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VA Rating Assistant

DC 7117 · 38 CFR 4.104

Raynaud's Syndrome C&P Exam Prep

To evaluate the current severity of Raynaud's Syndrome (primary or secondary) based on frequency and duration of vasospastic episodes, skin and tissue changes, and functional impairment of affected extremities under Diagnostic Code 7117.

Format:
Interview + Physical
Typical duration:
30-45 minutes
DBQ form:
Artery_and_Vein (Artery_and_Vein)
Examiner:
Vascular Surgeon, Cardiologist, or Internal Medicine

What the examiner evaluates

  • Whether the condition is Primary Raynaud's Disease (DC 7117 analog) or Secondary Raynaud's Syndrome and the underlying cause
  • Frequency, duration, and severity of vasospastic episodes (color changes: white/blue/red sequence)
  • Presence and severity of trophic changes (skin atrophy, nail changes, hair loss on digits)
  • Necrosis or gangrene of the fingers or toes
  • Numbness and paresthesia at the tips of fingers or toes
  • Pain in hands or feet during physical activity or at rest
  • Persistent coldness of affected extremities
  • Diminished upper or lower extremity pulses
  • Intermittent or persistent ulceration of digits
  • Functional impact on occupational and daily activities
  • Which extremities are affected (right upper, left upper, right lower, left lower)
  • Current medications and treatment history including surgical interventions
  • Associated or secondary conditions (e.g., scleroderma, lupus, hypothyroidism)

The exam will include a structured interview about episode history and a physical examination of hands, fingers, feet, and toes. The examiner will assess skin color, temperature, texture, pulse quality, and any tissue changes. Cold exposure testing is rarely performed in the C&P setting but prior cold provocation test results are highly relevant. Bring photos of episodes if available.

Measurements and tests

Clinical Assessment of Vasospastic Episodes

What it measures: Frequency (number of episodes per day/week/month), duration (minutes to hours), and severity of color change sequences (blanching/cyanosis/erythema) in digits

What to expect: The examiner will ask detailed questions about how often episodes occur, what triggers them (cold, stress, vibration), how long they last, and which fingers/toes are affected. They will inspect digits for current color, skin quality, and trophic changes.

Critical thresholds

  • Episodic attacks only, no permanent changes Potentially 10%-20% depending on frequency and duration
  • Trophic changes plus episodic attacks 20%-40% range depending on severity
  • Bilateral involvement with persistent coldness, trophic changes, and numbness 40%-60% range
  • Necrosis or gangrene of digits 60%-100% range; may warrant separate ratings for digit loss

Tips

  • Be prepared to describe your most severe and most typical episodes separately - report your worst days accurately
  • Quantify: 'I have approximately 3-5 episodes per day in cold weather lasting 20-40 minutes each'
  • Describe all three phases if they occur: white (pallor), blue (cyanosis), red (reactive hyperemia with burning pain)
  • Note which specific fingers are affected and whether feet/toes are also involved
  • If you have photos of your hands/feet during an attack, bring them - episodes cannot be induced at exam

Pain considerations: Accurately describe burning, aching, or throbbing pain during the hyperemic rewarming phase; pain during physical activity in the hands; and any baseline pain at rest between episodes. Note whether pain prevents use of hands for tasks.

Pulse Assessment (Diminished Upper/Lower Extremity Pulses)

What it measures: Adequacy of peripheral arterial blood flow to affected extremities; the examiner will palpate radial, ulnar, dorsalis pedis, and posterior tibial pulses

What to expect: The examiner will palpate pulses at the wrist and foot. Diminished or absent pulses may indicate more severe vascular compromise and will be noted on the DBQ.

Critical thresholds

  • Normal pulses with episodic symptoms only Lower rating range
  • Diminished pulses at rest Supports higher rating; indicates persistent vascular insufficiency

Tips

  • Inform the examiner if your pulses have been previously documented as diminished
  • Note whether your hands feel cold to touch even when not in a full vasospastic episode
  • Mention if prior vascular studies (Doppler ultrasound, cold stress testing) showed abnormal flow

Pain considerations: Persistent coldness of the extremity between episodes is a separately rated feature under DC 7117 and should be specifically described.

Skin and Tissue Examination (Trophic Changes Assessment)

What it measures: Permanent tissue damage resulting from chronic ischemia: skin atrophy, shiny skin, loss of digital hair, nail dystrophy, scarring at fingertips, digital pitting scars

What to expect: The examiner will visually inspect and palpate the skin and nails of affected digits. They will note atrophy, texture changes, nail deformity, scars, ulcerations, or any gangrenous tissue.

Critical thresholds

  • No trophic changes Lower severity rating
  • Beginning trophic changes (mild nail changes, early skin atrophy) Supports 20%-30% rating
  • Established trophic changes (significant atrophy, nail dystrophy, digital pitting scars) Supports 40%-60% rating
  • Ulceration or necrosis of digits Supports 60%+ rating; may require additional evaluation

Tips

  • Do not minimize visible changes - point out any shiny skin, thin skin, nail deformities, or fingertip scars
  • Mention any history of digital ulcers even if currently healed
  • Inform the examiner of any prior hospitalizations for severe Raynaud's episodes or digital ischemia

Pain considerations: Trophic skin changes can cause chronic sensitivity and pain with touch; describe any hyperalgesia or allodynia at fingertips.

Functional Impairment Assessment

What it measures: Impact of Raynaud's on occupational activities, activities of daily living, and any need for assistive devices or environmental modifications

What to expect: The examiner will ask how the condition affects your work and daily life. They will document loss of function in affected extremities and any assistive devices used.

Critical thresholds

  • Minimal limitation of fine motor tasks during attacks only Lower end of rating scale
  • Significant limitation of hand use with inability to work in cold environments Mid to higher rating range
  • Near-complete loss of digital function or inability to perform most occupational tasks Highest rating range

Tips

  • Describe specific tasks you cannot perform: buttoning clothing, typing, holding cold objects, working outdoors
  • Describe environmental limitations: inability to work in air-conditioned spaces, freezer sections, cold climates
  • Note how many hours per day your hands are functionally limited due to active or recovering episodes
  • Describe any job changes, accommodations, or loss of employment attributable to this condition

Pain considerations: Functional limitation during and after episodes (residual numbness and weakness during the rewarming phase) should be communicated explicitly, as the examiner needs to document loss of affected function.

Rating criteria by percentage

10%

Raynaud's phenomenon with episodic attacks of vasospasm but without persistent trophic changes, necrosis, or significant functional impairment. Attacks are mild to moderate in frequency.

Key symptoms

  • Episodic color changes in fingers (white/blue/red) with cold exposure or stress
  • Mild numbness or tingling during episodes
  • Normal or near-normal skin and nail appearance between episodes
  • Minimal functional limitation

From 38 CFR: Symptomatic Raynaud's with attacks triggered by cold or emotional stress, resolving completely between episodes, no permanent skin or tissue damage.

20%

Raynaud's with more frequent episodes, beginning trophic changes, persistent numbness or paresthesia at digit tips, and/or mild persistent coldness of extremities between attacks.

Key symptoms

  • Frequent episodic attacks (multiple times per week)
  • Beginning trophic changes: early nail changes, mild skin atrophy
  • Numbness and paresthesia at fingertip tips persisting between attacks
  • Mild persistent coldness of affected extremity
  • Diminished pulses in upper extremity

From 38 CFR: Attacks occurring in warm as well as cold conditions; early trophic changes beginning to manifest; paresthesia persisting beyond attack resolution.

40%

Established trophic changes, persistent coldness, frequent and prolonged vasospastic attacks, painful crises, bilateral involvement, or significant functional loss of affected extremities.

Key symptoms

  • Established trophic changes (significant skin atrophy, nail dystrophy, digital pitting scars)
  • Persistent coldness of extremity at baseline
  • Frequent attacks lasting more than 2 hours
  • Pain in hands at rest or during minimal activity
  • Bilateral extremity involvement
  • Significant limitation of fine motor function

From 38 CFR: Daily vasospastic attacks with established trophic tissue changes, inability to work in any temperature-variable environment, persistent pain requiring medication, bilateral hand involvement with grip weakness.

60%

Severe Raynaud's with necrosis or gangrene of the fingers, deep ischemic ulcers, or near-total loss of functional use of affected extremities.

Key symptoms

  • Necrosis of the fingers or toes
  • Deep ischemic ulcers of digits
  • Gangrene of one or more digits
  • Severely diminished or absent peripheral pulses
  • Extreme functional impairment of affected hands or feet
  • Persistent severe pain requiring strong analgesics or procedural intervention

From 38 CFR: Digital necrosis requiring debridement or amputation; ischemic ulcers resistant to healing; complete loss of fine motor function in dominant hand due to ischemic changes.

Describing your symptoms accurately

Vasospastic Episode Description

How to describe it: Describe the full sequence: which fingers or toes turn white (cold and numb), then blue/purple (painful), then red and burning upon rewarming. Specify exact fingers affected, average duration, frequency per day/week, and what triggers them (cold air, cold water, air conditioning, stress, vibration).

Example: On my worst days, all five fingers on both hands turn completely white within seconds of touching anything cold. The episodes last 30-45 minutes and the rewarming phase is extremely painful - a burning, throbbing sensation like pins and needles. This happens 4-6 times a day in winter and I cannot function during or for about 20 minutes after each episode.

Examiner listens for: Specific triggers, frequency, duration, bilateral vs. unilateral pattern, completeness of color change sequence, functional disability during and after attacks, and whether attacks occur at room temperature or only with cold exposure.

Avoid: Saying 'my fingers just get cold sometimes' - this minimizes a vascular condition. Instead accurately describe the full triphasic color change, the pain during rewarming, and how many times per day your function is disrupted.

Trophic Changes and Tissue Damage

How to describe it: Describe any visible permanent changes to your skin and nails: thinning or shiny skin on fingertips, loss of digital hair, nail deformities (ridging, brittleness, thickening), pitting scars at fingertips, healed or active ulcers. Point these out directly to the examiner during the physical exam.

Example: My fingertips are permanently shiny and thin - the skin tears easily. My nails on my right hand are deformed and grow in ridged and brittle. I have a small scar on the tip of my right index finger from a digital ulcer that took three months to heal. My fingertips are constantly sensitive to touch.

Examiner listens for: History of digital ulcers, current skin and nail appearance, whether trophic changes are progressive, any prior treatment for tissue breakdown, whether changes are permanent or reversible.

Avoid: Failing to mention healed ulcers or scars because they are 'better now.' Permanent trophic changes and healed ulcers are evidence of severity and should be described and pointed out physically.

Pain and Sensory Symptoms

How to describe it: Describe three separate pain components: (1) pain during the white/ischemic phase - deep, aching coldness; (2) pain during rewarming - burning, throbbing, pins and needles; (3) baseline pain or paresthesia between attacks - persistent numbness, tingling, or sensitivity at fingertips. Rate each on a 0-10 scale.

Example: During an attack, my pain reaches 8/10 during the blue phase - a deep, crushing cold ache. During rewarming it shifts to a burning 9/10 sensation. Between attacks, I have persistent numbness in my index and middle fingers that never fully goes away - about a 3/10 constant tingling that makes it hard to feel textures or button my shirt.

Examiner listens for: Whether pain is episodic only or persistent, severity ratings, how pain limits hand function, whether paresthesia is inter-episode (suggesting permanent nerve or tissue change), and whether pain is managed with medications.

Avoid: Saying 'it hurts during episodes' without specifying the phases, intensity, duration of pain, and any residual pain between attacks. The examiner needs to distinguish episodic from persistent pain.

Functional Impact and Occupational Limitations

How to describe it: Specifically describe what you cannot do because of this condition. Include: inability to work in cold environments, difficulty with fine motor tasks (writing, typing, buttoning, handling small objects), inability to hold cold items, avoidance of outdoor work in cold weather, any job accommodations or changes made, and how many hours per day your hands are functionally unreliable.

Example: On bad days I cannot type for more than 10 minutes before triggering an episode. I had to leave my job as a line cook because I could not work near the walk-in cooler. I wear gloves indoors in air conditioning and carry chemical hand warmers. Getting dressed takes twice as long because I cannot feel the buttons on my shirt during or after an attack.

Examiner listens for: Specific occupational and daily activities affected, whether condition has caused job loss or change, environmental accommodations required, duration of daily functional limitation, and whether bilateral involvement creates compounding impairment.

Avoid: Saying 'I just avoid the cold' without describing what that avoidance actually costs you in terms of employment, independence, and quality of life. Environmental restriction IS functional impairment.

Persistent Coldness and Vascular Changes

How to describe it: Describe any baseline cold temperature of affected extremities that persists even when NOT in a vasospastic attack. Note whether hands or feet feel permanently cooler than the rest of your body, whether others have commented on it, and whether it is worse on one side.

Example: My hands are cold to the touch even in warm rooms when I am not having an active attack. My wife says my hands always feel like ice. My right hand is noticeably colder than my left. My doctor measured my finger temperature and noted it was significantly lower than normal even at rest.

Examiner listens for: Whether coldness is persistent vs. episodic, bilateral vs. unilateral, whether it correlates with diminished pulses, and whether temperature records or prior Doppler studies confirm persistent vascular insufficiency.

Avoid: Treating persistent baseline coldness as a trivial symptom - it is a separately documented feature of DC 7117 severity and should be communicated clearly.

Common mistakes to avoid

Underreporting episode frequency because the exam day happens to be a better day

Why: VA rating is based on the condition as it typically exists, not just on the day of the exam. Raynaud's is episodic and unlikely to occur during a warm clinic visit.

Do this instead: Report your average frequency and your worst-day frequency explicitly. Bring a symptom log showing episodes over the past 3-6 months. State clearly: 'Today is not representative of my typical condition - I average X episodes per day.'

Impact: All rating levels - frequency is a primary driver of severity determination

Failing to bring documentation of prior vascular studies or cold provocation tests

Why: The examiner cannot induce a Raynaud's attack in the clinical setting. Objective documentation from cold stress testing, Doppler studies, or thermography is critical evidence.

Do this instead: Gather all prior vascular lab results, cold stress test reports, thermography results, and clinic notes documenting vasospastic episodes. Submit these to VA prior to the exam and bring copies.

Impact: All rating levels - objective evidence strengthens rating at every tier

Not mentioning all affected extremities - especially feet/toes

Why: The DBQ separately documents right upper, left upper, right lower, and left lower extremity involvement. Bilateral or multi-extremity involvement supports higher ratings.

Do this instead: Report involvement of all extremities affected, including feet and toes if applicable. If any extremity is only mildly affected, still report it accurately.

Impact: 40%-60% range where bilateral and multi-extremity involvement is critical

Failing to mention trophic changes or pointing them out during physical exam

Why: Trophic changes are a specific rating factor under DC 7117. If the examiner does not examine the skin and nails closely, these findings may be missed.

Do this instead: During the physical exam, specifically say: 'I'd like to show you some skin and nail changes I've noticed.' Point out shiny fingertips, nail deformities, digital scars, and any current or healed ulcers.

Impact: 20%-60% - trophic changes separate lower ratings from higher ones

Not reporting the condition as it was at its worst over the past year

Why: M21-1 guidance instructs examiners to evaluate the condition as it typically exists and at its worst, not just at the moment of examination.

Do this instead: Describe your worst recent period: 'Over this past winter, my condition was at its worst. I had attacks 6-8 times daily lasting up to an hour each. I want to make sure the examiner understands that today's presentation is not my worst.'

Impact: All rating levels

Omitting psychological and social impact of the condition

Why: Functional impairment for VA purposes includes inability to work, social limitations, and need for lifestyle modifications - all relevant to establishing true disability level.

Do this instead: Describe how Raynaud's has affected employment (inability to work in cold environments, job changes), social activities (avoiding outdoor activities, restaurants with strong AC), and relationships (partner/family accommodation of condition).

Impact: Functional impairment section - relevant across all levels especially 40%+

Not disclosing secondary conditions that may be driving the Raynaud's

Why: Secondary Raynaud's Syndrome (DC 7117) occurs in the context of connective tissue diseases (scleroderma, lupus, MCTD), hypothyroidism, or other conditions. These may themselves be ratable and service-connectable as secondary conditions.

