Part V, Subpart iii, Chapter 1, Section APainful Motion and Functional Loss

Revised 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.

3Principles 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.

Revised 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.

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.

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.

4Examples 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.

Revised 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.