Above-Knee Amputation of Thigh C&P Exam Prep

Amputation Level Determination

What it measures: The anatomical level of transfemoral amputation measured as a fraction of the distance from the ischial tuberosity to the knee joint line, determining rating tier under DC 5161

What to expect: Examiner will measure the residual limb length and compare it to the total femoral segment length to classify as upper third, middle third, or lower third amputation. Disarticulation at the hip (DC 5160) or transpelvic amputation (DC 5163) may also be documented.

Pain considerations: Phantom limb pain and residual limb (stump) pain during measurement and examination should be reported immediately to the examiner. Describe the quality (burning, stabbing, cramping), frequency, severity (0-10 scale), and duration of any pain experienced during or after the exam.

Stump Condition Assessment

What it measures: Physical integrity and functional status of the residual limb, including skin condition, scar tissue, neuromas, bone prominences, edema, and socket fit

What to expect: The examiner will visually inspect and palpate the residual limb. They will assess for skin breakdown, ulcers, adherent or painful scars, neuroma formation, heterotopic ossification, bony prominence, and overall stump shape. Socket fit issues with the prosthesis will be noted.

Pain considerations: Stump pain, particularly when weight-bearing on the prosthesis or during transfers, should be described in detail. Note whether pain worsens with prolonged use (DeLuca fatigue factor), whether it causes you to remove the prosthesis, and how it affects sleep, mobility, and daily function.

Hip Joint Range of Motion (Residual Limb Side)

What it measures: Flexion, extension, abduction, adduction, and rotation of the hip joint on the amputated side, which directly affects prosthetic gait and functional ambulation

What to expect: The examiner may measure active and passive hip ROM using a goniometer. Hip flexion contracture (inability to fully extend the hip) is particularly important as it affects prosthetic alignment and gait. Weight-bearing and non-weight-bearing assessments may be performed per Correia requirements.

Pain considerations: Any pain with hip flexion, extension, abduction, or rotation must be reported to the examiner during testing. Describe whether the pain is in the residual limb, hip joint, groin, or lower back. Note how pain limits your hip motion and whether it occurs with every movement or only at end-range.

Prosthetic Functional Assessment

What it measures: Type, frequency, and effectiveness of prosthetic use; hours per day worn; functional mobility level achieved with prosthesis; reasons for limited use or non-use

What to expect: The examiner will ask about your prosthesis type (conventional, microprocessor-controlled knee, osseointegrated), how many hours per day you wear it, what activities you can perform with it, and what prevents greater use. They may observe your gait with the prosthesis.

Pain considerations: Describe pain that occurs specifically with prosthetic use, including socket pressure pain, residual limb abrasions, and lower back or contralateral hip pain from altered gait mechanics. Note how pain during prosthetic use limits walking distance, speed, and duration.

Functional Mobility and Assistive Device Assessment

What it measures: Distance able to walk with and without prosthesis, transfers (bed, car, toilet), stair climbing, fall history, and required assistive devices

What to expect: The examiner will ask about your daily mobility, including walking distance, speed, terrain limitations, and need for canes, crutches, walker, or wheelchair. They may observe transfers and ambulation. All assistive devices should be brought to the exam.

Pain considerations: Report pain that limits walking distance (DeLuca fatigue and pain after repetitive use), pain when transferring, and back pain caused by compensatory gait mechanics. Describe how pain at end-of-day differs from pain at start of day.

100%

Amputation of the thigh at the upper third (proximal one-third of the distance from the ischial tuberosity to the knee joint line). Also applies to: amputation with defective stump (non-functional or requiring re-amputation); amputation not improvable by prosthesis controlled by natural knee action; hip disarticulation (DC 5160); or transpelvic amputation (DC 5163).

From 38 CFR: Under 38 CFR 4.71a DC 5161: 100% assigned for amputation at the upper third of the thigh. Also 100% for defective stump and for amputation not improvable by prosthesis. DC 5160 (hip disarticulation) and DC 5163 (transpelvic amputation) also rated at 100%.

90%

Amputation of the thigh at the middle or lower third (any level below the upper third and above the knee joint). The stump must be functional and the amputation must be improvable by prosthesis.

From 38 CFR: Under 38 CFR 4.71a DC 5161: 90% assigned for amputation of the thigh at the middle or lower third with a functional stump improvable by prosthesis.

Stump Pain and Phantom Limb Pain

How to describe it: Clearly distinguish between residual limb (stump) pain and phantom limb pain. For stump pain, describe the location (end of stump, over bony prominence, at scar), character (burning, stabbing, aching, pressure), severity (0-10), frequency (constant vs. intermittent), and triggers (socket wear, pressure, temperature). For phantom pain, describe the perceived location in the missing limb, character, and whether it is constant or episodic.

Example: On my worst days, the burning in my residual limb reaches a 9 out of 10 and starts within 20 minutes of putting on my prosthesis. I have to remove the prosthesis and spend the rest of the day in my wheelchair. The phantom cramping in my missing foot wakes me up 3-4 times per night and can last 30 to 45 minutes each episode.

Examiner listens for: Specific pain descriptors that indicate neuroma or skin breakdown; relationship between prosthetic use and pain onset; nighttime phantom pain disrupting sleep; pain that prevents or limits prosthetic wear hours; need for pain medication before prosthetic activities.

Avoid: Saying 'I have some pain sometimes' without specifying how it limits your function, duration, and frequency. Failing to mention phantom pain because you think it 'doesn't count' since there is no physical limb present - it absolutely counts and must be documented.

Prosthetic Use Limitations

How to describe it: Describe exactly how many hours per day you can wear your prosthesis, what forces you to remove it, what activities you cannot perform even with the prosthesis, and how your function has changed over time. Include the type of prosthesis (conventional vs. microprocessor-controlled) and any socket fit problems.

Example: On my worst days I can only wear my prosthesis for two to three hours before the stump skin breaks down or the pain becomes unbearable. I then switch to my wheelchair for the remainder of the day. Even on better days, I cannot walk more than one city block before I need to stop and rest due to residual limb pain and fatigue in my back and hip.

Examiner listens for: Total daily prosthetic wear time; specific reasons for discontinuing use; functional limitations despite prosthetic use; fall history with prosthesis; inability to navigate stairs, inclines, or uneven terrain; need for additional assistive devices even when wearing prosthesis.

Avoid: Only describing your best prosthetic day rather than your typical or worst day. Failing to mention that you use a wheelchair, crutches, or cane in addition to or instead of your prosthesis on difficult days.

Stump Condition and Skin Integrity

How to describe it: Describe any recurring skin problems on the residual limb, including blisters, sores, rashes, folliculitis, fungal infections, or chronic ulcerations. Note how often these occur, how long they take to heal, whether they have required medical treatment, and whether they prevent prosthetic use during healing.

Example: I develop pressure sores at the distal end of my stump approximately once every 6-8 weeks. These sores take 2-3 weeks to fully heal, during which time I cannot wear my prosthesis at all and must use my wheelchair exclusively. I have had to go to the VA wound clinic three times in the past year for treatment.

Examiner listens for: Frequency and duration of skin breakdown episodes; need for medical intervention; periods of complete prosthetic non-use due to skin problems; scarring or wound history on residual limb; whether skin problems are worsening over time.

Avoid: Saying your skin 'gets irritated sometimes' without quantifying how often, how severely, and for how long it prevents prosthetic use and forces wheelchair reliance.

Functional Mobility and Daily Activities

How to describe it: Describe your worst-day functional capacity: shortest walking distance, slowest speed, which activities of daily living you cannot perform independently, how long it takes to complete basic tasks like getting dressed, bathing, and preparing meals. Include stairs, driving, and community mobility.

Example: On my worst days I cannot walk more than 50 feet even with my prosthesis before I need to sit down from pain and fatigue. I cannot climb stairs without holding both railings and having someone spot me. I take over 45 minutes to get dressed in the morning due to difficulty donning the prosthesis and the pain involved. I cannot stand long enough to cook a meal and rely on my spouse for most household tasks.

Examiner listens for: Specific functional distances and time limitations; named activities of daily living that are impaired; need for assistance from another person; fall history and near-falls; inability to work or participate in leisure activities; sleep disruption from pain.

Avoid: Describing only what you can do on a good day. Saying 'I manage okay' when in reality you have adapted your entire lifestyle around the amputation limitations. Failing to mention secondary back, hip, or contralateral knee pain that further limits your function.

Secondary and Associated Conditions

How to describe it: Describe conditions that have developed as a direct result of the amputation and altered biomechanics, including low back pain from compensatory gait, contralateral hip or knee arthritis from overuse, psychological impact (depression, PTSD, anxiety about falling), and cardiovascular deconditioning from reduced activity.

Example: Since my amputation, I have developed severe lower back pain from walking with an uneven gait. My right (intact) knee has deteriorated significantly from bearing extra weight, and my orthopedist says I will likely need a knee replacement. I also struggle with depression because I can no longer participate in activities I used to enjoy, and I am afraid to go out alone because I fear falling.

Examiner listens for: Documented secondary conditions linked to the amputation; treatment being received for secondary conditions; whether secondary conditions are separately service-connected or claimed; how secondary conditions compound the functional impairment from the amputation.

Avoid: Failing to mention back pain, contralateral limb problems, or psychological symptoms because you think they are separate issues. These secondary conditions can support additional claims and also document the full scope of your disability.

DeLuca Factors: Pain, Fatigue, and Repetitive Use Effects

How to describe it: Describe how your function changes after prolonged or repetitive activity. Note how much worse your pain, fatigue, and mobility become after a full day of activity compared to first thing in the morning. Describe flare-up frequency, duration, triggers, and what is required to recover.

Example: After walking for more than 30 minutes with my prosthesis, my residual limb becomes so painful and swollen that I cannot continue. I then need to rest for at least 2 hours with my limb elevated before I can attempt any further activity. By end of day I am completely exhausted and my back pain has escalated to the point where I need prescription pain medication just to sleep.

Examiner listens for: Specific activity thresholds that trigger worsening symptoms; recovery time required after activity; flare-up frequency and duration; impact of fatigue on daily function and employment; whether symptoms are worse after any use compared to at rest.

Avoid: Only describing your resting level of pain and function without explaining how dramatically it worsens with activity. Failing to mention that what you can do in the morning is very different from what you can do in the afternoon or evening.