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C&P Exam Prep: Favorable Ankylosis - 5 Digits

DC 5220 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 nature, position, and functional impact of ankylosis (complete joint immobility or fixation) affecting all five digits of one hand under DC 5220, and to determine whether each ankylosed joint is in a favorable (neutral/functional) or unfavorable position per 38 CFR 4.71a rating criteria.

What the examiner evaluates:

  • Which specific joints are ankylosed (MCP, PIP, IP, CMC) across all five digits
  • Position of ankylosis: neutral (favorable) vs. flexion/extension/rotation/angulation (unfavorable)
  • Gap measurement between fingertips and the proximal transverse crease of the palm with fingers flexed to maximum extent
  • Gap between thumb pad and fingers for thumb opposition assessment
  • Whether both MCP and PIP joints of any individual digit are ankylosed (automatically unfavorable)
  • Active and passive range of motion of all ankylosed and non-ankylosed joints
  • Presence of angulation, rotation, or deformity at any ankylosed joint
  • Hand grip strength bilaterally
  • Functional loss including pain, weakness, fatigability, and incoordination
  • DeLuca factors: flare-ups, repetitive use effects, fatigue, weakness, and incoordination
  • Whether dominant or non-dominant hand is affected
  • Assistive devices, braces, or adaptive equipment used
  • Presence of muscle atrophy or circumference difference between extremities
  • Additional complicating diagnoses (post-traumatic arthritis, degenerative arthritis, instability)

Exam will include both interview and hands-on physical examination. The examiner will perform goniometric measurements of each digit joint and measure palm-to-fingertip gap distances using a ruler. Bring any splints, braces, or assistive devices you use. Wear clothing that allows easy access to your hands. Be prepared to demonstrate maximum grip and individual finger movements.

Typical duration: 30-45 minutes

Fingertip-to-Proximal Transverse Crease Gap Measurement

The distance in centimeters between the fingertip(s) of the ankylosed digit(s) and the proximal transverse crease of the palm when the digit is flexed to maximum extent. This is the critical determinant of favorable vs. unfavorable ankylosis for index, long, ring, and little fingers.

What to expect:

The examiner will ask you to flex each ankylosed finger as far as possible toward your palm, then measure the gap from your fingertip to the proximal transverse crease of the palm using a ruler or tape measure. A gap of 2 inches (5.1 cm) or less indicates favorable ankylosis; greater than 2 inches indicates unfavorable ankylosis.

Key thresholds:

  • -2 inches (-5.1 cm) — Favorable ankylosis - applies to DC 5220 rating at 50% or 40%
  • >2 inches (>5.1 cm) — Unfavorable ankylosis - rate under DC 5219 or higher rather than 5220
  • Both MCP and PIP joints ankylosed on same digit — Automatically unfavorable regardless of gap measurement

Tips:

  • Do not try to force your finger to flex further than it naturally goes - demonstrate your actual worst-day maximum flexion
  • If the gap varies by finger, each will be measured individually
  • If you have worse days when the gap is larger due to swelling or pain, describe that to the examiner verbally
  • The measurement is taken with fingers flexed as far as possible, not in the neutral or extended position

Pain considerations: If attempting to flex the finger causes significant pain that limits flexion, inform the examiner immediately. Under 38 CFR 4.40, pain limiting motion can affect the functional equivalence analysis. The examiner should note if pain is preventing full attempted flexion.

Thumb Opposition Gap Measurement

For the thumb, the gap in centimeters between the thumb pad and the fingers when the thumb attempts to oppose the fingers. Determines favorable vs. unfavorable ankylosis of CMC or IP joints of the thumb.

What to expect:

The examiner will ask you to bring your thumb toward your fingers as if pinching. They will measure the gap between the thumb pad and your fingers. A gap of 2 inches (5.1 cm) or less indicates favorable ankylosis; greater than 2 inches indicates unfavorable.

Key thresholds:

  • -2 inches (-5.1 cm) thumb pad to fingers — Favorable thumb ankylosis
  • >2 inches (>5.1 cm) thumb pad to fingers — Unfavorable thumb ankylosis
  • Both CMC and IP joints ankylosed — Automatically unfavorable regardless of gap

Tips:

  • Show the examiner your maximum opposition attempt honestly - do not try to compensate or stretch
  • Note if thumb rotation or angulation is present as this can independently constitute unfavorable ankylosis
  • Describe any pain during opposition attempts

Pain considerations: Pain during opposition should be stated aloud during the exam. If the thumb is fixed in a position that causes pain upon attempted use, describe the severity, frequency, and what activities trigger this pain.

Active Range of Motion (ROM) - All Digit Joints

The degrees of active flexion and extension at each joint (MCP, PIP, DIP for fingers; CMC, MCP, IP for thumb) of all five digits. Documents which joints have reduced or absent motion.

What to expect:

The examiner uses a goniometer to measure flexion and extension at each finger joint. For ankylosed joints, this will be 0 degrees active motion. For partially restricted joints, the degrees will be measured and recorded. Normal values include: MCP flexion to approximately 90-, PIP flexion to approximately 100-, DIP flexion to approximately 70-.

Key thresholds:

  • 0- active motion at a joint — Confirms ankylosis of that joint
  • MCP fixed in extension (0-) — Neutral position - potentially favorable if gap criterion also met
  • Joint fixed in flexion >0- — Flexion ankylosis - may be unfavorable depending on degree and gap

Tips:

  • Attempt each motion honestly - do not exaggerate limitation but do not push through severe pain either
  • If a joint is completely fused (ankylosed), simply state it cannot move
  • The examiner will note the angle at which each joint is fixed
  • Perform each movement slowly; do not rush through the exam

Pain considerations: Under the DeLuca factors (38 CFR 4.40), you must communicate if pain significantly limits your motion before the end range. State 'I am stopping because of pain at this point' rather than silently stopping. The examiner should document the degree at which pain-limited motion occurs, which can be separately rated.

Passive Range of Motion (ROM) - All Digit Joints

The degrees of motion achievable with the examiner gently moving the joint, compared to active motion. Helps distinguish true ankylosis from pain-limited active motion.

What to expect:

After active ROM, the examiner will gently hold and attempt to move your finger joints to assess if passive motion exceeds active motion. For truly ankylosed joints, passive ROM will equal active ROM (zero). Passive ROM should be documented per Correia requirements.

Key thresholds:

  • Passive ROM equals active ROM at 0- — Confirms true bony or fibrous ankylosis
  • Passive ROM exceeds active ROM — Suggests pain-limited active motion rather than true ankylosis; may affect rating pathway

Tips:

  • Do not resist the examiner's passive movement unless it causes genuine pain
  • If passive movement causes pain, state this aloud immediately
  • True ankylosis will have identical active and passive ROM; if passive goes further, communicate the pain this causes

Pain considerations: Passive motion causing pain is a separate and important finding. State any discomfort during passive testing. Pain with passive motion can support functional loss ratings under 38 CFR 4.40.

Hand Grip Strength

The grip strength of the affected hand compared to the contralateral (unaffected) hand, typically measured with a dynamometer or estimated clinically.

What to expect:

The examiner may use a hand dynamometer or assess grip strength by having you squeeze their fingers. Both hands will be tested. Significant reduction in grip strength in the affected hand documents functional impairment related to the ankylosis.

Key thresholds:

  • Significant reduction vs. contralateral hand — Supports functional loss and may warrant additional rating consideration under 38 CFR 4.40
  • Unable to grip at all — Severe functional loss documented

Tips:

  • Grip with your true maximum effort - the examiner needs accurate data
  • If grip causes pain, state this during the test
  • If you use a brace or splint that affects grip, test with and without if the examiner does not offer to do so

Pain considerations: Grip testing that causes pain should be reported immediately. If you have to stop early due to pain, state this. Weakness and pain during gripping are DeLuca factors that directly affect the functional rating.

Circumference / Atrophy Measurement

Circumference of the upper extremity at a defined location compared bilaterally to detect muscle atrophy from disuse, which can indicate severity and duration of impairment.

What to expect:

The examiner may measure forearm or upper arm circumference bilaterally using a measuring tape. A difference between the affected and unaffected side indicates disuse atrophy.

Key thresholds:

  • Measurable circumference difference >1-2 cm — Documents disuse atrophy supporting chronicity and functional loss

Tips:

  • Do not flex or tense the muscle during measurement - remain relaxed
  • If atrophy is visible, point it out to the examiner if they have not measured it

Pain considerations: Disuse atrophy often accompanies chronic pain conditions where the veteran avoids using the hand. If you use your hand less due to pain, describe specific activities you avoid and why.

Angulation and Rotation Assessment

Whether any ankylosed bone or joint is fixed in a rotated or angulated position. Rotation or angulation at an ankylosed joint is independently sufficient to classify the ankylosis as unfavorable and potentially elevate to a higher DC.

What to expect:

The examiner will visually inspect and palpate each ankylosed digit to assess whether bones are aligned in normal anatomical position or deviated. Photographs or x-ray findings may be referenced.

Key thresholds:

  • Rotation or angulation present — Constitutes unfavorable ankylosis regardless of gap measurement; may trigger higher DC than 5220

Tips:

  • Point out any visible deformity, rotation, or abnormal alignment to the examiner if not already noted
  • Describe whether rotation or angulation causes functional interference with adjacent fingers or overall hand function
  • Bring x-ray reports that document angulation or rotation if available

Pain considerations: Angulated or rotated bones may cause pain in adjacent fingers (scissoring). Describe any such pain, including when it occurs and how it affects specific tasks.

Estimate

Rating Criteria Breakdown

50% Favorable ankylosis of all five digits of one hand - dominan ...

Favorable ankylosis of all five digits of one hand - dominant hand or higher-impact rating. Under DC 5220, favorable ankylosis of five digits of one hand is rated at 50%. Favorable ankylosis means each ankylosed joint is fixed in a neutral (0-degree) or functional position, with a fingertip-to-proximal-transverse-crease gap of 2 inches or less per digit, and no joint ankylosed with both the MCP and PIP joints fixed on the same digit.

Key Symptoms

  • Complete immobility of all five digits of one hand
  • Each ankylosed joint fixed at or near neutral (0-) position
  • Fingertip gap -2 inches from proximal transverse crease for index, long, ring, and little fingers
  • Thumb pad gap -2 inches from fingers for thumb
  • No single digit with both MCP and PIP simultaneously ankylosed
  • No angulation or rotation of ankylosed bones
  • Severe functional impairment of hand despite favorable position
  • Grip strength significantly reduced
  • Unable to perform fine motor tasks

CFR: 38 CFR 4.71a DC 5220 states: 'Five digits of one hand, favorable ankylosis of: 50 40.' The 50% rating applies to the more severe presentation under this code, typically associated with the dominant hand or maximal functional loss consistent with favorable position criteria.

40% Favorable ankylosis of all five digits of one hand - lower p ...

Favorable ankylosis of all five digits of one hand - lower presentation under DC 5220. The 40% rating under DC 5220 applies when all five digits of one hand have favorable ankylosis but the functional impairment is less severe than the 50% level, typically associated with the non-dominant hand. All favorable ankylosis criteria must still be met: gap -2 inches per digit, no dual-joint ankylosis per digit, and no angulation or rotation.

Key Symptoms

  • Complete immobility of all five digits of one hand (non-dominant)
  • Each ankylosed joint fixed at neutral position
  • Fingertip gaps -2 inches for all digits
  • Reduced but not absent grip strength
  • Moderate impairment of hand function
  • Difficulty with daily tasks requiring hand use

CFR: 38 CFR 4.71a DC 5220: 'Five digits of one hand, favorable ankylosis of: 50 40.' The 40% rating applies under this code as the lower threshold, typically for the non-dominant hand.

How to Describe Your Symptoms

Pain

How to describe:

Describe pain at each ankylosed joint and surrounding structures accurately and specifically. Include pain location (which digit, which joint), quality (aching, burning, sharp, throbbing), intensity using a 0-10 scale, frequency (constant vs. intermittent), and what activities or positions worsen or relieve it. Be specific about worst-day pain levels vs. average daily pain.

Worst-day example:

“On my worst days, which happen approximately [X] times per month, the pain in my [right/left] hand at the ankylosed joints reaches a 9 out of 10. I cannot use my hand at all, and even light contact causes sharp pain. I cannot grip anything, button my shirt, or type. The pain radiates up my forearm and I sometimes drop items unexpectedly.”

What the examiner listens for:

The examiner will listen for whether pain is present at rest, with movement, or both; whether pain limits motion (DeLuca factor); pain severity and frequency; and how pain affects specific daily activities and work tasks.

Understatements to avoid:

Do not say 'it hurts a little' when your worst-day pain is severe. Do not say 'I manage fine' when you have actually stopped doing activities you used to do. The examiner needs to hear your actual worst-day experience, not an average or minimized version.

Functional Loss and Daily Activities

How to describe:

Describe specific activities you can no longer perform or have significant difficulty with due to the ankylosed digits. Be concrete: driving, cooking, typing, writing, buttoning clothing, opening jars, carrying bags, personal hygiene. State which activities you have modified, abandoned, or need assistance with.

Worst-day example:

“Because all five digits of my [right/left] hand are completely immobile, I cannot perform a full grip or pinch. I cannot button my shirt without using adaptive tools. I cannot write with that hand. I have had to switch all dominant-hand tasks to my other hand. I spill liquids because I cannot adequately grip a cup. I cannot safely hold tools at work.”

What the examiner listens for:

The examiner will listen for concrete examples of functional impairment that can be mapped to DBQ fields including interference with standing, sitting, daily activities, weakened movement, less movement than normal, and disturbance of locomotion or fine motor control.

Understatements to avoid:

Do not omit activities you have given up entirely - the fact that you no longer attempt an activity because it is impossible is important information. Do not say 'I can do most things' when you have made significant compensatory adaptations.

Weakness and Fatigability

How to describe:

Describe the weakness in your hand and how quickly your hand fatigues with use. Explain how weakness affects tasks requiring sustained grip or repeated fine motor movements. Describe how long you can perform hand-intensive tasks before needing to stop.

Worst-day example:

“My affected hand has very little grip strength. After trying to use it for more than a few minutes, the surrounding muscles ache and I lose what little function remains. I cannot hold a steering wheel or shopping bag for more than a minute or two without having to switch to my other hand or put it down.”

What the examiner listens for:

Weakness (PUBLICDBQMUSCHANDANDFINGER_1868_WEAKNESS, _1880_WEAKNESS, _1929_WEAKNESS, _1973_WEAKNESS) and fatigability/lack of endurance (PUBLICDBQMUSCHANDANDFINGER_1928_FATIGABILITY, _1869_LACKOFENDURANCE, _1881_LACKOFENDURANCE, _1930_LACKOFENDURANCE) are all DeLuca factors the examiner will check on the DBQ.

Understatements to avoid:

Do not fail to mention fatigue if it is a factor simply because you are not asked directly. Proactively state if your hand fatigues quickly or if strength drops off significantly after brief use.

Flare-Ups

How to describe:

Describe episodes when your condition is significantly worse than baseline. Include triggers (weather, overuse, prolonged activity, sleep position), frequency, duration, and what symptoms worsen during a flare. Include how flare-ups affect your ability to use the hand and how long recovery takes.

Worst-day example:

“I have flare-ups approximately [X] times per month, often triggered by cold weather or attempting to use my hand for extended tasks. During a flare, the joints become swollen and any contact with the ankylosed fingers causes sharp pain. During these periods I cannot use the hand at all for 1-3 days. The flare-ups significantly exceed my average daily symptoms.”

What the examiner listens for:

The examiner will ask directly about flare-ups (RG_2B_Flare_up) and document the veteran's description (PUBLICDBQMUSCHANDANDFINGER_270_IFYESDOCUMENTTHEVETERANSDESCRIPTIONOFTHEFLAREUPSHE). This is a critical DeLuca factor that can affect functional ROM estimates during flare conditions.

Understatements to avoid:

Do not underreport flare-up frequency or severity. Do not say 'they aren't that bad' if they prevent you from working or performing basic functions. If flare-ups are worse than your current day, say so explicitly.

Incoordination and Fine Motor Impairment

How to describe:

Describe difficulty with fine motor tasks that require precise finger control, including writing, typing, picking up small objects, using buttons or zippers, handling money, and using tools. Describe how the fixed position of each digit affects coordination.

Worst-day example:

“Because my fingers are locked in position and cannot flex or extend, I cannot pick up small objects like coins, pills, or screws. I drop items frequently because I cannot adjust my grip. I cannot type efficiently. Writing is extremely difficult and illegible. I cannot perform the precise movements required in my [work/hobby].”

What the examiner listens for:

Incoordination is documented in multiple DBQ fields (PUBLICDBQMUSCHANDANDFINGER_1870_INCOORDINATION, _1882_INCOORDINATION, _1931_INCOORDINATION, _1975_INCOORDINATION). The examiner will listen for examples that confirm functional incoordination directly attributable to the ankylosis.

Understatements to avoid:

Do not omit coordination difficulties simply because they seem minor. Even small coordination losses with ankylosed fingers can be significant in occupational settings. Describe workplace or hobby-specific impacts.

Dominant Hand and Occupational Impact

How to describe:

Clearly state whether the affected hand is your dominant hand. Describe how ankylosis of the dominant or non-dominant hand impacts your work, self-care, and quality of life. The dominant vs. non-dominant distinction affects the rating percentage under DC 5220.

Worst-day example:

“My [right/left] hand is my dominant hand. Because all five digits are ankylosed, I have had to relearn nearly every manual task using my non-dominant hand. I can no longer perform my occupational duties as a [job title], which require precise hand use. I have missed work, been reassigned to non-manual duties, and my income has been affected.”

What the examiner listens for:

The examiner documents dominant hand status (RG_Dominant_Hand) and whether the condition affects the dominant or non-dominant hand, which is a key factor in the 50% vs. 40% rating determination. They will also assess functional impact on occupation (RG_8A_Functioning).

Understatements to avoid:

Do not fail to clearly state your dominant hand. Do not understate occupational impact - if you have changed jobs, been demoted, lost income, or had to retire early, these are critical facts.

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 and contemporaneous C&P examination that includes both active and passive range of motion testing for all digit joints.
  • You have the right to request a gap measurement (fingertip-to-proximal transverse crease) be performed and documented during the exam.
  • You have the right to record your C&P examination in most states - check your specific state laws and inform the examiner before beginning.
  • You have the right to challenge an inadequate C&P examination by requesting a new examination if key measurements were omitted, the examiner did not examine you in person, or the DBQ was incomplete.
  • You have the right to submit lay statements (VA Form 21-4138 and 21-10210) to supplement the exam record with information not captured during the exam.
  • You have the right to be rated on your worst-day symptoms, not just how you present on the day of the exam - flare-up descriptions and functional impact on worst days are legitimate and supported by M21-1 guidance.
  • Under 38 CFR 4.40 (DeLuca v. Brown), the VA must consider pain, weakness, fatigability, and incoordination as functional loss even when they do not reduce measured degrees of motion.
  • Under 38 CFR 4.45 (DeLuca factors), additional loss of motion due to flare-ups and repetitive use over time must be considered even if not directly observed during the exam.
  • You have the right to have the dominant vs. non-dominant hand distinction properly documented, as it affects your rating percentage under DC 5220.
  • If any ankylosed joint is found to be in an unfavorable position (rotation, angulation, both MCP and PIP fixed, or gap >2 inches), you have the right to be rated under the appropriate higher diagnostic code rather than only DC 5220.
  • You have the right to a VA-provided examiner who is competent to evaluate musculoskeletal hand conditions - if you have concerns about the examiner's qualifications or the completeness of the exam, you may raise these concerns with your VSO.
  • You have the right to request a copy of your completed DBQ and all C&P exam reports through your MyHealtheVet account, the VBMS portal via your VSO, or a formal records request.

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.