C&P Exam for Ankle, ankylosis of (DC 5270)

Diagnostic code: 5270Condition: Ankle, ankylosis ofRegulation: 38 CFR § 4.71aDBQ: DBQ MUSC Ankle

Which form the examiner uses

For ankle, ankylosis of (DC 5270), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates ankle conditions including range of motion, ankylosis, joint stability, surgical procedures, and functional impact.

How DC 5270 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-V, IX, and XII-XIV of this form. Section V is the condition-specific section for this code. Sections VI-VIII and X-XI cover unrelated conditions on this DBQ and are skipped.

DIAGNOSIS (Section I)
  • 1A. List the claimed condition(s) that pertain to this questionnaire
  • 1B. Select diagnoses associated with the claimed condition(s) (check all that apply)
  • The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
  • Lateral collateral ligament sprain (chronic/recurrent) - Side affected / ICD code / Date of diagnosis
  • Deltoid ligament sprain (chronic/recurrent) - Side affected / ICD code / Date of diagnosis
  • Osteochondritis dissecans to include osteochondral fracture - Side affected / ICD code / Date of diagnosis
  • Impingement (anterior/posterior (or trigonum syndrome)/anterolateral) - Side affected / ICD code / Date of diagnosis
  • Tendonitis (Achilles/peroneal/posterior tibial) - Side affected / ICD code / Date of diagnosis
  • Retrocalcaneal bursitis - Side affected / ICD code / Date of diagnosis
  • Achilles' tendon rupture - Side affected / ICD code / Date of diagnosis
  • Avascular necrosis, talus - Side affected / ICD code / Date of diagnosis
  • Ankle joint replacement - Side affected / ICD code / Date of diagnosis
  • Ankylosis of ankle, subtalar or tarsal joint - Side affected / ICD code / Date of diagnosis
  • Shin splints/medial tibial stress syndrome - MTSS (including post-surgery or treatment) - Side affected / ICD code / Date of diagnosis
  • Degenerative arthritis, other than post-traumatic - Side affected / ICD code / Date of diagnosis
  • Arthritis, gonorrheal - Side affected / ICD code / Date of diagnosis
  • Arthritis, pneumococcic - Side affected / ICD code / Date of diagnosis
  • Arthritis, streptococcic - Side affected / ICD code / Date of diagnosis
  • Arthritis, syphilitic - Side affected / ICD code / Date of diagnosis
  • Arthritis, rheumatoid (multi-joints) - Side affected / ICD code / Date of diagnosis
  • Arthritis, post-traumatic - Side affected / ICD code / Date of diagnosis
  • Arthritis, typhoid - Side affected / ICD code / Date of diagnosis
  • Other specified forms of arthropathy (excluding gout) - Side affected / ICD code / Date of diagnosis
  • Osteoporosis, residuals of - Side affected / ICD code / Date of diagnosis
  • Osteomalacia, residuals of - Side affected / ICD code / Date of diagnosis
  • Bones, neoplasm, benign - Side affected / ICD code / Date of diagnosis
  • Bones, neoplasm, malignant, primary or secondary - Side affected / ICD code / Date of diagnosis
  • Osteitis deformans - Side affected / ICD code / Date of diagnosis
  • Gout - Side affected / ICD code / Date of diagnosis
  • Bursitis - Side affected / ICD code / Date of diagnosis
  • Myositis - Side affected / ICD code / Date of diagnosis
  • Heterotopic ossification - Side affected / ICD code / Date of diagnosis
  • Tendinopathy (select one if known): Tendinitis / Tendinosis / Tenosynovitis - Side affected / ICD code / Date of diagnosis
  • Other diagnosis #1 - Side affected / ICD code / Date of diagnosis
  • Other diagnosis #2 - Side affected / ICD code / Date of diagnosis
  • Other diagnosis #3 - Side affected / ICD code / Date of diagnosis
  • 1C. If there are additional diagnoses that pertain to ankle conditions, list using above format
MEDICAL HISTORY (Section II)
  • 2A. Describe the history, including onset and course, of the Veteran's ankle condition(s). Brief summary
  • 2B. Does the Veteran report flare-ups of the ankle?
  • If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he/she experiences during a flare-up of symptoms
  • 2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?
  • If yes, document the Veteran's description of functional loss or functional impairment in his/her own words
  • 2D. Does the Veteran report or have a history of instability of the ankle?
  • If yes, document the Veteran's description of instability in his/her own words
RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)
  • 3A. Initial ROM measurements: All Normal / Abnormal or outside of normal range / Unable to test / Not indicated
  • If 'Unable to test' or 'Not indicated', please explain
  • If ROM is outside of 'normal' range, but is normal for the Veteran (for reasons other than an ankle condition, such as age, body habitus, neurologic disease), please describe
  • If abnormal, does the range of motion itself contribute to a functional loss?
  • Can testing be performed?
  • If this is the unclaimed joint, is it: Damaged / Undamaged
  • Active Range of Motion (ROM) - Plantar flexion endpoint (45 degrees): degrees
  • Active Range of Motion (ROM) - Dorsiflexion endpoint (20 degrees): degrees
  • If noted on examination, which ROM exhibited pain (select all that apply): Plantar flexion / Dorsiflexion
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe
  • Plantar flexion degree endpoint (if different than above)
  • Dorsiflexion degree endpoint (if different than above)
  • Passive Range of Motion - Plantar flexion endpoint (45 degrees): degrees / Same as active ROM
  • Passive Range of Motion - Dorsiflexion endpoint (20 degrees): degrees / Same as active ROM
  • If noted on examination, which passive ROM exhibited pain (select all that apply): Plantar flexion / Dorsiflexion
  • Is there evidence of pain? Weight-bearing / Nonweight-bearing / Active motion / Passive motion / On rest/nonmovement / Causes functional loss / Does not result in/cause functional loss
  • Comments
  • Is there objective evidence of crepitus?
  • Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? If yes, please explain. Include location, severity, and relationship to condition(s).
  • 3B. Observed repetitive use ROM - Is the Veteran able to perform repetitive-use testing with at least three repetitions?
  • Is there additional loss of function or range of motion after three repetitions?
  • After three repetitions - Plantar flexion endpoint (45 degrees): degrees
  • After three repetitions - Dorsiflexion endpoint (20 degrees): degrees
  • Select factors that cause this functional loss. Check all that apply: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • 3C. Repeated use over time - Is the Veteran being examined immediately after repeated use over time?
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?
  • Select factors that cause this functional loss (repeated use over time): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • Estimate range of motion in degrees for this joint immediately after repeated use over time - Plantar flexion endpoint (45 degrees): degrees
  • Estimate range of motion in degrees for this joint immediately after repeated use over time - Dorsiflexion endpoint (20 degrees): degrees
  • Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
  • 3D. Flare-ups - Is the examination being conducted during a flare-up?
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?
  • Select factors that cause this functional loss (flare-ups): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • Estimate range of motion in degrees for this joint during flare-ups - Plantar flexion endpoint (45 degrees): degrees
  • Estimate range of motion in degrees for this joint during flare-ups - Dorsiflexion endpoint (20 degrees): degrees
  • 3E. Additional factors contributing to disability: None / Interference with sitting / Interference with standing / Swelling / Disturbance of locomotion / Deformity / Less movement than normal / More movement than normal / Weakened movement / Atrophy of disuse / Instability of station / Other
  • Please describe additional contributing factors of disability
MUSCLE ATROPHY (Section IV)
  • 4A. Does the Veteran have muscle atrophy?
  • 4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? If no, provide rationale
  • 4C. Right lower extremity - specify location of measurement such as '1cm above or below ankle'
  • Circumference of more normal side: cm
  • Circumference of atrophied side: cm
  • 4C. Left lower extremity - specify location of measurement such as '1cm above or below ankle'
  • Circumference of more normal side: cm (left)
  • Circumference of atrophied side: cm (left)
ANKYLOSIS (Section V)
  • 5A. Is there ankylosis of the ankle?
  • If yes, indicate the severity of ankle ankylosis: In plantar flexion, less than 30 degrees / In plantar flexion, between 30 degrees and 40 degrees / In plantar flexion at more than 40 degrees / In dorsiflexion, between 0 degrees and 10 degree / In dorsiflexion at more than 10 degrees / With an abduction deformity / With an adduction deformity / With an inversion deformity / With an eversion deformity
  • 5B. Indicate angle of ankle ankylosis in degrees: N/A no ankle ankylosis of joint / Plantar flexion / Dorsiflexion
  • 5C. Is there ankylosis of the subastragalar or tarsal joint? If yes, indicate severity: In good weight-bearing position / In poor weight-bearing position
JOINT STABILITY (Section VI)
  • 6A. Anterior Drawer Test: Is there absence of firm end point with asymmetric or excessive motion?
  • Talar Tilt Test: Is there asymmetric or excessive motion?
  • If unable to test, please explain why
  • 6B. If unable to test, is ankle instability suspected? If yes, please describe
ADDITIONAL COMMENTS (Section VII)
  • 7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?
  • Stress fracture of the lower leg - Describe current symptoms
  • Achilles tendonitis or Achilles tendon rupture - Describe current symptoms
  • Malunion of calcaneus (os calcis) or talus (astragalus) - Indicate severity: Moderate deformity / Marked deformity
  • 'Shin Splints' (medial tibial stress syndrome - MTSS) - Indicate length of treatment: no treatment received / treatment for less than 12 consecutive months / requiring treatment for 12 consecutive months or more
  • If Veteran underwent treatment, indicate response to treatment: responsive to surgery and/or treatment / unresponsive to either shoe orthotics or other conservative treatment / unresponsive to surgery and either shoe orthotics or other conservative treatment
  • Does this condition affect ROM of knee?
  • Talectomy - Describe current symptoms
SURGICAL PROCEDURES (Section VIII)
  • 8A. Indicate any surgical procedures that the Veteran has had performed: No surgery / Total ankle joint replacement / Arthroscopic or other ankle surgery
  • Total ankle joint replacement - Date of surgery
  • Total ankle joint replacement - Residuals: None / Intermediate degrees of residual weakness, pain or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other, describe
  • Arthroscopic or other ankle surgery - Type of surgery
  • Arthroscopic or other ankle surgery - Date of surgery
  • Residuals of arthroscopic or other ankle surgery - Describe residuals
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section IX)
  • 9A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above? If yes, describe (brief summary)
  • 9B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section?
ASSISTIVE DEVICES (Section X)
  • 10A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
  • Wheelchair - Frequency of use: Occasional / Regular / Constant
  • Brace(s) - Frequency of use: Occasional / Regular / Constant
  • Crutch(es) - Frequency of use: Occasional / Regular / Constant
  • Cane(s) - Frequency of use: Occasional / Regular / Constant
  • Walker - Frequency of use: Occasional / Regular / Constant
  • Other - Frequency of use: Occasional / Regular / Constant
  • 10B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.
REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XI)
  • 11A. Due to the Veterans ankle condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis?
  • If yes, indicate extremities for which this applies: Right lower / Left lower
  • 11B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary)
DIAGNOSTIC TESTING (Section XII)
  • 12A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination?
  • 12B. If yes, is degenerative or post-traumatic arthritis documented? If yes, indicate side: Right / Left / Both
  • 12C. If yes, provide type of test or procedure, date and results (brief summary)
  • 12D. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? If yes, provide type of test or procedure, date and results (brief summary)
  • 12E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions
FUNCTIONAL IMPACT (Section XIII)
  • 13A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
  • If yes, describe the functional impact of each condition, providing one or more examples
REMARKS (Section XIV)
  • 14A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

Rating Levels for DC 5270

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

What the Board discussed in granted decisions for DC 5270

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

  1. 22% Benefit of doubt doctrine cited as applicable standard
    The Board cited the statutory or regulatory benefit-of-the-doubt doctrine as the governing standard when evidence is in approximate balance, noting the claimant prevails in equipoise.
    112 of 500 sample sentences
  2. 18% Benefit of doubt inapplicable, evidence preponderates against claim
    The Board found the preponderance of evidence weighed against the claim and therefore found the benefit-of-the-doubt doctrine inapplicable, resulting in denial.
    92 of 500 sample sentences
  3. 18% Benefit of doubt applied to grant increased rating
    The Board applied the benefit-of-the-doubt doctrine affirmatively and awarded a specific percentage disability rating for an ankle or other service-connected condition.
    89 of 500 sample sentences
  4. 12% Evidence found in equipoise on rating or nexus question
    The Board found the lay and medical evidence at least in relative equipoise on a material factual issue, such as degree of limitation of motion or nexus to service, supporting a favorable finding.
    62 of 500 sample sentences
  5. 12% VA or private examiner nexus opinion cited as 'at least as likely as not'
    A VA or private medical examiner opined that a current disability was at least as likely as not caused by, incurred in, or aggravated by service or a service-connected condition.
    62 of 500 sample sentences
  6. 4% Ankylosis or marked limitation of ankle motion documented
    The Board recorded findings of ankylosis or marked limitation of dorsiflexion or plantar flexion of the ankle, supporting assignment of a higher disability rating under the applicable diagnostic code.
    18 of 500 sample sentences
  7. 4% Secondary service connection nexus opinion cited
    A medical examiner opined that a disability was proximately due to or aggravated beyond natural progression by a service-connected disability, supporting secondary service connection.
    18 of 500 sample sentences
  8. 3% Medical examiner request or remand instructions noted
    The Board or record reflected a request for a VA or private examiner to render an 'at least as likely as not' opinion on nexus, aggravation, or etiology of a claimed condition.
    17 of 500 sample sentences
  9. 2% Veteran's credible lay statements noted as probative evidence
    The Board noted the Veteran's competent and credible reports of pain, instability, or functional loss as probative evidence supporting a higher rating or service connection finding.
    10 of 500 sample sentences
  10. 2% Functional impairment or DeLuca factors documented
    The Board recorded additional functional loss beyond range-of-motion measurements, including pain on use, weakness, or flare-up symptoms, as supporting a higher disability rating.
    10 of 500 sample sentences
  11. 2% TDIU or unemployability finding noted in benefit-of-doubt context
    The Board found the evidence in equipoise or favoring the Veteran and applied the benefit-of-the-doubt doctrine to grant entitlement to TDIU or establish inability to maintain substantially gainful employment.
    9 of 500 sample sentences
  12. 0% Prior Board or rating decision findings on ankle rating noted
    The Board cited prior decisions, examination findings, or rating criteria determinations specifically addressing the ankle disability rating level under a diagnostic code as part of its staged-rating analysis.
    1 of 500 sample sentences
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Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.