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

Ankle Dorsiflexion / Plantar Flexion Range of Motion

What it measures: Movement of the ankle joint; limitation of dorsiflexion is a key rating criterion for flat foot under DC 5276

What to expect: Examiner will use a goniometer to measure how far you can flex and extend the ankle both with weight bearing (standing) and without (seated). Normal dorsiflexion is approximately 20 degrees; normal plantar flexion is approximately 45 degrees. Testing will be done actively (you move your foot) and passively (examiner moves your foot). Per Correia requirements, both weight-bearing and non-weight-bearing measurements must be documented.

Pain considerations: Under 38 CFR 4.59, pain on movement of a joint with arthritis or periarticular pathology must be considered. Even if ROM appears near normal, painful motion should be documented. Tell the examiner exactly where and when pain occurs during movement.

Tendo Achillis Assessment

What it measures: Inward bowing and spasm of the Achilles tendon, which is a specific structural criterion for moderate and pronounced ratings under DC 5276

What to expect: Examiner will visually assess and manually manipulate the Achilles tendon while you are standing and during passive manipulation. They will look for inward displacement and test for spasm. For pronounced rating, severe spasm not improved by orthotics must be documented.

Pain considerations: Spasm and pain on manipulation are distinct findings. Report both separately. If manipulation of the Achilles causes acute pain, say so immediately during the exam.

Plantar Surface Palpation / Heel Tenderness

What it measures: Tenderness of the plantar fascia insertion at the calcaneus and along the plantar surface; primary objective finding for plantar fasciitis under DC 5269

What to expect: Examiner will press on the heel, arch, and ball of the foot with their fingers. They will specifically palpate the medial calcaneal tubercle (heel bone insertion point of the plantar fascia) and the metatarsal heads. They will grade tenderness as definite, marked, or none, and assess for very painful callosities.

Pain considerations: The most common symptom of plantar fasciitis is heel pain per M21-1. Ensure you describe your heel pain in detail including morning stiffness, pain after rest, and pain that increases with prolonged activity.

Weight-Bearing Arch and Pronation Assessment

What it measures: Position of the weight-bearing line, degree of arch collapse (pes planus), and medial deviation; determines rating level under DC 5276

What to expect: Examiner will have you stand naturally and observe your foot posture from behind and the side. They assess whether the arch is collapsed, whether the weight-bearing line falls over or medial to the great toe, and the degree of pronation and abduction. This is done while standing (weight-bearing) and may be compared to seated (non-weight-bearing).

Pain considerations: Arch collapse that causes pain on weight-bearing and use is the central criterion. Describe the pain that occurs specifically when standing and walking on flat or hard surfaces.

DeLuca Factors Assessment (Repetitive Use and Flare-Up)

What it measures: Functional loss from pain, fatigue, weakness, incoordination, and lack of endurance with repetitive use; required under 38 CFR 4.40, 4.45, and DeLuca v. Brown

What to expect: The examiner should ask how your symptoms change with repeated use, prolonged activity, and during flare-ups. They may ask you to perform repetitive movements and document any change in pain, ROM, or function. This is a critical component that is often underreported.

Pain considerations: Flare-up pain is often more severe than baseline pain. Per M21-1 guidance, if you have incapacitating exacerbations of plantar fasciitis, this should support a higher evaluation. Describe specific flare-up events with dates, triggers, and duration.

0%

Flat foot (pes planus) DC 5276: Mild - symptoms relieved by built-up shoe or arch support. Even at 0%, service connection can be established for future increases.

From 38 CFR: Mild; symptoms relieved by built-up shoe or arch support - 0 percent. Note: 38 CFR 4.59 may still support a 10% rating if painful motion is present even when arch supports provide relief.

10%

Flat foot (pes planus) 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; bilateral or unilateral. Also: Plantar fasciitis DC 5269: Otherwise unilateral or bilateral (10%). Note: M21-1 states 38 CFR 4.59 supports 10% for pes planus with pain even when 0% DC criteria are not fully met.

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

20%

Flat foot (pes planus) DC 5276: Severe unilateral - objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Also: Plantar fasciitis DC 5269: No relief from both non-surgical and surgical treatment, unilateral 20%. Note: Occasional incapacitating exacerbations of plantar fasciitis support 20% per M21-1 exception.

From 38 CFR: Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities: Unilateral 20. Plantar fasciitis: No relief from both non-surgical and surgical treatment, unilateral 20.

30%

Flat foot (pes planus) DC 5276: Severe bilateral - objective evidence of marked deformity bilateral, pain accentuated, swelling on use, characteristic callosities. Also: Pronounced unilateral - marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spasm of tendo achillis, not improved by orthopedic shoes or appliances. Also: Plantar fasciitis DC 5269: No relief from both non-surgical AND surgical treatment, bilateral 30%.

From 38 CFR: Severe bilateral 30. Pronounced unilateral 30: marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. Plantar fasciitis bilateral no relief from non-surgical and surgical treatment 30.

50%

Flat foot (pes planus) DC 5276: Pronounced bilateral - 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%.

From 38 CFR: Pronounced bilateral 50: 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.

Heel and Plantar Pain (Plantar Fasciitis)

How to describe it: Describe the location (medial heel, arch, ball of foot), character (sharp, stabbing, burning, aching), timing (worst first steps in morning, after rest, after prolonged activity), and severity on a 0-10 scale. Specify what activities cause or worsen pain and what activities you avoid because of it.

Example: On my worst days, I wake up in the morning and the first few steps feel like stepping on a sharp rock or knife in my heel. The pain is an 8 out of 10. I have to limp to the bathroom and stand still for 5 to 10 minutes before I can walk more normally. After standing at work for 2 hours my heel pain climbs back to a 7 and I have to sit down. On bad days I cannot stand more than 20 minutes without a break and I cannot walk more than half a mile.

Examiner listens for: Duration of morning stiffness, pain with first steps after rest (post-static dyskinesia), functional walking distance limitation, activities completely avoided due to pain, frequency and severity of flare-ups, whether treatment (stretching, orthotics, cortisone, physical therapy) provides relief or not, and impact on employment.

Avoid: Do not say 'it hurts a little' or 'I manage okay.' Do not say 'it depends' without specifying your worst functional level. Do not say treatment 'helps' without clarifying it does not fully resolve pain or restore function.

Arch and Foot Structural Pain (Flat Foot / Pes Planus)

How to describe it: Describe pain along the arch, medial ankle, and plantar surface. Note whether pain occurs when standing, walking on hard surfaces, going up stairs, or during any weight-bearing activity. Describe any visible deformity you or your providers have noted, and whether your arch disappears entirely when you stand.

Example: When I stand on a hard floor for more than 30 minutes my entire arch aches with a deep throbbing pain, rated 7 out of 10. My foot rolls inward when I walk and I can see that my arch completely collapses when I stand. I have to walk on the inside of my foot. By the end of the day my ankle and the inside of my lower leg ache from compensating. I cannot stand on my feet for my job for more than one hour without needing to sit.

Examiner listens for: Objective reports correlating with collapse on weight-bearing, Achilles tendon involvement, inability of arch supports to relieve symptoms, bilateral versus unilateral symptoms, effect on occupational function, prior failed treatments.

Avoid: Do not say your orthotics 'fix the problem' if they only partially reduce pain. Do not downplay bilateral symptoms by discussing only the worse side. Do not omit ankle or leg pain caused by the flat foot mechanics.

DeLuca Factors: Fatigue, Weakness, and Lack of Endurance

How to describe it: Describe how your feet feel after repetitive use. Quantify how long you can walk or stand before fatigue, weakness, or increased pain forces you to stop. Describe any muscle weakness in your feet or lower legs related to the condition.

Example: After walking two blocks my feet feel heavy and fatigued, like I am wearing lead shoes. My arches ache and my calves feel tight from compensating for my foot posture. I have to stop and rest for at least 10 minutes before I can continue. I cannot walk more than a quarter mile before this happens on a bad day. I feel weak and unsteady on uneven surfaces because of the instability of my flat feet.

Examiner listens for: Quantified walking distance, need for rest breaks, progressive worsening with use, weakness affecting gait stability, incoordination or instability when ambulating.

Avoid: Do not say 'I can walk fine for short distances' without specifying what short means. Do not fail to mention that symptoms worsen significantly with increased activity duration.

Flare-Ups and Incapacitating Exacerbations

How to describe it: Describe distinct episodes when your symptoms become severely worse than baseline. Include frequency (how many times per month or year), duration (how many days each episode lasts), severity (pain level, mobility), and what activities are completely impossible during a flare-up. This is especially important for plantar fasciitis ratings because incapacitating exacerbations specifically support a 20% rating per M21-1.

Example: About three to four times per month I have flare-ups where my heel and arch pain spikes to a 9 out of 10. During these episodes, which last 2 to 3 days, I cannot walk without limping severely and I have had to miss work or work from home because I cannot stand or walk to perform my job duties. I cannot do any grocery shopping, yard work, or house cleaning during these episodes. I elevate my foot, use ice, and take over-the-counter pain relievers which provide only minimal relief.

Examiner listens for: Frequency, duration, functional impact, missed work or reduced activity, failed treatments during flare-ups, whether the veteran reports episodes consistent with incapacitating exacerbations.

Avoid: Do not minimize flare-ups as 'just bad days.' Do not fail to quantify frequency and duration. Do not omit describing what you specifically cannot do during a flare-up.

Response to Treatment (Orthotics, Arch Supports, Built-Up Shoes)

How to describe it: The rating criteria for flat foot specifically distinguishes between symptoms relieved by arch support (0%), symptoms not fully relieved (10%+), and symptoms not improved at all by orthopedic shoes or appliances (pronounced level). Be precise about whether your devices provide full relief, partial relief, or no relief.

Example: I wear custom orthotics every day but they do not eliminate my pain. They reduce my pain from about an 8 to a 5 or 6 but I still have significant pain with any prolonged standing or walking. Even with orthotics I cannot stand for more than 45 minutes without pain that forces me to sit. Without orthotics, standing for 10 minutes causes severe pain. My arch supports do not prevent my foot from rolling inward significantly when I walk.

Examiner listens for: Type of device (over-counter vs. custom), frequency of use, degree of symptom relief (full, partial, none), whether devices prevent structural deformity on weight-bearing, cost and accessibility of devices.

Avoid: Do not say your orthotics 'help a lot' without clarifying residual pain and limitation. Do not say you 'feel better with them' if you still cannot perform normal activities. Never suggest your devices resolve your symptoms completely.