Imagine this scenario:
You walk into a barber shop and ask for a shave and a haircut.
The barber sits you down in the chair, and starts madly trimming and cutting. In just a few seconds he is done.
“DONE!” he screams out, excited at his fast work.
To you, that seemed awful quick for a haircut, so you check yourself out in the mirror.
Turns out he only cut the front part of your hair. Why?
“Well, that’s the only part people pay attention to,” he says as he pockets your $15, and turns to his next victim
You might laugh at this story, but this is what the VA is doing – every single day – to Veterans that have service-connected arthritis of the knees.
The way the VA Rates Knee Arthritis turns out to be a bad haircut for many, many Veterans.
So How Should the VA Rate Arthritis of the Knees?
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Stick around and learn – from an insider who has worked hundreds of VA Claims and Appeals since 2007 – how the system REALLY works, and how you can make it work for you.
From the outset, it is important to remember that the VA generally is not permitted to pyramid ratings.
A “pyramid rating” occurs when the same disability is rated under multiple – and sometimes different – diagnoses. 38 CFR § 4.14.
The condition that is the topic of this blog entry – arthritis of the knees – is a little different than most other types of ratings.
In the case of arthritis of the knees, a Veteran may be entitled to 3 separate ratings for the same condition.
This is the case because arthritis of the knees is different from many other medical conditions – typically, it manifests differently for each person.
So, if a Veteran has service-connected arthritis of the knee, the VA Rater should look at 3 factors – and here’s the catch – give a separate rating for each factor that has supporting evidence:
Factor #1: Functional Loss.
The VA should rate your “functional loss” – in other words, the limit to the range of motion, primarily.
In rating this aspect of arthritis of the knee, the VA should focus is on the ability of the knee to perform its normal working movements with normal excursion, speed, strength, coordination and endurance (commonly rated under Diagnostic Codes 5000-5010).
Remember the haircut story above?
This is the part the VA rarely “misses” – like the barber in the story above, this is the part of the haircut that everyone sees.
Factor #2: Instability.
The VA has 3 ways to categorize this aspect when rating arthritis of the knee: slight (10%), moderate (20%), or severe (30%) under Diagnostic Code 5257.
Have your doctor specifically use this language when he/she explains your limitations due to knee arthritis. More important: have your doctor explain WHY your instability is slight, moderate or severe due to the knee arthritis.
Even better, take some Lay Evidence to your doctor and this should help the doctor to determine whether your instability is slight, moderate or severe.
Factor #3: Pain.
Pain is the most common manifestation of arthritis, and though pain is not normally a disability in the VA Rating scheme, when it comes to arthritis of the knee, it can yield a larger rating.
In fact, even if there is no limitation of motion or functional loss (a non-compensable rating), the VA can grant a rating if there is evidence that the range of motion is affected by pain when using the knee in normal repetitive use.
If you have a compensable rating, the VA should recognize, in your rating, how the pain impacts the functional loss of use – in other words, this could lead to an increased rating higher than you otherwise might have had.
Here are a couple examples:
Example 1: Veteran has service-connected arthritis, with limitation to his range of motion at 45 degrees of flexion. However, the Veteran experiences mild instability and pain when he uses his knee repetitively. How should the knee be rated for this Veteran (assuming degenerative arthritis, observable on x-ray):
ANSWER: Diagnostic Code 5003-5260 (or 5010-5260) should be used to assign a 10% rating for the functional loss of use. Diagnostic Code 5257 should be used to assign an additional 10% rating for instability of the knee. Since the impact of the pain is not greater than the limitation of the range of motion, there is no additional evaluation for pain.
Example 2: Veteran has service-connected arthritis of the knee, with no limitation to his range of motion, but severe instability and the pain of the arthritis impedes the Veteran’s functional use at 45 degrees of flexion. How should the knee be rated for this Veteran (assuming degenerative arthritis, observable on x-ray)?
ANSWER: Diagnostic Code 5003-5260 (or 5010-5260) should be used to assign a non-compensable rating for functional loss of use. However, because the pain impedes the use of the knee at a 10% compensable level, a rating of 10% would be appropriate. With severe instability, Diagnostic Code 5257 should be used to assign an additional 30% rating.
Confused about How the VA Rates Knee Arthritis?
Don’t worry. The VA probably is, too. In fact, sometimes talking to the VA about your claim can be like this:
[youtube id=”8pnoQ9w4HNY” width=”550″ height=”310″]
I have seen raters evaluate pain related to service-connected arthritis of the knee in the most unusual (and wrong) ways.
One recent case we looked at rated the arthritis as sciatica – a condition related to the nerves in the spinal cord.
When it comes to arthritis of the knee, it is crucial that you have someone experienced in handling VA Disability Benefits claims take a look at the VA Rating Decision – especially the code sheet.
(If you don’t know what the VA’s code sheet is, you definitely need to talk to a VSO representative or a VA Disability Benefits attorney!) These documents are in your C-File – if you don’t have a copy of your C-File, then you are “shooting blind” in your VA Claim.