RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01073
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20150507
Separation Date:  20061231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-4 (Infantry Assaultman) medically separated for left foot pain status post shrapnel removal.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “pain in joint involving ankle and foot” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (retained shrapnel fragment, left shoulder) for PEB adjudication.  The Informal PEB adjudicated the “persistent left foot pain status post (s/p) blast injury with shrapnel removal times two” as unfitting and rated it at 10%.  The PEB adjudicated retained shrapnel fragment to his left shoulder which is currently asymptomatic as a Category III (not separately unfitting).  The CI made no appeals, and was medically separated.

CI CONTENTION:  “The DOD gave me a 10 percent orthopedic rating for my left foot when it was well documented that I suffered from nerve damage and scarring.  The VA gave me a 20 percent evaluation for the nerve damage and a 10 percent evaluation for the scarring of the left foot.”

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:

Service IPEB – Dated 20061016	VA - (1 Month Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Left Foot Pain s/p Blast Injury with Shrapnel Removal Times Two	5284	10%	Traumatic Neuropathy to the Left Foot…	8525	20%	20061206	
			Scar on Left Foot	7804	10%	20061206	
Other x1 (Not In Scope)	Other x9	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20070502 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Persistent Left Foot Pain s/p Blast Injury with Shrapnel Removal times Two.  The CI sustained a shrapnel blast injury to his left foot while in Iraq on 8 May 2005.  He underwent two left foot incision and drain procedures to remove the shrapnel while in theater.  The primary care provider documented that the CI reported increased sharp pain with walking.  There were physical exam findings of left foot numbness from incision distally to the 5th digit, hyperesthesias and an antalgic gait.  The CI continued to complain of left foot tenderness, numbness and pain with ambulation.  The civilian orthopedist documented that the CI reported pain near his incision site, pain when ambulating and the area long the incision site produced a tremendous amount of pain on palpation.  There were physical exam findings of decreased sensation over the 4th and 5th digits of the left foot in the plantar lateral aspect; hyperesthesia along the 4 cm linear incision.  The examiner diagnosed traumatic left foot neuropathy and recommended a medication for neurogenic pain.  A left foot MRI showed a small focus of peri-neural fibrosis in the second interspace.  The neurologist documented that the CI reported throbbing left foot pain with numbness above the scar and down the two toes.  The pain was constant but worsened after walking or standing for more than 30 to 45 minutes.  There were physical exam findings of weakness of the dorsiflexion of the left toes; deep tendon reflexes 1+ symmetrical on all four extremities; decreased sensation to touch and pressure in the left distal foot and 4th and 5th toes on dorsal and ventral aspect.  He confirmed the diagnosis of left plantar neuralgia.  The MEB narrative summary (NARSUM) completed approximately 4 months prior to separation documented that the CI still had a significant amount of left foot pain which limited his walking and he was unable to run.  He had occasional mild swelling and hypersensitivity to the plantar and lateral aspects of his foot.  There were physical exam findings of a healed surgical scar to the lateral aspect of the foot; mild planovalgus; mild hypersensitivity over the lateral foot, minimal pain with deep palpation, and decreased sensation to light touch 4th and 5th toes.   There was normal foot strength.  

The VA Compensation and Pension (C&P) exam 21 days prior to separation documented that the CI reported persistent pain in his left foot, walking caused pain and if he ran, he had pain in the plantar aspect of the foot.  There were physical exam findings of decreased sensation, tingling in the 4th and 5th toes; gross sensation was present; a two inch scar on the plantar aspect of 5th metatarsal which was tender to touch and motion; the toes had dorsiflexion to 30 degrees and planar flexion to 30 degrees both with mild pain; a moderate lack of endurance; a moderate restriction of repetitive use; and marked pain with any pressure to the foot.  The examiner noted that from a functional standpoint there was one-half normal function of the left foot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the “persistent left foot pain s/p blast injury with shrapnel removal times two” condition as 5284 (other foot injuries) and rated at 10% for Moderate.  The VA coded the “traumatic neuropathy to the left foot…” condition as 8525 (paralysis of the posterior tibial nerve (tarsal tunnel)) and rated at 20% for Severe.  The Board discussed the fitness issue of the left foot scar.  After a thorough discussion, the Board agreed that the scar was not unfitting and could not be added as an unfitting condition.  There was ample evidence throughout the service treatment record that the CI had chronic left foot pain with decreased sensation, tingling in the 4th and 5th toes.  The Board considered the tenants of §4.124 Neuralgia, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis versus §4.123 Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis.  The Board agreed that the CI’s symptoms more closely aligned with the neuralgia criteria.  The Board next considered rating at 20% severe or 10% moderate.  The C&P examiner noted that from a functional standpoint there was one-half normal function of the left foot.  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 persistent left foot pain s/p blast injury with shrapnel removal times two condition coded 8725.

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 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 persistent left foot pain s/p blast injury with shrapnel removal times two condition, the Board unanimously recommends a disability rating of 20%, coded 8725 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Persistent Left Foot Pain s/p Blast Injury with Shrapnel Removal Times Two	8725	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, w/atchs
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 11 Aug 15 ICO XXXXXXXXXXXXXXX
       (c) PDBR ltr dtd 14 Aug 15 ICO XXXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 17 Aug 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 11 Aug 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 18 Aug 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

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

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

     b. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

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

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN:  Placement on Permanent Disability Retired List with a 30 percent disability rating 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.