GARP Chapter 3: Spine and Limbs — Why Two Bad Knees Only Get One Rating

This is the chapter almost every veteran meets. Backs, necks, shoulders, knees, ankles, hips — the musculoskeletal legacy of service is assessed here, and Chapter 3 is by a wide margin the largest chapter in the Guide.

It is also the chapter where the difference between a careful assessment and a careless one is worth the most points. Three features do the damage: the two lower limbs are rated as a single unit, only the highest joint rating counts, and age adjustment can move a rating by 20 points in either direction.

This is part of our series working through the GARP. Start with what the GARP is, the chapter map, Chapter 1 and Chapter 2.

How the chapter is built

Six parts:

3.1 Upper limbs · 3.2 Lower limbs · 3.3 Spine
3.4 Resting joint pain · 3.5 Ranges of joint movement · 3.6 Age adjustment

One boundary to note at the outset: Chapter 3 assesses the motor function of the spine and limbs. Sensory loss goes to Chapter 5 (Neurological Impairment), and so do impairments of the spinal cord as opposed to the spinal column.

Every part follows the same shape. Rate the joints on range of movement. Rate the limb or spine on overall function. Take the higher. Age adjust. Then check the Other Impairment tables and take the higher again.

Range of movement: what actually gets measured

Three rules govern every range-of-movement rating in this chapter, and each one costs veterans points when it is not understood.

It is estimated to the nearest quarter of normal. Not to the degree. The tables are built in quarters — loss of about one-quarter, one-half, three-quarters, almost all. Table 3.5.1 supplies the average normal ranges (shoulder abduction 150°, elbow flexion 150°, hip flexion 100°, knee flexion 150°, cervical flexion 45°, thoracolumbar flexion 90°, and so on) for converting measured degrees into a fraction. A goniometer is not essential; the Guide says visual assessment is usual.

It is active range of movement. The range through which you can move the joint using only the muscles whose normal job that is. The Guide's own example is unambiguous: if you cannot flex your right elbow with your right biceps but can bend it with your left hand, the elbow is assessed as having "loss of almost all movement". Being able to move a joint with your other hand does not reduce the rating.

Functionally important planes carry more weight. Table 3.5.1 marks them with an asterisk — shoulder abduction, forward elevation and external rotation; elbow flexion; wrist dorsiflexion; hip flexion, abduction and internal rotation; knee flexion; ankle dorsiflexion; cervical flexion and rotation; thoracolumbar flexion. A global assessment averages all planes but emphasises those. The angles in brackets are the position of function, which is what decides whether an ankylosis is "favourable" or "unfavourable" — and that distinction is worth 10 to 20 points.

Part 3.1: upper limbs

Each upper limb is rated separately — right and left get their own ratings, which later combine through Chapter 18.

Four joints or joint groups are considered: shoulder, elbow, wrist, and thumb and fingers together (one rating for all digits combined). Table 3.1.1 converts loss of movement into points, and the scales differ by joint. Loss of about one-quarter of normal is 10 at the shoulder and elbow but only 5 at the wrist. Loss of about half is 20 at shoulder and elbow, 10 at the wrist. Complete ankylosis in the position of function is 40 at shoulder and elbow; ankylosis in an unfavourable position, or a flail joint, is 50.

Only the highest of those joint ratings is taken for each side. A veteran with a bad shoulder and a bad wrist on the same arm does not get both.

Table 3.1.2 then rates the limb as a whole, on a scale from NIL to 60, and it is the only relevant table where the limb is restricted by vascular or neurological causes — muscle weakness, tremor, apraxia, loss of co-ordination, fatigue or pain — with no joint restriction. Its criteria are practical: can use the limb efficiently but with excessive fatigue by day's end (2); efficiently for no more than half an hour (5); for no more than ten minutes, or minor loss of dexterity or grip (10); through to needing splints for writing and eating (40), only movement against gravity (50), and unable to use the limb at all (60).

The higher of the range-of-movement rating and the whole-limb rating is taken, then age adjusted.

Total loss of function of an upper limb is 60 points — the same as amputation at the shoulder. With the sole exception of a forequarter amputation (70), no condition or combination affecting an arm may exceed 60. And for anyone aged 45 or under, if age adjustment pushes the figure above 60, it is capped back to 60.

Three Other Impairment tables follow: amputations of fingers and thumb (3.1.3, up to 45 points), amputations of the upper limb (3.1.4, 50 to 70), and dislocation of shoulder (3.1.5). That last one is small but frequently missed: a single dislocation rates NIL, recurrent dislocation surgically corrected rates 2, recurrent dislocation not surgically corrected rates 5, and dislocation resulting in prophylactic restriction of movement rates 10. If you have stopped reaching overhead because your shoulder comes out, that is a named criterion.

Part 3.2: lower limbs — the one that surprises people

Here is the rule that catches nearly everyone:

"Because the two lower limbs constitute a functional unit, a single functional impairment rating is calculated for both lower limbs together."

Not one rating per leg. One rating for both legs. A veteran with two destroyed knees receives one lower-limb functional rating, not two. This single sentence is the most common source of disappointment in a permanent impairment result, and it is worth understanding before the assessment rather than after the decision.

Eight joints are considered — right and left hip, knee, ankle and toes — each rated on Table 3.2.1, and again only the highest is taken. The scales mirror the upper limb: quarter loss is 10 at hip and knee, 5 at the ankle; half loss is 20 at hip and knee, 10 at the ankle; ankylosis in an unfavourable position or a flail joint is 50 at hip and knee.

Table 3.2.2 rates both lower limbs together on walking, and this is where most veterans' real impairment lives. Its criteria are concrete and worth knowing before you are asked:

5 — intermittent difficulty such as locking or giving way without falling; caution needed on steps and uneven ground; intermittent pain from weight-bearing; sciatic pain present some of the time when walking.
10 — normal pace on the level but constant difficulty on steps and uneven ground; a walking stick may be needed; pain restricts walking to 500 m or less at 4 km/h; daily sciatic pain present most of the time when walking.
20 — moderately reduced pace; unable to manage stairs or ramps without rails, or to rise from sitting without one hand; walking restricted to 250 m.
30 — significantly reduced pace; legs give way frequently causing falls; unable to negotiate stairs without personal assistance; unable to rise without both hands; walking restricted to 100 m.
40 — greatly reduced pace, unable to negotiate kerbs or uneven ground, restricted to home and around the block; walking restricted to 50 m.
50 to 70 — through quad stick or crutches, inability to transfer without assistance, to wheelchair-only mobility.

Note the distance thresholds: 500 m, 250 m, 100 m, 50 m. If nobody asks you how far you can walk before pain stops you, and nobody records the answer, the assessment cannot use this table properly. Note also that "transfer" is defined — moving from one seat to another, sitting to standing, on and off the toilet, in and out of bed. Table 3.2.2 permits no age adjustment.

Then the Other Impairment tables: amputations (3.2.3, from 2 points for a single lesser toe to 60 for hemipelvectomy) and joint replacements and realignments (3.2.4) — tibial osteotomy 5, total knee replacement 10, and so on. A veteran who has had a knee replaced and now walks reasonably well may still hold a rating under 3.2.4.

Total loss of function of a lower limb is 50 per cent whole-person impairment.

Part 3.3: spine

The spine is assessed in two separate parts — cervical, and thoracolumbar — each with its own rating, and the whole step sequence is run twice.

Table 3.3.1 rates spinal movement, and the two columns are scaled differently. For the cervical spine: half loss is 10, three-quarters 15, almost all movement or ankylosis in the position of function 20, ankylosis in an unfavourable position 30. For the thoracolumbar spine: quarter loss 10, half 20, three-quarters 30, almost all 40, and ankylosis in an unfavourable position or an unstable joint 50.

The Guide acknowledges that thoracic movement cannot be measured independently of lumbar. If only the thoracic spine is rated, all movements are measured but rotation is emphasised; if only the lumbar, forward flexion is emphasised. Either way only one thoracolumbar rating is given.

Table 3.3.2 is the one veterans should know about. It rates thoracolumbar function "that is not adequately measured by loss of range of movement" — in other words, the back that still bends but cannot tolerate being used:

2 — occasional difficulties in prolonged sitting or standing.
5 — difficulties in sitting or standing generally resulting in pain or undue fatigue by the end of the day.
10 — pain or undue fatigue within half an hour, requiring frequent changes of posture.
15 — pain or undue fatigue within five minutes, requiring very frequent changes of posture.

It applies only to the thoracolumbar spine, never the cervical. Its rating is compared with the Table 3.3.1 rating and the higher taken — they are never combined.

Crush fractures are the spine's Other Impairment table (3.3.3): less than 25% compression rates 2; a single vertebra at 25–50% rates 5; a single vertebra over 50%, or two or more vertebrae each over 25%, rates 10.

Two things make the spine unusual. First, there is no maximum spinal rating. The Guide explains why: limb maxima derive from the rating for amputating the limb, "but there is no such thing as amputation of the spine." Second, and importantly, a spinal condition's effects on the limbs are assessed as well and combined — a rating from Table 3.3.1 may be combined with one from Table 3.1.2 or 3.2.2, and any sensory loss is separately assessed under Chapter 5.

Part 3.4: resting joint pain — an additional rating

This is the only table in the chapter that gives an additional rating rather than competing with another. It applies to frequent joint pain that continues after the joint is no longer in use — knees still aching well after you stopped walking, shoulders still aching after hanging out the washing. Pain that limits range of movement or walking distance is already counted elsewhere and is not double-rated here.

