--- title: "Part V, Subpart iii, Chapter 1, Section B Musculoskeletal Disabilities of the Extremities and Spine" document: "M-21-1" section: "Part V, Subpart iii, Chapter 1, Section B" canonical: "https://veteranai.co/va-regulations/m21-1/v.iii.1.b-musculoskeletal-disabilities-of-the-extremities-and-spine" source: "https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000014410/M21-1-Part-V-Subpart-iii-Chapter-1-Section-B-Musculoskeletal-Disabilities-of-the-Extremities-and-Spine" updated: "2026-09-06T14:36:52.928720Z" --- April 13, 2018 ### V.iii.1.B.1.a. Considering Separate Evaluations for Disabilities of the Shoulder and Arm Separate evaluations may be given for disabilities of the shoulder and arm under [38 CFR 4.71a diagnostic codes (DCs) 5201, 5202, or 5203]() if the manifestations represent separate and distinct symptomatology that are neither duplicative nor overlapping.**Reference:** For more information concerning separate and distinct symptomatology, see * [38 CFR 4.14](), and * [ _Esteban v. Brown_](), 6 Vet.App. 259 (1994) ### V.iii.1.B.1.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 [38 CFR 4.71a, DC 5202-5201](), and * assign a separate 10-percent evaluation for malunion of the clavicle under [38 CFR 4.71a, DC 5203](). **Notes:** * The hyphenated evaluation DC is assigned under [38 CFR 4.71a, DC 5202-5201]() because the humerus impairment affects range of motion (ROM). * The separate evaluation for the clavicle disability is warranted because this disability does not affect ROM. **Exception:** Multiple evaluations cannot be assigned under [38 CFR 4.71a, DC 5201]() for limited flexion and abduction of the shoulder. **Reference:** For more information on evaluating shoulder conditions, see _[Yonek v. Shinseki]()_ , 722 F.3d 1355 (Fed. Cir. 2013). ### V.iii.1.B.1.c. Assigning Separate Evaluations for Disabilities of the Elbow, Forearm, and Wrist Impairments of the elbow, forearm, and wrist will be assigned separate disability evaluations. The motions of these joints are all viewed as clinically separate and distinct. Assign separate evaluations for impairment under the following DCs: * elbow * flexion under [38 CFR 4.71a, DC 5206](), or * extension under [38 CFR 4.71a, DC 5207]() * forearm supination and pronation under [38 CFR 4.71a, DC 5213](), and * wrist flexion or ankylosis under [38 CFR 4.71a, DC 5214]() or [38 CFR 4.71a, DC 5215](). **Notes:** * [38 CFR 4.59]() may be applied separately to the elbow, the forearm, and the wrist to result in potentially three separate evaluations for painful motion when the evidence otherwise supports such a finding. However, [38 CFR 4.59]() may only be applied once to the elbow and may not be separately applied to both elbow flexion and elbow extension. * When examination or other evidence denotes pain present in the joint or periarticular region but does not delineate the specific motions in which pain is present **_and_** there is a potential for a separate evaluation under [38 CFR 4.59]() as discussed in [M21-1, Part V, Subpart iii, 1.A.1](), obtain a medical opinion to determine which motions are painful. When the examiner cannot delineate which motions are associated with pain, resolve doubt in favor of the Veteran and consider painful motion to be present in the separate plane such as to allow assignment of the separate minimum compensable evaluation under [38 CFR 4.59](). **Reference:** For more information on assigning separate evaluations for elbow motion, see [M21-1, Part V, Subpart iii, 1. A.3.c](). ### V.iii.1.B.1.d. Example of Separate Evaluations for Disabilities of the Elbow, Forearm, and Wrist ** _Situation_** : A Veteran sustained multiple injuries to the right upper extremity in a vehicle rollover accident. The following impairments are due to the service-connected (SC) injuries: * elbow flexion limited to 90 degrees * elbow extension limited to 45 degrees * full ROM on supination and pronation with painful supination, and * full ROM of the wrist with pain on dorsiflexion. **Result:** Assign the following disability evaluations * 20-percent for limited elbow flexion under [38 CFR 4.71a, DC 5206]() * 10-percent for limited elbow extension under [38 CFR 4.71a, DC 5207]() * 10-percent for painful forearm supination under [38 CFR 4.71a, DC 5213](), and * 10-percent for painful wrist motion under [38 CFR 4.71a, DC 5215](). **Explanation:** * Compensable limitation of motion (LOM) of elbow flexion and extension is present. Separate evaluations are warranted for elbow flexion and extension. * Motion of the forearm is separate and distinct from elbow motion. Therefore, a separate evaluation is warranted for painful supination. * Motion of the wrist is separate and distinct from forearm motion. Therefore, a separate evaluation is warranted for painful motion of the wrist. **Note:** If elbow flexion is limited to 100 degrees and elbow extension is limited to 45 degrees, assign a single 20-percent disability evaluation under [38 CFR 4.71a, DC 5208]().**References:** For more information on * separate evaluations for motion of a single joint, see * [VAOPGCPREC 9-2004](), and * [M21-1, Part V, Subpart iii, 1.A.3.c](), and * separate evaluations for the elbow, forearm, and wrist, see M21-1, Part V, Subpart iii, 1.B.1.c. ### V.iii.1.B.1.e. Considering Impairment of Supination and Pronation of the Forearm When preparing ratings decisions involving impairment of supination and pronation of the forearm, consider 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. * 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 more information on considering painful motion when assigning multiple LOM evaluations for a joint, see [M21-1, Part V, Subpart iii, 1.A.3.e](). ## 2. Evaluating Musculoskeletal Disabilities of the Hands Introduction| | This topic contains information on evaluating musculoskeletal disabilities of the hands, including * identifying digits of the hand * evaluating * amputations of multiple fingers, and * ankylosis of one or more fingers * compensable evaluations for the fingers, and * rating Dupuytren’s contracture of the hand. Change Date| | February 8, 2021 ### V.iii.1.B.2.a. Identifying Digits of the Hand Follow the guidelines listed below to accurately specify the injured digits of the hand. * The digits of the hand are identified as * thumb * index * long * ring, or * little. * Do not use numerical designations for either the fingers or the joints of the fingers. * Each digit, except the thumb, includes three phalanges * the proximal phalanx (closest to the wrist) * the middle phalanx, and * the distal phalanx (closest to the tip of the finger). * The joint between the proximal and middle phalanges is called the _**proximal interphalangeal**_ or **_PIP_** joint. * The joint between the middle and distal phalanges is called the _**distal interphalangeal**_ or **_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**_ or _**IP**_ joint. * The joints connecting the phalanges in the hands to the metacarpals are the _**metacarpophalangeal**_ or **_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.**References:** For * more information on * determining dominant handedness, see [38 CFR 4.69](), and * the normal anatomical position (also called position of function) of the hand and fingers and normal range of motion of the fingers, see Note 1 preceding [38 CFR 4.71a, DC 5216](), and * an exhibit of the anatomy of the hand, see the illustration following [38 CFR 4.71a, DC 5156](). ### V.iii.1.B.2.b. Evaluating Amputations of Multiple Fingers Consider and apply the following principles as applicable when evaluating amputations of multiple fingers: * Amputations other than at the PIP joints or through the proximal phalanges will be rated as ankylosis of the fingers. * Amputations at distal joints, or through distal phalanges (other than negligible losses) will be rated as favorable ankylosis of the fingers. * Amputation through middle phalanges will be rated as unfavorable ankylosis of the fingers. * If there is amputation or resection of metacarpal bones (where more than one-half the bone is lost) in multiple finger injuries, add (not combine) 10 percent to the specified evaluation for the finger amputations subject to the amputation rule (at the forearm level). * When an evaluation is assigned under [38 CFR 4.71a, DC 5126 to 5130]() there will also be entitlement to special monthly compensation. * Loss of use of the hand exists when no effective function remains other than that which would be equally well served by an amputation stump with a suitable prosthetic appliance. ### V.iii.1.B.2.c. Evaluating Ankylosis of One or More Fingers When considering an evaluation for ankylosis of the index, long, ring or little finger, evaluate as: * _favorable ankylosis_ if **_either_** the MCP **_or_** PIP joint is ankylosed, **_and_** there is a gap of two inches (5.1 cm.) **_or less_** between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible * _unfavorable ankylosis_ if * ** _either_** the MCP **_or_** PIP joint is ankylosed, **_and_** there is a gap of **_more than_** two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, **_or_** * ** _both_** the MCP **_and_** PIP joints of a digit are ankylosed (even if each joint is individually fixed in a favorable position), **_or_** * _amputation without metacarpal resection at the PIP joint or proximal thereto_ ([38 CFR 4.71a, DC 5153 to 5156)]() if both the MCP and PIP joints of a digit are ankylosed, _and_ either is in extension or full flexion, _or_ there is rotation or angulation of a bone. When considering an evaluation for ankylosis of the thumb, evaluate as: * _favorable ankylosis_ if **_either_** the carpometacarpal **_or_** IP joint is ankylosed, **_and_** there is a gap of two inches (5.1 cm.) **_or less_** between the thumb pad and fingers with the thumb attempting to oppose the fingers * _unfavorable ankylosis_ if * ** _either_** the carpometacarpal **_or_** IP joint is ankylosed, **_and_** there is a gap of **_more than_** two inches (5.1 cm.) between the thumbpad and the fingers, with the thumb attempting to oppose the fingers, **_or_** * ** _both_** the carpometacarpal **_and_** IP joints are ankylosed (even if each joint is individually fixed in a favorable position), **_or_** * _amputation at the carpometacarpal joint or joints or through proximal phalange_ ([38 CFR 4.71a, DC 5152)]() if both the carpometacarpal and IP joints are ankylosed, _and_ either is in extension or full flexion, _or_ there is rotation or angulation of a bone. **Note:** Only joints ankylosed in normal anatomical position as defined in Note 1 preceding [38 CFR 4.71a, DC 5216]() are considered favorably ankylosed. **Reference:** For more information on evaluation of ankylosis of the fingers, see the notes prior to [38 CFR 4.71a, DC 5216](). ### V.iii.1.B.2.d. Compensable Evaluations for the Fingers When considering evaluations for the fingers based on LOM, a compensable evaluation can be assigned for any of the following: * LOM of the thumb as specified in [38 CFR 4.71a, DC 5228](). * LOM of the index or long finger as specified in [38 CFR 4.71a, DC 5229](). * X-ray evidence of arthritis or other condition rated under the criteria of [38 CFR 4.71a, DC 5003](), affecting a _group_ of minor joints of the fingers of _one_ hand. There must be * noncompensable LOM in more than one of the joints comprising the group of affected minor joints, _and_ * findings such as swelling, muscle spasm or satisfactory evidence of painful motion in the affected minor joints of the joint group. * X-ray-_only_ evidence of arthritis (where there is no LOM) under the criteria of [38 CFR 4.71a, DC 5003](), affecting _two or more_ _groups_ of minor joints – namely the fingers of _both_ hands or a group of minor joints in one hand in combination with another group of minor joints. * Painful motion of the thumb, index finger, or long finger as directed at [M21-1, Part V, Subpart iii, 1.A.1.l](). _**Note**_ : The Federal Circuit held in [_Spicer v. Shinseki_](), 752 F.3d 1367 (Fed. Cir. 2014) that when evaluating arthritis of the hand, the minor joint _group_ of IP joints of a hand is compensably disabled _only when two or more_ joints in the group are affected by LOM. Refer to [M21-1, Part V, Subpart iii, 1.A.3.a and b]() for more information on the applicability of the _Spicer_ holding. **References:** For more information on * use of the terms major and minor when evaluating joints, see [M21-1, Part V, Subpart iii, 1.A.3.a]() * assigning evaluations under [38 CFR 4.71a, DC 5003]() when a compensable rating based on LOM cannot be assigned under another DC, see [M21-1, Part V, Subpart iii, 1.C.4.b](), and * applying [38 CFR 4.59]() to minor joints, see [M21-1, Part V, Subpart iii, 1.A.1.l](). ### V.iii.1.B.2.e. Rating Dupuytren’s Contracture of the Hand The rating schedule 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 This topic contains information on evaluating musculoskeletal disabilities of the spine, including * evaluating manifestations of spine diseases and injuries * variations in terminology for intervertebral disc syndrome (IVDS) * definition of incapacitating episode of IVDS * objective neurological impairment associated with spinal disabilities * examples addressing neurological impairments associated with spinal disabilities * disability benefits questionnaire (DBQ) selections for radiculopathy * example of evaluating IVDS, and * evaluating ankylosing spondylitis. February 27, 2025 ### V.iii.1.B.3.a. Evaluating Manifestations of Spine Diseases and Injuries Evaluate diseases and injuries of the spine based on the criteria listed in the [38 CFR 4.71a](), General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under these criteria, evaluate conditions based on chronic orthopedic manifestations (for example, painful muscle spasm or LOM) and any associated neurological manifestations (for example, footdrop, muscle atrophy, or sensory loss) by assigning separate evaluations for the orthopedic and neurological manifestations.Evaluate intervertebral disc syndrome**(** IVDS) under [38 CFR 4.71a, DC 5243](), either based on the General Rating Formula or the Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episode Formula), whichever formula results in the higher evaluation when all disabilities are combined under [38 CFR 4.25]().**Notes:** * Utilize [38 CFR 4.71a, DC 5243]() _only_ when there is disc herniation with compression and/or irritation of the adjacent nerve root. Otherwise, assign [38 CFR 4.71a, DC 5242]() for all other disc diagnoses. * Irritation of the adjacent nerve root is evidenced by back pain and sciatica (pain along the course of the sciatic nerve) in the case of lumbar disc diseases. For cervical disc disease, neck and arm or hand pain will be shown. * If an evaluation is assigned based on incapacitating episodes, a separate evaluation may not be assigned for LOM, radiculopathy, or any other associated objective neurological abnormality as doing so would constitute pyramiding under [38 CFR 4.14](). * Spinal fusion is a type of fixation of the spine. Evaluation based on ankylosis of the spine due to fusion is only warranted when the fixation affects the entire thoracolumbar or cervical spine segment. Fusion of only a portion of the cervical or thoracolumbar spine segment should be evaluated based on range or motion or IVDS, as warranted by the evidence. * There is no presumption of service connection (SC) for degenerative disc disease (DDD). Desiccation of the disc or other degenerative changes without any radiographic evidence of arthritic changes is not indicative of arthritis and is not, consequently, subject to presumptive SC under [38 CFR 3.309(a)](). **References:** For more information on * evaluating * degenerative spinal disease, such as spondylosis, see * [M21-1, Part V, Subpart ii, 2.E.1.e](), and * [ _Cousin v. Wilkie_]() , 905 F.3d 1316 (Fed.Cir. 2018), and * co-existing SC and NSC disabilities affecting separate spinal segments, see * [M21-1, Part V, Subpart ii, 3.D.2.c](), and * _[Langdon v. McDonough]()_ , 1 F.4th 1008 (Fed. Cir. 2021), and * the historical application of * [38 CFR 4.40](), and [38 CFR 4.45]() to evaluations for IVDS, see [VAOPGCPREC 36-1997](), and * [38 CFR 4.71a, DC 5285](), for demonstrable deformity of a vertebral body, see [VAOPGCPREC 3-2006](). ### V.iii.1.B.3.b. Variations in Terminology for IVDS Variations of diagnostic terminology exist for IVDS. When used in the clinical setting, the following terminology is consistent with the general designation of IVDS: * slipped or herniated disc * ruptured disc * prolapsed disc * bulging or protruded disc * DDD * sciatica * discogenic pain syndrome * herniated nucleus pulposus, and * pinched nerve. ### V.iii.1.B.3.c. Definition: Incapacitating Episode of IVDS By definition, an incapacitating episode of IVDS requires bedrest prescribed by a physician. When evaluating IVDS based on incapacitating episodes, there must be evidence the associated symptoms required bedrest as prescribed by a physician. The medical evidence of prescribed bedrest must be * of record in the claims folder, **_or_** * reviewed and described by an examiner completing an examination or disability benefits questionnaire (DBQ). **Note:** If the records do not adequately document prescribed bedrest, use the General Rating Formula to evaluate IVDS and advise the Veteran to submit medical evidence documenting the periods of incapacitating episodes requiring bedrest prescribed by a physician. ### V.iii.1.B.3.d. Objective Neurological Impairment Associated With Spinal Disabilities Objective neurological abnormalities associated with spinal disabilities * are evaluated separately from the spinal disability (**_except_** , as noted in M21-1, Part V, Subpart iii, 1.B.3.a, when IVDS is evaluated based on incapacitating episodes), and * represent a medical progression or worsening of the spinal disease. * For that reason and because neurological complications of spinal disease are contemplated in the evaluation criteria for spinal conditions under [38 CFR 4.71a](), a claim asserting new complications of spinal disease is considered a claim for increase rather than a claim for secondary SC. * When evaluating an expressly claimed spinal disability, decision makers must consider entitlement to compensation for any neurological complications as within scope of the claim in accordance with [M21-1, Part V, Subpart ii, 3.A.2.c](). * Likewise, a primary spinal condition responsible for an expressly claimed neurological complication is considered within the scope of the expressly claimed issue, as discussed in [M21-1, Part V, Subpart ii, 3.A.1.c](). * When assigning effective dates for neurological spinal complications, consider effective date provisions specifically for increases as specified in [ M21-1, Part V, Subpart ii, 4.A.5.e](). _**Notes**_ : * When an SC thoracolumbar disability is present and objective neurological abnormalities or radiculopathy are diagnosed but the medical evidence does not identify a specific nerve root, rate the lower extremity radiculopathy under the sciatic nerve, [38 CFR 4.124a, DC 8520](). * Additional examinations of other body systems may be required if there are neurological complications of the peripheral nerves, bladder, and/or impairment of sphincter control. * Apply the previous provisions of historical [38 CFR 3.157(b)]() when determining the effective date for neurological abnormalities of the spine that are identified by requisite records prior to March 24, 2015. _**Example**_ : Veteran has been SC for DDD since 2012. Upon review of a claim for increase received on June 2, 2015, it is noted in Department of Veterans Affairs (VA) medical records that the Veteran received treatment for bladder impairment secondary to DDD on July 7, 2014. Because the VA medical records constitute a claim for increase under rules in effect prior to March 24, 2015, it is permissible to apply previous rules from [38 CFR 3.157 (b)]() in adjudicating the bladder impairment issue. **References:** For more information on * assigning disability evaluations for * peripheral nerve disabilities, to include radiculopathy, see [M21-1, Part V, Subpart iii, 12.A.2](), and * progressive spinal muscular atrophy, see [M21-1, Part V, Subpart iii, 12.A.1.c]() * issues within the scope of a claim, see * [38 CFR 3.155(d)(2)](), and * [M21-1, Part V, Subpart ii, 3.A.2]() * assigning effective dates for neurological spinal complications, see * [38 CFR 3.400(o)]() * [38 CFR 3.155](), and * [M21-1, Part V, Subpart ii, 4.A.5.e](), and * procedural guidance on handling the effective dates and coding complications of an SC disability in Veterans Benefits Management System - Rating (VBMS-R), see [M21-1, Part V, Subpart ii, 4.A.5.e](). ### V.iii.1.B.3.e. Examples Addressing Neurological Impairments Associated With Spinal Disabilities ** _Example 1_** : A Veteran files a claim for an increased evaluation for the SC condition of spinal stenosis. An intent to file (ITF) a claim was not received. The DBQ shows decreased ROM of the spine that is unchanged from the prior evaluation and a diagnosis of radiculopathy of the bilateral lower extremities. No other evidence indicates that radiculopathy was diagnosed prior to the date of this DBQ. The rating activity should evaluate the spinal stenosis and grant SC for bilateral radiculopathy with an effective date assigned based on the receipt of the claim for the increased evaluation in the spinal stenosis.**Example 2:** A Veteran submits a claim for SC of right leg pain and numbness, more than one year following discharge. An ITF is not associated with this claim. Development of the claim confirms a diagnosis of radiculopathy that is due to an unclaimed back injury. The back injury was sustained in service. Sufficient evidence to establish SC for the back disability is of record. Consider the unclaimed back disability within scope of the claimed radiculopathy and establish SC for both issues with an effective date assigned based on the date of the receipt of the claim for SC of radiculopathy.**Example 3:** The Veteran files a _[VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits]()_ , for an increased evaluation in an SC spinal disability. In conjunction with that claim, the Veteran submits private medical records showing a diagnosis of radiculopathy, related to the SC spinal disability, within the last year. An ITF is not associated with the claim. The private medical evidence is sufficient to evaluate the radiculopathy but does not contain ROM findings for the lumbosacral spine. The rating activity should grant SC for radiculopathy from the date of the diagnosis of radiculopathy (in accordance with [38 CFR 3.400(o)(2)]()) and defer the evaluation of the spinal disability for an increase evaluation examination. ### V.iii.1.B.3.f. DBQ Selections for Radiculopathy Radiculopathy is a common type of neurological impairment associated with spinal disabilities.Refer to the table below to determine which DBQ to request when the claimed disability is a thoracolumbar/cervical spine condition and/or lumbar/cervical radiculopathy. | **If the claimed condition is a/an ...**| **Then, request the ...** thoracolumbar spine condition (initial SC or increased evaluation) with or without a claim for radiculopathy| _Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire_ when otherwise necessary to decide the claim. **Important:** * The DBQ contains a section for radiculopathy that must be completed by the examiner if there is an indication of radiculopathy. * If the examiner fails to address radiculopathy, the examination must be returned as insufficient. cervical spine condition (initial SC or increased evaluation) with or without a claim for radiculopathy| _Neck (Cervical Spine) Conditions Disability Benefits Questionnaire_ when otherwise necessary to decide the claim. **Important:** * The DBQ contains a section for radiculopathy that must be completed by the examiner if there is an indication of radiculopathy. * If the examiner fails to address radiculopathy, the examination must be returned as insufficient. increased evaluation of * lower extremity or lumbar radiculopathy, or * upper extremity or cervical radiculopathy | _Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire._ upper extremity radiculopathy (initial SC) without a claim for cervical spine condition| _Neck (Cervical Spine) Disability Benefits Questionnaire_** _Important_** : If the examiner fails to address radiculopathy, the examination must be returned as insufficient. lower extremity radiculopathy (initial SC) without a claim for thoracolumbar spine condition| _Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire_ _ _**Important:** If the examiner fails to address radiculopathy, the examination must be returned as insufficient. _**Note**_ : Do not routinely request an examination for an issue(s) for which the evidence of record is sufficient to make a decision. This includes DBQs completed by a private or VA provider that are deemed adequate for rating purposes. **References:** For more information on * determining when an examination is necessary to decide a claim, see [M21-1, Part IV, Subpart i, 1.A]() * using medical evidence in lieu of an examination, see [M21-1, Part IV, Subpart i, 1.B.1.a](), and * sufficiency of examinations, see [M21-1, Part IV, Subpart i, 3.A](). ### V.iii.1.B.3.g. Example of Evaluating IVDS ** _Situation_** : A Veteran’s IVDS is being evaluated. * LOM warrants a 20-percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine * mild radiculopathy of the left lower extremity warrants a 10-percent evaluation as a neurological complication (evidence of irritation of the adjacent nerve root) under [38 CFR 4.124a, DC 8520](), and * medical evidence shows incapacitating episodes requiring bedrest prescribed by a physician of four weeks duration over the past 12 months which would result in a 40-percent evaluation based on the incapacitating episode formula. **Result:** Assign a 40-percent evaluation under [38 CFR 4.71a, DC 5243]() based on incapacitating episodes. **Explanation:** * Evaluating IVDS using incapacitating episodes results in the highest evaluation. * Since incapacitating episodes are used to evaluate IVDS, the associated LOM and neurological signs and symptoms will not be assigned a separate evaluation. ### V.iii.1.B.3.h. Evaluating Ankylosing Spondylitis Ankylosing spondylitis may be evaluated as an active disease process or based upon LOM of the spine. The table below describes appropriate action for evaluating ankylosing spondylitis.