Knee pain and dysfunction are common among veterans. According tothe Department of Veterans Affairs (VA)Annual Benefits Report for Fiscal Year 2020, limitation of flexion of the knee — just one of the knee conditions for which VA offers benefits — was the third-most commonly claimed disability.
VA’s disability rating schedule covers several knee conditions, each of which is rated using different criteria like mobility and pain. In this article, we will discuss the knee claims we encounter the most at Chisholm Chisholm & Kilpatrick, the questions that veterans often ask, and some issues to consider when planning a claim or appeal.
Who We Are: Chisholm Chisholm & Kilpatrick is the largest veterans law firm in the US. For more than 25 years, CCK has argued many of the cases that shape veterans law today. With over 300 years of combined experience, we have secured more than $1 billion in benefits for our clients.
How to Get Service Connected for a Knee Disability
One of the requirements for eligibility for VA disability benefits is a service-connected condition, which is an illness or injury that was caused by — or got worse because of — active military service.
Direct Service Connection for Knee Disabilities
To establish direct service connection, veterans must provide evidence of the following:
- A diagnosis of a current knee condition by a medical professional;
- An in-service event, injury, or illness; and
- A medical nexus linking the current, diagnosed knee condition to the in-service event.
For example, say a veteran was playing basketball while serving on active duty and fell and hurt their knee. Following discharge from service, they were diagnosed with degenerative arthritis in their knee. Ifthe knee condition can be traced back to the in-service injury, a doctor must provide an opinion linking the degenerative arthritis of the knee to the veteran’s in-service injury.
Secondary Service Connection for Knee Disabilities
A secondary service-connected condition is one that resulted from a separate condition that is already service-connected.
For example, say a veteran’sservice-connected spine injurycaused them to later develop knee injuries. Secondary service connection can be established if the veteran has a nexus connecting the two conditions.
Service Connection for Knee Disabilities by Aggravation
VA also compensates veterans for preexisting medical conditions “aggravated” by service.
For example, assume a veteran entered service with a mild preexisting knee condition. Following service, the knee condition worsened in severity and now impacts their day-to-day life. In this case, the veteran’s service may have aggravated their preexisting knee condition beyond the natural progression of the disability. Therefore, they may be eligible for service connection based on aggravation.
VA Disability Ratings for Knee Pain
Once a veteran’s knee condition is service-connected, VA will assign a disability rating ranging between 0 and 100 percent. More serious and disabling knee injuries are assigned higher ratings.
Overall, VA ratings for knee pain depend on various factors, such as:
- The type of knee injury
- The severity of the diagnosed knee condition
- The knee’s range of motion
- The pain it causes
Common Knee Disabilities and How VA Rates Them
Knee pain and knee-related conditions are typically rated under38 CFR § 4.71ausing different diagnostic codes. The following are common knee conditions and how VA rates them.
Limitation of Flexion of the Knee — Diagnostic Code 5260
Limitation of flexion of the knee, the most common service-connected knee condition, refers to the range of motion of the knee as the veteran moves it or curls it inward towards the body.
Generally, VA strictly rates this condition based on therange of motionthat exists as the veteran moves their knee in that direction rather than any pain it causes.
The most common rating VA assigns for limitation of flexion of the knee is10 percent, although the highest rating a veteran can receive is30 percent.
- 30%— flexion limited to 15 degrees
- 20%— flexion limited to 30 degrees
- 10%— flexion limited to 45 degrees
- 0%— flexion limited to 60 degrees
Limitation of Extension of the Knee — Diagnostic Code 5261
Limitation of extension of the kneerefers to when the knee is not frozen but rather is limited in extension and cannot straighten all the way.
This knee pain condition is rated under diagnostic code 5261 and the disability ratings available are0, 10, 20, 30, 40, and 50 percent. Typically, the greater limitation of extension (or the harder it is to straighten the knee), the higher the disability rating.
Similar to limitation of flexion of the knee, there are specific range of motion measurements that correspond with each disability rating. For example, if the leg can only straighten to within 45 degrees of being completely straight, then it is rated at50 percent, whereas if it can only straighten to 10 degrees, it is rated at10 percent.
- 50%— extension limited to 45 degrees
- 40%— extension limited to 30 degrees
- 30%— extension limited to 20 degrees
- 20%— extension limited to 15 degrees
- 10%— extension limited to 10 degrees
- 0%— extension limited to 5 degrees
Instability of the Knee — Diagnostic Code 5257
Instability of the kneerefers to when the knee has too much motion from side to side or dislocates regularly. This condition can occur when damaged tendons and cartilage can no longer support the knee joint properly. VA assigns a0, 10, 20, or 30 percentdisability rating for this knee condition based on the amount of instability present in the knee. To get a 30 percent rating, the knee must be so unstable that it gives out or dislocates on a regular basis.
Specifically, the rating criteria are based on the extent of the “recurrent subluxation or lateral instability” a veteran experiences in their knee. Subluxation refers to the dislocation of the kneecap while lateral instability refers to the knee giving out.
Below are the rating criteria for recurring subluxation or instability of the knee:
- 30%— Unrepaired or failed repair of complete ligament tear causing persistent instability.
- Additionally, a medical provider must prescribebothan assistive device, such as a cane, crutch, or walker, as well as bracing for ambulation.
- 20%— One of the following criteria must be met:
- Sprain, incomplete ligament tear, or complete ligament tear causing persistent instability.
- A medical provider must also prescribe a braceand/orassistive devices such as a cane, crutch, or walker, or bracing for ambulation.
- Unrepaired or failed repair of complete ligament tear causing persistent instability.
- A medical provider must also prescribe assistive devices such as a cane, crutch, or walker,and/orbracing for ambulation.
- Sprain, incomplete ligament tear, or complete ligament tear causing persistent instability.
- 10%— Sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability.
- A medical providerdoes notneed to proscribe assistive devices such as a cane, crutch, or walker, or bracing for ambulation to receive this rating.
Another impairment of the knee rated under this diagnostic code ispatellar instability. Patellar instability occurs when the kneecap, or the patella, is moved or displaced from its intended resting place.
A kneecap without impairment typically rests in a groove called the trochlea near the end of the thigh bone, or femur. When the patella is pushed completely out of this groove, the patella becomes dislocated. When the patella is pushed partially out of the groove, it is referred to as subluxation. Below are therating criteria for patellar instability:
- 30%— A diagnosed condition involving the patellofemoral complex with recurrent instability.
- A medical provider must prescribebothan assistive device, such as a cane, crutch, or walker, as well as bracing for ambulation.
- 20%— A diagnosed condition involving the patellofemoral complex with recurrent instability.
- A medical provider must prescribeoneof the following: a brace, cane, or walker.
- 10%— A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair).
- A medical providerdoes notneed to proscribe assistive devices such as a cane, crutch, or walker, or bracing for ambulation to receive this rating.
It is important to note that thepatellofemoral complex refers to the quadriceps tendon, the patella, and the patellar tendon. For the purposes of the rating criteria, a surgical procedure that does not involve one of these (quadriceps tendon, patella, or patellar tendon) cannot qualify as surgical repair for patellar instability. For example, arthroscopy to remove loose bodies and joint aspiration does not qualify as surgical repair for patellar instability.
Ankylosis of the Knee — Diagnostic Code 5256
Ankylosis, abnormal stiffening and immobility of the knee, can be assigned a30, 40, 50, or 60 percentdisability rating depending on the limitation of flexion. Again, the more limitation the veteran experiences, the higher the disability rating.
Ankylosis (i.e., abnormal stiffening and immobility) of the knee can be assigned a 30, 40, 50, or 60 percent disability rating depending on the limitation of flexion. The rating criteria are as follows:
- 60%— Extremely unfavorable, in flexion at an angle of 45 degrees or more
- 50%— In flexion between 20 and 45 degrees
- 40%— In flexion between 10 and 20 degrees
- 30%— Favorable angle in full extension, or in slight flexion between 0 and 10 degrees
Total Knee Replacements — Diagnostic Code 5055
If the entire knee joint has been replaced by a prosthesis, then thetotal knee replacementis rated100 percentfor the first four months following surgery.
After this four-month period, veterans will attend ato determine the severity of their knee pain condition. Following the exam, veterans will be assigned a new rating based on the rating criteria outlined below.
If there is weakness and severe pain with motion, then the veteran’s knee condition is rated at60 percent. If the pain is not severe but limits their range of motion, then it is rated under Diagnostic Code 5256, 5261, or 5262 based on the residual symptomology.
Importantly, the minimum rating for a total knee replacement is30 percent —regardless of how much motion it has.
- 100% — For four months following implantation of prosthesis or resurfacing. After the four-month period, the knee will be reevaluated for a permanent rating.
- 60%— With chronic residuals consisting of severe painful motion or weakness.
- 30%— With intermediate degrees of residual weakness, motion, or limitation of motion.
For the minimum 30 percent disability rating, VA should also look to other diagnostic codes related to knee conditions to see if the veteran is entitled to a higher evaluation.
Partial Knee Replacements
Unlike total knee replacements,partial knee replacementsdo not have their own diagnostic code. Instead, partial knee replacements are rated according to any symptoms that are caused by the replacement, such as limitation of motion.
Can Veterans Receive Multiple Disability Ratings for Knee Disabilities?
Veterans can receive more than one disability rating for knee conditions as long as each condition involvesdifferentmovements.
