Malunion or Nonunion - Tarsal or Metatarsal Bones C&P Exam Prep

What the examiner evaluates

• Confirmed diagnosis of malunion or nonunion of tarsal or metatarsal bones and which specific bones are affected
• Which foot is affected (right, left, or bilateral)
• Presence, location, and severity of bony deformity visible or palpable on examination
• Range of motion of the ankle and foot under weight-bearing and non-weight-bearing conditions
• Tenderness on palpation over the affected tarsal or metatarsal bones
• Functional loss attributable to the condition including gait disturbance, instability, and inability to bear weight
• DeLuca factors: pain with motion, fatigue, weakness, incoordination, and functional loss after repetitive use or during flare-ups
• Presence of associated findings such as callosities, hammer toes, or plantar fascia involvement
• History of surgical procedures including tarsal osteotomy, metatarsal head resection, or other foot surgeries
• Use of assistive devices (cane, brace, crutches, walker, wheelchair) and their frequency
• Impact on ability to stand, walk, sit, and perform occupational and daily activities
• Whether the condition constitutes actual loss of use of the foot (threshold for 40% rating under DC 5283 Note)
• Review of imaging studies including X-rays confirming malunion or nonunion

The examiner will conduct both an interview and a physical examination. Bring all relevant imaging (X-rays, CT scans, MRI reports). The examiner will observe your gait when you enter and walk during the exam. Weight-bearing and non-weight-bearing ROM measurements will both be taken per Correia requirements. The exam will typically be conducted in person; if conducted via telehealth, the examiner must note how the examination was conducted.

Measurements and tests

Rating criteria by percentage

Describing your symptoms accurately

Common mistakes to avoid

Prep checklist

• critical

  Gather and organize all imaging reports confirming malunion or nonunion

  Collect all X-ray reports, CT scan reports, and MRI reports that document the malunion or nonunion of the specific tarsal or metatarsal bones. Highlight radiologist language confirming impaired union or abnormal bone position. Bring both the reports and any physical films or CD copies if available. The examiner should have these in the file but do not assume they have been reviewed.

  before exam

• critical

  Write a detailed symptom narrative covering worst days, flare-ups, and all DeLuca factors

  Before your exam, write out your symptoms in detail: (1) baseline pain on an average day (location, severity 0-10, what triggers it, what helps); (2) worst-day symptoms (frequency of worst days, what they look like, what you cannot do); (3) flare-up description (frequency, triggers, duration, functional loss during flare-up); (4) fatigue and weakness with repetitive use; (5) all activities you can no longer do or have had to modify. Practice stating this clearly and bring the written notes to the exam.

  before exam

• critical

  Compile a complete list of all treatments, medications, and adaptive equipment

  List every treatment you have received: surgeries (with dates and procedures), physical therapy, injections, medications (name, dose, frequency, how much pain relief they provide), custom orthotics (who prescribed them, when fitted), braces, and assistive devices. Include over-the-counter items such as arch supports, heel cups, and padding. Note how your function would be without each treatment.

  before exam

• critical

  Review your service treatment records for documentation of the original fracture

  Confirm that your service records document the initial fracture event, treatment provided in service (casting, surgery, follow-up), and any subsequent fracture or bone condition noted at separation. If the malunion or nonunion was identified after service, gather the earliest post-service documentation of the problem.

  before exam

• critical

  Document the functional impact on employment and daily activities in writing

  Write down: (1) your current or most recent job and which specific duties are impossible or very difficult due to the foot condition; (2) daily activities you cannot do (grocery shopping, yard work, standing in kitchen, attending events); (3) social or recreational activities you have had to give up; (4) any help you require from others because of the foot condition. Concrete examples are much more useful than general statements.

  before exam

• recommended

  Request exam recording information for your state

  Research whether your state allows C&P examination recording. Many states permit recording with advance notice. Check with your VSO or legal representative about the process. If recording is permitted, bring a smartphone or recording device and notify the examination facility in advance. Document who you notified and when.

  before exam

• recommended

  Contact your VSO to review your claim file before the exam

  Ask your Veterans Service Organization representative to confirm what evidence is in your file, whether the C&P request is correctly framed for DC 5283, and whether any records are missing. A pre-exam file review ensures the examiner has all relevant evidence to review.

  before exam

• recommended

  Photograph any visible deformity, swelling, or secondary skin changes

  If you have visible bony prominence, foot deformity, callosities, or swelling that is present regularly, photograph it with good lighting from multiple angles. These photos can be submitted as evidence and provide documentation of your condition between medical visits.

  before exam

• critical

  Take your medications as prescribed - do not skip pain medications to 'show' how bad the pain is

  Skipping pain medication before the exam can impair your ability to cooperate with the examination and may not accurately represent your treated condition. Take your medications as prescribed. If you are concerned the examiner won't see your true baseline pain level, clearly state: 'I took my scheduled pain medication before this exam. Without medication, my pain level is typically X out of 10 higher than what I'm feeling right now.'

  day of

• critical

  Bring and wear all orthotics, braces, and assistive devices you normally use

  Bring every device you use for your foot: custom orthotics, ankle-foot orthosis, over-the-counter insoles, ankle brace, cane. Wear what you would normally wear to a doctor's appointment. Show the examiner what you use and explain how often. This directly populates DBQ fields for assistive device use.

  day of

• recommended

  Bring a trusted person who can describe what they observe about your condition

  A family member, friend, or caregiver who observes your daily limitations can provide a lay witness account. While they typically cannot be in the exam room, their observations can be submitted as a buddy statement. They can remind you of symptoms you might forget to mention.

  day of

• recommended

  Arrive early and observe your own pain and functional status when you arrive

  Note your pain level when you first get up in the morning, after driving or riding to the exam, and when you enter the exam room. These transitions often aggravate foot conditions. If you are limping when you enter the room, the examiner may note gait before the formal exam begins.

  day of

• recommended

  Bring written symptom notes to reference during the exam

  Having written notes prevents you from forgetting important symptoms under the stress of the exam. You are permitted to reference notes. Your notes should cover: worst-day symptoms, flare-up description, functional limitations, occupational impact, and list of treatments and devices.

  day of

• critical

  Clearly state pain at the beginning, middle, and end of range of motion during ROM testing

  When the examiner measures your range of motion, verbally report: (1) when pain begins with movement; (2) when pain stops further movement; (3) your pain level at the limit of motion (0-10 scale); (4) whether passive motion is more or less painful than active motion. Do not wait to be asked - volunteer this information for each movement tested.

  during exam

• critical

  Request that the examiner document both weight-bearing and non-weight-bearing ROM measurements separately

  Under Correia v. McDonald (522 F.3d. App. 520) and DBQ requirements, ROM should be measured under both weight-bearing and non-weight-bearing conditions. If the examiner performs only one type of measurement, respectfully request: 'Could you also measure my range of motion while I'm weight-bearing (or non-weight-bearing)? I understand that should be documented separately.'

  during exam

• critical

  Proactively raise flare-up symptoms and DeLuca factors if not asked

  If the examiner does not ask about flare-ups or how symptoms change with repetitive use, proactively say: 'I'd like to make sure my flare-up symptoms are documented. Can I describe what happens during my worst episodes?' Then describe frequency, triggers, duration, and functional loss. Also ask that the examiner document: 'How my symptoms change after prolonged use compared to the single measurement taken here today.'

  during exam

• critical

  Describe your worst-day function explicitly and label it as such

  Say clearly: 'Today is a moderate day for me. On my worst days, which happen approximately [X times per week/month], I experience [specific symptoms]. During those times I am unable to [specific activities].' This framing directly triggers the M21-1 requirement that the examiner document worst-day as well as typical function.

  during exam

• recommended

  Describe all secondary and downstream effects of the bone deformity

  Mention every problem caused by or worsened by the abnormal bone position: callosities under metatarsal heads, abnormal toe positions, plantar fascia tightness, secondary ankle pain from altered gait, skin breakdown, and any instability or falls. These secondary findings are all documented on the DBQ and support higher severity ratings.

  during exam

• recommended

  Ask for a copy of the completed DBQ

  Under 38 CFR 3.159, you are entitled to a copy of the examination report. At the conclusion of the exam, ask the examiner or examination company for a copy of the completed DBQ. Review it for accuracy and completeness. If the examiner has omitted critical symptoms you reported, note this in writing to your VSO.

  during exam

• critical

  Write a detailed record of what was and was not covered in the exam immediately afterward

  As soon as possible after the exam, write down: (1) what questions were asked; (2) what physical tests were performed; (3) what you reported that the examiner documented versus what may have been missed; (4) whether ROM was measured weight-bearing and non-weight-bearing; (5) whether flare-ups and worst-day symptoms were captured. This record is essential if the exam is later found to be inadequate.

  after exam

• critical

  Notify your VSO immediately if you believe the exam was inadequate

  If the examiner did not ask about flare-ups, did not perform physical examination, did not measure ROM in multiple positions, did not document your reported worst-day symptoms, or seemed unfamiliar with DC 5283 criteria, notify your VSO immediately. An inadequate exam can be the basis for a remand or supplemental claim. Document your concerns in writing.

  after exam

• recommended

  Submit a buddy statement from someone who witnesses your daily functional limitations

  A written statement from a spouse, family member, caregiver, or coworker describing what they observe about your daily functional limitations is highly valuable. Buddy statements can address flare-ups, assistive device use, activity limitations, and help you receive. Instructions for buddy statements (VA Form 21-10210) are available from your VSO.

  after exam

• recommended

  Review the examination report when it becomes available and flag inaccuracies

  When the C&P exam report is available in your VA file (accessible through eBenefits, VA.gov, or your VSO), review it carefully. Check that all reported symptoms are documented, that ROM measurements are correct, that the DeLuca factors are addressed, and that the severity assessment reflects your described worst-day function. If significant inaccuracies exist, discuss with your VSO whether a request for a new examination or a nexus addendum is appropriate.

  after exam

Your rights during a C&P exam

• You have the right to a thorough, in-person C&P examination conducted by a qualified healthcare provider who reviews your entire claims file before the exam.
• You have the right to have your claims file reviewed by the examiner prior to the examination, including all service treatment records and prior medical evidence (Sharp v. Shulkin, 29 Vet.App. 26, 2017).
• You have the right to have range of motion measured under both weight-bearing and non-weight-bearing conditions, and to have both active and passive ROM documented separately.
• You have the right to have functional loss due to pain, fatigue, weakness, and incoordination during repetitive use and flare-ups documented in your examination, even when these symptoms are not directly observable at the time of the exam (DeLuca v. Brown, 8 Vet.App. 202, 1995).
• You have the right to have your worst-day symptoms, not just your symptoms on the day of the exam, considered in the rating determination per M21-1 adjudication guidance.
• You have the right to request a copy of the completed DBQ examination report and to review it for accuracy and completeness.
• You have the right to request a new C&P examination if the original exam is found to be inadequate, incomplete, or based on an inaccurate or incomplete claims file review.
• You have the right to record your C&P examination in states where recording is permitted. Verify your state's law in advance and provide advance notice to the examination facility.
• You have the right to submit additional evidence including buddy statements, private medical opinions, and personal statements after the exam to supplement the examination record.
• You have the right to appeal a rating decision you believe does not accurately reflect the severity of your condition, and to request a Higher Level Review, Supplemental Claim, or Board of Veterans Appeals hearing.
• You have the right to representation by an accredited Veterans Service Officer, attorney, or claims agent at no charge through VSO services.
• You have the right to be treated with dignity and respect during your examination. If the examiner is dismissive, cuts you off, or refuses to document symptoms you report, note this and inform your VSO.
• Under 38 CFR 3.103(b)(1), you have the right to present evidence and argument at any point in the claims process, including after a C&P examination is completed.

Related conditions

• Os Calcis or Astragalus, Malunion of DC 5273 specifically covers malunion of the os calcis (calcaneus) or astragalus (talus) - the two major hindfoot bones. If your malunion involves these specific bones, the rater may evaluate under DC 5273 (20% for marked deformity, 10% for moderate) rather than DC 5283. Understand which bones are documented in your imaging and confirm which DC is being applied.
• Other Foot Injuries (DC 5284) DC 5284 covers foot injuries not specifically addressed by DCs 5276-5283 and 5269. Per M21-1, conditions listed under specific DCs like 5283 must be rated under those DCs and cannot be rated by analogy under 5284. However, if your foot condition involves multiple injuries, understand that 5284 is the catch-all for injuries not covered by specific codes.
• Flatfoot (Pes Planus) A malunion of tarsal bones can cause acquired flatfoot deformity by altering the arch-supporting structures. If flat foot exists as a secondary or concurrent condition, it may be separately ratable under DC 5276. Discuss with your VSO whether secondary flat foot deformity should be claimed separately.
• Post-Traumatic Arthritis of the Foot Malunion of tarsal or metatarsal bones commonly leads to post-traumatic arthritis in the affected joints over time due to altered biomechanics and abnormal joint loading. Post-traumatic arthritis can be separately claimed under DC 5010 (arthritis due to trauma) and may be ratable in addition to the malunion/nonunion rating if the joints involved are separately documented.
• Metatarsalgia Pain under the metatarsal heads (metatarsalgia) is a common secondary consequence of metatarsal malunion due to altered weight distribution. Metatarsalgia is evaluated under DC 5279 at 10% regardless of laterality. If you have documented metatarsal head tenderness as a separate condition from your malunion, discuss whether a separate claim is appropriate.
• Ankle Instability or Limitation of Motion Tarsal bone malunion frequently causes secondary ankle joint dysfunction, including limitation of dorsiflexion and plantarflexion. If ankle ROM limitation exists beyond what is explained by the tarsal malunion alone, an additional rating under DC 5271 (ankle, limited motion) or DC 5270 (ankle, ankylosis) may be appropriate.
• Plantar Fasciitis Altered foot mechanics from metatarsal or tarsal malunion can cause or worsen plantar fasciitis. If plantar fasciitis exists as a secondary condition resulting from the changed biomechanics of the malunited foot, it may be separately ratable. Document the temporal relationship between the malunion diagnosis and the onset of plantar fasciitis symptoms.
• TDIU (Total Disability Individual Unemployability) If your malunion or nonunion of tarsal or metatarsal bones, alone or in combination with other service-connected conditions, prevents you from maintaining substantially gainful employment, you may be eligible for TDIU under 38 CFR 4.16. The functional limitations of foot disability (inability to stand, walk, or ambulate) are directly relevant to TDIU claims in many occupations.