The Musculoskeletal Principles
Combined Ratings for Muscle Injuries
Evaluating Muscle Disabilities
Arthritis Due to Strain
The Amputation Rule
These principles are just for the Musculoskeletal System. All the principles discussed on the VASRD Principles page also apply.
The Joints (§4.45): Any joint condition will be rated on limitation of motion. If no limitation is present, however, the condition will then be rated based on factors including pain with motion, too much motion, weakness, deformity, arthritis, and any other problems that interfere with daily life. Not all of these extra rating factors apply to each joint, but this will be discussed on the individual joint pages.
This principle also defines major and minor joints. Major joints include the shoulder, elbow, wrist, hip, knee and ankle. Minor joints include the joints in fingers and toes, and the vertebrae in the spine.
Accurate Measurements (§4.46): Measurements are essential to proper ratings. Range of motion measurements for any body part should be clearly measured with a goniometer. All measurable deformities should also be carefully noted. This could include the length of a stump, the placement of a scar, and any muscle atrophy.
Combined Ratings for Muscle Injuries (§4.55): The muscles of the body are divided into groups. Each group of muscles controls a single function. For example, all the muscles in Group X control the pointing and flexing of the toes. The following bullet points lay down rules on combining ratings for muscles with other ratings (for nerves, limited motion, etc.).
- Muscle ratings cannot combine with nerve ratings for the same body part unless they affect completely different functions.
- If a joint is ankylosed then any injuries to muscles connected to that joint won’t be rated. Exceptions: If the knee is ankylosed, then the injured muscles in Group XIII can be rated but at a decreased rating. So if the muscles in that group would get a 30% rating by themselves, that would decrease to the next rating down, 10% in this case. Likewise, if the shoulder is ankylosed and the muscles in Groups I and II are considered severely disabled, then the shoulder rating (not the muscle rating) would be raised to the highest possible, 50% for the Dominant arm or 40% for the Non-dominant arm.
- If a joint can move (not ankylosed), then the combined rating for all the injured muscles that connect to it must be lower than the highest rating for that joint if it were ankylosed. For example, the highest rating for an ankylosed wrist is 50%, so the combined rating of all the injured muscles around the wrist must be lower than 50%.
- If there are injured muscles in the same region but that aren’t all connected to the same joint (i.e. all in the arm but not all attached to the elbow), then the rating for the worst injured muscle in the arm will be increased and then used as the only rating for all muscle injuries in the arm. So if Group I in the arm is moderately severe (30% for the dominant hand), and Group VII in the arm is moderate (10%), then the 30% rating for Group I would be raised to the next level (severe: 40%) and then the total rating for all the muscles in the entire arm would be 40%.
- All other muscle group injuries that are not related to each other as above will simply be rated individually. (Whew!)
Evaluating Muscle Disabilities (§4.56): This principle lays down a couple of specific rules.
- If the condition is an open comminuted fracture with muscle damage (if the wound is open, it will almost always have muscle damage unless it is strictly over a purely boney spot like the wrist), then it will be rated as severe damage to the muscles affected.
- A through-and-through muscle injury will be no less than moderate for each group of muscles damaged.
Muscle conditions can be rated on the Slight to Severe Scale. The severity of a muscle disability is decided by the presence of the “cardinal signs and symptoms.” These include loss of power, weakness, easily fatigued, pain with fatigue, lack of coordination, and decreased movement control. Definitions of the different severities are listed below, but each bullet point does not have to be met in order for the condition to qualify under that severity. For example, many muscle conditions are not caused by injuries, so the requirements for the type of wound or scar would not apply.
SLIGHT muscle disability:
- A simple wound without infection or debris (bits of bone, shrapnel, etc.).
- An easily treated wound with good healing and function.
- No Cardinal Signs and Symptoms.
- Small scar with no impairment of function.
MODERATE muscle disability:
- A through-and-through or deep penetrating wound without serious infection or debris.
- The regular presence of one or more of the Cardinal Signs and Symptoms.
- Small scars with some loss of muscle tone or substance. Some loss of power and a bit more easily fatigued.
MODERATELY SEVERE muscle disability:
- A through-and-through or deep penetrating wound with debris, prolonged infection, and the development of limiting scar tissue in the muscles.
- This wound would need hospitalization for treatment, have the constant presence of the Cardinal Signs and Symptoms, and would significantly interfere with the ability to work.
- Significant scars that stretch across one or more muscle groups. Loss of muscle substance and tone would be present, and there would be a definite decrease in function and use.
SEVERE muscle disability:
- A through-and-through or deep penetrating wound with shattered bones and lots of debris, prolonged infection, and seriously limiting scarring in the muscles.
- This wound would need lengthy hospitalization for treatment, have the constant and very serious presence of the Cardinal Signs and Symptoms, and a definite inability to work.
- Scars would be very large and jagged and would stretch across a large area. Serious loss of muscle substance and tone (even causing muscles to be flabby and weak) would cause significantly abnormal muscle function.
- Other evidence of severe disability could include X-ray evidence of foreign bodies in the muscles, skin attaching directly to the bone instead of the bone being covered by muscle, decreased response in the muscles to electric shocks, significant Atrophy, other muscle groups having to compensate for the injured muscle group, and atrophy of connected muscles not directly damaged.
Arthritis Due to Strain (§4.58): For the VA only–If arthritis is the result of a service-connected condition, then it is considered service-connected and ratable, even if it does not develop until years after the service member left the military. For arthritis to be the result of another condition, it has to be in a joint that was clearly under strain from compensating for that condition. For example, a left foot injury could cause arthritis in the right hip because it had to compensate for the left foot (maybe taking more weight because of limping).
Painful Motion (§4.59): This is the most commonly used principle. Basically, regardless of how much the service member can move their knee (or any joint), if it hurts when they move it, then they will get at least the lowest Compensable rating for the knee–for example, 10% (money) instead of 0% (no money). Pain with motion must be clearly documented by the physician in order for this principle to apply. Just because the service member may say that their knee hurts at the beginning of the exam does not mean that the physician will find proof of pain with motion.
The Painful Motion rule applies to mainly joint-specific conditions, like arthritis, but also comes into play for any condition that is rated primarily on limited motion. For example, this rule would apply to a muscle condition if the muscle condition is rated on limited motion but not if it is rated on the Slight to Severe Scale.
When deciding whether to apply this rule, the Rating Authorities will look for obvious notes that a physician should make during range of motion testing. Notes like limping, wincing, pained facial expressions, and other similar signs are good evidence of pain with motion. Crepitation is also good evidence of a diseased joint, but may not be enough in and of itself to support painful motion. If pain is not clearly noted in an exam, it is assumed that there is none (the service member saying it hurt yesterday is not enough). Keep in mind that there are tests that are used by the examining physician to see if the service member is faking the pain. The physician may not say it straight out in the notes, but the Rating Authorities are always looking for evidence of those tests.
The Amputation Rule (§4.68): The rating for the amputation of a body part is the maximum rating that body part can receive. So, if the hand has not been amputated, but has numerous conditions that can be rated separately and combined, then the combined rating for all of those hand conditions cannot be higher than the rating for the amputation of the hand.
Let’s expand this a little further. Let’s say that there is carpal tunnel in the right wrist that is rated 40%. There is also a muscle injury from shrapnel in the right hand that is also rated 40%. Additionally, there are two fingers that can’t move at all, again rated 40%. Those conditions all combined would equal 80% disability. However, the loss of use or amputation of the entire hand is only rated 70%. Thus, all those hand conditions can only be combined to equal 70%.
Now if the nerve condition was not carpal tunnel, but a pinched nerve from the shoulder that caused pain all the way down the arm and into the hand, then all the conditions could be combined, but could not equal more than the rating for the amputation of the entire arm up to the shoulder – 90%. So the rating of 80% for all these conditions would stand in this case.
Dominant Hand (§4.69): If a veteran has a condition that affects their arms and hands, then it is necessary to know which of their hands is the dominant one. Are they right-handed or left-handed? This is important because some conditions rate higher if they affect the dominant hand. The physician examining the veteran is required to note which hand is dominant. Only one hand can be considered dominant. If it is clear that the veteran is ambidextrous, then the hand with the worst condition will be considered dominant so the veteran can receive the higher rating.