Evaluating muscle injuries and residuals of shell fragment ... Muscle Injuries... · Muscle Injury Considerations ... scapula, pelvic Adhesion of scar to one of the long ... Evaluating

MOPH Training Orlando, FL March 2010 1

Evaluating muscle injuries and residuals of shell fragment and

gunshot wounds

Training conducted by: Michael Fishman and Sandrine Fisher


Objectives

To become familiar with the application of the rating schedule in evaluating muscle injuries


Muscle Injury Considerations

These ratings can be difficult, because the These ratings can be difficult, because the injuries that cause damage to muscles can injuries that cause damage to muscles can also damage bones, joints and nerves.also damage bones, joints and nerves.

When rating, 38 CFR 4.14 (rules of When rating, 38 CFR 4.14 (rules of pyramiding) must be considered.pyramiding) must be considered.


38 CFR 4.55 Combined Ratings for Muscle Injuries

(a) A muscle injury will not be combined (a) A muscle injury will not be combined with a peripheral nerve paralysis rating of with a peripheral nerve paralysis rating of the same body part the same body part unlessunless the injuries the injuries affect different functions.affect different functions.


Example – 4.55 (a)

If the veteran has an injury to muscle group If the veteran has an injury to muscle group X and involves the external popliteal X and involves the external popliteal nerve, separate evaluations could not be nerve, separate evaluations could not be assigned as both the nerve injury and assigned as both the nerve injury and muscle injury affect the same function.muscle injury affect the same function.



(b) The skeletal muscles are divided into 23 (b) The skeletal muscles are divided into 23 muscle groups in 5 anatomical regions:muscle groups in 5 anatomical regions:

Shoulder girdle and armShoulder girdle and armForearm and handForearm and handFoot and legFoot and legPelvic girdle and thighPelvic girdle and thighTorso and neckTorso and neck



(c) No ratings for muscles acting on (c) No ratings for muscles acting on ankylosed joints except:ankylosed joints except:

1. Muscle group XIII with ankylosed knee 1. Muscle group XIII with ankylosed knee –– in this case the muscle injury would be in this case the muscle injury would be evaluated at the next lower level than that evaluated at the next lower level than that which would be assigned which would be assigned


Example 4.55 c(1)

Vet has s/c for residuals of a shrapnel Vet has s/c for residuals of a shrapnel wound to the right knee. As the right knee wound to the right knee. As the right knee is ankylosed at 15 degrees, a 40 percent is ankylosed at 15 degrees, a 40 percent evaluation is assigned. Evidence also evaluation is assigned. Evidence also shows muscle group VIII is disabled and shows muscle group VIII is disabled and warrants a moderately severe evaluation. warrants a moderately severe evaluation. WhatWhat’’s the appropriate evaluation for s the appropriate evaluation for muscle group VIII?muscle group VIII?


Answer

Since the veteran is s/c for an ankylosed Since the veteran is s/c for an ankylosed right knee, the muscle injury must be right knee, the muscle injury must be evaluated as evaluated as ““moderatemoderate”” (the next lower (the next lower level). So the veteran would be entitled to level). So the veteran would be entitled to a 40 percent evaluation for the knee and a a 40 percent evaluation for the knee and a 10 percent evaluation for the muscle 10 percent evaluation for the muscle injury.injury.



(c) No ratings for muscles acting on (c) No ratings for muscles acting on ankylosed joints except:ankylosed joints except:

2. Muscle group I and II with ankylosed 2. Muscle group I and II with ankylosed shoulder shoulder –– in this case the evaluation of in this case the evaluation of the shoulder joint under DC 5200 would be the shoulder joint under DC 5200 would be elevated to the level for unfavorable elevated to the level for unfavorable ankylosis, if not already assigned, but the ankylosis, if not already assigned, but the muscle groups themselves will not be ratedmuscle groups themselves will not be rated


Example 4.55 c(2)

Vet is currently evaluated as 20 percent Vet is currently evaluated as 20 percent disabling for residuals of a gunshot wound disabling for residuals of a gunshot wound to the left shoulder under DC 5200 (based to the left shoulder under DC 5200 (based on unfavorable ankylosis on unfavorable ankylosis –– abduction to 70 abduction to 70 degrees). Exam results show severe degrees). Exam results show severe muscle injury to muscle group I and II. muscle injury to muscle group I and II. The shoulder is still favorably ankylosed.The shoulder is still favorably ankylosed.What is the appropriate evaluation? What is the appropriate evaluation?


Answer

As the evidence shows muscle groups I As the evidence shows muscle groups I and II are both severely disabled, the and II are both severely disabled, the evaluation for the shoulder under DC 5200 evaluation for the shoulder under DC 5200 should be increased to the level of should be increased to the level of unfavorable ankylosis for a nonunfavorable ankylosis for a non--dominant dominant shoulder which is 40 percent and no shoulder which is 40 percent and no separate evaluations under DC 5300 would separate evaluations under DC 5300 would be warranted. be warranted.



(d) The combined evaluation of muscle (d) The combined evaluation of muscle groups acting on a single groups acting on a single ununankylosed ankylosed joint joint must be lower than the evaluation must be lower than the evaluation for unfavorable ankylosisfor unfavorable ankylosis for that joint. for that joint.

(Exception: Muscle groups I and II acting (Exception: Muscle groups I and II acting on the shoulder on the shoulder –– in this case the in this case the evaluation can not exceed the rating for evaluation can not exceed the rating for unfavorable)unfavorable)


Example 4.55(d)

Vet is s/c for residuals of SFW to dominant Vet is s/c for residuals of SFW to dominant right arm. Exam results show moderately right arm. Exam results show moderately severe muscle injury to MG V and a severe muscle injury to MG V and a moderate injury to MG VI, which both act moderate injury to MG VI, which both act upon the elbow. There is no ankylosis of upon the elbow. There is no ankylosis of the right elbow. the right elbow. What is the appropriate evaluation?What is the appropriate evaluation?


Answer

Muscle group V warrants a 30 % evaluationMuscle group V warrants a 30 % evaluationMuscle group VI warrants a 10 % evaluationMuscle group VI warrants a 10 % evaluationSo as these combined to 40 %, which is less than So as these combined to 40 %, which is less than the 60 % that would be warranted for unfavorable the 60 % that would be warranted for unfavorable ankylosis of the elbow, separate evaluations for ankylosis of the elbow, separate evaluations for the muscle injuries is permitted and appropriate.the muscle injuries is permitted and appropriate.



(e) For compensable muscle group injuries in the (e) For compensable muscle group injuries in the same anatomical region, but not affecting the same anatomical region, but not affecting the same joint:same joint:-- the evaluation for the most severely injured the evaluation for the most severely injured muscle group will be elevated by one level and muscle group will be elevated by one level and used as the combined evaluation for the groups.used as the combined evaluation for the groups.-- Can only elevate the level if the muscle injury Can only elevate the level if the muscle injury is at least a moderate (compensable) injuryis at least a moderate (compensable) injury


Example 4.55(e)

Vet is s/c for residuals of SFW to the right Vet is s/c for residuals of SFW to the right thigh. Exam results show moderately thigh. Exam results show moderately severe injury to MG XIII (which affects severe injury to MG XIII (which affects hip and knee) and moderate injury to MG hip and knee) and moderate injury to MG XVI (which affects the hip only). XVI (which affects the hip only). What is the appropriate evaluation?What is the appropriate evaluation?


Answer

Muscle group XIII warrants a 30% evaluationMuscle group XIII warrants a 30% evaluationMuscle group XVI warrants a 10 % evaluationMuscle group XVI warrants a 10 % evaluationSince muscle group XIII is the most severely Since muscle group XIII is the most severely injury of the two and they act on separate joints injury of the two and they act on separate joints belonging to the same anatomical region, a 40 belonging to the same anatomical region, a 40 percent evaluation is warranted (one level percent evaluation is warranted (one level higher). higher).



(f) For muscle injuries in different (f) For muscle injuries in different anatomical regions that do not act on anatomical regions that do not act on ankylosed joints:ankylosed joints:-- rate separatelyrate separately


38 CFR 4.56 Evaluating Muscle Disabilities

Rate an open comminuted fracture with Rate an open comminuted fracture with muscle or tendon damage as a severe muscle or tendon damage as a severe injury of the muscle group involved, unless injury of the muscle group involved, unless evidence establishes that the muscle evidence establishes that the muscle damage is minimal, for locations such as in damage is minimal, for locations such as in the wrist or over the tibia. the wrist or over the tibia.



A throughA through--andand--through injury through injury with muscle with muscle damagedamage shall be evaluated as no less than a shall be evaluated as no less than a moderate injury for each group of muscles moderate injury for each group of muscles damaged.damaged.



Cardinal Signs of Muscle Disability:Cardinal Signs of Muscle Disability:Loss of powerLoss of powerWeaknessWeaknessLowered threshold of fatigueLowered threshold of fatigueFatigueFatigue--painpainImpairment of coordinationImpairment of coordinationUncertainty of movementUncertainty of movement



DCDC’’s 5301 s 5301 –– 5323 are used to rate muscle 5323 are used to rate muscle disabilities with the following disabilities with the following classifications:classifications:SlightSlightModerateModerateModerately SevereModerately SevereSevereSevere


Slight disability of muscles

Simple wound Simple wound without debridementwithout debridement or infection.or infection.Record of superficial wound with debridement Record of superficial wound with debridement and return to dutyand return to dutyHealing with good resultsHealing with good resultsNo cardinal signs or symptoms of muscle No cardinal signs or symptoms of muscle disability and minimal scardisability and minimal scarNo evidence of fascia defect, atrophy, or No evidence of fascia defect, atrophy, or impaired tonusimpaired tonusNo impairment of function or metallic fragments No impairment of function or metallic fragments retained retained in muscle tissuein muscle tissue


Example of a slight muscle disability

Exam results show a residual superficial Exam results show a residual superficial scar without tenderness or adherence of scar without tenderness or adherence of underlying tissue. Muscle strength was underlying tissue. Muscle strength was normal of 5/5. No evidence of metallic normal of 5/5. No evidence of metallic fragments retained in muscle tissue or fragments retained in muscle tissue or impairment of function. Diagnosis impairment of function. Diagnosis –– scar, scar, residuals of shell fragment wound without residuals of shell fragment wound without functional impairment.functional impairment.


Moderate disability of muscles

Through and through or deep penetrating Through and through or deep penetrating woundwound of short track of short track withoutwithout explosive explosive effective of high velocity missile, residuals effective of high velocity missile, residuals of debridement, or prolonged infectionof debridement, or prolonged infectionEvidence of inEvidence of in--service treatment for woundservice treatment for woundRecord of consistent complaint of one or Record of consistent complaint of one or more of the cardinal signs and symptoms more of the cardinal signs and symptoms of muscle disabilityof muscle disability


Moderate disability of muscles continued…

Entrance and (if present) exit scars, small or Entrance and (if present) exit scars, small or linear, indicating short track of missile through linear, indicating short track of missile through muscle tissuemuscle tissueSome loss of deep fascia or muscle substance or Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to lowered threshold of fatigue when compared to the sound sidethe sound sideRetained foreign bodies with residuals or Retained foreign bodies with residuals or evidence of muscle damageevidence of muscle damage


Example of a moderate muscle disability

Exam results show a small linear entrance Exam results show a small linear entrance and exit scar without objective findings of and exit scar without objective findings of tenderness. Muscle strength was 4/5 for tenderness. Muscle strength was 4/5 for the right leg when compared to the left the right leg when compared to the left side. On palpation, there was evidence of side. On palpation, there was evidence of loss of deep fascia. Following repetitive loss of deep fascia. Following repetitive motion of the right leg, there was evidence motion of the right leg, there was evidence of fatigue and pain.of fatigue and pain.


Moderate severe disability of muscles

Through and through or deep penetrating sound Through and through or deep penetrating sound withwith debridement, prolonged infection, or debridement, prolonged infection, or sloughing of soft parts, and intermuscular sloughing of soft parts, and intermuscular scarringscarringEvidence of Evidence of hospitalization for a prolonged hospitalization for a prolonged periodperiod of treatment of woundof treatment of woundRecord of consistent complaint of cardinal signs Record of consistent complaint of cardinal signs and symptoms of muscle disability and if present, and symptoms of muscle disability and if present, evidence of inability to keep up with work evidence of inability to keep up with work requirementsrequirements


Moderate severe disability of muscles continued….

Entrance and (if present) exits scars indicating Entrance and (if present) exits scars indicating track of missile through one or more muscle track of missile through one or more muscle groupsgroupsIndication on palpation of loss of deep fascia, Indication on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscle substance, or normal firm resistance of muscles compared with sound sidemuscles compared with sound sideEvidence of impairment in strength and Evidence of impairment in strength and endurance compared with sound sideendurance compared with sound side


Example of moderately severe muscle disability

Exam result show evidence of a entrance Exam result show evidence of a entrance wound without tenderness or adherence of wound without tenderness or adherence of underlying tissue. On palpation, there was underlying tissue. On palpation, there was loss of deep fascia. Muscle strength was loss of deep fascia. Muscle strength was 3/5 in the left upper extremity when 3/5 in the left upper extremity when compared to the right side. There was compared to the right side. There was evidence of lower threshold of fatigue and evidence of lower threshold of fatigue and complaints of difficulty working due to complaints of difficulty working due to fatigue.fatigue.


Severe disability of muscles

Through and through or deep penetrating wound Through and through or deep penetrating wound due to highdue to high--velocity missile, or large or multiple velocity missile, or large or multiple low velocity missiles, or low velocity missiles, or withwith shattering bone shattering bone fracture or open communited fracture with fracture or open communited fracture with extensive debridement, prolonged infection, or extensive debridement, prolonged infection, or sloughing of soft, intermuscular binding and sloughing of soft, intermuscular binding and scarringscarringEvidence of Evidence of hospitalization for a prolonged hospitalization for a prolonged periodperiod of treatment of woundof treatment of wound


Severe disability of muscles continued….

Record of consistent complaint of cardinal signs Record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than and symptoms of muscle disability, worse than those shown for moderately severe muscle those shown for moderately severe muscle injuries, and, if present, evidence of inability to injuries, and, if present, evidence of inability to keep up with work requirements. keep up with work requirements. Ragged, depressed and adherent scars indicating Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area.substance, or soft flabby muscles in wound area.


Severe disability of muscles continued….

Muscles swell and harden abnormally in Muscles swell and harden abnormally in contraction. contraction. Evidence of severe impairment of function Evidence of severe impairment of function in regards to strength, endurance, or in regards to strength, endurance, or coordinated movements compared with the coordinated movements compared with the corresponding muscles of the uninjured corresponding muscles of the uninjured side side


Severe disability of muscles continued…

If present, the following are also signs of If present, the following are also signs of severesevere muscle muscle disability:disability:XX--ray evidence of minute multiple scattered foreign ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive bodies indicating intermuscular trauma and explosive effect of the missile. effect of the missile. Adhesion of scar to one of the long bones, scapula, pelvic Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where the bone rather than true skin covering in an area where bone is normally protected by muscle.bone is normally protected by muscle.


Additional signs of severe muscle disability continued…

Diminished muscle excitability to pulsed electrical Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. current in electrodiagnostic tests. Visible or measurable atrophy.Visible or measurable atrophy.Adaptive contraction of an opposing group of muscles. Adaptive contraction of an opposing group of muscles. Atrophy of muscle groups not in the track of the missile, Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the particularly of the trapezius and serratus in wounds of the shoulder girdle. shoulder girdle. Induration or atrophy of an entire muscle following Induration or atrophy of an entire muscle following simple piercing by a projectile. simple piercing by a projectile.


Example of severe muscle disability

Exam results show an entrance and exit Exam results show an entrance and exit scar that is adherent to the underlying scar that is adherent to the underlying tissue. On palpation, there was loss of tissue. On palpation, there was loss of muscle substance. Strength was 3/5 when muscle substance. Strength was 3/5 when compared to the sound side. There was compared to the sound side. There was evidence of muscle atrophy. Xevidence of muscle atrophy. X--ray results ray results revealed minute multiple scattered foreign revealed minute multiple scattered foreign bodies. bodies.


Separate ratings…

If the veteranIf the veteran’’s scar is superficial and s scar is superficial and painful on examination painful on examination withoutwithout underlying underlying soft tissue damage, the scar should be soft tissue damage, the scar should be evaluated separately under DC 7804evaluated separately under DC 7804


Example of separate evaluations for muscle injury and scar

Exam results show that the veteran has a Exam results show that the veteran has a moderate injury of the muscle and a moderate injury of the muscle and a superficial tender scar. In this case, superficial tender scar. In this case, assigning a 10 percent evaluation for the assigning a 10 percent evaluation for the muscle group and a 10 percent evaluation muscle group and a 10 percent evaluation for the tender scar under DC 7804 is for the tender scar under DC 7804 is appropriate.appropriate.


Separate ratings….

Separate ratings for a joint disability and a Separate ratings for a joint disability and a muscle disability may be appropriate, if there is a muscle disability may be appropriate, if there is a joint injury leading to traumatic arthritis and a joint injury leading to traumatic arthritis and a muscle injury to a muscle in the same anatomical muscle injury to a muscle in the same anatomical region that does not act on that jointregion that does not act on that jointIf there is pain and limitation of motion due to If there is pain and limitation of motion due to arthritis, you could rate the muscle injury based arthritis, you could rate the muscle injury based on other cardinal signs and symptoms of muscle on other cardinal signs and symptoms of muscle disability (which is not a violation of 4.14)disability (which is not a violation of 4.14)


Separate ratings…

A veteran who sustains a gunshot wound of the head may A veteran who sustains a gunshot wound of the head may have one or more of the following residuals, all of which have one or more of the following residuals, all of which are separately ratable:are separately ratable:–– Skull lossSkull loss–– Injury to the facial musclesInjury to the facial muscles–– Injury to the cranial nervesInjury to the cranial nerves–– Impairment of visual acuity or field of visionImpairment of visual acuity or field of vision–– Seizure disorderSeizure disorder–– Organic brain syndrome due to trauma Organic brain syndrome due to trauma –– Facial disfigurement and scarsFacial disfigurement and scars–– Varying degrees of neurological deficit in the upper or Varying degrees of neurological deficit in the upper or

lower extremitieslower extremities


Notes under two of the diagnostic codes in the 5300 series

(1) (1) Muscle Group IX Muscle Group IX (the intrinsic muscles of the hand) (the intrinsic muscles of the hand) -- The note following Diagnostic Code 5309 advises that The note following Diagnostic Code 5309 advises that the hand is so compact a structure that isolated muscle the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. As such, injury to injuries of bones, joints, tendons, etc. As such, injury to Muscle Group IX is to be rated on the basis of limitation Muscle Group IX is to be rated on the basis of limitation of motion. The minimum rating is 10 percent.of motion. The minimum rating is 10 percent.

(2) (2) Muscle Group XMuscle Group X (the intrinsic muscles of the foot) (the intrinsic muscles of the foot) --The regulatory note following Diagnostic Code 5310 The regulatory note following Diagnostic Code 5310 provides that the minimum rating for throughprovides that the minimum rating for through--andand--through wounds of the foot is 10 percentthrough wounds of the foot is 10 percent


Important Reminders

AMPUTATION RULE 38 CFR 4.68 AMPUTATION RULE 38 CFR 4.68 -- The combined The combined rating for disabilities of an extremity may not exceed the rating for disabilities of an extremity may not exceed the rating for amputation at the elective level, were rating for amputation at the elective level, were amputation to be performed. amputation to be performed.

Example:Example: The combined evaluations for disabilities below The combined evaluations for disabilities below the knee shall not exceed the 40 percent evaluation the knee shall not exceed the 40 percent evaluation provided under DC 5165 (anatomical loss at a lower provided under DC 5165 (anatomical loss at a lower level, permitting prosthesis). The 40 percent rating may level, permitting prosthesis). The 40 percent rating may be further combined, pursuant to be further combined, pursuant to §§ 4.25, with an 4.25, with an evaluation for disabilities above the knee, but not to evaluation for disabilities above the knee, but not to exceed the above the knee amputation elective level.exceed the above the knee amputation elective level.


Important reminders continued..

Rules against pyramiding:Rules against pyramiding:

The evaluation of the same disability under various The evaluation of the same disability under various diagnoses is to be avoided. diagnoses is to be avoided.

The key is to look at the specific manifestations of the The key is to look at the specific manifestations of the disabilities involved, and determine whether there is disabilities involved, and determine whether there is additional impairment not accounted for by the rating additional impairment not accounted for by the rating assigned to the muscle injury.assigned to the muscle injury.

Documents

Evaluating muscle injuries and residuals of shell fragment ... Muscle Injuries... · Muscle Injury Considerations ... scapula, pelvic Adhesion of scar to one of the long ... Evaluating