**§4.71a Schedule of ratings---musculoskeletal system.**

**[Acute, Subacute, or Chronic Diseases]{.smallcaps}**

Rating

**5000** Osteomyelitis, acute, subacute, or chronic:

Of the pelvis, vertebrae, or extending into major joints,

or with multiple localization or with long history of

intractability and debility, anemia, amyloid liver

changes, or other continuous constitutional symptoms 100

Frequent episodes, with constitutional symptoms 60

With definite involucrum or sequestrum, with or without

discharging sinus 30

With discharging sinus or other evidence of active infection

within the past 5 years 20

Inactive, following repeated episodes, without evidence of

active infection in past 5 years 10

Note (1): A rating of 10 percent, as an exception to the amputation
rule, is to be assigned in any case of active osteomyelitis where the
amputation rating for the affected part is no percent. This 10 percent
rating and the other partial ratings of 30 percent or less are to be
combined with ratings for ankylosis, limited motion, nonunion or
malunion, shortening, etc., subject, of course, to the amputation rule.
The 60 percent rating, as it is based on constitutional symptoms, is not
subject to the amputation rule. A rating for osteomyelitis will not be
applied following cure by removal or radical resection of the affected
bone.

Note (2): The 20 percent rating on the basis of activity within the past
5 years is not assignable following the initial infection of active
osteomyelitis with no subsequent reactivation. The prerequisite for this
historical rating is an established recurrent osteomyelitis. To qualify
for the 10 percent rating, 2 or more episodes following the initial
infection are required. This 20 percent rating or the 10 percent rating,
when applicable, will be assigned once only to cover disability at all
sites of previously active infection with a future ending date in the
case of the 20 percent rating.

**5001** Bones and joints, tuberculosis of, active or inactive:

Active 100

Inactive: See §§ 4.88c and 4.89

**5002** Arthritis rheumatoid (atrophic) *as an active process*

With constitutional manifestations associated with

active joint involvement, totally incapacitating 100

**5002** Arthritis rheumatoid (atrophic) *as an active process* (cont.)

Less than criteria for 100% but with weight loss and anemia

productive of severe impairment of health or severely

incapacitating exacerbations occurring 4 or more times a year

or a lesser number over prolonged periods 60

Symptom combinations productive of definite impairment of

health objectively supported by examination findings or

incapacitating exacerbations occurring 3 or more times a year 40

One or two exacerbations a year in a well-established diagnosis 20

For chronic residuals:

For residuals such as limitation of motion or ankylosis, favorable or
unfavor­able, rate under the appropriate diagnostic codes for the
specific joints involved. Where, however, the limitation of motion of
the specific joint or joints involved is noncompensable under the codes
a rating of 10 percent is for application for each such major joint or
group of minor joints affected by limitation of motion, to be combined,
not added under diagnostic code 5002. Limitation of motion must be
objectively confirmed by findings such as swelling, muscle spasm, or
satisfactory evidence of painful motion.

Note: The ratings for the active process will not be combined with the
residual ratings for limitation of motion or ankylosis. Assign the
higher evaluation.

**5003** Arthritis, degenerative (hypertrophic or osteoarthritis):

Degenerative arthritis established by X-ray findings will be rated on
the basis of limitation of motion under the appropriate diagnostic codes
for the specific joint or joints involved (DC 5200 etc.). When however,
the limitation of motion of the specific joint or joints involved is
noncompensable under the appropriate diagnostic codes, a rating of 10
pct is for application for each such major joint or group of minor
joints affected by limitation of motion, to be combined, not added under
diagnostic code 5003. Limitation of motion must be objectively confirmed
by findings such as swelling, muscle spasm, or satisfactory evidence of
painful motion. In the absence of limitation of motion, rate as below:

With X-ray evidence of involvement of 2 or more major joints

or 2 or more minor joint groups, with occasional incapacitating

exacerbations 20

With X-ray evidence of involvement of 2 or more major joints

or 2 or more minor joint groups 10

Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above,
will not be combined with ratings based on limitation of motion.

Note(2): The 20 pct and 10 pct ratings based on X-ray findings, above,
will not be utilized in rating conditions listed under diagnostic code
5013 to 5024, inclusive.

**5004** Arthritis, gonorrheal.

**5005** Arthritis, pneumococcic.

**5006** Arthritis, typhoid.

**5007** Arthritis, syphilitic.

**5008** Arthritis, streptococcic.

**5009** Arthritis, other types (specify).

With the types of arthritis, diagnostic codes 5004 through 5009, rate
the

disability as rheumatoid arthritis.

**5010** Arthritis, due to trauma, substantiated by X-ray findings:

Rate as arthritis, degenerative.

**5011** Bones, caisson disease of:

Rate as arthritis, cord involvement, or deafness, depending on the
severity of disabling manifestations.

**5012** Bones, new growths of, malignant 100

Note: The 100 percent rating will be continued for 1 year following the
cessation of surgical, X-ray, antineoplastic chemotherapy or other
therapeutic procedure. At this point, if there has been no local
recurrence or metastases, the rating will be made on residuals.

**5013** Osteoporosis, with joint manifestations.

**5014** Osteomalacia.

**5015** Bones, new growths of, benign.

**5016** Osteitis deformans.

**5017** Gout.

**5018** Hydrarthrosis, intermittent.

**5019** Bursitis.

**5020** Synovitis.

**5021** Myositis.

**5022** Periostitis.

**5023** Myositis ossificans.

**5024** Tenosynovitis.

The diseases under diagnostic codes 5013 through 5024 Will be rated on
limita­tion of motion of affected parts, as arthritis, degenerative,
except gout which will be rated under diagnostic code 5002.

**5025** Fibromyalgia (fibrositis, primary fibromyalgia syndrome)

With widespread musculoskeletal pain and tender points, with or without
associated fatigue, sleep disturbance, stiffness, paresthesias,
headache, irritable bowel symptoms, depression, anxiety, or
Raynaud's-like symptoms:

That are constant, or nearly so, and refractory to therapy 40

That are episodic, with exacerbations often precipitated by

environmental or emotional stress or by overexertion, but that

are present more than one-third of the time 20

That require continuous medication for control 10

Note: Widespread pain means pain in both the left and right sides of the
body, that is both above and below the waist, and that affects both the
axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or
low back) and the extremities.

**[Prosthetic Implants]{.smallcaps}**

Rating

*Major Minor*

**5051** Shoulder replacement (prosthesis).

Prosthetic replacement of the shoulder joint:

For 1 year following implantation of prosthesis 100 100

With chronic residuals consisting of severe, painful motion

or weakness in the affected extremity 60 50

With intermediate degrees of residual weakness, pain or

limitation of motion, rate by analogy to diagnostic codes

5200 and 5203.

Minimum rating 30 20

**5052** Elbow replacement (prosthesis).

Prosthetic replacement of the elbow joint:

For 1 year following implantation of prosthesis 100 100

With chronic residuals consisting of severe painful motion

or weakness in the affected extremity 50 40

With intermediate degrees of residual weakness, pain or

limitation of motion rate by analogy to diagnostic codes 5205

through 5208.

Minimum evaluation 30 20

**5053** Wrist replacement (prosthesis).

Prosthetic replacement of wrist joint:

For 1 year following implantation of prosthesis 100 100

With chronic residuals consisting of severe, painful motion

or weakness in the affected extremity 40 30

With intermediate degrees of residual weakness, pain or limitation

of motion, rate by analogy to diagnostic code 5214.

Minimum rating 20 20

Note: The 100 pct rating for 1 year following implantation of prosthesis
will commence after initial grant of the 1-month total rating assigned
under §4.30 following hospital discharge.

**5054** Hip replacement (prosthesis).

Prosthetic replacement of the head of the femur or of the acetabulum:

For 1 year following implantation of prosthesis 100

Following implantation of prosthesis with painful motion or

weakness such as to require the use of crutches 901

Markedly severe residual weakness, pain or limitation of motion

following implantation of prosthesis 70

Moderately severe residuals of weakness, pain or limitation of motion 50

Minimum rating 30

**5055** Knee replacement (prosthesis).

Prosthetic replacement of knee joint:

For 1 year following implantation of prosthesis 100

With chronic residuals consisting of severe painful motion or

weakness in the affected extremity 60

With intermediate degrees of residual weakness, pain or limitation

of motion rate by analogy to diagnostic codes 5256, 5261, or 5262.

Minimum rating 30

**5056** Ankle replacement (prosthesis).

Prosthetic replacement of ankle joint:

For 1 year following implantation of prosthesis 100

With chronic residuals consisting of severe painful motion

or weakness 40

With intermediate degrees of residual weakness, pain or

limitation of motion rate by analogy to 5270 or 5271.

Minimum rating 20

Note (1): The 100 pct rating for 1 year following implantation of
prosthesis will commence after initial grant of the 1-month total rating
assigned under § 4.30 following hospital discharge.

Note (2): Special monthly compensation is assignable during the 100 pct
rating period the earliest date permanent use of crutches is
established.

[combinations of disabilities]{.smallcaps}

**5104** Anatomical loss of one hand and loss of use of one foot 1001

**5105** Anatomical loss of one foot and loss of use of one hand 1001

**5106** Anatomical loss of both hands 1001

**5107** Anatomical loss of both feet 1001

**5108** Anatomical loss of one hand and one foot 1001

**5109** Loss of use of both hands 1001

**5110** Loss of use of both feet 1001

**5111** Loss of use of one hand and one foot 1001

1Also entitled to special monthly compensation.

**[Amputations: Upper Extremity]{.smallcaps}**

Rating

*Major Minor*

Arm, amputation of:

**5120** Disarticulation 901 901

**5121** Above insertion of deltoid 901 801

**5122** Below insertion of deltoid 801 701

Forearm, amputation of:

**5123** Above insertion of pronator teres 801 701

**5124** Below insertion of pronator teres 701 601

**5125** Hand, loss of use of 701 601

[multiple finger amputations]{.smallcaps}

**5126** Five digits of one hand, amputation 701 601

Four digits of one hand, amputation of:

**5127** Thumb, index, long and ring 701 601

**5128** Thumb, index, long and little 701 601

**5129** Thumb, index, ring and little 701 601

**5130** Thumb, long, ring and little 701 601

**5131** Index, long, ring and little 60 50

Three digits of one hand, amputation of:

**5132** Thumb, index and long 60 50

**5133** Thumb, index and ring 60 50

**5134** Thumb, index and little 60 50

**5135** Thumb, long and ring 60 50

**5136** Thumb, long and little 60 50

**5137** Thumb, ring and little 60 50

**5138** Index, long and ring 50 40

**5139** Index, long and little 50 40

**5140** Index, ring and little 50 40

**5141** Long, ring and little 40 30

Two digits of one hand, amputation of:

**5142** Thumb and index 50 40

**5143** Thumb and long 50 40

**5144** Thumb and ring 50 40

**5145** Thumb and little 50 40

**5146** Index and long 40 30

**5147** Index and ring 40 30

**5148** Index and little 40 30

**5149** Long and ring 30 20

**5150** Long and little 30 20

**5151** Ring and little 30 20

\(a\) The ratings for multiple finger amputations apply to amputations
at the proximal interphalangeal joints or through proximal phalanges.

\(b\) Amputation through long phalanges will be rated as prescribed for
unfavorable ankylosis of the fingers.

\(c\) Amputations at distal joints, or through distal phalanges, other
than negligible losses, will be rated as prescribed for favorable
ankylosis of the fingers.

\(d\) Amputation or resection of metacarpal bones (more than one-half
the bone lost) in multiple fingers injuries will require a rating of 10
percent added to (not combined with) the ratings, multiple finger
amputations, subject to the amputation rule applied to the forearm.

\(e\) Combinations of finger amputations at various levels, or finger
amputations with ankylosis or limitation of motion of the fingers will
be rated on the basis of the grade of disability; i.e., amputation,
unfavorable ankylosis, most representative of the levels or
combinations. With an even number of fingers involved, and adjacent
grades of disability, select the higher of the two grades.

\(f\) Loss of use of the hand will be held to exist when no effective
function remains other than that which would be equally well served by
an amputation stump with a suitable prosthetic appliance.

[single finger amputations]{.smallcaps}

**5152** Thumb, amputation of:

With metacarpal resection 40 30

At metacarpophalangeal joint or through proximal phalanx 30 20

At distal joint or through distal phalanx 20 20

**5153** Index finger, amputation of

With metacarpal resection (more than one-half the bone lost) 30 20

**5153** Index finger, amputation of (cont.)

Without metacarpal resection, at proximal interphalangeal joint

or proximal thereto 20 20

Through long phalanx or at distal joint 10 10

**5154** Long finger, amputation of:

With metacarpal resection (more than one-half the bone lost) 20 20

Without metacarpal resection, at proximal interphalangeal joint

or proximal thereto 10 10

**5155** Ring finger, amputation of:

With metacarpal resection (more than one-half the bone lost) 20 20

Without metacarpal resection, at proximal interphalangeal joint

or proximal thereto 10 10

**5156** Little finger, amputation of:

With metacarpal resection (more than one-half the bone lost) 20 20

Without metacarpal resection, at proximal interphalangeal joint

or proximal thereto 10 10

Note: The single finger amputation ratings are the only applicable
ratings for amputations of whole or part of single fingers.

1Entitled to special monthly compensation.

**[Amputations: Lower Extremity]{.smallcaps}**

Thigh, amputation of:

**5160** Disarticulation, with loss of extrinsic pelvic girdle muscles
902

**5161** Upper third, one-third of the distance from perineum to knee
joint

measured from perineum 802

**5162** Middle or lower thirds 602

Leg, amputation of:

**5163** With defective stump, thigh, amputation recommended 602

**5164** Amputation not improvable by prosthesis controlled by

natural knee action 602

**5165** At a lower level, permitting prosthesis 402

**5166** Forefoot, amputation proximal to metatarsal bones (more than

one-half of metatarsal loss) 402

**5167** Foot, loss of use of 402

**5170** Toes, all, amputation of, without metatarsal loss 30

**5171** Toe, great, amputation of:

With removal of metatarsal head 30

Without metatarsal involvement 10

**5172** Toes, other than great, amputation of, with removal of
metatarsal head:

One or two 20

Without metatarsal involvement 0

**5173** Toes, three or four, amputation of, without metatarsal
involvement:

Including great toe 20

Not including great toe 10

2Also entitled to special monthly compensation.

**[The Shoulder and Arm]{.smallcaps}**

Rating

*Major Minor*

**5200** Scapulohumeral articulation, ankylosis of:

Note: The scapula and humerus move as one piece.

Unfavorable, abduction limited to 25º from side 50 40

Intermediate between favorable and unfavorable 40 30

Favorable, abduction to 60°, can reach mouth and head 30 20

**5201** Arm, limitation of motion of:

To 25° from side 40 30

Midway between side and shoulder level 30 20

At shoulder level 20 20

**5202** Humerus, other impairment of:

Loss of head of (flail shoulder) 80 70

Nonunion of (false flail joint) 60 50

Fibrous union of 50 40

Recurrent dislocation of at scapulohumeral joint.

With frequent episodes and guarding of all arm movements 30 20

With infrequent episodes, and guarding of movement

only at shoulder level 20 20

Malunion of:

Marked deformity 30 20

Moderate deformity 20 20

**5203** Clavicle or scapula, impairment of:

Dislocation of 20 20

Nonunion of:

With loose movement 20 20

Without loose movement 10 10

Malunion of 10 10

Or rate on impairment of function of contiguous joint.

**[The Elbow and Forearm]{.smallcaps}**

Rating

*Major Minor*

**5205** Elbow, ankylosis of:

Unfavorable, at an angle of less than 50° or with complete

loss of supination or pronation 60 50

Intermediate, at an angle of more than 90°, or between

70° and 50° 50 40

Favorable, at an angle between 90° and 70° 40 30

**5206** Forearm, limitation of flexion of:

Flexion limited to 45° 50 40

Flexion limited to 55° 40 30

Flexion limited to 70° 30 20

Flexion limited to 90° 20 20

Flexion limited to 100° 10 10

Flexion limited to 110° 0 0

**5207** Forearm, limitation of extension of:

Extension limited to 110° 50 40

Extension limited to 100° 40 30

Extension limited to 90° 30 20

Extension limited to 75° 20 20

Extension limited to 60° 10 10

Extension limited to 45° 10 10

**5208** Forearm, flexion limited to 100° and extension to 45° 20 20

**5209** Elbow, other impairment of Flail joint 60 50

Joint fracture, with marked cubitus varus or cubitus valgus

deformity or with ununited fracture of head of radius 20 20

**5210** Radius and ulna, nonunion of, with flail false joint 50 40

**5211** Ulna, impairment of:

Nonunion in upper half, with false movement:

With loss of bone substance (1 inch (2 5 cms.) or more)

and marked deformity 40 30

Without loss of bone substance or deformity 30 20

Nonunion in lower half 20 20

Malunion of, with bad alignment 10 10

**5212** Radius, impairment of:

Nonunion in lower half, with false movement:

With loss of bone substance (1 inch (2.5 cms.) or more)

and marked deformity 40 30

**5212** Radius, impairment of: (cont.)

Without loss of bone substance or deformity 30 20

Nonunion in upper half 20 20

Malunion of, with bad alignment 10 10

**5213** Supination and pronation, impairment of:

Loss of (bone fusion):

The hand fixed in supination or hyperpronation 40 30

The hand fixed in full pronation 30 20

The hand fixed near the middle of the arc or

moderate pronation 20 20

Limitation of pronation:

Motion lost beyond middle of arc 30 20

Motion lost beyond last quarter of arc, the hand does

not approach full pronation 20 20

Limitation of supination:

To 30º or less 10 10

Note: In all the forearm and wrist injuries, codes 5205 through 5213,
multiple impaired finger movements due to tendon tie-up, muscle or nerve
injury, are to be separately rated and combined not to exceed rating for
loss of use of hand.

**[The Wrist]{.smallcaps}**

Rating

*Major Minor*

**5214** Wrist, ankylosis of:

Unfavorable, in any degree of palmar flexion, or with

ulnar or radial deviation 50 40

Any other position, except favorable 40 30

Favorable in 20º to 30º dorsiflexion 30 20

Note: Extremely unfavorable ankylosis will be rated as loss of use of
hands under diagnostic code 5125.

**5215** Wrist, limitation of motion of:

Dorsiflexion less than 15º 10 10

Palmar flexion limited in line with forearm 10 10

**[Evaluation of Ankylosis or Limitation of Motion]{.smallcaps}**

**[of Single or Multiple Digits of the Hand]{.smallcaps}**

\(1\) For the index, long, ring, and little fingers (digits II, III, IV,
and V), zero degrees of flexion represents the fingers fully extended,
making a straight line with the rest of the hand. The position of
function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the
metacarpophalangeal and proximal interphalangeal joints flexed to 30
degrees, and the thumb (digit I) abducted and rotated so that the thumb
pad faces the finger pads. Only joints in these positions are considered
to be in favorable position. For digits II through V, the
metacarpophalangeal joint has a range of zero to 90 degrees of flexion,
the proximal interphalangeal joint has a range of zero to 100 degrees of
flexion, and the distal (terminal) interphalangeal joint has a range of
zero to 70 or 80 degrees of flexion.

\(2\) When two or more digits of the same hand are affected by any
combination of amputation, ankylosis, or limitation of motion that is
not otherwise specified in the rating schedule, the evaluation level
assigned will be that which best represents the overall disability
(i.e., amputation, unfavorable or favorable ankylosis, or limitation of
motion), assigning the higher level of evaluation when the level of
disability is equally balanced between one level and the next higher
level.

\(3\) Evaluation of ankylosis of the index, long, ring, and little
fingers:

> \(i\) If both the metacarpophalangeal and proximal interphalangeal
> joints of a digit are ankylosed, and either is in extension or full
> flexion, or there is rotation or angulation of a bone, evaluate as
> amputation without metacarpal resection, at proximal interphalangeal
> joint or proximal thereto.
>
> \(ii\) If both the metacarpophalangeal and proximal interphalangeal
> joints of a digit are ankylosed, evaluate as unfavorable ankylosis,
> even if each joint is individually fixed in a favorable position.
>
> \(iii\) If only the metacarpophalangeal or proximal interphalangeal
> joint is ankylosed, and there is a gap of more than two inches (5.1
> cm.) between the fingertip(s) and the proximal transverse crease of
> the palm, with the finger(s) flexed to the extent possible, evaluate
> as unfavorable ankylosis.
>
> \(iv\) If only the metacarpophalangeal or proximal interphalangeal
> joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less
> between the fingertip(s) and the proximal transverse crease of the
> palm, with the finger(s) flexed to the extent possible, evaluate as
> favorable ankylosis.

\(4\) Evaluation of ankylosis of the thumb:

> \(i\) If both the carpometacarpal and interphalangeal joints are
> ankylosed, and either is in extension or full flexion, or there is
> rotation or angulation of a bone, evaluate as amputation at
> metacarpophalangeal joint or through proximal phalanx.
>
> \(ii\) If both the carpometacarpal and interphalangeal joints are
> ankylosed, evaluate as unfavorable ankylosis, even if each joint is
> individually fixed in a favorable position.
>
> \(iii\) If only the carpometacarpal or interphalangeal joint is
> ankylosed, and there is a gap of more than two inches (5.1 cm.)
> between the thumb pad and the fingers, with the thumb attempting to
> oppose the fingers, evaluate as unfavorable ankylosis.
>
> \(iv\) If only the carpometacarpal or interphalangeal joint is
> ankylosed, and there is a gap of two inches (5.1 cm.) or less between
> the thumb pad and the fingers, with the thumb attempting to oppose the
> fingers, evaluate as favorable ankylosis.

\(5\) If there is limitation of motion of two or more digits, evaluate
each digit separately and combine the evaluations.

**I. Multiple Digits: Unfavorable Ankylosis**

Rating

*Major Minor*

**5216** Five digits of one hand, unfavorable ankylosis of 60 50

**Note:** Also consider whether evaluation as amputation is warranted.

**5217** Four digits of one hand, unfavorable ankylosis of:

Thumb and any three fingers 60 50

Index, long, ring, and little fingers 50 40

**Note:** Also consider whether evaluation as amputation is warranted.

**5218** Three digits of one hand, unfavorable ankylosis of:

Thumb and any two fingers 50 40

Index, long, and ring; index, long, and little; or

index, ring and little fingers 40 30

Long, ring, and little fingers 30 20

**Note:** Also consider whether evaluation as amputation is warranted.

**5219** Two digits of one hand, unfavorable ankylosis of:

Thumb and any finger 40 30

Index and long; index and ring; or index and little fingers 30 20

Long and ring; long and little; or ring and little fingers 20 20

**Note:** Also consider whether evaluation as amputation is warranted.

**II. Multiple Digits: Favorable Ankylosis**

Rating

*Major Minor*

**5220** Five digits of one hand, favorable ankylosis of 50 40

**5221** Four digits of one hand, favorable ankylosis of:

Thumb and any three fingers 50 40

Index, long, ring, and little 40 30

**5222** Three digits of one hand, favorable ankylosis of:

Thumb and any two fingers 40 30

Index, long, and ring; index, long, and little;

or index, ring, and little fingers 30 20

Long, ring, and little fingers 20 20

**5223** Two digits of one hand, favorable ankylosis of:

Thumb and any finger 30 20

Index and long; index and ring; or index and little fingers 20 20

Long and ring; long and little; or ring and little fingers 10 10

**III. Ankylosis of Individual Digits**

Rating

*Major Minor*

**5224** Thumb, ankylosis of:

Unfavorable 20 20

Favorable 10 10

> **Note**: Also consider whether evaluation as amputation is warranted
> and whether an additional evaluation is warranted for resulting
> limitation of motion of other digits or interference with overall
> function of the hand.

**5225** Index finger, ankylosis of:

Unfavorable or favorable 10 10

> **Note**: Also consider whether evaluation as amputation is warranted
> and whether an additional evaluation is warranted for resulting
> limitation of motion of other digits or interference with overall
> function of the hand.

**5226** Long finger, ankylosis of:

Unfavorable or favorable 10 10

> **Note**: Also consider whether evaluation as amputation is warranted
> and whether an additional evaluation is warranted for resulting
> limitation of motion of other digits or interference with overall
> function of the hand.

**5227** Ring or little finger, ankylosis of:

Unfavorable or favorable 0 0

> **Note**: Also consider whether evaluation as amputation is warranted
> and whether an additional evaluation is warranted for resulting
> limitation of motion of other digits or interference with overall
> function of the hand.

**IV. Limitation of Motion of Individual Digits**

Rating

*Major Minor*

**5228** Thumb, limitation of motion:

With a gap of more than two inches (5.1 cm.) between the

thumb pad and the fingers, with the thumb attempting to

oppose the fingers 20 20

With a gap of one to two inches (2.5 to 5.1 cm.) between the

thumb pad and the fingers, with the thumb attempting to

oppose the fingers\...\...\...\...\...\...\...\...\...\...\...\..... 10
10

With a gap of less than one inch (2.5 cm.) between the thumb

pad and the fingers, with the thumb attempting to oppose

the fingers 0 0

**5229** Index or long finger, limitation of motion:

With a gap of one inch (2.5 cm.) or more between the fingertip

and the proximal transverse crease of the palm, with the

finger flexed to the extent possible, or; with extension limited

by more than 30 degrees 10 10

With a gap of less than one inch (2.5 cm.) between the fingertip

and the proximal transverse crease of the palm, with the finger

flexed to the extent possible, and; extension is limited by no

more than 30 degrees 0 0

**5230** Ring or little finger, limitation of motion:

Any limitation of motion 0 0

**[The Spine]{.smallcaps}**

Rating

**General Rating Formula for Diseases and Injuries of the Spine**

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the
Formula for Rating

Intervertebral Disc Syndrome Based on Incapacitating Episodes):

With or without symptoms such as pain (whether or not it radiates),
stiffness, or aching in the area of the spine affected by residuals of
injury or disease

Unfavorable ankylosis of the entire spine 100

Unfavorable ankylosis of the entire thoracolumbar spine 50

Unfavorable ankylosis of the entire cervical spine; or, forward flexion

of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis
of

the entire thoracolumbar spine 40

Forward flexion of the cervical spine 15 degrees or less; or, favorable

ankylosis of the entire cervical spine 30

Forward flexion of the thoracolumbar spine greater than 30 degrees but
not

greater than 60 degrees; or, forward flexion of the cervical spine
greater

than 15 degrees but not greater than 30 degrees; or, the combined range
of

motion of the thoracolumbar spine not greater than 120 degrees; or, the

combined range of motion of the cervical spine not greater than 170
degrees;

or, muscle spasm or guarding severe enough to result in an abnormal gait

or abnormal spinal contour such as scoliosis, reversed lordosis, or

abnormal kyphosis 20

Forward flexion of the thoracolumbar spine greater than 60 degrees but
not

greater than 85 degrees; or, forward flexion of the cervical spine
greater than

30 degrees but not greater than 40 degrees; or, combined range of motion
of

the thoracolumbar spine greater than 120 degrees but not greater than
235

degrees; or, combined range of motion of the cervical spine greater than

170 degrees but not greater than 335 degrees; or, muscle spasm,
guarding,

or localized tenderness not resulting in abnormal gait or abnormal
spinal

contour; or, vertebral body fracture with loss of 50 percent or more of
the

height 10

**Note (1):** Evaluate any associated objective neurologic
abnormalities, including, but not limited to, bowel or bladder
impairment, separately, under an appropriate diagnostic code.

**Note (2):** (See also Plate V.) For VA compensation purposes, normal
forward flexion of the cervical spine is zero to 45 degrees, extension
is zero to 45 degrees, left and right lateral flexion are zero to 45
degrees, and left and right lateral rotation are zero to 80 degrees.
Normal forward flexion of the thoracolumbar spine is zero to 90 degrees,
extension is zero to 30 degrees, left and right lateral flexion are zero
to 30 degrees, and left and right lateral rotation are zero to 30
degrees. The combined range of motion refers to the sum of the range of
forward flexion, extension, left and right lateral flexion, and left and
right rotation. The normal combined range of motion of the cervical
spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The
normal ranges of motion for each component of spinal motion provided in
this note are the maximum that can be used for calculation of the
combined range of motion.

> **Note (3):** In exceptional cases, an examiner may state that because
> of age, body habitus, neurologic disease, or other factors not the
> result of disease or injury of the spine, the range of motion of the
> spine in a particular individual should be considered normal for that
> individual, even though it does not conform to the normal range of
> motion stated in Note (2). Provided that the examiner supplies an
> explanation, the examiner's assessment that the range of motion is
> normal for that individual will be accepted.

**Note (4):** Round each range of motion measurement to the nearest five
degrees.

**Note (5):** For VA compensation purposes, unfavorable ankylosis is a
condition in which the entire cervical spine, the entire thoracolumbar
spine, or the entire spine is fixed in flexion or extension, and the
ankylosis results in one or more of the following: difficulty walking
because of a limited line of vision; restricted opening of the mouth and
chewing; breathing limited to diaphragmatic respiration;
gastrointestinal symptoms due to pressure of the costal margin on the
abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or
dislocation; or neurologic symptoms due to nerve root stretching.
Fixation of a spinal segment in neutral position (zero degrees) always
represents favorable ankylosis.

**Note (6):** Separately evaluate disability of the thoracolumbar and
cervical spine segments, except when there is unfavorable ankylosis of
both segments, which will be rated as a single disability.

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

5242 Degenerative arthritis of the spine (see also diagnostic code 5003)

5243 Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or
postoperatively) either under the General Rating Formula for Diseases
and Injuries of the Spine or under the Formula for Rating Intervertebral
Disc Syndrome Based on Incapacitating Episodes, whichever method results
in the higher evaluation when all disabilities are combined under §4.25.

**Formula for Rating Intervertebral Disc Syndrome Based on
Incapacitating Episodes**

With incapacitating episodes having a total duration of at least 6 weeks
during the

past 12 months 60

With incapacitating episodes having a total duration of at least 4 weeks
but less than

6 weeks during the past 12 months 40

With incapacitating episodes having a total duration of at least 2 weeks
but less than

4 weeks during the past 12 months 20

With incapacitating episodes having a total duration of at least one
week but less than

2 weeks during the past 12 months 10

**Note (1):** For purposes of evaluations under diagnostic code 5243, an
incapacitating episode is a period of acute signs and symptoms due to
intervertebral disc syndrome that requires bed rest prescribed by a
physician and treatment by a physician.

**Note (2):** If intervertebral disc syndrome is present in more than
one spinal segment, provided that the effects in each spinal segment are
clearly distinct, evaluate each segment on the basis of incapacitating
episodes or under the General Rating Formula for Diseases and Injuries
of the Spine, whichever method results in a higher evaluation for that
segment.

**Plate V -- Range of Motion of Cervical and Thoracolumbar Spine**

**[The Hip and Thigh]{.smallcaps}**

Rating

**5250** Hip, ankylosis of:

Unfavorable, extremely unfavorable ankylosis,

the foot not reaching ground, crutches necessitated 903

Intermediate 70

Favorable in flexion at an angle between 20º and 40º and

slight adduction or abduction 60

**5251** Thigh, limitation of extension of:

Extension limited to 5º 10

**5252** Thigh, limitation of flexion of:

Flexion limited to 10º 40

Flexion limited to 20º 30

Flexion limited to 30º 20

Flexion limited to 45º 10

**5253** Thigh, impairment of:

Limitation of abduction of, motion lost beyond 10º 20

Limitation of adduction of, cannot cross legs 10

Limitation of rotation of, cannot toe-out more than 15º,

affected leg 10

**5254** Hip, flail joint 80

**5255** Femur, impairment of:

Fracture of shaft or anatomical neck of:

With nonunion, with loose motion (spiral or oblique fracture) 80

With nonunion, without loose motion, weightbearing preserved

with aid of brace. 60

Fracture of surgical neck of, with false joint 60

Malunion of:

With marked knee or hip disability 30

With moderate knee or hip disability 20

With slight knee or hip disability 10

3Entitled to special monthly compensation.

[**The Knee and Leg**]{.smallcaps}

Rating

**5256** Knee, ankylosis of:

Extremely unfavorable, in flexion at an angle of 45° or more 60

In flexion between 20° and 45° 50

In flexion between 10° and 20° 40

Favorable angle in full extension, or in slight flexion between 0° and
10° 30

**5257** Knee, other impairment of:

Recurrent subluxation or lateral instability:

Severe 30

Moderate 20

Slight 10

**5258** Cartilage, semilunar, dislocated, with frequent episodes of

"locking," pain, and effusion into the joint 20

**5259** Cartilage, semilunar, removal of, symptomatic. 10

**5260** Leg, limitation of flexion of:

Flexion limited to 15° 30

Flexion limited to 30° 20

Flexion limited to 45° 10

Flexion limited to 60° 0

**5261** Leg, limitation of extension of:

Extension limited to 45° 50

Extension limited to 30° 40

Extension limited to 20° 30

Extension limited to 15° 20

Extension limited to 10° 10

Extension limited to 5° 0

**5262** Tibia and fibula, impairment of:

Nonunion of, with loose motion, requiring brace 40

Malunion of:

With marked knee or ankle disability 30

With moderate knee or ankle disability 20

With slight knee or ankle disability 10

**5263** Genu recurvatum (acquired, traumatic, with weakness and

insecurity in weight-bearing objectively demonstrated) 10

**[The Ankle]{.smallcaps}**

Rating

**5270** Ankle, ankylosis of:

In plantar flexion at more than 40º, or in dorsiflexion at more

than 10° or with abduction, adduction, inversion or eversion

deformity 40

In plantar flexion, between 30º and 40º, or in dorsiflexion,

between 0º and 10º 30 30

In plantar flexion, less than 30º 20

**5271** Ankle, limited motion of:

Marked 20

Moderate 10

**5272** Subastragalar or tarsal joint, ankylosis of:

In poor weight-bearing position 20 ,,,,,, 20

In good weight-bearing position 10

**5273** Os calcis or astragalus, malunion of:

Marked deformity 20 ,,,., ,,,,,,,, .,,,,, 20

Moderate deformity 10

**5274** Astragalectomy 20

**[Shortening of the Lower Extremity]{.smallcaps}**

Rating

**5275** Bones, of the lower extremity, shortening of:

Over 4 inches (1 0.2 cms.) 603 3 60

3-1/2 to 4 inches (8.9 cms. to 10.2 cms.) 503

3 to 3-1/2 inches (7.6 cms.to 8.9 cms.) 40

2-1/2 to 3 inches (6.4 cms. to 7.6 cms.) 30 30

2 to 2-1/2 inches (5.1 cms. to 6.4 cms.) 20 20

1-1/4 to 2 inches (3.2 cms. to 5.1 cms.) 10

Note: Measure both lower extremities from anterior superior spine of the
ilium to the internal malleolus of the tibia. Not to be combined with
other ratings for fracture or faulty union in the same extremity.

