The knee is the anterior part of the leg at the point of articulation of the femur and tibia. It is formed by the femur, tibia, and patella. Impairment refers to any loss or abnormal change related to structure or function. In this case, the knee is involved.

Impairment of the knee may be caused by diseases of the bone or loss of bone. Tumors; loss of a limb; fractures; other traumas such as strains, sprains or crushing injuries; overuse of the joint; scar tissue; and a flail joint may also contribute to impairment. Other impairments of the knee may be caused by injury or disease to the articulating surfaces, including the menisci, the joint capsule and ligaments, or the muscles and tendons. Metabolic disorders such as the development of loose bodies may also cause impairment, as well as dislocation of the patella. Disorders may also be congenital in nature. Sports injury is a main cause of knee injuries.

There may be restricted ROM (normal ROM is 0° for knee extension to 140° for knee flexion); immobilization; and stiffness. Other signs and symptoms may arise from joint disease such as arthritis; pain or tenderness; swelling; deformity; and crepitus. Twinges; clicks; instability (feeling of giving way); weakness; inflammation; effusion or localized heat may also be present.

Physical examination may be performed to include: inspection; palpation; stability testing; and range of motion testing. X-ray; magnetic resonance imaging (MRI); synovial fluid analysis; and arthroscopy to confirm a diagnosis may be performed. Laboratory tests may be needed for evaluating non-mechanical disorders such as arthritis.

Depending on the type of injury, manipulation, surgery, joint replacement, immobilization, and physical therapy may be used in the treatment. Steroid injection may also be used for sprains along with deep friction massage of the sprained ligament.

Degenerative arthritis may result with operative repair of certain conditions. Rehabilitation may take a minimum of six months after surgery. There may be a need to modify activities of daily living (ADL). In addition, there may be recurrence of pain and swelling during the rehabilitation period. The outcome of achieving full range of motion is good for most surgical corrections and overuse syndromes.

• Please refer to the GC opinion (VAOGCPREC9-98) dated August 1998, which held:

  • For a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 CFR 4.59.

  • The provisions of 38 CFR §§ 4.40, 4.45, and 4.59 must be considered in assigning an evaluation for degenerative or traumatic arthritis under DC 5003 or DC 5010. Rating personnel must consider functional loss and clearly explain the impact of pain upon the disability.

  • If a musculoskeletal disability is rated under a specific diagnostic code that does not involve limitation of motion and another diagnostic code based on limitation of motion may be applicable, the latter diagnostic code must be considered in light of  38 CFR §§ 4.40, 4.45, and 4.59.

  • The medical nature of the particular disability to be rated under a given diagnostic code determines whether the diagnostic code is predicated on loss of range of motion. Reference should be made to appropriate medical authorities.

  • DC 5259 requires consideration of 38 CFR §§ 4.40 and 4.45 because removal of the semilunar cartilage may result in complications producing loss of motion. Depending on the nature of the foot injury, DC 5284 may involve limitation of motion and therefore require consideration under 38 CFR §§ 4.40 and 4.45.

• See VAOPGCPREC 9-2004

  • On September 17, 2004, General Counsel issued a precedent opinion concerning the rating of knee conditions under two separate diagnostic codes involving limitation of motion. Specifically, General Counsel held that separate ratings under diagnostic code 5260 (leg, limitation of flexion) and diagnostic code 5261 (leg, limitation of extension) may be assigned for a disability of the same knee. This letter provides guidance to implement this opinion.

  • Where a veteran meets the requirements for a 0% or higher evaluation under diagnostic code 5260 (limitation of flexion) and under diagnostic code 5261 (limitation of extension), an evaluation under each diagnostic code may be assigned.

  • You must ensure that all knee examinations record range of motion findings in both flexion and extension, in accordance with the Disability Examination Worksheets.

  • Although it is permissible to assign multiple evaluations under multiple diagnostic codes for a single knee, you must always abide by the amputation rule (38 CFR § 4.68).

  • As always, when evaluating knee function, the provisions of 38 CFR §§ 4.40, 4.45, and 4.59 must be considered.

  • Where knee motion is actually impeded by pain, fatigability, weakness, etc., the evaluation assigned based on limitation of motion must consider the level at which motion is limited. For example, if, on examination, a veteran has full range of knee motion, but on repetitive motion, the knee is actually limited to 10 degrees extension and 45 degrees flexion due to fatigue, a 10% evaluation would be warranted under diagnostic code 5260 and a separate 10% evaluation would be warranted under diagnostic code 5261.

  • Where, however, joint motion is not limited, but there is objective evidence of pain on motion, whether in flexion, extension, or both, only one compensable evaluation would be warranted under either diagnostic code 5260 or 5261. To assign a compensable evaluation solely based on painful motion under two separate diagnostic codes would be in violation of the rule of pyramiding, 38 CFR 4.14.

  • Similarly, if there is compensable limitation of flexion and extension, and there is objective evidence of pain on motion, but such pain does not actually impede motion, consider elevating one of the compensable evaluations, if it is determined that the painful motion results in additional disability beyond that reflected in the measured limitation of motion. Again, to elevate both evaluations solely based on painful motion, would constitute pyramiding.

  • This GC opinion is not a liberalizing interpretation of the rating schedule, and the provisions of 38 CFR § 3.114(a) do not apply. As such, this opinion applies to claims that are pending, i.e., claims that have not been decided, and claims that have been decided and not finally adjudicated (the appeal period has not expired), if a request for reconsideration is received.

Notes

• For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon.

• A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration).