VA Disability Ratings for Knee Pain: Do You Qualify for Benefits?
Pain is one of the most common causes of disability in the United States. However, it is often difficult to prove that pain is the cause of a person’s service-connected disability. This is because pain is not in itself a diagnosis.
So, can you get VA disability benefits for knee pain?
Fortunately, knee pain is often an indicator of an underlying illness or chronic condition that will qualify for a disability rating through the United States Department of Veterans Affairs.
If you are experiencing knee pain, a knee injury, or functional loss of the knee relating to your military service, you may be eligible for disability compensation based on a variety of factors. However, obtaining knee ratings and disability compensation for knee pain can be tricky. There are multiple ratings available for knee injuries, so it’s important for veterans to be aware of all of the various factors involved in each rating.
This guide will outline which knee conditions might qualify for VA disability compensation and how veterans can best prove service connection.
Which Knee Conditions Might Qualify a Veteran For VA Disability Benefits?
As mentioned above, obtaining VA disability benefits for knee pain can be challenging. However, while reported knee pain may not be enough to qualify a veteran for benefits, there are some knee conditions that can. These conditions include:
- Tuberculosis of the knee
- Rheumatoid arthritis that affects the knees
- Degenerative arthritis
- Knee Instability
- Limited range of motion
If you have a condition that leads to knee pain, the next step is to prove that the issue resulted from military service. You will need to prove service connection.
How Can You Prove Service Connection for Knee Pain?
The first option for obtaining a VA disability rating for knee pain is to establish a direct service connection. The stronger the connection between your military service and the injury you sustained, the more likely you are to have a successful disability claim. However, this process can be complicated. One of the most common reasons claims fail is that they fail to include three essential factors:
1. A current diagnosis that includes the disability that is being claimed
In this case, you will need a diagnosis that accounts for the knee pain you are experiencing. If your diagnosis loosely explains your knee pain, it is unlikely that it will apply to your disability claim. It is important to persist until you receive a diagnosis that directly connects your knee pain to the illness or knee condition.
2. Documentation of an in-service occurrence or incident that caused the disability, or at the very least, aggravated the condition
If you had a singular incident that caused your knee pain, it is important that you gather all of the possible documentation relative to that incident. Be sure your documentation includes the date and time the incident happened, any medical attention you received, whether your condition improved or deteriorated following the incident, and how the incident impacted your pain. Documentation is more difficult to obtain if knee pain is related to a chronic condition like degenerative osteoarthritis that developed over time. This is why service members are encouraged to have their pain and disability documented prior to leaving the military.
3. A medical nexus that connects the current, diagnosed disability to the in-service occurrence, incident, or exposure
The medical nexus can make or break a disability claim. A medical nexus letter from a medical provider can establish strong ties between the condition and military service. This evidence can be critical when the condition developed over time.
Secondary Service Connection for Knee Pain
A new disability that appears secondary to a service-connected injury or condition may allow veterans to prove secondary service connection. Secondary service connection can also be an aggravation of a non-service connected disability that is caused by a service-connected condition or incidence. In other words, your knee pain may not have happened while you were in the service, but it could be a symptom that shows up much later that is the result of a service-connected incident.
Knee pain can appear as a secondary service connection related to:
- Back injuries
- Injury to the opposite knee
- Foot injuries
- Hip injuries
- Partial or total joint replacements of either knee
For example, if a veteran injured their right foot during service, they may have started favoring their left leg while walking. This may have put strain on the left knee, resulting in knee pain. The same can apply to the left foot and right knee.
Service Connection by Aggravation
What if you were diagnosed with knee pain before service?
It is possible that you entered the service with a previous injury that resulted in knee pain. Even if that pain was not service-connected, it is possible that military service aggravated that condition. For example, you might have had knee arthritis prior to service that worsened during active duty. Mild discomfort may have turned into severe pain and limitation of motion due to the physical demands of service.
In this case, you will need to provide documentation that you had knee pain or a knee disability prior to your military service, as well as documentation that your military service made that knee pain worse. This documentation includes:
- A current diagnosis of your condition
- Documentation of your condition prior to military service, including x-rays, imaging scans, chart notes, surgical documentation, etc.
- Documentation of your condition after military service, including comparable x-rays, imaging scans, chart notes, surgical documentation, etc.
- A medical nexus connecting your aggravated knee pain to your military service.
This evidence can help prove that your knee pain is connected to aggravation during service, which can help support your VA disability claim.
Evaluating a Knee Disability: DBQs and C&P Exams
The VA often uses Disability Benefits Questionnaires (DBQs) to evaluate a veteran’s disability. These can be completed by your private doctor and submitted to the VA as evidence for your claim. The VA may also schedule you for a Compensation & Pension examination (C&P Exam) where the C&P examiner will complete a DBQ. Regardless of who is completing the DBQ form, it is important to remember that many knee ratings are based on range of motion measurements, and all range of motion measurements must be performed with a goniometer in order for the VA to accept them.
Compensation & Pension (C&P) Exams for Knee Pain
When you don’t have sufficient medical evidence to support your veterans disability claim, the VA may require a Compensation & Pension (C&P) exam for your knee pain. This exam generally happens at a VA hospital or clinic and is conducted by VA medical staff. The purpose of the C&P exam is to support or refute your claim. You will need to submit all medical records to the VA prior to the exam, as your provider will not be able to review any new information once you are there.
During your exam, the doctor will not treat you, provide referrals, or write prescriptions. They are simply there to gather information. They may do any of the following:
- Review your file with you
- Ask questions based on the medical records you have previously provided.
- Do a basic physical exam
- Ask you to have other tests done, like x-rays or blood draws, if necessary
Keep in mind that the doctor that performs your C&P exam is there to evaluate your injury or condition, not provide information about your claim. It is possible they may not even physically examine you if the documentation you have provided is sufficient for them to evaluate your condition. Once they have finished the C&P exam, they will write a report and send it to the VA claims processor in charge of your case.
If you are unhappy with any part of your C&P process, you are urged to share that feedback with the C&P exam supervisor at the VA medical center immediately. You can also reach out to the VA patient advocate or call the number on your appointment letter. Be sure to write a statement that details your concerns and submit it as a part of your claim file. If you have any concerns, do not wait until the results of your exam are submitted to share them. This will ensure your concerns are addressed prior to a final decision.
Evidence for Knee Pain Claims and Appealing Under The AMA System
In general, pain claims are among the most difficult to prove without an underlying condition. Fortunately, knee pain is often connected to another diagnosis that can be established with diagnostic testing. Be sure your knee pain claim includes:
- Ultrasound Images
- Range of Motion testing
- Stability testing
- Documentation of injuries, surgeries, or other conditions with knee pain as a secondary symptom
If your claim is initially denied for any reason, hope is not lost. The Appeals Modernization Act (AMA) System gives you three options to have your claim reviewed if you disagree with the decision. It also allows you to submit additional documentation that will support your claim without having to wade through a lengthy, step-by-step appeals process.
You can read more about these three review options here.
How Does The VA Rate Knee Pain?
The VA will rate knee pain and conditions under many different diagnostic codes, depending on the specific problem, or problems, caused by a knee condition. For example, there are ratings available for instability of the knee, limitation of extension, knee replacements, etc. It is important to be aware of all the different ratings, and whether you are entitled to compensation for multiple ratings. This way, you can make sure the VA is giving you the proper percent rating and all of the compensation you’re entitled to for your knee disability.
Below is a list of ratings that can potentially be assigned to the same underlying disability:
- Limitation of Flexion: The diagnostic code for limitation of flexion is 5260. According to the rating criteria, if the knee can straighten, but can’t bend all the way, it is rated under 5260. The different percentages available are 0%, 10%, 20%, and 30%. These ratings are assigned based on how much the knee can bend. So, the less the knee can bend, the higher the rating will be. There are specific range of motion measurements that correspond with each percentage which can be found here.
