[Federal Register Volume 68, Number 28 (Tuesday, February 11, 2003)]
[Proposed Rules]
[Pages 6998-7035]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-2119]



[[Page 6997]]

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Part II





Department of Veterans Affairs





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38 CFR Parts 3 and 4



Schedule for Rating Disabilities; the Musculoskeletal System; Proposed 
Rule

  Federal Register / Vol. 68, No. 28 / Tuesday, February 11, 2003 / 
Proposed Rules  

[[Page 6998]]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Parts 3 and 4

RIN 2900-AE91


Schedule for Rating Disabilities; the Musculoskeletal System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend 
that portion of its Schedule for Rating Disabilities that addresses 
musculoskeletal conditions. The intended effect is to update this 
portion of the rating schedule to ensure that it uses current medical 
terminology and unambiguous criteria, and that it reflects medical 
advances that have occurred since the last review. We also propose to 
make nonsubstantive editorial changes throughout this portion of the 
Schedule.

DATES: Comments must be received on or before April 14, 2003.

ADDRESSES: Mail or hand-deliver written comments to: Director, Office 
of Regulatory Law (02D), Department of Veterans Affairs, 810 Vermont 
Ave., NW., Room 1154, Washington, DC 20420; or fax comments to (202) 
273-9289; or e-mail comments to [email protected]. Comments 
should indicate that they are submitted in response to ``RIN 2900-
AE91.'' All comments received will be available for public inspection 
in the Office of Regulatory Law, Room 1158, between the hours of 8 a.m. 
and 4:30 p.m., Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Regulations Staff (211A), Compensation and Pension Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Ave., NW., Washington, DC 20420, (202) 273-7210.

SUPPLEMENTARY INFORMATION: As part of its first comprehensive review of 
the rating schedule since 1945, VA published in the Federal Register of 
December 28, 1990 (55 FR 53315), an advance notice of proposed 
rulemaking advising the public that it was preparing to revise and 
update the portion of VA's Schedule for Rating Disabilities (the rating 
schedule) that addresses the musculoskeletal system. On June 3, 1997, 
we published in the Federal Register a final rule (62 FR 303235) 
revising Sec.  4.73, which addresses muscle injuries. This proposed 
rule addresses the remainder of the musculoskeletal system, Sec.  
4.71a, which addresses primarily bone and joint disabilities. In the 
document revising Sec.  4.73, we stated our intent to designate the 
remainder of the musculoskeletal system as the orthopedic system. 
However, because some of the provisions of Sec.  4.71a also apply to 
muscle injuries, and some of the conditions are rheumatologic, rather 
than orthopedic, conditions, we now propose to retain the current 
designation, musculoskeletal system.
    In response to the advance notice of proposed rulemaking, we 
received two comments, one from the American Legion and one from a 
physician in the Department of Orthopedics at the University of 
Washington.
    One commenter recommended that this revision include revisions of 
the rating and examination guidelines in 38 CFR 4.40 to 4.70 as they 
relate to musculoskeletal disabilities. We are proposing to make many 
changes to these sections, and they are discussed in detail below.
    The same commenter stated that the current rating schedule does not 
reflect the use of new diagnostic methods, such as computed tomography 
(CT) and magnetic resonance imaging (MRI) scans, or reflect new 
operative procedures for joint replacements. We agree that the schedule 
is outdated in these areas and propose changes to update the schedule 
for many disabilities. For example, we propose to accept not only X-ray 
findings, but also reports from other imaging procedures (such as MRI 
or CT scans), as evidence of arthritis and other musculoskeletal 
conditions.
    The commenter also recommended that there be a review of the 
Veterans Health Administration's ``Physician's Guide for Disability 
Evaluation Examinations'' (a manual no longer in use that gave guidance 
to examining physicians who do compensation and pension examinations). 
The commenter felt that medical advances present an increased need for 
the examiner to provide specific findings and detailed measurement and 
assessment of disabling conditions. This comment is no longer pertinent 
because the former ``Physician's Guide'' is no longer in existence. (A 
new Clinician's Guide or handbook for examiners is, however, under 
development.) In place of the former Physician's Guide, VA developed a 
series of disability examination worksheets for various individual 
conditions or groups of conditions to assure that examiners provide all 
information necessary for rating. These worksheets, which are 
periodically updated as medical advances or rating needs arise, are now 
in use.
    A second commenter provided a set of guidelines for evaluating 
spine disabilities. We are revising certain parts of the current 
musculoskeletal portion of the rating schedule separately. These 
include ankylosis and limitation of motion of the digits of the hand, 
disabilities of the spine, and intervertebral disc syndrome (published 
as a proposed rule in the Federal Register of February 24, 1997 (62 FR 
8204)). Since these disabilities are not included in this proposed 
rule, this comment concerning the evaluation of spine disabilities will 
be addressed in the separate proposed rule providing criteria for 
evaluating disabilities of the spine.
    In addition to publishing an advance notice, we also hired an 
outside contract consultant to recommend changes to the evaluation 
criteria to ensure that the schedule uses current medical terminology 
and unambiguous criteria, and that it reflects medical advances that 
have occurred since the last review. The consultant convened a panel of 
non-VA specialists to review the portion of the rating schedule dealing 
with the musculoskeletal system in order to formulate recommendations. 
We are proposing to adopt many, although not all, of the 
recommendations the contractor submitted. In some cases, evaluations 
based on the revised criteria will be lower, in some cases, higher, 
and, in some cases, unchanged.
    Sections 4.40 through 4.46, 4.57 through 4.59, 4.61 through 4.64, 
and .66 through 4.71 in subpart B of 38 CFR part 4 deal with a variety 
of issues, including circulatory disturbances, osteomyelitis, loss of 
use of both buttocks, painful motion, foot deformities, dominant hand, 
and examination and assessment of the bones and joints. Much of the 
information in these sections was originally included in rating 
schedules of 1925, 1933 or 1945 to provide background medical 
information that was not otherwise available. We propose to consolidate 
and reorganize these sections and to delete the parts that are simply 
statements of medical fact rather than substantive rules of general 
applicability, statements of general policy, or interpretations of 
general applicability that raters must follow. A regulation is an 
agency statement of general applicability and future effect, which the 
agency intends to have the force and effect of law, that is designed to 
implement, interpret, or prescribe law or policy, or to describe the 
procedure or practice requirements of an agency (5 U.S.C. 551(4)). 
General medical information that is available in standard textbooks and 
other material that neither prescribes VA policy nor

[[Page 6999]]

establishes procedures a rater must follow fall outside of those 
parameters, and are therefore not appropriate in a regulation. We 
propose to retain, with editorial and sometimes substantive changes, 
Sec. Sec.  4.40, 4.42, 4.45, 4.46, 4.59, 4.67, 4.68, 4.69, 4.71, and 
4.71a. We propose to delete Sec. Sec.  4.41, 4.43, 4.44, 4.57, 4.58, 
4.61, 4.62, 4.63, 4.64, 4.66, and 4.70. The proposed changes are 
explained in detail below.
    In addition, we are proposing to make a number of editorial changes 
throughout this portion of the rating schedule to condense and clarify 
the schedule in the interests of efficiency, ease of use, and 
elimination of ambiguity.
    Introductory Sec. Sec.  4.40 through 4.45 are directed in part at 
examiners and in part at raters. Much of the material is medical 
information, some of it outdated, about musculoskeletal diseases. We 
propose to remove the nonregulatory material, that is, material that 
does not prescribe VA policy or establish procedures a rater must 
follow, and the material directed toward examiners because this 
material is not appropriate in a regulation.
    Section 4.40, currently titled ``Functional loss,'' describes 
disability of the musculoskeletal system as primarily the inability, 
due to damage or infection in parts of the system, to perform the 
normal working movements of the body with normal excursion, strength, 
speed, coordination and endurance. It states that it is essential that 
the examination on which ratings are based adequately portray the 
anatomical damage and functional loss with respect to all of these 
elements. It also states that weakness is as important as limitation of 
motion, and that a part that becomes painful on use must be regarded as 
seriously disabled. The intent of this section appears to be to provide 
a general description of musculoskeletal disability and guidelines to 
examination rather than a specific method for evaluating these 
functions in musculoskeletal disabilities. As discussed above, there 
are disability examination worksheets that provide examiners with 
detailed requirements for musculoskeletal examinations. The current 
criteria for musculoskeletal diseases do not always call for a rating 
commensurate with ``serious'' disability when there is pain on use of a 
joint. (See, for example, fibromyalgia, diagnostic code 5025 in Sec.  
4.71a, a condition that, by definition, includes widespread 
musculoskeletal pain, and flatfoot, diagnostic code 5276.) Pain is, in 
fact, almost the hallmark of musculoskeletal disease. We therefore 
propose to revise Sec.  4.59, to be titled ``Evaluation of pain in 
musculoskeletal conditions,'' and to provide criteria for the 
evaluation of pain, if appropriate, when pain is not taken into account 
in the evaluation criteria for a particular condition. Although pain is 
a subjective complaint, the more severe it is, the more likely there 
are to be correlative physical or laboratory findings, and this fact is 
the basis of the criteria in Sec.  4.59.
    Of the other characteristics of musculoskeletal disability listed 
in Sec.  4.40--impairment of normal excursion, strength, speed, 
endurance, and coordination--speed and endurance are not readily 
measurable in the setting of a medical examination, and there is no 
method of evaluating them consistently. They are therefore less useful 
than limitation of motion as measures of the extent of disability. 
Coordination is an issue in only a limited number of musculoskeletal 
conditions, being seen more often in neurological conditions, and is 
unlikely to occur due to musculoskeletal disorders in the absence of 
other findings, such as weakness, atrophy, or limitation of motion. In 
summary, the information in Sec.  4.40 does not prescribe VA policy or 
establish clear procedures a rater must follow. It is therefore not 
appropriate in a regulation, and we propose to delete it.
    We propose to retitle Sec.  4.40 ``Evaluation of musculoskeletal 
disabilities'' and to state that, except for application of the pain 
scale in Sec.  4.59 when appropriate, the evaluation criteria provided 
under the diagnostic codes are to be the sole basis of evaluation. 
Factors such as fatigability and impairment of coordination, speed, and 
endurance, are common in musculoskeletal disabilities, and Sec.  4.40 
would state that disability due to those functions is encompassed by 
the evaluation criteria that are provided. An evaluation based on one 
of these factors over and above what is called for under the evaluation 
criteria will therefore not be assigned. This change would eliminate 
the need to assess functions that cannot be consistently or readily 
assessed and would therefore promote consistency of evaluations in 
musculoskeletal conditions. To promote consistency in assessing muscle 
strength, we propose to address the evaluation of muscle strength in 
Sec.  4.46.
    Because Sec.  4.41, ``History of injury,'' is a restatement of 
parts of Sec. Sec.  4.1, 4.2, 4.6, and 4.9, we propose to delete it.
    Section 4.42, ``Complete medical examination of injury cases,'' 
discusses the importance of a complete initial examination, rephrasing 
basic rating principles that are stated in 38 CFR 4.1 and 4.2 and 
reflected in the examination worksheets. This material is therefore 
redundant, and we propose to delete it.
    We propose to retitle Sec.  4.42 ``Examination of joints''. It 
would state that the range of motion of a joint will be determined by 
measurement with a goniometer and indicate that, for VA rating 
purposes, the normal ranges of motion for major joints and the spine 
are provided on plates in Sec.  4.71a.
    Current Sec.  4.43, ``Osteomyelitis,'' outlines the principles of 
evaluating osteomyelitis. It states that osteomyelitis will be regarded 
as a continuously disabling process and will be entitled to a permanent 
rating unless the affected part is removed by amputation. This 
information is not consistent with modern medical knowledge; 
osteomyelitis can often be treated and cured without resort to 
amputation, and continuous disability is not always the aftermath. We 
are proposing revised guidelines for the evaluation of osteomyelitis 
under diagnostic code 5000 that we believe are clear and comprehensive 
enough to require no additional guidelines. The proposed criteria are 
also based on contemporary medical knowledge. We therefore propose to 
delete this section.
    Current Sec.  4.44, ``The bones,'' states that osseous 
abnormalities due to injury or disease should be depicted by study and 
observation of all available data from time of injury, through 
treatment, convalescence, progress of recovery, and permanent 
residuals. It also discusses the effect of angulation and deformity of 
bone, including the effect on other joints, which are medical facts or 
judgment. Sections 4.2 and 4.6 regulate interpretation of examination 
reports and the evaluation of evidence which Sec.  4.44 attempts to 
restate. Since Sec.  4.44 does not prescribe VA policy or establish 
procedures a rater must follow, is redundant with Sec. Sec.  4.2 and 
4.6, and is not based on current medical knowledge, we propose to 
delete it.
    Section 4.45, ``The joints,'' lists some of the functional effects 
of joint disability, including whether there is less movement than 
normal, more movement than normal, weakened movement, excess 
fatigability, incoordination, impaired ability to execute skilled 
movements smoothly, pain on movement, swelling, deformity, or atrophy 
of disuse, but does not address how to evaluate them. Since modern 
information about joint disability is available from numerous medical 
sources, and this portion of the section does not prescribe VA policy 
or establish procedures a rater must follow, we propose to delete this 
material. We propose to provide clear criteria for

[[Page 7000]]

evaluating specific conditions affecting joints under specific 
diagnostic codes and in Sec.  4.59, as discussed later in this 
document.
    Section 4.45 also defines major and minor joints and their rating 
significance. It states that for the purpose of rating disability from 
arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are 
considered major joints, and that multiple involvements of the 
interphalangeal, metacarpal, and carpal joints of the upper 
extremities, the interphalangeal, metatarsal and tarsal joints of the 
lower extremities, the cervical vertebrae, the dorsal vertebrae, and 
the lumbar vertebrae, are considered groups of minor joints, ratable on 
a parity with major joints. It also states that the lumbosacral 
articulation and both sacroiliac joints are considered to be a group of 
minor joints, ratable on disturbance of lumbar spine functions.
    Since this information is necessary for rating, we propose to 
retain regulatory definitions of major and minor joints for purposes of 
evaluating arthritis, but to revise them for clarity. We propose to 
retitle this section ``Major and Minor Joints for Arthritis 
Evaluations,'' which better describes the content. We propose to 
include two paragraphs, with paragraph (a) (Major joints) stating that 
for purposes of rating disability from arthritis, each shoulder, elbow, 
wrist, hip, knee and ankle joint is a major joint, and all other joints 
are minor joints. Paragraph (b) (Groups of minor joints) would state 
that a group of minor joints with arthritis will be rated as a major 
joint. A group of minor joints is defined as any combination of three 
or more interphalangeal or metacarpo-phalangeal joints of a single 
hand, any combination of three or more interphalangeal, metatarso-
phalangeal, tarso-metatarsal, or tarso-tarsal (or intertarsal) joints 
of a single foot; any combination of two or more cervical vertebral 
joints; any combination of two or more thoracolumbar vertebral joints; 
or a combination of the lumbosacral joint and both sacroiliac joints. 
This revision would resolve ambiguity in the current language by 
clearly indicating, for example, that the combination of minor joints 
in different parts of the body, such as two interphalangeal joints of 
one hand and a single cervical or thoracolumbar intervertebral joint, 
does not constitute a major joint and that the combination of one 
interphalangeal, one metatarso-phalangeal, and one intertarsal joint of 
a single foot would constitute a group of minor joints. These issues 
have been a source of confusion in applying the current schedule. This 
revision would also remove the vague term ``multiple involvements'' and 
specify the number of minor joints in various areas that would 
constitute a group of minor joints. The revision would also name 
specific joints, rather than naming bones, in order to eliminate 
confusion about determining, for example, whether or not the term 
``carpal joints'' includes the radiocarpal joint (between the radius 
and the carpal bones) the carpo-carpal (or intercarpal) joints (between 
two or more carpal bones), and the carpo-metacarpal joints (between the 
carpals and the metacarpals). Since all of these joints are involved in 
wrist motion, we propose to consider them all part of the wrist joint, 
and therefore part of a major joint.
    Section 4.46, ``Accurate Measurement,'' points out the importance 
of accurate measurements of the length of stumps, excursion of joints, 
and dimensions and locations of scars with respect to landmarks, in the 
disability examination process. It also states that a goniometer is 
indispensable in measuring limitation of motion. The importance of an 
adequate examination, which this section attempts to set forth, is 
already stated in Sec.  4.2, ``Interpretation of examination reports''. 
Disability examination worksheets for examiners give detailed 
guidelines for examining and measuring in the musculoskeletal system. 
We propose to put the requirement for use of a goniometer to measure 
joint range of motion in revised Sec.  4.42. We therefore propose to 
delete the contents of Sec.  4.46 because the material is redundant.
    We propose to retitle Sec.  4.46, ``Evaluation of muscle 
strength,'' and to state that, for VA rating purposes, muscle strength 
or weakness will be evaluated using a standard muscle grading table 
that is provided in paragraph (a). This will assure that assessment of 
muscle strength will be consistent and based on the system recommended 
by the consultants as the system used most widely by orthopedic 
surgeons, neurologists, physiatrists, and physical therapists. This 
system uses six levels of muscle grading: Absent (0): No palpable or 
visible muscle contraction; Trace (1): Palpable or visible muscle 
contraction, but muscle produces no movement, even with gravity 
eliminated; Poor strength (2): Muscle produces movement only when 
gravity is eliminated; Fair strength (3): Muscle produces movement 
against gravity but not against any added resistance; Good strength 
(4): Muscle produces movement against some, but no more than moderate, 
resistance; and Normal strength (5): Muscle produces movement against 
full or ``normal'' resistance. This system is derived from ``Aids to 
the Investigation of the Peripheral Nervous System,'' published by the 
Medical Research Council of Great Britain in 1945. The consultants 
pointed out that, although it is largely subjective, it has some 
objectivity in measuring strength by using gravity resistance in the 
assessment, and the term ``normal'' resistance is generally understood 
in medical usage. This table can be used for assessing both muscle and 
(motor) nerve disability. For convenience of use in assessing both 
musculoskeletal and neurologic disabilities, we also plan to add the 
table to the neurologic portion of the rating schedule when it is 
revised. We propose to add a second paragraph to Sec.  4.46 to provide 
a guide to the use of the results of the muscle grading system in 
assessing loss of muscle function, as follows: complete, no motor 
function (muscle grading system 1 or 0); incomplete, severe, marked 
weakness associated with muscle atrophy (muscle grading system 2); 
incomplete, moderate, weakness (muscle grading system 3); and 
incomplete, mild, weakness (muscle grading system 4). In our judgment, 
this material would assist raters in making consistent determinations 
of muscle strength or weakness, based on the muscle grading system, and 
it is in general accord with the recommendations of the consultants.
    Section 4.57, ``Static foot deformities,'' discusses in detail how 
to clinically differentiate flatfoot (pes planus) that is congenital 
from flatfoot that is acquired and discusses when flatfoot should be 
service-connected. Material that pertains more to a determination of 
service connection than to evaluation is not appropriate in the rating 
schedule, which is a guide to the evaluation of disabilities, and we 
propose to delete this material. Section 4.57 also states that in the 
absence of trauma or other definite evidence of aggravation, service 
connection is not in order for pes cavus, a foot deformity that is 
typically a congenital or juvenile disease. Differentiating congenital 
from acquired foot deformities is more of a medical determination than 
a rating determination. None of the information in this section is 
pertinent to how raters should evaluate flatfeet or pes cavus, and we 
therefore propose to delete this section.
    Current Sec.  4.58, ``Arthritis due to strain'' discusses when it 
is appropriate to service connect, on a secondary basis, arthritis of 
joints that are subject to direct strain when there has been amputation 
or shortening of a lower extremity, or amputation or injury of an upper 
extremity. This material also

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addresses the issue of service connection rather than evaluation. In 
addition, the determination of whether arthritis in a particular joint 
is secondary to another condition often requires a medical opinion. 
Since this material is not a guide to evaluation, and therefore is not 
appropriate in the rating schedule, and in addition is more of a 
medical than an adjudicatory decision, we propose to delete this 
section.
    Current Sec.  4.59, ``Painful motion,'' states that painful motion 
is an important factor of disability and that the intent of the 
schedule is to recognize painful motion with joint or periarticular 
pathology as productive of disability. It states that painful, 
unstable, or malaligned joints are entitled to at least the minimum 
compensable rating for the joint, and indicates how joints should be 
tested. However, the instructions for evaluating pain are ambiguous and 
subject to individual interpretation, for example, in that they direct 
the examiner to note facial expression, wincing, etc., on pressure or 
manipulation. Furthermore, the current rating schedule does not always 
follow these guidelines. For example, a zero-percent evaluation is 
assigned for lumbosacral strain (under diagnostic code 5295) when there 
are slight subjective symptoms (which would almost always include 
pain); for degenerative arthritis (under diagnostic code 5003) when 
there is limitation of motion due to pain unless there is objective 
confirmation; and for a fracture of the humerus (under diagnostic code 
5202) when there is malunion that is less than moderate. The 
instructions also fail to provide a way for raters to assign higher 
evaluations for extreme pain, which can be totally disabling in some 
cases. We propose to delete the current information in this section 
because it does not provide clear and objective instructions to raters 
on how to assess pain nor does it indicate how pain due to 
musculoskeletal conditions other than joint disability should be 
assessed. This follows the recommendation of the consultants, who felt 
that the additional disability resulting from pain may not be 
adequately considered in the current schedule and that we may wish to 
include more information on the evaluation of pain. They did not make 
specific recommendations about how to do this. Based in part on 
consultation with a committee of orthopedic surgeons from the Veterans 
Health Administration (the VHA Orthopedic Committee), we propose to 
change the name of this section to ``Evaluation of pain in 
musculoskeletal conditions'' in order to clarify the scope of the 
section and propose a specific set of criteria to be used for the 
evaluation of pain in these conditions. We propose that when the 
evaluation criteria for a condition listed in Sec.  4.71a do not take 
pain into account, but pain is present, that raters combine an 
evaluation based on the criteria under the particular diagnostic code 
with an evaluation for pain under Sec.  4.59. A single (combined) 
evaluation for the condition would then be assigned under the 
appropriate diagnostic code for the condition.
    We propose to provide a wide range of evaluations for pain in Sec.  
4.59, with 100-;, 30-, 20-, 10-, and zero-percent evaluation levels. 
The evaluation criteria are based on a combination of the degree of the 
subjective complaint of pain, which is largely unmeasurable, and 
associated correlative clinical or laboratory findings that are more 
objective. We propose that a 100-percent evaluation for pain be 
assigned when there is complaint of pain that globally interferes with 
and severely limits daily activities, as long as the requirements for a 
30-percent evaluation for pain are met, and a psychiatric evaluation 
has excluded other processes to account for the pain. We propose that a 
30-percent evaluation for pain be assigned when there is complaint of 
pain at rest, with pain on minimal palpation or on attempted range of 
motion on physical examination, plus X-ray or other imaging 
abnormalities, plus abnormal findings on a vascular or neurologic 
special study. We propose that a 20-percent evaluation for pain be 
assigned when there is complaint of pain on any use, with pain on 
palpation and through at least one-half of the range of motion on 
physical examination, plus X-ray or other imaging abnormalities. We 
propose that a 10-percent evaluation for pain be assigned when there is 
complaint of pain on performing some daily activities, with pain on 
motion (through any part of the range of motion) on physical 
examination, plus X-ray or other imaging abnormalities. We propose that 
a zero-percent evaluation for pain be assigned when there is complaint 
of mild or transient pain on performing some daily activities, with 
correlative finding(s) on physical examination (for example, pain on 
palpation or pain on stressing the joint), but without X-ray or other 
imaging abnormalities. Establishing these criteria for pain evaluation 
would assure that pain is taken into consideration in all cases where 
it is present, either under the criteria in Sec.  4.59 or in the 
criteria under the diagnostic code specific to the condition (if pain 
is part of those criteria). By linking the complaints of pain with 
objective findings, it will promote the consistent evaluation of pain. 
It would also provide a 100-percent level of evaluation for pain that 
severely limits all daily activities, an effect that is not addressed 
in the current rating schedule.
    We also propose to add two notes to Sec.  4.59. The first would 
direct that a rater not combine a 100-percent evaluation under this 
section with any other evaluation for the same condition. The second 
would state that the provisions of Sec.  4.68, ``Limitation of combined 
evaluation of musculoskeletal and neurologic disabilities of an 
extremity,'' will apply to the evaluation of conditions evaluated 
wholly or partly under Sec.  4.59, except for a 100-percent evaluation, 
that is, this will allow assignment of a 100-percent evaluation based 
on pain even if it would exceed the limits of an evaluation under the 
provisions of Sec.  4.68 (Limitation of combined evaluation of 
musculoskeletal and associated neurologic disabilities of an 
extremity).
    This set of criteria would replace all the current material in 
Sec.  4.59, which we propose to delete.
    Current Sec.  4.61, ``Examination,'' discusses the need for a 
thorough examination of all major joints, including the need to examine 
Haygarth's and Heberdon's nodes, in order to properly evaluate a 
claimant's disability due to arthritis. However, the presence or 
absence of these nodes has no bearing on evaluation. Furthermore, the 
term ``Haygarth's nodes,'' which means a swelling of joints related to 
rheumatoid arthritis, is no longer in common medical use. The examiner 
determines the type of arthritis that is present based on many factors, 
such as which joints are affected, the history, laboratory and imaging 
studies, physical findings, etc. Guidance for examiners in providing 
information sufficient to allow raters to evaluate joint disease is 
contained in disability examination worksheets. Since the material in 
this section is not pertinent to the evaluation of arthritis, is 
outdated, and is similar to material in Sec. Sec.  4.1 and 4.2, we 
propose to delete it.
    Current Sec.  4.62, ``Circulatory disturbances,'' reminds the rater 
not to overlook circulatory disturbances, especially of the lower 
extremity following injury to the popliteal space, and to rate them 
generally as phlebitis. Medical records should make it clear when a 
vascular injury is associated with a lower extremity injury. Evaluation 
will depend on the findings

[[Page 7002]]

on examination in the particular case. In our judgment, this section is 
unnecessary because it does not prescribe VA policy nor establish 
procedures a rater must follow, and we propose to delete it.
    Current Sec.  4.63, ``Loss of use of hand or foot,'' and Sec.  
4.64, ``Loss of use of both buttocks,'' are duplicates of 38 CFR 
3.350(a)(2) and 3.350(a)(3), portions of VA's adjudication regulations 
that implement statutory requirements for entitlement to special 
monthly compensation (SMC). Since this material addresses requirements 
for SMC rather than evaluating disabilities, it is not appropriate in 
part 4, and we propose to delete it.
    Current Sec.  4.66, ``Sacroiliac joint,'' describes disability of 
the sacroiliac joints. For example, it describes the clinical findings 
of sacroiliac joint disability, the X-ray findings of arthritis of the 
sacroiliac joints, and other material more pertinent to examiners than 
to raters. This medical information neither prescribes VA policy nor 
establishes procedures a rater must follow, and we propose to delete 
it. The section also includes a direction to consider the lumbosacral 
and sacroiliac joints as one anatomical segment. Section 4.45(b) states 
that the lumbosacral articulation and both sacroiliac joints are to be 
rated together as a group of minor joints. The Sec.  4.45 statement is 
a clearer explanation of the relationship of these joints than the 
statement in Sec.  4.66, and is more pertinent to the needs of raters. 
We therefore propose to delete all of Sec.  4.66.
    Section 4.67, ``Pelvic bones'' directs that pelvic bone fractures 
be evaluated based on faulty posture, limitation of motion, muscle 
injury, painful motion of the lumbar spine manifest by muscle spasm, 
mild to moderate sciatic neuritis, peripheral nerve injury, or 
limitation of hip motion. We propose to revise the title to more 
clearly indicate the subject matter of the section by changing it to 
``Pelvic bone fractures.'' We also propose to provide clearer and more 
succinct instructions on evaluation by directing that pelvic fractures 
be evaluated based on the specific residuals, such as ``limitation of 
motion of the spine or hip, muscle injury, or sciatic or other 
peripheral nerve neuropathy.''
    Current Sec.  4.68, ``Amputation rule,'' states that the combined 
rating for disabilities of an extremity will not exceed the rating for 
the amputation at the elective level, were amputation to be performed. 
Although this section is included in the musculoskeletal subdivision of 
the rating schedule, there has been confusion about whether it applies 
to disabilities of body systems other than the musculoskeletal system 
that might affect the extremities, such as the neurologic, skin, and 
cardiovascular systems. Therefore, we propose to revise it to clarify 
that the amputation rule applies to only musculoskeletal and associated 
neurological disabilities of an extremity. There are several 
nonmusculoskeletal disabilities of an extremity in the current rating 
schedule that can be evaluated at a level higher than an amputation at 
a comparable level would be evaluated. For example, in Sec.  4.104 in 
the cardiovascular section of the rating schedule, arteriosclerosis 
obliterans (diagnostic code 7114), thrombo-angiitis obliterans 
(diagnostic code 7115), varicose veins (diagnostic code 7120), and 
post-phlebitic syndrome (diagnostic code 7121) can all be evaluated at 
percentages that could exceed the percentage evaluation for amputation. 
Arteriosclerosis obliterans of a single lower extremity can be 
evaluated at 100 percent if there is ischemic limb pain at rest and 
either deep ischemic ulcers or an ankle/brachial index of 0.4 or less. 
There is no requirement that the arteriosclerosis obliterans affect a 
particular extent of a lower extremity for this evaluation to apply. 
Therefore, a 100-percent evaluation could be assigned when only the 
lower two-thirds of the extremity is affected, although an amputation 
of the extremity through even the upper one-third of the thigh warrants 
only an 80-percent evaluation. Section 4.68 currently states that 
painful neuroma of a stump after amputation shall be assigned the 
evaluation for the elective site of reamputation. This represents an 
exception to the rule based on the presence of a neurologic condition. 
In view of these facts, plus the fact that the amputation rule is 
located in the musculoskeletal system portion of subpart B (Disability 
Ratings) of the rating schedule rather than in subpart A, which 
addresses general rating policies, VA originally intended this rule to 
apply only to musculoskeletal disabilities. Injuries of an extremity 
may involve muscles, nerves, ligaments, joints, etc. The effects of 
these injuries are commonly inseparable. Nerve injuries, for example, 
may affect muscle strength and motion and produce effects almost 
identical to those of a muscle injury in the same area. We intend the 
rule to assure that the evaluation of the combined effects of even a 
severe musculoskeletal injury (including neurologic damage) will not 
exceed the evaluation for amputation, because, in general, all of these 
problems would be superseded or removed if an amputation were to be 
performed. However, Sec.  4.68 does not limit evaluations for the 
cardiovascular conditions mentioned above, nor would it be reasonable 
for it to do so, since an amputation might not ``cure'' or remove the 
disability. We therefore propose to clarify this section by stating 
that the combined rating for musculoskeletal and neurologic 
disabilities of an extremity will not exceed the rating that would be 
assigned for an amputation of the extremity at the level that would 
remove the affected areas, unless the evaluation criteria for a 
particular disability allow a higher evaluation. We also propose to 
revise the title of this section for further clarity to ``Limitation of 
combined evaluation of musculoskeletal and associated neurologic 
disabilities of an extremity.'' We propose to retain, but edit, the 
portion of the current section pertaining to a painful stump neuroma 
that develops following amputation.
    Current Sec.  4.69, ``Dominant hand,'' was revised in 1997. The 
revision modernized the terms ``major'' and ``minor'' to ``dominant'' 
and ``nondominant,'' which are now the preferred terms. We propose only 
editorial changes in this section.
    We propose to delete Sec.  4.70, ``Inadequate Examinations,'' from 
this section of the schedule as redundant since its provisions are not 
limited to the musculoskeletal system and are similar to material in 
Sec. Sec.  4.1 and 4.2, which apply to all VA disability examinations.
    Section 4.71, ``Measurement of ankylosis and joint motion,'' 
explains Plates I and II in the schedule, which show standard 
anatomical positions of the joints of the upper and lower extremities 
and their ranges of motion. It also describes the exceptions to using 
the anatomical position as the zero baseline for joint measurement. The 
section also mentions Plate III, bones of the hand, and explains how to 
measure limitation of motion of the fingers, which is information 
provided in the part of the schedule that addresses the evaluation of 
ankylosis and limitation of motion of the fingers. We propose to delete 
the redundant reference to measurement of motion of the fingers, but 
propose no other substantive change to this section. We do propose to 
revise the title to ``Baseline for joint motion measurement.''
    We propose to retain the illustrations currently in Plates I and 
II, demonstrating the normal range of motion of the upper and lower 
extremities. These plates are important for the evaluation of 
disabilities of the joints because they provide a

[[Page 7003]]

standardized description of joint measurements.
    Current Plate III, showing bones of the hand, and current Plate IV, 
showing bones of the foot, are incomplete and outdated, so we propose 
to remove them and replace them with updated Plates III and IV.
    We propose to add one additional plate to the musculoskeletal 
section of the rating schedule to illustrate range of motion of the 
cervical and dorsolumbar (thoracolumbar) spine (Plate V). This will be 
included with the separate regulation that would revise the portions of 
the musculoskeletal system that address disabilities of the spine.
    In the current rating schedule, next to the percentage evaluations 
following diagnostic codes 5054, 5104 through 5130, 5160 through 5167, 
5250, and 5275, superscripts are included directing that entitlement to 
special monthly compensation be considered. We are replacing the 
numbered superscript with asterisks that will refer to a single 
footnote containing similar information that will follow diagnostic 
code 5275, at the end of the area of the schedule that addresses 
shortening of the lower extremity, which is the last area of the 
musculoskeletal system in which special monthly compensation might be 
applicable. We propose to add a note at the beginning of Sec.  4.71a, 
preceding the coded evaluations of disabilities, instructing raters to 
refer to Sec.  3.350 whenever they rate an injury that has resulted in 
anatomical loss or loss of use of a limb. We believe that this will 
adequately notify the rater to ensure that there is a complete review 
for special monthly compensation. There is a footnote at diagnostic 
codes 5126 through 5130 indicating that entitlement to special monthly 
compensation is established if there is amputation of the thumb and any 
three fingers of a hand, since this is equivalent to the loss of use of 
one hand. This is not explicitly stated in Sec.  3.350, which is the 
regulation that addresses special monthly compensation (SMC). However, 
it is not appropriate in part 4, because it addresses SMC rather than 
the evaluation of disabilities, and we therefore propose to remove this 
rule from part 4 and add it to 38 CFR 3.350.
    Current table II, ``Ratings for multiple losses of extremities with 
dictator's rating code and 38 CFR citation,'' was prepared for use by 
raters when dictating a rating decision for transcription, but the 
codes are out of date. The updated codes, which are not regulatory, are 
located in Appendix A of VA's Adjudication Procedures Manual, M21-1. 
The codes are not needed for disability evaluation, and we therefore 
propose to delete Table II.

Osteomyelitis

    The current evaluation criteria for osteomyelitis, diagnostic code 
5000, provide ratings of 100 percent for osteomyelitis of the pelvis, 
vertebrae, or extending into major joints, or with multiple 
localization or with long history of intractability and debility, 
anemia, amyloid liver changes, or other continuous constitutional 
symptoms; 60 percent for frequent episodes, with constitutional 
symptoms; 30 percent if there is definite involucrum or sequestrum, 
with or without discharging sinus; 20 percent if there is a discharging 
sinus or other evidence of active infection within the past 5 years; 
and 10 percent if the infection is inactive, following repeated 
episodes, without evidence of active infection in past 5 years. There 
are also two complex notes under this diagnostic code.
    The current evaluation criteria are complex and difficult to apply 
consistently, and do not reflect the effectiveness of modern treatment 
techniques, such as aggressive antibiotic therapy and microsurgery. 
Although the consultants suggested no major changes to the current 
criteria, we propose substantial revisions for the sake of clarity, 
ease of use, and consistency of evaluations. We propose to restructure 
the criteria based on which bone or bones are affected, whether the 
infection is active or inactive, whether or not there are debilitating 
complications (such as anemia, septicemia, or amyloidosis), and the 
number of recurrences, if any, within the past 5 years.
    We propose to provide a 100-percent evaluation for chronic 
intractable osteomyelitis of any site when it is associated with 
debilitating complications such as anemia and amyloidosis. These 
criteria better define when chronic osteomyelitis is so disabling that 
it warrants a 100-percent evaluation. We also propose to evaluate 
osteomyelitis of the spine, pelvis, shoulder, elbow, wrist, hip, knee 
or ankle, or of two or more non-contiguous bones, when active or acute, 
with constitutional signs and symptoms, such as fever, fatigue, 
malaise, debility, and septicemia, at 100 percent. We propose to 
evaluate osteomyelitis at one of these sites that is inactive or 
chronic at 60 percent, if there were two or more recurrent episodes of 
active infection (following the initial infection) within the past 5 
years; at 30 percent if there was one recurrent episode of active 
infection (following the initial infection) within the past 5 years; 
and at zero percent if there were no recurrent episodes of active 
infection within the past 5 years.
    We propose to evaluate osteomyelitis that does not involve the 
spine, pelvis, shoulder, elbow, wrist, hip, knee or ankle, does not 
involve two or more non-contiguous bones, and does not involve only a 
finger or toe, at 40 percent if osteomyelitis is active or acute; at 30 
percent if the infection is inactive or chronic, with two or more 
recurrent episodes of active infection (following the initial 
infection) within the past 5 years; at 20 percent if the infection is 
inactive or chronic and there was one recurrent episode of active 
infection (following the initial infection) within the past 5 years; 
and at zero percent if there were no recurrent episodes of active 
infection within the past 5 years.
    We propose to evaluate osteomyelitis of a single finger or toe at 
10 percent when the infection is active or acute, at 10 percent when 
the infection is inactive and chronic, with two or more recurrent 
episodes of active infection (following the initial infection) within 
the past 5 years, and at zero percent when the infection is inactive or 
chronic, with one or no recurrent episodes of active infection 
(following the initial infection) within the past 5 years. These 
evaluations would be assigned even when they exceed the evaluation for 
amputation of a finger or toe, as is the case in the current schedule. 
The proposed criteria, although similar in scope to the current 
criteria, are clearer, less complex, and more objective and would 
promote more consistent evaluations. The proposed criteria are also 
more in keeping with disability due to osteomyelitis under modern 
medical treatment.
    We also propose to revise the notes under diagnostic code 5000. The 
current first note states that a rating of 10 percent, as an exception 
to the amputation rule, is to be assigned in any case of active 
osteomyelitis where the amputation rating for the affected part is no 
percent. It goes on to say that this 10-percent rating and the other 
partial ratings of 30 percent or less are to be combined with ratings 
for ankylosis, limited motion, nonunion or malunion, shortening, etc., 
subject, of course, to the amputation rule, and that the 60-percent 
rating, as it is based on constitutional symptoms, is not subject to 
the amputation rule. Finally, it states that a rating for osteomyelitis 
will not be applied following cure by removal or radical resection of 
the affected bone.
    The second note states that the 20-percent rating on the basis of 
activity within the past 5 years is not assignable

[[Page 7004]]

following the initial infection of active osteomyelitis without 
subsequent reactivation, that two or more episodes following the 
initial infection are required to assign a 10-percent rating, and that 
the 10- or 20-percent rating will be assigned only once to cover 
disability at all sites of previously active infection with a future 
ending date for the 20-percent rating. These notes are so complex that 
they have become not only a source of confusion, they are also 
inconsistently interpreted and applied. We propose to remove both notes 
and substitute two new notes, with similar information, but in clearer 
language. Note (1) would direct the rater, subject to the provisions of 
Sec.  4.68, to combine an evaluation for inactive or chronic 
osteomyelitis under diagnostic code 5000 with an evaluation for chronic 
residuals, such as limitation of motion, ankylosis, etc., and for pain 
(under Sec.  4.59) when appropriate, under the appropriate diagnostic 
code. Note (2) would direct the rater to evaluate, after removal or 
resection of the infected bone, under the diagnostic code most 
appropriate for evaluating the residuals, such as amputation, 
shortening, limitation of motion, etc., but not under the criteria for 
diagnostic code 5000. Removing the ambiguities and providing 
instructions for rating in more succinct and clearer language would 
promote consistency of ratings.

Arthritis

    Rheumatoid arthritis, diagnostic code 5002, is currently evaluated 
either as an active process or on the basis of chronic residuals. For 
active arthritis, a 100-percent evaluation is assigned if there are 
constitutional manifestations and active joint involvement, and the 
condition is totally incapacitating. A 60-percent evaluation is 
assigned when the criteria for a 100-percent evaluation are not met, 
but there are weight loss and anemia productive of severe impairment of 
health, or severely incapacitating exacerbations occurring four or more 
times a year, or a lesser number over prolonged periods. A 40-percent 
evaluation is assigned for symptom combinations productive of definite 
impairment of health objectively supported by examination findings or 
if there are incapacitating exacerbations occurring three or more times 
a year. A 20-percent evaluation is assigned if there are one or two 
exacerbations a year in a well-established diagnosis. Alternatively, 
chronic residuals, such as limitation of motion or ankylosis, favorable 
or unfavorable, are rated under the appropriate diagnostic codes for 
the specific joints involved. When the limitation of motion of the 
specific joints is noncompensable, 10 percent is assigned for each 
major joint or group of minor joints with limitation of motion, and 
these are combined. A note states that ratings for the active process 
will not be combined with the residual ratings for limitation of motion 
or ankylosis.
    The consultants suggested minor changes under diagnostic code 5002, 
such as listing specific constitutional manifestations that might 
occur. However, because the current criteria contain language that is 
subjective and undefined, such as ``severe'' and ``definite'' 
impairment of health, ``severely incapacitating'' and 
``incapacitating'' exacerbations, we propose to replace them with more 
objective criteria that are in accord with the consultants' 
recommendations. We propose that a 100-percent evaluation be assigned 
based on constant or near-constant debilitating signs and symptoms due 
to a combination of inflammatory synovitis (pain, swelling, tenderness, 
warmth, and morning stiffness in and around joints) and destruction of 
multiple joints, plus extra-articular (other than joint) 
manifestations. These are findings that represent the most severe, 
advanced form of rheumatoid arthritis. We propose that evaluations 
other than 100 percent be based on the frequency and total duration of 
incapacitating exacerbations or flares of rheumatoid arthritis. The 60-
percent evaluation would require incapacitating exacerbations or flares 
with a total duration of at least six weeks during the past 12-month 
period due either to inflammatory synovitis and destruction of multiple 
joints, or to a combination of joint problems and extra-articular 
manifestations. The 40-percent evaluation would require exacerbations 
or flares with a total duration of at least 4 weeks, but less than 6 
weeks, during the past 12-month period due to inflammatory synovitis, 
weakness, and fatigue. The 20-percent evaluation would require 
incapacitating exacerbations or flares with a total duration of at 
least 2 weeks but less than 6 weeks during the past 12-month period due 
to inflammatory synovitis, weakness, and fatigue. The 10-percent 
evaluation would require incapacitating exacerbations or flares with a 
total duration of at least 1 week but less than 2 weeks during the past 
12-month period due to inflammatory synovitis, weakness, and fatigue. 
These criteria are similar to those in the current schedule and to 
those recommended by the consultants, and are also consistent with the 
evaluation levels we have provided for other conditions characterized 
by incapacitating episodes, such as hepatitis C, diagnostic code 7354, 
in the digestive portion of the rating schedule.
    We propose to add four notes under diagnostic code 5002 to further 
assist evaluation. Note (1) would direct that rheumatoid arthritis be 
evaluated based either on the evaluation criteria under diagnostic code 
5002 or on the combined evaluation of chronic residuals of affected 
joints, whichever method results in a higher evaluation. This is 
similar to instructions in a current note.
    Note (2) would direct that when evaluating based on chronic joint 
residuals, each affected major joint or group of minor joints will be 
evaluated on findings such as limitation of motion, ankylosis, joint 
instability, etc., under the appropriate diagnostic code, and each will 
be combined with an evaluation for pain under Sec.  4.59 when 
appropriate. We propose to remove the current provision requiring that 
10 percent be assigned for each major joint or group of minor joints 
with limitation of motion that is less than 10-percent disabling, 
because painful motion would be assessed under the provisions of Sec.  
4.59, and limitation of motion otherwise will be evaluated at the same 
level as limitation of motion due to other conditions. This would 
promote both internal consistency in the rating schedule and 
consistency in rating veterans with similar degrees of disability due 
to different conditions. Proposed note (3) would direct raters to 
separately evaluate extra-articular manifestations of rheumatoid 
arthritis, such as pulmonary fibrosis; pleural inflammation; weakness 
or atrophy of muscles; emaciation; anemia; vasculitis (of skin or 
systemic); neuropathy, such as peripheral nerve neuropathy, entrapment 
neuropathy, and cervical myelopathy; pericarditis; Sjogren's syndrome 
(dry eyes and mouth); and eye complications (such as scleritis and 
episcleritis), under the appropriate diagnostic code, unless they have 
been used to support an evaluation at 60 or 100 percent under 
diagnostic code 5002. This will assure that all disabling 
manifestations of rheumatoid arthritis are appropriately evaluated, 
while also avoiding evaluating the same disability twice (see proposed 
Sec.  4.14, ``Avoiding overlapping of evaluations''). The current 
schedule does not provide directions for evaluating extra-articular 
manifestations.
    Proposed note (4) would define an incapacitating exacerbation or 
flare as one requiring bedrest or wheelchair use and treatment by a 
health care provider. This is similar to the definition of

[[Page 7005]]

incapacitating episodes we have provided for evaluating chronic liver 
disease without cirrhosis (diagnostic code 7345) and hepatitis C 
(diagnostic code 7354) in Sec.  4.114 of the rating schedule.
    We propose to change the heading of diagnostic code 5003 from 
``Arthritis, degenerative (hypertrophic or osteoarthritis)'' to 
``Osteoarthritis (degenerative or hypertrophic arthritis),'' as 
recommended by the consultants, because the disease is now most 
commonly referred to as osteoarthritis. Osteoarthritis established by 
X-ray findings is currently evaluated on the basis of limitation of 
motion under the appropriate diagnostic codes for the specific joint or 
joints involved. When the limitation of motion of the specific joint or 
joints is noncompensable, a rating of 10 percent is assigned for each 
major joint or group of minor joints with limitation of motion, and 
this 10 percent is combined, not added, under diagnostic code 5003. The 
limitation of motion must be objectively confirmed by findings such as 
swelling, muscle spasm, or satisfactory evidence of painful motion. 
There are additional directions: (1) In the absence of limitation of 
motion, when there is X-ray evidence of involvement of 2 or more major 
joints or 2 or more minor joint groups as the sole finding, with 
occasional incapacitating exacerbations, 20 percent will be assigned, 
and (2) with X-ray evidence of involvement of 2 or more major joints or 
2 or more minor joint groups as the sole finding, 10 percent will be 
assigned. Two notes address how to apply these ratings based on X-ray 
findings and state that they will not be used to rate conditions under 
diagnostic codes 5013 to 5024. The consultants suggested no substantive 
change to these criteria.
    The current provisions concerning evaluation of osteoarthritis are 
complex and have sometimes been misinterpreted. The criteria based on 
limitation of motion, including a noncompensable degree of limitation 
of motion, are the same as the current instructions for evaluating the 
chronic residuals of rheumatoid arthritis, and we propose changes 
similar to those we are proposing for rheumatoid arthritis, and for the 
same reasons. We propose to replace the current evaluation criteria for 
osteoarthritis with a direction to separately evaluate each major joint 
or group of minor joints affected with osteoarthritis based on 
limitation of motion, ankylosis, joint instability, etc., under the 
appropriate diagnostic code and to combine that evaluation with an 
evaluation for pain under Sec.  4.59 when appropriate.
    Osteoarthritis tends to be a steadily progressive disease (although 
it may be better or worse at times), rather than being subject to the 
incapacitating exacerbations or flares that are common in rheumatoid 
arthritis, and we therefore do not propose evaluation criteria based on 
exacerbations or incapacitating episodes. As with rheumatoid arthritis, 
we propose to remove evaluations based on noncompensable limitation of 
motion, because pain is the most common symptom of osteoarthritis, and 
we are proposing to combine an evaluation based on other disabling 
findings with an evaluation for pain. In our judgment, limitation of 
motion in osteoarthritis that does not reach the level of a compensable 
evaluation would not warrant a higher evaluation than a comparable 
degree of limitation of motion due to other conditions, and pain would 
be assessed under the provisions of Sec.  4.59, the same as pain due to 
any other type of musculoskeletal condition.
    We also propose to remove the evaluations based on X-ray findings 
alone or on X-ray findings plus incapacitating exacerbations because 
abnormal X-ray findings in the absence of signs or symptoms do not 
justify a compensable evaluation, as there would be no functional 
impairment. In fact, most people with X-ray evidence of osteoarthritis 
are asymptomatic (without any symptoms) (``Osteoarthritis: 
Presentation, Pathogenesis, and Pharmacologic Therapy,'' Paulette C. 
Hahn, M.D. and Lawrence Edwards, M.D., Clin. Rev. Summer: 9-13, 1998). 
More than 90 percent of people over the age of 40 have X-ray evidence 
of osteoarthritis in weight-bearing joints, but only 30 percent are 
symptomatic (``Harrison's Principles of Internal Medicine'' Eugene 
Braunwald, M.D., et al eds., ch. 322, 5, 15th ed. 2001). When pain is 
present, an evaluation under Sec.  4.59 would appropriately compensate 
the individual. In addition, since incapacitating exacerbations are not 
characteristic of osteoarthritis, they are not an appropriate basis of 
evaluation, and we propose to remove that criterion as well. The 
proposed criteria are clearer and easier to apply than the current 
criteria, and would promote internal consistency within the rating 
schedule and consistency in ratings among veterans with similar 
disabling effects from different musculoskeletal conditions.
    We also propose to add three notes. The first note would require 
that the diagnosis of osteoarthritis of any joint be confirmed (one 
time only) by X-ray or other imaging procedure. Modern imaging 
procedures such as magnetic resonance imaging, computed tomography, and 
bone scans may be used in some cases instead of or in addition to 
conventional X-rays, and the proposed note would assure that these more 
sophisticated procedures will be equally accepted for diagnosing 
osteoarthritis for VA disability compensation purposes.
    There is currently no regulatory guidance on whether osteoarthritis 
is or is not a systemic generalized disease. This has implications for 
compensation claims because if service-connected osteoarthritis is 
regarded as a generalized or systemic disease, osteoarthritis 
developing in other joints in the future would be considered part of 
the same disease process, and subject to additional compensation. The 
lack of guidance on this issue has led to inconsistency in rating. 
Having consulted with the VHA Orthopedic Committee and reviewed the 
medical literature, we propose to clarify this issue by establishing 
guidelines about generalized and localized osteoarthritis in two more 
notes.
    Current medical thinking is that osteoarthritis is a group of 
overlapping distinct diseases. One classification is based on whether 
the disease is localized or generalized, with indications that the 
generalized type is a distinct subtype that often affects the hands, 
hips, knees, and spine. Some clinicians consider osteoarthritis to be 
generalized only if three extra-spinal (other than spine) joints are 
affected. The concept of localized and generalized osteoarthritis is 
also discussed in a recent book on osteoarthritis (``Diagnosis and 
Nonsurgical Management of Osteoarthritis'' by Kenneth D. Brandt, M.D., 
1996), which states that idiopathic osteoarthritis is divided into 
localized and generalized types and that the generalized type involves 
three or more joint groups. The book references a 1952 classic article 
in the British Medical Journal (``Generalized Osteoarthritis and 
Heberden's Nodes,'' J. H. Kellgren, F.R.C.P., F.R.C.S. and R. Moore, 
M.R.C.P., British Medical Journal, 1952. 1:181-187), which also 
described generalized osteoarthritis as involving three or more joint 
groups. A new standard medical textbook (Harrison's, ch. 322, 1) also 
differentiates between localized and generalized osteoarthritis, 
indicating that primary localized osteoarthritis is present when there 
is involvement of the hands, feet, knees, hips, spine, or other single 
sites, such as the glenohumeral (shoulder) joint,

[[Page 7006]]

sacroiliac joints, or temperomandibular joints and that primary 
generalized osteoarthritis is characterized by involvement of three or 
more joints or groups of joints (distal interphalangeal and proximal 
interphalangeal joints are counted as one group each). The VHA 
Orthopedic Committee also suggested that we consider osteoarthritis to 
be the generalized type if there is positive evidence of osteoarthritis 
on X-ray or other imaging procedure and on physical examination of at 
least three joints during service.
    Therefore, with the generalized type of osteoarthritis, we propose 
that additional joints that later develop osteoarthritis would be 
recognized as part of the same generalized systemic process. If less 
than three joints have positive evidence of osteoarthritis on X-ray or 
other imaging procedure and on physical examination, the condition 
would be considered localized osteoarthritis, and joints later 
developing osteoarthritis would not be considered part of the same 
process. Since arthritis is a chronic condition subject to presumptive 
service condition under the provisions of 38 CFR 3.309(a), meaning that 
osteoarthritis of a joint is presumed to be service-connected if it 
manifests to at least a 10-percent level of disability within 1 year of 
the date of separation from service, we propose to include the 1-year 
period for presumptive service connection in our guidelines that 
determine when generalized osteoarthritis is present. We propose to add 
a second note titled ``Generalized osteoarthritis,'' which states that 
if osteoarthritis is diagnosed on the basis of positive X-ray or other 
imaging procedure and positive physical findings in three or more 
joints (major joints, groups of minor joints, or both) during service 
or within 1 year following the date of separation from service, the 
condition will be considered to be generalized osteoarthritis and 
recognized as a systemic condition. It also says that once generalized 
osteoarthritis has been established based on these criteria, all joints 
subsequently diagnosed with osteoarthritis will be considered to be 
part of the same condition.
    We propose to add a third note titled ``Localized osteoarthritis'' 
that would state that osteoarthritis diagnosed on the basis of positive 
X-ray or other imaging procedure and positive physical findings in 
fewer than three joints (major joints, groups of minor joints, or both) 
during service or within 1 year following the date of separation from 
service will be considered to be localized osteoarthritis rather than a 
systemic condition. It also says that with localized osteoarthritis, 
any joints subsequently diagnosed with osteoarthritis will not be 
considered to be part of the same condition. Adding notes (2) and (3) 
would promote more consistent determinations about when joints with 
osteoarthritis diagnosed after service and the 1-year period following 
separation from service will and will not be considered to be part of 
the osteoarthritis already related to service, and this guidance is 
consistent with current medical thinking.
    Other types of arthritis are currently evaluated under diagnostic 
code 5004 (Arthritis, gonorrheal), 5005 (Arthritis, pneumococcic), 5006 
(Arthritis, typhoid), 5007 (Arthritis, syphilitic), 5008 (Arthritis, 
streptococcic), 5009 (Arthritis, other types (specify)), 5010 
(Arthritis, due to trauma, substantiated by X-ray findings), and 5017 
(Gout or pseudogout), with directions that all but traumatic arthritis 
are to be rated as rheumatoid arthritis. Since the specific infectious 
types of arthritis are uncommon, we propose to combine them all under 
diagnostic code 5004, to be retitled ``Infectious arthritis 
(gonorrheal, pneumococcic, typhoid, syphilitic, streptococcic, etc.).'' 
We propose to retitle diagnostic code 5009 as ``Other types of 
noninfectious inflammatory arthritis (including ankylosing spondylitis, 
Reiter's syndrome, psoriatic arthritis, arthritis associated with 
inflammatory bowel disease, and other seronegative types of 
arthritis).'' We propose to retitle diagnostic code 5017, currently 
``Gout,'' as ``Gout or pseudogout'' to make it clear that it 
encompasses both conditions. These changes will provide the rater with 
clear instructions on evaluating each of these disabilities. The 
groupings are possible because of the similar effects of each of these 
groups of arthritis.
    Infectious arthritis is currently evaluated on the same basis as 
rheumatoid arthritis. However, infectious arthritis is ordinarily an 
acute condition involving only one joint. In about 60 percent of cases, 
the infection will heal without residuals if treatment is prompt and 
adequate, particularly with the use of modern antibiotics. However, 
some cases of infectious arthritis involve multiple joints, and some 
are intractable to treatment and leave severe joint disability. 
Infectious arthritis is therefore unlike rheumatoid arthritis, which is 
a chronic disease affecting multiple joints, and the current direction 
to evaluate as rheumatoid arthritis is not ideal. Infectious arthritis 
is somewhat similar in behavior to osteomyelitis. We therefore propose 
to provide two bases of evaluation that are similar to those for 
osteomyelitis, with one set of criteria to be used for evaluation 
during the active infection and for three months following cessation of 
therapy for active infectious arthritis, with the evaluation depending 
on which joint or joints are infected, as with osteomyelitis. The other 
set of criteria would be used for evaluating the chronic residuals of 
infectious arthritis after the three-month period following the 
cessation of therapy for the active infection has ended. We propose 
that active infectious arthritis of the spine, the pelvis, or a major 
joint be evaluated at 100 percent during and for three months following 
cessation of therapy; that active infectious arthritis not involving 
the spine, the pelvis, or a major joint, and not limited to a single 
finger or toe be evaluated at 40 percent during and for three months 
following cessation of therapy; and that active infectious arthritis of 
a single finger or toe be evaluated at 10 percent during and for three 
months following cessation of therapy. While the course may be 
prolonged, there are not usually multiple recurrences as with 
osteomyelitis, and we do not propose to use evaluation criteria based 
on recurrences as we have for osteomyelitis. We propose to add a note 
under diagnostic code 5004 directing that raters separately evaluate 
chronic residuals, if any, of each joint affected with infectious 
arthritis, based on limitation of motion, ankylosis, joint instability, 
post-surgical residuals (such as arthroplasty), etc., under the 
appropriate diagnostic code, and combine the evaluation for chronic 
residuals of each joint with an evaluation for pain under Sec.  4.59 
when appropriate, subject to the limitations of Sec.  4.68. This method 
of evaluating residuals is proposed because, although many active 
infections heal without residuals, some result in destruction of a 
joint resulting in arthritis, instability, etc., and some lead to such 
severe residuals that arthroplasty is required. These proposed criteria 
are more specific to the effects of infectious arthritis than the 
current criteria and provide a broad range of objective evaluations for 
both the active stage of infection and any chronic disability that 
might develop.
    We propose to retitle diagnostic code 5009, ``Arthritis, other 
types,'' as ``Other types of noninfectious inflammatory arthritis 
(including ankylosing spondylitis, Reiter's syndrome, psoriatic 
arthritis, arthritis associated with inflammatory bowel disease, and 
other seronegative types of arthritis)'' for clarity. There is 
currently a direction to

[[Page 7007]]

evaluate the types of arthritis specified under diagnostic codes 5004 
through 5009 as rheumatoid arthritis (5002). We propose to continue 
evaluating other types of noninfectious arthritis under the same 
criteria and range of evaluation as rheumatoid arthritis, except for 
providing a list of extra-articular manifestations more specific to 
these types of arthritis, namely, fever, eye problems (such as 
conjunctivitis, iritis, uveitis), genitourinary or gynecologic problems 
(such as urethritis, cystitis, prostatitis, cervicitis, salpingitis, 
vulvovaginitis), or heart problems (pericarditis, aortic valvular 
disease, heart block), in a note. We also propose to add four notes 
similar to those under diagnostic code 5002.
    For traumatic arthritis, diagnostic code 5010, we propose to remove 
from the current title the reference to a requirement for X-ray 
evidence and add a note stating that the diagnosis of traumatic 
arthritis of any joint must be confirmed (one time only) by X-ray or 
other imaging procedure. X-ray evidence of traumatic arthritis is 
currently required by the schedule, but newer imaging procedures are 
now often substituted for X-rays and provide comparable or better 
information about the presence of arthritis, so this provision is in 
keeping with current medical practice. Once traumatic arthritis has 
been demonstrated, there is no need for repeat X-rays or other imaging 
procedures, so we are requiring confirmation by imaging procedure only 
once to avoid unnecessary imaging studies. We also propose to add to 
the title the term ``secondary osteoarthritis'' because traumatic 
arthritis can occur, due not only to trauma, but also to other 
diseases, such as tuberculosis or gout, deformity of other joints, or 
stress due to amputation. Traumatic arthritis is currently evaluated as 
degenerative arthritis. We propose to continue this method of 
evaluation, since the findings clinically and on X-ray of traumatic and 
osteoarthritis are usually indistinguishable. For the convenience of 
raters, we propose to repeat the evaluation criteria for osteoarthritis 
under diagnostic code 5010.

Caisson Disease, Benign and Malignant Bone Neoplasms, Osteomalacia, 
Osteoporosis

    We propose to update the title of diagnostic code 5011, ``Bones, 
caisson disease of,'' to ``Caisson disease (residuals of decompression 
sickness or ``the bends'')'' and to broaden its scope by providing 
rating instructions for the evaluation of residuals other than those 
affecting bone. We propose that evaluation be made under an appropriate 
diagnostic code based on the actual residuals, such as aseptic necrosis 
or delayed osteoarthritis of the shoulder or hip or neurologic 
manifestations (such as weakness or paraplegia of lower extremities, 
vestibular dysfunction with vertigo, or paresthesias of the 
extremities). These are the most common disabling long-term effects of 
Caisson disease, and there is no other appropriate diagnostic code 
under which to rate them.
    We propose to modernize the title of diagnostic code 5012 from 
``Bones, new growths of, malignant'' to ``Malignant neoplasm of bone.'' 
The current schedule provides a 100-percent evaluation for one year 
following surgery or the cessation of antineoplastic therapy. This 
provision is applied at the time of rating by assigning a one-year 
total evaluation with a prospective reduction consistent with the 
protected or minimum evaluation. In our judgment, evaluating based on 
impairment of function due to the actual residuals found is the most 
accurate and equitable basis for evaluating residuals of malignancy, 
so, as we have done in the revisions of other portions of the rating 
schedule, for example, diagnostic code 7528 in Sec.  4.115b, 
``Malignant neoplasms of the genitourinary system,'' we propose to 
continue a 100-percent rating following the cessation of surgical, X-
ray, antineoplastic chemotherapy or other therapeutic procedure. Six 
months after discontinuance of such treatment, the appropriate 
disability evaluation shall be determined on the basis of a VA 
examination, or on available medical records if sufficient for 
evaluation. Before any reduction in evaluation based upon the 
examination can be made, the provisions of Sec.  3.105(e) (which would 
provide notice of any proposed reduction and afford claimants the 
opportunity to present evidence showing that a proposed reduction 
should not be made) must be implemented. Evaluation is then made on 
residuals if there has been no metastasis or recurrence.
    The current schedule evaluates ``Osteoporosis, with joint 
manifestations'' (diagnostic code 5013) based on limitation of motion 
of affected parts as degenerative arthritis. Osteoporosis is an age-
related condition characterized by decreased bone mass and structural 
deterioration of bone tissue, leading to bone fragility and an 
increased susceptibility to fractures--especially of the vertebral 
bodies of the spine, the hip (particularly the neck and 
intertrochanteric regions of the femur), and the wrist (distal radius). 
It is ordinarily asymptomatic until a fracture occurs. Joint 
manifestations are not always present; vertebral fractures, for 
example, may result primarily in neurologic complications. We therefore 
propose to revise the title to ``Osteoporosis'' and direct the rater to 
evaluate under the appropriate diagnostic code based on a combination 
of the residuals of fractures (such as shortening, deformity, 
limitation of motion, osteoarthritis) with an evaluation for pain 
(under Sec.  4.59) when appropriate, and to evaluate separately any 
secondary complications, such as neurologic manifestations, pulmonary 
restriction due to thoracic deformity from vertebral fractures, etc. 
These criteria would provide more specific and accurate guidance to 
raters concerning the disabling effects of osteoporosis.
    Diagnostic code 5014, ``Osteomalacia,'' is currently evaluated 
based on limitation of motion as osteoarthritis (diagnostic code 5003). 
Osteomalacia is a form of metabolic bone disease resulting from vitamin 
D deficiency. In children, the same condition is called rickets. In 
adults, osteomalacia is characterized by easy fatigability, malaise, 
poorly defined or localized bone pain, often with bone tenderness, and 
sometimes muscle weakness. Pathological fracture (due to weakened bone) 
or aseptic (avascular) necrosis of a bone may occur and be the initial 
evidence of the condition. Most cases are associated with chronic renal 
disease, but osteomalacia may also be associated with diseases of the 
gastrointestinal tract or other body systems. X-rays will usually show 
evidence of the condition. We propose to provide more detailed guidance 
on evaluation by directing the rater to evaluate under the appropriate 
diagnostic code, based on aseptic necrosis, residuals of fracture (such 
as shortening, deformity, limitation of motion, osteoarthritis), to be 
combined with an evaluation for bone pain (under Sec.  4.59) when 
appropriate. Constitutional manifestations, such as malaise and easy 
fatigability, would be evaluated as part of the underlying metabolic 
disease, such as renal or gastrointestinal disease, that has caused the 
osteomalacia.
    As with malignant neoplasms of bone, we propose to update the title 
of diagnostic code 5015, ``Bones, new growths of, benign,'' to ``Benign 
neoplasm of bones.'' The current schedule directs that these neoplasms 
be evaluated as degenerative arthritis based on limitation of motion. 
That method of evaluation would be appropriate when the neoplasm 
involves a joint, but many do not. At

[[Page 7008]]

times bone pain or pathologic fracture is the major problem. Many are 
asymptomatic and discovered as an incidental finding when a bone is X-
rayed for another problem. We therefore propose to expand the 
directions to include evaluation under the appropriate diagnostic code 
based on osteoarthritis (diagnostic code 5003), residuals of fracture 
(such as shortening, limitation of motion), etc., to be combined with 
an evaluation for bone pain (under Sec.  4.59) when appropriate.

Paget's Disease, Gout and Pseudogout

    We propose to update the title of diagnostic code 5016, currently 
``Osteitis deformans'' to the modern name for this disease, ``Paget's 
disease.'' Paget's disease is currently evaluated based on limitation 
of motion as osteoarthritis. It is a disease characterized by enlarged, 
heavily calcified, and often deformed, but also weak, bones in any area 
of the body, most commonly the pelvis, femur, tibia, skull, vertebrae, 
clavicle, and humerus. The most common symptom is bone pain, and 
deformity, arthritis, and fractures may occur. Pressure on cranial 
nerves due to enlargement of the skull by the disease can lead to 
impaired hearing or vision. We therefore propose to provide a broader 
set of evaluation criteria that encompass more of the disabling effects 
of Paget's disease by directing raters to evaluate it based on 
osteoarthritis or residuals of fracture, combined with an evaluation 
for pain (under Sec.  4.59) when appropriate, and to separately 
evaluate complications such as impaired hearing or vision.
    ``Gout'' (diagnostic code 5017), which we propose to retitle ``Gout 
or pseudogout,'' is currently evaluated as rheumatoid arthritis. 
However, there are major differences between rheumatoid arthritis and 
gout. Gout, for example, which is a type of arthritis in which uric 
acid crystals are deposited around joints, usually involves acute 
inflammation of only a single joint at a time, rather than the 
widespread joint involvement common in rheumatoid arthritis. Also, gout 
is not associated with the same types of extra-articular manifestations 
as rheumatoid arthritis, and there may be none at all except late in 
the course of the disease when tophi (deposits of sodium urate that 
develop in gout) have been deposited in tissues other than joint areas. 
Pseudogout (caused by deposits of calcium pyrophosphate crystals in 
joint tissues) has manifestations that are similar to gout, but usually 
milder. We therefore propose to provide a modified version of the 
rheumatoid arthritis evaluation criteria for evaluating gout and 
pseudogout. We propose not to provide a 100-percent evaluation level 
for gout or pseudogout, since neither condition is likely to be totally 
disabling. We propose to retain 60-, 40-, and 20-percent evaluation 
levels and to add a 10-percent evaluation level for gout and pseudogout 
based on inflammatory synovitis with such findings as weakness and 
fatigue, acute pain, swelling, heat, tenderness, or limitation of 
motion. The 60-percent level would require incapacitating exacerbations 
or flares with a total duration of at least 6 weeks during the past 12-
month period requiring treatment by a health care provider, due to 
inflammatory synovitis with such findings as weakness and fatigue, 
acute pain, swelling, heat, tenderness, or limitation of motion of 
multiple joints. The 40-percent level would be the same except that it 
requires incapacitating exacerbations or flares of multiple joints with 
a total duration of at least 4 weeks but less than 6 weeks during the 
past 12-month period. The 20-percent level would require incapacitating 
exacerbations or flares with a total duration of at least 2 weeks but 
less than 4 weeks during the past 12-month period of multiple joints. 
The 10-percent evaluation would require incapacitating exacerbations or 
flares with a total duration of at least 1 week but less than 2 weeks 
during the past 12-month period of a single joint or multiple joints. 
This would provide appropriate criteria to evaluate the acute attacks 
of inflammation of either single or multiple joints. We propose to 
provide notes similar to those under diagnostic code 5002 (rheumatoid 
arthritis). The first note would direct that evaluation be made either 
on the basis of incapacitating exacerbations or flares under the 
criteria for diagnostic code 5017 or on the combined evaluation of 
chronic residuals of gout or pseudogout, whichever results in the 
higher evaluation. The second note would direct that if not evaluating 
under the criteria under diagnostic code 5017, chronic residuals of 
each major joint or group of minor joints with gout or pseudogout will 
be separately evaluated based on limitation of motion, ankylosis, joint 
instability, etc., under the appropriate diagnostic code. It further 
directs that an evaluation for chronic residuals of each major joint or 
group of minor joints be combined with an evaluation for pain under 
Sec.  4.59 when appropriate. The third note would direct that 
manifestations of gout other than joint disease, such as urinary tract 
calculi or gouty nephropathy, be separately evaluated. The fourth note 
would define an incapacitating exacerbation or flare as one requiring 
bedrest or wheelchair use and treatment by a health care provider. The 
proposed criteria are more specific to gout and pseudogout than the 
current criteria and will therefore promote consistent and appropriate 
evaluations in veterans with one of these joint diseases.

Joint Effusion, Bursitis, Tenosynovitis, Synovitis, Myositis, 
Periostitis, Myositis Ossificans

    Diagnostic code 5018 is titled ``Hydrarthrosis, intermittent,'' 
which means fluid occurring in a joint from time to time. This finding 
may be a sign of various joint diseases and does not indicate a 
specific diagnosis. We propose updating the title of this code to 
``Joint effusion,'' which is the current medical term for this 
condition. The current schedule directs that evaluation be based on 
limitation of motion as osteoarthritis. Since osteoarthritis is one of 
the conditions that may result in joint effusion, it is more likely 
that osteoarthritis would be evaluated as joint effusion than vice 
versa. Joint effusion, being a nonspecific response to injury or 
disease of a joint, may result from any number of types of injury, both 
bone and soft tissue; from almost any type of arthritis, including 
infectious arthritis; from osteomyelitis; from surgery in or near a 
joint; etc. The criteria for evaluation under this diagnostic code 
would be used in evaluating musculoskeletal conditions where joint 
effusion is the predominant finding. We propose that evaluation of 
joint effusion be based on limitation of motion, a common concomitant 
of joint effusion, and this evaluation would be combined with an 
evaluation for pain under Sec.  4.59 when appropriate. The current 
schedule requires that the joint effusion be ``intermittent,'' but does 
not define ``intermittent''. To promote consistency, we propose to add 
a statement that a joint effusion that is present constantly, or nearly 
so, or if intermittent, that occurred at least two times during the 
past 12-month period, may be evaluated under this diagnostic code and 
that evaluation will be based on limitation of motion, to be combined 
with an evaluation for pain under Sec.  4.59 when appropriate. We 
require at least two episodes of joint effusion because a single 
episode would represent only an acute condition that might never recur. 
These criteria are both more objective and more specific to joint 
effusion than the current criteria.
    ``Bursitis,'' diagnostic code 5019, is currently evaluated based on 
limitation of motion as osteoarthritis, as are all the conditions in 
diagnostic codes 5013 through 5024 except gout. Bursae are

[[Page 7009]]

fluid-filled structures that assist motion between adjacent structures 
(skin, bones, muscles, tendons) by decreasing friction. Bursitis is an 
inflammation of the lining of the bursa, which is a sac made up of 
synovial tissue, the same tissue that lines joints. Bursitis is 
commonly due to chronic overuse or an injury, although it may also be 
associated with systemic diseases such as rheumatoid arthritis or 
scleroderma. The bursae in the area of the hip, patella or other knee 
area, shoulder, and olecranon process of the ulna are common sites of 
bursitis. Signs and symptoms of bursitis include pain, tenderness, 
redness, heat, swelling, and limitation of motion. We therefore propose 
to revise the evaluation criteria to base evaluation on limitation of 
motion, to be combined with an evaluation for pain under Sec.  4.59 
when appropriate.
    The causes of, and findings in, tenosynovitis, diagnostic code 
5024, and synovitis, diagnostic code 5020, are similar to those for 
bursitis, and they may also be infectious in origin. Tenosynovitis 
(also called tendinitis) is an inflammation of the tendon and tendon 
sheath and may result in pain, limitation of motion, tenderness, and 
swelling. Synovitis is an inflammation of the synovial (joint-lining) 
tissue only. We propose to provide the same evaluation criteria for 
synovitis and tenosynovitis as for bursitis.
    Myositis (diagnostic code 5021) is an inflammation of muscles with 
pain, tenderness, and sometimes swelling. It may be due to trauma or a 
virus, or may be drug-related. We propose that it be evaluated based on 
limitation of motion, to be combined with an evaluation for pain under 
Sec.  4.59 when appropriate. There is another category of more 
widespread myositis that includes systemic autoimmune connective tissue 
diseases like polymyositis, dermatomyositis, and inclusion body 
myositis. They are diseases that may also affect joints, the heart, 
lungs, intestines, and skin. Because these types of myositis affect 
multiple body systems, they are more appropriately evaluated in the 
``Infectious Diseases, Immune Disorders and Nutritional Deficiencies 
(Systemic Conditions)'' portion of the rating schedule, perhaps 
analogous to systemic lupus erythematosus (diagnostic code 6350), 
rather than under this diagnostic code.
    Periostitis (diagnostic code 5022) is another inflammatory 
condition (of the periosteum or outer covering of a bone) that may 
develop as a result of overuse or infection. At times it follows severe 
tenosynovitis. Periostitis is one of the causes, along with stress 
fractures and tenosynovitis, of shin splints (pain in the lower leg 
that occurs during exercise) or posterior tibial stress syndrome or 
lower leg stress. Tennis elbow (periostitis of the lateral epicondyle 
of the humerus, often following tendinitis of the extensor carpi 
radialis brevis in the area of the lateral epicondyle), golfer's elbow 
(periostitis of the medial epicondylitis of the humerus often following 
tendinitis of the flexor pronator muscles), and osteitis pubis are 
other common types of periostitis. We propose to evaluate this 
condition based on limitation of motion, and to combine this with an 
evaluation for pain under Sec.  4.59 when appropriate.
    Myositis ossificans, diagnostic code 5023, is a condition in which 
there is ossification (bone formation) in soft tissues such as muscle 
and tendons. It most often results from trauma or repetitive stress, 
sometimes representing an ossified intramuscular hematoma. In many 
cases, the cause is unknown. It may result in pain, tenderness, 
redness, heat, a palpable mass, and decreased range of motion. We 
therefore propose to evaluate it based on limitation of motion, and to 
combine this with an evaluation for pain under Sec.  4.59 when 
appropriate.
    Other than terminology changes, which we are proposing to adopt, 
the consultants offered few suggestions for changes under diagnostic 
codes 5011 to 5024. One exception was osteoporosis (diagnostic code 
5013), for which they suggested evaluation levels of zero, 20, 50, and 
100 percent, based on such criteria as X-ray evidence of ``some'' 
``moderate,'' ``severe'' demineralization, on the severity of spine 
pain (``mild,'' ``moderate,'' or ``disabling''), and on the history of 
fractures (requiring a history of two fractures for 50 percent, and 
three or more fractures for 100 percent). These criteria would require 
subjective determinations of various degrees of spine pain and X-ray 
findings. In addition, in our judgment, how many fractures have 
occurred is not as significant as how disabling the residuals of those 
fractures are. We therefore propose to evaluate based on the actual 
residuals of fractures and any secondary complications, as discussed 
above. We believe these criteria would provide an evaluation that 
presents a truer picture of disability and would promote consistent 
evaluations by correlating evaluations with disabling residuals of 
fractures rather than simply with numbers of fractures.

Prosthetic Joint Implants

    The diagnostic codes for prosthetic joint implants (joint 
replacements or arthroplasties) (5051 through 5056) currently provide a 
100-percent evaluation for one year of convalescence following hospital 
discharge. This provision is applied at the time of rating by assigning 
a 100-percent evaluation for one month under Sec.  4.30 (``Convalescent 
ratings''), followed by a 100-percent evaluation with a prospective 
reduction one year later based on medical findings. As the consultants 
recommended, we propose to continue the 100-percent evaluation 
indefinitely from date of hospital admission and to examine the veteran 
six months following discharge from the hospital, because almost all 
individuals are stabilized within six months of implant. Any reduction 
in the 100-percent evaluation would be effected under 38 CFR 3.105(e) 
in the same manner as proposed under diagnostic code 5012 (malignant 
neoplasm of bone). This would ensure that a veteran receives advance 
notice of any reduction and has the opportunity to submit additional 
evidence showing that the reduction is not warranted. We also propose 
to state that the same method of evaluation will be applied when an 
arthroplasty is revised or redone, since this procedure is at least as 
disabling as the original arthroplasty.
    The consultants suggested deleting separate evaluations for 
dominant and nondominant upper extremity joint replacements. We do not 
propose to do so, because joint replacements of a dominant side--that 
is, the side normally used for writing, feeding, grooming, and other 
important tasks--would clearly be more disabling to an individual than 
joint replacement of the less used nondominant side.
    Diagnostic code 5051, ``Shoulder replacement (prosthesis)'' is 
currently evaluated at 100 percent for one year following implantation; 
at 60 or 50 percent (for dominant or nondominant side) if there are 
chronic residuals consisting of severe, painful motion or weakness in 
the affected extremity; analogous to diagnostic codes 5200 (ankylosis 
of scapulohumeral articulation) and 5203 (impairment of clavicle or 
scapula) if there are intermediate degrees of residual weakness, pain, 
or limitation of motion; and at 30 or 20 percent as a minimum 
evaluation. The consultants suggested no change. We propose to revise 
and update the title to ``Total or partial shoulder arthroplasty or 
replacement (with prosthesis)'' and to make similar changes to the 
titles of arthroplasty of all major joints, elbow (diagnostic code 
5052), wrist (diagnostic code 5053), hip (diagnostic code 5054, knee 
(diagnostic code 5055), and ankle (diagnostic code

[[Page 7010]]

5056). These changes would indicate that evaluation is the same whether 
the entire joint or only one side of the joint has been replaced, (and 
whether this is an initial or a revision arthroplasty, as the note 
preceding the prosthetic implants diagnostic codes states) since 
complications and residuals may be the same. We also propose to revise 
the criteria to remove subjective language such as ``severe'' painful 
motion or weakness and ``intermediate'' degrees of weakness, pain, or 
limitation of motion, which could be subject to different 
interpretations by different individuals.
    We propose to replace these criteria with more objective criteria 
in order to promote consistent ratings. For example, we propose that 60 
or 50 percent be assigned if abduction (movement of the arm away from 
the body) is not possible beyond 45 degrees; and that the minimum 
evaluation of 30 or 20 percent following arthroplasty be unchanged. We 
also propose to add a note directing that if there is ankylosis of the 
glenohumeral joint, evaluation is to be made under diagnostic code 5200 
(ankylosis of glenohumeral articulation (shoulder joint)). There may be 
neurologic or other complications following arthroplasty. We therefore 
propose to add a second note directing that complications, such as 
peripheral neuropathy, causalgia (a severe burning pain that 
occasionally occurs following injury to a nerve), and reflex 
sympathetic dystrophy (soft tissue and bony changes that accompany 
causalgia), be separately evaluated under an appropriate diagnostic 
code and combined with an evaluation under diagnostic code 5051 that is 
less than total, as long as limitation of abduction is not used to 
support an evaluation for a complication. We propose to add a third 
note directing that an evaluation under diagnostic code 5051 be 
combined with an evaluation for pain under Sec.  4.59 when appropriate.
    Elbow replacement (diagnostic code 5052), following the initial 
100-percent evaluation, is currently evaluated at 50 or 40 percent if 
there is severe painful motion or weakness; by analogy to diagnostic 
codes 5205 through 5208 (which provide evaluation criteria for 
ankylosis or limitation of motion of the elbow) if there are 
intermediate degrees of residual weakness, pain or limitation of 
motion; and at 30 or 20 percent as a minimum evaluation. These criteria 
contain subjective language, and we propose to revise them to more 
objective criteria, directing the rater to evaluate based on the 
criteria under diagnostic codes 5205, 5206, 5207, or 5208, whichever 
results in the highest evaluation, combining this evaluation with an 
evaluation for pain under Sec.  4.59 when appropriate. We propose to 
retain the minimum evaluations of 30 (for dominant side) or 20 percent 
following arthroplasty.
    Wrist replacement (5053) is currently evaluated under the same 
criteria as elbow arthroplasty, but with evaluations of 40 or 30 
percent if there is severe painful motion or weakness; by analogy to 
diagnostic code 5214 (ankylosis of wrist) if there are intermediate 
degrees of residual weakness, pain or limitation of motion; and at 20 
percent as a minimum evaluation. We propose to revise these criteria to 
make them more objective, as we have proposed for other upper extremity 
arthroplasties, by directing the rater to evaluate based on ankylosis 
(diagnostic code 5214) or limitation of motion (diagnostic code 5215), 
whichever results in a higher evaluation, combining this evaluation 
with an evaluation for pain under Sec.  4.59 when appropriate. We 
propose to retain the minimum 20-percent evaluation following 
arthroplasty.
    Hip replacement (diagnostic code 5054) is currently evaluated at 
100 percent for 1 year, as discussed above; at 90 percent if there is 
painful motion or weakness such as to require the use of crutches; at 
70 percent if there is markedly severe residual weakness, pain, or 
limitation of motion; at 50 percent if there are moderately severe 
residuals of weakness, pain, or limitation of motion; and at 30 percent 
as a minimum. The consultants did not suggest substantive changes, 
other than to recommend that the 100-percent evaluation be reassessed 
six months following implantation, as for all joint prostheses.
    We propose to retitle 5054 as ``Total or partial hip arthroplasty 
or replacement (with prosthesis)''. In addition to following the 
consultants' recommendation concerning the 100-percent evaluation, we 
propose other changes to make the criteria more objective, after 
consultation with the VHA Orthopedic Committee. For example, the 
consultants did not address the subjective language such as 
``markedly'' and ``moderately'' severe in the current criteria. We 
propose to revise the criteria for the 90-percent evaluation to 
``requiring use of two crutches or a walker for ambulation,'' because a 
walker is equivalent to two crutches and is an indication of 
significant impairment in ambulation. We propose to base the next two 
lower levels of evaluation on the extent of need for ambulatory 
support, which is an objective basis of evaluation, assigning a 70-
percent evaluation if one crutch or two canes are required for most 
ambulation, due to pain, instability, or weakness (muscle strength 
grade zero to 2 out of 5), and a 50-percent evaluation if one crutch or 
two canes are required only for ambulating long distances (500 feet or 
more), due to pain, instability, or weakness (muscle strength grade 3 
to 4 out of 5), since the need to use two canes or one crutch is 
another indication of difficulty ambulating, and they are approximately 
equivalent. We propose to add a 40-percent level, to be assigned if one 
cane is required for ambulation, due to pain, instability, or weakness, 
or if there is recalcitrant thigh pain of longer than 2 years' 
duration, and to retain a 30-percent minimum evaluation following 
arthroplasty. The VHA Orthopedic Committee described the residual of 
thigh pain as a disabling finding that is common enough to be addressed 
and which could be the primary residual after 2 years. We also propose 
to add a note directing raters not to combine an evaluation under these 
criteria with an evaluation for pain under Sec.  4.59. Pain as a 
residual of arthroplasty is taken into account in these evaluation 
criteria.
    Knee replacement (diagnostic code 5055) currently has the same 
relatively subjective criteria as other arthroplasties, with 60 percent 
assigned if there are chronic residuals consisting of severe painful 
motion or weakness in the affected extremity; rating by analogy to 
diagnostic codes 5256, 5261, or 5262 (the codes for ankylosis of the 
knee, limitation of extension of the leg, and impairment of the tibia 
and fibula) if there are intermediate degrees of residual weakness, 
pain or limitation of motion; and a minimum evaluation of 30 percent. 
The consultants recommended criteria that retained much of the same 
subjective language. After consultation with the VHA Orthopedic 
Committee, however, we propose to provide more objective criteria that 
parallel the evaluation criteria for hip arthroplasty based on 
ambulation, plus criteria based on the extent of limitation of the 
normal whole arc of motion (the full range of flexion and extension) of 
the knee after arthroplasty, which is 0 degrees of extension to 110 
degrees of flexion. As with hip arthroplasty, we propose to assign a 
90-percent evaluation for residuals requiring use of two crutches or a 
walker for ambulation; a 70-percent evaluation for residuals requiring 
the use of one crutch or two canes for most ambulation, due to pain, 
instability, or weakness (muscle strength grade zero to 2 out of 5) or 
if there is loss of more than 40 degrees of the full arc of motion; at

[[Page 7011]]

50 percent if requiring use of one crutch or two canes only for 
ambulating long distances (500 feet or more), due to pain, instability, 
or weakness (muscle strength grade 3 to 4 out of 5), or if there is 
loss of 21 to 40 degrees of the full arc of motion; and at 40 percent 
if residuals require the use of one cane or brace for ambulation, due 
to pain, instability, or weakness, or if there is loss of 10 to 20 
degrees of the full arc of motion. We propose to retain a 30-percent 
evaluation for residuals as a minimum following arthroplasty. We also 
propose to add two notes, the first stating that a full arc of motion 
of the knee after arthroplasty is a range of motion of 0 to 110 
degrees, and the second directing raters not to combine an evaluation 
under these criteria with an evaluation for pain under Sec.  4.59. Pain 
as a residual of arthroplasty is taken into account in these evaluation 
criteria.
    Ankle replacement (diagnostic code 5056), is currently evaluated 
under the same criteria as other arthroplasties, with 40 percent 
assigned if there are chronic residuals consisting of severe painful 
motion or weakness in the affected extremity; rating by analogy to 
diagnostic codes 5270 or 5271 if there are intermediate degrees of 
residual weakness, pain or limitation of motion; and a minimum 
evaluation of 20 percent. We propose similar changes for this 
arthroplasty, removing the current subjective criteria and directing 
that evaluation be based on ankylosis (under diagnostic code 5270) or 
limitation of motion (under diagnostic code 5271), whichever results in 
a higher evaluation, combining this evaluation with an evaluation for 
pain under Sec.  4.59 when appropriate. We propose to retain the 20 
percent minimum evaluation level.

Anatomical Loss and Loss of Use of Hands and Feet

    The current list of potential combinations of disabilities under 
diagnostic codes 5104 through 5111 is incomplete because it does not 
include ``loss of use of one hand and anatomical loss of the other 
hand'' or ``loss of use of one foot and anatomical loss of the other 
foot.'' We propose to combine ``Anatomical loss of both hands'' 
(diagnostic code 5106) and ``Loss of use of both hands'' (diagnostic 
code 5109) into one code, diagnostic code 5106, titled ``Anatomical 
loss or loss of use of one hand and anatomical loss or loss of use of 
the other hand.'' Similarly, we propose to combine ``Anatomical loss of 
both feet'' (diagnostic code 5107) and ``Loss of use of both feet'' 
(diagnostic code 5110) into one code, diagnostic code 5107, titled 
``Anatomical loss or loss of use of one foot and anatomical loss or 
loss of use of the other foot.'' These changes will make diagnostic 
codes 5109 and 5110 redundant, and we propose to delete them. Finally, 
we propose to combine ``Anatomical loss of one hand and loss of use of 
one foot'' (diagnostic code 5104), ``Anatomical loss of one foot and 
loss of use of one hand'' (diagnostic code 5105), ``Anatomical loss of 
one hand and one foot'' (diagnostic code 5108), and ``Loss of use of 
one hand and one foot'' (diagnostic code 5111) into one code, 
diagnostic code 5104, titled ``Anatomical loss or loss of use of one 
hand and anatomical loss or loss of use of one foot.'' Diagnostic codes 
5105, 5108, and 5111 will then be redundant, and we propose to delete 
them.

Other Amputations

    Diagnostic codes 5123, 5124, and 5125 currently pertain to 
amputation of the forearm. Under diagnostic codes 5123, ``Forearm, 
amputation of, above insertion of pronator teres'' and 5124, ``Forearm, 
amputation of, below insertion of pronator teres,'' we propose to add 
the alternative titles of ``short, below elbow amputation'' and ``long, 
below elbow amputation,'' respectively, since these are terms commonly 
used in medical practice to distinguish levels of amputation. The 
insertion of the pronator teres is located at the middle one-third of 
the lateral surface of the radius, and, for the sake of clarity, we 
also propose to add that definition to the titles of diagnostic codes 
5123 and 5124. We propose to revise the current title of diagnostic 
code 5125 from ``Hand, loss of use of'' to ``Wrist disarticulation,'' 
because a wrist disarticulation procedure results in anatomical loss of 
the hand.
    Under the subheading ``Multiple finger amputations,'' we propose to 
edit paragraphs (a) through (f) and rename them notes, numbered one 
through five, consistent with the way we have designated rating 
instructions throughout this section. We also propose to move the notes 
from their current position following the diagnostic codes for multiple 
finger amputations to the beginning of the applicable diagnostic codes, 
for clarity and ease of reference. The last of these paragraphs defines 
loss of use of the hand. This is a duplication of Sec.  3.350 (a)(2), 
and we propose to delete it as unnecessary. We propose to change the 
term middle finger to long finger for disabilities resulting from 
finger amputations and ankylosis of the fingers because this is the 
current medical term for this finger.
    We propose to retitle diagnostic code 5160, now titled 
``Disarticulation, with loss of extrinsic pelvic girdle muscles'' under 
amputation of thigh, to ``Disarticulation of hip, with loss of 
extrinsic pelvic girdle muscles'' for the sake of clarity about the 
site of amputation.
    We propose to make editorial changes in the language of diagnostic 
codes 5163, 5164, and 5165, regarding leg amputations and diagnostic 
codes 5172 and 5173, regarding amputation of toes, for clarity. No 
substantive change is intended.

Shoulder and Arm

    Ankylosis of the shoulder is currently rated under diagnostic code 
5200, which is titled ``Scapulohumeral articulation, ankylosis of.'' 
Since the common term for the shoulder joint is the glenohumeral, 
rather than the scapulohumeral joint, we propose to change the heading 
of diagnostic code 5200 and other references to the joint accordingly. 
For the sake of clarity, we propose to change the word ``piece'' to 
``unit'' when referring to the scapula and humerus in the evaluation 
criteria under diagnostic code 5200. The current criteria for ankylosis 
of the shoulder are 50 and 40 percent (dominant and nondominant sides) 
for unfavorable ankylosis with abduction limited to 25 degrees from 
side; 40 and 30 percent for intermediate ankylosis between favorable 
and unfavorable; and 30 and 20 percent for favorable ankylosis, with 
abduction to 60 degrees, can reach mouth and head.
    The consultants suggested an 80-percent evaluation for unfavorable 
ankylosis, defined as abduction limited to 25 degrees from side, and a 
40-percent evaluation for favorable ankylosis, defined as abduction of 
60 degrees, can reach mouth and head. The consultants suggested 
removing the intermediate level because ankylosis is either favorable 
or unfavorable and suggested elevating the unfavorable ankylosis to 80 
percent and the favorable to 40 percent based on the same criteria for 
favorable and unfavorable as the current criteria. We consulted further 
with the VHA Orthopedic Committee, however, and the Committee indicated 
that an intermediate level is possible. We therefore propose to retain 
evaluations of 40 and 30 percent for intermediate ankylosis, which we 
propose to define as ankylosis with abduction limited to between 26 and 
59 degrees, and to retain evaluations of 50 and 40 percent for 
unfavorable ankylosis and 30 and 20 percent for favorable ankylosis, 
retaining the current criteria. This

[[Page 7012]]

would encompass those with limited motion of a degree that does not 
meet the criteria for either favorable or unfavorable. We also do not 
propose to adopt the higher levels suggested, as the consultants did 
not specify why they believe this condition is more disabling than it 
is currently evaluated.
    We propose to change the title of diagnostic code 5201 from ``Arm, 
limitation of motion of'' to ``Limitation of active abduction of 
shoulder'' to indicate that the criteria under this code are limited to 
the evaluation of active abduction of the shoulder rather than 
limitation of arm motion in general. The consultants suggested no other 
change. We propose no change other than to objectively specify in 
degrees the movements currently designated by reference to side and 
shoulder positions, that is, by changing ``Midway between side and 
shoulder'' to ``to between 26 degrees and 89 degrees from side'' and 
changing ``At shoulder level'' to ``to shoulder level (90 degrees)''. 
This more objective measurement of the disability will promote more 
consistent evaluations.
    Diagnostic code 5202 is currently called ``Humerus, other 
impairment of.'' For the sake of clarity, we propose to change the 
title to ``Residuals of fracture of humerus and residuals of 
dislocation of glenohumeral (shoulder) joint,'' because these are the 
specific conditions covered under this diagnostic code. In the current 
evaluation criteria, the term ``flail shoulder'' is a parenthetical 
expression after loss of head of humerus. However, we propose to delete 
the reference to flail shoulder joint because this is a neurological 
condition due to paralysis of shoulder motion from such things as 
brachial plexus or other nerve injuries or poliomyelitis, and is 
properly evaluated under the neurological section of the rating 
schedule. The level of evaluation for the paralysis would depend on the 
extent of loss of function. The term ``false flail joint'' is currently 
a parenthetical expression after nonunion of a fracture of the humerus. 
That term is rarely used medically, and we propose to delete it and 
replace it with ``nonunion of head of humerus with motion at fracture 
site'' because that phrase describes the disability in correct and 
commonly used medical terms. The current criteria include evaluation 
percentages of 80 and 70 (for dominant and nondominant side) for loss 
of head of humerus (flail shoulder), 60 and 50 for nonunion of humeral 
head (false flail joint), and 50 and 40 for fibrous union of humeral 
head. We propose to reduce the rating for loss of the head from 80 and 
70 to 60 and 50 percent because the consultants stated that this 
impairment is more amenable to treatment under modern medical 
techniques. We propose to retain the same evaluation percentages for 
nonunion and fibrous union.
    This diagnostic code (5202) also contains criteria for evaluating 
recurrent dislocation at the scapulohumeral (glenohumeral) joint, 
providing 30 and 20 percent for frequent episodes and guarding of all 
arm movements and 20 and 20 percent for infrequent episodes and 
guarding of movement only at shoulder level. We propose to change the 
subtitle to ``Recurrent dislocation of glenohumeral (shoulder) joint,'' 
which is the more common, current term, and to retain the percentage 
evaluations for frequent and infrequent episodes. We do, however, plan 
to specify what is meant by frequent (every 2 months or more 
frequently) and infrequent (less often than every 2 months, but at 
least once per year) episodes and to add a 10-percent level for 
evaluation when there has been at least one recurrence. We propose to 
add guarding of external rotation to the evaluation of infrequent 
dislocations under this code because this is a clearer description of 
the disability. These criteria are more clearly defined and will 
promote consistency.
    Diagnostic code 5202 also includes evaluation criteria for malunion 
of the humerus, with evaluations of 30 and 20 percent for ``marked'' 
and 20 and 20 percent for ``moderate.'' The consultants indicated that 
malunion is disabling only if it is symptomatic or there is functional 
impairment. We therefore propose to follow their recommendation and 
provide an evaluation level of 30 and 20 percent if the malunion is 
symptomatic and there is more than 45 degrees of angulation in the 
anterior-posterior plane or varus-valgus plane and a level of 20 
percent if the malunion is symptomatic and there is 30 to 45 degrees of 
angulation in the anterior-posterior plane or varus-valgus plane. These 
criteria are less subjective and better define the degree of deformity 
and indicate that symptoms are required. These changes would promote 
consistency of evaluations.
    Current diagnostic code 5203, ``Clavicle or scapula, impairment 
of,'' provides evaluations of 20 and 20 percent (for dominant and 
nondominant sides) for dislocation, 20 and 20 percent for nonunion with 
loose movement, 10 and 10 percent for nonunion without loose movement, 
and 10 and 10 percent for malunion. The consultants said that the 
impairments from these conditions are less than current criteria would 
indicate, and suggested a 10-percent evaluation for any of the 
following: acromioclavicular separation with chronic pain, 
sternoclavicular separation with chronic pain, and nonunion of the 
clavicle and scapula with chronic pain. Because their suggested 
criteria were no more objective than the current criteria, we consulted 
with the VHA Orthopedic Committee, who suggested the following more 
objective criteria, which we propose to adopt: For resection of the end 
of the clavicle; nonunion of the clavicle or scapula; or malunion of 
the clavicle or scapula with skin breakdown, skin irritation, or 
thoracic outlet syndrome, 20 and 10 percent; for dislocation of the 
acromioclavicular joint with pain and osteoarthritis; or painful 
sternoclavicular anterior dislocation, 10 and 10 percent; for malunion 
of the clavicle or scapula zero and zero percent unless skin breakdown, 
skin irritation or thoracic outlet syndrome is present. The thoracic 
outlet is an area behind each clavicle where an artery, a vein, and 
nerves cross over the first rib. Upper extremity symptoms, known as the 
thoracic outlet syndrome, can develop on one or both sides when the 
nerves or blood vessels in this area are compressed by any of several 
causes, including an abnormal position or shape of the clavicle after 
an injury. The symptoms may include pain, numbness, tingling, weakness, 
and aching of an arm or hand, and there also may be swelling and 
enlarged veins.
    Untreated sternoclavicular posterior dislocations will be evaluated 
separately, on the basis of complications, such as from pressure on 
blood vessels or trachea. We propose to add a note stating that these 
criteria encompass pain, so an evaluation under diagnostic code 5203 is 
not to be combined with an evaluation for pain (under Sec.  4.59). We 
propose to add a second note to explain what is meant by a thoracic 
outlet syndrome and to indicate that it can be separately evaluated if 
not used to support an evaluation under diagnostic code 5203. These 
objective criteria are more clearly related to the likely functional 
impairment of these various conditions, based on orthopedic experience.
    We propose to add a new diagnostic code, 5204, for ``Rotator cuff 
dysfunction and impingement syndrome,'' two common shoulder 
disabilities that warrant a separate diagnostic code because they may 
currently be rated under a variety of existing codes and therefore may 
not be rated consistently. The rotator cuff is a group of 4 muscles 
(the subscapularis, supraspinatus, infraspinatus, and teres minor, all 
originating from the scapula)

[[Page 7013]]

and their tendons that surround the glenohumeral (shoulder) joint. 
These structures stabilize the shoulder joint and allow the arm to 
rotate (``Essentials of Musculoskeletal Care'' 114 (Robert K. Snider, 
M.D., ed., 1999)). The rotator cuff may become symptomatic as a result 
of bursitis, tendinitis, or a tear or sprain affecting structures in 
the area. Both repetitive activity and acute injury can lead to rotator 
cuff damage. The major symptoms are pain, weakness, and loss of motion. 
Rotator cuff dysfunction is often associated with impingement syndrome, 
which is a condition in which the acromion or coracoid process of the 
scapula, the coracoacromial ligament, and the acromioclavicular joint 
press on the underlying bursa, biceps, tendon, and rotator cuff 
(Snider, 108). Impingement may lead to rotator cuff damage. Pain, 
weakness, and loss of function are possible outcomes of impingement 
syndrome. Because the effects of rotator cuff dysfunction and 
impingement syndrome are similar, and they often occur together, they 
can be rated under the same set of criteria. The consultants suggested 
adding impingement syndrome to the schedule with a single evaluation 
level of 10 percent for either side, based on the presence of the 
diagnosis and a positive impingement sign (a clinical test of arm 
movement that indicates the impingement syndrome is present). We 
propose to follow their suggestion for a 10-percent evaluation but to 
add an evaluation level of 20 and 20 percent for those with limitation 
of motion of internal rotation, external rotation, flexion, and 
abduction, since this limitation of motion would be more disabling than 
the presence of a positive impingement sign alone would warrant. 
Furthermore, since limitation of abduction alone may be rated under 
diagnostic code 5201 (limitation of active abduction of shoulder) at 
higher levels, we propose to add a note directing that evaluation be 
made under diagnostic code 5201 if a higher evaluation could be 
assigned based on limitation of abduction, but this evaluation may not 
be combined with an evaluation under diagnostic code 5204. We also 
propose to add a note directing the rater to combine an evaluation 
based on the criteria under diagnostic code 5204 with an evaluation for 
pain under Sec.  4.59 when appropriate, since pain may be the 
predominant symptom. These criteria would take into account the usual 
manifestations of these conditions in an objective way, and also take 
into account any pain that is present under a standardized method of 
evaluation.

Elbow and Forearm

    Current diagnostic code 5205, ``Elbow, ankylosis of,'' has 
evaluation levels of 60 and 50, 50 and 40, and 40 and 30 percent, based 
on whether the ankylosis is unfavorable, at an angle of less than 50 
degrees or with complete loss of supination or pronation; intermediate, 
at an angle of more than 90 degrees or between 70 degrees and 50 
degrees; or favorable, at an angle between 90 degrees and 70 degrees. 
The consultants recommended that all degrees of elbow ankylosis be 
rated at 80 percent because elbow ankylosis is very disabling 
regardless of position and it is impossible to distinguish between 
levels of disability. The VHA Orthopedic Committee also felt that the 
current criteria for unfavorable ankylosis would be equivalent to an 
above elbow amputation and agreed that a rating of 80 (for dominant) 
and 70 (for non-dominant) percent for unfavorable elbow ankylosis, at 
an angle of less than 50 degrees, or with complete loss of supination 
or pronation, is appropriate. They also felt that the intermediate and 
favorable ankylosis evaluations should be elevated, but not to the 
level that is equivalent to an amputation above the elbow. We therefore 
propose to retain the same criteria for elbow ankylosis, with editorial 
changes, but to elevate the evaluations for each level to 80 and 70 
percent for unfavorable, 60 and 50 percent for intermediate, and 50 and 
40 percent for favorable ankylosis. These evaluation levels are more 
consistent with the extent of disability these degrees of ankylosis 
produce, based on orthopedic experience and judgment.
    Diagnostic codes 5206, 5207, and 5208 currently refer to limitation 
of flexion and extension of the forearm. Because extension and flexion 
are actually functions of the elbow joint, we propose to change the 
word ``forearm'' to ``elbow'' in the headings of diagnostic codes 5206, 
5207, and 5208. We propose to retain the same criteria except for two 
nonsubstantive changes under diagnostic code 5207 that we are making 
because of language that has been a source of confusion. We propose to 
change the phrase ``extension limited to X degrees'' to ``extension is 
limited to minus X degrees (lacks X degrees of full extension)'' 
because full extension is zero degrees, and if less than full extension 
is possible, a negative number is required, since the range of 
extension is zero to minus 145 degrees. For example, if there is 110 
degrees of limitation of extension (or, extension is limited by 110 
degrees), it means that only minus 35 degrees of full extension is 
possible or that extension is limited to minus 35 degrees. For the sake 
of clarity, we propose to revise this language, using zero degrees as 
the reference point for full extension, as Plate I indicates is 
correct. Also currently, a 10-percent evaluation is provided both for 
limitation of extension to 60 degrees and for limitation of extension 
to 45 degrees. We propose to revise the criteria for a 10-percent level 
of evaluation to encompass both, by proposing a 10-percent evaluation 
if extension is limited to between minus 45 and minus 74 degrees 
(extension lacks at least 45 but less than 75 degrees of full 
extension). This eliminates the need for two sets of criteria for the 
10-percent evaluation level. Similarly, for diagnostic code 5208, we 
propose to change the current language of the title (and evaluation 
criteria) from ``Forearm, flexion limited to 100 degrees and extension 
to 45 degrees'' to ``Flexion of elbow is limited to 100 degrees, and 
extension is limited to minus 45 degrees (lacks 45 degrees of full 
extension).
    Diagnostic code 5209, ``Elbow, other impairment of,'' calls for 
evaluations of 60 and 50 percent for a flail joint, and of 20 and 20 
percent for joint fracture, with marked cubitus varus or cubitus valgus 
deformity or with ununited fracture of head of radius. The consultants 
recommended no changes. However, we propose to remove the criterion of 
``flail joint'' from this section, since it refers to complete 
paralysis at the elbow, a neurologic condition that would be more 
appropriately evaluated under Sec.  4.124a in the neurologic portion of 
the rating schedule. The specific diagnostic code and evaluation would 
depend on the exact findings. Complete paralysis of the shoulder and 
elbow due to upper radicular (fifth and sixth cervical nerves) 
impairment would warrant a 70-or 60-percent evaluation (for dominant 
and non-dominant side, respectively). If only the middle radicular 
cervical nerve group is impaired, the evaluation for complete paralysis 
of adduction, abduction, and rotation of arm, plus flexion of elbow and 
extension of wrist would also warrant a 70-or 60-percent evaluation. It 
is unlikely that elbow movements alone would be completely paralyzed in 
a given situation because the same nerves that innervate the muscles 
about the elbow innervate muscles that affect the movement of other 
parts of the arm. The VHA Orthopedic Committee stated that the normal 
position of the elbow is 10-15 degrees of valgus and that any degree of 
cubitus varus (i.e., any degree of varus greater than zero degrees) 
will greatly

[[Page 7014]]

interfere with positioning of the hand and would be considered 
``marked.'' They also indicated that marked cubitus valgus essentially 
doesn't occur. They also suggested we add an evaluation level of 10 
percent for excision of the radial head and add malunion of radial head 
at the 20-percent level. Based on this information, we propose to 
revise the criteria for the 20 and 20 percent level to ``Joint fracture 
with cubitus varus deformity; or ununited or malunited head of radius' 
and to add a level of 10 and 10 percent for ``excised radial head.''
    We propose no change to diagnostic code 5210, ``Radius and ulna, 
nonunion of with flail false joint'' except for revising the title to 
``Nonunion of radius and ulna, with motion at the fracture site,'' 
since the term ``false flail joint'' is seldom used medically, and the 
revised title would adequately describe the disability.
    We propose to revise the criteria for diagnostic codes 5211, 
``Ulna, impairment of'' and 5212, ``Radius, impairment of,'' for the 
sake of clarity and in order to provide guidance on evaluating nonunion 
in the upper half of the ulna or the lower half of the radius with 
false movement when there is either deformity or loss of bone 
substance, but not both. Currently 40 or 30 percent is assigned under 
diagnostic code 5211 for nonunion in the upper half of the ulna with 
false movement with loss of bone substance and marked deformity, and 30 
or 20 percent is assigned for nonunion in the upper half of the ulna 
without loss of bone substance or deformity. There is no guidance on 
evaluating an intermediate condition where either deformity or loss of 
bone substance, but not both, is present. We propose to retain the 40 
or 30 percent with the same criteria, but to assign 30 or 20 percent if 
there is either deformity or loss of bone substance and 20 percent if 
neither deformity nor loss of bone substance is present. Providing a 
third method of evaluating nonunion in the upper half of the ulna would 
promote consistent evaluations for those who have the intermediate 
level of disability.
    We propose to provide a similar intermediate evaluation under 
diagnostic code 5212, with 30 or 20 percent assigned if there is 
nonunion of the lower half of the radius with false movement and either 
deformity or loss of bone substance and 20 percent if neither deformity 
nor loss of bone substance is present. For both diagnostic code 5211 
and 5212, we propose to change the current criterion for 10 percent 
from ``Malunion of, with bad alignment'' to ``Malunion of, 
symptomatic'' because disability from these types of injuries is 
related to function rather than position of the joint. We also propose 
to add a note under each diagnostic code (5211 and 5212) directing 
that, alternatively, malunion (of the ulna or the radius) be evaluated 
based on limitation of motion if that would result in a higher 
evaluation. We also propose, for both diagnostic codes 5211 and 5212, 
to remove the word ``marked'' which currently precedes ``deformity'' in 
the evaluation criteria at the 40- and 30-percent level. This 
disability level will be distinguished from the next lower one by 
whether or not both deformity and loss of bone substance are present.
    Impairment of supination and pronation of forearm, diagnostic code 
5213, is currently evaluated at 40 or 30 percent (for dominant and 
nondominant side, respectively) if there is bone fusion and the hand is 
fixed in supination or hyperpronation; at 30 or 20 percent if the hand 
is fixed in full pronation; and at 20 percent if the hand is fixed near 
the middle of the arc or moderate pronation. For limitation of 
pronation, 30 or 20 percent is assigned if motion is lost beyond the 
middle of the arc, and 20 percent is assigned for motion lost beyond 
the last quarter of the arc, the hand does not approach full pronation. 
For limitation of supination, 10 percent is assigned for supination to 
30 degrees or less. We propose to clarify the evaluation criteria by 
specifying in degrees what is meant by currently used terms such as 
``hyperpronation'', ``Motion lost beyond middle of arc,'' etc., in 
order to remove any ambiguity. We propose that when there is bone 
fusion, an evaluation of 40 or 30 percent be assigned when the hand is 
fixed in supination (between one and 85 degrees of supination) or in 
hyperpronation (in greater than 80 degrees of pronation); of 30 or 20 
percent be assigned when the hand is fixed in full pronation (at 80 
degrees of pronation); and of 20 percent when the hand is fixed at 40 
to 45 degrees of pronation. We propose to evaluate limitation of 
pronation at 30 or 20 percent when pronation is limited to 40 degrees 
and at 20 percent when pronation is limited to 60 degrees. We propose 
to evaluate limitation of supination at 10 percent when supination is 
limited to 30 degrees. We also propose to edit the note that currently 
says that in all forearm and wrist injuries, codes 5205 through 5213, 
multiple impaired finger movements due to tendon tie-up, muscle or 
nerve injury, are to be separately rated and combined not to exceed 
rating for loss of use of hand. We propose instead to have the note say 
that evaluations for forearm and wrist injuries, diagnostic codes 5205 
through 5213, will be combined with separate evaluations for limitation 
of motion of the fingers, subject to the provisions of Sec.  4.68 
(which limits the combined evaluation of musculoskeletal and associated 
neurologic disabilities of an extremity).

Wrist

    The consultants suggested no changes for diagnostic code 5214, 
``Wrist, ankylosis of,'' except for suggesting that we add a second 
note stating that bilateral wrist ankyloses are more functional if one 
wrist is in a flexed position and the other is in an extended position. 
We propose no change based on this comment. We propose to continue 
rating each wrist separately as though only one is impaired, a method 
that would in general be more beneficial to the veteran, and a method 
that the VHA Orthopedic Committee believe to be appropriate. It seems 
unlikely, in any case, that more than a few veterans would be service-
connected for ankylosis of both wrists. There is currently a note under 
5214 stating that extremely unfavorable ankylosis will be rated as loss 
of use of hands under diagnostic code 5125, but the note does not 
define ``extremely unfavorable ankylosis.'' We propose to remove this 
instruction because there is already a provision in Sec.  3.350 (a)(2) 
of this chapter (the criteria for determining when loss of use of a 
hand or foot is present) that indicates that special monthly 
compensation is payable when no effective function of the hand remains. 
This applies, whatever the cause, and need not be repeated here. We 
also propose editorial changes for clarity.
    We propose to revise the evaluation criteria under diagnostic code 
5215, ``Wrist, limitation of motion of,'' by changing the current 
criteria for a 10-percent evaluation, ``Dorsiflexion less than 15 
degrees'' or ``Palmar flexion limited in line with forearm'' to 
``Dorsiflexion limited to 14 degrees, or palmar flexion limited to zero 
degrees (no palmar flexion possible)''. These are clarifying, rather 
than substantive, changes.

Upper Extremity Digit Ankylosis and Limitation of Motion, Fractures of 
Hand and Feet Phalanges, Metacarpals, and Metatarsals

    Revised criteria and guidance for the evaluation of upper extremity 
digit ankylosis and limitation of motion (diagnostic codes 5216 through 
5227) will be addressed in a separate rulemaking, so they are not being 
addressed in this proposed rule.

