Vertebral Fracture or Dislocation (Thoracolumbar) C&P Exam Prep

Forward Flexion (Active)

What it measures: How far you can bend forward at the waist; normal is 0-90 degrees. This is the primary driver of your spine disability rating under the General Rating Formula.

What to expect: You will stand and bend forward as far as possible toward your toes. The examiner records the degree at which you stop due to pain or limitation. They will note whether you can touch your fingertips to your knee, mid-shin, or floor.

Pain considerations: Pain that begins during motion and causes you to stop counts toward functional loss even if the measured ROM appears relatively normal. Report the exact degree at which pain begins, not just where you stop. Under DeLuca v. Brown, pain, fatigue, weakness, and incoordination after repetitive use must be documented and can result in a higher effective rating.

Extension (Active)

What it measures: Backward bending of the spine; normal is 0-30 degrees.

What to expect: You will be asked to bend backward. The examiner records the degree of motion and notes pain behavior.

Pain considerations: Extension is frequently more painful than flexion for vertebral fracture patients due to posterior element involvement. Note if extension reproduces or worsens radicular or referred leg pain.

Lateral Flexion - Right and Left (Active)

What it measures: Side bending; normal is 0-30 degrees each direction.

What to expect: You will slide your hand down your outer thigh toward your knee on each side. The examiner documents degrees and pain behavior.

Pain considerations: Pain during lateral flexion often reflects paraspinal muscle involvement and can indicate guarding, which itself is a separately ratable functional loss factor under 38 CFR 4.40 and 4.45.

Rotation - Right and Left (Active)

What it measures: Rotational movement; normal is 0-30 degrees each direction for the thoracolumbar spine.

What to expect: The examiner may stabilize your pelvis and ask you to rotate your upper body. Degrees are recorded.

Pain considerations: Report any nerve pain, muscle spasm, or back pain triggered by rotation. This adds to the overall picture of functional loss.

Passive ROM Testing

What it measures: ROM achieved when the examiner moves your spine (typically via assisted flexion); compared to active ROM to assess pain-limited versus structural limitation.

What to expect: The examiner may gently assist your forward flexion or lateral bending. Any difference between active and passive ROM is noted.

Pain considerations: Pain reproduced on passive motion is objective evidence of functional loss and should be clearly communicated during the exam.

Repetitive Use Testing (DeLuca)

What it measures: Whether ROM decreases or pain worsens after repeated movements - critical for documenting functional loss under DeLuca v. Brown.

What to expect: You may be asked to perform flexion or other movements three times in a row. The examiner records whether motion decreases.

Pain considerations: This is one of the most important and most often overlooked components of the exam. Fatigue and pain during repetitive use are legally required to be documented and factored into the rating.

Straight Leg Raise (SLR) Test

What it measures: Nerve root tension; a positive SLR (pain radiating below the knee when the leg is raised) suggests L4-S1 nerve root involvement (sciatic nerve distribution).

What to expect: While lying flat, the examiner raises your straightened leg. A positive test reproduces pain radiating down the leg, typically below the knee.

Pain considerations: Radiculopathy from a vertebral fracture is separately ratable and can significantly increase your overall combined evaluation. Do not conflate back pain with radicular leg pain - describe each distinctly.

Neurological Examination (Reflexes, Sensation, Motor Strength)

What it measures: Lower extremity reflex integrity (patellar L3-4, Achilles S1), sensory function in dermatomal distributions, and motor strength in specific muscle groups.

What to expect: The examiner will tap your knee and ankle with a reflex hammer, test your ability to feel light touch or pinprick in specific leg areas, and may test your ability to raise your foot or stand on your toes.

Pain considerations: Neurological deficits from vertebral fracture compression of nerve roots are separately ratable from the spine condition itself. Ensure all radicular symptoms are fully described to enable the examiner to complete the radiculopathy section of the DBQ.

Muscle Circumference Measurement (Atrophy)

What it measures: Thigh or calf circumference compared bilaterally to detect disuse muscle atrophy, which can indicate severe or prolonged neurological or functional deficit.

What to expect: The examiner may measure the circumference of both thighs or calves with a tape measure at a specific point above or below the knee.

Pain considerations: Atrophy is an objective physical finding that strengthens the overall claim. If you have experienced leg weakness or decreased use of one limb, this is an important corroborating finding.

100%

Unfavorable ankylosis of the entire spine.

From 38 CFR: Unfavorable ankylosis of the entire spine. Under 38 CFR 4.71a General Rating Formula for Diseases and Injuries of the Spine.

50%

Unfavorable ankylosis of the entire thoracolumbar spine.

From 38 CFR: Unfavorable ankylosis of the entire thoracolumbar spine. Under 38 CFR 4.71a General Rating Formula.

40%

Favorable ankylosis of the entire thoracolumbar spine, OR forward flexion of the thoracolumbar spine 30 degrees or less, OR the combined range of motion of the thoracolumbar spine not greater than 120 degrees with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

From 38 CFR: Forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. General Rating Formula for Diseases and Injuries of the Spine, 38 CFR 4.71a.

20%

Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; OR the combined range of motion of the thoracolumbar spine not greater than 120 degrees; OR muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

From 38 CFR: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. General Rating Formula, 38 CFR 4.71a.

10%

Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; OR combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; OR muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; OR vertebral body fracture with loss of 50 percent or more of the height.

From 38 CFR: Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. General Rating Formula, 38 CFR 4.71a.

Pain - Location, Quality, and Severity

How to describe it: Describe your pain using specific anatomical language: 'I have constant aching pain at the [T12/L1/L2/L3] level of my spine that I rate as a 6 out of 10 at rest and increases to a 9 out of 10 when I bend, lift, or stand for more than 15 minutes.' Include whether the pain radiates - for example: 'The pain travels from my mid-back into my right buttock and down the back of my right leg to my knee.' Distinguish between axial back pain (stays in the spine area) and radicular pain (travels into the extremities following a nerve path).

Example: On my worst days, which happen about three times a week, I wake up with a stabbing pain at the fracture level that rates a 9 out of 10. I cannot sit for more than 10 minutes, I cannot stand without leaning on something, and the pain radiates down both legs causing my feet to feel numb and tingly. I have to use my cane on these days and cannot drive. I have missed work or been unable to perform normal household tasks on these days.

Examiner listens for: Specific anatomical pain location, radiation pattern, pain rating at rest versus activity, frequency of severe episodes, whether pain wakes you from sleep, and whether pain limits specific functional activities.

Avoid: Do not say 'It's not that bad' or 'I manage okay.' Do not minimize pain you experience regularly. Do not describe your best day as your typical day. Do not forget to mention nighttime pain, which is a significant indicator of severity.

Range of Motion and Functional Limitation

How to describe it: Be specific about what movements you cannot do and why: 'I cannot bend forward past my knees because the pain at the fracture site becomes unbearable and I feel like my back will give out. I cannot pick anything up from the floor without kneeling. I cannot put on my own socks without sitting and leaning against a wall.' Quantify limitations: 'I can only stand for about 10 minutes before I have to sit down due to increasing back pain.'

Example: On my worst days, I cannot bend at all from the waist. Even trying to flex forward 10 to 15 degrees causes sharp pain and muscle spasm that makes me gasp. I have to sit on the edge of the bed for 20 minutes before I can stand up straight in the morning. My gait is affected - I walk hunched forward and take small steps because straightening up causes pain.

Examiner listens for: Specific activities limited by pain, morning stiffness duration, how quickly pain returns after rest, whether ROM worsens with repeated movement, and whether you use compensatory movement patterns.

Avoid: Do not perform movements at the exam that you cannot do in daily life. Do not try your hardest to maximize ROM without reporting the pain you experience at each point. Do not forget to mention that bending gets worse the more times you do it - this is the DeLuca factor.

Flare-Ups

How to describe it: Describe flare-up triggers, frequency, duration, and impact: 'My back flares up about two to three times per week. Triggers include sitting longer than 20 minutes, lifting anything over five pounds, walking more than half a block, and cold or damp weather. During a flare, my pain goes from a baseline of 5 to a 9 or 10, I cannot stand or walk without my cane, and the episode lasts between four and eight hours. I sometimes have to lie flat on the floor with a heating pad just to get the pain down enough to function.'

Example: My worst flare-up this month lasted two full days where I could not leave my bed except to use the bathroom. The pain was a constant 10 out of 10, I had severe muscle spasms in my lower back that made any movement agonizing, and I had tingling and weakness in both legs. I could not dress myself, cook, or drive.

Examiner listens for: Flare frequency, duration, specific triggers, severity on a numeric scale, functional limitations during flare, and whether flares require emergency care or increased medication.

Avoid: Do not describe flare-ups as occasional if they happen weekly. Do not forget that the examiner is required to document your description of flare-ups - make sure this information is captured even if you have to proactively volunteer it.

Neurological Symptoms - Radiculopathy

How to describe it: Clearly differentiate radicular from axial pain: 'In addition to back pain, I have constant numbness and tingling in my right leg from my hip to my foot. I also have weakness in my right foot - I trip on uneven ground because I cannot lift my foot properly (foot drop). The right side of my calf feels like it is always partially asleep.' Map the distribution: 'The tingling follows the outside of my right leg down to my little toe.'

Example: On my worst days, the electric shock sensation that goes down my right leg is so severe that I cannot bear any weight on it. My right foot goes completely numb and I have dragged it when walking. I have fallen twice in the past three months because of this weakness.

Examiner listens for: Dermatomal distribution of sensory symptoms, motor weakness pattern, whether symptoms are constant or intermittent, how long symptoms have been present, and whether neurological symptoms correlate with imaging findings.

Avoid: Do not combine radicular leg pain with back pain as if they are the same symptom. Radiculopathy is separately ratable - ensure the examiner documents it in the dedicated radiculopathy section of the DBQ. Do not minimize tingling or numbness as 'just a little pins and needles.'

Fatigue, Weakness, and Incoordination (DeLuca Factors)

How to describe it: Under DeLuca v. Brown, you must describe how your spine condition causes fatigue and weakness beyond the initial movement: 'When I stand for more than 10 minutes, the muscles in my lower back tire rapidly and I begin to lean to one side. After 20 minutes of any physical activity involving my back, I experience a significant increase in pain and my movements become slower and more guarded. My legs feel weak after walking more than one block, and I occasionally stumble.'

Example: On my worst days, I become exhausted from simple tasks like getting dressed or making coffee because every movement requires conscious effort to protect my spine. By noon I am in bed resting due to fatigue from pain management. I cannot complete a grocery shopping trip without sitting or stopping multiple times.

Examiner listens for: Whether symptoms worsen with activity, whether you require rest periods during the day, whether you have had to change jobs or reduce work hours due to back-related fatigue and weakness, and whether you can complete a full day of normal activities.

Avoid: Do not omit fatigue and endurance limitations - these are legally required factors under DeLuca and are explicitly captured in the DBQ (weakness, lack of endurance, incoordination checkboxes). These factors can increase your effective rating even when ROM measurements fall short of a threshold.

Assistive Devices and Accommodations

How to describe it: Be specific about what you use and when: 'I use a single-point cane on my right side whenever I am outside the house or when I am in a flare-up. I wear a lumbar support brace during all physical activity and for standing periods longer than five minutes. I have installed grab bars in my shower and a raised toilet seat because I cannot bend down safely.'

Example: During my worst episodes I use both my cane and my back brace simultaneously. I have also used a wheelchair on two occasions at medical appointments because I could not walk the distance from the parking lot to the clinic.

Examiner listens for: Whether devices are prescribed or self-purchased, how frequently devices are used, whether device use has increased over time, and whether device use is related to spine condition or radiculopathy.

Avoid: Do not forget to bring your actual assistive devices to the exam. Do not underreport usage - if you use a cane three times a week, do not say 'occasionally.' Do not omit braces even if they are over-the-counter.