RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00119
BRANCH OF SERVICE:  Army	BOARD DATE:  20150310
SEPARATION DATE:  20070304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for right foot pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards although he was authorized to perform an alternate physical fitness test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Residual/recurrent hallux valgus with metatarsus primus varus deformity of the right foot was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated his right foot pain as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20061127	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Pain	5299-5280	10%	S/P Surgery Hallux Valgus Right Foot	5280	0%	20070510	
			S/p Surgical Scar Hallux Valgus Right Foot	7805	0%	20070510	
Other x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070731 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Foot Condition.  The CI noted a bunion of his right foot for a year prior to seeking medical care on 9 August 2005 when it became painful at all times.  It reached a severity level of 8/10 when running and 4/10 when walking.  At a podiatry visit on 21 August 2005, examination of the right foot showed protrusion of the medial (inner) aspect of the first metatarsal head (base of the big toe) and mild erythema (redness) from pressure, no evidence of pes planus, and a slightly enlarged 5th metatarsal head (base of the little toe).  Additionally, the CI had tenderness of the sesamoid bones of the ball of the foot.  An orthotic device was ordered for a congenital foot deformity, talipes cavus (exaggerated normal arch or high arch).  Pain persisted and a nonsteroidal medication was prescribed along with a limited profile.  Surgery was performed on 17 January 2006 and post-operative pain was treated with Indocin (a nonsteroidal anti-inflammatory medication).  Three months post-operatively pain persisted and Neurontin (medication for nerve pain) was prescribed.  Custom arch supports were fabricated and modified to fit the CI’s footwear in June 2006.  Examination on 7 September 2006 revealed extreme tenderness to palpation along the incision site and almost no active movement of the right great toe; and foot pain was elicited throughout the range-of-motion (ROM).

A permanent L3 profile was issued on 25 July 2006 for right foot pain with limitations of no moving with a fighting load, no doing rushes under direct and indirect fire, and no running, rucking, jumping or marching.  At the MEB examination dated 25 August 2006, the CI reported constant pain in the right foot, which impaired his ability to run, carry weight, stand for long periods, or walk medium distances.  The MEB physical examiner noted increased sensitivity to touch along the right foot incision and extreme limited mobility of the right great toe and mid foot.  The commander’s statement dated 15 September 2006 indicated the CI’s condition began on 9 August 2005 when he experienced pain in his right foot while participating in a morning physical training run.  After surgery he still experienced a high level of pain and hypersensitivity of the foot.  X-rays showed one of the bones in his foot had begun to slip back to its pre-surgical condition.  No treatments, profiles, or medications were able to relieve the pain in his foot.  As an infantryman, his condition prevented him from withstanding extensive physical hardship.

The MEB narrative summary (NARSUM) dated 16 October 2006, performed approximately 5 months prior to separation, noted that CI had undergone conservative management for a bunion of the right foot with custom fabricated orthoses (an external device to control alignment or to correct or accommodate a deformity), temporary duty profiles, digital splints and different types of athletic and military shoe gear.  However, pain persisted and surgery was performed on 17 January 2006.  Several months later there appeared to be some residual recurrence of the deformity.  A number of conservative measures were not successful and the CI chose not to undergo further surgery.  Examination revealed a residual hallux valgus (bunion) with a metatarsus primus varus deformity (first metatarsal inward) with some discomfort with the ROM of the first metatarsal phalangeal (MTP) joint and no crepitus (grinding sensation).  The CI had full motor function and muscle strength was 5/5 of all muscle groups in the lower extremities; and sensation was intact.  The first MTP joint ROM on the right was approximately 60 degrees dorsiflexion passively and 15-20 degrees plantar flexion, while on the left it was 75 degrees dorsiflexion and approximately 30 degrees plantar flexion.  X-ray of the foot revealed residual hallux valgus of the right foot with no signs of degenerative arthrosis of the first MTP joint.  The intensity of the pain was minimal and the frequency was frequent.  The CI was unable to perform duties of his MOS due to chronic right foot discomfort and the pain precluded him from performing strenuous physical activity.

At the VA Compensation and Pension examination dated 10 May 2007, performed approximately 2 months after separation, the CI reported pain at the big toe joint since 13 January 2006, which was described as squeezing and cramping in nature with the pain level at 8/10.  He was unable to jog and run and many physical activities were limited.  He also noted a right foot scar caused by the bunion removal, but had no symptoms and no functional impairment from it.  Examination of the right foot revealed no tenderness, painful motion, weakness, edema, atrophy or disturbed circulation.  No hallux valgus or hallux rigidus was present nor was there pes planus (flat foot) or pes cavus (claw foot).  He had limitations with standing and walking, which were painful.  He did not require any type of support with his shoes.  A depressed scar was present at the right dorsum (top) of the foot, which measured about 9 cm by 0.75 cm with hyperpigmentation.  There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hypopigmentation and abnormal texture.  An X-ray series also dated 10 May 2007 revealed a healed osteotomy (cutting of the bone) of the first metatarsal of the right foot with two retained screws and no evidence of a post-procedural complication.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5280 for right foot pain (residual/recurrent hallux valgus).  The VA assigned a 0% rating using code 5280 for status post surgery for (hallux valgus) of the right foot.  The Board sought a route for a higher rating, but was unable to find one since the maximum rating for code 5280 with resection of the metatarsal head offers only a 10% rating.  The VA applied a 0% rating for the scar post bunionectomy; however, the PEB did not adjudicate the condition; and it did not cause any functional impairment.  The Board concluded that the scar condition could not be recommended for additional disability rating since it was not in the scope of review and was asymptomatic.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the painful right foot condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board noted the NARSUM description of the pain was based on the US Army Physical Disability Ageny pain policy, but did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the painful right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131231, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20150012762 (PD201400119)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA