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C&P Exam Prep: Thigh, Limitation of Extension

DC 5251 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Hip_and_Thigh
Form Code
Hip_and_Thigh
Page Count
13
Examiner Type
Physician or Physician Assistant
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To evaluate the degree of limitation of extension of the thigh (hip extension) for disability rating purposes under 38 CFR 4.71a, Diagnostic Code 5251. The examiner will measure active and passive range of motion, assess pain on motion, and document all functional loss including that occurring during flare-ups or with repetitive use.

What the examiner evaluates:

  • Active range of motion for hip extension (degrees)
  • Passive range of motion for hip extension
  • Weight-bearing vs. non-weight-bearing range of motion
  • Pain on motion - at initial contact, throughout arc, and at endpoint
  • Additional functional loss with repetitive use (DeLuca factors)
  • Flare-up frequency, duration, severity, and additional range of motion loss
  • Weakness, fatigability, incoordination, and lack of endurance
  • Additional hip motions: flexion, abduction, adduction, internal rotation, external rotation
  • Assistive device use (cane, crutches, walker, wheelchair, brace)
  • Leg length discrepancy
  • Functional impact on daily activities, occupational duties, standing, sitting, and walking
  • Surgical history (total hip replacement, resurfacing, arthroscopy)
  • Relevant diagnoses (osteoarthritis, post-traumatic arthritis, avascular necrosis, heterotopic ossification, etc.)
  • Objective signs: swelling, deformity, muscle atrophy, instability of station
  • Disturbance of locomotion

The exam will typically occur at a VA medical center or a VA-contracted examiner clinic (such as LHI, QTC, or VES). Bring all relevant medical records, imaging reports, and treatment notes. Wear loose-fitting clothing that allows easy access to the hip and thigh area. You may be asked to walk, stand, lie down, and perform hip movements. The examiner will use a goniometer to objectively measure your range of motion.

Typical duration: 30-45 minutes

Active Hip Extension (Thigh Extension)

The maximum degree of hip extension you can achieve using your own muscle strength. Normal hip extension is 0- (neutral/fully extended) to approximately 20-30- hyperextension. Under DC 5251, the critical threshold is extension limited to 5-.

What to expect:

You will likely be asked to lie prone (face down) or stand and extend your leg backward. The examiner will place a goniometer at your hip joint and measure the angle achieved. They will record where pain begins, where motion stops, and whether the endpoint differs from where pain starts.

Key thresholds:

  • Extension limited to 5- or less — 10% rating under DC 5251
  • Extension greater than 5- — 0% schedular rating under DC 5251; however, pain on motion, functional loss, and DeLuca factors must still be fully documented and may support rating under other codes

Tips:

  • Perform the movement to your actual comfortable limit - do not push past pain to demonstrate full motion.
  • If pain stops your motion before your anatomical limit, tell the examiner exactly where pain begins.
  • If your extension is worse after walking, standing, or during a flare-up, clearly communicate that to the examiner even if you cannot demonstrate it at the moment.
  • Ask the examiner to record both the initial pain point and the endpoint of motion if they differ.
  • Note whether your limitation is worse on weight-bearing (standing) compared to non-weight-bearing (lying down).

Pain considerations: Pain on active extension - even if extension exceeds 5- - can still support additional functional loss findings under DeLuca v. Brown and Mitchell v. Shinseki. Tell the examiner the exact degree where pain begins, whether pain is sharp or aching, whether it radiates, and whether pain causes you to stop the motion early. Pain at endpoint is different from pain throughout the arc; both are important.

Passive Hip Extension

The maximum degree of hip extension the examiner can achieve by physically moving your leg, without your muscle effort. This isolates structural/anatomical limitation from pain-inhibited active motion.

What to expect:

The examiner will gently move your leg into extension while you remain relaxed. This is typically performed in the prone position. The examiner will note whether passive ROM is the same as, or greater than, active ROM, and whether passive motion causes pain.

Key thresholds:

  • Same as active ROM — Confirms structural limitation rather than pain-inhibited limitation
  • Greater than active ROM — Suggests pain is limiting active motion beyond the structural limit - supports DeLuca functional loss finding

Tips:

  • Relax your muscles as fully as possible during passive testing.
  • If passive motion causes pain, verbalize it immediately.
  • If passive extension exceeds your active extension, this is important - it means your true structural limitation may be worse than active motion shows AND that pain is limiting your active function further.

Pain considerations: Even if passive ROM is greater than active ROM, the presence of pain during passive motion at the functional endpoint is relevant to rating. The examiner should note whether passive motion causes localized tenderness or referred pain.

Weight-Bearing vs. Non-Weight-Bearing Range of Motion

Whether your hip extension range of motion differs depending on whether you are bearing weight through the joint (standing/walking) versus in a non-weight-bearing position (lying down). Per Correia v. McDonald, both should be tested.

What to expect:

The examiner should test hip extension both while you are standing (weight-bearing) and while lying prone (non-weight-bearing). If only one position is tested, politely ask whether both positions will be evaluated.

Key thresholds:

  • Greater restriction in weight-bearing than non-weight-bearing — Supports higher functional impairment; weight-bearing measurements are typically more representative of daily functional limitations

Tips:

  • If your extension is noticeably worse when standing/walking, be sure to communicate this.
  • If you use a cane or brace when weight-bearing, tell the examiner this reflects your actual functional state.
  • Correia requires the examiner to document both conditions; if only one is tested, note this in your post-exam follow-up.

Pain considerations: Weight-bearing activities like walking, climbing stairs, and standing from a chair typically provoke more pain and greater functional restriction than lying still. Describe exactly how your hip extension limitation affects these activities and how it compares to rest.

Range of Motion After Repetitive Use (DeLuca Testing)

Whether your hip extension limitation worsens after performing the movement three times (or after a period of activity). Per DeLuca v. Brown and Mitchell v. Shinseki, the examiner must assess additional functional loss due to pain, weakness, fatigability, or incoordination with repeated use.

What to expect:

The examiner may ask you to perform hip extension (or walking) multiple times and then re-measure your range of motion. They must ask about and document any additional loss with repetition even if they cannot objectively measure the flare-up state.

Key thresholds:

  • Additional ROM loss after repetition — Can support a higher effective rating or serve as additional evidence for the overall disability picture

Tips:

  • Tell the examiner if your hip feels more stiff, painful, or restricted after you have been on your feet for a period of time.
  • Describe your worst-day scenario accurately: 'After walking two blocks, my hip locks up and I cannot extend my leg at all.'
  • If your condition has not been fully measured during a flare-up, the examiner must still address the issue based on your history and clinical judgment - remind them of this obligation if needed.
  • Be specific: 'On bad days, I cannot walk more than 50 feet without stopping due to pain and stiffness in my hip.'

Pain considerations: DeLuca factors include pain, weakness, fatigability, and incoordination. When describing repetitive use, address each factor: Does the hip become progressively more painful with activity? Does your leg feel weak or give out? Do you tire quickly when walking? Do you stumble or compensate with a limp?

Additional Hip Range of Motion (Flexion, Abduction, Adduction, Rotation)

All other planes of hip motion. While DC 5251 specifically rates extension limitation, the examiner will also measure flexion (DC 5252), abduction, adduction, and rotation (DC 5253). Separate evaluations may be assigned without pyramiding.

What to expect:

Normal hip ROM: Flexion 0-125-, Extension 0-20/30-, Abduction 0-45-, Adduction 0-30-, Internal Rotation 0-45-, External Rotation 0-45-. Each will be measured actively and passively. The examiner records degrees for each plane of motion.

Key thresholds:

  • Flexion limited to 45- — 10% under DC 5252 (separate from DC 5251)
  • Flexion limited to 30- — 20% under DC 5252
  • Flexion limited to 20- — 30% under DC 5252
  • Flexion limited to 10- — 40% under DC 5252
  • Abduction lost beyond 10- — 20% under DC 5253
  • Adduction limited - cannot cross legs — 10% under DC 5253
  • Rotation limited - cannot toe-out more than 15- on affected side — 10% under DC 5253

Tips:

  • Each plane of motion can receive a separate rating without pyramiding - ensure the examiner measures and documents ALL planes.
  • If you cannot cross your legs, demonstrate this honestly and tell the examiner.
  • If you toe-in when walking or cannot externally rotate your foot, describe this clearly.
  • Abduction restriction affects activities like getting in and out of a car - describe this specifically.

Pain considerations: Pain during any plane of motion should be verbalized. Even motions that do not meet a compensable threshold may support pain-on-motion findings under 38 CFR 4.59 or additional functional loss under DeLuca.

Estimate

Rating Criteria Breakdown

10% Hip extension limited to 5 degrees or less under Diagnostic ...

Hip extension limited to 5 degrees or less under Diagnostic Code 5251. This is the only compensable rating level under DC 5251. Normal hip extension is 0- (neutral/anatomical position) to approximately 20-30- of hyperextension. Extension limited to 5- means the veteran cannot extend the thigh beyond 5 degrees from the neutral/fully-extended position.

Key Symptoms

  • Inability to fully extend the hip/thigh when walking or standing
  • Antalgic gait or hip flexion contracture
  • Pain at or before the 5- endpoint
  • Difficulty with activities requiring hip extension: stair climbing, walking uphill, rising from seated position
  • Compensatory lumbar lordosis or contralateral hip strain
  • Weakness and fatigability with prolonged walking or standing
  • Additional functional loss with repetitive use

CFR: Per M21-1 guidance: 'Examination shows flexion of the hip limited to 60 degrees and extension limited to 5 degrees. Normal hip ROM is from 0 degrees (fully extended) to 125 degrees (fully flexed). The limitation of extension to 5 degrees is rated 10 percent under 38 CFR 4.71a, DC 5251.' This is the only rating level available under DC 5251.

0% Hip extension greater than 5 degrees. Under DC 5251, there i ...

Hip extension greater than 5 degrees. Under DC 5251, there is no compensable rating below the 5- threshold. However, a 0% (noncompensable) rating may still be assigned for service-connection purposes if the extension limitation does not meet the 5- threshold. Additional codes (DC 5252 for flexion, DC 5253 for abduction/adduction/rotation) may still produce compensable ratings independently.

Key Symptoms

  • Pain on extension that stops motion before the anatomical endpoint
  • Mild stiffness after rest or prolonged inactivity
  • Minor limitation that does not reach the 5- threshold
  • Symptoms that worsen during flare-ups but are not demonstrable at exam time

CFR: Per M21-1: 'DC 5252 (limitation of flexion) does not list criteria for a 0-percent evaluation, but a 10-percent evaluation requires flexion limited to 45 degrees. Because there is limited flexion not meeting the 10-percent criteria and there is no defined schedular 0-percent evaluation criteria, a 0-percent evaluation is warranted for limited flexion of the hip under DC 5252.' The same logic applies to DC 5251 - extension greater than 5- yields a 0% under DC 5251 specifically.

How to Describe Your Symptoms

Pain on Hip Extension

How to describe:

Be specific about when pain starts during the motion arc, where it is located (anterior hip, groin, posterior hip, buttock, thigh), its quality (sharp, aching, burning, stabbing), severity (use a consistent 0-10 scale), and whether it radiates. Distinguish between pain at rest, pain at the start of motion, pain throughout the arc, and pain at the endpoint.

Worst-day example:

“On my worst days, any attempt to extend my hip beyond a few degrees causes a sharp 8/10 pain in my groin and anterior hip that immediately stops me. I cannot walk without a limp and have to take small, shuffling steps to avoid extending my hip.”

What the examiner listens for:

Objective confirmation of pain - visible grimacing, guarding, or stopping motion early. They will check whether the pain endpoint matches the measured ROM endpoint or precedes it. They are also listening for whether pain is consistent with the reported diagnosis.

Understatements to avoid:

Saying 'it's a little sore' when in fact pain causes you to stop the motion. Do not minimize pain to appear cooperative - accurately report the exact degree of pain and its functional impact.

Functional Limitations on Walking, Standing, and Climbing

How to describe:

Quantify your limitations: How far can you walk before hip pain or stiffness forces you to stop? Can you climb stairs normally or do you need a railing and take one step at a time? How long can you stand before your hip gives you problems? Can you rise from a chair without using your arms to push up?

Worst-day example:

“On my worst days, I cannot walk more than half a block without stopping. I cannot climb stairs without holding both rails. I cannot stand at a kitchen counter for more than five minutes without needing to sit down. Getting up from a low chair requires me to roll to one side and push off with both arms.”

What the examiner listens for:

Specific, quantifiable functional limitations that correlate with the measured ROM restriction. They will note whether the described functional impact is consistent with the degree of extension limitation found on exam.

Understatements to avoid:

Saying 'I can get around okay' when in reality you use a cane, avoid stairs, or have significantly curtailed your daily activities. Report your ACTUAL functional state, not what you wish you could do.

Flare-Up Description

How to describe:

Describe how often flare-ups occur (daily, weekly, monthly), what triggers them (activity, weather, prolonged standing, sleeping position), how long they last, what symptoms occur during a flare (increased pain, greater stiffness, inability to bear weight), and how they impact your function beyond your baseline.

Worst-day example:

“I have flare-ups about twice a week, typically after any significant walking or after being on my feet for more than 20 minutes. During a flare, my hip locks up completely, I cannot extend my leg at all, and the pain is 9/10. I may be unable to walk without a cane for 1-2 days. I have to lie down and apply heat to recover.”

What the examiner listens for:

Consistency between reported flare pattern and diagnosis. The examiner must document flare-up information even if they cannot observe a flare. Per M21-1, they must address additional functional loss during flare-ups based on the veteran's history and clinical judgment.

Understatements to avoid:

Failing to mention flare-ups at all because you are not currently in one. Your exam-day presentation may not reflect your worst or even typical functioning - the examiner must ask about and document your flare-up history.

DeLuca Factors - Weakness, Fatigability, Incoordination

How to describe:

Weakness: Describe whether your hip/thigh muscle strength has decreased, whether your leg gives way or buckles, whether you have difficulty with activities requiring hip strength (rising from a squat, climbing, pushing off when walking). Fatigability: How quickly does your hip fatigue during activity? Do you tire more quickly than before your injury? Incoordination: Do you have an unsteady gait, stumble, or compensate in ways that affect your balance or posture?

Worst-day example:

“My hip gives out when I try to walk uphill or up stairs. After walking even one block, the entire hip and thigh feel exhausted and weak - a feeling that used to require miles of walking before my injury. I walk with a visible limp and sometimes catch my foot on the ground because I cannot extend my hip normally for a proper gait cycle.”

What the examiner listens for:

Evidence of any of the four DeLuca factors (pain, weakness, fatigability, incoordination) that would further restrict function beyond what the ROM measurements alone capture. These factors can support an effectively higher rating even when the measured degrees technically fall at the threshold.

Understatements to avoid:

Saying 'I'm just in pain' without describing the specific DeLuca components. Each factor (weakness, fatigability, incoordination) is independently ratable as additional functional loss - address each one explicitly.

Assistive Device Use

How to describe:

Specify every device you use, when you use it, and why. Do you use a cane for all walking or only when you anticipate longer distances? Do you use a brace? Have you been prescribed any of these by a physician or did you self-procure?

Worst-day example:

“I use a single-point cane every time I leave my home because I cannot trust my hip not to give way. On my worst days, I need crutches. I also use a raised toilet seat and grab bars because I cannot extend my hip sufficiently to lower myself or rise without assistance.”

What the examiner listens for:

Prescription vs. self-procured devices, frequency of use, whether the device is medically necessary, and whether it compensates for extension limitation specifically or for general hip instability.

Understatements to avoid:

Leaving your assistive device at home or in the car on exam day to 'look better.' Bring and use any device you normally use. The examiner records device use on the DBQ and it directly impacts the overall disability picture.

Impact on Activities of Daily Living and Employment

How to describe:

Describe how the hip extension limitation affects specific daily tasks: dressing (putting on shoes and socks, pants), bathing, sleeping positions, driving, household chores, and any occupational tasks. Be specific about what you can no longer do or do only with difficulty or assistance.

Worst-day example:

“I cannot put on my own shoes and socks without sitting on the bed and bending forward because I cannot extend my hip to reach my feet normally. I cannot sleep on my stomach. I had to stop my job in construction because I cannot walk on uneven terrain or go up ladders. I need help from my spouse to load the dishwasher because bending and extending my hip causes sharp pain.”

What the examiner listens for:

Specific, concrete examples of functional impairment in daily life that correlate with the documented ROM restriction. The DBQ has a dedicated functional impact section (field _851) - the examiner should document this thoroughly.

Understatements to avoid:

General statements like 'it affects my life a lot' without specific examples. Name the exact activity, describe exactly how the limitation prevents or restricts it, and note whether you have stopped doing it entirely or need assistance.

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 an adequate C&P examination - one that addresses all elements required by law, including DeLuca factors (pain, weakness, fatigability, incoordination with repetitive use), flare-up history, and both active and passive range of motion per Correia v. McDonald.
  • You have the right to request a new or supplemental examination if the original examination is found to be inadequate, incomplete, or does not address required factors.
  • You have the right to submit a personal statement (VA Form 21-4138) or buddy statement to supplement the examination record and provide additional information about your condition.
  • You have the right to request a copy of the completed DBQ and all examination results. Review these for accuracy and completeness.
  • In most U.S. states, you have the right to record your C&P examination under one-party consent laws. Check your specific state's law before recording.
  • You have the right to have a VSO representative, accredited claims agent, or VA-accredited attorney assist you with your claim, including preparation for the C&P examination.
  • You have the right to a rating based on your worst typical functioning, not just your exam-day presentation. M21-1 guidance and DeLuca require consideration of additional functional loss during flare-ups and with repeated use.
  • You have the right to separate ratings for distinct disabilities - for example, DC 5251 (extension) and DC 5252 (flexion) can be rated separately without pyramiding under VAOPGCPREC 9-2004.
  • You have the right to an examination by a qualified medical professional (physician or physician assistant for musculoskeletal conditions). You may request a different examiner if you believe the assigned examiner lacks appropriate qualifications.
  • You have the right to disagree with a rating decision and file a Notice of Disagreement (NOD), supplemental claim, or appeal to the Board of Veterans' Appeals (BVA) or Court of Appeals for Veterans Claims (CAVC) if you believe your condition was not accurately evaluated.

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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.