[[Page 7015]]

    There are currently no diagnostic codes in the rating schedule for 
the evaluation of disability due to fractures of the phalanges of the 
hand or foot or of the metacarpals of the hand or carpals of the wrist. 
These disabilities must now be rated by analogy to other conditions. 
Since they are such common injuries in veterans, we propose to add 
three new diagnostic codes: 5231 for residuals of fracture of a phalanx 
of finger or thumb, 5232 for residuals of fracture of a carpal or 
metacarpal bone, and 5233 for residuals of fracture of a phalanx of a 
toe (residuals of fractures of the tarsals and metatarsals can be 
evaluated under diagnostic code 5283, ``Malunion or nonunion of tarsal 
or metatarsal bones (except talus and calcaneus)''). We propose that 
each of these fractures be evaluated based on the specific residuals, 
such as limitation of motion or ankylosis, under the appropriate 
code(s), to be combined with an evaluation for pain under Sec.  4.59 
when appropriate.

Hip and Femur

    Diagnostic code 5250, ``Hip, ankylosis of,'' currently provides for 
an evaluation of 90 percent if the ankylosis is extremely unfavorable, 
with the foot not reaching the ground and crutches necessary; an 
evaluation of 70 percent if the ankylosis is intermediate; and an 
evaluation of 60 percent if the ankylosis is favorable, in flexion at 
an angle between 20 degrees and 40 degrees, with slight adduction or 
abduction. The consultants suggested that we remove the intermediate 
level because there is no middle ground with this disability. They also 
suggested we revise the criteria for favorable ankylosis to ``in slight 
flexion, at an angle between 20 degrees and 40 degrees and minimal 
adduction or abduction, not requiring assistive devices.'' The VHA 
Orthopedic Committee indicated that unfavorable ankylosis would be 
present when there is more than 60 degrees of flexion so that the foot 
cannot reach the ground and crutches are required. We propose to adopt 
both suggestions in part and make the evaluation criteria more 
specific. For a 90-percent evaluation, we propose that the criteria be 
``Unfavorable ankylosis, meaning fixed in more than 60 degrees of 
flexion so that the foot cannot reach the ground, and crutches are 
required for ambulation.'' We propose that the criteria for a 60-
percent evaluation be ``Favorable ankylosis, meaning fixed in 20 
degrees to 39 degrees of flexion, in slight adduction or abduction, and 
assistive devices are not required.'' These criteria are similar to the 
current criteria and the criteria recommended by the consultants. This 
leaves ankylosis in flexion at an angle between 40 and 60 degrees 
undefined, and we therefore propose to retain the 70-percent level of 
evaluation with criteria of ``Intermediate ankylosis, meaning fixed in 
40 to 60 degrees of flexion, and assistive devices may be needed.''
    We propose to change the title of diagnostic code 5251 from 
``Thigh, limitation of extension of'' to ``Limitation of extension of 
hip'; the title of diagnostic code 5252 from ``Thigh, limitation of 
flexion of'' to ``Limitation of flexion of hip'; and the title of 5253 
from ``Thigh, impairment of'' to ``Limitation of abduction, adduction, 
or rotation of hip'' to reflect more clearly that these diagnostic 
codes refer to movement at the hip joint.
    The current evaluation criteria for diagnostic code 5251, ``Thigh, 
limitation of extension of,'' provide a single level of evaluation of 
10 percent for limitation of extension of the thigh to five degrees. 
The consultants recommended no change. However, we propose to revise 
the criteria because the current criterion for a 10-percent evaluation 
does not take into account the fact that some individuals have only 10 
degrees of extension normally. According to the VHA Orthopedic 
Committee, comparing the affected and non-affected sides would be a 
better indicator of the extent of disability, because some people have 
a small degree of limitation of extension with no symptoms. We 
therefore propose to assign a 10-percent evaluation if there is 
limitation of extension of the affected hip that is at least 10 degrees 
more than the limitation of extension of the non-affected hip, and 
there is a positive Thomas test (test for flexion contracture of the 
hip). The normal range of motion of the hip for flexion and extension 
is zero degrees (full extension) to 125 degrees (full flexion). A 
Thomas test shows the degree of flexion deformity (contracture) of a 
hip and confirms the limitation of extension (which is the equivalent 
of a flexion contracture, since extension is always limited to less 
than zero if there is a flexion contracture). In the Thomas test, the 
patient is supine (lying on back), with one leg flexed so that the knee 
touches the chest, and the angle between the other hip and the 
examination table represents the degree of flexion deformity or 
contracture (limitation of extension) that is present.
    We propose no change in the criteria for limitation of flexion of 
the hip under diagnostic code 5252. We propose no change in the 
criteria for limitation of abduction, adduction, or rotation of the hip 
under diagnostic code 5253, except for editorial changes.
    Diagnostic code 5254 is currently titled ``Hip, flail joint'' with 
a single evaluation level of 80 percent based solely on the diagnosis. 
``Flail joint'' is an obsolete term, and we propose to modernize the 
title to ``Resection arthroplasty of hip (removal of femoral head and 
neck without replacement by a prosthesis)'', as recommended by the 
consultants, and to continue a single evaluation of 80 percent for the 
condition.
    We propose to change the title of diagnostic code 5255 from 
``Femur, impairment of'' to ``Residuals of fracture of femur'' because 
that is the condition evaluated under this diagnostic code. This 
diagnostic code currently includes evaluation criteria for fractures of 
the shaft or anatomical neck with nonunion, for fracture of the 
surgical neck with a false joint, and for malunion with knee or hip 
disability. Fracture of the shaft or anatomical neck of the femur with 
nonunion, with loose motion (spiral or oblique fracture) is currently 
evaluated at 80 percent. If there is nonunion without loose motion and 
weightbearing is preserved with the aid of a brace, it is evaluated at 
60 percent. Sixty percent is also assigned for fracture of the surgical 
neck of the femur with a false joint. Malunion of a fracture of the 
femur is currently rated at 30 percent if there is malunion and marked 
knee or hip disability, at 20 percent if there is moderate knee or hip 
disability, and at 10 percent if there is slight knee or hip 
disability. These criteria contain subjective adjectives such as 
``marked'' and ``moderate'' and do not provide the rater with objective 
criteria for evaluating the disability.
    The consultants suggested a reorganization and expansion of the 
types of fractures and residuals, and we propose to do that, as well as 
to remove the subjective language. They also pointed out that these 
conditions respond well to treatment, and impairment under current 
treatment is not as great as in past years, so some reductions in 
percentage levels are warranted. We propose to follow their 
recommendations. We propose that a fracture of the femoral neck, 
intertrochanteric area, or shaft be evaluated at 60 percent if there is 
symptomatic malunion or symptomatic nonunion; at 40 percent if there is 
asymptomatic nonunion, or if there is a fracture of the femoral head or 
subcapital area with excision of 25 percent or more of the 
weightbearing portion; and at 30 percent if there is a fracture of the 
femoral shaft with symptomatic malunion and either more

[[Page 7016]]

than 10 degrees of angulation in the varus-valgus plane or more than 15 
degrees of angulation in the anterior-posterior plane. We also propose 
to add two notes. The first directs that a fracture of the femoral head 
or subcapital area with excision of less than 25 percent of the 
weightbearing portion be evaluated as aseptic necrosis under diagnostic 
code 5265. The second defines malunion of an intertrochanteric fracture 
as having a varus deformity, shortening, or rotation. These criteria 
are based on modern medical treatment and focus on the femoral 
impairment. Currently, additional disability of the knee or hip 
resulting from a femoral fracture is evaluated at 10, 20, or 30 
percent, depending on whether the impairment is mild, moderate, or 
marked. These criteria are subjective and therefore difficult to apply 
consistently, and any hip or knee impairment can be separately rated as 
a secondary condition to the femoral shaft fracture. Therefore it is 
unnecessary to take into consideration impairment of the hip or knee in 
evaluating femoral shaft fracture, and we propose to remove those 
criteria.

Knee and Lower Leg

    Ankylosis of the knee, diagnostic code 5256, is currently evaluated 
at 60 percent if the ankylosis is extremely unfavorable, in flexion at 
an angle of 45 degrees or more; at 50 percent if the ankylosis is in 
flexion between 20 and 45 degrees; at 40 percent if the ankylosis is in 
flexion between 10 and 20 degrees; and at 30 percent if the ankylosis 
is at a favorable angle in full extension, or flexion between zero and 
10 degrees. We propose to revise the criteria to avoid the overlap of 
the required degrees of flexion in the current criteria by making the 
required flexion be more than 45 degrees for 60 percent; between 21 and 
45 degrees for 50 percent; between 11 and 20 degrees for 40 percent; 
and in full extension, or in flexion between zero and 10 degrees for 30 
percent.
    Diagnostic code 5257 is currently titled ``Knee, other impairment 
of,'' but the criteria are based only on the extent of recurrent 
subluxation or lateral instability. Thirty percent is assigned if the 
condition is ``severe,'' 20 percent if it is ``moderate,'' and 10 
percent if it is ``slight.'' We propose to change the title to ``Knee 
instability'' because this more precisely describes the content. The 
consultants recommended that evaluations be based on whether the 
instability is correctable by bracing and the extent to which it 
interferes with activities of daily living and athletic activities, 
such as running and jumping. We propose to follow this recommendation, 
providing a 30-percent evaluation if there is documented instability 
that is not correctable by bracing and that interferes with activities 
of daily living; a 20-percent evaluation if there is documented 
instability that is correctable with bracing, but that interferes at 
times with activities of daily living and that prevents activities such 
as running and jumping; and a 10-percent evaluation if there is 
documented instability that is correctable by bracing and that does not 
interfere with activities of daily living, but at times may interfere 
with activities such as running and jumping. We also propose to add a 
note directing that an evaluation under diagnostic code 5257 may be 
combined with an evaluation for pain (under Sec.  4.59) when 
appropriate. The proposed criteria are more objective than the current 
criteria, a change that will promote consistent evaluations.
    Diagnostic code 5258 is currently titled ``Cartilage, semilunar, 
dislocated, with frequent episodes of `locking,' pain, and effusion 
into the joint''. It provides a single evaluation level of 20 percent. 
The consultants suggested we change the title of diagnostic code 5258 
to ``Meniscus, tear with episodes of give way, locking and/or 
swelling''. They suggested a single evaluation level of 10 percent, 
because they felt the impairment is not as great as in the original 
schedule. Diagnostic code 5259 is currently titled ``Cartilage, 
semilunar, removal of, symptomatic,'' with a single evaluation level of 
10 percent. The consultants suggested changing the condition to 
``Patellofemoral subluxation or dislocation'' and to base evaluation on 
the frequency of episodes.
    We propose to follow their suggestion in part by combining meniscus 
injuries, pre-or post-operatively, under diagnostic code 5258 and by 
changing the title to ``Injury of meniscus (semilunar cartilage) of 
knee (pre-or post-operatively),'' which is both a more current medical 
term and more reflective of the content. We also propose to provide a 
20-percent evaluation for meniscus injury with episodes of giving way, 
locking, or joint effusion that interfere at times with activities of 
daily living and prevent activities such as running and jumping, and a 
10-percent evaluation for meniscus injury with episodes of giving way, 
locking, or joint effusion that do not interfere with activities of 
daily living, but that at times interfere with activities such as 
running and jumping. We propose that evaluation alternatively be based 
on instability, degenerative arthritis, etc., depending on the specific 
findings, under the appropriate diagnostic code, because these are 
possible effects of meniscus injury or surgery. We also propose to add 
a note directing that an evaluation under diagnostic code 5258 be 
combined with an evaluation for pain (under Sec.  4.59) when 
appropriate. Diagnostic code 5259 would be unnecessary under this 
reorganization, and we propose to remove it.[FEDREG][VOL]*[/VOL][NO]*[/
NO][DATE]*[/DATE][PRORULES][PRORULE][PREAMB][AGENCY]*[/
AGENCY][SUBJECT]*[/SUBJECT][/PREAMB][SUPLINF][HED]*[/HED]?
    Diagnostic codes 5260 and 5261 currently pertain to limitation of 
flexion of the leg and limitation of extension of the leg, 
respectively. Because the terms extension and flexion are functions of 
the knee joint, we propose to change the word ``leg'' to ``knee'' in 
the titles of diagnostic codes 5260 and 5261. We propose to retitle 
diagnostic code 5260 ``Limitation of flexion of knee.'' Flexion of the 
knee limited to 15 degrees is currently evaluated at 30 percent, 
flexion limited to 30 degrees is evaluated at 20 percent, flexion 
limited to 45 degrees is evaluated at 10 percent, and flexion limited 
to 60 degrees is evaluated at zero percent. The consultants pointed out 
that 30, 60, and 90 degrees are the important angles of measurement and 
are better measures of impairment than those in the current schedule. 
The VHA Orthopedic Committee agreed. We therefore propose to provide a 
30-percent evaluation if flexion is limited to 30 degrees, a 20-percent 
evaluation if it is limited to 60 degrees, and a 10-percent evaluation 
if it is limited to 90 degrees.
    Under diagnostic code 5261, currently ``Leg, limitation of 
extension of,'' which we propose to retitle ``Limitation of extension 
of knee,'' current evaluations are 50 percent if extension is limited 
to 45 degrees, 40 percent if it is limited to 30 degrees, 30 percent if 
it is limited to 20 degrees, 20 percent if it is limited to 15 degrees, 
10 percent if it is limited to 10 degrees, and zero percent if it is 
limited to 5 degrees. The consultants pointed out that the three 
relevant ranges of measurement for limitation of extension are lack of 
extension of 5 to 15 degrees, lack of extension of 15 to 30 degrees, 
and lack of extension of 30 degrees or more. We therefore propose to 
provide evaluation levels of 50 percent if extension is limited to more 
than minus 30 degrees (lacks more than 30 degrees of full extension), 
30 percent if extension is limited to between minus 16 and 30 degrees 
(lacks 16 to 30 degrees of full extension), and 10 percent if extension 
is limited to between minus 5 and 15 degrees (lacks 5 to 15 degrees of 
full extension). Reducing the number of levels of evaluation for 
limitation of flexion and extension to three will help simplify the

[[Page 7017]]

rating process and will be in accord with the consultants' 
recommendation about relevant ranges. These levels will also be clearer 
in reference to Plate II, which shows the range of motion of the knee 
as zero to 140 degrees (which includes both flexion and extension of 
the knee), and which therefore requires that less than full extension 
be expressed as a negative number.
    Diagnostic code 5262, Tibia and fibula, impairment of, currently 
has evaluation criteria pertaining to residuals of fracture of the 
tibia or fibula. Evaluations are 40 percent if there is nonunion, with 
loose motion, requiring a brace, 30 percent if there is malunion with 
marked knee or ankle disability, 20 percent if there is malunion with 
moderate knee or ankle disability, and 10 percent if there is malunion 
with slight knee or ankle disability. The consultants suggested no 
change. However, we propose changes in order to eliminate the 
subjective terms ``marked,'' ``moderate,'' and ``slight'' and the 
indefinite term ``ankle or knee disability.'' We propose to use 
evaluation criteria similar to those we are proposing for fractures of 
the femur. We propose a 40-percent evaluation if there is nonunion, 
with loose motion, requiring a brace; a 30-percent evaluation if there 
is an asymptomatic nonunion; a 20-percent evaluation if there is a 
symptomatic malunion with either more than 10 degrees of angulation in 
the varus-valgus plane or more than 15 degrees of angulation in the 
anterior-posterior plane; and a 10-percent evaluation if there is a 
symptomatic malunion with neither more than 10 degrees of angulation in 
the varus-valgus plane nor more than 15 degrees of angulation in the 
anterior-posterior plane. These would provide more objective criteria 
to promote consistent evaluations. We also propose to revise the title 
to ``Nonunion or malunion of fracture of tibia or fibula,'' in order to 
better identify the content of this diagnostic code.
    We propose to delete diagnostic code 5263, ``Genu recurvatum,'' 
since the consultants said this diagnosis is no longer used. Some 
degree of genu recurvatum (which means backward curving or 
hyperextended knee) is normal in females, and when acquired, is a 
finding that occurs as part of other conditions, such as nerve 
paralysis or osteoarthritis, rather than being a primary diagnosis or 
disability. Its evaluation would be encompassed by the evaluation for 
the primary underlying condition.

Aseptic Necrosis of Femoral Head

    We propose to add a new diagnostic code, 5265, for aseptic necrosis 
(or avascular necrosis or osteonecrosis) of the femoral head. The 
consultants recommended this addition and suggested criteria similar to 
those we propose, although they used subjective terms that we have 
replaced with more objective criteria. For example, they suggested a 
100-percent evaluation for a ``severe'' level with ``severe'' pain 
requiring use of ambulatory support, a 50-percent evaluation for a 
``moderate'' level with ``moderate'' pain aggravated by activity and 
requiring intermittent ambulatory support, a 10-percent level for a 
``mild'' level with previous severe or moderate disease that has 
stabilized, without collapse of the femoral head (at least 2 years 
after onset) and minimal pain; and a zero-percent evaluation for a 
``minimal'' level with previous severe or moderate disease that has 
stabilized (at least 2 years after onset) with minimal residual 
deformity. They felt that if there is mild or minimal aseptic necrosis, 
there should also be an assessment of limitation of motion, with the 
higher rating being given.?
    Aseptic necrosis (or avascular necrosis or osteonecrosis) of the 
hip is seen commonly if there has been interference of the blood supply 
to the head of the femur due to trauma, metabolic disease, vascular 
disease, etc., with resulting bone death of part or all of the femoral 
head. Eventually, the affected bone collapses. It is likely that it 
would currently be rated analogous to fracture of the femur (diagnostic 
code 5255), which has current evaluations ranging from 10 to 80 percent 
(and for which we propose to have evaluation levels of 30 to 60 
percent, as described above). The proposed new criteria under 
diagnostic code 5255 are not appropriate for aseptic necrosis of the 
femur because a fracture of the femur is not always present, and the 
findings are not necessarily similar. Aseptic necrosis may be painless 
early but then cause progressive pain with weight bearing or even at 
rest. Eventually, a hip replacement may be needed because of bone 
destruction. We propose to base evaluations on whether ambulatory 
support is needed and whether the femoral head is collapsed, and to 
evaluate pain, when present, separately under Sec.  4.59, rather than 
assessing pain on the subjective criteria of whether it is ``mild,'' 
``moderate,'' or ``severe''. We propose to evaluate aseptic necrosis at 
60 percent if there is collapse of the femoral head and constant 
ambulatory support is required; at 40 percent if there is collapse of 
the femoral head and intermittent ambulatory support is required; and 
at 10 percent if there is evidence of aseptic necrosis without collapse 
of the femoral head. We do not propose to include a 100-percent 
evaluation as the consultants suggested because their evaluation levels 
included subjective complaints of pain, and we propose to add a note 
directing that an evaluation under diagnostic code 5265 will be 
combined with a separate evaluation for pain under Sec.  4.59 when 
appropriate. We also propose to add a note indicating that the 
condition may be alternatively evaluated as limitation of motion of the 
hip combined with an evaluation for pain when appropriate, if that 
would result in a higher evaluation.

Other Knee Conditions

    There are two relatively common areas of disability of the knee 
that are not addressed in the current schedule--fracture, subluxation, 
or dislocation of the patella and patellofemoral pain syndrome. The 
consultants recommended we add diagnostic codes for these conditions, 
and we propose to do so.
    We propose to add diagnostic code 5266 as ``Patellar fracture and 
instability.'' This would include subluxation and dislocation of the 
patella, residuals of patellectomy (removal of the patella), and 
patellar fracture. The consultants suggested two levels of evaluation 
for subluxation and dislocation of the patella, with 20 percent 
assigned for patellofemoral subluxation or dislocation that is 
``frequent,'' occurring more than once a month, and 10 percent for 
patellofemoral subluxation or dislocation that is ``infrequent,'' 
occurring less than once a month. They also suggested a separate 
diagnostic code for patellar fracture, with a 30-percent evaluation for 
symptomatic nonunion and a 20-percent evaluation for patellectomy. We 
propose instead that all of these conditions be evaluated under a 
single diagnostic code with three levels of evaluation. We propose to 
evaluate subluxation (a partial dislocation in which the patella 
spontaneously goes back into normal position) based on different 
criteria from the more severely disabling dislocation (which requires 
manual replacement of the patella). We propose an evaluation of 30 
percent if there is symptomatic nonunion of a fracture of the patella, 
or if there is patellectomy, or if there is recurrent patellar 
dislocation occurring six or more times during the past 12-month 
period. We propose a 20-percent evaluation if there is patellofemoral 
subluxation (partial or incomplete dislocation of the patella) 
occurring

[[Page 7018]]

three or more times per month during the past 12-month period or if 
there is recurrent patellar dislocation occurring three to five times 
during the past 12-month period. We propose a 10-percent evaluation if 
there is patellofemoral subluxation one to two times per month during 
the past 12-month period or if there is recurrent patellar dislocation 
occurring one or two times during the past 12-month period. The VHA 
Orthopedic Committee felt that patellectomy warrants a higher rating 
than the consultants recommended because it can result in substantial 
functional impairment of the knee, and we propose to follow that 
recommendation. We also propose to add a note indicating that the 
evaluation criteria for diagnostic code 5266 encompass pain, since pain 
is ordinarily present in these conditions, so a separate evaluation for 
pain under Sec.  4.59 is not warranted.
    We also propose to add diagnostic code 5267 for patellofemoral pain 
syndrome (chondromalacia of patella, retropatellar pain syndromes, 
patellofemoral syndrome). This diagnostic code includes a group of 
disorders characterized by anterior knee pain between the patella and 
the femur, especially on climbing or descending stairs or on squatting. 
There may be deep tenderness on palpation and pressure on the patella, 
crepitus on motion, a grinding sensation behind the patella, and 
occasionally swelling. The diagnosis may be made clinically or based on 
X-ray or other imaging procedure or on arthroscopic findings. We 
propose that the condition be evaluated based on pain, which is the 
main disabling effect, under the criteria in Sec.  4.59.

Ankle and Foot

    Diagnostic code 5270, ankylosis of the ankle, currently provides a 
40-percent evaluation if the ankylosis is in plantar flexion at more 
than 40 degrees or in dorsiflexion at more than 10 degrees, or with 
abduction, adduction, inversion, or eversion deformity; a 30-percent 
evaluation if it is in plantar flexion between 30 and 40 degrees or in 
dorsiflexion between zero and 10 degrees; and a 20-percent evaluation 
if it is in plantar flexion at less than 30 degrees. The consultants 
suggested evaluations ranging from zero to 40 percent for 10 different 
situations that apply to foot and ankle ankylosis and fusion. For 
example, they suggested a 40-percent evaluation for fusion of the ankle 
in poor weightbearing position and a 20-percent evaluation for fusion 
of the ankle in good weightbearing position; a 20-percent evaluation 
for fusion of the subtalar joint in poor weightbearing position and a 
10-percent evaluation for fusion of the subtalar joint in good 
weightbearing position, etc. However, they did not define ``good'' and 
``poor'' weightbearing positions. The VHA Orthopedic Committee 
indicated that good weightbearing would mean the foot is in a 
plantograde position, meaning it is in the proper position for walking. 
In our judgment, neither of these provides more objective guidance for 
rating than the current criteria, and we therefore propose only 
editorial changes.
    The evaluation criteria for evaluating limitation of motion of the 
ankle (diagnostic code 5271) are currently divided into levels of 20 
and 10 percent, based on whether the disability is ``marked'' or 
``moderate.'' These terms are subjective, and we propose to substitute 
the more objective criteria recommended by the consultants. We propose 
to assign 20 percent if there is less than 5 degrees passive 
dorsiflexion or less than 10 degrees passive plantar flexion and 10 
percent if there is less than 15 degrees passive dorsiflexion or less 
than 30 degrees passive plantar flexion. These more objective criteria 
should promote consistent evaluations.
    Diagnostic code 5272 is currently titled ``Subastragalar or tarsal 
joint, ankylosis of.'' In order to reflect current medical terminology, 
we propose to change the term ``subastragalar'' to ``subtalar'' and 
retitle 5272 as ``Ankylosis of subtalar or tarsal joint.'' We propose 
no change in the criteria except to add ``no varus, no valgus'' to 
clarify what ``good weightbearing position'' means and to add ``not in 
plantograde position'' to indicate what ``poor weightbearing position'' 
means.
    Diagnostic code 5273 is currently titled ``Os calcis or astragalus, 
malunion of.'' We propose to update the language and retitle 5273 as 
``Malunion of calcaneus (os calcis) or talus.'' Currently, the 
condition is evaluated at 20 percent if there is ``marked'' deformity 
and at 10 percent if there is ``moderate'' deformity. These are 
subjective criteria that allow for different interpretations. The 
consultants suggested no change in the criteria. However, the VHA 
Orthopedic Committee offered objective criteria that we propose to 
adopt. They suggested that marked deformity would mean deformity of the 
talocalcaneal joint or spreading of the calcaneus deforming the 
weightbearing surface of the heel, because either deformity would 
interfere with walking. They also suggested a higher evaluation would 
be warranted for such deformities, and we propose to assign a 30-
percent evaluation for this deformity. They suggested that moderate 
deformity would mean malunion of either the talus or calcaneus without 
deformity of the subtalar joint or weightbearing surface of the heel.
    Diagnostic code 5274 is currently titled ``Astragalectomy.'' We 
propose to update the term ``astragalectomy'' to ``talectomy,'' which 
is the only change suggested by the consultants. We propose to further 
change the title to ``Total or partial talectomy without subsequent 
arthrodesis,'' as suggested by the VHA Orthopedic Committee. The 
Committee also suggested this is much more disabling than the current 
evaluation of 20 percent because it causes a severe disruption of the 
entire mechanism of the ankle, and we therefore propose to assign a 40-
percent evaluation for talectomy.
    There is currently a single diagnostic code, 5275, for ``Bones, of 
the lower extremity, shortening of'' under the heading ``Shortening of 
the Lower Extremity.'' Under this diagnostic code there are six levels 
of evaluation between 10 and 60 percent, but the criteria overlap. For 
example, a 10-percent evaluation is assigned for shortening of 1\1/4\ 
to 2 inches and a 20-percent evaluation for shortening of 2 to 2\1/2\ 
inches so that a shortening of 2 inches could be evaluated at either 10 
or 20 percent. The consultants suggested eliminating all but the 10-, 
20-, and 40-percent levels because they felt these levels are more 
precisely related to impairment than the original levels, but their 
suggested criteria did not remove the overlap. We propose to retain the 
current levels since the objectivity of the criteria allows us to 
readily distinguish six levels closely related to incremental degrees 
of shortening. The VHA Orthopedic Committee suggested no change in the 
current criteria. We do propose to eliminate the overlapping, for 
example, by assigning 10 percent if there is shortening of at least 
1\1/4\ but less than 2 inches (3.2 to less than 5.1 cm.) and 20 percent 
if there is shortening of at least 2 but less than 2\1/2\ inches (5.1 
to less than 6.4 cm.). These represent only minimal changes in the 
criteria for the sake of clarity. We also propose to edit the 
instructions in two notes for measuring leg length and the prohibition 
against combining shortened leg with other evaluations for fracture or 
faulty union in the same extremity.
    Diagnostic code 5276 is currently titled ``Flatfoot, acquired.'' We 
propose to remove the term ``acquired'' because, as the consultants 
noted, it is not of assistance in distinguishing this condition, which 
may or may not have

[[Page 7019]]

preexisted service, may or may not have been congenital, and, if 
preexisting service, may or may not have undergone aggravation during 
service. Making all of those determinations is part of the rating 
process that decides whether the condition should be service-connected, 
but they are not inherent to evaluation. We also propose to add the 
term ``pes planus'' to the title, since this is the medical term for 
flatfoot. The current criteria provide an evaluation of 50 percent if 
bilateral and 30 percent if unilateral for the pronounced condition, 
with marked pronation, extreme tenderness of the plantar surfaces of 
the feet, marked inward displacement and severe spasm of the tendo 
achillis on manipulation, not improved by orthopedic shoes or 
appliances. It provides an evaluation of 30 percent if bilateral and 20 
percent if unilateral for the severe condition, with objective evidence 
of marked deformity (pronation, abduction, etc.), pain on manipulation 
and use accentuated, indication of swelling on use, characteristic 
callosities. It provides an evaluation of 10 percent for either the 
unilateral or bilateral condition if it is moderate, with weightbearing 
line over or medial to great toe, inward bowing of the tendo achillis, 
pain on manipulation and use of the feet. It also provides an 
evaluation of zero percent if mild, with symptoms relieved by built-up 
shoe or arch support.
    The consultants suggested only three levels of disability with 
deletion of the ``pronounced'' category, which they said was not 
clearly differentiated from the ``severe'' category. Raters have also 
been confused by the criteria for the ``severe'' and ``pronounced'' 
levels. The consultants suggested new, more detailed and comprehensive 
criteria ranging from 40 percent (for the bilateral condition) to zero 
percent. We propose to adopt their criteria, with one exception. 
Instead of the single evaluation level of 10 percent for unilateral or 
bilateral flatfeet of moderate deformity that they suggested, we 
propose to evaluate each foot separately at every level, since it is 
clearly more disabling to have deformed feet bilaterally than 
unilaterally, and assigning the same evaluation whether only one foot 
or both feet are involved is not equitable. We propose to assign a 20-
percent evaluation for deformity with, on weightbearing, significant 
eversion of the heel, flattened arch, collapse of the midfoot 
structures with the talar head displaced both medial and plantar, 
forefoot abduction; pain in the arch; not significantly relieved by the 
use of appliances, orthoses, or orthopedic shoes. We propose a 10-
percent evaluation for deformity with a perpendicular position to 
slight eversion of the heel, the presence of a slight arch on non-
weightbearing which totally collapses on weightbearing; forefoot 
abduction; pain in the arch and legs; partially relieved by the use of 
appliances, orthoses, or orthopedic shoes. We propose a zero-percent 
evaluation if there is deformity but a normal arch on non-
weightbearing, a perpendicular heel position; tenderness in the arch or 
muscles and tendons attaching to the midfoot; symptoms completely 
relieved by, or do not require, the use of appliances, orthoses, or 
orthopedic shoes. We propose to add a note directing that each foot be 
separately evaluated, with the evaluations to be combined. This would 
represent a change in procedure from the current criteria and is 
warranted because flatfoot may be either a unilateral or bilateral 
condition and is clearly more disabling if both feet are affected, even 
at the milder level. In addition, the feet may not be at the same level 
of severity, and these evaluations allow an individual assessment of 
each foot. We propose to add a second note, for the sake of clarity, 
directing raters not to combine an evaluation under this diagnostic 
code with an evaluation for pain under Sec.  4.59 because pain is 
encompassed by these evaluation criteria.
    Diagnostic code 5277 is currently titled ``Weak foot, bilateral.'' 
This is a vague condition. The consultants suggested a change to 
``Compromised (or weak) foot, bilateral'' because this is how the 
condition is described in current medical practice and suggested it be 
rated based on the underlying condition, with a minimum evaluation of 
10 percent. They noted that it may include single or multiple 
conditions affecting function, including muscle atrophy, loss, 
weakness, and stiffness; bone atrophy or loss; joint stiffness; 
vascular compromise; or neurological compromise. We propose instead to 
delete this diagnostic code, as suggested by the VHA Orthopedic 
Committee, because there are specific rating criteria under other 
diagnostic codes for disabilities such as arthritis, neuropathy, and 
vascular disease that may affect the foot, and the existing and 
recommended criteria under 5277 are not necessary for evaluation.
    Diagnostic code 5278 is currently titled ``Claw foot (pes cavus), 
acquired,'' and we propose to update it to ``Pes cavus (clawfoot),'' 
removing ``acquired,'' because the consultants pointed out that it is 
difficult to distinguish an acquired pes cavus from a congenital one. 
It is currently evaluated at 50 percent if bilateral and 30 percent if 
unilateral if there is marked contraction of the plantar fascia with 
dropped forefoot, all toes hammertoes, very painful callosities, and 
marked varus deformity. It is evaluated at 30 percent if bilateral and 
20 percent if unilateral if all toes tend to dorsiflexion, and there 
are limitation of dorsiflexion at ankle to right angle, shortened 
plantar fascia, and marked tenderness under metatarsal heads. It is 
evaluated at 10 percent whether bilateral or unilateral if the great 
toe is dorsiflexed, and there are some limitation of dorsiflexion at 
ankle and definite tenderness under metatarsal heads. If the condition 
is ``slight,'' it is evaluated at zero percent. These criteria contain 
several subjective terms, for example, ``marked,'' ``definite,'' and 
``slight,'' that inject an element of subjectivity.
    The consultants recommended three levels instead of four, with 40 
percent the highest level, when bilateral, comparable to other lower 
extremity conditions. They also suggested that 10 percent be assigned 
for moderate pes cavus bilaterally, because the impairment is 
considerably less. We propose to revise the criteria, with each foot 
being separately evaluated, using the most objective of the criteria 
related to disability as a basis of evaluation, namely, whether 
appliances, orthoses, or orthopedic shoes are required and whether they 
relieve symptoms of pain and tenderness, and callosities, if present. 
These criteria represent a modification of the consultants' 
recommendations. We propose that a 20-percent evaluation be assigned if 
symptoms and callosities are not significantly relieved by appliances, 
orthoses, or orthopedic shoes; a 10-percent evaluation if symptoms and 
callosities are partially relieved by appliances, orthoses, or 
orthopedic shoes; and a zero-percent evaluation if symptoms are 
completely relieved by, or do not require, the use of appliances, 
orthoses, or orthopedic shoes. We propose to add two notes under this 
diagnostic code, the first directing that each foot be separately 
evaluated, with the evaluations to be combined. This would allow each 
foot to be separately evaluated, which will be of value when the 
condition differs in severity from one foot to the other. We propose to 
add a second note stating that in the absence of trauma or other 
specific cause of aggravation, pes cavus is to be considered a 
congenital or developmental abnormality.
    Diagnostic code 5279 is currently titled ``Metatarsalgia, anterior 
(Morton's disease), unilateral, or bilateral''. There

[[Page 7020]]

is currently a single evaluation level of 10 percent. We propose to 
change the title to ``Metatarsalgia (including Morton's neuroma)'' for 
clarity. Metatarsalgia is a term that refers to chronic pain in the 
ball of the foot from any of a variety of causes, one of which is 
Morton's neuroma. Morton's neuroma (or disease) is a painful neuropathy 
of the digital plantar nerve that usually results in pain in the ball 
of the foot between the third and fourth metatarsal heads. The 
consultants suggested no change in the evaluation criteria but did 
suggest we add a note saying that treatment should be attempted before 
the patient is given a permanent disability rating. We propose to 
incorporate some of this information within the revised criteria. The 
rating we give, however, is not necessarily a permanent one in most 
cases because we frequently re-evaluate veterans with disability if 
they have a condition that is not stable and is subject to improvement. 
As with pes cavus and flatfoot, the symptoms of metatarsalgia may be 
unilateral or bilateral, and may be relieved with appliances, orthoses, 
or orthopedic shoes. Occasionally, surgery is needed for relief. We 
propose to use this information as a basis of evaluation and to direct 
that each foot be evaluated separately, with the evaluations to be 
combined. Assigning a separate evaluation for each foot will allow more 
appropriate evaluation of the total disabling effects, since bilateral 
metatarsalgia is clearly more disabling than unilateral metatarsalgia, 
and the severity of the effects may not be the same in both feet when 
the condition is bilateral. We propose that 10 percent be assigned if 
there is pain in the ball of the foot not significantly relieved by the 
use of appliances, orthoses, or orthopedic shoes, or by surgery, if 
that was done, and that zero percent be assigned if there is pain in 
the ball of the foot largely or completely relieved by, or does not 
require, the use of appliances, orthoses, or orthopedic shoes, or by 
surgery, if that was done.
    Diagnostic code 5280 is currently titled ``Hallux valgus, 
unilateral.'' The consultants suggested we add ``with or without bunion 
deformity'' to the title to make the description more complete. We rely 
on the examiner to make the diagnosis and do not propose to add the 
suggested language because it would not assist in evaluation. We do 
propose to remove ``unilateral'' from the title and add, as for the 
other foot conditions, a note indicating that each foot is to be 
separately evaluated, and the evaluations combined. There are currently 
two criteria for a 10-percent evaluation, the only level defined. They 
are ``operated, with resection of metatarsal head'' and ``severe, if 
equivalent to amputation of great toe.'' The consultants suggested we 
delete the reference to resection of the metatarsal head since that is 
no longer done, and we propose to do so. They also suggested we add 
``symptomatic'' to the other criterion, since not all individuals have 
symptoms. The major findings in hallux valgus (bunion) are pain or 
discomfort in the first metatarsophalangeal joint (the joint at the 
base of the great toe) or under the ball of the foot, deformity at that 
joint, and sometimes redness and swelling. The VHA Orthopedic Committee 
felt evaluation based on amputation was inappropriate and suggested 
that criteria be based on symptoms and their response to treatment. 
Taking both of these suggestions into account, we propose to provide a 
10-percent evaluation if there are symptoms that are not significantly 
relieved by the use of appliances, orthoses, or orthopedic shoes, or by 
surgery, if that was done, and a zero-percent evaluation if symptoms 
are largely or completely relieved by, or not requiring, the use of 
appliances, orthoses, or orthopedic shoes, or by surgery, if that was 
done. These criteria are more appropriate to the condition than 
assessing whether it is equivalent to an amputation, which is likely to 
result in interference with walking and a gait abnormality rather than 
pain as a primary symptom, as in the case of hallux valgus. We propose 
to add a second note, for the sake of clarity, directing raters not to 
combine an evaluation under diagnostic code 5280 with an evaluation for 
pain under Sec.  4.59, because pain is encompassed by these evaluation 
criteria.
    Diagnostic code 5281 is currently titled ``Hallux rigidus, 
unilateral, severe.'' The consultants suggested we include the term 
``hallux limitus,'' another name for the condition, in the title, and 
we propose to do so. Hallux rigidus is a painful degenerative arthritis 
with limited or no motion at the first metatarsal-phalangeal joint. We 
propose to add a note directing that each foot be evaluated separately, 
as other foot conditions are, rather than using ``unilateral'' in the 
title. It is currently evaluated as severe hallux valgus, with a 10% 
evaluation. At the suggestion of the VHA Orthopedic Committee, we 
propose to remove the current note stating that this condition is not 
to be combined with claw foot ratings because the condition has nothing 
to do with clawfoot. The consultants suggested no change from the 
current evaluation. However, the VHA Orthopedic Committee felt that 
hallux rigidus with ankylosis of the first metatarsal-phalangeal joint 
warrants a 20-percent evaluation because it results in pain on any 
activity, such as walking or running, and may affect the gait. We 
therefore propose to revise the criteria to provide three levels of 
evaluation based on the extent of limitation of motion and extent of 
pain. We propose a 20-percent evaluation if there is pain with any 
motion of the joint, including walking, with ankylosis (no motion) of 
the first metatarsal-phalangeal joint and gait abnormality; a 10-
percent evaluation if there is pain on walking, with limitation of 
motion of the first metatarsal-phalangeal joint; and a zero-percent 
evaluation if there is pain only on extremes of motion, with limitation 
of motion of the first metatarsal-phalangeal joint. These criteria are 
more specific to hallux rigidus than the criteria for hallux valgus and 
should support more consistent evaluations. We propose to delete the 
note that now reads ``not to be combined with claw foot ratings'' as 
unnecessary, since these conditions are unrelated and unlikely to occur 
together.
    Diagnostic code 5282 is currently titled ``Hammer toe.'' We propose 
to add ``contracted or deviated toes'' to the heading of hammertoe, as 
suggested by the consultants, in order to describe this category of 
disability more accurately. The condition is currently evaluated at 10 
percent if all toes of one foot are affected, without clawfoot, and at 
zero percent if a single toe is affected. The consultants simply 
suggested that ``clawfoot'' be replaced with ``pes cavus.'' We propose 
criteria that are based on signs and symptoms rather than solely on the 
presence of the condition, since not everyone with this condition is 
equally disabled. Some develop painful calluses on top of the toe or on 
the ball of the feet, some have occasional muscle cramping and 
weakness, and some require surgery because of these problems. We 
therefore propose criteria similar to those for other foot problems 
discussed above, based on symptoms and response to treatment.
    We propose to assign a 10-percent evaluation if there is hammertoe 
with pain and calluses not relieved by the use of appliances, orthoses, 
or orthopedic shoes, or by surgery, if that was done; and a zero-
percent evaluation if there is hammertoe with pain and calluses largely 
or completely relieved by, or not requiring the use of, appliances, 
orthoses, or orthopedic shoes, or by surgery, if that was done. These 
criteria better correlate with

[[Page 7021]]

disability from hammertoe. We propose to add a note directing that each 
foot, but not each toe, be evaluated separately, with the evaluations 
to be combined, and we propose to add a second note directing that an 
evaluation not be assigned both under diagnostic code 5282 and 
diagnostic code 5278 (pes cavus (clawfoot)) because the findings may be 
similar and overlapping.
    Diagnostic code 5283, malunion or nonunion of the metatarsal or 
tarsal bones, currently provides levels of 30, 20, and 10 percent, and 
each percentage level is determined by whether the disability is 
``severe,'' ``moderately severe,'' or ``moderate.'' No criteria are 
provided to explain what these words are intended to mean. The 
consultants suggested criteria for the three levels of ``extreme, not 
amenable to surgical correction,'' ``severe,'' and ``moderate.'' These 
criteria, however, would not adequately remove the subjectivity of the 
current criteria. The VHA Orthopedic Committee suggested we develop 
criteria based on symptoms interfering with activities of daily living, 
athletic activity, and response to treatment, and we propose to follow 
their suggestion. We propose that a 30-percent evaluation be assigned 
if there are signs and symptoms (such as pain, calluses, abnormal or 
limited motion of affected bones or joints) that interfere with 
activities of daily living and that are not significantly relieved by 
appliances, orthoses, or orthopedic shoes, or by surgery, if that was 
done; a 20-percent evaluation if there are signs and symptoms that are 
partly relieved by appliances, orthoses, or orthopedic shoes, or by 
surgery, if that was done, but that interfere at times with activities 
of daily living and with most athletic activity; and a ten-percent 
evaluation if there are signs and symptoms that are largely or 
completely relieved by appliances, orthoses, or orthopedic shoes, or by 
surgery, if that was done, and that do not interfere with activities of 
daily living but that may at times prevent activities such as running 
and jumping. These are more objective than the current criteria and 
provide guidelines that should promote consistent evaluations. They 
provide levels of 30, 10, and zero rather than 30, 20, and 10 because 
these levels are more fitting to these criteria and are consistent with 
the evaluations for malunion of the talus and calcaneus. We propose to 
add to the title ``except talus and calcaneus'' because these tarsal 
bones are evaluated under diagnostic code 5273. There is currently a 
note under diagnostic code 5283 directing that if there is actual loss 
of use of the foot, the evaluation should be 40 percent. We propose to 
delete this note, as these criteria are adequate for evaluating this 
condition. Disability that approaches loss of use of a foot is likely 
to have neurologic or vascular compromise and would be more 
appropriately evaluated under another diagnostic code.
    We propose to change the title of diagnostic code 5284, currently 
``Foot injuries, other.'' The category of disability this code is 
intended to cover is so vague, and its evaluation criteria so 
subjective, consisting of 30 percent for ``severe,'' 20 percent for 
``moderately severe,'' and 10 percent for ``moderate,'' that it is 
unclear what conditions would be evaluated under this code and on what 
basis. There are several other diagnostic codes with clear criteria 
under which foot injuries can be appropriately rated, but we propose to 
title this diagnostic code ``Neurotrophic disorders of the foot'' 
because these are common conditions that do not fall under any other 
specific diagnostic code, either in the orthopedic or neurologic 
sections of the rating schedule. This category would include Charcot's 
foot, diabetic neurotrophic feet, etc. The VHA Orthopedic Committee 
recommended its addition. We propose four levels of evaluation, with 30 
percent assigned for chronic ulceration that cannot be controlled by 
the use of orthoses; 20 percent for recurrent ulcers that can be 
controlled by the use of orthoses; 10 percent for pain that is not 
relieved by orthoses or shoe modification; and zero percent for pain 
that is relieved by orthoses or shoe modification. We also propose to 
add a note directing that if there is osteomyelitis of the foot (which 
may be associated with chronic ulcers that are infected), it will be 
rated under diagnostic code 5000 (osteomyelitis). We propose to add a 
second note directing that a 20- or 30-percent evaluation under 
diagnostic code 5284 may be combined with an evaluation for pain under 
Sec.  4.59.

Skull

    Under the subheading of ``The Skull,'' diagnostic code 5296 
encompasses loss of part of the inner and outer tables of the skull. 
The current criteria are 80 percent if there is a brain hernia; and if 
there is not a brain hernia, 50 percent if there is an area larger than 
a 50-cent piece or 1.140 square inches (7.355 square centimeters); 30 
percent if the area is intermediate; and 10 percent if the area is 
smaller than the size of a 25-cent piece or 0.716 square inches (4.619 
square centimeters). We propose to delete the references to coins and 
round off the measurements, which are carried out to more decimal 
places than are reasonably measurable or are necessary. If a skull 
defect has been repaired by a cranioplasty (covering of the defect by 
bone, metal, or other material), it is not considered disabling. For 
this reason, we propose to add to the title the phrase ``without 
cranioplasty (covering of defect by bone, metal, or other material).'' 
A current note directs that intracranial complications, such as 
seizures or paralysis, be rated separately. We propose to add a second 
note stating that skull loss covered by bone or a prosthesis will not 
be used in calculating the area of skull loss, because these lessen the 
danger of injury to the brain.

Ribs

    We propose only minor changes, largely editorial, in diagnostic 
code 5297, ``Ribs, removal of'' under the subheading ``The Ribs.'' A 
current note states that the rating for rib resection or removal is not 
to be applied with ratings for purulent pleurisy, lobectomy, 
pneumonectomy or injuries of pleural cavity. Purulent pleurisy no 
longer has a diagnostic code in the rating schedule, and we propose to 
change the note to read: ``Do not combine an evaluation under 
diagnostic code 5297 with an evaluation under diagnostic code 6844 
(post-surgical residual (lobectomy, pneumonectomy, etc.)) or 6845 
(chronic pleural effusion or fibrosis)''.

Coccyx

    We propose to change the current heading of diagnostic code 5298 
from ``Coccyx, removal of,'' to ``Partial or complete removal of the 
coccyx,'' and to retain a 10-percent evaluation if there are painful 
residuals. We propose to remove the zero-percent criterion ``without 
painful residuals'' as unnecessary (see Sec.  4.31 of this part).

Section 4.14

    We also propose, for the sake of clarity, to revise 38 CFR 4.14, 
``Avoidance of pyramiding,'' in subpart A of part 4 (General Policy in 
Rating) because evaluating orthopedic disabilities commonly requires 
application of this section, and the principles in this section have 
sometimes been misunderstood. Section 4.14 currently states that the 
evaluation of the same disability under various diagnoses is to be 
avoided and that both the use of manifestations not resulting from 
service-connected disease or injury in establishing the service-
connected evaluation, and the evaluation of the same manifestation 
under different

[[Page 7022]]

diagnoses are to be avoided. This has sometimes been unclear to raters. 
We propose to retitle this section ``Avoiding overlapping of 
evaluations,'' which more clearly reflects its intent. We propose that 
there be four paragraphs, with the first (a) directing raters not to 
use the same sign(s) or symptom(s) to support more than one evaluation 
(under different diagnostic codes) for a single disability. We propose 
that paragraph (b) direct raters not to use the same sign(s) or 
symptom(s) to support an evaluation for more than one disability. 
Paragraphs (c) and (d) would be the converse of (a) and (b), with (c) 
directing raters not to evaluate the same disability at the same time 
(under different diagnostic codes) using the same sign(s) or symptom(s) 
as the basis of evaluation, and (d) directing raters not to evaluate 
more than one disability using the same sign(s) or symptom(s) as the 
basis of evaluation. This section means, for example, that low back 
pain present in someone who has both lumbar intervertebral disc 
syndrome (diagnostic code 5293) and limitation of motion of the lumbar 
spine due to degenerative arthritis (diagnostic code 5292) cannot be 
used to support separate evaluations for these two back conditions, and 
cold injury residuals such as numbness of the toes cannot be used to 
support both an evaluation for cold injury under diagnostic code 7122 
(cold injury residuals) and another evaluation for peripheral 
neuropathy with numbness due to cold injury under diagnostic code 8521 
(paralysis of external popliteal nerve). In our judgment, the revised 
language is more straightforward and clearer and will resolve the 
difficulty raters have had in interpreting the current language.

Executive Order 12866

    This regulatory amendment has been reviewed by the Office of 
Management and Budget under the provisions of Executive Order 12866, 
Regulatory Planning and Review, dated September 30, 1993.

Paperwork Reduction Act

    This document contains no provisions constituting a collection of 
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).

Unfunded Mandates

    The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that 
agencies prepare an assessment of anticipated costs and benefits before 
developing any rule that may result in an expenditure by State, local, 
or tribal governments, in the aggregate, or by the private sector of 
$100 million or more in any given year. This rule would have no 
consequential effect on State, local, or tribal governments.

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed regulatory 
amendment would not have a significant economic impact on a substantial 
number of small entities as they are defined in the Regulatory 
Flexibility Act, 5 U.S.C. 601-612. The reason for this certification is 
that this proposed regulatory amendment would not directly affect any 
small entities. Only VA beneficiaries could be directly affected. 
Therefore, pursuant to 5 U.S.C. 605(b), this proposed regulatory 
amendment is exempt from the initial and final regulatory flexibility 
analysis requirements of sections 603 and 604.

    The Catalog of Federal Domestic Assistance numbers are 64.104 
and 64.109.

List of Subjects

38 CFR Part 3

    Administrative practice and procedure, Claims, Disability benefits, 
Health care, Pensions, Veterans, Vietnam.

38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Approved: October 24, 2002.
Anthony J. Principi,
Secretary of Veterans Affairs.
    For the reasons set out in the preamble, we propose to amend 38 CFR 
parts 3 and 4 as set forth below:

PART 3--ADJUDICATION

Subpart A--Pension, Compensation, and Dependency and Indemnity 
Compensation

    1. The authority citation for part 3, subpart A continues to read 
as follows:

    Authority: 38 U.S.C. 501(a), unless otherwise noted.

    2. In Sec.  3.350 paragraph(a)(2)(i)(c) is added to read as 
follows:


Sec.  3.350  Special monthly compensation ratings.

* * * * *
    (a) * * *
    (2) * * *
    (i) * * *
    (c) Amputation of the thumb and any three fingers of a single hand 
will constitute loss of use of the hand.
* * * * *

PART 4--SCHEDULE FOR RATING DISABILITIES

    3. The authority citation for part 4 continues to read as follows:

    Authority: 38 U.S.C. 1155, unless otherwise noted.

Subpart A--General Policy in Rating

    4. Section 4.14 is revised to read as follows:


Sec.  4.14  Avoiding overlapping of evaluations.

    (a) Do not use the same sign(s) or symptom(s) to support more than 
one evaluation (under different diagnostic codes) for a single 
disability.
    (b) Do not use the same sign(s) or symptom(s) to support an 
evaluation for more than one disability.
    (c) Do not evaluate the same disability at the same time (under 
different diagnostic codes) using the same sign(s) or symptom(s) as the 
basis of evaluation.
    (d) Do not evaluate more than one disability using the same sign(s) 
or symptom(s) as the basis of evaluation.

(Authority: 38 U.S.C. 1155)

Subpart B--Disability Ratings

    5. Section 4.40 is revised to read as follows:


Sec.  4.40  Evaluation of musculoskeletal disabilities.

    The evaluation criteria provided for each condition, or to which 
the rater is referred for evaluating a given condition, are generally 
to be the sole basis of evaluation. In conditions where pain is a 
complaint, but pain is not addressed in the evaluation criteria under 
the diagnostic code for the condition, however, apply the provisions of 
Sec.  4.59, combining an evaluation for pain with an evaluation under 
the diagnostic code for the condition. Factors such as fatigability or 
impaired coordination, speed, or endurance are encompassed by the 
evaluation criteria under each diagnostic code. An additional 
evaluation based on one of these factors will not be assigned.

(Authority: 38 U.S.C. 1155)


Sec.  4.41  [Removed and Reserved]

    6. Section 4.41 is removed and reserved.
    7. Section 4.42 is revised to read as follows:


Sec.  4.42  Examination of joints

    For VA rating purposes, the range of motion of a joint must be 
determined by measurement with a goniometer. The normal ranges of 
motion for major joints

[[Page 7023]]

and the spine are provided on Plates I, II, and V in Sec.  4.71a.

(Authority: 38 U.S.C. 1155)


Sec. Sec.  4.43 and 4.44  [Removed and Reserved]

    8. Sections 4.43 and 4.44 are removed and reserved.
    9. Sections 4.45 and 4.46 are revised to read as follows:


Sec.  4.45  Major and Minor Joints for Arthritis Evaluations.

    For the purpose of rating disability from arthritis, the various 
joints are classified as follows:
    (a) Major Joints: Each shoulder, elbow, wrist, hip, knee and ankle 
joint is a major joint. All other joints are minor joints.
    (b) Groups of Minor Joints to be Rated as Major Joints: A group of 
minor joints with arthritis will be rated as a major joint. Any of the 
following constitutes a group of minor joints:
    (1) Any combination of three or more interphalangeal or metacarpo-
phalangeal joints of a single hand.
    (2) Any combination of three or more interphalangeal, metatarso-
phalangeal, tarso-metatarsal, or tarso-tarsal (or intertarsal) joints 
of a single foot.
    (3) Any combination of two or more cervical vertebral joints.
    (4) Any combination of two or more thoracolumbar vertebral joints.
    (5) A combination of the lumbosacral joint and both sacroiliac 
joints.

(Authority: 38 U.S.C. 1155)


Sec.  4.46  Evaluation of muscle strength.

    (a) Evaluate muscle strength or weakness for rating purposes based 
on the following muscle grading system:

------------------------------------------------------------------------
              Muscle grading                         Description
------------------------------------------------------------------------
Absent (0)................................  No palpable or visible
                                             muscle contraction.
Trace (1).................................  Palpable or visible muscle
                                             contraction, but muscle
                                             produces no movement, even
                                             with gravity eliminated.
Poor strength (2).........................  Muscle produces movement
                                             only when gravity is
                                             eliminated.
Fair strength (3).........................  Muscle produces movement
                                             against gravity but not
                                             against any added
                                             resistance.
Good strength (4).........................  Muscle produces movement
                                             against some, but no more
                                             than moderate, resistance.
Normal strength (5).......................  Muscle produces movement
                                             against full or ``normal''
                                             resistance.
------------------------------------------------------------------------

    (b) Evaluate loss of muscle function as follows:
    (1) Complete: No motor function (muscle grading system 1 or zero).
    (2) Incomplete, severe: Marked weakness associated with muscle 
atrophy (muscle grading system 2).
    (3) Incomplete, moderate: Weakness (muscle grading system 3).
    (4) Incomplete, mild: Weakness (muscle grading system 4).

(Authority: 38 U.S.C. 1155)


Sec. Sec.  4.57 and 4.58  [Removed and Reserved]

    10. Sections 4.57 and 4.58 are removed and reserved.
    11. Section 4.59 is revised to read as follows:


Sec.  4.59  Evaluation of pain in musculoskeletal conditions.

    When the evaluation criteria for a condition in Sec.  4.71a are 
based on signs and symptoms other than pain, and pain is a complaint, 
combine (do not add) the evaluation based on criteria other than pain 
with an evaluation for pain based on the following scale, and assign a 
single (combined) evaluation for the condition under the appropriate 
diagnostic code:

(a) Complaint of pain that globally interferes with and severely     100
 limits daily activities; meets the requirement for a 30-percent
 evaluation under this section; and a psychiatric evaluation has
 excluded other processes to account for the pain................
(b) Complaint of pain at rest, with pain on minimal palpation or      30
 on attempted range of motion on physical examination; X-ray or
 other imaging abnormalities; and abnormal findings on a vascular
 or neurologic special study.....................................
(c) Complaint of pain on any use, with pain on palpation and          20
 through at least one-half of the range of motion on physical
 examination; and X-ray or other imaging abnormalities...........
(d) Complaint of pain on performing some daily activities, with       10
 pain on motion (through any part of the range of motion) on
 physical examination; and X-ray or other imaging abnormalities..
(e) Complaint of mild or transient pain on performing some daily       0
 activities, with correlative finding(s) on physical examination
 (for example, pain on palpation or pain on stressing the joint),
 but without X-ray or other imaging abnormalities................
Note (1): Do not combine a 100-percent evaluation assigned under
 this section with any other evaluation for the same condition.
Note (2): The provisions of Sec.   4.68, ``Limitation of combined
 evaluation of musculoskeletal and neurologic disabilities of an
 extremity,'' will apply to the evaluation of conditions
 evaluated wholly or partly under Sec.   4.59, except that a 100-
 percent evaluation may be assigned under Sec.   4.59 when
 appropriate, regardless of the percentage evaluation allowed
 under a particular diagnostic code.
 

