RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00615
BRANCH OF SERVICE:  MARINE CORPS	SEPARATION DATE:  20041215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Radio Operator, medically separated for “adult acquired symptomatic flat foot,” with a disability rating of 10%. 

CI CONTENTION:  The CI’s condition continues to worsen.  The applicant’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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:
  
SERVICE PEB - 20041021	VARD - 20060124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Adult Acquired Symptomatic Flat Foot	5276	10%	Status Post Resection of Right Foot Talocalcaneal Joint Middle Facet Bony Coalition with Scars	5271	20%	20051227	
Talocalcaneal Joint Coalition, Surgically Treated	Category II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY: 

Right Lower Extremity Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right foot and ankle were initially injured approximately 4 years prior to referral for MEB.  The MEPS enlistment physical documented mild asymptomatic pes planus (flatfoot).  A right foot X-ray showed suspected talocalcaneal (talus [ankle bone that articulates with calcaneus, tibia, and navicular] / calcaneus [heel bone]) coalition. 
A right foot CT showed a bony talocalcaneal coalition, associated joint sclerotic changes, and degenerative changes of the talonavicular joint.  Podiatry performed two anesthetic/steroid injections into the articulation between the talus and calcaneous (talocalcaneal or subtalar or subastragalar joint) without significant relief.  The podiatrist recommended a joint arthrodesis (surgical fixation/fusion of a joint) but the CI declined and stated “He’s too young to lose motion at the joint.”  The CI opted for a resection of the subtalar joint coalition in attempt for pain relief.  The podiatrist advised that there was a high rate of recurrence that might necessitate a subsequent arthrodesis.  The podiatrist opined that a full return to duty may not be possible.  Podiatry performed a resection of the right bony subtalar middle facet coalition.  The postoperative course was complicated by wound dehiscence (wound rupture along a surgical incision) which subsequently closed after three weeks.  The NARSUM, 3 months before separation, recounted the history and interventions.  The CI related a history of recurrent ankle injuries as a high school athlete.  He reported he sustained a right ankle injury in basic training and the pain did not resolve.  The CI failed conservative management which included activity modification, a controlled ankle movement (CAM) boot, physical therapy (PT), ultrasound, a transcutaneous electrical nerve stimulation (TENS) unit, anti-inflammatory medications, and steroid injections.  He requested surgical intervention, refused the recommended subtalar joint arthrodesis, and opted for resection of the bony coalition.  The CI was back to walking and wearing regular shoes.  He stated the pain had abated since he had moved to a desk job, but he still had low grade pain with intense physical activity.  The physical exam documented good ambulation, no need for supports, and the gait was not antalgic (assuming a gait or posture to lessen pain).  The lower extremity exam revealed equal leg length with no signs of genu valgum or genu recurvatum.  The right ankle exam showed “… limitations on dorsiflexion, limiting it to zero degrees with the knee flexed and extended.”  The right foot exam “… displays a unilateral collapsed arched on static weight bearing exam with 5 degrees of heel valgus.  There is talar head prominence on the medial side with forefoot abduction.  There is heel inversion on heel raise test.  Foot circumduction is possible but does not display a smooth movement as the contralateral side.”  Strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  A right foot X-ray showed talocalcaneal resection postoperative changes.  The diagnoses listed surgically treated talocalcaneal joint coalition (EPTS, service aggravated) and adult acquired symptomatic flat foot.  The examiner opined that the CI would benefit from a fusion type of procedure aimed at the talocalcaneal joint and the progressively pronating foot.  He recommended a triple arthrodesis to address the talocalcaneal joint and the collapsing medial longitudinal arch and that the CI continued to wear custom insoles to control foot pronation.  A podiatry right ankle/foot exam documented good range-of-motion (ROM).  At an orthopedic surgery evaluation the CI complained of continued right medial and lateral hindfoot pain and ankle sprains.  The right ankle/foot exam revealed a well-healed surgical incision along the medial aspect of the hindfoot.  There was reasonable forefoot alignment with a mild hallux valgus (bunion) deformity.  Ankle ROM was very good.  There was reasonable pronation and supination of the midfoot with essentially no mobility in inversion and eversion of the subtalar joint.  The heel was in a reasonably neutral position.  Pulses and DTRs were normal.  The X-rays showed subtalar arthritis status post medial talocalcaneal coalition and resection, a dorsal talar boss (bony overgrowth) with anterior ankle impingement, and a tight gastrocnemius soleus complex.  The surgeon recommended a subtalar arthrodesis, excision of the dorsal talar boss, and Achilles tendon lengthening.  Orthopedic surgery performed a subtalar arthrodesis.  At the postoperative orthopedic surgery evaluation, the CI denied any specific complaints of pain.  He was quite pleased with how he was doing but reported he was unable to do a single heel raise on the right.  The right ankle/foot exam revealed excellent alignment of the foot.  Dorsiflexion, plantar flexion, and ROM was documented as “good.”  Inversion and eversion were limited secondary to the subtalar arthrodesis.  Right ankle strength was grossly in the 4/5 range.  Right ankle X-rays showed excellent position and alignment with what appeared to be excellent fusion.  The assessment listed eleven weeks status post right subtalar arthrodesis.  The plan was to allow full weight-bearing, start PT, and have him return in 3 months. 
The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI reported reduction of the right foot and ankle pain with the second surgery, but had less flexibility as it was a fusion procedure.  He complained of average daily 6-7/10 pain that was worse at night.  Pain was exacerbated by cold weather, walking barefoot, prolonged walking, prolonged standing, and stairs and relieved by avoidance of activity, warm baths, and medication (Tylenol).  The CI reported flare-ups twice weekly, which returned to the baseline pain by the following morning.  He found that arch supports were not reliably helpful and did not consistently wear them.  The CI was independently ambulatory but he described an abnormal gait following his two surgeries.  The right ankle/foot exam revealed non-tender healed surgical incisions.  Peripheral pulses and hair growth were normal and there was no edema or unusual cutaneous lesions.  There was tenderness at the subtalar joint, with mild-moderate direct pressure, and on mid foot mobilization.  There was normal alignment of the Achilles tendon relative to the calcaneus and no significant abduction of the forefoot or deviation of the great toe.  The arch was normal both at rest and weight bearing.  The goniometer measured ROM values were dorsiflexion of 5 (20 normal) and volar (plantar) flexion of 5 (45) degrees.  There was tenderness and stiffness with repeated assessments on change.  There was reduced inversion and eversion with active and passive ROM.  The ankle ROM was not further limited by pain, fatigability, or incoordination on repetitive testing.  Right foot and ankle X-rays showed postoperative changes with no complicating postoperative abnormalities.  The examiner reported there was no evidence of pes planus by physical exam or X-rays.  The diagnosis listed right subtalar fusion.

