Knee and Lower Leg C&P Exam Prep

Knee Flexion (Active and Passive)

What it measures: Degrees of bending motion from full extension (0-) toward the buttock. Normal is 0-140-.

What to expect: The examiner will have you bend your knee as far as possible while seated or lying down. They will measure the angle with a goniometer. Passive testing means the examiner moves your leg for you. Both weight-bearing and non-weight-bearing positions may be tested per Correia requirements.

Pain considerations: Under DeLuca v. Brown, the examiner must document pain on motion, pain with weight bearing, and whether pain causes functional loss. Tell the examiner: 'I feel sharp pain at approximately [X] degrees of flexion.' If your knee is worse after walking or repeated movement, say so explicitly.

Knee Extension (Active and Passive)

What it measures: Degrees of straightening motion. Normal is 0- (full extension). Limitation of extension is rated under DC 5261.

What to expect: You will be asked to straighten your knee fully. The examiner notes any extensor lag or flexion contracture (inability to fully extend). They will also test passive extension.

Pain considerations: Pain preventing full extension is a ratable finding. Clearly state: 'I cannot fully straighten my knee without pain, and it stops at approximately [X] degrees.'

Instability Testing (Lateral, Anterior-Posterior, Patellar)

What it measures: The degree to which the knee joint moves beyond normal limits in medial-lateral, anterior-posterior, or patellar directions. DC 5257 specifically addresses other impairment including instability.

What to expect: The examiner will apply stress to your knee in various directions while stabilizing your leg. Anterior drawer, posterior drawer, varus/valgus stress tests, and patellar grind/apprehension tests may be performed. The examiner will document mild, moderate, or severe instability.

Pain considerations: Instability accompanied by pain is more significant than painless laxity. Say: 'My knee gives way approximately [X] times per week/month, often causing pain rated [X/10], and I have fallen [X] times in the past year.'

Repetitive Use Testing (DeLuca)

What it measures: Whether ROM worsens after repeated movement, reflecting the functional reality of daily activities. This is legally required under DeLuca v. Brown (1995) and Correia v. McDonald (2016).

What to expect: The examiner may ask you to flex and extend the knee multiple times, then re-measure ROM. You may be asked to walk. The examiner must document whether ROM decreases or pain increases with repeated use.

Pain considerations: You must communicate: 'After walking for [X] minutes my knee swells and range of motion decreases significantly compared to when I started. My pain increases from [X/10] to [X/10].'

Weight-Bearing vs. Non-Weight-Bearing ROM (Correia)

What it measures: Per Correia v. McDonald (2016), ROM must be tested in weight-bearing and non-weight-bearing positions when applicable for the knee. This captures functional limitations during actual use.

What to expect: The examiner may measure flexion while you are standing (weight-bearing) and again while seated or lying down (non-weight-bearing). Differences between these measurements are clinically significant.

Pain considerations: State specifically: 'When I put weight on my knee I can only bend it to approximately [X] degrees before the pain stops me, but lying down I can reach [X] degrees.'

Joint Effusion and Swelling Assessment

What it measures: Presence of fluid accumulation in the knee joint. Frequent episodes of joint effusion are specifically ratable findings on the DBQ.

What to expect: The examiner will visually inspect and palpate your knee for swelling, warmth, and ballottement of the patella (fluid test). They will ask about frequency of swelling episodes.

Pain considerations: Effusion causes both pain and functional limitation. Say: 'My knee swells approximately [X] times per month. The swelling makes it impossible to fully bend my knee and causes an aching pressure pain rated [X/10].'

Muscle Circumference / Atrophy Measurement

What it measures: Thigh or calf circumference compared bilaterally to assess disuse atrophy. Atrophy indicates chronic functional limitation and reduced use of the limb.

What to expect: The examiner uses a tape measure at a specified anatomical landmark above or below the knee on both legs and records the difference in centimeters.

Pain considerations: Atrophy is objective evidence of chronic pain and avoidance. State: 'I have been unable to use my [right/left] knee normally for [X] years, causing noticeable muscle loss compared to my other leg.'

30%

Severe instability: marked laxity on clinical examination consistent with significant ligamentous disruption or patellar instability with objective findings. Under DC 5257 for other impairment of the knee.

From 38 CFR: DC 5257 provides ratings of 30, 20, and 10 percent based on the severity of instability. At 30%, the impairment is characterized by severe instability with marked objective findings on examination.

20%

Moderate instability: moderate laxity on clinical examination with functional limitation. Includes moderate patellar instability or recurrent subluxation with objective findings.

From 38 CFR: DC 5257 at 20% reflects moderate impairment. This level requires objective findings of instability that significantly impair the veteran's ability to perform physical activities.

10%

Mild instability: mild laxity on clinical examination with some functional limitation. Minimum compensable rating for knee instability under DC 5257.

From 38 CFR: DC 5257 at 10% is the minimum compensable evaluation for other impairment of the knee. Objective findings of at least mild instability must be present.

0%

No compensable impairment found, or impairment below the minimum threshold for a 10% rating. The condition may be service-connected at 0% (noncompensable) if a current diagnosis exists with a service nexus.

From 38 CFR: A 0% rating establishes service connection and creates a record for future increases if the condition worsens. It also allows for secondary condition claims.

Pain

How to describe it: Describe pain using a 0-10 scale, specifying location (medial, lateral, anterior, posterior, behind kneecap), character (sharp, aching, burning, throbbing), and triggers (walking, stairs, bending, prolonged sitting, standing, weather changes). Distinguish between baseline daily pain and worst-day pain.

Example: On my worst days, I have constant sharp pain rated 8/10 across the front and inner side of my right knee. I cannot stand for more than 5 minutes, climbing a single step causes stabbing pain, and I need to sit with my leg elevated most of the day. Over-the-counter medications provide minimal relief and I have to plan my entire day around knee pain.

Examiner listens for: Specific pain location and character, relationship of pain to activity or rest, how pain limits specific activities, whether pain wakes the veteran at night, and whether pain is constant or episodic.

Avoid: Saying 'my knee hurts sometimes' or 'it's not that bad.' Avoid minimizing by saying you 'manage' or 'push through' pain - this conceals the true burden. Do not say the pain is a 3/10 if on average it is a 6/10 during activities.

Instability and Giving Way

How to describe it: Describe how often your knee buckles or gives way, specific triggers (pivoting, uneven ground, descending stairs, stepping off a curb), whether you have fallen, and how you compensate (avoiding activities, using a brace, holding railings, shortening stride).

Example: My knee gave way three times last week. Twice going down stairs I had to grab the railing to avoid falling. Once it buckled completely while I was walking across a parking lot on flat ground and I fell, bruising my hand. I now avoid stairs when possible and refuse to walk on uneven terrain without my brace.

Examiner listens for: Frequency of giving-way episodes, circumstances that trigger instability, whether instability has caused falls or injuries, compensatory behaviors, and whether a brace was prescribed and how much it helps.

Avoid: Saying instability only happens 'occasionally' without quantifying it. Not mentioning falls or near-falls. Failing to describe how instability has changed your activities, social life, or employment.

Swelling and Effusion

How to describe it: Describe how often your knee swells, what it looks like (can you see the swelling, does it feel tight), how long it lasts, what triggers it, and how you treat it (ice, elevation, compression, prescription anti-inflammatories, aspiration procedures).

Example: After working a half-day shift I came home with my knee visibly swollen - it looked like a grapefruit and felt like it was going to burst. I had to keep it elevated all evening and night. I could not bend it more than 30 degrees. I could not get comfortable in any position and did not sleep well. The swelling lasted three days. My orthopedist has drained it twice in the last year.

Examiner listens for: Frequency and duration of effusion, whether it has required medical intervention such as aspiration, objective relationship between activity and swelling, and how effusion limits ROM.

Avoid: Saying your knee 'gets a little puffy' instead of describing the full extent. Not mentioning medical visits for swelling management. Minimizing the interference effusion has on sleep, work, and daily function.

Flare-Ups (DeLuca Factor)

How to describe it: A flare-up is a period when your condition is significantly worse than baseline. Describe frequency (how often), duration (how long), severity (pain level, ability to walk, work), triggers (activity, weather, stress), and recovery time.

Example: I have severe flare-ups about twice a month. They last 3-5 days each. During a flare I cannot walk more than 50 feet without stopping, my pain reaches 9/10, I cannot sleep through the night, I cannot drive, and I miss work or cannot perform my job duties. It takes 3-5 days of rest, ice, and prescription anti-inflammatories before I return to my baseline, which is still a 4/10 pain level.

Examiner listens for: The examiner must document flare-up information per M21-1 and DeLuca requirements. They are specifically listening for how much worse you are during a flare compared to baseline and how this limits function.

Avoid: Saying you 'don't really have flare-ups' if your condition fluctuates. The exam is a snapshot - if you happen to be having a moderate day, the examiner will only see that. You must proactively describe your worst days and how frequently they occur.

Weakness and Fatigability (DeLuca Factors)

How to describe it: Describe whether your knee feels weak (difficulty bearing weight, difficulty rising from a chair, difficulty climbing stairs), and whether the knee becomes more painful or limited with extended use over time - meaning after 30 minutes of activity it is worse than at the start.

Example: When I try to climb stairs, my right leg feels like it will collapse. I have to lead with my left leg going up and come down one step at a time holding the rail. After walking for about 15 minutes my knee begins to ache more severely and I have to slow down. After 30 minutes it is so painful I must stop and rest. By the end of a normal work day my knee is significantly more limited than in the morning.

Examiner listens for: Whether weakness causes falls or near-falls, how far the veteran can walk before symptoms increase, whether the veteran can perform weight-bearing activities at work or home, and objective evidence of muscle atrophy.

Avoid: Not mentioning that your knee gets progressively worse with use. Forgetting to describe specific activities you can no longer do due to weakness (kneeling, squatting, lifting while standing, prolonged walking).

Incoordination and Gait Disturbance (DeLuca Factor)

How to describe it: Describe any abnormal gait pattern (limping, antalgic gait), whether you have difficulty with balance, and whether you avoid certain movements entirely due to fear of falling or pain.

Example: I have a noticeable limp that worsens throughout the day. My coworkers and family frequently comment on it. I cannot walk without consciously planning each step to avoid shifting weight onto my right knee. I cannot run, change direction quickly, or walk on uneven ground without losing my balance. I have started using a cane regularly because I no longer trust my knee to hold me.

Examiner listens for: Antalgic gait, changes in walking pattern, fear-avoidance behaviors, use of assistive devices, and whether gait disturbance is supported by objective findings such as atrophy or reduced ROM.

Avoid: Not mentioning an antalgic limp if you have one. Failing to report compensatory movements such as always climbing stairs one step at a time or always parking near the elevator. Not describing the impact of gait disturbance on employment or daily activities.