Do this instead: Accurately disclose any associated diagnoses. These may support secondary service connection or additional ratings. The DBQ specifically distinguishes Primary Raynaud's Disease from Secondary Raynaud's Syndrome.

Impact: Service connection and combined ratings - affects overall compensation package

Prep checklist

  • critical

    Compile a written symptom diary covering the past 3-6 months

    Document episode frequency per day/week, average duration, worst-day duration, specific triggers, all extremities affected, and any treatments used. Bring this to the exam and offer it to the examiner as supporting documentation.

    before exam

  • critical

    Gather all prior vascular diagnostic test results

    Collect cold provocation test results, digital Doppler studies, thermography reports, nail fold capillaroscopy results, and any vascular surgery or cardiology records. Submit to VA records and bring copies to the exam.

    before exam

  • critical

    Obtain and review your current C-file and relevant service treatment records

    Identify any service records documenting cold injury, cold-weather operations, complaints of cold hands or feet, or diagnoses of Raynaud's. Bring these to confirm the evidentiary record is complete.

    before exam

  • critical

    Take photographs of your hands and feet during an active vasospastic attack

    Photos showing the white (pallor), blue (cyanosis), or red (erythema) phases are powerful objective evidence. Also photograph trophic changes, nail deformities, and any digital scars or ulcers. Date-stamp all photos.

    before exam

  • critical

    List all medications taken for Raynaud's syndrome

    Include calcium channel blockers (nifedipine, amlodipine), vasodilators (sildenafil), topical nitrates, aspirin, and any experimental treatments. Note dosages and dates started. Use of medication demonstrates treatment-refractory severity.

    before exam

  • recommended

    Document any surgical or procedural treatments received

    Note any cervical sympathectomy, digital sympathectomy, botulinum toxin injections, or other vascular procedures. Collect operative and procedure reports with dates.

    before exam

  • recommended

    Prepare a written functional impact statement

    Write a concise 1-2 page description of how Raynaud's affects your work, daily activities, and quality of life. Include specific tasks you cannot perform, jobs you cannot hold, and accommodations you require. Submit as a buddy statement or personal statement prior to exam.

    before exam

  • recommended

    Identify and document any associated conditions (secondary Raynaud's drivers)

    If diagnosed with scleroderma, lupus, mixed connective tissue disease, hypothyroidism, or other conditions associated with secondary Raynaud's, document these and consider whether secondary service connection claims should be filed.

    before exam

  • recommended

    Request a buddy statement from someone who witnesses your episodes

    A spouse, family member, or coworker who has observed your attacks and their impact on your functioning can submit a VA buddy statement (VA Form 21-4142a). This provides corroborating lay evidence.

    before exam

  • recommended

    Dress appropriately but do not over-bundle to avoid triggering an attack en route

    Wear your typical protective clothing (gloves, layered warm clothing) if cold weather is present, but arrive in a condition that reflects your normal state. Do not artificially warm your hands before the exam as this could mask the persistent coldness that is a rating factor.

    day of

  • critical

    Bring all gathered documentation in a clearly organized folder

    Organize: (1) symptom diary, (2) medical records, (3) test results, (4) medication list, (5) photos of episodes and trophic changes, (6) functional impact statement, (7) buddy statements. Offer copies to the examiner.

    day of

  • recommended

    Avoid warming or cold-conditioning your hands artificially before the exam

    Do not soak hands in warm water to reduce appearance of trophic changes or coldness. The examiner's assessment of your actual skin temperature, color, and texture is part of the physical evaluation.

    day of

  • optional

    Confirm your right to record the examination if applicable in your state

    Veterans have the right to record C&P examinations in many states. Bring a recording device and inform the examiner at the start that you intend to record for your personal records. Check your state's law on single vs. dual party consent.

    day of

  • critical

    Proactively identify your worst-day presentation to the examiner

    At the start of the exam clearly state: 'I want to make sure you know that today is not representative of my worst days. My condition fluctuates significantly and is much worse in cold weather and during stressful periods. I'd like to describe my typical and worst presentations.' This contextualizes any appearance of normalcy on exam day.

    during exam

  • critical

    Describe all three phases of vasospastic attacks in sequence

    Explain the triphasic response: pallor (white, cold, numb), cyanosis (blue/purple, aching), and erythema (red, burning, throbbing pain). Specify which phases you experience - some patients have only biphasic or monophasic attacks, which is also clinically relevant.

    during exam

  • critical

    Physically point out trophic changes and skin findings during the examination

    When the examiner examines your hands, actively guide attention: 'These fingertips are shiny and thin - that started about 2 years ago. This scar is from a digital ulcer. My nails are ridged and brittle compared to how they used to be.' Do not assume the examiner will notice all findings independently.

    during exam

  • critical

    Accurately report the full extent of extremity involvement

    Report all affected extremities: upper and lower, right and left. If your feet and toes are also affected, explicitly state this. Clarify dominant hand if relevant to functional impairment assessment.

    during exam

  • critical

    Report frequency and duration of attacks using specific numbers

    Avoid vague terms like 'often' or 'a lot.' Use: 'I average 3-4 attacks per day in cold weather, each lasting 20-40 minutes. My worst attack lasted over 2 hours. In summer I may have 1-2 per week, but in winter it is daily or multiple times daily.'

    during exam

  • critical

    Describe functional impairment in specific occupational terms

    Name the specific tasks you cannot do: 'I cannot work as a [job title] because the environment is too cold.' 'I cannot hold a pen for more than 5 minutes without triggering an attack.' 'I require gloves and hand warmers even indoors in air conditioning.'

    during exam

  • recommended

    Ask the examiner to document the duration of attacks (>2 hours threshold)

    The DBQ has a specific checkbox for attacks lasting an average of more than 2 hours each. If your worst attacks meet this threshold, make sure you clearly communicate this and ask whether this is being documented.

    during exam

  • critical

    Request a copy of the completed DBQ examination report

    You are entitled to a copy of the C&P examination report. Request it from the VA facility or monitor your VA.gov records. Review it for accuracy once available - especially the episode frequency, duration, trophic changes, and functional impact sections.

    after exam

  • critical

    File a supplemental statement if the examination report contains inaccuracies

    If the DBQ report does not accurately reflect what you reported (e.g., episode frequency is understated, trophic changes are not documented), submit a signed personal statement correcting the record as quickly as possible.

    after exam

  • recommended

    Continue documenting symptoms in a diary between exam and rating decision

    Maintain a daily log of attacks, duration, severity, and functional impact. If your condition worsens before a rating decision, you can submit updated evidence. This also creates a strong record for future increased rating claims.

    after exam

Your rights during a C&P exam

  • You have the right to request a copy of your C&P examination report under the Privacy Act; monitor VA.gov or submit a Privacy Act request to the examining facility.
  • You have the right to record your C&P examination in most states; check your state's consent laws and inform the examiner at the start of the exam if you choose to record.
  • You have the right to submit additional evidence (medical records, buddy statements, personal statements, photographs) before and after your C&P examination until a final rating decision is issued.
  • You have the right to request a new C&P examination if you believe the original examination was inadequate, used an incorrect examination protocol, or did not address all claimed symptoms.
  • You have the right to have a Veterans Service Organization (VSO) representative, accredited claims agent, or attorney present during your C&P examination as an advocate or observer.
  • You have the right to challenge a C&P examination report you believe is inaccurate by submitting a Notice of Disagreement (NOD), requesting a Higher-Level Review (HLR), or filing a Supplemental Claim with new and relevant evidence.
  • You have the right to request that the VA obtain a private medical opinion (nexus letter) to supplement or rebut findings from the C&P examiner.
  • You have the right to have all relevant service treatment records, VA medical records, and private medical records considered by the examiner before the DBQ is finalized.
  • Under the PACT Act and benefit of the doubt standard (38 CFR 3.102), when evidence is in approximate balance, the decision must be made in your favor.
  • You have the right to request an earlier effective date if you can demonstrate the condition was inadequately rated in a prior decision or if CUE (Clear and Unmistakable Error) occurred in a prior rating.

Related conditions

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.