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C&P Exam Prep: Spondylolisthesis or Segmental Instability (Thoracolumbar)
DBQ Overview
Interview + Physical- Form Name
- Back_Thoracolumbar_Spine
- Form Code
- Back_Thoracolumbar_Spine
- 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 current severity of spondylolisthesis or segmental instability of the thoracolumbar spine, including range of motion, neurological findings, functional limitations, and impact on daily activities, for purposes of establishing or increasing a VA disability rating under DC 5239.
What the examiner evaluates:
- Active and passive range of motion (forward flexion, extension, lateral flexion, lateral rotation) with goniometer or inclinometer
- Pain on motion, at rest, and with repetitive use
- Muscle strength and reflexes in bilateral lower extremities
- Sensory deficits including numbness, tingling, and paresthesias in dermatomes
- Radiculopathy involving sciatic nerve (L4-S1-S3) and/or femoral nerve (L2-L4)
- Muscle spasm, guarding, and localized tenderness on palpation
- Functional loss due to flare-ups, fatigue, weakness, or incoordination
- Assistive devices currently used (cane, brace, walker, wheelchair, crutches)
- History of spinal surgery, fusion, or other procedures
- Vertebral instability signs, deformity, or disturbance of locomotion
- Impact on ability to sit, stand, and ambulate
- Neurological findings (reflex changes, muscle atrophy, bladder/bowel involvement)
Exam is typically conducted in-person at a VA medical center or contract exam site (e.g., VES, Optum, LHI). In some circumstances a telehealth review may be used; however, range of motion testing requires an in-person exam. Request in-person examination if a telehealth exam is scheduled. You have the right to record the exam in most states - notify the examiner at the start.
Typical duration: 30-45 minutes
Forward Flexion (Active)
How far you can bend forward at the waist; normal is 0-90-. This is the single most important ROM measurement for thoracolumbar spine ratings under the General Rating Formula.
What to expect:
You will stand upright and bend forward as far as possible. The examiner uses an inclinometer or goniometer. The endpoint where pain limits further movement should be clearly noted and verbally reported.
Key thresholds:
- Greater than 90- — Non-compensable (0%) under General Rating Formula unless painful motion is noted
- Greater than 30- but not greater than 60- — 40% under General Rating Formula
- 30- or less — 40% under General Rating Formula; 50% if combined with unfavorable ankylosis or neurological involvement
- Favorable ankylosis (at 0-) — 40%
- Unfavorable ankylosis (not at 0-) or combined range of motion -30- — 50-100% depending on involvement
Tips:
- Bend only as far as your pain honestly allows - do not push through severe pain to show effort.
- Verbally state 'I am stopping here due to pain' so the examiner documents the pain endpoint.
- If your range varies significantly day to day, tell the examiner your typical worst-day measurement.
- Do not warm up or stretch before the exam - come in your typical daily condition.
Pain considerations: Per DeLuca v. Brown, pain on motion is separately evaluated. If pain limits motion before the anatomical endpoint, this must be documented. Tell the examiner exactly where in the arc of motion pain begins and where it stops your movement.
Extension (Active)
Ability to bend backward; normal is 0-30-. Extension is often more limited and painful with spondylolisthesis due to posterior element loading.
What to expect:
Standing, you will lean backward. Extension is frequently painful in spondylolisthesis and may be severely limited.
Key thresholds:
- 0-30- — Contributes to combined ROM calculation; limited extension alone is not a separate threshold but affects overall picture
Tips:
- Extension commonly aggravates spondylolisthesis pain - accurately report the degree to which it hurts.
- If extension causes radiating leg pain, report this immediately to the examiner.
Pain considerations: Extension loading the posterior elements is a classic pain generator in spondylolisthesis. Report any reproduction of radicular symptoms (shooting leg pain, numbness) during this movement.
Lateral Flexion (Right and Left, Active)
Side-bending range; normal is 0-30- bilaterally.
What to expect:
You will slide your hand down the outside of your leg. Both sides are measured separately.
Key thresholds:
- Combined thoracolumbar ROM -30- — 40% under General Rating Formula
Tips:
- Report any asymmetry - more pain or restriction on one side is clinically significant.
- Lateral flexion toward the side of a lateral listhesis slip may be particularly painful.
Pain considerations: Pain and muscle guarding during lateral flexion directly impacts the combined ROM calculation that determines the rating level.
Lateral Rotation (Right and Left, Active)
Twisting range of the thoracolumbar spine; normal is 0-30- bilaterally.
What to expect:
You may be asked to rotate your torso or the examiner may stabilize your pelvis. Both sides are measured.
Key thresholds:
- Combined ROM -120- — 10% under General Rating Formula
- Combined ROM -30- — 40% under General Rating Formula
Tips:
- Rotation is included in the combined ROM calculation - do not minimize any restriction.
- If rotation reproduces radicular symptoms, verbalize this during the exam.
Pain considerations: Rotational stress can provoke instability symptoms. Report any 'giving way,' catching, or sharp pain that occurs with rotation.
Passive Range of Motion
ROM when the examiner moves the joint for you (without your active effort). Required under Correia v. McDonald.
What to expect:
The examiner will gently assist your spine through its range of motion. This is compared to your active ROM.
Key thresholds:
- Passive ROM exceeds active ROM — Suggests pain-limited active motion - supports higher functional loss finding
Tips:
- If the examiner does not perform passive ROM testing, politely ask: 'Will you also be testing passive range of motion?'
- Passive ROM testing is required by VA regulation - if skipped, this may be grounds for an inadequate exam.
Pain considerations: Passive ROM may be less painful and thus greater than active ROM, demonstrating that active restriction is pain-driven rather than structural.
Repetitive Use Testing (Three Repetitions)
Whether ROM decreases after three repetitions of each movement, reflecting DeLuca functional loss from fatigue or pain with use.
What to expect:
You may be asked to perform a movement three times. The examiner should note if the range decreases, pain increases, or fatigue develops.
Key thresholds:
- ROM decreases after 3 repetitions — Supports additional functional loss finding under DeLuca - can effectively lower the 'compensable' ROM to a higher rating level
Tips:
- If repetitive motion causes increased pain or decreased range, say so clearly: 'My range gets worse with repeated movement.'
- If the examiner does not perform repetitive use testing, note this for your records - it may support an inadequate exam claim.
- Describe how your back feels during a full workday of bending, sitting, standing compared to a single test movement.
Pain considerations: The DeLuca factors require documentation of pain, weakness, fatigue, and incoordination on repetitive use. This is particularly important for spondylolisthesis where instability may worsen with sustained activity.
Straight Leg Raise (SLR)
Positive SLR at less than 60- suggests nerve root tension/radiculopathy, particularly L4-S1 involvement common with low-grade spondylolisthesis.
What to expect:
You lie on your back while the examiner raises each leg. A positive test reproduces radiating pain down the leg (not just back pain).
Key thresholds:
- Positive SLR (reproduces radicular pain <60-) — Supports radiculopathy finding - separately ratable neurological impairment (e.g., sciatic nerve DC 8520)
Tips:
- Distinguish between hamstring tightness (back of thigh) and true radicular reproduction of leg/foot symptoms.
- Report the exact location of pain reproduction - buttock, posterior thigh, calf, foot.
- Mention if the pain is accompanied by tingling, numbness, or burning.
Pain considerations: True radiculopathy documented via positive SLR opens a separate, stackable neurological rating - this can significantly increase your overall combined rating.
Muscle Strength Testing (Lower Extremity)
Motor function in L2-S1 myotomes. Tests hip flexion (L2-L3), knee extension (L3-L4), ankle dorsiflexion (L4-L5), great toe extension (L5), and plantar flexion (S1).
What to expect:
The examiner will ask you to push against resistance in various positions. Results are graded 0-5 on the Medical Research Council scale.
Key thresholds:
- Grade 3 or less (movement against gravity only) — Supports moderate-to-severe neurological impairment rating for associated nerve
- Grade 0-1 (absent or trace) — Supports complete paralysis rating - maximum neurological rating
Tips:
- Perform the test honestly - do not exaggerate weakness.
- If one leg is notably weaker than the other, point this out.
- Fatigue-related weakness matters - if you could not sustain the effort, say so.
Pain considerations: Pain inhibition can reduce test performance. If pain prevents full effort, tell the examiner specifically: 'I cannot push harder because it causes sharp pain in my lower back/leg.'
Sensory Examination (Dermatomal)
Whether you have decreased sensation (numbness), abnormal sensation (tingling/burning), or loss of sensation in nerve root distributions.
What to expect:
The examiner uses a pin or light touch on specific areas of your legs and feet. Report honestly whether sensation is normal, reduced, or absent.
Key thresholds:
- Documented sensory deficits in dermatomal pattern — Supports neurological (radiculopathy) rating for the affected nerve; mild = 10%, moderate = 20%, severe = 40-60%
Tips:
- Do not guess - report exactly what you feel.
- If areas of numbness are present chronically, tell the examiner where they are and when they started.
- Describe whether symptoms are constant or intermittent and what worsens them.
Pain considerations: Painful paresthesias (burning, electric sensations) are themselves a form of neurological impairment and should be specifically reported.
Deep Tendon Reflexes
Patellar reflex (L3-L4) and Achilles reflex (S1) integrity - diminished or absent reflexes indicate nerve root impairment.
What to expect:
The examiner taps specific tendons with a reflex hammer. This is passive - just relax your muscles.
Key thresholds:
- Diminished or absent reflex(es) — Objective neurological finding supporting radiculopathy diagnosis - strengthens neurological component of rating
Tips:
- Relax completely for accurate testing.
- Asymmetric reflexes (one side normal, other side diminished) are clinically significant.
- Reflexes cannot be faked - this is purely objective and important for your claim.
Pain considerations: Absent reflexes paired with sensory and motor deficits create a complete neurological picture supporting a higher radiculopathy rating.
Muscle Atrophy Measurement
Circumferential measurement of thighs and calves bilaterally to detect disuse or neurogenic atrophy.
What to expect:
The examiner uses a tape measure at specific anatomical landmarks on both legs. A difference of 2+ cm between sides is clinically significant.
Key thresholds:
- -2 cm difference between limbs — Objective evidence of neurogenic or disuse atrophy - supports more severe neurological impairment rating
Tips:
- If you have noticed one leg looks smaller or feels weaker, mention this.
- Atrophy may reflect either nerve damage from spondylolisthesis or disuse from pain-limited activity.
- Bring this up proactively if the examiner does not measure - ask: 'Will you be checking for muscle atrophy today?'
Pain considerations: Atrophy from disuse due to pain is also a compensable functional finding and should be documented regardless of its cause.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 100% | Unfavorable ankylosis of the entire spine (both cervical and thoracolumbar). Extremely rare and requires documentation of complete spinal immobility in an unfavorable position affecting the whole spine. |
CFR: 100% under the General Rating Formula requires ankylosis of the entire spine, not just thoracolumbar. This level is uncommon for isolated spondylolisthesis but may apply when combined with cervical conditions and extensive surgical fusion. |
| 50% | Unfavorable ankylosis of the entire thoracolumbar spine (spine fused in a flexed, extended, or laterally deviated position that causes functional loss). Not typical for spondylolisthesis unless post-surgical fusion has occurred in an unfavorable position. |
CFR: 50% applies when unfavorable ankylosis of the entire thoracolumbar spine is documented. Veterans who have undergone spinal fusion surgery for spondylolisthesis and developed a fused, non-neutral posture may qualify. This level requires objective imaging confirmation. |
| 40% | Forward flexion of the thoracolumbar spine 30- or less, OR favorable ankylosis of the entire thoracolumbar spine. This is a key threshold for spondylolisthesis. Also applies when combined ROM is -30-. |
CFR: 40% is the maximum orthopedic rating under the General Rating Formula for thoracolumbar spine conditions absent unfavorable ankylosis. DC 5239 spondylolisthesis with severe forward flexion restriction of 30- or less reaches this level. Associated neurological findings (radiculopathy) are rated separately and can significantly increase combined disability. |
| 20% | Forward flexion of the thoracolumbar spine greater than 30- but not greater than 60-, OR combined ROM of the thoracolumbar spine not greater than 120-, OR muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour (such as scoliotic deformity). |
CFR: 20% is a commonly assigned level for spondylolisthesis with moderate ROM restriction. Segmental instability can cause guarding-induced gait disturbance that pushes the rating to this level even if ROM is borderline. |
| 10% | Forward flexion of the thoracolumbar spine greater than 60- but with pain on motion, OR combined ROM of the thoracolumbar spine greater than 120- but not greater than 235-, OR muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. |
CFR: Evaluate under 38 CFR 4.71a General Rating Formula. Applies to spondylolisthesis via DC 5239 rated by analogy. Painful arc of motion under 38 CFR 4.59 may support this level even if measured ROM is technically within normal limits. |
| 0% | Thoracolumbar forward flexion greater than 60- with no more than slight limitation, OR combined ROM greater than 240-, with guarding of the thoracolumbar area. Pain on movement is present but ROM does not fall within compensable thresholds. |
CFR: Non-compensable under the General Rating Formula for Diseases and Injuries of the Spine. Note: painful motion alone, even without measurable limitation, may entitle the veteran to a minimum compensable evaluation under 38 CFR 4.59. |
100% Unfavorable ankylosis of the entire spine (both cervical and ...
Unfavorable ankylosis of the entire spine (both cervical and thoracolumbar). Extremely rare and requires documentation of complete spinal immobility in an unfavorable position affecting the whole spine.
Key Symptoms
- Total spinal ankylosis in unfavorable position
- Complete loss of spinal motion in all segments
- Severe functional impairment of all daily activities
- Typically accompanied by severe neurological deficits
CFR: 100% under the General Rating Formula requires ankylosis of the entire spine, not just thoracolumbar. This level is uncommon for isolated spondylolisthesis but may apply when combined with cervical conditions and extensive surgical fusion.
50% Unfavorable ankylosis of the entire thoracolumbar spine (spi ...
Unfavorable ankylosis of the entire thoracolumbar spine (spine fused in a flexed, extended, or laterally deviated position that causes functional loss). Not typical for spondylolisthesis unless post-surgical fusion has occurred in an unfavorable position.
Key Symptoms
- Spine fused in non-neutral position (flexed forward, laterally tilted, or extended)
- Inability to assume upright posture
- Severe gait disturbance
- Post-surgical spinal fusion with poor outcome
- Total loss of spinal motion
CFR: 50% applies when unfavorable ankylosis of the entire thoracolumbar spine is documented. Veterans who have undergone spinal fusion surgery for spondylolisthesis and developed a fused, non-neutral posture may qualify. This level requires objective imaging confirmation.
40% Forward flexion of the thoracolumbar spine 30- or less, OR f ...
Forward flexion of the thoracolumbar spine 30- or less, OR favorable ankylosis of the entire thoracolumbar spine. This is a key threshold for spondylolisthesis. Also applies when combined ROM is -30-.
Key Symptoms
- Forward flexion 30- or less
- Severe pain limiting nearly all bending activity
- Favorable ankylosis (spine fused in neutral or near-neutral position)
- Significant instability of station
- Unable to perform most bending/lifting tasks
- May require assistive device (cane, brace)
- Severe muscle spasm at rest
CFR: 40% is the maximum orthopedic rating under the General Rating Formula for thoracolumbar spine conditions absent unfavorable ankylosis. DC 5239 spondylolisthesis with severe forward flexion restriction of 30- or less reaches this level. Associated neurological findings (radiculopathy) are rated separately and can significantly increase combined disability.
20% Forward flexion of the thoracolumbar spine greater than 30- ...
Forward flexion of the thoracolumbar spine greater than 30- but not greater than 60-, OR combined ROM of the thoracolumbar spine not greater than 120-, OR muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour (such as scoliotic deformity).
Key Symptoms
- Forward flexion 31-60-
- Combined thoracolumbar ROM -120-
- Abnormal gait due to muscle spasm or guarding
- Observable scoliotic deformity
- Interference with sitting and/or standing
- Radiating pain without documented radiculopathy
CFR: 20% is a commonly assigned level for spondylolisthesis with moderate ROM restriction. Segmental instability can cause guarding-induced gait disturbance that pushes the rating to this level even if ROM is borderline.
10% Forward flexion of the thoracolumbar spine greater than 60- ...
Forward flexion of the thoracolumbar spine greater than 60- but with pain on motion, OR combined ROM of the thoracolumbar spine greater than 120- but not greater than 235-, OR muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour.
Key Symptoms
- Pain on motion with forward flexion >60-
- Combined thoracolumbar ROM 121-235-
- Muscle spasm or guarding without gait disturbance
- Localized tenderness on palpation
- Mild limitation in daily activities
CFR: Evaluate under 38 CFR 4.71a General Rating Formula. Applies to spondylolisthesis via DC 5239 rated by analogy. Painful arc of motion under 38 CFR 4.59 may support this level even if measured ROM is technically within normal limits.
0% Thoracolumbar forward flexion greater than 60- with no more ...
Thoracolumbar forward flexion greater than 60- with no more than slight limitation, OR combined ROM greater than 240-, with guarding of the thoracolumbar area. Pain on movement is present but ROM does not fall within compensable thresholds.
Key Symptoms
- Mild back pain with activity
- Forward flexion greater than 60-
- Combined ROM above 240-
- No neurological deficits
- No muscle spasm at rest
CFR: Non-compensable under the General Rating Formula for Diseases and Injuries of the Spine. Note: painful motion alone, even without measurable limitation, may entitle the veteran to a minimum compensable evaluation under 38 CFR 4.59.
How to Describe Your Symptoms
Back Pain Character and Location
How to describe:
Describe the pain as accurately as possible: location (lumbar region, mid-back, across the lower back), character (aching, stabbing, burning, cramping, pressure), and radiation pattern. Specify whether pain is constant or comes in episodes.
Worst-day example:
“On my worst days, I have a constant stabbing pain in my lower back at about a 7-8 out of 10 that starts the moment I try to get out of bed. The pain radiates into my right buttock and down the back of my thigh to my knee. I cannot stand for more than 10 minutes or sit for more than 20 minutes without needing to change position or lie down.”
What the examiner listens for:
Specific pain location correlating to the spondylolisthesis level, presence of mechanical pain (worse with activity, better with rest), and any neurological character (burning, electric, shooting) suggesting nerve root involvement.
Understatements to avoid:
Saying 'it's not that bad' or 'I manage it.' Also avoid saying 'I'm used to it' - being conditioned to pain does not mean the pain is mild. Report the pain as it is on a typical bad day.
Flare-Ups
How to describe:
Describe what triggers a flare-up (lifting, prolonged sitting, bending, weather changes, physical activity), how frequently they occur, how long they last, and what you must do to manage them (bed rest, ice, heat, medications, stopping activity).
Worst-day example:
“I have severe flare-ups approximately 2-3 times per week. A flare-up starts when I try to bend to pick something up or after sitting for 30 minutes at a desk. The pain spikes to an 8-9 out of 10, my back seizes up and I cannot straighten fully, my leg goes numb, and I have to lie flat for 1-2 hours before I can function again. During a flare I cannot drive, cook, or care for myself.”
What the examiner listens for:
Frequency and duration of flare-ups, whether they are incapacitating, how they affect daily function, and what activities trigger them. Under M21-1 and DeLuca, the examiner must document flare-up information.
Understatements to avoid:
Saying 'I have some flare-ups sometimes.' Be specific - give numbers (how many per week/month, how many hours/days they last). If flare-ups prevent work or basic self-care, say so explicitly.
Functional Loss and Daily Activity Limitations
How to describe:
Describe specific activities you cannot do or can only do with significant pain or modification. Connect the limitation directly to your spondylolisthesis.
Worst-day example:
“I can no longer carry groceries because lifting more than 5 pounds causes immediate pain and my back feels like it will give out. I cannot mow the lawn, vacuum, or do laundry without taking breaks every 5 minutes. I stopped driving long distances because sitting in a car for more than 20 minutes causes severe back and leg pain. I cannot sleep more than 2-3 hours in a row because I wake up in pain when I try to roll over.”
What the examiner listens for:
Specific named activities that are limited or impossible, whether limitations affect employment (cannot stand or sit at work), and whether the condition causes or exacerbates sleep disturbance, mood changes, or social isolation.
Understatements to avoid:
Avoid vague statements like 'I can't do as much as I used to.' Name the specific activity, the specific limitation, and how long you can do it before pain forces you to stop.
Neurological Symptoms (Radiculopathy/Radicular Pain)
How to describe:
Describe any shooting, burning, electric, or numbing sensations that travel from your back down into your buttocks, thighs, legs, or feet. Specify which leg(s), which area of the leg, and whether the sensation is constant or intermittent.
Worst-day example:
“I have a constant burning and tingling sensation that runs from my lower right back, through my right buttock, down the back of my right thigh, and into my calf. On bad days the pain reaches my foot and my toes feel numb. I drop objects because my right hand compensates but also my right foot sometimes drags when I walk on bad days. I wake up at night with electrical shooting pain in my right leg.”
What the examiner listens for:
Dermatomal distribution of symptoms, consistency of the pattern with the level of spondylolisthesis, and whether symptoms are constant versus intermittent. The examiner needs to determine if sciatic (L4-S1-S3) or femoral (L2-L4) nerve root involvement is present for separate neurological ratings.
Understatements to avoid:
Saying 'I have some leg tingling' is not enough. Name the leg, describe the path of the symptom from proximal to distal, and describe whether it is numbness, burning, electric shocks, or weakness. These details determine which nerve root is involved and the severity of radiculopathy rated separately.
Weakness, Fatigue, and Incoordination
How to describe:
Describe any episodes of your legs feeling weak, buckling, or giving out. Report fatigue that comes on quickly with activity. Report any stumbling, tripping, or difficulty with coordination of gait.
Worst-day example:
“My right leg feels weak and unreliable, especially after I have been standing for 15 minutes. Sometimes my knee buckles without warning and I almost fall. I have to hold onto walls or furniture when I walk around my house. I trip frequently because I do not lift my right foot fully when walking. My back tires out extremely quickly - what used to be a 30-minute task now makes my back feel completely exhausted after 5 minutes.”
What the examiner listens for:
DeLuca factors - specifically weakness, fatigue, and incoordination that produce functional loss beyond what ROM measurements alone would reflect. These symptoms can support a higher effective rating even if a single ROM measurement falls short of a threshold.
Understatements to avoid:
Not mentioning weakness or fatigue at all. Many veterans focus only on pain and forget that weakness, lack of endurance, and incoordination are separately compensable functional loss factors under DeLuca v. Brown.
Instability of Station and Disturbance of Locomotion
How to describe:
If your back instability causes you to be unsteady on your feet, to use a cane, brace, or other assistive device, or to have an abnormal walking pattern, describe these specifically.
Worst-day example:
“I use a lumbar back brace every day because without it my back feels like it will collapse. I started using a cane 6 months ago because on bad days my back gives out and I nearly fall. I walk with a forward-leaning posture to avoid the pain of standing fully upright, and my gait is slow and shuffling compared to before my injury. I cannot walk more than half a block without stopping.”
What the examiner listens for:
Objective signs of instability or locomotion disturbance that the examiner can observe during gait examination, as well as the veteran's self-report of assistive device use. The DBQ has specific checkboxes for instability of station and disturbance of locomotion that directly affect the rating.
Understatements to avoid:
Leaving your cane or brace at home for the exam. Bring all assistive devices you actually use. Do not try to walk more normally than you do on a typical day - walk as you typically walk when in pain.
Common Mistakes to Avoid
Performing range of motion without reporting pain
If you push through pain to show maximum effort and do not verbalize where pain occurs and stops your motion, the examiner may record only the anatomical endpoint rather than the functionally limited pain endpoint.
Instead: Say clearly during each movement: 'I am stopping here because of pain' or 'Pain starts at approximately this point and increases from here.' The examiner must document the pain endpoint separately from the anatomical endpoint.
Impact: Can cause a 10% or 20% rating to appear as 0% if pain is not documented in the range of motion findings.
Performing your best single range of motion on the exam day without disclosing typical or worst-day function
VA exams capture a single-point-in-time measurement. If you had a relatively good day or stretched before the exam, the measured ROM may be significantly better than your typical function.
Instead: Tell the examiner: 'My range of motion today is better than on a typical bad day. On my worst days, my forward flexion is approximately X degrees and I cannot [specific activity].' Ask the examiner to document your typical and worst-day range per M21-1 guidance.
Impact: Can result in a 10% rating when the actual condition warrants 20-40%.
Failing to disclose all neurological symptoms
Radiculopathy (sciatic or femoral nerve involvement) is rated separately from the orthopedic back condition and can add 10-60% additional rating depending on severity. Veterans who do not report leg symptoms lose this additional rating.
Instead: Before the exam, write down every neurological symptom in detail: which leg, where exactly the pain/numbness/tingling travels, whether it is constant or intermittent, and what worsens it. Report all symptoms proactively even if the examiner does not ask.
Impact: Failure to document radiculopathy means missing a separate 10-60% neurological rating that stacks with the orthopedic back rating.
Not mentioning assistive devices or using them during the exam
If you typically use a cane, back brace, or walker but do not bring it to the exam or do not use it, the examiner cannot document these functional needs. Assistive device use directly impacts DBQ fields related to instability and locomotion.
Instead: Bring all assistive devices you routinely use. Use them as you normally would. Tell the examiner when each device was prescribed or first used and why.
Impact: Missing documentation of assistive device use can underrate instability of station and disturbance of locomotion, affecting the 20-40% range.
Saying 'I'm doing OK' or minimizing symptoms when asked how you are doing
The examiner often begins with a general conversational check-in. Automatic social responses like 'I'm fine' or 'I'm managing' can be interpreted clinically and noted in the history section of the DBQ.
Instead: When asked how you are doing or how you have been, respond accurately: 'My back has been quite difficult lately' or 'I have been struggling with this condition significantly.' Set the accurate tone from the start.
Impact: Can undermine all rating levels by creating an inconsistent record where the history says the veteran is 'doing OK' but the physical findings show significant limitation.
Forgetting to report the impact on employment and work
Functional impairment that affects employability is a critical component of the overall disability picture. The DBQ captures functional impact, and raters consider how the condition affects your ability to maintain substantial gainful employment.
Instead: Describe how your spondylolisthesis has affected your work: missed days, job changes, inability to perform physical duties, needing frequent breaks, being placed on limited duty, or being separated from service due to the condition.
Impact: Relevant to TDIU (Total Disability based on Individual Unemployability) eligibility at any rating level and to supporting higher rating levels across the board.
Not connecting your current symptoms back to the in-service event or origin
The examiner fills out a medical history section and may write only what you tell them. If the nexus (service connection link) is not clearly reiterated, the DBQ history may be incomplete.
Instead: Briefly and clearly tell the examiner: when the condition started (service dates), what happened in service (injury, physical demands, specific event), and how symptoms have progressed since service separation.
Impact: Affects service connection determination (nexus), not just the rating percentage. Critical for initial claims.
Not asking the examiner to perform repetitive use testing and passive ROM testing
Some examiners skip these required components. Without repetitive use testing, DeLuca factors cannot be properly evaluated. Without passive ROM, the pain-limited nature of active ROM cannot be confirmed.
Instead: If these tests are not performed, politely ask: 'Will you be doing passive range of motion and repetitive use testing today?' If the examiner refuses or the exam ends without these tests, document this on your own notes immediately after.
Impact: Missing these tests can result in an inadequate exam finding and grounds for requesting a new exam - affects all rating levels.
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 have a physician or physician assistant (not just a nurse practitioner or technician) conduct your C&P examination for a musculoskeletal condition of this complexity.
- You have the right to request an in-person examination if a telehealth exam is scheduled - range of motion testing for the spine requires physical presence.
- You have the right to audio-record your C&P examination in most states (one-party consent states). Notify the examiner before the exam begins.
- You have the right to submit a written statement about your symptoms and flare-ups and to ask the examiner to include it in the DBQ medical history section.
- You have the right to request a copy of the completed DBQ form through the Freedom of Information Act (FOIA) after the examination is completed.
- You have the right to challenge an inadequate C&P examination by requesting a new examination, submitting a private Independent Medical Opinion (IMO), or filing a Notice of Disagreement if the resulting rating is inaccurate.
- You have the right to bring a VSO representative or support person to your exam (though they may not participate in the physical examination itself - confirm local facility policy).
- You have the right to have all DeLuca factors documented - specifically, the examiner must ask about and record the effect of pain, fatigue, weakness, and incoordination on your range of motion and function.
- You have the right to have passive range of motion testing performed pursuant to Correia v. McDonald - if the examiner skips this, it is a basis for challenging the adequacy of the examination.
- You have the right to have your flare-up history documented in the DBQ per M21-1 adjudication guidance - if you describe flare-ups and the examiner does not record them, this is grounds for challenging the exam.
- You have the right to request that the examiner note your typical worst-day function, not just the single-point snapshot observed during the exam.
- You have the right under 38 CFR 4.59 to a minimum compensable evaluation if your condition causes painful motion even if your ROM measurements technically fall above a compensable threshold.
Related Conditions
- Intervertebral Disc Syndrome (Thoracolumbar) Spondylolisthesis frequently co occurs with disc pathology at the level of the slip. IVDS is rated under DC 5243 and includes a separate incapacitating episode component. Veterans may be ratable under both DC 5239 and DC 5243 for the same spine if distinct findings support both diagnoses.
- Lumbar Radiculopathy (Sciatic Nerve) Spondylolisthesis at L4 L5 or L5 S1 commonly compresses L4 S1 nerve roots causing sciatic radiculopathy, rated separately under DC 8520 (sciatic nerve) at 10 80% depending on severity (mild, moderate, severe, complete paralysis). This is a separate, stackable rating.
- Lumbar Radiculopathy (Femoral Nerve) Higher lumbar spondylolisthesis (L2 L4) can compress femoral nerve roots, causing anterior thigh pain and weakness. Rated separately under DC 8515 (femoral nerve) at 10 60%. Veterans with upper lumbar spondylolisthesis should report anterior thigh and knee symptoms.
- Spinal Stenosis Degenerative spondylolisthesis commonly causes secondary spinal stenosis through foraminal narrowing and central canal compromise. Rated under DC 5238. Neurogenic claudication (leg pain/weakness with walking, relieved by sitting) is the hallmark symptom and should be specifically reported.
- Degenerative Arthritis of the Spine Segmental instability accelerates facet joint arthritis and disc degeneration. When degenerative arthritis is documented on imaging at the spondylolisthesis level, it may be separately ratable under DC 5003 or subsumed in the 5239 rating, depending on adjudication.
- Vertebral Fracture or Dislocation Traumatic (isthmic) spondylolisthesis may have originated from a pars interarticularis stress fracture or acute fracture, which is separately ratable under DC 5235. Veterans with traumatic onset should ensure the fracture history is documented to support service connection.
- Hip Condition (Secondary to Gait Alteration) Antalgic gait from lumbar spondylolisthesis can cause secondary hip pathology (bursitis, labral strain, early arthritis) due to compensatory movement patterns. May be ratable as a secondary service connected condition under 38 CFR 3.310.
- Bladder or Bowel Dysfunction (Neurogenic) Severe spondylolisthesis with significant neural element compression (cauda equina) can cause neurogenic bladder or bowel dysfunction. If present, this is separately ratable under genitourinary or gastrointestinal DCs and is a medical emergency requiring urgent care. Report any bladder/bowel changes at the 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.