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C&P Exam Prep: Muscle Group XIII Injury (Hamstrings)

DC 5313 musculoskeletal 38 CFR 4.73

DBQ Overview

Interview + Physical
Form Name
Muscle_Injuries
Form Code
Muscle_Injuries
Page Count
12
Examiner Type
Orthopedic Surgeon, Physiatrist, or appropriate clinician
Estimated Duration
30-60 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To evaluate the current severity of a service-connected or potentially service-connected injury to Muscle Group XIII (posterior thigh/hamstring muscles: biceps femoris, semitendinosus, semimembranosus), assess functional impairment, and provide the VA rater with objective findings needed to assign an accurate disability rating under 38 CFR 4.73, Diagnostic Code 5313.

What the examiner evaluates:

  • Identification and confirmation of the specific muscle group(s) injured (Group XIII: biceps femoris, semitendinosus, semimembranosus)
  • Severity classification: slight, moderate, moderately severe, or severe injury per 38 CFR 4.73
  • Presence and extent of scar characteristics (minimal, entrance/exit wound scars, ragged/depressed/adherent scars, adhesion to bone)
  • Muscle tonus, substance loss, atrophy (visible or measurable), and fascial integrity
  • Weakness and loss of power in the hamstring muscle group
  • Lowered threshold of fatigue with repetitive use
  • Pain on use or at rest with functional activities
  • Impairment of coordination and uncertainty of movement
  • Active and passive range of motion of the knee (flexion and extension) and hip
  • Manual muscle testing grades for knee flexion (primary hamstring function)
  • Functional limitations in walking, climbing, kneeling, squatting, and running
  • Presence of muscle atrophy with circumferential thigh measurements (normal vs. atrophied side)
  • Use of assistive devices (cane, crutches, walker, wheelchair, braces)
  • Flare-ups: frequency, severity, precipitating factors, and duration
  • Retained foreign bodies (shell fragments, shrapnel) via X-ray evidence if applicable
  • Impact on occupational and daily functioning
  • Any additional diagnoses or complications related to the muscle injury

The exam will be conducted in person at a VA facility, VAMC, or contracted examiner office. The examiner will review your claims file and service treatment records before or during the exam. You may be asked to change into a gown for direct physical examination of the posterior thigh. Bring all assistive devices you use regularly. If you use a brace or knee sleeve for your hamstring injury, wear or bring it. In most states you have the right to record the examination - notify the examiner at the start if you intend to do so.

Typical duration: 30-60 minutes

Active Knee Flexion Range of Motion

The degree to which you can actively bend your knee using hamstring muscle contraction, measured with a goniometer. Normal active knee flexion is 0-140 degrees.

What to expect:

You will be asked to bend your knee as far as possible while lying prone or sitting. The examiner measures the angle achieved. This is the primary functional movement of the hamstring group. Both sides will be compared.

Key thresholds:

  • Full range (0-140-) with pain or fatigue — Supports at minimum slight injury; DeLuca factors for pain/fatigue on use become critical
  • Noticeably limited flexion with weakness — Supports moderate to moderately severe injury rating; document exact degree
  • Significant limitation with atrophy and loss of power — Supports moderately severe to severe injury; document circumferential measurements

Tips:

  • Perform the movement at your actual capacity - do not push through severe pain to appear capable
  • If you experience pain before reaching end range, say so clearly: 'I stop here because of pain in the back of my thigh'
  • If your range is worse in the morning or after prolonged sitting, mention this timing
  • Ask the examiner to test after repetitive use if your condition worsens with repeated movement
  • Report if your knee feels unstable or gives way during the test

Pain considerations: Under DeLuca v. Brown, pain on use that limits motion must be separately noted. If your active ROM is limited by pain before reaching the endpoint of structural limitation, state this explicitly. The examiner should record both the pain-free arc and the total arc achieved.

Passive Knee Flexion Range of Motion

The degree of knee flexion achievable when the examiner moves your leg without your muscle effort, isolating structural/capsular restriction from muscle weakness.

What to expect:

While relaxed, the examiner will gently flex your knee to its maximum comfortable range. Compare with active ROM to assess how much of any limitation is due to muscle weakness vs. joint/structural restriction.

