The leg bones include the femur, tibia, fibula, and patella. Limitation of motion refers to a point or line beyond which motion is restricted, and movement cannot progress normally (i.e., range of motion [ROM] of joints). In this case, the limitation in flexion is at the knee.

Flexion is the process of bending or the state of being bent, such as flexion of the fingers results in a clenched fist. Limitation of flexion can be articular (involving the joint), or nonarticular (involving muscles and connective tissue); inflammatory or non-inflammatory, acute or chronic in duration and localized to the joint or diffuse around the affected area.

Articular structures include the joint synovium, synovial fluid, articular cartilage, intra-articular ligaments, joint capsule and juxtaarticular bone. Nonarticular structures include supportive extra-articular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin. Nonarticular disorders usually are the cause of joint complaints.

Limited flexion of the leg may result from: diseases of the joints of the knee; contractures; fractures; tumors; fluid in the joint spaces; trauma; infection; muscle weakness; strains or sprains; shin splints; blood clot in a vein; congenital disorders; or inflammation of the tendons.

Medications, fibromyalgia, chronic illnesses (e.g. gout from renal insufficiency, psoriasis), cancer, overuse, degenerative processes, meniscal or cruciate ligament tears, inflammation of the bursa behind the knee or in the hip can also cause limitation of movement.

Manifestations associated with limited flexion of the leg may include the following:

• Articular symptoms may be characterized by deep or diffuse pain, pain with limited motion on active and passive movement, and swelling, crepitation, instability, "locking" or deformity.

• Nonarticular symptoms are painful on active but not passive movement of the joint, demonstrate point or focal tenderness in regions adjacent to articular structures and have physical findings remote from the joint capsule. Nonarticular disorders seldom involve swelling, crepitus, instability or deformity.

• Inflammatory conditions are characterized by erythema (redness), warmth, pain or swelling; and fatigue, fever, rash or weight loss. Morning stiffness and severe pain lasting for hours characterizes inflammatory disorders and is precipitated by long periods of rest. Inflammatory conditions may be associated with involvement of other organ systems including the eye (sarcoidosis, spondyloarthritis), gastrointestinal tract (scleroderma, inflammatory bowel disease), genitourinary tract (reactive arthritis, gonococcemia), or the nervous system (vasculitis, Lyme disease). Other causes of inflammation include infections (tuberculosis, gonorrhea), crystal-induced (gout), immune related (rheumatoid arthritis, systemic lupus erythrematosis) reactive (rheumatic fever, Reiter's syndrome) or idiopathic.

• Non-inflammatory disorders are characterized by pain. Pain is the predominant complaint without swelling, warmth and normal laboratory findings. Brief pain (less than 60 mins.) is precipitated by short periods of rest, and with increased activity. Non-inflammatory symptoms may be related to trauma, repetitive use, degeneration, neoplasm or fibromyalgia.

Diagnostic measures may include physical examination and range of motion (ROM) testing. Shortening of the leg; flexion contracture; limping; muscle weakness; or decreased range of motion may be present. Normal ROM for hip flexion is from 0 to 125° degrees and for the knee flexion is from 0 to 140° degrees. Measurement of the level of pain, weakness, stiffness and physical limitation using one of many functional measures should be performed.

Laboratory tests are based on the underlying disease or condition. Tests include a complete blood count (CBC), and white cell count (WBC) with differential. Acute phase reactant tests such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and aspiration and analysis of synovial fluid from the knee can help determine if the condition is inflammatory or non-inflammatory.

X-rays, computed tomography (CT) scan, ultrasonography, and magnetic resonance imaging (MRI) are used in the diagnosis. Other diagnostic studies that may be used in evaluating limitation of flexion include: electromyography (EMG); goniometer (device for measuring joint movements and angles); bone scans; and nerve conduction tests.

Treatment will vary according to the underlying cause of the limitation. Treatments may include: physical therapy; range of motion (ROM) exercises; braces; surgery to restore motion through joint replacement; intra-articular injections with steroids, anti-inflammatory and/or analgesic medications, or medications to decrease arthritic symptoms or inflammation.

There may be impaired physical mobility, and limited activities of daily living (ADL) depending on the degree of limitation in normal ROM of the affected parts.

• 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.

• None.