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345 Subpart B—Disability Ratings Department of Veterans Affairs § 4.42 (Effective as to outpatient treatment ogy, or it may be due to pain, sup- March 10, 1976.) ported by adequate pathology and evi- A reduction in the total rating will not denced by the visible behavior of the be subject to § 3.105(e) of this chapter. claimant undertaking the motion. The total rating will be followed by an Weakness is as important as limitation open rating reflecting the appropriate of motion, and a part which becomes schedular evaluation; where the evi- painful on use must be regarded as seri- dence is inadequate to assign the ously disabled. A little used part of the schedular evaluation, a physcial exam- musculoskeletal system may be ex- ination will be scheduled prior to the pected to show evidence of disuse, ei- end of the total rating period. ther through atrophy, the condition of (b) A total rating under this section the skin, absence of normal callosity or will require full justification on the the like. rating sheet and may be extended as follows: § 4.41 History of injury. (1) Extensions of 1, 2 or 3 months be- In considering the residuals of injury, yond the initial 3 months may be made it is essential to trace the medical-in- under paragraph (a) (1), (2) or (3) of this dustrial history of the disabled person section. from the original injury, considering (2) Extensions of 1 or more months up the nature of the injury and the at- to 6 months beyond the initial 6 tendant circumstances, and the re- months period may be made under quirements for, and the effect of, treat- paragraph (a) (2) or (3) of this section ment over past periods, and the course upon approval of the Adjudication Offi- of the recovery to date. The duration of cer. the initial, and any subsequent, period of total incapacity, especially periods [41 FR 34256, Aug. 13, 1976, as amended at 54 FR 4281, Jan. 30, 1989] reflecting delayed union, inflamma- tion, swelling, drainage, or operative § 4.31 Zero percent evaluations. intervention, should be given close at- tention. This consideration, or the ab- In every instance where the schedule sence of clear cut evidence of injury, does not provide a zero percent evalua- may result in classifying the disability tion for a diagnostic code, a zero per- as not of traumatic origin, either re- cent evaluation shall be assigned when flecting congenital or developmental the requirements for a compensable etiology, or the effects of healed dis- evaluation are not met. ease. [58 FR 52018, Oct. 6, 1993] § 4.42 Complete medical examination Subpart BÐDisability Ratings of injury cases. The importance of complete medical THE MUSCULOSKELETAL SYSTEM examination of injury cases at the time of first medical examination by the De- § 4.40 Functional loss. partment of Veterans Affairs cannot be Disability of the musculoskeletal overemphasized. When possible, this system is primarily the inability, due should include complete neurological to damage or infection in parts of the and psychiatric examination, and other system, to perform the normal working special examinations indicated by the movements of the body with normal physical condition, in addition to the excursion, strength, speed, coordina- required general and orthopedic or sur- tion and endurance. It is essential that gical examinations. When complete ex- the examination on which ratings are aminations are not conducted covering based adequately portray the anatomi- all systems of the body affected by dis- cal damage, and the functional loss, ease or injury, it is impossible to vis- with respect to all these elements. The ualize the nature and extent of the functional loss may be due to absence service connected disability. Incom- of part, or all, of the necessary bones, plete examination is a common cause joints and muscles, or associated struc- of incorrect diagnosis, especially in the tures, or to deformity, adhesions, de- neurological and psychiatric fields, and fective innervation, or other pathol- frequently leaves the Department of 345 VerDate 25<JUN>98 11:37 Aug 04, 1998 Jkt 179138 PO 00000 Frm 00341 Fmt 8010 Sfmt 8010 Y:\SGML\179138T.XXX 179138t PsN: 179138T § 4.43 38 CFR Ch. I (7±1±98 Edition) Veterans Affairs in doubt as to the eral nerves, divided or lengthened ten- presence or absence of disabling condi- dons, etc.). tions at the time of the examination. (d) Excess fatigability. (e) Incoordination, impaired ability § 4.43 Osteomyelitis. to execute skilled movements smooth- Chronic, or recurring, suppurative os- ly. teomyelitis, once clinically identified, (f) Pain on movement, swelling, de- including chronic inflammation of formity or atrophy of disuse. Instabil- bone marrow, cortex, or periosteum, ity of station, disturbance of loco- should be considered as a continuously motion, interference with sitting, disabling process, whether or not an standing and weight-bearing are relat- actively discharging sinus or other ob- ed considerations. For the purpose of vious evidence of infection is manifest rating disability from arthritis, the from time to time, and unless the focus shoulder, elbow, wrist, hip, knee, and is entirely removed by amputation will ankle are considered major joints; mul- entitle to a permanent rating to be tiple involvements of the interphalan- combined with other ratings for resid- geal, metacarpal and carpal joints of ual conditions, however, not exceeding the upper extremities, the interphalan- amputation ratings at the site of elec- geal, metatarsal and tarsal joints of tion. the lower extremities, the cervical ver- tebrae, the dorsal vertebrae, and the § 4.44 The bones. lumbar vertebrae, are considered The osseous abnormalities incident groups of minor joints, ratable on a to trauma or disease, such as malunion parity with major joints. The with deformity throwing abnormal lumbosacral articulation and both sac- stress upon, and causing malalignment roiliac joints are considered to be a of joint surfaces, should be depicted group of minor joints, ratable on dis- from study and observation of all avail- turbance of lumbar spine functions. able data, beginning with inception of injury or disease, its nature, degree of § 4.46 Accurate measurement. prostration, treatment and duration of Accurate measurement of the length convalescence, and progress of recov- of stumps, excursion of joints, dimen- ery with development of permanent re- sions and location of scars with respect siduals. With shortening of a long bone, to landmarks, should be insisted on. some degree of angulation is to be ex- The use of a goniometer in the meas- pected; the extent and direction should urement of limitation of motion is in- be brought out by X-ray and observa- dispensable in examinations conducted tion. The direction of angulation and within the Department of Veterans Af- extent of deformity should be carefully fairs. Muscle atrophy must also be ac- related to strain on the neighboring curately measured and reported. joints, especially those connected with [41 FR 11294, Mar. 18, 1976] weight-bearing. §§ 4.47Ð4.54 [Reserved] § 4.45 The joints. As regards the joints the factors of § 4.55 Principles of combined ratings disability reside in reductions of their for muscle injuries. normal excursion of movements in dif- (a) A muscle injury rating will not be ferent planes. Inquiry will be directed combined with a peripheral nerve pa- to these considerations: ralysis rating of the same body part, (a) Less movement than normal (due unless the injuries affect entirely dif- to ankylosis, limitation or blocking, ferent functions. adhesions, tendon-tie-up, contracted (b) For rating purposes, the skeletal scars, etc.). muscles of the body are divided into 23 (b) More movement than normal muscle groups in 5 anatomical regions: (from flail joint, resections, nonunion 6 muscle groups for the shoulder girdle of fracture, relaxation of ligaments, and arm (diagnostic codes 5301 through etc.). 5306); 3 muscle groups for the forearm (c) Weakened movement (due to mus- and hand (diagnostic codes 5307 cle injury, disease or injury of periph- through 5309); 3 muscle groups for the 346 VerDate 25<JUN>98 11:37 Aug 04, 1998 Jkt 179138 PO 00000 Frm 00342 Fmt 8010 Sfmt 8010 Y:\SGML\179138T.XXX 179138t PsN: 179138T Department of Veterans Affairs § 4.56 foot and leg (diagnostic codes 5310 as no less than a moderate injury for through 5312); 6 muscle groups for the each group of muscles damaged. pelvic girdle and thigh (diagnostic (c) For VA rating purposes, the car- codes 5313 through 5318); and 5 muscle dinal signs and symptoms of muscle groups for the torso and neck (diag- disability are loss of power, weakness, nostic codes 5319 through 5323). lowered threshold of fatigue, fatigue- (c) There will be no rating assigned pain, impairment of coordination and for muscle groups which act upon an uncertainty of movement. ankylosed joint, with the following ex- (d) Under diagnostic codes 5301 ceptions: through 5323, disabilities resulting (1) In the case of an ankylosed knee, from muscle injuries shall be classified if muscle group XIII is disabled, it will as slight, moderate, moderately severe be rated, but at the next lower level or severe as follows: than that which would otherwise be as- (1) Slight disability of musclesÐ(i) Type signed. of injury. Simple wound of muscle with- (2) In the case of an ankylosed shoul- out debridement or infection. der, if muscle groups I and II are se- (ii) History and complaint. Service de- verely disabled, the evaluation of the partment record of superficial wound shoulder joint under diagnostic code with brief treatment and return to 5200 will be elevated to the level for un- duty. Healing with good functional re- favorable ankylosis, if not already as- sults. No cardinal signs or symptoms of signed, but the muscle groups them- muscle disability as defined in para- selves will not be rated.
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