(Authority: 38 U.S.C. 1155)


Sec. Sec.  4.61 through 4.64 and 4.66  [Removed and Reserved]

    12. Sections 4.61 through 4.64, and 4.66, are removed and reserved.
    13. Sections 4.67 through 4.69 are revised to read as follows:


Sec.  4.67  Pelvic bone fractures.

    Evaluate fractures of the pelvic bones based on the specific 
residuals, such as limitation of motion of the spine or hip, muscle 
injury, or sciatic or other peripheral nerve neuropathy.

(Authority: 38 U.S.C. 1155)


Sec.  4.68  Limitation of combined evaluation of musculoskeletal and 
neurologic disabilities of an extremity.

    Unless the evaluation criteria for a particular condition allow for 
a higher evaluation, the combined evaluation for musculoskeletal and 
neurologic disabilities of an extremity will not exceed the rating that 
would be assigned for an amputation of the extremity at the level that 
would remove the affected areas. When a painful stump neuroma develops 
following amputation, the amputation will be evaluated as though it had 
been performed one level higher (as described under the diagnostic 
codes for evaluation of amputations of the extremities) than the actual 
amputation site.

(Authority: 38 U.S.C. 1155)


Sec.  4.69  Dominant hand.

    Handedness, for the purpose of assigning a dominant or nondominant 
rating, will be determined by the evidence of record or by testing on 
examination. Only one hand will be considered dominant; the other will 
be considered nondominant. In the case of an ambidextrous individual, 
the injured hand, or the more severely injured hand, will be considered 
the dominant hand, for rating purposes.

(Authority: 38 U.S.C. 1155)

[[Page 7024]]

Sec.  4.70  [Removed and Reserved]

    14. Section 4.70 is removed and reserved.
    15. Section 4.71 is revised to read as follows:


Sec.  4.71  Baseline for joint motion measurement

    Plates I and II show the normal range of motion of joints of the 
upper and lower extremities. The baseline for joint range of motion 
measurement, or zero degrees, is the normal anatomical position (arms 
at side, palms forward, legs extended), with two exceptions:
    (a) The zero degrees position for shoulder rotation is the arm 
abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm 
pronated to 90 degrees. The forearm is then midway between internal and 
external rotation of the shoulder (Plate I).
    (b) The zero degrees position for forearm supination and pronation 
is the arm next to the body in normal anatomical position and the elbow 
flexed to 90 degrees. The forearm is then midway between supination and 
pronation (Plate I).

(Authority: 38 U.S.C. 1155)

    16. Section 4.71a is amended by:
    a. Removing Diagnostic Codes 5005 through 5008, 5105, 5108 through 
5111, 5259, 5263, and 5277.
    b. Revising Diagnostic Codes 5000 through 5004, 5009 through 5024, 
5051 through 5056, 5104, 5106, 5107, 5120 through 5156, 5160 through 
5167, 5170 through 5173, 5200 through 5203, 5205 through 5215, 5250 
through 5258, 5260 through 5262, 5270 through 5276, 5278 through 5284, 
and 5296 through 5298.
    c. Adding Diagnostic Codes 5204, 5231 through 5233, and 5265 
through 5267.
    The revisions and additions read as follows:


Sec.  4.71a  Schedule of ratings--musculoskeletal system.

                  Acute, Subacute, or Chronic Diseases
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
    Note: When evaluating any disability of the
     musculoskeletal system, refer to Sec.   3.350 of
     this chapter to determine whether the veteran may
     be entitled to special monthly compensation due
     either to anatomical loss or loss of use of a limb
     or to combinations of losses with other specified
     disabilities.
5000 Osteomyelitis, acute, subacute, or chronic:
    Chronic intractable osteomyelitis of any site                    100
     associated with debilitating complications such as
     anemia and amyloidosis.............................
    Osteomyelitis of the spine, pelvis, shoulder, elbow,
     wrist, hip, knee or ankle, or of two or more non-
     contiguous bones:
    When active or acute, with constitutional signs and              100
     symptoms, such as fever, fatigue, malaise,
     debility, and septicemia...........................
    When inactive or chronic, with two or more recurrent              60
     episodes of active infection (following the initial
     infection) within the past 5 years.................
    When inactive or chronic, with one recurrent episode              30
     of active infection (following the initial
     infection) within the past 5 years.................
    When inactive or chronic, without a recurrent                      0
     episode of active infection within the past 5 years
    Osteomyelitis not involving the spine, pelvis,
     shoulder, elbow, wrist, hip, knee or ankle, not
     involving two or more non-contiguous bones, and not
     involving only a single finger or toe:
    When active or acute................................              40
    When inactive or chronic, with two or more recurrent              30
     episodes of active infection (following the initial
     infection) within the past 5 years.................
    When inactive or chronic, with one recurrent episode              20
     of active infection (following the initial
     infection) within the past 5 years.................
    When inactive or chronic, without a recurrent                      0
     episode of active infection within the past 5 years
    Osteomyelitis of a single finger or toe (these
     evaluations apply even if they exceed the
     evaluation for amputation of a finger or toe, i.e.,
     they are exceptions to Sec.   4.68):
    When active or acute................................              10
    When inactive or chronic, with two or more recurrent              10
     episodes of active infection (following the initial
     infection) within the past 5 years.................
    When inactive or chronic, with one or no recurrent                 0
     episodes of active infection (following the initial
     infection) within the past 5 years.................
    Note (1): Subject to the limitations of Sec.   4.68,
     combine an evaluation for inactive or chronic
     osteomyelitis under diagnostic code 5000 with an
     evaluation for chronic residuals, such as
     limitation of motion, ankylosis, etc., under the
     appropriate diagnostic code and for pain (under
     Sec.   4.59) when appropriate.
    Note (2): After removal or resection of the infected
     bone, evaluate under the diagnostic code most
     appropriate for evaluating the residuals, such as
     amputation, shortening, limitation of motion, etc.,
     but not under the criteria for diagnostic code
     5000.
5001 Bones and joints, tuberculosis of, active or
 inactive:
    Active..............................................             100
    Inactive: Rate under Sec.   4.88c or 4.89, whichever
     is appropriate.
5002 Rheumatoid arthritis:
    Constant or near-constant debilitating signs and                 100
     symptoms due to a combination of inflammatory
     synovitis (pain, swelling, tenderness, warmth, and
     morning stiffness in and around joints),
     destruction of multiple joints, and extra-articular
     (other than joint) manifestations..................
    Incapacitating exacerbations or flares with a total               60
     duration of at least 6 weeks during the past 12-
     month period, due either to inflammatory synovitis
     and destruction of multiple joints or to a
     combination of joint problems and extra-articular
     manifestations.....................................
    Incapacitating exacerbations or flares with a total               40
     duration of at least 4 weeks but less than 6 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Incapacitating exacerbations or flares with a total               20
     duration of at least 2 weeks but less than 4 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Incapacitating exacerbations or flares with a total               10
     duration of at least 1 week but less than 2 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Note (1): Evaluate rheumatoid arthritis based either
     on the evaluation criteria under diagnostic code
     5002 or on the combined evaluation of chronic
     residuals of affected joints, whichever method
     results in a higher evaluation.

[[Page 7025]]

 
    Note (2): When evaluating based on chronic joint
     residuals, evaluate each affected major joint or
     group of minor joints on findings such as
     limitation of motion, ankylosis, joint instability,
     etc., under the appropriate diagnostic code, and
     combine each with an evaluation for pain under Sec.
       4.59 when appropriate.
    Note (3): Separately evaluate extra-articular
     manifestations of rheumatoid arthritis, such as
     pulmonary fibrosis; pleural inflammation; weakness
     or atrophy of muscles; emaciation; anemia;
     vasculitis (of skin or systemic); neuropathy, such
     as peripheral nerve neuropathy, entrapment
     neuropathy, and cervical myelopathy; pericarditis;
     Sjogren's syndrome (dry eyes and mouth); and eye
     complications (such as scleritis and episcleritis),
     under the appropriate diagnostic code(s), unless
     used to support an evaluation under diagnostic code
     5002.
    Note (4): An incapacitating exacerbation or flare
     means one requiring bedrest or wheelchair use and
     treatment by a health care provider.
5003 Osteoarthritis (degenerative or hypertrophic
 arthritis):
    Separately evaluate each major joint or group of
     minor joints affected with osteoarthritis based on
     limitation of motion, ankylosis, joint instability,
     etc., under the appropriate diagnostic code, and
     combine that evaluation with an evaluation for pain
     under Sec.   4.59 when appropriate, subject to the
     limitations of Sec.   4.68.
    Note (1): The diagnosis of osteoarthritis of any
     joint must be confirmed (one time only) by X-ray or
     other imaging procedure.
    Note (2): Generalized osteoarthritis. If
     osteoarthritis is diagnosed on the basis of
     positive X-ray or other imaging procedure and
     positive physical findings in three or more joints
     (major joints, groups of minor joints, or both)
     during service or within 1 year following the date
     of separation from service, the condition will be
     considered to be generalized osteoarthritis and
     recognized as a systemic condition. Once
     generalized osteoarthritis has been established
     based on these criteria, consider all joints
     subsequently diagnosed with osteoarthritis to be
     part of the same condition.
    Note (3): Localized osteoarthritis. Osteoarthritis
     diagnosed on the basis of positive X-ray or other
     imaging procedure and positive physical findings in
     fewer than three joints (major joints, groups of
     minor joints, or both) during service or within 1
     year following the date of separation from service
     will be considered to be localized osteoarthritis
     rather than a systemic condition. With localized
     osteoarthritis, do not consider any joints
     subsequently diagnosed with osteoarthritis to be
     part of the same condition.
5004 Infectious arthritis (gonorrheal, pneumococcic,
 typhoid, syphilitic, streptococcic, etc.):
    During and for 3 months following cessation of                   100
     therapy for active infectious arthritis of the
     spine, the pelvis, or a major joint................
    During and for three months following cessation of                40
     therapy for active infectious arthritis not
     involving the spine, the pelvis, or a major joint
     and not limited to a single finger or toe..........
    During and for three months following cessation of                10
     therapy for active infectious arthritis of a single
     finger or toe......................................
    Note: Following the three-month period after
     cessation of therapy, separately evaluate chronic
     residuals, if any, of each joint affected with
     infectious arthritis, based on limitation of
     motion, ankylosis, joint instability, post-surgical
     residuals (such as arthroplasty), etc., under the
     appropriate diagnostic code, and combine the
     evaluation for chronic residuals of each joint with
     an evaluation for pain under Sec.   4.59 when
     appropriate, subject to the limitations of Sec.
     4.68.
5009 Other types of noninfectious inflammatory arthritis
 (including ankylosing spondylitis, Reiter's syndrome,
 psoriatic arthritis, arthritis associated with
 inflammatory bowel disease, and other seronegative
 types of arthritis):
    Constant or near-constant debilitating signs and                 100
     symptoms, due to a combination of inflammatory
     synovitis (pain, swelling, tenderness, warmth, and
     morning stiffness in and around joints),
     destruction of multiple joints, and extra-articular
     (other than joint) manifestations..................
    Incapacitating exacerbations or flares with a total               60
     duration of at least 6 weeks during the past 12-
     month period, due either to inflammatory synovitis
     and destruction of multiple joints or to a
     combination of joint problems and extra-articular
     manifestations.....................................
    Incapacitating exacerbations or flares with a total               40
     duration of at least 4 weeks but less than 6 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Incapacitating exacerbations or flares with a total               20
     duration of at least 2 weeks but less than 4 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Incapacitating exacerbations or flares with a total               10
     duration of at least 1 week but less than 2 weeks
     during the past 12-month period due to inflammatory
     synovitis, weakness, and fatigue...................
    Note (1): Evaluate based either on the evaluation
     criteria under diagnostic code 5009 or on the
     combined evaluation of chronic residuals of
     affected joints, whichever method results in a
     higher evaluation.
    Note (2): When evaluating based on chronic joint
     residuals, evaluate each major joint or group of
     minor joints with arthritis based on limitation of
     motion, ankylosis, joint instability, etc., under
     the appropriate diagnostic code, and combine each
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
    Note (3): Separately evaluate the extra-articular
     manifestations of the arthritis under the
     appropriate diagnostic code(s), unless they have
     been used to support an evaluation under diagnostic
     code 5009. Extra-articular manifestations include
     such findings as fever, eye problems (such as
     conjunctivitis, iritis, uveitis), genitourinary or
     gynecologic problems (such as urethritis, cystitis,
     prostatitis, cervicitis, salpingitis,
     vulvovaginitis), and heart problems (such as
     pericarditis, aortic valvular disease, heart
     block).
    Note (4): An incapacitating exacerbation or flare
     means one requiring bedrest or wheelchair use and
     treatment by a health care provider.
5010 Traumatic arthritis (secondary osteoarthritis):
    Separately evaluate each major joint or group of
     minor joints with traumatic arthritis based on
     limitation of motion, joint instability, ankylosis,
     etc., under the appropriate diagnostic code, and
     combine that evaluation with an evaluation for pain
     under Sec.   4.59 when appropriate subject to the
     limitations of Sec.   4.68.
    Note: The diagnosis of traumatic arthritis of any
     joint must be confirmed (one time only) by X-ray or
     other imaging procedure.
5011 Caisson disease (residuals of decompression
 sickness or the bends):
    Evaluate using the criteria under an appropriate
     diagnostic code based on the actual residuals, such
     as aseptic necrosis or delayed osteoarthritis of
     the shoulder or hip, or neurologic manifestations
     (such as weakness or paraplegia of lower
     extremities, vestibular dysfunction with vertigo,
     or paresthesias of the extremities).
5012 Malignant neoplasm of bone.........................             100

[[Page 7026]]

 
    Note: A rating of 100% shall continue beyond the
     cessation of any surgical, X-ray, antineoplastic
     chemotherapy or other therapeutic procedure. Six
     months after discontinuance of such treatment, the
     appropriate disability evaluation shall be
     determined on the basis of a VA examination, or on
     available medical records if sufficient for
     evaluation. Any reduction in the evaluation based
     upon that or any subsequent examination shall be
     subject to the provisions of Sec.   3.105(e) of
     this chapter. If there has been no local recurrence
     or metastasis, rate on residuals.
5013 Osteoporosis:
    Evaluate under the appropriate diagnostic code based
     on the residuals of fractures (such as shortening,
     deformity, limitation of motion, osteoarthritis)
     and combine the evaluation based on residuals of
     fracture with an evaluation for pain (under Sec.
     4.59) when appropriate. Separately evaluate any
     secondary complications, such as neurologic
     manifestations, pulmonary restriction due to
     thoracic deformity from vertebral fractures, etc.
5014 Osteomalacia:
    Evaluate under the appropriate diagnostic code,
     based on aseptic necrosis, residuals of fracture
     (such as shortening, deformity, limitation of
     motion, osteoarthritis), and combine with an
     evaluation for bone pain (under Sec.   4.59) when
     appropriate. Evaluate constitutional manifestations
     of osteomalacia, such as malaise and easy
     fatigability, as part of the underlying metabolic
     condition, such as renal disease or
     gastrointestinal disease, that has caused the
     osteomalacia.
5015 Benign neoplasm of bones:
    Evaluate under the appropriate diagnostic code based
     on osteoarthritis (diagnostic code 5003), residuals
     of fracture (such as shortening, limitation of
     motion), etc., and combine with an evaluation for
     bone pain (under Sec.   4.59) when appropriate.
5016 Paget's disease:
    Evaluate based on osteoarthritis (5003) or on
     residuals of fracture (such as shortening,
     limitation of motion, etc.) of any affected bones,
     and combine with an evaluation for bone pain (under
     Sec.   4.59) when appropriate. Separately evaluate
     complications such as loss of hearing or visual
     impairment.
5017 Gout or pseudogout:
    Incapacitating exacerbations or flares with a total               60
     duration of at least 6 weeks during the past 12-
     month period requiring treatment by a health care
     provider, due to inflammatory synovitis with such
     findings as weakness and fatigue, acute pain,
     swelling, heat, tenderness, or limitation of motion
     of multiple joints.................................
    Incapacitating exacerbations or flares with a total               40
     duration of at least 4 weeks but less than 6 weeks
     during the past 12-month period requiring treatment
     by a health care provider, due to inflammatory
     synovitis with such findings as weakness and
     fatigue, acute pain, swelling, heat, tenderness, or
     limitation motion of multiple joints...............
    Incapacitating exacerbations or flares with a total               20
     duration of at least 2 weeks but less than 4 weeks
     during the past 12-month period requiring treatment
     by a health care provider, due to inflammatory
     synovitis with such findings as weakness and
     fatigue, acute pain, swelling, heat, tenderness, or
     limitation motion of multiple joints...............
    Incapacitating exacerbations or flares with a total               10
     duration of at least 1 week but less than 2 weeks
     during the 12-month period requiring treatment by a
     health care provider, due to inflammatory synovitis
     with such findings as weakness and fatigue, acute
     pain, swelling, heat, tenderness, or limitation of
     motion of a single joint or multiple joints........
    Note (1): Evaluate either on the basis of the total
     duration of incapacitating exacerbations or flares
     under the criteria for diagnostic code 5017 or on
     the combined evaluation of chronic residuals of
     gout or pseudogout, whichever results in the higher
     evaluation.
    Note (2): If not evaluating under the criteria under
     diagnostic code 5017, separately evaluate chronic
     residuals of each major joint or group of minor
     joints with gout or pseudogout based on limitation
     of motion, ankylosis, joint instability, etc.,
     under the diagnostic code for that finding. Combine
     the evaluation for chronic residuals of each major
     joint or group of minor joints with an evaluation
     for pain under Sec.   4.59 when appropriate.
    Note (3): Separately evaluate manifestations of gout
     other than joint disease, such as urinary tract
     calculi or gouty nephropathy.
    Note (4): An incapacitating exacerbation or flare
     means one requiring bedrest or wheelchair use and
     treatment by a health care provider.
5018 Joint effusion (Hydrarthrosis):
    A joint effusion that is present constantly, or
     nearly so, or if intermittent, that occurred at
     least two times during the past 12-month period,
     may be evaluated under this diagnostic code.
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
5019 Bursitis:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
5020 Synovitis:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
5021 Myositis:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
5022 Periostitis:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
5023 Myositis ossificans:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate
5024 Tenosynovitis:
    Evaluate based on limitation of motion, and combine
     with an evaluation for pain under Sec.   4.59 when
     appropriate.
 
                              * * * * * * *
------------------------------------------------------------------------


[[Page 7027]]


                           Prosthetic Implants
------------------------------------------------------------------------
                                                      Rating
                                         -------------------------------
                                             Dominant       Nondominant
------------------------------------------------------------------------
    Note: The 100-percent evaluation for
     implantation of Prosthesis
     (diagnostic codes 5051 through
     5056) will be assigned as of the
     date of hospital admission. Six
     months following the date of
     hospital discharge, the appropriate
     disability evaluation shall be
     determined on the basis of a VA
     examination, or on available
     medical records if sufficient for
     evaluation. Any reduction in
     evaluation based upon that or any
     subsequent examination is subject
     to the provisions of Sec.
     3.105(e) of this chapter. The same
     method of evaluation will be
     applied when an arthroplasty is
     revised or redone.
5051 Total or partial shoulder
 arthroplasty or replacement (with
 prosthesis):
    From date of hospital admission for              100             100
     arthroplasty, either initial or
     revision...........................
    With inability to abduct (move the                60              50
     arm away from the body) more than
     45 degrees.........................
    Minimum evaluation following                      30              20
     arthroplasty.......................
    Note (1): If there is ankylosis of
     the glenohumeral joint, evaluate
     under diagnostic code 5200
     (ankylosis of glenohumeral
     articulation (shoulder joint)).
    Note (2): Separately evaluate
     complications, such as peripheral
     neuropathy, causalgia, and reflex
     sympathetic dystrophy, under an
     appropriate diagnostic code. An
     evaluation for a complication may
     be combined with an evaluation
     under diagnostic code 5051 that is
     less than total, as long as
     limitation of abduction is not used
     to support an evaluation for a
     complication.
    Note (3): Combine an evaluation
     under diagnostic code 5051 with an
     evaluation for pain under Sec.
     4.59 when appropriate.
5052 Total or partial elbow arthroplasty
 or replacement (with prosthesis):
    From date of hospital admission for              100             100
     arthroplasty, either initial or
     revision...........................
    Evaluate residuals based on
     ankylosis of elbow (under
     diagnostic code 5205), limitation
     of flexion of elbow (under
     diagnostic code 5206), limitation
     of extension of elbow (under
     diagnostic code 5207), or for
     limitation of flexion and extension
     of elbow (under diagnostic code
     5208), whichever results in the
     highest evaluation, combining this
     evaluation with an evaluation for
     pain under Sec.   4.59 when
     appropriate.
    Minimum evaluation following                      30              20
     arthroplasty.......................
5053 Total or partial wrist arthroplasty
 or replacement (with prosthesis):
    From date of hospital admission for              100             100
     arthroplasty, either initial or
     revision...........................
    Evaluate residuals based on
     ankylosis (under diagnostic code
     5214) or limitation of motion
     (under diagnostic code 5215),
     whichever results in a higher
     evaluation, combining this
     evaluation with an evaluation for
     pain under Sec.   4.59 when
     appropriate.
    Minimum evaluation following                      20              20
     arthroplasty.......................
5054 Total or partial hip arthroplasty
 or replacement (with prosthesis):
    From date of hospital admission for   ..............             100
     arthroplasty, either initial or
     revision...........................
    Requiring use of two crutches or a    ..............          \1\ 90
     walker for ambulation..............
    Requiring use of one crutch or two    ..............              70
     canes for most ambulation, due to
     pain, instability, or weakness
     (muscle strength grade zero to 2
     out of 5)..........................
    Requiring use of one crutch or two    ..............              50
     canes only for ambulating long
     distances (500 feet or more), due
     to pain, instability, or weakness
     (muscle strength grade 3 to 4 out
     of 5)..............................
    Requiring use of one cane for         ..............              40
     ambulation, due to pain,
     instability, or weakness; or with
     recalcitrant thigh pain of longer
     than 2 years' duration.............
    Minimum evaluation following          ..............              30
     arthroplasty.......................
    Note: Do not combine an evaluation
     under this diagnostic code with an
     evaluation for pain under Sec.
     4.59.
5055 Total or partial knee arthroplasty
 or replacement (with prosthesis):
    From date of hospital admission for   ..............             100
     arthroplasty, either initial or
     revision...........................
    Requiring use of two crutches or a    ..............          \1\ 90
     walker for ambulation..............
    Requiring use of one crutch or two    ..............              70
     canes for most ambulation, due to
     pain, instability, or weakness
     (muscle strength grade zero to 2
     out of 5); or with loss of more
     than 40 degrees of the full arc of
     motion.............................
    Requiring use of one crutch or two    ..............              50
     canes only for ambulating long
     distances (500 feet or more), due
     to pain, instability, or weakness
     (muscle strength grade 3 to 4 out
     of 5); or with loss of 21 to 40
     degrees of the full arc of motion..
    Requiring use of one cane or brace    ..............              40
     for ambulation, due to pain,
     instability, or weakness; or with
     loss of 10 to 20 degrees of the
     full arc of motion.................
    Minimum evaluation following          ..............              30
     arthroplasty.......................
    Note (1): A full arc of motion of
     the knee after arthroplasty is a
     range of motion of 0 to 110
     degrees.
    Note (2): Do not combine an
     evaluation under this diagnostic
     code with an evaluation for pain
     under Sec.   4.59.
5056 Total or partial ankle arthroplasty
 or replacement (with prosthesis):
    From date of hospital admission for   ..............             100
     arthroplasty, either initial or
     revision...........................
    Evaluate residuals based on
     ankylosis (under diagnostic code
     5270) or limitation of motion
     (under diagnostic code 5271),
     whichever results in a higher
     evaluation, combining this
     evaluation with an evaluation for
     pain under Sec.   4.59 when
     appropriate.
    Minimum evaluation following          ..............             20
     arthroplasty.......................
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation. Refer to
  Sec.   3.350 for specific instructions regarding claims involving loss
  of loss of use of limbs.


[[Page 7028]]


                      Combinations of Disabilities
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5104 Anatomical loss or loss of use of one hand and              \1\ 100
 anatomical loss or loss of use of one foot.............
5106 Anatomical loss or loss of use of one hand and              \1\ 100
 anatomical loss or loss of use of the other hand.......
5107 Anatomical loss or loss of use of one foot and             \1\ 100
 anatomical loss or loss of use of the other foot.......
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation. Refer to
  Sec.   3.350 for specific instructions regarding claims involving loss
  of loss of use of limbs.


                      Amputations: Upper Extremity
------------------------------------------------------------------------
                                                      Rating
                                         -------------------------------
                                             Dominant       Nondominant
------------------------------------------------------------------------
    Amputation of upper extremity:
5120 Disarticulation....................          \1\ 90          \1\ 90
5121 Above insertion of deltoid.........          \1\ 90          \1\ 80
5122 Below insertion of deltoid.........          \1\ 80          \1\ 70
    Amputation of forearm:
5123 Amputation of forearm above                  \1\ 80          \1\ 70
 insertion of pronator teres (located at
 the middle one-third of the lateral
 surface of the radius), also called
 short, below elbow amputation..........
5124 Amputation of forearm below                  \1\ 70          \1\ 60
 insertion of pronator teres (at the
 middle one-third of the lateral surface
 of the radius), also called long, below
 elbow amputation.......................
5125 Wrist disarticulation..............          \1\ 70          \1\ 60
-----------------------------------------
               Multiple Finger Amputations
---------------------------------------------------------
    Note (1): These ratings apply only
     to amputations at the proximal
     interphalangeal joints or through
     proximal phalanges.
    Note (2): Amputation through middle
     phalanges will be rated as
     unfavorable ankylosis of the
     fingers.
    Note (3): Except for negligible
     losses, amputations at distal
     joints or through distal phalanges
     will be rated as favorable
     ankylosis of the fingers.
    Note (4): Amputation or resection of
     more than one-half the metacarpal
     bones in injuries of multiple
     fingers will be assigned an
     evaluation of 10 percent added to
     (not combined with) the evaluations
     for multiple finger amputations,
     subject to the provisions of Sec.
     4.68.
    Note (5): Combinations of finger
     amputations at various levels, or
     finger amputations with ankylosis
     or limitation of motion of the
     fingers will be rated on the basis
     of the grade of disability, i.e.,
     amputation, unfavorable ankylosis,
     most representative of the levels
     or combinations. With an even
     number of fingers involved, and
     adjacent grades of disability,
     select the higher of the two
     grades.
5126 Amputation of five fingers of one            \1\ 70          \1\ 60
 hand...................................
    Amputation of four fingers of one
     hand:
5133 Thumb, index and ring..............              60              50
5134 Thumb, index and little............              60              50
5135 Thumb, long and ring...............              60              50
5136 Thumb, long and little.............              60              50
5137 Thumb, ring and little.............              60              50
5138 Index, long and ring...............              50              40
5139 Index, long and little.............              50              40
5140 Index, ring and little.............              50              40
5141 Long, ring and little..............              40              30
    Amputation of two fingers of one
     hand:
5142 Thumb and index....................              50              40
5143 Thumb and long.....................              50              40
5144 Thumb and ring.....................              50              40
5145 Thumb and little...................              50              40
5146 Index and long.....................              40              30
5147 Index and ring.....................              40              30
5148 Index and little...................              40              30
5149 Long and ring......................              30              20
5150 Long and little....................              30              20
5151 Ring and little....................              30              20
-----------------------------------------
                Single Finger Amputations
---------------------------------------------------------
    Note: These single finger amputation
     ratings are the only ratings that
     may be applied to amputations of
     all or part of a single finger.
5152 Amputation of thumb:
    With metacarpal resection...........              40              30
    At metacarpophalangeal joint or                   30              20
     through proximal phalanx...........
    At distal joint or through distal                 20              20
     phalanx............................
5153 Amputation of index finger:
    With metacarpal resection (more than              30              20
     one-half the bone lost)............
    Without metacarpal resection, at                  20              20
     proximal interphalangeal joint or
     proximal thereto...................
    Through middle phalanx or at distal               10              10
     joint..............................

