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C&P Exam Prep: Genu Recurvatum

DC 5263 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Knee_and_Lower_Leg
Form Code
Knee_and_Lower_Leg
Page Count
14
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, severity, and functional impact of acquired or traumatic genu recurvatum (hyperextension deformity of the knee beyond 0 degrees), including objective demonstration of weakness and insecurity in weight-bearing, for disability rating purposes under 38 CFR 4.71a DC 5263.

What the examiner evaluates:

  • Presence of hyperextension deformity beyond 0 degrees of knee extension
  • Degree of recurvatum measured in degrees past neutral
  • Objective demonstration of weakness and insecurity in weight-bearing
  • Active and passive range of motion of the knee (flexion and extension)
  • Functional loss due to pain, weakness, fatigue, incoordination, and flare-ups
  • Stability testing of the knee joint
  • Presence of associated knee instability
  • Leg length discrepancy if present
  • Assistive device use
  • Impact on activities of daily living and occupational functioning
  • Surgical and treatment history

Exam will include a physical examination in a clinic setting. The examiner will observe your gait on entry, assess your knee during standing, weight-bearing, and non-weight-bearing conditions. Wear loose-fitting clothing that allows easy access to both knees. Bring all assistive devices you use (braces, cane, etc.).

Typical duration: 30-45 minutes

Knee Flexion Range of Motion

Active and passive flexion of the knee joint; normal is 0-140 degrees

What to expect:

Examiner will use a goniometer to measure how far you can bend your knee. You will be tested in both active (you move it) and passive (examiner moves it) conditions, and in weight-bearing and non-weight-bearing positions. Expect testing before and after repetitive use.

Key thresholds:

  • flexion limited to 60 degrees — 30% under DC 5260
  • flexion limited to 90 degrees — 20% under DC 5260
  • flexion limited to 100 degrees — 10% under DC 5260
  • flexion limited to 110 degrees — 10% under DC 5260

Tips:

  • Do not push through pain to demonstrate a full range - stop at the point pain or mechanical resistance naturally limits movement
  • Report any increase in pain during or after repeated motion testing
  • If your range is worse on bad days, describe that verbally even if today is a better day

Pain considerations: Inform the examiner at exactly which degree of flexion pain begins, not just the endpoint. Per DeLuca v. Brown, pain on movement, weakness, and fatigability must be documented as they can support additional limitation of motion beyond the measured endpoint.

Knee Extension / Genu Recurvatum Measurement

The degree to which the knee hyperextends beyond 0 degrees of neutral extension; this is the primary measurement for DC 5263

What to expect:

Examiner will measure passive and active extension of the knee. Hyperextension (recurvatum) is documented in degrees past 0. The examiner will also observe your knee during standing and walking for objective evidence of buckling, instability, or abnormal gait pattern indicative of weakness and insecurity in weight-bearing.

Key thresholds:

  • Acquired/traumatic genu recurvatum with objective weakness and insecurity in weight-bearing — 10% under DC 5263 (only available rating level)

Tips:

  • Stand naturally - do not lock your knee artificially or try to compensate
  • Walk normally for the examiner to observe your true gait pattern
  • If your knee buckles, collapses, or gives way during weight-bearing, allow that to happen naturally and describe it verbally
  • Point out visible hyperextension in the standing position
  • Report any falls or near-falls caused by knee giving way

Pain considerations: Describe pain that occurs specifically when weight is placed on the affected knee, including aching, instability, or the sensation of the knee 'giving out.' These are directly relevant to the 'insecurity in weight-bearing' criterion under DC 5263.

Repetitive Use Range of Motion Testing

Whether range of motion decreases after repeated movement, reflecting fatigue and functional deterioration

What to expect:

After initial ROM testing, the examiner may ask you to perform repeated knee flexion/extension cycles (typically 3 repetitions). ROM is then re-measured. Any decrease in ROM, increase in pain, or onset of weakness or fatigue is documented.

Key thresholds:

  • ROM decreases after repetitive use — Supports additional functional impairment finding under 38 CFR 4.40/4.45, potentially justifying higher effective rating
  • Pain, weakness, or fatigue during repetitive use — DeLuca factors - must be documented to capture full functional impairment

Tips:

  • Do not pace yourself - perform the repetitions at your normal functional capacity
  • If your knee hurts more after the repetitions, tell the examiner immediately
  • Report fatigue, muscle burning, or weakness that develops during repetitive use
  • Even if ROM does not change numerically, pain and fatigue during repetition must be verbalized

Pain considerations: State clearly if the pain or instability is worse after repeated use than at the start of the exam. This directly supports a finding of functional impairment beyond what the initial measurement captures.

Weight-Bearing vs. Non-Weight-Bearing ROM

Differences in range of motion and symptoms when the joint bears body weight versus when it is unloaded

What to expect:

Per Correia requirements, ROM should be measured in both weight-bearing (standing) and non-weight-bearing (seated or supine) positions for the knee. Your examiner should compare these values.

Key thresholds:

  • Greater ROM limitation in weight-bearing position — Demonstrates true functional impairment under real-world conditions; supports higher evaluation
  • Visible recurvatum deformity in weight-bearing only — Critical for demonstrating the 'objectively demonstrated' criterion of DC 5263

Tips:

  • If your knee hyperextends more when you are standing, point this out to the examiner
  • Do not brace or compensate your posture during weight-bearing assessment
  • If the knee buckles or shifts when you put weight on it, describe this clearly
  • Ask the examiner to observe your knee in both standing and seated positions

Pain considerations: Pain and instability in weight-bearing that is absent at rest is highly relevant to DC 5263, which specifically requires insecurity in weight-bearing to be objectively demonstrated. Verbalize this distinction clearly.

Knee Instability Assessment

Degree of anterior, posterior, medial, or lateral instability of the knee joint

What to expect:

Examiner will perform stress tests (Lachman, anterior/posterior drawer, valgus/varus stress tests) to assess ligamentous stability. Findings of instability are relevant if they coexist with genu recurvatum and may qualify for separate evaluation under DC 5257 if the instability is not overlapping with the recurvatum evaluation.

Key thresholds:

  • Slight instability (less than 1/4 inch lateral motion) — 10% under DC 5257 (if separately evaluated)
  • Moderate instability (1/4 to 1/2 inch) — 20% under DC 5257 (if separately evaluated)
  • Severe instability (more than 1/2 inch) — 30% under DC 5257 (if separately evaluated)

Tips:

  • Describe any episodes of the knee giving out, collapsing, or buckling during daily activities
  • Note the frequency of instability episodes - daily, weekly, or monthly
  • Mention if instability has caused falls or near-falls
  • Per M21-1 V.iii.1.B.4.g: DC 5263 and DC 5257 should NOT both be evaluated for the same instability from genu recurvatum; however, if instability meets separate criteria, the rating providing the highest evaluation governs

Pain considerations: Instability that occurs on uneven ground, on stairs, or when pivoting is especially important to mention. Describe the sensation of the knee shifting, buckling, or collapsing under load.

Estimate

Rating Criteria Breakdown

10% Acquired and/or traumatic genu recurvatum with weakness and ...

Acquired and/or traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. This is the only rating level available under DC 5263. The deformity must be (1) acquired or traumatic in origin, (2) involve hyperextension of the knee beyond 0 degrees, and (3) be accompanied by objectively demonstrated weakness and insecurity in weight-bearing. A purely congenital or positional genu recurvatum without objective functional impairment does not qualify.

Key Symptoms

  • Hyperextension of the knee beyond 0 degrees of neutral extension
  • Objective weakness in the knee during weight-bearing activities
  • Insecurity or instability when bearing weight on the affected leg
  • Abnormal gait pattern attributable to the recurvatum
  • Buckling or giving-way episodes under load
  • Difficulty with prolonged standing or ambulation on uneven surfaces
  • Muscle weakness in the quadriceps or hamstrings contributing to the deformity
  • History of traumatic or acquired onset (not congenital)

CFR: 38 CFR 4.71a DC 5263: 'Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) - 10%'. The rating note references the Ankle Rating schedule for consideration of analogous codes.

How to Describe Your Symptoms

Weight-Bearing Insecurity and Instability

How to describe:

Describe the specific sensations and events that occur when you put weight on the affected knee. Use concrete language: the knee 'buckles,' 'gives out,' 'collapses,' or 'feels like it will bend backward.' Quantify frequency (e.g., 'several times per week'), triggers (uneven ground, stairs, pivoting, prolonged standing), and consequences (falls, near-falls, compensating gait).

Worst-day example:

“On my worst days, my right knee buckles at least two to three times while walking on flat ground. I have fallen twice this month because the knee bent backward unexpectedly when I shifted my weight. I cannot stand for more than 10 minutes without gripping a wall or furniture because I do not trust the knee to hold me up. I avoid stairs without a railing entirely.”

What the examiner listens for:

Specific description of objective episodes where the knee fails under load; frequency and predictability of instability; adaptive behaviors that confirm functional insecurity; history of falls attributable to the knee giving way; use of assistive devices or bracing

Understatements to avoid:

Do not say 'my knee is a little weak' or 'it sometimes feels unstable.' These vague descriptions may not be sufficient to document the 'objectively demonstrated' standard. Use specific, event-based language.

Hyperextension Deformity (Recurvatum)

How to describe:

Explain when you first noticed the knee bending backward past straight, the circumstances of the injury or condition that caused it, and how it has changed over time. Describe whether the hyperextension is visible to others, whether it is worse with fatigue, and whether it causes pain or structural discomfort when it occurs.

Worst-day example:

“My left knee bends backward past straight every time I stand up from a chair or lock my leg while standing. My physical therapist pointed it out on video - the knee visibly bows backward about 10 degrees when I stand. It is worse at the end of the day when my muscles are fatigued; the hyperextension becomes more pronounced and I feel a sharp pull behind the knee.”

What the examiner listens for:

Observable or reported hyperextension beyond neutral; correlation with fatigue and functional use; traumatic or acquired onset distinguishable from congenital presentation; description of the deformity worsening with activity or at end of day

Understatements to avoid:

Do not minimize the deformity by saying 'my knee just goes straight.' Clarify that it goes beyond straight - past 0 degrees into hyperextension. The distinction is clinically and legally meaningful for DC 5263.

Pain with Weight-Bearing and Activity

How to describe:

Describe pain using location (behind the knee, along the joint line, diffuse), character (aching, sharp, burning, pressure), onset timing (immediate with weight, after prolonged standing, during or after activity), and severity on a 0-10 scale for typical and worst-day scenarios. Include pain at rest versus during motion versus at the end of range.

Worst-day example:

“On my worst days, the pain in the back of my right knee is a 7 out of 10 when I am standing or walking. It starts as a deep ache within the first five minutes of standing and becomes sharp when the knee hyperextends. Even at night I wake up with a 4 out of 10 aching pain that prevents restful sleep. I took 800mg of ibuprofen three times yesterday and it only took the edge off.”

What the examiner listens for:

Pain that is specifically provoked by or worsened during weight-bearing; pain at end-range of extension; pain that persists after activity; use of pain medications and their effectiveness; sleep disruption attributable to pain

Understatements to avoid:

Do not say you are 'doing okay' or 'managing the pain fine.' If you take medications, use ice, or limit activity because of pain, those are important facts. Describe what your life looks like on a bad day, not your best adapted day.

Weakness, Fatigue, and Lack of Endurance

How to describe:

Per DeLuca v. Brown, weakness, fatigability, and lack of endurance are separately ratable factors of functional impairment. Describe specifically how the knee muscles fatigue faster than normal, how weakness prevents or limits activities, and how the knee performs worse after repeated use compared to initial use.

Worst-day example:

“My quadriceps on the left leg are noticeably weaker than the right - I cannot do a single-leg squat on that side without the knee collapsing. After walking one block, the knee feels heavy and unreliable, and I have to sit down. By mid-afternoon I cannot trust the knee to hold me through a normal gait cycle, so I switch to using a cane. The weakness is worse at the end of the day compared to the morning.”

What the examiner listens for:

Muscle atrophy or asymmetry; functional deficit in quadriceps or hamstring strength testing; decreased performance after repetitive use; veteran's subjective account of earlier onset of fatigue compared to before injury; adaptive behaviors due to weakness

Understatements to avoid:

Do not say 'I get tired' without connecting it to the knee specifically. Describe the knee giving out, the thigh muscle burning or cramping, or the leg feeling like it cannot support your weight after a certain amount of activity.

Flare-Ups

How to describe:

Describe periods when the genu recurvatum and associated symptoms are significantly worse than baseline. Include triggers (weather changes, increased activity, prolonged standing, stress), duration of flare-ups, symptoms during flare-ups, and how they impact daily functioning and work capacity.

Worst-day example:

“I have flare-ups two to three times per month, usually triggered by any activity involving more than 20 minutes of walking or standing. During a flare-up, the hyperextension is much more pronounced and I cannot bear full weight on the leg. The knee swells slightly behind the joint, and the pain increases to 8 out of 10. Flare-ups last two to four days during which I am essentially housebound and cannot work or perform basic household tasks.”

What the examiner listens for:

Distinct periods of worsened symptoms beyond baseline; identifiable triggers; duration and frequency; impact on work and daily function during flare-ups; treatment required during flare-ups (rest, ice, medication escalation)

Understatements to avoid:

Do not omit flare-ups because you are having a good day at the exam. The examiner is required to rate your condition at its worst typical presentation, not only as observed on exam day. Proactively describe your worst-day scenario even if today is better.

Functional Impact and Activities of Daily Living

How to describe:

Connect the genu recurvatum directly to specific limitations in daily activities, work tasks, and recreational activities. Be specific: which tasks, how frequently impacted, what workarounds you use, what you can no longer do that you previously could.

Worst-day example:

“I can no longer walk more than a quarter mile without stopping due to knee giving out and pain. I cannot kneel, squat, or climb ladders safely. I was a construction worker and had to change careers because I cannot stand on scaffolding or uneven surfaces. I cannot play with my children on the floor. I dropped a plate last week when my knee buckled without warning while I was standing at the sink.”

What the examiner listens for:

Direct causal link between the knee condition and functional limitations; impact on employment and vocational activities; personal care activities affected; social and recreational restrictions; safety risks from instability

Understatements to avoid:

Do not say 'I get around okay' or 'I adapt.' Describe what you cannot do, what you have stopped doing, and what you do differently because of the knee - not how well you have compensated.

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 your C&P examination be recorded in states and at facilities that permit it - inform the examiner at the start of the appointment.
  • You have the right to a thorough and accurate examination - an examiner must conduct an in-person physical examination, review your claims file, and document all required elements including ROM, functional loss, and flare-up history.
  • You have the right to submit additional evidence after the C&P exam, including buddy statements, private medical opinions, and supplemental lay statements, before a rating decision is issued.
  • You have the right to challenge an inadequate examination - if the examiner did not perform weight-bearing and non-weight-bearing ROM testing, repetitive use testing, or failed to document DeLuca factors, you or your VSO can request a new or supplemental examination.
  • You have the right to have your condition rated on its worst typical presentation, not just on the single snapshot observed at the examination - proactively describe your worst-day symptoms.
  • You have the right to a rating that accounts for all functional impairment including pain, weakness, fatigability, incoordination, and lack of endurance, not just measured range of motion angles (38 CFR 4.40, 4.45, DeLuca v. Brown).
  • You have the right to separate evaluations for non-overlapping manifestations of genu recurvatum - for example, limitation of knee flexion under DC 5260 may be separately evaluated in addition to DC 5263 if the limitation of flexion is a distinct finding attributable to the same condition (per M21-1 V.iii.1.B.4.g).
  • You have the right to appeal a rating decision if you believe the examiner's findings were inadequate, inaccurate, or did not reflect your actual level of disability.
  • You have the right to request a higher-level review or submit a supplemental claim with new and relevant evidence if your initial rating does not accurately reflect the severity of your condition.
  • You have the right to be treated professionally and respectfully during the examination - the examiner's role is to document your condition accurately, not to advocate for or against your claim.

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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.