Hey folks. First time posting here, have been lurking for a while. I just want to say thanks to everyone that contributes here and makes this place great.
I have 16 years in. Unfitting condition is flat feet and ankle issues w/two surgeries. Anyone willing to take a stab at this for me? Thanks!
-----------------------------------------------------------
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXX
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ: left ankle
posterior
tibial tendon dysfunction with pes planus
b. Select diagnoses associated with the claim condition(s) (Check all that
apply):
CONFIDENTIAL Page 37 of 133
[X] Tendonitis (achilles/peroneal/posterior tibial)
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: M76.822
Date of diagnosis: Left 2014
[X] Other (specify):
Other diagnosis: Sinus tarsi syndrome, left
ICD Code: M77.9
Side affected: Left
Date of diagnosis: Left:2015
********************************************************************
Other diagnosis: Peroneus brevis tendonitis, left
ICD Code: M76.72
Side affected: Left
Date of diagnosis: Left:17 June 2016
********************************************************************
c. Comments (if any): No response provided
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
ankle
condition (brief summary): Veteran states his foot pain started in sometime
in 2010 and 2011. States the pain started with swelling to the left ankle
with pain to the medial foot/ankle and points to the posterior tibial area.
States he went to medical and was told he had flat feet, and treated his
foot pain with custom foot orthoses. The pain progressively worsened and he
had surgery to the left foot. He had a subtalar joint implant
(arthroeresis)
in April 2014, which was then removed in May 2015.
Currently, states he has pain to left ankle and points to the posterior
tibial tendon and sinus tarsi, and to the plantar arch of both feet. States
he has pain with standing for more than a few minutes to both his feet, and
walking up to 1/2 mile at one time. States he is unable to run, or any high
impact activities. Continues to wear custom foot orthoses, which gives
partial relief.
b. Does the Veteran report flare-ups of the ankle?
[ ] Yes [X] No
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ (regardless of
repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional
impairment in his or her own words:
CONFIDENTIAL Page 38 of 133
standing for more than a few minutes to both his feet, and walking up to
1/2 mile at one time. States he is unable to run, or any high impact
activities
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
a. Initial range of motion
Left ankle
----------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 4 degrees
Plantar Flexion (0-45): 0 to 45 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
disturbance locomotion
Description of pain (select best response):
No pain noted on exam
Is there evidence of pain with weight bearing? [X] Yes [ ] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
Moderate pain on palpation to sinus tarsi, to posterior tibial tendon
from insertion on navicular to inferior medial malleolus, and to
peroneus brevis tendon from insertion on navicular to inferior lateral
malleolus. Moderate pain to sinus tarsi with inversion of subtalar
joint.
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Left ankle
----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
CONFIDENTIAL Page 39 of 133
c. Repeated use over time
Left ankle
----------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Lack of endurance
Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 4 degrees
Plantar Flexion (0-45): 0 to 45 degrees
d. Flare-ups: No response provided
e. Additional factors contributing to disability
Left ankle
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc., Swelling,
Disturbance of locomotion
4. Muscle strength testing
--------------------------
a. Muscle strength - rate strength according to the following scale
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right ankle:
Rate Strength: Plantar Flexion: /5
Dorsiflexion: /5
Left ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
CONFIDENTIAL Page 40 of 133
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if Veteran has ankylosis of the ankle
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side: Left side:
[ ] In plantar flexion [ ] In plantar flexion
[ ] In dorsiflexion [ ] In dorsiflexion
[ ] With an abduction deformity [ ] With an abduction deformity
[ ] With an inversion deformity
[ ] With an inversion deformity
[ ] With an eversion deformity [ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing
position
[ ] In poor weight-bearing position [ ] In poor weight-bearing
position
[ ] No ankylosis [X] No ankylosis
b. Comments, if any:
No response provided
6. Joint stability
------------------
Right ankle
No response provided
Left ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints",
stress
fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus
(os calcis) or talus (astragalus), or has the Veteran had a talectomy
(astragalectomy)? [ ] Yes [X] No
8. Surgical procedures
----------------------
Indicate any surgical procedures that the Veteran has had performed and
provide
CONFIDENTIAL Page 41 of 133
the additional information as requested (check all that apply):
Right side:
No response provided
Left side:
[X] Arthroscopic or other ankle surgery
Type of surgery: Subtalar joint implant [and removal]
Date of surgery: April 2014 [May 2015]
[X] Residuals of arthroscopic or other ankle surgery
Decribe residuals:
pain, swelling
9. Other pertinent physical findings, complications conditions, signs,
symptoms
and scars
-------------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above? [ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above? [X] Yes [ ] No
If yes, are any of these scars painful or unstable, have a total area
equal to or greater than 39 square cm (6 square inches) or are located on
the head, face or neck? (An "unstable scar" is one where, for
any reason,
there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters
Location: Left foot, over the sinus tarsi (anterolateral ankle)
Measurements: length 2.0 cm X width 0.1 cm
c. Comments, if any:
No response provided
10. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and indicate
frequency):
[ ] Wheelchair
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
CONFIDENTIAL Page 42 of 133
[ ] Brace(s)
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Crutches
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Cane(s)
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Walker
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[X] Other: custom foot orthoses
Frequency of use: [ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
custom foot orthoses for foot pain
11. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's ankle condition, is there functional impairment of
an
extremity such that no effective functions remain other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
12. Diagnostic testing
----------------------
a. Have imaging studies of the ankle been performed and are the results
available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
Report Status: Verified Date Reported: JUN 17,
2016
Date Verified: JUN 17,
2016
Verifier E-Sig:
CONFIDENTIAL Page 43 of 133
Report:
Impression:
Weight-bearing AP, lateral oblique images of the left
ankle.
Comparison:
Findings: The Ankle mortise is intact. The dome of the talus
is
unremarkable.
Distal tibia and fibula are unremarkable. No fracture or
dislocation. No air in the soft tissues. No foreign body. An
etiology for the patient's symptom is not identified.
Negative study
Primary Diagnostic Code:
Primary Interpreting Staff:
MARK L JACKSON, Radiologist
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
13. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[ ] Yes [X] No
14. Remarks, if any
-------------------
No response provided
****************************************************************************
Foot Conditions, including Flatfoot (Pes Planus)
Disability Benefits Questionnaire
Name of patient/Veteran: CONFIDENTIAL Page 44 of 133
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
left ankle posterior tibial tendon dysfunction with pes planus
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus)
ICD code: Q66.51 (Rt) and Q66.52 (Lt)
Side affected: Both
Date of diagnosis: Right: 2014
Date of diagnosis: Left: 2014
[X] Plantar fasciitis
ICD Code: M72.2
Side affected: Both
Date of diagnosis: Right 17 June 2016
Date of diagnosis: Left 17 June 2016
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[ ] Yes [X] No [ ] N/A
2. Medical history
CONFIDENTIAL Page 45 of 133
------------------
a. Describe the history (including onset and course) of the Veteran's
foot
condition (brief summary):
Veteran states his foot pain started in sometime in 2010 and 2011. States
the pain started with swelling to the left ankle with pain to the medial
foot/ankle and points to the posterior tibial area. States he went to
medical and was told he had flat feet, and treated his foot pain with
custom
foot orthoses. The pain progressively worsened and he had surgery to the
left foot. He had a subtalar joint implant (arthroeresis) in April 2014,
which was then removed in May 2015.
Currently, states he has pain to left ankle and points to the posterior
tibial tendon and sinus tarsi, and to the plantar arch of both feet. States
he has pain with standing for more than a few minutes to both his feet, and
walking up to 1/2 mile at one time. States he is unable to run, or any high
impact activities. Continues to wear custom foot orthoses, which gives
partial relief.
b. Does the Veteran report pain of the foot being evaluated on this DBQ?
[X] Yes [ ] No
If yes, document the Veteran's description of pain in his or her
own
words:
tates he has pain to left ankle and points to the posterior tibial
tendon and sinus tarsi, and to the plantar arch of both feet. States he
has pain with standing for more than a few minutes to both his feet,
and
walking up to 1/2 mile at one time. States he is unable to run, or any
high impact activities.
c. Does the Veteran report that flare-ups impact the function of the foot?