Key thresholds:

  • Passive ROM greater than active ROM — Indicates muscle weakness/fatigue is the primary limiting factor - important for hamstring injury rating
  • Passive ROM equals active ROM limitation — Suggests combined structural and muscular limitation; supports higher severity rating

Tips:

  • Stay relaxed and let the examiner move your leg; do not assist or resist
  • Report any pain, tightness, or pulling sensation in the posterior thigh during passive flexion
  • Mention if passive stretching triggers spasms in the hamstring

Pain considerations: Pain or tightness felt at the posterior thigh during passive flexion may indicate scar tissue, adhesions, or persistent muscle injury - report exactly where you feel it.

Manual Muscle Testing (MMT) - Knee Flexion

The strength of hamstring muscles on a 0-5 scale: 5=normal strength against full resistance, 4=movement against some resistance, 3=movement against gravity only, 2=movement with gravity eliminated, 1=visible/palpable contraction only, 0=no contraction.

What to expect:

You will be asked to flex your knee while the examiner applies resistance at the ankle/lower leg. The examiner grades the strength. Both sides are tested for comparison.

Key thresholds:

  • Grade 5/5 bilaterally — Does not support significant weakness finding; focus on fatigue, pain, and functional loss
  • Grade 4/5 — Supports moderate weakness; consistent with moderate injury rating
  • Grade 3/5 or below — Supports moderately severe to severe injury; significant functional limitation

Tips:

  • Give your honest maximum effort - the examiner needs accurate data
  • If you can only sustain maximum effort briefly before fatigue, tell the examiner: 'I feel my strength drop off quickly with repetition'
  • If one side is noticeably weaker than the other, make sure the examiner tests both
  • Report if the weakness is worse after activity or at certain times of day

Pain considerations: Pain inhibition - where pain prevents you from exerting maximum effort - should be noted. Tell the examiner if pain is what is limiting your push rather than true muscle weakness, so they can document both factors.

Thigh Circumference Measurement (Atrophy Assessment)

Circumferential measurement of both thighs at a standardized point (typically 10-15 cm above the superior patellar pole) to detect and quantify muscle atrophy. A difference of 2 cm or more is generally considered clinically significant.

What to expect:

The examiner uses a tape measure around both thighs at the same anatomical level and records the normal side and the atrophied side measurements.

Key thresholds:

  • No measurable difference — Does not support atrophy finding; document other objective signs of injury
  • 1-2 cm difference — Borderline atrophy; supports moderate injury; document alongside strength and functional findings
  • >2 cm difference — Visible/measurable atrophy confirmed; strongly supports moderately severe or severe rating

Tips:

  • Atrophy may be present even if not visually obvious - the measurement will capture it
  • If you have noticed your injured thigh looks thinner or feels weaker, point this out to the examiner
  • Long-term disuse following an old injury can result in atrophy that persists for years - mention this history

Pain considerations: Atrophy from chronic pain-related disuse is a valid and rateable finding. If you avoid using the injured leg due to pain, explain this connection to the examiner.

Active Hip Range of Motion (Extension and Flexion)

Hip extension (hamstrings assist gluteus maximus) and hip flexion (opposing group). Limitation in hip extension may reflect hamstring scarring or tightness across the posterior thigh.

What to expect:

You will be asked to move your hip in various directions. Hamstring tightness often limits straight-leg raise and hip flexion when the knee is extended (indicating hamstring length restriction).

Key thresholds:

  • Straight-leg raise limited to <60- — Indicates significant hamstring tightness/scarring; supports moderate to severe injury finding
  • Hip extension limitation — May support Group XIII involvement in conjunction with Group XVII (pelvic girdle) - document both

Tips:

  • Report tightness, pulling, or pain in the posterior thigh during hip flexion with knee extended (straight-leg raise)
  • Distinguish pain location: back of thigh vs. low back vs. knee

Pain considerations: Posterior thigh pain during straight-leg raise is a key indicator of hamstring pathology - be specific about the location and intensity.

Functional Endurance Assessment

How your hamstring injury affects sustained functional activities: walking distance, stair climbing, rising from seated/kneeling, and any activities requiring repetitive knee flexion.

What to expect:

The examiner will ask about your functional capacity. They may observe your gait. They are assessing lowered threshold of fatigue, pain on prolonged use, and functional impairment.

Key thresholds:

  • Unable to walk >1 block without stopping due to posterior thigh pain/weakness — Supports moderately severe to severe rating with functional overlay
  • Fatigue and pain after moderate activity requiring rest — Supports lowered threshold of fatigue finding - key DeLuca factor

Tips:

  • Describe a specific worst-day scenario: 'On my worst days, I cannot walk to my mailbox and back without the back of my thigh burning and giving out'
  • Report activities you have stopped doing entirely because of the condition
  • Describe how long you can stand, walk, or climb stairs before symptoms force you to stop

Pain considerations: Fatigue and pain that develop with use - even if not present at rest - are rateable findings under the DeLuca doctrine. Do not underreport symptoms that only appear during activity.

Estimate

Rating Criteria Breakdown

40% Severe: With extensive scar formation, muscle hernias, or if ...

Severe: With extensive scar formation, muscle hernias, or if the record shows: marked loss of muscle substance (atrophy of muscle groups not in the track of the missile, from loss of nerve supply), tests of endurance or coordinated movements compared with the sound side show marked impairment of all muscle functions.

Key Symptoms

  • Extensive scar formation throughout posterior thigh
  • Muscle hernias present
  • Marked loss of muscle substance (significant visible atrophy)
  • Atrophy of muscle groups beyond the direct injury track (neurogenic atrophy)
  • Tests of endurance show marked impairment compared to unaffected side
  • Coordinated movements severely impaired compared to sound side
  • Loss of power: grade 3/5 or below on manual muscle testing for knee flexion
  • Significant functional limitation: cannot climb stairs, cannot perform activities requiring knee flexion under load
  • Adhesion of scar to underlying bone (femur)
  • Requiring assistive devices (cane, crutches) for ambulation
  • Severe flare-ups that incapacitate for extended periods

CFR: Per 38 CFR 4.73, DC 5313: Severe injury. Extensive scarring, muscle hernias, marked atrophy beyond missile track, tests of endurance and coordination show marked impairment vs. sound side. Maximum schedular rating under DC 5313.

30% Moderately Severe: With more of the following: ragged, depre ...

Moderately Severe: With more of the following: ragged, depressed, and adherent scars indicating wide damage to muscle groups; palpation shows loss of deep fascia or muscle substance; atrophy shown by measurement (visible or measurable); weakness, fatigue, and/or lowered endurance of affected muscle group; impairment of coordination and uncertainty of movement.

Key Symptoms

  • Ragged, depressed, and adherent scars indicating wide damage to posterior thigh muscles
  • Palpation reveals loss of deep fascia or significant muscle substance loss
  • Visible or measurable atrophy of affected thigh (2+ cm circumference difference)
  • Adaptive contraction of opposing muscle group (quadriceps shortening)
  • Induration or atrophy of entire muscle following history of infection
  • Muscles swell and harden abnormally in contraction
  • Weakness and fatigue with ordinary use - not just extreme exertion
  • Impairment of coordination and uncertainty of movement when walking, climbing stairs, or squatting
  • Functional limitation: difficulty with stairs, kneeling, prolonged walking

CFR: Per 38 CFR 4.73, DC 5313: Moderately severe injury. Multiple objective findings of significant muscle damage: adherent scars, measurable atrophy, weakness, coordination impairment, lowered fatigue threshold.

20% Moderate: In part, entrance and exit scars are larger, indic ...

Moderate: In part, entrance and exit scars are larger, indicating track of missile through muscles; some loss of muscle substance, soft flabby muscles in wound area, or some impairment of muscle tonus.

Key Symptoms

  • Entrance/exit scars indicating missile track through muscle
  • Some loss of muscle substance in the posterior thigh
  • Soft or flabby muscles in the hamstring region on palpation
  • Some impairment of muscle tonus
  • Weakness and fatigue on moderate use
  • Mild but measurable functional limitation with knee flexion and ambulation

CFR: Per 38 CFR 4.73, DC 5313: Moderate injury. Scars indicate track through muscles, some muscle substance loss, soft flabby muscles, or impaired tonus in the posterior thigh.

10% Slight: Injury with minimum disability. Minimal impairment; ...

Slight: Injury with minimum disability. Minimal impairment; entrance and exit scars are small or linear; muscles are essentially intact with only slight residual symptoms.

Key Symptoms

  • Minimal scars (small or linear entrance/exit wound scars)
  • Muscles essentially intact and functional
  • Slight weakness or fatigue only with extreme exertion
  • No measurable atrophy
  • No significant loss of power or coordination
  • Minimal functional limitation in daily activities

CFR: Per 38 CFR 4.73, DC 5313: Slight injury with minimum disability. Scars are minimal. No significant muscle substance loss, no atrophy, minimal residuals.

How to Describe Your Symptoms

Pain - Location, Quality, and Triggers

How to describe:

Describe pain as precisely as possible: location (posterior thigh, behind the knee, ischial tuberosity), quality (burning, aching, sharp, pulling), triggers (walking, climbing stairs, bending knee under load, prolonged sitting, getting up from chair), and severity on a consistent 0-10 scale. Distinguish resting pain from activity-induced pain.

Worst-day example:

“On my worst days, the back of my right thigh burns at a 7/10 from the moment I get out of bed. Walking to the bathroom causes a sharp pulling pain that forces me to limp. I cannot bend my knee enough to go down stairs without gripping the railing and going one step at a time. I have to take ibuprofen and lie down within 30 minutes of any activity.”

What the examiner listens for:

The examiner is listening for whether pain is present at rest or only on use, whether it is proportionate to the injury, whether it limits functional activities, and whether it correlates with objective findings like atrophy or scar tissue.

Understatements to avoid:

Do not say 'it's not that bad' or 'I can manage.' Do not describe your best days as typical. Do not minimize pain by saying 'I take Advil and it's fine' without explaining how often you need medication and what you still cannot do even with medication.

Weakness and Loss of Power

How to describe:

Describe functional manifestations of weakness: inability to climb stairs without a rail, difficulty rising from low chairs or the floor, leg giving way when going down inclines, inability to run or jog, dropping objects or stumbling due to knee buckling. Connect weakness to specific daily activities.

Worst-day example:

“My hamstring feels completely dead on bad days. I have fallen twice this year because my knee buckled going down stairs. I cannot get up off the floor without pulling myself up on furniture. I had to stop my job that required climbing ladders because my right leg is too unreliable.”

What the examiner listens for:

The examiner is assessing whether weakness is functional - meaning it actually limits what you can do - and whether it matches the objective manual muscle test findings. Descriptions that correlate with exam findings are most credible.

Understatements to avoid:

Do not demonstrate that you can do something during the exam that you cannot do in real life, then fail to explain the discrepancy. If you can do a task during the exam due to adrenaline or because it is only a short effort, say: 'I can do this briefly but I could not sustain this for normal daily activities.'

Fatigue and Lowered Endurance Threshold

How to describe:

Explain how quickly your hamstring fatigues compared to before the injury and compared to your other leg. Provide specific distances, durations, or repetitions: 'After walking half a block, the back of my thigh begins to burn and feel heavy and I have to stop and rest for 5-10 minutes before continuing.' Describe what happens with repetitive use - does it get worse?

Worst-day example:

“Even on an average day, I cannot walk more than one block without stopping. The muscle in the back of my thigh starts burning and trembling, and by the second block it feels like the muscle is going to cramp and lock up. I used to walk 3-4 miles without issue before my injury. Now I plan all errands around benches or places I can sit.”

What the examiner listens for:

The examiner is listening for whether fatigue develops with ordinary use (not just maximal exertion), how quickly it develops, and whether it resolves with rest or persists. This directly supports the 'lowered threshold of fatigue' criterion that distinguishes moderate from moderately severe ratings.

Understatements to avoid:

Do not say 'I get a little tired.' Be specific about how much activity triggers fatigue, how long recovery takes, and how this compares to your pre-injury baseline or your unaffected leg.

Flare-Ups

How to describe:

Describe flare-ups as distinct episodes of worsening: frequency (how many per month), duration (hours to days), triggers (weather, overactivity, sitting or standing too long), severity during the flare versus baseline, and what you cannot do during a flare. Explain whether they are predictable or unpredictable.

Worst-day example:

“I have severe flare-ups about twice a month, usually triggered by anything more than 20 minutes of walking or any activity involving bending and squatting. During a flare, the back of my thigh swells, the muscle cramps involuntarily, and the pain reaches 9/10. I cannot walk more than a few steps and I need to ice my thigh and stay in bed for 1-3 days until it settles down.”

What the examiner listens for:

The examiner needs to document flare-up characteristics to apply DeLuca factors. They are listening for whether flares represent a meaningful addition to baseline disability - particularly any additional functional loss during flares.

Understatements to avoid:

Do not say 'I have some bad days sometimes.' Give numbers: frequency, duration, severity scale, and specific functional losses. If flares are unpredictable and affect your ability to maintain employment, state this explicitly.

Impairment of Coordination and Uncertainty of Movement

How to describe:

Describe situations where you are uncertain whether your leg will support you: fear of falling on uneven terrain, difficulty judging how much to bend your knee, involuntary movement or trembling of the posterior thigh, difficulty with precise movements like stepping over curbs, and any compensatory changes in your gait.

Worst-day example:

“I never know when my leg is going to give out. I hold the wall when I walk down the hall at home. I stopped hiking and going to crowded places because any unexpected movement - stepping off a curb, someone bumping me - can make my knee buckle. My physical therapist told me my gait pattern has completely changed because I cannot trust my right hamstring.”

What the examiner listens for:

The examiner is looking for whether coordination impairment and movement uncertainty are present as separate, rateable findings beyond simple weakness. These are specifically listed criteria at the moderately severe level under 38 CFR 4.73.

Understatements to avoid:

Do not frame this only as 'my leg is weak.' The specific language of 'impairment of coordination' and 'uncertainty of movement' are enumerated criteria - use these terms or describe exactly what they mean for you functionally.

Scars and Physical Changes to the Muscle

How to describe:

Describe any visible scars, their size and texture, whether they are raised, depressed, adherent (stuck to underlying tissue), or affect movement. Describe whether palpation of the scar or posterior thigh is painful. Note any lumps, muscle herniations, or areas where the muscle feels absent or abnormal.

Worst-day example:

“The scar on the back of my thigh is about 4 inches long, deeply indented, and sticks to the muscle underneath so that when I try to flex my knee I can feel it pull. There is a divot where muscle tissue is clearly missing. The area around the scar is hypersensitive and painful when touched or when clothing rubs against it.”

What the examiner listens for:

The examiner is identifying scar characteristics that correspond to the rating levels: minimal scars vs. scars indicating missile track vs. ragged/depressed/adherent scars indicating wide damage vs. bone adhesion. Be accurate and detailed.

Understatements to avoid:

Do not downplay scars as 'just a scar.' The type and characteristics of scars are the primary objective determinants of the injury severity level under 38 CFR 4.73. Point the examiner to all scars related to the injury, including surgical scars.

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 have the examination conducted by a qualified clinician (typically an Orthopedic Surgeon, Physiatrist, or appropriately trained clinician) - if the examiner does not have relevant expertise in musculoskeletal conditions, you may request a different examiner.
  • You have the right to record the C&P examination in most states - notify the examiner at the start of the session and confirm your state's consent requirements beforehand.
  • You have the right to accurate and complete documentation - if the examiner does not test something relevant to your condition (e.g., bilateral thigh measurements, repetitive-use effects), you may request they do so and note the omission if they refuse.
  • You have the right to review the completed DBQ - request a copy through your VSO, MyHealtheVet, or by filing a FOIA/Privacy Act request; review it for accuracy against what you reported.
  • You have the right to challenge an inadequate examination - if the DBQ is incomplete, contradicts your records, omits DeLuca factors, or was conducted without a proper physical examination, you can file a notice of disagreement or request a new examination.
  • You have the right to submit additional evidence (personal statements, buddy statements, private medical opinions) to supplement the C&P exam findings - this evidence must be considered by VA raters.
  • Under the PACT Act and existing VA regulations, VA must consider all lay evidence - including your own testimony about your symptoms - as competent evidence of your condition's severity.
  • You have the right to a fully reasoned rating decision that explains how the VA evaluated your evidence - if the decision does not explain why it rejected medical or lay evidence, this is grounds for appeal.
  • Under 38 CFR 3.102 (benefit of the doubt), when there is an approximate balance of positive and negative evidence, the question must be resolved in your favor - ensure all positive evidence is in your file before a rating decision is made.
  • You have the right to free representation by an accredited VSO, claims agent, or attorney at no charge until after a final BVA decision - use this resource to review your claim before and after the C&P exam.

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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.