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C&P Exam Prep: Favorable Ankylosis - 2 Digits

DC 5223 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Hand_and_Finger
Form Code
Hand_and_Finger
Page Count
17
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 presence, nature, and functional impact of favorable ankylosis of two digits of one hand under 38 CFR 4.71a DC 5223. The examiner must determine which two digits are affected, whether ankylosis is truly 'favorable' (fixed in a neutral/functional position), and accurately measure fingertip-to-palm gap to distinguish favorable from unfavorable ankylosis.

What the examiner evaluates:

  • Which two digits are ankylosed and on which hand (dominant vs. non-dominant)
  • Whether ankylosis is favorable (MCP or PIP fixed near neutral, fingertip-to-palm gap -2 inches/5.1 cm) or unfavorable
  • Active and passive range of motion of all finger joints (MCP, PIP, DIP) and thumb joints (CMC, MCP, IP)
  • Fingertip-to-proximal transverse palm crease gap measurement in centimeters
  • Presence of angulation, rotation, or deformity at the ankylosed joint
  • DeLuca factors: pain with motion, fatigability, weakness, incoordination, and effect of flare-ups and repetitive use
  • Functional impact on grip strength, pinch, overall hand function, and activities of daily living
  • Hand grip strength measurement (dynamometer if available)
  • Presence of associated conditions: post-traumatic arthritis, degenerative arthritis, instability, swan neck or boutonniere deformity
  • Use of assistive devices, braces, or splints
  • Muscle atrophy (circumference measurement of both upper extremities)

Exam will include both a history interview and a hands-on physical examination. The examiner will observe your hand at rest, during attempted active motion, and during passive manipulation. Bring any splints, braces, or assistive devices you use. The exam may be conducted in person or via telehealth in some cases.

Typical duration: 30-45 minutes

Fingertip-to-Proximal Transverse Palm Crease Gap

The distance (in centimeters) between the fingertip(s) of the ankylosed digit(s) and the proximal transverse crease of the palm when the finger is flexed as far as possible. This is the critical measurement that separates favorable from unfavorable ankylosis.

What to expect:

The examiner will ask you to flex your finger as far as you can toward your palm. They will then measure the straight-line distance from your fingertip to the proximal crease at the base of your fingers. This is done with a ruler or tape measure.

Key thresholds:

  • -2 inches (-5.1 cm) — Favorable ankylosis - rating under DC 5223 applies (10%-30% depending on which two digits)
  • >2 inches (>5.1 cm) — Unfavorable ankylosis - higher rating under DC 5222 may apply; examiner must document this distinction
  • Both MCP and PIP ankylosed in same digit — Unfavorable ankylosis by definition, even if each joint individually appears in a favorable position

Tips:

  • Attempt to flex your finger as fully as possible during this measurement - do not hold back effort
  • If pain prevents full flexion, tell the examiner this clearly so it is documented
  • Ask the examiner to record the measurement in both inches and centimeters
  • If your fingertip does not reach the palm crease, confirm the examiner is measuring from the correct anatomical landmark

Pain considerations: If pain during flexion prevents you from reaching your maximum potential flexion, tell the examiner. Per DeLuca and 38 CFR 4.40, pain-limited motion must be recorded. The gap measurement taken at a pain-limited endpoint is still valid and should reflect your functional limitation.

Active Range of Motion - MCP Joint Flexion/Extension (each affected digit)

Degrees of motion available at the metacarpophalangeal joint of each ankylosed digit under the veteran's own muscle power. Normal MCP flexion is approximately 90-; extension to 0- or slightly beyond.

What to expect:

The examiner will use a goniometer (small angle-measuring device) to measure how far you can actively bend and straighten each finger at the knuckle. You will be asked to make a fist and then straighten your fingers.

Key thresholds:

  • 0- motion (fixed/no movement) — Confirms ankylosis at MCP joint; joint position angle determines favorable vs. unfavorable
  • Minimal movement with pain — May constitute functional ankylosis under 38 CFR 4.40/4.45 - document carefully

Tips:

  • Perform the movement genuinely and to your true maximum - do not exaggerate limitation but do not push through severe pain
  • If the joint is truly fixed (ankylosed), state clearly 'this joint does not move at all'
  • Report any crepitus, clicking, or catching you feel during movement

Pain considerations: Tell the examiner at what point in the range of motion pain begins, and at what degree pain prevents further movement. This is the DeLuca painful arc documentation.

Active Range of Motion - PIP Joint Flexion/Extension (each affected digit)

Degrees of motion at the proximal interphalangeal joint. Normal PIP flexion is approximately 100-110-; extension to 0-.

What to expect:

The examiner will stabilize the proximal phalanx and ask you to bend and straighten the middle joint of your finger. A goniometer will be placed alongside the finger for measurement.

Key thresholds:

  • 0- motion (fixed/no movement) — Confirms PIP ankylosis; joint angle at fixation determines favorable vs. unfavorable
  • Fixed in >20- flexion — May indicate unfavorable position depending on functional impact and gap measurement

Tips:

  • If both MCP and PIP are ankylosed in the same digit, inform the examiner - this is automatically unfavorable ankylosis
  • Report the exact position in which the joint feels 'stuck'
  • Do not confuse normal joint stiffness with true ankylosis - true ankylosis means the joint cannot be moved even passively

Pain considerations: Even in an ankylosed joint, surrounding structures may produce pain with any attempted movement. Report this pain as it supports additional evaluation under DeLuca factors.

Passive Range of Motion - MCP and PIP Joints

Degrees of motion when the examiner moves the joint using external force (no muscle effort from the veteran). Passive ROM is expected to equal or exceed active ROM in most conditions.

What to expect:

The examiner will gently move your finger themselves while you relax. They will note whether passive motion exceeds active motion (suggesting a muscle/tendon rather than joint problem) or equals it (suggesting true joint restriction or ankylosis).

Key thresholds:

  • Passive = Active ROM — Suggests true joint restriction (ankylosis or severe arthritis)
  • Passive > Active ROM — Suggests tendon/muscle limitation rather than pure joint ankylosis - may affect diagnostic coding

Tips:

  • Relax your hand completely during passive testing - do not assist or resist the examiner's movement
  • Report any pain or discomfort immediately when it occurs during passive movement
  • If the examiner finds passive ROM equals zero (no movement), that confirms true ankylosis

Pain considerations: If passive motion causes pain even at the fixed angle, clearly state this. Painful passive motion is relevant to overall functional impairment documentation.

Hand Grip Strength (Dynamometer)

The maximum isometric grip force generated by the affected hand versus the unaffected hand. Expressed in pounds or kilograms.

What to expect:

You will be asked to squeeze a handheld device (dynamometer) as hard as you can, typically three times on each hand. The examiner records the average or maximum reading.

Key thresholds:

  • >20% reduction vs. contralateral hand — Documents clinically significant grip weakness contributing to functional loss
  • Unable to perform — Examiner must document inability and reason - relevant to severity assessment

Tips:

  • Squeeze with your genuine maximum effort - underperforming may cause the examiner to underestimate your disability
  • If pain prevents a full effort, say so before testing begins so it is documented
  • Compare both hands; the affected hand should show measurable reduction if ankylosis significantly limits function

Pain considerations: If gripping with the ankylosed digits causes pain, state this clearly. Pain during grip testing supports DeLuca factor documentation.

Joint Position Angle Assessment (Ankylosis Position)

The fixed angle at which the ankylosed joint is locked. Favorable ankylosis is fixation near neutral (0-slight flexion, functional position). Unfavorable is fixation in significant flexion, extension, or with angulation/rotation.

What to expect:

The examiner will use a goniometer to measure the exact angle at which your joint is fixed. They will also visually inspect for any sideways angulation or rotational deformity.

Key thresholds:

  • Fixed at or near 0- (neutral/functional position) — Favorable ankylosis - DC 5223 applies
  • Fixed in marked flexion, hyperextension, significant angulation, or rotation — Unfavorable ankylosis - higher rating under DC 5222 may apply
  • Angulation or rotation present at any angle — Constitutes unfavorable ankylosis regardless of gap measurement

Tips:

  • Do not adjust or attempt to straighten the finger for the exam - present your finger in its natural resting ankylosed position
  • Point out any deformity, angulation, or rotation you notice in your own finger to ensure the examiner documents it
  • If you notice one digit appears to cross over another when you try to flex, mention this as rotational deformity

Pain considerations: The fixed position itself may cause pain in surrounding structures. Report any chronic aching or positional pain at the fixed joint angle.

Muscle Atrophy Circumference Measurement

Circumference of the forearm or hand to document muscle wasting (atrophy of disuse) from chronic non-use of the ankylosed digits.

What to expect:

The examiner may use a tape measure at a standardized location on both forearms to compare circumference. A difference of >3 cm indicates clinically significant atrophy.

Key thresholds:

  • >3 cm difference between affected and unaffected side — Documents significant disuse atrophy, supporting higher functional impairment rating

Tips:

  • Ensure the examiner measures at the same anatomical location on both sides
  • If you have noticed your hand or forearm looking or feeling thinner on the affected side, mention this before testing

Pain considerations: Atrophy is often painless but may contribute to overall weakness that limits function and causes secondary pain in adjacent joints.

Estimate

Rating Criteria Breakdown

30% Favorable ankylosis of two digits of one hand where the affe ...

Favorable ankylosis of two digits of one hand where the affected digits are the THUMB and ANY FINGER (index, long, ring, or little), dominant hand. The ankylosed joint (MCP or PIP of the finger, or CMC/MCP/IP of thumb) must be fixed in a favorable (functional/neutral) position, and the fingertip-to-palm crease gap must be -2 inches (5.1 cm).

Key Symptoms

  • Thumb completely immobile at one joint (CMC, MCP, or IP) in neutral/functional position
  • One additional finger similarly ankylosed in favorable position
  • Fingertip of ankylosed finger reaches within 2 inches (5.1 cm) of proximal palm crease on maximum flexion
  • Dominant hand affected (higher functional loss)
  • Significant impairment of pinch strength and opposition
  • Difficulty with fine motor tasks, buttoning, writing, tool use
  • Pain with any attempted use of affected digits

CFR: 38 CFR 4.71a DC 5223: Thumb and any finger, dominant hand = 30%. The combination of thumb ankylosis with any finger ankylosis receives the highest rating under DC 5223 due to the critical functional role of the thumb in grip, pinch, and opposition.

20% Favorable ankylosis of two digits of one hand where the affe ...

Favorable ankylosis of two digits of one hand where the affected combination is: (1) Thumb and any finger - non-dominant hand; OR (2) Index and long fingers; OR (3) Index and ring fingers; OR (4) Index and little fingers. Joint fixation must be in a favorable (neutral/functional) position, fingertip-to-palm crease gap -2 inches (5.1 cm).

Key Symptoms

  • Two adjacent or specified digits fixed in functional position
  • Fingertip-to-palm crease gap -2 inches on maximum attempted flexion
  • Impaired grip strength and fine motor control
  • Difficulty with keyboard use, tool operation, writing, or heavy grasping
  • Non-dominant thumb and one finger: reduced but somewhat compensable impairment
  • Index finger involvement: significant impact on pinch and precision grip
  • Pain during any attempted use or flare-up with sustained activity

CFR: 38 CFR 4.71a DC 5223: Index and long; index and ring; or index and little fingers = 20% (both dominant and non-dominant). Thumb and any finger, non-dominant hand = 20%. Index finger involvement in any two-digit combination triggers the 20% level due to the index finger's importance in precision activities.

10% Favorable ankylosis of two digits of one hand where the affe ...

Favorable ankylosis of two digits of one hand where the affected combination is: Long and ring; long and little; OR ring and little fingers (either hand). Joint fixation must be in a favorable position, fingertip-to-palm crease gap -2 inches (5.1 cm). Neither thumb nor index finger is involved.

Key Symptoms

  • Two of the three ulnar-side digits (long, ring, little) ankylosed in functional position
  • Fingertip-to-palm gap -2 inches on maximum attempted flexion
  • Reduced grip strength, particularly power grip
  • Difficulty with heavy grasping, carrying, or sustained grip tasks
  • Less impact on fine precision tasks compared to index/thumb involvement
  • Pain with sustained gripping or repetitive hand use
  • Functional limitations in occupational tasks requiring full hand closure

CFR: 38 CFR 4.71a DC 5223: Long and ring; long and little; or ring and little fingers = 10% for either hand. These digit combinations have the lowest impact on overall hand function under the rating schedule because the thumb and index finger (key precision grip components) remain mobile.

How to Describe Your Symptoms

Pain

How to describe:

Describe pain at the ankylosed joint(s), in surrounding tendons/ligaments from abnormal stress, and any referred pain. Be specific: location (which joint, which side of the finger), character (aching, sharp, burning), severity (0-10 scale), triggers (grip, pinch, cold weather, prolonged use), and duration of pain episodes.

Worst-day example:

“On my worst days, I wake up with a deep, throbbing ache in my fused knuckle and the fingers on either side. Even picking up a coffee cup sends a sharp pain through my hand that lasts for 30 minutes. I cannot use a pen or type without pain building to a 7 or 8 out of 10 after just a few minutes.”

What the examiner listens for:

Pain with active motion attempts, pain on passive manipulation of adjacent joints, pain at rest versus with use, pain that worsens with repetitive activity, and whether pain restricts the veteran's actual daily activities.

Understatements to avoid:

Do not say 'it's not that bad' or 'I manage.' Do not describe only baseline pain without mentioning your worst episodes. Do not omit rest pain or nocturnal pain if you experience it.

Functional Loss / Range of Motion

How to describe:

Describe exactly which movements are impossible (full fist closure, pinching small objects, spreading fingers) and which are severely limited. Quantify functional loss in daily activities: 'I cannot button my shirt,' 'I drop objects,' 'I cannot open a jar,' 'I cannot type without compensating with my other fingers.'

Worst-day example:

“On bad days, my fused fingers feel like blocks of wood. I cannot close my hand enough to hold a grocery bag. I have to use a rubber grip pad just to open a water bottle. Writing more than a sentence causes my whole hand to cramp because I am compensating with my other fingers.”

What the examiner listens for:

Specific activities the veteran can no longer perform or can only perform with modification, compensatory strategies used, and whether the veteran's occupation or daily routine has been altered due to the condition.

Understatements to avoid:

Do not demonstrate better function during the exam than you typically have. Do not omit occupational impacts. Do not say 'I've learned to work around it' without first clearly describing what the limitations are.

Flare-Ups

How to describe:

Describe episodes when your condition is significantly worse than baseline. Include: frequency (how many times per week or month), duration (hours or days), triggers (cold weather, overuse, repetitive gripping, stress), and what additional limitation you experience during flare-ups versus your baseline.

Worst-day example:

“During a flare-up, which happens two or three times a week, my whole hand swells noticeably and the ankylosed fingers become even more rigid. I cannot use my hand for any tasks for the rest of that day. The flare lasts 12-24 hours. Cold weather or doing dishes triggers it reliably.”

What the examiner listens for:

The examiner will ask about flare-ups specifically (DBQ field 270). They want to know frequency, triggers, duration, and whether motion is further restricted during flare-ups. This information should also address whether flare-ups would prevent you from maintaining employment.

Understatements to avoid:

Do not say 'I don't really have flare-ups' if you have any periods of worsening - describe them. Do not give only your average day; describe your worst flare-up scenario in detail.

Weakness and Fatigability

How to describe:

Describe reduced grip strength, inability to sustain grip over time, and how quickly your hand tires with use. Include both objective (failed grip tests) and subjective (hand 'gives out' when carrying objects) experiences.

Worst-day example:

“I can barely grip a half-full water bottle with my affected hand anymore. After typing for five minutes, my grip fails and I drop things without warning. By midday my hand is too fatigued to do any precision work at all.”

What the examiner listens for:

Whether weakness and fatigability are present beyond just the range of motion limitation - these are separate DeLuca factors that can support additional functional loss ratings even when measured ROM appears minimal.

Understatements to avoid:

Do not omit weakness if you experience it just because the examiner focuses on ROM. If your grip fails after repeated use, state this explicitly before and during the grip strength test.

Incoordination

How to describe:

Describe difficulty with fine motor tasks, dropped objects, inability to perform delicate movements. Ankylosis of digits - especially index finger involvement - can cause significant incoordination because the fixed joint disrupts the normal coordinated movement pattern of the hand.

Worst-day example:

“I routinely drop coins, cannot pick up pins or small screws, and spilled a full glass of water last week because my grip just did not coordinate properly. Writing looks like I have tremors because my fused finger cannot adjust its position.”

What the examiner listens for:

Evidence that incoordination - not just weakness - independently limits hand function. This is a distinct DeLuca factor that the examiner should note on the DBQ.

Understatements to avoid:

Do not attribute all your difficulty to pain or weakness if coordination is also independently affected. Describe specific incidents of incoordination-related drops or failures.

Impact on Work and Daily Activities

How to describe:

Directly connect your symptoms to specific job tasks you cannot perform or daily activities you must modify or avoid. Be concrete: 'I cannot perform my former job as a mechanic because I cannot grip tools.' 'I need help buttoning my uniform.' 'I had to change careers because of this condition.'

Worst-day example:

“On my worst days, I cannot perform any tasks requiring two-handed coordination. I cannot type, cannot prepare food safely with a knife, cannot carry objects heavier than a cell phone with my affected hand. I have missed work and had to ask coworkers to complete manual tasks I should be able to do myself.”

What the examiner listens for:

The DBQ specifically asks about functional impact (field 1293). The examiner must document how the condition affects the veteran's ability to work and perform daily activities. Specific examples are more persuasive than general statements.

Understatements to avoid:

Do not generalize with 'it affects everything.' List specific tasks. Do not omit occupational modifications or accommodations you have needed.

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 a thorough examination by a qualified physician or physician assistant who is knowledgeable about musculoskeletal conditions and the DBQ requirements for hand and finger conditions.
  • You have the right to record your C&P examination in most states. Check your state's recording consent laws beforehand. Notify the examiner at the start of the exam if you intend to record.
  • You have the right to request a copy of the completed DBQ/examination report after the examination. Submit this request in writing to your VA Regional Office.
  • You have the right to request a new examination if you believe the initial examination was inadequate, the examiner failed to document required findings (such as the fingertip-to-palm gap measurement), or the DBQ contains factual errors.
  • You have the right to submit your own medical evidence, including a private independent medical examination (IME) or a nexus letter from your treating physician, to supplement or rebut the VA examination findings.
  • You have the right to bring a Veterans Service Organization (VSO) representative or a trusted person to your examination for moral support, though they typically cannot speak or participate in the medical examination itself.
  • You have the right to describe your worst-day symptoms and functionality during the examination. Per M21-1 guidance, the examiner should document your worst-day presentation, not only what they observe on that single day.
  • You have the right to have all DeLuca factors (pain, weakness, fatigability, incoordination, lack of endurance, and effect of flare-ups and repetitive use) considered and documented in your examination report, per 38 CFR 4.40 and 4.45.
  • You have the right to have your dominant hand documented and considered in the rating, as hand dominance affects the rating percentage for certain digit combinations under DC 5223.
  • You have the right to appeal a rating decision you believe is inaccurate, including submitting a Higher-Level Review (HLR), Supplemental Claim with new evidence, or a Board of Veterans' Appeals (BVA) appeal.
  • You have the right to have related secondary conditions (such as adjacent digit strain, wrist pain, or post-traumatic arthritis) considered for separate service connection if they result from your service-connected ankylosis.
  • You have the right to a clear explanation of why your claim was rated at a particular percentage, including which diagnostic code was applied and what findings were considered.

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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.