Overall guidance on evaluating muscle injuries
💡 This section jumps right into dense descriptions of how various injuries are rated. The use of the words slight, moderate, moderately severe and severe are defined.
💡 Paragraph "A" above creates a rebuttable presumption. If the injury is an open comminuted fracture with muscle or tendon damage it will be rated as severe (the highest rating for the muscle group) unless evidence shows the damage is minimal. A single unhelpful opinion should not be enough to show minimal damage, and any question as to whether the damage is "more than minimal" should be resolved in the veteran's favor.
Open Comminuted fracture means two things: 1) open means that your skin has broken from the wound. 2) Comminuted means the bone has broken in more than one place. There is a reasonable question as to whether paragraph (a) should apply to a "closed" comminuted fracture (where the skin didn't break but the bone did and the muscle or tendon damage is equivalent). In these cases, the argument should be made that paragraph (a) most closely reflects the situation and "severe" should be assigned.
(b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged.
A through-and-through injury is defined by the VA's internal manual under M21-1 Part V, Subpart iii, Chapter 1 Section E(1)(a):
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Through and through wound
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Injuring instrument enters and exits one or multiple muscle groups.
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Two wounds result
Reference: For more information on the potential for multiple through and through wounds from a single injuring instrument, see Jones v. Principi, 18 Vet.App. 248 (2004).
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(c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.
Importantly - these are also signs of significant neurological injuries, and so, any injury that may involve both the muscles and the nerves should be considered under both Rating Schedules to assess the more beneficial rating. The remaining sections of this regulation get into specifics on the rating for specific muscles and the evidence needed to support various ratings.
(d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows:
(1) Slight disability of muscles—(i) Type of injury. Simple wound of muscle without debridement or infection.
(ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section.
(iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue.
(2) Moderate disability of muscles—(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection.
💡 Note that the language does not accommodate injuries not from projectiles. Here the VA's internal advice provides the following:
Generally, apply 38 CFR 4.73 to muscle injuries such as those arising from shrapnel, GSWs, or other projectiles or similar foreign objects entering the muscle from outside the body since the criteria for the evaluation weigh heavily on the type of wound, treatment, and current manifestations of the wound.Generally, a disability such as that arising from injuries such as muscle strains, tears not resulting from injury by a foreign object entering the muscle, or muscle atrophy due to a SC joint or nerve injury should be evaluated under an appropriate DC based on associated functional impairment.
M21-1, Part V, Subpart iii, Chapter 1, Section E.2.L- Evaluating Muscle Disabilities Not Involving Shrapnel, GSWs, or Other Projectile-Type Injury
In other words, veteran's should look to both the relevant muscle injury diagnostic code and the neurological and other ratings to find the rating that most closely reflects the nature of the injury.
(ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles.
(iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side.
(3) Moderately severe disability of muscles—(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring.
(ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements.
(iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment.
(4) Severe disability of muscles—(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring.
(ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements.
(iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability:
(A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile.
(B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle.
(C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests.
(D) Visible or measurable atrophy.
(E) Adaptive contraction of an opposing group of muscles.
(F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle.
(G) Induration or atrophy of an entire muscle following simple piercing by a projectile.