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)
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
b/l flatfeet, hallux valgus, plantar fasciitis
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus) Side affected: Both
[X] Hallux valgus
Side affected: Both
[X] Plantar fasciitis Side affected: Both
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):
The veteran reports b/l foot pain. It's been diagnosed as b/l pes
planus,
hallux valgus and plantar fasciitis. Treatment has included orthotics, shoes, Mobic, night splints and PT. Now, the feet hurt daily.
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:
"my feet hurt daily"
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)?
[ ] Yes [X] No
3. Flatfoot (pes planus)
------------------------
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
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
c. Is there indication of swelling on use? [ ] Yes [X] No
d. Does the Veteran have characteristic callouses? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic -----------------------------
[ ] No
Device
[X] Built-up Shoes [X] Orthotics
Side Not Relieved:
[ ] Right [ ] Left [X] Both
[ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [ ] Yes [X] No
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 [ ] Left [X] Both
i. Is there marked pronation of one or both feet? [ ] Yes [X] No
j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [ ] Yes [X] No
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? [ ] Yes [X] No
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: No comments provided
4. Morton's neuroma (Morton's disease) and metatarsalgia --------------------------------------------------------
No response provided
5. Hammer toe -------------
No response provided
6. Hallux valgus
----------------
a. Does the Veteran have symptoms due to a hallux valgus condition?
[X] Yes [ ] No
If yes, indicate severity:
[X] Mild or moderate symptoms
Side affected: [ ] Right [ ] Left [X] Both
b. Has the Veteran had surgery for hallux valgus? [ ] Yes [X] No
c. Comments: No comments 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
10. Foot injuries and other conditions --------------------------------------
No response provided
11. Surgical procedures -----------------------
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] Excess fatigability
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on movement
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on non weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Disturbance of locomotion
Side affected: [ ] Right [ ] Left [X] Both
[X] Interference with standing
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: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No
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?
[ ] Yes [X] No
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? [ ] 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?
[ ] Yes [X] No
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:
difficulty standing long periods, walking long distances
19. Remarks, if any: --------------------
No remarks provided
Question
Kinfolk
What type of rating can I expect?
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)
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
b/l flatfeet, hallux valgus, plantar fasciitis
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus) Side affected: Both
[X] Hallux valgus
Side affected: Both
[X] Plantar fasciitis Side affected: Both
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):
The veteran reports b/l foot pain. It's been diagnosed as b/l pes
planus,
hallux valgus and plantar fasciitis. Treatment has included orthotics, shoes, Mobic, night splints and PT. Now, the feet hurt daily.
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:
"my feet hurt daily"
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)?
[ ] Yes [X] No
3. Flatfoot (pes planus)
------------------------
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
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
c. Is there indication of swelling on use? [ ] Yes [X] No
d. Does the Veteran have characteristic callouses? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic -----------------------------
[ ] No
Device
[X] Built-up Shoes [X] Orthotics
Side Not Relieved:
[ ] Right [ ] Left [X] Both
[ ] Right [ ] Left [X] Both
f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [ ] Yes [X] No
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 [ ] Left [X] Both
i. Is there marked pronation of one or both feet? [ ] Yes [X] No
j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [ ] Yes [X] No
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? [ ] Yes [X] No
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: No comments provided
4. Morton's neuroma (Morton's disease) and metatarsalgia --------------------------------------------------------
No response provided
5. Hammer toe -------------
No response provided
6. Hallux valgus
----------------
a. Does the Veteran have symptoms due to a hallux valgus condition?
[X] Yes [ ] No
If yes, indicate severity:
[X] Mild or moderate symptoms
Side affected: [ ] Right [ ] Left [X] Both
b. Has the Veteran had surgery for hallux valgus? [ ] Yes [X] No
c. Comments: No comments 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
10. Foot injuries and other conditions --------------------------------------
No response provided
11. Surgical procedures -----------------------
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] Excess fatigability
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on movement
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on non weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Disturbance of locomotion
Side affected: [ ] Right [ ] Left [X] Both
[X] Interference with standing
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: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No
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?
[ ] Yes [X] No
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? [ ] 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?
[ ] Yes [X] No
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:
difficulty standing long periods, walking long distances
19. Remarks, if any: --------------------
No remarks provided
****************************************************************************
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