VA Form 21-0960M-1 Muscle Injuries Disability Benefits Questionnaire

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

MUSCLE INJURIES DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the
information you provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH A MUSCLE INJURY?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES:
DIAGNOSIS #1 -

ICD CODE -

DIAGNOSIS #2 -

DATE OF DIAGNOSIS -

ICD CODE -

DIAGNOSIS #3 -

DATE OF DIAGNOSIS DATE OF DIAGNOSIS -

ICD CODE -

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES, LIST USING ABOVE FORMAT:

NOTE - If there are multiple muscle injuries, complete the assessment for all muscle injuries on this questionnaire, if possible. If unable to complete assessment for all
muscle injuries on this questionnaire, also complete an additional questionnaire for each additional injury. If the veteran has or has had a muscle injury that results in any
conditions that are not covered in this questionnaire, also complete any other appropriate questionnaires (e.g., if peripheral nerve injury also exists due to the muscle
injury, complete VA Form 21-0960C-10, Peripheral Nerve Conditions (not including diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire.
SECTION II - HISTORY OF MUSCLE INJURY
2A. DOES THE VETERAN HAVE A PENETRATING MUSCLE INJURY, SUCH AS A GUNSHOT OR SHELL FRAGMENT WOUND?
YES

NO

2B. DOES THE VETERAN HAVE A NON-PENETRATING MUSCLE INJURY (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)?
YES

NO

2C. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S MUSCLE INJURY (brief summary)

2D. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - LOCATION OF MUSCLE INJURY
NOTE - For VA purposes, muscles are classified into groups I-XXIII. In this section, indicate the location of the veteran's muscle injury(ies) by checking the
muscle group(s) involved.
SHOULDER GIRDLE AND ARM

3. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?
YES

NO
(If "Yes," check muscle group(s) and side affected (check all that apply)
GROUP I: Extrinsic muscles of shoulder girdle: trapezius, levator scapulae, serratus magnus
Function: Upward rotation of scapula, elevation of arm above shoulder level
Both
Right
Left
Side affected:
GROUP II: Muscles of shoulder girdle: pectoralis major, latissimus dorsi and teres major, pectoralis minor, rhomboid
Function: Depression of arm from vertical overhead to hanging at side, downward rotation of scapula, forward and
backward swing of arm
Both
Right
Left
Side affected:
GROUP III: Intrinsic muscles of shoulder girdle: pectoralis major, deltoid
Function: Elevation and abduction of arm to level of shoulder, forward and backward swing of arm

Both
Right
Left
Side affected:
GROUP IV: Shoulder girdle muscles: supraspinatus, infraspinatus and teres minor, subscapularis, coracobrachialis
Function: Stabilization of shoulder, abduction, rotation of arm
Both
Right
Left
Side affected:
GROUP V: Flexor muscles of elbow: biceps, brachialis, brachioradialis
Function: Flexion of elbow
Side affected:

Right

Left

Both

GROUP VI: Extensor muscles of elbow: triceps
Function: Extension of elbow
Right
Both
Left
Side affected:
VA FORM
JAN 2011

21-0960M-10

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SECTION III - LOCATION OF MUSCLE INJURY (Continued)
FOREARM AND HAND
4. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?
NO
YES
(If "Yes," check muscle group(s) and side affected (check all that apply)
GROUP VII: Muscles of forearm: flexors of the wrist, fingers and thumb
Function: Flexion of wrist and fingers
Side affected:
Right
Left
Both
GROUP VIII: Muscles: extensors of the wrist, fingers and thumb
Function: Extension of wrist, fingers and thumb
Right

Side affected:

Left

Both

GROUP IX: Intrinsic muscles of hand, including muscles in the thenar and hypothenar eminence, lumbricales, dorsal
and palmar interossei
Function: Intrinsic muscles of the hand assist in delicate manipulative movements
Right
Left
Both
Side affected:

FOOT AND LEG
5. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?
YES
NO
(If "Yes," check muscle group(s) and side affected (check all that apply)
GROUP X: Muscles of the foot: flexor digitorum brevis, abductor hallucis, abductor digiti minimi, quadratus plantae, lumbricales,
flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis, dorsal and plantar interossei
Function: Movements of forefoot and toes, propulsion thrust in walking
Side affected:

Left
Both
Right
GROUP XI: Muscles of the foot, ankle and calf: gastrocnemius, soleus, tibialis posterior, peroneus longus, peroneus brevis,
flexor hallucis longus, flexor digitorum longus
Function: Propulsion, plantar flexion of foot, stabilization of arch, flexion of toes

Both
Right
Left
Side affected:
GROUP XII: Anterior muscles of the leg, tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius
Function: Dorsiflexion, extension of toes, stabilization of arch
Side affected:
Right
Left
Both

PELVIC GIRDLE AND THIGH
6. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?
YES
NO
(If "Yes," check muscle group(s) and side affected (check all that apply)
GROUP XIII: Posterior thigh/hamstring muscles: biceps femoris, semimembranosus, semitendinosus
Function: Flexion of knee
Side affected:

Right

Left

Both

GROUP XIV: Anterior thigh muscles: sartorius, rectus femoris, quadriceps
Function: Extension of knee
Both
Right
Left
Side affected:
GROUP XV: Medial thigh muscles: adductor longus, adductor brevis, adductor magnus, gracilis
Function: Adduction of hip
Both
Right
Left
Side affected:
GROUP XVI: Pelvic girdle muscles: psoas, iliacus, pectineus
Function: Flexion of hip
Right
Both
Left
Side affected:
GROUP XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius, gluteus minimus
Function: Extension of hip, abduction of thigh, postural support of body
Right
Both
Left
Side affected:
If checked, is there severe damage to muscle group XVII, such that the veteran is unable to rise from a seated and stooped position and to
maintain postural stability without assistance of any type?
YES

NO

GROUP XVIII: Pelvic girdle muscles: pyriformis, gemelli, obturator, quadratus femoris
Function: Outward rotation of thigh and stabilization of hip joint
Right
Left
Both
Side affected:

TORSO AND NECK
7. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP IN THE TORSO AND/OR NECK?
YES
NO
(If "Yes," check muscle group(s) and side or region affected (check all that apply)
GROUP XIX: Muscles of the abdominal wall: rectus abdominis, external oblique, internal obliques, transversalis, quadratus lumborum
Function: Support of abdominal wall and lower thorax, flexion and lateral movement of spine
Both
Right
Left
Side affected:
GROUP XX: Spinal muscles: sacrospinalis, erector spinae
Function: Postural support of body, extension and lateral movement of the spine
Region affected:
Thoracic
Cervical
Lumbar
GROUP XXI: Muscles of respiration: thoracic muscle group
Function: Respiration
Both
Side affected:
Right
Left
GROUP XXII: Muscles of the front of the neck: trapezius, sternocleidomastoid, hyoid muscles, sternothyroid, digastric
Function: Rotation and flexion of the head, respiration, swallowing
Both
Side affected:
Right
Left
GROUP XXIII: Muscles of the side and back of the neck: suboccipital, lateral vertebral and anterior vertebral muscles
Function: Movements of the head, fixation of shoulder movements
Side affected:

Right

VA FORM 21-0960M-10, JAN 2011

Left

Both

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SECTION IV - ADDITIONAL CONDITIONS

8A. DOES THE VETERAN HAVE A HISTORY OF RUPTURE OF THE DIAPHRAGM WITH HERNIATION?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960H-1, Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire)
8B. DOES THE VETERAN HAVE A HISTORY OF AN EXTENSIVE MUSCLE HERNIA OF ANY MUSCLE, WITHOUT OTHER INJURY TO THE MUSCLE?
YES

NO

(If "Yes," provide name of muscle and describe current residuals):________________________________________________________________

8C. DOES THE VETERAN HAVE A HISTORY OF INJURY TO THE FACIAL MUSCLES?
YES

NO

(If "Yes," complete VA Form 21-0960C-3, Cranial Nerve Conditions Disability Benefits Questionnaire or VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire, etc., as
indicated by type of residuals)
(If "Yes," is there interference to any extent with mastication?)
YES

NO

SECTION V - MUSCLE INJURY EXAM
SCAR, FACSIA AND MUSCLE FINDINGS
9A. DOES THE VETERAN HAVE ANY SCAR(S) ASSOCIATED WITH A MUSCLE INJURY?
YES

NO

(If "Yes," indicate severity of scar(s) caused by the muscle injury (ies) (check all that apply if there is more
than one area or type of scarring):
Minimal scar(s)
Entrance and (if present) exit scars are small or linear, indicating short track of missile through muscle tissue
Entrance and (if present) exit scars indicating track of missile through one or more muscle groups
Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track
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
Other (including surgical scars related to muscle injuries shown above, ALSO complete VA Form 21-0960F-1, Scars/Disfigurement
Disability Benefits Questionnaire):

9B. DOES THE VETERAN HAVE ANY KNOWN FASCIAL DEFECTS OR EVIDENCE OF FASCIAL DEFECTS ASSOCIATED WITH ANY MUSCLE INJURIES?
YES

NO

(If "Yes," indicate severity of fascial defect(s) caused by the muscle injury(ies) (check all that apply if there is more than one area/type of fascial defect)
Some loss of deep fascia
Palpation shows loss of deep fascia
Other, describe:

9C. DOES THE VETERAN'S MUSCLE INJURY(IES) AFFECT MUSCLE SUBSTANCE OR FUNCTION?
YES

NO

(If "Yes," indicate effect of the muscle injury(ies) on muscle substance or function - check all that apply)
Some impairment of muscle tonus
Some loss of muscle substance
Soft flabby muscles in wound area
Muscles swell and harden abnormally in contraction
Induration or atrophy of an entire muscle following history of simple piercing by a projectile
Adaptive contraction of an opposing group of muscles
Visible or measurable atrophy
Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle
Tests of endurance or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function
Other, describe:______________________________________________________________________________________________

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SECTION V - MUSCLE INJURY EXAM (Continued)
CARDINAL SIGNS AND SYMPTOMS OF MUSCLE DISABILITY

10. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS AND/OR SYMPTOMS ATTRIBUTABLE TO ANY MUSCLE INJURIES?
YES

NO

(If "Yes," check all that apply, and indicate side affected, muscle group and frequency/severity):
Loss of power
(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Weakness
(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Lowered threshold of fatigue
(If checked, indicate sided affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Fatigue-pain
(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Impairment of coordination
(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Uncertainty of movement
(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

If further clarification is needed due to injuries of multiple muscle groups, describe which findings, signs and/or symptoms are attributable to each muscle injury:

VA FORM 21-0960M-10, JAN 2011

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SECTION V - MUSCLE INJURY EXAM (Continued)
MUSCLE STRENGTH TESTING
11A. TEST MUSCLE STRENGTH ONLY FOR AFFECTED MUSCLE GROUPS AND FOR THE CORRESPONDING SOUND (NON-INJURED) SIDE.
RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
Shoulder abduction (Group III)
Elbow flexion (Group V)
Elbow extension (Group VI)
Wrist flexion (Group VII)
Wrist extension (Group VIII)
Hip flexion (Group XVI)
Knee flexion (Group XIII)
Knee extension (Group XIV)
Ankle plantar flexion (Group XI)
Ankle dorsiflexion (Group XII)
If other movements/muscle groups
were tested, specify:

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

11B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

(If muscle atrophy is present, indicate location (such as calf, thigh, forearm, upper arm):
(Indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):
Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk:
Normal side:

cm.

Atrophied side:

cm.

If muscle atrophy is present in more than one muscle group, provide location and measurements, using the same format:

SECTION VI - ASSISTIVE DEVICES

12. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES
NO

(If "Yes," identify assistive devices used (check all that apply and indicate frequency):
Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

(If the veteran uses any assistive devices specify the condition and identify the assistive device used for each condition):

VA FORM 21-0960M-10, JAN 2011

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SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
13. DUE TO THE VETERAN'S MUSCLE CONDITIONS IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE
FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity
include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," indicate extremity(ies) for which this applies):
Left upper

Right upper

Right lower

Left lower

(For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples - brief summary)

SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

14. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(If "Yes," describe - brief summary)
SECTION IX - DIAGNOSTIC TESTING

NOTE - If there is reason to believe there are retained metallic fragments in the muscle tissue, appropriate x-rays are required to determine location of retained metallic
fragment. Once retained metallic fragments have been documented, further imaging studies are usually not indicated.
15A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

15B. IS THERE X-RAY EVIDENCE OF RETAINED METALLIC FRAGMENTS (such as shell fragments or shrapnel) IN ANY MUSCLE GROUP?
YES
NO (If "Yes," indicate results):
X-ray evidence of retained shell fragment(s) and/or shrapnel
Location (specify muscle Group I-XXIII, if possible):
(Indicate side affected):

Right

Left

Both

X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile
Location (specify muscle Group I -XXIII, if possible):
(Indicate side affected):
Right
15C. WERE ELECTRODIAGNOSTIC TESTS DONE?
YES

Left

Both

NO (If "Yes," was there diminished muscle excitability to pulsed electrical current?)
YES

NO (If "Yes," name affected muscles)_____________________________________________________________________

15D. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO (If "Yes," provide type of test or procedure, date and results - brief summary)

SECTION X - FUNCTIONAL IMPACT

16. DOES THE VETERAN'S MUSCLE INJURY(IES) IMPACT HIS OR HER ABILITY TO WORK? (For example the muscle injury(ies) results in the veteran's inability to keep up
with work requirements)
NO (If "Yes," describe the impact of each of the veteran's muscle injuries, providing one or more examples):
YES

SECTION XI - REMARKS

17. REMARKS (If any)

SECTION XII- PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
18A. PHYSICIAN'S SIGNATURE
18D. PHYSICIAN'S PHONE AND FAX NUMBER

18B. PHYSICIAN'S PRINTED NAME
18E. PHYSICIAN'S MEDICAL LICENSE NUMBER

18C. DATE SIGNED
18F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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VA FORM 21-0960M-10, JAN 2011
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