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C&P Exam Prep: Paget's Disease of Bone (Osteitis Deformans)
DBQ Overview
Interview + Physical- Form Name
- Bones_and_Other_Skeletal_Conditions
- Form Code
- Bones_and_Other_Skeletal_Conditions
- Page Count
- 7
- Examiner Type
- Orthopedic Surgeon, Oncologist, or appropriate clinician
- Estimated Duration
- 30-45 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To evaluate the current severity, functional impact, and complications of Paget's Disease of Bone (Osteitis Deformans) for VA disability rating purposes under Diagnostic Code 5016. The exam establishes the nature, extent, and functional limitations of the disease as it affects bones and related structures, including any associated malignant transformation, neurological complications, or secondary joint disease.
What the examiner evaluates:
- Current diagnosis confirmation and ICD coding for Paget's Disease
- Bones and skeletal regions affected (skull, spine, pelvis, femur, tibia, etc.)
- Severity of bone pain at rest, with activity, and during flare-ups
- Presence and degree of bone deformity (bowing of long bones, skull enlargement, spinal curvature)
- Pathological fracture history and risk
- Associated malignant transformation (osteosarcoma) - primary or secondary bone neoplasm
- Neurological complications: hearing loss, cranial nerve involvement, spinal cord or nerve root compression
- Secondary osteoarthritis of adjacent joints
- Range of motion limitations of affected extremities and spine
- Gait disturbance, limb length discrepancy, and ambulatory ability
- Cardiovascular complications (high-output cardiac failure in severe/widespread disease)
- Treatment history: bisphosphonate therapy, surgery, radiation, other modalities
- Assistive device use (cane, crutches, walker, wheelchair, braces)
- Functional impact on activities of daily living, employment, and self-care
- Laboratory findings: serum alkaline phosphatase, urinary hydroxyproline, bone scan findings
- Imaging studies: X-ray, bone scan, CT, MRI findings and dates
Examination is typically conducted in person at a VA facility or contracted QTC/LHI clinic. The examiner will review your claims file, conduct a medical history interview, perform a physical examination of affected body regions, assess gait and ambulation, and review available laboratory and imaging results. In some circumstances, examinations may be conducted via telehealth; if so, the examiner must document how the examination was conducted. Bring all private medical records, imaging CDs, and a written symptom summary to ensure completeness.
Typical duration: 30-45 minutes
Range of Motion (ROM) - Affected Joints and Spine
Degree of motion limitation in joints adjacent to Pagetic bone (e.g., hip, knee, spine) caused by secondary osteoarthritis, bone deformity, or pain. Measured in degrees using a goniometer.
What to expect:
Examiner will measure active ROM (you move the joint yourself), passive ROM (examiner moves it), and may assess weight-bearing versus non-weight-bearing positions per Correia requirements. Testing may include the spine (flexion, extension, lateral flexion, rotation), hips, and knees depending on affected areas.
Key thresholds:
- Hip flexion limited to 45- or less — Supports higher rating under analogous hip/thigh codes when secondary osteoarthritis is present
- Knee flexion limited to 30- or less — Supports higher rating under analogous knee codes when secondary osteoarthritis is present
- Lumbar flexion limited to 30- or less — Relevant if spinal Paget's causes secondary spondylosis or stenosis
- Any additional limitation after repetitive use — Must be documented by examiner per DeLuca; supports higher functional impairment rating
Tips:
- Perform movements slowly and stop at the point where pain becomes significant - do not push through disabling pain
- If your ROM is worse after walking or repeated movement, tell the examiner before testing begins
- Inform the examiner of your worst-day ROM, not just how you feel at that moment
- Request that passive ROM, weight-bearing, and non-weight-bearing positions all be tested and documented
- If bone deformity (bowing of femur or tibia) limits ROM independent of pain, explain this clearly
Pain considerations: Per DeLuca v. Brown, the examiner must record the degree of ROM at which pain begins and any additional limitation caused by pain, weakness, fatigue, or incoordination. Explicitly state: 'I experience pain at [X] degrees of motion, and after walking or repetitive use, my motion is further limited and my pain increases significantly.'
Gait Assessment and Limb Length Discrepancy
Ability to ambulate safely and without assistive devices; presence of antalgic gait, bowing deformity causing leg length discrepancy, and fall risk.
What to expect:
Examiner will observe you walk, assess for limp, bowing, or use of assistive devices. Leg length may be measured if bowing of femur or tibia is present. Note any uneven gait, pain with weight-bearing, or need for orthotic support.
Key thresholds:
- Limb length discrepancy >2.5 cm — Supports rating under leg length inequality provisions; affects ambulation rating
- Inability to ambulate without assistive device — Documents need for cane, crutches, walker, or wheelchair - critical for SMC and functional ratings
- Antalgic gait with observable pain — Supports functional impairment and pain severity documentation
Tips:
- Do not perform better on exam day than you typically do - use your assistive device if you normally use one
- Describe how far you can walk before pain forces you to stop
- Mention if bowing of the legs causes you to walk differently or increases fall risk
- Note any falls related to your condition in the past 12 months
Pain considerations: Explain that on bad days, weight-bearing through Pagetic bone causes severe deep, aching pain that forces you to limit walking distance significantly. Describe the worst occasion when ambulation was most severely affected.
Alkaline Phosphatase (ALP) and Bone Turnover Markers
Serum alkaline phosphatase is the primary laboratory marker reflecting disease activity and extent of Paget's Disease. Elevated ALP indicates active bone remodeling. Urinary hydroxyproline or serum CTX/P1NP may also reflect disease activity.
What to expect:
Examiner will review any available laboratory results in your claims file or treatment records. If recent labs are not available, they may order them or note their absence. Ensure your most recent ALP results are included in your records.
Key thresholds:
- ALP markedly elevated (>3x upper limit of normal) — Indicates active, widespread disease; supports higher severity rating
- Persistently elevated despite bisphosphonate treatment — Indicates treatment-refractory disease with ongoing active destruction
- Normal ALP on treatment — Biochemical remission; examiner must still assess structural damage, pain, and functional loss independently
Tips:
- Bring copies of all recent ALP lab results to the exam
- Note that normal ALP on medication does not mean you are symptom-free - structural deformity, pain, and secondary arthritis persist
- Ask your treating physician to document ALP trends over time to show disease course
Pain considerations: Emphasize that even with biochemical control, Pagetic bone already deformed or damaged continues to cause chronic pain, mechanical joint problems, and neurological complications independent of ALP levels.
Bone Scan (Radionuclide Scintigraphy)
Extent of skeletal involvement - identifies which bones have active Pagetic lesions. Critical for establishing polyostotic versus monostotic disease and for identifying sites at risk for fracture or malignant transformation.
What to expect:
Examiner will review existing bone scan results in your records. The DBQ has a specific field for bone scan date and results. Ensure your most recent bone scan is in your claims file.
Key thresholds:
- Polyostotic involvement (multiple bones) — Supports more severe disability rating; increases risk of complications including cardiac involvement
- Involvement of weight-bearing bones (femur, tibia, pelvis, spine) — Directly associated with pain, fracture risk, and ambulation impairment
- Skull or vertebral involvement — Supports neurological complications including hearing loss, cranial nerve palsy, or spinal stenosis claims
Tips:
- Bring your most recent bone scan report and CD/images if available
- If a bone scan has not been done recently, request one from your treating physician before the exam
- Identify each bone affected on the scan and describe corresponding symptoms at each site
Pain considerations: Correlate each bone scan positive site with specific pain locations and functional limitations you experience. This helps the examiner document each affected anatomical region accurately.
X-Ray / MRI / CT Imaging of Affected Bones
Structural changes: cortical thickening, trabecular coarsening, bone enlargement, lytic or sclerotic phases, deformity (bowing), fracture lines, secondary osteoarthritis, and early malignant transformation (osteosarcoma).
What to expect:
Examiner will review existing imaging in your records and may order new films. The DBQ has fields for X-ray, MRI, CT, and bone biopsy results. Bring all imaging records and radiology reports.
Key thresholds:
- Pathological fracture on imaging — Critical finding; supports higher disability rating and demonstrates severity of structural compromise
- Bowing deformity of femur or tibia — Supports limb length discrepancy, gait abnormality, and secondary joint disease ratings
- Spinal stenosis from Pagetic vertebral enlargement on MRI — Supports neurological complication claims (radiculopathy, myelopathy)
- Aggressive lytic lesion on imaging — Raises concern for malignant sarcomatous transformation - critical for oncology evaluation and 100% rating consideration
Tips:
- Bring all imaging CDs and written radiology reports
- Note the date of each imaging study - old films may not reflect current structural damage
- If imaging shows new aggressive changes, request urgent oncology referral and document this urgency in your claim
- MRI is more sensitive for early malignant transformation and spinal cord compression - request if not already performed
Pain considerations: Use imaging findings to anchor your pain complaints anatomically. For example: 'The bowing of my right femur shown on X-ray causes me to walk with a limp and puts abnormal stress on my right knee, causing constant aching pain rated 7/10 on my worst days.'
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 100% | Active malignant neoplasm (osteosarcoma or other sarcomatous transformation of Pagetic bone) - rated 100% while active, with a mandatory VA exam scheduled 6 months after completing treatment. Alternatively, severe widespread Paget's Disease with major complications equivalent to total disability (e.g., paraplegia from spinal cord compression, high-output cardiac failure, complete bilateral hearing loss from skull involvement) may support a 100% rating via TDIU or SMC provisions. |
CFR: DC 5016 rates Paget's Disease analogously to the bones involved or complications present. Malignant transformation is rated under the bone neoplasm provisions (DC 5012-5015 range) at 100% while active. Total occupational and social impairment from combined orthopedic and neurological sequelae may support TDIU. |
| 60% | Severe Paget's Disease with significant structural deformity, multiple affected bones, and substantial functional impairment. Includes significant secondary complications such as moderate hearing loss from skull involvement, secondary severe osteoarthritis of major joints, recurrent pathological fractures, significant spinal disease with radiculopathy, or inability to ambulate without assistive devices for extended distances. Analogous rating based on affected bones and resulting functional impairment. |
CFR: Under DC 5016 and analogous codes, severe functional impairment from deformity, secondary arthritis, fractures, or neurological complications of Pagetic bone disease at major joints or the spine supports ratings in the 40-60% range depending on the body part involved and the specific analogous DC applied. |
| 40% | Moderate Paget's Disease with documented structural changes in weight-bearing or functionally significant bones, moderate pain, and measurable functional limitations. Includes moderate secondary osteoarthritis, intermittent radiculopathy from spinal involvement, documented limb deformity causing gait abnormality, or moderate restriction of motion at major joints. Disease may be partially controlled with bisphosphonate therapy but structural damage and pain persist. |
CFR: Moderate limitation of motion, intermittent incapacitating pain episodes, and documented structural deformity from Paget's Disease in weight-bearing regions support ratings in the 20-40% range under analogous orthopedic diagnostic codes. |
| 20% | Mild-to-moderate Paget's Disease with confirmed diagnosis, some pain, and mild functional limitation. Disease may be monostotic or limited polyostotic involvement of non-critical bones. Symptoms are manageable with medication but pain is present and function is mildly impaired. Some ROM restriction may be present at affected areas. |
CFR: Mild functional impairment with confirmed diagnosis and objective findings on imaging and laboratory tests supports a minimum compensable rating. Even when symptoms are mild, structural bone changes and persistent pain should be accurately documented. |
100% Active malignant neoplasm (osteosarcoma or other sarcomatous ...
Active malignant neoplasm (osteosarcoma or other sarcomatous transformation of Pagetic bone) - rated 100% while active, with a mandatory VA exam scheduled 6 months after completing treatment. Alternatively, severe widespread Paget's Disease with major complications equivalent to total disability (e.g., paraplegia from spinal cord compression, high-output cardiac failure, complete bilateral hearing loss from skull involvement) may support a 100% rating via TDIU or SMC provisions.
Key Symptoms
- Confirmed malignant bone tumor arising in Pagetic bone (osteosarcoma, fibrosarcoma, chondrosarcoma)
- Active oncologic treatment (surgery, chemotherapy, radiation therapy)
- Paraplegia or severe myelopathy from vertebral Paget's with cord compression
- High-output congestive heart failure from extensive polyostotic disease
- Total inability to ambulate or perform self-care
- Severe pathological fractures with non-union at multiple sites
CFR: DC 5016 rates Paget's Disease analogously to the bones involved or complications present. Malignant transformation is rated under the bone neoplasm provisions (DC 5012-5015 range) at 100% while active. Total occupational and social impairment from combined orthopedic and neurological sequelae may support TDIU.
60% Severe Paget's Disease with significant structural deformity ...
Severe Paget's Disease with significant structural deformity, multiple affected bones, and substantial functional impairment. Includes significant secondary complications such as moderate hearing loss from skull involvement, secondary severe osteoarthritis of major joints, recurrent pathological fractures, significant spinal disease with radiculopathy, or inability to ambulate without assistive devices for extended distances. Analogous rating based on affected bones and resulting functional impairment.
Key Symptoms
- Polyostotic disease with weight-bearing bone involvement causing severe pain and gait impairment
- Significant bowing deformity of femur or tibia with limb length discrepancy >2.5 cm
- Severe secondary osteoarthritis of hip or knee requiring assistive devices
- Spinal Paget's with lumbar or cervical stenosis causing radiculopathy or neurogenic claudication
- Recurrent pathological fractures
- Moderate-to-severe sensorineural hearing loss from skull base involvement
- Constant severe bone pain (7-10/10) refractory to standard analgesia
- Requirement for walker or crutches for ambulation
CFR: Under DC 5016 and analogous codes, severe functional impairment from deformity, secondary arthritis, fractures, or neurological complications of Pagetic bone disease at major joints or the spine supports ratings in the 40-60% range depending on the body part involved and the specific analogous DC applied.
40% Moderate Paget's Disease with documented structural changes ...
Moderate Paget's Disease with documented structural changes in weight-bearing or functionally significant bones, moderate pain, and measurable functional limitations. Includes moderate secondary osteoarthritis, intermittent radiculopathy from spinal involvement, documented limb deformity causing gait abnormality, or moderate restriction of motion at major joints. Disease may be partially controlled with bisphosphonate therapy but structural damage and pain persist.
Key Symptoms
- Moderate constant or frequently recurring bone pain (4-6/10) at affected sites
- Demonstrable bowing of long bones on imaging with some gait abnormality
- Moderate secondary osteoarthritis at hip, knee, or ankle
- Intermittent spinal pain and stiffness from vertebral involvement
- Mild-to-moderate sensorineural hearing loss from skull involvement
- Use of cane for prolonged ambulation
- ROM moderately restricted at affected joints
- Fatigue and weakness limiting physical activity
CFR: Moderate limitation of motion, intermittent incapacitating pain episodes, and documented structural deformity from Paget's Disease in weight-bearing regions support ratings in the 20-40% range under analogous orthopedic diagnostic codes.
20% Mild-to-moderate Paget's Disease with confirmed diagnosis, s ...
Mild-to-moderate Paget's Disease with confirmed diagnosis, some pain, and mild functional limitation. Disease may be monostotic or limited polyostotic involvement of non-critical bones. Symptoms are manageable with medication but pain is present and function is mildly impaired. Some ROM restriction may be present at affected areas.
Key Symptoms
- Mild intermittent or constant bone pain (1-3/10) at affected sites
- Confirmed abnormal bone scan or imaging showing Pagetic changes
- Elevated alkaline phosphatase
- Minimal deformity or early-stage bowing
- Mild restriction of motion at affected joints
- Fatigue related to disease activity
- Currently on bisphosphonate therapy
- Pain with prolonged standing or walking but not at rest
CFR: Mild functional impairment with confirmed diagnosis and objective findings on imaging and laboratory tests supports a minimum compensable rating. Even when symptoms are mild, structural bone changes and persistent pain should be accurately documented.
How to Describe Your Symptoms
Bone Pain
How to describe:
Describe the exact location of pain (skull, spine, pelvis, femur, tibia, etc.), the character of the pain (deep, aching, boring, constant vs. intermittent), severity on a 0-10 scale on your worst day, and what makes it worse (weight-bearing, activity, weather changes, nighttime). State how long pain episodes last and how frequently they occur.
Worst-day example:
“On my worst days, the deep aching pain in my right femur and lower back rates 9 out of 10. The pain wakes me from sleep at night and I cannot stand for more than 10 minutes. I require prescription pain medication plus a heating pad and I cannot leave my home. These worst days occur approximately 3-4 times per month and last 1-2 days.”
What the examiner listens for:
Specific anatomical locations, chronic versus acute pain pattern, nocturnal pain (classic for Paget's), pain with weight-bearing, pain at rest, medication requirements, frequency of worst episodes, and functional impact during pain episodes.
Understatements to avoid:
Do not say 'the pain is manageable' or 'I just push through it.' These phrases underrepresent your actual disability level. Instead, describe the specific accommodations you make and what you cannot do because of the pain.
Bone Deformity and Gait
How to describe:
Describe any visible changes in bone shape: bowing of legs, enlarged skull, spinal curvature, chest wall deformity. Explain how deformity affects your walking - limping, uneven leg length, instability, increased fall risk. State how far you can walk on a typical day and your worst day before pain or fatigue stops you.
Worst-day example:
“My right leg bows outward significantly and is about an inch shorter than my left. On bad days, after walking one city block I develop severe right hip and knee pain and must stop and rest for 20 minutes before continuing. I have fallen twice in the past year due to instability from the leg length difference. I use a cane every time I leave the house.”
What the examiner listens for:
Objective evidence of deformity, functional limitation of ambulation, fall risk, assistive device use, correlation between imaging findings and reported symptoms, and consistency between gait observed during exam and reported limitations.
Understatements to avoid:
Do not leave your cane in the car or attempt to walk without it during the exam to appear stronger. Use your assistive device as you normally would. Do not say you 'get around fine' if you actually require a cane or have walking limitations.
Neurological Complications
How to describe:
If skull involvement is present, describe any hearing loss (unilateral or bilateral), tinnitus, headaches, vision changes, or cranial nerve symptoms. If spinal involvement is present, describe radiating pain, numbness, tingling, or weakness in extremities. Describe when symptoms began, whether they are progressive, and how they affect daily function.
Worst-day example:
“The Paget's has affected my skull and I have lost significant hearing in my left ear - I cannot follow conversations in any group setting and struggle even one-on-one without hearing aids. On my worst days, the pressure headaches from skull thickening are severe enough that I cannot read, watch television, or concentrate on anything. My spine involvement causes pain that shoots down both legs when I walk more than a few steps.”
What the examiner listens for:
Specific neurological deficits correlated with documented Pagetic involvement of skull or spine, documented hearing testing results, presence of cranial nerve findings on examination, radicular symptoms, and any progressive neurological deterioration.
Understatements to avoid:
Do not minimize hearing loss by saying 'I just turn up the TV.' Describe the full impact: missed conversations, social isolation, difficulty at work, safety concerns. For spinal symptoms, specify that the leg pain, numbness, or weakness is directly connected to your Paget's spinal involvement.
Fatigue and Functional Limitations
How to describe:
Paget's Disease causes systemic fatigue due to the high metabolic demands of abnormal bone remodeling. Describe daily fatigue level, how much activity you can perform before exhaustion, impact on employment, self-care, household activities, and social functioning. Include how fatigue interacts with pain to compound your disability.
Worst-day example:
“Even on relatively good days, by mid-afternoon I am exhausted and must lie down for 1-2 hours. On bad days, I am fatigued from the moment I wake up and cannot complete basic household tasks like cooking or laundry without sitting down to rest multiple times. This fatigue has prevented me from maintaining full-time employment.”
What the examiner listens for:
The DeLuca factors - fatigue, weakness, and pain on repetitive use - must be documented. Examiner should note functional limitations beyond what a single ROM measurement captures, including how your function degrades over the course of a day or week.
Understatements to avoid:
Do not say 'I manage okay' or 'I stay busy.' This obscures how much energy management and accommodation you require to function. Be specific about what you can no longer do compared to before your condition worsened.
Pathological Fracture History
How to describe:
If you have experienced fractures of Pagetic bone, describe each occurrence: which bone, date, mechanism (minor trauma or spontaneous), treatment required, recovery time, and any residual impairment. Explain that Pagetic bone is structurally abnormal and fractures at lower force thresholds than normal bone.
Worst-day example:
“In [year], I fractured my right femur with minimal trauma - I simply stepped off a curb. This required surgical repair with an intramedullary rod. I was non-weight-bearing for 4 months and have never regained full strength or pain-free ambulation in that leg. I live in fear of another fracture.”
What the examiner listens for:
History of pathological fractures, treatment required, residual impairment from fractures, current fracture risk, and how fracture risk affects daily activity choices and functional capacity.
Understatements to avoid:
Do not omit past fractures because they happened years ago. All fractures of Pagetic bone are relevant to the current disability picture, especially if they resulted in surgical treatment or lasting functional impairment.
Treatment Effects and Medication Side Effects
How to describe:
Describe all treatments you have received: bisphosphonate infusions or pills (zoledronic acid, pamidronate, alendronate, risedronate), pain medications, surgical procedures, and their effects. Describe side effects including jaw osteonecrosis risk, esophageal symptoms, flu-like reactions after IV bisphosphonates, and any surgical complications.
Worst-day example:
“After each IV zoledronic acid infusion I experience 2-3 days of severe flu-like symptoms - fever, chills, bone pain flare, and complete inability to function. I must plan ahead and arrange help at home during these post-infusion days. The medication is necessary but temporarily disabling.”
What the examiner listens for:
Active treatment status, treatment response (ALP normalization versus continued elevation), treatment complications, and whether symptoms persist despite optimal treatment - indicating structural rather than purely metabolic disability.
Understatements to avoid:
Do not say treatment has 'fixed' the problem. Bisphosphonates control disease activity but do not reverse structural deformity, secondary arthritis, or established neurological damage. Clearly state what symptoms remain despite treatment.
Common Mistakes to Avoid
Saying 'I'm doing fine' or 'the medication is working' without clarifying persistent structural symptoms
Bisphosphonates may normalize alkaline phosphatase, but structural deformity, bone pain, secondary arthritis, and neurological complications persist independently of biochemical control. An examiner may document 'disease controlled' and underrate functional impairment.
Instead: Clearly distinguish between biochemical markers (ALP may be normal on medication) and structural/functional disability (deformity, pain, limited ROM, neurological effects). State: 'My lab values may look better on medication, but my bone deformity, pain, and functional limitations have not improved and are permanent.'
Impact: All rating levels
Failing to bring assistive devices to the exam or not using them during the exam
If you normally use a cane, walker, or brace but do not bring it or use it, the examiner may document that you ambulate without assistive devices, significantly underrepresenting your disability.
Instead: Use every assistive device you normally rely on during the exam, including cane, walker, brace, or orthotic insert. The examiner is required to document assistive device use and its frequency.
Impact: 40%-100%
Not mentioning all affected bones
The DBQ has fields for side and location of affected bones. If you only discuss your most symptomatic area, other Pagetic lesions may not be documented, resulting in incomplete rating consideration.
Instead: Before the exam, prepare a written list of every bone identified on your bone scan or imaging as affected by Paget's Disease. Mention each site and the corresponding symptoms, even if some are currently less symptomatic.
Impact: All rating levels
Not disclosing neurological symptoms related to skull or spinal involvement
Hearing loss, cranial nerve symptoms, headaches, spinal stenosis, radiculopathy, and myelopathy from Paget's are ratable complications that may be rated separately or affect the overall rating, but only if the examiner documents them.
Instead: Proactively describe all neurological symptoms: hearing loss, tinnitus, headaches, vision changes, facial pain, neck pain, radiating arm or leg pain, numbness, weakness, or bowel/bladder changes. Connect each symptom to the corresponding bone involvement documented on imaging.
Impact: 40%-100%
Not reporting worst-day symptoms; instead describing only average or best-day function
VA rating instructions (M21-1) require that the examiner document the full range of disability, including worst-day presentations. Rating on average function alone systematically underestimates actual disability.
Instead: When asked how you are doing, describe your worst-day scenario first: 'On my worst days, which occur [X] times per month, I [specific limitations]. On an average day I [average function].' This ensures both worst and typical function are documented.
Impact: All rating levels
Omitting pathological fracture history because it happened in the past
Past pathological fractures in Pagetic bone are clinically significant, demonstrate disease severity, and may have left residual impairment. Omitting them results in a less complete medical history and potentially underrated severity.
Instead: List every fracture with date, bone affected, treatment, and residual limitations. Bring operative reports, discharge summaries, and follow-up records documenting each fracture event.
Impact: 40%-100%
Not providing records of bone scans, ALP trends, or imaging to the examiner
Without objective diagnostic evidence, the examiner has less information to document disease extent and severity accurately. The DBQ specifically requires bone scan, X-ray, MRI, CT, biopsy, and lab data.
Instead: Bring complete copies of all bone scans (with dates and results), serial ALP measurements, all relevant imaging studies and radiology reports, biopsy results if applicable, and treating physician notes. Submit copies to your VA claims file before the exam.
Impact: All rating levels
Failing to describe the DeLuca factors: how pain, fatigue, weakness, and incoordination worsen with activity and repetitive use
A single ROM measurement at rest does not capture functional disability. DeLuca v. Brown requires documentation of additional limitation after repetitive use and at end of day. Without this, ratings may not reflect true functional impairment.
Instead: Before or during ROM testing, state: 'After walking or using this joint repeatedly, my range of motion becomes further limited, my pain increases significantly, and I experience fatigue and weakness that prevent me from continuing activity. By the end of the day I am much more limited than I am right now.'
Impact: 20%-60%
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to request a copy of your completed C&P examination DBQ and any associated documents through a Freedom of Information Act (FOIA) request or through your VA MyHealtheVet records portal.
- You have the right to record your C&P examination in states that permit one-party consent audio recording. Notify the examiner at the start of the exam that you are recording. Check your specific state's consent laws before the exam.
- You have the right to have a VSO, VA-accredited claims agent, or attorney accompany you to the exam as a witness, subject to individual facility policies.
- You have the right to request a new or additional C&P examination if you believe the initial examination was inadequate, incomplete, or contained factual errors - submit this request to your VA regional office with specific documented reasons.
- You have the right to submit independent medical opinions (IMOs) or private nexus letters from qualified physicians to supplement or rebut C&P exam findings.
- You have the right to submit a written statement or Buddy Statement (VA Form 21-4142B equivalent) describing your symptoms and functional limitations to be included in your claims file.
- You have the right to be examined by a clinician with appropriate expertise. For Paget's Disease, you may request that the examination be conducted or reviewed by an orthopedic surgeon, endocrinologist, or oncologist if malignant transformation is a concern.
- Under 38 CFR 3.304 and the benefit of the doubt standard (38 CFR 3.102), when evidence is approximately equal for and against your claim, the decision must be made in your favor.
- You have the right to have all evidence in your claims file reviewed by the examiner prior to conducting the examination. If the examiner states they have not reviewed your file, document this and report it to your VSO.
- If your condition has worsened since your last rating, you have the right to file for an increased rating at any time. You do not need to wait a specific period between claims.
- You have the right to a fully reasoned rating decision that explains specifically which criteria your condition does and does not meet. If the decision does not address all claimed conditions, you have the right to appeal.
- Veterans who have been treated for malignant transformation of Paget's Disease (osteosarcoma) should be aware that active malignancy is rated at 100% and that a mandatory follow-up examination is scheduled 6 months after treatment completion - at that point, residuals are rated on their own merits.
Related Conditions
- Sensorineural Hearing Loss Paget's Disease affecting the skull base and temporal bones can compress the auditory nerve (cranial nerve VIII) causing progressive sensorineural hearing loss and tinnitus. This is a well documented complication of cranial Paget's Disease and may be separately ratable under DC 6100.
- Tinnitus Pagetic involvement of the skull and temporal bones frequently causes tinnitus as a secondary complication of nerve compression or abnormal bone conducted sound transmission. May be separately ratable under DC 6260.
- Secondary Osteoarthritis (Hip) Paget's Disease of the proximal femur or pelvis causes abnormal joint mechanics and secondary degenerative osteoarthritis of the hip. This is a direct secondary condition and may be separately ratable under DC 5252 5255.
- Secondary Osteoarthritis (Knee) Bowing of the tibia or femur from Paget's Disease produces abnormal biomechanical forces at the knee, causing secondary osteoarthritis. May be separately ratable under DC 5258 5261.
- Spinal Stenosis / Lumbar Radiculopathy Vertebral involvement in Paget's Disease causes bone enlargement that narrows the spinal canal and neural foramina, producing spinal stenosis, neurogenic claudication, and radiculopathy. Secondary neurological conditions may be separately ratable under DC 8520 8730 range.
- Pathological Fracture Residuals Pagetic bone has abnormal architecture and fractures at reduced force thresholds. Residual impairment from healed or malunited pathological fractures (e.g., femur, tibia) may be separately ratable based on the bones affected and residual functional impairment.
- Osteosarcoma (Malignant Transformation) Approximately 1% of patients with polyostotic Paget's Disease develop malignant sarcomatous transformation, most commonly osteosarcoma. This is a life threatening complication rated at 100% while active and requires oncology evaluation and specialized treatment. Must be reported immediately if suspected.
- Depression / Anxiety Chronic pain, progressive disability, loss of mobility, body image changes from deformity, hearing loss, and the psychological burden of a progressive bone disease frequently cause secondary depression and anxiety. These mental health conditions may be separately ratable as secondary to the service connected Paget's Disease.
- Obstructive Sleep Apnea Skull base and facial bone involvement in Paget's Disease can alter upper airway anatomy, potentially contributing to obstructive sleep apnea. Additionally, chronic pain disrupts sleep. This secondary relationship should be explored with a sleep medicine specialist if symptoms are present.
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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.