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C&P Exam Prep: Subastragalar or Tarsal Joint Ankylosis
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 nature, severity, and functional impact of ankylosis (abnormal stiffness or fusion) of the subastragalar (subtalar) or tarsal joints of the foot, and to determine whether the ankylosis is in a good or poor weight-bearing position for rating purposes under DC 5272.
What the examiner evaluates:
- Presence and confirmation of ankylosis of the subtalar or tarsal joints
- Weight-bearing position of the ankylosed joint (good vs. poor)
- Presence of deformity including inversion, eversion, abduction, or adduction
- Active and passive range of motion of the ankle and subtalar joints
- Pain on motion, at rest, and with weight bearing
- DeLuca factors: pain, fatigue, weakness, incoordination, and lack of endurance with repetitive use
- Muscle atrophy or weakness in the lower extremity
- Functional impact on standing, walking, and daily activities
- Use of assistive devices such as braces, canes, orthotics, or walkers
- Surgical history including talectomy, total ankle replacement, or arthroscopic procedures
- Flare-up frequency, severity, and duration
- Diagnostic imaging findings (X-ray, MRI, CT) confirming ankylosis
- Scars or disfigurement in the ankle and foot region
Exam will include a seated interview followed by a physical examination. Weight-bearing testing will be conducted while standing. Bring all relevant imaging, treatment records, and assistive devices you normally use. Wear comfortable shoes that are easy to remove.
Typical duration: 20-30 minutes
Subtalar/Tarsal Joint Range of Motion Assessment
The degree of inversion and eversion available in the subtalar joint, and the presence or absence of true ankylosis (complete or near-complete immobility).
What to expect:
The examiner will attempt to move your foot inward (inversion) and outward (eversion) both actively (you move it) and passively (they move it). They may also assess the midtarsal joints. For a true ankylosis, motion will be severely restricted or absent. Testing will occur both weight-bearing and non-weight-bearing.
Key thresholds:
- Good weight-bearing position (neutral or near-neutral alignment) — 10% under DC 5272
- Poor weight-bearing position (inversion, eversion, abduction, or adduction deformity) — 20% under DC 5272
Tips:
- Allow the examiner to fully test the joint; do not voluntarily restrict motion beyond your actual limitation.
- If testing causes pain, tell the examiner immediately and describe the pain clearly.
- Report whether the pain or limitation is worse at the end of the day or after prolonged activity.
- If you use an ankle-foot orthosis (AFO) or brace, bring it and wear it as you normally would.
Pain considerations: Under DeLuca v. Brown, pain that limits motion must be fully documented. If weight-bearing causes pain that reduces your functional ROM below what non-weight-bearing testing shows, clearly communicate this to the examiner. State that your pain is worse when bearing weight and describe how this limits walking distance, stair use, and prolonged standing.
Ankle Dorsiflexion and Plantar Flexion (Tibiotalar Joint ROM)
The range of motion of the ankle joint itself, which is often co-examined alongside subtalar joint function and may be separately rated under DC 5270 if ankylosis of that joint is also present.
What to expect:
Using a goniometer, the examiner measures how far you can pull your foot toward your shin (dorsiflexion, normal ~20-) and point it down (plantar flexion, normal ~50-). Testing will occur actively, passively, weight-bearing, and non-weight-bearing.
Key thresholds:
- Plantar flexion > 40- or dorsiflexion > 10- with deformity — 40% under DC 5270 if ankle ankylosis is also present
- Plantar flexion 30-40- or dorsiflexion 0-10- — 30% under DC 5270 if ankle ankylosis is also present
- Plantar flexion < 30- — 20% under DC 5270 if ankle ankylosis is also present
Tips:
- Perform the movement to your true maximum, noting any pain at end-range.
- Report if repetitive movement makes the ROM worse or increases pain.
- If your ankle also has significant restriction, ask whether DC 5270 is being considered as well.
Pain considerations: Clearly describe any pain that occurs before you reach the end of your range of motion, as this may support additional functional loss documentation under DeLuca.
Weight-Bearing Position Assessment
Whether the ankylosed subtalar or tarsal joint is fused in a position that allows functional weight-bearing (good position) or in a compromised position such as inversion, eversion, abduction, or adduction (poor position). This is the single most critical determinant under DC 5272.
What to expect:
The examiner will observe your foot alignment while standing and walking. They will note whether your foot is in a neutral position (good weight-bearing) or tilted inward (inversion), outward (eversion), turned in (adduction), or turned out (abduction).
Key thresholds:
- Poor weight-bearing position (any deformity: inversion, eversion, abduction, or adduction) — 20% under DC 5272
- Good weight-bearing position (neutral or functional alignment) — 10% under DC 5272
Tips:
- Stand and walk naturally during the exam; do not attempt to compensate or correct your posture artificially.
- If you normally walk with a noticeable limp or altered gait, walk normally so the examiner can observe it.
- If deformity is visible in your foot at rest, point this out explicitly.
- Bring photographs taken on a bad day if visible deformity varies.
Pain considerations: If your foot deformity causes skin breakdown, callus formation, or pressure sores from poor weight distribution, describe these to the examiner as evidence of a functionally poor weight-bearing position.
Muscle Strength and Atrophy Assessment
Whether disuse from ankylosis has caused measurable muscle wasting (atrophy) in the lower leg, and whether muscle weakness is present.
What to expect:
The examiner may measure the circumference of both calves in centimeters at a specified distance from a bony landmark. They will compare the affected and unaffected sides. Muscle strength may be manually tested.
Key thresholds:
- Measurable circumference difference between affected and unaffected calf — Supports functional loss documentation; may support higher overall rating or additional muscle group rating
Tips:
- Do not flex or tighten the calf during measurement.
- Mention if you have noticed your calf or foot muscles becoming smaller or weaker over time.
- Describe any difficulty with activities that require calf strength such as walking uphill or climbing stairs.
Pain considerations: Weakness and fatigability are separate DeLuca factors. Even if strength testing appears normal at rest, describe how prolonged walking or standing causes weakness and fatigue that limits your activity.
Repetitive Use / DeLuca Functional Loss Testing
Whether repeated use of the joint causes additional pain, weakness, fatigue, or reduced range of motion beyond the initial measurement.
What to expect:
The examiner may ask you to perform repeated movements or walk and then retest. More commonly, you will be asked to describe how your symptoms change with activity. Document any worsening after the first set of movements.
Key thresholds:
- Demonstrable loss of function after repetitive use — Supports functional loss rating above the baseline ROM findings; critical for DeLuca compliance
Tips:
- Specifically state: 'After walking more than X minutes, my pain increases to Y/10 and I develop weakness/swelling.'
- Describe what happens at the end of a workday versus the morning.
- Mention if you must sit down, rest, or elevate your foot after activity.
Pain considerations: Per DeLuca v. Brown, functional loss due to pain, fatigue, weakness, or incoordination during or after use must be considered separately from static ROM measurements. Tell the examiner explicitly if your condition gets worse with use.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 20% | Ankylosis of the subastragalar (subtalar) or tarsal joint in a poor weight-bearing position. Poor position means the joint is fused with the foot in an abnormal alignment such as inversion (foot tilted inward), eversion (foot tilted outward), abduction (foot turned outward), or adduction (foot turned inward), which compromises normal walking mechanics and places abnormal stress on the foot, ankle, knee, and hip. |
CFR: 38 CFR 4.71a, DC 5272: 'In poor weight-bearing position - 20%'. A foot fused in marked inversion forcing the veteran to walk on the outer edge of the foot is a classic example of poor weight-bearing position. |
| 10% | Ankylosis of the subastragalar (subtalar) or tarsal joint in a good weight-bearing position. Good position means the joint is fused with the foot in a relatively neutral, functional alignment that allows for reasonable weight-bearing, though all inversion and eversion motion is absent. The veteran can walk with a near-normal gait pattern despite the complete loss of subtalar motion. |
CFR: 38 CFR 4.71a, DC 5272: 'In good weight-bearing position - 10%'. A foot surgically fused in neutral alignment following a calcaneal fracture that allows walking on flat surfaces but with absent subtalar motion is the prototypical example. |
20% Ankylosis of the subastragalar (subtalar) or tarsal joint in ...
Ankylosis of the subastragalar (subtalar) or tarsal joint in a poor weight-bearing position. Poor position means the joint is fused with the foot in an abnormal alignment such as inversion (foot tilted inward), eversion (foot tilted outward), abduction (foot turned outward), or adduction (foot turned inward), which compromises normal walking mechanics and places abnormal stress on the foot, ankle, knee, and hip.
Key Symptoms
- Fixed inversion or eversion deformity of the foot
- Visible foot tilt or abnormal foot alignment when standing
- Abnormal gait pattern or limp due to foot malalignment
- Pain along the lateral or medial border of the foot from abnormal weight distribution
- Callus formation, skin breakdown, or pressure sores due to uneven weight bearing
- Difficulty with any weight-bearing activity including walking, standing, or climbing stairs
- Compensatory knee, hip, or low back pain from altered biomechanics
CFR: 38 CFR 4.71a, DC 5272: 'In poor weight-bearing position - 20%'. A foot fused in marked inversion forcing the veteran to walk on the outer edge of the foot is a classic example of poor weight-bearing position.
10% Ankylosis of the subastragalar (subtalar) or tarsal joint in ...
Ankylosis of the subastragalar (subtalar) or tarsal joint in a good weight-bearing position. Good position means the joint is fused with the foot in a relatively neutral, functional alignment that allows for reasonable weight-bearing, though all inversion and eversion motion is absent. The veteran can walk with a near-normal gait pattern despite the complete loss of subtalar motion.
Key Symptoms
- Complete or near-complete absence of inversion and eversion at the subtalar joint
- Foot fixed in neutral or near-neutral alignment
- Relatively preserved ability to walk on flat surfaces
- Difficulty with uneven terrain, inclines, and stairs due to absent subtalar motion
- Pain with prolonged walking or standing despite good alignment
- Compensatory increased stress on the ankle and midfoot joints
- Stiffness after rest that may worsen with activity
CFR: 38 CFR 4.71a, DC 5272: 'In good weight-bearing position - 10%'. A foot surgically fused in neutral alignment following a calcaneal fracture that allows walking on flat surfaces but with absent subtalar motion is the prototypical example.
How to Describe Your Symptoms
Pain
How to describe:
Describe the exact location of your pain (medial ankle, lateral foot, heel, arch), its character (aching, stabbing, throbbing, burning), intensity on a 0-10 scale on your worst day, what makes it worse (walking, standing, uneven ground, cold weather, end of day), and what provides partial relief (rest, elevation, ice, medications). Distinguish between resting pain, pain with activity, and pain after activity.
Worst-day example:
“On my worst days, the pain in my right heel and outer foot reaches 8/10 after standing for 20 minutes. I cannot walk more than half a block without stopping. The pain keeps me awake at night and radiates up to my knee from altered walking.”
What the examiner listens for:
Objective evidence of pain on palpation, pain-limited range of motion, antalgic gait, and the veteran's credible description of pain that limits function beyond what static ROM testing shows.
Understatements to avoid:
Do not say 'I manage okay' or 'it depends on the day.' Say specifically: 'On bad days, which occur X times per week, I cannot do Y because of pain reaching Z/10.'
Weight-Bearing Position and Deformity
How to describe:
Describe the visible position of your foot. Explain whether your foot tilts inward or outward, whether you walk on the inner or outer edge of your foot, whether you have developed calluses in abnormal locations, and whether your shoe wears unevenly. Reference any physician or podiatrist observations of your foot alignment.
Worst-day example:
“My right foot is turned inward when I stand and I walk on the outer edge of my foot. My podiatrist told me the subtalar joint is fused in inversion. I have a large callus on the outside of my foot from uneven pressure. My right shoe wears out on the outer edge much faster than the left.”
What the examiner listens for:
Visible deformity on weight-bearing exam, documentation of poor position in imaging, and the veteran's report of altered gait mechanics and secondary complications from poor alignment.
Understatements to avoid:
Do not minimize deformity by saying 'it's not that bad.' If your foot is in a poor weight-bearing position, this is the difference between a 10% and 20% rating - ensure it is clearly documented.
Functional Loss and Daily Activity Limitations
How to describe:
Describe specific activities you can no longer do or must modify: walking distance, standing duration, navigating stairs, walking on uneven ground, driving, working, recreational activities. Give concrete numbers (I can only stand X minutes, I can walk X feet before pain forces me to stop). Describe how this has changed from before your condition.
Worst-day example:
“On a bad day I cannot stand for more than 10 minutes without needing to sit down. I cannot walk on grass, gravel, or uneven pavement without risk of falling. I can no longer do yard work, hike, or stand in a checkout line. I have had to stop working in jobs that require prolonged standing.”
What the examiner listens for:
Specific, credible limitations tied directly to the ankle/foot condition, use of assistive devices, employment impact, and consistency between reported limitations and physical exam findings.
Understatements to avoid:
Do not give best-day performance. The DBQ asks to document functional loss - always describe your condition as it exists on a typical bad day or flare-up, not when you are having a good day.
Flare-Ups
How to describe:
Describe how often flare-ups occur (X times per week or month), what triggers them (prolonged standing, walking, cold weather, physical activity), how long they last, how severe they are compared to your baseline, and what you must do to recover (rest, ice, elevation, medications, bracing).
Worst-day example:
“I have flare-ups 3-4 times per week triggered by walking more than one block or standing longer than 15 minutes. During a flare, my pain goes from a baseline 4/10 to 8-9/10. I must sit or lie down for 1-2 hours with my foot elevated before the pain subsides. During flare-ups I cannot put any weight on the foot.”
What the examiner listens for:
M21-1 requires examiners to consider flare-up frequency and severity in the overall assessment of functional loss. The examiner should document your description of flare-ups in the DBQ narrative section.
Understatements to avoid:
Do not simply say 'I have flare-ups sometimes.' Quantify frequency, duration, severity, and functional impact. Flare-up documentation is critical when your exam-day presentation may not reflect your worst functional status.
Fatigue, Weakness, and Incoordination (DeLuca Factors)
How to describe:
Describe specific fatigue that affects your ankle and foot with use. Explain that after walking or standing, your ankle and foot feel weak, give way, or become uncoordinated. Describe any falls or near-falls. Explain that you tire faster than before on the affected side.
Worst-day example:
“After walking about 100 feet, my ankle feels weak and my foot drags slightly. I have nearly fallen twice on uneven ground because the ankle gives out unexpectedly. By mid-afternoon my entire lower leg is fatigued and I must rest for hours before I can walk again.”
What the examiner listens for:
DeLuca requires the examiner to document whether repetitive use causes additional loss of function due to pain, fatigue, weakness, or incoordination - beyond what the initial static ROM measurement captures.
Understatements to avoid:
Do not assume the examiner will automatically ask about these factors. Proactively state: 'With repeated use my ankle becomes increasingly weak and painful, which reduces my functional ability beyond what you see at rest.'
Secondary and Compensatory Effects
How to describe:
Describe pain or problems in other joints that have developed because of your abnormal gait or altered weight-bearing: knee pain, hip pain, low back pain, contralateral foot pain from overuse, skin breakdown or pressure sores on the foot.
Worst-day example:
“Because of the way my right foot is positioned, I've developed chronic right knee pain and left hip pain from compensating. I also have calluses and a blister on the outer edge of my right foot from the abnormal pressure when I walk.”
What the examiner listens for:
Secondary conditions may support separate service-connected claims as secondary to the tarsal ankylosis. Skin findings may also support additional ratings.
Understatements to avoid:
Do not omit secondary complications. They support the overall picture of functional impairment and may lead to additional disability ratings for secondary conditions.
Common Mistakes to Avoid
Describing your condition on a 'good day' or after resting before the exam
VA ratings are based on the average functional impact of the condition, with particular weight given to worst-day presentation per M21-1 guidance. Presenting better than average leads to an underrated exam.
Instead: Describe your worst-day symptoms explicitly. State: 'Today may not be my worst day. On my worst days, which happen X times per week, my symptoms are...' Do not rest or ice the ankle for extended periods immediately before the exam.
Impact: Could result in 10% rating when condition warrants 20%
Failing to clearly describe the position of foot deformity (inversion, eversion, etc.)
The entire difference between a 10% and 20% rating under DC 5272 depends on whether the joint is ankylosed in a good or poor weight-bearing position. The examiner must document this clearly.
Instead: Before the exam, look at your foot while standing. Note whether it tilts inward, outward, turns in, or turns out. Use a mirror if needed. Bring photographs. Explicitly tell the examiner: 'My foot is fused tilted [inward/outward] and I walk on the [inner/outer] edge of my foot.'
Impact: Directly determines 10% vs. 20% rating
Not mentioning flare-up frequency and severity
The C&P exam is a snapshot in time. If your exam day happens to be a low-symptom day, the examiner may underrate your condition without documentation of flare-ups.
Instead: Proactively tell the examiner: 'Although today my pain is X/10, I typically have flare-ups X times per week reaching Y/10 that last Z hours.' The examiner is required by M21-1 to consider flare-up information.
Impact: Affects both diagnosis confirmation and functional loss documentation
Not requesting documentation of DeLuca factors (pain, fatigue, weakness, incoordination with repetitive use)
Examiners sometimes only record static ROM measurements and omit whether repetitive use causes additional functional loss. DeLuca v. Brown requires these factors to be evaluated.
Instead: After ROM testing, explicitly state: 'With repeated walking or standing, my pain increases, my ankle weakens, and my function declines significantly beyond what you see now at rest. Can you please document that?'
Impact: Can affect overall disability rating and combined evaluation
Downplaying the need for assistive devices or not bringing them to the exam
The use of braces, orthotics, canes, or walkers is documented on the DBQ and supports the overall severity of the condition. Not using or disclosing these devices understates functional impairment.
Instead: Bring every assistive device you use - ankle brace, AFO, custom orthotics, cane, walker. Wear them as you normally would. Tell the examiner which devices you use and how often.
Impact: Affects functional impairment documentation across all rating levels
Failing to report secondary complaints such as knee, hip, or back pain from altered gait
Secondary conditions caused by an altered gait from tarsal ankylosis may be separately ratable. Failing to report these means lost rating opportunities.
Instead: Tell the examiner about any joint pain, skin problems, or other conditions that developed or worsened after the onset of your tarsal ankylosis. These may support secondary service connection claims.
Impact: Affects potential secondary condition ratings
Agreeing with the examiner if they misidentify the joint as the ankle (tibiotalar) rather than the subtalar or tarsal joint
DC 5272 specifically covers the subastragalar (subtalar) and tarsal joints. DC 5270 covers the ankle joint. These are different joints. Misidentification could result in the wrong diagnostic code and rating criteria being applied.
Instead: Know your anatomy: the subtalar joint connects the talus to the calcaneus (heel bone). Confirm with your treating physician prior to the exam which joint is ankylosed and bring documentation specifying this.
Impact: Affects which diagnostic code is applied and the resulting rating
Prep Checklist
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 the completed DBQ (Disability Benefits Questionnaire) after your C&P examination.
- You have the right to record your C&P examination in states where one-party consent recording is permitted. Check your state's specific laws before doing so.
- You have the right to submit a personal statement (buddy statement or veteran statement in support of claim) if you believe the examiner failed to accurately document your symptoms.
- You have the right to request a second opinion or supplemental examination if you believe the initial C&P exam was inadequate, incomplete, or contained errors.
- You have the right to submit a nexus letter from your own treating physician to supplement or rebut the C&P examiner's opinion.
- You have the right to have your claim evaluated under the benefit of the doubt standard (38 CFR 3.102): when evidence is approximately balanced, VA must resolve the doubt in your favor.
- You have the right to have all DeLuca factors (pain, fatigue, weakness, incoordination, and lack of endurance with repetitive use) considered in the evaluation of your musculoskeletal condition, per DeLuca v. Brown.
- You have the right to an exam that evaluates flare-up severity and frequency as part of your overall functional loss assessment, per M21-1 guidance.
- You have the right to appeal any rating decision you believe is incorrect through the Supplemental Claim, Higher-Level Review, or Board of Veterans Appeals pathways under the AMA (Appeals Modernization Act).
- You have the right to free assistance from an accredited Veterans Service Organization (VSO), VA-accredited attorney, or VA-accredited claims agent in preparing and presenting your claim.
Related Conditions
- Ankle Joint Ankylosis DC 5270 covers ankylosis of the tibiotalar (ankle) joint itself, which is a separate joint from the subtalar/tarsal joints covered under DC 5272. Both joints may be ankylosed simultaneously, potentially resulting in separate ratings under each diagnostic code. The ankle joint is directly above the subtalar joint, and both are commonly affected by calcaneal fractures, severe arthritis, or surgical fusion.
- Arthritis, Post-Traumatic (Ankle) Post traumatic arthritis is a common precursor to tarsal joint ankylosis. Service connected arthritis of the subtalar or tarsal joint may progress to ankylosis. If the condition is not yet fully ankylosed, it may be rated under DC 5010 (post traumatic arthritis) analogously to DC 5003, or under limitation of motion codes. DC 5272 applies once true ankylosis is established.
- Calcaneus or Talus Malunion Malunion of the calcaneus (os calcis) or talus (astragalus) following fracture is a direct cause of subtalar joint ankylosis and poor weight bearing position. If malunion is present, it may be separately rated under the appropriate fracture residual code, or the overall disability may be rated under DC 5272 if ankylosis is the predominant finding. The DBQ specifically includes a field for malunion of these bones.
- Avascular Necrosis of the Talus Avascular necrosis (death of bone tissue due to loss of blood supply) of the talus can cause collapse and fusion of the subtalar joint, resulting in ankylosis. If avascular necrosis is the underlying cause of the tarsal ankylosis, both conditions may be relevant to the rating. DC 5271 and related codes may apply concurrently.
- Pes Planus (Flatfoot) Severe acquired pes planus (flat foot) associated with posterior tibial tendon dysfunction can eventually lead to collapse and stiffening of the subtalar and tarsal joints. Veterans with service connected pes planus who develop tarsal joint ankylosis may have a secondary service connection claim for DC 5272.
- Degenerative Arthritis of the Subtalar Joint Degenerative (osteo)arthritis of the subtalar joint is a common cause of subtalar joint ankylosis and is often rated under DC 5003 or analogous codes before progressing to true ankylosis rated under DC 5272. Veterans should ensure the rating transitions from an arthritis code to an ankylosis code once true joint fusion is documented.
- Knee Conditions (Secondary) Abnormal gait mechanics secondary to tarsal joint ankylosis, particularly if the joint is ankylosed in a poor weight bearing position (inversion or eversion), can cause increased mechanical stress on the ipsilateral knee and contralateral lower extremity joints. Veterans may file secondary service connection claims for knee, hip, or low back conditions secondary to the gait disturbance caused by tarsal ankylosis.
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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.