Va Form 21-0960m-10 - Muscle Injuries Disability Benefits Questionnaire Page 2
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6SECTION 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?
YES
NO
(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
Left
Both
Side affected:
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
Side affected:
Right
Left
Both
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:
Right
Left
Both
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
Right
Both
Side affected:
Left
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
Right
Both
Side affected:
Left
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
Side affected:
Left
GROUP XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius, gluteus minimus
Function: Extension of hip, abduction of thigh, postural support of body
Right
Both
Side affected:
Left
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
Side affected:
Right
Left
Both
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
Right
Left
Both
Side affected:
GROUP XX: Spinal muscles: sacrospinalis, erector spinae
Function: Postural support of body, extension and lateral movement of the spine
Region affected:
Cervical
Thoracic
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
Side affected:
Right
Left
Both
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:
Left
Both
Right
VA FORM 21-0960M-10, OCT 2012
Page 2
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