Supination refers to turning the palm or the hand facing upward. Pronation is the act of turning the hand so that the palm faces downward or backward. Impairment refers to any loss or abnormal change related to structure or function. In this case, impairment of either supination or pronation refers to the hand, wrist, or forearm.

Inability to supinate or pronate may result from injury to the joints, or to the nerves of the arm. It may also be associated with nerve lesions of the neck, shoulder and upper limb; or injury to the muscles, ligaments or tendons of the arm, wrist or hand. Inhibition of supination or pronation may also be related to joint or muscle disease and deformity; fractures; crush injuries; tumors; or infections. Acquired radioulnar synostosis can occur whenever sub-periostial stripping is performed and the radius and ulna are exposed through the same incision. Bone dust in the wound can also lead to synostosis and loss of supination and pronation.

Manifestations may include: numbness; paresthesia; pain; decreased sensory and motor function; incoordination; spasticity; hyperreflexia; pain; limited range of motion; weakness; swelling; crepitus; or infection.

Diagnostic measures may include: physical and neurovascular examinations; laboratory studies; and radiology studies such as, x-ray, magnetic resonance imaging (MRI), bone scan, or computed tomography (CT) scan. Passive and resistive testing of joint movements; range of motion testing; and a goniometer to measure range of motion may be used. Electrodiagnostic studies may be performed to confirm a diagnosis.

Rarely is it possible to achieve a full arc of pronation-supination. A functional arc of motion is achieved 50% of the time. Rest, limitation of activities, and splinting are used as treatment measures. Surgery may be indicated for correction of fractures, or if other treatments fail. Physical therapy and medications for pain, infection or inflammation may be indicated.

The ability to rotate the forearm, wrist or hand may range from full mobility to complete immobility, depending on the severity of disease or injury and the treatment course. Chronic pain or weakness may be a residual factor. Chronic reoccurrence of the inflammatory process may occur.

• The rating schedule for musculoskeletal was updated on February 7, 2021. Protection still does apply and should be considered with existing evaluations (38 CFR 3.951(a)).

• To properly rate disability, it is important to understand the range of motion chart Plate I, 38 CFR 4.71 [Measurement of ankylosis and joint motion] and §4.71 (a) [Schedule of ratings-musculoskeletal system]. The use of a goniometer in the measurement of range of forearm pronation and supination is indispensable. 38 CFR 4.46 [Accurate measurement]

• Full pronation is the position of the hand flat on a table. Full supination is the position of the hand palm up. In examining limitation of pronation, the "arc" is from full supination to full pronation. The "middle" of the arc is the position of the hand, palm vertical to the table. Assign the lowest 20% evaluation when pronation cannot be accomplished through more than the first three-quarters of the arc from full supination.

• Do not assign a compensable evaluation for both limitation of pronation and limitation of supination of the same extremity.

• Impairments of the elbow, forearm, and wrist will be assigned separate disability evaluations.  The motions of these joints are all viewed as clinically separate and distinct.  Assign separate evaluations for impairment under the following DCs:

  • elbow: flexion under 38 CFR 4.71a, DC 5206, or extension under 38 CFR 4.71a, DC 5207

  • forearm supination and pronation under 38 CFR 4.71a, DC 5213, and

  • wrist flexion or ankylosis under 38 CFR 4.71a, DC 5214 or 38 CFR 4.71a, DC 5215.

• 38 CFR 4.59 may be applied separately to the elbow, the forearm, and the wrist to result in potentially three separate evaluations for painful motion when the evidence otherwise supports such a finding.  However, 38 CFR 4.59 may only be applied once to the elbow and may not be separately applied to both elbow flexion and elbow extension.

• When examination or other evidence denotes pain present in the joint or periarticular region but does not delineate the specific motions in which pain is present and there is a potential for a separate evaluation under 38 CFR 4.59, obtain a medical opinion to determine which motions are painful. When the examiner cannot delineate which motions are associated with pain, resolve doubt in favor of the Veteran, per 38 CFR 4.3, and consider painful motion to be present in the separate plane such as to allow assignment of the separate minimum compensable evaluation under 38 CFR 4.59.

• In all the forearm and wrist injuries, codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of hand. 38 CFR 4.71 (a) [Schedule of ratings-musculoskeletal system]