Does This Seem Right?

[Andyman73]

Ok, just got VA letter stating 30% for pes cavus(claw foot) w/plantar fasciitis. It does not say bilateral or not. Ebennies says same as well. On myHealthevet on the notes it has from the C&P exam, the examiner wrote this;

For both feet,

pes cavus(736.71)

plantar fasciitis(726.73)

Metatarsalgia(no code listed)

sequelae of heel and arch pain w/plantar fasciitis

metatarsal pain.

And for L foot only,

Hallux rigialis, mild to moderate.

Should not all these things be listed on my letter and disabilities list on ebennies? I know the VA likes to lowball everything they can, or just give one condition and ignore the rest. What say you?

[Vync]

The VA award letter is supposed to provide additional details about the rating and justify how/why you are rated, and also inform you of what would be necessary to get to the next higher rating level. Looking at what you posted from the C&P is helpful, but what does the award letter say?

[Andyman73]

I will have to look at it and post on here. I'm at work, and only have a short amount of break time, through out the day to come here. I just put on the key focal points.

I know for sure that the award letter only mentions the pes cavus and plantar fasciitis. It does give info on reaching the next level of 50%.

[Buck52]

Andman73

it don't seem right to me either,if there just rating on one foot? they should be rated as bilateral both feet!

JMO

...............Buck

[Andyman73]

Buck,

I was thinking the same thing, since the examiner opined that most of his findings were bilateral, and not limited to just one foot. I will be checking the award letter and going onto myhealthevet this evening. On Monday I have an appt at my VAMC, so I will be hitting the records office and get print outs of my most recent visits to include the c&p exam.

Andy

[Andyman73]

Well, I tried to copy and paste from my downloaded VA notes from myhealthevet...no luck, such is my poor computer useage skills. But any way, I can certainly type the VA award letter...here goes...

acquired pes cavus with plantar fasciitis/ 30%.

We have assigned a 30% evaluation for your acquired pes cavus with plantar fasciitis based on - marked tenderness under metatarsal heads - Shortened plantar fascia Additional symptom(s) include - Definite tenderness under metatarsal heads.

Higher eval of 50% not warrented for acquired claw foot unless the evidence shows bilateral involvement with marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, market varus deformity.

The examiner opined that this condition at least as likely as not incurred in or caused by claimed in-service injury, event, or illness. The examiner's rationale was upon review of STRs and after performing physical exam; current symptoms are consistent with symptoms suffered during active service in 1998. His pes cavus foot type will have likely residuals of heel/arch pain and plantar metatarsal pain consistent with current symptoms.

That's all from the VA letter.

Ok, here is what I could get from myhealthevet...

CONFIDENTIAL Page 5 of 16

Disability Benefits Questionnaire

ACE and Evidence Review

-----------------------

Indicate method used to obtain medical information to complete this document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process because the

existing medical evidence provided sufficient information on which to prepare

the DBQ and such an examination will likely provide no additional relevant

evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the ACE

process because the existing medical evidence supplemented with a telephone

interview provided sufficient information on which to prepare the DBQ and such

an examination would likely provide no additional relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

a. Evidence Review

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes [ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[ ] Yes [X] No

If no, check all records reviewed:

[X] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[X] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] Other:

[ ] No records were reviewed

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

1. Diagnosis

------------

a. List the claimed condition(s) that pertain to this DBQ:

Bilateral plantar fasciitis

b. Select diagnoses associated with the claimed condition(s):

[X] Acquired pes cavus (claw foot)

ICD Code: 736.71

Side affected: Both

Date of diagnosis: Right Not specified

Date of diagnosis: Left Not Specified

[X] Plantar fasciitis

ICD Code: 726.73

Side affected: Both

Date of diagnosis: Right Not Specified

Date of diagnosis: Left Not Specified

c. Comments (if any):

No response provided

d. Was an opinion requested about this condition (internal VA only)?

