RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
  
NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01577
BRANCH OF SERVICE:  marine corps 			           SEPARATION DATE:  20071231 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “chronic left lower extremity edema, weak left foot, with secondary vascular abnormality, and left foot tarsal coalition of the calcaneal navicular joint,” with a disability rating of 10%.  

CI CONTENTION:  The CI contends the PEB rendered an improper diagnosis.  The CI’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 Physical Evaluation Board (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 - 20071026	VARD – 20090715	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Lower Extremity Edema, Weak Left Foot, with Secondary Vascular Abnormality, and Left Foot Tarsal Coalition of the Calcaneal Navicular Joint	5284	10%	Left Ankle Sprain	5271	10%	20090616	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Lower Extremity (LLE) Condition.  In November 2005, this Marine injured his LLE during a hike in boot camp.  He was treated with conservative measures, but continued to have significant problems with the left foot and ankle.  In October 2006, radiologic imaging showed possible calcaneal-navicular coalition.  In spite of all treatment efforts, the LLE condition did not improve adequately to meet the physical requirements of his military specialty and he was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “edema,” “muscle weakness (generalized),” and “calcaneal spur” for PEB adjudication.  The left ankle range of motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Left Ankle ROM (Degrees)	MEB ~3 Mo. Pre-Sep
	VA C&P ~18 Mo. Post-Sep
	
Dorsiflexion (20 Normal)	10	10	
Plantar Flexion (45)	(not recorded)	35	
Comments	painful motion, antalgic gait, edema, and instability   	painful motion, antalgic gait, edema, and instability	

At the MEB NARSUM examination, the CI reported daily pain that increased with high impact activity.  On physical examination (PE) of the left ankle, the anterior drawer sign was positive (a test for stability of the ankle joint).  There was tenderness to palpation, increased swelling of the extremity, and difficulties with wearing a shoe.  The CI had an antalgic gait.  He was unable to walk normally because of limited mid-foot ROM.  At the VA Compensation and Pension (C&P) examination on 16 June 2009, performed 18 months after separation, the CI reported constant pain and swelling of the left ankle.  PE showed an antalgic gait, tenderness, swelling, instability and weakness.  Left ankle motion was painful, and the ROM is recorded in the chart above.  

The Board directed attention to its rating recommendation based on the evidence.  The PEB combined the left ankle and left foot into a single unfitting condition.  The unfitting LLE condition was characterized as: “Chronic left lower extremity edema, weak left foot, with secondary vascular abnormality, and left foot tarsal coalition of the calcaneal navicular joint.”  The condition was coded 5284 (foot injury), and rated at 10%.  The Board evaluated whether it was appropriate for the two conditions to be “bundled” together.  The Board must determine if the PEB’s approach of combining the conditions under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate codes and ratings in its recommendation if compensable ratings for each condition are achieved IAW the Veterans Affairs Schedule for Rating Disabilities (VASRD).  If the Board judges that two or more separate ratings are warranted, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board determined that the evidence does not support a conclusion that each of the conditions, separately, would have rendered the CI unable to perform his required military duties.  Accordingly, the Board does not recommend a separate disability rating for each problem.  It was reasonably justified for the left foot and ankle to be “bundled” together, and treated as a single unfitting LLE condition.  

The PEB assigned a 10% rating the LLE condition, coded 5284 (foot injury, other). The VA also rated the LLE condition at 10%, but used code 5271 (limited motion of the ankle).  The Board carefully reviewed the clinical information in the record.  At the September 2007 MEB NARSUM exam, the CI reported daily pain that increased with high impact activity.  On PE of the left ankle, the anterior drawer sign was positive.  There was tenderness to palpation, increased swelling of the extremity, and difficulties with wearing a shoe.  The CI was unable to walk normally because of limited mid-foot ROM.  At the June 2009 VA C&P examination, the CI reported constant pain and swelling of the left ankle.  PE showed an antalgic gait, tenderness, swelling, instability and weakness.  Left ankle motion was painful.  The Board noted that the coalition of the calcaneal navicular joint was analogous to malunion. The Board determined that the CI’s left lower extremity disability was best described as “moderate.”  There was insufficient evidence in the record to justify describing his LLE disability as “marked.”  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 unfitting LLE condition, coded 5299-5262.  

BOARD FINDINGS:  In the matter of the unfitting LLE condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5262, 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Lower Extremity Edema, Weak Left Foot, with Secondary Vascular Abnormality, and Left Foot Tarsal Coalition of the Calcaneal Navicular Joint	5299-5262	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141203, 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 15 Apr 16 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 09 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(g) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXX 
	(i) PDBR ltr dtd 14 Apr 16 ICO XXXXXXXXXXXXXXXXXX

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

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

     a. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

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

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

     d. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

     e. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge.

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

     h. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 
     
     i. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 70 percent disability rating (increased from 10 percent) effect date of discharge.
 
     j. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect 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.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)