RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02452
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Sonar Technician (Surface), medically separated for “pain, right foot, postoperative” and “hammer toes, left foot,” rated 10% and existed prior to service (EPTS), respectively, with a disability rating of 10%.

CI CONTENTION:  The CI contends that his left foot condition should have been rated and that his right foot condition continues to worsen and now affects his neck and back.  The CI’s 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 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.  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 determinations 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 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 - 20050922	VARD - 20060303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain, Right Foot, Postoperative	5299-5003	10%	S/P Right Foot Surgery Secondary to Hammertoes	5282	10%	20050908	
			Right Foot Scars, Post Hammertoe Surgery	7802	0%		
Hammer Toes, Left Foot	--	EPTS	Left Hammertoes	5282	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Foot Condition.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the “patient has had crooked toes all his life.”  On 21 November 2003 podiatry performed arthroplasty (surgical joint repair) of proximal interphalangeal (PIP) joints of 2nd to 5th toes,  metatarsal phalangeal (MTP) joint release and arthroplasty of 3rd toe, and distal interphalangeal (DIP) joints with pinning of 2nd, 3rd, and 4th toes.  The 6 January 2004 right foot X-rays showed interval removal of surgical pins and postsurgical osteotomy (surgical bone cutting or excision) changes to the 2nd to 5th proximal phalanges.  There was good anatomic alignment of the 2nd to 4th, but medial angulation of the 5th proximal phalange.  

The 10 March 2004 podiatry right foot examination revealed well healed incisions and grossly intact neurovascular status.  There was mild adhesion of the 2nd to 5th MTP joints with 2 degrees of plantar flexion, and dorsiflexion was limited to 5 degrees.  The assessment listed postoperative MTP joint adhesion of 2nd to 5th toes.  

At the 28 June 2004 pain management evaluation, the CI complained of persistent, dull, pulsating, pain in the postoperative toes (2nd to 5th).  He denied frequent numbness or burning sensation in the toes.  The physical examination documented a slightly guarded limp when ambulating.  The right foot examination revealed well-healing scars in the 2nd to 5th digits.  There was no edema (excess tissue fluid swelling), temperature changes, allodynia (pain from stimuli which are not normally painful), or radicular pain appreciated in the lower extremity.  The range of motion (ROM) at the metatarsal joints was painful.  The impression listed persistent toe pain status post surgery to correct hammer toes.  The examiner opined “pain does not appear consistent with a neuropathic or nerve-related injury.”  

The 16 November 2004 physical therapy (PT) examination noted the 2nd to 4th toes were stuck in 5 degrees of dorsiflexion and there was no active ROM of the PIP-DIP joints.

The 14 July 2005 MEB NARSUM examination, 6 months prior to separation, documented that after the pins were removed, the CI has had significant pain and stiffness.  The condition was exacerbated by prolonged standing, walking and running.  The encounter documented that “his gait [was] good.”  The bilateral foot examination revealed normal warmth, intact skin, and no edema.  The right foot examination revealed well-healed scars.  The toes were straight with good alignment and position except for the 5th toe.  There were 5th toe contractures which held the MTP joint in extension and the PIP joint in flexion.  The ROM at the 2nd to 5th MTP joints was painful and limited.  

The 8 September 2005 VA compensation and pension (C&P) evaluation, 5 months before separation, the CI reported that he was unable to move his right toes without significant (6/10) pain.  He was able to walk approximately two miles a day during the normal course of activities of daily living.  He lifted weights three times weekly.  The CI was prescribed shoe inserts and he stated that he wore them all the time, but the examiner noted he was not wearing them that day.  The physical examination documented a normal gait and shoe wear did not demonstrate any evidence of abnormal weight-bearing.  The bilateral foot examination revealed well aligned Achilles tendons with no local tenderness over the forefoot or hindfoot.  There was no scar tenderness or evidence of allodynia.  There were flexion contractures of the 4th DIP and 5th MTP joints.  The neurologic examination was within normal limits

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing postoperative right foot pain, existed prior to service (EPTS), and reduced by 0%.  The VA assigned a 10% rating under the 5282 code (hammer toe) based on the VA C&P examination 5 months before separation, citing chronic right foot pain post hammertoe surgery.  The panel agreed that there was no weakness for consideration under 5277 (weak foot); no evidence of sensory pathology for consideration under 5279 (metatarsalgia); and no deformity for consideration under 5276 (acquired flatfoot), 5278 (claw foot), 5280 (hallux valgus), or 5281 (hallux rigidus).  While there was a history of hammertoes, the CI underwent surgical correction.  There was no postoperative deformity for consideration under 5282 (hammer toe).  Following surgical correction, postoperative X-rays showed medial angulation of the 5th proximal phalange for consideration under 5283 (metatarsal bones malunion/nonunion of), but there was also disability for consideration under 5284 (foot injuries, other).  The panel concluded the right foot disability more closely approximated the moderate (10%) than the moderately severe (20%) rating under 5284.  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 right foot condition, coded 5284.  

Contended Left Foot EPTS Condition.  Although the CI’s Military accession physical dated 31 May 2002 reflected a normal foot evaluation, the PEB determined the left foot condition existed prior to service (EPTS) and was not aggravated by service.  The panel considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  

The MEB NARSUM examination documented that “the patient has had severely contracted toes all of his life.”  The encounter documented that “his gait [was] good.”  The bilateral foot examination revealed normal warmth, intact skin, and no edema.  The left foot examination revealed “flexion contractures of the lesser digits, especially of the proximal interphalangeal joint and distal interphalangeal joint of the left third toe with painful callus at the tip of the toe.”  The diagnoses listed left foot hammer toes.

The 18 August 2005 NARSUM addendum, 5 months prior to separation, documented that the CI reported that his contracted toes were worsened due to Military-issued boots bilaterally and that his left foot was getting progressively worse.   

The VA C&P physical examination documented a normal gait and shoe wear did not demonstrate any evidence of abnormal weight-bearing.  The bilateral foot examination revealed well aligned Achilles tendons with no local tenderness over the forefoot or hindfoot.  The left foot examination revealed 2nd to 5th digit hammertoes.  The neurologic examination was within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned no rating citing left foot hammer toes was a preexisting condition.  The VA denied service connection under the 5282 code (hammer toe) based on the VA C&P examination 5 months before separation, citing left hammer toes were not service connected, and not aggravated by service.  The panel agreed that there was no weakness for consideration under 5277; no evidence of sensory pathology for consideration under 5279; and no deformity for consideration under 5276, 5278, 5280, 5281, 5283, or 5284.  The panel agreed a 10% rating was not supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  However, there were 2nd to 5th digit hammertoes for consideration under 5282.  The panel concluded the deformity more closely approximated the single toes (0%) than the all toes, unilateral without claw foot (10%) rating under 5282.  After due deliberation, considering all of the evidence the panel concluded the left foot condition was permanently aggravated by service and recommends a disability rating of 0%, coded 5282.  

BOARD FINDINGS:  In the matter of the right foot condition, the panel unanimously recommends a disability rating of 10%, coded 5284 IAW VASRD §4.71a.  In the matter of the contended left foot EPTS condition, the panel unanimously concluded there was permanent service aggravation and recommends a disability rating of 0%, coded 5282 IAW VASRD §4.71a.  There were 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	
Pain, Right Foot, Post-Operative	5284	10%	
Hammer Toes, Left Foot	5282	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150928, w/atchs
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 USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

							  XXXXXXXXXXXXXXXXXX
	     				  Acting