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VA Rating Assistant

DC 5011 · 38 CFR 4.71a

Caisson Disease (Decompression Sickness / Bone Necrosis) C&P Exam Prep

To document the current severity, functional impact, and service-connection of dysbaric osteonecrosis (bone necrosis caused by decompression sickness / Caisson disease) incurred or aggravated during military service involving hyperbaric or compressed-air environments (e.g., diving, tunnel work, caisson work). The DBQ findings directly determine the disability rating under DC 5011.

Format:
Interview + Physical
Typical duration:
30-45 minutes
DBQ form:
Bones_and_Other_Skeletal_Conditions (Bones_and_Other_Skeletal_Conditions)
Examiner:
Orthopedic Surgeon, Oncologist, or appropriate clinician

What the examiner evaluates

  • Confirmation of current diagnosis of dysbaric osteonecrosis or decompression sickness sequelae
  • Which bones and joints are affected and on which side(s) (commonly femoral head, humeral head, tibial plateau)
  • Active and passive range of motion of affected joints under weight-bearing and non-weight-bearing conditions
  • Pain on motion, at rest, and during flare-ups - with numeric pain scale ratings
  • Functional loss due to pain, weakness, fatigue, incoordination, and repetitive-use degradation (DeLuca factors)
  • Presence and severity of joint collapse, articular surface involvement, or secondary osteoarthritis
  • Imaging findings (X-ray, MRI, bone scan) documenting osteonecrotic lesions and staging
  • History and results of any surgical intervention (core decompression, bone grafting, total joint replacement)
  • Use of assistive devices (cane, crutches, walker, wheelchair) and frequency
  • Any coexisting bone neoplasm (benign or malignant) or other skeletal conditions
  • Impact on activities of daily living, occupational function, and ambulation
  • Residuals, complications, and relationship of all findings to the claimed condition

Examination will typically be conducted in person at a VA facility, VAMC, or contracted QTC/LHI clinic. The examiner will review service treatment records and any civilian medical records in advance. Bring all imaging reports (X-rays, MRIs, bone scans), surgical operative reports, and a written personal statement describing your worst-day functional limitations. You have the right to request the exam be recorded in most states.

Measurements and tests

Range of Motion (ROM) - Affected Joints (Hip, Shoulder, Knee)

What it measures: Degrees of active and passive motion in the joint(s) affected by osteonecrosis; used to assign a rating under the applicable joint diagnostic code when analogous rating is applied alongside DC 5011.

What to expect: The examiner uses a goniometer to measure active ROM (you move the joint yourself), passive ROM (examiner moves the joint), weight-bearing ROM (standing), and non-weight-bearing ROM (lying down). Measurements are taken before and after repetitive use to assess DeLuca fatigue-related loss.

Critical thresholds

  • Hip flexion - 90- (normal ~125-) May support 20% rating under DC 5252 (thigh, limitation of flexion) if hip is primary site of osteonecrosis
  • Hip flexion - 45- Supports 30% rating under DC 5252
  • Shoulder abduction - 90- (normal 180-) Supports 20% rating under DC 5201 if humeral head is affected
  • Shoulder abduction - 45- Supports 30% rating under DC 5201
  • Any joint: painful motion throughout entire ROM DeLuca credit - examiner must note where pain begins in the arc; functional loss is rated at the point pain begins
  • Repeated-use ROM loss from initial measurement Any measurable ROM reduction after repetitive testing must be documented; supports higher functional rating

Tips

  • Do NOT 'push through' pain to demonstrate a larger range of motion - stop at the point where pain occurs and state clearly 'this is where it hurts'
  • If weight-bearing worsens your ROM compared to non-weight-bearing, make sure the examiner tests both positions
  • After the initial ROM is measured, ask the examiner to document the DeLuca repetitive-use testing - perform the motion 3 times and report any increase in pain or decrease in range
  • Report any warmth, crepitus, or clicking in the joint during motion
  • If you had a joint replacement (total hip or shoulder arthroplasty), inform the examiner - this may be rated under a separate DC

Pain considerations: Per 38 CFR 4.59, painful motion must be considered at least minimally compensable. State clearly at what degree of motion pain begins. If pain is present even at rest or during light activity, describe this explicitly. Dysbaric osteonecrosis pain is often deep, aching, and worsened by weight-bearing - describe these characteristics precisely.

Bone Scan / MRI / X-ray Staging Assessment

What it measures: Documents the presence, location, and staging of osteonecrotic lesions. Ficat and Arlet staging (Stages I-IV) or ARCO staging is used to characterize disease severity: Stage I = normal X-ray with MRI changes; Stage II = sclerosis/cysts without collapse; Stage III = articular surface collapse (crescent sign); Stage IV = osteoarthritis with joint space narrowing.

What to expect: The examiner will review existing imaging. If no recent imaging exists, a bone scan, MRI, or X-ray may be ordered. MRI is the gold standard for early-stage detection. The examiner will note findings on the DBQ including bone scan date/results and MRI date/results.

Critical thresholds

  • Stage III-IV (articular surface collapse or secondary osteoarthritis) Supports highest rating levels under DC 5011 and analogous joint codes; Stage IV with joint space loss mirrors severe arthritis criteria
  • Bilateral involvement (e.g., both femoral heads) Each separately affected joint may be rated independently, potentially yielding combined bilateral ratings
  • Multiple anatomic sites affected Each distinct skeletal site may support a separate disability rating under the applicable joint or bone DC

Tips

  • Bring copies of all prior MRI, X-ray, and bone scan reports with dates - do not assume the VA has them all
  • If imaging was performed by a private orthopedist, bring the radiology report AND the films/CD if possible
  • Ask the examiner to document the staging of osteonecrosis (Ficat stage or equivalent) in the DBQ remarks section
  • If your imaging shows bilateral involvement, specifically mention both sides and both sites to the examiner

Pain considerations: Advanced imaging stages (III-IV) correlate with greater pain and functional limitation. When describing pain, connect it to the confirmed imaging findings: 'My MRI showed Stage III collapse of the femoral head - this is consistent with the constant, deep aching pain I feel in my hip when standing or walking.'

Functional Ambulation and Weight-Bearing Assessment

What it measures: Evaluates the veteran's ability to walk, stand, climb stairs, and bear weight on the affected extremity - critical for lower-extremity osteonecrosis of the hip, knee, or ankle.

What to expect: The examiner may observe your gait, ask you to walk a short distance, and assess whether you use assistive devices. They will document which assistive devices you use (cane, crutches, walker, wheelchair) and how frequently.

Critical thresholds

  • Inability to bear weight without assistive device Supports high-level functional rating; may also support Special Monthly Compensation (SMC) consideration
  • Wheelchair use (full-time or part-time) Documents severe functional loss; examiner marks wheelchair frequency on DBQ
  • Cane or crutch use due to pain/instability Documents functional limitation beyond ROM measurements alone

Tips

  • Use your prescribed assistive device(s) during the exam - do not leave them at home to 'appear capable'
  • If you use different devices on different days (cane on good days, crutches on bad days), tell the examiner and describe the frequency
  • Describe how far you can walk before pain forces you to stop
  • Report any falls, near-falls, or instability related to the affected joint

Pain considerations: If walking causes pain after a certain distance or time, state this explicitly: 'I can walk approximately one block before the pain in my hip becomes a 7-8 out of 10 and forces me to stop.' Describe the post-activity pain increase and how long it takes to recover.

Rating criteria by percentage

100%

Active decompression sickness in service; or dysbaric osteonecrosis with functional equivalent of total disability - joint replacement of multiple sites, inability to ambulate without wheelchair, or equivalent total functional loss of affected extremity(ies). Rated as active disease during treatment or based on analogy to highest applicable joint/bone criteria.

Key symptoms

  • Inability to ambulate without wheelchair or bilateral assistive devices
  • Multiple joint sites affected with articular collapse (Stage III-IV bilateral)
  • Joint replacement surgery with residual severe functional loss
  • Constant severe pain (9-10/10) at rest and with any activity
  • Complete loss of useful motion of affected major joint(s)
  • Inability to perform sedentary work due to pain and functional loss

From 38 CFR: DC 5011 is rated by analogy to the applicable joint code based on functional limitation. Total disability at the major joint level (e.g., hip - DC 5250 ankylosis in unfavorable position) or under 38 CFR 4.16 TDIU when functional impairment prevents substantially gainful employment.

60%

Dysbaric osteonecrosis with articular surface involvement (Stage III-IV), severe limitation of motion of a major joint (hip, shoulder, or knee), or following total joint arthroplasty prior to stabilization. Rated by analogy to applicable joint DC at the 60% level (e.g., DC 5250 hip ankylosis in unfavorable position, or severe limitation of motion equivalents).

Key symptoms

  • Articular collapse of femoral or humeral head (Stage III-IV on imaging)
  • Severe limitation of hip flexion (- 30-) or shoulder motion
  • Inability to walk more than a few steps without severe pain
  • Post-surgical arthroplasty with poor functional outcome
  • Constant moderate-to-severe pain (6-8/10) limiting all weight-bearing activity
  • Crutch or bilateral cane dependency

From 38 CFR: Analogous rating under DC 5250 (thigh, ankylosis unfavorable) or DC 5201 (arm, limitation of motion) at 60% level based on severity of functional impairment from osteonecrotic joint destruction.

40%

Moderate-to-marked limitation of motion of the affected joint, Stage II-III osteonecrosis on imaging without complete collapse, moderate pain on weight-bearing, significant interference with work and daily activities. Rated by analogy to applicable joint DC at the 40% level.

Key symptoms

  • Hip flexion limited to 45- or less
  • Shoulder abduction limited to 45- or less
  • Moderate constant pain (5-6/10) with all weight-bearing activity
  • Inability to stand more than 30-60 minutes without significant pain
  • Single cane use for all ambulation outside the home
  • MRI/bone scan showing Stage II-III necrosis with partial articular involvement

From 38 CFR: Analogous to DC 5252 (thigh, limitation of flexion) at 40% or DC 5203 (clavicle or scapula) at applicable level; DeLuca factors applied to document functional loss beyond baseline ROM.

20%

Mild-to-moderate limitation of motion, Stage I-II osteonecrosis on imaging, pain with prolonged activity or weight-bearing, some interference with work and recreational activities but able to ambulate without assistive device on most days.

Key symptoms

  • Hip flexion limited to 90- or below normal
  • Shoulder abduction limited to 90- or below normal
  • Pain (3-5/10) with prolonged standing or walking
  • Occasional use of cane for flare-ups
  • MRI showing Stage I-II lesion without articular collapse
  • Reduced endurance and fatigue with physical activity

From 38 CFR: Analogous to DC 5252 (thigh, limitation of flexion) at 20% or DC 5251 (thigh, limitation of extension) at 20%; DeLuca fatigue and flare-up factors should be documented to support this level.

10%

Slight limitation of motion or pain only with significant exertion or flare-ups; Stage I lesion on imaging; condition is diagnosed but minimally limiting daily function. Minimum compensable level.

Key symptoms

  • Mild aching in affected joint with strenuous activity
  • Pain (1-3/10) only with heavy exertion
  • Full or nearly full range of motion maintained
  • No assistive device use
  • Stage I MRI findings without functional impairment
  • Occasional stiffness after prolonged inactivity

From 38 CFR: Minimum compensable rating under analogous joint DC; must still document painful motion per 38 CFR 4.59 to ensure minimum compensable rating is assigned.

Describing your symptoms accurately

Pain - Character, Location, and Severity

How to describe it: Describe the pain as deep, aching, and boring in nature - located within the joint itself (not just the surrounding muscles). Specify whether it is constant or episodic, the numeric pain scale rating at rest versus with activity, and what activities aggravate it (walking, climbing stairs, lifting arm overhead). State clearly: 'The pain begins at [X degrees] of motion and reaches a [X/10] level with any weight-bearing.'

Example: On my worst days, the pain in my right hip is a constant 8 out of 10 even when lying still. I cannot walk from my bedroom to the bathroom without stopping twice due to severe, deep bone pain. Getting dressed requires sitting because I cannot bear weight on the leg long enough to stand. I require crutches for all ambulation and have been unable to leave my home without assistance for the past two days.

Examiner listens for: Specific pain location (intra-articular vs. soft tissue), consistency of pain narrative with imaging stage, relationship between pain onset and activity level, effect on sleep, and daily functional limitations. Examiner notes whether pain is present at rest - a higher-severity indicator.

Avoid: Do not say 'it's manageable' or 'I just push through it' - these phrases lead the examiner to underestimate severity. Do not minimize rest pain if it exists. Do not fail to mention that pain medications only partially control symptoms.

Flare-Ups - Frequency, Triggers, and Duration

How to describe it: A flare-up is a temporary worsening of your baseline symptoms. Per M21-1 guidance, describe your worst-day functioning - not just your average day. State: how often flare-ups occur (e.g., 2-3 times per week), what triggers them (prolonged standing, cold weather, physical activity), how long they last (hours, days), and what you cannot do during a flare-up.

Example: I have severe flare-ups approximately 3 times per week, each lasting 1-2 days. During a flare, my shoulder pain increases to 9/10 and I cannot raise my arm above my waist, cannot dress myself, and cannot drive. I have to use a sling and ice packs and am confined to bed for most of the day. These flare-ups are unpredictable and have caused me to miss work on multiple occasions.

Examiner listens for: Frequency and predictability of flare-ups, impact on work attendance and daily activities, any emergency room visits or urgent care for pain crises, and whether flare-ups are worsening over time (progressive disease).

Avoid: Do not describe only your average day - the examiner is required by M21-1 to evaluate your worst-day functioning. Do not skip mentioning flare-ups just because you are not currently in one at the time of the exam.

Fatigue and Weakness with Activity

How to describe it: Dysbaric osteonecrosis causes not only pain but also profound fatigue and weakness due to compensatory gait, muscle guarding, and post-surgical deconditioning. Describe how quickly the affected limb fatigues: 'After walking two blocks, my hip gives out from fatigue - not just pain.' Distinguish muscle weakness (the limb does not respond as expected) from pain-limited motion.

Example: On my worst days, my left leg feels as though it belongs to someone else - I have almost no strength in it after walking even a short distance. I stumble, catch myself on walls, and have fallen twice in the past six months. I cannot climb stairs without holding both rails and frequently have to rest mid-flight.

Examiner listens for: DeLuca fatigue factor - whether repeated use of the joint within a 24-hour period causes additional functional loss beyond baseline ROM measurement. Falls, near-falls, and muscle guarding patterns are relevant.

Avoid: Do not omit weakness because it is less obvious than pain. Do not perform physical tasks during the exam that you would not normally be able to do - this misrepresents your typical functional capacity.

Functional Impact on Work, Daily Living, and Recreation

How to describe it: Connect your symptoms directly to functional limitations: 'Because of the pain and limited motion in my hip from Caisson disease, I cannot sit for more than 20 minutes, stand for more than 10 minutes, walk more than half a block, or carry more than 5 pounds.' Be specific about jobs you can no longer perform and activities you have given up.

Example: Before my diagnosis I worked as a [job]. I can no longer do this because I cannot stand or walk for the required duration. I have been unable to play with my children, perform yard work, or exercise. I cannot drive for more than 15 minutes because the hip pain becomes unbearable. I have stopped attending social events because I cannot stand at gatherings.

Examiner listens for: Specific occupational and recreational tasks that are no longer possible, impact on ability to perform sedentary versus physical work, and whether functional limitations are consistent with the objective imaging and ROM findings.

Avoid: Do not speak in generalities ('it affects my life'). Be specific with time, distance, and weight limitations. Do not downplay recreational losses - these demonstrate real-world functional impact beyond clinical measurements.

Service-Connection Nexus - Military Diving or Hyperbaric Exposure

How to describe it: Clearly state your military occupational specialty and the nature of your hyperbaric exposure: dive duties, caisson or tunnel work, hyperbaric chamber operations. Describe any known decompression sickness incidents in service, how they were treated, and whether they were documented in service treatment records. If STRs are incomplete, describe the events with as much specificity as possible (date, location, unit, nature of the dive/incident).

Example: While serving as a Navy diver from [year] to [year] at [unit/location], I performed over [X] dives, including [types of dives]. In [year], I experienced a decompression sickness incident involving [describe symptoms - joint pain, neurological symptoms, skin mottling] and was treated with recompression therapy. My symptoms progressed after service and MRI in [year] confirmed osteonecrosis of my right femoral head, which my orthopedist has attributed to my history of decompression sickness.

Examiner listens for: Clear temporal relationship between military hyperbaric exposure and development of osteonecrosis, any in-service documentation of DCS incidents, and consistency between the anatomic location of necrosis and the type of diving (e.g., lower-extremity involvement more common with caisson work).

Avoid: Do not assume the examiner knows your MOS or dive history - state it explicitly. Do not rely solely on STRs if they are incomplete; supplement with a personal statement and buddy statements describing the hyperbaric exposure and any DCS incidents.

Common mistakes to avoid

Performing movements at the exam that you would not normally be able to do

Why: Adrenaline, examiner pressure, or the desire to appear capable can cause veterans to push past their actual functional limits during the exam, resulting in measured ROM that is better than their real daily capacity.

Do this instead: Move only to the point of pain onset and clearly state 'This is where it hurts - I cannot go further without significant pain.' Your daily functional capacity, not your exam-day best effort, is what should be documented.

Impact: All levels - can result in underrating by one or more rating tiers

Failing to describe flare-ups and worst-day symptoms

Why: Veterans often describe their average day or current status at the exam, not realizing that M21-1 explicitly requires examiners to document the veteran's worst-day functioning and the impact of flare-ups.

Do this instead: Prepare a written worst-day statement in advance describing the most severe episode in the past month. Hand it to the examiner and ask that it be considered in the evaluation.

Impact: 20%-60% range - flare-up documentation can mean the difference between adjacent rating tiers

Not mentioning all affected anatomic sites

Why: Dysbaric osteonecrosis often affects multiple sites (both hips, humeral heads, tibial plateaus). Veterans may focus on the most painful site and omit others, resulting in missed separate ratings.

Do this instead: Before the exam, list every joint or bone that has been diagnosed with or is symptomatic for osteonecrosis. Mention each one to the examiner and ensure each is listed in the DBQ diagnosis fields.

Impact: Can result in missing entire separate ratings - each affected site may warrant its own evaluation

Leaving assistive devices at home to 'not look weak'

Why: Veterans sometimes feel embarrassed using a cane or crutches at the exam. However, assistive device use is a key DBQ data point that directly supports higher functional loss ratings.

Do this instead: Always bring and use any prescribed or regularly used assistive devices to the exam. The examiner is required to document what devices you use and how frequently. This is objective evidence of functional impairment.

Impact: 40%-100% range - assistive device use is a critical differentiator at higher rating levels

Not connecting military service to the osteonecrosis diagnosis

Why: The examiner must address service connection. If you do not provide a clear history of hyperbaric exposure and any in-service DCS incidents, the examiner may not have enough information to render a positive nexus opinion.

Do this instead: Provide a written summary of your dive/hyperbaric duty history, any documented DCS incidents, and a timeline connecting service exposure to the onset of osteonecrotic symptoms. Bring any private physician nexus letters.

Impact: Service connection itself - failure here results in denial regardless of severity

Not requesting DeLuca testing (repetitive-use ROM assessment)

Why: Examiners sometimes perform only a single ROM measurement and do not test for ROM degradation after repetitive use, which is legally required per 38 CFR 4.45 and the DeLuca decision.

Do this instead: If the examiner does not perform repeated ROM measurements (three repetitions), respectfully note: 'I understand the VA requires testing for additional limitation with repeated use - can we also document that?' After repetitions, clearly state any increase in pain or decrease in range.

Impact: 20%-40% range - DeLuca credit can add 10-20 percentage points to functional rating

Omitting the impact on employment and inability to work

Why: The functional impact section of the DBQ is critical for TDIU claims and for documenting that the disability causes more than minimal occupational impairment. Veterans often focus on pain and omit work impact.

Do this instead: Explicitly state how many days of work you have missed due to the condition, what job tasks you can no longer perform, and whether you have been forced to change jobs, reduce hours, or stop working entirely due to the osteonecrosis.

Impact: TDIU and 60%-100% range - occupational impact is essential for these levels

Prep checklist

  • critical

    Gather all imaging reports and CDs/films

    Collect all MRI, X-ray, CT, and bone scan reports related to your osteonecrosis. Include dates of each study and the radiologist's report identifying the stage (Ficat Stage I-IV or equivalent). Bring physical copies and/or CDs. Do not assume the VA has all of your private imaging.

    before exam

  • critical

    Document your complete military hyperbaric exposure history

    Write a detailed statement listing: your MOS/rate (e.g., Navy Diver ND, EOD, SEABEE), dates and locations of dive duty, number and types of dives performed, any decompression sickness incidents (symptoms, treatment, recompression chamber use), and any in-service medical records related to DCS. If STRs are incomplete, describe events in your personal statement.

    before exam

  • critical

    Prepare a written worst-day symptom statement

    Write 1-2 pages describing: your worst-day pain level (0-10 scale), what you cannot do during a flare-up, how often flare-ups occur, what triggers them, how long they last, and how they affect your work, family, and daily life. Print two copies - one for the examiner and one for your records. Per M21-1, the examiner must consider worst-day functioning.

    before exam

  • critical

    Obtain all surgical and operative reports

    If you have had core decompression, vascularized fibula grafting, total hip or shoulder arthroplasty, or any other surgical procedure for osteonecrosis, bring the operative report(s) and any post-operative notes. These documents the anatomic severity and treatment history.

    before exam

  • critical

    Obtain a private nexus letter if possible

    A letter from your treating orthopedic surgeon or diving medicine physician stating that your osteonecrosis is 'at least as likely as not' caused by your military hyperbaric exposure is extremely valuable. Ask your doctor to cite your dive history, the known causal relationship between decompression sickness and dysbaric osteonecrosis, and the specific bones affected.

    before exam

  • recommended

    List all assistive devices you use

    Write down every assistive device you use (cane, crutches, walker, wheelchair, shower chair, grab bars, orthotic shoe inserts) and how frequently you use each. Include whether they were prescribed (by whom and when) or self-purchased out of necessity.

    before exam

  • recommended

    Review your current medications for the condition

    List all medications you take for pain and inflammation related to osteonecrosis: NSAIDs, opioid analgesics, bisphosphonates, bone-strengthening medications, muscle relaxants, topical pain treatments. Note dosages and frequency. The fact that you require prescription pain medication is objective evidence of severity.

    before exam

  • recommended

    Obtain buddy statements from fellow service members

    Statements from other veterans who served with you and can attest to your dive duties, any DCS incidents they witnessed, or the current functional limitations they observe, can corroborate your claim. Buddy statements must be signed, dated, and describe what the person personally witnessed.

    before exam

  • recommended

    Research whether your state allows exam recording

    Most states permit you to record your C&P exam. Check current VA policy and your state law. If recording is permitted, use your phone or a small recorder. Inform the examiner you are recording. A recording protects you if the DBQ contains inaccuracies.

    before exam

  • critical

    Do not take extra pain medication before the exam

    Take only your normal prescribed medications as usual. Do not take extra doses to 'get through' the exam - this masks your true daily functioning and results in an underrepresented picture of your disability. Similarly, do not skip medications to 'appear worse' - report your condition as it typically is.

    day of

  • critical

    Bring all documents in an organized folder

    Organize your documents: (1) Imaging reports, (2) Surgical reports, (3) Nexus letter, (4) Personal worst-day statement, (5) Medication list, (6) Assistive device list, (7) Service exposure history, (8) Buddy statements. Number your pages and bring two sets if possible.

    day of

  • critical

    Bring and use all prescribed assistive devices

    Bring every assistive device you use - cane, crutches, walker, AFO brace. Use them as you normally would. If you use a wheelchair for longer distances, arrange transport accordingly. Do not present a more capable picture than your reality.

    day of

  • recommended

    Dress comfortably for physical examination

    Wear loose, comfortable clothing that allows the examiner to access the affected joints (hips, shoulders, knees). For hip osteonecrosis, shorts or athletic pants are ideal. For shoulder involvement, a loose short-sleeve shirt or tank top. You may be asked to change into a gown.

    day of

  • recommended

    Arrive early and note your pain level upon arrival

    Arrive 15 minutes early. Before entering the exam room, note your current pain level on a 0-10 scale and write it down. If waiting in the waiting room causes your pain to increase (e.g., sitting in a hard chair), note this and tell the examiner.

    day of

  • critical

    Stop all range of motion at the point of pain

    When the examiner asks you to move the affected joint, stop at the exact point where pain occurs and state: 'This is where my pain begins - I can feel it at approximately [describe position].' Do not push through pain to show a larger range of motion. The rating is based on the point of pain onset, not maximum possible movement.

    during exam

  • critical

    Explicitly request DeLuca repetitive-use testing

    After initial ROM is measured, ask: 'Can you also document any additional limitation after repeated use of the joint? I understand the regulations require testing for fatigue-related ROM loss.' Perform the motion three times and report any increase in pain or decrease in range after repetition.

    during exam

  • critical

    Describe both rest pain and activity pain

    Do not wait for the examiner to ask - proactively state whether you have pain at rest, pain with light activity, and pain with exertion. Rate each on a 0-10 scale. Rest pain (pain without movement) is a key indicator of higher severity ratings.

    during exam

  • critical

    Provide your worst-day statement to the examiner

    Hand the examiner your printed worst-day symptom statement and ask that it be reviewed and incorporated into the DBQ findings. State: 'I have prepared a written description of my worst-day symptoms as required under VA examination guidelines. Can you please include this in your report?'

    during exam

  • critical

    Confirm all affected anatomic sites are documented

    Before the exam concludes, confirm with the examiner that every affected site (both hips, both shoulders, knees, etc.) has been listed on the DBQ. Ask: 'Have you documented all of the bone sites affected by my osteonecrosis on both sides?'

    during exam

  • critical

    Describe the nexus between your service and the condition

    Proactively describe your military diving/hyperbaric history to the examiner, any in-service DCS incidents, and how your symptoms developed after service. Provide your service exposure statement and any nexus letter. Ask that the examiner address whether the osteonecrosis is at least as likely as not related to your service exposure.

    during exam

  • recommended

    Report all secondary conditions and complications

    Mention any secondary conditions that have developed as a result of the osteonecrosis: secondary osteoarthritis, nerve damage, muscle atrophy, gait abnormalities, hip labral tears, or psychological impact (depression, sleep disturbance from chronic pain). Each may be separately ratable.

    during exam

  • critical

    Request a copy of the completed DBQ

    You are entitled to a copy of the DBQ completed at your exam. Submit a written request to the VA Regional Office or exam contractor within 30 days. Review it carefully for accuracy - especially ROM measurements, functional impact descriptions, and the nexus opinion.

    after exam

  • recommended

    File a buddy statement or personal statement if exam was inadequate

    If the examiner spent less than 15 minutes with you, did not perform ROM testing, did not ask about flare-ups or daily function, or appeared unfamiliar with dysbaric osteonecrosis, document these deficiencies immediately and submit a written complaint and supplemental statement to the VA RO within 30 days.

    after exam

  • recommended

    Review the rating decision carefully when received

    When your rating decision arrives, review it against the DBQ findings. Confirm the correct diagnostic code (5011) was used, all affected sites were rated, and DeLuca factors were applied. If errors exist, file a supplemental claim with a private nexus opinion or request a Higher-Level Review within one year of the decision.

    after exam

Your rights during a C&P exam

  • You have the right to a thorough and contemporaneous examination - the examiner must personally examine you, not rely solely on records, unless a records review examination was specifically ordered.
  • You have the right to have range of motion testing performed under weight-bearing and non-weight-bearing conditions, actively and passively, per 38 CFR 4.45 and Correia v. McDonald.
  • You have the right to have DeLuca factors documented - including pain on motion, weakness, fatigue, incoordination, and ROM loss after repetitive use (DeLuca v. Brown, 8 Vet. App. 202, 1995).
  • You have the right to have your worst-day symptoms considered - not just your condition at the moment of examination, per M21-1 adjudication guidance.
  • You have the right to request a recording of your C&P examination in most states - check current VA policy and your state law before your appointment.
  • You have the right to a copy of the completed DBQ - submit a written request to the VA Regional Office or exam contractor.
  • You have the right to submit a personal statement, buddy statements, and private medical opinions as evidence to supplement or rebut the C&P findings.
  • You have the right to challenge an inadequate examination - if the DBQ is vague, incomplete, or fails to address your claimed condition, you may request a new examination by filing a Notice of Disagreement or Supplemental Claim.
  • You have the right to have all separately affected anatomic sites rated independently - bilateral osteonecrosis (e.g., both hips, both shoulders) should yield separate ratings for each affected extremity.
  • You have the right to claim Total Disability based on Individual Unemployability (TDIU) under 38 CFR 4.16 if your dysbaric osteonecrosis, alone or in combination with other service-connected conditions, prevents you from maintaining substantially gainful employment.
  • You have the right to have secondary conditions (e.g., secondary osteoarthritis, depression secondary to chronic pain) evaluated and rated if caused or aggravated by your service-connected dysbaric osteonecrosis.
  • You have the right to a fully explained rating decision - if the decision does not explain why a specific rating was assigned or why the nexus opinion was accepted or rejected, you may request clarification through the appeals process.

Related conditions

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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.