RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03808
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20080730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a reserve E3, Rifleman, medically separated for “left foot Morton’s neuroma,” with a disability rating of 10%.

CI CONTENTION:  The CI requested consideration of all conditions. 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 - 20080603	VARD - 20100530	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Morton’s Neuroma	5279	10%	No VA Placement	
Bilateral Pes Planus	EPTS 	Mild Pes Planus and Plantar Fasciitis	5276	0%	20100225	
Mechanical Back Pain	Cat III	Thoracolumbar Strain with Subjective Complaints of Radicular Pain Associated with Bunion First Metatarsophalangeal, Status Post Removal of Morton’s’ Neuroma with Residual Tender Scar	5237	10%	20100320	
		Cervical Strain Associated with Bunion First Metatarsophalangeal, Status Post Removal of Morton’s Neuroma with Residual Tender Scar	5237	10%	20100320	
Early Bunion Left Foot	Cat III	Bunion First Metatarsophalangeal, Status Post Removal of Morton’s Neuroma with Residual Tender Scar	5280-7804	10%	20100225	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY: 

Left Foot.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot Morton’s neuroma condition began in boot camp with symptoms of pain, numbness, and tingling of the middle three toes.  Diagnoses included plantar fasciitis (PF), bilateral PP (flatfoot) and bunion left foot.  Serial examinations in the STR noted normal lower extremity (LE) strength, sensation, and reflexes.  The CI was separated from active duty in April 2007.  Magnetic resonance imaging in May 2007, did not identify any abnormality of the foot.  The CI was diagnosed with “metatarsalgia, probably Morton” neuroma” by an orthopedic surgeon who referred him to an orthopedic foot specialist.  A visit with the orthopedic surgeon on 4 March 2008 noted that the CI was seen by a military doctor and he was “essentially requesting to be removed from the military.”  A military primary care noted dated 20 March 2008 indicated that the CI was referred for a PEB for the left foot neuroma because “he is a reservist unable to drill and LimDu not an option.”  Left foot X-rays on 13 May 2008 showed mild hallux valgus, some loss of the arch of the foot and no arthritis.  At a primary care visit on 20 March 2008, the CI reported continued left foot symptoms and he was referred for an MEB.  The MEB forwarded “lesion of plantar nerve,” “flat foot,” and “bunion” for PEB adjudication.  At the MEB NARSUM examination on 8 April 2008, 2 months prior to separation, the CI reported severe left foot pain and was ambulating on crutches.  Physical examination showed tenderness to palpation (TTP) between the third and fourth toes, with radiating pain down the toes and TTP of the great toe.  Strength and sensation were normal to examination.  “Mild” pes planus was noted “only when weight bearing.”  The MEB examiner indicated that the CI may benefit from surgery for the neuroma, but could not guarantee that it would render the CI fit for duty.  

The CI was seen by the orthopedic foot specialist after the MEB NARSUM examination, and he thought that the CI had a Morton’s neuroma, but indicated it was unclear if surgical removal would give him “significant relief.”  Surgery was eventually performed on 9 January 2009 by the initial orthopedic surgeon, approximately 7 months after separation.  At surgery, a “very large neuroma, with a small cystic neuroma” was removed from between the third and fourth toes.  

At an initial pain management evaluation on 4 February 2009, 8 months after separation, the CI reported sharp shooting left foot pain, with pain of the bottom of the foot and heel causing difficulty weight bearing.  The physical examination noted a stable gait, but difficulty with heel and toe walking due to pain.  There was moderate tenderness with squeezing the left foot (metatarsalgia).  There was limited foot dorsiflexion.  The examiner stated that “most of the weakness and restriction was due to pain noted by me.”  There was normal strength and reflexes of the left lower extremity.  Sensation was decreased along the third metatarsal, and along the bottom of the left foot and toes.  

At a physical therapy evaluation on 16 March 2009, 9 months after separation, the CI reported constant left foot pain on the bottom of his foot.  Lumbar MRI in February 2009 was noted to be negative.  The examination noted pain to palpation along the surgical incision, but noted that during ROM testing there was no guarding or complaint of pain, even of the toes.  