| **If ankylosing spondylitis is ...**| **Then ...** an active process| evaluate under [38 CFR 4.71a, DC 5009]()(using the criteria in [38 CFR 4.71a, DC 5002]() for the acute phase). inactive| * evaluate based on chronic residuals affecting the spine under [38 CFR 4.71a, DC 5003 or DC 5240](), and * separately evaluate other affected joints or body systems under the appropriate DC. ## 4. Evaluating Musculoskeletal Disabilities of the Legs **Introduction**| | This topic contains information on evaluating musculoskeletal disabilities of the lower extremities (not including the feet), including * evaluating noncompensable knee conditions * definition of instability and subluxation of the knee * evaluating instability of the knee * separate evaluations * for knee instability and LOM, and * of meniscal disabilities * examples of evaluating meniscal disabilities * separate evaluations – genu recurvatum * evaluating impairment of the tibia and fibula * evaluating pain associated with shin splints, and * ankle instability. Change Date| | March 25, 2026 ### V.iii.1.B.4.a. Evaluating Noncompensable Knee Conditions Evaluate a noncompensable knee condition by analogy to [38 CFR 4.71a, DC 5257]() if * there is no associated arthritis * the schedular criteria for a noncompensable evaluation under [38 CFR 4.71a, DC 5260]() or [DC 5261]() are not met, _and_ * the condition cannot be appropriately evaluated under [38 CFR 4.71a, DC 5258, 5259, 5262, or 5263](). **References:** For more information on * using analogous DCs, see [38 CFR 4.20](), and * when to assign a 0-percent evaluation, see [38 CFR 4.31](). ### V.iii.1.B.4.b. Definitions: Instability and Subluxation of the Knee ** _Instability_** , as referred to in [38 CFR 4.71a, DC 5257](), includes * patellar instability due to recurrent patellar subluxation or patellar dislocation, and/or * any other instability or laxity of the knee that involves other stabilizing structure of the knee such as the collateral or cruciate ligaments. **_Subluxation_** refers to partial or incomplete dislocation of the knee joint (_tibiofemoral_ dislocation/subluxation) or tendency for the patella to dislocate from its track (_patellar_ dislocation/subluxation). Evaluations under [38 CFR 4.71a, DC 5257]() may be assigned based on the requirement for assistive device(s) and/or bracing. The assistive device or bracing must be prescribed by a medical provider and there must be objective evidence of the prescription in the evidentiary record. ### V.iii.1.B.4.c. Evaluating Instability of the Knee Evaluations for instability of the knee are assigned based on whether the instability arises from * sprain or a ligament tear, or * patellar instability. When there is persistent instability but the medical evidence and/or examination report does not identify the instability as related to either a ligament tear/sprain or a diagnosed condition involving the patellofemoral complex (such as instability due to osteoarthritis or osteoarthrosis), then evaluate it using the patellar instability criteria under [38 CFR 4.71a, DC 5257]()._**Note**_ : The presence of persistent instability is sufficient to satisfy the requirement of recurrent symptoms for the 10-percent evaluation. ### V.iii.1.B.4.d. Separate Evaluations for Knee Instability and LOM A separate evaluation for knee instability may be assigned in addition to any evaluation(s) assigned based on limitation of knee motion. The Office of General Counsel has issued precedent opinions that an evaluation under [38 CFR 4.71a, DC 5257](), does not pyramid with evaluations based on LOM. **References:** For more information on * pyramiding and separating individual findings in a rating decision, see [M21-1, Part V, Subpart ii, 3.D.2.b]() * separate evaluation of knee instability, see * [VAOPGCPREC 23-1997](), and * [VAOPGCPREC 9-1998](), and * evaluation of joint replacement or resurfacing, see [M21-1, Part V, Subpart iii, 1.A.3.h-l](). ### V.iii.1.B.4.e. Separate Evaluation of Meniscal Disabilities Evaluation of a knee disability under [38 CFR 4.71a, DC 5257, DC 5260](), or [5261]() does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under * [38 CFR 4.71a, DC 5258]() (dislocated semilunar cartilage), or * [38 CFR 4.71a, DC 5259]() (symptomatic removal of semilunar cartilage). A meniscal disability may be rated separately under [38 CFR 4.71a, DC 5258/5259]() apart from * [38 CFR 4.71a, DC 5257]() for manifestations of the knee disability other than recurrent subluxation and instability, and/or * [38 CFR 4.71a, DC 5260/5261]() if a manifestation of the meniscal disability did not result in an elevation of the disability evaluation warranted under [38 CFR 4.71a, DC 5260/5261]() via application of [38 CFR 4.40]() and [38 CFR 4.45]() pursuant to [_DeLuca v. Brown_]() , 8 Vet.App. 202 (1995). **Important:** * A repaired meniscal tear (s/p partial meniscectomy) is not directly synonymous with either [38 CFR 4.71a, DC 5258]() or [38 CFR 4.71a, DC 5259](). Therefore, it is most appropriate to rate the disability analogous to whichever code most closely approximates the current symptoms. * Entitlement to a separate evaluation for the meniscal disability depends on whether the manifestations are utilized to assign an evaluation under a different DC. Evaluation of the same manifestation under multiple diagnoses is prohibited under [38 CFR 4.14](). Thus, when all the symptoms of the meniscal disability are used to support elevation of an evaluation under [38 CFR 4.71a, DC 5260/5261]() or assignment of an evaluation under [38 CFR 4.71a, DC 5257](), a separate evaluation cannot be assigned under [38 CFR 4.71a, DC 5258/5259](). * When considering applicability of [38 CFR 4.59]() for meniscal disabilities, * when _only_ a meniscal disability is present, utilize the procedures at [M21-1, Part V, Subpart iii, 1.A.1.m](), and * when multiple knee disabilities are present and the painful motion is attributable to a knee disability other than the meniscal condition, assign separate evaluations when otherwise warranted under [38 CFR 4.14](). * The policy and procedures identified in this block reflect a change in policy resulting from the holding in [_Lyles v. Shulkin_](), 29 Vet.App. 107 (2017), effective November 29, 2017. Prior to the _Lyles_ holding, separate evaluations for meniscal disabilities under [38 CFR 4.71a, DC 5258]() or [DC 5259]() and other knee evaluations under [38 CFR 4.71a, DC 5257, 5260, or DC 5261]() were prohibited. This is not considered a liberalizing change. **References:** For more information on * evaluation of meniscal disabilities, see [_Lyles v. Shulkin_](), 29 Vet.App. 107 (2017), and * examples of evaluation of meniscal disabilities, see M21-1, Part V, Subpart iii, 1.B.4.f. ### V.iii.1.B.4.f. Examples-- Evaluating Meniscal Disabilities ** _Example 1_** : A Veteran’s left knee disability, which includes a meniscal condition, is evaluated as 30-percent disabling on the basis of limitation of extension under [38 CFR 4.71a, DC 5261](). The knee also manifests pain, swelling, popping, locking, and grinding due to the meniscus disability. These symptoms, which are consistent with the manifestations identified under [38 CFR 4.40]() and [38 CFR 4.45](), were considered and did not result in a higher evaluation under [38 CFR 4.71a, DC 5261](). Therefore, they may be considered for assignment of a separate evaluation under [38 CFR 4.71a, DC 5258/5259](). **Example 2:** The evaluations and fact pattern for Example 1 are the same _except_ that the VA examiner indicates that the pain, swelling, popping, locking, and grinding of the knee, which results from the meniscal disability, result in additional limitation of extension to 30 degrees during flare-ups or with repeated use over a period of time, which warrants an elevation of the rating to 40-percent under [38 CFR 4.71a, DC 5261](). A separate evaluation under [38 CFR 4.71a, DC 5258/5259]() is not warranted for the symptoms of pain, swelling, popping, locking, and grinding since these symptoms were considered under [38 CFR 4.40]() and [38 CFR 4.45]() in accordance with the _DeLuca_ holding to elevate the evaluation to 40-percent under [38 CFR 4.71a, DC 5261](). Assignment of a separate evaluation under [38 CFR 4.71a, DC 5258/5259]() would constitute pyramiding. **Example 3:** A Veteran’s left knee disability, which includes meniscal impairment, is evaluated as 30-percent disabling on the basis of limitation of extension under [38 CFR 4.71a, DC 5261](). Pain is present due to the meniscus disability. A VA examiner indicated that pain during repetitive motion testing as well as functional loss due to pain during flare-ups additionally limit extension to 30 degrees, which results in elevation of the 30-percent evaluation under [38 CFR 4.71a, DC 5261]() to 40-percent. A separate evaluation under [38 CFR 4.71a, DC 5258/5259]() is not warranted for the symptoms of pain since it was considered under [38 CFR 4.40]() and [38 CFR 4.45]() in accordance with the _DeLuca_ holding to elevate the evaluation to 40-percent under [38 CFR 4.71a, DC 5261](). Assignment of a separate evaluation under [38 CFR 4.71a, DC 5258/5259]() would constitute pyramiding. **Example 4:** A Veteran’s right knee disability is evaluated as 20-percent disabling on the basis of limitation of extension. This disability includes arthritis of the joint and a post-operative meniscal condition. The knee also manifests pain, swelling, popping, locking, and grinding due to both arthritis and the meniscal condition. A VA examiner found that repetitive motion testing additionally limited extension by five degrees, from 15 to 20 degrees, due to pain. The consideration of pain on motion, which is a manifestation identified under [38 CFR 4.40]() and [38 CFR 4.45](), results in elevation of the evaluation under [38 CFR 4.71a, DC 5261]() to 30-percent. Since the swelling, popping, locking, and grinding, which were at least in part due to the meniscal condition, were not considered in awarding a higher evaluation under [38 CFR 4.71a, DC 5261]() with application of [38 CFR 4.40]() and [38 CFR 4.45](), a separate evaluation may be awarded for the meniscus removal. **Example 5:** Examination of the left knee disability reveals an unrepaired incomplete ligament tear that results in persistent instability. The Veteran’s physician has prescribed a brace and a cane for ambulation. Additionally, the Veteran has a history of meniscectomy with residual symptoms of stiffness, crepitus, and pain without effusion or locking. ROM is full with no additional functional impairment following repeated ROM testing. Since the stiffness, crepitus, and pain are separate symptoms and not used to support an evaluation under [38 CFR 4.71a, DC 5257/5260/5261]() and the persistent instability is not used to support an evaluation for the meniscal symptoms, a 20-percent evaluation is warranted under [38 CFR 4.71a, DC 5257]() with a separate 10-percent evaluation assigned under [38 CFR 4.71a, DC 5259](). ### V.iii.1.B.4.g. Separate Evaluations – Genu Recurvatum When evaluating genu recurvatum, which involves hyperextension of the knee beyond 0 degrees of extension, under [38 CFR 4.71a, DC 5263]() * do _not also_ evaluate separately under [38 CFR 4.71a, DC 5261](), but * _do_ evaluate separately under other evaluations _if_ manifestations that are not overlapping, such as limitation of flexion under [38 CFR 4.71a, DC 5260](), are attributed to genu recurvatum, and * do _not_ evaluate separately under [38 CFR 4.71a, DC 5257](); however, if instability is manifested from genu recurvatum evaluate based on the criteria that will provide the highest evaluation. ### V.iii.1.B.4.h. Evaluating Impairment of the Tibia and Fibula Utilize [38 CFR 4.71a, DC 5262]() for evaluating impairment of the tibia and fibula including nonunion, malunion (evaluated under the corresponding knee or ankle codes based on associated impairment), medial tibial stress syndrome (MTSS) , or shin splints. Evaluations for shin splints may be based on the use of conservative treatment. For this purpose, conservative treatment includes but is not limited to treatment of symptoms using the following: * rest * ice * elevation * medication * compression socks, and/or * massage. **Notes:** * MTSS is synonymous with shin splints. Related assessments, such as compartment syndrome and/or stress fractures, may also appear in treatment records. When compartment syndrome is the predominant diagnosis, however, assign an evaluation under [38 CFR 4.73, DC 5331](). * When evaluating shin splints, assign a single evaluation under [38 CFR 4.71a, DC 5262](), whether the shin splints affect one or both legs. ### V.iii.1.B.4.i. Evaluating Pain Associated With Shin Splints MTSS, or shin splints, is a type of joint or periarticular pathology. When evaluating shin splints, apply [38 CFR 4.59]() and assign the minimum compensable evaluation under [38 CFR 4.71a, DC 5262]() when painful motion is shown and shin splints are otherwise noncompensable. The following principles apply: * Shin splints with pain that is not associated with motion, such as pain on palpation, are noncompensable under [38 CFR 4.59](). * The minimum compensable evaluation is warranted when painful motion due to shin splints occurs in nearby affected joints such as the ankle or knee or when shin pain or other similar pain occurs with motion. However, when a separate knee or ankle disability exists and has been compensably evaluated, do not assign a compensable evaluation under [38 CFR 4.59]() for shin splints causing painful motion in an already-compensable SC knee or ankle joint as this would be in violation of the pyramiding rules in [38 CFR 4.14](). Use the table below to determine if a compensable evaluation can be assigned for shin splints based on painful motion under [38 CFR 4.59]().| **Step**| **Action** 1| Do the symptoms qualify for a compensable evaluation based on the criteria in [38 CFR 4.71a, DC 5262]()? * If _yes_ , * assign the appropriate compensable evaluation based on the criteria listed in [38 CFR 4.71a, DC 5262](), and * disregard the remaining steps of this table. * If _no_ , go to the next step. 2| Are the shin splints associated with painful motion of the shin, ankle, or knee? * If _yes_ , use the table below to determine the next step. * If _no_ , * do not apply [38 CFR 4.59](), and * assign a noncompensable evaluation for the shin splints under [38 CFR 4.71a, DC 5262](). | **If the shin splints are associated with painful motion of the …**| **Then …** shin| assign a compensable evaluation based on [38 CFR 4.59](). ankle or knee| go to Step 3. 3| Is the same joint(s) already compensably evaluated? * If _yes_ , * do not apply [38 CFR 4.59](), and * assign a noncompensable evaluation for the shin splints under [38 CFR 4.71a, DC 5262](). * If _no_ , assign a compensable evaluation based on [38 CFR 4.59](). _**Note**_ : When evaluating shin splints, assign a single evaluation under [38 CFR 4.71a, DC 5262](), whether the shin splints affect one or both legs, as noted in M21-1, Part V, Subpart iii, 1.B.4.h. **Reference:** For more information on the applicability of [38 CFR 4.59]() to ratings for shin splints, see * [M21-1, Part V, Subpart iii, 1.A.1.i](), and * _[Southall-Norman v. McDonald]()_ , 28 Vet.App. 346 (2016). ### V.iii.1.B.4.j. Ankle Instability Do not assign separate evaluations for LOM and instability of the ankle. The intent of the ankle DCs, including [38 CFR 4.71a, DC 5271](), is to address the overall ankle disability without limiting the focus to one specific type of ankle symptomatology. Although [38 CFR 4.71a, DC 5271]() is titled, _Ankle, limited motion of_ and utilizes objective ROM measurements to guide the decision maker as to the meaning of marked and moderate in evaluating symptoms, this DC may also be used to rate instability of the ankle with or without associated LOM. **Note:** [38 CFR 4.20]() provides that when a condition is not listed in the rating schedule, an analogous rating is to be assigned. Based on the facts found, the DC most appropriate to the findings and that results in the highest evaluation should be selected. **Reference:** For more information on analogous ratings, see * [M21-1, Part V, Subpart ii, 3.D.1.c](), and * [M21-1, Part V, Subpart iv, 1.C.2.a and b](). ## 5. Evaluating Musculoskeletal Disabilities of the Feet **Introduction**| | This topic contains information on evaluating musculoskeletal disabilities of the feet, including * selecting a DC for foot disabilities * identifying the digits of the foot * assigning separate evaluations for multiple foot disabilities * evaluating * arthritis of the minor joints of the toes, and * plantar fasciitis * definition of metatarsalgia or Morton’s disease, and * evaluating * metatarsalgia or Morton’s disease, and * metatarsalgia and * plantar fasciitis, and * pes planus. Change Date| | February 8, 2021 ### V.iii.1.B.5.a. Selecting a DC for Foot Disabilities Foot injuries are rated under [38 CFR 4.71a, DC 5284](). The application of this DC is limited to disabilities resulting from actual injuries to the foot, as opposed to disabilities caused by, for example, degenerative conditions. However, conditions that are not specifically listed under [38 CFR 4.71a, DC 5284]() may be rated by analogy under DC 5284. [38 CFR 4.71a, DC 5284]() does not apply to the other conditions of the foot specifically listed under [38 CFR 4.71a, DCs 5276 through 5283 and 5269](). The listed conditions must be rated under the specified DCs and cannot be rated by analogy under [38 CFR 4.71a, DC 5284]().In cases where a foot injury _and_ either arthritis or another foot disability is involved * consider functional impairment, and * determine whether, depending on the nature of the disability and history of injury, it is more advantageous to evaluate the condition under [38 CFR 4.71a, DC 5284]() or another DC. **Reminder:** Consider the guidance in [M21-1, Part V, Subpart iv, 1.C.4.b]() concerning applicability of the bilateral factor when a DC provides one evaluation for a bilateral condition.**References:** For more information on * limited applicability of [38 CFR 4.71a, DC 5284]() to foot injuries, see [_Yancy v. McDonald_](), 27 Vet.App. 484 (2016) * prohibition of evaluating specific foot disabilities otherwise listed in [38 CFR 4.71a]() analogously under [38 CFR 4.71a, DC 5284](), see [_Copeland v. McDonald_](), 27 Vet.App. 333 (2015), and * applying [38 CFR 4.59]() to disabilities of minor joints, see [M21-1, Part V, Subpart iii, 1.A.1.l](). ### V.iii.1.B.5.b. Identifying the Digits of the Foot Follow the guidelines listed below to accurately specify the injured digits of the foot. * Refer to the digits of the foot as * first or great toe * second * third * fourth, or * fifth. * Each digit, except the great toe, includes three phalanges * the proximal phalanx (closest to the ankle) * the middle phalanx, and * the distal phalanx (closest to the tip of the 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 great toes each have only two phalanges, the proximal phalanx and the distal phalanx. Therefore, each great toe has only a single joint, called the _**interphalangeal**_ (IP) joint. * The joints connecting the phalanges in the feet to the metatarsals are the _**metatarsophalangeal**_ (MTP) joints. * Designate either right or left for the digits of the foot. **Note:** If the location of the injury is unclear, obtain x-rays to clarify the exact point of injury. ### V.iii.1.B.5.c. Assigning Separate Evaluations for Multiple Foot Disabilities [38 CFR 4.14]() requires that the evaluation of the same disability and/or the same manifestation under various diagnoses is to be avoided. The compact anatomical structure of the foot as well as the inter-related physiological functioning may make it difficult to differentiate the etiology of certain disability symptoms. When multiple SC foot disabilities are present but the etiology of the symptoms cannot be separated, assign a single disability evaluation for the predominant symptoms. If, however, the etiology of the symptoms can be delineated, separate disability evaluations may be assigned under multiple DCs for foot disabilities provided that the principles of [38 CFR 4.14]() have not been violated. **Reference:** For more information on evaluating SC and non-service-connected (NSC) symptoms that cannot be separated, see [M21-1, Part V, Subpart ii, 3.D.2.c](). ### V.iii.1.B.5.d. Evaluating Arthritis of the Minor Joints of the Toes For guidance on evaluating arthritis of a group of minor joints of the toes refer to the table below. | **If arthritis ...**| **Then ...** * is degenerative * affects a group of minor joints in one foot * is documented by x-ray evidence * results in LOM, **_and_** * is confirmed by satisfactory evidence of painful motion, pain on use or other findings such as swelling | assign a 10-percent evaluation under [38 CFR 4.71a, DC 5003](). * is degenerative * affects minor joint groups in _both_ feet, **_and_** * is documented by x-ray evidence, **_but_** * does not result in LOM | assign a 10-percent evaluation under [38 CFR 4.71a, DC 5003](). **Exception:** Assign a 20-percent evaluation if there are occasional incapacitating exacerbations). is post-traumatic| evaluate under [38 CFR 4.71a, DC 5010-5284]() with consideration given to [38 CFR 4.59]() when warranted. **References:** For more information on * assigning evaluations under [38 CFR 4.71a, DC 5003]() when a compensable rating cannot be assigned under a DC for LOM of a joint, see [M21-1, Part V, Subpart iii, 1.C.4.b](), and * considering painful motion when evaluating functional loss for purpose of applying [38 CFR 4.71a, DC 5003](), pursuant to the holding in [_Mitchell v. Shinseki_](), 25 Vet.App. 32 (2011), see [M21-1, Part V, Subpart iii, 1.A.1.e](). ### V.iii.1.B.5.e. Evaluating Plantar Fasciitis Evaluate plantar fasciitis under [38 CFR 4.71a, DC 5269](). The most common symptom seen with plantar fasciitis is heel pain. The following considerations apply when evaluating the heel pain. * When painful motion with joint or periarticular pathology is present and is a symptom of the plantar fasciitis, [38 CFR 4.59]() is applicable. However, at least a 10-percent evaluation would most often be warranted under [38 CFR 4.71a, DC 5269]() without consideration of [38 CFR 4.59](). * When SC is established for pes planus and plantar fasciitis, evaluate the symptoms of both conditions together under the DC warranting the highest evaluation for the combined impairment. * Pes planus is characterized by pain on manipulation and use of the feet or other foot pain as included in the higher evaluation criteria. The evaluation criteria for pes planus and plantar fasciitis are similar enough that providing separate evaluations will compensate the same facet of disability, foot pain, violating the prohibition against pyramiding in [38 CFR 4.14](). * If, however, one or both conditions resulted from an injury to the foot, an evaluation for the combined conditions under [38 CFR 4.71a, DC 5284]() may be assigned in lieu of evaluation under either the pes planus or plantar fasciitis criteria when doing so is more advantageous. **Reference:** For more information on rating by analogy, see * [M21-1, Part V, Subpart iv, 1.C.2](), and * [M21-1, Part V, Subpart ii, 3.D.1.c](). ### V.iii.1.B.5.f. Definition of Metatarsalgia or Morton’s Disease ** _Metatarsalgia_** means pain in the forefoot – under the metatarsal heads. **_Morton’s Disease_** or **_Morton’s Neuroma_** refers to a painful lesion of a plantar interdigital nerve. ### V.iii.1.B.5.g. Evaluating Metatarsalgia or Morton’s Disease Anterior metatarsalgia of any type, to include cases due to Morton’s Disease, will be evaluated under [38 CFR 4.71a, DC 5279](). The DC provides for an evaluation of 10 percent regardless of whether the condition is unilateral or bilateral. ### V.iii.1.B.5.h. Evaluating Metatarsalgia and Plantar Fasciitis Since metatarsalgia refers to pain in the forefoot while plantar fasciitis is associated with pain in the heel, the symptoms should generally not overlap and separate evaluations may be assigned _unless_ assessment of the evidence reveals that separate evaluation would be in violation of the pyramiding rules at [38 CFR 4.14](). ### V.iii.1.B.5.i. Evaluating Metatarsalgia and Pes Planus Do not assign separate evaluations for pes planus and metatarsalgia. * Pes planus is accompanied by pain on manipulation and use of the feet or other foot pain, as included in the higher evaluation criteria. The evaluation criteria are similar enough that providing separate evaluations will compensate the same facet of disability, foot pain, violating the prohibition against pyramiding in [38 CFR 4.14](). * Assign a single evaluation for pes planus with metatarsalgia using the predominant DC. * Do not rate by analogy when there is an applicable DC. * If, however, one or both conditions resulted from an injury to the foot, an evaluation for the combined conditions under [38 CFR 4.71a, DC 5284]() may be assigned in lieu of evaluation under either the pes planus or metatarsalgia criteria when doing so is more advantageous.