RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03879
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Information Systems Technician, medically separated for “right hallux rigidus,” with a disability rating of 10%.  

CI CONTENTION:  “Please consider 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 based on 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 - 20061130	VARD - 20080117	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hallux Rigidus	5280	10%	Right Hallux Rigidus	5281	Not Service Connected (NSC)	20071105	
Right Hallux Valgus Status Post Hallux Valgus Corrective Surgery	Category II	Residuals of Right Hallux Valgus Surgery	7804	10%	20071105	
Bilateral Flexible Pes Planus with Hypermobile First Ray	Category II	Residuals of Bilateral Pes Planus	5276	10%	20071105	
Chronic Right Foot Pain	Category II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Hallux Rigidus.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hallux rigidus (HR) condition (painful limited motion of the first metatarsophalangeal (MTP) joint) began in 2002.  The CI was treated for a left tibial stress fracture in boot camp and while on limited duty (LIMDU) reported bilateral foot pain, worse on the right.  Serial podiatry evaluations noted congenital pes planus, “mild” bunion deformity, Morton’s neuroma, sesamoiditis (inflammation of small bones that develop in tendons over joints), metatarsalgia, and hallux valgus (HV).  Despite treatment including custom orthotics, the CI underwent surgery in September 2003 for bunionectomy and debridement of degenerative changes (cheilectomy) and removal of a sesamoid bone.  Following surgery, the CI continued to have right foot pain with HR and underwent a second surgical procedure 28 July 2004 with soft tissue release of the first MTP joint.  Following this surgery, the CI reported she returned to her baseline level of pain before either surgery, had some improvement in to range of motion (ROM), and was able to run slowly on a treadmill.  She was returned to full duty, but her symptoms recurred and progressed to include pain of the bottom of her foot and in the joints.  Despite treatment, the right foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for a MEB.  The MEB forwarded “chronic right foot pain,” “right hallux valgus,” “right hallux rigidus,” “right foot Morton’s neuroma” and “bilateral flexible pes planus” for PEB adjudication.  

At the MEB NARSUM examination on 22 July 2006, 12 months prior to separation, the CI reported chronic right foot pain, aggravated by running, climbing ladders, and some types of foot wear.  The pain was not relieved by orthotics.  On physical examination there was tenderness to palpation (TTP) of the first MTP joint and TTP over the third intertarsal webspace and over the tarsometatarsal joints (metatarsalgia).  There was no TTP of the heel or ankle.  There was a well-healed scar over the right first MTP joint with a positive Tinel’s sign, which reproduced electrical pain to the toe (nerve related pain) and diminished sensation of the top of the toe.  Sensation was otherwise normal and there were normal reflexes of the right lower extremity.  Pes planus (flatfoot) was noted while standing, which reduced with heel rise, and the first ray of both feet was hypermobile.  Right foot X-rays (weight bearing) showed a mild hallux valgus and post-surgical and degenerative changes of the first MTPJ.  

At the VA Compensation and Pension (C&P) examination on 5 November 2007, 4 months after separation, the CI reported foot pain (graded 10/10) and stiffness, but that at the time of pain, she could function without medication.  She reported foot pain was aggravated by prolonged walking or standing.  She denied weakness or swelling.  She was not being treated for the conditions.  Physical examination showed a normal gait.  There was TTP of the right foot and painful motion and no circulation problem, muscle atrophy or weakness of the foot.  The examiner noted “there is active motion” in the right MTP joint.  Pes planus was noted, with a moderate degree of valgus and slight TTP of the bottom of the foot.  There was no metatarsalgia, pes cavus, HV, or HR present, or other deformity or malalignment of the foot noted.  The CI required arch supports and shoe inserts.  Examination of the right ankle was normal with full ROM.  Right foot X-rays (weight bearing and non-weight bearing) noted only pes planus without other abnormalities.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the hallux rigidus condition 10%, coded 5280 (hallux valgus) and adjudicated right hallux valgus, bilateral pes planus, and chronic right foot pain as related Category II conditions.  The VA did not service connect the hallux rigidus condition  The VA did rate residuals of right hallux valgus 10%, coded 5280; residuals of bilateral pes planus 10%, coded 5276 (acquired flatfoot); and, residuals of right hallux valgus surgery scar 10%, coded 7804 (scars, unstable or painful).  All VA ratings were based on the C&P examination 4 months after separation.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right hallux valgus status post hallux valgus corrective surgery, bilateral flexible pes planus with hypermobile first ray, and chronic right foot pain were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  These three conditions adjudicated by the PEB as Category II were all conditions related to the CI’s right foot pain and the disability due to right foot pain can only be provided a single rating IAW VASRD §4.14 (avoidance of pyramiding).  Therefore, the Board considered a single rating for the right foot conditions.  The CI continued to have right foot pain after the second surgery.  There is support for a 10% rating for hallux rigidus (5281), which is rated as hallux valgus (5280), or for pes planus (5276).  The Board reviewed to see if a higher rating was warranted with any applicable VASRD §4.71a code.  However, 10% is the highest rating available under 5280 and 5281 and there was no evidence of “severe” pes planus with objective evidence of marked deformity, pain on use or manipulation, with swelling or characteristic callosities for a 20% rating under 5276.  The Board also considered alternatively rating the foot pain IAW VASRD §4.124a for the residual nerve related toe pain coding analogous to tarsal tunnel as 8799-8725 (posterior tibial nerve), but members agreed the decreased sensation and radiating pain of the right great toe, could be rated 10% and no higher for “mild incomplete paralysis of the posterior tibial nerve.”  The Board does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  Any contribution from the scar on pain or limitation of ROM was addressed above under the §4.71a rating and the Board concluded that the scar condition could not be recommended for additional disability rating.  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.

BOARD FINDINGS:  In the matter of the right hallux rigidus condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended Category II conditions, the Board unanimously recommends no change from the PEB determinations as contributing to the unfitting condition.  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 20140605, with 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 21 Jun 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 USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						(Manpower & Reserve Affairs)