Possible lowball

[Andyman73]

Ok, got a question for ya'll.  I recently was awarded 30% for pes cavus(claw foot) w/plantar fasciitis.  I am to believe that it is bilateral, since the C&P examiner stated it as such.  I was looking at the CFR regs, yesterday for something else, and thought I'd look up this as well.

According to the CFR regs, it states the pes cavus, unilateral is to be rated at 30%, and bilateral at 50%. I first developed this issued in the 2nd half of 1997, whilst on AD.  I don't have the exam notes handy, but will post them here ASAP. And same with award letter, too.

Anyone have any early guesses before I post the info?

Thanks,

Andy

[Buck52]

Andyman  was this a recent decision  under a year?

You can file A NOD and disagree with there decision  and quote these CFR Regs back to them  but also go get a private Doc to state its bilateral also.

So the 30% you disagree with, I was told when filing for comp the first time or for increase always ask for the highest rating allowed by Law that your symptoms warrant.& quote the CFR's back to them.

 

jmo

 

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

[USMC_VET]

5278   Claw foot (pes cavus), acquired:
Marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity:
Bilateral	50
Unilateral	30
All toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads:
Bilateral	30
Unilateral	20
Great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads:
Bilateral	10
Unilateral	10
Slight	0

Pes Clavus if you meet the "Marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity:" bilateral you get 50%

If you meet the "All toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads:" bilateral you will get 30%.

All depends on what is in the C&P.

Did they rate the plantar fasciitis with the pes clavus rating? or did they rate them seperately?  I would imagine since plantar fascia is part of the symptoms and rating for pes clavus that it is rated together.

 

 

 

Edited September 11, 2015 by USMC_VET

[broncovet]

The only thing VA likes better than lowball is noball.  I agree with the above, if you feel your rating should be higher, then so state on a NOD.  Nod's "work better" when you cite specific regulations, such as that above, along with a specific doctor(s) exams that state it is bilateral.  Remember, most raters are illiterate, literacy is optional when it comes to working at VA, so you have to appeal it and push it up to a level where they can read.  The judges at CAVC can read, and some of the BVA judges can read, but not the ones that did my claim.  

[USMC_VET]

a 30% for bilateral is not outside the realm of fair since we dont know yet what your actual symptoms are though.

[Andyman73]

I tried to go on myHealthevet, from work, and it blocks me when I try to access the blue button.  So it will have to wait until I get home tonight, or this weekend.

Looking at the chart USMC_VET provided, I think maybe I was mistaken in my understanding.  I think I probably fall into the middle bracket, which would make my rating accurate, at least at this time. Either way, I do know that they did not separate the plantar fasciitis from the pes cavus. Ebennies shows it as one rating.

Question pt. II, they didn't ask if my Achilles tendons were bothering me, or not. Should that have been something included in the foot exam, or would that be a secondary contention claim on its own?  I ask because they are sore! And I have developed a lump on both, right where a low back shoe would go. Both are tender when squeezed, too. 

Thanks again, guys.

Andy

[Andyman73]

Ok, now I can post the explanation from the award letter.  Sorry in advance about the double spacing between lines.

We made the following decision(s):

Issue/Contention Percent (%) Assigned Effective Date

acquired pes cavus with plantar fasciitis

30% May 13, 2015

Explanation

We have assigned a 30 percent 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.

A higher evaluation of 50 percent is not warranted 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, marked varus deformity.

The examiner opined that this condition at least as likely as not incurred in or caused by

the claimed in-service injury, event or illness. The examiner's rationale was 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 residuals of heel/arch pain and plantar metatarsal pain consistent with

current symptoms.The effective date of May 13, 2015 is based on the date we received Veteran's intent to file a new claim for benefits

And here is the C&P exam.

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

e v i d e n c e .

[ ] 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

r e c o r d s )

[ ] 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

CLIN DOC: Progress Note Page: 1

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

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

c o n d i t i o n s .

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

f e e t .

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.

CLIN DOC: Progress Note Page: 2

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

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

w o r d s :

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

w a l k .

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

CLIN DOC: Progress Note Page: 3

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

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

d e s c r i b e d ?

[ ] 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)?

CLIN DOC: Progress Note Page: 4

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

[ ] 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

a f f e c t e d ) :

[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

CLIN DOC: Progress Note Page: 5

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

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

i n c r e a s e d .

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

i n c r e a s e d .

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

CLIN DOC: Progress Note Page: 6

System: VISTA.LEBANON.MED.VA.GOV Division: 595

COPY MADE BY VARMC, ST. LOUIS FROM A RECORD IN VA'S POSSESSION

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

a v a i l a b l e ?

[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

PODIATRIST

Signed: 07/17/2015 09:53:12

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