RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01744
BRANCH OF SERVICE:  Army	BOARD DATE:  20141218
SEPARATION DATE:  20081009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Fire Repair specialist) medically separated for right forefoot injury.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right forefoot injury condition, characterized as “right foot metatarsalgia” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated right forefoot injury condition as unfitting rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  No other conditions were submitted by the MEB.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Consider all conditions found unfitting and not unfitting by the physical evaluation board.”  

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 20080804	VA - (7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Forefoot Injury	5279	10%	Right Foot Strain w/Plantar Fasciitis	5284	10%	20090518	
Other x0	Other x4	20090518	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20090805 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Right Forefoot Injury Condition.  In July 2006, the CI suffered a crush injury to her right foot when it was run over by a motor vehicle tire.  All radiographic exams including plain film X-rays and magnetic resonance imaging studies were normal.  She was treated with immobilization and by physical therapy, pain medicine (steroid injections and oral medications) without a resolution of her pain.  She was issued custom shoe inserts that produced fair pain relief and she was able to walk more comfortably.  She also had electromyography/nerve conduction studies of both legs that were normal.  The narrative summary prepared approximately 4 months prior to separation noted constant right foot pain primarily on the sole of her mid foot and heel area, sometimes on the top of the foot.  The pain was described as a constant, 5/10 dull achy pain at rest, that increased to 8/10 with exertion or standing greater than 10 minutes.  Examination of the right foot revealed tenderness of the plantar surface (sole) at the mid foot and heel.  She had a normal arch with no structural abnormalities and normal pulses, strength and reflexes.  Ankle range-of-motion (ROM) was plantar flexion 30 degrees (45 degrees normal) and dorsiflexion of 10 degrees (20 degrees normal).  

At the VA Compensation and Pension exam performed 7 months after separation, the CI reported continued right foot pain.  She reported the following functional impairments: She could not walk long distances.  On a good day she could walk up to a mile and on a bad day she was home bound.  Her pain was relieved by rest and by oral narcotic medications which allowed her to function.  The physical exam revealed a normal gait with moderate tenderness of the plantar surface right foot.  There was no weakness, swelling, atrophy or instability.  The ankle ROM was normal and the examiner specifically noted “Morton's Metatarsalgia is not present.”  Weight bearing and non-weight bearing plain film X-rays of the right foot were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied VASRD code 5279 (anterior Metatarsalgia [Morton’s disease]), and rated it 10%, the only rating level for that code.  The VA applied code 5284 (other foot injuries) and also rated it 10% consistent with “moderate.”  The Board noted that the CI’s condition was the result of an acute injury rather than Morton’s disease which is a neuroma located in the interspace between the metatarsal heads and is most commonly associated with overuse.  Board members agree that the CI’s impairment is best coded under 5284 (as applied by the VA) and is copied below for the reader’s convenience:

5284 Foot injuries, other:
Severe .................................................................. 30
Moderately severe ................................................ 20
Moderate .............................................................. 10
NOTE: With actual loss of use of the foot, rate 40 percent.

As rating under code 5284 requires assigning subjective levels of impairment, the Board uses the following criteria as a starting point for deliberations to provide consistency across all deliberations:

Moderately severe disability connotes significant joint muscle etc damage or deformity and pain with minimal use, imposing limitations on some critical tasks mobility and routine activities.
Moderate disability connotes significant or near constant pain with functional limitations on some occupational tasks and domestic chores; but little interference with routine activities, and no interference with essential activities of daily living.
Mild or Slight disability is a reasonable characterization for impairment or pain not resulting in at least moderate functional limitations as described above; generally interfering only with relatively strenuous or non-essential activities.
As all objective radiographic evidence was normal, the CI’s gait was normal, and she did experience some relief with shoe inserts, Board members agreed that her disability did not reach the moderately severe criteria as required for the next higher 20% rating.  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 right forefoot pain 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 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 right forefoot Injury 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 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150009535 (PD201401744)

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			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA