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C&P Exam Prep: Hip Ankylosis

DC 5250 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Hip_and_Thigh
Form Code
Hip_and_Thigh
Page Count
13
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 degree and position of hip joint ankylosis, determine whether the ankylosis is favorable or unfavorable, assess functional loss, and establish a disability rating under 38 CFR 4.71a DC 5250.

What the examiner evaluates:

  • Presence and confirmation of true hip joint ankylosis (complete immobility or abnormal stiffness/fusion)
  • Position of the ankylosed hip - specifically whether it is in flexion between 20- and 40- with slight adduction or abduction (favorable) or outside this range (unfavorable/intermediate)
  • Whether the foot reaches the ground during standing
  • Necessity of crutches or other assistive devices for ambulation
  • Active and passive range of motion in both hips (affected and contralateral)
  • Weight-bearing vs. non-weight-bearing range of motion differences
  • DeLuca factors: pain on use, fatigability, weakness, incoordination during and after repetitive use
  • Functional loss including disturbance of locomotion, interference with standing and sitting
  • Muscle atrophy, deformity, swelling, instability
  • Leg length discrepancy
  • Surgical history including total hip replacement, hip resurfacing, or arthroscopic procedures
  • Radiographic and diagnostic imaging evidence
  • Impact on occupational and daily activities

Exam will include both interview and physical examination. Bring all imaging (X-rays, MRI, CT scans), surgical records, and current medication list. Wear comfortable, loose-fitting clothing for easy access to the hip area. Be prepared to walk, stand, and attempt lower extremity movements. The examiner will observe your gait. If you use an assistive device (cane, crutches, walker), bring it and use it as you normally would.

Typical duration: 30-45 minutes

Hip Flexion (Active)

How far you can bring your knee toward your chest under your own power; normal is 0-125-. In ankylosis, this motion will be severely limited or absent.

What to expect:

Examiner asks you to lift your knee toward your chest while standing or lying supine. A goniometer may be used to measure the angle. You will be asked to report pain onset and endpoint.

Key thresholds:

  • 20-40- flexion — Favorable ankylosis position - supports 60% rating if combined with slight adduction or abduction
  • Outside 20-40- range (hyperextension, extreme flexion, or neutral) — Intermediate (70%) or Unfavorable/Extremely Unfavorable (90%) ankylosis position
  • Complete immobility — Confirms true ankylosis; rating determined by fixed position

Tips:

  • Report the angle at which pain begins, not just the final endpoint
  • If you can only move a few degrees before severe pain stops you, clearly say so
  • Do not push through pain to demonstrate a greater range - report your honest functional limit
  • Describe whether the limitation is due to pain, mechanical block, or stiffness

Pain considerations: Per DeLuca, pain that prevents further motion counts as a functional endpoint. Tell the examiner: 'I can only move to [X] degrees before the pain stops me.' This should be documented as pain-limited ROM.

Hip Extension (Active)

Ability to move the leg backward behind the body; normal is 0-20-. In ankylosis, this is typically absent or severely restricted.

What to expect:

Examiner asks you to move your leg backward while standing or lying prone. Document any pain onset and endpoint angle.

Key thresholds:

  • 0- — No extension contributes to unfavorable or intermediate ankylosis determination
  • Any measurable extension — May indicate incomplete ankylosis - examiner must reconcile with diagnosis

Tips:

  • Report pain at the very first sign, not just at your endpoint
  • If you cannot safely bear weight during testing, inform the examiner

Pain considerations: Extension is often the most painful movement in hip ankylosis. Clearly communicate whether pain is constant at rest or only provoked by movement.

Hip Abduction and Adduction (Active)

Movement of the leg away from (abduction, normal 0-45-) and across (adduction, normal 0-30-) the midline. Position of adduction or abduction at the ankylosed joint affects favorable vs. unfavorable classification.

What to expect:

Examiner asks you to move your leg outward and inward. In true ankylosis, this movement is absent or minimal.

Key thresholds:

  • Slight adduction or abduction at ankylosed position — Supports favorable ankylosis (60%) when combined with 20-40- flexion
  • Extreme adduction or abduction at fixed position — Contributes to unfavorable or extremely unfavorable classification (70-90%)

Tips:

  • If the hip is fixed in a specific position, clearly describe that position to the examiner
  • Report any compensatory movement from the pelvis or lumbar spine that substitutes for true hip motion

Pain considerations: Even minimal attempts at abduction/adduction in an ankylosed hip can cause severe pain. Communicate this clearly.

Internal and External Rotation (Active)

Rotational capacity of the hip joint; normal internal rotation 0-45-, external rotation 0-45-. Rotation is typically absent in true ankylosis.

What to expect:

Examiner may test rotation with you sitting or lying, rotating the knee inward and outward. May also be tested passively.

Key thresholds:

  • 0- rotation in any plane — Consistent with true ankylosis; documents complete joint immobility
  • Any preserved rotation — May indicate fibrous vs. bony ankylosis - still rated under DC 5250 if functional ankylosis confirmed

Tips:

  • If rotation causes sharp pain before any measurable movement occurs, state this explicitly
  • Distinguish between rotation occurring at the hip vs. rotation compensated by the knee or pelvis

Pain considerations: Report pain with any rotational attempt and describe its character: sharp, burning, aching, radiating.

Passive Range of Motion Testing

Examiner moves your hip through its range without your muscular effort; compares to active ROM. Per Correia requirements, both active and passive ROM must be documented.

What to expect:

Examiner will hold your leg and attempt to move the hip through its range while you relax. Differences between active and passive ROM are clinically significant.

Key thresholds:

  • Passive ROM equal to active ROM — Indicates true structural immobility consistent with bony or fibrous ankylosis
  • Passive ROM greater than active ROM — May indicate muscle weakness or pain-limited motion rather than true ankylosis; examiner must distinguish

Tips:

  • Relax your muscles as completely as possible during passive testing
  • If passive movement causes pain, say so immediately - do not tolerate pain silently
  • The examiner is required to document passive ROM separately from active ROM

Pain considerations: Pain during passive motion is highly relevant - it demonstrates true joint pathology rather than muscular guarding. State 'Even when you move my leg passively, I have pain at [X] degrees.'

Weight-Bearing vs. Non-Weight-Bearing Assessment

Whether the veteran can bear weight on the affected limb and how weight-bearing affects pain and function. Required under Correia standards.

What to expect:

Examiner observes your gait, asks you to stand, and may compare ROM measurements taken while standing versus lying down.

Key thresholds:

  • Foot does not reach ground — Critical criterion for 90% (extremely unfavorable) rating - documents severity of fixed deformity
  • Crutches necessitated for ambulation — Second criterion required for 90% rating

Tips:

  • If you normally use crutches or other assistive devices, bring them and demonstrate your actual gait
  • Describe how long you can stand or walk before pain, fatigue, or instability forces you to stop
  • Report whether your foot naturally rests on the ground or is elevated/displaced due to the fixed hip position

Pain considerations: Weight-bearing pain that limits standing and walking is a DeLuca factor. Quantify: 'I can stand for [X] minutes before pain forces me to sit or use my crutches.'

Repetitive Use Testing (DeLuca Factor)

Whether ROM decreases and pain/fatigue increases after repetitive use of the hip, reflecting the true functional burden of the condition.

What to expect:

Examiner may ask you to perform movements multiple times and reassess ROM and pain after repeated use. Functional loss after activity is documented under DeLuca.

Key thresholds:

  • Measurable ROM decrease after repetitive use — Supports higher functional loss finding; examiner must document in DBQ
  • Increased pain or fatigability after repetitive use — DeLuca factors must be checked on DBQ - pain, fatigability, weakness, incoordination checkboxes

Tips:

  • Be honest about how your hip feels after walking even a short distance
  • Describe your condition at the end of an active day vs. the beginning
  • If the examiner only tests you once at the start of the appointment, mention 'By the end of the day, my hip is much more painful and stiff than it is right now'

Pain considerations: The law requires examiners to account for DeLuca factors. If these are not assessed, politely note: 'I wanted to mention that my pain and stiffness are significantly worse after any activity, and at the end of the day it is much worse than what you are seeing now.'

Estimate

Rating Criteria Breakdown

90% Unfavorable or extremely unfavorable ankylosis where the foo ...

Unfavorable or extremely unfavorable ankylosis where the foot does not reach the ground AND crutches are necessitated. This represents the most severe functional impairment - the fixed position of the hip prevents the foot from making ground contact, making independent ambulation without assistive devices impossible.

Key Symptoms

  • Hip fixed in position that raises the foot off the ground during standing
  • Crutches required for all or most ambulation
  • Complete inability to bear normal weight through the affected extremity
  • Severely altered or absent gait pattern
  • Total loss of hip joint mobility
  • Major interference with all activities of daily living requiring standing or walking
  • Potential for falls and instability

CFR: 38 CFR 4.71a DC 5250: 'Unfavorable, extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated' - rated 90%.

70% Intermediate ankylosis - the hip is ankylosed in a position ...

Intermediate ankylosis - the hip is ankylosed in a position that is neither clearly favorable nor extremely unfavorable. The foot does reach the ground but the fixed position significantly impairs function. The position does not meet criteria for the favorable 60% rating (20-40- flexion with slight adduction/abduction) but is not severe enough for 90%.

Key Symptoms

  • Hip fixed in position outside the 20-40- favorable flexion range
  • Foot reaches the ground but with significant difficulty or altered posture
  • Ambulation possible without crutches but severely limited or painful
  • Major gait disturbance such as severe limp or Trendelenburg gait
  • Significant interference with standing, sitting, and walking
  • Inability to perform normal work tasks requiring lower extremity use
  • Possible leg length discrepancy due to fixed position

CFR: 38 CFR 4.71a DC 5250: 'Intermediate' ankylosis position - rated 70%. Hip ankylosed outside the favorable range of 20-40- flexion with slight adduction/abduction, but without the extreme presentation of foot not reaching the ground.

60% Favorable ankylosis - the hip is fixed in flexion between 20 ...

Favorable ankylosis - the hip is fixed in flexion between 20- and 40- AND in slight adduction or abduction. This position, while still representing complete joint immobility, allows for relatively functional standing and walking posture. Despite being the lowest rating under DC 5250, 60% still represents substantial disability.

Key Symptoms

  • Hip fixed in flexion between 20- and 40-
  • Slight adduction or abduction at the fixed position
  • Foot reaches the ground
  • Ambulation possible but limited and painful
  • Gait disturbance present but less severe than intermediate/unfavorable
  • Sitting possible with modification
  • Endurance significantly reduced due to compensatory posture strain
  • Lumbar and contralateral hip secondary strain from compensation

CFR: 38 CFR 4.71a DC 5250: 'Favorable, in flexion at an angle between 20- and 40-, and slight adduction or abduction' - rated 60%. Both conditions must be met: the angular position AND the adduction or abduction component.

How to Describe Your Symptoms

Pain - Location, Character, and Triggers

How to describe:

Describe pain using specific anatomical locations (groin, lateral hip, buttock, radiating down the thigh), character (sharp, aching, burning, throbbing), triggers (weight-bearing, position changes, prolonged sitting or standing, any attempted movement), and severity on a 0-10 scale at rest and with activity. Describe your worst day, not your best day.

Worst-day example:

“On my worst days, the pain in my left hip and groin is a constant 8 out of 10 even at rest. When I try to stand up from a chair, it spikes to a 10 and I have to grab onto something to not fall. I cannot walk more than half a block before the pain forces me to stop. By evening, the pain is so severe I cannot find a comfortable position and my sleep is disrupted every night.”

What the examiner listens for:

Pain onset during range of motion testing, pain at rest vs. on movement, pain that limits repetitive use, radicular or referred pain patterns, pain requiring medication, and functional limitations caused directly by pain.

Understatements to avoid:

Saying 'it's manageable' or 'I'm used to it' minimizes documented severity. If you have adapted your life around your limitations, that adaptation itself is evidence of disability - describe what you can no longer do, not how you cope.

Ankylosis Position and Fixed Deformity

How to describe:

Describe precisely how your hip is fixed. Can you straighten your leg fully? Is your leg held in a bent position at rest? Does your foot reach the floor when you stand? Do you lean or tilt to compensate? Has anyone measured the angle of fixation on imaging or examination?

Worst-day example:

“My hip is completely frozen - I cannot move it at all. My leg is stuck in a slightly bent and turned-out position. When I stand up, my foot just barely touches the floor but my pelvis tilts severely to one side to make it happen. I have to use my crutches for any distance because I cannot generate any power from that leg.”

What the examiner listens for:

Confirmation of immobility, description of the resting position, ability to achieve ground contact with the foot, and need for assistive devices. These directly determine favorable vs. intermediate vs. unfavorable classification.

Understatements to avoid:

Do not describe partial ankylosis as 'some stiffness.' If the joint does not move in any plane, state clearly: 'My hip does not move at all - it is completely locked.' Minimizing the immobility can result in rating under a limitation-of-motion code rather than the higher ankylosis code.

Ambulation and Assistive Device Use

How to describe:

Describe exactly what you use for walking (cane, crutches, walker, wheelchair), when you use it (all the time, only on bad days, only outside), how far you can walk, and what happens when you push beyond your limit.

Worst-day example:

“I use crutches every time I leave my home. Inside the house, I hold onto walls and furniture. Without crutches, I fall or my hip gives out within a few steps. The last time I tried to walk without crutches, I fell and injured myself. On my worst days, I cannot get from my bedroom to the bathroom without stopping due to pain and exhaustion.”

What the examiner listens for:

Consistent use of assistive devices, prescribed vs. self-initiated device use, distance walked before stopping, fall history, and whether crutches are truly necessitated (relevant to 90% rating criterion).

Understatements to avoid:

Do not say 'I only use the crutches sometimes' if you need them for anything more than truly optional use. If your doctor prescribed them or you would fall without them, they are necessitated. Bring them to the exam and use them as you normally would.

DeLuca Factors - Fatigue, Weakness, and After-Activity Worsening

How to describe:

Describe how your condition changes after activity. Does walking a short distance make your hip worse for the rest of the day? Do you experience muscle weakness or give-way episodes? Do you fatigue significantly faster than before the injury?

Worst-day example:

“If I walk more than half a block, my entire leg becomes so weak and fatigued that I have to lie down for the rest of the afternoon. My hip and thigh muscles feel like they have no strength left. By the end of any active day, my pain increases from a 4 to a 9 and I am completely exhausted from the effort of just moving around.”

What the examiner listens for:

Pain, fatigability, weakness, and incoordination that are specifically provoked or worsened by use - the examiner must check these boxes on the DBQ. If they only test you once at rest, these factors may not be captured.

Understatements to avoid:

Do not only describe your baseline - explicitly state 'After activity, my condition is much worse than what you are observing right now.' The exam typically happens in the morning; your end-of-day condition may be your more representative worst-day experience.

Interference with Activities of Daily Living

How to describe:

Describe specific activities you cannot do or can only do with modification or assistance: bathing, dressing (putting on pants, shoes, socks), driving, climbing stairs, sitting for extended periods, sexual activity, exercise, household chores, and employment tasks.

Worst-day example:

“I cannot put on my own shoes and socks because I cannot bend my hip far enough to reach my foot. I have to use a shower chair because I cannot stand on one leg. I cannot drive a standard vehicle. I cannot sit in a normal chair for more than 20 minutes before the pain becomes unbearable. I had to leave my job because I could not stand or walk for any meaningful period.”

What the examiner listens for:

Concrete functional limitations, occupational impact, and how the ankylosed hip affects the veteran's ability to perform work and self-care - directly relevant to the functional impact field on the DBQ.

Understatements to avoid:

Do not say 'I get by' without explaining the workarounds required. Each adaptation (shower chair, sock aid, handicap parking, home aide) is evidence of functional limitation.

Flare-Ups

How to describe:

Describe episodes when your condition is significantly worse than your baseline - what triggers them, how long they last, how severe they get, and what you must do to recover (bed rest, medication, ER visits, increased assistive device use).

Worst-day example:

“When I overdo any activity - even just a short shopping trip - I have flare-ups that last 3-5 days where I am essentially bedridden. The pain goes from a 6 baseline to a 10, I cannot bear any weight at all, and I need help from my family for everything including getting to the bathroom. I have these flares at least twice a month.”

What the examiner listens for:

Frequency, duration, severity, and triggers of flare-ups - the DBQ has a specific field for flare-up description. This is a required DeLuca consideration that can significantly impact functional loss documentation.

Understatements to avoid:

Veterans often minimize flare-ups by only describing their stable baseline. If you have regular episodes of severely worsened function, describe them in detail. The examiner must document the veteran's own description of flare-ups in the DBQ.

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 (audio or video) in most states - notify the examiner at the start of the appointment and confirm whether this is permitted under your state's law and current VA policy.
  • You have the right to receive a copy of your completed DBQ examination report through your claims file via eVetRecs or VA records request.
  • You have the right to a thorough, competent examination - an inadequate exam (one that fails to test required elements, omits DeLuca factors, or is unsupported by clinical findings) can be challenged and a new exam requested.
  • You have the right to submit a personal statement (VA Form 21-4138) or private medical opinion to supplement or rebut the C&P findings.
  • You have the right to bring a representative, accredited claims agent, or VSO representative to your C&P examination.
  • You have the right to have lay evidence (buddy statements, caregiver statements, your own personal statement) considered alongside clinical findings - lay evidence is particularly valuable for documenting daily functional limitations.
  • You have the right to request a second C&P examination if the original exam was inadequate, the examiner lacked appropriate qualifications, or the exam report contains factual errors or omissions.
  • You have the right under the PACT Act and AMA (Appeals Modernization Act) to multiple review lanes (Supplemental Claim, Higher Level Review, Board of Veterans Appeals) if your initial rating decision is unfavorable.
  • You have the right to have your condition rated at its worst presentation, including worst-day symptoms and post-activity functional loss - per M21-1 guidance, the examiner is required to document the veteran's own description of their functional limitations including on bad days.
  • You have the right to claim secondary conditions caused or aggravated by your hip ankylosis - including lumbar spine conditions, contralateral joint conditions, and mental health conditions secondary to chronic pain.

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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.