Radiculopathy / Peripheral Nerves C&P Exam Prep

Manual Muscle Strength Testing (0-5 Scale)

What it measures: Motor nerve function and degree of muscle weakness in affected extremities. Grade 0 = no contraction; Grade 1 = trace contraction; Grade 2 = movement with gravity eliminated; Grade 3 = movement against gravity; Grade 4 = movement against some resistance (subdivided 4-, 4, 4+); Grade 5 = normal strength.

What to expect: The examiner will ask you to push, pull, or resist pressure in specific directions for multiple muscle groups in each limb. Testing typically includes grip strength (squeeze examiner's fingers), pinch strength, wrist flexion and extension, elbow flexion and extension, knee extension, ankle dorsiflexion and plantarflexion, and toe flexion/extension.

Pain considerations: Pain-inhibited weakness is still clinically relevant. If pain prevents full effort, state: 'The pain in my [location] prevents me from exerting full force.' This is documented as pain-limited function.

Deep Tendon Reflexes (DTR)

What it measures: Integrity of specific reflex arcs corresponding to nerve roots and peripheral nerves. Biceps (C5/C6), Brachioradialis (C6), Triceps (C7), Patellar/Knee jerk (L3/L4), Achilles/Ankle jerk (S1).

What to expect: Examiner uses a reflex hammer on tendons at the elbow, wrist, knee, and ankle. Graded 0 (absent) to 4+ (hyperreflexic with clonus). Grade 0 = absent (suggests lower motor neuron or peripheral nerve lesion); Grade 1+ = diminished; Grade 2+ = normal; Grade 3+ = brisk; Grade 4+ = clonus.

Pain considerations: Reflex testing itself is generally not painful. However, if the tapping causes radiating pain or paresthesias, tell the examiner immediately.

Tinel's Sign

What it measures: Regenerating or compressed nerve fibers. Examiner taps along a nerve pathway. A positive test produces tingling or electric shock sensation in the nerve's distribution.

What to expect: Examiner taps at the wrist (carpal tunnel area), elbow (ulnar nerve groove), or other nerve entrapment sites with a fingertip or reflex hammer. Both right and left sides will be tested.

Pain considerations: If Tinel's testing reproduces your characteristic pain or paresthesias, clearly state: 'Yes, that's exactly the sensation I experience with my radiculopathy.'

Phalen's Test

What it measures: Median nerve compression at the wrist (carpal tunnel). Examiner holds your wrists in maximum flexion for 60 seconds.

What to expect: You will hold your wrists flexed (back of hands together) for up to 60 seconds. A positive test reproduces numbness or tingling in the thumb, index, middle, and radial half of the ring finger.

Pain considerations: If the position itself causes pain before tingling develops, report both the pain onset time and any subsequent tingling.

Muscle Circumference / Atrophy Measurement

What it measures: Presence and degree of muscle wasting (atrophy) due to denervation or disuse. Measured in centimeters at a standardized point on both the affected and unaffected limb.

What to expect: Examiner measures limb circumference at a specific anatomic landmark (e.g., mid-thigh, mid-calf, mid-forearm) on both sides with a tape measure. The difference between normal and atrophied sides is recorded.

Pain considerations: Measurement itself is not painful. If the examiner must move the limb to position for measurement and this causes pain, note it.

Sensory Testing (Light Touch, Pin Prick, Vibration)

What it measures: Integrity of sensory nerve fibers in specific dermatomal and peripheral nerve distributions. Maps the geographic area of sensory loss or alteration.

What to expect: Examiner uses a cotton wisp, pin, or tuning fork to test sensation at multiple points along your arms, hands, legs, and feet. You will be asked to respond to each stimulus. The examiner maps areas of normal, reduced (hypesthesia), absent (anesthesia), or abnormal sensation (paresthesia, dysesthesia).

Pain considerations: If pin prick testing causes an abnormally painful or burning response (allodynia/hyperalgesia), immediately describe this to the examiner - it is an important neuritis/neuralgia finding.

Gait Assessment

What it measures: Functional ambulation impairment related to peripheral nerve deficit, including foot drop (anterior tibial nerve), steppage gait, antalgic gait, or circumduction.

What to expect: Examiner observes you walking. They note gait pattern, foot clearance, balance, use of assistive devices, and any compensatory movements.

Pain considerations: If walking causes pain or paresthesias in your leg, back, or buttock, describe the type, location, and radiation of that pain during gait.

10%

Mild incomplete paralysis of the affected nerve. Under DC 8621, neuritis with mild incomplete paralysis. Mild sensory disturbance or mild motor weakness without significant functional loss. For neuralgia (DC 8711/8712), neuralgia with characteristic features of pain, tingling, or burning that is mild in character.

From 38 CFR: Under 38 CFR 4.124a, mild incomplete paralysis of the nerve, less than described for moderate incomplete paralysis. Neuritis rated on degree of nerve impairment.

20%

Moderate incomplete paralysis of the affected nerve. Under DC 8621, neuritis with moderate incomplete paralysis. Moderate sensory disturbance or moderate motor weakness causing functional limitation. For neuralgia, moderate pain with characteristic features.

From 38 CFR: Moderate incomplete paralysis. Neuritis rated at moderate level under 38 CFR 4.124a.

40%

Moderately severe incomplete paralysis of the affected nerve. Under DC 8621, neuritis with moderately severe incomplete paralysis. Significant motor and/or sensory loss with functional impairment of the extremity.

From 38 CFR: Moderately severe incomplete paralysis under 38 CFR 4.124a. Near-complete loss of functional use of affected nerve distribution.

60%

Severe incomplete paralysis or complete paralysis of the affected nerve. The most severe end of the rating spectrum under DC 8621/8711/8712. Complete or near-complete loss of nerve function with maximal functional impairment.

From 38 CFR: Complete paralysis under 38 CFR 4.124a for the specific nerve (e.g., complete paralysis of the sciatic nerve, complete paralysis of the median nerve). Rating percentages for complete paralysis vary by nerve - the examiner's documentation of the degree of paralysis drives the applicable rating.

Pain Character and Distribution

How to describe it: Describe pain using precise neurological language: quality (burning, electric, stabbing, lancinating, aching, shooting), distribution (follows a specific nerve path - e.g., from lower back down the back of the thigh to the calf and into the foot), intensity (0-10 scale on a typical day and on a worst day), and triggers (sitting, standing, walking, bending, sleeping).

Example: On my worst days, I have a constant 8/10 burning and electric pain starting in my lower back that radiates down the back of my right leg to my heel. I cannot sit for more than 10 minutes, and the pain wakes me from sleep 3-4 times per night. I cannot drive, and I have to lie flat to get any relief.

Examiner listens for: Radicular pain patterns that follow specific dermatomal or peripheral nerve distributions, distinguishing characteristics of neuropathic pain (burning, electric quality), whether pain is constant vs. episodic, and what activities provoke or relieve symptoms.

Avoid: Do not say 'it bothers me a little' when you mean the pain significantly limits your activities. Do not say 'I manage okay' if you have substantially changed your daily routine to accommodate pain. Avoid minimizing by saying 'I can push through it' - this obscures how the condition truly affects function.

Numbness and Sensory Changes

How to describe it: Identify the exact geographic distribution of sensory changes. Use anatomical landmarks: 'The outer two fingers of my right hand are constantly numb.' Distinguish between complete numbness (can't feel anything), reduced sensation (feels dulled), tingling (pins and needles), burning, or altered sensation (things feel abnormal). Note whether constant or intermittent.

Example: The entire sole of my left foot feels like it is wrapped in thick cotton - I cannot feel the ground properly when I walk, which causes me to trip. My toes also have a constant burning sensation that is worse at night, keeping me from sleeping.

Examiner listens for: Whether sensory changes follow a specific nerve's anatomical distribution, consistency of symptoms, and whether sensory changes are associated with functional problems such as loss of balance, difficulty with fine motor tasks, or difficulty walking.

Avoid: Do not omit intermittent symptoms - 'sometimes my hand goes numb' is still ratable. Do not describe sensory symptoms only in vague terms; map them geographically. Do not forget to mention sensory changes at night or during specific activities.

Motor Weakness and Functional Loss

How to describe it: Describe specific functional deficits: 'I drop objects because my grip is weak.' 'I cannot lift my foot when walking and trip on flat surfaces.' 'I cannot open jars or turn doorknobs with my right hand.' Connect the weakness to real-world limitations in work, self-care, and daily activities.

Example: On a bad day, my right hand is so weak I cannot button my shirt, use a keyboard for more than a few minutes, or carry a full coffee cup without spilling. I have dropped things and broken them because my grip gives out without warning.

Examiner listens for: Specific muscle groups affected, whether weakness is constant or fluctuates with activity or time of day, functional consequences in daily living and employment, and whether weakness has been progressive or stable.

Avoid: Do not demonstrate full effort during strength testing if pain prevents it - tell the examiner the pain limit. Do not say 'my arm is weak' without specifying what tasks you cannot do because of it.

Fatigue and Repetitive Use Impact

How to describe it: Describe how symptoms worsen with sustained or repeated use of the affected extremity. Note that initial strength or function may appear better than actual capacity because you are tested only once, at rest, not after sustained effort.

Example: When I first start walking I can manage about two blocks, but after that my leg becomes extremely weak, the pain intensifies to 9/10, and I have to stop and rest for 15-20 minutes before I can continue. By the end of the day my leg is significantly weaker than in the morning.

Examiner listens for: Whether symptoms worsen with activity, how long activities can be sustained, recovery time needed, and whether the veteran's functional capacity at the exam accurately represents their typical capacity.

Avoid: Do not only describe your initial capacity - describe how long you can sustain activity before symptoms worsen. Mention that a single strength test does not reflect your sustained work capacity.

Flare-Ups

How to describe it: Describe the frequency, duration, severity, and triggers of flare-ups. Quantify how much worse symptoms become: 'During a flare my pain goes from my baseline of 4/10 to 9/10, I cannot bear weight at all, and I am bedbound for 2-3 days.' State what triggers flares (activity, cold weather, prolonged sitting, stress).

Example: I have severe flare-ups 2-3 times per month, usually triggered by any activity involving prolonged standing or walking. During a flare the burning and electric pain becomes unbearable, I cannot wear shoes, I cannot sleep, and I require rescue pain medication that leaves me too drowsy to function. Each flare lasts 2-4 days.

Examiner listens for: Frequency and predictability of flares, severity relative to baseline, functional impact during flares, and what the veteran cannot do during a flare-up that they might be able to do on a good day.

Avoid: Do not present only your good-day function to the examiner. Actively volunteer information about flare-ups. VA examinations often occur on relatively functional days - report your worst-day reality.

Impact on Work and Daily Activities

How to describe it: Specifically address how the peripheral nerve condition affects your ability to work (both your current or last job and general work capacity). Describe activities of daily living that are impaired: dressing, grooming, cooking, driving, household tasks, recreation. Be specific about what you cannot do or can only do with difficulty or assistance.

Example: I can no longer perform my previous job as a warehouse worker because I cannot stand for more than 15 minutes, cannot carry loads over 10 pounds with my right hand, and cannot operate machinery safely due to the numbness in my feet affecting my balance. I now require help from my spouse to put on my socks and shoes due to the combination of pain and hand weakness.

Examiner listens for: Whether the condition limits the ability to perform sedentary or physically demanding work, specific occupational tasks that are impaired, changes in employment or work duties attributable to the condition, and social/recreational impact.

Avoid: Do not understate work limitations. Do not omit unpaid work (household tasks, caregiving). Do not fail to mention if you have changed jobs, reduced hours, or been unable to maintain employment because of the condition.