--- title: "Part V, Subpart iii, Chapter 1, Section A Painful Motion and Functional Loss" document: "M-21-1" section: "Part V, Subpart iii, Chapter 1, Section A" canonical: "https://veteranai.co/va-regulations/m21-1/v.iii.1.a-painful-motion-and-functional-loss" source: "https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000014407/M21-1-Part-V-Subpart-iii-Chapter-1-Section-A-Painful-Motion-and-Functional-Loss" updated: "2026-09-06T14:36:52.714755Z" --- March 25, 2026 ### V.iii.1.A.2.a. Painful Motion of the Shoulder The following examples demonstrate the proper procedures for considering [38 CFR 4.59]() when evaluating shoulder disabilities.**Example 1:** Assume a shoulder strain with forward elevation and abduction limited to 145 degrees with credible evidence of pain while performing each motion, starting at 140 degrees. Assign a 20-percent evaluation under [38 CFR 4.71a, DC 5201](). Under [38 CFR 4.59]() there is actually painful motion and joint or periarticular pathology (a strain). Therefore, the intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for shoulder motion under the DC is 20 percent. **Example 2:** Assume the same facts as in Example 1 but the diagnosis is traumatic arthritis of the shoulder based on x-rays. Assign a 20-percent evaluation under [38 CFR 4.71a, DC 5010-5201]() with application of [38 CFR 4.59](). The ROM does not meet the criteria for a 20-percent evaluation under [38 CFR 4.71a, DC 5201]() because arm motion is not limited at shoulder height. However, pursuant to [38 CFR 4.59]() there is actually painful motion and joint or periarticular pathology (arthritis). Therefore, the intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for shoulder motion under [38 CFR 4.71a, DC 5201]() is 20 percent. **Example 3:** Assume the same facts as in Example 2 except that there was no pain on motion and the arthritis is degenerative rather than traumatic. There was a minor amount of swelling of the shoulder. Assign a 10-percent evaluation under [38 CFR 4.71a, DC 5003](). There is x-ray evidence of degenerative arthritis and motion that is noncompensable under the applicable DC. There is no indication of painful motion, so [38 CFR 4.59]() is not applicable. Under [38 CFR 4.71a, DC 5003](), LOM must be “objectively confirmed” by findings such as swelling, spasm, or satisfactory evidence of painful motion. In this case there was objective evidence supporting the LOM – namely the minor swelling of the shoulder. ### V.iii.1.A.2.b. Non-Objective Pain Under 38 CFR 4.59 ** _Example 1_** : On examination, a claimant reports current symptoms of regular pain of the right knee (particularly when fully straightening the knee) that is worsened with increased activity. The examiner finds normal ROM without pain on examination. Repetitive motion testing produces no evidence of pain or loss of motion. The assessment is right knee strain. Assign a 10-percent evaluation under [38 CFR 4.71a, DC 5261](). The claimant’s reports of joint pain are found to be credible. There is no basis to reject the complaints of pain as lacking in credibility. [38 CFR 4.59]() does not require objective evidence of painful motion. The claimant’s statement establishes that there is actually painful motion of the joint, even though it was not objectively verified on VA examination. **Example 2:** On examination, a claimant reports constant pain of the left elbow (particularly when bending the arm). The examiner finds normal ROM without pain on examination. Repetitive motion testing produces no evidence of pain or loss of motion. There is no swelling or spasm. The assessment is degenerative arthritis of the left elbow corroborated by x-rays. Assign a 10-percent evaluation under [38 CFR 4.71a, DC 5003-5206](). The claimant’s reports of joint pain are found to be credible. There is no basis to reject the complaints of pain as lacking in credibility. Although [38 CFR 4.71a, DC 5003]() requires noncompensable LOM and objective confirmation of LOM by spasm, swelling, or satisfactory evidence of painful motion, [38 CFR 4.59]() provides an alternative basis for a compensable evaluation and does not require objective evidence of painful motion. The claimant’s statement establishes that there is actually painful motion of the joint, even though pain was not objectively verified on VA examination. **Example 