RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00598
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20030221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aviation and Electronic Specialist, medically separated for “submetatarsal 1 metatarsalgia, secondary to hallux limitus and degenerative joint disease, secondary to trauma” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel 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, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20021115	VARD - 20030514	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Submetatarsal 1 Metatarsalgia…	5299-5281	10%	Metatarsalgia, Secondary to Hallux Limitus and Degenerative Joint Disease, Secondary  to Trauma, Right	5299-5281	10%	20030121	
Sesamoid Complex Pain, sub-metatarsal 1 First Metaphalangeal Joint, Right Foot	Cat II	Sesamoid Complex Pain, Submetatarsal of First Meta-phalangeal Joint, of Right Foot	5299-5281	NSC	20030121	
Chronic Right Shoulder Pain Status Post (S/P) Weaver-Dunn Procedure for Type 2 Distal Clavicle Fracture in 1992	Cat III	S/P Right Clavicular Fracture, Postoperative Weaver-Dunn Procedure	5203	10%	20030121	
S/P Right Clavicular Scapular Fracture, Anterior Shoulder Dislocation in 1992	Cat III					
Chronic Trigger Points about the Infraspinatus Musculature of the Right Shoulder	Cat III	Chronic Trigger Points about the Infraspinatus Musculature of the Right Shoulder	5299-5203	NSC	20030121	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:  

Submetatarsal 1 Metatarsalgia.  According to the service treatment record (STR), the CI’s right big toe condition began in March 2001 when she tripped over a grocery bag.  She underwent an operation to remove bone spurs and improve range of motion (ROM) in October 2001, with very little effect, and continued to have pain with no additional surgery indicated.  

During the 22 August 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported arthritis of the right big toe and that she was undergoing physical therapy (PT).  The physical examination did not address the toe pain.  

At the 24 September 2002 PT examination, 5 months prior to separation, the CI reported constant foot pain that increased with prolonged walking or standing and decreased with rest.  She also stated that she had been walking on the outside of her foot since the original injury.  Physical examination revealed tenderness of the ball of the foot, no active plantar flexion and 25 degrees of dorsiflexion.  Painful motion was not addressed.  

The 30 September 2002 podiatry evaluation for the MEB addendum, 5 months prior to separation, noted CI complaints of “chronic sesamoid [small bone within a tendon in the foot] pain with ambulation.”  The podiatrist noted she had the surgery due to a hyperflexion injury in March 2001 that resulted in hallux limitus (progressive arthritis of the big toe). 

At the 21 January 2003 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported continued right big toe pain after trauma.  Physical examination demonstrated abnormal weight bearing in the right foot with callus formation over the lateral side of the foot and a scar on the dorsal aspect of the foot over the medial side.  The examiner noted decreased ROM (no measurements) with an inability to flex the metatarsal joint (presumably of the great toe).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the metatarsalgia condition 10%, coded 5299-5281 (analogous to hallux rigidus, unilateral, severe).  The Category II diagnosis of “sesamoid complex pain, submetatarsal first metatarsophalangeal joint, right foot” is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed under the same rating.  The VA also rated the metatarsalgia condition 10%, analogously coded 5299-5281, based on the C&P examination, citing severe hallux rigidus if equivalent to amputation of the great toe.  Members noted the highest rating for metatarsalgia, unilateral or bilateral, is 10% and does not provide a rating advantage to the CI.  Additionally, the only rating available for hallux rigidus is 10% as adjudicated by the PEB.  There was no evidence of malunion or nonunion of the tarsal or metatarsal to support a rating under code 5283, and members agreed there was no evidence of a moderately severe or severe foot injury to support a rating higher than adjudicated by the PEB using code 5284.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right foot condition.  

Contended PEB Conditions:  Right Shoulder Pain; Right Clavicular Scapular Fracture; and Chronic Trigger Points Right Shoulder.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The panel noted the CI was on an 8-month limited duty period for the combined shoulder condition at the time the MEB was submitted, the combined shoulder condition was the reason the MEB was submitted, and the shoulder condition placed limits on the CI’s ability to perform a physical fitness test and some occupational duties.  Members concluded there was sufficient cause to recommend a change in the PEB fitness determination for the Category III contended conditions and recommends an additional disability.  However, the panel found the diagnoses of right clavicular scapular fracture and chronic trigger points right shoulder to bee intrinsic to the shoulder pain condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, they are appropriately subsumed under the same rating.  

According to the STR, the CI’s right shoulder condition began in 1992 after a fall causing a clavicle fracture and shoulder separation.  A procedure to reduce the shoulder separation was initially successful, but the pain returned and no additional surgery was indicated.  At the 19 June 2001 primary care clinic evaluation, 19 months prior to separation, the CI complained of 3 years of right shoulder pain with recurrent muscle spasms.  She had no significant decrease in ROM, but could not do push-ups or lift heavy objects due to pain.  Physical examination found “elevation” (flexion or abduction) to 160 degrees (normal 180) and shortening of the clavicle.  Pain was noted with external rotation against resistance.  

During the 21 August 2002 primary care clinic evaluation, 6 months before separation, the CI reported chronic right shoulder pain worsened by lifting and overhead activities.  Physical examination demonstrated full, active right shoulder ROM with mild supraspinatus muscle (one of the rotator cuff muscles) atrophy and tender points in the shoulder muscles.  

At the 24 September 2002 PT examination, 5 months prior to separation, the CI complained of spasms around the right shoulder blade that began in approximately 1998, and worsening right shoulder pain that increased with overhead activities or when maintaining positions for prolonged periods.  She reported a medical board was pending for her right shoulder.  Physical examination revealed ROM was “within functional limits” with increased pain on abduction and internal rotation.  

At the 21 January 2003 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported pain with right shoulder ROM and decreased upper arm strength. Physical examination demonstrated flexion to 130 degrees and abduction to 90 degrees, with pain in both planes.  External and internal rotation were reported as 60 and 90 degrees, respectively, with pain.  The examiner also noted “shortening of the lateral length of the right shoulder,” with “absence of the acromioclavicular region.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the right shoulder condition.  The VA rated the “s/p right clavicular fracture, postoperative Weaver-Dunn procedure” 10%, coded 5203 (clavicle or scapula, impairment of), based on the C&P examination, citing malunion of the clavicle or scapula.  Members noted great disparity between examinations proximate to separation.  After deliberating the probative value of these conflicting evaluations and carefully reviewing the entire file for corroborating evidence from the period near separation, the panel noted the C&P was the only evaluation with ratable restriction in ROM; all other examinations showed full or nearly full ROM.  The VASRD §4.71a threshold for rating ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the preponderance of examinations proximate to separation did not demonstrated motion limited to this level.  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher ratings available under the 5203 code. After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of right shoulder condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5201 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the metatarsalgia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended right shoulder pain condition, the panel majority agrees it was unfitting and recommends a disability rating of 10%, coded 5201 IAW VASRD §4.71a.  The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Submetatarsal 1 Metatarsalgia	5299-5281	10%	
Right Shoulder Pain	5201	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 May 18 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 07 Jun 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 05 Jun 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 13 May 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 May 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

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

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.  

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

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

     e. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.  
 
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Assistant General Counsel
                                  (Manpower and Reserve Affairs)