RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2016-00134
BRANCH OF SERVICE:  Marines	SEPARATION DATE:  20031201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Marine Corps active duty, Captain, Infantry Officer, medically separated for “stump neuroma of third and fourth intermetatarsal space, left foot” with a 10% disability rating.  

CI CONTENTION:  The CI requested the panel review all conditions and he submitted a lengthy contention attached to his application.  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 - 20021209	VARD - 20040209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stump Neuroma…L Foot	5279	10%	Residuals, Left Foot Stump Neuromas…	5003-5279	10%	20030916	
Plantar Fasciitis…L Foot	CAT II					
Adhesions…L Foot	CAT II					
DJD…L Foot	CAT II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Stump Neuroma of Third and Fourth Intermetatarsal Space, Left Foot.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left foot while running in 1998.  He sustained a fracture to the base of the 5th metatarsal (MT), the long bone between the little toe and heel, near the heel, and was treated with casting and non-weight bearing.  Despite this, his pain persisted and he was found to have a non-union of the fracture which was excised on 2 April 1999.  Following surgery he had continued pain and was thought to have plantar fasciitis and pain from the scar, as well as possible neuroma (an abnormal growth after a nerve is damaged).  He was placed on LIMDU status and continued treatment in both podiatry and physical therapy.  On 12 April 2000, he was recommended for return to full duty.  The record then falls silent until 19 April 2001 at which time he had removal of an extra bone over the top of the left mid-foot.  He continued to have pain following this and underwent a series of injections to sclerose (to destroy the nerve) a neuroma.  This was not successful and the neuroma was then surgically removed on 2 November 2001.  This was revised on 17 January 2002 and a second neuroma was excised.  Despite rehabilitation, he was unable to return to full duty and an MEB initiated.  

The MEB NARSUM examination was dated 1 October 2002, 14 months prior to separation.  It noted that the CI was not able to tolerate the pain associated with full duty including running and humping.  On examination, there was minimal edema of the lateral (outside) left forefoot.  The range of motion (ROM) of the ankle, foot, and toes was normal aside from the mid-tarsal joint which was somewhat limited and uncomfortable.  There was also pain to compression over the soft tissue between the balls of the 3rd and 4th toes and mid-foot.  A high arch was also noted.  The CI was diagnosed with a stump neuroma of the 3rd and 4th MT spaces, degenerative joint disease (DJD) at the site of the bone excision, plantar fasciitis, and post-surgical adhesions.  

A VA Compensation and Pension (C&P) evaluation was performed on 14 November 2002, 12 months prior to separation.  The CI had a normal gait.  Tenderness was present, but painful motion, flat feet, bunions, edema, and atrophy were absent.  The CI used orthotics (shoe inserts) which were beneficial.  

The PEB rated the stump neuroma condition 10%, coded 5279 (metatarsalgia).  The plantar fasciitis with heel spur, adhesions, and DJD of the lateral aspect of the left foot were related Category II conditions contended by the CI.  The CI non-concurred with the PEB and requested a 30% combined rating using the code 5284 (other foot injuries).  This was supported by a letter dated 27 January 2003 from one of his podiatrists.  As documented in an addendum to the MEB NARSUM, dated 10 June 2003, following the PEB, the CI deployed from 2 February 2003 until 19 May 2003.  This was at the request of his unit.  While deployed, he noted an increase in his symptoms.  A podiatry note dated 25 June 2003 noted the above diagnoses as well as a plantar wart on the left foot which was under treatment.  The same podiatrist provided a summary of care note dated 5 September 2003, 3 months prior to separation.  It noted that the CI had ongoing problems with the foot conditions as well as knee and back pain secondary to the abnormal gait.  

The VA C&P evaluation most proximate to separation was performed on 16 September 2003, just over 2 months prior to separation.  It noted that the CI was pain free at rest, but had pain with standing or walking.  On examination, his posture was normal, but the gait was abnormal as there appeared to be “some limitation of movement of the left ankle.”  Sensation was reduced in the areas of the prior neuroma treatment (ablation and surgery).  The scars were well healed.  Squeezing the forefoot was painful.  Motion of the ankle was painful, but the ROM was not quantified.  X-rays showed a heel spur (associated with plantar fasciitis) and a bunion.  The diagnoses mirrored those of the MEB, but with the addition of the bunion to the list.  The VA also rated the left foot condition 10%, coded 5003-5279 (degenerative arthritis-metatarsalgia), citing the STRs and the VA examination accomplished on 16 September 2003.  It was noted that the symptoms did not rise to the severe level.  

The panel directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA observed that there were multiple diagnoses for the left foot all of which contributed to the unfitting limitation in activity due to foot pain.  The assignment of the same limitation to multiple diagnoses is not permitted IAW VASRD §4.14, avoidance of pyramiding.  Accordingly, a single rating is recommended for the unfitting stump neuroma and related Category II conditions.  The panel then considered the appropriate rating for the combined disability from all of the different foot diagnoses.  The codes 5271 (limited motion of the ankle) and 5273 (malunion of the talus) both support a 10% rating at the moderate level.  There is no specific code for plantar fasciitis, but neither the coded 5020 (synovitis) nor 5310 (Group X muscles) would support a rating higher than 10% either.  The neuroma excisions were of a digital branch of the tibial nerve in the foot and a rating of higher than higher than 10% was not supported using this code either.  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 left foot condition.  

BOARD FINDINGS:  In the matter of the stump neuroma of the 3rd and 4th intermetatarsal space left foot condition (and related Category II conditions) and IAW VASRD §4.71a and 4.124a, 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 «ApplicationDate», w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (o) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     h. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     k. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     l. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     m. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting