Os Calcis or Astragalus Malunion C&P Exam Prep

Ankle Dorsiflexion (Active and Passive)

What it measures: Upward bending of the foot toward the shin. Normal is approximately 20 degrees. This motion is commonly restricted in calcaneal or talar malunion due to altered joint mechanics and bony impingement.

What to expect: The examiner will ask you to pull your foot upward as far as possible (active), then may gently assist the motion further (passive). This will be performed seated (non-weight-bearing) and may also be assessed standing (weight-bearing). Report any pain immediately when it begins - do not wait until maximum motion is reached.

Pain considerations: Under DeLuca v. Brown, the examiner must document whether pain limits motion before the anatomical endpoint. State clearly: 'Pain begins at approximately X degrees and I cannot move further because of the pain, not because of stiffness alone.'

Ankle Plantar Flexion (Active and Passive)

What it measures: Downward pointing of the foot. Normal is approximately 45 degrees. Malunion of the calcaneus or talus may restrict or alter this motion due to altered bone architecture.

What to expect: You will be asked to point your foot downward as far as possible. The examiner notes the degree of motion achieved and whether pain limits movement. Both active and passive measurements are typically recorded. Report the exact point at which pain begins.

Pain considerations: If plantar flexion causes a sharp, stabbing pain or a deep aching pain in the heel or ankle, describe both the quality and location precisely. Example: 'I feel sharp pain in my heel at about 30 degrees that stops me from going further.'

Subtalar Joint Motion (Inversion and Eversion)

What it measures: Side-to-side rolling motion of the foot at the subtalar joint, which is directly formed by the talus sitting on the calcaneus. Malunion of either bone often severely disrupts subtalar mechanics. Normal inversion is approximately 20 degrees; eversion approximately 10 degrees.

What to expect: The examiner will hold your heel and attempt to roll it inward (inversion) and outward (eversion). This may be uncomfortable or impossible if the subtalar joint is fused, blocked, or severely deformed. Report pain clearly.

Pain considerations: Subtalar restriction from calcaneal or talar malunion is often more disabling than ankle ROM alone. Communicate: 'Any turning motion of my heel causes immediate deep pain and I cannot walk on uneven surfaces without significant pain and risk of falling.'

Deformity Assessment (Visual and Palpation)

What it measures: The examiner visually inspects and palpates the calcaneus (heel bone) and talus (ankle bone) for visible bony deformity, widening, shortening, malalignment, varus/valgus deformity, and abnormal contour. This is the PRIMARY rating driver under DC 5273.

What to expect: The examiner will look at both feet side by side, observe your standing posture and arch, palpate bony prominences, and assess for deformity. X-rays are typically reviewed. The examiner must distinguish between 'marked' and 'moderate' deformity - ensure they have access to all prior imaging.

Pain considerations: While deformity is the primary rating factor, associated pain amplifies the functional picture. State: 'The deformity causes me to walk on the outside/inside edge of my foot, which creates pain throughout my entire lower extremity on worst days.'

Functional Gait Observation and Weight-Bearing Assessment

What it measures: How the malunion affects your walking pattern, stance, and ability to bear weight. The examiner observes antalgic gait (limping due to pain), foot drop, inability to heel-walk or toe-walk, and compensatory postures.

What to expect: The examiner will observe you walk, possibly ask you to walk on your heels and toes, and assess standing posture. Report any pain that increases with prolonged standing or walking. If you use an assistive device or brace, bring it and use it if that is your normal practice.

Pain considerations: Describe your walking limitations in terms of time and distance: 'On a bad day I can only walk about one block before the pain in my heel and ankle forces me to stop and rest for 5-10 minutes.'

20%

Marked deformity of the os calcis (calcaneus) or astragalus (talus) due to malunion. This rating requires evidence of significant bony malalignment, substantial alteration of normal foot architecture, and functional impairment consistent with a more severe structural abnormality.

From 38 CFR: 38 CFR 4.71a, DC 5273: 'Marked deformity - 20%.' The term 'marked' implies a substantial degree of structural abnormality that is clearly visible and clinically significant, producing notable functional consequences beyond what would be expected with a minor malunion.

10%

Moderate deformity of the os calcis (calcaneus) or astragalus (talus) due to malunion. This rating applies when there is demonstrable bony malalignment that is clinically evident but less severe in degree, with functional limitations that are present but do not reach the threshold of 'marked' deformity.

From 38 CFR: 38 CFR 4.71a, DC 5273: 'Moderate deformity - 10%.' The term 'moderate' implies a clinically visible malunion with functional consequences that are real but less severe than marked deformity. This is the minimum compensable rating under DC 5273.

Bony Deformity and Structural Changes

How to describe it: Describe specifically what you can see and feel about your heel and ankle shape compared to your other foot. Be specific: widened heel, shortened heel height, heel tilted inward (valgus) or outward (varus), prominent bony bump, flattened arch, or visible misalignment when standing.

Example: On my worst days, the deformity in my heel causes my entire foot to roll inward so severely that I cannot stand for more than a few minutes without intense pain radiating from my heel up into my ankle and lower leg. The misalignment is so pronounced that standard shoes cannot fit properly and create pressure sores on the deformed area.

Examiner listens for: Specific description of visible and palpable deformity, comparison to the unaffected foot, impact of the deformity on footwear and weight-bearing, and whether the deformity has worsened over time.

Avoid: Do not say 'my heel looks a little different' - instead say 'my heel is visibly wider, shorter, and angled inward compared to my other heel, which causes my foot to pronate severely when I stand.'

Pain - Quality, Location, and Triggers

How to describe it: Describe pain using specific language: location (heel, ankle, bottom of foot, inner or outer ankle), quality (sharp, stabbing, aching, burning, throbbing), triggers (first steps in morning, prolonged standing, walking on hard surfaces, stairs, uneven ground), and intensity on a 0-10 scale on both average and worst days.

Example: On my worst days, I wake up with a 9 out of 10 stabbing pain in my heel that is so severe I cannot put weight on it for the first 15-20 minutes after getting out of bed. After prolonged standing or walking, the pain escalates to a constant 8 out of 10 deep aching pain throughout my entire heel and ankle that does not fully resolve until I have been off my feet for several hours.

Examiner listens for: Pain that is present at rest, on first weight-bearing, with activity, and during flare-ups. The examiner needs to document pain on movement (which can justify rating based on painful motion even if ROM is not severely reduced), pain limiting ROM before anatomical endpoint, and pain causing functional loss under DeLuca factors.

Avoid: Do not say 'it hurts sometimes when I walk.' Instead say: 'I have pain every single day. On average it is a 6 out of 10. On bad days it is a 9 out of 10. Pain begins immediately when I start walking and gets worse the longer I am on my feet.'

Flare-Ups - Frequency, Duration, and Functional Impact

How to describe it: Describe flare-ups as distinct episodes of worsening that go beyond your baseline pain. Specify how often they occur, what triggers them (prolonged walking, weather changes, specific activities), how long they last, and what you cannot do during a flare-up.

Example: I have severe flare-ups approximately 2-3 times per week, lasting 1-3 days each. During a flare-up, my heel and ankle swell visibly, the pain reaches 9-10 out of 10, I cannot walk more than a few steps, and I am confined to limited mobility requiring use of my cane at all times. I cannot perform my job duties, cook, or care for myself normally during these episodes.

Examiner listens for: Frequency and pattern of flare-ups, functional consequences during flare-ups, whether flare-ups are triggered by normal daily activities (not just extraordinary exertion), and time lost from work or daily activities during flare-up periods. This is a required DeLuca factor.

Avoid: Do not omit flare-ups or say 'it comes and goes.' Describe them as distinct, recurring episodes with specific functional consequences: 'During flare-ups I cannot perform even light housework and am limited to moving between the bed and bathroom.'

Functional Limitations - Walking, Standing, and Daily Activities

How to describe it: Quantify your limitations in concrete terms: maximum walking distance before pain forces you to stop, maximum standing time, inability to climb stairs or walk on inclines, inability to carry loads while walking, impact on employment, household activities, and recreation.

Example: On my worst days, I can only stand for about 5 minutes and walk about half a block before the pain in my heel and ankle becomes so severe that I must sit and rest. I cannot climb stairs without holding the rail and significant pain. I cannot stand long enough to cook a full meal, do laundry, or perform my previous job duties that required standing for hours.

Examiner listens for: Specific functional limitations that are directly attributable to the foot deformity, impact on ability to maintain employment or perform occupational duties, and whether limitations reflect the veteran's typical or worst-day experience rather than best-day performance.

Avoid: Do not say 'I try not to complain' or 'I manage.' Say: 'I have had to change jobs, give up recreational activities, and rely on others for help with tasks that require prolonged standing or walking because of my foot condition.'

Fatigue and Weakness with Repetitive Use

How to describe it: Describe how your foot and ankle function deteriorates with repeated use throughout the day. This includes progressive worsening of pain, development of limping, muscle fatigue in the calf and lower leg, and inability to sustain activities that were manageable at the start.

Example: When I try to push through and walk longer distances, my entire lower leg becomes fatigued and weak by the end of the day. I develop a significant limp that gets worse the more I walk. By the evening, even partial weight-bearing is extremely painful and I must elevate my foot and use ice to manage the swelling and pain.

Examiner listens for: Progressive functional decline with activity - this is the DeLuca 'repeated use over time' factor. The examiner must document whether functional ability is significantly more limited after repeated use compared to initial testing, which is critical for an accurate rating.

Avoid: Do not only describe how you feel at the start of the day. Explicitly describe how your condition worsens with activity: 'What I can do in the first 10 minutes of walking is not representative of how I function after an hour of activity.'

Instability and Incoordination

How to describe it: Describe any episodes of the ankle or foot giving way, feeling unstable, rolling, or causing you to stumble or fall. Note any difficulty with balance on the affected side, particularly on uneven surfaces, stairs, or during direction changes.

Example: On my worst days, my ankle and heel feel completely unstable and unpredictable. I have had the foot roll outward while walking on flat ground, causing me to catch myself from falling. I cannot walk on grass, gravel, or any uneven surface without significant fear of falling and actual near-falls on a weekly basis.

Examiner listens for: Documented instability of station, incoordination as a functional loss factor under DeLuca, and history of falls or near-falls attributable to the foot/ankle instability - these are separately checked on the DBQ and contribute to the overall functional loss documentation.

Avoid: Do not omit near-falls or stumbles. Say: 'I have stumbled and nearly fallen multiple times per week because of the instability in my foot, and I have fallen [X times] in the past year as a direct result.'