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C&P Exam Prep: Above-Knee Amputation of Thigh

DC 5161 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
amputations
Form Code
amputations
Page Count
6
Examiner Type
Orthopedic Surgeon, Physiatrist, or Prosthetist
Estimated Duration
30-60 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the level, nature, and functional consequences of an above-knee (transfemoral) amputation of the thigh under Diagnostic Code 5161, establishing the appropriate disability rating based on amputation level, stump condition, prosthetic use, and residual functional impairment.

What the examiner evaluates:

  • Exact anatomical level of amputation (upper third, middle or lower third of thigh)
  • Stump condition: length, shape, skin integrity, adherent scars, neuroma, bone spurs, or edema
  • Prosthetic use: type of prosthesis worn, hours per day of use, functional effectiveness
  • Whether amputation is improvable by prosthesis or not improvable due to stump condition
  • Presence of a defective stump requiring re-amputation or surgical revision
  • Hip joint range of motion and residual hip flexion contracture
  • Phantom limb pain, residual limb pain, and stump pain
  • Assistive device use: wheelchair, crutches, cane, walker, or brace
  • Functional mobility: ability to walk, stand, transfer, and perform activities of daily living
  • Secondary conditions: back pain, contralateral limb overuse, skin breakdown, fall history
  • Bilateral lower extremity amputation status if applicable
  • Disarticulation at the hip or transpelvic amputation status

Bring your prosthesis and any assistive devices to the exam. Wear clothing allowing easy access to the residual limb and hip. The examiner will physically inspect the stump, assess hip ROM, and observe your gait and transfers. Arrive early to ensure adequate time. You have the right to request the exam be recorded in most states.

Typical duration: 30-60 minutes

Amputation Level Determination

The anatomical level of transfemoral amputation measured as a fraction of the distance from the ischial tuberosity to the knee joint line, determining rating tier under DC 5161

What to expect:

Examiner will measure the residual limb length and compare it to the total femoral segment length to classify as upper third, middle third, or lower third amputation. Disarticulation at the hip (DC 5160) or transpelvic amputation (DC 5163) may also be documented.

Key thresholds:

  • Upper third (proximal one-third of distance from ischial tuberosity to knee) — 100% - amputation of the thigh at the upper third
  • Middle or lower third — 90% - amputation of the thigh at the middle or lower third
  • Defective stump (non-functional, requiring re-amputation or surgical revision) — 100% - amputation with defective stump, same rate as upper-third amputation
  • Not improvable by prosthesis (stump condition prevents prosthetic fitting) — 100% - amputation not improvable by prosthesis
  • Hip disarticulation (complete removal of femur) — 100% - disarticulation involving complete removal of the femur (DC 5160)
  • Transpelvic amputation (complete removal of femur and loss of part of pelvis) — 100% - transpelvic amputation (DC 5163)

Tips:

  • Know the exact date of your amputation and the surgical report findings to help the examiner document the level accurately.
  • If your stump has changed over time due to revision surgeries, bring documentation of each procedure.
  • Ensure the examiner documents whether the amputation is at the upper third versus middle/lower third, as this is the key distinction for the 100% versus 90% rating.
  • If your stump is non-functional or has been recommended for revision by your treating physician, make sure this is clearly communicated and supported by medical records.

Pain considerations: Phantom limb pain and residual limb (stump) pain during measurement and examination should be reported immediately to the examiner. Describe the quality (burning, stabbing, cramping), frequency, severity (0-10 scale), and duration of any pain experienced during or after the exam.

Stump Condition Assessment

Physical integrity and functional status of the residual limb, including skin condition, scar tissue, neuromas, bone prominences, edema, and socket fit

What to expect:

The examiner will visually inspect and palpate the residual limb. They will assess for skin breakdown, ulcers, adherent or painful scars, neuroma formation, heterotopic ossification, bony prominence, and overall stump shape. Socket fit issues with the prosthesis will be noted.

Key thresholds:

  • Defective stump: painful, unstable, or non-functional; prevents prosthetic use — 100% - qualifies as defective stump under DC 5161
  • Stump not improvable by prosthesis due to medical or anatomical factors — 100% - documented inability to benefit from prosthesis
  • Functional stump with successful prosthetic fitting — 90% (middle/lower third) or 100% (upper third) based on level

Tips:

  • Report all stump skin problems, including blisters, sores, rashes, folliculitis, contact dermatitis, or cysts that develop from prosthetic socket use.
  • Describe how often you must remove your prosthesis due to stump pain, skin breakdown, or discomfort.
  • If you have neuromas (painful nodules), identify their exact location and describe how they are triggered.
  • Bone spurs or heterotopic ossification that press against the socket should be described in terms of the pain and limitation they cause.
  • If your stump has changed shape (atrophy, weight gain/loss) requiring frequent socket adjustments, document this.

Pain considerations: Stump pain, particularly when weight-bearing on the prosthesis or during transfers, should be described in detail. Note whether pain worsens with prolonged use (DeLuca fatigue factor), whether it causes you to remove the prosthesis, and how it affects sleep, mobility, and daily function.

Hip Joint Range of Motion (Residual Limb Side)

Flexion, extension, abduction, adduction, and rotation of the hip joint on the amputated side, which directly affects prosthetic gait and functional ambulation

What to expect:

The examiner may measure active and passive hip ROM using a goniometer. Hip flexion contracture (inability to fully extend the hip) is particularly important as it affects prosthetic alignment and gait. Weight-bearing and non-weight-bearing assessments may be performed per Correia requirements.

Key thresholds:

  • Hip flexion contracture > 20 degrees — Significantly impacts prosthetic gait quality and functional ambulation; supports higher functional impairment documentation
  • Hip abductor weakness or Trendelenburg gait — Documents gait instability and fall risk, supports assistive device requirements

Tips:

  • Report any pain with hip movement before, during, and after range of motion testing.
  • Inform the examiner if you have a hip flexion contracture that prevents you from walking with a normal gait pattern.
  • Note if pain or fatigue increases after repeated hip movements (DeLuca repetitive-use factor).
  • If you experience pain with weight-bearing through the residual limb during gait, explicitly state this.
  • Active ROM (what you can do yourself) may be less than passive ROM (what the examiner can move you through); both matter.

Pain considerations: Any pain with hip flexion, extension, abduction, or rotation must be reported to the examiner during testing. Describe whether the pain is in the residual limb, hip joint, groin, or lower back. Note how pain limits your hip motion and whether it occurs with every movement or only at end-range.

Prosthetic Functional Assessment

Type, frequency, and effectiveness of prosthetic use; hours per day worn; functional mobility level achieved with prosthesis; reasons for limited use or non-use

What to expect:

The examiner will ask about your prosthesis type (conventional, microprocessor-controlled knee, osseointegrated), how many hours per day you wear it, what activities you can perform with it, and what prevents greater use. They may observe your gait with the prosthesis.

Key thresholds:

  • Prosthesis worn and functional (walks independently) — Rating based on amputation level (90% or 100%); functional capacity documented separately
  • Prosthesis worn but significantly limited use (<4 hours/day or unable to ambulate independently) — Supports documentation of functional impairment beyond base amputation rating; may support SMC claims
  • Cannot use prosthesis (stump not improvable) — 100% - not improvable by prosthesis; also supports SMC (k) or higher if loss of use of extremity
  • Requires wheelchair as primary mobility device — Supports Special Monthly Compensation (SMC) for loss of use; documents severe functional impairment

Tips:

  • Bring your prosthesis to the exam and wear it if possible so the examiner can observe your functional gait.
  • Be specific about how many hours per day you wear your prosthesis and why you cannot wear it longer.
  • Describe the K-level classification your prosthetist has assigned and whether it accurately reflects your functional ability.
  • If you use a microprocessor knee or other advanced prosthesis, describe its limitations as well as its benefits.
  • Report falls, near-falls, or gait instability that occur even with prosthesis use.

Pain considerations: Describe pain that occurs specifically with prosthetic use, including socket pressure pain, residual limb abrasions, and lower back or contralateral hip pain from altered gait mechanics. Note how pain during prosthetic use limits walking distance, speed, and duration.

Functional Mobility and Assistive Device Assessment

Distance able to walk with and without prosthesis, transfers (bed, car, toilet), stair climbing, fall history, and required assistive devices

What to expect:

The examiner will ask about your daily mobility, including walking distance, speed, terrain limitations, and need for canes, crutches, walker, or wheelchair. They may observe transfers and ambulation. All assistive devices should be brought to the exam.

Key thresholds:

  • Requires wheelchair as primary means of mobility — Supports SMC (l) for loss of use of extremity at or above the knee
  • Requires crutches or cane for all ambulation with prosthesis — Documents significant functional impairment; supports higher combined rating and SMC consideration
  • Unable to perform transfers independently — Supports Aid and Attendance (SMC-l or higher) consideration

Tips:

  • Bring all assistive devices you use: wheelchair, crutches, cane, walker, and prosthesis.
  • Be honest about your worst-day mobility - how far can you walk on your worst day, not your best?
  • Describe specific terrain limitations: stairs, inclines, uneven surfaces, curbs.
  • Report if you have fallen in the past 12 months due to prosthetic instability or balance issues.
  • Describe your morning routine and how the amputation affects getting out of bed, bathing, dressing, and driving.

Pain considerations: Report pain that limits walking distance (DeLuca fatigue and pain after repetitive use), pain when transferring, and back pain caused by compensatory gait mechanics. Describe how pain at end-of-day differs from pain at start of day.

Estimate

Rating Criteria Breakdown

100% Amputation of the thigh at the upper third (proximal one-thi ...

Amputation of the thigh at the upper third (proximal one-third of the distance from the ischial tuberosity to the knee joint line). Also applies to: amputation with defective stump (non-functional or requiring re-amputation); amputation not improvable by prosthesis controlled by natural knee action; hip disarticulation (DC 5160); or transpelvic amputation (DC 5163).

Key Symptoms

  • Amputation level confirmed at upper third of thigh
  • Defective stump: painful, unstable, non-functional, or requiring surgical revision
  • Stump condition prevents functional prosthetic fitting
  • Hip disarticulation with complete removal of femur
  • Transpelvic amputation with loss of part of pelvis
  • Unable to use prosthesis due to stump pathology
  • Neuromas, heterotopic ossification, or bony prominences preventing socket use
  • Skin breakdown or chronic ulceration preventing prosthetic wear

CFR: Under 38 CFR 4.71a DC 5161: 100% assigned for amputation at the upper third of the thigh. Also 100% for defective stump and for amputation not improvable by prosthesis. DC 5160 (hip disarticulation) and DC 5163 (transpelvic amputation) also rated at 100%.

90% Amputation of the thigh at the middle or lower third (any le ...

Amputation of the thigh at the middle or lower third (any level below the upper third and above the knee joint). The stump must be functional and the amputation must be improvable by prosthesis.

Key Symptoms

  • Amputation level confirmed at middle or lower third of thigh
  • Functional residual limb capable of prosthetic use
  • Stump improvable by prosthesis controlled by natural knee action
  • May have residual pain, phantom pain, or skin problems but stump remains functional
  • Prosthetic gait may be impaired but amputation level is middle or lower third

CFR: Under 38 CFR 4.71a DC 5161: 90% assigned for amputation of the thigh at the middle or lower third with a functional stump improvable by prosthesis.

How to Describe Your Symptoms

Stump Pain and Phantom Limb Pain

How to describe:

Clearly distinguish between residual limb (stump) pain and phantom limb pain. For stump pain, describe the location (end of stump, over bony prominence, at scar), character (burning, stabbing, aching, pressure), severity (0-10), frequency (constant vs. intermittent), and triggers (socket wear, pressure, temperature). For phantom pain, describe the perceived location in the missing limb, character, and whether it is constant or episodic.

Worst-day example:

“On my worst days, the burning in my residual limb reaches a 9 out of 10 and starts within 20 minutes of putting on my prosthesis. I have to remove the prosthesis and spend the rest of the day in my wheelchair. The phantom cramping in my missing foot wakes me up 3-4 times per night and can last 30 to 45 minutes each episode.”

What the examiner listens for:

Specific pain descriptors that indicate neuroma or skin breakdown; relationship between prosthetic use and pain onset; nighttime phantom pain disrupting sleep; pain that prevents or limits prosthetic wear hours; need for pain medication before prosthetic activities.

Understatements to avoid:

Saying 'I have some pain sometimes' without specifying how it limits your function, duration, and frequency. Failing to mention phantom pain because you think it 'doesn't count' since there is no physical limb present - it absolutely counts and must be documented.

Prosthetic Use Limitations

How to describe:

Describe exactly how many hours per day you can wear your prosthesis, what forces you to remove it, what activities you cannot perform even with the prosthesis, and how your function has changed over time. Include the type of prosthesis (conventional vs. microprocessor-controlled) and any socket fit problems.

Worst-day example:

“On my worst days I can only wear my prosthesis for two to three hours before the stump skin breaks down or the pain becomes unbearable. I then switch to my wheelchair for the remainder of the day. Even on better days, I cannot walk more than one city block before I need to stop and rest due to residual limb pain and fatigue in my back and hip.”

What the examiner listens for:

Total daily prosthetic wear time; specific reasons for discontinuing use; functional limitations despite prosthetic use; fall history with prosthesis; inability to navigate stairs, inclines, or uneven terrain; need for additional assistive devices even when wearing prosthesis.

Understatements to avoid:

Only describing your best prosthetic day rather than your typical or worst day. Failing to mention that you use a wheelchair, crutches, or cane in addition to or instead of your prosthesis on difficult days.

Stump Condition and Skin Integrity

How to describe:

Describe any recurring skin problems on the residual limb, including blisters, sores, rashes, folliculitis, fungal infections, or chronic ulcerations. Note how often these occur, how long they take to heal, whether they have required medical treatment, and whether they prevent prosthetic use during healing.

Worst-day example:

“I develop pressure sores at the distal end of my stump approximately once every 6-8 weeks. These sores take 2-3 weeks to fully heal, during which time I cannot wear my prosthesis at all and must use my wheelchair exclusively. I have had to go to the VA wound clinic three times in the past year for treatment.”

What the examiner listens for:

Frequency and duration of skin breakdown episodes; need for medical intervention; periods of complete prosthetic non-use due to skin problems; scarring or wound history on residual limb; whether skin problems are worsening over time.

Understatements to avoid:

Saying your skin 'gets irritated sometimes' without quantifying how often, how severely, and for how long it prevents prosthetic use and forces wheelchair reliance.

Functional Mobility and Daily Activities

How to describe:

Describe your worst-day functional capacity: shortest walking distance, slowest speed, which activities of daily living you cannot perform independently, how long it takes to complete basic tasks like getting dressed, bathing, and preparing meals. Include stairs, driving, and community mobility.

Worst-day example:

“On my worst days I cannot walk more than 50 feet even with my prosthesis before I need to sit down from pain and fatigue. I cannot climb stairs without holding both railings and having someone spot me. I take over 45 minutes to get dressed in the morning due to difficulty donning the prosthesis and the pain involved. I cannot stand long enough to cook a meal and rely on my spouse for most household tasks.”

What the examiner listens for:

Specific functional distances and time limitations; named activities of daily living that are impaired; need for assistance from another person; fall history and near-falls; inability to work or participate in leisure activities; sleep disruption from pain.

Understatements to avoid:

Describing only what you can do on a good day. Saying 'I manage okay' when in reality you have adapted your entire lifestyle around the amputation limitations. Failing to mention secondary back, hip, or contralateral knee pain that further limits your function.

Secondary and Associated Conditions

How to describe:

Describe conditions that have developed as a direct result of the amputation and altered biomechanics, including low back pain from compensatory gait, contralateral hip or knee arthritis from overuse, psychological impact (depression, PTSD, anxiety about falling), and cardiovascular deconditioning from reduced activity.

Worst-day example:

“Since my amputation, I have developed severe lower back pain from walking with an uneven gait. My right (intact) knee has deteriorated significantly from bearing extra weight, and my orthopedist says I will likely need a knee replacement. I also struggle with depression because I can no longer participate in activities I used to enjoy, and I am afraid to go out alone because I fear falling.”

What the examiner listens for:

Documented secondary conditions linked to the amputation; treatment being received for secondary conditions; whether secondary conditions are separately service-connected or claimed; how secondary conditions compound the functional impairment from the amputation.

Understatements to avoid:

Failing to mention back pain, contralateral limb problems, or psychological symptoms because you think they are separate issues. These secondary conditions can support additional claims and also document the full scope of your disability.

DeLuca Factors: Pain, Fatigue, and Repetitive Use Effects

How to describe:

Describe how your function changes after prolonged or repetitive activity. Note how much worse your pain, fatigue, and mobility become after a full day of activity compared to first thing in the morning. Describe flare-up frequency, duration, triggers, and what is required to recover.

Worst-day example:

“After walking for more than 30 minutes with my prosthesis, my residual limb becomes so painful and swollen that I cannot continue. I then need to rest for at least 2 hours with my limb elevated before I can attempt any further activity. By end of day I am completely exhausted and my back pain has escalated to the point where I need prescription pain medication just to sleep.”

What the examiner listens for:

Specific activity thresholds that trigger worsening symptoms; recovery time required after activity; flare-up frequency and duration; impact of fatigue on daily function and employment; whether symptoms are worse after any use compared to at rest.

Understatements to avoid:

Only describing your resting level of pain and function without explaining how dramatically it worsens with activity. Failing to mention that what you can do in the morning is very different from what you can do in the afternoon or evening.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to have a VSO representative present during your C&P exam as an observer in most circumstances - contact your Regional Office to confirm current policy.
  • You have the right to record your C&P exam in most states - research your state's recording consent laws and VA policy before the exam and inform the examiner if you choose to record.
  • You have the right to request a different examiner if you believe the assigned examiner lacks the relevant specialty expertise (e.g., a general practitioner examining a complex amputation case) - raise this concern with your VSO before the exam.
  • You have the right to review the completed DBQ exam report - request a copy through your VSO, MyHealtheVet, or by filing a FOIA request after the exam is completed.
  • You have the right to challenge an inadequate exam - if the exam report fails to address all required elements (stump condition, prosthetic use, functional mobility, secondary conditions), you can request a new exam as part of a Notice of Disagreement, Supplemental Claim, or Board Appeal.
  • You have the right to submit a private Independent Medical Opinion (IMO) or nexus letter from your own treating physician or specialist to supplement or rebut the C&P exam findings.
  • You have the right to bring medical records, photos of stump condition, and written symptom documentation to the exam - the examiner should review all evidence you provide.
  • Under the benefit of the doubt standard (38 CFR 3.102), when there is an approximate balance of positive and negative evidence, the decision must be made in your favor.
  • You have the right to appeal any rating decision you believe is inaccurate through the Supplemental Claim lane, Higher-Level Review lane, or Board of Veterans' Appeals.
  • You have the right to be evaluated for Special Monthly Compensation (SMC) for loss of use of an extremity, regardless of your combined disability rating - ask your VSO to evaluate SMC eligibility specifically for your amputation level and functional limitations.

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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.