RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02230
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Watercraft Operator, medically separated for “chronic left foot pain,” with a disability rating of 0%.

CI CONTENTION:  The CI requests 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 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 – 20061221	VARD - 20070806	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain	5099-5003	0%	Neuritis, Left Foot Injury	8621	10%	200715	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot pain began in September 2005 after her horse stepped on her left foot.  The first record in evidence is a primary care note dated 27 September 2005 in which she was evaluated for the left foot as well as sinus and hip pain.  On examination, there was swelling, tenderness, and an abrasion over the great toe.  A bone scan was recommended due to the long standing hip pain and accomplished on 23 March 2006 (the reason for the delay is not clear from the record).  It was normal other than some increased activity of the right ankle.  There was no evidence for either an occult fracture, soft tissue injury, of reflex sympathetic dystrophy (RSD, now called complex regional pain syndrome [CRPS]).  In podiatry on 12 May 2006, tenderness was present over the second toe and decreased, but pain free motion of the 2nd, 3rd, and 4th toes was noted.  The neurological examination and gait were normal.  An MRI on 20 June 2006 was also normal without evidence for a fracture, stress changes, or RSD.  In urgent care on 12 July 2006, tenderness of the first three MTPJs (joints between the toes and the foot) were tender, but the range of motion (ROM) of the toes was normal.  The neurovascular and skin examinations were normal.  Two weeks later she was again seen in primary care.  She was noted to have redness at the site of a prior steroid injection.  Sensation was normal, but the motor function of the toes was reduced and the gait abnormal due to pain.  However, the next day in podiatry (27 July 2006), the ROM was reduced due to pain, but sensation, strength, and gait were normal.  In orthopedics 4 days later, she was noted to have the redness at the site of the steroid injection and tenderness, but normal sensation.  The bone scan and MRI were reviewed and no etiology for her pain was determined.  

During the 4 October 2006 MEB examination (recorded on DD Forms 2807-1 and 2808, 5 months prior to separation.  The CI reported that the toes of her left foot tingled.  The examination was unremarkable.  At the 6 December 2006 MEB NARSUM examination, 3 months prior to separation the CI reported constant pain and that the first 2 toes of her left foot were numb and tingled on both the top and bottom of her foot.  On examination, she had tenderness of the 2nd and 3rd toes on the top and bottom of her foot.  Sensation and capillary refill were normal.  She was noted to have left foot pain without a specific diagnosis being made.  

At the 15 May 2007 VA Compensation and Pension (C&P) podiatry evaluation, performed 3 months after separation, the CI reported that she was limited in walking to ¼ mile.  A scar was present, but well healed.  Motion was symmetric bilaterally.  Sensation and vascular supply were normal.  Tenderness of the 2nd and 3rd toes was present.  X-rays were normal.  She was thought to have a neuritis of the left foot; the specific nerve was not recorded.  The same day, the CI was noted to have a normal gait in the general and neurological examinations.  The latter examination additionally noted normal neurological examination.  It was also noted that there were “no signs of damage at this time” and that the CI had no signs of RSD.  Examinations remote from separation also documented a normal gait and that she enjoyed hiking for recreation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 0%, analogously coded 5009-5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy rated for constant and minimal pain.  The VA rated the left foot condition 10%, coded 8621 (external popliteal nerve (common peroneal) neuritis), based on the VA C&P foot examination 3 months after separation, citing mild incomplete paralysis.  The panel considered the evidence.  The treating orthopedists were unable to make a definitive diagnosis for the left foot pain.  She was diagnosed with a neuritis after separation by a podiatrist on a VA C&P examination.  However, no specific nerve was cited and a neurology evaluation the same day did not make this or any other diagnosis.  She was consistently noted to have tenderness, but the majority of the examinations recorded a normal neurological examination, vascular examination, and gait.  The evidence did not support the use of an alternate code other than the 5003.  The panel considered the use of the code 5279 (metatarsalgia, Mortons Disease), but noted that this was not diagnosed and is typically in a different location of the foot (between the bases of the 3rd and 4th toes on the sole of the foot).  The panel considered if a higher rating could be obtained using a code for a peripheral nerve, as the VA did, but noted that no etiology for the pain had been determined by separation and that the neurological examination done by a neurologist a few months after separation was normal.  The CI was found unfit for pain, a symptom, for which no etiology had been found.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority 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 secondary to an injury condition and IAW VASRD §4.71a, the panel majority 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150810, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012150 , 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,