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C&P Exam Prep: Ulna, Impairment of
DBQ Overview
Interview + Physical- Form Name
- Elbow_and_Forearm
- Form Code
- Elbow_and_Forearm
- Page Count
- 15
- 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 nature and severity of ulnar impairment, including nonunion, malunion, false movement, loss of bone substance, deformity, and resulting functional limitations of the forearm and elbow, for VA disability rating purposes under 38 CFR 4.71a, DC 5211.
What the examiner evaluates:
- Diagnosis and confirmation of ulnar condition (nonunion, malunion, or other impairment)
- Location of nonunion: upper half versus lower half of ulna
- Presence of false movement at nonunion site
- Loss of bone substance (measurement in inches/cm, threshold is 1 inch or 2.5 cm)
- Degree of deformity (marked deformity versus none)
- Active and passive range of motion of elbow (flexion/extension) and forearm (pronation/supination)
- Pain during motion, at rest, and with repeated use
- Weakness, fatigability, incoordination, and lack of endurance
- Functional loss due to the condition
- Flare-up history and impact on range of motion
- Radiographic and surgical history
- Use of assistive devices or braces
- Impact on activities of daily living and occupational function
Exam is conducted in person with physical examination of the affected forearm and elbow. The examiner will observe gait, posture, and arm use during check-in. Be accurate in your movements throughout the entire appointment, not just during formal testing.
Typical duration: 30-45 minutes
Elbow Flexion Range of Motion
Active and passive flexion of the elbow joint, normal endpoint is 145 degrees.
What to expect:
Examiner will ask you to bend your elbow as far as possible (active), then may gently assist to determine passive range. Both weight-bearing and non-weight-bearing positions may be tested.
Key thresholds:
- 145 degrees (normal) — No limitation noted
- Less than 145 degrees — Limitation of flexion may support functional loss finding
- Severely limited (e.g., 60 degrees or less) — Supports higher functional impairment documentation
Tips:
- Move only as far as you can without forcing through pain
- Do not warm up or stretch the joint before the exam
- Report when pain begins, not just when motion stops
- If your range is worse after repetitive use, tell the examiner before testing begins
Pain considerations: If flexion causes pain before the anatomical endpoint, state clearly: 'I can bend to this degree but pain stops me from going further.' The examiner must document the point at which pain limits motion, not just the maximum angle achieved.
Elbow Extension Range of Motion
Active and passive extension of the elbow, normal endpoint is 0 degrees (full extension).
What to expect:
Examiner will ask you to straighten your arm fully. Inability to fully extend is called an extension lag and is clinically significant.
Key thresholds:
- 0 degrees (full extension, normal) — No limitation
- Greater than 0 degrees (incomplete extension) — Extension lag supports functional loss finding
Tips:
- Report pain with straightening accurately
- Do not hyperextend to compensate
- Note if swelling or instability prevents full extension
Pain considerations: Pain with extension should be described in terms of location (e.g., along the ulnar shaft, at the elbow joint) and intensity on a 0-10 scale.
Forearm Pronation Range of Motion
Rotational motion of the forearm turning the palm downward; normal endpoint is 80 degrees. Especially critical for DC 5211 ulnar impairment.
What to expect:
Examiner will ask you to rotate your forearm from a neutral (handshake) position toward palm-down. Both active and passive motion will be assessed.
Key thresholds:
- 80 degrees (normal endpoint) — No limitation
- Motion lost beyond middle of arc — Supports limitation of pronation rating under supination/pronation DC
- Motion lost beyond last quarter of arc (hand does not approach full pronation) — Supports higher limitation of pronation rating
- Complete loss of pronation — Maximum limitation of pronation rating applicable
Tips:
- Keep elbow at 90 degrees flexion during testing for accuracy
- Report any crepitus, catching, or instability during rotation
- Note if ulnar nonunion site is painful with rotation
Pain considerations: Ulnar fracture malunion or nonunion often creates pain specifically with rotational motion. Describe the pain location along the ulnar shaft precisely.
Forearm Supination Range of Motion
Rotational motion of the forearm turning the palm upward; normal endpoint is 85 degrees.
What to expect:
Examiner tests active and passive supination from neutral position. Limitation of supination is separately rated and directly relevant to daily functional tasks.
Key thresholds:
- 85 degrees (normal endpoint) — No limitation
- 30 degrees or less — Supports limitation of supination 30 degrees or less rating
- Complete loss of supination — Maximum limitation of supination rating applicable
Tips:
- Turning a doorknob, pouring a drink, or accepting change are daily tasks requiring supination - mention these if affected
- Passive supination may exceed active supination; both matter
- Report grinding, clicking, or instability at the distal radioulnar joint
Pain considerations: Supination often aggravates distal ulnar nonunion or malunion. Describe whether pain is worse at the wrist end versus elbow end of the ulna during rotation.
Bone Substance Loss Measurement
Physical measurement of gap or defect at ulnar nonunion site; threshold of 1 inch (2.5 cm) is critical for higher rating levels.
What to expect:
Examiner may palpate the forearm and review imaging to assess bone gap. Radiographs are essential for this determination.
Key thresholds:
- 1 inch (2.5 cm) or more loss of bone substance — Qualifies for 40% (dominant) or 30% (non-dominant) rating with false movement and marked deformity at upper half nonunion
- Less than 1 inch loss or no loss — Rating at 30%/20% level without bone substance loss qualifier
Tips:
- Ensure recent X-rays are in your claims file prior to the exam
- Reference any operative reports documenting bone loss if surgery occurred
- Ask the examiner to confirm imaging has been reviewed
Pain considerations: Bone defect areas are often hypersensitive to direct palpation. Report this accurately.
False Movement Assessment (Nonunion)
Presence of abnormal motion at the nonunion site indicating failure of fracture healing.
What to expect:
Examiner may palpate along the ulnar shaft while asking you to perform gentle movements to detect abnormal mobility at a suspected nonunion site.
Key thresholds:
- False movement present at upper half nonunion — Meets criteria for 30-40% rating range depending on bone substance loss
- False movement present at lower half nonunion — Meets criteria for 20% rating
- No false movement (malunion) — Rated at 10% level under malunion with bad alignment
Tips:
- Do not brace or stiffen the arm to prevent the examiner from detecting instability
- Report any sensation of clicking, giving way, or motion at the fracture site
- Mention if the forearm feels unstable during lifting or gripping
Pain considerations: Abnormal motion at a nonunion site is typically painful. Describe pain character (sharp, aching, radiating) and what activities provoke it.
Deformity Assessment
Visual and palpatory assessment of angular deformity, rotation, or shortening of the ulna following fracture.
What to expect:
Examiner will visually inspect both forearms for comparison, noting any visible angulation, rotation, or bony prominence. Cubitus valgus and cubitus varus deformities of the elbow may also be assessed.
Key thresholds:
- Marked deformity present — Combined with nonunion upper half and bone loss supports 40%/30% rating
- No significant deformity — Rating without deformity qualifier
Tips:
- Stand or sit naturally - do not attempt to straighten the arm to hide deformity
- Point out any visible bony irregularities to the examiner
- Bring pre-injury and post-injury photos if available to demonstrate changes
Pain considerations: Deformity areas may have chronic soft tissue pain. Describe any aching at the deformity site and whether it worsens with activity or weather changes.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 40% | Nonunion in upper half of ulna with false movement, with loss of bone substance of 1 inch (2.5 cm) or more AND marked deformity. This rating applies to the dominant extremity. |
CFR: 38 CFR 4.71a, DC 5211: Nonunion in upper half, with false movement, with loss of bone substance (1 inch or more) and marked deformity - 40% dominant, 30% non-dominant. |
| 30% | Nonunion in upper half of ulna with false movement, WITHOUT loss of bone substance or deformity (dominant extremity); OR nonunion in upper half WITH bone loss and marked deformity (non-dominant extremity). |
CFR: 38 CFR 4.71a, DC 5211: Nonunion in upper half without loss of bone substance or deformity - 30% dominant, 20% non-dominant. |
| 20% | Nonunion in lower half of ulna (both dominant and non-dominant rated identically at 20%); OR nonunion in upper half without bone loss or deformity (non-dominant extremity). |
CFR: 38 CFR 4.71a, DC 5211: Nonunion in lower half - 20% for both dominant and non-dominant extremity. |
| 10% | Malunion of ulna with bad alignment (both dominant and non-dominant rated identically at 10%). Fracture healed but in a malaligned position causing functional deficit. |
CFR: 38 CFR 4.71a, DC 5211: Malunion of ulna with bad alignment - 10% for both dominant and non-dominant extremity. |
40% Nonunion in upper half of ulna with false movement, with los ...
Nonunion in upper half of ulna with false movement, with loss of bone substance of 1 inch (2.5 cm) or more AND marked deformity. This rating applies to the dominant extremity.
Key Symptoms
- Documented nonunion in upper half of ulna
- Confirmed false movement at nonunion site
- Loss of bone substance measuring 1 inch or more
- Marked visible deformity of the forearm or ulna
- Significant functional limitation of forearm rotation and/or elbow motion
- Pain with palpation at nonunion site
- Weakness of grip and forearm rotation
CFR: 38 CFR 4.71a, DC 5211: Nonunion in upper half, with false movement, with loss of bone substance (1 inch or more) and marked deformity - 40% dominant, 30% non-dominant.
30% Nonunion in upper half of ulna with false movement, WITHOUT ...
Nonunion in upper half of ulna with false movement, WITHOUT loss of bone substance or deformity (dominant extremity); OR nonunion in upper half WITH bone loss and marked deformity (non-dominant extremity).
Key Symptoms
- Documented nonunion in upper half of ulna
- Confirmed false movement at nonunion site
- No significant loss of bone substance OR non-dominant arm with full criteria
- Functional limitation of pronation and/or supination
- Pain with forearm rotation
- Instability during load-bearing activities with the arm
CFR: 38 CFR 4.71a, DC 5211: Nonunion in upper half without loss of bone substance or deformity - 30% dominant, 20% non-dominant.
20% Nonunion in lower half of ulna (both dominant and non-domina ...
Nonunion in lower half of ulna (both dominant and non-dominant rated identically at 20%); OR nonunion in upper half without bone loss or deformity (non-dominant extremity).
Key Symptoms
- Documented nonunion in lower half of ulna
- False movement may or may not be present at this level
- Functional limitation of wrist rotation and distal radioulnar joint stability
- Pain at distal ulna or wrist level
- Weakness of grip strength
- Possible instability of distal radioulnar joint (DRUJ)
CFR: 38 CFR 4.71a, DC 5211: Nonunion in lower half - 20% for both dominant and non-dominant extremity.
10% Malunion of ulna with bad alignment (both dominant and non-d ...
Malunion of ulna with bad alignment (both dominant and non-dominant rated identically at 10%). Fracture healed but in a malaligned position causing functional deficit.
Key Symptoms
- Radiographically confirmed malunion with angular or rotational malalignment
- Reduced forearm rotation (pronation and/or supination)
- Pain with forearm rotation or load-bearing
- Visible or palpable deformity without false movement
- Weakness with gripping or carrying
- Possible cosmetic deformity with functional impact
CFR: 38 CFR 4.71a, DC 5211: Malunion of ulna with bad alignment - 10% for both dominant and non-dominant extremity.
How to Describe Your Symptoms
Pain at Rest and During Motion
How to describe:
Describe the location of pain precisely (e.g., 'along the outer edge of my forearm about mid-shaft,' 'at the bump where my ulna didn't heal right,' or 'deep in my forearm when I rotate my hand'). Use a consistent 0-10 pain scale. Distinguish between resting pain, pain with activity, and pain that appears during repetitive use.
Worst-day example:
“On my worst days, even resting my forearm on a table causes a 6/10 aching pain along the ulna. Any rotation of my forearm, like turning a steering wheel or opening a jar, spikes to 8-9/10 and I have to stop immediately. The pain lingers for hours after.”
What the examiner listens for:
Examiner needs to hear specific location, quality (sharp/dull/burning/aching), onset triggers, severity, duration, and radiation pattern. They are populating pain checkboxes and narrative fields on the DBQ.
Understatements to avoid:
Do not say 'it's not that bad' or 'I manage.' If you have adapted your life to avoid pain, describe what you've stopped doing and why, rather than minimizing current symptoms.
Weakness and Grip Strength Reduction
How to describe:
Describe functional weakness in concrete terms: what tasks you can no longer perform, how much weight you can carry, and how grip strength has changed since the injury. Distinguish between true weakness (muscle cannot generate force) and pain-limited strength (you stop because it hurts before the muscle fails).
Worst-day example:
“On bad days I cannot carry a grocery bag with my affected arm without dropping it. I can't use a manual can opener, wrench, or screwdriver. Even holding a coffee mug for more than a few minutes causes the arm to feel like it's going to give out.”
What the examiner listens for:
The examiner will document weakness as a DeLuca factor. They need to understand whether weakness is constant or variable, and how it relates to the ulnar condition specifically.
Understatements to avoid:
Avoid saying 'I still have some strength.' Quantify loss: 'I used to lift 40 lbs; now I can't safely lift more than 10 lbs with this arm without pain and instability.'
Fatigability and Lack of Endurance
How to describe:
Explain how quickly the arm tires with use and how long recovery takes. This is distinct from weakness - it means the arm can perform a task initially but fails after repeated use. Give time-based examples.
Worst-day example:
“I can stir something on the stove for maybe 30 seconds before my forearm feels exhausted and starts throbbing. After I stop, it takes 20 to 30 minutes before I can try again. By the end of a workday that involves any arm use, the forearm is completely spent and painful for the rest of the night.”
What the examiner listens for:
The examiner must document fatigability as a DeLuca factor. They are looking for evidence that repeated use over time results in additional functional limitation beyond the initial range of motion measurement.
Understatements to avoid:
Do not assume the examiner will ask about fatigue. Volunteer this information. Many veterans report initial ROM normally but fail to mention that the third or fourth repetition is dramatically worse.
Incoordination
How to describe:
Describe any loss of fine motor control, trembling, or unsteadiness of the affected forearm. Incoordination in the context of ulnar impairment often manifests as difficulty with precise forearm rotation tasks - such as typing, writing, using tools, or buttoning clothing.
Worst-day example:
“I often fumble when trying to use a screwdriver because my forearm won't rotate smoothly - it jerks or catches partway through. When I try to write, my forearm shakes slightly and my handwriting has become illegible. I drop small objects frequently from the affected hand.”
What the examiner listens for:
Incoordination is a DeLuca factor that must be documented if present. Examiner will check the incoordination box on the DBQ and include narrative description if provided.
Understatements to avoid:
Many veterans do not associate clumsiness or trembling with their forearm fracture. If your coordination has changed since the injury, this is directly relevant and must be communicated.
Flare-Ups
How to describe:
Describe what triggers a flare-up, what symptoms worsen during a flare-up, how often they occur, how long they last, and how they affect your ability to function. Include weather changes, activity-related flares, and morning stiffness if applicable.
Worst-day example:
“When I do any sustained work with my hands - even 10 to 15 minutes of typing or carrying things - I get a flare-up that night where the forearm throbs constantly, I can't pronate or supinate without sharp pain, and I can't sleep on that side. These flares happen 3 to 4 times a week and last 12 to 24 hours.”
What the examiner listens for:
Examiner must document flare-up impact per DeLuca and Mitchell requirements. They need to understand estimated additional range of motion loss during a flare and the frequency and duration of flares.
Understatements to avoid:
Do not say 'I don't have flare-ups' if you have bad days and better days. Variable symptoms ARE flare-up behavior. Describe your worst functional state, not your average state.
False Movement and Instability
How to describe:
If you have a nonunion, describe any sensation of abnormal motion, clicking, giving way, or instability at the fracture site. Explain what activities provoke this and whether it is painful. This is a key objective finding for higher rating levels.
Worst-day example:
“When I try to lift or rotate my forearm under load, I can feel and sometimes hear a clicking or shifting at the spot where my ulna didn't heal. It feels unstable, like the bone is moving when it shouldn't be. It causes sharp pain and I reflexively drop whatever I'm holding.”
What the examiner listens for:
The examiner will palpate for false movement. Your reported subjective experience of instability corroborates the physical finding and should be clearly communicated before and during physical examination.
Understatements to avoid:
Do not assume the examiner can always detect subtle false movement. Describe the sensation specifically so it is documented in the narrative even if not definitively confirmed on exam.
Functional and Occupational Impact
How to describe:
Describe specifically how the ulnar impairment limits your ability to work, perform self-care, and engage in activities of daily living. Be concrete: list job tasks you can no longer perform, tools you can no longer use, and hobbies or ADLs that are now impossible or limited.
Worst-day example:
“I used to work as a mechanic and cannot return to that work because I cannot torque fasteners, use impact tools, or hold my arm in the positions required. At home I cannot carry my groceries, lift my child, mow the lawn, or do home repairs. I need help opening jars, carrying laundry, and doing yard work.”
What the examiner listens for:
The examiner will complete the functional impact section of the DBQ. Specific, concrete examples of lost function are far more useful than general statements like 'it affects my daily life.'
Understatements to avoid:
Do not list only dramatic losses. Even modest functional limitations like difficulty typing, writing, or using a phone are relevant and should be described.
Common Mistakes to Avoid
Not disclosing dominant arm status
DC 5211 ratings differ between dominant and non-dominant extremity at most levels. A 40% rating (dominant) versus 30% (non-dominant) for the same pathology depends on which arm is affected.
Instead: Clearly state which arm is your dominant arm at the start of the exam. Confirm this is correctly noted in the DBQ.
Impact: 40% vs 30% and 30% vs 20% distinctions
Performing range of motion at maximum effort to appear cooperative
Performing beyond your actual pain-limited range produces inaccurate measurements that underrepresent your true disability. The exam should reflect your condition, not your effort to please.
Instead: Move only to the point where pain, instability, or weakness stops you. Clearly verbalize 'This is as far as I can go without significant pain' at the endpoint.
Impact: All rating levels - functional loss documentation
Failing to mention repetitive use fatigue before ROM testing
If you have been sitting in a waiting room and your arm is relatively rested, the initial ROM measurement may not reflect your true functional capacity. After repeated use, your range is likely worse.
Instead: Before ROM testing begins, tell the examiner: 'I want to note that my range of motion is typically much worse after I've used the arm for a while - the measurement you take right now may be better than what I experience during normal daily activity.'
Impact: All rating levels - DeLuca functional loss
Not bringing imaging or operative reports to the exam
DC 5211 ratings depend critically on objective findings: location of nonunion (upper vs lower half), presence of false movement, and bone substance loss measurement. These cannot be accurately assessed without imaging.
Instead: Verify that all X-rays, CT scans, and operative reports related to your ulnar fracture are in your VA claims file at least 2 weeks before the exam. Bring copies on exam day if possible.
Impact: 20% vs 30% vs 40% determinations
Describing only average symptoms rather than worst-day symptoms
VA adjudicators must rate the condition at its worst severity per M21-1 guidance. Describing only average or good-day function results in an underestimate of disability.
Instead: Explicitly describe your worst-day symptoms, frequency of bad days, and what a bad day looks like functionally. You may note 'This is my worst-day experience, which happens approximately X days per week.'
Impact: All rating levels
Not reporting instability or false movement symptoms
The presence of false movement directly determines whether a nonunion qualifies for the 30-40% range (with false movement) versus lower ratings. Veterans sometimes do not connect their instability sensation to the technical term 'false movement.'
Instead: Describe any sensation of the bone shifting, clicking, giving way, or moving abnormally at the fracture site. Use your own words; the examiner will translate this to the appropriate clinical finding.
Impact: 20% vs 30-40% distinction
Minimizing symptoms out of stoicism or embarrassment
Underreporting is the most common cause of under-rating. Examiners can only document what is reported and observed. If you adapt well to your disability, the examiner may not detect the true severity.
Instead: Describe the disability honestly and completely. Veteran stoicism is admirable but should not prevent accurate documentation of genuine functional loss.
Impact: 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 an accurate and thorough C&P examination that addresses all elements required for rating under the applicable diagnostic code. If the examination is inadequate, you can request a new examination.
- You have the right to submit a personal statement (buddy statement or lay statement) documenting your symptoms and functional limitations in your own words. This statement carries evidentiary weight.
- In most states, you have the right to record your C&P examination. Check your state's recording consent laws and the VA facility's policy before the exam. Inform the examiner if you choose to record.
- You have the right to bring a representative (VSO, attorney, claims agent) or a support person to the exam. The support person typically may not answer questions on your behalf but may be present.
- You have the right to request a copy of the completed DBQ examination report after it is finalized. You or your authorized representative may request this through the VA.
- If you believe the C&P examination was inadequate, incomplete, or inaccurate, you have the right to submit a Notice of Disagreement (NOD) and request a new examination or submit additional private medical evidence.
- You are not required to agree with the examiner's findings. If findings are inaccurate, you may address this through the appeals process, a supplemental claim, or by submitting a nexus letter from a private physician.
- You have the right under the PACT Act and AMA to request a Higher-Level Review or submit a Supplemental Claim with new and relevant evidence if you disagree with the rating decision following the examination.
- The VA has a duty to assist you in obtaining evidence necessary to substantiate your claim. This includes obtaining relevant medical records and, when warranted, ordering additional diagnostic testing or a specialist examination.
- You are entitled to the benefit of the doubt under 38 CFR 3.102. When there is an approximate balance of positive and negative evidence, the decision must be made in your favor.
Related Conditions
- Radius, Impairment of DC 5212 covers radius impairment and is evaluated on the same Elbow and Forearm Conditions DBQ. Ulnar and radial conditions frequently co occur following forearm fractures and may each be separately ratable if the manifestations are distinct and not duplicative under M21 1 V.iii.1.B.
- Supination and Pronation, Impairment of DC 5213 evaluates isolated limitations of forearm supination and pronation. If ulnar impairment under DC 5211 produces pronation or supination limitation, the rating may be assigned under DC 5211 or 5213, whichever is higher, but not both for the same functional loss.
- Radius and Ulna, Nonunion of, with Flail/False Joint DC 5214 applies when both radius and ulna have nonunion with flail or false joint formation. If only the ulna is involved, DC 5211 applies. Combined involvement of both bones may be rated under DC 5214 at a higher level.
- Ankylosis of Elbow Joint If ulnar impairment results in or coexists with elbow ankylosis, DC 5206 applies to the elbow joint itself. Separate ratings may apply for the ulna impairment and the elbow joint condition if the manifestations are distinct.
- Elbow Osteoarthritis or Post-Traumatic Arthritis Post traumatic arthritis of the elbow frequently develops following ulnar fractures and may be separately ratable under DC 5010 or 5003 based on radiographic evidence of arthritis with at least 10% limitation of motion, provided it is not duplicative of the ulnar impairment rating.
- Ulnar Nerve Paralysis or Neuritis The ulnar nerve runs in close proximity to the ulna and may be injured by ulnar fractures, nonunions, or malunions. If ulnar nerve involvement is present (weakness of intrinsic hand muscles, ring/little finger sensory loss), a separate rating under DC 8516 (ulnar nerve paralysis) may apply in addition to DC 5211.
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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.