## Section A. Musculoskeletal Conditions

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  1            General Information on Musculoskeletal         4-A-2
               Conditions                                     

  2            Nomenclature of Digits                         4-A-5

  3            Congenital Conditions                          4-A-7

  4            Rheumatoid Arthritis                           4-A-8

  5            Degenerative Arthritis                         4-A-13

  6            Limitation of Motion in Arthritis Cases        4-A-15

  7            Osteomyelitis                                  4-A-18

  8            Exhibit 1: Examples of Rating Decisions for    4-A-20
               Limited Motion                                 

  9            Exhibit 2: Examples of the Proper Rating       4-A-22
               Procedure for Osteomyelitis                    
  ------------ ---------------------------------------------- ------------

#### 1. General Information on Musculoskeletal Conditions

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on musculoskeletal    |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   considering impairment of supination and pronation  |
|            |                                                         |
|            | -   considering functional loss due to pain in          |
|            |     evaluating musculoskeletal conditions               |
|            |                                                         |
|            | -   when functional loss is not used to evaluate        |
|            |     musculoskeletal conditions                          |
|            |                                                         |
|            | -   evaluating limitation of motion due to pain         |
|            |                                                         |
|            | -   considering Dupuytren's contracture, and            |
|            |                                                         |
|            | -   considering conflicting decisions regarding loss of |
|            |     use.                                                |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > When preparing ratings involving impairment of        |
| Considerin | > pronation and supination, bear in mind the following  |
| g Impairme | > facts:                                                |
| nt of Supi |                                                         |
| nation and | -   full pronation is the position of the hand flat on  |
|  Pronation |     a table                                             |
|            |                                                         |
|            | -   full supination is the position of the hand palm    |
|            |     up, and                                             |
|            |                                                         |
|            | -   when examining limitation of pronation, the         |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   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 information on painful motion,   |
|            | > see                                                   |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     4.59](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [M21-1MR, Part III, Subpart iv,                     |
|            |     4.A.1.b](../pt03_sp04_ch04_secA#III.iv.4.A.1.b).    |
+------------+---------------------------------------------------------+

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1\. General Information on Musculoskeletal Conditions, Continued

+------------+---------------------------------------------------------+
| ##### b.   | > Functional loss due to pain is a factor in the        |
| Considerin | > evaluation of musculoskeletal conditions under        |
| g Function | > diagnostic codes that involve limitation of motion.   |
| al Loss Du | >                                                       |
| e to Pain  | > It is the responsibility of the examining physician   |
| in Evaluat | > to assess how pain and other factors related to       |
| ing Muscul | > functional impairment equate to limitation of motion. |
| oskeletal  | > The examiner should either                            |
| Conditions |                                                         |
|            | -   report this additional functional loss as range of  |
|            |     motion in degrees, or                               |
|            |                                                         |
|            | -   indicate that he/she cannot determine, without      |
|            |     resort to mere speculation, whether any of these    |
|            |     factors cause additional functional loss.           |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The pain may be caused by the actual joint,         |
|            |     connective tissues, nerves, or muscles.             |
|            |                                                         |
|            | -   The medical nature of the particular disability     |
|            |     determines whether the diagnostic code is based on  |
|            |     limitation of motion.                               |
|            |                                                         |
|            | > ***References***: For more information on             |
|            |                                                         |
|            | -   functional loss, see                                |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   [38 CFR                                             |
|            |     4.40](http:/                                        |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_40.DOC) |
|            |                                                         |
|            | -   [*DeLuca v.                                         |
|            |     Brown*]                                             |
|            | (http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmd) |
|            |     (1995)                                              |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   disability of the joints, see [38 CFR               |
|            |     4.45](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_45.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   painful motion, see [38 CFR                         |
|            |     4.59](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c. W | > Functional loss as discussed in [38 CFR               |
| hen Functi | > 4.40](http://                                         |
| onal Loss  | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_40.DOC), |
| Is Not Use | > [38 CFR                                               |
| d to Evalu | > 4.45](http://                                         |
| ate Muscul | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_45.DOC), |
| oskeletal  | > and [38 CFR                                           |
| Conditions | > 4.59](http:/                                          |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC) |
|            | > is not used to evaluate musculoskeletal conditions    |
|            | > that do not involve range of motion findings.         |
|            | >                                                       |
|            | > ***Example***: A rating under diagnostic code (DC)    |
|            | > 5257 for lateral knee instability.                    |
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1\. General Information on Musculoskeletal Conditions, Continued

+------------+---------------------------------------------------------+
| ##         | > When evaluating limitation of motion due to pain,     |
| ### d. Eva | > keep in mind that                                     |
| luating Li |                                                         |
| mitation o | -   the limitation must at least meet the level of a    |
| f Motion D |     noncompensable evaluation for the affected joint to |
| ue to Pain |     warrant an additional evaluation                    |
|            |                                                         |
|            | -   for painful motion to be the basis for a higher     |
|            |     evaluation than the one based solely on actual      |
|            |     limitation of motion, the examination or other      |
|            |     medical evidence must                               |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   clearly indicate the exact degree of movement at    |
|            |     which pain limits motion in the affected joint, and |
|            |                                                         |
|            | -   include the findings of at least three repetitions  |
|            |     of range of motion.                                 |
|            |                                                         |
|            | > ***Reference***: For more information on multiple     |
|            | > ratings for musculoskeletal disability, see           |
|            | > [*VAOPGCPREC                                          |
|            | > 9-98*](http://www1.va.gov/ogc/docs/prc09-98.doc) and  |
|            | > [*VAOPGCPREC                                          |
|            | > 9-2004*](http://www1.va.gov/ogc/docs/PREC92004.doc).  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > In the absence of an assigned evaluation for          |
| # e. Consi | > Dupuytren's contracture as a disease entity in the    |
| dering Dup | > rating schedule, assign an evaluation on the basis of |
| uytren's C | > limitation of finger movement.                        |
| ontracture |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Forward the claims folder to the Director,            |
| # f. Consi | > Compensation and Pension (C&P) Service (211B), for an |
| dering Con | > advisory opinion under [M21-1MR, Part III, Subpart    |
| flicting D | > vi,                                                   |
| ecisions R | > 1.A.2.a](../pt03_sp06_ch01_secA.xml#III.vi.1.A.2.a)   |
| egarding L | > to resolve a conflict if                              |
| oss of Use |                                                         |
|            | -   the Insurance Center determines loss of use of two  |
|            |     extremities prior to rating consideration involving |
|            |     the same issue, and                                 |
|            |                                                         |
|            | -   the determination conflicts with the proposed       |
|            |     rating decision.                                    |
|            |                                                         |
|            | > ***Note***: This issue will generally be brought to   |
|            | > the attention of the Rating Veterans Service          |
|            | > Representative (RVSR) as a result of the type of      |
|            | > personal injury, correspondence, or some indication   |
|            | > in the claims folder that the insurance activity is   |
|            | > involved.                                             |
+------------+---------------------------------------------------------+

#### 2. Nomenclature of Digits

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on the nomenclature   |
| troduction | > of digits, including                                  |
|            |                                                         |
|            | -   specifying injured digits and phalanges, and        |
|            |                                                         |
|            | -   identifying the digits of the hand and foot.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > Follow the guidelines listed below to accurately      |
|  Specifyin | > specify the injured digits of the upper and lower     |
| g Injured  | > extremities.                                          |
| Digits and |                                                         |
|  Phalanges | -   Each digit, except the thumb and the great toe,     |
|            |     includes three phalanges                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   the proximal phalanx (closest to the wrist or       |
|            |     ankle)                                              |
|            |                                                         |
|            | -   the middle phalanx, and                             |
|            |                                                         |
|            | -   the distal phalanx (closest to the tip of the       |
|            |     finger or toe).                                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   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 thumb and great toe each have only two          |
|            |     phalanges, the proximal phalanx and the distal      |
|            |     phalanx. Therefore, each thumb and each great toe   |
|            |     has only a single joint, called the interphalangeal |
|            |     (IP) joint.                                         |
|            |                                                         |
|            | -   The joints connecting the phalanges in the hands to |
|            |     the metacarpals are the metacarpophalangeal (MCP)   |
|            |     joints.                                             |
|            |                                                         |
|            | -   The joints connecting the phalanges in the feet to  |
|            |     the metatarsals are the metatarsophalangeal (MTP)   |
|            |     joints.                                             |
|            |                                                         |
|            | > ***Note***: If the location of the injury is unclear, |
|            | > obtain x-rays to clarify the exact point of injury.   |
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2\. Nomenclature of Digits, Continued

+------------+---------------------------------------------------------+
| ##         | > Use the table below to correctly identify the digits  |
| ### b. Ide | > of the hand and foot.                                 |
| ntifying t | >                                                       |
| he Digits  | > ***Note***: Designate either right or left for the    |
| of the Han | > digits of the hand or foot.                           |
| d and Foot |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| If the extremity is the ...       | Then identify the digit as the    |
|                                   | ...                               |
+-----------------------------------+-----------------------------------+
| hand                              | -   thumb                         |
|                                   |                                   |
|                                   | -   index                         |
|                                   |                                   |
|                                   | -   long                          |
|                                   |                                   |
|                                   | -   ring, or                      |
|                                   |                                   |
|                                   | -   little.                       |
|                                   |                                   |
|                                   | ***Note***: Do not use numerical  |
|                                   | designations for either the       |
|                                   | fingers or joints of the fingers. |
+-----------------------------------+-----------------------------------+
| foot                              | -   first or great toe            |
|                                   |                                   |
|                                   | -   second                        |
|                                   |                                   |
|                                   | -   third                         |
|                                   |                                   |
|                                   | -   fourth, or                    |
|                                   |                                   |
|                                   | -   fifth.                        |
+-----------------------------------+-----------------------------------+

#### 3. Congenital Conditions

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on congenital         |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   recognizing variations in development and           |
|            |     appearance, and                                     |
|            |                                                         |
|            | -   considering notable defects.                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Individuals vary greatly in their musculoskeletal     |
| #### a. Re | > development and appearance. Functional variations are |
| cognizing  | > often seen and can be attributed to                   |
| Variations |                                                         |
|  in Develo | -   the type of individual, and                         |
| pment and  |                                                         |
| Appearance | -   his/her inherited or congenital variations from the |
|            |     normal.                                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b    | > Give careful attention to congenital or developmental |
| . Consider | > defects such as                                       |
| ing Notabl |                                                         |
| e Defects  | -   absence of parts                                    |
|            |                                                         |
|            | -   subluxation (partial dislocation of a joint)        |
|            |                                                         |
|            | -   deformity or exostosis (bony overgrowth) of parts,  |
|            |     and/or                                              |
|            |                                                         |
|            | -   accessory or supernumerary (in excess of the normal |
|            |     number) parts.                                      |
|            |                                                         |
|            | > Note congenital defects of the spine, especially      |
|            |                                                         |
|            | -   spondylolysis                                       |
|            |                                                         |
|            | -   spina bifida                                        |
|            |                                                         |
|            | -   unstable or exaggerated lumbosacral joints or       |
|            |     angle, or                                           |
|            |                                                         |
|            | -   incomplete sacralization.                           |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Do not automatically classify spondylolisthesis as  |
|            |     a congenital condition, although it is commonly     |
|            |     associated with a congenital defect.                |
|            |                                                         |
|            | -   Do not overlook congenital diastasis of the rectus  |
|            |     abdominus, hernia of the diaphragm, and the various |
|            |     myotonias.                                          |
|            |                                                         |
|            | > ***Reference***: For more information on congenital   |
|            | > or developmental defects, see [38 CFR                 |
|            | > 4.9](http:/                                           |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_3.DOC). |
+------------+---------------------------------------------------------+

