Toes are bones located at the ends 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 toes being removed with loss of the head of the metatarsal (with exception of the big toe).

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 one or two toes, manifestations may include: pain; tenderness; weakness; paleness; cyanosis; numbness; stiffness; decreased sensation; ulcers; deformities; swelling; paralysis; and decreased or absent pulses. After the amputation, 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 ultrasonography; arthroscopy and bone scan may also be done.

Amputation of one or two toes is the treatment based on the underlying causes identified. Postoperatively, there will be a need for specific treatment to the toe stumps 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 one or two toes 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 area of the metatarsal head removed which could lead 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