2 — pain often present at rest but mild; or back pain limiting comfortable sitting to under 30 minutes.
5 — pain often present at rest that improves after several hours' rest or responds to medication or therapy; or back pain limiting comfortable sitting to under 10 minutes.
10 — severe pain often present at rest that does not respond adequately to medication or therapy.
15 — severe pain always present at rest, not adequately responsive, and regularly interfering with sleep.

One selection only, across every joint, and no age adjustment. Sciatic pain is excluded — it is rated on Table 3.2.2 instead.

Fifteen points for pain that wakes you is not a small number, and it is claimed far less often than it should be, because veterans describe their pain in terms of what it stops them doing rather than whether it is there at rest.

Part 3.6: age adjustment — the largest single swing in the chapter

Table 3.6.1 converts a measured musculoskeletal rating into an age-adjusted one, across seven age bands: under 36, 36–45, 46–55, 56–65, 66–75, 76–85, and over 85.

46–55 is the neutral band — no change. Under that, ratings go up; above it, ratings come down. The effect is substantial. A measured rating of 50 becomes 60 for someone under 36, stays 50 at 46–55, and falls to 30 for someone over 85. A rating of 20 becomes 24 under 36 and 12 over 85.

The logic is that the same physical loss costs a younger person more of their remaining function. The practical consequence is that your age at the relevant time materially changes your result, which is one more reason not to leave an assessment sitting.

Critically, it does not apply everywhere. Table 3.6.1 applies only to ratings from Tables 3.1.1, 3.1.2, 3.2.1, 3.3.1 and 3.3.2. It expressly does not apply to Tables 3.1.3, 3.1.4, 3.2.2, 3.2.3, 3.2.4, 3.3.3 or 3.4.1 — so the walking table, the amputation tables, joint replacements, crush fractures and resting joint pain are all unadjusted.

What this means in practice

Know that your legs are one unit. Two bad knees produce one lower-limb functional rating. If you expected two, the disappointment is in the Guide, not in the assessment.

Only your worst joint counts on each side. Which makes accurate measurement of the worst joint far more important than a quick sweep of all of them.

Know your walking distance before you go in. 500 m, 250 m, 100 m, 50 m are the thresholds in Table 3.2.2, and they are worth 10, 20, 30 and 40 points. Pace it out. The answer "not far" cannot be rated.

Describe your back by time, not just movement. Table 3.3.2 asks how long you can sit or stand before pain or undue fatigue — half an hour is 10 points, five minutes is 15. A back that still bends can still rate.

Mention resting pain, and mention sleep. Part 3.4 gives an additional rating on top of everything else, and its top criterion turns on pain that regularly interferes with sleep.

Do not demonstrate movement with your other hand. Active range is what is measured. Helping the joint along understates your impairment.

Get the non-accepted contribution addressed. Chapter 19 is applied wherever non-accepted conditions contribute to a loss of movement or function. Better done on evidence than on assumption.

Frequently asked questions

Do I get a separate rating for each knee?

No. The Guide treats both lower limbs as a single functional unit and calculates one functional impairment rating for them together. Upper limbs are different — each arm is rated separately.

My hip, knee and ankle are all affected. Do they add up?

No. Only the highest of the joint ratings is taken. The whole-limb table (3.2.2) may produce a higher figure, and if it does, that is the one used.

What if my back moves fine but I cannot sit for long?

That is precisely what Table 3.3.2 is for. Pain or undue fatigue within half an hour rates 10; within five minutes, 15. It applies to the thoracolumbar spine only.

Is my neck rated with my back?

No. Cervical and thoracolumbar are assessed separately, each with its own rating, and the cervical scale is different from the thoracolumbar one.

Does age really change my rating?

Substantially. 46–55 is neutral; under that ratings increase and above it they decrease. A measured 50 becomes 60 under 36 and 30 over 85. It applies only to Tables 3.1.1, 3.1.2, 3.2.1, 3.3.1 and 3.3.2.

Can I claim for pain on its own?

Resting joint pain gives an additional rating of up to 15 points under Table 3.4.1, provided the pain persists after the joint is no longer in use. Pain that limits movement or walking is already counted in the other tables and is not rated twice.

I had a knee replacement and walk well now. Is it worth anything?

Yes. Total knee replacement carries a rating under Table 3.2.4 regardless of how well you now walk, and that rating is compared with your functional rating with the higher taken.

What about numbness or pins and needles down my leg?

Sensory loss is not assessed in Chapter 3. It goes to Chapter 5, and it is assessed as well as the spinal rating, not instead of it.

Next in this series

Chapter 4: emotional and behavioural impairment — how PTSD, depression and anxiety are actually rated.

Talk to us

If you have a permanent impairment assessment coming up and want it done by a doctor who applies this Guide every week, call 0429 146 039 or email reception@vhc.org.au.