3Also entitled to special monthly compensation.

**[The Foot]{.smallcaps}**

Rating

**5276** Flatfoot, acquired:

Pronounced; marked pronation, extreme tenderness of plantar

surfaces of the feet, marked inward displacement and severe spasm

of the tendo achillis on manipulation, not improved by orthopedic

shoes or appliances:

Bilateral 50 ,.,, ,,,,.,,,,,,,,.,,,,,.,,, , ,,,,,,,,,,,,,,,,,,,,, 50

Unilateral 30

Severe; objective evidence of marked deformity (pronation,

abduction, etc.), pain on manipulation and use accentuated,

indication of swelling on use, characteristic callosities:

Bilateral 30

Unilateral 20 , ,, ,,,,,,,,,,, 20

Moderate; weight-bearing line over or medial to great toe, inward

bowing of the tendo achillis, pain on manipulation and use of

the feet, bilateral or unilateral 10

Mild: symptoms relieved by built-up shoe or arch support 0

**5277** Weak Foot, bilateral:

A symptomatic condition secondary to many constitutional conditions,

characterized by atrophy of the musculature, disturbed circulation,

and weakness:

Rate the underlying condition, minimum rating 10

**5278** Claw foot (pes cavus), acquired:

Marked contraction of plantar fascia with dropped forefoot, all toes

hammer toes, very painful callosities, marked varus deformity:

Bilateral 50

Unilateral 30

All toes tending to dorsiflexion, limitation of dorsiflexion at ankle

to right angle, shortened plantar fascia, and marked tenderness

under metatarsal heads:

Bilateral 30

Unilateral 20

Great toe dorsiflexed, some limitation of dorsiflexion at ankle,

definite tenderness under metatarsal heads:

Bilateral 10

Unilateral 10

Slight 0

**5279** Metatarsalgia, anterior (Morton's disease), unilateral, or
bilateral 10

**5280** Hallux valgus, unilateral:

Operated with resection of metatarsal head 10

Severe, if equivalent to amputation of great toe 10

**5281** Hallux rigidus, unilateral, severe:

Rate as hallux valgus, severe.

Note: Not to be combined with claw foot ratings.

**5282** Hammer toe:

All toes, unilateral without claw foot 10

Single toes 0

**5283** Tarsal, or metatarsal bones, malunion of, or nonunion of:

Severe 30

Moderately severe 20

Moderate 10

Note: With actual loss of use of the foot, rate 40 percent.

**5284** Foot injuries, other:

Severe 30

Moderately severe 20

Moderate 10

Note: With actual loss of use of the foot, rate 40 percent.

**[The Skull]{.smallcaps}**

Rating

**5296** Skull, loss of part of, both inner and outer tables:

With brain hernia 80

Without brain hernia:

Area larger than size of a 50-cent piece or 1.140 in2 (7.355 cm2 ) 50

Area intermediate 30

Area smaller than the size of a 25-cent piece

or 0.716 in2 (4.619 cm2 ) 10

Note: Rate separately for intracranial complications.

**[The Ribs]{.smallcaps}**

Rating

**5297** Ribs, removal of:

More than six 50

Five or six 40

Three or four 30

Two 20

One or resection of two or more ribs without regeneration 10

**Note (1):** The rating for rib resection or removal is not to be
applied with ratings for purulent pleurisy, lobectomy, pneumonectomy or
injuries of pleural cavity.

**Note (2):** However, rib resection will be considered as rib removal
in thoracoplasty performed for collapse therapy or to accomplish
obliteration of space and will be combined with the rating for lung
collapse, or with the rating for lobectomy, pneumonectomy or the
graduated ratings for pulmonary tuberculosis.

**[The Coccyx]{.smallcaps}**

Rating

**5298** Coccyx, removal of:

Partial or complete, with painful residuals 10

Without painful residuals 0

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

\[29 FR 6718, May 22,1964, as amended at 34 FR 5062, Mar. 11, 1969; 40
FR 42536, Sept. 15, 1975; 41 FR 11294, Mar. 18, 1976; 43 FR 45350, Oct.
2, 1978; 51 FR 6411, Feb. 24, 1986; 61 FR 20439, May 7, 1996; 64 FR
32410, June 17, 1999; 67 FR 48785, July 26, 2002; 67 FR 54349, Aug. 22,
2002; 68 FR 51456, Aug. 27, 2003; 69 FR 32450, June 10, 2004\]

**Supplement *Highlights* references**: 16(1), 26(2), 30(1), 31(1),
33(1), 35(1).