[ ] Yes [X] No
d. Does the Veteran report having any functional loss or functional impairment
of the foot being evaluated on this DBQ (regardless of repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:
standing for more than a few minutes to both his feet, and walking up
to
1/2 mile at one time. States he is unable to run, or any high impact
activities
3. Flatfoot (pes planus)
------------------------
CONFIDENTIAL Page 46 of 133
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
c. Is there indication of swelling on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
d. Does the Veteran have characteristic callouses? [ ] Yes [X] No
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic
-----------------------------
Device Side Not Relieved:
[X] Orthotics [ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both
feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
Is the tenderness improved by orthopedic shoes or appliances?
RIGHT - [X] Yes [ ] No [ ] N/A
LEFT - [X] Yes [ ] No [ ] N/A
g. Does the Veteran have decreased longitudinal arch height of one or both
feet
on weight-bearing? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
h. Is there objective evidence of marked deformity of one or both feet
(pronation, abduction etc.)? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
i. Is there marked pronation of one or both feet? [X] Yes [ ] No
CONFIDENTIAL Page 47 of 133
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
Is the condition improved by orthopedic shoes or appliances?
LEFT - [X] Yes [ ] No [ ] N/A
j. For one or both feet, does the weight-bearing line fall over or medial to
the great toe? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
k. Is there a lower extremity deformity other than pes planus, causing
alteration of the weight-bearing line? [ ] Yes [X] No
l. Does the Veteran have "inward" bowing of the Achilles tendon
(i.e., hindfoot
valgus, with lateral deviation of the heel) of one or both feet?
[X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
m. Does the Veteran have marked inward displacement and severe spasm of the
Achilles tendon (rigid hindfoot) on manipulation of one or both feet?
[ ] Yes [X] No
n. Comments: pes planus bilateral, mild to right, moderate to left
4. Morton's neuroma (Morton's disease) and metatarsalgia
--------------------------------------------------------
No response provided
5. Hammer toe
-------------
No response provided
6. Hallux valgus
----------------
No response provided
7. Hallux rigidus
-----------------
No response provided
8. Acquired pes cavus (clawfoot)
--------------------------------
No response provided
9. Malunion or nonunion of tarsal or metatarsal bones
-----------------------------------------------------
No response provided
CONFIDENTIAL Page 48 of 133
10. Foot injuries and other conditions
--------------------------------------
a. Does the Veteran have any foot injuries or other foot conditions not
already
described?
[X] Yes [ ] No
If yes, describe the foot injury or other conditions (including
frequency and physical exam findings) and complete question b.
(severity
and side affected).
Moderate pain on palpation to bilateral medial band of the plantar
fascia from proximal insertion to distal arch.
b. Indicate severity and side affected:
[X] Moderate [ ] Right [ ] Left [X] Both
c. Does the foot condition chronically compromise weight bearing?
[X] Yes [ ] No
d. Does the foot condition require arch supports, custom orthotic inserts or
shoe modifications?
[X] Yes [ ] No
e. Comments: No comments provided
11. Surgical procedures
-----------------------
a. Has the Veteran had foot surgery (arthroscopic or open)?
[X] Yes [ ] No
If yes, indicate side affected, type of procedure and date of surgery:
[X] Left foot procedure: Subtalar joint implant [and removal]
Date of surgery: April 2014 [May 2015]
b. Does the Veteran have any residual signs or symptoms due to arthroscopic or
other foot surgery?
[X] Yes [ ] No
If yes, describe residuals: pain, swelling
12. Pain
--------
RIGHT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
CONFIDENTIAL Page 49 of 133
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
LEFT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
13. Functional loss and limitation of motion
--------------------------------------------
a. Contributing factors of disability (check all that apply and indicate side
affected):
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Disturbance of locomotion
Side affected: [ ] Right [ ] Left [X] Both
[X] Lack of endurance
Side affected: [ ] Right [ ] Left [X] Both
Contributing factors of disability associated with limitation of motion:
b. Is there pain, weakness, fatigability, or incoordination that significantly
limits functional ability during flare-ups or when the foot is used
repeatedly over a period of time?
RIGHT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
and/or when the joint is used repeatedly over a period of time) please
describe the functional loss:
see section 13A for limitations/functional loss
LEFT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
CONFIDENTIAL Page 50 of 133
and/or when the joint is used repeatedly over a period of time) please
describe the functional loss:
see section 13A for limitations/functional loss
c. Is there any other functional loss during flare-ups or when the foot is
used
repeatedly over a period of time?
RIGHT FOOT: [ ] Yes [X] No
LEFT FOOT: [ ] Yes [X] No
14. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[X] Yes [ ] No
If yes, are any of these scars painful or unstable; have a total area
equal to or greater than 39 square cm (6 square inches); or are located
on the head, face or neck? (An "unstable scar" is one where,
for any
reason, there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: Left foot, over the sinus tarsi (anterolateral ankle)
Measurements: Length 2.0cm X width 0.1cm
c. Comments: No comments provided
15. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
----------------- -----------------
[X] Other: custom foot orthoses
CONFIDENTIAL Page 51 of 133
[ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
custom foot orthoses for foot pain
16. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's foot condition, is there functional impairment of an
extremity such that no effective function remains other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
17. Diagnostic testing
----------------------
a. Have imaging studies of the foot been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
Report Status: Verified Date Reported: JUN 17,
2016
Date Verified: JUN 17,
2016
Verifier E-Sig:
Report:
Impression:
3 views of the right and left foot with weightbearing show no
bony or joint abnormality.
Primary Diagnostic Code:
Primary Interpreting Staff:
HERMENEGILDO H ALMARIA JR, Staff Radiologist
c. If any test results are other than normal, indicate relationship of
abnormal
CONFIDENTIAL Page 52 of 133
findings to diagnosed condition:
No response provided
18. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[ ] Yes [X] No
19. Remarks, if any:
--------------------
No remarks provided
I have 16 years in. Unfitting condition is flat feet and ankle issues w/two surgeries. Anyone willing to take a stab at this for me? Thanks!
-----------------------------------------------------------
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXX
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ: left ankle
posterior
tibial tendon dysfunction with pes planus
b. Select diagnoses associated with the claim condition(s) (Check all that
apply):
CONFIDENTIAL Page 37 of 133
[X] Tendonitis (achilles/peroneal/posterior tibial)
Side affected: [ ] Right [X] Left [ ] Both
ICD Code: M76.822
Date of diagnosis: Left 2014
[X] Other (specify):
Other diagnosis: Sinus tarsi syndrome, left
ICD Code: M77.9
Side affected: Left
Date of diagnosis: Left:2015
********************************************************************
Other diagnosis: Peroneus brevis tendonitis, left
ICD Code: M76.72
Side affected: Left
Date of diagnosis: Left:17 June 2016
********************************************************************
c. Comments (if any): No response provided
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
ankle
condition (brief summary): Veteran states his foot pain started in sometime
in 2010 and 2011. States the pain started with swelling to the left ankle
with pain to the medial foot/ankle and points to the posterior tibial area.
States he went to medical and was told he had flat feet, and treated his
foot pain with custom foot orthoses. The pain progressively worsened and he
had surgery to the left foot. He had a subtalar joint implant
(arthroeresis)
in April 2014, which was then removed in May 2015.
Currently, states he has pain to left ankle and points to the posterior
tibial tendon and sinus tarsi, and to the plantar arch of both feet. States
he has pain with standing for more than a few minutes to both his feet, and
walking up to 1/2 mile at one time. States he is unable to run, or any high
impact activities. Continues to wear custom foot orthoses, which gives
partial relief.
b. Does the Veteran report flare-ups of the ankle?
[ ] Yes [X] No
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ (regardless of
repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional
impairment in his or her own words:
CONFIDENTIAL Page 38 of 133
standing for more than a few minutes to both his feet, and walking up to
1/2 mile at one time. States he is unable to run, or any high impact
activities
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
a. Initial range of motion
Left ankle
----------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 4 degrees
Plantar Flexion (0-45): 0 to 45 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
disturbance locomotion
Description of pain (select best response):
No pain noted on exam
Is there evidence of pain with weight bearing? [X] Yes [ ] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
Moderate pain on palpation to sinus tarsi, to posterior tibial tendon
from insertion on navicular to inferior medial malleolus, and to
peroneus brevis tendon from insertion on navicular to inferior lateral
malleolus. Moderate pain to sinus tarsi with inversion of subtalar
joint.
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Left ankle
----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
CONFIDENTIAL Page 39 of 133
c. Repeated use over time
Left ankle
----------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Lack of endurance
Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 4 degrees
Plantar Flexion (0-45): 0 to 45 degrees
d. Flare-ups: No response provided
e. Additional factors contributing to disability
Left ankle
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc., Swelling,
Disturbance of locomotion
4. Muscle strength testing
--------------------------
a. Muscle strength - rate strength according to the following scale
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right ankle:
Rate Strength: Plantar Flexion: /5
Dorsiflexion: /5
Left ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
CONFIDENTIAL Page 40 of 133
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if Veteran has ankylosis of the ankle
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side: Left side:
[ ] In plantar flexion [ ] In plantar flexion
[ ] In dorsiflexion [ ] In dorsiflexion
[ ] With an abduction deformity [ ] With an abduction deformity
[ ] With an inversion deformity
[ ] With an inversion deformity
[ ] With an eversion deformity [ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing
position
[ ] In poor weight-bearing position [ ] In poor weight-bearing
position
[ ] No ankylosis [X] No ankylosis
b. Comments, if any:
No response provided
6. Joint stability
------------------
Right ankle
No response provided
Left ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints",
stress
fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus
(os calcis) or talus (astragalus), or has the Veteran had a talectomy
(astragalectomy)? [ ] Yes [X] No
8. Surgical procedures
----------------------
Indicate any surgical procedures that the Veteran has had performed and
provide
CONFIDENTIAL Page 41 of 133
the additional information as requested (check all that apply):
Right side:
No response provided
Left side:
[X] Arthroscopic or other ankle surgery
Type of surgery: Subtalar joint implant [and removal]
Date of surgery: April 2014 [May 2015]
[X] Residuals of arthroscopic or other ankle surgery
Decribe residuals:
pain, swelling
9. Other pertinent physical findings, complications conditions, signs,
symptoms
and scars
-------------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above? [ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above? [X] Yes [ ] No
If yes, are any of these scars painful or unstable, have a total area
equal to or greater than 39 square cm (6 square inches) or are located on
the head, face or neck? (An "unstable scar" is one where, for
any reason,
there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters
Location: Left foot, over the sinus tarsi (anterolateral ankle)
Measurements: length 2.0 cm X width 0.1 cm
c. Comments, if any:
No response provided
10. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and indicate
frequency):
[ ] Wheelchair
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
CONFIDENTIAL Page 42 of 133
[ ] Brace(s)
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Crutches
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Cane(s)
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Walker
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[X] Other: custom foot orthoses
Frequency of use: [ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
custom foot orthoses for foot pain
11. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's ankle condition, is there functional impairment of
an
extremity such that no effective functions remain other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
12. Diagnostic testing
----------------------
a. Have imaging studies of the ankle been performed and are the results
available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
Report Status: Verified Date Reported: JUN 17,
2016
Date Verified: JUN 17,
2016
Verifier E-Sig:
CONFIDENTIAL Page 43 of 133
Report:
Impression:
Weight-bearing AP, lateral oblique images of the left
ankle.
Comparison:
Findings: The Ankle mortise is intact. The dome of the talus
is
unremarkable.
Distal tibia and fibula are unremarkable. No fracture or
dislocation. No air in the soft tissues. No foreign body. An
etiology for the patient's symptom is not identified.
Negative study
Primary Diagnostic Code:
Primary Interpreting Staff:
MARK L JACKSON, Radiologist
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
13. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[ ] Yes [X] No
14. Remarks, if any
-------------------
No response provided
****************************************************************************
Foot Conditions, including Flatfoot (Pes Planus)
Disability Benefits Questionnaire
Name of patient/Veteran: CONFIDENTIAL Page 44 of 133
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
left ankle posterior tibial tendon dysfunction with pes planus
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus)
ICD code: Q66.51 (Rt) and Q66.52 (Lt)
Side affected: Both
Date of diagnosis: Right: 2014
Date of diagnosis: Left: 2014
[X] Plantar fasciitis
ICD Code: M72.2
Side affected: Both
Date of diagnosis: Right 17 June 2016
Date of diagnosis: Left 17 June 2016
c. Comments (if any):
No response provided
d. Was an opinion requested about this condition (internal VA only)?
[ ] Yes [X] No [ ] N/A
2. Medical history
CONFIDENTIAL Page 45 of 133
------------------
a. Describe the history (including onset and course) of the Veteran's
foot
condition (brief summary):
Veteran states his foot pain started in sometime in 2010 and 2011. States
the pain started with swelling to the left ankle with pain to the medial
foot/ankle and points to the posterior tibial area. States he went to
medical and was told he had flat feet, and treated his foot pain with
custom
foot orthoses. The pain progressively worsened and he had surgery to the
left foot. He had a subtalar joint implant (arthroeresis) in April 2014,
which was then removed in May 2015.
Currently, states he has pain to left ankle and points to the posterior
tibial tendon and sinus tarsi, and to the plantar arch of both feet. States
he has pain with standing for more than a few minutes to both his feet, and
walking up to 1/2 mile at one time. States he is unable to run, or any high
impact activities. Continues to wear custom foot orthoses, which gives
partial relief.
b. Does the Veteran report pain of the foot being evaluated on this DBQ?
[X] Yes [ ] No
If yes, document the Veteran's description of pain in his or her
own
words:
tates he has pain to left ankle and points to the posterior tibial
tendon and sinus tarsi, and to the plantar arch of both feet. States he
has pain with standing for more than a few minutes to both his feet,
and
walking up to 1/2 mile at one time. States he is unable to run, or any
high impact activities.
c. Does the Veteran report that flare-ups impact the function of the foot?
[ ] Yes [X] No
d. Does the Veteran report having any functional loss or functional impairment
of the foot being evaluated on this DBQ (regardless of repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:
standing for more than a few minutes to both his feet, and walking up
to
1/2 mile at one time. States he is unable to run, or any high impact
activities
3. Flatfoot (pes planus)
------------------------
CONFIDENTIAL Page 46 of 133
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
c. Is there indication of swelling on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
d. Does the Veteran have characteristic callouses? [ ] Yes [X] No
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic
-----------------------------
Device Side Not Relieved:
[X] Orthotics [ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both
feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
Is the tenderness improved by orthopedic shoes or appliances?
RIGHT - [X] Yes [ ] No [ ] N/A
LEFT - [X] Yes [ ] No [ ] N/A
g. Does the Veteran have decreased longitudinal arch height of one or both
feet
on weight-bearing? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
h. Is there objective evidence of marked deformity of one or both feet
(pronation, abduction etc.)? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
i. Is there marked pronation of one or both feet? [X] Yes [ ] No
CONFIDENTIAL Page 47 of 133
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
Is the condition improved by orthopedic shoes or appliances?
LEFT - [X] Yes [ ] No [ ] N/A
j. For one or both feet, does the weight-bearing line fall over or medial to
the great toe? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
k. Is there a lower extremity deformity other than pes planus, causing
alteration of the weight-bearing line? [ ] Yes [X] No
l. Does the Veteran have "inward" bowing of the Achilles tendon
(i.e., hindfoot
valgus, with lateral deviation of the heel) of one or both feet?
[X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
m. Does the Veteran have marked inward displacement and severe spasm of the
Achilles tendon (rigid hindfoot) on manipulation of one or both feet?
[ ] Yes [X] No
n. Comments: pes planus bilateral, mild to right, moderate to left
4. Morton's neuroma (Morton's disease) and metatarsalgia
--------------------------------------------------------
No response provided
5. Hammer toe
-------------
No response provided
6. Hallux valgus
----------------
No response provided
7. Hallux rigidus
-----------------
No response provided
8. Acquired pes cavus (clawfoot)
--------------------------------
No response provided
9. Malunion or nonunion of tarsal or metatarsal bones
-----------------------------------------------------
No response provided
CONFIDENTIAL Page 48 of 133
10. Foot injuries and other conditions
--------------------------------------
a. Does the Veteran have any foot injuries or other foot conditions not
already
described?
[X] Yes [ ] No
If yes, describe the foot injury or other conditions (including
frequency and physical exam findings) and complete question b.
(severity
and side affected).
Moderate pain on palpation to bilateral medial band of the plantar
fascia from proximal insertion to distal arch.
b. Indicate severity and side affected:
[X] Moderate [ ] Right [ ] Left [X] Both
c. Does the foot condition chronically compromise weight bearing?
[X] Yes [ ] No
d. Does the foot condition require arch supports, custom orthotic inserts or
shoe modifications?
[X] Yes [ ] No
e. Comments: No comments provided
11. Surgical procedures
-----------------------
a. Has the Veteran had foot surgery (arthroscopic or open)?
[X] Yes [ ] No
If yes, indicate side affected, type of procedure and date of surgery:
[X] Left foot procedure: Subtalar joint implant [and removal]
Date of surgery: April 2014 [May 2015]
b. Does the Veteran have any residual signs or symptoms due to arthroscopic or
other foot surgery?
[X] Yes [ ] No
If yes, describe residuals: pain, swelling
12. Pain
--------
RIGHT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
CONFIDENTIAL Page 49 of 133
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
LEFT FOOT:
Is there pain on physical exam?
[X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to
functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
13. Functional loss and limitation of motion
--------------------------------------------
a. Contributing factors of disability (check all that apply and indicate side
affected):
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Disturbance of locomotion
Side affected: [ ] Right [ ] Left [X] Both
[X] Lack of endurance
Side affected: [ ] Right [ ] Left [X] Both
Contributing factors of disability associated with limitation of motion:
b. Is there pain, weakness, fatigability, or incoordination that significantly
limits functional ability during flare-ups or when the foot is used
repeatedly over a period of time?
RIGHT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
and/or when the joint is used repeatedly over a period of time) please
describe the functional loss:
see section 13A for limitations/functional loss
LEFT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
CONFIDENTIAL Page 50 of 133
and/or when the joint is used repeatedly over a period of time) please
describe the functional loss:
see section 13A for limitations/functional loss
c. Is there any other functional loss during flare-ups or when the foot is
used
repeatedly over a period of time?
RIGHT FOOT: [ ] Yes [X] No
LEFT FOOT: [ ] Yes [X] No
14. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[X] Yes [ ] No
If yes, are any of these scars painful or unstable; have a total area
equal to or greater than 39 square cm (6 square inches); or are located
on the head, face or neck? (An "unstable scar" is one where,
for any
reason, there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: Left foot, over the sinus tarsi (anterolateral ankle)
Measurements: Length 2.0cm X width 0.1cm
c. Comments: No comments provided
15. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
----------------- -----------------
[X] Other: custom foot orthoses
CONFIDENTIAL Page 51 of 133
[ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
custom foot orthoses for foot pain
16. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's foot condition, is there functional impairment of an
extremity such that no effective function remains other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
17. Diagnostic testing
----------------------
a. Have imaging studies of the foot been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
Report Status: Verified Date Reported: JUN 17,
2016
Date Verified: JUN 17,
2016
Verifier E-Sig:
Report:
Impression:
3 views of the right and left foot with weightbearing show no
bony or joint abnormality.
Primary Diagnostic Code:
Primary Interpreting Staff:
HERMENEGILDO H ALMARIA JR, Staff Radiologist
c. If any test results are other than normal, indicate relationship of
abnormal
CONFIDENTIAL Page 52 of 133
findings to diagnosed condition:
No response provided
18. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[ ] Yes [X] No
19. Remarks, if any:
--------------------
No remarks provided