#### 4. Rheumatoid Arthritis

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about rheumatoid      |
| troduction | > arthritis, including                                  |
|            |                                                         |
|            | -   characteristics of rheumatoid arthritis             |
|            |                                                         |
|            | -   periods of flares and remissions of rheumatoid      |
|            |     arthritis                                           |
|            |                                                         |
|            | -   clinical signs of rheumatoid arthritis              |
|            |                                                         |
|            | -   radiologic changes in rheumatoid arthritis          |
|            |                                                         |
|            | -   disability factors associated with rheumatoid       |
|            |     arthritis, and                                      |
|            |                                                         |
|            | -   points to consider in the rating decision.          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > The following are characteristics of rheumatoid       |
|  Character | > arthritis, also diagnosed as atrophic or infectious   |
| istics of  | > arthritis, or arthritis deformans:                    |
| Rheumatoid |                                                         |
|  Arthritis | -   the onset                                           |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   occurs before middle age, and                       |
|            |                                                         |
|            | -   may be acute, with a febrile attack, and            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   the symptoms include a usually laterally            |
|            |     symmetrical limitation of movement                  |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   first affecting proximal interphalangeal and        |
|            |     metacarpophalangeal joints                          |
|            |                                                         |
|            | -   next causing atrophy of muscles, deformities,       |
|            |     contractures, subluxations, and                     |
|            |                                                         |
|            | -   finally causing fibrous or bony ankylosis (abnormal |
|            |     adhesion of the bones of the joint).                |
|            |                                                         |
|            | > ***Important***: Marie-Strumpell disease, also called |
|            | > rheumatoid spondylitis or ankylosing spondylitis, is  |
|            | > *not* the same disease as rheumatoid arthritis.       |
|            | > Rheumatoid arthritis and Marie-Strumpell disease have |
|            | > separate and distinct clinical manifestations and     |
|            | > progress differently.                                 |
+------------+---------------------------------------------------------+

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4\. Rheumatoid Arthritis, Continued

+------------+---------------------------------------------------------+
| #####      | The symptoms of rheumatoid arthritis come and go,       |
|  b. Period | depending on the degree of tissue inflammation. When    |
| s of Flare | body tissues are inflamed, the disease is active. When  |
| s and Remi | tissue inflammation subsides, the disease is inactive   |
| ssions in  | (in remission).                                         |
| Rheumatoid |                                                         |
|  Arthritis | Remissions can occur spontaneously or with treatment,   |
|            | and can last weeks, months, or years. During            |
|            | remissions, symptoms of the disease disappear, and      |
|            | patients generally feel well. When the disease becomes  |
|            | active again (relapse), symptoms return.                |
|            |                                                         |
|            | > ***Note***: The return of disease activity and        |
|            | > symptoms is called a flare. The course of rheumatoid  |
|            | > arthritis varies from patient to patient, and periods |
|            | > of flares and remissions are typical.                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > The table below contains information about the        |
| . Clinical | > clinical signs of rheumatoid arthritis.               |
|  Signs of  |                                                         |
| Rheumatoid |                                                         |
|  Arthritis |                                                         |
+------------+---------------------------------------------------------+

+----------+-----------------------------------------------------------+
| Stage of | Symptoms                                                  |
| Disease  |                                                           |
+----------+-----------------------------------------------------------+
| Initial  | -   periarticular and articular swelling, often free      |
|          |     fluid, with proliferation of the synovial membrane,   |
|          |     and                                                   |
|          |                                                           |
|          | -   atrophy of the muscles                                |
|          |                                                           |
|          | ***Note***: Atrophy is increased to wasting if the        |
|          | disease is unchecked.                                     |
+----------+-----------------------------------------------------------+
| Late     | -   deformities and contractures                          |
|          |                                                           |
|          | -   subluxations, or                                      |
|          |                                                           |
|          | -   fibrous or bony ankylosis                             |
+----------+-----------------------------------------------------------+

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4\. Rheumatoid Arthritis, Continued

+------------+---------------------------------------------------------+
| #          | > The table below contains information about the        |
| #### d. Ra | > radiologic changes found in rheumatoid arthritis.     |
| diologic C |                                                         |
| hanges in  |                                                         |
| Rheumatoid |                                                         |
|  Arthritis |                                                         |
+------------+---------------------------------------------------------+

+----------+-----------------------------------------------------------+
| Stage of | Radiologic Changes                                        |
| Disease  |                                                           |
+----------+-----------------------------------------------------------+
| Early    | -   slight diminished density of bone shadow, and         |
|          |                                                           |
|          | -   increased density of articular soft parts without     |
|          |     bony or cartilaginous changes of articular ends       |
|          |                                                           |
|          | ***Note***: Rheumatoid arthritis and some other types of  |
|          | infectious arthritis do not require x-ray evidence of     |
|          | bone changes to substantiate the diagnosis, since x-rays  |
|          | do not always show their existence.                       |
+----------+-----------------------------------------------------------+
| Late     | -   diminished density of bone shadow                     |
|          |                                                           |
|          | -   loss of bone substance or articular ends, and         |
|          |                                                           |
|          | -   subluxation or ankylosis.                             |
+----------+-----------------------------------------------------------+

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4\. Rheumatoid Arthritis, Continued

+------------+---------------------------------------------------------+
| ####       | > Give special attention to the following disability    |
| # e. Disab | > factors associated with rheumatoid arthritis in       |
| ility Fact | > addition to, or in advance of, demonstrable x-ray     |
| ors Associ | > changes:                                              |
| ated With  |                                                         |
| Rheumatoid | -   muscle spasms                                       |
|  Arthritis |                                                         |
|            | -   periarticular and articular soft tissue changes,    |
|            |     such as                                             |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   synovial hypertrophy                                |
|            |                                                         |
|            | -   flexion contracture deformities                     |
|            |                                                         |
|            | -   joint effusion, and                                 |
|            |                                                         |
|            | -   destruction of articular cartilage, and             |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   constitutional changes such as                      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   emaciation                                          |
|            |                                                         |
|            | -   dryness of the eyes and mouth (Sjogren's syndrome)  |
|            |                                                         |
|            | -   pulmonary complications, such as inflammation of    |
|            |     the lining of the lungs or lung tissue              |
|            |                                                         |
|            | -   anemia                                              |
|            |                                                         |
|            | -   enlargement of the spleen                           |
|            |                                                         |
|            | -   muscular and bone atrophy                           |
|            |                                                         |
|            | -   skin complications, such as nodules around the      |
|            |     elbows or fingers                                   |
|            |                                                         |
|            | -   gastrointestinal symptoms                           |
|            |                                                         |
|            | -   circulatory changes                                 |
|            |                                                         |
|            | -   imbalance in water metabolism, or dehydration       |
|            |                                                         |
|            | -   vascular changes                                    |
|            |                                                         |
|            | -   cardiac involvement, including pericarditis         |
|            |                                                         |
|            | -   dry joints                                          |
|            |                                                         |
|            | -   low renal function                                  |
|            |                                                         |
|            | -   postural deformities, and                           |
|            |                                                         |
|            | -   low-grade edema of the extremities.                 |
|            |                                                         |
|            | > ***Reference***: For more information on the features |
|            | > of rheumatoid arthritis, see                          |
|            | > <http://www.ni                                        |
|            | ams.nih.gov/Health_Info/Rheumatic_Disease/default.asp>. |
+------------+---------------------------------------------------------+

Continued on next page

4\. Rheumatoid Arthritis, Continued

+------------+---------------------------------------------------------+
| ##### f. P | > In the rating decision, note the presence of joints   |
| oints to C | > affected by any of the following:                     |
| onsider in |                                                         |
|  the Ratin | -   synovial hypertrophy or joint effusion              |
| g Decision |                                                         |
|            | -   severe postural changes; scoliosis; flexion         |
|            |     contracture deformities                             |
|            |                                                         |
|            | -   ankylosis or limitation of motion of joint due to   |
|            |     bony changes, and/or                                |
|            |                                                         |
|            | -   destruction of articular cartilage.                 |
+------------+---------------------------------------------------------+

#### 5. Degenerative Arthritis

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about degenerative    |
| troduction | > arthritis, including                                  |
|            |                                                         |
|            | -   characteristics of degenerative arthritis           |
|            |                                                         |
|            | -   diagnostic symptoms of degenerative arthritis       |
|            |                                                         |
|            | -   radiologic changes in degenerative arthritis        |
|            |                                                         |
|            | -   symptoms of degenerative arthritis of the spine,    |
|            |     and                                                 |
|            |                                                         |
|            | -   points to consider in the rating decision.          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a. C | > The following are characteristics of degenerative     |
| haracteris | > arthritis, also diagnosed as osteoarthritis or        |
| tics of De | > hypertrophic arthritis:                               |
| generative |                                                         |
|  Arthritis | -   The onset generally occurs after the age of 45.     |
|            |                                                         |
|            | -   It has no relation to infection.                    |
|            |                                                         |
|            | -   It is asymmetrical (more pronounced on one side of  |
|            |     the body than the other).                           |
|            |                                                         |
|            | -   There is limitation of movement in the late stages  |
|            |     only.                                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Diagnostic symptoms of degenerative arthritis include |
| # b. Diagn |                                                         |
| ostic Symp | -   the presence of Heberden's nodes or calcific        |
| toms of De |     deposits in the terminal joints of the fingers with |
| generative |     deformity                                           |
|  Arthritis |                                                         |
|            | -   ankylosis, in rare cases                            |
|            |                                                         |
|            | -   hyperostosis and irregular, notched articular       |
|            |     surfaces of the joints                              |
|            |                                                         |
|            | -   destruction of cartilage                            |
|            |                                                         |
|            | -   bone eburnation, and                                |
|            |                                                         |
|            | -   the formation of osteophytes.                       |
|            |                                                         |
|            | > ***Note***: The flexion contracture deformities and   |
|            | > severe constitutional symptoms described under        |
|            | > rheumatoid arthritis do not usually occur in          |
|            | > degenerative arthritis.                               |
+------------+---------------------------------------------------------+

Continued on next page

5\. Degenerative Arthritis, Continued

+------------+---------------------------------------------------------+
| ###        | > The table below contains information about the        |
| ## c. Radi | > radiologic changes found in degenerative arthritis.   |
| ologic Cha |                                                         |
| nges in De |                                                         |
| generative |                                                         |
|  Arthritis |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| Stage      | Radiologic Changes                                      |
+------------+---------------------------------------------------------+
| Early      | delicate spicules of calcium at the articular margins   |
|            | without                                                 |
|            |                                                         |
|            | -   diminished density of bone shadow, and              |
|            |                                                         |
|            | -   increased density of articular of parts.            |
+------------+---------------------------------------------------------+
| Late       | -   ridging of articular margins                        |
|            |                                                         |
|            | -   hyperostosis                                        |
|            |                                                         |
|            | -   irregular, notched articular surfaces, and          |
|            |                                                         |
|            | -   ankylosis only in the spine.                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Degenerative arthritis of the spine and pelvic joints |
| d. Symptom | > is characterized clinically by the same general       |
| s of Degen | > characteristics as arthritis of the major joints      |
| erative Ar | > except that                                           |
| thritis of |                                                         |
|  the Spine | -   limitation of spine motion occurs early             |
|            |                                                         |
|            | -   chest expansion and costovertebral articulations    |
|            |     are not usually affected                            |
|            |                                                         |
|            | -   referred pain is commonly called "*intercostal      |
|            |     neuralgia"* and "*sciatica*," and                   |
|            |                                                         |
|            | -   localized ankylosis may occur if spurs on bodies of |
|            |     vertebrae impinge.                                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### e. P | > Degenerative and traumatic arthritis require x-ray    |
| oints to C | > evidence of bone changes to substantiate the          |
| onsider in | > diagnosis.                                            |
|  the Ratin | >                                                       |
| g Decision | > ***Reference***: For more information on considering  |
|            | > x-ray evidence when evaluating arthritis, see [38 CFR |
|            | > 4.71a, DC                                             |
|            | > 5003](http://vba                                      |
|            | w.vba.va.gov/bl/21/publicat/Regs/Part4/4_71a.htm#5003). |
+------------+---------------------------------------------------------+

#### 6. Limitation of Motion in Arthritis Cases

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on limitation of      |
| troduction | > motion due to arthritis, including                    |
|            |                                                         |
|            | -   conditions compensable under other diagnostic codes |
|            |                                                         |
|            | -   conditions not compensable under other diagnostic   |
|            |     codes                                               |
|            |                                                         |
|            | -   examples of rating decisions                        |
|            |                                                         |
|            | -   arthritis previously rated as a single disability   |
|            |                                                         |
|            | -   using DCs 5013 through 5024, and                    |
|            |                                                         |
|            | -   considering the effects of a change of diagnosis in |
|            |     arthritis cases.                                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a. C | > For a joint or group of joints affected by            |
| onditions  | > degenerative arthritis, use the diagnostic code which |
| Compensabl | > justifies the assigned evaluation.                    |
| e Under Ot | >                                                       |
| her Diagno | > ***Example***: When the compensable requirements for  |
| stic Codes | > limited motion of a joint are met under a code other  |
|            | > than 5003, hyphenate that code in the conclusion with |
|            | > a preceding 5003*-*. Then list the appropriate code,  |
|            | > such as 5261, limited extension of the knee, 10       |
|            | > percent, creating the code 5003-5261.                 |
|            | >                                                       |
|            | > ***Exception***: If other joints affected by          |
|            | > arthritis are compensably evaluated in the same       |
|            | > rating, use only the code appropriate to these        |
|            | > particular joints which support the assigned          |
|            | > evaluation and omit the modifying 5003.               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Whenever limited motion is noncompensable under codes |
| # b. Condi | > appropriate to a particular joint, assign 10 percent  |
| tions Not  | > under 5003 for each major joint or group of minor     |
| Compensabl | > joints affected by limited or painful motion as       |
| e Under Ot | > prescribed under DC 5003.                             |
| her Diagno | >                                                       |
| stic Codes | > If there is no limited or painful motion, but there   |
|            | > is x-ray evidence of degenerative arthritis, assign   |
|            | > under 5003 either a 10 percent evaluation or a 20     |
|            | > percent for occasional incapacitating exacerbations,  |
|            | > based on the involvement of two or more major joints  |
|            | > or two or more groups of minor joints.                |
|            | >                                                       |
|            | > ***Important***: Do *not* combine under [38 CFR       |
|            | > 4.25](http:/                                          |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_25.DOC) |
|            | > a 10 or 20 percent rating that is based solely on     |
|            | > x-ray findings with ratings that are based on limited |
|            | > or painful motion.                                    |
+------------+---------------------------------------------------------+

Continued on next page

6\. Limitation of Motion in Arthritis Cases, Continued

+------------+---------------------------------------------------------+
| ##### c    | > For more information on rating decisions for          |
| . Examples | > limitation of motion, see [M21-1MR, Part III, Subpart |
|  of Rating | > iv, 4.A.8](../pt03_sp04_ch04_secA.xml#III.iv.4.A.8).  |
|  Decisions |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > The RVSR may encounter cases where arthritis of       |
|  Arthritis | > multiple joints is rated as a single disability.      |
|  Previousl | >                                                       |
| y Rated as | > Use the information in the table below to handle      |
|  a Single  | > cases where arthritis was previously rated as a       |
| Disability | > single disability.                                    |
+------------+---------------------------------------------------------+

+---------------------------------+------------------------------------+
| If ...                          | Then ...                           |
+---------------------------------+------------------------------------+
| -   the separate evaluation of  | rerate using the current procedure |
|     the arthritic disability    | with the same effective date as    |
|     results in no change in the | previously assigned.               |
|     combined degree previously  |                                    |
|     assigned, and               |                                    |
|                                 |                                    |
| -   a rating is required        |                                    |
+---------------------------------+------------------------------------+
| rerating the arthritic joint    | apply [38 CFR                      |
| separately results in an        | 3.10                               |
| increased combined evaluation   | 5(a)](http://www.warms.vba.va.gov/ |
|                                 | regs/38CFR/BOOKB/PART3/S3_105.DOC) |
|                                 | to retroactively increase the      |
|                                 | assigned evaluation.               |
+---------------------------------+------------------------------------+
| rerating the arthritic joint    | -   request an examination, and    |
| separately results in a reduced |                                    |
| combined evaluation             | -   if still appropriate, propose  |
|                                 |     reduction under [38 CFR        |
|                                 |     3.10                           |
|                                 | 5(a)](http://www.warms.vba.va.gov/ |
|                                 | regs/38CFR/BOOKB/PART3/S3_105.DOC) |
|                                 |     and [38 CFR                    |
|                                 |     3.105                          |
|                                 | (e)](http://www.warms.vba.va.gov/r |
|                                 | egs/38CFR/BOOKB/PART3/S3_105.DOC). |
|                                 |                                    |
|                                 | ***Exception***: Do not apply [38  |
|                                 | CFR                                |
|                                 | 3.10                               |
|                                 | 5(a)](http://www.warms.vba.va.gov/ |
|                                 | regs/38CFR/BOOKB/PART3/S3_105.DOC) |
|                                 | if the assigned percentage is      |
|                                 | protected under [38 CFR            |
|                                 | 3.                                 |
|                                 | 951](http://www.warms.vba.va.gov/r |
|                                 | egs/38CFR/BOOKB/PART3/S3_950.DOC). |
|                                 |                                    |
|                                 | ***Reference***: For more          |
|                                 | information on protected ratings,  |
|                                 | see [M21-1MR, Part III, Subpart    |
|                                 | iv,                                |
|                                 | 8.C](../pt                         |
|                                 | 03_sp04_ch08_secC.xml#III.iv.8.C). |
+---------------------------------+------------------------------------+

Continued on next page

6\. Limitation of Motion in Arthritis Cases, Continued

+------------+---------------------------------------------------------+
| ##### e    | > Use the table below to rate cases that use DC 5013    |
| . Rating C | > through 5024.                                         |
| ases with  |                                                         |
| DC 5013 Th |                                                         |
| rough 5024 |                                                         |
+------------+---------------------------------------------------------+

+---------------------------+------------------------------------------+
| If the DC of the case is  | Then ...                                 |
| ...                       |                                          |
+---------------------------+------------------------------------------+
| gout under DC 5017        | rate the case as rheumatoid arthritis,   |
|                           | 5002.                                    |
+---------------------------+------------------------------------------+
| -   5013 through 5016,    | evaluate the case according to the       |
|     and                   | criteria for limited motion or painful   |
|                           | motion under DC 5003, degenerative       |
| -   5018 through 5024     | arthritis.                               |
|                           |                                          |
|                           | ***Note***: The provisions under DC 5003 |
|                           | regarding a compensable minimum          |
|                           | evaluation of 10 percent for limited or  |
|                           | painful motion apply to these diagnostic |
|                           | codes and no others.                     |
|                           |                                          |
|                           | ***Reference***: For more information on |
|                           | 10 and 20 percent ratings based on x-ray |
|                           | findings, see [38 CFR 4.71a, DC 5003,    |
|                           | Note                                     |
|                           | (2)](http://www.warms.vba.va             |
|                           | .gov/regs/38CFR/BOOKC/PART4/S4_71a.DOC). |
+---------------------------+------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > A change of diagnosis among the various types of      |
|  f. The Ef | > arthritis, particularly if joint disease has been     |
| fects of a | > recognized as service-connected for several years,    |
|  Change in | > has no significant bearing on the question of service |
|  Diagnosis | > connection.                                           |
|  in Arthri | >                                                       |
| tis Cases  | > ***Note***: In older individuals, the effects of more |
|            | > that one type of joint disease may coexist.           |
|            | >                                                       |
|            | > ***Reference***: For information on rating rheumatoid |
|            | > arthritis, see                                        |
|            | >                                                       |
|            | > [38 CFR 4.71a, DC                                     |
|            | > 5002](http://w                                        |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_71a.DOC), |
|            | > Arthritis rheumatoid.                                 |
+------------+---------------------------------------------------------+

#### 7. Osteomyelitis

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about osteomyelitis,  |
| troduction | > including                                             |
|            |                                                         |
|            | -   requiring constitutional symptoms                   |
|            |                                                         |
|            | -   historical ratings                                  |
|            |                                                         |
|            | -   assigning historical ratings, and                   |
|            |                                                         |
|            | -   the reasons to discontinue a historical rating.     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Constitutional symptoms are a prerequisite to the     |
| ### a. Req | > assignment of either the 100 percent or 60 percent    |
| uiring Con | > evaluations under DC 5000.                            |
| stitutiona | >                                                       |
| l Symptoms | > Since both the 60 and 100 percent evaluations are     |
|            | > based on constitutional symptoms, neither is subject  |
|            | > to the amputation rule.                               |
|            | >                                                       |
|            | > ***Reference***: For more information on the          |
|            | > amputation rule, see [38 CFR                          |
|            | > 4.68](http://                                         |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_68.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b    | > Both the 10 percent evaluation and that part of the   |
| . Historic | > 20 percent evaluation that is based on "other         |
| al Ratings | > evidence of active infection within the last five     |
|            | > years" are                                            |
|            |                                                         |
|            | -   historical ratings, and                             |
|            |                                                         |
|            | -   based on recurrent episodes of osteomyelitis.       |
|            |                                                         |
|            | > ***Note***: The 20 percent historical evaluation      |
|            | > based on evidence of active infection within the past |
|            | > five years *must* be distinguished from the 20        |
|            | > percent evaluation authorized when there is a         |
|            | > discharging sinus.                                    |
+------------+---------------------------------------------------------+

Continued on next page

7\. Osteomyelitis, Continued

+------------+---------------------------------------------------------+
| ##### c    | > An initial episode of active osteomyelitis is *not* a |
| . Assignin | > basis for either of the historical ratings.           |
| g Historic | >                                                       |
| al Ratings | > Assign the historical rating as follows:              |
|            |                                                         |
|            | -   When the first *recurrent* episode of osteomyelitis |
|            |     is shown                                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   assign a 20 percent historical evaluation, and      |
|            |                                                         |
|            | -   extend the evaluation for five years from the date  |
|            |     of examination showing the osteomyelitis to be      |
|            |     inactive.                                           |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Assign a closed rating at the expiration of the     |
|            |     five-year extension.                                |
|            |                                                         |
|            | -   Assign the 10 percent historical evaluation only if |
|            |     there have been two or more recurrences of active   |
|            |     osteomyelitis following the initial infection.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d. R | > Do *not* discontinue the historical rating, even if   |
| easons to  | > treatment includes saucerization, sequestrectomy, or  |
| Discontinu | > guttering, because the osteomelitis is not considered |
| e Historic | > cured.                                                |
| al Ratings | >                                                       |
|            | > ***Exception***: If there has been removal or radical |
|            | > resection of the affected bone                        |
|            |                                                         |
|            | -   consider osteomyelitis cured, and                   |
|            |                                                         |
|            | -   discontinue the historical rating.                  |
+------------+---------------------------------------------------------+

#### 8. Exhibit 1: Examples of Rating Decisions for Limited Motion

+------------+---------------------------------------------------------+
| ##### In   | > This exhibit contains three examples of ratings for   |
| troduction | > limited motion in arthritis cases.                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > ***Situation***: The veteran has residuals of         |
|  Example 1 | > degenerative arthritis with limitation of abduction   |
|            | > of the right shoulder (major) to 90 degrees and       |
|            | > limitation of flexion of the right knee to 45         |
|            | > degrees.                                              |
+------------+---------------------------------------------------------+

+-------------------+--------------------------------------------------+
| ***Coded          |                                                  |
| Conclusion:***    |                                                  |
+-------------------+--------------------------------------------------+
| 1\. SC (VE INC)   |                                                  |
+-------------------+--------------------------------------------------+
| 5003-5201         | > Degenerative arthritis, right shoulder         |
|                   | > (dominant)                                     |
+-------------------+--------------------------------------------------+
| > 20% from        |                                                  |
| > 12-14-03        |                                                  |
+-------------------+--------------------------------------------------+
|                   |                                                  |
+-------------------+--------------------------------------------------+
| > 5260            | > Degenerative arthritis, right knee             |
+-------------------+--------------------------------------------------+
| > 10% from        |                                                  |
| > 12-14-03        |                                                  |
+-------------------+--------------------------------------------------+
|                   |                                                  |
+-------------------+--------------------------------------------------+
| > COMB            | 30% from 12-14-03                                |
+-------------------+--------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Rationale***: The shoulder and knee separately     |
|            | > meet compensable requirements under diagnostic codes  |
|            | > 5201 and 5260, respectively.                          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > ***Situation***: The veteran has X-ray evidence of    |
|  Example 2 | > degenerative arthritis of both knees without          |
|            |                                                         |
|            | -   limited or painful motion of any of the affected    |
|            |     joints, or                                          |
|            |                                                         |
|            | -   incapacitating episodes.                            |
+------------+---------------------------------------------------------+

+-------------------+--------------------------------------------------+
| ***Coded          |                                                  |
| Conclusion:***    |                                                  |
+-------------------+--------------------------------------------------+
| 1\. SC (PTE INC)  |                                                  |
+-------------------+--------------------------------------------------+
| 5003              | Degenerative arthritis of the knees, x-ray       |
|                   | evidence                                         |
+-------------------+--------------------------------------------------+
| > 10% from        |                                                  |
| > 12-30-01        |                                                  |
+-------------------+--------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Rationale***: There is no limited or painful       |
|            | > motion in either joint, but there is x-ray evidence   |
|            | > of arthritis in more than one joint to warrant a 10   |
|            | > percent evaluation under DC 5003.                     |
+------------+---------------------------------------------------------+

Continued on next page

8\. Exhibit 1: Examples of Rating Decisions for Limited Motion,
Continued

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: The veteran has X-ray evidence of    |
|  Example 3 | > degenerative arthritis of the right knee without      |
|            | > limited or painful motion.                            |
+------------+---------------------------------------------------------+

+-------------------+--------------------------------------------------+
| ***Coded          |                                                  |
| Conclusion:***    |                                                  |
+-------------------+--------------------------------------------------+
| 1\. SC (PTE INC)  |                                                  |
+-------------------+--------------------------------------------------+
| 5003              | Degenerative arthritis, right knee, x-ray        |
|                   | evidence only                                    |
+-------------------+--------------------------------------------------+
| > 0% from         |                                                  |
| > 12-30-01        |                                                  |
+-------------------+--------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Rationale***: There is no limited or painful       |
|            | > motion in the right knee or x-ray evidence of         |
|            | > arthritis in more than one joint to warrant a         |
|            | > compensable evaluation under DC 5003.                 |
+------------+---------------------------------------------------------+

#### 9. Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis

+------------+---------------------------------------------------------+
| ##### In   | > This exhibit contains eight examples of the proper    |
| troduction | > procedure for rating osteomyelitis.                   |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > ***Situation***: The veteran was diagnosed with       |
|  Example 1 | > osteomyelitis in service, with discharging sinus. At  |
|            | > separation from service the osteomyelitis was         |
|            | > inactive with no involucrum or sequestrum. There is   |
|            | > no evidence of recurrence.                            |
|            | >                                                       |
|            | > ***Result***: As there has been no recurrence of      |
|            | > active osteomyelitis following the initial episode in |
|            | > service, the historical evaluation of 20 percent is   |
|            | > not for application. The requirements for a 20        |
|            | > percent evaluation based on activity are not met      |
|            | > either.                                               |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia                      |
+--------------------+-------------------------------------------------+
| > 0% from 12-2-93  |                                                 |
+--------------------+-------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > ***Situation***: Same facts as in Example 1, but the  |
|  Example 2 | > veteran had a discharging sinus at the time of        |
|            | > separation from service.                              |
|            | >                                                       |
|            | > ***Result***: The veteran meets the criteria for a 20 |
|            | > percent evaluation based on a discharging sinus.      |
|            | > Schedule a future examination to ascertain the date   |
|            | > of inactivity.                                        |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, active              |
+--------------------+-------------------------------------------------+
| > 20% from 12-2-93 |                                                 |
+--------------------+-------------------------------------------------+

Continued on next page

9\. Exhibit 2: Examples of the Proper Rating Procedure for
Osteomyelitis, Continued