3:** Start with the same facts as Example 2. However, in this example, claimant reports significant pain on elbow motion consistently for the last year and particularly in the last week. However, treatment records from the past year show normal, painless range of elbow motion and no history of pain at rest, or on motion. Notably, in a VA outpatient report from two days before the VA examination, the claimant told the treating doctor that the elbow was not painful and had not been painful at all in the last year. Continue the 0-percent evaluation. Review of all the evidence satisfactorily demonstrates that the complaints of painful motion were not credible. Elbow motion is not found to be actually painful. ### V.iii.1.A.2.c. Pain With Passive ROM Under 38 CFR 4.59 Service connection (SC) is established for left rotator cuff impingement. The Veteran reports shoulder pain when lifting the left arm – particularly with repetitive motion of the arm at or above shoulder height. The Veteran reported a feeling of weakness with repeated over the head motions like painting. On examination, the Veteran had full active forward elevation, abduction, and external and internal rotation of the shoulder including on repeated motion. There was no report of pain with active motion. Passive ROM testing for impingement including the Hawkin’s Sign was positive and reproduced impingement with the guided movements at shoulder height. Assign a 20-percent evaluation under [38 CFR 4.71a, DC 5201](). The Hawkin’s Sign is a test for pain on passive ROM. Under [38 CFR 4.59]() the shoulder is actually painful to passive ROM and there is joint or periarticular pathology (rotator cuff impingement). The intention of the rating schedule is that the decision maker will assign the minimum compensable evaluation provided under the DC appropriate to the disability at issue. The lowest specified compensable evaluation for limited ROM of the shoulder under the DC is 20 percent. **Note:** [Medical Electronic Performance Support System (EPSS)]() provides that a rotator cuff tear should be rated by analogy to [38 CFR 4.71a, DC 5203]() (clavicle or scapula, impingement of) because the rotator cuff holds the humeral head in the glenoid fossa of the scapula and consists of the muscles around the scapula. However, [38 CFR 4.71a, DC 5203]() in turn provides that rather than rating impairment of the scapula by dislocation, nonunion, or malunion it may also be rated “on impairment of function of the contiguous joint.” [Medical EPSS]() notes that rotator cuff impingement is characterized by pain and weakness with motions at or above shoulder height and advises that there may be LOM of the arm for the purposes of [38 CFR 4.71a, DC 5201]() in cases of rotator cuff disease. ### V.iii.1.A.2.d. Painful Motion of Minor Joints ** _Example 1_** : Hallux valgus with painful motion of the first toe is most appropriately evaluated under [38 CFR 4.71a, DC 5280](). The minimum compensable evaluation for this DC is 10 percent. Therefore, a 10-percent evaluation is warranted for painful motion of the first toe. This is applicable only when the disability evaluated is hallux valgus or another disability warranting analogous evaluation under this DC. **Example 2:** Residuals of fracture of the little finger with painful motion is most appropriately evaluated under [38 CFR 4.71a, DC 5230](). The only possible evaluation under this DC is a 0 percent. Therefore, a compensable evaluation cannot be assigned for painful motion of the little finger. **Example 3:** Painful motion due to fracture of the index or long finger is most appropriately evaluated under [38 CFR 4.71a, DC 5229](). The minimum compensable evaluation for this DC is 10 percent. Therefore, a 10-percent evaluation is available for painful motion of the index finger and an additional 10-percent evaluation is warranted for painful motion of the long finger, each under [38 CFR 4.71a, DC 5229](). ### V.iii.1.A.2.e. Painful Motion Associated With Flatfoot ** _Situation_** : SC is warranted for flat feet under [38 CFR 4.71a, DC 5276](). The clinical evidence shows complete relief of symptoms, including foot pain, with arch supports. However, the record also contains credible lay reports of pain. **Outcome:** Although no more than a 0-percent evaluation is warranted under [38 CFR 4.71a, DC 5276]() on the basis of complete symptom relief due to an orthotic device, application of [38 CFR 4.59]() warrants assignment of a 10-percent evaluation. **Rationale:** * Subjective, credible reports of painful motion trigger application of [38 CFR 4.59]() pursuant to the _Petitti_ holding. * The criteria for assignment of the minimum compensable evaluation under [38 CFR 4.59]() are entirely independent of the criteria for evaluation under the DC. Thus, the relief of symptoms of pain is immaterial to assignment of the minimum compensable evaluation for painful motion under [38 CFR 4.59]() for pes planus or other analogously rated disabilities. * Additionally, the _Southall-Norman_ holding requires VA to apply [38 CFR 4.59]() to all musculoskeletal codes involving joint or periarticular pathology to include even those, such as [38 CFR 4.71a, DC 5276](), that do not specifically consider LOM. **Note:** The minimum compensable evaluation under [38 CFR 4.71a, DC 5276]() is a single 10 percent whether for unilateral or bilateral pes planus. Accordingly, assignment of a single 10-percent evaluation for painful motion due to pes planus is warranted per [38 CFR 4.59]() regardless of whether the painful motion is unilateral or bilateral. ### V.iii.1.A.2.f. Painful Motion Associated With Shin Splints ** _Situation_** : A Veteran has SC bilateral shin splints that have not required treatment, but which result in painful motion in both ankles. The Veteran is also SC for right ankle arthritis, currently evaluated as 10-percent disabling based on painful motion under [38 CFR 4.71a, DC 5271](). **Outcome:** Assign a compensable evaluation under [38 CFR 4.71a, DC 5262](), for bilateral shin splints based on the painful motion of the left ankle. **Rationale:** Even though the Veteran is receiving a compensable evaluation for painful motion of the right ankle under 38 CFR 4.59, the shin splints are also causing painful motion in the left ankle that is not being separately compensated.**Reference:** For more information on evaluating shin splints, see [M21-1, Part V, Subpart iii, 1.B.3.h and i](). ## 3. Principles for Evaluating Joint Conditions and Functional Loss This topic contains information on evaluating joint conditions and functional loss, including * use of the terms major and minor * importance of accurate measurements in joint cases * assigning * multiple LOM evaluations for a joint, and * a separate noncompensable evaluation when schedular 0-percent criteria are not specified * considering pain when assigning multiple LOM evaluations for a joint * ankylosis of the joints * functional equivalence of ankylosis * joint replacement and resurfacing * evaluating * joint replacement and resurfacing, and * residuals of joint resurfacing * partial knee replacement regulatory history * severe painful motion following joint replacement, and * use of active ROM findings. March 25, 2026 ### V.iii.1.A.3.a. Use of the Terms Major and Minor The use of the terms major and minor joint in [38 CFR 4.45(f)]() applies solely to the evaluation of joint conditions affected by arthritis as discussed in [_Spicer v. Shinseki_](), 752 F.3d 1367 (2014). These terms are applicable when evaluating any form of arthritis using the evaluation criteria at [38 CFR 4.71a, DC 5003](). Refer to the table below for more information on the use of the terms major and minor in joint evaluations.| **Type of Joint**| **Specific Joints Included** major| * shoulder * elbow * wrist * hip * knee, or * ankle minor| * interphalangeal joint (of the hand or foot) * a metacarpal joint (hand) * a metatarsal joint (foot) * a carpal joint (hand) * a tarsal joint (foot) * cervical vertebrae * dorsal vertebrae * lumbar vertebrae * the lumbosacral articulation, or * a sacroiliac joint minor joint group| * multiple involvements of the interphalangeal, metacarpal, and carpal joints of the same upper extremity, namely, combinations of * distal interphalangeal (DIP) joints * proximal interphalangeal (PIP) joints * metacarpophalangeal (MCP) joints, and/or * carpometacarpal (CMC) joints * multiple involvements of the interphalangeal, metatarsal, and tarsal joints of the same lower extremity, namely, combinations of * interphalangeal (IP) joints * metatarsophalangeal (MTP) joints, and/or * transverse tarsal joints * the cervical vertebrae * the dorsal (thoracic) vertebrae * the lumbar vertebrae, or * the lumbosacral articulation together with both sacroiliac joints ** _References_** : For more information on * considering minor joints under [38 CFR 4.59](), see M21-1, Part V, Subpart iii, 1.A.1.l * evaluations for the fingers, see [M21-1, Part V, Subpart iii, 1.B.2]() * evaluating arthritis of the minor joints of the toes, see [M21-1, Part V, Subpart iii, 1.B.5.d](), and * arthritis where a compensable evaluation cannot be assigned under another DC, see [M21-1, Part V, Subpart iii, 1.C.5.b and c](). ### V.iii.1.A.3.b. Importance of Accurate Measurements in Joint Cases Accurate measurements are very important in joint cases. VA examinations must measure joint motion with a goniometer. A number of disability benefits questionnaires (DBQ) relating to joints require use of a goniometer. **Important:** There is a presumption that examiners will conduct examinations in line with examination standards. Accordingly, treat measurements on examinations that require a goniometer as having been taken using the device unless there is clear evidence that a goniometer was not used. Do not seek clarification of DBQs requiring goniometer use, or return the examination as insufficient, merely because the report does not explicitly refer to goniometer use.**References:** For more information on * the importance of accurate measurement of joints, see [38 CFR 4.46](), and * determining the sufficiency of examinations, see [M21-1, Part IV, Subpart i, 3.A](). ### V.iii.1.A.3.c. Assigning Multiple LOM Evaluations for a Joint In [VAOPGCPREC 9-2004](), the Office of General Counsel held that separate evaluations under [38 CFR 4.71a, DC 5260](), (limitation of knee flexion) and [38 CFR 4.71a, 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 and forearm movement DCs, flexion ([38 CFR 4.71a, DC 5206]()), extension ([38 CFR 4.71a, DC 5207]()), and impairment of either supination or pronation ([38 CFR 4.71a, DC 5213]()), and * qualifying hip movement DCs, extension ([38 CFR 4.71a, DC 5251]()), flexion ([38 CFR 4.71a, DC 5252]()), and abduction, adduction or rotation ([38 CFR 4.71a, DC 5253]()). * Always ensure that multiple evaluations do not violate the amputation rule in [38 CFR 4.68](). **Note:** Multiple evaluations for the shoulder under [38 CFR 4.71a, DC 5201]() _,_ are not permitted. _[Yonek v. Shinseki]()_ , 722 F.3d 1355 (Fed. Cir. 2013), held that a Veteran is entitled to a single rating under [38 CFR 4.71a, DC 5201]() _,_ even though a shoulder disability results in LOM in both flexion (raising the arm in front of the body) and abduction (raising the arm away from the side of the body).**References:** For more information on * pyramiding of evaluations, see * [38 CFR 4.14](), and * [ _Esteban v. Brown_]() , 6 Vet.App. 259 (1994) * painful motion in multiple evaluations for joint LOM, see M21-1, Part V, Subpart iii, 1.A.3.e * assignment of separate evaluations for disabilities of the elbow, forearm, and wrist, see [M21-1, Part V, Subpart iii, 1.B.1.c](), and * examples of actual LOM of two knee motions, see M21-1, Part V, Subpart iii, 1.A.4.a. ### V.iii.1.A.3.d. Assigning a Separate Noncompensable Evaluation When Schedular 0-Percent Criteria Are Not Specified When considering a separate evaluation for a motion of a joint specified in M21-1, Part V, Subpart iii, 1.A.3.c, where 0-percent evaluation criteria are not provided by the DC, _any_ LOM for that specific movement falling short of criteria for a compensable level of evaluation will be assigned a separate 0-percent evaluation. [38 CFR 4.31]() provides that in every instance where the schedule does not provide a 0-percent evaluation for a DC, a 0-percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. The motions include * [38 CFR 4.71a, DC 5207](), limitation of extension of the elbow * [38 CFR 4.71a, DC 5213](), impairment of supination and pronation of the forearm * [38 CFR 4.71a, DC 5251](), limitation of extension of the hip * [38 CFR 4.71a, DC 5252](), limitation of flexion of the hip, and * [38 CFR 4.71a, DC 5253](), impairment of rotation, adduction, or abduction of the hip. **Example:** Examination shows flexion of the hip limited to 60 degrees and extension limited to 5 degrees. Normal hip ROM is from 0 degrees (fully extended) to 125 degrees (fully flexed). The limitation of extension to 5 degrees is rated 10 percent under [38 CFR 4.71a, DC 5251](). [38 CFR 4.71a, DC 5252]() (limitation of flexion) does not list criteria for a 0-percent evaluation, but a 10-percent evaluation requires flexion limited to 45 degrees. Because there is limited flexion not meeting the 10-percent criteria and there is no defined schedular 0-percent evaluation criteria, a 0-percent evaluation is warranted for limited flexion of the hip under [38 CFR 4.71a, DC 5252](). ### V.iii.1.A.3.e. Considering Pain When Assigning Multiple LOM Evaluations for a Joint When considering the role of pain in evaluations for multiple motions of a single joint, the following guidelines apply. * When more than one qualifying joint motion is actually limited to a compensable degree and there is painful but otherwise noncompensable limitation of the complementary movement(s), **_only one compensable evaluation can be assigned_**. * [_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 [38 CFR 4.71a, DC 5003](), not for the purpose of [38 CFR 4.71a, DC 5260](), and [38 CFR 4.71a, 5261](). For degenerative arthritis, if one motion is actually compensable under its 52XX-series DC, then a 10-percent evaluation under [38 CFR 4.71a, DC 5003]() is not available and the complementary motion cannot be treated as limited at the point where it is painful. * [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 evaluation 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, excluding post-traumatic arthritis, established by x-ray may be evaluated as 10-percent disabling under [38 CFR 4.71a, DC 5003](). * For common joint conditions that are not evaluated under the degenerative 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 [38 CFR 4.59](). Do not apply instructions from Note (1) under [38 CFR 4.71a, DC 5003](), for non- degenerative arthritis conditions, since the instructions are strictly limited to degenerative arthritis. See an example in M21-1, Part V, Subpart iii, 1.A.4.f. **References:** For more information on * assigning multiple evaluations for a single joint, see M21-1, Part V, Subpart iii, 1.A.3.c, and * examples of evaluations for which one or both joint motions are not actually limited to a compensable degree but there is painful motion, see M21-1, Part V, Subpart iii, 1.A.4.b and c. ### V.iii.1.A.3.f. Ankylosis of the Joints ** _Ankylosis_** is a condition of, or term used for the sign/symptom of, abnormal stiffness, immobility, or abnormal bending of a joint. It is a stiffness or immobility in a joint caused by bones fusing as a result of disease or injury or by intentional fusion through surgery. **_Favorable ankyloses_** is fixation of a joint in a neutral position (at 0 degrees). **_Unfavorable ankyloses_** is fixation of a joint in flexion or extension that results in significant functional impairment. **Reference:** For more information on spinal ankylosis, see the General Rating Formula for Diseases and Injuries of the Spine at [38 CFR 4.71a (affiliated with DCs 5235-5243)](), Notes 5 and 6. ### V.iii.1.A.3.g. Functional Equivalence of Ankylosis [38 CFR 4.40]() and [4.45]() apply when considering whether LOM results in the functional equivalence of ankylosis of the joint. The functional equivalence of ankylosis arises when application of theeffect of pain or other factors identified under [38 CFR 4.40]() or [4.45](), to include during flare-ups and repetitive use over time, results in additional loss of motion to the joint that effectively results in functional impairment consistent with ankylosis. **Reference:** For more information on the functional equivalence of ankylosis, see [_Chavis v. McDonough_](), 34 Vet.App. 1 (2021). ### V.iii.1.A.3.h. Joint Replacement and Resurfacing Joint replacement and resurfacing are evaluated under [38 CFR 4.71a, DCs 5051-5056](). * There are important similarities between joint resurfacing and prosthetic joint replacement. Joint resurfacing takes about the same time to perform and the recovery/rehabilitation periods are similar to comparable prosthetic joint replacement. * There are significant differences with joint resurfacing that lead to less residual disability. These differences include the following factors: * Joint resurfacing preserves more of the original anatomy. * In most cases, joint resurfacing restores more of the original joint function than the prosthetic joint replacement. _**Reference**_ : For more information on evaluating residuals of joint resurfacing, see M21-1, Part V, Subpart iii, 1.A.3.j. ### V.iii.1.A.3.i. Evaluating Joint Replacement and Resurfacing Refer to the table below for a comparison of policies and procedures applicable to evaluating joint replacements and resurfacing.| **Policy/Procedure**| **Replacement**| **Resurfacing** applicable joints| * shoulder * elbow * wrist * hip * knee, and * ankle * hip, and * knee length of temporary total evaluation| * one month under [38 CFR 4.30](), then * four months for knee or hip, and * 12 months for other joints * one month under [38 CFR 4.30](), then * four months for knee or hip evaluation following temporary 100 percent| * provided by the rating schedule under the joint replacement/resurfacing DC, or * evaluated based on residuals under the DCs applicable for the joint * ** _not_** provided by the rating schedule under the joint replacement/resurfacing DC, but * evaluated based on residuals under the DCs applicable for the joint review examination following temporary 100 percent| not routinely warranted| routinely warranted separate evaluations for the same joint under [38 CFR 4.71a]()| cannot be assigned during the temporary 100 percent or when the residuals are evaluated under a DC for joint replacement| * cannot be assigned during the temporary 100 percent, but * can be assigned after cessation of the evaluation assigned under the joint resurfacing code separate evaluations for residuals not evaluated under [38 CFR 4.71a]()| can be assigned| can be assigned ** _Note_** : Follow applicable due process and protected evaluation procedures when the combined evaluation for the joint is greater pre-surgically than it will be following surgery. **References:** For more information on * determining the effective date for the one-month temporary total evaluation for convalescence following a joint replacement or resurfacing under [38 CFR 4.30](), see * [M21-1, Part VIII, Subpart iv, 8.C.3.a]() * the [_Convalescence Effective Date Job Aid_]() * DCs such as [38 CFR 4.71a, DC 5051-5056](), that provide for definite periods of schedular temporary total evaluation, see [M21-1, Part VIII, Subpart iv, 8.D.1]() * due process issues pertinent to joint replacement or resurfacing including * change of DC for a protected disability evaluation or rating schedule changes, see * [38 CFR 3.951]() * [M21-1, Part X, Subpart ii, 1.B.1.k](), and * [M21-1, Part X, Subpart ii, 1.B.4](), and * additional reduction procedures that would apply prior to assignment of a post-surgical minimum evaluation lower than the running award rate, see * [38 CFR 3.105(e)]() * [M21-1, Part X, Subpart ii, 4.A.1](), and * [M21-1, Part X, Subpart ii, 4.B](). ### V.iii.1.A.3.j. Evaluating Residuals of Joint Resurfacing Unlike a joint replacement, there is no minimum schedular evaluation after a joint resurfacing procedure. Therefore, following the temporary 100-percent evaluation for joint resurfacing, * reinstate the evaluation in place prior to the joint resurfacing procedure * schedule a review exam , and * evaluate the residuals based on impairment of the joint as shown on the examination. _**Note**_ : When evaluating residuals of joint resurfacing, * reductions in evaluation are subject to the provisions of [38 CFR 3.105(e)](), and * increased evaluations will be effective on the day following the temporary 100-percent evaluation period, unless the facts clearly demonstrate that the increased level of impairment occurred on a later date, in which case the increase will be assigned based on the date entitlement arose. ### V.iii.1.A.3.k. Partial Knee Replacement Regulatory History VA published an interpretative rule effective July 16, 2015, revising [38 CFR 4.71a]() to add a note stating that the term “prosthetic replacement” as used in [38 CFR 4.71a, DCs 5051-5056]() means “total replacement of the named joint” except that in [38 CFR 4.71a, DC 5054]() it means “total replacement of the head of the femur or of the acetabulum.” Effective February 7, 2021, after proposed rule and comment period, a final rule was issued updating rating schedule provisions pertaining to the musculoskeletal system, and explicitly stating that a minimum evaluation is assignable only for total joint replacement, not partial knee joint replacement. In a September 20, 2022, decision, [_NOVA v. Secretary of Veterans Affairs_](), 48 F.4th 1307 (2022) concluded that prior to February 7, 2021, [38 CFR 4.71a, DC 5055](), as then written, did not exclude a partial knee replacement. The court vacated the rule change that was effective from July 15, 2015, to February 6, 2021.When deciding any claim involving evaluation of a partial knee joint replacement that was pending and not finally adjudicated on September 20, 2022, rate as follows: * For any rating period at issue prior to February 7, 2021, apply the text of [38 CFR 4.71a, DC 5055]() in effect at that time, but without the note added effective July 16, 2015. * For the rating period on or after February 7, 2021, apply the text of the current [38 CFR 4.71a, DC 5055]() and the prefatory notes (as applicable). However, always follow [38 CFR 3.951(a)]() on preservation of disability ratings when the rating schedule has been changed. ​​​​​​​ _**Reference**_ : For more information on effective dates based on changes of regulation and judicial precedents, see [M21-1, Part V, Subpart ii, 4.A.6 and 7](). ### V.iii.1.A.3.l. Severe Painful Motion Following Joint Replacement Severe painful motion and LOM, as utilized to evaluate residuals of joint replacements, are distinct concepts. * A finding of severe painful motion does not require that LOM be present. * LOM is, however, a factor that may be considered when evaluating painful motion. **Reference:** For more information on considering severe painful motion in a joint replacement evaluation, see [_Tedesco v. Wilkie_](), 31 Vet.App. 360 (2019). ### V.iii.1.A.3.m. Use of Active ROM Findings Active ROM testing is required to measure functional loss as is utilized in DCs based on LOM.**Note:** Passive ROM is for consideration in evaluating painful motion, as described in [38 CFR 4.59]() and M21-1, Part V, Subpart iii, 1.A.1. ## 4. Examples of Evaluating Joint Conditions and Functional Loss This topic contains examples of evaluating joint conditions and functional loss, including * compensable limitation of * two joint motions, and * one motion with pain in another motion * noncompensable limitation of two motions with pain * evaluating * a joint with * full ROM and functional loss due to pain, and * LOM and functional loss due to pain, and * joints with arthritis by x-ray evidence only with other joint(s) affected by a non-arthritic condition. September 15, 2021 ### V.iii.1.A.4.a. Compensable Limitation of Two Joint Motions ** _Situation_** : 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 painful motion. * There is no additional limitation of flexion or extension on additional repetitions or during flare-ups. **Result:** Assign a 10-percent evaluation under [38 CFR 4.71a, DC 5260](), and a separate 10-percent evaluation under [38 CFR 4.71a, DC 5261]().**Explanation:** Each disability (limitation of flexion and limitation of extension)warrants a separate evaluation and the evaluations are for distinct types of impairment. ### V.iii.1.A.4.b. Compensable Limitation of One Motion With Pain in Another Motion ** _Situation_** : 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 is limited by pain to 5 degrees. **Result:** Assign a 10-percent evaluation under [38 CFR 4.71a, DC 5024-5260]() and a noncompensable evaluation under [38 CFR 4.71a, DC 5024-5261](). **Explanation:** * Flexion is compensable under [38 CFR 4.71a, DC 5260]() _,_ but extension remains limited to a noncompensable degree under [38 CFR 4.71a, DC 5261](). * Under [_Mitchell v. Shinseki_](), 25 Vet. App. 32 (2011), the painful extension could only be considered limited for the purpose of determining whether a 10-percent evaluation can be assigned for the joint under [38 CFR 4.71a, DC 5003](), which is not applicable in this example because a compensable evaluation was already assigned for flexion under [38 CFR 4.71a, DC 5260](). * [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 evaluation 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. ### V.iii.1.A.4.c. Noncompensable Limitation of Two Motions With Pain ** _Situation_** : Evaluation of knee degenerative 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 [38 CFR 4.71a, DC 5260-5003]().**Explanation:** * There is limitation of major joint motion to a noncompensable degree under [38 CFR 4.71a, DC 5260]() and [38 CFR 4.71a, DC 5261](), x-ray evidence of arthritis, and satisfactory evidence of painful motion. Painful motion is limited motion for the purpose of applying [38 CFR 4.71a, DC 5003](). Therefore, a 10-percent evaluation is warranted for the joint. * Alternatively, it would also be permissible to assign a 10-percent evaluation under [38 CFR 4.71a, DC 5003-5260]() with consideration given to painful motion as provided in [38 CFR 4.59](). * Assigning two compensable evaluations, each for pain, would be pyramiding. * Neither [38 CFR 4.71a, DC 5003](), nor [38 CFR 4.59]() permits separate 10-percent evaluations for painful flexion and extension; they provide for a 10-percent evaluation for a joint. * If the fact pattern involved chondromalacia patella or a knee strain rather than degenerative arthritis, a 10-percent evaluation, not separate evaluations, would still be warranted. However, the authority would be [38 CFR 4.59](), and [38 CFR 4.71a, DC 5260]() would be used rather than [38 CFR 4.71a, DC 5003](). ### V.iii.1.A.4.d. Evaluating a Joint With Full ROM and Functional Loss Due to Pain ** _Situation_** : Evaluation of a knee condition with normal initial ROM and additional functional loss indicated on _DeLuca_ and _Mitchell_ assessments. * Examination reveals normal ROM for extension of the knee, but pain on motion is present. * In applying the _DeLuca_ repetitive use test, the examiner determines that after repetitive use, extension of the knee is additionally limited and the post-test ROM is to 10 degrees due to pain. * The examiner provides a _Mitchell_ assessment that during flare-ups the extension of the knee would be additionally limited to 15 degrees due to pain. **Result:** Assign one 20-percent disability evaluation under [38 CFR 4.71a, DC 5261]() for limited extension of the knee.**Explanation:** A 15-degree limitation of extension, expressed in the _Mitchell_ opinion, is the most advantageous assessment of functional loss for extension of the knee in this scenario. Therefore, the knee will be evaluated based on extension limited to 15 degrees, resulting in a 20-percent evaluation under [38 CFR 4.71a, DC 5261](). ### V.iii.1.A.4.e. Evaluating a Joint With LOM and Functional Loss Due to Pain ** _Situation_** : Evaluation of a knee condition with limited initial ROM and additional functional loss indicated on _DeLuca_ and _Mitchell_ assessments. * Flexion of the knee is limited to 70 degrees with pain on motion during initial examination. * In applying the _DeLuca_ repetitive use test, the examiner determines that after repetitive use flexion of the knee is additionally limited, and the post-test ROM is 50 degrees as a result of pain with repetitive use. * The examiner provides a _Mitchell_ assessment that during flare-ups the estimated ROM for flexion of the knee would be 30 degrees due to pain. **Result:** Assign one 20-percent disability evaluation under [38 CFR 4.71a, DC 5260]() for limited flexion of the knee.**Explanation:** Flexion of the knee would be assessed at 30 degrees, as the ROM estimated in the _Mitchell_ assessment is the most advantageous representation of the Veteran’s limitation of flexion. **Reference:** For more information on the _Deluca_ and _Mitchell_ holdings, see M21-1, Part V, Subpart iii, 1.A.1.c and e. ### V.iii.1.A.4.f. Evaluating Joints With Arthritis by X-Ray Evidence Only With Other Joint(s) Affected by a Non-Arthritic Condition ** _Example_** : A Veteran is rated 10 percent for bilateral degenerative arthritis of the elbows confirmed by x-ray evidence, without limited or painful motion or incapacitating exacerbations. The Veteran subsequently files a claim for SC for chondromalacia of the right knee and is awarded a 20-percent evaluation based on VA examination, which revealed limitation of flexion of the right knee to 30 degrees. **Analysis:** A 10-percent evaluation for bilateral arthritis of the elbows and a separate 20-percent evaluation for right knee chondromalacia is justified. In this case, the rating does not violate Note (1) under [38 CFR 4.71a, DC 5003](), because the knee condition is not an arthritic condition. **Reference:** For additional information on the principle in [38 CFR 4.71a, DC 5003](), Note 1, see * M21-1, Part V, Subpart iii, 1.A.3.e * [M21-1, Part V, Subpart iii, 1.C.4.b](), and * [M21-1, Part V, Subpart iii, 1.C.5.d]().