RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX			CASE: PD-2014-02678
BRANCH OF SERVICE:  MARINE CORPS		SEPARATIONDATE:  20011027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Food Service Specialist, medically separated for “pes planus bilateral, symptomatic” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  His 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 based upon a 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 - 20010815	VARD - 20020327	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Pes Planus, Symptomatic	5276	10%	Right Metatarsophalangeal Degenerative Arthritis; status post Right Bunionectomy with Residuals; Pes Planus and Calluses	5003-5284	10%	20010905	
			Left Metatarsophalangeal Degenerative Arthritis; status post Right Bunionectomy with Residuals; Pes Planus and Calluses	5003-5284	10%	20010905	
Sinus Tarsi	Category II	No VA Placement	
Anterior/Posterior Tibialis Tendonitis	Category II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Bilateral Pes Planus.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral feet pain began in August 1999 when he was working as a cook.  He underwent a left bunionectomy in April 1999 and had less pain postoperatively.  He received a right bunionectomy in June 2000.  In March 2001 he noted right foot great toe and first two phalanges’ numbness as a result of standing constantly for 12 hour shifts, 12 days on and 2 days off.  A right foot over-use syndrome with cutaneous nerve paresthesia diagnosis was made and he was advised to take periodic breaks.  A podiatry evaluation in March 2001 diagnosed the condition as moderate pes planus, Joplin’s neuritis (inflammation of the cutaneous nerve to the toe), and hallux rigidus based on the CI’s inability to dorsiflex the first toe.  In May 2001, treatment consisted of inserts which the CI reported did not alleviate his pain.  Examination revealed edema at the right metatarsophalangeal (MTP) joint and the first metatarsals bilaterally were elevated compared to the other metatarsals; the first range of motion (ROM) on record was severely limited.  Revision surgery risks and benefits were discussed.  Despite treatment, the bilateral pes planus condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “pes planus bilateral symptomatic to military” for PEB adjudication.

The MEB NARSUM examination dated 23 May 2001, 5 months prior to separation, noted pain in both feet, status post bilateral bunionectomies with hardware removal on the right, with standing, walking, running, marching, or field activities.  Various arch supports, pads, rest, light duty and non-steroidal anti-inflammatory drugs had been used without relief of symptoms.  Physical examination revealed a loss of the normal longitudinal arch and there was excessive heel valgus.  The forefoot was pronated.  The midtarsal and hindfoot joints were painful and supple.  There was excessive plantar callous formation.  Hammer toes of the second to fifth digits were present.  The CI had a pronated gait with many toe signs.  There were associated foot or ankle deformities.  There was pain on palpation of the sinus tarsi (where ligaments, blood vessels, and nerves pass on through on the lateral foot) and there was posterior tendinitis at the insertion into the navicular bone.  The CI had a maximally pronated foot when weight bearing.  Orthotics helped to decrease some of the pain, but did not resolve the deformity.  X-rays demonstrated normal findings of a flat foot with a decreased calcaneal inclination angle and anterior break in the cyma line (the S-shaped line on X-rays at the articulation of the talonavicular and calcaneocuboid bones of the foot), and with a metatarsus primus elevatus (elevation of the first metatarsal), status post crescentic bunionectomy.

At the MEB examination (recorded on Standard Forms 93 and 88) dated 8 June 2001, 4 months prior to separation, the CI reported foot surgery and bilateral “foot problems.”  The examiner annotated that the CI had a right hallux rigidus, right metatarsalgia, right metatarsus primus elevatus, pes planus, Joslin’s neuritis, persistent use of orthotics, and bilateral bunionectomies.  Physical examination showed bilateral pes planus.

In August 2001 the CI reported increased pain in the right foot after running about two miles a few days earlier.  On examination there was a positive Tinel’s test (to determine nerve irritation) of the right tibial nerve with numbness of the hallux (great toe) and the medial aspect of the second toe with tenderness to palpation of the medial aspect of the hallux and the contiguous metatarsals as well as the sesamoids of the right plantar aspect.  There was no dorsiflexion of the right first MTP joint and approximately 5 degrees of the left first MTP joint.

