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C&P Exam Prep: Astragalectomy

DC 5274 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
ankle
Form Code
ankle
Page Count
14
Examiner Type
Physician or Physician Assistant
Estimated Duration
20-30 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of residuals following surgical removal of the talus (astragalus) bone, establish the degree of functional limitation, and evaluate shortening of the lower extremity for rating purposes under DC 5274.

What the examiner evaluates:

  • Confirmation of talectomy (surgical removal of the talus/astragalus bone)
  • Date and circumstances of the surgery
  • Degree of shortening of the lower extremity (measured in centimeters)
  • Range of motion of the ankle: dorsiflexion and plantarflexion (active, passive, weight-bearing, non-weight-bearing)
  • Ankylosis or near-ankylosis of the ankle, subtalar, or tarsal joints
  • Functional loss due to pain, weakness, fatigability, and incoordination
  • Gait disturbance, instability of station, and disturbance of locomotion
  • Muscle atrophy in the affected lower extremity
  • Presence and nature of any deformity (inversion, eversion, abduction, adduction)
  • Need for assistive devices (cane, brace, crutches, walker, wheelchair)
  • Effect on ability to stand, walk, sit, and perform repetitive activities
  • Flare-ups: frequency, duration, precipitating factors, and functional impact
  • Surgical residuals including scarring or disfigurement
  • Associated secondary conditions (post-traumatic arthritis, avascular necrosis of adjacent bones)
  • Imaging studies (X-ray, MRI, CT) documenting post-surgical changes

Exam will be conducted in person at a VA facility or contractor location. The examiner will review your claims folder prior to the exam (required per Sharp v. Shulkin). ROM testing will be performed in both weight-bearing and non-weight-bearing positions per Correia v. McDonald. You may be asked to walk, stand on one leg, or perform repeated ankle movements. Bring all assistive devices you regularly use. Wear loose-fitting clothing or bring shorts to allow full access to both lower extremities for comparison.

Typical duration: 20-30 minutes

Ankle Dorsiflexion Range of Motion

Ability to flex the foot upward toward the shin; normal is 0-20 degrees. Severely restricted in most astragalectomy cases due to loss of the talus.

What to expect:

Examiner will use a goniometer to measure the angle of dorsiflexion. Testing will be done actively (you move it yourself), passively (examiner moves it), while weight-bearing (standing), and non-weight-bearing (sitting or lying). The examiner will note the point at which pain begins.

Key thresholds:

  • 0-10 degrees dorsiflexion — Relevant to ankylosis rating under DC 5270 if applicable as a secondary condition; documents severe restriction
  • More than 10 degrees dorsiflexion — Still documents significant functional limitation even if not meeting ankylosis threshold

Tips:

  • Perform the movement slowly and stop when you feel pain - do not push through pain to demonstrate maximum effort
  • Clearly state when pain begins, not just when motion stops
  • If the ankle locks or catches, describe this to the examiner
  • Post-talectomy ankles often have near-zero dorsiflexion - accurately report this regardless of how minor it may seem

Pain considerations: Under DeLuca v. Brown, pain that limits motion before the anatomical endpoint must be documented. Tell the examiner: 'My motion stops here due to pain, not just because the joint won't go further.' Distinguish pain on motion from pain at rest.

Ankle Plantarflexion Range of Motion

Ability to point the foot downward; normal is 0-45 degrees. Commonly significantly limited after talectomy.

What to expect:

Same protocol as dorsiflexion - active, passive, weight-bearing, and non-weight-bearing. Examiner notes starting point and endpoint in degrees.

Key thresholds:

  • Less than 30 degrees plantarflexion — Indicates severe limitation consistent with higher functional disability
  • 30-40 degrees plantarflexion — Moderate limitation; documents ongoing functional impairment
  • More than 40 degrees plantarflexion — Closer to normal range but still may reflect functional loss depending on pain and other factors

Tips:

  • If plantarflexion is nearly absent due to the surgery, clearly communicate this
  • Note any crepitus (grinding, clicking) during movement - tell the examiner if you hear or feel it
  • Repeated use testing: if the examiner asks you to move the ankle multiple times, accurately communicate increased pain or fatigue with each repetition

Pain considerations: Report the exact degree at which pain begins, not just the maximum degree reached. After repeated movements, communicate if pain increases - this documents DeLuca fatigability and reduced ROM with repetitive use.

Lower Extremity Length Measurement (Shortening)

The measurable difference in leg length between the affected and unaffected extremity caused by the loss of the talus bone. DC 5274 is rated at 20% with a note to also consider shortening of the lower extremity.

What to expect:

Examiner will measure both lower extremities, typically from the anterior superior iliac spine to the medial malleolus, and calculate the difference in centimeters. Standing height comparison may also be used.

Key thresholds:

  • Shortening documented in cm — Degree of shortening may allow rating under DC 5275 (shortening of the lower extremity) if it warrants a higher evaluation than the 20% flat rate under DC 5274
  • 1.3 cm or less shortening — Non-compensable under DC 5275 shortening criteria
  • 1.3-3.8 cm shortening — 10% under DC 5275
  • 3.8-6.4 cm shortening — 20% under DC 5275
  • More than 6.4 cm shortening — 30% or higher under DC 5275

Tips:

  • Understand that DC 5274 provides a flat 20% rating for the astragalectomy itself, but VA must also consider if shortening warrants a higher rating under DC 5275
  • Do not attempt to stand straighter or compensate during measurement - stand naturally as you normally would
  • Mention any shoe lift, heel insert, or orthotic you use to compensate for shortening
  • If you have noticed your pelvis tilting or gait has changed due to leg length difference, report this

Pain considerations: Leg length discrepancy can cause secondary low back pain, knee pain, and hip pain. Mention these to the examiner as they may support secondary service connection claims.

Muscle Circumference / Atrophy Assessment

Difference in muscle mass between the affected and unaffected leg, indicating disuse atrophy from reduced weight-bearing and altered gait.

What to expect:

Examiner will measure the circumference of both calves at the same anatomical location (typically 10 cm below the tibial tuberosity) using a tape measure.

Key thresholds:

  • Measurable difference in circumference (cm) — Objective evidence of disuse atrophy supports functional loss findings and DeLuca weakness documentation

Tips:

  • Do not flex or tense the calf muscle during measurement
  • Mention if you have noticed muscle wasting compared to your other leg
  • Atrophy supports weakness claims - both should be reported consistently

Pain considerations: Atrophy is an objective finding. It corroborates your subjective reports of weakness and reduced function. You do not need to describe pain during this test, but you may mention that you avoid using that leg due to pain, which explains the atrophy.

Gait and Functional Ambulation Assessment

How the absence of the talus affects your ability to walk, bear weight, maintain balance, and perform functional activities. Examiner observes for antalgic gait, limping, instability, and compensatory mechanisms.

What to expect:

Examiner will likely observe you walking into and within the exam room. They may ask you to walk a short distance, possibly unassisted and with your assistive device. Note any limping, favoring of the affected side, or difficulty turning.

Key thresholds:

  • Antalgic gait observed — Supports disturbance of locomotion finding on DBQ
  • Requires assistive device for ambulation — Documented need for cane, brace, crutches, or walker supports higher functional disability rating
  • Unable to ambulate without assistance — May support total disability rating or Special Monthly Compensation (SMC) consideration

Tips:

  • Use your actual assistive device if you normally use one - do not leave it in the car to 'look better'
  • Walk at your natural pace - do not try to walk normally if you normally limp
  • If you experience increased pain after walking even a short distance, mention it immediately to the examiner
  • Describe how far you can walk before pain forces you to stop (your actual functional walking distance)

Pain considerations: Gait disturbance is a DeLuca factor. Accurately communicate: 'I can walk approximately [X] yards/blocks before the pain becomes severe enough that I have to stop or sit down.' This documents functional walking distance under real-world conditions.

Estimate

Rating Criteria Breakdown

20% Astragalectomy (talectomy - surgical removal of the talus/as ...

Astragalectomy (talectomy - surgical removal of the talus/astragalus bone). This is a flat 20% rating under DC 5274 for the procedure itself. VA must also evaluate whether the degree of lower extremity shortening warrants a higher rating under DC 5275. Additionally, residuals such as post-traumatic arthritis, ankylosis, or other secondary conditions may be separately rated if they meet criteria under other DCs (e.g., 5270 for ankle ankylosis, 5271 for ankle limitation of motion, 5003 for arthritis).

Key Symptoms

  • Confirmed surgical removal of the talus (astragalus) bone
  • Measurable shortening of the lower extremity
  • Significant limitation of ankle dorsiflexion and plantarflexion
  • Gait disturbance and disturbance of locomotion
  • Instability of station
  • Post-surgical pain and swelling
  • Muscle atrophy of the lower leg
  • Need for orthotics, shoe lifts, or assistive devices
  • Functional limitation with standing, walking, and uneven terrain

CFR: 38 CFR 4.71a, DC 5274: Astragalectomy rated at 20%, with reference to the shortening of the lower extremity rating. VA must consider whether shortening under DC 5275 warrants a higher evaluation. Under 38 CFR 4.59, painful motion must be considered. Under 38 CFR 4.40 and 4.45, functional loss due to pain, weakness, fatigability, and incoordination must be evaluated.

How to Describe Your Symptoms

Pain

How to describe:

Describe the location (ankle, heel, mid-foot), character (aching, sharp, burning, throbbing), severity on a 0-10 scale at rest and with activity, and what makes it worse (walking, standing, uneven ground, stairs, prolonged activity, weather changes). Distinguish between your average day, your best day, and your worst day.

Worst-day example:

“On my worst days, the pain in my ankle and heel is a 9 out of 10. I cannot put weight on my foot for more than a few minutes without the pain becoming unbearable. I have to use my cane for even short trips around the house. The pain wakes me up at night if I roll onto that side, and I cannot stand at the kitchen counter long enough to cook a meal.”

What the examiner listens for:

The examiner needs to document pain on motion (for 38 CFR 4.59), pain at rest (for functional loss), pain that limits ROM before the anatomical endpoint, and pain that increases with repeated use or during flare-ups. They will note whether pain is present on active motion, passive motion, weight-bearing, and non-weight-bearing per Correia requirements.

Understatements to avoid:

Do not say 'it's manageable' or 'I deal with it.' Accurately state the impact: 'The pain significantly limits what I can do every day.' Do not minimize because you take pain medication - describe your symptoms as they are without medication, or describe how much medication you need to reach a 'manageable' level.

Functional Loss and Limitation of Motion

How to describe:

Explain what activities you can no longer do or can only do in a limited way because of the missing talus. Be specific about distances, durations, and frequencies. Address your ability to walk on uneven ground, climb stairs, stand for prolonged periods, use a ladder, drive, and exercise.

Worst-day example:

“On a bad day, I can walk maybe half a block before I have to stop and rest because of the pain and instability. I cannot walk on grass or gravel without serious risk of falling because my ankle has no stability. I have not been able to jog, hike, or stand for more than 10 minutes at a time since the surgery. I use a cane every day when I leave the house.”

What the examiner listens for:

The DBQ asks the examiner to document disturbance of locomotion (field 534/547), interference with standing (532/545), and any instability. The examiner will also document functional loss caused by factors such as weakened movement, less movement than normal, and incoordination. These directly support the DeLuca analysis required for musculoskeletal claims.

Understatements to avoid:

Do not say 'I get around okay.' Accurately describe what you cannot do. If you have modified your daily life to avoid pain (e.g., you no longer take walks, you sit instead of standing while cooking, you avoid stairs), describe these compensations - they are evidence of functional loss.

Flare-Ups

How to describe:

Describe what triggers your flare-ups (overactivity, weather, prolonged standing/walking, carrying weight), how often they occur (weekly, monthly), how long they last, how severe they are compared to your baseline, and what you have to do when they occur (rest, ice, elevate, take additional medication, use your wheelchair instead of cane).

Worst-day example:

“If I overdo it - even just going grocery shopping - I will have a severe flare-up for two to three days where my ankle swells to twice its normal size, the pain goes to a 10, and I cannot walk without my walker. This happens at least twice a month. During a flare, I am completely off my feet and dependent on others to do basic tasks.”

What the examiner listens for:

Per DeLuca v. Brown, the examiner must document additional functional limitation during flare-ups or with repeated use over time. Field PUBLICDBQMUSCANKLE_312 specifically asks for documentation of the veteran's description of flare-ups. Provide concrete details about frequency, duration, and how much more limited you are during a flare compared to your baseline.

Understatements to avoid:

Do not say 'I just take it easy when it flares.' Specifically describe the magnitude of additional limitation: 'During a flare, my ROM drops further, I cannot bear weight at all, and I require maximum assistance with daily activities for several days.'

Weakness, Fatigue, and Incoordination

How to describe:

Describe muscle weakness in the affected calf and foot, fatigue that develops with activity, and any incoordination (e.g., tripping, ankle giving way, inability to maintain balance on the affected side). Explain how quickly fatigue sets in compared to before the surgery or compared to your unaffected side.

Worst-day example:

“My calf on the operated side is noticeably smaller than my other leg, and it feels weak all the time. After walking more than a block, my leg feels like it gives out - it gets shaky and I feel like I am going to fall. My ankle turns unexpectedly when I step on anything other than a completely flat surface, and I have fallen twice in the past year because of this.”

What the examiner listens for:

The DBQ has specific checkboxes for weakness (462, 476, 491, 506, 521), fatigability (446, 461, 475, 490, 505, 520), lack of endurance (448, 463, 477, 492, 507, 522), and incoordination (449, 464, 478, 493, 508, 523). These are all DeLuca factors. Each one checked adds to the documented functional loss beyond what ROM alone captures.

Understatements to avoid:

Do not skip mentioning these symptoms just because the examiner does not ask directly. Proactively state: 'I also experience significant weakness and fatigue in that leg, and my ankle gives way unexpectedly.' These are separate from ROM and can support a higher combined functional disability finding.

Impact on Daily Life and Work

How to describe:

Describe the concrete impact on your daily activities, occupational limitations, social life, sleep, and ability to care for yourself. Be specific about what you can and cannot do, and how long it takes you versus how long it would take an uninjured person.

Worst-day example:

“I had to leave my job as a warehouse worker because I cannot stand or walk for extended periods. I now work a desk job but even that is difficult because I cannot sit with my foot in a normal position for long. I cannot play with my children on the ground without serious pain. I sleep with a pillow under my ankle every night and I still wake up in pain several nights per week.”

What the examiner listens for:

Field PUBLICDBQMUSCANKLE_751 asks the examiner to document functional impact. Field PUBLICDBQMUSCANKLE_315 asks for the veteran's own description of functional loss. The rater will use these to evaluate whether the 20% rating under DC 5274 accurately reflects total disability or whether secondary conditions like arthritis or shortening warrant additional ratings.

Understatements to avoid:

Do not say 'I manage.' Accurately describe all the ways this condition has changed your life. If you have had to give up hobbies, change jobs, modify your home, rely on others for help, or limit your social activities, these are all relevant and should be communicated clearly.

Instability and Falls

How to describe:

Describe ankle instability specifically - does the ankle give way without warning? Have you fallen because of it? How often do you feel like you might fall? Do you avoid certain surfaces or activities because of fall risk?

Worst-day example:

“My ankle gives way at least two or three times a week without warning. I have actually fallen twice in the last six months - once on a sidewalk crack and once on stairs. I now grip handrails with both hands and I avoid any surface that is not completely flat. I will not go outside alone at night because the instability in low light is dangerous.”

What the examiner listens for:

Instability of station is documented on fields 540 and 553. Falls history and ankle giving way support findings of incoordination, instability, and functional loss. The examiner may also note this supports the need for an assistive device.

Understatements to avoid:

Do not downplay falls or near-falls. Accurately report them. A history of falls is an objective safety and functional concern that directly supports your disability rating and may also support SMC or adaptive equipment claims.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to have your claims file reviewed by the examiner before the examination begins (Sharp v. Shulkin, 29 Vet.App. 26, 2017). If the examiner has not reviewed your file, this constitutes an inadequate examination.
  • You have the right to have ROM testing performed under all four required conditions: active motion, passive motion, weight-bearing, and non-weight-bearing (Correia v. McDonald, 28 Vet.App. 158, 2016).
  • You have the right to have additional functional loss during flare-ups and with repeated use documented, even if a flare-up is not occurring on the day of the exam (DeLuca v. Brown, 8 Vet.App. 202, 1995; Mitchell v. Shinseki, 25 Vet.App. 32, 2011).
  • You have the right to have pain that limits motion recognized as functional loss under 38 CFR 4.59 (painful motion), even if ROM measurements appear relatively preserved.
  • You have the right to record your C&P examination in many states. Check whether your state uses single-party or two-party consent laws. Inform the examiner as a courtesy even where consent is not legally required.
  • You have the right to request a copy of the completed DBQ through your VSO or via FOIA after the examination.
  • You have the right to challenge an inadequate, insufficient, or inaccurate examination. If the DBQ does not accurately reflect what you reported, or if the exam was clearly inadequate (too brief, no physical examination performed, examiner did not review records), your VSO can argue for a new examination.
  • You have the right to submit a personal statement (VA Form 21-4138 or 21-10210) to supplement the DBQ with your own description of symptoms and functional limitations. This can be submitted before or after the exam.
  • You have the right to submit a buddy statement from a family member, caregiver, or fellow veteran who witnesses your daily functional limitations.
  • You have the right to present a nexus letter or independent medical opinion from a private physician if you disagree with the C&P examiner's findings.
  • You have the right to the benefit of the doubt under 38 CFR 3.102 - when evidence is in approximate balance, VA must rule in your favor.
  • You have the right to a rating that considers all separately ratable residuals of your astragalectomy, including shortening of the lower extremity (DC 5275), post-traumatic arthritis (DC 5003/5010), and ankylosis of the ankle or subtalar joint (DC 5270), in addition to the DC 5274 flat rate, subject to the anti-pyramiding rule.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.