Certain vascular conditions or neurological conditions of the upper limb, such as muscle weakness, tremor, apraxia, and loss of co‑ordination, may have an effect on the function of the upper limb without restricting the range of movement of any joint of the limb. The assessment of such conditions is to be made under Step 4 of this Part.
Step 3: Calculate the functional impairment due to restriction of range of movement of joints in the right upper limb as a result of accepted conditions of the right upper limb.
Single functional impairment ratings may be obtained for each of the following four joints or sets of joints based on restriction of range of movement due to accepted conditions:
shoulder;
elbow;
wrist; and
thumb and fingers.
These impairment ratings are to be obtained by applying Table 3.1.1. Such functional impairment ratings are referred to as the functional impairment rating of the upper limb based on restriction of range of movement of the shoulder, elbow, wrist, or thumb and fingers respectively.
The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.
The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non‑affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right elbow in the normal fashion, by use of the right biceps, but can use the left hand to bend the right elbow, the right elbow should be assessed as having “loss of almost all movement”.)
The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.1.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement must be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.
The average ranges of movement of various normal joints of the upper limb may be obtained from Table 3.5.1 in Part 3.5. These values are to be used in arriving at the fractional loss of range of movement when the actual movements of a joint are known in degrees.
If non‑accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.1.
For the purposes of this chapter:
“position of function” means the position that interferes least with the total function of the limb or the spine; and
“unfavourable position” means a position that is significantly different from the position of function; and
“flail joint” means a joint that is completely unstable in all directions.
Functional Loss Table 3.1.1 Combined male and female symbol
LOSS OF MUSCULOSKELETAL FUNCTION: UPPER LIMB JOINTS
Impairment Ratings Shoulder Elbow Wrist Thumb and Fingers
NIL No abnormality. X‑ray changes only with normal range of movement. No abnormality. X‑ray changes only with normal range of movement. No abnormality. X‑ray changes only with normal range of movement. No abnormality. X‑ray changes only with normal range of movement.
FIVE Loss of about one‑quarter normal range of movement. Ankylosis in any position of joints of 4th or 5th finger. Ankylosis in any position of function of any joints of 2nd or 3rd finger.
TEN Loss of about one‑quarter normal range of movement. Loss of about one‑quarter normal range of movement. Loss of about one‑half normal range of movement. Ankylosis in an unfavourable position of any or all joints of 2nd and 3rd finger. Thumb: loss of almost all movement or complete ankylosis of any or all joints (in position of function).
FIFTEEN Loss of about three‑quarters normal range of movement. Thumb: ankylosis of any or all joints in an unfavourable position.
TWENTY Loss of about one‑half normal range of movement. Loss of about one‑half normal range of movement. Loss of almost all movement, or complete ankylosis in position of function.
THIRTY Loss of about three‑quarters normal range of movement. Loss of about three‑quarters normal range of movement. Ankylosis in an unfavourable position, or a flail joint.
FORTY Loss of almost all movement, or complete ankylosis in position of function. Loss of almost all movement, or complete ankylosis in position of function.
FIFTY Ankylosis in an unfavourable position, or a flail joint. Ankylosis in an unfavourable position, or a flail joint.
Only one rating is to be selected from this table fro each shoulder, elbow, or wrist; and only one rating is to be selected from this table for the thumb and fingers together. Of these ratings only the highest is to be taken for each side.
Ratings from this table are age adjusted (see Table 3.6.1)
Step 4: Calculate the functional impairment rating for the right upper limb as a whole using Table 3.1.2.
Table 3.1.2 measures the loss of function relating to the upper limb as a whole. Only one rating is to be given from this table, for the right upper limb, for any condition or combination of conditions. To attract a particular rating, the degree of impairment must be greater than that described at all lower levels.
Table 3.1.2 is the only relevant table if the use of an upper limb is restricted by vascular conditions or neurological conditions, such as muscle weakness, tremor, apraxia, loss of co‑ordination, fatigue or pain, and when no condition affecting the range of movement of a joint is present.
If non‑accepted conditions contribute to the loss of function, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.2.
Step 5: Compare the impairment rating for loss of function of the right upper limb with the impairment rating from any restricted range of movement. Take the higher of these two as the final functional impairment rating for the right upper limb.
After the application of Chapter 19 (Partially Contributing Impairment) in Step 3, the functional impairment rating from loss of range of movement is to be compared with the functional impairment for the use of the limb as whole.
The higher of these two ratings is then taken as the final functional impairment rating for the right upper limb.
Step 6: Make any applicable age adjustment to the final functional impairment rating for the right upper limb by applying Table 3.6.1 in Part 3.6 of this chapter.
The functional impairment rating obtained in Step 4 is to be age adjusted by applying Table 3.6.1.
Total loss of function of each upper limb is considered to be 60 per cent impairment of the whole person. Amputation of an arm at the shoulder joint, or total loss of use of an arm is equivalent to 60 impairment points.
With the exception of a forequarter amputation, no condition or combination of conditions affecting an arm shall receive an impairment rating exceeding 60 points.
In the case of a veteran aged 45 years or less, if the application of age adjustment to the functional impairment rating of an accepted condition affecting the right upper limb results in an impairment rating higher than 60 impairment points, the functional impairment rating for the right upper limb is to be taken as 60 impairment points and not at the higher rating obtained by applying Table 3.6.1.
Functional Loss Table 3.1.2 Combined male and female symbol
LOSS OF MUSCULOSKELETAL FUNCTION: (BASED ON USE OF LIMB AS A WHOLE)
Impairment Ratings Criteria
NIL Can use limb efficiently for normal tasks and without undue fatigue.
TWO Can use limb efficiently for normal tasks but with excessive fatigue towards the end of the day.
FIVE Can use limb efficiently for normal tasks without excessive fatigue for no more than half an hour.
TEN Can use limb reasonably well in most circumstances, but frequent difficulties are manifested by:‑ minor loss of digital dexterity causing handwriting changes, or difficulty in manipulation of small or fine objects, or‑ minor loss of grip strength causing difficulty in gripping moderately heavy to heavy objects. Can use limb efficiently for normal tasks without excessive fatigue for no more than ten minutes.
FIFTEEN Can use limb reasonably well in most circumstances, but frequent difficulties are manifested by: ‑ minor loss of digital dexterity causing handwriting changes, or difficulty in manipulation of small or fine objects, and ‑ minor loss of grip strength causing difficulty in gripping moderately heavy to heavy objects.
TWENTY Can use limb reasonably well in some circumstances, but with more noticeable difficulty manifested by either or both of:‑ minor loss of digital dexterity and reduced grip strength causing difficulty in manipulation of larger objects, or‑ major loss of digital dexterity causing marked difficulty in handwriting or manipulation of everyday domestic objects.
THIRTY Can use limb reasonably well in a few circumstances only. Use of limb is otherwise inefficient, with increasing difficulty for self‑care activities. Poor digital co‑ordination and markedly reduced grip strength in, eg, lifting light objects. Problems with dressing, feeding or writing.
FORTY Uses limb inefficiently in all circumstances. Use of limb subject to major limitations, capable of light grip only. Aids, eg, splints, required for everyday activities such as writing and eating.
FIFTY Has only some movement against gravity at elbow, shoulder or wrist.
SIXTY Unable to use upper limb at all.
Only one rating is to be selected from this table for each upper limb, for any condition or combination of conditions.
Ratings from this table are age adjusted (see Table 3.6.1)
Step 7: Determine if any Other Impairment rating applies to the right upper limb.
There are three Other Impairment tables relating to the upper limb. These are:
Table 3.1.3 — Amputations of Fingers and Thumb; and
Table 3.1.4 — Amputations of Upper Limb; and
Table 3.1.5 — Dislocation of Shoulder.
Not more than one rating may be selected from either Table 3.1.3 or Table 3.1.4, if the veteran has an amputation affecting the right upper limb.
An additional rating may be selected from Table 3.1.5 if it is applicable to the right shoulder.
If no ratings from Tables 3.1.3 or 3.1.4 or 3.1.5 apply to the right upper limb, then the functional impairment rating obtained under Step 6 is the final functional impairment rating for the right upper limb.
Step 8: Compare the final functional impairment rating for the right upper limb with any Other Impairment rating applicable to the right upper limb. Take the higher of these ratings.
The final functional impairment rating obtained in Step 6 is to be compared with the impairment rating for that limb obtained in Step 7 (if any).
The higher of the two ratings is then to be taken as the total final impairment rating for the right upper limb.
If multiple accepted conditions are responsible for the impairment of an upper limb, the situation will be more complicated and may require applying Chapter 20 (Apportionment).
If the veteran has received a rating from either Table 3.1.3 or Table 3.1.4 and also a rating from Table 3.1.5 the substeps below are to be followed.
Substep 8A
The functional impairment rating for the right upper limb, obtained in Step 6, is to be apportioned into two or three parts, as appropriate, by applying Chapter 20 (Apportionment). The parts are:<br> one part corresponding to the impairment due to amputations affecting the right upper limb;<br> one part corresponding to the impairment due to dislocation of the right shoulder;<br> one part corresponding to the impairment (if any) of the right upper limb due to all causes other than dislocation of shoulder and amputations.<br>
Other Impairment Table 3.1.3 Combined male and female symbol
AMPUTATIONS OF FINGERS AND THUMB
Impairment Ratings Criteria
NIL No amputation of fingers or thumb.
TWO Amputation of little finger of one hand.
FIVE Amputation of ring finger of one hand.
TEN Amputation of index finger of one hand Amputation of middle finger of one hand. Amputation of ring and little fingers of one hand.
FIFTEEN Amputation of index and little fingers of one hand. Amputation of middle and little fingers of one hand. Amputation of index and ring fingers of one hand. Amputation of middle and ring fingers of one hand.
TWENTY Amputation of thumb of one hand. Amputation of index and middle fingers of one hand Amputation of index, ring, and little fingers of one hand. Amputation of middle, ring, and little fingers of one hand.
TWENTY‑FIVE Amputation of thumb and ring finger of one hand. Amputation of thumb and little finger of one hand. Amputation of index, middle, and ring fingers of one hand. Amputation of index, middle, and little fingers of one hand.
THIRTY Amputation of thumb and index finger of one hand. Amputation of thumb and middle finger of one hand. Amputation of thumb, index and little fingers of one hand. Amputation of thumb, middle and little fingers of one hand. Amputation of thumb, ring, and little fingers of one hand. Amputation of index, middle, ring and little finger, but not thumb, of one hand.
THIRTY‑FIVE Amputation of thumb, index, and middle fingers of one hand. Amputation of thumb, index and ring fingers of one hand. Amputation of thumb, middle and ring fingers of one hand. Amputation of thumb, index, ring, and little fingers of one hand. Amputation of thumb, middle, ring, and little fingers of one hand.
FORTY Amputation of thumb, index, middle, and ring fingers of one hand. Amputation of thumb, index, middle, and little fingers of one hand.
FORTY‑FIVE Amputation of index, middle, ring, and little fingers, and thumb, of one hand.
One rating may be given from this table for each side, as applicable.
No age adjustment permitted for this table
Other Impairment Table 3.1.4 Combined male and female symbol
AMPUTATIONS OF UPPER LIMB
Impairment Ratings Criteria
NIL No amputations involving the upper limb.
FIFTY Mid‑carpal amputation of one hand. Mid‑metacarpal amputation of one hand. Disarticulation at wrist joint. Amputation of forearm distal to biceps tendon insertion.
SIXTY Amputation of forearm proximal to biceps tendon insertion. Disarticulation at elbow. Amputation between deltoid insertion and elbow. Amputation above deltoid insertion. Disarticulation at shoulder.
SEVENTY Forequarter amputation.
One rating may be given from this table for each upper limb, as applicable.
No age adjustment permitted for this table
Other Impairment Table 3.1.5 Combined male and female symbol
DISLOCATION OF SHOULDER
Impairment Ratings Criteria
NIL No recurrent dislocation of shoulder. Dislocation of shoulder on a single occasion.
TWO Recurrent dislocation of shoulder surgically corrected.
FIVE Recurrent dislocation of shoulder not surgically corrected.
TEN Dislocation of shoulder resulting in prophylactic restriction of movement.
Only one rating is to be selected from this table for each shoulder.
No age adjustment permitted for this table
Substep 8B
Compare the apportioned functional impairment rating corresponding to the impairment due to amputations affecting the right upper limb (obtained in substep 8A) with the Other Impairment rating from either Table 3.1.3 or Table 3.1.4 (obtained in Step 7). The higher of these two ratings is to be selected.
Substep 8C
Compare the apportioned functional impairment rating corresponding to the impairment due to dislocations of the right shoulder (obtained in substep 8A) with the Other Impairment rating from Table 3.1.5 (obtained in Step 7). The higher of these two ratings is to be selected.
Substep 8D
The veteran’s accepted right upper limb condition(s) will receive (up to) three impairment ratings:<br> The functional impairment rating corresponding to the impairment of the right upper limb due to all causes other than amputations and dislocation of shoulder (if such a rating is obtained in substep 8A);<br> The impairment rating obtained in substep 8B; and<br> The impairment rating obtained in substep 8C.<br>These ratings are not to be combined at this stage but are to be included in the final combining of all ratings.
Examples
Example 1
A veteran has an amputation of the right thumb as the only accepted disability of the right upper limb.
By following steps 1 to 7 inclusive, a rating will have been selected
from Table 3.1.2:
probably 20 to 40 impairment points (depending on the severity of the effect on the hand)
from Table 3.1.3:
20 impairment points.
These two ratings are compared and the veteran receives the higher as the final impairment rating for the right upper limb.
Example 2
A veteran has an amputation of his right thumb and dislocation of the right shoulder as the only accepted conditions of the right upper limb.
By following steps 1 to 7 inclusive, a rating will have been selected
from Table 3.1.2:
say, 40 impairment points (the veteran can use the right upper limb reasonably well in a few circumstances only)
from Table 3.1.3:
20 impairment points; and
from Table 3.1.5:
10 impairment points.
Medical evidence shows that the incapacity of the veteran’s right upper limb is due 80% to the shoulder condition and 20% to the amputated thumb. Apportioning the 40 impairment points in the ratio of 4:1, 34 points are obtained for the shoulder, and 9 points for the thumb (Table 20.1).