The initial VA Compensation and Pension examination for the feet was performed on 25 February 2010, approximately 20 months after separation.  At the C&P examination, the CI reported constant left foot pain, aggravated by weight bearing and denied flare-ups.  He reported wearing orthotics with wide shoes and sometimes, but rarely, used a cane.  The physical examination noted the CI was ambulating without assistance.  He had an antalgic gait with mild pes planus, sensation was decreased in the third and fourth toes in the area of the surgical scar.  No callosities were noted.  Toes had normal ROM and position.  A mild deviation of the first MTP joint was noted (hallux valgus or bunion) and there was TTP of all MT heads.  There was no heel tenderness, the AT was not tender and was normal in alignment.  There was point tenderness of the PF.  The examiner stated “joint motion is not painful on motion and the range of motion or joint function is not additionally limited by pain, fatigue, incoordination, or lack of endurance following repetitive use x 3”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, coded 5279 (metatarsalgia or Morton’s disease).  The VA assigned a 10% rating using a combined code of 5280-7804 (hallux valgus-scars, unstable or painful) and a 0% rating using the 5276 code (acquired flatfoot) based on the VA C&P examination 20 months after separation.  At the time of the MEB NARSUM examination 2 months before separation, the CI was using crutches due to difficulty bearing weight on the left foot.  The CI underwent surgery 7 months after separation with removal of the neuroma.  At a PT evaluation 9 months after separation, there was evidence of TTP of the surgical scar, with no painful motion of the foot or toes noted during ROM testing.  There was support for rating the left foot 10% for the neuroma coded 5279 as adjudicated by the PEB, which is the sole rating available under this code.  The VA later chose to rate the foot according to 7804 scar code criteria for the tenderness between the third and fourth toes, which also supports a 10% rating and no higher and therefore provides no ratings benefit.  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 left foot neuroma condition.

Bilateral Pes Planus.  The PEB determined the bilateral pes planus condition existed prior to service.  However, on the military enlistment physical dated 25 August 2006 it was noted that the CI had normal foot arches and the feet were asymptomatic and the MEB DD Form 2808 examination dated April 2008 noted mild symptomatic pes planus.  A presumption of service aggravation (SA) may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  In this case the CI reported that foot pain began in basic training due to his military footwear and he was treated for foot pain with diagnoses including left PF and bilateral pes planus as elaborated earlier under the left foot condition.  The Board concluded that the PEB had not met the threshold to overcome the presumption of service aggravation and the bilateral pes planus was therefore eligible for ratings consideration.  The Board first considered if the left and right pes planus conditions each remained unfitting when separated from the combined adjudication.  The commander’s statement noted only foot pain.  Only the left foot had been diagnosed and treated for PF (often a consequence of pes planus) in Service.  Members agreed, therefore, that the left foot pes planus pes planus condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating.  Accordingly, it should be afforded separate disability rating.  However, there was no performance based evidence in record that the right foot significantly interfered with satisfactory duty performance.  Board members concluded that the preponderance of evidence showed the right foot condition would not reasonably have caused the CI to be referred into the DES, nor would the CI have been found unfit due to the right foot condition and separate disability rating is not recommended.  Therefore, the Board considered a rating for the bilateral pes planus condition

The Board directed attention to its rating recommendation for the bilateral PP based on the above evidence.  At the MEB NARSUM flexible pes planus was noted only on weight bearing and at the C&P examination the CI noted that wide shoes and orthotics were helpful.  On examination there was TTP of the plantar fascia with no other criteria supporting a higher than 10% rating for “moderate” PP, coded 5279.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded the left pes planus condition was permanently aggravated by service and recommends a 10% rating, coded 5276 IAW VASRD §4.71a, for “moderate” PP, “whether unilateral or bilateral.”

Contended PEB Conditions: Early Bunion Left Foot; Mechanical Back Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the “left foot Morton’s neuroma” condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the “bilateral pes planus” condition, the Board unanimously concluded there was permanent service aggravation and recommends a 10% rating, coded 5276.  In the matter of the contended “early bunion left foot” and “mechanical back pain” conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Foot Morton’s Neuroma 	5279	10%	
Bilateral Pes Planus	5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140818, 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 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 27 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

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

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

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
     d. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.
     
     d. XXXXXXXXXXXXXXXXXXXX, 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.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)