As a part of the assessment conducted in accordance with , 8 Vet.App. 202 (1995), the medical evidence must 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 ROM. Per , 25 Vet.App. 32 (2011),when pain is associated with movement, an examiner must opine or the medical evidence must show whether pain could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time, and if there is functional impairment found during flare-ups or with repeated use over a period of time, the examiner must provide, if feasible, the degree of additional LOM due to pain on use or during flare-ups. Important: If the examiner is unable to provide any of the above findings, he or she must indicate that he/she cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss, and provide the rationale for this opinion. Note: Per , 23 Vet.App. 382 (2010), the VA may only accept a medical examiner’s conclusion that an opinion would be speculative if the examiner has explained the basis for such an opinion, identifying what facts cannot be determined, or the basis for the opinion is otherwise apparent in VA’s review of the evidence. Reference: For more information on evaluating functional impairment due to pain, see M21-1, Part III, Subpart iv, 4.A.1.g. i. Entering DeLuca and Mitchell Data in the Evaluation Builder The findings of DeLuca repetitive ROM testing or the functional loss expressed in the Mitchell opinion will be used to evaluate the functional impairment of a joint due to pain. Only the most advantageous finding will be utilized to evaluate the joint condition. Do not “add” the LOM on DeLuca exam to the LOM expressed in a Mitchell opinion. Note: For purposes of data entry in the Evaluation Builder tool, if evaluating a joint where data fields are present for only initial ROM and for DeLuca (but not for Mitchell), enter either the DeLuca or the Mitchell data in the DeLuca field, whichever results in the higher disability evaluation. Examples: For examples of how to evaluate functional loss due to pain, refer to M21-1, Part III, Subpart iv, 4.A.1.j-k.
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 has only two phalanges, the proximal phalanx and the distal phalanx. Therefore, each thumb 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. Designate either right or left for the digits of the hand. Note: If the location of the injury is unclear, obtain x-rays to clarify the exact point of injury. Reference: For more information on determining dominant handedness, refer to . g. Rating Dupuytren’s Contracture of the Hand The rating schedule for disabilities does not specifically list Dupuytren’s contracture as a disease entity; therefore, assign an evaluation on the basis of limitation of finger movement. 3. Evaluating Musculoskeletal Disabilities of the Spine and Lower Extremities Introduction This topic contains information on evaluating musculoskeletal disabilities of the spine and lower extremities, including evaluating manifestations of spine diseases and injuries definition of incapacitating episode of IVDS example of evaluating IVDS evaluating ankylosing spondylitis evaluating noncompensable knee conditions separate evaluations for knee instability and LOM separate evaluations – LOM and meniscus disabilities separate evaluations, knee instability and meniscus disabilities separate evaluations – genu recurvatum evaluating shin splint defining moderate and marked LOM of the ankle considering ankle instability evaluating plantar fasciitis, and identifying the digits of the foot.
Coded Conclusion: 1. SC (PTE INC) 5000 Osteomyelitis, right tibia 0% from 12-2-93 b. Example of Evaluating an Active Initial Episode of Osteomyelitis Situation: Same facts as example shown in M21-1, Part III, Subpart iv, 4.A.10.a, but the 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 c. Example of Evaluating Osteomyelitis Following Review Exam for Initial Active Episode Situation: Same facts as example shown in M21-1, Part III, Subpart iv, 4.A.10.b. 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 evaluation of 20 percent is not for application. Take rating action under . Coded Conclusion: 1. SC (PTE INC) 5000 Osteomyelitis, right tibia, inactive 20% from 12-2-93 0% from 3-1-95 d. Example of Evaluating Osteomyelitis With Current Discharging Sinus Situation: Same facts as example shown in M21-1, Part III, Subpart iv, 4.A.10.b. The 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
e. Fractures Associated With GSW/SFW All fractures associated with a GSW and/or shell fragment wound (SFW) will be considered open because all of them involve an opening to the outside. Most GSW/SFW fractures are also comminuted due to the shattering nature of the injury. f. Determining Whether 38 CFR 4.55 Applies to Muscle Injuries applies to certain combinations of muscle injuries and joint conditions. Consider the provisions of if there are multiple MGs involved the MG acts on a joint or joints, and/or there is peripheral nerve damage to the same body part affected by the muscle. g. Applying 38 CFR 4.55 to Muscle Injuries If more than one MG is injured or affected or if the injured MG acts on a joint, conduct a preliminary review of the evidence to gather information needed to properly apply the provisions of . The information needed will include whether the affected MGs are in the same or different anatomic regions whether the MGs are acting on a single joint or multiple joints, and whether the joint or joints is/are ankylosed. After the preliminary review is complete, use the evidence gathered and apply the following table to determine how affects the evaluation of the muscle injury. Step Action 1 Does the MG(s) act on an ankylosed joint? If yes, go to Step 2. If no, go to Step 4 2 For MG(s) that act on an ankylosed joint, is the joint an ankylosed knee and is MG XIII disabled? If yes, grant separate evaluations for the ankylosed knee and the MG XIII injury. For the MG XIII injury, assign the next lower level than that which would otherwise be assigned. Then go to Step 3. If no, then is the ankylosed joint the shoulder and are MGs I and II severely disabled? If yes, then assign a single evaluation for the muscle injury and the shoulder ankylosis under DC 5200. The evaluation will be at the level of unfavorable ankylosis. If no, then no evaluation will be assigned for the muscle injury. The combined disability arising from the ankylosis and the muscle injury will be evaluated as ankylosis.