For example, if a veteran experiences difficulty in both bending and straightening their knee, they may be able to receive service-connected compensation for both limitation of flexion and extension.
However, in these cases it is important to avoidpyramiding— VA’s term for rating the same disability or samemanifestation(i.e., symptom) of a disability twice.
TDIU for Knee Pain or Dysfunction
If a veteran’s knee injury or condition does not qualify them for a 100 percent rating, they can apply fortotal disability based on individual unemployability(TDIU) if their knee pain prevents them from working. TDIU offers compensation at a100 percent rateto veterans who are unable to secure or maintain substantially gainful employment due to their service-connected conditions.
Additional VA Rules for Knee Disability Claims
VA’s Painful Motion Rule: 10% Ratings
VA’s regulations state that veterans should be afforded a10 percent ratingeven if they do not necessarily meet the specific diagnostic code criteria for limited range of motion but can otherwise show they have painful motion.
However, we have found that VA often makes mistakes when it comes to this. VA is supposed to pay attention to other indicators of functional loss such as weakness, interference with sitting and standing, pain during motion, and fatigability. If VA does not take such factors into consideration, veterans should consider appealing for a higher disability rating.
VA’s Bilateral Factor Rule: When Both Knees Have Disabilities
VA recognizes that if veterans have a disability that affects both knees, the ability to function on a daily basis is going to be even more limited. In this case, VA will combine the ratingsof the left and right knees andadd anadditional 10 percent.
For example, if a veteran had a 20 percent rating in their right knee for limitation of flexion and a 10 percent rating in their left knee for instability, VA will first take those two ratings and combine them to get a total of 28 percent. From there, VA will take 10 percent from that 28 percent (i.e., 2.8 percent) and add it to the 28 percent. The new combined rating would be 31 percent (or 30 percent based on the rounding).
In this specific example, the veteran’scombined disability ratingdoes not change, but in other cases, thisbilateral factorcan be the difference between a 20 and 30 percent combined rating, a 90 and 100 percent combined rating, etc.
VA’s Functional Loss Rule
VA should also evaluate functional loss when rating a veteran’s knee condition.Functional lossrefers to how the condition affects the veteran’s ability to function in daily life.
This test considers factors such as pain, how severe the condition is during flare-ups, and how frequently flare-ups occur. Even if a veteran has full range of motion, if they are in so much pain that they cannot function, then this should be accounted for in their disability rating.
VA’s Major Joint Rule and Arthritis of the Knees
VA’smajor joint rulebasically says that if a veteran has a diagnosis of arthritis of the knees, VA should apply the normal range of motion tests and determine if the veteran qualifies for a disability rating under Diagnostic Codes 5260 or 5261. However, if VA completes the range of motion testing and determines the veteran has a good range of motion overall but still experiences pain, VA will apply Diagnostic Code 5003 for arthritis.
If a veteran has confirmation of arthritis through X-ray evidence, VA should assign either a 10 or 20 percent disability rating based on the severity of the arthritis and whether it affects one or both knees. This allows VA to maximize the veteran’s benefits.
Insights from Chisholm Chisholm & Kilpatrick
How to Use Lay Evidence for Knee Claims
Lay evidenceincludes statements from veterans, veterans’ friends and family members, and fellow service members.
Veterans can use lay statements to outline the onset and progression of their knee condition. They can also describe its severity and how it affects daily life. Lay evidence can be very helpful when a veteran lacks certain medical evidence.
Tips for C&P Exams for Knee Pain and Dysfunction
A is a medical examination of a veteran’s disability, performed by a VA healthcare provider or a VA-contracted provider. VA uses C&P exams to gather more evidence on a veteran’s claimed disability before issuing a decision and assigning a rating. C&P examsfor knee-related claims are primarily based on range of motion.
Range of motionshould be testedafterrepetitive motion to determine how limited motion is following prolonged use. C&P examiners should also ask veterans about flare-ups and how they affect their functioning. Finally, C&P examiners should address functional loss due to pain. If C&P examiners do not address these issues, the exam may be inadequate for rating purposes.
It is important for veterans to be upfront and honest about limitations caused by their knee pain and report any functional loss they experience. If they do not report their symptomatology, VA may not fully comprehend the severity of the condition.
Additionally, if veterans believe their C&P exam results were unfavorable, they can submit contrasting evidence.
Did VA Deny Your Claim for a Knee Disability? Contact CCK!
If VA denied your disability claim for knee pain or conditions, Chisholm Chisholm & Kilpatrick LTD may be able to help.
The experienced veterans’ advocates at CCK have worked extensively on behalf of veteran clients for years. We know what it takes to put together a winning appeal, and we may be able to put our tools, resources, and successful history to work for you.
Reach out today for a free case evaluation at (800) 544-9144.