- Limitation of Extension: The diagnostic code for limitation of extension is 5261. This diagnostic code is used when the knee’s mobility isn’t frozen, but it can’t straighten all the way. The different percentages available are: 0%, 10%, 20%, 30%, 40%, and 50%. These ratings are assigned based on the knee’s ability to straighten. The more the knee disability prevents the leg from straightening, the higher the rating will be. Again, there are specific range of motion measurements that correspond with each percentage, and can be found here.
- Instability of the Knee: The VA rates instability of the knee under diagnostic code 5257. This diagnostic code is used with the knee has too much motion from side to side, or dislocates regularly. Instability of the knee can occur when damaged tendons and cartilage can no longer support the knee joint properly. The different percentages available are: 10%, 20%, and 30%. The more instability present in the knee, the higher the rating. In order to get the highest rating of 30%, the knee must be so unstable that it gives out or dislocates regularly.
- Total Knee Replacements: If your knee disability becomes so severe that a total knee replacement is required you will automatically receive a temporary 100% rating for one year post surgery. After that one year period, the knee will be rated according to the severity of any remaining problems. The highest rating available for residuals of the total knee replacement is 60%. A 60% rating will be assigned when there is weakness and severe pain with motion. If the pain is not severe, but you have limited range of motion in your knee, your knee will be rated according to the criteria set forth for limitation of flexion and/or limitation of extension.
- Partial Knee Replacements: Unlike total knee replacements, partial knee replacements do not have their own diagnostic code. Instead, partial knee replacements are rated according to any symptoms that are caused by the replacement such as limited motion.
Rating decisions for one disability can be complicated. The general rule regarding multiple ratings for the same disability is, “the evaluation of the same disability under various diagnoses is to be avoided.” However, VA regulations specifically provide that the knee joint can be evaluated under multiple diagnostic codes where there are different manifestations of the same disability. So, as long as the knee disability affects you in separate and distinct ways, you can receive multiple ratings.
Knowing these different ratings allows you to be aware of whether you’re entitled to receive more compensation from the VA. For example, bending and straightening your knee both involve your ability to move your knee, but they involve different movements. Therefore, you can receive ratings for both limitation of flexion and limitation of extension for the same knee. If the knee can move, but is limited in its ability to bend or straighten, it should be rated under diagnostic code 5260 and 5261.
Remember that instability of the knee is a rating that is often overlooked. However, if you have problems with your knee dislocating or giving out because of a service-connected disability, instability of the knee can be rated in addition to other ratings for the same knee.
To break the multiple-rating system down, if you have trouble bending your knee, straightening your leg, and your knee gives out on you, then you are entitled to three separate ratings (limitation of flexion, limitation of extension, and instability of the knee). All of these different rating combinations also come into play when evaluating residuals from total and partial knee replacements.
Hospitalization for Knee Pain and Temporary Ratings
The only time a temporary rating for knee pain is given is when a total knee replacement is performed. After total knee replacement surgery, there is an automatic 100% disability rating for one year. After that year has lapsed, veterans will require additional tests for knee flexion, extension, and instability. The results of these tests will determine the ongoing rating. If there are any additional problems, it is possible to receive a disability rating of up to 60%.
TDIU for Knee Pain
TDIU stands for Total Disability Rating based on Individual Unemployability. On its own, knee pain will not qualify you for TDIU. As mentioned above, the only time knee pain qualifies for a 100% disability rating is following total knee replacement surgery. However, if you already have at least one service-connected disability rated at 60% or more, or two or more disabilities for a combined total rating of 70% or more, and you can’t hold down a job due to knee pain, you may qualify for TDIU.
VA Disability and Knee Pain: Getting Help With Your Claim
If your knee disability claim has been denied, or you disagree with the VA’s rating decision, the team at Hill & Ponton is available to help. Our team of knowledgeable attorneys specialize in social security and veterans disability law, helping former military service members obtain appropriate compensation for their injuries and illnesses. We value attorney-client relationships, treating each veteran as an individual. Contact our law firm today for a free case evaluation.