Radiculopathy / Peripheral Nerves C&P Exam Prep

Deep Tendon Reflex (DTR) Testing

What it measures: Integrity of specific nerve root pathways; diminished or absent reflexes indicate nerve root or peripheral nerve impairment. Biceps (C5-C6), brachioradialis (C5-C6), triceps (C7), patellar/knee (L3-L4), Achilles/ankle (S1).

What to expect: The examiner will tap specific tendons with a reflex hammer. Responses are graded 0 (absent) to 4+ (hyperreflexic). Absent (0) or diminished (1+) reflexes in the affected extremity are significant neurological findings.

Pain considerations: Reflex testing itself is not painful, but if the examiner strikes the tendon and you feel radiating pain or a shock-like sensation, report this immediately as it may indicate nerve irritability.

Manual Muscle Strength Testing (MRC Scale)

What it measures: Motor function of muscles innervated by specific nerve roots or peripheral nerves. Graded 0/5 (no contraction) to 5/5 (normal strength). Used to determine level of motor paralysis for rating purposes.

What to expect: The examiner will ask you to push or pull against resistance with specific muscle groups (e.g., wrist extension for radial nerve, thumb opposition for median nerve, intrinsic hand muscles for ulnar nerve, dorsiflexion for peroneal nerve, plantar flexion for tibial nerve). Both sides will be compared.

Pain considerations: If muscle testing causes sharp, radiating, or burning pain into the affected extremity, verbalize this during the test. Pain that limits your ability to generate full force is a DeLuca factor that must be documented.

Sensory Testing (Light Touch, Pinprick, Vibratory)

What it measures: Integrity of sensory fibers in specific dermatomal or peripheral nerve distributions. Documents the presence, location, and degree of numbness (hypoesthesia), heightened sensitivity (hyperesthesia), or altered sensation (dysesthesia).

What to expect: The examiner will use a pin, cotton swab, or tuning fork to test sensation across different skin regions, comparing the affected side to the unaffected side. You will be asked to report whether you feel the stimulus and whether it feels normal, diminished, or exaggerated.

Pain considerations: Allodynia (pain from non-painful stimuli such as light touch or clothing) is a significant finding. If the examiner's touch causes pain, clearly state 'that is painful' rather than just reporting it as different sensation.

Tinel's Sign

What it measures: Nerve regeneration or irritability at a specific anatomical site. A positive sign (tingling radiating distally when the nerve is tapped) indicates nerve involvement at that location. Commonly tested at the carpal tunnel (median nerve), cubital tunnel (ulnar nerve), and other entrapment sites.

What to expect: The examiner will lightly tap over specific nerve locations. A positive result feels like a brief electric or tingling sensation that shoots into the fingers or hand (upper extremity) or foot (lower extremity).

Pain considerations: A strong, painful Tinel's response (rather than just tingling) may indicate significant nerve irritability. Report the quality and intensity of any sensation produced.

Phalen's Test

What it measures: Carpal tunnel compression of the median nerve. The wrists are held in forced flexion for up to 60 seconds to reproduce symptoms of carpal tunnel syndrome or median nerve entrapment.

What to expect: The examiner will ask you to press the backs of your hands together with wrists fully flexed for 30-60 seconds. A positive test reproduces numbness, tingling, or pain in the thumb, index, middle, and radial half of the ring finger.

Pain considerations: If the position itself is painful (not just tingling), report both the pain and any tingling/numbness separately, as they may reflect different components of nerve involvement.

Muscle Atrophy Measurement

What it measures: Circumferential measurements of the affected vs. unaffected limb (arm or thigh) to document muscle wasting from denervation or disuse. Atrophy is a hallmark of significant motor nerve impairment.

What to expect: The examiner will use a tape measure to measure the circumference of both limbs at the same anatomical level. A difference of 2 cm or more is generally considered significant.

Pain considerations: Atrophy itself is not painful but may be associated with weakness and pain. Describe any pain you experience in the atrophied muscle or the nerve distribution.

10%

Mild incomplete paralysis. Minor neurological symptoms that are present but cause minimal functional impairment. For neuritis (DC 8620), rated analogously to the nerve affected at the level of incomplete paralysis - mild. Symptoms may include mild, intermittent numbness, tingling, or mild sensory alteration in the distribution of the affected nerve with little or no motor deficit.

From 38 CFR: Under 38 CFR 4.124a, DC 8620 (Neuritis) is rated analogously based on the specific nerve affected. For most peripheral nerves, mild incomplete paralysis corresponds to the lowest rating level (often 10%). The rating reflects substantially less impaired function than complete paralysis.

20%

Moderate incomplete paralysis. Symptoms are more persistent and functionally limiting. Moderate sensory loss in the affected nerve distribution, possible mild-to-moderate motor weakness, diminished reflexes, and symptoms that interfere with work or daily activities.

From 38 CFR: Under 38 CFR 4.124a, moderate incomplete paralysis of the affected nerve. For neuritis (DC 8620), the rating reflects moderate impairment of nerve function with objective clinical findings supporting the level of disability. Functional impairment must be considered in full.

40%

Moderately severe incomplete paralysis. Significant motor and sensory impairment. Marked weakness in muscles innervated by the affected nerve, persistent sensory loss, and functional limitations that substantially impair occupational capacity and daily activities.

From 38 CFR: Under 38 CFR 4.124a, moderately severe incomplete paralysis of the specific nerve. The VA must consider the full clinical picture including motor, sensory, reflex, and functional findings. Muscle atrophy, if present, provides objective evidence supporting this level.

60%

Severe incomplete paralysis. Severe motor and sensory loss approaching but not reaching complete paralysis. Minimal functional use of affected extremity for the specific nerve distribution, profound sensory loss, and near-complete loss of specific motor functions.

From 38 CFR: Under 38 CFR 4.124a, severe incomplete paralysis of the specific nerve. This level requires clinical findings that clearly document near-complete loss of nerve function while still distinguishing from complete paralysis.

80%

Complete paralysis of the specific nerve. Total loss of motor and/or sensory function in the nerve distribution. The specific percentage for complete paralysis varies by nerve (e.g., complete paralysis of the external popliteal nerve is 80%). This level requires objective findings consistent with total nerve dysfunction.

From 38 CFR: Under 38 CFR 4.124a, complete paralysis of the named nerve. Note: DC 8620 (Neuritis) is rated analogously to the specific nerve affected at the level of paralysis present. Complete paralysis ratings vary by nerve (e.g., sciatic: 80%, external popliteal/peroneal: 80%, internal popliteal/tibial: 40%, musculocutaneous: 40%, radial: 70%, median: 70%, ulnar: 60%).

Pain (Neuritis / Neuralgia)

How to describe it: Describe the quality (burning, sharp, stabbing, electric shock-like, aching, throbbing), intensity (0-10 scale on your worst day and typical day), location (specific nerve distribution), radiation pattern (where the pain travels), duration (constant vs. intermittent), and frequency. Explain what makes it worse (activity, prolonged sitting/standing, weather, position changes) and what makes it better (rest, medication, positioning).

Example: On my worst days, I have a constant burning and electric shock sensation running from my lower back down my left leg to the bottom of my foot. It feels like my leg is on fire and someone is stabbing needles into my calf. The pain is a 9/10 and prevents me from sleeping, sitting for more than 15 minutes, or walking more than half a block. Any vibration, like riding in a car, makes it significantly worse.

Examiner listens for: Specific dermatomal or peripheral nerve distribution of pain, quality consistent with neuropathic pain (burning, electric, shooting), factors that aggravate or relieve symptoms, impact on sleep and daily function, and correlation with nerve examination findings.

Avoid: Saying 'it is just some tingling' or 'it only bothers me sometimes' without quantifying how often and how severely. Do not minimize to appear stoic - the examiner rates what you report and documents.

Numbness and Sensory Loss

How to describe it: Identify the specific area that is numb or has altered sensation. Distinguish between complete numbness (cannot feel touch at all), partial numbness (feels like wearing a thick glove or having a layer of cotton between skin and stimulus), tingling (pins and needles), burning sensation, or hypersensitivity (painful response to normal light touch). Describe whether the numbness is constant or intermittent and whether it has spread or worsened over time.

Example: The entire bottom of my right foot and my little toe and ring toe are completely numb - I cannot feel the floor when I walk. I have burned my foot on hot pavement twice because I could not feel the heat. The numbness spreads up my calf when I sit for more than 20 minutes and does not go away even after I stand up.

Examiner listens for: Consistency between reported sensory symptoms and the anatomical nerve distribution, dermatomal pattern suggesting specific nerve root involvement, progression of symptoms, functional safety concerns (falling, burns, inability to detect injury), and bilateral vs. unilateral presentation.

Avoid: Only mentioning numbness when asked directly, failing to describe the extent of the affected area, and not reporting sensory symptoms that cause safety hazards (burns, falls, cuts you did not feel).

Weakness and Motor Loss

How to describe it: Describe specific functional losses: dropping objects, inability to open jars, difficulty buttoning clothes, tripping or foot drop, inability to stand on tiptoes, difficulty climbing stairs, or loss of grip strength. Quantify the weakness by describing what you can no longer do that you previously could. Report whether weakness is constant or worsens with repeated use (DeLuca factor).

Example: My right hand is so weak that I drop my coffee mug at least twice a week without warning. I cannot grip tools at work or open any sealed container. After typing for 10 minutes, my grip strength deteriorates to almost nothing and it takes 2-3 hours to recover. On bad days, I have foot drop on the left side and I have tripped four times in the past year, once resulting in a fall.

Examiner listens for: Specific muscle groups affected (consistent with nerve distribution), functional task limitations, deterioration with repeated use (fatigue-related weakness), safety incidents (falls, injuries), and correlation between reported weakness and objective muscle testing.

Avoid: Pushing through with compensatory strategies (using the unaffected hand) during the exam without telling the examiner why, or demonstrating full strength during a brief exam when typical daily function is much more limited due to fatigue.

Flare-Ups and Intermittent Symptom Patterns

How to describe it: Describe what triggers a flare (physical activity, weather changes, prolonged sitting or standing, specific movements, stress), how long flare-ups last, how frequently they occur, and how severe they are compared to your baseline. Explain what you cannot do during a flare-up that you might be able to do on a good day.

Example: I have flare-ups about 3-4 times per week triggered by walking more than 15 minutes or sitting at a desk. During a flare, the burning pain increases from a 4/10 baseline to an 8-9/10, I lose nearly all grip strength, and I have to lie down for 2-4 hours before the symptoms reduce. I cannot drive, cook, or work during these episodes.

Examiner listens for: Pattern of flare-ups consistent with the nerve condition, triggers that correlate with known aggravating factors for the specific nerve, duration and severity of flare-ups, and functional impact during peak symptom periods. Under M21-1 guidance, the examiner must document the condition at its worst, not just on a good day.

Avoid: Describing only your baseline 'good day' symptoms. Under VA rules, your rating should reflect how the condition impacts you at its worst reasonably anticipated state, including during flare-ups.

Functional and Occupational Impact

How to describe it: Describe specifically how your nerve condition limits your ability to work (specific job tasks you cannot perform), perform self-care (bathing, dressing, cooking, driving), manage household duties, sleep, and participate in recreational activities. Be specific about distances you can walk, how long you can stand or sit, how much weight you can lift, and what activities you have had to stop entirely.

Example: I was a mechanic for 20 years and I had to stop working entirely because I cannot grip tools with my right hand or stand for more than 20 minutes. I cannot drive more than 10 minutes due to leg pain and numbness. I need help putting on my socks and shoes because bending forward compresses the nerve and causes severe shooting pain. I sleep only 3-4 hours per night due to burning leg pain and have to use a cane whenever I leave the house.

Examiner listens for: Specific work tasks that can no longer be performed, ADL limitations that correlate with the nerve affected, need for assistive devices or caregiver assistance, sleep disruption from neuropathic pain, and any hospitalizations or emergency care for nerve-related falls or injuries.

Avoid: Saying 'I manage' or 'I get by' without explaining the compensatory strategies, modifications, and limitations involved. What you do despite your condition is different from what you would be able to do without limitation.

Assistive Device and Adaptive Equipment Use

How to describe it: List every assistive device you use and how often: cane, forearm crutches, ankle-foot orthosis (AFO), wrist splint, TENS unit, wheelchair. Describe when and why you use each device. If prescribed by a physician, bring the prescription. If you use the device only on bad days, state how often bad days occur.

Example: I use a cane every time I leave my house because my left leg gives out without warning due to foot drop and weakness. I wear an AFO brace on my left ankle daily to prevent tripping. My neurologist prescribed both. I also use a wrist brace on my right hand at night for the burning and tingling and sometimes during the day when the pain is severe.

Examiner listens for: Whether assistive devices are prescribed vs. self-obtained, frequency of use, the specific functional necessity for each device, and whether device use is consistent with the objective examination findings.

Avoid: Leaving assistive devices at home to appear more capable during the exam. Bring and use all devices you normally use. The examiner needs to see your actual functional status.