The Board directed its attention to its rating recommendation based on the above evidence.  The Board does not challenge service EPTS determinations, but does exercise the prerogative of assessing the Presumption of Service Aggravation (PSA) element IAW DoDI 1332.38 (Presumption of Aggravation).  The PEB assigned a 10% rating under 5276 (flatfoot, acquired: moderate) citing EPTS with a reduction of 0%.  The listed Category II condition (talocalcaneal joint coalition, surgically treated) was considered to contribute to the unfitting right lower extremity condition.  The VA assigned a 20% rating under 5271 (ankle, limited motion of: marked) based on the VA C&P exam 10 months postoperatively, and 12 months after separation.  The VA cited pain, history of two surgeries, fusion procedure, reduction of pain, less mobility, no post-operative complications, surgical incisions, subtalar joint tenderness, mid foot tenderness, very reduced inversion and eversion, ROM, tenderness and stiffness with repeated assessments, ROM not further limited by pain, fatigability, or incoordination on repetitive testing, and X-rays showing postoperative changes with no complicating postoperative abnormalities.  The VA denied service-connection for pes planus.  While the CI had pes planus, it was characterized as mild and asymptomatic per the entrance enlistment physical.  The NARSUM examiner recommended the CI continue to wear custom insoles to control foot pronation.  Following the second surgery, the C&P examiner documented there was no evidence of pes planus by physical exam or X-rays.  The CI reported that arch supports were not reliably helpful and he did not consistently wear them.  Board members agreed the condition did not exceed the mild (0%) rating under 5276 (flatfoot, acquired).  The Board assigned little probative value to the more proximate NARSUM exam because it occurred before the second surgery.  Recognizing the temporal relationship, the Board assigned higher probative value to the C&P exam because it occurred after surgery and a period of convalescence.  The CI underwent a subtalar (subastragalar) arthrodesis and imaging showed metallic screw fusion of the calcaneus and talus with excellent position and alignment.  While there was fusion of the subastragalar joint, it was in good weight-bearing position, consistent with the 10% rating under 5272 (subastragalar or tarsal joint, ankylosis of).  While there was fusion of the calcaneus with the talus, there was no deformity for consideration under 5273 (os calcis [calcaneus] or astragalus [talus], malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  There was no significant weakness for consideration under 5277 (weak foot).  There was no evidence of sensory pathology for consideration under 5279 (metatarsalgia).  There was no deformity for consideration under 5270 (ankle, ankylosis), 5275 (lower extremity bone shortening of), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  Board members agreed that the ankle limitations in motion (5271) more closely approximated the marked (20%) than the moderate (10%) rating.  Board members agreed that there was sufficient evidence of pain with use prior, as well objective exam and imaging findings, to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the right lower extremity condition.

BOARD FINDINGS:  In the matter of the right lower extremity condition, the Board unanimously recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Status Post Resection of Right Foot Talocalcaneal Joint Middle Facet Bony Coalition	5271	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140127, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 2 Mar 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 2 Mar 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 22 Feb 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Feb 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (e) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.