RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01941
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20020315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty  E3, System Organizational Apprentice Maintenance Technician, medically separated for “chronic left foot pain” with a disability rating of 20%.   

CI CONTENTION:  The CI makes no contentions.  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 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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The request for assistance with VA benefits is not within the purview of the Physical Disability Board of Review and must be directed to the Department of Veterans Affairs.  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.   The request for assistance with VA benefits is not within the purview of the Physical Disability Board of Review and must be directed to the Department of Veterans Affairs.

RATING COMPARISON:  

SERVICE PEB - 20020208	VARD - 20030417	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain	5299-5283	20%	Residuals, Lisfranc Fracture, Left Foot with Decreased Sensation	5271	10%	20030320	
	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Chronic Left Foot Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot condition began in May 2000 after he slipped on a ladder and twisted his left foot, which was caught on a rung of the ladder.  On 18 May 2000, X-rays of the left lower leg and foot were unremarkable.  Pain occurred when the CI was on his feet for a long period of time.  On 23 October 2000, at a physical therapy visit, the CI indicated he could not run, walking was painful, and lifting was hard.  Left ankle dorsiflexion was -5 degrees as compared to the right at 5 degrees and crepitus was present.  On 29 November 2000 at the orthopedic clinic visit, the CI indicated he was treated conservatively for an ankle sprain and “instability” with an ankle brace.  Physical therapy provided no relief. On examination his gait was grossly abnormal and he surged significantly on the affected side.  He had strong ankle and toe dorsi- and plantar flexion with strong inversion and eversion.  Palpation of the foot and ankle revealed relatively mild tenderness along the anterior fibulotalar ligament and significant tenderness at the base of the fifth metatarsal.  Palpation in the Lisfranc (midfoot) region was significantly associated with increased pain and tenderness along the cuboid bone.  Direct palpation over the lateral border of the foot reproduced his symptoms.  X-rays were normal, although the medial cortex of the third ray did not exactly meet the medial cortex of the cuboid.  The examiner suspected the CI sustained an injury to the Lisfranc joint, primarily over the lateral aspect.  On 1 December 2000 bone scan study demonstrated a focal increased uptake in the vicinity of the left calcaneocuboid joint, which was nonspecific.  On 15 December 2000 -rays of the left foot and ankle were unremarkable.  Immobilization provided no improvement.  On 17 January 2001, podiatry evaluation noted a painful palpable area of the interspace of the left foot consistent with a neuroma, which was treated with and injection of Celestone (betamethasone, a steroid) and Marcaine (bupivacaine, an anesthetic).  A note dated 24 January 2001 indicated the CI had no help with casting, shoe inserts, physical therapy, a steroid injection, NSAIDs, and time.  Maximal symptoms were near the third and fourth metatarsal heads along with numbness and tingling of the toes.  Manipulation of the ankle, which seemed stable, produced pain in the forefoot; however any manipulation or palpation of the forefoot caused increased pain.  On 7 February 2001 additional injections were given in the second and third interspaces of the left foot.  Magnetic resonance imaging (MRI) of the left foot dated 20 March 2001 was unremarkable.  On 21 March 2001, podiatry examination noted painful palpable masses at the second and third interspaces of the left foot, which were diagnosed as neuromas.  On 11 April 2001, surgical excision was carried out and pathology revealed the masses removed were Morton’s neuromas.  Satisfactory healing was noted with hypertrophic scars and palpable moderate adhesions in the operative sites on 11 July 2001.  On 8 August 2001 the CI developed neuritis from adhesions.  Treatment consisted of Naprosyn (naproxen, an NSAID).  On 29 August 2001, adhesions and a stump neuroma were considered as the sources of residual foot pain.  Treatment consisted of an injection of dexamethasone (a steroid) and lidocaine (an anesthetic).  On 21 November 2001 a second podiatry opinion noted the second metatarsal was shorter on the left foot compared to the right with an abnormal metatarsal parabola typical of an old Lisfranc injury.  The examiner had “not much to offer” and further surgery was not recommended.  

The 11 January 2002 MEB NARSUM examination, 2 months prior to separation, noted complaints of continued left foot pain with radiation to the proximal leg with any increased activity and deep pain and ache to the middle aspect of the left foot with eventual radiation into the toes.  Physical examination of the lower extremity showed no edema or erythema of the left foot or ankle with 5/5 muscle power to all groups of both lower legs.  Neurovascular status was intact except for some patchy numbness to the dorsal aspect of the second through the fourth digits.  There were two healed hypertrophic surgical scars overlying the dorsal aspect of the left foot in the second and third intermetatarsal spaces.  The CI had rectus alignment and plantar grade foot to both feet.  There was pain to palpation of the left mid foot and upon mobilization of the Lisfranc joint.  Use of the extensor and flexor muscles was without pain.  The examiner’s diagnosis was chronic left foot pain secondary to a Lisfranc injury.  During the 14 January 2002 MEB examination (recorded on SF Forms 93 and 88), 2 months prior to separation, the CI reported a left foot injury and foot surgery for neuromas.  The physical examiner noted pain over the second, third, and fourth metatarsals and scars between the toes.  

At the 20 March 2003 VA Compensation and Pension (C&P) evaluation, 12 months after separation, the CI reported pain in his left foot that was fairly constant and walking was difficult.  Physical examination showed no edema, cyanosis or clubbing.  There were two hypertrophic scars in the second and third intermetatarsal spaces.  The scars were nontender and non-adherent to underlying tissues.  There was no tenderness on palpation of the toes or metatarsals.  Range of motion (ROM) of the left foot was intact.  Neurologic examination showed decreased sensation along the plantar surface of the left foot at the level of the third toe.  The sensation at the dorsum of the left foot was unremarkable.  Tandem and heel gait were intact.  The CI appeared to drag the left foot slightly while doing toe gait and also when normally walking.  X-ray studies were normal with no evidence of any skeletal abnormality.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 20%, coded 5299-5283 (analogous to tarsal, or metatarsal bones, malunion of, or nonunion of), moderately severe.  The VA rated the left foot condition 10%, coded 5271, (ankle, limited motion of), citing moderate limited motion of the ankle along with continued pain.  Members discussed several factors related the genesis and persistence of the CI’s left foot pain—the initial Lisfranc injury, the Morton’s neuromas with a possible residual stump neuroma, and a neuritis secondary to scarring.  The PEB’s use of code 5299-5283 was reasonable and it captured the moderately severe condition.  To additionally rate using code 5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral) would invoke pyramiding IAW VASRD §4.14, which is to be avoided.  Scarring was not in the scope of review and by the time of the C&P examination the scars although hypertrophic, were nontender and non-adherent to underlying tissues.  Neuritis was raised as a result of entrapment from the scars, but there was no motor deficit, although the CI appeared to drag the left foot when walking; and, at the C&P examination sensation was only decreased along the plantar surface of the left foot at the level of the third toe and sensation at the dorsum of the left foot was unremarkable.  Apparently, some of the pain that the CI experienced appeared to have resolved with time.  Panel members then considered whether use of code 5284 (foot injuries, other) could provide a higher rating; however, the disability at the time of separation was moderately severe, which for code 5284 also warrants a 20% rating that offers no benefit to the CI.  In the absence of objective evidence of more significant changes in osseous structures, muscles, tendons, ligaments, soft tissues, or nerves, the disability did not rise to a severe level with a 30% rating at the time of separation.  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 chronic left foot pain condition.    

BOARD FINDINGS:  In the matter of the chronic left foot pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150630, w/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

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

		
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