Select Page

M21-1, Part III, Subpart iv, Chapter 4, Section B – Musculoskeletal Diseases and Muscle Injuries

Overview


In This Section
This section contains the following topics:
Topic
Topic Name
1
2
3
4
5
6
7

1.  RA

 


Introduction

This topic contains information about RA, including

Change Date

May 11, 2015

III.iv.4.B.1.a.  Characteristics of RA

The following are characteristics of rheumatoid arthritis (RA), also diagnosed as atrophic or infectious arthritis, or arthritis deformans:
  • the onset
    • occurs before middle age, and
    • may be acute, with a febrile attack, and
  • the symptoms include a usually laterally symmetrical limitation of movement
    • first affecting proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints
    • next causing atrophy of muscles, deformities, contractures, subluxations, and
    • finally causing fibrous or bony ankylosis (abnormal adhesion of the bones of the joint).
Important:  Marie-Strumpell disease, also called rheumatoid spondylitis or ankylosing spondylitis, is not the same disease as RA.  RA and Marie-Strumpell disease have separate and distinct clinical manifestations and progress differently.
Reference:  For more information on evaluating ankylosing spondylitis, see M21-1, Part III, Subpart iv, 4.A.5.d.

III.iv.4.B.1.b.  Periods of Flares and Remissions of RA

The symptoms of RA come and go, depending on the degree of tissue inflammation.  When body tissues are inflamed, the disease is active.  When tissue inflammation subsides, the disease is inactive (in remission).
Remissions can occur spontaneously or with treatment, and can last weeks, months, or years.  During remissions, symptoms of the disease disappear, and patients generally feel well.  When the disease becomes active again (relapse), symptoms return.
Note:  The return of disease activity and symptoms is called a flare.  The course of RA varies from patient to patient, and periods of flares and remissions are typical.

III.iv.4.B.1.c.  Clinical Signs of RA

The table below contains information about the clinical signs of RA.
Stage of Disease
Symptoms
Initial
  • Periarticular and articular swelling, often free fluid, with proliferation of the synovial membrane, and
  • atrophy of the muscles.
Note:  Atrophy is increased to wasting if the disease is unchecked.
Late
  • Deformities and contractures
  • subluxations, or
  • fibrous or bony ankylosis.

III.iv.4.B.1.d.  Radiologic Changes Found in RA

The table below contains information about the radiologic changes found in RA.
Stage of Disease
Radiologic Changes
Early
  • Slight diminished density of bone shadow, and
  • increased density of articular soft parts without bony or cartilaginous changes of articular ends.
Note:  RA and some other types of infectious arthritis do not require x-ray evidence of bone changes to substantiate the diagnosis, since x-rays do not always show their existence.
Late
  • Diminished density of bone shadow
  • loss of bone substance or articular ends, and
  • subluxation or ankylosis.

III.iv.4.B.1.e.  Disability Factors Associated With RA

Give special attention to the following disability factors associated with RA in addition to, or in advance of, demonstrable x-ray changes:
  • muscle spasms
  • periarticular and articular soft tissue changes, such as
    • synovial hypertrophy
    • flexion contracture deformities
    • joint effusion, and
    • destruction of articular cartilage, and
  • constitutional changes such as
    • emaciation
    • dryness of the eyes and mouth (Sjogren’s syndrome)
    • pulmonary complications, such as inflammation of the lining of the lungs or lung tissue
    • anemia
    • enlargement of the spleen
    • muscular and bone atrophy
    • skin complications, such as nodules around the elbows or fingers
    • gastrointestinal symptoms
    • circulatory changes
    • imbalance in water metabolism, or dehydration
    • vascular changes
    • cardiac involvement, including pericarditis
    • dry joints
    • low renal function
    • postural deformities, and
    • low-grade edema of the extremities.
Reference:  For more information on the features of RA, seehttp://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp.

III.iv.4.B.1.f.  Points to Consider in Rating Decisions Involving Joints Affected by RA

In the DIAGNOSIS field of the rating decision, state which joints are affected by RA as evidenced by any of the following findings:
  • synovial hypertrophy or joint effusion
  • severe postural changes; scoliosis; flexion contracture deformities
  • ankylosis or limitation of motion (LOM) of joint due to bony changes, and/or
  • destruction of articular cartilage.

 

2.  Degenerative Arthritis

 


Introduction

This topic contains information about degenerative arthritis, including

Change Date

January 11, 2016

III.iv.4.B.2.a.  Characteristics of Degenerative Arthritis

The following are characteristics of degenerative arthritis, also diagnosed as osteoarthritis or hypertrophic arthritis:
  • The onset generally occurs after the age of 45.
  • It has no relation to infection.
  • It is asymmetrical (more pronounced on one side of the body than the other).
  • There is limitation of movement in the late stages only.

III.iv.4.B.2.b.  Diagnostic Symptoms of Degenerative Arthritis

Diagnostic symptoms of degenerative arthritis include
  • the presence of Heberden’s nodes or calcific deposits in the terminal joints of the fingers with deformity
  • ankylosis, in rare cases
  • hyperostosis and irregular, notched articular surfaces of the joints
  • destruction of cartilage
  • bone eburnation, and
  • the formation of osteophytes.
Note:  The flexion contracture deformities and severe constitutional symptoms described under RA do not usually occur in degenerative arthritis.

III.iv.4.B.2.c.  Radiologic Changes Found in Degenerative Arthritis

The table below contains information about the radiologic changes found in degenerative arthritis.
Stage
Radiologic Changes
Early
Delicate spicules of calcium at the articular margins without
  • diminished density of bone shadow, and
  • increased density of articular of parts.
Late
  • Ridging of articular margins
  • hyperostosis
  • irregular, notched articular surfaces, and
  • ankylosis only in the spine.

III.iv.4.B.2.d.  Symptoms of Degenerative Arthritis of the Spine and Pelvic Joints

Degenerative arthritis of the spine and pelvic joints is characterized clinically by the same general characteristics as arthritis of the major joints except that
  • limitation of spine motion occurs early
  • chest expansion and costovertebral articulations are not usually affected
  • referred pain is commonly called “intercostal neuralgia” and “sciatica,” and
  • localized ankylosis may occur if spurs on bodies of vertebrae impinge.

III.iv.4.B.2.e.  Points to Consider in the Rating Decision for Degenerative and Traumatic Arthritis

Degenerative and traumatic arthritis require x-ray evidence of bone changes to substantiate the diagnosis.
Note:  In evaluating arthritis of the spine, the principles for extending service connection (SC) to joints affected by the subsequent development of degenerative arthritis (as contemplated under 38 CFR 4.71a, diagnostic code (DC) 5003), is not dependent on the choice of DC.
Example:  Veteran is service-connected (SC) for degenerative arthritis of the spine under 38 CFR 4.71a, DC 5242 and subsequently develops degenerative arthritis in the right elbow, with no intercurrent cause noted.  In this case, the principles of extending SC to joints, as contemplated in 38 CFR 4.71a, DC 5003, also apply even though the Veteran is rated under 38 CFR 4.71a, DC 5242.  Thus, SC for arthritis of the right elbow may be established.
Reference:  For more information on considering x-ray evidence when evaluating arthritis and non-specific joint pain, see

 

3.  LOM in Arthritis Cases

 


Introduction

This topic contains information on LOM due to arthritis, including

Change Date

September 23, 2016

III.iv.4.B.3.a.  Arthritis Compensable Under DCs Based on ROM

For a joint or group of joints affected by degenerative arthritis (or a condition evaluated using the arthritis criteria such as traumatic arthritis), first attempt to assign an evaluation using the DC for range of motion (ROM) of the affected joint (38 CFR 4.71a, DC 5200-series).
When the requirements for compensable LOM of a joint are met under a DC other than 38 CFR 4.71a, DC 5003, hyphenate that DC in the conclusion with a preceding “5003.”
Example:  Degenerative arthritis of the knee manifested by limitation of knee extension justifying a 10-percent evaluation under 38 CFR 4.71a, DC 5261 would use the hyphenated DC “5003-5261.”
Exception:  If other joints affected by arthritis are compensably evaluated in the same rating decision, use only the DC appropriate to these particular joints which supports the assigned evaluation and omit the modifying “5003.”

III.iv.4.B.3.b.  Joint Conditions Not Compensable Under DCs Not Based on ROM

Whenever LOM due to arthritis is noncompensable under codes appropriate to a particular joint, assign 10 percent under 38 CFR 4.71a, DC 5003 for each major joint or group of minor joints affected by limited or painful motion as prescribed under 38 CFR 4.71a, DC 5003.
If there is no limited or painful motion, but there is x-ray evidence of degenerative arthritis, assign under 38 CFR 4.71a, DC 5003 either a 10- or a 20-percent evaluation for occasional incapacitating exacerbations, based on the involvement of two or more major joints or two or more groups of minor joints.
Important:  Do not combine under 38 CFR 4.25 a 10- or 20-percent evaluation that is based solely on x-ray findings with evaluation that are based on limited or painful motion.  See example in M21-1, Part III, Subpart iv, 4.B.4.d.
Reference:  For more information on assigning a minimum evaluation based on painful motion as provided in 38 CFR 4.59 in cases rated under 38 CFR 4.71a, DC 5003, see M21-1, Part III, Subpart iv, 4.A.1.a.

