RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02104
BRANCH OF SERVICE:  mARINE CORPS	BOARD DATE:  20150212
SEPARATION DATE:  20071031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, (Packing Specialist) medically separated for a left foot condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “enthesopathy [disorder of bone attachments] of the ankle and tarsus, unspecified,” was forwarded as the sole condition to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated “unilateral metatarsalgia plantar, left foot” as unfitting, rated 10%, under criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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 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 20070910	VA (~1 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Unilateral Metatarsalgia Plantar, Left Foot	5279	10%	Residuals of Bilateral Stress Fracture of the Toes	5299-5279	10%	20071119 	
Other x 0 (Not In Scope)	Other x 2(Not In Scope)	
RATING:  10%	RATING:  20%	
Derived from VA Rating Decision (VARD) dated 20071210 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Foot.  The service treatment record (STR) documents an onset of bilateral foot pain in 2003 (boot camp).  Initial X-rays were normal, and the CI was managed conservatively.  The pain worsened and there are multiple STR entries over the course of service for the evaluation and treatment of the condition.  Imaging (X-rays and bone scans) demonstrated slowly healing metatarsal stress fractures of both feet.  Surgery was initially planned for the left foot, but was deferred after symptoms improved (with orthotics, physical therapy, and activity restrictions) and imaging confirmed healing of the fractures.  Most STR entries document bilateral symptoms, although some indicate that the left foot was the most problematic.  The pain worsened during a 2006 deployment, improved on re-deployment, but worsened again after resumption of more aggressive physical training.  It did not respond adequately to trials of LIMDU and a MEB was initiated by podiatry.  Final X-rays from July 2007 demonstrated healed metatarsal stress fractures (left 2nd and 3rd and right 3rd).

The narrative summary conducted on 27 July 2007 (3 months prior to separation), and notes 7/10 pain with running or standing longer than one hour.  The physical exam recorded a normal gait, with “slight” tenderness of the right foot (3rd metatarsal head) and more pronounced tenderness on the left (plantar, 2nd and 3rd metatarsal heads).  The examiner provided the left unilateral diagnosis quoted by the PEB without a directed rationale for excluding the right foot.

A VA Compensation and Pension (C&P) foot examination was conducted on 20 November 2007 (a month after separation) and addressed bilateral symptoms without differentiating left from right.  The VA podiatrist recorded flares of pain “weekly or more often ... duration 1 to 2 days” precipitated by standing “for 15-30 minutes” and walking “more than 1/4 but < 1 mile.”  The VA podiatry exam recorded a “slight limp,” although the general C&P exam a day earlier recorded a normal gait.  The foot exam noted bilateral metatarsal tenderness with no swelling, and weakness (“flail ... flaccid”) of the left third toe.  The VA podiatrist specifically excluded various diagnoses subject to separate VASRD rating: hammertoe, hallux valgus or rigidus, pes cavus (claw foot), “malunion or nonunion of the tarsal or metatarsal bones”, and flat foot.

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated under code 5279 (metatarsalgia) which confers 10% (sole option) for either unilateral or bilateral involvement.  The Board considered whether, IAW VASRD §4.7 (higher of two evaluations), a higher rating could be recommended under an alternate code.  As explicitly elaborated by the VA podiatrist, there are no other clinically specific codes under VASRD §4.71a except 5279; but, analogous coding to 5283 (tarsal and metatarsal bones, malunion of, or nonunion of) or 5284 (foot injuries, other) is arguably applicable.  Both of these codes offer the same rating spectrum: “moderate” 10%, “moderately severe” 20%, and “severe” 30%.  Members agreed, however, that neither of these alternatives was as clinically specific to the condition in this case as code 5279 (endorsed by both the PEB and VA); and, furthermore, that “moderate” is a fair characterization of the disability in evidence, thus eliminating any advantage to alternate coding.  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 of the left 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 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 left 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 20140505, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 30 Nov 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC

						  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)