After comparing the apportioned functional impairment rating of 34 for the right shoulder with the Other Impairment rating of 10 from Table 3.1.5, the veteran gets 34 points for the shoulder. After comparing the apportioned functional impairment rating of 9 for the amputated right thumb with the Other Impairment rating of 20 from Table 3.1.3, the veteran gets 20 points for the amputation of the right thumb.
In this case the final impairment ratings for the right upper limb are 34 points and 20 points. These are to be included in the final combining of all ratings.
An Upper Limb Worksheet is provided on page 70.<br>
A separate Upper Limb Worksheet is to be used for each upper limb. If, for either upper limb, two Other Impairment ratings are applicable the Functional Impairment rating (E) is to be compared with the Other Impairment ratings in accordance with Step 8.
PART 3.2: LOWER LIMBS
Because the two lower limbs constitute a functional unit, a single functional impairment rating is calculated for both lower limbs together.
Calculation of the impairment rating for conditions of the lower limbs
Follow the steps below to calculate the impairment rating due to accepted conditions of the lower limbs:
(Each step is elaborated in the following pages.)
Step 1
Establish which joints in the lower limbs, if any, have some restriction of movement as a result of accepted conditions affecting the lower limbs.
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Step 2
(Omit this step if there is no restriction of joint movement in the limbs.)<br>Calculate the functional impairment due to restriction of the range of movement of joints in the lower limbs as a result of accepted conditions of the lower limbs.
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Step 3
Make any applicable age adjustment to the final functional impairment rating for the limbs by applying Table 3.6.1 in Part 3.6 of this chapter.
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Step 4
Calculate the functional impairment rating for the lower limbs as a whole by applying Table 3.2.2.
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Step 5
Compare the functional impairment rating for the lower limbs as a whole with the functional impairment rating due to any restricted range of movement. Take the higher of these two ratings as the final functional impairment rating for the limb.
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Step 6
Determine if any Other Impairment rating applies to the lower limbs.
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Step 7
(Omit this step if no Other Impairment rating applies to the limbs.)<br>Compare the final functional impairment rating for the limbs with any Other Impairment rating applicable to the limbs. Take the higher of these ratings.
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Step 1: Establish which joints in the lower limbs, if any, have some restriction of movement as a result of accepted conditions affecting the lower limbs.
For the purposes of assessment under this Guide, the major joints of the lower limbs are the hip, the knee and the ankle.
In addition, the joints of the toes are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the toes of one foot considered together.
Conditions such as chondromalacia patellae and torn medial meniscus may affect the range of movement of the knee. A condition such as fractured neck of femur will be likely to affect the range of movement of the hip. In cases of a fracture, the ranges of movements of the joints both proximal to and distal to the fracture site should generally be considered as joints the range of movement of which may be affected. The closer a fracture site is to a joint, the more likely it is that it will have some effect on the range of movement of that joint.
Hence, it must be determined which, if any, of both right and left:
hip;
knee;
ankle; and
toes;
potentially have loss of range of movement due to accepted conditions.
Certain vascular conditions or neurological conditions of the lower limb, such as muscle weakness, tremor, apraxia, or loss of co‑ordination may have an effect on the function of the lower limb without restricting the range of movement of any joint of the limbs. The assessment of such conditions is made under Step 4 of this Part.
Step 2: Calculate the functional impairment due to restriction of the range of movement of joints in the lower limbs as a result of accepted conditions of the lower limbs.
Single functional impairment ratings may be obtained for each of the following eight joints or sets of joints based on restriction of range of movement due to accepted conditions:
Right hip;
Left hip;
Right knee;
Left knee;
Right ankle;
Left ankle; and
Right toes;
Left toes.
These impairment ratings are obtained by applying Table 3.2.1. Such functional impairment ratings are referred to as the functional impairment rating of the relevant lower limbs based on restriction or range of movement of the right or left hip, knee, ankle, or toes 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 knee in the normal fashion, by use of the hamstring muscles, but can use a hand to bend the right knee, the right knee should be assessed as having “loss of almost all movement”.)
“Unfavourable position” and “position of function” and “flail joint” are defined at page 41.
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 3.2.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement is to 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 lower limbs may be obtained from Table 3.5.1 in Part 3.5 of this Chapter. These values are to be used in arriving at the fractional loss of range of movement when the 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 used in conjunction with Table 3.2.1.
If various impairment ratings have been obtained for lower limb joints, and Chapter 19 has been applied to them, take the highest resultant rating. This is the final functional impairment rating for the lower limbs based on loss of range of movement. If Chapter 19 did not have to be applied, then take the highest of the various impairment ratings that have been obtained for each lower limb joint. In that case, this is the final functional impairment rating for the lower limbs.
Functional Loss Table 3.2.1 Combined male and female symbol
LOSS OF MUSCULOSKELETAL FUNCTION: LOWER LIMB JOINTS
Impairment Ratings Hip Knee Ankle Toes
NIL X‑ray changes only with normal range of movement. X‑ray changes only with normal range of movement. X‑ray changes only with normal range of movement. Incomplete loss of range of movement of any toe.
TWO Ankylosis of any toe other than hallux.
FIVE Loss of about one‑quarter normal range of movement. Hallux: ankylosis in favourable position of either interphalangeal joint; or metatarsophalangeal joint.
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. Hallux: ankylosis in an unfavourable position of either interphalangeal joint and/or metatarso‑phalangeal joint.
FIFTEEN Loss of about three‑quarters normal range of movement.
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.
FOURTY 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 for each hip, knee, or ankle; and only one rating is to be selected from this table for the toes of each foot. Of these ratings only the highest is to be taken.
Ratings from this table are age adjusted (see Table 3.6.1)
Step 3: Make any applicable age adjustment to the functional impairment rating for the lower limbs based on loss of range of movement by applying Table 3.6.1 in Part 3.6 of this chapter.
The functional impairment rating based on loss of range of movement obtained in Step 2 is to be age adjusted using Table 3.6.1.
For veterans aged 46 to 55 years at the relevant time, age adjustment will not result in any change of the impairment rating. For veterans aged 56 years and older at the relevant time, the impairment rating will be reduced by an amount dependent upon their age. For veterans aged 45 years or less at the relevant time, the impairment rating will be increased by an amount dependent upon their age.
Total loss of function of each lower limb is considered to be 50 per cent impairment of the whole person. Amputation of a lower limb at the hip joint, or total loss of the use of a lower limb is equivalent to 50 impairment points.
With the exception of a hindquarter amputation, no condition or combination of conditions causing impairment in a lower limb shall receive an impairment rating exceeding 50 points.
In the case of a veteran aged 45 years or less, if the application of age adjustment to the functional impairment rating results in an impairment rating higher than 50 impairment points, the functional impairment rating for that lower limb is to be taken as 50 impairment points and not as the higher rating obtained by applying Table 3.6.1.
Step 4: Calculate the functional impairment rating for the lower limbs as a whole by applying Table 3.2.2.
Table 3.2.2 measures the loss of function relating to the two lower limbs together. Only one rating is to be given from this table 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.
Impairment ratings derived from Table 3.2.2 are not to be age adjusted by applying Table 3.6.1. The reason is that many of the criteria within the table are age‑dependent: they compare veterans with others of the same age.
Table 3.2.2 is the only relevant table if the use of lower limbs 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 3.2.2.
Functional Loss Table 3.2.2 Combined male and female symbol
LOSS OF MUSCULOSKELETAL FUNCTION: LOWER LIMBS (BASED ON USE OF BOTH LOWER LIMBS TOGETHER)
Impairment Ratings Criteria
NIL Walks in a manner normal for age on a variety of different terrains and at varying speeds. Sciatic pain — occasional twinges but no effect on walking most of the time.
FIVE Walks with intermittent difficulty, such as locking or giving way, without falling. Caution needed on steps and uneven ground, or when running. Has intermittent pain from weight‑bearing, ie, not all the time, or only after weight‑bearing for some time. Sciatic pain occurring frequently: present some of the time when walking.
TEN Walks at normal pace on level ground, but has constant difficulty up and down steps and over uneven ground. Need for a walking stick may be manifested: Pain and/or slowness; or constant pain from weight‑bearing. Pain restricts walking to 500 m or less, at a slow to moderate pace (4 km/h). Can walk further after resting. Sciatic pain daily — present most of the time during walking.
TWENTY Walks at moderately reduced pace in comparison with peers on flat ground; and is unable to manage stairs or ramps without rails; or rise from the sitting position without the assistance of one hand. Pain restricts walking (4 km/h) to 250 m or less at a time. Can walk further after resting.
THIRTY Walks at significantly reduced pace in comparison with peers and: legs give way frequently, resulting in falls. Can walk more efficiently with a brace or an artificial limb; or is unable to negotiate stairs without personal assistance; or is unable to rise to standing position without the assistance of both hands. Pain restricts walking (4 km/h) to 100 m or less at a time. Can walk further after resting.
FORTY Walks at greatly reduced pace in comparison with peers, is unable to negotiate kerbs, gutters or uneven ground, and is restricted to walking in home and around block. Probably needs a walking aid; or finds transfer difficult without personal assistance. Pain restricts walking (4 km/h) to 50 m or less at a time. Can walk further after resting.
FIFTY Restricted to walking in and around home; and requires quad stick, crutches or similar walking aid; is unable to transfer without personal assistance.
SIXTY Restricted to walking in and around home. Can walk only with personal assistance, or with a walking aid such as a pickup frame.
SEVENTY Unable to walk or stand. Mobile only in a wheelchair.
Only one rating is to be selected from this table for any condition or combination of conditions.
No age adjustment permitted for this table
For the purposes of Table 3.2.2 “transfer” means:
a move from one seat to another;
a move from sitting to standing;
a move on and off the toilet; or
a move in and out of bed.
Step 5: Compare the functional impairment rating for the lower limbs as a whole with the functional impairment rating due to any restricted range of movement. Take the higher of these two ratings as the final functional impairment rating for the limbs.
After applying Chapter 19 (Partially Contributing Impairment) in Step 4, the functional impairment rating from loss of range of movement is to be compared with the functional impairment for the use of the limbs as whole.
The higher of these two ratings is the final functional impairment rating for the limbs.
Step 6: Determine if any Other Impairment rating applies to the lower limbs.
There are two Other Impairment tables relating to the lower limbs:
Table 3.2.3 — Amputations of Lower Limbs; and
Table 3.2.4 — Lower Limbs ‑ Joint Replacements.
Step 7: Compare the final functional impairment rating for the lower limbs with any Other Impairment rating applicable to the lower limbs. Take the higher of these.
Substep 7A
When the only Other Impairment rating relates to amputations.<br>The final functional impairment rating of the lower limbs (obtained in Step 5) is to be compared with the Other Impairment rating or ratings from Table 3.2.3.<br>The higher of the two ratings is then taken as the total final impairment rating for the lower limbs.
Other Impairment Table 3.2.3 Combined male and female symbol
AMPUTATIONS OF LOWER LIMBS
Impairment Ratings Criteria
NIL No amputation of any toes.
TWO Amputation of single toe other than great toe.
FIVE Amputation of 2 to 4 toes on foot excluding great toe.
TEN Amputation of great toe. Amputation of great toe and one other toe on one foot.
FIFTEEN Amputation of great toe and 2 or more other toes on one foot. Mid‑metatarsal amputation.
TWENTY Mid‑tarsal amputation.
THIRTY Amputation at ankle. Amputation below knee with functional stump.
FORTY Amputation above knee with functional stump. Disarticulation at knee. Amputation below knee with short stump (that is 7.5 cm or less below intercondylar notch).
FIFTY Disarticulation at hip joint. Amputation above knee with short stump (that is 7.5 cm or less below tuber ischii).
SIXTY Hemipelvectomy.
If applicable, ratings may be given from this table for each of the lower limbs.
No age adjustment permitted for this table
Other Impairment Table 3.2.4 Combined male and female symbol
LOWER LIMBS: JOINT REPLACEMENTS AND REALIGNMENTS
Impairment Ratings Criteria
NIL No joint replacement or realignment in lower limbs.
FIVE Tibial osteotomy
TEN Total knee replacement. Total hip replacement
Where applicable, up to four ratings may be made from this table — one rating for each knee and one for each hip.
No age adjustment permitted for this table
Example:
A veteran has an amputation of his right foot as the only accepted condition of his lower limbs which upon investigation is found to fit the description of “amputation below knee with functional stump”.
By following steps 1 to 6 inclusive, a rating will have been selected:
from Table 3.2.2:
probably 10 to 30 impairment points (depending on the severity of the effect of the amputation on the particular veteran);
from Table 3.2.3:
30 impairment points.
These two ratings are to be compared and the veteran receives the higher as the total final impairment rating for his amputation of right foot.
If multiple accepted conditions are responsible for the impairment of the lower limbs, the situation will be more complicated and may require applying Chapter 20 (Apportionment).