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: Same facts as in Example 2.          |
|  Example 3 | > Subsequent review examination reveals the sinus tract |
|            | > was healed and there is no other evidence of active   |
|            | > infection.                                            |
|            | >                                                       |
|            | > ***Result***: Since the veteran has not had a         |
|            | > recurrent episode of osteomyelitis since service, a   |
|            | > historical rating of 20 percent is not for            |
|            | > application. Take rating action under 38 CFR          |
|            | > 3.105(e).                                             |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, inactive            |
+--------------------+-------------------------------------------------+
| > 20% from 12-2-93 |                                                 |
+--------------------+-------------------------------------------------+
| 0% from 3-1-95     |                                                 |
+--------------------+-------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > ***Situation***: Same facts as in Example 2. The      |
|  Example 4 | > veteran is hospitalized July 2l, 1996, with active    |
|            | > osteomyelitis of the right tibia shown with           |
|            | > discharging sinus. There is no involucrum,            |
|            | > sequestrum, or constitutional symptom. Upon release   |
|            | > from the hospital the discharging sinus is still      |
|            | > present.                                              |
|            | >                                                       |
|            | > ***Result***: Assign the 20 percent evaluation based  |
|            | > on evidence showing draining sinus from the proper    |
|            | > effective date. Schedule a future examination to      |
|            | > ascertain date of inactivity.                         |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, active              |
+--------------------+-------------------------------------------------+
| > 0% from 3-1-95   |                                                 |
+--------------------+-------------------------------------------------+
| 20% from 7-21-96   |                                                 |
+--------------------+-------------------------------------------------+

Continued on next page

9\. Exhibit 2: Examples of the Proper Rating Procedure for
Osteomyelitis, Continued

+------------+---------------------------------------------------------+
| ##### e.   | > ***Situation***: Same facts as in Example 3. A        |
|  Example 5 | > routine future examination was conducted on July 8,   |
|            | > 1997, showing the osteomyelitis to be inactive. There |
|            | > was no discharging sinus, no involucrum, sequestrum,  |
|            | > or constitutional symptom. The most recent episode of |
|            | > active osteomyelitis (July 21, 1996) constitutes the  |
|            | > first "recurrent" episode of active osteomyelitis.    |
|            | >                                                       |
|            | > ***Result***: Continue the previously assigned 20     |
|            | > percent evaluation, which was granted on the basis of |
|            | > discharging sinus as a historical evaluation for 5    |
|            | > years from the examination showing inactivity.        |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, inactive            |
+--------------------+-------------------------------------------------+
| > 20% from 7-21-96 |                                                 |
+--------------------+-------------------------------------------------+
| 0% from 7-8-02     |                                                 |
+--------------------+-------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f.   | > ***Situation***: Same facts as in Example 4. In       |
|  Example 6 | > October 1999, the veteran was again found to have     |
|            | > active osteomyelitis with a discharging sinus,        |
|            | > without involucrum, sequestrum, or constitutional     |
|            | > symptoms.                                             |
|            | >                                                       |
|            | > ***Result***: Continue the 20 percent evaluation.     |
|            | > Rerating is necessary to remove the future reduction  |
|            | > to 0 percent, and to schedule a future examination to |
|            | > establish the date of inactivity.                     |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, active              |
+--------------------+-------------------------------------------------+
| > 20% from 7-21-96 |                                                 |
+--------------------+-------------------------------------------------+

Continued on next page

9\. Exhibit 2: Examples of the Proper Rating Procedure for
Osteomyelitis, Continued

+------------+---------------------------------------------------------+
| ##### g.   | > ***Situation***: Same facts as in Example 5. A review |
|  Example 7 | > examination was conducted on April 8, 2000. The       |
|            | > examination showed the discharging sinus was          |
|            | > inactive, and there was no other evidence of active   |
|            | > osteomyelitis. The most recent episode of             |
|            | > osteomyelitis (October 1999) constitutes the second   |
|            | > \"recurrent\" episode of active osteomyelitis.        |
|            | >                                                       |
|            | > ***Result***: The historical evaluations of 20 and 10 |
|            | > percent both apply.                                   |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| ***Coded           |                                                 |
| Conclusion:***     |                                                 |
+--------------------+-------------------------------------------------+
| 1\. SC (PTE INC)   |                                                 |
+--------------------+-------------------------------------------------+
| 5000               | Osteomyelitis, right tibia, inactive            |
+--------------------+-------------------------------------------------+
| > 20% from 7-21-96 |                                                 |
+--------------------+-------------------------------------------------+
| 10% from 4-8-05    |                                                 |
+--------------------+-------------------------------------------------+

Continued on next page

9\. Exhibit 2: Examples of the Proper Rating Procedure for
Osteomyelitis, Continued

+------------+---------------------------------------------------------+
| ##### h.   | > ***Situation***: Same facts as in Example 6. The      |
|  Example 8 | > veteran was hospitalized June 10, 2002, with a        |
|            | > recurrent episode of active osteomyelitis. A radical  |
|            | > resection of the right tibia was performed and at     |
|            | > hospital discharge (June 21, 2002), the osteomyelitis |
|            | > was shown to be cured.                                |
|            | >                                                       |
|            | > ***Result***: Assign a temporary total rating of 100  |
|            | > percent under paragraph 30 with a 1-month period of   |
|            | > convalescence. Following application of 38 CFR        |
|            | > 3.105(e), reduce the evaluation for osteomyelitis to  |
|            | > 0 percent as a rating for osteomyelitis will not be   |
|            | > applied following cure by removal or radical          |
|            | > resection of the affected bone.                       |
+------------+---------------------------------------------------------+

+----------------------------+-----------------------------------------+
| ***Coded Conclusion:***    |                                         |
+----------------------------+-----------------------------------------+
| 1\. SC (PTE INC)           |                                         |
+----------------------------+-----------------------------------------+
| 5000                       | Osteomyelitis, right tibia, P.O.        |
+----------------------------+-----------------------------------------+
| > 20% from 7-21-96         |                                         |
+----------------------------+-----------------------------------------+
| 100% from 6-10-02 (Par.    |                                         |
| 30)                        |                                         |
+----------------------------+-----------------------------------------+
| 20% from 8-1-02            |                                         |
+----------------------------+-----------------------------------------+
| 0% from 10-1-02            |                                         |
+----------------------------+-----------------------------------------+