RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01576
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20051031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O2, Student, medically separated for “stress fractures of 2nd and 3rd metatarsals bilaterally,” “osteopenia with unknown etiology,” “pes planovalgus bilaterally,” “Haglund’s deformity bilaterally,” “sinus tarsi syndrome right,” “lateral ankle instability on the right,” “hallux limitus bilaterally” and “hammertoes bilaterally,” rated 20% and existed prior to service (EPTS) for the remaining 7 conditions, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Not rated for 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 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, 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 – 20050815	VARD - 20070116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Stress Fracture of 2nd and 3rd Metatarsal	5003-5279	10%	Right Foot Stress Fractures of the 2nd and 3rd Metatarsals…	5283	10%	20061030	
Neuromas in 1st and 2nd Inner Spaces Bilaterally	Cat II					
		Left Foot Stress Fractures of the 2nd and 3rd Metatarsals…	5283	10%		
Left Stress Fracture of 2nd and 3rd Metatarsal	5003-5279	10%					
Sinus Tarsi Syndrome Right	--	EPTS	Right Ankle Strain with Instability…Sinus Tarsi Syndrome	5271	10%		
Lateral Ankle Instability on the Right	--	EPTS					
Osteopenia	--	EPTS	Osteopenia	5099-5013	NSC		
Pes Planovalgus Bilaterally	--	EPTS	Pes Planovalgus, Hallux Limitus, Hammer Toes, Haglund’s Deformity, Posterior Calcaneal Spur, Bilaterally	5276-5282	NSC		
Hallus Limitus Bilaterally	-- 	EPTS					
Hammer Toes Bilaterally	--	EPTS					
Haglund’s Deformity Bilaterally	--	EPTS					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Stress Fractures of 2nd and 3rd Metatarsals Bilaterally.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s first foot stress fracture was in his left foot in August 1998 while the CI was in Officer Candidate School.  The CI reported this injury was slow to heal.  The bilateral foot pain condition increased in February 2004, while in the basic school with no traumatic onset.  A Bone scan in March 2004 showed multiple stress fractures in both feet.  The stress fractures were treated with rest and avoiding high impact activities.  The pain resolved and the CI began running again increasing to 2 ½ miles by June 2004.  Pain returned to both feet and plain film X-rays in July 2004 showed healed metatarsal stress fractures.  In September 2004, the CI was evaluated by sports medicine where he was diagnosed with metatarsalgia (also known as Morton’s disease or Morton’s neuroma).  The CI was then treated with orthotics as well as 2 steroid injections with very little or no improvement in pain.  A bone scan in February 2005 showed no new bone abnormalities.  There was no surgical indication and the CI’s bilateral foot pain condition could not be rehabilitated to allowed unrestricted activity and for the CI to complete all activities and duties required of his military specialty. 

At a rheumatology consultation visit on 5 May 2005, 5 months prior to separation, the CI reported bilateral foot pain, right more than left, that was worse at the end of the day.  Foot pain was worse with activity and better with elevation and ice.  In addition, the pain was moderately improved with anti-inflammatory medications.  The focus of the pain was the dorsum of the foot at the shaft of the metatarsal bone.  

The MEB NARSUM examination on 29 July 2005, 3 months prior to separation, noted complaints of bilateral foot pain.  Physical examination showed tenderness to palpation of the second and third metatarsal bones and the 1st and 2nd inner space bilaterally.  

At the 30 June 2006 VA Compensation and Pension (C&P) evaluation, performed 7 months after separation, the CI reported bilateral foot pain that was constant and traveled up the calves.  Pain was elicited by physical activity and relieved by rest and anti-inflammatory medications.  Because of the pain, the CI reported he could not run, jump or stand for a long period of time.  Physical examination showed a normal stance and gait with no signs of abnormal weight bearing.  
There was tenderness of both feet.  The examiner noted Morton’s metatarsalgia at the 1st and 2nd interspace bilaterally.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain condition 10% each, with a bilateral factor applied for an overall 20% rating, coded 5003-5279 (degenerative arthritis – metatarsalgia, anterior (Morton’s disease)).  The Navy PEB also listed neuromas in 1st and 2nd inner spaces bilaterally as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the neuromas were properly subsumed under the overall rating for the bilateral foot condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  

The VA rated the right and left foot stress fractures of the 2nd and 3rd metatarsals with 1st and 2nd interspace neuromas conditions 10% each, coded 5283 (tarsal or metatarsal bones, malunion of, or nonunion of), based on the VA C&P examination 7 months after separation, citing tenderness and painful motion.  

The panel noted that by all of the evidence presented, the stress fractures had heeled months before the time of the MEB NARSUM with no evidence of recurrence prior to the C&P evaluation.  With respect to the bilateral neuromas, the panel concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB using code 5279 and that there were no other applicable codes.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral 2nd and 3rd metatarsal stress fracture and neuromas in the 1st and 2nd inner space bilaterally condition.  

Contended PEB Conditions:  Osteopenia, Pes Planovalgus Bilaterally, Haglund’s Deformity Bilaterally, Sinus Tarsi Syndrome Right, Lateral Ankle Instability on the Right, Hallux Limitus Bilaterally and Hammertoes Bilaterally.  The CI’s bilateral foot and ankle conditions began approximately February 2004 with no traumatic onset.  

At a rheumatology consultation visit 5 May 2005, 5 months prior to separation, the CI reported bilateral foot pain, right more than left, that was worse at the end of the day.  Foot pain was worse with activity and better with elevation and ice.  In addition, the pain was moderately improved with anti-inflammatory medications.  The focus of the pain was the dorsum of the foot at the shaft of the metatarsal bone.  The rheumatologist found no evidence of arthritis or related condition in the metatarsal phalangeal joints of the feet.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated July 2005, 3 months prior to separation, the CI reported bilateral foot pain.  Physical examination showed normal arches bilaterally as well as the lower extremities (except feet) were otherwise normal.  

The MEB NARSUM examination on 29 July 2005, 3 months prior to separation, noted complaints of bilateral foot pain.  Physical examination showed bilateral flat feet as well as tightening of the calf muscles.  The examiner noted 40 degrees of dorsiflexion in the 1st metatarsal phalangeal joint (normal 65).  There was tenderness to palpation of the second and third metatarsal bones as well as a positive Tinel’s sign in the first and second inner space (tapping over the space between bones caused pain).  The examination also showed contraction of the small toe bilaterally as well as tenderness over the right anterior talofibular ligament and the calcaneofibular ligament with an anterior drawer sign (instability).  

At the 30 June 2006 VA C&P evaluation, performed 7 months after separation, the CI reported bilateral foot pain that was constant and traveled up the calves.  Pain was elicited by physical activity and relieved by rest and anti-inflammatory medications.  Because of the pain, the CI reported he could not run, jump or stand for a long period of time.  Physical examination showed a normal stance and gait with no signs of abnormal weight bearing.  There was right ankle tenderness but no abnormal movements or guarding.  Range of Motion (ROM) of the right ankle was dorsiflexion 20 degrees (20 normal) with pain at the end of the movement and plantar flexion of 45 degrees (45 normal).  There was no additional limitation after repetitive use.  The examiner found no evidence of pes planus, hammertoes or hallux rigidus.  Radiographic tests performed in conjunction with the C&P evaluation include a bone density test which confirmed osteopenia of the lumbar spine and the left hip, weight bearing and non-weight bearing X-rays of bilateral feet showed no bone or joint abnormality, the radiologist did not find collapse of the longitudinal arch, Haglund’s deformity in either foot or recurrence of stress fractures.  

The panel directed attention to its rating recommendation based on the above evidence. 

The PEB determined all the conditions were EPTS, without service aggravation.  

The VA rated the right ankle strain with instability, also claimed as  sinus tarsi syndrome conditions 10% coded 5271 (ankle, limitation of motion of, moderate), citing no evidence of sinus tarsi syndrome, tenderness on examination and painful motion.  The VA rated the pes planovalgus, hallux limitus, hammer toes, Haglund’s deformity (posterior calcaneal spur), bilaterally conditions, not service connected (NSC), citing no evidence of the conditions and the conditions neither occurred in nor were caused by service based on the VA C&P examination 7 months after separation.  The VA rated the osteopenia condition NSC, citing the condition is not considered an actually disabling condition.  

The panel considered whether or not there was evidence of service aggravation.  A presumption of service aggravation 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.  The panel found no clinic evaluations for ankle sprains, complaints of ankle pain or instability by the CI and the only reference to ankle instability is by the podiatrist at the time of the MEB NARSUM.  The only evidence found for sinus tarsi syndrome was pain with tapping over the area that was tender due to the neuromas.  Avoidance of pyramiding would prohibit evaluation of the same disability or set of symptoms under various diagnoses.  The panel found that pes palanoalgus, hallux limitus and Haglund’s deformities were only mentioned by the podiatrist who wrote the MEB NARSUM and there was no evidence of disability from these conditions or evidence that they were unfitting.  

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 osteopenia, pes planovalgus bilaterally, Haglund’s deformity bilaterally, sinus tarsi syndrome right, lateral ankle instability on the right, hallux limitus bilaterally and hammertoes bilaterally conditions.  

BOARD FINDINGS:  In the matter of the stress fractures of 2nd and 3rd metatarsals bilaterally condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  

In the matter of the contended neuromas in 1st and 2nd inner spaces bilaterally conditions, the panel unanimously recommends no change from the PEB determinations as not additionally unfitting and agrees that it cannot recommend them for additional disability rating.  

In the matter of the contended osteopenia, pes planovalgus bilaterally, Haglund’s deformity bilaterally, sinus tarsi syndrome right, lateral ankle instability on the right, hallux limitus bilaterally and hammertoes bilaterally conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications and agrees that it cannot recommend them for additional disability rating.  

There were no other conditions within the panel’s scope of review for consideration.  

The panel, 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 20150623, 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: PHYSICIU. DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDAT IONS Ref:	(a) DoDI 6040.44
In accordance with reference (a), I have reviewed the cases listed below and 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 :

-	XXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXX, former USMC
-XXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXX, former USMC

                        XXXXXXXXXXXXXXXXXX
                        Acting