multiple evaluations for musculoskeletal disability, see , and . h. Assessing Medical Evidence for Functional Loss Due to Pain Medical evidence used to evaluate functional impairment due to pain must account for painful motion, pain on use, and pain during flare-ups or with repeated use over a period of time. 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 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 due to pain. Only the most advantageous finding will be utilized to evaluate the joint condition.
2. Evaluating Musculoskeletal Disabilities of the Upper Extremities Introduction This topic contains information on evaluating musculoskeletal disabilities of the upper extremities, including considering separate evaluations for disabilities of the shoulder and arm example of separate evaluations for disabilities of the shoulder and arm assigning separate evaluations for disabilities of the elbow, forearm, and wrist example of separate evaluations for multiple disabilities of the elbow, forearm, and wrist considering impairment of supination and pronation of the forearm identifying digits of the hand, and rating Dupuytren’s contracture of the hand. Change Date January 11, 2016 a. Considering Separate Evaluations for Disabilities of the Shoulder and Arm Separate evaluations may be given for disabilities of the shoulder and arm under if the manifestations represent separate and distinct symptomatology that are neither duplicative nor overlapping. Reference: For additional information concerning separate and distinct symptomatology, refer to , and , 6 Vet.App. 259 (1994). b. Example of Separate Evaluations for Disabilities of the Shoulder and Arm Situation: A Veteran was involved in an automobile accident that resulted in multiple injuries to the upper extremities. The Veteran sustained the following injuries a humeral fracture resulting in restriction of arm motion at shoulder level, and a clavicular fracture resulting in malunion of the clavicle. Result: assign a 20-percent evaluation for the impairment of the humerus under , and assign a separate 10-percent evaluation for malunion of the clavicle under . Notes:
Rationale: There is no limited or painful motion in either joint, but there is evidence of arthritis in more than one joint to warrant a 10-percent evaluation under . c. Example of Degenerative Arthritis of a Single Joint Situation: The Veteran has x-ray evidence of degenerative arthritis of the knee without limited or painful motion. Coded Conclusion: 1. SC (PTE INC) 5003 Degenerative arthritis, 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 . d. Example of Degenerative Arthritis Evaluated Based on Evidence Only and Another Compensable Evaluation Situation: The Veteran has x-ray evidence of degenerative arthritis of both knees without limited or painful motion or incapacitating exacerbations. The Veteran also has residuals of degenerative arthritis with limitation of abduction of the right shoulder (major) to 90 degrees. Coded Conclusion: 1. SC (VE INC) 5003-5201 Degenerative arthritis, right shoulder (dominant) 20% from 12-14-03 5260 Degenerative arthritis, right knee 0% from 12-14-03 5260 Degenerative arthritis, left knee 0% from 12-14-03 COMB 20% from 12-14-03 Rationale: the shoulder condition meets compensable requirements under , each knee condition must be evaluated under separate DCs. Based on Note (1) under , ratings of arthritis based on x-ray findings only (without
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 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, 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: 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 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
explosive effect of high velocity missile, residuals of debridement, or prolonged infection Important: No single factor is controlling for the assignment of a disability evaluation for a muscle injury. The entire evidence picture must be taken into consideration. Reference: For more information on assigning disability evaluations for muscle injuries, see , 20 Vet.App. 317 (2006) , 5 Vet.App. 70 (1993) , 18 Vet.App. 248 (2004), and . 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 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 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?
b. SC for Osteopenia Osteopenia is clinically defined as mild bone density loss that is often associated with the normal aging process. Low bone density does not necessarily mean that an individual is losing bone, as this may be a normal variant. Osteopenia is comparable to a laboratory finding which is not subject to SC compensation. Use the following table to determine the appropriate action to take when SC for osteopenia has been granted. If ... Then ... SC for osteopenia was granted by rating decision prior to December 19, 2013 (the date on which guidance was issued to clarify the proper procedures for considering SC for osteopenia) do not sever SC, as it was properly established based on guidance available at the time the decision was made, do not reduce the previously assigned evaluation unless the condition has improved, and consider claims for increased evaluation and schedule examination as warranted based on the facts of the case. Note: Provisions of and regarding protection of SC remain applicable. SC for osteopenia was granted by rating decision dated on or after December 19, 2013 propose to sever SC based on a finding of clear and unmistakable error (CUE). Note: Osteoporosis, in contrast to osteopenia, is considered a disease entity characterized by severe bone loss that may interfere with mechanical support, structure, and function of the bone. SC for osteoporosis under is warranted when the requirements are otherwise met. c. Evaluating Fibromyalgia The criteria for evaluation of fibromyalgia under does not exclude assignment of separate evaluations when disabilities are diagnosed secondary to fibromyalgia. This includes, but is not limited to, disability diagnoses for which symptoms are included in the evaluation criteria under , such as depression anxiety headache, and irritable bowel syndrome. Notes: