Toes are bones located at the ends of the feet, and are referred to as digits, or phalanges. An amputation is the removal of a limb or a part of a limb. This amputation refers to removal of all the toes without loss of the metatarsal bones.

Underlying causes for the amputation may include: trauma; frostbite; systemic disease, e.g., diabetes mellitus or peripheral vascular disease; surgery; congenital anomalies; fractures; bone infection, e.g., osteomyelitis; neurologic problems, e.g., neuroma or neuralgia; and muscular conditions.

Prior to an amputation of the toes, manifestations may include: pain; tenderness; weakness; paleness; cyanosis; numbness; stiffness; decreased sensation; ulcers; deformities; swelling; paralysis; and decreased or absent pulses. Postoperatively, there may be pain, blood loss, deformity, possible infection, and shock.

Diagnostic examinations to evaluate the need for an amputation would most likely include: general physical and examinations of nerve function. Focused examinations on the patient's musculoskeletal system for swelling, deformity, tenderness, range of motion, and circulation; and laboratory studies to determine the underlying causes and possible complications. X-rays; magnetic resonance imaging (MRI); computed tomography (CT) scan; electromyography (EMG); angiography; Doppler studies; arthroscopy; and bone scan may also be done.

Amputation is the treatment. Postoperatively, there will be a need for specific treatment to the foot stump to attain satisfactory wound healing. There may be a need for assistive devices such as walkers, special shoes with orthotics, splints, crutches, canes or wheelchairs. Physical therapy and rehabilitation may be required to regain satisfactory mobility.

• Loss of use of a body part, altered gait, and disability may result in a self- concept disturbance which would require counseling. Phantom limb pain may require special treatment.

• When deciding expressly claimed issues, decision makers must consider entitlement to any complications that are within scope of the claim, including those identified by the rating criteria for that condition in 38 CFR Part 4. This could include but is not limited to, scars as the result of surgical intervention for an SC disability.    

• Each digit, except the great toe, includes three phalanges: the proximal phalanx (closest to the ankle); the middle phalanx, and the distal phalanx (closest to the tip of the toe). Refer to the digits of the foot as

  • first or great toe

  • second

  • third

  • fourth, or

  • fifth.

• The rating schedule for musculoskeletal was updated on February 7, 2021. Protection still does apply and should be considered with existing evaluations (38 CFR 3.951(a)).

• To properly rate this disability, accurate and complete descriptions of the affected extremity are necessary. Descriptions of the affected extremity should include exact place of amputation or resection, length of stump, limitations of motion, pain, weakness, carriage, gait, and posture. An occupational therapy work-up is extremely beneficial, especially when amputation of the hands or fingers is involved.

• Consider entitlement to SMC under 38 CFR 3.350 as an issue in every case where there is a severe degree of disability involving the loss or loss of use of an extremity or sensory organ or any other functional loss providing entitlement to SMC. 

• 38 CFR 4.30 provides for a temporary 100-percent evaluation without regard to other provisions of the rating schedule if treatment of a service-connected (SC) disability resulted in surgery necessitating at least one month convalescence surgery with severe postoperative residuals, or immobilization of at least one major joint by cast without surgery, including procedures performed at an outpatient clinic.

• Compensation is payable under 38 U.S.C. 1160 for disabilities involving certain paired organs or extremities, one SC and the other non-service-connected (NSC), provided the NSC disability is not the result of the Veteran’s own willful misconduct.

• A determination as to loss of use (LOU) of a hand or foot is not restricted to organic loss; it includes functional LOU as well.

• Where an NSC cause necessitates amputation of an extremity resulting in elimination of an SC disability distal to the site of the amputation, do not sever SC for or reduce the evaluation of the SC disability.

• If the location of the injury is unclear, obtain x-rays to clarify the exact point of injury.

• Plate IV – AMPUTATIONS: LOWER EXTREMITY