RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00272
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061229

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “right first metatarsophalangeal sesamoiditis, complicated by pain” with a disability rating of°10%.

CI CONTENTION:  The CI contended that multiple diagnosis were not reviewed.  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 - 20061013	No VA Claim in Evidence	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right First Metatarsophalangeal Sesamoiditis, Complicated by Pain	5299-5279	10%	No VA Examination in Evidence	
Seasonal Allergic Rhinitis/Bronchitis	Not Unfitting 		
Flexible Pes Planus			
Migraine Headaches			
Mechanical Low Back Pain			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right First Metatarsophalangeal (MTP) Sesamoiditis, Complicated by Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “right first MTP sesamoiditis, complicated by pain” condition began in May 2005 after a trunk fell on her foot.  A physical therapist noted swelling over the sesamoid bones and tenderness to palpation of the sesamoid bones.  
X-rays were felt to be suggestive of a probable right medial sesamoid fracture; however, the osseous structures, soft tissues and joints were reported as normal, although a note dated 29 July 2005 indicated that the X-rays showed a bipartite sesamoid bone on the first metatarsal.  The CI reported pain in the area of the right first metatarsophalangeal (MTP) joint and tenderness on palpation.  At a podiatry visit on 13 September 2005 the CI reported soft tissue pain when wearing shoes.  She was given a corticosteroid injection at the tendon insertion.  On 19 October 2005, a dancer’s (foam) pad was dispensed and surgical excision was recommended.  On 9 January 2006, the CI reported pain of the right fibular sesamoid (lateral) and no pain of the tibial (medial) sesamoid.  There was a full range of motion (ROM) of the first MTP joint.  A Silipos gel metatarsal pad was dispensed.  On 1 February 2006 the CI had right foot plantar pain, which was worse with weight bearing.  At a physical therapy visit on 5 April 2006 the CI was noted to have a mildly antalgic gait with her ankle and mid-foot normal.  The active ROM of the first MTP was within normal limits with end-rage plantar pain with both directions and tenderness at the plantar aspect of the MTP joint.  X-rays of the right foot on 27 June 2006, ordered for an injury 24 hours earlier with tenderness to palpation over the third MTP along with plantar swelling, were normal. 

The 19 April 2006 MEB NARSUM examination, 8 months prior to separation, noted complaints of pain intensity of 9/10 (10 being the worst pain) with radiation from the right first MTP to the heel, which was exacerbated by prolonged standing, walking, running, and wearing or carrying extra weight.  Physical examination showed the neurovascular status of the right foot was intact with tenderness to palpation at the plantar aspect of the right tibial sesamoid bone.  Dermatologic examination revealed no erythema (redness), edema, ecchymosis (black and blue), scars, cysts, or lesions.  There was a full ROM at the right first MTP without crepitance (grinding sensation).  She had a flexible pes planus foot type.  Focused ROMs of the right first MTP joint were 5/5/5 degrees plantar flexion and 30/30/30 degrees dorsiflexion, while the left first MTP joint ROMs were 10/10/10 degrees plantar flexion and 75/75/75 degrees dorsiflexion.  The CI had moderate pain during the ROMs of the right first MTP joint, which were reduced secondary to pain.  At the 11 July 2006 and 8 August 2006 MEB examinations (recorded on DD Forms 2807-1 and 2808), 5 and 4 months prior to separation, the CI reported a foot injury to the right sesamoid.  Physical examination showed tenderness to palpation over the right great toe MTP joint and decreased ROM of the right great toe MTP joint.  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 “right first MTP sesamoiditis, complicated by pain” condition 10%, coded 5299-5279 (metatarsalgia, anterior (Morton’s disease), unilateral), citing pain and tenderness on palpation.  Members discussed a rating option using analogous code 5099-5003 since there was decreased motion of the right first MTP joint with pain.  However, VASRD §4.45 (the joints) speaks of groups of minor joints, and in this case only the first MTP joint was involved.  Nevertheless, even if a 10% rating were proffered for the limited ROM with pain of that joint, it offers no advantage to the CI, since combining that code with code 5279 would evoke pyramiding IAW VASRD §4.14), which is to be avoided.  While the CI had a foot injury (code 5284), it did not rise to the level of moderately severe to warrant a 20% rating nor was there malunion or nonunion of tarsal or metatarsal bones (code 5283) since the CI had a bipartite sesamoid rather than a fractured sesamoid.  Even using an analogous code 5299-5283, the metatarsal involvement did not rise to a moderately severe level.  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 “right first MTP sesamoiditis, complicated by pain” condition.  

Contended PEB Conditions:  Seasonal Allergic Rhinitis/Bronchitis, Flexible Pes Planus, Migraine Headaches, Mechanical Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the “right first MTP sesamoiditis, complicated by pain” and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended seasonal allergic rhinitis/bronchitis, flexible pes planus, migraine headaches, and mechanical low back pain conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification of re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160503, with attachments
Exhibit B.  Service Treatment Record

AR20180001660, 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,					      
					      					
Enclosure