Foot Conditions (Plantar Fasciitis / Flat Feet) C&P Exam Prep

Ankle Dorsiflexion / Plantar Flexion Range of Motion

What it measures: The degree of upward (dorsiflexion) and downward (plantar flexion) movement at the ankle joint, which is critically impaired in pes planus and plantar fasciitis.

What to expect: The examiner will ask you to move your foot up and down as far as possible (active motion), then may manually move your foot through its range (passive motion). This will be done both seated (non-weight-bearing) and standing (weight-bearing). Normal dorsiflexion is approximately 20 degrees; plantar flexion approximately 45 degrees. Limitation of dorsiflexion to a right angle (90 degrees total) is a specific rating criterion for pes planus.

Pain considerations: Under 38 CFR 4.59 and DeLuca, pain on motion - even without dramatic ROM limitation - can support a compensable rating. Tell the examiner at what point in the range of motion you begin to feel pain and how severe it is on a 0-10 scale. Passive ROM may exceed active ROM; this discrepancy should be noted as it reflects true functional limitation.

Subtalar / Inversion-Eversion Range of Motion

What it measures: Side-to-side rocking motion of the heel, reflecting the degree of hindfoot deformity and stiffness common in flat foot and plantar fasciitis.

What to expect: Examiner will assess inversion (turning the sole inward) and eversion (turning the sole outward). This may be assessed weight-bearing and non-weight-bearing. Normal inversion is approximately 20 degrees; eversion approximately 10 degrees.

Pain considerations: Spasm of the Achilles tendon on manipulation is a specific criterion for the highest rating level under DC 5276. If your Achilles feels tight or goes into spasm when your foot is manipulated, point this out to the examiner.

Weight-Bearing Foot Assessment (Arch Height, Pronation, Valgus Deformity)

What it measures: Structural deformity of the foot including arch collapse, inward rolling (pronation), inward bowing of the tendo achillis (Helbing's sign), and marked varus/valgus deformity.

What to expect: The examiner will observe your feet both standing and walking. They will look for the weight-bearing line relative to the great toe, heel position (valgus/varus), arch collapse, and skin changes such as callosities. The DBQ specifically requires weight-bearing assessment for pes planus.

Pain considerations: Characteristic callosities under metatarsal heads are a criterion for severe pes planus. Extreme tenderness of the plantar surface is a criterion for pronounced pes planus. If either apply, state this clearly when the examiner palpates your foot.

Plantar Fascia Palpation (Plantar Fasciitis Assessment)

What it measures: Tenderness, shortened fascia, contraction, and heel spur formation at the insertion of the plantar fascia at the calcaneus, as well as along the medial band of the fascia.

What to expect: The examiner will press on your heel and along the arch, particularly at the medial calcaneal tubercle (where plantar fasciitis most commonly inserts). They will also assess for shortened plantar fascia and marked contraction with dropped forefoot. This may be performed both weight-bearing and non-weight-bearing.

Pain considerations: The DBQ asks about pain during active motion, passive motion, weight-bearing, non-weight-bearing, and at rest. Describe all four scenarios accurately. Morning stiffness that gradually loosens is classic plantar fasciitis - but if you also have pain at rest or at night, make sure to report this as it indicates a more severe presentation.

Repetitive Use / DeLuca Factors Assessment

What it measures: How your symptoms change after repetitive use of the feet - specifically pain increase, fatigue, weakness, incoordination, and lack of endurance after repeated weight-bearing activity.

What to expect: The examiner may ask you to walk briefly or perform repetitive ankle movements and then re-assess ROM or pain. More commonly, they will ask you to describe what happens to your feet after prolonged walking, standing, or activity. Under DeLuca v. Brown, the examiner must address these factors in the DBQ.

Pain considerations: Per DeLuca v. Brown and M21-1 guidance, the examiner is required to document functional loss due to pain, fatigue, weakness, and incoordination after repetitive use and during flare-ups. If the examiner does not ask about these factors, proactively volunteer this information. State: 'I also want to make sure you have information about how my symptoms change with activity and during flare-ups.'

0%

Pes planus (flat foot) - Mild: symptoms relieved by built-up shoe or arch support. No compensable rating assigned under DC 5276.

From 38 CFR: 38 CFR 4.71a, DC 5276: 'Mild; symptoms relieved by built-up shoe or arch support - 0 percent.' Note: Even at 0% under DC 5276, painful motion via 38 CFR 4.59 can still support a 10% rating.

10%

Plantar fasciitis (DC 5269): Unilateral or bilateral with treatment providing some relief. OR Pes planus moderate (DC 5276): Weight-bearing line over or medial to great toe, inward bowing of tendo achillis, pain on manipulation and use of feet, bilateral or unilateral. OR Foot injury other (DC 5284): Moderate.

From 38 CFR: DC 5269: 'Otherwise, unilateral or bilateral - 10%.' DC 5276: 'Moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet - 10%.' DC 5284: 'Moderate - 10%.'

20%

Plantar fasciitis unilateral (DC 5269): No relief from BOTH non-surgical AND surgical treatment, unilateral. OR Pes planus severe unilateral (DC 5276): Objective evidence of marked deformity (pronation, abduction), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. OR Foot injury other moderate-severe (DC 5284): Moderately severe.

From 38 CFR: DC 5269: 'No relief from both non-surgical and surgical treatment, unilateral - 20%.' DC 5276: 'Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities - Unilateral 20%.' DC 5284: 'Moderately severe - 20%.'

30%

Plantar fasciitis bilateral (DC 5269): No relief from BOTH non-surgical AND surgical treatment, bilateral. OR Pes planus severe bilateral (DC 5276): Same as unilateral severe criteria but affecting both feet. OR Pes planus pronounced unilateral (DC 5276): Marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spasm of tendo achillis on manipulation, not improved by orthopedic shoes or appliances. OR Foot injury other severe (DC 5284): Severe.

From 38 CFR: DC 5269: 'No relief from both non-surgical and surgical treatment, bilateral - 30%.' DC 5276 Pronounced Unilateral: '30%.' DC 5276 Severe Bilateral: '30%.' DC 5284: 'Severe - 30%.'

40%

Any foot condition (DC 5269, 5276, 5284): With actual loss of use of the foot. This is noted in all three primary diagnostic codes and represents the maximum evaluation for a single foot.

From 38 CFR: DC 5269 Note 1: 'With actual loss of use of the foot, rate 40 percent.' DC 5276 (analogous): Same principle. DC 5284 Note: 'With actual loss of use of the foot, rate 40 percent.' Loss of use means the foot is so disabled that no effective function remains, equivalent to a service-connected amputation.

50%

Pes planus pronounced bilateral (DC 5276): Marked pronation, extreme tenderness of plantar surfaces of BOTH feet, marked inward displacement and severe spasm of tendo achillis on manipulation bilaterally, not improved by orthopedic shoes or appliances.

From 38 CFR: DC 5276: 'Pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances - Bilateral 50%.'

Heel and Arch Pain (Plantar Fasciitis)

How to describe it: Describe the pain as sharp, stabbing, or burning, locating it specifically at the heel (medial calcaneal tubercle) and/or along the arch. Describe the 'first-step pain' that is characteristic of plantar fasciitis - pain that is worst immediately upon standing after rest. Rate pain on a 0-10 scale at rest, with first steps, during prolonged standing, and after activity.

Example: On my worst days, my heel pain is a 9/10 when I first stand up in the morning. I have to hobble to the bathroom grabbing the wall for support. After about 20 minutes of moving around it drops to a 6/10, but if I stand for more than 30 minutes it climbs back to an 8/10. I cannot stand at the kitchen counter without shifting all my weight to one foot. Some days I cannot put my heel down at all and have to walk on my toes.

Examiner listens for: Location of pain (heel vs. arch vs. metatarsal heads), quality of pain (sharp/stabbing vs. aching), temporal pattern (morning vs. after activity vs. constant), severity scale, and whether pain has responded to any treatment.

Avoid: Do not say 'it's not too bad' or 'I manage.' Do not describe only your best days. If the examiner asks how you are doing today, clarify: 'Today is relatively okay, but I want to make sure you understand what my worst days are like, as they are more representative of my typical experience.'

Treatment Response and Failure (Critical for Plantar Fasciitis Rating)

How to describe it: Provide a complete treatment history: conservative treatments tried (physical therapy, NSAIDs, steroid injections, orthotics, night splints, ice, RICE protocol, ESWT shock wave therapy, PRP injections) and whether each provided relief. If you have had surgery, describe the procedure and whether it improved, worsened, or did not change your symptoms. The distinction between 'some relief' (10%) and 'no relief from both non-surgical AND surgical treatment' (20-30%) is the primary driver of rating level under DC 5269.

