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VA Rating Assistant

DC 5162 · 38 CFR 4.71a

Below-Knee Amputation of Leg C&P Exam Prep

To document the precise anatomical level of your below-knee amputation, evaluate stump condition, assess prosthetic fit and function, identify complications such as phantom pain or neuroma, and determine the functional impact on your daily life and mobility to assign an accurate disability rating under DC 5162.

Format:
Interview + Physical
Typical duration:
30-60 minutes
DBQ form:
amputations (amputations)
Examiner:
Orthopedic Surgeon, Physiatrist, or Prosthetist

What the examiner evaluates

  • Exact anatomical level of amputation relative to knee joint
  • Stump condition including length, shape, skin integrity, and scar tissue
  • Presence and quality of prosthetic fit and whether it permits normal gait
  • Stump complications: neuromas, bone spurs, ulceration, infection, contracture
  • Phantom limb pain or phantom sensations
  • Residual limb pain, tenderness, or hypersensitivity
  • Need for assistive devices: cane, crutches, wheelchair, brace
  • Functional mobility and walking ability with and without prosthesis
  • Impact on activities of daily living and occupational function
  • Presence of complicating conditions such as vascular disease, diabetes, or skin breakdown
  • Secondary joint problems in knee, hip, or spine due to altered gait

You will likely be asked to remove your prosthesis for direct stump examination. Bring your prosthesis and any assistive devices to the exam. The examiner may observe your gait with and without the prosthesis. Wear clothing that allows easy access to the residual limb. Arrive prepared to demonstrate functional limitations honestly.

Measurements and tests

Amputation Level Assessment

What it measures: Precise anatomical location of the amputation relative to anatomical landmarks used in 38 CFR rating criteria (e.g., below knee with stump permitting prosthesis vs. defective stump)

What to expect: Examiner will visually inspect and palpate the residual limb, measure stump length from the knee joint line, and document the level relative to rating thresholds. You may be asked to remove the prosthetic socket.

Critical thresholds

  • Below knee with prosthesis permitting normal gait 40% rating under DC 5162 (amputation between forefoot and knee permitting prosthesis)
  • Below knee with defective stump or amputation not improvable by prosthesis 60% rating under DC 5162 (defective stump) or higher depending on specific circumstances
  • Amputation not improvable by prosthesis, controlled by natural knee 60% rating minimum; evaluate for higher rating based on stump condition

Tips

  • Do not wear a new or recently adjusted prosthesis that fits better than usual - use your typical daily-wear device
  • Ask the examiner to document any skin breakdown areas before and after prosthesis removal
  • If your stump changes shape throughout the day, mention this to the examiner
  • Note any areas of the stump that are painful, sensitive, or prone to skin breakdown

Pain considerations: Residual limb pain, phantom pain, and neuroma pain are all separately ratable and must be specifically described. Do not assume the examiner will ask about pain - proactively report all pain types, their location, frequency, intensity on a 0-10 scale, and what triggers or worsens them.

Stump Condition Evaluation

What it measures: Skin integrity, scar quality, bony prominences, neuroma formation, contracture, and prosthetic fit quality of the residual limb

What to expect: Examiner will palpate the stump, look for ulceration, skin breakdown, adherent scars, bony prominences causing socket problems, and assess whether the stump shape allows reliable prosthetic fitting. Gait observation with prosthesis is likely.

Critical thresholds

  • Stump permits well-fitting prosthesis with near-normal gait 40% rating - indicates functional amputation level
  • Defective stump: skin breakdown, poor socket fit, chronic ulceration, or painful neuroma preventing reliable prosthetic use 60% rating - defective stump classification
  • Stump not improvable by prosthesis at all 60% or higher; evaluate for special monthly compensation (SMC) if loss of use is established

Tips

  • Show the examiner any areas of skin breakdown, calluses, or socket sores you experience regularly
  • Describe how long you can wear your prosthesis each day before needing to remove it due to pain or skin irritation
  • Bring photos of stump irritation or skin breakdown if available
  • Mention if you frequently change liners, suspension systems, or socket adjustments due to fit problems

Pain considerations: Socket interface pain that limits daily prosthetic wear time is a critical functional finding. Report specifically: how many hours per day you wear the prosthesis, why you remove it, and what the stump looks like after prosthetic wear.

Gait Analysis and Functional Ambulation

What it measures: Quality and safety of ambulation with prosthesis, need for assistive devices, distance limitations, and fall risk

What to expect: Examiner may observe you walking in the exam room with your prosthesis. They will note gait deviations, use of assistive devices, and any instability. Be honest about your typical functional walking distance.

Critical thresholds

  • Independent ambulation with prosthesis, no assistive devices Supports 40% rating level; functional amputation
  • Requires cane, crutches, or brace for safe ambulation with prosthesis Supports higher functional limitation; may affect rating or SMC consideration
  • Unable to use prosthesis, wheelchair dependent or limited to very short distances Supports defective stump finding or SMC consideration for loss of use of extremity

Tips

  • Walk as you normally do - do not perform better than your typical daily function
  • If you use a cane or other assistive device at home, bring it and use it at the exam
  • Report your realistic walking distance before pain, fatigue, or safety concerns require stopping
  • Describe terrain limitations: stairs, uneven ground, slopes

Pain considerations: Gait-related pain in the residual limb, contralateral knee/hip, low back, or shoulders from crutch use all represent functional impairment. Report each separately with location, onset, and how it limits distance or activity.

Phantom Pain and Sensation Assessment

What it measures: Presence, character, frequency, and functional impact of phantom limb pain and sensations

What to expect: Examiner will ask whether you experience sensations in the amputated portion of the limb. Phantom pain is separately ratable and must be described accurately. Do not minimize phantom pain.

Critical thresholds

  • Phantom pain absent or minimal with no functional impact No additional rating impact beyond amputation level
  • Phantom pain moderate to severe, disrupting sleep, ADLs, or prosthetic use May support separate rating for neuralgia or affect overall functional assessment
  • Phantom pain requiring ongoing medications, nerve blocks, or behavioral treatment Documents severity; supports functional limitation narrative

Tips

  • Describe phantom pain separately from stump pain - they are different symptoms
  • Note frequency: daily, several times per week, triggered by weather or activity
  • Rate intensity on a 0-10 scale during average episodes and worst episodes
  • Describe character: burning, electric, stabbing, cramping, pressure
  • Report impact on sleep - phantom pain often worsens at night

Pain considerations: Phantom pain is real, documented, and ratable. Never dismiss it as 'just phantom pain' to the examiner. It affects prosthetic tolerance, sleep, mood, and functional capacity. Report it fully and specifically.

Rating criteria by percentage

40%

Amputation below the knee with amputation between the forefoot and knee, permitting the use of a prosthesis. This is the baseline rating for a functional below-knee amputation where a prosthesis can be worn and permits reasonably functional ambulation.

Key symptoms

  • Below-knee amputation at any level between forefoot and knee joint
  • Prosthesis worn and permits ambulation
  • Stump in generally acceptable condition for prosthetic socket fit
  • May have mild phantom pain or sensation
  • Reasonable daily prosthetic wear time

From 38 CFR: DC 5162 - Amputation, leg, below knee: amputation between the forefoot and knee, permitting prosthesis. Rate at 40%.

60%

Amputation below the knee with defective stump, OR amputation not improvable by prosthesis but controlled by the natural knee. A defective stump is one that prevents reliable prosthetic use due to skin breakdown, poor shape, neuroma, bony prominence, or chronic ulceration. This rating reflects significantly greater functional impairment than a functional stump.

Key symptoms

  • Chronic skin breakdown or ulceration at prosthetic interface
  • Neuroma causing intractable pain with prosthetic wear
  • Bony prominence preventing comfortable socket fit
  • Stump shape (conical, adherent scar, redundant tissue) preventing reliable prosthetic fit
  • Amputation level or stump condition not improvable by any prosthetic modification
  • Significant daily prosthetic wear time limitation due to stump problems
  • Frequent prosthetic adjustments or inability to maintain socket fit

From 38 CFR: DC 5162 - Amputation, leg, below knee: amputation with defective stump; or amputation not improvable by prosthesis, controlled by natural knee. Rate at 60%.

100%

Special Monthly Compensation (SMC) consideration applies when there is loss of use of the foot or when bilateral amputations or other combinations of disability result in entitlement to SMC under 38 CFR 3.350. The C&P examiner must document loss of use findings and functional capacity to support SMC determinations by the rating specialist.

Key symptoms

  • Complete inability to use prosthesis
  • Wheelchair dependence for all mobility
  • Loss of use of the extremity equivalent to amputation at higher level
  • Bilateral lower extremity amputations
  • Combination of amputation with other severe disabilities

From 38 CFR: 38 CFR 3.350 - Special Monthly Compensation based on loss of use of an extremity. Rating specialist applies SMC rates; examiner documents functional findings supporting loss of use determination.

Describing your symptoms accurately

Residual Limb (Stump) Pain

How to describe it: Describe pain at the end of or along the residual limb separately from phantom pain. Note whether it is constant or intermittent, what aggravates it (prosthetic wear, pressure, activity, weather), what relieves it, and how it limits your ability to wear the prosthesis or walk.

Example: On my worst days, the pain at the end of my stump is a burning 8 out of 10 that starts within 30 minutes of putting on my prosthesis. The socket edge digs into the sensitive scar tissue and I have to remove the leg entirely. On those days I can only walk with crutches or stay home. This happens at least three to four times per week.

Examiner listens for: Specific pain descriptors, functional limitation in prosthetic wear time, relationship between pain and activity level, pain at rest versus with use, pain that disrupts sleep

Avoid: Do not say 'I manage fine' or 'the pain is not too bad' if you are limiting your activities, taking medication, or removing your prosthesis due to pain. These statements will be recorded and may support a lower rating.

Phantom Limb Pain

How to describe it: Describe pain felt in the foot or lower leg that no longer exists. Specify the character (burning, cramping, electric shock, pressure), frequency, duration, intensity, triggers, and any treatments used. Note whether it disrupts sleep, work, or daily activities.

Example: At least four nights per week I wake up with severe cramping and burning pain in my phantom foot, rated 7 to 9 out of 10. It lasts anywhere from 20 minutes to two hours. I take medication but it only partially helps. During the day, unexpected electric shock sensations in my phantom toes startle me and cause me to lose focus at work.

Examiner listens for: Frequency, intensity, character, duration, sleep disruption, functional impact, treatments tried and their effectiveness

Avoid: Do not say 'it is just phantom pain' as if it does not count. Phantom pain is a documented neurological condition that is fully ratable. Do not omit it because you think the examiner will dismiss it.

Prosthetic Fit and Wear Limitations

How to describe it: Describe how many hours per day you can realistically wear your prosthesis, why you remove it, what happens to the stump after wear (redness, skin breakdown, blistering, swelling), and how fit problems affect your mobility and independence.

Example: On average I can only wear my prosthesis for four to five hours before I have to remove it because of skin breakdown at the distal stump. After removal I see redness, open areas, and sometimes blistering. Without my prosthesis I rely on crutches or a wheelchair for the rest of the day. This means I cannot work a full day, attend events, or complete errands without planning around my prosthetic limitations.

Examiner listens for: Daily wear time, reasons for removal, skin complications observed, impact on independence and employment, frequency of prosthetic adjustment or repair

Avoid: Do not imply your prosthesis works perfectly if you have daily limitations. The examiner needs to know your actual functional capacity, not your best-case scenario.

Mobility, Gait, and Assistive Device Use

How to describe it: Describe your realistic walking distance, terrain limitations, need for assistive devices, fall history, and activities you can no longer safely perform. Be specific about distances in blocks or minutes, not vague terms like 'short distances.'

Example: On my worst days I cannot walk more than half a block with my prosthesis before severe stump pain forces me to stop. I use a cane every time I walk outside because my balance is poor on uneven ground and I have fallen three times in the past year. I cannot climb stairs without holding the railing with both hands, and I avoid any terrain that is not completely flat.

Examiner listens for: Specific distance limitations, fall history with dates if possible, specific activities abandoned, need for and consistent use of assistive devices, stairs and terrain limitations

Avoid: Do not underestimate your walking distance or say 'I can walk okay' if you avoid walking, require rest breaks, use a cane, or have fallen. Vague positive statements undermine your claim.

Functional Impact on Activities of Daily Living

How to describe it: Describe specific tasks you cannot perform or perform with difficulty: bathing, dressing, standing for cooking, working, driving, recreational activities. Connect limitations directly to the amputation and its complications.

Example: I cannot stand long enough to cook a full meal. I shower seated. Getting dressed takes twice as long because I must put on my prosthesis before I can stand at the sink. I had to leave my job in construction because I cannot stand, climb ladders, or walk on uneven surfaces. I have given up hiking, sports, and long walks with my family.

Examiner listens for: Specific named activities, time required to complete basic tasks, employment impact, recreational losses, social limitations, need for assistance from others

Avoid: Do not say 'I adjust' or 'I find ways around it' without also describing what you gave up or how your life has changed. Adaptation is admirable but it does not mean you are not disabled.

Common mistakes to avoid

Wearing your best-fitting or newest prosthesis to the exam

Why: A well-fitting prosthesis may lead the examiner to document superior function that does not reflect your daily experience. Rating criteria are based on typical function, not optimal conditions.

Do this instead: Wear your usual daily prosthesis. If fit varies by day or you have multiple devices, explain this to the examiner and describe your typical daily experience honestly.

Impact: Could push rating from 60% to 40% by making the stump appear functional when it is typically defective

Not removing the prosthesis for examination unless directly asked

Why: The examiner must inspect the stump directly. A clothed or socketed stump cannot be properly evaluated for defective stump findings, skin breakdown, neuroma, or bony prominence.

Do this instead: Be prepared and willing to remove your prosthesis completely. Bring extra clothing if needed. The stump examination is the most critical part of the rating determination.

Impact: Missing defective stump finding can result in 40% instead of 60%

Minimizing phantom pain because it feels intangible or hard to explain

Why: Phantom pain is a real, documented, neurological condition. Failing to report it fully means the examiner cannot document it, and it disappears from the rating record.

Do this instead: Report phantom pain with the same detail as any other pain: frequency, intensity, character, duration, triggers, treatments, and functional impact including sleep disruption.

Impact: Unreported phantom pain misses secondary rating opportunities and understates overall functional impairment

Describing your best day rather than your typical or worst day

Why: VA raters use the M21-1 guidance that ratings should reflect the veteran's actual disability picture, including bad days. Describing only good days leads to an underrated outcome.

Do this instead: When the examiner asks how you function, describe your worst days and your typical days. Specifically say 'on my worst days' and 'on average' to provide the full picture.

Impact: Affects overall rating at all levels - most commonly results in 40% when 60% is warranted

Failing to mention assistive device use or downplaying it

Why: Use of canes, crutches, braces, or wheelchairs is directly documented on the DBQ and affects both the rating and Special Monthly Compensation eligibility. Omitting or minimizing this is a significant error.

Do this instead: Bring all assistive devices to the exam. Use them as you normally would. Tell the examiner exactly which devices you use, how often, and why. The examiner documents this on the DBQ.

Impact: Missed SMC eligibility; may affect functional finding between 40% and 60%

Not disclosing secondary conditions caused by the amputation

Why: Altered gait from below-knee amputation frequently causes secondary knee, hip, and lumbar spine problems on both the amputated and intact side. These are separately ratable as secondary conditions.

Do this instead: Report any pain or problems in your knee, hip, back, or contralateral leg that developed after your amputation. These may support separate secondary service connection claims.

Impact: Missing secondary conditions means significant combined rating loss beyond the primary amputation rating

Prep checklist

  • critical

    Gather all medical records related to your amputation

    Collect operative reports, hospitalization records, prosthetic clinic notes, physical therapy records, and any imaging (X-rays, MRI) of the residual limb. Organize chronologically. VA examiner will review evidence but having your own copies allows you to correct omissions.

    before exam

  • critical

    Document your typical prosthetic wear time and stump condition diary

    For at least one to two weeks before your exam, keep a daily log of hours wearing prosthesis, reasons for removal, skin conditions observed, pain levels, and assistive device use. This contemporaneous record is powerful evidence.

    before exam

  • critical

    Photograph stump complications

    If you experience skin breakdown, ulceration, socket sores, or visible stump problems, photograph them with a date stamp. Photos provide objective evidence of defective stump conditions that may not be visible at the moment of examination.

    before exam

  • critical

    Write out your symptom statement covering all pain types

    Write a one-page summary covering: stump pain (frequency, intensity, triggers), phantom pain (character, frequency, sleep impact), prosthetic wear time and limitations, assistive device use, walking distance, terrain limitations, falls, employment impact, and ADL limitations. Review it the night before.

    before exam

  • recommended

    Check your state's recording laws and plan accordingly

    Many states allow one-party consent recording of your C&P exam. Research your state's laws. If recording is permitted, use your phone to record the full examination for your records and any future appeals. Notify the examiner you are recording.

    before exam

  • critical

    List all current medications for amputation-related conditions

    Write down all medications taken for stump pain, phantom pain, nerve pain, sleep disruption, or related conditions. Include dosage, frequency, prescribing physician, and effectiveness. Medication lists document treatment burden and symptom severity.

    before exam

  • recommended

    Identify and prepare to describe secondary conditions

    Make a list of any joint pain, back pain, contralateral leg problems, skin conditions, or psychological conditions that developed or worsened after your amputation. These may be separately ratable.

    before exam

  • critical

    Bring your standard daily prosthesis, not your best-fitting device

    Use the prosthesis you wear on a typical day. If you have multiple devices, bring them all and explain when you use each. The examiner needs to assess your typical function, not your optimal function.

    day of

  • critical

    Bring all assistive devices you use

    Bring your cane, crutches, brace, or wheelchair if you use any of them. Use them during the exam as you would in daily life. The examiner documents these on the DBQ and they directly affect your rating and SMC eligibility.

    day of

  • critical

    Wear clothing allowing easy stump access

    Wear loose-fitting shorts or pants that can be easily rolled up or removed to allow full stump inspection without undressing completely. The examiner must inspect the bare stump.

    day of

  • critical

    Do not take extra pain medication before the exam

    Take only your normal prescribed medications as usual. Do not take additional doses to manage exam-day pain, as this may suppress symptoms below your typical daily level and result in an exam that does not reflect your true condition.

    day of

  • recommended

    Arrive early and note your condition upon arrival

    Note your pain level, any stump issues from the morning, and your mobility status before entering. If traveling to the exam was difficult or painful, report this to the examiner - transportation burden is part of your functional picture.

    day of

  • critical

    Request stump inspection and document what the examiner does

    Ensure the examiner actually removes your prosthesis and inspects the bare stump. If they do not offer to do so, ask them to examine the stump directly. A DBQ that does not document stump condition examination is inadequate.

    during exam

  • critical

    Report all three types of pain separately and specifically

    Clearly distinguish between stump pain, phantom limb pain, and pain in secondary areas (knee, hip, back). Give specific numbers for frequency, intensity (0-10), duration, and character for each. Do not bundle them together.

    during exam

  • critical

    Describe worst days and typical days, not best days

    When asked how you function, explicitly say 'on my worst days' and 'on a typical day.' Volunteer information about flare-ups, bad days, and limitations the examiner does not specifically ask about.

    during exam

  • critical

    Report all assistive device use even if examiner does not ask

    If the examiner does not ask about canes, crutches, wheelchair, or braces, volunteer this information. Say 'I also want to make sure you document that I use a cane for all outdoor ambulation.'

    during exam

  • critical

    Disclose employment and ADL limitations

    The functional impact section of the DBQ requires documentation of how your condition affects work and daily life. Proactively describe job limitations, career changes, activities abandoned, and tasks requiring assistance.

    during exam

  • recommended

    Ask the examiner to document secondary conditions

    If you have knee, hip, or back problems resulting from altered gait, mention them and ask if they can be noted. If the examiner cannot address them in this DBQ, note that you plan to file secondary condition claims.

    during exam

  • critical

    Request a copy of the completed DBQ

    You are entitled to receive a copy of the completed DBQ. Request it before you leave or ask how to obtain it. Review it for accuracy - if findings are missing or inaccurate, this is grounds for a supplemental claim or nexus letter.

    after exam

  • critical

    Write notes about what occurred in the exam within 24 hours

    Document everything you remember: what the examiner did and did not do, questions asked, your answers, your pain level during the exam, and whether the stump was inspected. This contemporaneous record is essential for any appeal.

    after exam

  • critical

    Review the DBQ when received and check for errors or omissions

    When you receive the completed DBQ, compare it against your symptom statement. Missing findings, minimized symptoms, or inaccurate descriptions are grounds for requesting an addendum, filing a buddy statement, or submitting a private nexus opinion.

    after exam

  • recommended

    Consider a private Independent Medical Opinion if DBQ is inadequate

    If the examiner's DBQ does not accurately reflect your condition, consult a VSO or VA-accredited attorney about obtaining a private medical opinion (IMO/IME) to support your claim on appeal or supplemental submission.

    after exam

Your rights during a C&P exam

  • You have the right to receive a copy of the completed DBQ and any examination report generated from your C&P exam.
  • You have the right to record your C&P examination in states that permit one-party consent recording - verify your state's law before the exam.
  • You have the right to have a VSO representative, accredited claims agent, or attorney present or available by phone during your C&P exam in most circumstances - check current VA policy.
  • You have the right to submit a buddy statement (VA Form 21-10210) from family members, caregivers, or coworkers who can describe your functional limitations as they observe them.
  • You have the right to submit a personal statement describing your symptoms, functional limitations, and how your condition affects your daily life - this statement becomes part of your claims file.
  • You have the right to a second opinion or an Independent Medical Examination (IME) from a private provider, which can be submitted as evidence in your claim or appeal.
  • You have the right to request an inadequate exam be returned for additional development if the DBQ fails to address required elements - this can be raised through your VSO or in an appeal.
  • You have the right to appeal any rating decision through the Supplemental Claim lane, Higher-Level Review lane, or Board of Veterans Appeals within the established timeframes.
  • You have the right to Special Monthly Compensation (SMC) consideration if your amputation results in loss of use of the extremity - this must be affirmatively raised and is not automatically assigned.
  • You have the right to have all submitted evidence considered before a rating decision is made, including private medical records, personal statements, and lay evidence describing your symptoms.

Related conditions

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This guide covers what to expect for any veteran with this condition. If you have already uploaded your medical records, sign in to generate a packet that maps your specific symptoms to the DBQ fields your examiner will fill out.

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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.