RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02029
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20070713

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Journalist, medically separated for “dorsal medial cutaneous nerve neuritis” 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 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 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 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 – 20070604	VARD - 20080225	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dorsal Medial Cutaneous Nerve Neuritis	8699-8623	10%	Right Foot Hallux Valgus, Status Post Bunionectomy, with Pes Planus	5276-5280	10%	20070815	
			Painful Scar	7804	10%		
Carpal Tunnel Syndrome	Not Unfitting	Post-Operative Residuals, Carpal Tunnel Syndrome Left Hand	8515	10%		
		Post-Operative Residuals, Carpal Tunnel Syndrome Right Hand	8515	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Dorsal Medial Cutaneous Nerve Neuritis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bunion (inflammation and enlargement of joint at base of first [big] toe) condition began approximately 8 years prior to referral for MEB.  Bilateral foot X-rays showed (R>>L) hallux (big toe) valgus (medial deviation of first metatarsal and lateral deviation/rotation of hallux) deformities.  Because a symptomatic right bunion, the CI opted for surgical intervention.  On 27 March 2002, orthopedic surgery performed a right hallux bunionectomy chevron osteotomy (surgical bone cutting or excision) and distal soft tissue procedure.  Because of persistent pain over the dorsum of her right hallux metatarsal, and a prominent surgical screw, the CI opted for surgical intervention.  On 18 December 2002 orthopedic surgery performed right hallux symptomatic hardware removal and manipulation under anesthesia.  The 3 month follow-up documented “She relates that her pain is much improved since having the hardware removed, but she still has persistent pain and stiffness particularly in the cold and with prolonged standing in outdoor activities.  She also has persistent stiffness of her metatarsophalangeal [MTP] joint, although she feels her motion is improved over her interphalangeal joint.”  The right foot examination revealed a well healed incision without evidence of infection and no tenderness over the old screw site.  The right big toe MTP joint range of motion (ROM) was dorsiflexion (extension) of 60 (70 normal) and plantar flexion (flexion) of 20 (45) degrees.  The interphalangeal (IP) joint ROM was dorsiflexion of 0 (0) and plantar flexion of 30 (90) degrees.  In August 2006 a podiatrist performed a corticosteroid injection at the proximal end of the scar which increased her pain.  The September 2006 right foot X-rays revealed stable degenerative joint disease (DJD) and postsurgical changes.  The September 2006 bone scan revealed mild hallux 1st MCP joint DJD and stress changes in the midfoot.  At the 8 February 2007 physical medicine and rehabilitation (PM&R) evaluation the CI complained for 4 years of chronic right foot pain following a bunionectomy.  “Pt experiences severe pain with tingling sensations in R dorsal 1st metatarsal and 1st phalanx area (same area as bunionectomy), requiring her to wear CAM [controlled ankle motion] -walker.  Refractory to multiple medications, as well as casting, Gabapentin and Amitriptyline.”  The right foot examination revealed extensor hallucis longus tendon tenderness, anterior dorsal pain with motion, and a normal medial longitudinal arch.  There was no swelling, erythema (redness), induration (loss of elasticity and pliability), or abnormal warmth.  A tactile dysesthesia (abnormal sensation)/hyperesthesia (abnormal increased sensitivity to stimulation) was noted on dorsal foot and hallux.  The assessment listed right foot neuropathic pain (sensory nerve injury pain) with point tenderness over the scar/incision line.  On 12 February 2007, physical therapy (PT) measured repetitive (X3) active ROM for the MEB.  The right big toe MTP joint ROM was dorsiflexion of 65/65/68 (70) and plantar flexion of 7/9/11 (45) degrees.  At the 15 February 2007 podiatry evaluation the CI complained of pain to right medial forefoot along the surgical incision.  The right foot examination documented “Tenderness on palpation of the shaft of the first metatarsal along the incision and the course of the medial cutaneous nerve.  There is evident tissue atrophy of the subcutaneous fat and skin in this area.  This is likely due to subcutaneous triamcinolone, but this is only speculation.”  The assessment listed nerve injury and the podiatrist documented, “We recommend a proximal neurolysis [application or physical or chemical agents to interrupt nerve transmission] to the involved nerve(s).  The involved structures may include parts of the superficial peroneal nerve, the deep peroneal nerve, and the saphenous nerve.”  The 5 March 2007 orthopedic surgery evaluation documented “Post-operatively her bunion pain improved, but she developed pain dorsally at the proximal aspect of her incision.  Despite adequate treatment at the time, this incisional pain developed into a chronic problem, most likely related to neuritis involving the dorsal medial cutaneous nerve. … She received a corticosteroid shot in the painful area in Aug 2006, which made the pain worse.”  The CI did not experience significant relief from multiple treatment modalities (oral analgesics, Neurontin, shoe modification, and formal desensitization therapy).  She was wearing a CAM walker boot because the bending moment exerted on the forefoot during a normal gait was painful.  The right foot examination revealed supple skin with no discoloration or atrophy.  There was a well-healed dorsal incision (5 cm) with some scar adherence to deep tissue.  “There is a + Tinel's [percussing elicits tingling over nerve distribution] at the proximal-medial aspect of the incision scar, along with marked tenderness in this area.”  The right big toe ROM was dorsiflexion of 60 (70) and plantar flexion of 30 (45) degrees.  Strength, light touch sensation, and capillary refill were normal.  A right foot X-ray revealed a well-healed bunionectomy, no metatarsal deformity, a congruent MTP joint, and no arthritis changes.  The assessment listed a painful post-operative neuroma (reactive tumor of disorganized axons).  The surgeon offered 2 operative treatments, but “Neither of these is acceptable to the patient.”  The 14 March 2007 MEB NARSUM, 4 months before separation, recounted the history and interventions.  The CI complained of pain near the area of the scar in the upper aspect of the great toe.  “Pain is present if she lies down or if she walks, lasting 1-4 minutes.”  The CI did not experience significant relief from multiple treatment modalities.  The physical examination documented the CI walked with a cane.  The right foot examination revealed no hematoma (localized collection of extravasated blood) of flatfoot.  There was a mildly depressed scar on superior aspect of the right foot with area being “hypersensitive to touch.”  Circulation and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of X-rays and bone scan.  The impression listed right foot pain status post surgery.  The 15 August 2007 right foot X-rays revealed mild hallux valgus deformity with early degenerative changes in the MTP joint of the great toe.  The 15 August 2007 VA compensation and pension (C&P) examination, 1 month after separation, recounted the history and interventions.  The CI complained of right foot and big toe pain which was exacerbated by prolonged standing (> 20-30 min) and walking (> 1 block).  She used a cane secondary to the limping because of the right toe pain.  “Veteran states that she only wears Crocs at this point because that is the only shoe that does not rub up against the toe.”  The physical examination documented the CI walked with a cane and an antalgic (assuming a gait or posture to lessen pain) gait.  The right foot examination revealed a scar (2 inch) over the first metatarsal which was extremely tender.  There was mild pes planus with weight-bearing.  There was no evidence of abnormal shoe wear, abnormal skin findings, calluses, or tenderness over the Achilles tendon insertion.  The metatarsals ROM was full.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the X-rays.  The diagnosis listed right first metatarsal chronic pain and scar hypersensivity/hyperesthesia status post, bunionectomy.  The 25 September 2007 podiatry right foot examination revealed a scar over the dorsum of the 1st ray with no keloid (abnormal/excessive scar tissue) or hypertrophic scar.  There was hypersensitivity and pain out of proportion noted with light touch to the proximal aspect of the scar.  There was no pain with manipulation of the 1st ray or the 1st MTP joint, edema, or ligamentous laxity.  Strength, sensation, and pulses were normal.  The assessment listed chronic painful scar with reflex sympathetic dystrophy ([RSD] chronic extremity pain, swelling, limited ROM, vasomotor instability, skin changes, and patchy bone demineralization following injury).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 8623 code (anterior tibial nerve [deep peroneal] neuritis) citing dorsal medial cutaneous nerve neuritis following a bunionectomy, constant pain,  taking non-opioid and opioid pain medications, X-ray findings, and tenderness on examination.  

The VA assigned a 10% rating under the 5276-5280 codes (flatfoot, acquired-hallux valgus, unilateral) based on the C&P examination 1 month after separation, citing hallux valgus status post bunionectomy, mild pes planus, X-ray findings, tenderness on examination, and continuing moderate symptoms.  The VA also assigned a 10% rating under the 7804 code (scar[s], unstable or painful) citing examination of the post-operative scar noted extreme tenderness to palpation.  The mere presence of a scar does not, of itself, justify a finding of unfitness because of physical disability.  Only conditions determined to be unfitting can be compensated by the military.  The fact that the CI suffered residual scarring does not automatically result in disability compensation.  All of the medical and performance data support a conclusion that the painful neuritis was unfitting, and that the scar did not impose any functional limitations on the CI’s ability to perform his assigned duties.  The fact that the Department of Veterans’ Affairs provides compensation for scars, without any relationship to fitness for duty industrial capacity, is not relevant to the military disability.  

Panel members agreed the condition did not exceed the mild (0%) rating under 5276 (flatfoot, acquired).  The maximum rating under 5279 (metatarsalgia) is 10% and panel members agreed the sensory pathology was consistent with the 10% rating.  The maximum rating under 5280 (hallux valgus) is 10% (operated with resection of metatarsal head or severe, if equivalent to amputation of great toe) and panel members agreed the history of the surgical correction was consistent with the 10% rating.  There was no weakness for consideration under 5277 (weak foot).  There was no deformity for consideration under 5278 (claw foot), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  The 5284 (foot injuries, other) code characterizes and rates impairment as moderate (10%), moderately severe (20%), and severe (30%).  Panel members agreed the limitations and examinations did not exceed a moderate level.  Peripheral neuritis is usually characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating.  The neuritis codes rate based on an assessment of functional impairment of the nerve involved expressed in terms of severity of paralysis.  The neuritis code (8623) is limited to a maximum of severe incomplete paralysis (§4.123) which is a 20% rating.  The codes used are rated based on functional impairment assessed in terms of severity of paralysis.  Absent motor loss or abnormal reflexes, the 20% rated under 8623 is the maximum allowed as the neuritis code, which is used for purely sensory manifestations IAW §4.123 and §4.124.  In multiple examinations, the peripheral nerve neuritis findings documented were characterized as sensory disturbances and pain.  There was no evidence of associated loss of reflexes, motor loss, or muscle atrophy.  The scar was noted as tender and was recorded as restricting use of military foot wear.  The panel considered the impairment associated with hyperesthesia and painful use.  Sensory abnormalities and pain limited her ability to engage in strenuous activities, but the absence of muscle atrophy suggested regular use.  The majority of members agreed that findings were concordant with moderate incomplete paralysis, consistent with a 10% rating under 8623.  

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 dorsal medial cutaneous nerve neuritis.  

Contended PEB Conditions:  Carpal Tunnel Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the dorsal medial cutaneous nerve neuritis condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 20% and did not elect to submit a minority opinion.  In the matter of the carpal tunnel syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009986, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,