Example: I have tried physical therapy for 12 weeks, two cortisone injections, custom orthotics, and a night splint for 6 months. None of these provided lasting relief - the cortisone helped for about 3 weeks but the pain returned. I had a plantar fascia release surgery in [year] and actually had more pain after surgery than before. I still cannot walk more than a half block without significant pain.

Examiner listens for: Whether conservative treatment was attempted, what specific interventions were tried, duration of each treatment, degree of relief (none, partial, complete), surgical history, post-surgical outcome, and current treatment plan.

Avoid: Do not omit treatments that failed - every failed treatment strengthens your claim. Do not say 'the injections helped' if they only helped temporarily. Be specific: 'The injection provided about 30% relief for 3 weeks, then symptoms returned to baseline.'

Flat Foot / Arch Deformity (Pes Planus)

How to describe it: Describe the visible and functional aspects of your flat feet: whether your arches have collapsed, whether your ankles roll inward, whether you can see the entire inner side of your foot touching the ground when standing. Describe whether arch supports or built-up shoes relieve your symptoms - and critically, whether they provide only PARTIAL relief.

Example: When I stand for more than 10-15 minutes, my arches ache intensely and my ankles roll inward so badly that I can see my shoe wear unevenly on the inside edge. My arch supports reduce the aching from a 7 to a 4, but do not eliminate the pain. After a day on my feet at work, the bottoms of my feet are burning and I have to sit with my feet elevated for hours.

Examiner listens for: Degree of arch collapse, whether symptoms are weight-bearing dependent, effectiveness of orthotics or built-up shoes, bilateral vs. unilateral involvement, and callosities.

Avoid: Do not say 'the arch supports help' without qualifying the extent: 'They help somewhat but do not take away the pain.' The difference between full relief (0%) and incomplete relief (10%+) is critical to your rating.

Functional Loss - Walking, Standing, and Daily Activities

How to describe it: Quantify exactly how far you can walk before pain forces you to stop, how long you can stand, and what daily activities you have modified or given up due to foot pain. Be specific with distances and times.

Example: I can only walk about half a city block - maybe 200 feet - before my foot pain becomes severe enough that I have to stop and rest. I can stand for about 5-10 minutes before I need to sit down. I no longer go grocery shopping without using a cart to lean on, I avoid parking lots, I stopped exercising and have gained weight as a result. I cannot do yard work, cannot attend my children's sporting events, and had to change to a desk job because I could no longer stand at a counter all day.

Examiner listens for: Specific distance and time limitations, activities abandoned due to foot pain, compensation behaviors (leaning, limping, avoiding activity), impact on employment, and impact on daily living.

Avoid: Do not say 'I can walk a little.' Give specific numbers. Do not say 'I get by.' If you have made lifestyle changes due to foot pain, these are losses and should be described as such.

Flare-Ups (DeLuca Factor)

How to describe it: Describe how often flare-ups occur, what triggers them, how long they last, and what you are unable to do during a flare-up. The examiner must document this in the DBQ under M21-1 guidance.

Example: I have severe flare-ups about 2-3 times per month, usually triggered by any activity involving more than 10-15 minutes of walking or standing. During a flare-up, my heel swells noticeably, becomes hot to the touch, and I cannot bear full weight. These last 1-3 days. I have had to call in sick to work multiple times because I literally cannot walk during these episodes.

Examiner listens for: Frequency (times per month or year), duration of each flare-up, severity during flare-up (pain scale, functional limitation), triggers, and what you cannot do during a flare-up.

Avoid: Do not minimize flare-ups by saying 'sometimes it gets bad.' Give specific frequencies and functional impact. The examiner needs to document this in the DBQ's flare-up section, so give them the information they need.

Sleep Disruption and Rest Pain

How to describe it: Describe whether your foot pain wakes you up at night, prevents you from finding a comfortable sleeping position, or causes pain even when not bearing weight. Rest pain is a marker of more severe disability.

Example: Some nights the burning and aching in my feet wakes me up even though I am not standing. I cannot sleep on my stomach because pointing my toes down causes arch pain. I wake up 2-3 times a week from foot pain.

Examiner listens for: Whether pain is present at rest and at night, sleep disruption frequency, and requirement for pain medication to sleep.

Avoid: Do not omit rest pain. Rest pain indicates a more severe condition than pain only with activity and supports higher rating consideration.