RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02255
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070823

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “metatarsalgia due to bilateral hallux limitus” and “left Achilles tendinitis,” rated 10% and 0%, respectively, with a combined 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 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 - 20070613	VARD - 20070907	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Metatarsalgia due to Bilateral Hallux Limitus	5279	10%	Hallux Limitus, Bilateral	5279	10%	STR	
Left Achilles Tendinitis	5024	0%	Achilles Tendonitis, Bilateral	5024	NSC	STR	
Right Achilles Tendinitis	Not Unfitting					
Peroneal Tendinitis Bilaterally	Not Unfitting	Peroneal Tendonitis	5024	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY: 

Metatarsalgia due to Bilateral Hallux Limitus.  The PEB combined the right and the left metatarsalgia diagnoses as a single unfitting condition coded 5279 (metatarsalgia, unilateral or bilateral) rated 10%. The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right foot and left metatarsalgia conditions are presented jointly, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s metatarsalgia due to bilateral hallux limitus (bilateral big toe) conditions began in August 2004 when the he was in basic training doing sprints.  The CI reported a sudden pain in his right big toe joint, with swelling and redness.  The CI was placed on a profile resulting in the symptoms decreasing.  Later, the CI had a similar subsequent injury to his left foot, with pain decreasing immediately after the injury.  The CI reported increased pain with running activities thereafter.  An MRI on 17 November 2006 revealed mild degenerative changes of the metatarsal phalangeal (MTP) joint of the great toe bilaterally.  Despite orthotic support devices, physical therapy, and medications the CI continued to have big toe pain.  

During the 2 February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported bilateral foot and ankle pain, inability to wear a ruck sack, run or participate in impact activities.  Physical examination showed full active ROM of both feet.  The CI had pain with toe walking.  

The 4 April 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of moderate bilateral foot and ankle pain (sharp and stabbing) with all weight bearing activities.  Physical examination showed pain with attempted ROM of the left great toe MTP.  ROM was noted to be “limited” in both dorsiflexion and plantar flexion bilaterally at the great toe MTP.  

There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the metatarsalgia due to bilateral hallux limitus condition 10%, coded 5279 (metatarsalgia, anterior, unilateral or bilateral).  The VA also rated the metatarsalgia due to bilateral hallux limitus condition 10%, coded 5279, citing the CI had been diagnosed with the condition and 10% is the highest evaluation for the condition.  

The panel agreed that, in the evaluations proximate to separation, each great toe was equally disabling; causing the CI not to be able to run, perform sit-ups or perform many MOS specific tasks and recommends that each be separately unfitting.  The panel noted that with metatarsalgia (5279) the condition is rated as unilateral or bilateral and the maximum rating is 10%.  Members agreed that hallux rigidus (hallux limitus) (5281) did not rise to the level of severe, equivalent to amputation of the great toe to validate a 10% rating for each toe.  There was no avenue to a higher rating that the 10% adjudicated by the PEB for the bilateral metatarsalgia condition.  

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 metatarsalgia condition.  

Left Achilles Tendinitis.  According to the STR and MEB NARSUM, in addition to the above history, the CI also reported stepping out of bed and experiencing bilateral heel pain daily which responded initially to steroid injection.  He was also placed in a short leg cast for 3 months followed by physical therapy which temporarily improved his Achilles pain.  Despite multiple profiles, casting, physical therapy and steroid injections; the left Achilles tendinitis could not be resolved.  Radiographic studies on 6 June 2006 and 7 November 2006 showed small bilateral Achilles spurs.  

During the 1 February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, physical examination showed full active range of motion, tenderness to palpation (TTP) of both Achilles tendons with the left worse than the right.  Heel-walk was within normal limits and toe walk was normal, but with pain.  

