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C&P Exam Prep: Tibia and Fibula - Impairment of

DC 5262 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Knee_and_Lower_Leg
Form Code
Knee_and_Lower_Leg
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 nature, severity, and functional impact of impairment of the tibia and/or fibula, including nonunion, malunion, deformity, leg length discrepancy, and residual symptoms such as pain, weakness, and limited motion, for VA disability rating purposes under DC 5262.

What the examiner evaluates:

  • Fracture history including tibia and/or fibula fracture type and healing status
  • Presence of nonunion (loose motion requiring brace) or malunion
  • Range of motion (ROM) of the knee and ankle joints active, passive, weight-bearing, and non-weight-bearing
  • DeLuca factors: pain, fatigue, weakness, incoordination, and functional loss with repetitive use and during flare-ups
  • Leg length discrepancy with bilateral measurements
  • Deformity including genu recurvatum, varus/valgus angulation
  • Instability of the lower leg or adjacent joints
  • Muscle atrophy or disuse changes
  • Assistive device use (cane, crutch, brace, walker, wheelchair)
  • Scar presence and characteristics from surgery or injury
  • Functional impact on standing, walking, sitting, and activities of daily living
  • Imaging results (X-rays, MRI) relevant to fracture healing and deformity
  • Residual symptoms: pain at rest and with motion, swelling, joint effusion, locking
  • Surgical history including type and date of any procedures

Exam is typically conducted in person at a VA facility or contracted examination center. You have the right to request the exam be recorded in most states. Bring all relevant imaging records, treatment notes, and assistive devices you regularly use.

Typical duration: 30-45 minutes

Knee Range of Motion (Active)

Active flexion and extension of the knee joint on the affected side

What to expect:

Examiner asks you to bend and straighten your knee as far as you can without assistance. Normal flexion is 0-140 degrees; normal extension is 0 degrees.

Key thresholds:

  • Flexion limited to 45 degrees or less — Approaches ankylosis-level ratings under DC 5256
  • Flexion limited to 60 degrees — Moderate limitation; influences overall functional loss rating
  • Extension limited beyond 10 degrees (flexion contracture) — Significant functional impairment; evaluated under DC 5261

Tips:

  • Move only as far as your pain and condition honestly allow - do not push through pain to appear capable
  • Perform the movement at your actual functional capacity, not your best possible effort
  • If your knee locks or gives way during testing, tell the examiner immediately

Pain considerations: Tell the examiner exactly where pain occurs during the arc of motion (e.g., 'I feel sharp pain in the front of my lower leg at about 60 degrees of flexion'). This pain documentation is critical for DeLuca functional loss findings.

Knee Range of Motion (Passive)

How far the examiner can move your knee without your active muscle effort

What to expect:

Examiner will gently move your knee through its range while you relax. Per Correia v. McDonald, both active and passive ROM must be tested.

Key thresholds:

  • Passive ROM significantly greater than active ROM — Suggests muscle guarding, pain inhibition, or functional overlay - important for functional loss documentation

Tips:

  • Relax as fully as possible; do not resist the examiner's movement
  • Report any pain, catching, or discomfort during passive movement
  • Note if passive range equals or differs from active range

Pain considerations: Inform the examiner of any pain, crepitus, or tenderness elicited during passive testing. These findings go into the DBQ pain-on-passive-motion fields.

Weight-Bearing vs. Non-Weight-Bearing ROM

Whether bearing weight on the limb further restricts motion or increases pain

What to expect:

Per Correia requirements, the examiner should test the joint in both weight-bearing and non-weight-bearing positions when feasible.

Key thresholds:

  • Significant difference between weight-bearing and non-weight-bearing ROM — Documents additional functional impairment consistent with structural instability or pain-limited use

Tips:

  • If standing on the affected leg causes increased pain or instability, say so clearly
  • Report any tendency to favor the unaffected leg while standing
  • Do not attempt weight-bearing testing if it is unsafe - inform the examiner

Pain considerations: Weight-bearing pain in the lower leg directly supports functional loss and may reflect incomplete union or malunion of the tibia/fibula.

Repetitive Use Testing

Whether repeated movement of the joint causes additional pain, weakness, fatigue, or reduced ROM

What to expect:

Examiner may ask you to flex/extend the knee multiple times, or may ask about your experience with repetitive activity. Per DeLuca v. Brown, the report must address functional limitation after repetitive use.

Key thresholds:

  • Demonstrated decrease in ROM or increase in pain after repetitive use — Supports a higher functional loss rating beyond the measured ROM at rest

Tips:

  • If you experience increased pain or fatigue after walking a short distance, say so unprompted
  • Describe how symptoms worsen over the course of a day with activity
  • Mention specific activities that aggravate your condition (e.g., climbing stairs, standing for 20 minutes)

Pain considerations: This is one of the most underreported aspects. State clearly: 'After walking two blocks, the pain in my lower leg increases from a 4 to an 8 out of 10 and I have to stop and rest.'

Leg Length Discrepancy Measurement

Whether the tibia/fibula fracture or malunion has caused shortening of the affected extremity relative to the contralateral leg

What to expect:

Examiner measures from a bony landmark (e.g., anterior superior iliac spine to medial malleolus) on both legs. Results are recorded in centimeters.

Key thresholds:

  • Shortening present — Documented under DC 5275 (shortening of the leg) if significant; also affects gait and contributes to functional impairment
  • Discrepancy of 3.2 cm or greater — Can independently support a compensable rating under DC 5275

Tips:

  • If you have noticed one leg appears shorter or you walk with a limp, mention this explicitly
  • If your shoe has been modified or you use a heel lift, bring this information
  • Note any compensatory back or hip pain caused by the discrepancy

Pain considerations: Leg length discrepancy from tibia/fibula malunion can cause secondary spine and hip strain - mention any related pain patterns.

Assessment for Nonunion vs. Malunion

Whether the tibia/fibula fracture healed improperly (malunion - healed but in abnormal position) or failed to heal (nonunion - loose motion at fracture site)

What to expect:

Examiner will palpate the fracture site, review imaging, and assess for abnormal mobility or deformity. Nonunion with loose motion requiring a brace is rated at 40% under DC 5262.

Key thresholds:

  • Nonunion with loose motion requiring brace — 40% rating under DC 5262
  • Malunion — Rated under DC 5256 (ankylosis), 5257 (instability), 5260 (flexion limitation), or 5261 (extension limitation) depending on functional impairment

Tips:

  • If you wear a brace for your lower leg, bring it to the exam
  • Describe any abnormal motion, clicking, or instability at the fracture site
  • Provide all imaging records showing nonunion or malunion if available

Pain considerations: Pain at the fracture site with weight-bearing or palpation directly supports the severity of the impairment.

Ankle Range of Motion

Whether the tibia/fibula impairment has affected ankle joint function (plantar flexion, dorsiflexion, inversion, eversion)

What to expect:

If the fracture involved the distal tibia or fibula (near the ankle), the examiner will assess ankle ROM in active, passive, weight-bearing, and non-weight-bearing positions.

Key thresholds:

  • Dorsiflexion limited to 0 degrees or less (foot drop) — Significant functional impairment; may be rated under DC 5271
  • Plantar flexion limited to less than 30 degrees — Moderate limitation of ankle function

Tips:

  • Inform the examiner if ankle pain or stiffness is related to your tibia/fibula injury
  • Describe any difficulty walking on uneven surfaces, stairs, or inclines
  • Report any foot drop, toe dragging, or need to lift your knee high to clear your foot

Pain considerations: Ankle pain during ROM testing should be reported immediately with location, character, and severity.

Muscle Circumference / Atrophy Measurement

Whether disuse atrophy has developed in the thigh or calf musculature due to pain, immobility, or nerve involvement

What to expect:

Examiner may measure calf or thigh circumference bilaterally at a defined landmark to document muscle wasting.

Key thresholds:

  • Greater than 1 cm difference in circumference between sides — Supports muscle atrophy of disuse; contributes to functional loss documentation

Tips:

  • Report if you have noticed your affected leg is smaller or weaker than the other
  • Describe any difficulty with activities requiring calf or quad strength (rising from a chair, climbing stairs)
  • Mention if you have avoided using the leg and why

Pain considerations: Disuse atrophy from pain avoidance is a legitimate finding - describe how pain has limited your use of the affected leg.

Estimate

Rating Criteria Breakdown

40% Nonunion of tibia and/or fibula with loose motion requiring ...

Nonunion of tibia and/or fibula with loose motion requiring a brace. This is the highest specific rating under DC 5262. The fracture has failed to heal and the fracture site demonstrates abnormal motion (loose/unstable). The veteran must require a brace to stabilize the lower leg.

