RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00908
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Radiographic (X-ray) Specialist, medically separated for “chronic bilateral plantar foot pain,” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 PEB, but determined 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.  Furthermore, the Panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Panel’s assessment of the PEB rating determination 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 conditions 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, operating 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 the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20011217	VARD - 20020212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Plantar Foot Pain	5099-5003	0%	Chronic Bilateral Foot Pain Status Post Morton’s Neuroma and Stump Neuroma	5279	10%	20010910	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right foot condition began approximately 8 years prior to referral for MEB.  The CI complained of progressive burning pain on the bottom of his right foot and was diagnosed with a Morton’s neuroma (foot interdigital reactive tumor of disorganized nerve axons) between the 3rd and 4th digits.  He failed conservative management which included activity modification, arch supports, NSAIDs, and 2 corticosteroid injections.  On 12 November 1998 the CI underwent a right foot 3rd interspace Morton’s neuroma excision.  Postoperatively, he developed a stump neuroma (reactive tumor of disorganized nerve axons at proximal end of severed nerve) which was subsequently resected on 15 June 1999.  
The 10 September 2001 VA Compensation and Pension (C&P) examination, 5 months before separation, recounted the history and interventions.  The CI reported incomplete relief of his right foot pain with multiple surgeries.  He complained of daily 4/10 sharp burning pain which lasted for minutes to hours.  Symptoms were exacerbated by activity and standing or walking for a few hours.  The physical examination recorded the CI used arch supports and documented a normal gait, no assistive devices, and no unusual shoe wear pattern.  The right foot examination revealed a tingling, burning tenderness with deep palpation between the 3rd and 4th metatarsal heads.  There was a plantar (7 cm) and dorsal (4 cm) scar which were soft, flat, non-adherent, non-tender, and without underlying tissue loss, disfigurement, keloid formation, or limitation of function.  The feet showed no signs of abnormal weight bearing, callosities, or skin breakdown.  There was no pes planus, high arch, hallux valgus, hammer toe, or claw foot deformity.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The diagnosis listed chronic right foot discomfort status post excision of neuroma.  

The 9 November 2001 NARSUM, 3 months before separation, recounted the history and interventions.  The CI complained of near daily sharp burning right foot pain between the proximal 2nd and 3rd metatarsals with associated toe tingling.  Symptoms were exacerbated by activity, walking barefoot, running, jumping, marching, pushups, and military footgear.  The right foot examination revealed tenderness between the proximal 3rd and 4th metatarsals.  There were well healed surgical incisions over the dorsal and plantar aspects of the 3rd interspace.  There was no edema (excess tissue fluid swelling), discoloration, or warmth.  There was no pain on range of motion (ROM) of the toes, foot or ankle.  Strength and sensation were normal except for decreased sensation of the plantar aspect of the 3rd web space.  The 8 November 2001 radiographic (X-rays) studies appeared normal.  The assessment listed chronic right foot plantar aspect pain secondary to stump neuroma formation after previous removal of Morton's neuroma.  

The panel directed attention to its rating recommendation based on the above evidence.  The Panel must first considered whether the right foot condition remained separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating for the bilateral feet under an analogous 5003 code (arthritis, degenerative) citing constant, minimal bilateral plantar foot pain, status post-surgical removal of Morton's neuroma and stump neuroma, and rated IAW US Army Physical Disability Agency Pain Policy.  The VA  assigned a 10% rating for the bilateral feet under the 5279 code (metatarsalgia [Morton’s disease]) based on the C&P examination, citing chronic bilateral foot pain status post Morton's neuroma and stump neuroma and rated on evidence of chronic metatarsalgia or foot pain.  

There was no weakness for consideration under 5277 (weak foot) or deformity for consideration under 5276 (flatfoot), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  There was evidence of pathology for consideration under 5279 (metatarsalgia).  The maximum rating under 5279, unilateral or bilateral, is 10%.  

Left Foot Pain.  According to STRs and the MEB NARSUM, the left foot condition began approximately 8 years prior to referral for MEB.  The CI complained of burning pain between the 3rd and 4th digits of his left foot and was diagnosed with a Morton’s neuroma.  He failed conservative management and on 18 November 1999 underwent a left foot 3rd interspace Morton’s neuroma excision.  Postoperatively, he developed a recurrent 3rd interspace stump neuroma which was resected on 16 May 2000.  

The 10 September 2001 C&P examination recounted the history and interventions.  The CI reported incomplete relief of his left foot pain with multiple surgeries.  He complained of daily 4/10 sharp burning pain which lasted for minutes to hours.  Symptoms were exacerbated by activity and standing or walking for a few hours.  The physical examination recorded the CI used arch supports and documented a normal gait, no assistive devices, and no unusual shoe wear pattern.  The left foot examination revealed a tingling, burning tenderness with deep palpation between the 3rd and 4th metatarsal heads.  There was a plantar (6 cm) and dorsal (5 cm) scar which were soft, flat, non-adherent, non-tender, and without underlying tissue loss, disfigurement, keloid formation, or limitation of function.  The feet showed no signs of abnormal weight bearing, callosities, or skin breakdown.  There was no pes planus, high arch, hallux valgus, hammer toe, or claw foot deformity.  Strength, sensation, and DTRs were normal.  The diagnosis listed chronic left foot discomfort status post excision of neuroma.  

The 9 November 2001 NARSUM, 3 months before separation, recounted the history and interventions.  The CI complained of near daily sharp burning left foot pain between the proximal 2nd and 3rd metatarsals with associated toe tingling.  Symptoms were exacerbated by activity, walking barefoot, running, jumping, marching, pushups, and military footgear.  The left foot examination revealed tenderness between the proximal 3rd and 4th metatarsals.  There were well healed surgical incisions over the dorsal and plantar aspects of the 3rd interspace.  There was no edema, discoloration, or warmth.  There was no pain on ROM of the toes, foot, or ankle.  Strength and sensation were normal except for decreased sensation of the plantar aspect of the 3rd web space.  The 8 November 2001 X-rays appeared normal.  The assessment listed chronic left foot plantar aspect pain secondary to stump neuroma formation after previous removal of Morton's neuroma.

The panel directed attention to its rating recommendation based on the above evidence.  The panel must first considered whether the left foot condition remained separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating for the bilateral feet under an analogous 5003 code (arthritis, degenerative) citing constant, minimal bilateral plantar foot pain, status post-surgical removal of Morton's neuroma and stump neuroma, and rated IAW USAPDA pain policy.  The VA assigned a 10% rating for the bilateral feet under the 5279 code (metatarsalgia [Morton’s disease]) based on the VA C&P examination citing chronic bilateral foot pain status post Morton's neuroma and stump neuroma and rated on evidence of chronic metatarsalgia or foot pain.  

There was no weakness for consideration under 5277 (weak foot) or deformity for consideration under 5276 (flatfoot), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  There was evidence of pathology for consideration under 5279 (metatarsalgia).  The maximum rating under 5279, unilateral or bilateral, is 10%.  

The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Panel recommends a disability rating of 10% for the bilateral foot condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral foot condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Chronic Bilateral Foot Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011784, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure