The great toes are more solid and less movable than the other toes of the feet because of their role in supporting the body in standing and movement. They 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 the great toe removal with loss of the metatarsal tip or great toe removal without loss of the metatarsal tip.

In general, underlying causes for an amputation may include: trauma; frostbite; systemic disease, e.g., diabetes mellitus; 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 great toe, 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, circulation; and laboratory studies to determine the underlying causes and possible complications are usually done. X-rays; magnetic resonance imaging (MRI); computed tomography (CT) scan; electromyography (EMG); angiography; Doppler studies; arthroscopy; and bone scan may also be done.

Amputation of the great toe is the treatment based on the underlying causes identified. Postoperatively, there will be a need for specific treatment to the toe stump to attain satisfactory wound healing. There may be a need for assistive devices such as walkers, special shoes with orthotic devices, splints, crutches, canes or wheelchairs. Physical therapy and rehabilitation may be required to regain satisfactory mobility.

• Loss of use of a great toe may alter the gait, resulting in a disability. There may be an associated self-concept disturbance which would require counseling. Phantom limb pain may require special treatment. Residuals may also include new local pressure areas, callus formation, or ulceration. Plantar and lateral ulcers may occur around the metatarsal head leading to bone exposure and osteomyelitis.

• 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. 

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

• 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.

• 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.

• 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.

• Plate IV – AMPUTATIONS: LOWER EXTREMITY