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Updated Mar 25, 2022
In This Section
This section contains the following topics:
Topic
Topic Name
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1.  Multi-Joint Arthritis

Introduction
This topic contains information about multi-joint arthritis, including

Change Date
February 8, 2021

V.iii.1.C.1.a.  Rating Multi-Joint Arthritis
38 CFR 4.71a, diagnostic code (DC) 5002 applies to multi-joint arthritis.  Common examples of multi-joint arthritis include (but are not limited to)
  • rheumatoid arthritis (RA)
  • psoriatic arthritis, and
  • spondyloarthropathies.
Multi-joint arthritis is evaluated on the basis of
Note:
  • The ratings for the active process will not be combined with ratings for residuals.
  • RA and some other types of infectious arthritis do not require x-ray evidence of bone changes to substantiate the diagnosis, since x-rays do not always show their existence.
Reference:  For more information on multi-joint arthritis, see Medical Electronic Performance Support System (MEPSS).

V.iii.1.C.1.b.  Identification of Active Multi-Joint Arthritis
When evaluating multi-joint arthritis as an active process, in the DIAGNOSIS field of the rating decision
  • provide the specific diagnosis for the multi-joint arthritis (for example, rheumatoid arthritis), and
  • state which joints are affected.

V.iii.1.C.1.c.  Marie-Strumpell Disease
Marie-Strumpell disease, also called rheumatoid spondylitis or ankylosing spondylitis, is not the same disease as RA.  RA and Marie-Strumpell disease have separate and distinct clinical manifestations and progress differently. Reference:  For more information on evaluating ankylosing spondylitis, see M21-1, Part V, Subpart iii, 1.A.3.f.

2.  Arthritis (Other Than Multi-Joint)

Introduction
This topic contains basic principles for rating arthritis, other than multi-joint, including

Change Date
February 8, 2021

V.iii.1.C.2.a.  X-Ray Evidence of Arthritis
X-ray evidence of bone changes must be present to substantiate a diagnosis of arthritis.
Reference:  For more information on considering x-ray evidence when evaluating arthritis and non-specific joint pain, see

V.iii.1.C.2.b.  Establishing SC for Degenerative Arthritis
Degenerative arthritis is evaluated using 38 CFR 4.71a, DC 5003.  Degenerative arthritis can affect multiple joints, and its cause is likely multi-factorial.
When 38 CFR 4.71a, DC 5003 is assigned for an arthritic condition, every joint or group of joints affected by this disease is subject to service connection (SC) in the absence of an intervening cause.
  • If it has been medically determined that the Veteran has service-connected (SC) degenerative arthritis, and not post-traumatic arthritis, there is no need for a medical opinion to establish SC for each affected joint.
  • Once degenerative arthritis has been clinically diagnosed and SC has been properly established for one affected joint, establish SC for and evaluate each joint as it becomes affected, with x-rays used to verify involvement of individual joints.
Note:  In evaluating arthritis of the spine, the principles for establishing SC for joints affected by the subsequent development of degenerative arthritis (as contemplated under 38 CFR 4.71a, DC 5003) are not dependent on the choice of DC.
Example:  Veteran is SC for degenerative arthritis of the spine under 38 CFR 4.71a, DC 5242, and subsequently develops degenerative arthritis in the right elbow, with no intercurrent cause noted.  In this case, the principles of establishing SC for arthritic joints, as contemplated in 38 CFR 4.71a, DC 5003, also apply even though the Veteran is rated under 38 CFR 4.71a, DC 5242.  Thus, SC for arthritis of the right elbow may be established.
References:  For more information on

V.iii.1.C.2.c.  Post-Traumatic Arthritis
When there is evidence showing a history of in-service trauma to a joint, utilize 38 CFR 4.71a, DC 5010 for rating purposes, which indicates the etiology of the condition is trauma-based.
Post-traumatic arthritis is
  • evaluated based on limitation of motion (LOM), dislocation, or other specified instability of the affected joint under the corresponding DC for the joint, and
  • not evaluated utilizing arthritis criteria, such as 38 CFR 4.71a, DC 5003.
Important:  This principle applies even if the examiner or medical evidence
  • diagnoses arthritis but does not indicate within the diagnosis whether the disability is due to injury
  • does not provide a specific diagnosis of post-traumatic arthritis, and/or
  • diagnoses degenerative or osteoarthritis.

V.iii.1.C.2.d.  Historical Evaluation of Post-Traumatic Arthritis
Under the version of the rating schedule in effect prior to February 7, 2021, post-traumatic arthritis (previously called arthritis, due to trauma) was evaluated under 38 CFR 4.71a, DC 5003.
In accordance with 38 CFR 3.951, evaluations of post-traumatic arthritis assigned using the degenerative arthritis rating criteria cannot be reduced based solely on the readjustment of the rating schedule.  Reduction may be made only when medical evidence establishes that the disability has actually improved.
Reference:  For more information on the effect of rating schedule readjustment, see M21-1, Part V, Subpart ii, 3.D.2.i.

V.iii.1.C.2.e.  Considering the Effects of a Change in Diagnosis in Arthritis Cases
A change of diagnosis among the various types of arthritis, particularly if joint disease has been recognized as SC for several years, has no significant bearing on the question of SC.
Note:  In older individuals, the effects of more than one type of joint disease may coexist.
Reference:  For information on evaluating multi-joint arthritis, see 38 CFR 4.71a, DC 5002.

3.  Distinguishing Between Degenerative and Post-Traumatic Arthritis

Introduction
This topic contains information on distinguishing between degenerative and post-traumatic arthritis, including
Change Date
February 8, 2021

V.iii.1.C.3.a.  Determining the Type of Arthritis
Diagnoses of degenerative arthritis, osteoarthritis, and degenerative joint disease are generally used interchangeably in a clinical setting.  Clinicians may also use these diagnoses to refer to post-traumatic arthritis.
  • In degenerative arthritis, designated for rating purposes under 38 CFR 4.71a, DC 5003, age is the most powerful risk factor.
  • For cases of arthritis due to trauma
    • the disability affects only the joint that received trauma, and
    • although medical evidence may provide an etiological discussion of the disease, many clinicians do not routinely furnish a diagnosis of post-traumatic arthritis.
Notes:
  • History alone, and not x-ray findings or physical exam, may be the only distinguishing element for a medical diagnosis of arthritis due to trauma as opposed to other causes of arthritis.
  • Often a combination of age and repetitive use or age and major trauma can contribute to an arthritis disability picture.

V.iii.1.C.3.b.  Handling Unclear Etiology of Arthritis
When the etiology of the arthritis is unclear relative to whether the condition is degenerative or post-traumatic, obtain a medical opinion to determine the etiology.  Ask the medical examiner whether the arthritis is due to, or the result of, an in-service injury.
References:  For more information on

V.iii.1.C.3.c.  Example of Post-Traumatic Arthritis
Situation:  Service treatment records (STRs) show the Veteran fractured his left ankle when he fell from a tank.  Treatment notes show ongoing complaints of ankle pain and LOM following the injury.  The Veteran was subsequently diagnosed with degenerative arthritis of the left ankle in service.  The x-ray report noted degenerative arthritis forming at the exact site of the fracture.  The STRs show no other complaints, treatment, or diagnosis of arthritis affecting other joints during the Veteran’s remaining period of service.
A current VA exam shows a diagnosis of degenerative arthritis of the left ankle.  The Veteran provided a history of fracturing his left ankle when he fell from a tank.
Result:  Grant SC under 38 CFR 4.71a, DC 5010 for degenerative arthritis of the left ankle.  Do not change the diagnosis to post-traumatic arthritis.  The condition is evaluated under 38 CFR 4.71a, DC 5010 establishing its origin from trauma.  The rating activity does not have the authority to change a medical diagnosis.  38 CFR 4.71a, DC 5010 will be a hyphenated DC, most likely followed by 38 CFR 4.71a, DC 5271, based on the residual symptoms such as limited range of motion (ROM) of the ankle.
Important:  The medical evidence must clearly show the arthritis is a result of trauma, and no other causes, in order to evaluate under 38 CFR 4.71a, DC 5010.

V.iii.1.C.3.d.  Example of Handling Unclear Etiology for an Arthritis Diagnosis
Situation:  The Veteran sprained his left ankle during service with no further treatment or complaints for the remaining period of service.  The Veteran submitted private medical evidence showing a diagnosis of degenerative arthritis and provided a history of a left ankle sprain during service.
Result:  The etiology of the Veteran’s arthritis is not clear.  Do not assume the arthritis is or is not related to the ankle sprain.  Since there is evidence of an in-service injury and a current diagnosis of arthritis involving the same joint, obtain a medical opinion to determine the etiology of the arthritis.
Important:  If the resulting opinion links the in-service injury to the arthritis, evaluate the disability under 38 CFR 4.71a, DC 5010 (hyphenated with the DC for the predominant symptomatology).

4.  LOM in Arthritis Cases Evaluated Under DC 5003

Introduction
This topic contains information on LOM due to arthritis evaluated under or analogously to 38 CFR 4.71a, DC 5003, including

Change Date
February 8, 2021

V.iii.1.C.4.a.  Arthritis Compensable Under DCs Based on ROM
For a joint or group of joints affected by degenerative arthritis (or a condition evaluated using the degenerative arthritis criteria), first attempt to assign an evaluation using the DC for ROM of the affected joint (38 CFR 4.71a, DC 5200-series).
When the requirements for compensable LOM of a joint are met under a DC other than 38 CFR 4.71a, DC 5003, hyphenate that DC in the conclusion with a preceding “5003–.”
Example:  Degenerative arthritis of the knee manifested by limitation of knee extension justifying a 10-percent evaluation under 38 CFR 4.71a, DC 5261 would use the hyphenated DC “5003-5261.”
Reference:  For more information on evaluating LOM due to arthritis, see M21-1, Part V, Subpart iii, 1.C.5.

V.iii.1.C.4.b.  Joint Conditions Not Compensable Under DCs Not Based on ROM
Whenever LOM due to degenerative arthritis is noncompensable under codes appropriate to a particular joint, assign 10 percent under 38 CFR 4.71a, DC 5003 for each major joint or group of minor joints affected by limited or painful motion as prescribed under 38 CFR 4.71a, DC 5003.
If there is no limited or painful motion, but there is x-ray evidence of degenerative arthritis, assign under 38 CFR 4.71a, DC 5003 either a 10- or a 20-percent evaluation for occasional incapacitating exacerbations, based on the involvement of two or more major joints or two or more groups of minor joints.
Important:
  • Do not combine under 38 CFR 4.25 a 10- or 20-percent evaluation that is based solely on x-ray findings with evaluation that are based on limited or painful motion.  See example in M21-1, Part V, Subpart iii, 1.C.5.d.
  • When subjective painful motion is shown, consider assignment of the minimal compensable evaluation under 38 CFR 4.59, when otherwise appropriate.
References:  For more information on

V.iii.1.C.4.c.  Arthritis Previously Rated as a Single Disability
In some cases, arthritis of multiple joints is rated as a single disability.
Use the information in the table below to process cases for which arthritis was previously evaluated as a single disability but the criteria for assignment of separate evaluations for affected joints was met at the time of the prior decision.
If …
Then …
  • the separate evaluation of the arthritic disability results in no change in the combined degree previously assigned, and
  • a rating decision is required
reevaluate using the current procedure with the same effective date as previously assigned.
reevaluating the arthritic joint separately results in an increased combined evaluation
apply 38 CFR 3.105(a) to retroactively increase the assigned evaluation.
reevaluating the arthritic joint separately results in a reduced combined evaluation
Exception:  Do not apply 38 CFR 3.105(a) if the assigned percentage is protected under 38 CFR 3.951.
Reference:  For more information on protected rating decisions, see M21-1, Part X, Subpart ii, 1.B.

V.iii.1.C.4.d.  Using DCs 5013 Through 5024
For 38 CFR 4.71a, DCs 5013 through 5024, evaluate the disability according to the criteria for limited or painful motion under 38 CFR 4.71a, DC 5003, degenerative arthritis.
Notes:
  • Do not analogously evaluate a disability unrelated to or not included in 38 CFR 4.71a, DCs 5013 through 5024, under these DCs.
  • The provisions of 38 CFR 4.71a, DC 5003, regarding assignment of a compensable minimum evaluation of 10 percent for limited or painful motion are applicable to these DCs when the disability is not more favorably evaluated under the rating criteria for the corresponding joint.
Example:  Right shoulder tendonitis is shown on examination with no pain, 0 to 175 degrees of flexion but otherwise full ROM, and evidence of swelling.  Assign a 10-percent evaluation under 38 CFR 4.71a, DC 5201-5024.
Reference:  For more information on evaluations of 10 and 20 percent based on x-ray findings, see 38 CFR 4.71a, DC 5003, Notes (1) and (2).

5.  Examples of Rating Decisions for LOM in Arthritis Cases

Introduction
This exhibit contains four examples of rating decisions for LOM in arthritis cases evaluated under or analogously to 38 CFR 4.71a, DC 5003 including an example of

Change Date
May 9, 2019

V.iii.1.C.5.a.  Example of Degenerative Arthritis With Separately Compensable Joints Affected
Situation:  The Veteran has residuals of degenerative arthritis with limitation of abduction of the right shoulder (major) to 90 degrees and limitation of flexion of the right knee to 45 degrees.
Coded Conclusion:
1. SC (VE INC)
5003-5201
Degenerative arthritis, right shoulder (dominant)
20% from 12-14-03
5003-5260
Degenerative arthritis, right knee
10% from 12-14-03
COMB
30% from 12-14-03
Rationale:  The shoulder and knee separately meet compensable requirements under 38 CFR 4.71a, DCs 5201 and 38 CFR 4.71a, DC 5260, respectively.

V.iii.1.C.5.b.  Example of Degenerative Arthritis Evaluated Based on X-Ray Evidence Only
Situation:  The Veteran has x-ray evidence of degenerative arthritis of both knees without
  • limited or painful motion of any of the affected joints, or
  • incapacitating episodes.
Coded Conclusion:
1. SC (PTE INC)
5003
Degenerative arthritis of the knees, x-ray evidence
10% from 12-30-01
Rationale:  There is no limited or painful motion in either joint, but there is x-ray evidence of arthritis in more than one joint to warrant a 10-percent evaluation under 38 CFR 4.71a, DC 5003.

V.iii.1.C.5.c.  Example of Noncompensable Degenerative Arthritis of a Single Joint
Situation:  The Veteran has x-ray evidence of degenerative arthritis of the right knee without limited or painful motion.
Coded Conclusion:
1. SC (PTE INC)
5003
Degenerative arthritis, right knee, x-ray evidence only
0% from 12-30-01
Rationale:  There is no limited or painful motion in the right knee or x-ray evidence of arthritis in more than one joint to warrant a compensable evaluation under 38 CFR 4.71a, DC 5003.

V.iii.1.C.5.d.  Example of Degenerative Arthritis Evaluated Based on X-Ray Evidence Only and Another Compensable Evaluation
Situation:  The Veteran has x-ray evidence of degenerative arthritis of both knees without limited or painful motion or incapacitating exacerbations.  The Veteran also has residuals of degenerative arthritis with limitation of abduction of the right shoulder (major) to 90 degrees.
Coded Conclusion:
1. SC (VE INC)
5003-5201
Degenerative arthritis, right shoulder (dominant)
20% from 12-14-03
5257-5003
Degenerative arthritis, right knee
0% from 12-14-03
5257-5003
Degenerative arthritis, left knee
0% from 12-14-03
COMB
20% from 12-14-03
Rationale:  Since the shoulder condition meets compensable requirements under 38 CFR 4.71a, DCs 5201, each knee condition must be evaluated under separate DCs.  Based on Note (1) under 38 CFR 4.71a, DC 5003, ratings of arthritis based on x-ray findings only (without limited or painful motion or incapacitating exacerbations) cannot be combined with ratings of arthritis based on LOM.