Claw Foot (Pes Cavus) C&P Exam Prep

Ankle Dorsiflexion Range of Motion

What it measures: The maximum upward bend of the ankle joint; normal is approximately 20 degrees beyond neutral (right angle = 0 degrees).

What to expect: The examiner will ask you to pull your foot upward as far as possible (active motion), then will passively move it, and will test both weight-bearing and non-weight-bearing. This should be done for both feet. Goniometer measurement should be recorded.

Pain considerations: Under DeLuca v. Brown and 38 CFR 4.40/4.45, if pain limits your dorsiflexion before the mechanical end of range, the examiner must document at what point in the range of motion pain begins. Inform the examiner clearly: 'My ankle starts hurting when I try to flex it upward at about [X] degrees and I cannot push through that pain.'

Plantar Fascia Assessment

What it measures: The degree of shortening or contraction of the plantar fascia, and whether a dropped forefoot (forefoot plantarflexion) is present.

What to expect: The examiner will visually inspect the arch and may palpate the plantar fascia from heel to ball of foot. They will assess whether the forefoot has dropped relative to the hindfoot.

Pain considerations: Report any pain along the plantar fascia at rest, with first steps in the morning, and after prolonged standing or walking.

Metatarsal Head Tenderness Assessment

What it measures: The degree of tenderness (pressure pain) at the ball of the foot beneath the metatarsal heads.

What to expect: The examiner will apply direct pressure beneath each metatarsal head. You should verbally indicate any tenderness and its severity. This is a critical distinguishing factor between rating tiers.

Pain considerations: Inform the examiner of burning or aching pain at the ball of the foot with walking, standing, going up/down stairs, and wearing standard footwear.

Toe Position Evaluation

What it measures: Whether toes are in hammer toe configuration, tendency toward dorsiflexion (toes curling upward), and whether the great toe is dorsiflexed.

What to expect: The examiner will visually inspect all toes both weight-bearing and non-weight-bearing, assess flexibility vs. rigidity of deformities, and document which toes are affected.

Pain considerations: Describe how hammer toes or dorsiflexed toes cause pain against shoe uppers, difficulty gripping the ground, and altered gait patterns.

Callosity Assessment

What it measures: The location, size, and painfulness of callosities (thickened skin) resulting from abnormal pressure distribution from the pes cavus deformity.

What to expect: The examiner will visually inspect the soles, toe tips, and dorsal toe surfaces for callosities. They will ask about pain associated with them.

Pain considerations: Very painful callosities are a specific criterion - communicate whether standing or walking on these areas causes significant, limiting pain rather than just mild discomfort.

Varus Deformity Assessment

What it measures: Whether the hindfoot (heel) is turned inward (varus), which is a component of the highest severity tier under DC 5278.

What to expect: The examiner will observe your heel alignment from behind during standing and walking. They may measure the degree of varus angulation.

Pain considerations: Describe how the inward heel lean affects your balance, causes lateral ankle strain, and contributes to your overall foot pain pattern.

50%

Bilateral pes cavus with marked contraction of plantar fascia with dropped forefoot, all toes in hammer toe configuration, very painful callosities, AND marked varus deformity. ALL components must be present for the bilateral 50% rating.

From 38 CFR: 38 CFR 4.71a DC 5278: 'Marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity: Bilateral 50'

30%

Bilateral pes cavus with all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle (cannot dorsiflexion beyond 0 degrees), shortened plantar fascia, AND marked tenderness under metatarsal heads. Also the unilateral rating for the most severe tier (all criteria from 50% tier present on one foot).

From 38 CFR: 38 CFR 4.71a DC 5278: 'All toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads: Bilateral 30 [also] Unilateral 30 [for the highest severity tier]'

20%

Unilateral pes cavus with all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads. Represents the second severity tier on one foot.

From 38 CFR: 38 CFR 4.71a DC 5278: 'All toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads: Unilateral 20'

10%

Bilateral OR unilateral pes cavus with great toe dorsiflexed, some limitation of dorsiflexion at ankle (not as severe as right angle limitation), and definite tenderness under metatarsal heads. This is the third severity tier and applies at 10% whether bilateral or unilateral.

From 38 CFR: 38 CFR 4.71a DC 5278: 'Great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads: Bilateral 10 Unilateral 10'

0%

Slight pes cavus - structural deformity is present but symptoms are minimal and there is no significant functional limitation meeting any of the above criteria.

From 38 CFR: 38 CFR 4.71a DC 5278: 'Slight 0' - Note: Under 38 CFR 4.59, if painful motion is present, a minimum compensable evaluation may be warranted even when structural criteria for 10% are not fully met. Consult with a VSO about this provision.

Pain - Plantar and Metatarsal

How to describe it: Describe the pain as burning, aching, or sharp pressure at the ball of the foot (metatarsal heads) and along the arch. Specify when it occurs: first steps of the day, after 10-15 minutes of standing, after walking one block, after climbing stairs. Use a 0-10 numeric scale.

Example: On my worst days, the pain under the ball of my foot feels like I am walking on sharp rocks. I cannot stand for more than five minutes without the burning becoming severe. I limp from the moment I get out of bed. By midday I have to sit down and elevate my feet.

Examiner listens for: Specific activities that provoke pain, duration of tolerable activity before pain onset, pain at rest vs. with use, whether pain is constant or episodic, and whether orthotics or special footwear reduce but do not eliminate pain.

Avoid: Saying 'my feet hurt sometimes' without specifying severity. Avoid 'I manage OK' - instead say 'I manage only by significantly limiting what I do.' Do not normalize the pain by comparing yourself to others.

Ankle Dorsiflexion Limitation

How to describe it: Tell the examiner that you feel tightness or pain when you try to pull your foot upward. Specify whether you can bring your foot to a right angle (neutral) or whether it stops before that. Note if limitation worsens after activity or on bad days.

Example: On bad days, I cannot pull my foot up to a right angle without sharp pain in my ankle and calf. Walking uphill or on uneven ground is very difficult because I cannot flex my ankle enough. I trip more often because of this.

Examiner listens for: Whether the limitation reaches the right angle threshold (critical for 30%/20% vs. 10% rating differentiation), whether pain limits motion before the end of range, and whether the limitation is the same on both feet.

Avoid: Do not say 'my ankle is a little stiff' - instead describe the functional consequence. Avoid allowing the examiner to assume full range because you did not verbally report that the motion was painful at its limit.

Toe Deformity and Shoe Fit Problems

How to describe it: Describe the curled or upward-bent position of your toes, which toes are affected, whether they are rigid or flexible, and how they create pressure points against shoe uppers. Mention difficulty finding footwear that accommodates the deformity and any corns or blisters that result.

Example: My toes are permanently curled and pushed upward. I cannot wear standard shoes without blisters and corns forming within an hour. I have to buy shoes two sizes wider and have cut holes in shoe uppers to accommodate my toes. On bad days the pain from my toes rubbing against any shoe material prevents me from walking at all.

Examiner listens for: Whether all toes are affected (required for highest tier), whether hammer toe configuration is present in addition to dorsiflexion tendency, the degree of rigidity, and the functional consequence on footwear and ambulation.

Avoid: Avoid saying 'my toes look a little bent' - describe the full deformity. Do not fail to mention shoe modification needs, as these document severity.

Callosity Pain

How to describe it: Describe the location of callosities (balls of feet, toe tips, dorsal toe surfaces), their size, and most importantly their pain level. Describe whether walking on them feels like walking on a stone or causes sharp, shooting pain.

Example: I have thick, very painful calluses on the balls of both feet and on the tips of my toes. When I walk, it feels like stepping on nails. Even light shoe pressure on these spots causes me to flinch and shorten my steps. I have had to see a podiatrist to have them pared down because they become so thick they split and bleed.

Examiner listens for: The distinction between 'very painful' (required for highest tier) versus merely present callosities. The examiner will want to know if the pain is disabling or merely uncomfortable.

Avoid: Do not minimize callosity pain as 'just a callus.' If they genuinely cause significant pain that limits walking, say so explicitly. Do not treat them right before the exam in a way that conceals them.

Varus Deformity and Balance

How to describe it: Describe any inward roll of your heels when standing, ankle instability or tendency to sprain the ankle, difficulty walking on uneven ground, and any history of ankle sprains related to the foot structure.

Example: My heels roll inward significantly when I stand, which throws my whole balance off. I have sprained my ankles multiple times because of this alignment problem. I feel very unsteady on uneven surfaces and I have fallen. I have to watch every step I take.

Examiner listens for: The degree of varus alignment (marked vs. mild), associated ankle instability, and functional consequences for ambulation and safety.

Avoid: Do not omit the ankle sprain history or balance problems - these document the real-world impact of the varus deformity.

DeLuca Factors - Functional Loss with Use

How to describe it: Describe how your foot symptoms change with repeated use, prolonged activity, or at the end of the day. Include increased pain, fatigue, weakness, and incoordination with repetitive walking. Per DeLuca v. Brown, these factors must be considered even if not directly observed during the exam.

Example: After walking for 15 minutes, my foot pain becomes severe, my legs feel heavy and weak, and I start to stumble. By the time I finish a grocery store trip my feet are throbbing. I have to rest for an hour afterward. My gait becomes awkward and I trip more easily when my feet are fatigued.

Examiner listens for: Evidence of pain, fatigue, weakness, and incoordination with use - all of which can support additional functional loss documentation on the DBQ and potentially support a higher effective rating under 38 CFR 4.40 and 4.45.

Avoid: Do not only describe how you feel at rest. The examiner sees you briefly - your worst functional state with activity is equally or more important for rating purposes.

Flare-Ups

How to describe it: Describe episodes when your symptoms are significantly worse than baseline - how often they occur, what triggers them (prolonged standing, weather, activity), how long they last, and what you cannot do during a flare-up.

Example: I have flare-ups about three to four times per month, usually triggered by being on my feet for more than 20 minutes. During a flare-up both feet ache severely, I cannot stand at all, and I have to lie down with my feet elevated. The flare lasts one to three days. I have missed work because of this.

Examiner listens for: Frequency, duration, triggers, and functional impact of flare-ups. The DBQ has a dedicated field for this (field 357/360). Flare-up severity may support a higher effective rating.

Avoid: Do not say 'I have bad days sometimes' without specifics. Quantify flare frequency, duration, and functional impact.