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Updated Nov 08, 2021
In This Section
This section contains the following topics:
Topic
Topic Name
1
2

1.  Osteomyelitis

Introduction

 This topic contains information about osteomyelitis, including

Change Date

 November 8, 2021

V.iii.1.D.1.a.  Historical Evaluation for Osteomyelitis

 Both the 10-percent evaluation and that part of the 20-percent evaluation that is based on “other evidence of active infection within the last five years” are
  • historical evaluations, and
  • based on recurrent episodes of osteomyelitis.
Note:  The 20-percent historical evaluation based on evidence of active infection within the past five years must be distinguished from the 20-percent evaluation authorized when there is a discharging sinus.

V.iii.1.D.1.b.  Assigning Historical Evaluations for Osteomyelitis

 An initial episode of active osteomyelitis is not a basis for either of the historical evaluations. Assign the historical evaluation as follows:
  • When the first recurrent episode of osteomyelitis is shown
    • assign a 20-percent historical evaluation, and
    • extend the evaluation for five years from the date of examination showing the osteomyelitis to be inactive.
  • Assign a closed evaluation at the expiration of the five-year extension.
  • Assign the 10-percent historical evaluation only if there have been two or more recurrences of active osteomyelitis following the initial infection.

V.iii.1.D.1.c.  Reasons to Discontinue a Historical  Evaluation for Osteomyelitis

 Do not discontinue the historical evaluation, even if treatment includes saucerization, sequestrectomy, or guttering, because the osteomyelitis is not considered cured. Exception:  If there has been removal or radical resection of the affected bone
  • consider osteomyelitis cured, and
  • discontinue the historical evaluation.

V.iii.1.D.1.d.  Constitutional Symptoms of Osteomyelitis

 Constitutional symptoms are a prerequisite to the assignment of a 60-percent evaluation under 38 CFR 4.71a, diagnostic code (DC) 5000. Under the 100 percent criteria, as discussed in M21-1, Part V, Subpart iii, 1.D.1.e, the presence of continuous constitutional symptoms is one facet for consideration in the assignment of the 100-percent evaluation. When the evaluation of osteomyelitis is based on constitutional symptoms, it is not subject to the amputation rule. References:  For more information on the
  • amputation rule, see 38 CFR 4.68, and
  • historical policy interpretation of the requirement for constitutional systems for 100-percent evaluations, see the attachment Historical_M21-1V_iii_1_SecD_9-15-21.

V.iii.1.D.1.e.  Criteria for a 100-Percent Osteomyelitis Evaluation

 The plain language of 38 CFR 4.71a, DC 5000 does not require an active infection to establish a 100-percent evaluation for osteomyelitis.  Demonstration of chronic, acute, or subacute osteomyelitis with any of the following warrants entitlement to a 100-percent evaluation:
  • involvement
    • of the pelvis
    • of the vertebrae, or
    • extending into the major joints
  • with multiple locations, or
  • with a long history of intractability and debility, anemia, amyloid liver changes, or other continuous constitutional symptoms.
Note:  The guidance in this block represents a change in the Department of Veterans Affairs policy related to the evaluation of osteomyelitis at the 100-percent rate as effected by the holding of the Court of Appeals for Veterans Claims in Huerta v. McDonough, 34 Vet.App. 76 (2021), decided on April 27, 2021. Reference:  For more information on assigning effective dates based on judicial precedents, see M21-1, Part V, Subpart ii, 4.A.6.n.

V.iii.1.D.1.f.  Active Osteomyelitis Associated With Noncompensable Amputation

 When the evaluation for amputation of an extremity or body part affected by osteomyelitis would be zero percent, assign a 10-percent evaluation if there is active osteomyelitis.

V.iii.1.D.1.g.  Application of the Amputation Rule to Evaluations for Osteomyelitis
Use the following table to determine how the amputation rule affects evaluations assigned for osteomyelitis.
If the osteomyelitis evaluation is …
Then the amputation rule …
10 percent based on active osteomyelitis of a body part where the amputation evaluation would normally be zero percent
does not apply.
  • 10 percent based on active osteomyelitis of a body part where the amputation evaluation would normally be zero percent, or
  • 30 percent or less under 38 CFR 4.71a, DC 5000, and
  • the 10-percent evaluation is combined with evaluations for
    • ankylosis
    • limited motion
    • nonunion or malunion
    • shortening, or
    • other musculoskeletal impairment
applies to the combined evaluation.
Note:  For osteomyelitis of the vertebrae or pelvis, extending into major joints, or affecting multiple locations, refer to the final row of this table.
60 percent based on constitutional symptoms of osteomyelitis, per 38 CFR 4.71a, DC 5000
does not apply since the 60-percent evaluation is based on constitutional symptoms.
100 percent, as described in M21-1, Part V, Subpart iii, 1.D.1.e (including osteomyelitis of the pelvis or extending into the major joints)
does not apply.
Reference:  For more information on the amputation rule, see

2.  Examples of the Proper Rating Procedure for Osteomyelitis

Introduction
This exhibit contains eight examples of the proper procedure for rating osteomyelitis, including an example of evaluating

Change Date
November 8, 2021

V.iii.1.D.2.a.  Example of Evaluating Osteomyelitis Based on a History of a Single Active Initial Episode
Situation:  The Veteran was diagnosed with osteomyelitis in service with discharging sinus.  At separation from service the osteomyelitis was inactive with no involucrum or sequestrum.  There is no evidence of recurrence.
Result:  As there has been no recurrence of active osteomyelitis following the initial episode in service, the historical evaluation of 20 percent is not for application.  The requirements for a 20-percent evaluation based on activity are not met either.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia
0% from 12-2-93
Note:  For the scenarios discussed in M21-1, Part V, Subpart iii, 1.D.2.a–h, when the scenario involves dates, review the scenarios as if the actions are being taken at or near the time of the evidence presented in each scenario.  In other words, for the purposes of reviewing these scenarios only, do not apply protection of evaluation under 38 CFR 3.951(b).

V.iii.1.D.2.b.  Example of Evaluating an Active Initial Episode of Osteomyelitis
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.a, but the Veteran had a discharging sinus at the time of separation from service.
Result:  The Veteran meets the criteria for a 20-percent evaluation based on a discharging sinus.  Schedule a future examination to ascertain the date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
20% from 12-2-93
Reference:  For more information on the assignment of a 20-percent evaluation when there is a discharging sinus, see M21-1, Part V, Subpart iii, 1.D.1.a and b.

V.iii.1.D.2.c.  Example of Evaluating Osteomyelitis Following Review Exam for Initial Active Episode
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.b.  Subsequent review examination reveals the sinus tract was healed and there is no other evidence of active infection.
Result:  Since the Veteran has not had a recurrent episode of osteomyelitis since service, a historical rating of 20 percent is not for application.  Take rating action under 38 CFR 3.105(e).
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 12-2-93
0% from 3-1-95

V.iii.1.D.2.d.  Example of Evaluating Osteomyelitis With Current Discharging Sinus
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.b.  The Veteran is hospitalized July 21, 1996, with active osteomyelitis of the right tibia shown with discharging sinus.  There is no involucrum, sequestrum, or constitutional symptom.  Upon release from the hospital the discharging sinus is still present.
Result:  Assign the 20-percent evaluation based on evidence showing draining sinus from the proper effective date.  Schedule a future examination to ascertain date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
0% from 3-1-95
20% from 7-21-96
Reference:  For more information on the assignment of a 20-percent evaluation when there is a discharging sinus, see M21-1, Part V, Subpart iii, 1.D.1.a and b.

V.iii.1.D.2.e.  Example of Evaluating Osteomyelitis With a Historical Evaluation Following a Single Recurrence With Scheduled Reduction Due to Inactivity
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.d.  A routine future examination was conducted on July 8, 1997, showing the osteomyelitis to be inactive.  There was no discharging sinus, no involucrum, sequestrum, or constitutional symptom.  The most recent episode of active osteomyelitis (July 21, 1996) constitutes the first “recurrent” episode of active osteomyelitis.
Result:  Continue the previously assigned 20-percent evaluation, which was awarded on the basis of discharging sinus as a historical evaluation for five years from the examination showing inactivity.  Assign a future ending date for the historical 20-percent evaluation 5 years from the date evidence shows inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 7-21-96
0% from 7-8-02
References:  For more information on

V.iii.1.D.2.f.  Example of Evaluating a Recurrence of Osteomyelitis
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.e.  In October 1999, the Veteran was again found to have active osteomyelitis with a discharging sinus, without involucrum, sequestrum, or constitutional symptoms.
Result:  Continue the 20-percent evaluation.  Reevaluation is necessary to remove the future reduction to zero percent and to schedule a future examination to establish the date of inactivity.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, active
20% from 7-21-96

V.iii.1.D.2.g.  Example of Evaluating Osteomyelitis Following Second Recurrence
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.f.  A review examination was conducted on April 8, 2000.  The examination showed the discharging sinus was inactive, and there was no other evidence of active osteomyelitis.  The most recent episode of osteomyelitis (October 1999) constitutes the second “recurrent” episode of active osteomyelitis.
Result:  The historical evaluations of 20 and 10 percent both apply.  Continue the 20-percent evaluation based on the historical criteria requiring activity within the past 5 years.  Assign a future ending date for the 20-percent evaluation 5 years from the date of last activity via assigning the lower 10-percent evaluation based on the historical criteria requiring inactive osteomyelitis following repeated episodes without active infection in the past 5 years.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, inactive
20% from 7-21-96
10% from 4-8-05
References:  For more information on

V.iii.1.D.2.h.  Example of Evaluating Osteomyelitis Following Curative Resection of Affected Bone
Situation:  Same facts as example shown in M21-1, Part V, Subpart iii, 1.D.2.g.  The Veteran was hospitalized June 10, 2002, with a recurrent episode of active osteomyelitis.  A radical resection of the right tibia was performed and at hospital discharge (June 21, 2002), the osteomyelitis was shown to be cured.
Result:  Assign a temporary total evaluation of 100 percent under 38 CFR 4.30 with a 1-month period of convalescence.  Following application of 38 CFR 3.105(e), reduce the evaluation for osteomyelitis to zero percent as an evaluation for osteomyelitis will not be applied following cure by removal or radical resection of the affected bone.
Coded Conclusion:
1. SC (PTE INC)
5000
Osteomyelitis, right tibia, P.O.
20% from 7-21-96
100% from 6-10-02 (Par. 30)
20% from 8-1-02
0% from 10-1-02

V.iii.1.D.2.i.  Example of Evaluating Chronic Osteomyelitis
Situation:  During active service, a Veteran sustained an injury requiring a bone graft from the pelvis.  A year later, the Veteran was found to have osteomyelitis at the site of the bone graft.  Symptoms were treated with a course of antibiotics.  The Veteran’s symptoms recurred four years later.  Surgical intervention was utilized to treat soft tissue residuals of the osteomyelitis infection.  A chronic sinus tract was found during the surgery.  Two years later, the bone graft site again became infected and was treated with antibiotics, incision, and drainage.  An x-ray confirmed active osteomyelitis at that time.  A follow-up record one year later confirmed no further drainage or symptoms.  Further treatment and follow-up was recommended as physicians suspected that the disease process continued.  However, records thereafter reveal no further treatment.
The Veteran submitted a claim for service connection twenty years after the treatment of the last active episode.  No current active infection or symptomatology is shown.
Result:  Assign a 100-percent evaluation based on the history of chronic osteomyelitis extending into the pelvis.