III.iv.4.B.3.c.  Reference:  Rating Decisions Involving LOM

For more information on rating decisions involving LOM, see

III.iv.4.B.3.d.  Arthritis Previously Rated as a Single Disability

The rating activity may encounter cases for which arthritis of multiple joints is rated as a single disability.
Use the information in the table below to process cases for which arthritis was previously evaluated as a single disability but the criteria for assignment of separate evaluations for affected joints was met at the time of the prior decision.
If …
Then …
  • the separate evaluation of the arthritic disability results in no change in the combined degree previously assigned, and
  • a rating decision is required
reevaluate using the current procedure with the same effective date as previously assigned.
reevaluating the arthritic joint separately results in an increased combined evaluation
apply 38 CFR 3.105(a) to retroactively increase the assigned evaluation.
reevaluating the arthritic joint separately results in a reduced combined evaluation
Exception:  Do not apply 38 CFR 3.105(a) if the assigned percentage is protected under 38 CFR 3.951.
Reference:  For more information on protected rating decisions, see M21-1, Part III, Subpart iv, 8.C.

III.iv.4.B.3.e.  Using DCs 5013 Through 5024 in Rating Decisions

Use the table below to evaluate cases that use 38 CFR 4.71a, DCs 5013 through 5024.
If the DC of the case is …
Then …
evaluate the case as RA, 38 CFR 4.71a, 5002.
evaluate the case according to the criteria for limited motion or painful motion under 38 CFR 4.71a, DC 5003, degenerative arthritis.
Note:  The provisions under 38 CFR 4.71a, DC 5003, regarding a compensable minimum evaluation of 10-percent for limited or painful motion apply to these DCs and no others.
Reference:  For more information on evaluations of 10 and 20 percent based on x-ray findings, see 38 CFR 4.71a, DC 5003, Note (2).

III.iv.4.B.3.f.  Considering the Effects of a Change in Diagnosis in Arthritis Cases

A change of diagnosis among the various types of arthritis, particularly if joint disease has been recognized as SC for several years, has no significant bearing on the question of SC.
Note:  In older individuals, the effects of more than one type of joint disease may coexist.
Reference:  For information on evaluating RA, see 38 CFR 4.71a, DC 5002.

 

4.  Examples of Rating Decisions for LOM in Arthritis Cases

 


Introduction

This exhibit contains four examples of rating decisions for LOM in arthritis cases including

Change Date

January 11, 2016

III.iv.4.B.4.a.  Example of Degenerative Arthritis With Separately Compensable Joints Affected

Situation:  The Veteran has residuals of degenerative arthritis with limitation of abduction of the right shoulder (major) to 90 degrees and limitation of flexion of the right knee to 45 degrees.

Coded Conclusion:

1. SC (VE INC)
5003-5201 Degenerative arthritis, right shoulder (dominant)
20% from 12-14-03
5260 Degenerative arthritis, right knee
10% from 12-14-03
COMB 30% from 12-14-03
Rationale:  The shoulder and knee separately meet compensable requirements under 38 CFR 4.71a, DCs 5201 and 38 CFR 4.71a, DC 5260, respectively.

III.iv.4.B.4.b.  Example of Degenerative Arthritis Evaluated Based on X-Ray Evidence Only

Situation:  The Veteran has x-ray evidence of degenerative arthritis of both knees without
  • limited or painful motion of any of the affected joints, or
  • incapacitating episodes.

Coded Conclusion:

1. SC (PTE INC)
5003 Degenerative arthritis of the knees, x-ray evidence
10% from 12-30-01
Rationale:  There is no limited or painful motion in either joint, but there is x-ray evidence of arthritis in more than one joint to warrant a 10-percent evaluation under38 CFR 4.71a, DC 5003.

III.iv.4.B.4.c.  Example of Noncompensable Degenerative Arthritis of a Single Joint

Situation:  The Veteran has x-ray evidence of degenerative arthritis of the right knee without limited or painful motion.

Coded Conclusion:

1. SC (PTE INC)
5003 Degenerative arthritis, right knee, x-ray evidence only
0% from 12-30-01
Rationale:  There is no limited or painful motion in the right knee or x-ray evidence of arthritis in more than one joint to warrant a compensable evaluation under 38 CFR 4.71a, DC 5003.

III.iv.4.B.4.d.  Example of Degenerative Arthritis Evaluated Based on X-Ray Evidence Only and Another Compensable Evaluation

Situation:  The Veteran has x-ray evidence of degenerative arthritis of both knees without limited or painful motion or incapacitating exacerbations.  The Veteran also has residuals of degenerative arthritis with limitation of abduction of the right shoulder (major) to 90 degrees.
Coded Conclusion:
1. SC (VE INC)
5003-5201
Degenerative arthritis, right shoulder (dominant)
20% from 12-14-03
5260
Degenerative arthritis, right knee
0% from 12-14-03
5260
Degenerative arthritis, left knee
0% from 12-14-03
COMB
20% from 12-14-03
Rationale:  Since the shoulder condition meets compensable requirements under38 CFR 4.71a, DCs 5201, each knee condition must be evaluated under separate DCs.  Based on Note (1) under 38 CFR 4.71a, DC 5003, ratings of arthritis based on x-ray findings only (without limited or painful motion or incapacitating exacerbations) cannot be combined with ratings of arthritis based on LOM.

 

5.  Osteomyelitis

 


Introduction

This topic contains information about osteomyelitis, including

Change Date

May 11, 2015

III.iv.4.B.5.a.  Requiring Constitutional Symptoms for Assignment of a 100-Percent or 60-Percent Evaluation Under DC 5000

Constitutional symptoms are a prerequisite to the assignment of either the 100-percent or 60-percent evaluations under 38 CFR 4.71a, DC 5000.
Since both the 60- and 100-percent evaluations are based on constitutional symptoms, neither is subject to the amputation rule.
Reference:  For more information on the amputation rule, see 38 CFR 4.68.

III.iv.4.B.5.b.  HistoricalEvaluation for Osteomyelitis

Both the 10-percent evaluation and that part of the 20-percent evaluation that is based on “other evidence of active infection within the last five years” are
  • historical evaluations, and
  • based on recurrent episodes of osteomyelitis.
Note:  The 20-percent historical evaluation based on evidence of active infection within the past five years must be distinguished from the 20-percent evaluation authorized when there is a discharging sinus.

III.iv.4.B.5.c.  Assigning Historical Evaluations for Osteomyelitis

An initial episode of active osteomyelitis is not a basis for either of the historical evaluations.
Assign the historical evaluation as follows:
  • When the first recurrent episode of osteomyelitis is shown
    • assign a 20-percent historical evaluation, and
    • extend the evaluation for five years from the date of examination showing the osteomyelitis to be inactive.
  • Assign a closed evaluation at the expiration of the five-year extension.
  • Assign the 10-percent historical evaluation only if there have been two or more recurrences of active osteomyelitis following the initial infection.

III.iv.4.B.5.d.  Reasons to Discontinue a Historical  Evaluation for Osteomyelitis

Do not discontinue the historical evaluation, even if treatment includes saucerization, sequestrectomy, or guttering, because the osteomyelitis is not considered cured.
Exception:  If there has been removal or radical resection of the affected bone
  • consider osteomyelitis cured, and
  • discontinue the historical evaluation.

III.iv.4.B.5.e.  Assigning a 10-Percent Evaluation for Active Osteomyelitis

When the evaluation for amputation of an extremity or body part affected by osteomyelitis would be zero percent, assign a 10-percent evaluation if there is active osteomyelitis.
References:  For more information on

III.iv.4.B.5.f.  Application of the Amputation Rule to Evaluations for Osteomyelitis

Use the following table to determine how the amputation rule affects evaluations assigned for osteomyelitis.
If the osteomyelitis evaluation is …
Then the amputation rule …
10 percent based on active osteomyelitis of a body part where the amputation evaluation would normally be zero percent
does not apply.
  • 10 percent based on active osteomyelitis of a body part where the amputation evaluation would normally be zero percent, or
  • 30 percent or less under 38 CFR 4.71a, DC 5000and
  • the 10-percent evaluation is combined with evaluations for
    • ankylosis
    • limited motion
    • nonunion or malunion
    • shortening, or
    • other musculoskeletal impairment
applies to the combined evaluation.
60 percent based on constitutional symptoms of osteomyelitis, per 38 CFR 4.71a, DC 5000
does not apply since the 60-percent evaluation is based on constitutional symptoms.
Reference:  For more information on the amputation rule, see

6.  Examples of the Proper Rating Procedure for Osteomyelitis

 


Introduction

This exhibit contains eight examples of the proper procedure for rating osteomyelitis, including

Change Date

May 11, 2015

III.iv.4.B.6.a.  Example of Evaluating Osteomyelitis Based on a History of a Single Active Initial Episode

Situation:  The Veteran was diagnosed with osteomyelitis in service with discharging sinus.  At separation from service the osteomyelitis was inactive with no involucrum or sequestrum.  There is no evidence of recurrence.
Result:  As there has been no recurrence of active osteomyelitis following the initial episode in service, the historical evaluation of 20 percent is not for application.  The requirements for a 20-percent evaluation based on activity are not met either.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia
0% from 12-2-93

III.iv.4.B.6.b.  Example of Evaluating an Active Initial Episode of Osteomyelitis

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.a, but the Veteran had a discharging sinus at the time of separation from service.
Result:  The Veteran meets the criteria for a 20-percent evaluation based on a discharging sinus.  Schedule a future examination to ascertain the date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
20% from 12-2-93

III.iv.4.B.6.c.  Example of Evaluating Osteomyelitis Following Review Exam for Initial Active Episode

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.b.  Subsequent review examination reveals the sinus tract was healed and there is no other evidence of active infection.
Result:  Since the Veteran has not had a recurrent episode of osteomyelitis since service, a historical rating of 20 percent is not for application.  Take rating action under 38 CFR 3.105(e).
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 12-2-93
0% from 3-1-95

III.iv.4.B.6.d.  Example of Evaluating Osteomyelitis With Current Discharging Sinus

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.b.  The Veteran is hospitalized July 21, 1996, with active osteomyelitis of the right tibia shown with discharging sinus.  There is no involucrum, sequestrum, or constitutional symptom.  Upon release from the hospital the discharging sinus is still present.
Result:  Assign the 20-percent evaluation based on evidence showing draining sinus from the proper effective date.  Schedule a future examination to ascertain date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
0% from 3-1-95
20% from 7-21-96

III.iv.4.B.6.e.  Example of Evaluating Osteomyelitis With a Historical Evaluation Following a Single Recurrence With Scheduled Reduction Due to Inactivity

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.d.  A routine future examination was conducted on July 8, 1997, showing the osteomyelitis to be inactive.  There was no discharging sinus, no involucrum, sequestrum, or constitutional symptom.  The most recent episode of active osteomyelitis (July 21, 1996) constitutes the first “recurrent” episode of active osteomyelitis.
Result:  Continue the previously assigned 20-percent evaluation, which was awarded on the basis of discharging sinus as a historical evaluation for five years from the examination showing inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 7-21-96
0% from 7-8-02

III.iv.4.B.6.f.  Example of Evaluating a Recurrence of Osteomyelitis

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.e.  In October 1999, the Veteran was again found to have active osteomyelitis with a discharging sinus, without involucrum, sequestrum, or constitutional symptoms.
Result:  Continue the 20-percent evaluation.  Reevaluation is necessary to remove the future reduction to zero percent, and to schedule a future examination to establish the date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
20% from 7-21-96

III.iv.4.B.6.g.  Example of Evaluating Osteomyelitis Following Second Recurrence

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.f.  A review examination was conducted on April 8, 2000.  The examination showed the discharging sinus was inactive, and there was no other evidence of active osteomyelitis.  The most recent episode of osteomyelitis (October 1999) constitutes the second “recurrent” episode of active osteomyelitis.
Result:  The historical evaluations of 20 and 10 percent both apply.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 7-21-96
10% from 4-8-05

III.iv.4.B.6.h.  Example of Evaluating Osteomyelitis Following Curative Resection of Affected Bone

Situation:  Same facts as example shown in M21-1, Part III, Subpart iv, 4.B.6.g.  The Veteran was hospitalized June 10, 2002, with a recurrent episode of active osteomyelitis.  A radical resection of the right tibia was performed and at hospital discharge (June 21, 2002), the osteomyelitis was shown to be cured.
Result:  Assign a temporary total evaluation of 100 percent under 38 CFR 4.30with a 1-month period of convalescence.  Following application of 38 CFR 3.105(e), reduce the evaluation for osteomyelitis to zero percent as an evaluation for osteomyelitis will not be applied following cure by removal or radical resection of the affected bone.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, P.O.
20% from 7-21-96
100% from 6-10-02 (Par. 30)
20% from 8-1-02
0% from 10-1-02

 

7.  Muscle Injuries

 


Introduction

This topic contains information about rating muscle injuries, including


Change Date

October 24, 2017

III.iv.4.B.7.a.  Types of Muscle Injuries

A missile that penetrates the body results in two problems
  • it destroys muscle tissue in its direct path by crushing it, then
  • the temporary cavitation forces stretch the tissues adjacent to the missile track and result in additional injury or destruction.
Muscles are much more severely disrupted if multiple penetrating projectiles strike in close proximity to each other.  Examples of this type of injury are
  • explosive device injuries
  • deforming or fragmenting rifle projectiles, or
  • any rifle projectile that strikes bone.
For additional information regarding types of injuries, the effects of explosions and projectiles, and symptoms and complications, refer to the table below.

Type of Injury

Initial Effects

Signs, Symptoms, and Complications

Gunshots Entrance and exit wounds result. The amount of damage and relative size of entrance and exit wounds depends on many factors such as

  • caliber of bullet
  • distance from victim
  • organs, bone, blood vessels, and other structures hit.
  • Exit wounds are generally larger than entrance wounds, and
  • bullets are essentially sterile when they reach the body but carry particles into wound which could be sources of infection.
Fragments from explosive devices Most result in decreased tissue penetration compared to denser rifle bullets. Multiple fragments in a localized area result in tissue disruption affecting a wide area.
Tears and lacerations Muscles that become isolated from nerve supply by lacerations will be non-functional.

 

  • Torn muscle fibers heal with very dense scar tissue, but the nerve stimulation will not cross this barrier.
  • Parts of muscle isolated from the nerve will most likely remain non-contractile resulting in a strength deficit proportional to amount of muscle tissue disrupted.
  • Treatment for small tears is symptomatic.
  • Large tears/lacerations may require reconstruction.
Through and through wound Injuring instrument enters and exits the body. Two wounds result

  • entrance wound, and
  • exit wound.
References:  For more information on

III.iv.4.B.7.b.  Standard Muscle Strength Grading System  for Examinations

Refer to the table below for information about how muscle strength is evaluated on an examination.

Numeric Grade

Corresponding Strength Assessment

Indications on Exam

(0)

absent

no contraction felt

(1)

trace

muscle can be felt to tighten but no movement is produced

(2)

poor

muscle movement is produced against gravity but cannot overcome resistance

(3)

fair

muscle movement is produced against gravity but cannot overcome resistance

(4)

good

muscle movement is produced against resistance, however, less than normal resistance

(5)

normal

muscle movement can overcome a normal resistance

III.iv.4.B.7.c.  Identification of MG in Examination Reports

The examination report must include information to adequately identify the MG affected by either

  • specifically noting which MG is affected, or
  • noting which muscles are involved so that the name of the muscles may be used to identify the MG affected.

III.iv.4.B.7.d.  General Criteria for Muscle Evaluations

Evaluation of muscle disabilities is the result of a multi-factorial consideration.  However, there are hallmark traits that are suggestive of certain corresponding evaluations.  Refer to the following table for additional information regarding these hallmark traits and the suggested corresponding disability evaluation.
If the evidence shows a history of … Then consider evaluating the muscle injury as …
open comminuted fracture with

  • muscle damage, or
  • tendon damage
severe.

Note:  This level of impairment is specified by regulation at 38 CFR 4.56(a).

through and through or deep penetrating wound by small high velocity missile or large low velocity missile with

  • debridement
  • prolonged infection, or
  • sloughing of soft parts, and
  • intermuscular scarring
at least moderately severe.
through and through injury with muscle damage no less than moderate.

Note:  This level of impairment is specified by regulation at 38 CFR 4.56(b).

retained fragments in muscle tissue at least moderate.
deep penetrating wound without

  • explosive effect of high velocity missile
  • residuals of debridement, or
  • prolonged infection
at least moderate.
Important:  No single factor is controlling for the assignment of a disability evaluation for a muscle injury. The entire evidence picture must be taken into consideration.
Reference:  For more information on assigning disability evaluations for muscle injuries, see

III.iv.4.B.7.e.  Fractures Associated With GSW/SFW

All fractures associated with a GSW and/or shell fragment wound (SFW) will be considered open because all of them involve an opening to the outside.  Most GSW/SFW fractures are also comminuted due to the shattering nature of the injury.

III.iv.4.B.7.f.  Determining Whether 38 CFR 4.55 Applies to Muscle Injuries

38 CFR 4.55 applies to certain combinations of muscle injuries and joint conditions.  Consider the provisions of 38 CFR 4.55 if

  • there are multiple MGs involved
  • the MG acts on a joint or joints, and/or
  • there is peripheral nerve damage to the same body part affected by the muscle.

III.iv.4.B.7.g.  Applying 38 CFR 4.55 to Muscle Injuries

If more than one MG is injured or affected or if the injured MG acts on a joint, conduct a preliminary review of the evidence to gather information needed to properly apply the provisions of 38 CFR 4.55.  The information needed will include whether the

  • affected MGs are in the same or different anatomic regions
  • MGs are acting on a single joint or multiple joints, and
  • joint or joints is/are ankylosed.
After the preliminary review is complete, use the evidence gathered and apply the following table to determine how 38 CFR 4.55 affects the evaluation of the muscle injury.
Step
Action
1
Does the MG(s) act on an ankylosed joint?
  • If yes, go to Step 2.
  • If no, go to Step 4
2
For MG(s) that act on an ankylosed joint, is the joint an ankylosed kneeand is MG XIII disabled?
  • If yes, grant separate evaluations for the ankylosed knee and the MG XIII injury.  For the MG XIII injury, assign the next lower level than that which would otherwise be assigned.  Then go to Step 3.
  • If no, then is the ankylosed joint the shoulder and are MGs I and II severely disabled?
    • If yes, then assign a single evaluation for the muscle injury and the shoulder ankylosis under DC 5200.  The evaluation will be at the level of unfavorable ankylosis.
    • If no, then no evaluation will be assigned for the muscle injury.  The combined disability arising from the ankylosis and the muscle injury will be evaluated as ankylosis.
3
For the injury to MG XIII with an associated ankylosed knee, are there other MG injuries in the same anatomical region affecting the pelvic girdle and/or thigh?
  • If no, then no additional change to the evaluation for the muscle injury is warranted.
  • If yes, do the affected MG injuries act on the ankylosed knee?
    • If yes, then no separate evaluation for the muscle injury to a MG other than MG XIII can be assigned, as indicated in Step 2.
    • If no, then for the MG XIII injury that acts on the knee and the injury to another MG of the pelvic girdle and thigh acting on a different joint, is the different joint ankylosed?
      • If yes, then no separate evaluation can be assigned for the other MG injury of the pelvic girdle and thigh, as indicated in Step 2.  No further action is warranted.
      • If no, then assign a single evaluation for the MG XIII injury and the injury to the other MG of the pelvic girdle and thigh anatomical region by determining the most severely injured MG and increasing by one level.
4
For muscle injury(ies) acting on unankylosed joint(s), is a single MG injury involved?
  • If yes, then grant a single evaluation for the muscle injury.
  • If no, then are the MG injuries in the same anatomical region?
    • If yes, go to Step 5.
    • If no, go to Step 6
5
Do the MGs in the same anatomical region act on a single joint?
  • If yes, are the MGs involved MG I and II acting on a shoulder joint?
    • If yes, then
      • assign separate disability evaluations for the MGs, but
      • the combined evaluation cannot exceed the evaluation for unfavorable ankylosis of the shoulder.
    • If no, then for the muscles in the same anatomical region acting on a single joint,
      • assign separate disability evaluations for the MGs, but
      • the combined evaluation must be less than the evaluation that would be normally assigned for unfavorable anklyosis of the joint involved.
  • If no, for the MGs in the same anatomical region acting on different joints, are the MG injuries compensable?
    • If yes, then assign a single disability evaluation for the affected MGs by
      • determining the evaluation for the most severely injured MG, and
      • increasing by one level and using as the combined evaluation.
    • If no, then assign a noncompensable evaluation for the combined MG injuries.
6
For MG injuries in different anatomical areas, is a single unankylosed joint affected?
  • If yes, are MG I and II affected and acting upon the shoulder?
    • If yes, then
      • assign separate disability evaluations for the muscle injuries, but
      • the combined evaluation cannot exceed the evaluation for unfavorable ankylosis of the shoulder.
    • If no, for the MG injuries in different anatomical areas affecting a single unankylosed joint (not including MG I and II acting on the shoulder)
      • assign separate disability evaluations for the muscle injuries, but
      • the combined evaluation must be lower than the evaluation that would be assigned for unfavorable ankylosis of the affected joint.
  • If no, then for MG injuries in different anatomical areas acting on different unankylosed joints, assign separate disability evaluations for each MG injury.
References:  For additional information on evaluating

III.iv.4.B.7.h.  Evaluating Joint Manifestations and Muscle Damage Acting on the Same Joint

A separate evaluation for joint manifestations and muscle damage acting on the same joint are prohibited if both conditions result in the same symptoms.
Although LOM is not directly discussed in 38 CFR 4.56, the DC provisions within38 CFR 4.73 describing the functions of various MGs are describing motion.
  • The muscles move the joint.
  • If the joint manifestation is LOM, that manifestation is already compensated through the evaluation assigned by a muscle rating decision.
  • Evaluating the same symptoms under multiple DCs is prohibited by 38 CFR 4.14.
Note:  Consider the degree of disability under the corresponding muscle DC and joint DC and assign the higher evaluation.
Exception:  Per 38 CFR 4.55(c)(1), if MG XIII is disabled and acts on an ankylosed knee, separate disability evaluations can be assigned for the muscle injury and the knee ankylosis.  However, the evaluation for the MG injury will be rated at the next lower level than that which would have otherwise been assigned.
Reference:  For additional information on applying 38 CFR 4.55 when evaluating muscle injuries and joint conditions, see M21-1, Part III, Subpart iv, 4.B.7.f andg.