[[Page 7029]]

 
5154 Amputation of long finger:
    With metacarpal resection (more than              20              20
     one-half the bone lost)............
    Without metacarpal resection, at or               10              10
     proximal to the interphalangeal
     joint..............................
5155 Amputation of ring finger:
    With metacarpal resection (more than              20              20
     one-half the metacarpal bone lost).
    Without metacarpal resection, at or               10              10
     proximal to the Interphalangeal
     joint..............................
5156 Amputation of little finger:
    With metacarpal resection (more than              20              20
     one-half the bone lost.............
    Without metacarpal resection, at or               10              10
     proximal to the interphalangeal
     joint..............................
 
                              * * * * * * *
5160 Disarticulation of hip, with loss    ..............          \1\ 90
 of extrinsic pelvic girdle muscles.....
5161 Amputation through the upper one-    ..............          \1\ 80
 third of the thigh, one-third of the
 distance from the perineum to the knee
 joint measured from perineum...........
5162 Amputation through the middle or     ..............          \1\ 60
 lower third of thigh...................
5163 Amputation of lower extremity, at    ..............          \1\ 60
 or below knee, with defective stump,
 thigh amputation indicated.............
5164 Amputation of lower extremity below  ..............          \1\ 60
 the knee at a level not permitting
 prosthesis controlled by natural knee
 action.................................
5165 Amputation of lower extremity below  ..............          \1\ 40
 the knee at a level permitting
 prosthesis controlled by natural knee
 action.................................
5166 Amputation of forefoot proximal to   ..............          \1\ 40
 the metatarsal bones (with more than
 one-half of the metatarsals amputated).
5167 Loss of use of foot................  ..............          \1\ 40
5170 Amputation of all toes, without      ..............              30
 metatarsal loss........................
5171 Amputation of great toe:
    With removal of metatarsal head.....  ..............              30
    Without removal of metatarsal head..  ..............              10
5172 Amputation of one or two toes,
 other than great toe:
    With removal of metatarsal head.....  ..............              20
    Without removal of metatarsal head..  ..............               0
5173 Amputation of three or four toes,
 without metatarsal involvement:
    Including great toe.................  ..............              20
    Not including great toe.............  ..............             10
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation. Refer to
  Sec.   3.350 for specific instructions regarding claims involving loss
  or loss of use of limbs.
 
 * * * * * * *


                     Humerus, Clavicle, and Scapula
------------------------------------------------------------------------
                                                      Rating
                                         -------------------------------
                                             Dominant       Nondominant
------------------------------------------------------------------------
5200 Ankylosis of glenohumeral
 articulation (shoulder joint):
    Note: The scapula and humerus move
     as one unit.
    Unfavorable, abduction limited to 25              50              40
     degrees from side..................
    Intermediate, abduction limited to                40              30
     between 26 degrees and 59 degrees..
    Favorable, abduction limited to 60                30              20
     degrees, but can reach mouth and
     head...............................
5201 Limitation of active abduction of
 shoulder:
    Abduction limited to 25 degrees from              40              30
     side...............................
    Abduction limited to between 26                   30              20
     degrees and 89 degrees from side...
    Abduction limited to shoulder level               20              20
     (90 degrees).......................
5202 Residuals of fracture of humerous
 and residuals of dislocation of
 glenohumeral (shoulder) joint:
    At least one recurrence of                        10              10
     dislocation........................
    Malunion of fracture of humerus:
        Symptomatic, with more than 45                30              20
         degrees of angulation in the
         anterior-posterior plane or
         varus-valgus plane.............
        Symptomatic, with 30 to 45                    20              20
         degrees of angulation in the
         anterior-posterior plane or
         varus-valgus plane.............
5203 Impairment of clavicle or scapula:
    Resection of the end of the                       20              10
     clavicle; nonunion of the clavicle
     or scapula; malunion of the
     clavicle or scapula with skin
     breakdown, skin irritation, or
     thoracic outlet syndrome (upper
     extremity symptoms due to
     compression of nerves or blood
     vessels)...........................
    Dislocation of the acromioclavicular              10              10
     joint with pain and localized
     osteoarthritis; or painful
     sternoclavicular anterior
     dislocation........................
    Malunion of clavicle or scapula                    0               0
     without skin breakdown, skin
     irritation, or thoracic outlet
     problems...........................
    With untreated sternoclavicular
     posterior dislocation, separately
     evaluate complications, such as
     from pressure on blood vessels or
     trachea.

[[Page 7030]]

 
    Note (1): These criteria encompass
     pain, so do not combine an
     evaluation under diagnostic code
     5203 with an evaluation for pain
     under Sec.   4.59.
    Note (2): Thoracic outlet syndrome
     is a group of symptoms, mainly of
     the upper extremity, that may
     include pain, weakness, numbness,
     and tingling of an arm or hand, as
     well as swelling and enlargement of
     veins of the arm or chest. It is
     due to compression of the area
     behind each clavicle where an
     artery, a vein, and nerves cross.
     Thoracic outlet syndrome can be
     evaluated separately as long as it
     is not used to support an
     evaluation under diagnostic code
     5203.
5204 Rotator cuff dysfunction and
 impingement syndrome:
    Limitation of internal rotation,                  20              20
     external rotation, flexion, and
     abduction..........................
    Minimum, with positive impingement                10              10
     sign...............................
    Note (1): Combine an evaluation
     based on the criteria under
     diagnostic code 5204 with an
     evaluation for pain under Sec.
     4.59 when appropriate.
    Note (2): Evaluate under diagnostic
     code 5201 if a higher evaluation
     could be assigned based on
     limitation of abduction, but do not
     combine with an evaluation under
     diagnostic code 5204.
------------------------------------------------------------------------


                          The Elbow and Forearm
------------------------------------------------------------------------
                                                      Rating
                                         -------------------------------
                                             Dominant       Nondominant
------------------------------------------------------------------------
5205 Ankylosis of elbow:
    Unfavorable, at an angle of less                  80              70
     than 50 degrees or with complete
     loss of supination or pronation....
    Intermediate, at an angle of more                 60              50
     than 90 degrees or between 70
     degrees and 50 degrees.............
    Favorable, at an angle between 90                 50              40
     degrees and 70 degrees.............
5206 Limitation of flexion of elbow:
    Flexion limited to 45 degrees.......              50              40
    Flexion limited to 55 degrees.......              40              30
    Flexion limited to 70 degrees.......              30              20
    Flexion limited to 90 degrees.......              20              20
    Flexion limited to 100 degrees......              10              10
    Flexion limited to 110 degrees......               0               0
5207 Limitation of extension of elbow:
    Extension is limited to minus 110                 50              40
     degrees (lacks 110 degrees of full
     extension).........................
    Extension is limited to minus 100                 40              30
     degrees (lacks 100 degrees of full
     extension).........................
    Extension is limited to minus 90                  30              20
     degrees (lacks 90 degrees of full
     extension).........................
    Extension is limited to minus 75                  20              20
     degrees (lacks 75 degrees of full
     extension).........................
    Extension is limited to between                   10              10
     minus 45 and minus 74 degrees
     (lacks at least 45 but less than 75
     degrees of full extension).........
5208 Flexion of elbow is limited to 100               20              20
 degrees, and extension is limited to
 minus 45 degrees: (lacks 45 degrees of
 full extension)........................
5209 Other impairment of elbow:
    Joint fracture with cubitus varus                 20              20
     deformity (any degree of varus
     greater than zero degrees); or
     ununited or malunited head of
     radius.............................
    Excised radial head.................              10              10
5210 Nonunion of radius and ulna, with                50              40
 motion at the fracture site............
5211 Impairment of ulna:
    Nonunion in upper half, with false                40              30
     movement, deformity, and loss of
     bone substance (1 inch (2.5 cm.) or
     more)..............................
    Nonunion in upper half, with false                30              20
     movement, with either deformity or
     loss of bone substance (1 inch (2.5
     cm.) or more)......................
    Nonunion in upper half, with false                20              20
     movement, without deformity and
     without loss of bone substance (1
     inch (2.5 cm.) or more); or
     nonunion in lower half.............
    Malunion of, symptomatic............              10              10
     Note: Alternatively, evaluate
     malunion of the ulna based on
     limitation of motion if that would
     result in a higher evaluation.
5212 Impairment of radius:
    Nonunion in lower half, with false                40              30
     movement, deformity, and loss of
     bone substance (1 inch (2.5 cm.) or
     more)..............................
    Nonunion in lower half, with false                30              20
     movement, with either deformity or
     loss of bone substance (1 inch (2.5
     cm.) or more)......................
    Nonunion in lower half, with false                20              20
     movement, without deformity and
     without loss of bone substance (1
     inch (2.5 cm.) or more); or
     nonunion in upper half.............
    Malunion of, symptomatic............              10              10
    Note: Alternatively, evaluate
     malunion of the radius based on
     limitation of motion if that would
     result in a higher evaluation.
5213 Impairment of supination and
 pronation of forearm:
    (1) With bone fusion:
        The hand fixed in supination                  40              30
         (between one and 85 degrees of
         supination) or in
         hyperpronation (in greater than
         80 degrees of pronation).......

[[Page 7031]]

 
        The hand fixed in full pronation              30              20
         (at 80 degrees of pronation)...
        The hand fixed at 40 to 45                    20              20
         degrees of pronation...........
    (2) Limitation of pronation:
        Pronation limited to 40 degrees.              30              20
        Pronation limited to 60 degrees.              20              20
    (3) Limitation of supination:                     10              10
     Supination limited to 30 degrees...
    Note: Evaluations for forearm and
     wrist injuries, diagnostic codes
     5205 through 5213, will be combined
     with separate evaluations for
     limitation of motion of the
     fingers, subject to the provisions
     of Sec.   4.68.
------------------------------------------------------------------------


                                The Wrist
------------------------------------------------------------------------
                                                      Rating
                                         -------------------------------
                                             Dominant       Nondominant
------------------------------------------------------------------------
5214 Ankylosis of the wrist:
    Unfavorable, meaning fixed in any                 50              40
     degree of palmar flexion, or with
     ulnar or radial deviation..........
    Intermediate, meaning fixed in any                40              30
     position other than that for
     favorable or unfavorable...........
    Favorable, meaning fixed in 20                    30              20
     degrees to 30 degrees dorsiflexion,
     without ulnar or radial deviation..
5215 Limitation of motion of wrist:
    Dorsiflexion limited to 14 degrees,               10              10
     or palmar flexion limited to zero
     degrees (no palmar flexion
     possible)..........................
 
                              * * * * * * *
5231 Fracture of phalanx of finger or
 thumb:
    Evaluate based on residuals, such as
     limitation of motion or ankylosis
     of digit under the appropriate
     code(s), and combine with an
     evaluation for pain under Sec.
     4.59 when appropriate.
5232 Fracture of carpal or metacarpal
 bone:
    Evaluate based on residuals under
     the appropriate code(s), such as
     limitation of motion or ankylosis
     of wrist, and combine with an
     evaluation for pain under Sec.
     4.59 when appropriate.
5233 Fracture of phalanx of toe:
    Evaluate based on residuals under
     the appropriate code(s), such as
     limitation of motion or ankylosis
     of toe (for example, using criteria
     for diagnostic codes 5278 through
     5283), and combine with an
     evaluation for pain under Sec.
     4.59 when appropriate.
------------------------------------------------------------------------


                            The Hip and Thigh
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5250 Ankylosis of hip:
    Unfavorable ankylosis, meaning fixed in more than 60          \1\ 90
     degrees of flexion so that the foot cannot reach
     the ground, and crutches are required for
     ambulation.........................................
    Intermediate ankylosis, meaning fixed in 40 to 60                 70
     degrees of flexion, and assistive devices may be
     needed.............................................
    Favorable ankylosis, meaning fixed in 20 degrees to               60
     39 degrees of flexion, in slight adduction or
     abduction, and assistive devices are not required..
5251 Limitation of extension of hip (normal full
 extension is zero degrees):
    If there is limitation of extension of the affected               10
     hip that is at least 10 degrees more than the
     limitation of extension of the non-affected hip,
     and there is a positive Thomas test (test for
     flexion contracture of hip)........................
5252 Limitation of flexion of hip:
    Flexion limited to 10 degrees.......................              40
    Flexion limited to 20 degrees.......................              30
    Flexion limited to 30 degrees.......................              20
    Flexion limited to 45 degrees.......................              10
5253 Limitation of abduction, adduction, or rotation of
 hip:
    Abduction limited to 10 degrees.....................              20
    Adduction limited, so that cannot cross legs; or                  10
     rotation limited, so that cannot toe-out more than
     15 degrees.........................................
5254 Resection arthroplasty of hip (removal of femoral                80
 head and neck without replacement by a prosthesis).....
5255 Residuals of fracture of femur:
    Fracture of the femoral neck, intertrochanteric                   60
     area, or shaft with symptomatic malunion or
     symptomatic non-union..............................
    Fracture of the femoral neck, intertrochanteric                   40
     area, or shaft with asymptomatic non-union; or
     fracture of the femoral head or subcapital area
     with excision of 25% or more of the weightbearing
     portion............................................
    Fracture of the femoral shaft with symptomatic                    30
     malunion and either more than 10 degrees of
     angulation in the varus-valgus plane or more than
     15 degrees of angulation in the anterior-posterior
     plane..............................................
    Note (1): Evaluate fracture of the femoral head or
     subcapital area with excision of less than 25% of
     the weightbearing portion as aseptic necrosis of
     the femoral head, diagnostic code 5265.
    Note (2): Malunion of an intertrochanteric fracture
     is indicated by a varus deformity, shortening, or
     rotation.
------------------------------------------------------------------------
\1\ Review for entitlement of special monthly compensation. Refer to
  Sec.   3.350 for specific instructions regarding claims involving loss
  or loss of use of limbs.


[[Page 7032]]


                            The Knee and Leg
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5256 Ankylosis of knee:
    Ankylosed in more than 45 degrees of flexion........              60
    Ankylosed in flexion, between 21 and 45 degrees.....              50
    Ankylosed in flexion, between 11 and 20 degrees.....              40
    Ankylosed in full extension, or in flexion between                30
     zero and 10 degrees................................
5257 Knee instability:
    Documented instability that is not correctable by                 30
     bracing and that interferes with activities of
     daily living.......................................
    Documented instability that is correctable by                     20
     bracing, but that interferes at times with
     activities of daily living and prevents activities
     such as running and jumping........................
    Documented instability that is correctable by                     10
     bracing and that does not interfere with activities
     of daily living, but at times may interfere with
     activities such as running and jumping.............
     Note: Combine with an evaluation for pain (under
     Sec.   4.59) when appropriate.
5258 Injury of meniscus (semilunar cartilage) of knee
 (pre- or post-operatively):
    With episodes of giving way, locking, or joint                    20
     effusion that interfere at times with activities of
     daily living and prevent activities such as running
     and jumping........................................
    With episodes of giving way, locking, or joint                    10
     effusion that do not interfere with activities of
     daily living, but that at times interfere with
     activities such as running and jumping.............
    Alternatively, depending on the specific findings,
     evaluate based on instability, degenerative
     arthritis, etc., under the appropriate diagnostic
     code.
    Note: Combine an evaluation under diagnostic code
     5258 with an evaluation for pain (under Sec.
     4.59) when appropriate.
5260 Limitation of flexion of knee (normal full flexion
 is 140 degrees):
    Flexion limited to 30 degrees.......................              30
    Flexion limited to 60 degrees.......................              20
    Flexion limited to 90 degrees.......................              10
5261 Limitation of extension of knee (normal full
 extension is zero degrees):
    Extension is limited to more than minus 30 degrees                50
     (lacks more than 30 degrees of full extension).....
    Extension is limited to between minus 16 and 30                   30
     degrees (lacks 16 to 30 degrees of full extension).
    Extension is limited to between minus 5 and 15                    10
     degrees (lacks 5 to 15 degrees of full extension)..
5262 Nonunion or malunion of fracture of tibia or
 fibula:
    Nonunion, with loose motion, requiring brace........              40
    Asymptomatic nonunion...............................              30
    Symptomatic malunion with either more than 10                     20
     degrees of angulation in the varus-valgus plane or
     more than 15 degrees of angulation in the anterior-
     posterior plane....................................
    Symptomatic malunion with neither more than 10                    10
     degrees of angulation in the varus-valgus plane nor
     more than 15 degrees of angulation in the anterior-
     posterior plane....................................
5265 Aseptic necrosis (or avascular necrosis or
 osteonecrosis) of the femoral head:
    With collapse of the femoral head, and requiring                  60
     constant ambulatory support........................
    With collapse of the femoral head, and requiring                  40
     intermittent ambulatory support....................
    Without collapse of the femoral head................              10
     Note: Combine an evaluation under diagnostic code
     5265 with an evaluation of pain under Sec.   4.59
     when appropriate. Alternatively, evaluate as
     limitation of motion of the hip, combined with an
     evaluation for pain under Sec.   4.59 when
     appropriate, if that would result in a higher
     evaluation.
5266 Patellar fracture and instability:
    Symptomatic nonunion of fracture of patella; or                   30
     patellectomy; or recurrent patellar dislocation
     occurring six or more times during the past 12-
     month period.......................................
    Patellofemoral subluxation (partial or incomplete                 20
     dislocation of the patella) occurring three or more
     times per month during the past 12-month period; or
     recurrent patellar dislocation occurring three to
     five times during the past 12-month period.........
    Patellofemoral subluxation occurring one to two                   10
     times per month during the past 12-month period; or
     recurrent patellar dislocation occurring one or two
     times during the past 12-month period..............
    Note: The evaluation criteria for diagnostic code
     5266 encompass pain, so a separate evaluation for
     pain under Sec.   4.59 is not warranted.
5267 Patellofemoral pain syndrome (chondromalacia of
 patella, retropatellar pain syndrome, patellofemoral
 syndrome):
    Evaluate based on pain under Sec.   4.59.
------------------------------------------------------------------------


                                The Ankle
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5270 Ankylosis of the ankle:
    Ankylosed in more than 40 degrees of plantar                      40
     flexion; or ankylosed in more than 10 degrees of
     dorsiflexion; or ankylosed with abduction,
     adduction, inversion or eversion deformity.........
    Ankylosed in 30 to 40 degrees of plantar flexion; or              30
     ankylosed in zero to 10 degrees of dorsiflexion....
    Ankylosed in less than 30 degrees of plantar flexion              20
5271 Limitation of motion of the ankle:
    Less than 5 degrees passive dorsiflexion; or less                 20
     than 10 degrees passive plantar flexion............
    Less than 15 degrees passive dorsiflexion; or less                10
     than 30 degrees passive plantar flexion............
5272 Ankylosis of subtalar or tarsal joint:
    In poor weightbearing position (not in plantograde                20
     position)..........................................
    In good weightbearing position (no varus, no valgus)              10
5273 Malunion of calcaneus (os calcis) or talus:
    Deformity of the talocalcaneal joint or spreading of              30
     the calcaneus deforming the weightbearing surface
     of the heel........................................

[[Page 7033]]

 
    Malunion of either the talus or calcaneus without                 10
     deformity of the subtalar joint or weightbearing
     surface of the heel................................
5274 Total or partial talectomy without subsequent                    40
 arthrodesis............................................
------------------------------------------------------------------------


                    Shortening of the Lower Extremity
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5275 Shortening of bones of lower extremity:
    Of 4 inches (10.2 cm.) or more......................          \1\ 60
    Of at least 3\1/2\ but less than 4 inches (8.9 to             \1\ 50
     less than 10.2 cm.)................................
    Of at least 3 but less than 3\1/2\ inches (7.6 to                 40
     less than 8.9 cm.).................................
    Of at least 2\1/2\ but less than 3 inches (6.4 to                 30
     less than 7.6 cm.).................................
    At least 2 but less than 2\1/2\ inches (5.1 to less               20
     than 6.4 cm.)......................................
    At least 1\1/4\ but less than 2 inches (3.2 to less               10
     than 5.1 cm.)......................................
    Note (1): Each lower extremity will be measured from
     the anterior superior spine of the ilium to the
     internal malleolus of the tibia.
    Note (2): Do not combine an evaluation under
     diagnostic code 5275 with an evaluation for healed
     fracture, malunion, or nonunion of a fracture in
     the same extremity.
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation. Refer to
  Sec.   3.350 for specific instructions regarding claims involving loss
  or loss of use of limbs.


                                The Foot
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5276 Flatfoot (pes planus):
    Deformity, including, on weightbearing, significant               20
     eversion of the heel, flattened arch, collapse of
     the midfoot structures with the talar head
     displaced both medial and plantar, and forefoot
     abduction; pain in the arch; and symptoms not
     significantly relieved by the use of appliances,
     orthoses, or orthopedic shoes......................
    Deformity, including a perpendicular position to                  10
     slight eversion of the heel, the presence of a
     slight arch on non-weightbearing which totally
     collapses on weightbearing, and forefoot abduction;
     pain in the arch and legs; and symptoms partially
     relieved by the use of appliances, orthoses, or
     orthopedic shoes...................................
    Deformity, but a normal arch on non-weightbearing                  0
     and a perpendicular heel position; tenderness in
     the arch or muscles and tendons attaching to the
     midfoot; and symptoms completely relieved by, or
     not requiring, the use of appliances, orthoses, or
     orthopedic shoes...................................
    Note (1): Evaluate each foot separately and combine
     the evaluations.
    Note (2): Pain is encompassed by these evaluation
     criteria, so do not combine an evaluation under
     diagnostic code 5276 with an evaluation for pain
     under Sec.   4.59.
5278 Pes cavus (clawfoot):
    Symptoms of pain and tenderness, and callosities, if              20
     present, not significantly relieved by the use of
     appliances, orthoses, or orthopedic shoes..........
    Symptoms of pain and tenderness, and callosities, if              10
     present, partially relieved by the use of
     appliances, orthoses, or orthopedic shoes..........
    Symptoms of pain and tenderness, and callosities, if               0
     present, completely relieved by, or do not require,
     the use of appliances, orthoses, or orthopedic
     shoes..............................................
    Note (1): Evaluate each foot separately and combine
     the evaluations.
    Note (2): In the absence of trauma or other specific
     cause of aggravation, consider pes cavus to be a
     congenital or developmental abnormality.
5279 Metatarsalgia (including Morton's neuroma):
    Pain in the ball of the foot not significantly                    10
     relieved by the use of appliances, orthoses, or
     orthopedic shoes, or by surgery, if that was done..
    Pain in the ball of the foot largely or completely                 0
     relieved by, or does not require, the use of
     appliances, orthoses, or orthopedic shoes, or by
     surgery, if that was done..........................
    Note: Evaluate each foot separately and combine the
     evaluations.
5280 Hallux Valgus:
    Symptoms not significantly relieved by the use of                 10
     appliances, orthoses, or orthopedic shoes, or by
     surgery, if that was done..........................
    Symptoms largely or completely relieved by, or not                 0
     requiring, the use of appliances, orthoses, or
     orthopedic shoes, or by surgery, if that was done..
    Note (1): Evaluate each foot separately and combine
     the evaluations.
    Note (2): Pain is encompassed by these evaluation
     criteria, so do not combine an evaluation under
     diagnostic code 5280 with an evaluation for pain
     under Sec.   4.59.
5281 Hallux limitus, hallux rigidus:
    Pain with any motion of the joint, including                      20
     walking, with ankylosis (no motion) of the first
     metatarsal-phalangeal joint and gait abnormality...
    Pain on walking, with limitation of motion of the                 10
     first metatarsal-phalangeal joint..................
    Pain only on extremes of motion, with limitation of                0
     motion of the first metatarsal-phalangeal joint....
    Note: Evaluate each foot separately, regardless of
     number of toes affected by hammertoe, and combine
     the evaluations.
5282 Hammertoe, contracted or deviated toes:
    Hammertoe with pain and calluses not significantly                10
     relieved by the use of appliances, orthoses, or
     orthopedic shoes, or by surgery, if that was done..

[[Page 7034]]

 
    Hammertoe with pain and calluses largely or                        0
     completely relieved by, or not requiring, the use
     of appliances, orthoses, or orthopedic shoes, or by
     surgery, if that was done..........................
    Note (1): Evaluate each foot, but not each toe,
     separately, and combine the evaluations.
    Note (2): Do not assign an evaluation for the same
     foot both under diagnostic code 5282 and under
     diagnostic code 5278 (pes cavus (clawfoot)).
5283 Malunion or nonunion of tarsal or metatarsal bones
 (except talus and calcaneus):
    Signs and symptoms (such as pain, calluses, abnormal              30
     or limited motion of affected bones or joints) that
     interfere with activities of daily living and that
     are not significantly relieved by appliances,
     orthoses, or orthopedic shoes, or by surgery, if
     that was done......................................
    Signs and symptoms (such as pain, calluses, abnormal              20
     or limited motion of affected bones or joints) that
     are partly relieved by appliances, orthoses, or
     orthopedic shoes, or by surgery, if that was done,
     but that interfere at times with activities of
     daily living and with most athletic activity.......
    Signs and symptoms (such as pain, calluses, abnormal              10
     or limited motion of affected bones or joints) that
     are largely or completely relieved by appliances,
     orthoses, or orthopedic shoes, or by surgery, if
     that was done and that do not interfere with
     activities of daily living but that may at times
     prevent activities such as running and jumping.....
5284 Neurotrophic disorders of the foot (Charcot joint,
 diabetic foot, etc.):
    Chronic ulceration not controlled by the use of                   30
     orthoses...........................................
    Recurrent ulcers controlled by the use of orthoses..              20
    Pain not relieved by orthoses or shoe modification..              10
    Pain relieved by orthoses or shoe modification......               0
    Note (1): If osteomyelitis of the foot is present,
     evaluate under diagnostic code 5000
     (osteomyelitis), and do not assign an evaluation
     under diagnostic code 5284.
    Note (2): A 20- or 30-percent evaluation under
     diagnostic code 5284 may be combined with an
     evaluation for pain under Sec.   4.59.
 
                              * * * * * * *
------------------------------------------------------------------------


                                The Skull
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5296 Loss of part of both inner and outer tables of
 skull without cranioplasty (covering of defect by bone,
 metal, or other material).
    With brain hernia...................................              80
    Without brain hernia:
    Area larger than 1.1 sq. inches (7.4 sq. cm.).......              50
    0.7 to 1.1 sq. inches (4.6 to 7.4 sq. cm.)..........              30
    Area smaller than 0.7 sq. inches (4.6 sq. cm.)......              10
    Note (1): Rate intracranial complications, such as
     seizures or paralysis, separately.
    Note (2): Skull loss covered by bone or a prosthesis
     will not be used in calculating the area of skull
     loss.
------------------------------------------------------------------------


                                The Ribs
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5297 Removal of ribs:
    More than six.......................................              50
    Five or six.........................................              40
    Three or four.......................................              30
    Two.................................................              20
    Removal of one, or resection of two or more ribs                  10
     without regeneration...............................
    Note (1): Do not combine an evaluation under
     diagnostic code 5297 with an evaluation under
     diagnostic code 6844 (post-surgical residuals of
     lobectomy, pneumonectomy, etc.) or 6845 (chronic
     pleural effusion or fibrosis).
    Note (2): Evaluate rib resection as rib removal when
     thoracoplasty has been performed for collapse
     therapy or to obliterate space, and combine with
     the evaluation for lung collapse, lobectomy,
     pneumonectomy, or the graduated evaluations for
     pulmonary tuberculosis.
------------------------------------------------------------------------


                               The Coccyx
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
5298 Partial or complete removal of the coccyx:
    With painful residuals..............................              10
------------------------------------------------------------------------


[[Page 7035]]

(Authority: 38 U.S.C. 1155)

[FR Doc. 03-2119 Filed 2-10-03; 8:45 am]
BILLING CODE 8320-01-P