Written by Dr. Ryan, DO · Updated September 28, 2026
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Free Viability Check →The compensation and pension (C&P) exam is often the single most important event in a veteran's knee claim. A well-prepared veteran who understands what the examiner will assess, and how to accurately report symptoms, is far more likely to receive a rating that reflects the true severity of the disability.
The examiner's job is not to treat you. Their role is to document the current severity of your condition and render an opinion on whether it is related to your military service. Those are two separate functions, and the exam addresses both.
For a veteran whose service connection is already established, the exam focuses almost entirely on severity. For a veteran whose claim is pending a nexus determination, the examiner also writes a medical opinion on causation, which is why knowing what makes a nexus letter strong matters before you walk into the exam room.
This is the core of most knee exams. The examiner uses a goniometer (a hinged angle-measuring device) to record:
These measurements map directly to the VA rating schedule under DC 5260 (flexion) and DC 5261 (extension).
The examiner is required under 38 CFR 4.59 to document painful motion throughout the range of motion arc, not just the maximum angle you can achieve. This matters because pain that limits functional range of motion can support a higher rating even if the measured range appears adequate.
A goniometer is essentially a protractor with two arms. One arm is aligned with the fixed segment (the thigh for knee measurements, the trunk for the shoulder), and the other follows the moving segment (the lower leg, the arm) through its range.
The examiner measures active range of motion (you move the joint yourself) and may also measure passive range of motion (the examiner moves it for you). Passive motion is useful for documenting the physiological capacity of the joint independent of muscle strength or pain-limited effort.
Under VA regulations and M21 manual guidance, examiners are expected to assess range of motion after repetitive use, not just at the first measurement. With musculoskeletal conditions, motion often decreases after repeated movement (fatigability), and that worsening is part of the disability. A complete examination includes:
If the report contains only a single measurement without noting whether repetitive testing was performed, and your condition causes significant fatigability, the exam may underrate the actual disability.
Ligamentous stability is evaluated through specific maneuvers:
Documented instability supports a rating under DC 5257, which ranges from 10% to 30% based on severity. If the examiner skips stability testing and your primary complaint includes instability or giving way, that's a significant gap in the exam.
McMurray's test, Thessaly's test, and the Apley grind test assess for meniscus pathology. Positive findings on these tests, combined with imaging confirming a tear, support a rating under DC 5258.
The examiner also documents:
Many joint conditions are characterized by flares: periods of significantly worse pain and function between more manageable baseline periods. The VA is required to account for the impact of flares on range of motion even if the veteran is not in a flare at the time of the exam.
If you're having a moderate day at your C&P exam but typically have severe days with markedly limited motion, say so explicitly. The examiner should document your reported flare-up limitations, and the rating should take that information into account.
When both sides of a paired joint are claimed, the examiner should document each side separately with goniometric measurements: the right knee and the left knee each get independent measurements. Bilateral conditions with separate ratings then benefit from the bilateral factor in combined rating calculations.
The same measurement principles apply to other claimed joints. Every joint has a normal range of motion in degrees, and limitation in a given direction corresponds to a rating level under that joint's diagnostic code. Reference values for commonly claimed joints:
For shoulder conditions, strength testing and impingement signs supplement the range of motion measurements, much as stability and meniscus testing do for the knee.
When service connection has not been established, the examiner is asked to provide a nexus opinion. This opinion answers whether the current condition is at least as likely as not related to an in-service event, injury, or disease.
The quality of this opinion varies enormously. Some examiners write thoughtful opinions that engage with the veteran's service history and the relevant medical literature. Others write brief, conclusory opinions that simply state "less likely than not" without adequate rationale.
A legally inadequate nexus opinion is a basis for appeal under Nieves-Rodriguez v. Peake (22 Vet App 295, 2008), which established that VA medical opinions must contain supporting rationale to be given probative weight.
To recognize whether the nexus opinion in your own exam report is adequate, compare it against these examples.
Inadequate nexus rationale: "The veteran's knee condition is less likely than not related to military service. The veteran's MOS does not document knee injuries."
This is deficient: it reaches a conclusion without explaining the medical reasoning and fails to address cumulative stress mechanisms or the veteran's occupational history.
Adequate nexus rationale: "Review of the veteran's service treatment records and personnel records reveals an infantry MOS with 12 years of active service, including documented rucking activities and field training exercises. The veteran's current diagnosis of knee osteoarthritis, confirmed by X-ray showing medial compartment narrowing and osteophyte formation, is consistent with accelerated degenerative changes caused by sustained compressive loading. It is my opinion that the current condition is at least as likely as not related to the veteran's military occupational demands."
If the nexus section in your exam report is closer to the first example, that opinion is challengeable.
Veterans should be alert to these deficiencies:
If any of these apply to your exam, the resulting rating decision may be challengeable.
Painful motion documentation and repetitive-use testing are the components most often omitted, including by contracted examiners (from QTC, LHI, VES, and similar vendors). After a C&P exam, veterans have the right to request a copy of the DBQ that was completed. Comparing it against the components described in this article shows whether required fields were left blank or required tests were marked "not performed."
Preparation is straightforward and doesn't require gaming the system. It requires accurate reporting.
For secondary knee conditions like knee pain from a service-connected back condition, the exam addresses the secondary relationship as well.
Flat Rate Nexus offers a free C&P exam preparation resource at flatratenexus.com/cp-exam-prep.html, along with physician-signed independent medical opinions and a nexus letter grader. These tools are designed to help veterans walk into the exam prepared.
Thinking about your own claim? Every nexus letter we write goes through a full physician record review, cites peer-reviewed research, and is built around the actual evidence in your case.
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