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If you experienced a back injury during active duty, or an injury that later contributed to back pain, you may be eligible for disability benefits. As with most medical conditions, the VA disability rating for back pain depends on a variety of factors. This guide will break down how the VA rates back pain and spinal disabilities, so you can take the first steps toward making a claim.
Understanding Back Pain VA Ratings
Claims involving both the cervical spine and the thoracolumbar spine are rated under the same general rating formula. The following spinal conditions are all rated under the same general rating formula:
- Lumbosacral or cervical strain (diagnostic code 5237): This would be the diagnostic code assigned to a veteran experiencing pain in their neck or back.
- Spinal stenosis (diagnostic code 5238): Spinal stenosis is when the spaces in the spine are narrowed and cause pressure on the spinal cord and nerves. Frequently, spinal stenosis is present in the low back, but can be present in the cervical spine area as well.
- Spondylolisthesis or segmental instability (diagnostic code 5239): This is a condition that causes one bone in your back (a vertebra) to slide forward over the bone below it. The condition can result in the spinal cord or nerve roots being squeezed can cause back pain and numbness, or even weakness in one or both legs.
- Ankylosing spondylitis (diagnostic code 5240): This is a form of spinal arthritis that causes inflammation of the spinal joints and can result in severe, chronic pain. Ankylosing spondylitis can also cause inflammation, pain, and stiffness in the shoulders, hips, ribs, heels, and small joints of the hands and feet.
- Spinal fusion (diagnostic code 5241): Spinal fusion is a type of surgery that is performed to join two or more vertebrae together so that there is no movement between the two vertebrae. This surgery is often performed in individuals with spondylolisthesis and spinal stenosis.
- Vertebral fracture or dislocation (diagnostic code 5235): A vertebral fracture occurs when a vertebra becomes compressed due to trauma. Typically, a vertebral fracture results in symptoms such as limited spinal mobility, and standing/walking will make the pain worse while lying down on the back makes the pain better. A vertebral dislocation is when one of the small vertebrae in the neck is displaced following a traumatic injury to the head or neck. Symptoms of a vertebral dislocation include pain that spread into the shoulder and arms, tingling or numbness in the arm, muscle spasms in the neck, and weakness in the arms.
The general rating formula that is used to rate the conditions listed above is mainly based on range of motion (ROM) measurements. The cervical spine (neck) and the thoracolumbar spine (low back) are rated according to the following criteria:
|Cervical Spine||Thoracolumbar Spine|
|0%||Flexion ≥45 degrees, OR combined ROM ≥ 340 degrees||Flexion ≥ 90 degrees, OR combined ROM ≥ 240 degrees|
|10%||Flexion between 30 and 45 degrees, OR combined ROM between 175 and 340 degrees||Flexion between 60 and 90 degrees, OR combined ROM between 125 and 240 degrees|
|20%||Flexion between 15 and 35 degrees, OR combined ROM ≤ 170 degrees||Flexion between 30 and 65 degrees, OR combined ROM ≤ 120 degrees|
|30%||Flexion ≤ 15 degrees, OR entire cervical spine is frozen in a favorable position||Not applicable to thoracolumbar spine|
|40%||Entire cervical spine is frozen in an unfavorable position||Flexion ≤ 30 degrees, OR entire thoracolumbar spine is frozen in a favorable position|
|50%||Not applicable to cervical spine||Entire thoracolumbar spine is frozen in an unfavorable position|
|100%||Entire spine is frozen in an unfavorable position||Entire spine is frozen in an unfavorable position|
As you can see, ROM measurements play a significant role in rating spinal conditions. Because the rating formula is almost entirely based on ROM measurements, it’s important to make sure that a doctor performs ROM testing as accurately as possible. Also, the VA requires that all ROM measurements be taken with a goniometer. If a doctor doesn’t use a goniometer to measure your ROM, the VA will not consider the results.
In addition to the ROM measurements, the general rating criteria for spinal involves whether the cervical and/or thoracolumbar spine is frozen in a favorable vs. unfavorable position. A favorable position means the ROM measurement for flexion or extension is 0 degrees. Unfavorable means any position that is not 0 degrees in flexion or extension.
Secondary Spinal Conditions
Oftentimes, spinal conditions will cause other conditions, and these conditions qualify a veteran for another rating. For example, fractured and/or dislocated vertebrae can lead to pain and weakness in the arms, hips, shoulders, etc. People with spinal conditions also often change how they walk to compensate for the pain which can lead to knee and hip problems.
Spinal conditions can cause nerve problems as well. One of the most common conditions secondary to spinal conditions is radiculopathy. Radiculopathy is caused by compressed nerves in the spine and results in pain, numbness, tingling, or weakness along the nerve. If radiculopathy is caused by a low back condition, the individuals will feel the symptoms in the lower extremities (thigh, calf, foot). If radiculopathy is caused by a neck condition, the symptoms will be felt in the shoulder and can travel down the arm and into the hand.
If your spinal condition results in the development of a new disability or makes an existing disability worse, remember that you may be entitled to secondary service-connection for the new or aggravated disability. These secondary conditions would be rated separately from the underlying spinal condition.
VA Ratings For Spinal Arthritis & Back Pain
In order to ensure that you’re getting the most out of your disability claim, you need to understand how the VA rates your condition. Errors are frequently made when rating conditions. The VA not only makes mistakes in evaluation the severity of a condition, but sometimes they evaluate a condition according to the completely wrong rating criteria.
With this in mind, it’s important to know which spinal conditions are not rated under the general rating formula. The VA has a separate rating system for these conditions. Some of the conditions included in this category are degenerative arthritis, traumatic arthritis, and rheumatoid arthritis.
The rating systems used for arthritis of the spine is the second most common rating system for spine conditions. There are two types of arthritis that are rated under the same rating system; degenerative arthritis, and traumatic arthritis. Rheumatoid arthritis is rated under its own rating system.
Degenerative And Traumatic Arthritis
Degenerative arthritis is the chronic breakdown of the cartilage surrounding the joints. Degenerative arthritis of the spine, sometimes referred to as facet joint osteoarthritis, causes a breakdown of the cartilage between the facet joints in the back of the spine. Lack of cartilage causes pain and limitation of motion.
Traumatic arthritis occurs after an injury, excessive movement, or other physical trauma. Traumatic arthritis causes symptoms similar to other types of arthritis such as pain, inflammation, and build-up of fluid around the affected joint.
Both degenerative arthritis and traumatic arthritis, regardless of the joint affected, are rated under diagnostic code 5003. Depending on what joint is affected, there will be an identifying diagnostic code assigned to the condition. For example, the specific code for degenerative arthritis of the spine is 5242. However, the VA still rates degenerative arthritis of the spine under the criteria listed for diagnostic code 5003. Because there are technically two diagnostic codes associated with one condition, you would see the condition listed on rating decisions as 5242-5003.
What is the diagnostic code for traumatic arthritis?
The diagnostic code for traumatic arthritis is 5010. So if a veteran has traumatic arthritis in his spine, the final diagnostic code would appear as 5010-5003. Think of the first number as an identifying diagnostic code that tells you what joint is affected, while the second diagnostic code tells you the rating system the condition is being rated under.
Keep in mind that arthritis will only be rated under diagnostic code 5003 when the condition does not result in severe enough limitation of motion to be rated under the general rating formula for the spine. If there is decreased range of motion of the cervical or thoracolumbar spine, the condition would be rated according to the general rating formula for the spine that is based off of range of motion measurements. There must be x-ray evidence of arthritis in the cervical or thoracolumbar joints for the VA to rate a spinal condition under the code for degenerative arthritis.
As mentioned above, many different joints are rated under the rating criteria for degenerative arthritis. This includes the shoulder, wrist, elbow, hip, knee ankle, fingers, toes, spine, and the sacroiliac joint. Some joints are referred to as major joints, while others are referred to as minor joints. The spine is considered as a minor joint. The rating assigned under the rating criteria for degenerative arthritis depends on how many joint groups are affected and whether there is painful motion. If two or more major OR minor groups are affected a 20% rating will be assigned if the arthritis is occasionally incapacitating. If the arthritis does not cause any episodes of incapacitation, but 2 or more joint groups are involved, then a 10% rating will be assigned. If a veteran only has one joint group affected by arthritis then there must also be painful motion present in order for a rating higher than 0% to be assigned. If there is painful motion, a 10% rating will be assigned. For example, if a veteran has degenerative arthritis of the spine with no other joints affected, and he experiences pain when bending over he will receive a 10% rating.
Rheumatoid Arthritis and Back Pain
Rheumatoid arthritis is a disease that causes destruction of the joints in the body. Although this type of arthritis is most common in the small joints of the hands and feet, it can occur in any joint. When rheumatoid arthritis affects the spine, it typically occurs in the cervical spine (the neck) rather than the thoracolumbar spine (the low back). Rheumatoid arthritis of the spine leads to neck pain, back pain, and sometimes causes pain to radiate into the arms and legs. Symptoms are similar to the symptoms involved with degenerative arthritis and include pain and swelling of the joints.
The diagnostic code for rheumatoid arthritis is 5002. The VA assigns rating percentages based on the frequency of incapacitating episodes. The following percentages are available under the rating criteria for rheumatoid arthritis:
- 100% if you are completely incapacitated and are confined to staying in bed
- 60% if there are severe incapacitating episodes that occur 4 or more times per year
- 40% if there are incapacitating episodes that occur 3 or more times per year if there is a definite (but not necessarily significant) decrease in health
- 20% if there are less than 3 incapacitating episodes per year
It’s possible for rheumatoid arthritis to be rated under diagnostic code 5003 like degenerative and traumatic arthritis. If the condition is not severe enough to meet the above criteria, then the VA rating for back pain / arthritis will be based on specific symptoms. For example, if rheumatoid arthritis of the spine results in pain with motion, the condition will be rated according to the criteria set forth in 5003 as described above.
When pursuing a VA disability rating for back pain, it’s important to know your options. Keep in mind that a veterans disability law firm can work with you to build a claim for a higher rating.