Part V, Subpart iii, Chapter 1, Section FOther Musculoskeletal Considerations

Revised February 8, 2021

V.iii.1.F.1.a#SC for Fractures

Decision makers must not automatically award service connection (SC) for fracture or fracture residuals based on a mere service treatment record (STR) reference to a fracture.

• Where SC of a fracture or fracture residuals is claimed , SC will be established when sufficient evidence, such as x-rays, a surgical report, casting, or a physical evaluation board report, documents the fracture.
• If SC of a fracture has not been claimed and objective evidence such as x-ray report documents an in-service fracture, invite a claim for SC for the fracture.

The following considerations apply when granting SC for a fracture:

• SC will be established for a healed fracture even without current residual limited motion or functional impairment of a joint.
• Assign a diagnostic code (DC) consistent with the location of the fracture. The fracture will be rated as noncompensable in the absence of any disabling manifestations.

Reference: For more information on unclaimed chronic disabilities found in STRs, see M21-1, Part II, Subpart iii, 2.G.2.

V.iii.1.F.1.b#SC for Osteopenia

Osteopenia is clinically defined as mild bone density loss that is often associated with the normal aging process. Low bone density does not necessarily mean that an individual is losing bone, as this may be a normal variant. Osteopenia is comparable to a laboratory finding which is not subject to service-connected (SC) compensation. Use the table below to determine the appropriate action to take when SC for osteopenia has been granted.

Note: Osteoporosis, in contrast to osteopenia, is considered a disease entity characterized by severe bone loss that may interfere with mechanical support, structure, and function of the bone. SC for osteoporosis under 38 CFR 4.71a, DC 5013 is warranted when the requirements are otherwise met.

V.iii.1.F.1.c#Evaluating Fibromyalgia

The criteria for evaluation of fibromyalgia under 38 CFR 4.71a, DC 5025 does not exclude assignment of separate evaluations when disabilities are diagnosed secondary to fibromyalgia. This includes, but is not limited to, disability diagnoses for which symptoms are included in the evaluation criteria under 38 CFR 4.71a, DC 5025, such as

• depression
• anxiety
• headache, and
• irritable bowel syndrome.

Notes:

• If signs and symptoms are not sufficient to warrant a diagnosis of a separate condition, then they are evaluated with the musculoskeletal pain and tender points under 38 CFR 4.71a, DC 5025.
  • Widespread musculoskeletal pain characteristic of fibromyalgia does not warrant assignment of separate evaluations for affected joints when only fibromyalgia is diagnosed.
  • Co-existing, diagnosed musculoskeletal disabilities are evaluated separately.
• The same signs and symptoms cannot be used to assign separate evaluations under different DCs, per 38 CFR 4.14.
  • Widespread musculoskeletal pain associated with fibromyalgia is not necessarily synonymous with painful motion of joint or periarticular pathology.
  • Assignment of a compensable evaluation under 38 CFR 4.71a, DC 5025 for fibromyalgia with widespread musculoskeletal pain does not prevent assignment of a compensable evaluation under 38 CFR 4.59 for a separately diagnosed disability associated with painful motion of joint or periarticular pathology.

References: For more information on

• evaluating chronic pain syndrome (somatic symptom disorder), see M21-1, Part V, Subpart iii, 13.1.i, and
• evaluating co-existing fibromyalgia and mental disorders, see M21-1, Part V, Subpart iii, 13.1.h.

V.iii.1.F.1.d#Considering Conflicting Decisions Regarding LOU of an Extremity

Forward the claims folder to Compensation Service, for an advisory opinion under M21-1, Part X, Subpart v, 1.A.2 to resolve a conflict if

• the Insurance Center determines loss of use (LOU) of two extremities prior to rating consideration involving the same issue, and
• the determination conflicts with the proposed rating decision.

Note: This issue will generally be brought to the attention of the rating activity as a result of the type of personal injury, correspondence, or some indication in the claims folder that the insurance activity is involved.

V.iii.1.F.1.e#Applying the Amputation Rule

The combined evaluation for disabilities of an extremity shall not exceed the evaluation for the amputation at the elective level, were amputation to be performed. The amputation rule is included in the musculoskeletal section of the rating schedule and, consequently, applies only to musculoskeletal disabilities and not to disabilities affecting other body systems.Notes:

• Any peripheral nerve injury associated with the musculoskeletal injury will be considered when applying the amputation rule.
• Actual amputation with associated painful neuroma will be evaluated at the next-higher site of elective reamputation.
• The amputation rule does not apply to evaluations of peripheral nerve disabilities of the extremities including, but not limited to, diabetic neuropathy, radiculopathy/sciatica due to a spinal disorder, or peripheral nerve injuries of non-musculoskeletal etiology.
• The amputation rule does not apply to bilateral evaluations assigned under single DCs found in 38 CFR 4.71a, such as those assigned for bilateral foot disabilities, except when being compared to a bilateral amputation of the same extremities.

References: For more information on the

• amputation rule, see
  • 38 CFR 4.68, and
  • Moyer v. Derwinski, 2 Vet.App. 289 (1992)
• application of the amputation rule to rating decisions for osteomyelitis, see M21-1, Part V, Subpart iii, 1.D.1.g
• application of the amputation rule to rating decisions for muscle injuries, see M21-1, Part V, Subpart iii, 1.E.2.j, and
• Veterans Benefits Management System – Rating (VBMS-R) amputation rule instructions, see the VBMS Job Aid – Amputation Rule for VBMS-R.

V.iii.1.F.1.f#NSC Amputation Eliminating a Distal SC Disability

For guidance on disability evaluation considerations when an non-service-connected (NSC) disability results in amputation that eliminates a distal SC disability, see M21-1, Part V, Subpart ii, 3.D.5.c.

V.iii.1.F.1.g#Recognizing Variations in Musculoskeletal Development and Appearance

Individuals vary greatly in their musculoskeletal development and appearance. Functional variations are often seen and can be attributed to

• the type of individual, and
• his/her inherited or congenital variations from the normal.

V.iii.1.F.1.h#Considering Notable Congenital or Developmental Defects

Give careful attention to congenital or developmental defects such as

• absence of parts
• subluxation (partial dislocation of a joint)
• deformity or exostosis (bony overgrowth) of parts, and/or
• accessory or supernumerary (in excess of the normal number) parts.

Note congenital defects of the spine, especially

• spondylolysis
• spina bifida
• unstable or exaggerated lumbosacral joints or angle, or
• incomplete sacralization.

Notes:

• Do not automatically classify spondylolisthesis as a congenital condition, although it is commonly associated with a congenital defect.
• Do not automatically classify joint subluxation as a developmental or congenital condition.
• Do not overlook congenital diastasis of the rectus abdominus, hernia of the diaphragm, and the various myotonias.

References: For more information on

• congenital or developmental defects, see
  • 38 CFR 4.9, and
  • M21-1, Part V, Subpart ii, 2.E, and
• knee subluxation, see M21-1, Part V, Subpart iii, 1.B.4.

V.iii.1.F.1.i#Changes in the Rating Schedule

The rating criteria for musculoskeletal disabilities have undergone revisions. The most recent large-scale revisions were effective on February 7, 2021. Note: These changes in rating criteria

• are not considered liberalizing, and
• should not be the basis for a reduction in disability rating unless medical evidence establishes that the disability has actually improved.

References: For more information on the

• history of changes to the rating schedule for musculoskeletal disabilities
  • through 2014, refer to the Board of Veterans Appeals Research Tools website for historical 38 CFR 4.71a (or other applicable references)
  • from 2015 and after, see the Electronic Code of Federal Regulations website (using the browse feature for the date needed), and
  • listed by DC, see 38 CFR Part 4, Appendix A, and
• procedures for rating musculoskeletal disabilities prior to the February 7, 2021, update to the rating schedule, see the attachment Historical_M21-1III_iv_4_SecA___1-21-21.docx.