RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02249
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “shrapnel injury, right foot” with a disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 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 - 20041001	VARD - 20051130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Shrapnel Injury, Right Foot	5284	20%	Left Foot Injury	5284	0%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  The PEB listed the CI’s disability description on DA Form 199 as “Shrapnel Injury, Right Foot;” however, the service treatment record (STR) and the Medical Evaluation Board (MEB) Proceedings indicate the shrapnel injury was to the left foot.  Therefore, the panel will adjudicate the disability to the left foot rather than the right foot.

Shrapnel Injury, Left Foot.  According to STR and the MEB narrative summary (NARSUM), the CI’s shrapnel injury, left foot condition began on 12 November 2003 after he was hit by shrapnel from an improvised explosive device (IED) while in combat, that sent pieces through his left foot with an entrance wound medially and exit wound laterally.  He was then emergently treated with removal of fragments and wound care.  

Computed tomography (CT) of the left foot on 11 December 2003 post I&D (incision and drainage) and treatment revealed evidence of a blast injury with a tract extending through the first through fifth metatarsals.  There were markedly comminuted fragments at the bases of the metatarsals, especially the fourth and fifth.  External fixator pins extended from the lateral foot and transfixed the third, fourth, and fifth metatarsals; and there was no evidence of soft tissue air or focal soft tissue abscess collection.  

An orthopedic note dated 19 December 2003 indicated the CI sustained a blast injury to his left foot and was discharged on a 7 day course of dicloxacillin (an antibiotic) for a MRSA (methicillin resistant staphylococcus aureus) wound infection that had a good granulation bed without symptoms of infection.  

A note dated 16 January 2004 indicated the pins were removed on 6 January 2004 and there was an 8 cm x 5.5 cm open wound with surrounding granulation tissue without any erythema (redness) and a central area of fibrous tissue.  A skin graft was performed to cover the wounds and was reported to have an “excellent take” on 16 March 2004.  Radiographic (X-rays) studies of the left foot on 20 February 2004 demonstrated healing fractures of the fourth and fifth metatarsal bones with instability of the fifth metatarsal fracture and disuse osteoporosis throughout the remaining bony structures of the left foot.  X-rays of the left foot showed healing of the fourth metatarsal fracture, but an unusual configuration (an abnormal angulation of the distal and proximal fracture fragments) of the fifth metatarsal fracture in April 2004.  

The CI underwent physical therapy for 2 months to improve his range of motion (ROM), to strengthen his muscles and to undergo gait training.  On 29 June 2004 the CI was fitted and provided with one pair of foot supports.  On 16 July 2004 the CI was treated for a 2 cm x 3 cm non-healing ulcer of the medial arch of the left foot, which developed as a result of blistering of the wound.  Healthy granulation tissue was present.  Treatment consisted of an open sandal with an unloading orthosis.  

During the 23 June 2004, MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported debridement and skin grafts.  Physical examination showed multiple surgical/graft/traumatic scars and skin breakdown.     
  
The 28 June 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of skin breakdown on the lateral aspect of his mid foot.  As a result he walked with a limp and was unable to flex or push off with his toes.  The metatarsophalangeal (MTP) joints were nearly frozen and he had significant pain when he tried pushing over the ball of his foot.  He also had pain with prolonged standing and the foot ached at the end of a long day.  He was unable to run at all or do toe pushups.  Physical examination showed the left foot to be slightly swollen.  The medial aspect of the mid foot showed a well healed, nontender scar, which was nontender to palpation and not affixed to the subcutaneous tissues.  On the lateral aspect of the foot was a large 8 cm x 7 cm area of wound that was grafted.  It had good granulation tissue around the site of graft loosening with some serous fluid, but otherwise appeared healthy.  

ROM measurements of the left ankle showed a dorsiflexion of 0 degrees (normal 20 degrees), plantar flexion of 70 degrees (normal 45 degrees), inversion of 20 degrees (normal 35) , and eversion of 20 degrees (normal 15).  The first MTP joint flexion was 0 degrees and extension 15 degrees.   The remaining MTP and interphalangeal (IP) joints had a ROM of 0 to 15 degrees each.  There was no ankle effusion, but there was slight swelling in and around the areas of the MTP and IP joints.  The Achilles tendon was palpable without defects or tenderness nor was there medial or lateral malleolar tenderness; and the plantar arch seemed to be normal.  The examiner noted the CI was recovering well from a very serious injury to his left foot with “what will be reasonable cosmetic recovery but also good function.”  However, the CI was “totally not able to push off with his toes” and “will likely have persistent pain and discomfort in that foot with prolonged activities such as standing, walking, etc.” The examiner further noted that “it is not clear at this time whether at any point he will be able to run.”  

At an examination on 29 June 2004 there was a well healed lateral wound.  The medial wound had two 1.5 cm x 0.5 cm superficial breakdown sites at the rim around the FTSG (full thickness skin graft).  There was no tenderness on palpation of the feet and no pain was elicited by motion of the foot.  An X-ray showed the fourth and fifth metatarsals appeared to have fused together and to the mid-foot across the Lisfranc joint.  The examiner thought skin breakdown sites should heal with some local wound care.  A custom insert was prescribed to off-load the medial insensate area along with a 2 degree varus heel wedge.  

At the 10 September 2005 VA Compensation and Pension (C&P) evaluation/general medical examination, 10 months after separation, the CI reported an injury sustained in November 2003, which occurred when a roadside bomb caused shrapnel injury to his left lower extremity.  He used no ambulatory aids.  The CI had a post-surgical scar secondary to the traumatic injury on the medial aspect of the left foot, which was significant and disfiguring.  There were no amputations.  There was no abnormality noted to gait, but he had decreased flexion and extension of the foot with 4/5 strength on the left foot.  The examiner deferred full evaluation of the foot problem to specialty orthopedics; however, the CI failed to report for the VA C&P Feet and Joint examinations on 27 October 2005.  

A VA Rating Decision dated 9 March 2006 based on a VA examination dated 24 January 2006, 14 months after separation, indicated there was a 1 inch by 2 inch scar on the lateral aspect of the foot with some tissue loss, while on the medial aspect there was an extensive, deeply pigmented region of approximately 5 inches by 3.5 inches that had a scarred region of approximately 1 inch by 1.5 inches.  There was a normal ROM of the left ankle without edema, instability, weakness, or tenderness in the ankle joint. The left second, third, fourth, and fifth toes were fixed in the extended position at the MTP joint, and were fixed in the flexed position at the PIP joint.  There was tenderness to palpation in the medial aspect of the foot.  There was no significant callus breakdown or unusual shoe wear.  The left foot was smaller than the right foot by approximately 0.75 inch and the left foot was narrower than the right.  X-rays revealed post traumatic deformities with shortening involving the fourth and fifth metatarsals.  There were no radiopaque foreign bodies.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the shrapnel injury, foot condition 20%, coded 5284 (foot injury, other), citing “moderate/severe.”  The VA rated the shrapnel injury, left foot condition 0%, coded 5284 (foot injury, other), based on the STR, citing the absence of any current medical evidence to determine severity of condition.   

Panel members considered what the actual level of disability of the shrapnel injury was at the time of the separation and within a year thereafter.  The CI had comminuted fractures of all metatarsal bases of the left foot with most involvement of the fourth and fifth metatarsals.  While healing of metatarsals was well documented; nevertheless, the fifth metatarsal had an abnormal angulation of the distal and proximal fracture fragments and the MTP joints were nearly frozen; and, he was unable to push off without pain.  VASRD code 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) addresses that constellation of anatomical defects quite clearly.  Furthermore, dorsiflexion of the ankle was 0 degrees and that limitation raises code 5271 (ankle, limited motion).  Additionally, since the CI had difficulty pushing off, a muscle code 5310 (Group X. Function:  Movements of forefoot and toes; propulsion thrust in walking) would have credence, but for the fact no muscle injuries were mentioned in the STRs, although operative procedure notes were not included in the submission to the PDBR.  Additionally, the CI had skin grafting to close the wounds caused by the explosive device, the lateral one of which had not fully closed and had granulation tissue along an edge at the time of the NARSUM examination.  Therefore, code 7804 (scar(s), unstable or painful) had a rightful place in determining the CI’s left foot total disability picture since at least one scar was unstable proximate to separation.  However, to rate each of the components under separate codes, even at 10% each, the end result could conceivably approach a 30% rating, although VASRD §4.14 (avoidance of pyramiding) might be invoked.   

Panel members were aware of the words of the NARSUM examiner who indicated the CI had “a very serious injury to his left foot . . . not able to push off with his toes . . . and will likely have persistent pain and discomfort in that foot with prolonged activities such as standing, walking, etc. . . It is not clear at this time whether at any point he will be able to run.”  Nevertheless, at the VA examination within 12 months of separation there was no abnormality noted to gait, but he had decreased flexion and extension of the foot with 4/5 strength on the left foot and by 14 months after separation there was a normal ROM of the left ankle without edema, instability, weakness, or tenderness in the ankle joint.  Additionally, while metatarsal bones of the foot were fused, nevertheless, there was no significant callus breakdown or unusual shoe wear.  

Panel members had a long and detailed discussion about what an appropriate rating should be.  There was no doubt that the initial injury was severe, but as time and healing progressed, the CI’s gait improved such that he used no ambulatory aids on a regular basis, had a normal ROM of the ankle, and had no calluses or unusual changes in his footwear, albeit 2 months beyond the 12 month look forward time IAW DoDI 6040.44.  Therefore, panel members were in accord that the 20% rating assigned by the PEB was neither unreasonable, inappropriate nor inconsistent with a moderately severe foot injury proximate to 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 shrapnel injury, left foot condition.  

BOARD FINDINGS:  In the matter of the shrapnel injury, left foot 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150717, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012858, 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,