Elbow, Other Impairment (Flail Joint / Joint Fracture Nonunion / Head of Radius Fracture) C&P Exam Prep

Elbow Flexion (Active and Passive)

What it measures: The degree to which the veteran can bend the elbow from full extension (0-) toward the shoulder. Normal flexion endpoint is 145-.

What to expect: The examiner will ask you to actively bend your elbow as far as possible, then may passively move your arm to assess passive ROM. The endpoint in degrees will be recorded. The examiner will note whether pain is produced and at what point in the arc pain begins.

Pain considerations: Tell the examiner exactly where in the arc of flexion pain begins (e.g., 'Pain starts at 80 degrees and becomes severe by 60 degrees'). Per 38 CFR 4.59, painful motion can justify rating at the point where pain begins, not just the final endpoint.

Elbow Extension (Active and Passive)

What it measures: The degree to which the veteran can straighten the elbow from a flexed position back toward 0- (full extension). An extension deficit means the arm cannot fully straighten.

What to expect: The examiner will ask you to fully straighten your elbow. Any deficit from full extension (e.g., 'extension limited to 30- means there is a 30- flexion contracture) will be recorded. Both active and passive measurements may be taken.

Pain considerations: Pain on attempted extension should be described by location (e.g., lateral, medial, posterior elbow) and by the degree at which it begins. Rest pain at the elbow should also be reported as it supports a higher severity finding.

Forearm Pronation (Active and Passive)

What it measures: The ability to rotate the forearm so the palm faces downward. Normal pronation endpoint is 80-. This motion is evaluated separately from elbow flexion/extension per M21-1.

What to expect: With your elbow at 90- flexion, the examiner will ask you to rotate your forearm so the palm faces the floor. The degree of available pronation will be measured with a goniometer. Passive motion may also be assessed.

Pain considerations: Pain with pronation, especially over the radial head, is a classic finding with ununited radial head fractures. Describe the pain as sharp, aching, or catching, and whether it radiates. Note if activities like using a screwdriver, opening jars, or turning a door handle are painful or impossible.

Forearm Supination (Active and Passive)

What it measures: The ability to rotate the forearm so the palm faces upward. Normal supination endpoint is 85-. Evaluated separately from elbow and wrist motion per M21-1.

What to expect: With elbow at 90-, the examiner asks you to turn the palm upward as far as possible. Degree of motion is measured and documented. Passive motion may also be tested.

Pain considerations: Supination is often more painful than pronation in radial head fracture cases. If you have complete loss of supination, tell the examiner you cannot carry a plate level, turn a doorknob fully, or receive objects in an outstretched hand.

Instability / Flail Joint Assessment

What it measures: Whether the elbow exhibits abnormal motion or lacks structural integrity (flail joint), indicating complete functional loss of the joint as a stable lever.

What to expect: The examiner will apply gentle stress to assess medial, lateral, and rotatory stability. They will observe for abnormal motion beyond the normal range (hypermobility), false joint movement (pseudoarthrosis), and whether the joint can bear functional load.

Pain considerations: Instability itself causes pain and functional loss beyond what ROM measurements capture. Describe how instability prevents you from performing weight-bearing tasks with the affected arm (e.g., pushing up from a chair, doing push-ups, carrying groceries).

Muscle Circumference / Atrophy Measurement

What it measures: Whether disuse atrophy has developed in the arm, forearm, or biceps due to reduced use of the affected extremity. Measured in centimeters at specified anatomical locations.

What to expect: The examiner will use a tape measure to compare the circumference of the affected and unaffected upper arm or forearm at the same anatomical level on both sides. A difference suggests muscle wasting from disuse.

Pain considerations: Disuse atrophy often develops because pain makes it too uncomfortable to use the limb fully. Tell the examiner how long you have been avoiding certain activities and what activities you have abandoned.

60%

Flail joint of the elbow, major (dominant) extremity.

From 38 CFR: 38 CFR 4.71a DC 5209: Flail joint, major extremity = 60%.

50%

Flail joint of the elbow, minor (non-dominant) extremity.

From 38 CFR: 38 CFR 4.71a DC 5209: Flail joint, minor extremity = 50%.

20%

Joint fracture with marked cubitus varus or cubitus valgus deformity, OR joint fracture with ununited fracture of the head of the radius. Rating is the same for major and minor extremity at this level.

From 38 CFR: 38 CFR 4.71a DC 5209: Joint fracture, with marked cubitus varus or cubitus valgus deformity, or with ununited fracture of head of radius = 20% (major and minor).

Pain on Motion (DeLuca Factor)

How to describe it: Describe the location of pain (e.g., lateral elbow at the radial head, medial elbow, posterior elbow over the olecranon), the type of pain (sharp, aching, burning, stabbing), and at exactly what point in the range of motion pain begins. Distinguish between pain on active motion, pain on passive motion, and pain at rest.

Example: On my worst days, I cannot bend my elbow past 90 degrees before a sharp pain at the outer elbow stops me completely. Any attempt to turn my palm up causes a grinding pain at the side of my elbow that makes me drop things. The pain continues for hours after any activity.

Examiner listens for: Specific degree at which pain begins, pain location tied to anatomical structures, whether pain limits motion before the structural endpoint is reached, presence of rest pain, and whether pain causes functional loss beyond the measured ROM.

Avoid: Do not say 'it just hurts a little' or 'I manage.' Say exactly where pain begins in the arc and how it stops you from completing the motion or the task at hand.

Instability and Giving Way (Flail Joint / Nonunion)

How to describe it: Describe episodes where the elbow 'gives way,' feels unstable, or buckles under load. Note whether you avoid carrying objects, pushing, or pulling because the elbow cannot be trusted to hold. If a physician has told you the elbow is structurally unstable or has a false joint, use those terms.

Example: On my worst days, my elbow buckles when I try to pick up anything heavier than a coffee cup. I dropped a full gallon of milk because my elbow gave way without warning. I cannot push myself up from a chair using that arm at all.

Examiner listens for: Spontaneous giving way under load, avoidance of specific activities due to instability risk, prior injuries caused by the instability, and whether there is objective abnormal motion in the joint.

Avoid: Do not minimize instability as 'a little weak.' Describe it as structural failure of the joint under functional demand.

Fatigue and Lack of Endurance with Repetitive Use (DeLuca Factor)

How to describe it: Describe how the elbow performs over time during repeated activities. Note that the first repetition may feel manageable but subsequent ones become progressively more painful, weak, or limited. Quantify how many repetitions you can perform before you must stop.

Example: I can type or write for maybe five minutes before the elbow starts aching and my grip weakens. By the tenth minute, I have to stop entirely. On bad days, even one minute of repetitive hand use causes the elbow to ache for the rest of the day.

Examiner listens for: Whether ROM decreases, pain increases, or weakness develops with repetitive use - all of which are required to be documented per DeLuca v. Brown. The examiner must note if repetitive motion testing worsens functional findings.

Avoid: Do not only report your resting or initial ROM. Proactively tell the examiner: 'My range of motion gets worse after I use it repeatedly, and I would like that documented.'

Weakness (DeLuca Factor)

How to describe it: Describe inability to perform tasks requiring grip, lifting, pushing, or pulling. Quantify the limitation: maximum weight you can lift, whether you can carry a bag, shake hands firmly, or open a tight jar. Note if the weak extremity is the dominant hand.

Example: On my worst days I cannot lift a gallon of water, open a childproof cap, or shake someone's hand without the elbow giving a sharp jolt of pain. My grip on that side is probably half of what it used to be and my arm tires out far faster than the other side.

Examiner listens for: Functional limitations directly caused by weakness, whether weakness is constant or episodic, comparison to the unaffected side, and whether tasks requiring stable elbow positioning are impossible.

Avoid: Do not say 'I'm a little weak' without examples. Give concrete functional equivalents: 'I can only lift 5 pounds before pain forces me to stop.'

Flare-Ups (DeLuca Factor)

How to describe it: Describe the frequency (how often), duration (how long each lasts), severity (pain level, functional impact), and triggers (weather changes, overuse, sleep position, stress). Note what you cannot do during a flare-up that you can partially do on a good day.

Example: I have flare-ups two to three times a week, typically triggered by any overhead work or lifting. During a flare, my elbow swells, becomes hot to the touch, and any motion beyond 45 degrees of flexion is impossible. I need to ice it and rest for 24 to 48 hours before I regain even my baseline limited function.

Examiner listens for: Objective triggers, measurable frequency and duration, functional impact during flare-ups versus baseline, and whether the flare-up pattern reflects the chronic, variable nature of the condition.

Avoid: Do not say 'I sometimes have bad days.' Quantify: 'I have severe flare-ups approximately twice per week lasting 1-2 days each.'

Incoordination (DeLuca Factor)

How to describe it: Describe any loss of fine motor control, trembling, or inability to perform precise movements with the affected hand/arm due to the elbow instability or pain. Note tasks like writing, buttoning, typing, using utensils, or handling small objects that have become difficult or impossible.

Example: On my worst days, I cannot write legibly because my elbow shakes when I try to hold it at the angle needed for writing. I drop small objects frequently and can no longer thread a needle or handle coins reliably.

Examiner listens for: Whether incoordination is caused by structural elbow instability, pain avoidance, or neurological compromise from the elbow condition (e.g., ulnar nerve irritation), and how it affects occupational and daily functional tasks.

Avoid: Do not attribute incoordination only to 'nervousness.' Describe it as a functional consequence of the elbow impairment.