Knee and Lower Leg C&P Exam Prep

Knee Flexion - Active ROM

What it measures: The degree to which you can bend your knee toward your buttock under your own muscle power. Normal is 0-140 degrees.

What to expect: The examiner will have you bend your knee as far as possible while seated or lying down, and measure the angle with a goniometer. This is performed weight-bearing and non-weight-bearing.

Pain considerations: Under DeLuca v. Brown, pain that limits motion before the anatomical endpoint must be documented. Tell the examiner 'I feel pain at [X degrees] and cannot comfortably go further.' The examiner should document both the pain onset degree and the final ROM endpoint.

Knee Extension - Active ROM

What it measures: The degree to which you can straighten your knee. Normal is 0 degrees (full extension). Limitation of extension (flexion contracture) is separately ratable under DC 5261.

What to expect: Examiner will ask you to straighten your leg fully. Any failure to reach 0 degrees is a flexion contracture and is documented separately.

Pain considerations: Pain on extension may indicate posterior compartment pathology or PCL involvement. Describe the character of pain (sharp, burning, aching) and its location (medial, lateral, posterior).

Passive ROM Testing (Correia Requirements)

What it measures: ROM when the examiner moves your knee without your muscular effort. Passive ROM may differ from active ROM and must be separately documented per Correia v. McDonald.

What to expect: After active ROM testing, the examiner will gently move your knee through its range. They must also note crepitus (grinding sounds/feelings), localized tenderness, and evidence of pain during passive motion.

Pain considerations: The examiner must document whether passive motion causes or worsens pain. If the examiner does not ask, state: 'I feel pain at [X degrees] when you move my knee passively.'

Weight-Bearing vs. Non-Weight-Bearing ROM

What it measures: Whether your ROM differs when your knee bears your body weight versus when you are lying down or seated. Weight-bearing ROM is often more restricted in meniscal pathology.

What to expect: Examiner may test ROM in both standing and supine/seated positions. Report if standing or walking worsens your limitation.

Pain considerations: Weight-bearing pain is a key DeLuca factor. State: 'When I stand or walk, the pain in my knee is [X/10] and I can only walk [X distance] before I must stop.'

Repetitive Use Testing (DeLuca Factors)

What it measures: Whether ROM or pain worsens after repeated use of the joint. Under DeLuca v. Brown, the examiner must assess whether repeated use over time causes additional functional loss.

What to expect: The examiner may ask you to perform repeated knee bends or assess your history of symptom worsening with activity. They must document whether symptoms worsen with use.

Pain considerations: State: 'After I [walk X distance / climb X stairs / stand for X minutes], my knee pain increases from [X] to [Y] out of 10, and I notice more swelling and stiffness that lasts [X hours].'

Joint Locking Assessment

What it measures: The frequency and severity of episodes where the knee mechanically locks in a fixed position due to displaced meniscal cartilage. Under DC 5258, 'frequent episodes of locking' is required for a 20% rating.

What to expect: The examiner will ask about the frequency, duration, and circumstances of locking episodes. Locking is distinct from stiffness - it is a mechanical block to motion caused by cartilage displacement.

Pain considerations: A true locking episode is when the knee mechanically freezes and you cannot extend it. Distinguish this from 'giving way' (instability) or 'stiffness.' Describe the sensation accurately: 'My knee locks in a bent position and I cannot straighten it without [manipulation/resting/pushing on it].'

Joint Effusion Assessment

What it measures: Whether fluid accumulates in the knee joint (effusion/swelling), and how frequently this occurs. Frequent effusion is part of the DC 5258 rating criteria.

What to expect: The examiner will physically examine the knee for effusion (ballottement test, bulge sign) and ask about the frequency and triggers for swelling.

Pain considerations: Effusion often causes a heavy, tight, aching sensation. Describe the pain associated with swelling: 'When my knee swells, I feel a tight pressure inside the joint rated [X/10], and I cannot fully bend or straighten it until the swelling subsides.'

Knee Instability Testing

What it measures: Lateral, medial, anterior, and posterior stability of the knee. Instability may be separately ratable under DC 5257.

What to expect: Examiner will perform varus/valgus stress tests, Lachman test, anterior/posterior drawer tests, and pivot shift test to assess ligamentous integrity.

Pain considerations: Instability often causes fear of falling and activity restriction. Describe: 'My knee gives out [X times per week] when I [activity], which has caused me to [fall/avoid activity/use a brace].'

20%

Cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint. This is the only rating level under DC 5258 and requires all three elements: frequent locking, pain, AND effusion.

From 38 CFR: 38 CFR 4.71a, DC 5258: 'Cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint - 20%.' Note: Per Lyles v. Shulkin, this rating may be assigned simultaneously with separate ratings under DC 5257 (instability) or DC 5261 (limitation of extension), provided each is based on distinct manifestations.

10%

While DC 5258 has only one rating level (20%), veterans with less frequent locking or post-meniscectomy residuals may be rated under DC 5259 (cartilage, semilunar, removed, symptomatic) at 10%. Additionally, after Lyles v. Shulkin, concurrent ratings under DC 5261 (limitation of extension), DC 5260 (limitation of flexion), or DC 5257 (instability) may be appropriate, each potentially contributing to the combined evaluation.

From 38 CFR: DC 5259: 'Cartilage, semilunar, removed, symptomatic - 10%.' Post-Lyles, evaluate whether additional ratings under DC 5257, 5260, or 5261 are warranted based on distinct symptom manifestations.

Joint Locking Episodes

How to describe it: Describe locking as a mechanical event - the knee freezes in position and you cannot extend or flex it without external manipulation or rest. Include frequency (times per week or month), duration (seconds, minutes), triggers (pivoting, stepping off curb, rising from chair), and what resolves it.

Example: On my worst days, my knee locks 3-4 times. The worst episode lasted about 15 minutes where I was completely unable to straighten my leg. I was in the kitchen and had to call my spouse to help me manipulate the knee back into position. The pain during the lock was a 9/10 sharp, stabbing sensation on the inside of my knee.

Examiner listens for: Distinction between true mechanical locking (cartilage displacing and blocking joint movement) versus stiffness or giving way. Frequency that qualifies as 'frequent.' Functional impact of locking episodes.

Avoid: Saying 'my knee sometimes gets stiff' instead of accurately describing mechanical locking. Minimizing frequency by averaging good and bad weeks - report frequency during a typical bad period.

Joint Effusion (Swelling)

How to describe it: Describe how often the knee swells with visible fluid, what activities trigger it, how long it lasts, and how it affects function. Include whether a doctor has drained the joint.

Example: After walking more than half a block, my knee swells significantly - I can see and feel the fluid build-up. The swelling lasts 2-3 days and during that time I cannot fully bend or straighten my knee. I've had my knee drained [X times] by my doctor.

Examiner listens for: Frequency of effusion events, association with locking or activity, whether effusion has been clinically confirmed by a physician, functional limitation caused by effusion.

Avoid: Saying 'my knee sometimes gets puffy' - use precise language like 'my knee joint fills with fluid' and describe the functional limitation this causes.

Knee Pain (Quality, Severity, Location)

How to describe it: Describe pain using the PQRST method: Provocation/Palliation, Quality (sharp, burning, aching, stabbing), Region/Radiation, Severity (0-10 scale), and Timing (constant vs. intermittent). Include pain at rest, with motion, and at worst.

Example: On my worst days, my knee pain is a constant 8/10 aching pain along the medial joint line, which spikes to 10/10 sharp stabbing pain when the knee locks or when I try to walk more than 50 feet. Even at rest I have a baseline pain of 5/10 that wakes me from sleep 2-3 times per week.

Examiner listens for: Pain at rest vs. with motion, pain that limits motion before end-range (DeLuca), pain during weight-bearing, pain that radiates, nighttime pain, and pain that worsens with repeated use.

Avoid: Saying 'my knee is sore' or 'it bothers me sometimes' - provide a specific pain scale, character, location, and functional context. Do not understate chronic baseline pain by only reporting it when asked about worst pain.

Functional Loss and DeLuca Factors

How to describe it: Describe how pain, weakness, fatigability, and incoordination limit your daily activities. Be specific about distances walked, stairs climbed, time standing, and activities avoided. Per DeLuca v. Brown, these factors must be documented by the examiner.

Example: I can walk no more than 50 feet before the pain forces me to stop. After climbing one flight of stairs, my knee is weak and I must hold the railing with both hands. By the afternoon, after minimal activity, my knee is so fatigued and painful that I must elevate it for hours. I can no longer play with my grandchildren, shop without a motorized cart, or perform yard work I used to do daily.

Examiner listens for: Whether ROM or functional capacity decreases after repetitive use, evidence of pain-limited motion, weakness, fatigue, and incoordination affecting locomotion and daily activities.

Avoid: Answering 'I'm doing okay' or 'I manage' - describe the true cost of managing: the compensations, the activities abandoned, and the pain associated with any function you retain.

Flare-Up Description

How to describe it: Describe what triggers a flare-up, how severe it gets, how long it lasts, and what you must do to manage it. Flare-up severity often exceeds baseline and must be separately documented.

Example: My worst flare-ups are triggered by walking more than a block, cold weather, or prolonged sitting. During a flare, the knee swells visibly, locks 2-3 times, and pain reaches 10/10. I am bedridden for 1-3 days, require prescription anti-inflammatories, ice, and elevation, and cannot perform any weight-bearing activity.

Examiner listens for: Whether flare-up ROM limitation would change the rating, frequency and predictability of flare-ups, and whether flare-up severity exceeds the baseline examination findings.

Avoid: Saying 'I have good days and bad days' without specifying what bad days actually involve. The examiner should be rating your bad days, not your average days.

Assistive Device Use

How to describe it: Report every assistive device used, how frequently, and for what activities. Include braces, canes, crutches, walkers, and wheelchairs. Note whether the device was prescribed by a physician.

Example: I wear a prescribed knee brace every day for walking and standing. On my worst days I also use a single cane in my right hand to offload weight from my left knee. Without the brace, I cannot walk to my mailbox without the knee giving way or locking.

Examiner listens for: Physician-prescribed vs. self-selected devices, frequency of use, functional necessity of the device, and whether the device fully resolves the functional limitation.

Avoid: Leaving the device in the car because you don't want to 'look like you need it' - always bring and use any device that helps you on examination day.