The 4 April 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain that was 10/10 along the left Achilles tendon.  Physical examination showed decreased dorsiflexion of the left ankle which was related to pain in the Achilles tendon.  There was pain with eversion and plantar flexion and TTP at the proximal aspect of the left Achilles tendon and no distal tenderness.  There was also pain in the left Achilles tendon with double-and single toe raises on the left. 

There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left Achilles tendinitis condition 0%, coded 5024 (tenosynovitis), citing no mechanical loss of motion.  The VA did not service connect the left Achilles tendonitis, citing medical evidence was not sufficient enough to show the condition was chronic in nature.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  However, there was evidence of painful motion supporting the minimum 10% rating (based on §4.59).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left Achilles tendinitis condition, coded 5024 (tenosynovitis).  

Contended PEB Condition: Right Achilles Tendinitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended right Achilles tendinitis condition was not unfitting.  It is challenging to separate the various foot and ankle problems because the profile and commander’s statement were not specific, only stating “chronic bilateral foot and ankle pain.”  The panel considered that the CI had been on a very limiting profile for approximately 18 months at the time of the NARSUM and he still complained of mild heel/Achilles pain.  Members opined that if the CI were to be removed from his very limiting profile and forced to accomplish MOS specific tasks of an Infantryman, his right Achilles tendinitis condition would more likely have prevented him from being able to perform his MOS and would have posed a risk to the welfare of other service members.  After due deliberation, the panel concluded that there was sufficient cause to recommend a change in the PEB fitness determination for the contended right Achilles tendinitis condition and an additional disability rating is recommended.  

According to the STR and the MEB NARSUM, the CI’s right Achilles tendinitis condition began prior to September 2005 with no inciting event noted.  He was treated with night splints, a steroid injection and physical therapy.  By July 2006, the right Achilles pain had improved but not resolved.  Due to other foot problems, he remained on an activity-limiting profile; however, the right Achilles tendinitis did not resolve.  Radiographic studies 6 June 2006 and 7 November 2006 showed small bilateral Achilles spurs.  

During the 1 February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, physical examination showed full active range of motion of the right ankle.  There was TTP of both Achilles tendons, with the left worse than the right.  Heel-walk was within normal limits and toe walk was normal, but with pain.  

The 4 April 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain that was 5-6/10 along the right Achilles tendon.  Physical examination showed full ROM of the right ankle without pain or crepitus.  No TTP of the right Achilles tendon was recorded.  No pain was recorded in the right Achilles tendon with double-and-single toe raises.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the right Achilles tendinitis saying it was not unfitting.  The VA did not service connect the right Achilles tendinitis, citing medical evidence was not sufficient enough to show the condition was chronic in nature.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  There was no evidence of painful motion causing functional loss supporting the minimum rating (based on §4.59, §4.40 and §4.45).  There are no other applicable codes.  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the right Achilles tendinitis favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5024 and meets the VASRD §4.71a criteria for a 0% rating.  

Contended PEB Condition:  Peroneal Tendinitis Bilaterally.  Again, the panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  As previously stated, it is challenging to separate the various foot and ankle problems because the profile and commander’s statement are not specific, only stating “chronic bilateral foot and ankle pain.”  Concerning the bilateral peroneal tendinitis, this was first found in the STR on an MRI that was reviewed on 21 November 2006 then listed as a diagnosis without supporting history or examination findings to validate a disability from the condition.  The only other mention of peroneal tendinitis was at the MEB NARSUM examination again, with no supporting history or examination findings to validate a disability from the condition.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended bilateral peroneal tendinitis conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the metarsalgia due to bilateral hallux limitus condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left Achilles tendinitis condition, the panel unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the contended right Achilles tendinitis condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 0%, coded 5024 IAW VASRD §4.71a.  In the matter of the contended bilateral peroneal tendinitis condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  

There are no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Metatarsalgia due to Bilateral Hallux Limitus	5279	10%	
Left Achilles Tendinitis	5024	10%	
Right Achilles Tendinitis	5024	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150819, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012860, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure