RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX 	CASE: PD-2014-02199  
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE: 20020401  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Field Radio Operator) medically separated for right foot conditions.  The “tarsometatarsal fusion right foot secondary to arthritis” condition was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded two other conditions detailed in the chart below for PEB adjudication.  The Informal PEB adjudicated “tarsometatarsal fusion right foot secondary to arthritis” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting, Category II (contributing to the unfitting condition) and Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requested that the Board review all of his conditions.  The complete submission is at Exhibit A. 

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 20020213	VA* - ~13 Months  Pre-Separation 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Tarsometatarsal Fusion, Right Foot	5271	10%	No VA Placement, subsumed under Lisfranc's fracture	
Lisfranc’s Injury, Right Foot	Not Unfitting, Cat II	Lisfranc's Fracture, Right Foot with Pes Planus	5299-5284	20%	20010126	
Right Hand Carpometacarpal Arthrosis	Not Unfitting,  Cat III	Carpometacarpal Arthrosis, Post Fracture	5003-5223	10%		
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20020620 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

Tarsometatarsal Fusion Right Foot/Lisfranc’s Injury.  An operative note dated 25 October 1999 indicated the CI fell off the top of a bunk bed a week earlier and was unable to bear weight on his right foot.  Plain X-rays suggested a Lisfranc fracture dislocation (a midfoot injury), which was confirmed on a CT scan that showed a disruption of Lisfranc’s joint as well as a fracture of the fourth metatarsal bone (of the midfoot) and a fracture of the lateral distal calcaneus (heel bone) at the calcaneal cuboid joint.  Surgical repair consisted of an open reduction and internal fixation (ORIF) and percutaneous (through the skin) pinning.  Three weeks later the CI walked on his right foot and had exquisite pain, but there was no obvious acute fracture on X-rays and examination failed to reveal any breakthrough of tissue from the hardware.  Three months postoperatively, he was able to dorsiflex his right foot 10 degrees and plantar flex 25 degrees. Hardware, consisting of two screws, was removed in March 2000.  Eleven months postoperatively, the CI was still having extreme pain with activity in spite of being on limited duty (LIMDU).  He was unable to do toe raises.  X-rays demonstrated a retained cuboid pin and the joint spaces were well preserved.  In September 2000 a physical therapist observed the CI had an antalgic gait, minimal edema of the right foot, plantar flexion of 30 degrees and dorsiflexion of -2 degrees.  Right foot pain persisted in spite of medication including Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  X-rays revealed arthritic changes throughout the midfoot complex.  On 17 July 2001, the CI underwent a right Lisfranc fusion.  In September 2001, the CI was ambulating with crutches and a CAM walker, had right foot edema, plantar flexion of 50 degrees and -10 degrees of dorsiflexion.  By 30 January 2002, the CI’s walking improved with full weight bearing in the CAM walker, but he was unable to run and had continued pain with occasional waking at night.

The MEB narrative summary (NARSUM) dated 20 September 2001 noted the CI was still recovering from his right foot fusion, which was only 50% weight-bearing in a CAM walker.  Examination revealed two well healed incisions on his foot with mild swelling around his mid foot with erythema (redness) but without evidence of cellulitis.  He had pain to palpation along the mid food.  His ankle ROM was 25 degrees dorsiflexion and 35 degrees plantar flexion with   mid foot pain at the extreme of motion.  Additionally, he had limited flexion of all of his toes that caused dorsal pain.  Sensation was decreased to the first web space.  Alignment was good with a slightly valgus hind foot.

The non-medical assessment dated 17 October 2000 indicated the CI could not perform the duties of his military occupational specialty.  Specifically, he could not hike under any circumstances, lift equipment, stand for prolonged periods (including formations), fire his weapon, participate in field duty or complete physical fitness testing or training.  He was placed on limited duty on 27 June 2000 for 8 months with limitations of no running, marching, PFT, carrying or lifting over 20 pounds and no uneven ground or standing more than 30 minutes because of the foot injury.  The CI was reported to put forth a tremendous effort in all tasks assigned, but his efforts were countered by tremendous pain and resulted in increased trauma that produced negligible improvements in mobility.
  
The CI reported on a DD Form 2697 dated 20 June 2001 that he had more pain in his right foot than previously and that the right foot Lisfranc fracture limited his ability to work in his primary military specialty.  On DD Form 93 dated 17 September 2001, the CI reported the internal fixation of the right Lisfranc fracture and subsequent bone fusion.  The MEB physical examination dated 17 September 2001 was annotated “see physical dated 20 November 2001.” However, no document with that date was available for review, although a DD Form 88 dated 20 November 2000 was present, but did not address any findings related to the right foot.

At the VA Compensation and Pension (C&P) examination dated 26 January 2001, performed 13 months before separation, the CI reported he sustained a Lisfranc’s fracture of the right foot in October 1999.  In spite of surgeries, he continued to experience persistent pain in the right foot associated with stiffness, swelling, and instability on a constant basis.  Vioxx (a nonsteroidal anti-inflammatory drug) and Percocet improved his symptoms only temporarily.  He walked with an antalgic gait favoring the right and did not use an assistive aid.  Examination of the right foot revealed tenderness in the dorsum of the foot.  

In January 2003, 8 months post-separation, he had exacerbation of right foot pain with tenderness over the fifth metatarsal with no change in X-ray findings and was treated with Percocet.  In September 2003, 17 months post-separation, the CI noted continued pain and X-rays at a VAMC revealed fracture of at least one of the pins.  On 15 November 2003, 19 months post-separation, he underwent removal of hardware, bone grafting and a revision nonunion of the fourth and fifth tarsometatarsal (TMT) joints.     

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5271 for the Category I tarsometatarsal fusion secondary to arthritis condition.  The VA assigned a 20% rating using code 5299-5284 for status post Lisfranc’s fracture right foot with pes planus.  The Board sought a route to a higher rating and considered use of analogous code 5299-5283 (Tarsal, or metatarsal bone, malunion or nonunion) or analogous code 5299-5284 (Foot injuries) for the moderately severe condition with a rating of 20%, which required two surgical procedures prior to separation with continued pain and antalgic gait.  The Category II condition Lisfranc’s injury to the right foot contributed to Category I condition and is not separately unfitting or ratable.  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 tarsometatarsal fusion right foot/Lisfranc’s Injury condition.  

Contended PEB Condition-Right Hand Carpometacarpal Arthrosis. 

There was no evidence in the record relating to limited duty specifically for the right hand carpometacarpal arthrosis condition and a commanding officer’s note dated 17 October 2000 referred to the CI’s right hand and noted it was immobilized pending a corrective surgical procedure.  The STR indicated the CI sustained a fracture of the right hand on 12 July 1999 when he hit a locker while wrestling.  Notes dated 21 and 29 September 2000 indicated the CI had a boxer fracture a year earlier and complained of pain.  X-rays were consistent with a remote healed base of the fifth metacarpal fracture.  Clinically, carpometacarpal instability was suspected, although there was no obvious subluxation on dynamic fluoroscopy.  A volar splint was instituted in October 2000.  An X-ray series of the right hand dated 26 January 2001 was normal.  At the VA C&P examination dated 26 January 2001, the CI reported continued pain with weakness in his right hand associated with stiffness, swelling, inflammation, and instability on a constant basis.  The VA examiner indicated the fracture was of the fourth metacarpal and the CI was scheduled to undergo surgery with a bone graft.  Examination of the right hand revealed the hand strength was 4/5 secondary to pain; the left was normal.  There was evidence of tenderness in the fourth metacarpal with a mild bony prominence.  ROM measurements of the right ring finger and right wrist were normal and were not limited with repetitive motions.  Functional activity was intact, but the CI had mild difficulty buttoning and unbuttoning.  A note dated 11 June 2001 indicated surgery was requested for the hand.  The MEB NARSUM dated 20 September 2001 noted the CI had “right hand pain making it difficult to crutch ambulation,” while the MEB NARSUM dated 22 January 2002 indicated the CI had the diagnosis of right hand carpometacarpal arthrosis of the fourth and fifth joints and did not wish further treatment.  X-rays revealed a small dorsal piece of the fourth and fifth metacarpals that would not require surgical treatment. From a hand surgery standpoint, he had no limitations of his hand, although it was anticipated that the CI had a chance for future arthritis of the fourth and fifth metacarpals.  
The aforementioned details were reviewed and considered by the Board.   There was no performance based evidence from the record that the right hand carpometacarpal arthrosis condition significantly interfered with satisfactory duty performance.  However, the VA assigned a 10% rating using code 5223 (Two digits of one hand, favorable ankylosis), based on MEB complaints of pain in the lateral border of the right hand in the presence of normal ROMs of the ring finger and wrist that were not limited by repetition.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right hand carpometacarpal arthrosis condition and so no additional disability rating is recommended.

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 tarsometatarsal right foot/Lisfranc’s injury condition, the Board unanimously recommends a disability rating of 20% coded 5299-5284 IAW VASRD §4.71a.  In the matter of the contended right hand carpometacarpal arthrosis condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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:  

CONDITION	VASRD CODE	RATING	
Tarsometatarsal Fusion Right Foot/Lisfranc’s Injury	5299-5284	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 200140415, 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 16 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 16 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 11 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 30 Nov 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 30 Nov 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 01 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 04 Jan 16 ICO  XXXXXXXXXXXXXXXXXXXX

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

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

     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 60 percent (increased from 20 percent) disability rating.

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 50 percent (increased from 10 percent) disability rating.

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 40 percent (increased from 10 percent) disability rating. 

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

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

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

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 30 percent (increased from 10 percent) disability rating. 

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 50 percent (increased from 20 percent) disability rating. 

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 30 percent (increased from 20 percent) disability rating. 

     j. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 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.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)