[X] Yes [ ] No [ ] N/A

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

foot

condition (brief summary):

41 yo male veteran seen today for C&P examination for bilateral foot

conditions.

Veteran relates pain in his feet dating back to 1997-1998 during his active

mititary service. He was diagnosed with plantar fasciitis and dispensed

custom molded orthotics.

He relates that it is difficult to find shoes that provide comfort for his

feet.

Steroid injection therapy was attempted in 2007 at the VAMC Lebanon, PA for

heel pain with temporary results. He was then followed by a non-VA

Podiatrist and kept using custom molded orthotics.

He was recently dispensed new custom molded orthotics at Lebanon VAMC with

no benefits. An EMG was ordered due to a "lazy foot" complaint;

however the

EMG results were normal.

He is awaiting a left ankle ASO for stability.

Currently symptoms include pain in both arches upon weightbearing; worse by

the end of the day; along with pain in the left great toe joint when

standing or walking.

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:

Constant pain in both arches when standing or walking.

"Shooting" pain

in the left great toe radiating back toward the ankle when walking.

c. Does the Veteran report that flare-ups impact the function of the foot?

[X] Yes [ ] No

If yes, document the Veteran's description of flare-ups in his or

her

own words:

Pain in the feet limit the amount of time that he is able to stand or

walk.

d. Does the Veteran report having any functional loss or functional impairment

of the foot being evaluated on this DBQ (regardless of repetitive use)?

[ ] Yes [X] No

3. Flatfoot (pes planus)

------------------------

No response provided

4. Morton's neuroma (Morton's disease) and metatarsalgia

--------------------------------------------------------

a. Does the Veteran have Morton's neuroma?

[ ] Yes [X] No

b. Does the Veteran have metatarsalgia?

[X] Yes [ ] No

If yes, indicate side affected:

[ ] Right [ ] Left [X] Both

c. Comments: Pain upon palpation of the plantar metatarsal head areas of both

feet due to plantarflexed metatarsals.

5. Hammer toe

-------------

No response provided

6. Hallux valgus

----------------

No response provided

7. Hallux rigidus

-----------------

a. Does the Veteran have symptoms due to hallux rigidus?

[X] Yes [ ] No

If yes, indicate severity (check all that apply):

[X] Mild or moderate symptoms

Side affected: [ ] Right [X] Left [ ] Both

b. Comments: No comments provided

8. Acquired pes cavus (clawfoot)

--------------------------------

a. Effect on toes due to pes cavus (check all that apply):

[X] None

b. Pain and tenderness due to pes cavus (check all that apply):

[X] Definite tenderness under metatarsal heads

[X] Right [ ] Left [ ] Both

[X] Marked tenderness under metatarsal heads

[ ] Right [X] Left [ ] Both

c. Effect on plantar fascia due to pes cavus (check all that apply):

[X] Shortened plantar fascia

[ ] Right [ ] Left [X] Both

d. Dorsiflexion and varus deformity due to pes cavus (check all that apply):

[X] None

[ ] Right [ ] Left [X] Both

e. Comments: No comments provided

9. Malunion or nonunion of tarsal or metatarsal bones

-----------------------------------------------------

No response provided

10. Foot injuries and other conditions

--------------------------------------

a. Does the Veteran have any foot injuries or other foot conditions not

already

described?

[ ] Yes [X] No

b. Indicate severity and side affected:

No response provided

c. Does the foot condition chronically compromise weight bearing?

No response provided

d. Does the foot condition require arch supports, custom orthotic inserts or

shoe modifications?

No response provided

e. Comments: No comments provided

11. Surgical procedures

-----------------------

a. Has the Veteran had foot surgery (arthroscopic or open)?

[ ] Yes [X] No

b. Does the Veteran have any residual signs or symptoms due to arthroscopic or

other foot surgery?

No response provided

12. Pain

--------

RIGHT 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.)

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 movement

Side affected: [ ] Right [ ] Left [X] Both

[X] Pain on weight-bearing

Side affected: [ ] Right [ ] Left [X] Both

[X] Disturbance of locomotion

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:

Limitation on amount of time walking or standing when heel pain is

increased.

LEFT 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:

Limitation on amount of time walking or standing when heel pain is

increased.

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?

[X] Yes [ ] No

If yes, describe (brief summary):

EMG performed 13JUL15 on left lower extremity reveals WNL results.

Normal shoe wear pattern noted to bilateral shoes.

Gait analysis is propulsive gait without limp or drop foot.

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?

[ ] Yes [X] No

c. Comments: No comments provided

15. Assistive devices

---------------------

a. Does the Veteran use any assistive device as a normal mode of locomotion,

although occasional locomotion by other methods may be possible?

[ ] Yes [X] No

b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

No response provided

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?

[X] Yes [ ] No

If yes, indicate foot: [ ] Right [ ] Left [X] Both

b. Are there any other significant diagnostic test findings or results?

[ ] Yes [X] No

c. If any test results are other than normal, indicate relationship of

abnormal

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.)?

[X] Yes [ ] No

If yes, describe the functional impact of each condition, providing one or

more examples:

Consideration should be made for limited weightbearing activities due to

heel pain.

19. Remarks, if any:

--------------------

No remarks provided

****************************************************************************

Medical Opinion

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed? No

If no, check all records reviewed:

[X] Military service treatment records

[X] Veterans Health Administration medical records (VA treatment

records)

MEDICAL OPINION SUMMARY

-----------------------

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks:

DBQ MUSC Foot Conditions including Flatfoot (pes planus)

____________________________________________________________________________

_________

The following contentions need to be examined:

any bilateral foot condition to include plantar faciitis

Active duty service dates:

Branch: Marine Corps

EOD: 11/16/1992

RAD: 11/15/1998

DBQ MUSC Foot Conditions including Flatfoot (pes planus):

Please review the Veteran's electronic folder in VBMS and state that it

was

reviewed in your report.

MEDICAL OPINION REQUEST

TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

OPINION: Direct service connection

Does the Veteran have a diagnosis of (a)any bilateral foot condition to

include plantar faciitis that is at least as likely as not (50 percent or

greater probability) incurred in or caused by (the) complaints of any

bilateral foot condition noted on page 137 of strs dated July of 1998 during

service?

Rationale must be provided in the appropriate section.

Please direct any questions regarding this request to:

Please Review The Veteran's VBMS File state that the VBMS file has been

reviewed and Advise.

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: Upon review of medical records and after perfomring a physical

examination; the current symptoms are consistent with the symptoms suffered

during active service in 1998. His Pes cavus foot type will have likely

sequelae of heel/arch pain and plantar metatarsal pain consistent with

current symptoms.

*************************************************************************

/es/ NEIL D BISER DPM

PODIATRIST

Signed: 07/17/2015 09:53

Date/Time:

13 Jul 2015 @ 1301

Note Title:

CONSULTATION REPORT

Location:

KEENAN,BARBARA F

Co-signed By:

KEENAN,BARBARA F

Date/Time Signed:

13 Jul 2015 @ 1532

Note

LOCAL TITLE: CONSULTATION REPORT

STANDARD TITLE: CONSULT

DATE OF NOTE: JUL 13, 2015@13:01 ENTRY DATE: JUL 13, 2015@13:01:47

AUTHOR: KEENAN,BARBARA F EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Chief complaint: Back pain, numbness and tingling left foot

Veteran self-identified by stating full name, last 4 SSN, and DOB.

History: 41-year-old male Veteran complains of 5 years intermittent numbness

and tingling in the left foot in the area of the arch particularly during

episodes of back pain. Also complains of burning in the right great toe and ball

of the right foot, and fatigue on the dorsum of the right foot also for five

years. No persistent lower extremity weakness, however, when the left foot

develops numbness on the dorsum of the foot with prolonged walking the left

ankle feels weak in dorsiflexion. Describes it as "lazy foot."

Sometimes feels

he is catching his left foot when he walks. No bowel or bladder issues.

PMH and medications: Reviewed in computerized record. No history of diabetes.

No anticoagulants.

Physical examination:

Well-developed, well-nourished, no atrophy or fasciculations in the lower

extremities.

Strength 5/5 for all major muscle groups in the lower extremities.

Sensation intact in the lower extremities.

Reflexes 2/4 symmetric knees and ankles.

Babinski negative, no ankle clonus.

MRI of the lumbar spine 3/17/2015 is reported to show mild disc degeneration and

mild circumferential disc bulge at L5-S1; minor facet changes at that level;

moderate to severe stenosis of the right and left neural foramina and possible

compromise of either L5 nerve root.

Full report and images are available in the record.

Informed consent was obtained in iMed; EMG/NCS of the bilateral lower

extremities was performed.

Veteran tolerated the procedure well.

FINDINGS: This is a NORMAL STUDY with NO electrodiagnostic evidence of peroneal

nerve entrapment on either side, tarsal tunnel syndrome on either side, lumbar

radiculopathy on either side, or generalized peripheral neuropathy. (The left

and right lateral plantar ortho sensory nerves showed reduced amplitude on both

sides; this is of doubtful clinical significance as the latencies are normal.)

For full results see report in Vista imaging when scanning is completed.

Results were discussed with the patient.

He is being referred to Physical Therapy for a left ASO.

He was also advised to follow up with referring provider in Podiatry and with

his Primary Care provider for further care.

The patient expressed understanding of the information and agreement with the

recommendation. No further follow-up is scheduled in the EMG Clinic. Please

follow the patient.

/es/ BARBARA F KEENAN, M.D.

PHYSIATRIST

Signed: 07/13/2015 15:32

[TALON II FE]

With the standard caveat that this is only my opinion (why do we always have to say this, unless we identify ourselves as healthcare professionals, this should be assumed, right?), here are some of the annotations that put you in a 30% rather than higher. If you don't agree with any of these, then these may give you a starting point for contesting the decision. The DBQ 'feels' like it is taking both sides into consideration and may not be designed to rate left and right individually, but I did not research that so I could be completely wrong. I highlighted in red what appears 'off' on the paperwork and added comments in blue.

a. Effect on toes due to pes cavus (check all that apply):

[X] None (how is this possible when you look at the overall answers and from posts me and you have shared in the past?)

b. Pain and tenderness due to pes cavus (check all that apply):

[X] Definite tenderness under metatarsal heads

[X] Right [ ] Left [ ] Both

[X] Marked tenderness under metatarsal heads

[ ] Right [X] Left [ ] Both

c. Effect on plantar fascia due to pes cavus (check all that apply):

[X] Shortened plantar fascia

[ ] Right [ ] Left [X] Both

d. Does the foot condition require arch supports, custom orthotic inserts or

shoe modifications?

No response provided (it was addressed in the narrative, from my understanding, that you have had inserts for years from both private practice and VA, correct?)

e. Comments: No comments provided

5. Hammer toe

-------------

No response provided (It appears that this may be a minimum required item for 50%. Is this an issue for you or not? He passed right over it)

moderate to severe stenosis of the right and left neural foramina and possible

compromise of either L5 nerve root. (This IS an issue and may be the 'root' (bad pun, I know) of many of your issues. It seems like they cruised right past this since it is not in your foot, but stenosis can be interpreted as pain anywhere along the 'nerve tree to which it is connected. I am not sure how or why this was not addressed but I would get an appointment with Ortho as soon as you can and see if they can do anything for you, or investigate this issue further.)

Hope this helps some, I always like to get another set of eyes on things myself, especially when it comes to things as important as health or money. If anyone else sees anything wrong with my impressions, please post corrections, no hurt feelings, just us trying to help us.