RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02544
BRANCH OF SERVICE:  Marine Corps	SEPARATION DATE:  20090830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Towed Artillery Systems Technician, medically separated for “[bilateral] metatarsalgia, Achilles tendinitis, with forefoot overloading” with a disability rating of 10%.

CI CONTENTION:  “Time passed has healed conditions.  I also have two med board evaluations that I haven’t heard from when I tried to go back into the Marines.”  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 - 20090423	VARD - 20120314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Metatarsalgia, Achilles Tendinitis, with Forefoot Overloading	5399-5310	10%	Bilateral Achilles Tendonitis	5271	NSC	20110316	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:

Bilateral Metatarsalgia, Achilles Tendinitis, with Forefoot Overloading.  The PEB combined the metatarsalgia, bilateral, Achilles tendinitis, with forefoot overloading conditions as a single unfitting condition analogously coded 5399-5310 (Group X. Function:  Movements of forefoot and toes) and 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 metatarsalgia, bilateral, Achilles tendinitis, with forefoot overloading conditions are presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s metatarsalgia, bilateral, Achilles tendinitis, with forefoot overloading conditions began in August 2007 after impact activities.  Feet X-rays showed signs of bilateral stress reactions.

The MEB NARSUM examination on 11 March 2009, 6 months prior to separation, noted complaints of bilateral foot and ankle pain.  Physical examination showed an antalgic gait, and forefoot and bilateral plantar fascia tenderness.  Ankle joint range of motion (ROM) with the knee extended was approximately 2 degrees bilateral at the ankle joint.  Flexed, there was minimal change in his ROM.  Subtalar joint ROM was inversion of approximately 40 degrees and eversion of 10 degrees bilateral.  He had Achilles tendon tenderness at the insertion on the posterior superior aspect of the calcaneus (heel).  Plantar flexion and strength is 5/5 over the bilateral feet.  The inverter muscles (foot) were 5/5.  There was bilateral evertor muscles (foot) weakness.  Metatarsalgia, bilateral, Achilles tendinitis, with forefoot overloading was diagnosed.

There was not VA examination proximate to separation for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the metatarsalgia, bilateral, Achilles tendinitis, with forefoot overloading conditions 10%, analogously coded 5399-5310 (Group X. Function: Movements of forefoot and toes).  The VA did not service connect the bilateral foot condition, coded the left ankle 5271 (ankle, limited motion), based on the C&P examination 19 months after separation.

The panel first considered if the each foot’s metatarsalgia and bilateral Achilles tendinitis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both feet were profiled but the above diagnoses were not separated.  Limitations included no running, no high impact activities, no prolonged standing and no physical training.  Panel members agreed that the evidence reasonably justified that the functional limitations of each foot condition contributed to the CI’s inability to perform his military duties, and accordingly separate disability ratings are recommended.

Bilateral Metatarsalgia:  All panel members agreed the bilateral metatarsalgia was no more than mild, therefore supporting a 10% rating coded 5279 (metatarsalgia, anterior, unilateral, or bilateral).  The condition was less than moderate, to support a 10% rating coded 5284 (foot injuries, other).  There was no acquired flatfoot, weak foot, claw foot, to support rating under their respective codes 5276, 5277, or 5278.  There was no tarsal or metatarsal bone malunion or non-union under 5283.  There was no ankle limitation of motion to support a 10% rating (5271).  There was no ankle ankylosis to support a rating coded 5270.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to the CI’s rating.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left foot.  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 bilateral metatarsalgia with forefoot overloading condition, coded 5279.

Left Achilles Tendonitis with Forefoot Overloading:  All panel members agreed the left foot pain due to Achilles tendonitis with forefoot overloading was no more than mild, therefore supporting a 0% rating coded 5024 (tenosynovitis).  The left condition was less than moderate, to support a 10% rating coded 5284.  There was no ankle limitation of motion to support a 10% rating (5271).  Panel members also agreed that the Achilles tendonitis, left forefoot overloading were diagnoses related to the foot pain and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  There was no ankle ankylosis to support a rating coded 5270.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to the CI’s rating.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left Achilles tendonitis with forefoot overloading condition, coded 5024.

Right Achilles Tendonitis with Forefoot Overloading:  All panel members agreed the right foot pain due to Achilles tendonitis with forefoot overloading was no more than mild, therefore supporting a 0% rating coded 5024.  The left condition was less than moderate, to support a 10% rating coded 5284.  There was no ankle limitation of motion to support a 10% rating (5271).  Panel members also agreed that the Achilles tendonitis, right forefoot overloading were diagnoses related to the foot pain and were not separate conditions which could be separately rated IAW §4.14.  There was no ankle ankylosis to support a rating coded 5270.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to the CI’s rating.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right Achilles tendonitis with forefoot overloading condition, coded 5024.

PANEL FINDINGS:  In the matter of the bilateral metatarsalgia condition, the panel unanimously recommends a disability rating of 10%, coded 5279 IAW VASRD §4.71a.  In the matter of the left and right Achilles tendonitis with forefoot overloading condition, the panel unanimously recommends a disability rating of 0% each , coded 5024 IAW VASRD §4.71a.  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 20150615, 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

		
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