ࡱ>   bjbj :0xxj # # # # ####8W#,$#umO)k/(///0&%1 11l,lllllloql #20022l # #//hm(';';';2 #/ #/kN';2l';';`tf/pTc#3Bd8nk9m<umzd0t88tpft #f91>w1,';1$1(919191ll:F919191um2222t919191919191919191 !: Section A. Musculoskeletal Conditions  PRIVATE INFOTYPE="OTHER" Overview In this SectionThis section contains the following topics: TopicTopic NameSee Page1General Information on Musculoskeletal Conditions4-A-22Nomenclature of Digits4-A-93Congenital Conditions4-A-114Rheumatoid Arthritis4-A-125Degenerative Arthritis4-A-176Limitation of Motion in Arthritis Cases4-A-197Osteomyelitis4-A-228Exhibit 1: Examples of Rating Decisions for Limited Motion4-A-249Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis4-A-26 1. General Information on Musculoskeletal Conditions  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on musculoskeletal 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 Dupuytrens contracture considering conflicting decisions regarding loss of use considering multiple limitation of motion evaluations for a joint pain and multiple limitation of motion evaluations for a joint example 1: compensable limitation of two joint motions example 2: compensable limitation of one motion with pain in another, and example 3: noncompensable limitation of two motions with pain. Change DateJune 5, 2012 PRIVATE INFOTYPE="PRINCIPLE"  a. Considering Impairment of Supination and PronationWhen preparing ratings involving impairment of pronation and supination, bear in mind the following facts: full pronation is the position of the hand flat on a table full supination is the position of the hand palm up, and when examining limitation of pronation, the arc is from full supination to full pronation, and middle of the arc is the position of the hand, palm vertical to the table. Assign the lowest 20 percent evaluation when pronation cannot be accomplished through more than the first three-quarters of the arc from full supination. Do not assign a compensable evaluation for both limitation of pronation and limitation of supination of the same extremity. Reference: For information on painful motion, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC" 38 CFR 4.59, and  HYPERLINK "pt03_sp04_ch04_secA" \l "III.iv.4.A.1.b" M21-1MR, Part III, Subpart iv, 4.A.1.b.Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="PRINCIPLE"  b. Considering Functional Loss Due to Pain in Evaluating Musculoskeletal ConditionsFunctional loss due to pain is a factor in the evaluation of musculoskeletal conditions under any diagnostic code (DC) that involves limitation of motion. It is the responsibility of the examining physician to assess how pain and other factors related to functional impairment equate to limitation of motion. The examiner should either 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, and provide the rationale for this opinion. 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 DC is based on limitation of motion. Per HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmj"Jones (M.) v. Shinseki, 23 Vet.App. 382 (2010), VA may only accept a medical examiners 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 VAs review of the evidence. References: For more information on functional loss, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_40.DOC"38 CFR 4.40  HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmd" DeLuca v. Brown, 8 Vet.App. 202 (1995) disability of the joints, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_45.DOC" 38 CFR 4.45, and painful motion, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC"38 CFR 4.59. PRIVATE INFOTYPE="PRINCIPLE"  c. When Functional Loss is Not Used to Evaluate Musculoskeletal ConditionsFunctional loss as discussed in  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_40.DOC" 38 CFR 4.40,  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_45.DOC" 38 CFR 4.45, and HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_59.DOC"38 CFR 4.59 is not used to evaluate musculoskeletal conditions that do not involve range of motion findings. Example: A rating under DC 5257 for lateral knee instability. Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="PRINCIPLE"  d. Evaluating Limitation of Motion Due to PainWhen evaluating limitation of motion due to pain, keep in mind that the limitation must at least meet the level of a noncompensable evaluation for the affected joint to 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 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 HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/98op/Prc09_98.doc"VAOPGCPREC 9-98 and HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/04op/pc0904.doc"VAOPGCPREC 9-2004.  PRIVATE INFOTYPE="PRINCIPLE"  e. Considering Dupuytrens ContractureIn the absence of an assigned evaluation for Dupuytrens contracture as a disease entity in the rating schedule, assign an evaluation on the basis of limitation of finger movement. PRIVATE INFOTYPE="PRINCIPLE"  f. Considering Conflicting Decisions Regarding Loss of UseForward the claims folder to the Director, Compensation and Pension (C&P) Service (211B), for an advisory opinion under  HYPERLINK "pt03_sp06_ch01_secA.xml" \l "III.vi.1.A.2.a" M21-1MR, Part III, Subpart vi, 1.A.2.a to resolve a conflict if 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.Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="PRINCIPLE"  g. Considering Multiple Limitation of Motion Evaluations for a Joint In  HYPERLINK "http://www.va.gov/ogc/docs/2004/PREC92004.doc" VAOPGCPREC 9-2004 Office of General Counsel held that separate evaluations under DC 5260 (limitation of knee flexion) and DC 5261 (limitation of knee extension) can be assigned without pyramiding. Despite the fact that knee flexion and extension both occur in the same plane of motion, limitation of flexion (bending the knee) and limitation of extension (straightening the knee) represent distinct disabilities. Important: The same principle and handling apply only to qualifying elbow movement diagnostic codes, flexion (DC 5206), extension (DC 5207), and impairment of either supination or pronation (DC 5213). qualifying hip movement diagnostic codes, extension (DC 5251), flexion (DC 5252), and abduction, adduction or rotation (DC 5253). Always ensure that multiple evaluations do not violate the amputation rule in  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_68.DOC" 38 CFR 4.68. References: for more information on pyramiding of evaluations, see  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_14.DOC" 38 CFR 4.14, and  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bme" Esteban v. Brown, 6 Vet.App. 259 (1994), for information on painful motion in multiple evaluations for joint limitation of motion, see  HYPERLINK "imi-internal:M21-1MRIII.iv.4.A.1.h" M21-1MR Part III, Subpart iv, 4.A.1.h, and for an example of actual limitation of motion of two knee motions, see HYPERLINK "imi-internal:M21-1MRIII.iv.4.A.1.i"M21-1MR Part III, Subpart iv, 4.A.1.i.Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="PRINCIPLE"  h. Pain and Multiple Limitation of Motion Evaluations for a JointBe aware of the following when considering the role of pain in evaluations for multiple motions of a single joint: When either of two qualifying joint motions is actually limited to a compensable degree and there is painful but otherwise noncompensable limitation of the complementary movement, only one compensable evaluation can be assigned.  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bmm" Mitchell v. Shinseki, 25 Vet. App. 32 (2011) reinforced that painful motion is the equivalent of limited motion only based on the specific language and structure of DC 5003, not for the purpose of DC 5260 and 5261. For arthritis, if one motion is actually compensable under its 52XX-series DC, then a 10 percent rating under DC 5003 is not available and the complementary motion cannot be treated as limited at the point where it is painful.  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_59.DOC" 38 CFR 4.59 does not permit separate compensable evaluations for each painful joint motion. It only provides that VA policy is to recognize actually painful motion as entitled to at least the minimum compensable rating for the joint. When each qualifying joint motion is painful but motion is not actually limited to a compensable degree under its applicable 52XX-series DC, only one compensable evaluation can be assigned. Assigning multiple compensable evaluations for pain is pyramiding. A joint affected by arthritis established by x-ray may be evaluated 10 percent disabling under DC 5003. For common joint conditions that are not rated under the arthritis criteria such as a knee strain or chondromalacia patella, a 10 percent evaluation can be assigned for the joint based on pain on motion under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_59.DOC"38 CFR 4.59. References: for more information on pyramiding of evaluations, see  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_14.DOC" 38 CFR 4.14, and  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bme" Esteban v. Brown, 6 Vet.App. 259 (1994) for more information on assigning multiple evaluations for a single joint, see  HYPERLINK "imi-internal:M21-1MRIII.iv.4.A.1.g" M21-1MR Part III, Subpart iv, 4.A.1.g, and for examples of rating where one or both joint motions are not actually limited to a compensable degree but there is painful motion, see  HYPERLINK "imi-internal:M21-1MRIII.iv.4.A.1.j" M21-1MR Part III, Subpart iv, 4.A.1.j and  HYPERLINK "imi-internal:M21-1MRIII.iv.4.A.1.k" M21-1MR Part III, Subpart iv, 4.A.1.k.Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="CONCEPT"  i. Example 1: Compensable Limitation of Two Joint MotionsSituation: Evaluation of chronic knee strain with the following examination findings: Flexion is limited to 45 degrees. Extension is limited by 10 degrees. There is no pain on motion. There is no additional limitation of flexion or extension on additional repetitions or during flare-ups. Result: Assign a 10 percent evaluation under DC 5260 and a separate 10 percent evaluation under DC 5261. Explanation: Each rating warrants a separate evaluation and the ratings are for distinct disability.  PRIVATE INFOTYPE="CONCEPT"  j. Example 2: Compensable Limitation of One Motion With Pain in AnotherSituation: Evaluation of knee tenosynovitis with the following examination findings: Flexion is limited to 45 degrees with pain at that point and no additional loss with repetitive motion. Extension is full to the 0 degree position, but active extension was limited by pain to 5 degrees. Result: Assign one 10 percent evaluation under DC 5260. Explanation: Flexion is compensable under DC 5260 but extension remains limited to a noncompensable degree under DC 5261. Under Mitchell, the painful extension could only considered limited for the purpose of whether a 10 percent evaluation can be assigned for the joint under DC 5003, which is not applicable in this example because a compensable evaluation was already assigned for flexion under DC 5260.  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_59.DOC" 38 CFR 4.59 does not support a separate compensable evaluation for painful extension. The regulation states that the intention of the rating schedule is to recognize actually painful joints due to healed injury as entitled to at least the minimum compensable rating for the joint, not for each painful movement. If the fact pattern involved chondromalacia patella or a knee strain rather than tenosynovitis the result would be the same. Continued on next page  STYLEREF "Map Title" 1. General Information on Musculoskeletal Conditions, Continued  PRIVATE INFOTYPE="CONCEPT"  k. Example 3: Noncompensable Limitation of Two Motions With PainSituation: Evaluation of knee arthritis shown on x-ray with the following examination findings: Flexion is limited to 135 degrees with pain at that point. Extension is full to the 0 degree position with pain at that point. There is no additional loss of flexion or extension on repetitive motion. Result: Assign one 10 percent evaluation for the knee under DC 5003. Explanation: There is limitation of major joint motion to a noncompensable degree under DC 5260 and 5261, x-ray evidence of arthritis and satisfactory evidence of painful motion. Painful motion is limited motion for the purpose of applying DC 5003. Therefore a 10 percent evaluation is warranted for the joint. Assigning two compensable evaluations, each for pain, would be pyramiding. Neither DC 5003 nor  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_59.DOC" 38 CFR 4.59 permit separate 10 percent evaluations for painful flexion and extension; they provide for a 10 percent rating for a joint. If the fact pattern involved chondromalacia patella or a knee strain rather than arthritis you would still assign a 10 percent evaluation, not separate evaluations. However the authority would be  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_59.DOC" 38 CFR 4.59 and you should use DC 5260 rather than DC 5003.  2. Nomenclature of Digits  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on the nomenclature of digits, including specifying injured digits and phalanges, and identifying the digits of the hand and foot. Change DateDecember 13, 2005 PRIVATE INFOTYPE="CONCEPT"  a. Specifying Injured Digits and PhalangesFollow the guidelines listed below to accurately specify the injured digits of the upper and lower extremities. Each digit, except the thumb and the great toe, includes three phalanges 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). 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.Continued on next page  STYLEREF "Map Title" 2. Nomenclature of Digits, Continued  PRIVATE INFOTYPE="CONCEPT"  b. Identifying the Digits of the Hand and FootUse the table below to correctly identify the digits of the hand and foot. Note: Designate either right or left for the digits of the hand or foot.  If the extremity is the Then identify the digit as the handthumb index long ring, or little. Note: Do not use numerical designations for either the fingers or joints of the fingers.footfirst or great toe second third fourth, or fifth. 3. Congenital Conditions  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on congenital conditions, including recognizing variations in development and appearance, and considering notable defects. Change DateDecember 13, 2005 PRIVATE INFOTYPE="CONCEPT"  a. Recognizing Variations in Development and AppearanceIndividuals vary greatly in their musculoskeletal development and appearance. Functional variations are often seen and can be attributed to the type of individual, and his/her inherited or congenital variations from the normal. PRIVATE INFOTYPE="PRINCIPLE"  b. Considering Notable Defects Give careful attention to congenital or developmental defects such as 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 HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_3.DOC"38 CFR 4.9. 4. Rheumatoid Arthritis  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about rheumatoid 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. Change DateDecember 29, 2007 PRIVATE INFOTYPE="CONCEPT"  a. Characteristics of Rheumatoid ArthritisThe following are characteristics of rheumatoid arthritis, also diagnosed as atrophic or infectious arthritis, or arthritis deformans: the onset occurs before middle age, and may be acute, with a febrile attack, and the symptoms include a usually laterally symmetrical limitation of movement 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.Continued on next page  STYLEREF "Map Title" 4. Rheumatoid Arthritis, Continued  PRIVATE INFOTYPE="CONCEPT"  b. Periods of Flares and Remissions in Rheumatoid ArthritisThe symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). 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. PRIVATE INFOTYPE="CONCEPT"  c. Clinical Signs of Rheumatoid ArthritisThe table below contains information about the clinical signs of rheumatoid arthritis. Stage of DiseaseSymptomsInitialperiarticular 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.Latedeformities and contractures subluxations, or fibrous or bony ankylosisContinued on next page  STYLEREF "Map Title" 4. Rheumatoid Arthritis, Continued  PRIVATE INFOTYPE="CONCEPT"  d. Radiologic Changes in Rheumatoid ArthritisThe table below contains information about the radiologic changes found in rheumatoid arthritis. Stage of DiseaseRadiologic ChangesEarlyslight 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.Latediminished density of bone shadow loss of bone substance or articular ends, and subluxation or ankylosis.Continued on next page  STYLEREF "Map Title" 4. Rheumatoid Arthritis, Continued  PRIVATE INFOTYPE="CONCEPT"  e. Disability Factors Associated With Rheumatoid ArthritisGive special attention to the following disability factors associated with rheumatoid arthritis in addition to, or in advance of, demonstrable x-ray changes: muscle spasms periarticular and articular soft tissue changes, such as synovial hypertrophy flexion contracture deformities joint effusion, and destruction of articular cartilage, and constitutional changes such as emaciation dryness of the eyes and mouth (Sjogrens 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  HYPERLINK "http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp" http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp.Continued on next page  STYLEREF "Map Title" 4. Rheumatoid Arthritis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  f. Points to Consider in the Rating DecisionIn the rating decision, note the presence of joints affected by any of the following: synovial hypertrophy or joint effusion 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  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about degenerative 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. Change DateDecember 13, 2005 PRIVATE INFOTYPE="CONCEPT"  a. Characteristics of Degenerative ArthritisThe following are characteristics of degenerative arthritis, also diagnosed as osteoarthritis or hypertrophic 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. PRIVATE INFOTYPE="CONCEPT"  b. Diagnostic Symptoms of Degenerative ArthritisDiagnostic symptoms of degenerative arthritis include the presence of Heberdens nodes or calcific deposits in the terminal joints of the fingers with deformity 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 styleref "Map Title"5. Degenerative Arthritis, Continued  PRIVATE INFOTYPE="CONCEPT"  c. Radiologic Changes in Degenerative ArthritisThe table below contains information about the radiologic changes found in degenerative arthritis. StageRadiologic ChangesEarlydelicate spicules of calcium at the articular margins without diminished density of bone shadow, and increased density of articular of parts.Lateridging of articular margins hyperostosis irregular, notched articular surfaces, and ankylosis only in the spine. PRIVATE INFOTYPE="CONCEPT"  d. Symptoms of Degenerative Arthritis of the SpineDegenerative arthritis of the spine and pelvic joints is characterized clinically by the same general characteristics as arthritis of the major joints except that 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.  PRIVATE INFOTYPE="PRINCIPLE"  e. Points to Consider in the Rating DecisionDegenerative and traumatic arthritis require x-ray evidence of bone changes to substantiate the diagnosis. Reference: For more information on considering x-ray evidence when evaluating arthritis, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_71a.DOC"38 CFR 4.71a, DC 5003. 6. Limitation of Motion in Arthritis Cases  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on limitation of motion due to arthritis, including conditions compensable under other diagnostic codes conditions not compensable under other diagnostic codes reference for rating decisions involving limitation of motion arthritis previously rated as a single disability using DCs 5013 through 5024 in rating decisions, and considering the effects of a change of diagnosis in arthritis cases. Change DateDecember 13, 2005 PRIVATE INFOTYPE="PRINCIPLE"  a. Conditions Compensable Under Other Diagnostic CodesFor a joint or group of joints affected by degenerative arthritis, use the diagnostic code which justifies the assigned evaluation. Example: When the compensable requirements for 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. PRIVATE INFOTYPE="PRINCIPLE"  b. Conditions Not Compensable Under Other Diagnostic CodesWhenever limited motion is noncompensable under codes appropriate to a particular joint, assign 10 percent under 5003 for each major joint or group of minor joints affected by limited or painful motion as prescribed under DC 5003. 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 HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_25.DOC"38 CFR 4.25 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 styleref "Map Title"6. Limitation of Motion in Arthritis Cases, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Reference: Rating Decisions Involving Limitation of MotionFor more information on rating decisions involving limitation of motion, see  HYPERLINK "pt03_sp04_ch04_secA.xml" \l "III.iv.4.A.8" M21-1MR, Part III, Subpart iv, 4.A.8. PRIVATE INFOTYPE="PRINCIPLE"  d. Arthritis Previously Rated as a Single DisabilityThe RVSR may encounter cases where arthritis of multiple joints is rated as a single disability. Use the information in the table below to handle cases where arthritis was previously rated as a single disability. If Then the separate evaluation of the arthritic disability results in no change in the combined degree previously assigned, and a rating is requiredrerate using the current procedure with the same effective date as previously assigned.rerating the arthritic joint separately results in an increased combined evaluationapply  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_105.DOC" 38 CFR 3.105(a) to retroactively increase the assigned evaluation.rerating the arthritic joint separately results in a reduced combined evaluationrequest an examination, and if still appropriate, propose reduction under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_105.DOC" 38 CFR 3.105(a) and  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_105.DOC" 38 CFR 3.105(e). Exception: Do not apply  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_105.DOC" 38 CFR 3.105(a) if the assigned percentage is protected under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_950.DOC" 38 CFR 3.951. Reference: For more information on protected ratings, see  HYPERLINK "pt03_sp04_ch08_secC.xml" \l "III.iv.8.C" M21-1MR, Part III, Subpart iv, 8.C.Continued on next page styleref "Map Title"6. Limitation of Motion in Arthritis Cases, Continued  PRIVATE INFOTYPE="PRINCIPLE"  e. Using DCs 5013 Through 5024 in Rating DecisionsUse the table below to rate cases that use DCs 5013 through 5024. If the DC of the case is Then gout under DC 5017rate the case as rheumatoid arthritis, 5002.5013 through 5016, and 5018 through 5024evaluate the case according to the criteria for limited motion or painful motion under DC 5003, degenerative 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 HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_71a.DOC"38 CFR 4.71a, DC 5003, Note (2). PRIVATE INFOTYPE="PRINCIPLE"  f. Considering the Effects of a Change in Diagnosis in Arthritis Cases A change of diagnosis among the various types of arthritis, particularly if joint disease has been recognized as service-connected for several years, has no significant bearing on the question of service connection. Note: In older individuals, the effects of more that one type of joint disease may coexist. Reference: For information on rating rheumatoid arthritis, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_71a.DOC" 38 CFR 4.71a, DC 5002, Arthritis rheumatoid. 7. Osteomyelitis  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about osteomyelitis, including requiring constitutional symptoms historical ratings assigning historical ratings, and the reasons to discontinue a historical rating. Change DateDecember 13, 2005 PRIVATE INFOTYPE="PRINCIPLE"  a. Requiring Constitutional SymptomsConstitutional symptoms are a prerequisite to the assignment of either the 100 percent or 60 percent evaluations under DC 5000. 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  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_68.DOC" 38 CFR 4.68. PRIVATE INFOTYPE="PRINCIPLE"  b. Historical RatingsBoth the 10 percent evaluation and that part of the 20 percent evaluation that is based on other 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 styleref "Map Title"7. Osteomyelitis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Assigning Historical RatingsAn initial episode of active osteomyelitis is not a basis for either of the historical ratings. Assign the historical rating as follows: When the first recurrent episode of osteomyelitis is shown assign a 20 percent historical evaluation, and extend the evaluation for five years from the date of examination showing the osteomyelitis to be inactive. 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. PRIVATE INFOTYPE="PRINCIPLE"  d. Reasons to Discontinue Historical RatingsDo not discontinue the historical rating, even if treatment includes saucerization, sequestrectomy, or guttering, because the osteomelitis is not considered cured. 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  PRIVATE INFOTYPE="OTHER"  IntroductionThis exhibit contains three examples of ratings for limited motion in arthritis cases. Change DateDecember 13, 2005 PRIVATE INFOTYPE="PRINCIPLE"  a. Example 1Situation: The Veteran has residuals of 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)5003-5201Degenerative arthritis, right shoulder (dominant)20% from 12-14-035260Degenerative arthritis, right knee10% from 12-14-03COMB30% from 12-14-03 Rationale: The shoulder and knee separately meet compensable requirements under diagnostic codes 5201 and 5260, respectively. PRIVATE INFOTYPE="PRINCIPLE"  b. Example 2Situation: The Veteran has X-ray evidence of 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)5003Degenerative arthritis of the knees, x-ray evidence10% 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  STYLEREF "Map Title" 8. Exhibit 1: Examples of Rating Decisions for Limited Motion, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Example 3Situation: The Veteran has X-ray evidence of degenerative arthritis of the right knee without limited or painful motion. Coded Conclusion:1. SC (PTE INC)5003Degenerative arthritis, right knee, x-ray evidence only0% 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  PRIVATE INFOTYPE="OTHER"  IntroductionThis exhibit contains eight examples of the proper procedure for rating osteomyelitis. Change DateDecember 13, 2005 PRIVATE INFOTYPE="PRINCIPLE"  a. Example 1Situation: The Veteran was diagnosed with 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)5000Osteomyelitis, right tibia0% from 12-2-93 PRIVATE INFOTYPE="PRINCIPLE"  b. Example 2Situation: Same facts as in Example 1, 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)5000Osteomyelitis, right tibia, active20% from 12-2-93Continued on next page  STYLEREF "Map Title" 9. Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Example 3Situation: Same facts as in Example 2. 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)5000Osteomyelitis, right tibia, inactive20% from 12-2-930% from 3-1-95 PRIVATE INFOTYPE="PRINCIPLE"  d. Example 4Situation: Same facts as in Example 2. 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)5000Osteomyelitis, right tibia, active0% from 3-1-9520% from 7-21-96Continued on next page  STYLEREF "Map Title" 9. Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  e. Example 5Situation: Same facts as in Example 3. A 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)5000Osteomyelitis, right tibia, inactive20% from 7-21-960% from 7-8-02 PRIVATE INFOTYPE="PRINCIPLE"  f. Example 6Situation: Same facts as in Example 4. In 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)5000Osteomyelitis, right tibia, active20% from 7-21-96Continued on next page  STYLEREF "Map Title" 9. Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  g. Example 7Situation: Same facts as in Example 5. A review 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)5000Osteomyelitis, right tibia, inactive20% from 7-21-9610% from 4-8-05 Continued on next page  STYLEREF "Map Title" 9. Exhibit 2: Examples of the Proper Rating Procedure for Osteomyelitis, Continued  PRIVATE INFOTYPE="PRINCIPLE"  h. Example 8Situation: Same facts as in Example 6. The 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 CF R 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)5000Osteomyelitis, right tibia, P.O.20% from 7-21-96100% from 6-10-02 (Par. 30)20% from 8-1-020% from 10-1-02 ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT  ADDIN \* MERGEFORMAT      M21-1MR, Part III, Subpart iv, Chapter 4, Section A M21-1MR, Part III, Subpart iv, Chapter 4, Section A 4-A- PAGE 8 4-A- PAGE 7 '(BC  < > ^ _ > ? y z   ! @ B N + 0 4 ? 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