, violating the prohibition against pyramiding in 38 CFR 4.14.
Assign a single evaluation for pes planus with metatarsalgia using the predominant DC.
Do not rate by analogy when there is an applicable DC.
If, however, one or both conditions resulted from an injury to the foot, an evaluation for the combined conditions under 38 CFR 4.71a, DC 5284 may be assigned in lieu of evaluation under either the pes planus or metatarsalgia criteria when doing so is more advantageous.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 1, Section B (U.S. government work, reproduced for reference). Browse all sections →