At the VA Compensation and Pension (C&P) general examination on 5 September 2001, less than 2 months before separation, the CI reported that for many years he felt as if he had been stepping on fluid within his foot when walking on the metatarsal heads, which was greater on the right than the left.  He noted numbness of the left and right first toes and that he had a history of intermittent gout attacks.  On examination his posture was normal with mild genu varus of the bilateral lower extremities.  His gait and stance were within normal limits.  Examination of the feet did not reveal signs of abnormal weight bearing.  There was callus formation in the bilateral heels and in the lateral aspect of the first toe.  There was no breakdown or unusual shoe wear pattern.  No assistive devices were used for ambulation.  According to the examiner the CI did not have flat feet; weight bearing alignment of the Achilles tendon was normal; there was no hallux valgus; and there were no skin or vascular changes.

During the VA C&P bilateral feet examination on 26 October 2002, performed 1 day before separation, the CI reported a history of bilateral pes planus and symptomatic bunions that were operated on.  He was unable to walk long distances secondary to pain in both feet.  Physical examination showed ankle dorsiflexion of 15 degrees bilaterally with pain limitation and plantar flexion of 35 degrees bilaterally without pain limitation. He had minimal flexion to 20 degrees at the first MTP joint of the left and right foot, which was painful with motion at 20 degrees and had well-healed scars over the anterior aspects of both the MTP joints.  He was able to walk on his heels and toes, had a normal gait, and was able to recreate his arch with toe walk and heel varus with toe walk.  There was no weakness with heel raise or toe raise.  X-rays of both feet demonstrated significant metatarsophalangeal (MTP) arthrosis bilaterally and pes planus bilaterally, but there was no evidence of navicular or tarsal coalition.

The PEB combined the bilateral pes planus conditions as a single unfitting condition.  This approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was directed at determining if a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board must consider if each bundled condition is reasonably justified as separately unfitting.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral pes planus conditions was presented together above.  In this case, a bilateral condition was implicated by the NARSUM, but not mentioned in the commander’s non-medical assessment.  Members agreed that each foot condition is separately unfitting and that identical coding and ratings are applicable.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral pes planus condition 10%, coded 5276 (flatfoot acquired).  The VA rated each foot 10%, analogously coded 5003-5284 (degenerative arthritis-foot injuries (moderate)) based on the VA C&P examination 5 months before separation, citing right and left first metatarsophalangeal degenerative arthritis; status post right bunionectomy with residuals; pes planus and calluses.  The VA also rated each foot 10%, coded 7804 (scar, painful).

Board members discussed the 5276 code and noted the CI’s condition more appropriately was moderate for each foot, although the right was somewhat more involved than the left, but both feet had pes planus and underwent a bunionectomy and both required orthotics that were not effective in resolving symptoms.  Therefore, a 10% rating for each foot is not unreasonable; however, the VASRD code 5276 only provides a 10% rating whether the condition is unilateral or bilateral.  Therefore, members discussed the use of an analogous code 5299-5284 at 10% for each foot, although the right foot condition exceeded the severity of that of the left foot, but not enough to warrant a higher rating of 20% for the right foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right foot pes planus and a rating of 10% for the left foot pes planus conditions.

Contended Conditions:  Sinus Tarsi and Anterior/Posterior Tibialis Tendonitis.  The PEB listed the sinus tarsi and anterior/posterior tibialis tendonitis conditions as category II conditions (conditions that are related to the primary unfitting conditions and contribute to the primary unfitting conditions).  The Board’s first charge for these Navy PEB category II conditions is to assess whether either of them can be reasonably justified as separately unfitting for rating consideration.  The Board concluded that the sinus tarsi condition alone was not unfitting nor was the anterior/posterior tibialis tendonitis condition.  Neither condition was implicated in the commander’s non-medical assessment; each was only mentioned in passing in the MEB NARSUM as pain on palpation of the sinus tarsi and posterior tibial tendinitis at the insertion into the navicular bone.  No other entries were found in the submitted STRs or VA records.  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 sinus tarsi and anterior/posterior tibialis tendonitis conditions as category II conditions; therefore, no additional ratings are recommended nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).

BOARD FINDINGS:  In the matter of the bilateral pes planus condition the Board unanimously recommends separate ratings for the right and left pes planus conditions, with disability ratings of 10% for each foot, coded 5299-5284 IAW VASRD §4.71a, for a combined disability rating of 20%.  In the matter of the sinus tarsi and anterior/posterior tibialis tendonitis conditions and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication of category II.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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	
Right Pes Planus	5299-5284	10%	
Left Pes Planus	5299-5284	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, 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 24 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX    
       (c) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
       (d) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
       (e) PDBR ltr dtd 27 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
       (f) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
       (g) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

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

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

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

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

     e.  former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     f.  former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 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.