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VA Rating Assistant

DC 5252 · 38 CFR 4.71a

Thigh, Limitation of Flexion C&P Exam Prep

To evaluate the degree of limitation of flexion of the thigh (hip joint) and its functional impact on daily activities, work, and quality of life under 38 CFR 4.71a, Diagnostic Code 5252.

Format:
Interview + Physical
Typical duration:
30-45 minutes
DBQ form:
Hip_and_Thigh (Hip_and_Thigh)
Examiner:
Physician or Physician Assistant

What the examiner evaluates

  • Active range of motion of hip flexion in degrees
  • Passive range of motion of hip flexion in degrees
  • Weight-bearing vs. non-weight-bearing range of motion
  • Pain on motion and its location along the range of motion arc
  • Additional loss of motion with repetitive use (DeLuca factors)
  • Functional loss due to pain, weakness, fatigability, and incoordination
  • Flare-up history and estimated additional ROM loss during flare-ups
  • Assistive device use (cane, crutches, walker, wheelchair, brace)
  • Objective findings such as muscle atrophy, swelling, deformity
  • Leg length discrepancy
  • Surgical history including total hip replacement, hip resurfacing, arthroscopic procedures
  • Diagnosis type (osteoarthritis, post-traumatic arthritis, avascular necrosis, etc.)
  • Functional impact on work, standing, sitting, and locomotion

Exam will include both an interview and a physical examination. You will be asked to perform active hip flexion movements. Wear loose-fitting clothing for easy access to the hip. Bring any assistive devices you regularly use. The examiner is a physician or physician assistant. In most states you have the right to record the exam - check your state law in advance.

Measurements and tests

Active Hip Flexion Range of Motion

What it measures: The degree to which you can actively flex (bend) your thigh toward your chest without assistance, measured with a goniometer.

What to expect: You will lie on your back or sit and lift your knee toward your chest as far as pain allows. The examiner places a goniometer on your hip to measure the angle. Normal active hip flexion is 0-125 degrees.

Critical thresholds

  • Flexion limited to 45- 10% rating under DC 5252
  • Flexion limited to 30- 20% rating under DC 5252
  • Flexion limited to 20- 30% rating under DC 5252
  • Flexion limited to 10- 40% rating under DC 5252
  • Flexion greater than 45- but still limited 0% (non-compensable) under DC 5252 - but document carefully as this still constitutes a disability

Tips

  • Stop at the point of PAIN, not at your absolute maximum - report your actual pain-limited range
  • Move at your typical pace, not your best effort pace
  • Do not warm up or stretch before the exam - come in your typical daily condition
  • If you have worse ROM on some days, tell the examiner this is not your worst day
  • Ask the examiner to record both where pain begins and where motion ends

Pain considerations: If pain prevents you from reaching the full arc of motion, stop and tell the examiner 'This is where the pain becomes too severe to continue.' The point where pain stops you is legally significant and can be recorded as the end-point. Per DeLuca v. Brown, pain-limited motion is functional loss.

Passive Hip Flexion Range of Motion

What it measures: The degree of hip flexion when the examiner moves your leg for you, without your muscle effort. Required per Correia v. McDonald.

What to expect: While you lie relaxed, the examiner lifts your leg and flexes your hip to measure how far it goes when you are not actively contracting muscles. Passive ROM is often slightly greater than active ROM.

Critical thresholds

  • Passive ROM same as active ROM Suggests pain or weakness limits active motion - document the difference
  • Passive ROM significantly greater than active ROM Suggests muscle weakness or pain-avoidance limiting active movement - supports DeLuca factors

Tips

  • Let your leg be completely relaxed during passive testing
  • Tell the examiner if passive movement also causes pain
  • Note whether the examiner documents both active and passive measurements separately

Pain considerations: Pain during passive range of motion is significant and should be verbally reported to the examiner. Passive ROM pain indicates intra-articular pathology.

Weight-Bearing vs. Non-Weight-Bearing ROM Assessment

What it measures: How hip flexion ROM differs when bearing body weight (standing) versus not bearing weight (lying down). Required per Correia v. McDonald.

What to expect: The examiner may assess your range of motion in both standing and supine (lying) positions. Weight-bearing testing more closely mimics functional daily activity.

Critical thresholds

  • Reduced ROM in weight-bearing position More accurately reflects real-world functional limitation; supports higher rating
  • Greater limitation when weight-bearing Demonstrates that your condition is worse in functional positions relevant to work and daily life

Tips

  • Tell the examiner if you have more pain or less range of motion when standing versus lying down
  • Describe how your hip feels when walking, climbing stairs, or getting out of a chair compared to lying in bed
  • If you cannot perform weight-bearing testing, tell the examiner why (e.g., pain, instability)

Pain considerations: Weight-bearing pain that limits range of motion should be specifically described to the examiner - this directly affects functional capacity assessments.

Repetitive Use Testing (DeLuca Factors)

What it measures: Whether hip flexion ROM decreases after repeated use, simulating real-world functional activity. Mandated by DeLuca v. Brown (1995).

What to expect: The examiner may ask you to perform the flexion motion multiple times and then remeasure. Alternatively, the examiner may ask about your typical daily experience with repeated use.

Critical thresholds

  • Additional ROM loss after repetition Supports higher effective rating; examiner must document estimated additional loss
  • Increased pain with repetition Constitutes functional loss under 38 CFR 4.40 and 4.45; document pain, weakness, fatigability, incoordination

Tips

  • Before the exam, prepare specific examples of how your hip worsens with activity (e.g., 'After walking one block, I can barely lift my leg')
  • Report any increase in pain, stiffness, or weakness after repeated movements during the exam
  • Tell the examiner how long it takes to recover after activity flares your symptoms
  • If you cannot perform repetitive testing due to pain, say so clearly

Pain considerations: Fatigue, increased pain, and weakness after repeated use all constitute functional loss. Per DeLuca, the examiner must address these factors even if they occur only after the exam.

Flare-Up Assessment

What it measures: The frequency, duration, severity, and estimated ROM loss during flare-up episodes. Examiners must address flare-ups per M21-1 and DeLuca.

What to expect: The examiner will ask about flare-ups - episodes when your condition is significantly worse than baseline. They should ask about frequency, triggers, duration, and functional impact.

Critical thresholds

  • Flare-ups that would reduce flexion to a lower threshold If flare-up ROM would meet a higher rating criterion, the examiner should note this estimated loss
  • Frequent disabling flare-ups Supports overall disability picture; may affect TDIU or combined rating

Tips

  • Come prepared with a written log of your 3 worst recent flare-ups including dates, triggers, duration, and what activities you could not perform
  • Describe flare-ups in terms of degrees if possible ('During a flare, I can barely lift my knee off the bed')
  • Mention what causes flare-ups: cold weather, prolonged walking, stairs, standing
  • Tell the examiner how flare-ups affect your work and daily activities

Pain considerations: During flare-ups your pain, weakness, and limited mobility are at their worst. Accurately describe your worst-day function - this is exactly what the rating criteria need to assess.

Rating criteria by percentage

40%

Hip flexion limited to 10 degrees or less. This represents the most severe limitation of flexion under DC 5252. The hip can barely move from the neutral position.

Key symptoms

  • Inability to lift the thigh more than a few degrees
  • Cannot bend to put on shoes or socks
  • Cannot climb stairs without assistive device
  • Severe gait disturbance
  • Cannot rise from a seated position without arm assistance
  • Constant pain with any attempt at hip flexion

From 38 CFR: Flexion limited to 10- = 40% under 38 CFR 4.71a, DC 5252.

30%

Hip flexion limited to 20 degrees or less. Severely restricted hip motion that significantly impacts all weight-bearing activities and most ADLs.

Key symptoms

  • Cannot bend hip more than approximately 20 degrees
  • Significant difficulty getting in and out of chairs
  • Cannot perform personal hygiene tasks requiring hip flexion
  • Antalgic gait requiring assistive device
  • Cannot climb stairs without rail and significant difficulty
  • Sleep disturbed by hip pain and inability to position comfortably

From 38 CFR: Flexion limited to 20- = 30% under 38 CFR 4.71a, DC 5252.

20%

Hip flexion limited to 30 degrees or less. Moderate-to-severe restriction that limits most activities requiring hip bending.

Key symptoms

  • Cannot flex hip past 30 degrees
  • Difficulty with stairs, inclines, and prolonged walking
  • Cannot sit in low chairs or car seats without significant pain
  • Cannot bend to pick objects off the floor
  • Pain with most weight-bearing activities
  • Requires modified techniques for dressing and bathing

From 38 CFR: Flexion limited to 30- = 20% under 38 CFR 4.71a, DC 5252.

10%

Hip flexion limited to 45 degrees or less. Moderate limitation that affects activities requiring significant hip bending but preserves basic ambulation.

Key symptoms

  • Cannot flex hip past 45 degrees
  • Pain with climbing stairs and hills
  • Difficulty with low seating (car seats, couches)
  • Cannot perform activities requiring full hip flexion (kneeling, squatting)
  • Pain after prolonged walking or standing
  • Stiffness that worsens with rest and improves briefly with activity

From 38 CFR: Flexion limited to 45- = 10% under 38 CFR 4.71a, DC 5252. Note: If flexion is greater than 45- but still limited (e.g., limited to 60-), a 0% (non-compensable) evaluation applies per M21-1 guidance, though the limitation still constitutes a disability of record.

Describing your symptoms accurately

Pain During Hip Flexion

How to describe it: Describe the pain location (groin, anterior hip, lateral hip, buttock), character (sharp, aching, stabbing, burning), intensity on 0-10 scale, and specifically at what degree of flexion the pain begins and forces you to stop. Distinguish between baseline pain and pain during movement.

Example: On my worst days, I feel a sharp stabbing pain in my groin as soon as I try to lift my knee even slightly off the bed. The pain is an 8 out of 10 and prevents me from bending my hip more than about 10 to 15 degrees. I cannot get out of bed without rolling to my side and pushing myself up.

Examiner listens for: Specific degree at which pain begins, pain that limits ROM below rating thresholds, pain at rest versus with motion, radiating pain that could indicate nerve involvement, pain that worsens with weight-bearing.

Avoid: Saying 'it hurts a little' or 'I manage.' Instead say: 'The pain forces me to stop at approximately X degrees and prevents me from completing the movement.'

Functional Loss from Weakness

How to describe it: Describe inability to hold your leg in a flexed position, leg giving way during activities, difficulty initiating the flexion movement, and how weakness prevents completion of tasks like stair climbing or rising from a seated position.

Example: On bad days my hip is so weak that I cannot lift my leg to step over a curb without using my hands to physically lift my thigh. When I try to climb stairs, my hip gives out and I have nearly fallen multiple times. I rely on the handrail with both hands.

Examiner listens for: Specific activities limited by weakness, whether weakness exists independently of pain, fall risk, compensatory strategies used.

Avoid: Minimizing weakness as just tiredness. Specify: 'My hip muscle gives way when I try to flex it against any resistance.'

Fatigability and Loss of Endurance

How to describe it: Describe how your hip function deteriorates over the course of a day or after activity. Specify how many minutes or steps you can take before your hip ROM or pain level significantly worsens.

Example: I can walk about half a block before the pain and stiffness become so severe that I have to stop and rest. After walking, my hip becomes so stiff that I can barely flex it at all. What takes a normal person 5 minutes to walk takes me 20 minutes with rest breaks.

Examiner listens for: Quantifiable activity tolerance, how quickly symptoms worsen with activity, recovery time needed, whether symptoms prevent completing full workday or household tasks.

Avoid: Saying 'I get tired.' Instead say: 'After approximately X minutes of activity, my hip function drops to where I can only flex about X degrees and the pain reaches an 8 out of 10.'

Incoordination and Gait Disturbance

How to describe it: Describe any limping, altered gait pattern, tendency to catch your foot, inability to walk in a straight line, or compensatory movements you make to avoid hip flexion during walking.

Example: I have a pronounced limp every day because I cannot swing my leg forward normally. I have to hike my whole hip up to advance my affected leg. People regularly comment on my limp and I have stumbled and fallen twice in the past year because my leg did not flex properly.

Examiner listens for: Antalgic gait, Trendelenburg sign, compensatory trunk movements, history of falls related to hip dysfunction, need for assistive devices.

Avoid: Downplaying the limp by saying 'I just walk a little funny.' Describe the specific mechanics and safety concerns your gait abnormality creates.

Flare-Up Description

How to describe it: Describe triggers (weather, activity, prolonged sitting/standing), frequency (how many times per month), duration (hours or days), peak severity, and what activities become impossible during a flare-up.

Example: I have severe flare-ups about twice a week, usually triggered by cold weather or after any activity lasting more than 10 minutes. During a flare, the pain reaches 9 out of 10 and I am essentially bedridden. I cannot flex my hip more than a few degrees and I need assistance to get to the bathroom. Flare-ups last 1 to 3 days.

Examiner listens for: Quantified frequency and duration, specific ROM limitation during flare-ups, functional activities that become impossible, whether the day of the exam represents a typical or atypical day.

Avoid: Failing to mention that the exam day may not reflect your worst function. Say: 'Today is an average to better day for me - on my worst days my condition is significantly more limited than what you are seeing today.'

Impact on Activities of Daily Living and Work

How to describe it: Describe specific ADLs affected: dressing (putting on socks, shoes, pants), bathing (getting in/out of tub or shower), sitting in a car, rising from chairs, climbing stairs, household chores, and occupational tasks.

Example: I cannot put on my own socks or shoes without a grabber tool. I cannot get into or out of a standard car without physically lifting my leg with my hands. I have had to install grab bars in my bathroom and I shower with a shower chair. At work, I cannot sit for more than 15 minutes or stand for more than 10 minutes without severe hip pain that forces me to change position.

Examiner listens for: Specific named activities that are limited or impossible, adaptive equipment used, modifications made to living space or work environment, whether the veteran has reduced hours or changed job duties.

Avoid: Vague statements like 'it affects my life.' Name the specific activities: shoes, socks, bathing, driving, stairs, prolonged sitting/standing.

Common mistakes to avoid

Performing your best ROM on exam day rather than your pain-limited ROM

Why: Veterans often push through pain out of habit or a desire to appear cooperative. The examiner records what is demonstrated, not what you report as typical.

Do this instead: Stop at the point where pain would normally cause you to stop in real daily life. Tell the examiner: 'I am stopping here because this is where the pain becomes too severe to continue.'

Impact: Could cause underrating by 1-2 levels - e.g., being rated 10% instead of 30%

Not mentioning that the exam day is better than typical

Why: C&P exams capture a single moment in time. If you are having a good day due to medication timing, rest, or chance, the ROM measurement will not reflect your actual disability level.

Do this instead: At the start of the exam say: 'I want to note that today is [better/worse/average] than my typical day. On my worst days, my flexion is limited to approximately X degrees.'

Impact: Can cause significant underrating across all rating levels

Failing to describe DeLuca factors - how symptoms worsen with repeated use

Why: The examiner must ask about pain, weakness, fatigability, and incoordination during and after repetitive use. If you do not proactively describe these, they may not be documented.

Do this instead: Volunteer information: 'After performing that movement repeatedly, I would experience significantly more pain and stiffness. My hip typically worsens after just a few repetitions.'

Impact: Can prevent documentation of effective higher rating under DeLuca - most commonly affects 10-30% range

Not bringing documentation of assistive device use or prior imaging

Why: If the DBQ field for assistive devices is blank or the examiner has no imaging to reference, critical evidence supporting your claim may be omitted.

Do this instead: Bring your cane, brace, or other devices to the exam. Bring copies of recent X-rays, MRI reports, or operative notes. Remind the examiner if you use an assistive device regularly.

Impact: Affects all rating levels - assistive device use and imaging findings support the overall disability picture

Describing only pain at the end of ROM rather than pain throughout the arc of motion

Why: Pain that begins early in the range of motion (even if you can push through) is legally significant and documents a greater degree of impairment than pain only at the endpoint.

Do this instead: Say: 'Pain begins at approximately X degrees and becomes severe at approximately Y degrees. I feel pain throughout the entire movement, not just at the end.'

Impact: Particularly important at the 10-20% boundary

Understating flare-up severity because you are not currently in a flare-up

Why: Many veterans minimize flare-up descriptions if they are having a relatively good day. The rating must reflect your worst functional state, not just the exam-day snapshot.

Do this instead: Describe your 3 most recent severe flare-ups in detail, including dates, triggers, duration, ROM during flare-up, and what activities you could not perform. Bring a written log.

Impact: Can affect rating by 1-2 levels at 20-40% range

Not disclosing all functional limitations including non-motion symptoms

Why: The DBQ captures pain, weakness, fatigability, incoordination, instability, swelling, atrophy, and functional interference. Veterans often focus only on ROM and miss documenting these critical elements.

Do this instead: Proactively mention each DeLuca factor: 'I also experience weakness that causes my hip to give out, muscle fatigue that worsens throughout the day, and instability when walking on uneven ground.'

Impact: Affects documentation quality at all rating levels and supports secondary conditions and TDIU claims

Prep checklist

  • critical

    Gather and organize all relevant medical records

    Collect VA treatment records, private provider notes, X-ray and MRI reports, operative reports for any hip surgeries, and physical therapy records. Organize chronologically. Flag records that document your hip flexion limitation or functional loss.

    before exam

  • critical

    Know your exact ROM measurements from prior exams or visits

    If any provider has previously measured your hip flexion, record those measurements. Being able to say 'My orthopedist measured 30 degrees of flexion in March' gives the examiner objective reference points and demonstrates consistency.

    before exam

  • critical

    Write a flare-up log covering the past 3 months

    Document at least 3-5 significant flare-up episodes with: date, trigger, duration, pain level (0-10), estimated ROM limitation during flare, and specific activities you could not perform. Bring this written log to the exam.

    before exam

  • critical

    Prepare your functional impact statement

    Write a one-page description of exactly how your hip flexion limitation affects your daily life: dressing (socks, shoes), bathing, driving (getting in/out of car), stairs, sitting tolerance, standing tolerance, walking distance, sleep, and work tasks. Be specific with time and distance.

    before exam

  • recommended

    Research your right to record the examination in your state

    Many states permit veterans to record C&P examinations. Check current VA policy and your state law. If recording is permitted, bring a small audio recorder or use your smartphone. Notify the examiner at the start of the exam.

    before exam

  • critical

    Do NOT perform unusual exercise or stretching the day before

    Do not try to stretch or warm up your hip joint before the exam. Do not take extra anti-inflammatory medication that might temporarily reduce your typical pain level. Arrive in your usual daily condition.

    before exam

  • recommended

    List all current medications for hip pain

    Write down all medications you take for your hip condition: NSAIDs, opioids, muscle relaxants, steroid injections, topical treatments, supplements. Include dosage and frequency. This helps document the severity requiring pharmacological management.

    before exam

  • critical

    Identify and document your assistive device use

    If you use a cane, crutches, walker, brace, or wheelchair for your hip condition, document when you started using it, who prescribed it, and under what circumstances you use it. Bring the device to the exam.

    before exam

  • recommended

    Wear loose, comfortable clothing with easy access to the hip

    Wear shorts or loose-fitting pants that can be easily rolled up or removed. Avoid tight jeans, belts, or clothing that would require significant hip flexion to remove and might influence how you move during the exam.

    day of

  • critical

    Bring all documentation and written logs

    Bring your flare-up log, functional impact statement, medication list, imaging reports, and any prior ROM measurements documented by a provider. Organize them in a folder for easy reference.

    day of

  • critical

    Bring your assistive devices

    Bring any cane, brace, crutches, or other assistive devices you use for your hip condition. If you own a shower chair or grab bar, mention these adaptations even if you cannot bring them.

    day of

  • recommended

    Arrive at your typical activity level - not rested

    Do not rest excessively before the exam. Arrive having done your usual morning routine. Your hip should reflect its typical daily state, not an artificially rested state.

    day of

  • critical

    Note whether today is a typical, better-than-typical, or worse-than-typical day

    Be prepared to tell the examiner at the start where today falls relative to your typical experience. If today is a better day (e.g., less pain, more ROM), explicitly state this so the record reflects it.

    day of

  • critical

    Stop ROM testing at your actual pain limit - not maximum effort

    When the examiner asks you to flex your hip, stop at the point where pain or weakness would normally stop you in daily life. Do not push through to show your maximum range. The measurement should reflect your functional limitation.

    during exam

  • critical

    Verbally report pain at each point during ROM testing

    As you move through the range of motion, describe your pain out loud: 'Pain begins at about 20 degrees. It becomes sharp at 30 degrees. I am stopping here because the pain is a 7 out of 10 and I cannot go further.'

    during exam

  • critical

    Proactively describe all DeLuca factors

    If the examiner does not ask about pain, weakness, fatigability, and incoordination with repeated use, volunteer this information: 'I should mention that if I repeated that movement several times, my ROM would decrease significantly and pain would worsen substantially.'

    during exam

  • critical

    Describe your worst day, not your best day

    Per M21-1 guidance, your rating should reflect the overall disability picture including bad days. Proactively state: 'On my worst days, which occur about [frequency], my hip flexion is limited to approximately X degrees and I cannot [specific activity].'

    during exam

  • critical

    Mention flare-ups and their impact on ROM

    Tell the examiner about your flare-up frequency, severity, and estimated ROM loss during flare-ups. Reference your written log. The examiner should document estimated ROM loss during flare-ups.

    during exam

  • critical

    Describe all activities of daily living affected

    When the examiner asks about functional impact, be specific and comprehensive: socks, shoes, getting in/out of car, low chairs, bathing, stairs, sleep position, driving, work tasks. Do not give vague answers.

    during exam

  • critical

    Do not minimize symptoms to appear stoic or cooperative

    This is not the time for understatement. The examiner's job is to document your condition accurately. Every symptom you fail to describe is a symptom that may not appear in the rating decision.

    during exam

  • recommended

    Confirm the examiner is addressing both active and passive ROM

    If the examiner only measures active ROM, politely ask: 'Should you also be measuring passive range of motion?' Per Correia v. McDonald, both should be assessed.

    during exam

  • recommended

    Write down everything that happened in the exam immediately after

    As soon as you leave, write down everything the examiner measured, asked, and said. Note any symptoms you forgot to mention. This documentation may be important for a Supplemental Claim or appeal if needed.

    after exam

  • recommended

    Request a copy of the DBQ once it is completed

    You have the right to obtain a copy of the completed DBQ. Request it through your MyHealtheVet portal or by contacting the VA regional office. Review it for accuracy and completeness.

    after exam

  • recommended

    File a buddy statement if symptoms were not fully captured

    If you feel the exam did not accurately capture your symptoms, ask a family member or friend who witnesses your daily functional limitations to write a buddy statement (VA Form 21-10210) describing what they observe.

    after exam

  • optional

    Consider a Nexus letter or Independent Medical Opinion if the DBQ is inadequate

    If the completed DBQ significantly underrepresents your condition or fails to address DeLuca or Correia requirements, consult with a VSO or VA-accredited attorney about obtaining an independent medical opinion.

    after exam

Your rights during a C&P exam

  • You have the right to be treated respectfully and professionally during your C&P examination.
  • You have the right to have the examiner address DeLuca factors - pain, weakness, fatigability, and incoordination with repeated use. If the examiner does not address these, you may point out that you have additional symptoms with repeated use.
  • You have the right to have both active AND passive range of motion assessed per Correia v. McDonald (2016). You may ask if both will be measured.
  • You have the right to request a copy of the completed DBQ/examination report through MyHealtheVet or your VA Regional Office.
  • In most states you have the right to record your C&P examination. Check current VA policy and your state law. Notify the examiner before recording begins.
  • You have the right to submit a statement to VA (VA Form 21-4138 or equivalent) clarifying or supplementing the examination findings if you believe the report is inaccurate or incomplete.
  • You have the right to a fully adequate examination. If the examination is inadequate - for example, if the examiner did not measure ROM, did not address flare-ups, or did not consider DeLuca factors - you may request a new examination through your VSO or by filing a Supplemental Claim.
  • You have the right to bring a VSO representative, accredited claims agent, or accredited attorney as an observer to your C&P examination.
  • You have the right to submit buddy statements (VA Form 21-10210) from people who witness your daily limitations to supplement the examination record.
  • You have the right to an independent medical examination or opinion. If you disagree with the C&P findings, you may obtain your own medical opinion and submit it as evidence.
  • You are not required to perform any physical movement that causes you extreme pain or that you believe could cause injury. You may stop and tell the examiner why you cannot complete a movement.
  • You have the right to have your claimed condition evaluated on its worst-day presentation, not just the snapshot taken during the exam. M21-1 guidance supports considering the overall disability picture.

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.