VA Disability Benefits for Knee Pain
Prevalence of Knee Pain Among Veterans
Knee pain problems are commonly-claimed conditions for VA disability benefits. According to VA’s Annual Benefits Report for Fiscal Year 2018, limitation of flexion of the knee was the fifth most commonly-claimed disability, with over 80,000 veterans receiving service-connected compensation for this issue. However, limitation of flexion of the knee is just one type of knee condition that can receive service-connected compensation. There are many different ways that knee conditions can be evaluated under the Veterans Affairs Schedule for Rating Disabilities. Veterans filing a claim or appealing a claim denial for a knee condition should be aware of the various ways that knee conditions can be rated.
Service Connection for Knee Pain and Conditions
Veterans can receive service connection for knee pain and conditions in a number of different ways, including the following:
Direct Service Connection
To establish direct service connection, veterans must provide the following:
- A current, diagnosed knee condition
- An in-service event, injury, or illness
- A medical nexus linking the current, diagnosed knee condition to the in-service incurrence
For example, you were playing basketball while serving on active duty during which time you fell and hurt your knee. Following discharge from service, you are diagnosed with degenerative arthritis in your knee. If your knee condition can be traced back to your injury in service, a doctor must provide an opinion linking the degenerative arthritis of your knee to your in-service injury.
Secondary Service Connection
A secondary service-connected condition is one that resulted from a separate condition that is already service-connected. For example, a veteran is service-connected for a knee condition and later develops arthritis in that knee. Then the veteran’s arthritis may warrant secondary service connection if it is the result of their service-connected knee condition.
Service Connection by Aggravation
VA will compensate veterans for medical conditions that existed at the time of entry into service that were made worse or “aggravated” by service. According to 38 CFR § 3.306, “a preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease”. For example, if a veteran entered service with a pre-existing knee condition considered to be mild. Following service, the knee condition worsens and becomes severe, now impacting activities of daily living. In this case, the veteran’s active duty service aggravated their pre-existing knee condition beyond the natural progression of the disability. In this case, the veteran may be eligible for service connection based on aggravation.
Common Types of Knee Conditions and How They Are Rated
Knee pain can be rated under several different diagnostic codes (see below), but overall, they are rated under 38 CFR § 4.71a.
Limitation of Flexion of the Knee – Diagnostic Code 5260
Limitation of flexion of the knee is the most common knee condition for which veterans receive VA disability benefits. This condition refers to the range of motion of the knee as the veteran moves it or curls it inward towards the body. Generally speaking, VA rates this condition based on the range of motion that exists as the veteran moves their knee in that direction. The most common rating VA assigns for limitation of flexion of the knee is 10 percent, although the highest rating a Veteran can receive is 30 percent. This low evaluation speaks to how VA rates knee conditions. Namely, there are strict rating criteria veterans must meet to have their knee conditions rated at certain levels. It is not just about how painful it is or how much it hurts. Instead, VA will literally measure the range of motion and assign a rating based largely off that alone.
Within VA’s regulations, veterans should be afforded a 10 percent rating even 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, VA often makes mistakes when it comes to this. VA is also required to pay attention to other indicators of functional loss such as weakness, interference with sitting and standing, pain on motion, and fatigability. If VA does not take such factors into consideration, veterans should consider appealing for a higher disability rating.
Limitation of Extension of the Knee – Diagnostic Code 5261
Limitation of extension of the knee refers to when the knee is not frozen, but 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 are 0, 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 will be. Similar to limitation of flexion of the knee, there are specific range of motion measurements that correspond with each disability evaluation. For example, if the leg can only straighten to within 45 degrees of being completely straight, then it is rated at 50 percent, whereas if it can only straighten to 10 degrees it is rated at 10 percent.
Instability of the Knee – Diagnostic Code 5257
Instability of the knee refers 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 a 0, 10, 20, or 30 percent disability rating for this knee pain condition based on the amount of instability present in the knee. In order to get the highest evaluation, the knee must be so unstable that it gives out or dislocates on a regular basis.
Ankylosis of the Knee – Diagnostic Code 5256
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. Again, the more limitation of the knee the veteran experiences, the higher the disability rating should be.
Total Knee Replacements – Diagnostic Code 5055
If the entire knee joint has been replaced by a prosthesis, then the condition is rated 100 percent for the first year following surgery. After this one-year period, the veteran will attend a Compensation & Pension examination to determine the severity of their knee pain condition. Following the examination, the veteran 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 at 60 percent. If the pain is not severe, but does limit the veteran’s 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 is 30 percent regardless of how much motion it has.
Partial Knee Replacements
Unlike total knee replacements, partial knee replacements do 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 More Than One Disability Rating for Knee Pain?
It is important to note that veterans can receive more than one disability rating for knee conditions as long as each condition involves different movements. For example, if a veteran experiences difficulty in both bending and straightening their knee, they might be able to receive service-connected compensation for limitation of flexion and extension. However, in these cases it is important to avoid pyramiding – the VA term for rating the same disability, or same manifestation (i.e. symptom) of a disability, twice. Therefore, it may be beneficial to talk to a representative to learn more about which disability ratings are appropriate for your knee condition(s).
Lay Evidence and How it Can Help Your Knee Pain VA Claim
Lay evidence includes statements from veterans, veterans’ friends and family members, and fellow service members. Basically, lay statements outline the onset and progression of the veteran’s knee condition. These statements also describe the severity of the conditions and how it affects their everyday life. Importantly, lay evidence can be very helpful when veterans are lacking medical evidence.
VA’s Painful Motion Rule: 10% Ratings
Again, VA’s regulations state that veterans should be afforded a 10 percent rating even if they do not necessarily meet the specific diagnostic code criteria for limited range of motion but can otherwise show they have painful motion.
When Both Knees Have Disabilities: VA’s Bilateral Factor Rule
VA recognizes that if you have a disability that affects both knees, your ability to function day-to-day is going to be even more limited. In this case, VA will provide additional compensation based on the disability ratings assigned. 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 should first take those two ratings and combine them to get a raw total of a 28 percent disability rating. From there, VA will take 10 percent from that 28 percent (i.e., 2.8 percent) and add it on. The new combined rating would be 31 percent, which would be 30 percent based on the rounding. In this specific example, the veteran’s combined disability rating does not change, but in other cases, this additional rating can be the difference between a 20 and 30 percent combined rating, a 90 and 100 percent combined rating, etc.
VA’s Functional Loss Rule
When rating a veteran’s knee condition, VA is supposed to look at functional loss as well. Functional loss refers to how the condition actually affects the veteran’s ability to function in everyday life. This goes beyond the objective range of motion testing that VA conducts. It should be looking at things like pain, how severe it is during flare-ups, how frequently flare-ups occur, and more. Even if a veteran has full range of motion, if they are in so much pain that they are still unable to function, then this should be accounted for and considered in their assigned disability rating.
VA’s Major Joint Rule and Arthritis of the Knees
VA’s major joint rule basically says that if a veteran has a diagnosis of arthritis of the knees, VA is going to go through the normal range of motion tests and determine if the veteran would be able to receive a disability rating under Diagnostic Codes 5260 or 5261. However, if VA completes range of motion testing and determines the veteran has good range of motion overall but experiences pain, VA will look to Diagnostic Code 5003 for arthritis. As long as veterans have arthritis that is confirmed 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 of the veteran’s knees. This is VA’s way of maximizing the veteran’s benefits. Again, VA will look at the veteran’s range of motion first to see if a higher disability rating is warranted based on that. If not, VA will look to the rating criteria for arthritis.
Compensation & Pension Exams for Knee Pain and Conditions: What to Watch Out For
Again, C&P exams for knee pain and conditions will primarily be based on a veteran’s range of motion. Range of motion is also supposed to be tested after repetitive motion to determine how much the veteran’s motion is limited after use over time. C&P examiners should also be asking veterans about the presence of flare-ups and how such flare-ups may further limit the veteran’s functioning. Finally, C&P examiners should address functional loss due to pain. Functional loss can relate to issues with standing, walking, sitting, climbing stairs, kneeling, and other activities of daily life. If C&P examiners do not address these issues, the exam may be inadequate for rating purposes.
Tips for C&P Exams
It is important for veterans to be very upfront and honest about the limitations caused by their knee conditions. If they are not reporting their symptomatology, it is not guaranteed that VA will be aware of the severity of the condition. Therefore, veterans should be ready to report any functional loss that they experience. Additionally, if veterans believe their C&P exam results were unfavorable, they should respond with contrasting evidence.
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