III.iv.4.B.7.i.  Evaluating Damage to Multiple Muscles Within the Same MG

A separate evaluation cannot be assigned for each muscle within a single MG.  Muscle damage to any of the muscles within the group must be included in a single evaluation assigned for the MG.

III.iv.4.B.7.j.  Considering Peripheral Nerve Involvement in Muscle Injuries

When there is nerve damage associated with the muscle injury, use the table below to determine appropriate actions to take to evaluate the nerve damage and the muscle injury.
If … Then …
  • the nerve damage is in the same body part as the muscle injury,and
  • the muscle injury and the nerve damage affect the same functions of the affected body part
assign a single evaluation for the combined impairment by determining whether the nerve code or the muscle code will result in a higher evaluation. Assign the higher evaluation.
Note:  If the muscle and nerve evaluations are equal, evaluate with the DC with the highest maximum evaluation available.
  • the nerve damage is in the same body part as the muscle injury,and
  • the muscle injury and the nerve damage affect entirely different functions of the affected body part
assign separate evaluations for the nerve damage and the muscle injury.

III.iv.4.B.7.k.  Evaluating Muscle Injuries with Peripheral Nerve Conditions of Different Etiology

The provisions of 38 CFR 4.55 preclude the combining of a muscle injury rating with a peripheral nerve paralysis evaluation involving the same body part when the same functions are affected.  A muscle injury and a peripheral nerve paralysis of the same body part, originating from separate etiologies, may not be rated separately.

  • The exception to this rule is only when entirely different functions are affected.
  • Etiology of the disability is irrelevant in rendering a determination regarding combining evaluations for muscle injuries and peripheral nerve paralysis.

Example:  A Veteran is SC for GSW to the right leg MG XI at 10-percent.  He develops SC diabetic peripheral neuropathy many years later.  The peripheral neuropathy affects the external popliteal nerve.  Since MG XI and the external popliteal nerve both control the same functions, dorsiflexion of the foot and extension of the toes, only a single disability evaluation can be assigned under either 38 CFR 4.73, DC 5311 or 38 CFR 4.73, DC 8521, whichever is more advantageous.


III.iv.4.B.7.l.  Evaluating Scars Associated With Muscle Injuries

Use the table below to determine appropriate action to take when evaluating scars associated with muscle injuries.
If … Then …
there is scarring associated with the muscle injury assign a separate evaluation for the scar, even if noncompensable.
there is painful or unstable scarring associated with the muscle injury assign a separate compensable disability evaluation under 38 CFR 4.118, DC 7804.
there is scarring that results in functional loss under 38 CFR 4.118, DC 7805 that is compensable do not assign a separate evaluation if the body part affected and the functional impairment resulting from the scar are the same as the part and function affected by the muscle injury.
Reference:  For more information on assigning separate evaluations for the muscle injury and associated scarring, see

III.iv.4.B.7.m.  Applying the Amputation Rule to Muscle Injuries

The amputation rule applies to musculoskeletal conditions and any associated peripheral nerve injuries.  Therefore, when assigning separate evaluations for the muscle injury, peripheral nerve injury directly related to that muscle injury must be considered in applying the amputation rule.
References:  For more information on

III.iv.4.B.7.n.  Evaluating Muscle Disabilities Not Involving Shrapnel, GSWs, or Other Projectile-Type Injury

Generally, apply 38 CFR 4.73 to muscle injuries such as those arising from shrapnel, GSWs, or other projectiles or similar foreign objects entering the muscle from outside the body since the criteria for the evaluation weigh heavily on the type of wound, treatment, and current manifestations of the wound.
Generally, a disability such as that arising from injuries such as muscle strains, tears not resulting from injury by a foreign object entering the muscle, or muscle atrophy due to a SC joint or nerve injury should be evaluated under an appropriate DC based on associated functional impairment.
Historical_M21-1III_iv_4_SecB_11-8-16.docx May 15, 2019 109 KB
Historical_M21-1III_iv_4_SecB_10-26-16.docx May 15, 2019 110 KB
5-9-19_Key-Changes_M21-1III_iv_4_SecB.docx May 15, 2019 82 KB
Historical_M21-1III_iv_4_SecB_1-11-16.docx May 15, 2019 107 KB
Historical_M21-1III_iv_4_SecB_4-13-18.docx May 15, 2019 101 KB
Change-May-8-2015-Transmittal-Sheet-M21-1III_iv_4_SecB_TS.docx May 15, 2019 44 KB
M21-1MRIII_iv_4_B_TS.docx May 15, 2019 47 KB
Did this article answer your question?

Leave a Reply





Pin It on Pinterest

Share This