Of all the disabilities listed on the VA’s Schedule for Rating Disabilities, the ratings involving the knee are one of the most difficult for veterans to understand – and for the VA to get right. Much of the confusion stems from the fact that a veteran may be able to receive multiple ratings for the same knee, depending on the severity of his or her condition. Today we are going to discuss one particular set of ratings for limitation of motion of the knee – flexion and extension.
Before we get into flexion and extension specifically, it is important to understand why exactly it is that multiple ratings are allowed for the knee. Normally, you would think that this would be forbidden under the “Rule against Pyramiding.” That rule (38 C.F.R. § 4.14) states that a veteran cannot be compensated more than once for the same disability or the same manifestation of that disability. However, there is another rating principle to keep in mind. 38 C.F.R. § 3.103(a) states that the VA must “render a decision which grants every benefit that can be supported in law” – maximizing the benefits due to the veteran.
How do these two seemingly conflicting regulations come together? Well, separate disability ratings may be assigned to different conditions where none of the symptomatology for the separately rated conditions is duplicative or overlapping. This is particularly important for the knee, where one injury may cause many different issues, and these separate manifestations of that injury may all be entitled to separate ratings.
Limitation of Motion
For the knee, “flexion” refers to the ability to bend the knee backward, bringing the foot to the buttocks. The term “extension” refers to bringing the knee forward from a bent position so that it is completely straight. A normal range of motion for the knee is 0 to 140 degrees. A veteran can be awarded separate ratings for limitation of motion of flexion and extension, even if both limitations resulted from the same disease or injury. This is because they are different motions and therefore are separate manifestations.
The ratings for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261 are, predictably, based on the veteran’s range of movement. For example, flexion limited to 15 degrees warrants a 30 percent rating (which is the maximum rating for limitation of flexion) and flexion limited to 60 degrees warrants a 0 percent rating. Extension limited to 45 degrees warrants a 50 percent rating (which is the maximum rating for limitation of extension) and extension limited to 5 degrees warrants a 0 percent rating. However, when the VA assigns these ratings, they often forget a key step.
“Functional loss” refers to the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Pain alone is not a functional loss, but pain may cause weakness, lack of strength, incoordination, or loss of endurance. The VA is supposed to rate a knee disability under DC 5260 and 5261 where functional loss begins. For example, if a veteran has a full range of motion of his knee, but has weakness of movement that begins at 45 degrees flexion, he should be awarded a 10 percent rating under DC 5260. Curiously, the Disability Benefits Questionnaire used by the VA for C&P examinations does not ask the examiners to note the point where functional loss begins. As such, if a veteran has an independent medical examination, or goes to an outside doctor for range of motion testing, he or she should have the doctor note where functional loss begins so that an argument can be made that the veteran is entitled to a higher rating for his or her limitation of flexion and/or extension.
There is one other important consideration when evaluating flexion and extension of the knee – arthritis. Arthritis is rated under Diagnostic Codes 5003 and 5010. It is important to note that for VA rating purposes, arthritis must be diagnosed by X-ray. A notation in the veteran’s medical records that he or she has arthritis is not sufficient without corresponding X-ray evidence. If a veteran’s limitation of motion is non-compensable under DC 5260 and 5261, there is X-ray evidence of arthritis of the knee, and the veteran has some limitation of movement, he or she is entitled to a 10 percent rating under DC 5003. It is important to note that the veteran’s limitation of motion does not need to be at the 0 percent rating level (60 degrees of flexion or 5 degrees of extension), but there does need to be some limitation of movement confirmed by objective evidence.