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C&P Exam Prep: Foot Amputation or Loss of Use of Foot

DC 5167 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
amputations
Form Code
amputations
Page Count
6
Examiner Type
Orthopedic Surgeon, Physiatrist, or Prosthetist
Estimated Duration
30-60 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the anatomical level of foot amputation or functional loss of use, evaluate prosthetic fit and function, assess residual limb condition, and determine the impact on ambulation and daily functioning for VA disability rating purposes under DC 5167.

What the examiner evaluates:

  • Exact anatomical level of amputation (forefoot, transmetatarsal, Chopart, Syme, or loss of use determination)
  • Residual limb (stump) condition including length, shape, skin integrity, and scar quality
  • Presence and severity of phantom limb pain or residual limb pain
  • Current prosthetic use, fit, function, and whether ambulation is improved by prosthesis
  • Whether the amputation is improvable by prosthesis or is considered non-improvable
  • Presence of neuroma, skin breakdown, osteophytes, or other stump complications
  • Assistive device use (cane, crutches, walker, wheelchair, brace)
  • Functional ambulation capacity including distance walked, terrain limitations, and endurance
  • Presence of flare-ups, fatigue, weakness, or pain with use
  • Impact on occupational and daily activities
  • Any additional amputations of the same or other extremities
  • Associated conditions such as peripheral vascular disease, diabetes, or neuropathy affecting the residual limb

The exam will include both an interview and a physical examination of the residual limb and remaining extremity. Wear or bring your prosthesis if you have one. Bring all assistive devices you use. The examiner will inspect the stump, assess your gait, and evaluate functional capacity. You may be asked to walk a short distance with and without your prosthesis. Be prepared to discuss your worst-day functioning, not just how you feel on a good day.

Typical duration: 30-60 minutes

Amputation Level Classification

The anatomical level at which the foot was amputated, which directly determines the applicable diagnostic code and minimum rating percentage.

What to expect:

The examiner will visually inspect and palpate the residual limb to determine the precise level of amputation. They will compare the stump length and tissue to anatomical landmarks such as the metatarsals, tarsals, and ankle joint.

Key thresholds:

  • Amputation of toes without metatarsal loss or transmetatarsal — 10% minimum under DC 5152/5153/5154; combined rating depends on which toes
  • Amputation of toes with up to half metatarsal loss or transmetatarsal — 20% minimum under DC 5155
  • Amputation of forefoot proximal to metatarsals — 40% under DC 5156
  • Amputation between forefoot and knee permitting prosthetic use — 40% under DC 5161
  • Amputation not improvable by prosthesis (loss of use equivalent) — 90% under DC 5167
  • Loss of use of foot without actual amputation — 90% under DC 5167

Tips:

  • Ask the examiner to clearly document the exact amputation level in their report, not just a general description
  • If you have a Syme amputation (ankle disarticulation), ensure this is distinguished from a below-knee amputation
  • If your stump does not permit prosthetic use due to pain, skin breakdown, or neuroma, clearly communicate this
  • If your condition is loss of use rather than physical amputation, ensure the examiner understands you cannot use the foot effectively for locomotion

Pain considerations: Phantom limb pain, residual limb pain, and pain with prosthetic use all directly affect whether the amputation is 'improvable by prosthesis' - a key distinction for the highest rating levels. Communicate any pain that prevents or limits prosthetic wear.

Residual Limb (Stump) Assessment

The condition of the stump, including length, skin integrity, scarring, neuromas, bony prominences, and ability to tolerate prosthetic socket fit.

What to expect:

Physical inspection and palpation of the residual limb. The examiner will look for skin breakdown, ulceration, infection, adherent or unstable scars, painful neuromas, and bony spurs. They may measure stump length.

Key thresholds:

  • Defective stump (painful, unstable scar, neuroma, or osteophyte) — Qualifies for higher rating as 'defective stump' under DC 5170 or affects improvability determination
  • Stump permitting functional prosthetic use — Lower rating tier; improvable by prosthesis
  • Stump NOT permitting prosthetic use — Higher rating tier; not improvable by prosthesis, approaching loss-of-use equivalency

Tips:

  • Point out all areas of pain, skin breakdown, or irritation on the stump during physical examination
  • If you have a neuroma, describe exactly where it is and how it affects weight-bearing and prosthetic wear
  • Document any history of stump revisions or surgical corrections
  • If your stump has changed over time (e.g., volume fluctuations, socket fit problems), describe this clearly

Pain considerations: Pain on palpation of the stump, pain with prosthetic socket contact, and phantom limb pain all contribute to the overall disability picture. Do not minimize stump pain - it directly affects whether the amputation is considered improvable.

Prosthetic Fit and Function Assessment

Whether the veteran can effectively use a prosthesis, how long they can wear it daily, and whether it adequately restores function.

What to expect:

The examiner will assess whether you have a prosthesis, whether it fits well, how many hours per day you can wear it, what activities you can perform with it, and whether it permits comfortable ambulation. They may observe your gait with and without the prosthesis.

Key thresholds:

  • Prosthesis worn comfortably for most of waking hours, good ambulation — Amputation considered 'improvable by prosthesis' - lower rating tier
  • Prosthesis worn but with significant limitations (pain, short wear time, limited terrain) — May support higher rating or secondary complications
  • Prosthesis cannot be worn or provides no functional benefit — Supports 'not improvable by prosthesis' determination - highest rating tier (90%)

Tips:

  • Bring your prosthesis to the exam even if you rarely wear it
  • Tell the examiner exactly how many hours per day you can wear the prosthesis
  • Describe what activities you CANNOT do even with the prosthesis (stairs, uneven ground, prolonged standing)
  • If the prosthesis causes skin breakdown, blisters, or pain that limits wear, describe this in detail
  • If you have never been fit with a prosthesis or cannot be fit due to stump condition, clearly state this

Pain considerations: Pain during prosthetic use is a DeLuca factor that must be documented. Describe the type, location, and severity of pain, how quickly it occurs after donning the prosthesis, and how it limits your wear time and activity level.

Functional Ambulation and Mobility Assessment

The veteran's actual ability to walk, stand, and perform mobility-dependent activities, both with and without the prosthesis or assistive devices.

What to expect:

The examiner may observe your gait, ask about walking distance, terrain limitations, and time on your feet. They will ask about assistive device use. They may note whether you use a cane, crutches, walker, or wheelchair.

Key thresholds:

  • Independent ambulation without assistive device for community distances — Supports lower rating with prosthesis functioning well
  • Requires cane or single crutch for ambulation — Supports higher functional impairment rating
  • Requires bilateral crutches, walker, or wheelchair — Supports loss-of-use equivalent or highest rating tier

Tips:

  • Report your WORST-DAY walking capacity, not your best or average
  • Describe specific distances (e.g., 'I can walk one block before I have to stop due to pain and fatigue')
  • Mention all terrains you cannot navigate (stairs, inclines, uneven ground, wet surfaces)
  • Report how long you can stand without needing to sit or elevate the limb
  • Bring all assistive devices to the exam and use them as you normally would

Pain considerations: Under DeLuca factors, report pain, fatigue, weakness, and incoordination that occur both at rest and with repetitive use. If walking causes phantom pain, residual limb pain, or referred pain up the leg, describe each separately with specific onset timing and severity.

Loss of Use Determination (DC 5167 Specific)

Whether the foot, though potentially anatomically present (or with minor amputation), has lost effective function for locomotion - equivalent to amputation at the ankle.

What to expect:

For loss-of-use claims, the examiner will assess whether the foot can bear weight, propel ambulation, and function for locomotion. They will look for severe pain, paralysis, deformity, or circulatory insufficiency that renders the foot non-functional.

Key thresholds:

  • Foot can bear weight and assist in locomotion to any degree — May not meet loss-of-use threshold; rated under specific toe/forefoot amputation codes
  • Foot cannot bear weight or assist locomotion; equivalent to amputation at ankle — 90% under DC 5167 - highest rating for foot

Tips:

  • If claiming loss of use, clearly explain why the foot cannot perform locomotion even without amputation
  • Describe inability to bear weight, push off, or maintain balance on the affected foot
  • Reference any medical documentation of severe peripheral vascular disease, neuropathy, chronic ulceration, or paralysis
  • If you use a wheelchair or cannot walk without the foot being completely off the ground, state this explicitly

Pain considerations: Severe intractable pain that prevents any weight-bearing can support a loss-of-use finding. Document the character, frequency, and intensity of pain, and how it prevents functional use of the foot for walking or standing.

Estimate

Rating Criteria Breakdown

90% Amputation of the foot that is NOT improvable by prosthesis ...

Amputation of the foot that is NOT improvable by prosthesis (due to defective stump, severe pain, neuroma, poor circulation, or other cause), OR loss of use of the foot without actual amputation. Functionally equivalent to complete loss of the foot for locomotion purposes.

Key Symptoms

  • Prosthesis cannot be worn due to stump pain, skin breakdown, neuroma, or infection
  • Cannot bear weight on the affected foot or residual limb
  • Requires wheelchair, bilateral crutches, or walker for mobility
  • Phantom limb pain or residual limb pain severe enough to prevent prosthetic use
  • Defective stump with unstable scar, osteophyte, or chronic ulceration
  • Loss of use: foot anatomically present but cannot perform locomotion
  • Severe peripheral vascular disease or neuropathy rendering foot non-functional
  • Thigh amputation or equivalent (if applicable related codes apply)

CFR: DC 5167: amputation of foot not improvable by prosthesis, or loss of use of foot (90%). This is the highest rating for foot conditions and is equivalent to ankle-level amputation functionally. Defective stump criteria also rated at high levels under DC 5170.

40% Amputation of the forefoot proximal to the metatarsals (e.g. ...

Amputation of the forefoot proximal to the metatarsals (e.g., Lisfranc or Chopart amputation), or amputation between the forefoot and knee permitting prosthetic fitting and use. Significant gait impairment but prosthesis is functional.

Key Symptoms

  • Loss of all metatarsal bones and toes
  • Significantly altered gait requiring prosthesis for ambulation
  • Prosthesis permits walking but with limitations
  • Pain, fatigue, and weakness with extended use
  • Cannot walk on uneven terrain comfortably
  • Requires shoe modification or custom prosthetic foot

CFR: DC 5156: amputation of forefoot proximal to metatarsals (40%). DC 5161: amputation between forefoot and knee permitting prosthetic use (40%). Prosthesis must be functional and worn regularly.

20% Amputation of toes with up to half metatarsal loss, or trans ...

Amputation of toes with up to half metatarsal loss, or transmetatarsal amputation. Moderate impact on gait mechanics and push-off phase of walking.

Key Symptoms

  • Partial foot amputation with metatarsal involvement
  • Altered gait mechanics requiring accommodative footwear or partial foot prosthesis
  • Fatigue with prolonged walking
  • Moderate pain with weight-bearing activities

CFR: DC 5155: amputation of toes with up to half metatarsal loss or transmetatarsal amputation. Requires documentation of metatarsal bone involvement.

10% Amputation of one or more toes without metatarsal bone loss ...

Amputation of one or more toes without metatarsal bone loss (transmetatarsal amputation at or near the metatarsophalangeal joint). Minimum rating for minor toe amputations under related DCs.

Key Symptoms

  • Amputation of lesser toe(s) without metatarsal involvement
  • Minor impact on ambulation
  • Prosthetic filler or shoe insert may be used
  • Minimal pain with walking on level ground

CFR: DC 5152 (amputation of great toe) and DC 5153/5154 (lesser toes) at minimum rating; DC 5155 may apply for transmetatarsal with up to half metatarsal loss at higher levels.

How to Describe Your Symptoms

Phantom Limb Pain

How to describe:

Describe the character (burning, stabbing, cramping, electric shock-like), location (where in the absent foot/toes you feel it), frequency (how many episodes per day/week), severity (0-10 scale), duration of each episode, and what triggers or worsens it (cold weather, barometric pressure changes, stress, fatigue, physical activity).

Worst-day example:

“On my worst days, the phantom pain in my missing toes feels like someone is crushing them in a vice grip. It's an 8 out of 10 and lasts for 3-4 hours. I can't sleep, I can't concentrate, and I can't put on my prosthesis when it's that bad. This happens at least 3-4 times per week.”

What the examiner listens for:

Specific description of phantom pain character, frequency, and severity; impact on sleep and daily function; whether phantom pain prevents prosthetic use; triggers and pattern of onset.

Understatements to avoid:

Saying 'it's just phantom pain' or minimizing it as expected and manageable - phantom pain that disrupts sleep, prevents prosthetic use, or limits function is a legitimate disability factor that must be fully documented.

Residual Limb (Stump) Pain

How to describe:

Distinguish stump pain from phantom pain. Describe pain at the residual limb itself: location (tip, scar, bone prominence, neuroma site), what worsens it (prosthetic socket pressure, weight-bearing, prolonged standing), what relieves it (elevation, rest, medication), and how it limits prosthetic wear time.

Worst-day example:

“When my stump swells in the afternoon, the prosthetic socket digs into the scar at the end of my stump. The pain is a 7 out of 10, burning and throbbing. I have to take the prosthesis off and elevate my leg for at least an hour. On bad days, I can only wear it for 2-3 hours total.”

What the examiner listens for:

Stump pain that limits prosthetic wear time, evidence of neuroma or sensitive scar tissue, pain that prevents full weight-bearing through the prosthesis, history of skin breakdown or ulceration from socket pressure.

Understatements to avoid:

Saying you 'manage the pain' without explaining what managing it actually requires - e.g., taking off the prosthesis, taking opioid pain medication, lying down, or using a wheelchair for the rest of the day.

Prosthetic Use Limitations

How to describe:

Be specific about how many hours per day you can wear your prosthesis, what activities you cannot perform even with it, what terrain you cannot navigate, and why (pain, instability, skin problems, balance issues). Report both the absolute maximum and your typical daily use.

Worst-day example:

“On a typical bad day, I can wear my prosthesis for maybe 2 hours before the pain and skin irritation force me to take it off. Without it, I use a cane or sometimes my wheelchair. I cannot walk on grass, gravel, or stairs safely even with the prosthesis. I have to plan every outing around where I can sit down.”

What the examiner listens for:

Limited daily wear time, inability to perform specific functional activities with prosthesis, dependence on assistive devices even when prosthesis is worn, history of skin breakdown or falls attributable to prosthetic use.

Understatements to avoid:

Saying 'I have a prosthesis and I can walk' without clarifying the significant limitations - how far, for how long, on what surfaces, with how much pain, and what you cannot do at all even with the prosthesis.

Ambulation and Functional Capacity

How to describe:

Describe your actual walking capacity on your worst days: distance before pain/fatigue stops you, time on your feet before needing to rest, inability to stand in lines or at counters, difficulty with stairs or inclines, and activities you have had to give up entirely.

Worst-day example:

“On my worst days I can barely walk from the bedroom to the bathroom without stopping to rest. I cannot stand in the kitchen to cook a full meal, shop in a grocery store without a motorized cart, or attend my grandchildren's outdoor events. I spend most of the day either sitting or lying with my leg elevated.”

What the examiner listens for:

Specific functional limitations that go beyond just the amputation level - impact on work, self-care, recreation, and community participation. Quantified limits (distance, time, frequency) are more credible than vague descriptions.

Understatements to avoid:

Saying 'I get around okay' when in reality you have made significant life adaptations - using a wheelchair, avoiding stairs, stopped working, moved to a single-story home, or rely on family members for transportation and errands.

Fatigue, Weakness, and Flare-Ups (DeLuca Factors)

How to describe:

Describe how the energy cost of walking with an amputation or loss of use causes fatigue disproportionate to the activity. Note any weakness in the residual limb or compensatory muscle groups (hip, knee, back). Describe flare-up frequency, triggers, duration, and what you cannot do during a flare.

Worst-day example:

“After walking even a short distance, my whole leg feels exhausted and weak. I have developed hip and low back pain from compensating for the amputation. My flare-ups happen 2-3 times per week, last 1-2 days, and during those times I am essentially confined to a chair or bed. I cannot drive, cook, or perform any activity requiring standing.”

What the examiner listens for:

DeLuca factors: pain on use, weakness, fatigue, incoordination, and flare-ups with repetitive use. These factors are critical for accurate functional assessment and can support higher ratings when the amputation-level alone would result in a lower rating.

Understatements to avoid:

Failing to mention secondary musculoskeletal effects (hip pain, knee pain, back pain) caused by altered gait mechanics from the amputation - these may be separately ratable as secondary conditions.

Sleep Disruption and Psychological Impact

How to describe:

Describe how phantom pain, residual limb pain, positioning difficulties, or inability to bear weight affect sleep quality, duration, and the number of times you wake per night. Also note any anxiety, depression, or PTSD related to the traumatic amputation event.

Worst-day example:

“I wake up 4-5 times a night because of phantom pain or because I roll onto my stump and it hurts. I have to sleep in a recliner some nights. The amputation has also caused significant depression and anxiety about my ability to work and care for my family.”

What the examiner listens for:

Sleep disruption quantified by frequency and duration; psychological symptoms that may warrant separate mental health claims; total daily functional impact including both waking and sleeping hours.

Understatements to avoid:

Not mentioning sleep disruption at all, or mentioning it but failing to quantify it - the number of times awakened per night and the cause are important functional data points.

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 request a copy of your completed DBQ and C&P exam report from the VA after the examination is completed.
  • You have the right to record your C&P examination in states that allow one-party consent audio recording. Check your state's recording consent laws before the exam.
  • You have the right to submit a rebuttal or supplemental statement if you believe the examiner's report is inadequate, inaccurate, or failed to consider symptoms you reported.
  • You have the right to request a new C&P examination if you believe the original exam was inadequate. Grounds include: failure to examine all claimed conditions, failure to apply the correct diagnostic criteria, reliance on a brief or cursory review without physical examination, or examiner error.
  • You have the right to bring a support person (family member, caregiver, or VSO representative) to your C&P examination.
  • You have the right to have your claim decided under the benefit of the doubt standard - if the evidence is in approximate balance, the decision must be made in your favor (38 CFR 3.102).
  • You have the right to submit independent medical evidence (nexus letters, private DBQs, medical opinions) to supplement or rebut VA examination findings.
  • You have the right to a fully explained rating decision that identifies the evidence considered, the diagnostic code applied, and the rationale for the assigned rating.
  • You have the right to appeal any rating decision through the Supplemental Claim lane, the Board of Veterans' Appeals, or the Higher-Level Review lane under the Appeals Modernization Act (AMA).
  • You have the right to have DeLuca factors - pain, fatigue, weakness, incoordination, and flare-ups - considered as part of your functional assessment for all musculoskeletal conditions, including amputations.
  • You have the right to claim secondary service connection for conditions caused or aggravated by your service-connected foot amputation or loss of use, including hip pain, knee pain, lumbar spine conditions, and mental health conditions.

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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.