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C&P Exam Prep: Elbow, Other Impairment (Flail Joint / Joint Fracture Nonunion / Head of Radius Fracture)

DC 5209 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Elbow_and_Forearm
Form Code
Elbow_and_Forearm
Page Count
15
Examiner Type
Physician or Physician Assistant
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of elbow impairment under DC 5209, including flail joint, joint fracture nonunion, and/or ununited fracture of the head of the radius, for purposes of establishing or increasing a VA disability rating.

What the examiner evaluates:

  • Presence and type of elbow impairment (flail joint, joint fracture nonunion, ununited radial head fracture)
  • Active and passive range of motion (ROM) for elbow flexion, extension, forearm pronation, and supination
  • Pain on motion and at rest, including where in the arc pain begins
  • Functional loss due to pain, weakness, fatigability, incoordination, or lack of endurance
  • Presence of cubitus varus or cubitus valgus deformity
  • Instability, crepitus, tenderness, and swelling
  • Surgical history including total elbow arthroplasty or arthroscopic procedures
  • Muscle atrophy or circumferential difference between affected and unaffected limbs
  • Effect on employment, activities of daily living, and functional use of the extremity
  • Any assistive devices used
  • Flare-up frequency, duration, and severity
  • Whether the condition affects the dominant (major) or non-dominant (minor) upper extremity

Exam will include seated and standing components. Wear loose-fitting clothing that allows easy access to both elbows and forearms. Bring all relevant medical records, imaging reports, and a list of current medications. You may request that the exam be recorded in most states. Bring a trusted support person if needed but be aware they may be asked to wait outside during the physical examination portion.

Typical duration: 30-45 minutes

Elbow Flexion (Active and Passive)

The degree to which the veteran can bend the elbow from full extension (0-) toward the shoulder. Normal flexion endpoint is 145-.

What to expect:

The examiner will ask you to actively bend your elbow as far as possible, then may passively move your arm to assess passive ROM. The endpoint in degrees will be recorded. The examiner will note whether pain is produced and at what point in the arc pain begins.

Key thresholds:

  • Limited to 110- — 10% under DC 5206 (can also be considered under DC 5209 residuals)
  • Limited to 100- — 20% under DC 5206
  • Limited to 90- — 30% under DC 5206
  • Limited to 60- — 40% under DC 5206
  • Flail joint present — 50-60% under DC 5209 depending on major/minor extremity

Tips:

  • Perform the motion at your true maximum - do not push through severe pain to demonstrate a better range.
  • If your worst days are significantly more restricted than your exam-day ROM, tell the examiner explicitly.
  • If flexion worsens after repetitive use, request that the examiner note this per DeLuca factors.
  • If passive ROM exceeds active ROM significantly, ask the examiner to document both.

Pain considerations: Tell the examiner exactly where in the arc of flexion pain begins (e.g., 'Pain starts at 80 degrees and becomes severe by 60 degrees'). Per 38 CFR 4.59, painful motion can justify rating at the point where pain begins, not just the final endpoint.

Elbow Extension (Active and Passive)

The degree to which the veteran can straighten the elbow from a flexed position back toward 0- (full extension). An extension deficit means the arm cannot fully straighten.

What to expect:

The examiner will ask you to fully straighten your elbow. Any deficit from full extension (e.g., 'extension limited to 30- means there is a 30- flexion contracture) will be recorded. Both active and passive measurements may be taken.

Key thresholds:

  • Extension limited to 45- — 10% under DC 5207
  • Extension limited to 30- — 20% under DC 5207
  • Flail joint with complete loss of useful motion — 50-60% under DC 5209

Tips:

  • A flexion contracture (inability to fully straighten) is just as ratable as limited flexion - make sure the examiner documents it.
  • Describe any locking, catching, or giving-way during extension attempts.
  • If instability prevents full extension attempts, tell the examiner before attempting the motion.
  • Note whether extension is worse after prolonged activity or upon waking.

Pain considerations: Pain on attempted extension should be described by location (e.g., lateral, medial, posterior elbow) and by the degree at which it begins. Rest pain at the elbow should also be reported as it supports a higher severity finding.

Forearm Pronation (Active and Passive)

The ability to rotate the forearm so the palm faces downward. Normal pronation endpoint is 80-. This motion is evaluated separately from elbow flexion/extension per M21-1.

What to expect:

With your elbow at 90- flexion, the examiner will ask you to rotate your forearm so the palm faces the floor. The degree of available pronation will be measured with a goniometer. Passive motion may also be assessed.

Key thresholds:

  • Motion lost beyond middle of arc (hand approaching but not reaching full pronation) — Rated under DC 5213; may support DC 5209 finding
  • Motion lost beyond last quarter of arc (hand does not approach full pronation) — Higher rating under DC 5213
  • Complete loss of pronation — Significant impairment under DC 5213; relevant to DC 5209 flail joint
  • Hand fixed in full pronation (loss of bone/fusion) — Rated under DC 5213 fixed position criteria

Tips:

  • Forearm pronation is evaluated separately from elbow motion - ensure the examiner records it independently.
  • If pronation is limited due to pain from a radial head fracture nonunion, describe the pain's location (lateral elbow, radial head area) clearly.
  • A fixed pronation deformity should be described in terms of degree of fixation.
  • Report any grinding, crepitus, or clicking with rotation.

Pain considerations: Pain with pronation, especially over the radial head, is a classic finding with ununited radial head fractures. Describe the pain as sharp, aching, or catching, and whether it radiates. Note if activities like using a screwdriver, opening jars, or turning a door handle are painful or impossible.

Forearm Supination (Active and Passive)

The ability to rotate the forearm so the palm faces upward. Normal supination endpoint is 85-. Evaluated separately from elbow and wrist motion per M21-1.

What to expect:

With elbow at 90-, the examiner asks you to turn the palm upward as far as possible. Degree of motion is measured and documented. Passive motion may also be tested.

Key thresholds:

  • Supination limited to 30- or less — Rated under DC 5213; relevant to DC 5209 combined impairment
  • Complete loss of supination — Significant impairment; relevant to flail joint characterization
  • Hand fixed in supination — Rated under DC 5213 fixed position criteria

Tips:

  • Limited supination severely affects daily activities like carrying a tray, receiving change, or washing the face - describe these impacts.
  • If supination is painful secondary to the radial head fracture nonunion, locate the pain precisely (e.g., 'pain at the lateral elbow at the radial head when I try to turn my palm up').
  • Report asymmetry between the affected and unaffected arm.
  • Note whether supination has worsened over time since the original injury.

Pain considerations: Supination is often more painful than pronation in radial head fracture cases. If you have complete loss of supination, tell the examiner you cannot carry a plate level, turn a doorknob fully, or receive objects in an outstretched hand.

Instability / Flail Joint Assessment

Whether the elbow exhibits abnormal motion or lacks structural integrity (flail joint), indicating complete functional loss of the joint as a stable lever.

What to expect:

The examiner will apply gentle stress to assess medial, lateral, and rotatory stability. They will observe for abnormal motion beyond the normal range (hypermobility), false joint movement (pseudoarthrosis), and whether the joint can bear functional load.

Key thresholds:

  • Flail joint confirmed (major extremity) — 60% under DC 5209
  • Flail joint confirmed (minor extremity) — 50% under DC 5209
  • Joint fracture with marked cubitus valgus or varus, or ununited radial head fracture (major) — 20% under DC 5209
  • Joint fracture with marked cubitus valgus or varus, or ununited radial head fracture (minor) — 20% under DC 5209

Tips:

  • If you have been told by a physician that your elbow is 'unstable,' 'loose,' or has a 'false joint,' use those exact terms with the examiner.
  • Describe any sensation of the elbow 'giving way' during use, especially under load.
  • A flail joint means the joint has essentially no useful function as a stable fulcrum - emphasize inability to lift, push, pull, or carry.
  • If you have radiographic confirmation of nonunion or failed bony fusion, bring those imaging reports.

Pain considerations: Instability itself causes pain and functional loss beyond what ROM measurements capture. Describe how instability prevents you from performing weight-bearing tasks with the affected arm (e.g., pushing up from a chair, doing push-ups, carrying groceries).

Muscle Circumference / Atrophy Measurement

Whether disuse atrophy has developed in the arm, forearm, or biceps due to reduced use of the affected extremity. Measured in centimeters at specified anatomical locations.

What to expect:

The examiner will use a tape measure to compare the circumference of the affected and unaffected upper arm or forearm at the same anatomical level on both sides. A difference suggests muscle wasting from disuse.

Key thresholds:

  • Measurable atrophy present — Supports higher severity rating and functional loss findings
  • Significant bilateral difference (typically -2 cm) — Strong objective evidence of chronic disuse and functional impairment

Tips:

  • Do not compensate by using the affected arm more than usual in the days before the exam.
  • Tell the examiner if you have stopped using the arm for heavy tasks due to pain or instability.
  • Atrophy is objective evidence that supports your subjective complaints of weakness and pain.
  • Note whether you have had to modify your dominant hand activities to the non-dominant side.

Pain considerations: Disuse atrophy often develops because pain makes it too uncomfortable to use the limb fully. Tell the examiner how long you have been avoiding certain activities and what activities you have abandoned.

Estimate

Rating Criteria Breakdown

60% Flail joint of the elbow, major (dominant) extremity.

Flail joint of the elbow, major (dominant) extremity.

Key Symptoms

  • Complete instability of the elbow joint with no useful function as a stable lever
  • Inability to perform any load-bearing activity with the affected arm
  • Abnormal motion in all planes beyond normal anatomical limits
  • False joint movement (pseudoarthrosis) present
  • Severe pain with any attempted use
  • Gross muscle atrophy from chronic disuse
  • Complete loss of grip strength or functional use of the hand dependent on elbow stability

CFR: 38 CFR 4.71a DC 5209: Flail joint, major extremity = 60%.

50% Flail joint of the elbow, minor (non-dominant) extremity.

Flail joint of the elbow, minor (non-dominant) extremity.

Key Symptoms

  • Complete instability of the elbow joint with no useful function as a stable lever, non-dominant arm
  • Inability to perform load-bearing or fine motor tasks requiring elbow stability
  • Abnormal multi-directional motion beyond normal limits
  • Pseudoarthrosis confirmed on imaging or clinical exam
  • Severe chronic pain and functional loss
  • Disuse atrophy of the forearm and/or upper arm

CFR: 38 CFR 4.71a DC 5209: Flail joint, minor extremity = 50%.

20% Joint fracture with marked cubitus varus or cubitus valgus d ...

Joint fracture with marked cubitus varus or cubitus valgus deformity, OR joint fracture with ununited fracture of the head of the radius. Rating is the same for major and minor extremity at this level.

Key Symptoms

  • Visible angular deformity of the elbow (valgus = elbow points outward; varus = elbow points inward)
  • Ununited (nonunion) fracture of the head of the radius confirmed on imaging
  • Pain over the lateral elbow/radial head with rotation (pronation/supination)
  • Crepitus with forearm rotation
  • Tenderness to palpation over the radial head
  • Limited or painful supination and/or pronation
  • Intermittent locking or catching of the elbow joint
  • Chronic pain with gripping or load-bearing

CFR: 38 CFR 4.71a DC 5209: Joint fracture, with marked cubitus varus or cubitus valgus deformity, or with ununited fracture of head of radius = 20% (major and minor).

How to Describe Your Symptoms

Pain on Motion (DeLuca Factor)

How to describe:

Describe the location of pain (e.g., lateral elbow at the radial head, medial elbow, posterior elbow over the olecranon), the type of pain (sharp, aching, burning, stabbing), and at exactly what point in the range of motion pain begins. Distinguish between pain on active motion, pain on passive motion, and pain at rest.

Worst-day example:

“On my worst days, I cannot bend my elbow past 90 degrees before a sharp pain at the outer elbow stops me completely. Any attempt to turn my palm up causes a grinding pain at the side of my elbow that makes me drop things. The pain continues for hours after any activity.”

What the examiner listens for:

Specific degree at which pain begins, pain location tied to anatomical structures, whether pain limits motion before the structural endpoint is reached, presence of rest pain, and whether pain causes functional loss beyond the measured ROM.

Understatements to avoid:

Do not say 'it just hurts a little' or 'I manage.' Say exactly where pain begins in the arc and how it stops you from completing the motion or the task at hand.

Instability and Giving Way (Flail Joint / Nonunion)

How to describe:

Describe episodes where the elbow 'gives way,' feels unstable, or buckles under load. Note whether you avoid carrying objects, pushing, or pulling because the elbow cannot be trusted to hold. If a physician has told you the elbow is structurally unstable or has a false joint, use those terms.

Worst-day example:

“On my worst days, my elbow buckles when I try to pick up anything heavier than a coffee cup. I dropped a full gallon of milk because my elbow gave way without warning. I cannot push myself up from a chair using that arm at all.”

What the examiner listens for:

Spontaneous giving way under load, avoidance of specific activities due to instability risk, prior injuries caused by the instability, and whether there is objective abnormal motion in the joint.

Understatements to avoid:

Do not minimize instability as 'a little weak.' Describe it as structural failure of the joint under functional demand.

Fatigue and Lack of Endurance with Repetitive Use (DeLuca Factor)

How to describe:

Describe how the elbow performs over time during repeated activities. Note that the first repetition may feel manageable but subsequent ones become progressively more painful, weak, or limited. Quantify how many repetitions you can perform before you must stop.

Worst-day example:

“I can type or write for maybe five minutes before the elbow starts aching and my grip weakens. By the tenth minute, I have to stop entirely. On bad days, even one minute of repetitive hand use causes the elbow to ache for the rest of the day.”

What the examiner listens for:

Whether ROM decreases, pain increases, or weakness develops with repetitive use - all of which are required to be documented per DeLuca v. Brown. The examiner must note if repetitive motion testing worsens functional findings.

Understatements to avoid:

Do not only report your resting or initial ROM. Proactively tell the examiner: 'My range of motion gets worse after I use it repeatedly, and I would like that documented.'

Weakness (DeLuca Factor)

How to describe:

Describe inability to perform tasks requiring grip, lifting, pushing, or pulling. Quantify the limitation: maximum weight you can lift, whether you can carry a bag, shake hands firmly, or open a tight jar. Note if the weak extremity is the dominant hand.

Worst-day example:

“On my worst days I cannot lift a gallon of water, open a childproof cap, or shake someone's hand without the elbow giving a sharp jolt of pain. My grip on that side is probably half of what it used to be and my arm tires out far faster than the other side.”

What the examiner listens for:

Functional limitations directly caused by weakness, whether weakness is constant or episodic, comparison to the unaffected side, and whether tasks requiring stable elbow positioning are impossible.

Understatements to avoid:

Do not say 'I'm a little weak' without examples. Give concrete functional equivalents: 'I can only lift 5 pounds before pain forces me to stop.'

Flare-Ups (DeLuca Factor)

How to describe:

Describe the frequency (how often), duration (how long each lasts), severity (pain level, functional impact), and triggers (weather changes, overuse, sleep position, stress). Note what you cannot do during a flare-up that you can partially do on a good day.

Worst-day example:

“I have flare-ups two to three times a week, typically triggered by any overhead work or lifting. During a flare, my elbow swells, becomes hot to the touch, and any motion beyond 45 degrees of flexion is impossible. I need to ice it and rest for 24 to 48 hours before I regain even my baseline limited function.”

What the examiner listens for:

Objective triggers, measurable frequency and duration, functional impact during flare-ups versus baseline, and whether the flare-up pattern reflects the chronic, variable nature of the condition.

Understatements to avoid:

Do not say 'I sometimes have bad days.' Quantify: 'I have severe flare-ups approximately twice per week lasting 1-2 days each.'

Incoordination (DeLuca Factor)

How to describe:

Describe any loss of fine motor control, trembling, or inability to perform precise movements with the affected hand/arm due to the elbow instability or pain. Note tasks like writing, buttoning, typing, using utensils, or handling small objects that have become difficult or impossible.

Worst-day example:

“On my worst days, I cannot write legibly because my elbow shakes when I try to hold it at the angle needed for writing. I drop small objects frequently and can no longer thread a needle or handle coins reliably.”

What the examiner listens for:

Whether incoordination is caused by structural elbow instability, pain avoidance, or neurological compromise from the elbow condition (e.g., ulnar nerve irritation), and how it affects occupational and daily functional tasks.

Understatements to avoid:

Do not attribute incoordination only to 'nervousness.' Describe it as a functional consequence of the elbow impairment.

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 request that the C&P exam be recorded (audio or video) in most states - notify the examiner before the exam begins and check current VA policy and your state's recording laws.
  • You have the right to have a representative (VSO, accredited claims agent, or attorney) assist you in preparing for the exam, though they generally cannot be present during the physical examination itself.
  • You have the right to submit a personal statement (lay statement) describing your symptoms, functional limitations, and worst-day experiences, which the rater must consider alongside the DBQ.
  • You have the right to request a new or supplemental C&P examination if the original exam was inadequate (e.g., failed to address DeLuca factors, ROM was not measured, or the examiner did not consider flare-up severity).
  • You have the right to receive a copy of the completed DBQ - request it through VA.gov or your VSO after the exam is completed.
  • You have the right to submit buddy statements from family members, coworkers, or caregivers who can describe the functional impact of your condition on a daily basis.
  • Under 38 CFR 4.59, you are entitled to a rating based on painful motion, meaning the rating may be assigned at the point where pain limits motion rather than the final structural endpoint - the examiner must document where pain begins.
  • Under the DeLuca v. Brown precedent, the examiner is required to document all five DeLuca factors (pain, weakness, fatigability, incoordination, and flare-ups/repetitive use effects) - you may request that these be addressed if the examiner omits them.
  • You have the right to the benefit of the doubt - when the evidence is approximately equally for and against your claim, the benefit must be given to you per 38 CFR 3.102.
  • Under M21-1 guidance, separate disability evaluations must be assigned for elbow flexion, elbow extension, and forearm supination/pronation - ensure the examiner evaluates and documents each motion independently.
  • You are not required to prove your condition is the worst possible case - you only need to accurately represent your actual symptoms, and the rating criteria will be applied to what you describe and what is observed.

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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.