RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03252
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20040515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Engineer Equipment Mechanic, medically separated for “left foot,” with a disability rating of 10%.

CI CONTENTION:  “Please review all documents related to disability.”  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 - 20040311	VARD - 20041103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neuromas Left Foot	8724	10%	Left Foot Fractures, Residuals of Neuromas	5284	30%	20040811	
Intrinsic Strength Loss, Left Foot	Cat II					
		Scar, Left Fourth Toe	7801	0%	20040811	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Neuromas Left Foot.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a crush injury (dropped bowling ball onto distal/lateral left foot) in December 2002 (18 months prior to separation).  Radiologic (X-ray) studies showed comminuted (in pieces) fractures of the fourth and fifth toes with no other injury.  An associated laceration was sutured and there was no subsequent surgical intervention.  The CI was treated with progressive weight bearing and orthotics but continued to experience localized foot pain and numbness.  There was evidence in outpatient STR entries for decreased strength and limited range of motion (ROM) of the fourth and fifth toes, but none for limited ROM or strength at the ankle or hind foot.  After a program of progressive weight-bearing, there were no STR entries (which included multiple podiatry notes) documenting a gait disturbance, and bilateral ankle ROM was normal.  The diagnoses listed by podiatry included left foot neuromas (2) due to crush injury, metatarsalgia, and plantar fasciitis.  There was temporary relief with injections but no sustained improvement permitting unrestricted duty, and the CI was referred for an MEB which in turn forwarded “neuromas left foot” and “intrinsic muscle strength loss left foot” for PEB adjudication.  

The NARSUM examination on 20 January 2004 (3 months prior to separation), documented “continued left fourth and fifth toe painful numbness that was affecting him with prolonged standing, weight bearing and impact activities.”  The physical examination recorded localized edema and tenderness over the fourth and fifth metatarsals with decreased sensation (6/10 with monofilament testing) over the lateral toes and foot.  No evidence probative to gait or ROM was provided.  The NARSUM provider was the podiatrist who had followed the CI throughout later clinical course, and the NARSUM findings were well corroborated by STR entries over an extended period of time preceding separation.  

At the 11 August 2004 VA Compensation and Pension (C&P) examination, performed 3 months after separation, noted that the CI was working full-time at a job requiring standing and lifting all day, and the examiner noted that by “3-4 hours” he developed worsening pain which “reached 5-6/10 by the end of the day;” and, interfered with “any kind of foot maneuvers [requiring] coordination for the left foot.”  The physical examination recorded confusing gait descriptions from more than one examiner.  It was variously described as “abnormal gait walking down onto left leg with each set of steps,” “limped on left foot,” and “abnormal with walking down onto right leg which is shorter than the left leg.”  Paradoxically tandem gait was noted to be normal, and the consultant for an occupational/functional assessment documented that only toe walking was impaired.  The C&P examiner described a contracture of a small dorsal scar (8 X 2 millimeters over the fourth MTP joint) which held the fourth toe in “rigid, fixed flexion at 45 degrees,” tenderness of the lateral dorsum of the foot, sensory loss of the fourth and fifth toes and lateral sole, and impaired strength (flexion and extension) of all toes (most severe laterally).  Ankle ROM was plantar flexion to 45 degrees (normal), but dorsiflexion (normal 20) was confusingly recorded as “-13 degrees from -45 degrees” (incompatible with the recorded plantar flexion, and with all other evidence).  Overall functional impairment was opined to be “moderate” by the C&P examiner.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, under the nerve code 5724 (tibial nerve neuralgia) for “mild” impairment.  The PEB additionally adjudicated “intrinsic muscle strength loss left foot” as Category II (contributes to the unfitting condition but is not separately ratable).  Members agreed, the loss of strength appeared to be confined to the toes, that the Category II condition could not be separately coded and rated without violation of VASRD §4.14 (avoidance of pyramiding), and thus was appropriately subsumed in the rating for the unfitting condition.  Members agreed that rating under a nerve code was reasonable given the nature of the diagnosis; although, it was noted that anatomically the nerve impairment was better aligned with the superficial peroneal nerve (code 8722 for neuralgia), which confers 0% for “mild,” 10% for “moderate,” and 20% for “severe” impairment.  The VA rated the left foot condition 30%, under code 5284 (foot injuries, other) to which the rater attributed “severe” disability.

There was no ROM limitation or other ratable finding that would support a rating higher than 10% under any other applicable code available in VASRD §4.71a.  In that regard, the Board considered codes 5271 for ROM limitation of the ankle (20% for “severe”), 5277 for weak foot (10% maximum for bilateral), and 5279 for metatarsalgia (10% maximum).  Members agreed, the nerve anatomy as elaborated above, that no rating higher than 10% was justified by any nerve code under VASRD §4.124a.  Members considered a higher rating under 5284, however, that the functional impairment in evidence was better aligned with “moderate” (10%) disability (as opined by the VA examiner).  This was based on the occupational functioning reflected in the C&P examination, the overall objective functional evidence from both the Service and VA files, the rather localized functional impairment in evidence (mostly toes), and the fairly circumscribed trauma and clinical severity of the injury itself.  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:  In the matter of the neuromas left foot condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140630, w/attachments
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 8 Aug 16

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

					  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
					  (Manpower & Reserve Affairs)