Key Symptoms

  • Abnormal motion at the fracture site (pseudarthrosis)
  • Pain and instability at the nonunion site
  • Requirement for brace or orthotic device to ambulate safely
  • Possible deformity or shortening of the lower leg
  • Chronic pain with weight-bearing
  • Difficulty with prolonged standing or walking

CFR: 38 CFR - 4.71a, DC 5262: 'Nonunion of, with loose motion, requiring brace - 40'

0% Malunion of tibia and/or fibula. DC 5262 does not independen ...

Malunion of tibia and/or fibula. DC 5262 does not independently rate malunion - instead, malunion is evaluated under DC 5256 (ankylosis of knee), DC 5257 (other impairment of knee), DC 5260 (limitation of flexion of the leg), or DC 5261 (limitation of extension of the leg), depending on the specific functional impairment resulting from the malunion. The rating assigned will reflect the degree of limitation of motion, instability, or ankylosis present.

Key Symptoms

  • Healed fracture in abnormal alignment
  • Angular deformity (varus, valgus, apex anterior/posterior)
  • Rotational deformity
  • Leg length discrepancy from shortening
  • Pain with weight-bearing
  • Limitation of knee or ankle range of motion
  • Joint instability from altered biomechanics

CFR: 38 CFR - 4.71a, DC 5262: 'Malunion of: Evaluate under diagnostic codes 5256, 5257, 5260, or [5261]'

How to Describe Your Symptoms

Pain - Location, Character, and Severity

How to describe:

Describe the exact location (e.g., mid-shaft tibia, distal fibula, fracture site), character (sharp, aching, burning, throbbing), severity on a 0-10 scale at rest and with activity, and what makes it better or worse.

Worst-day example:

“On my worst days, the pain at the fracture site on my shin is a 9 out of 10 when I try to walk more than half a block. The pain is sharp and stabbing when I step down on my heel and a constant deep ache at rest that wakes me from sleep.”

What the examiner listens for:

Examiner is documenting pain for the DBQ pain checkboxes (active motion, passive motion, rest) and for DeLuca functional loss. They want specificity about timing, triggers, and severity.

Understatements to avoid:

Do not say 'it's not too bad' or 'I manage.' Do not minimize pain when asked about your worst days. Do not conflate your average pain with your best pain.

Functional Loss - What You Cannot Do

How to describe:

Describe specific activities you can no longer perform or perform with difficulty: walking distance, climbing stairs, standing duration, kneeling, squatting, carrying weight, recreational activities, occupational tasks.

Worst-day example:

“On bad days I cannot walk more than 100 feet without stopping due to pain and instability in my lower leg. I cannot stand at a kitchen counter for more than five minutes. I have not been able to run, jump, or participate in any sports since my fracture. I dropped a grocery bag last week because the pain was so severe I lost my balance.”

What the examiner listens for:

The examiner needs to document disturbance of locomotion, interference with standing and sitting, weakened movement, and instability of station for the DBQ functional loss section.

Understatements to avoid:

Do not say 'I can do most things.' Do not compare yourself to before your military service. Describe your current functional reality on your worst days.

Instability and Loose Motion at Fracture Site

How to describe:

If you have nonunion, describe any sensation of abnormal motion, clicking, giving way, or instability specifically at the fracture site. Explain that you rely on a brace to prevent the leg from buckling.

Worst-day example:

“Without my brace, I feel my lower leg shift at the old fracture site when I try to put weight on it. It feels like the bones are not connected. I fell last month because I tried to walk without my brace for a few seconds and my leg gave out completely.”

What the examiner listens for:

Documentation of loose motion at a nonunion site is the key clinical finding for the 40% DC 5262 rating. The examiner needs to observe or confirm abnormal mobility and brace requirement.

Understatements to avoid:

Do not fail to mention the brace if you use one. Do not describe instability vaguely - be specific about what happens when you try to weight-bear without the brace.

Deformity and Leg Length Discrepancy

How to describe:

Describe any visible or functional deformity: bowing of the lower leg, rotational asymmetry, the affected leg appearing shorter, altered gait pattern (limp, toe-out, compensatory lean).

Worst-day example:

“My right lower leg is visibly bowed outward since the fracture healed. My right leg is about an inch shorter than my left, which causes me to limp and has led to hip and back pain from the uneven gait. My shoe has been modified with a lift but it still does not fully correct the discrepancy.”

What the examiner listens for:

Examiner is documenting deformity, leg length discrepancy measurements, and related gait disturbance for the DBQ fields on shortening and deformity.

Understatements to avoid:

Do not fail to mention secondary problems caused by the deformity (back pain, hip pain, altered gait). Bring heel lift or shoe modification if applicable.

Fatigue, Weakness, and Incoordination (DeLuca Factors)

How to describe:

Describe how the lower leg becomes weaker, more painful, or uncoordinated with sustained or repeated use. Quantify how quickly fatigue sets in and how long recovery takes.

Worst-day example:

“After climbing one flight of stairs, my lower leg muscles feel completely exhausted and the pain triples. I then have to sit for at least 20 minutes before I can use the leg normally again. By the end of the day I am dragging my foot slightly because the leg muscles are so fatigued.”

What the examiner listens for:

The DBQ has specific checkboxes for pain, weakness, fatigability, incoordination, and lack of endurance. The examiner must address each DeLuca factor. Your descriptions drive these findings.

Understatements to avoid:

Do not focus only on pain. Weakness, fatigue, and incoordination are separately ratable factors under DeLuca and must be reported independently.

Flare-Ups - Frequency, Duration, and Triggers

How to describe:

Describe how often flare-ups occur, how long they last, what triggers them, and what your functional capacity is during a flare-up versus a typical day.

Worst-day example:

“I have severe flare-ups two to three times per week, triggered by walking more than a block, cold weather, or standing longer than ten minutes. During a flare-up, the fracture site swells, the pain reaches 9 out of 10, and I am completely unable to weight-bear. These episodes last 24 to 48 hours and I cannot leave my home during them.”

What the examiner listens for:

The examiner is required under DeLuca to address functional limitation during flare-ups. Your description of flare-up severity directly affects the rating assigned.

Understatements to avoid:

Do not say 'I occasionally have bad days.' Quantify frequency, severity, duration, and functional impact of each flare-up. This is critical for the DBQ narrative fields.

Assistive Device Use

How to describe:

Describe every assistive device you use, how often you use it, for what activities, and what happens if you try to function without it.

Worst-day example:

“I wear a custom ankle-foot orthosis (AFO) brace every day from the moment I get out of bed. Without it, I cannot safely weight-bear because my lower leg is unstable at the fracture site. On days when my leg is particularly bad, I also use a single cane in my opposite hand to redistribute weight.”

What the examiner listens for:

Examiner documents specific assistive devices (cane, crutch, brace, walker, wheelchair) in multiple DBQ sections. Brace use is specifically required for the 40% DC 5262 nonunion rating.

Understatements to avoid:

Do not leave your brace or assistive device at home. Do not downplay how often you use it. Bring the actual device to the exam so it can be documented.

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 a thorough and adequate C&P examination that addresses all DeLuca factors (pain, fatigue, weakness, incoordination with repetitive use) and flare-up limitations under DeLuca v. Brown, 8 Vet.App. 202 (1995).
  • Under Correia v. McDonald, 28 Vet.App. 158 (2016), the examiner is required to test ROM in active motion, passive motion, weight-bearing, and non-weight-bearing conditions. If this testing is not performed, the exam may be inadequate for rating purposes.
  • You have the right to request a copy of the completed DBQ and examination report from the VA or examination vendor.
  • In most states, you have the right to audio or video record your C&P examination. Check your state's consent laws before recording and notify the examiner at the start of the exam.
  • If you believe the examination was inadequate - for example, if the examiner failed to address DeLuca factors, did not assess for nonunion loose motion, or did not document your brace requirement - you have the right to request a new examination or supplemental opinion.
  • You may bring a representative (VSO, accredited claims agent, attorney) to your C&P examination as an observer.
  • You have the right to submit a personal statement (VA Form 21-4138) or lay statements describing your symptoms and functional limitations. Lay evidence is valid evidence under 38 CFR - 3.303.
  • You have the right to submit a nexus letter from a private physician if you believe the VA examiner's opinion is inadequate or incorrect.
  • Under 38 CFR - 4.7, when the evidence is in approximate balance for and against a higher rating, the benefit of the doubt must be given to you.
  • You have the right to appeal any rating decision you believe is incorrect within one year of the decision date using the Appeals Modernization Act (AMA) lanes: Supplemental Claim, Higher-Level Review, or Board of Veterans Appeals.

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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.