RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00854
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20040821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Combat Engineer, medically separated for “Lisfranc injury left foot, status post open reduction internal fixation” with a disability rating of 20%.  

CI CONTENTION:  “Please 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 - 20040122	VARD - 20050304	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lisfranc Injury, Left Foot…	5299-5003-5279	20%	Degenerative Changes Left Midfoot, Status Post Crushing Injury, also with Hallux Valgus	5284	30%	20041209	
Fifth Metatarsalgia	Cat II					
Mid Foot Arthritis, Left	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Lisfranc Injury, Left Foot.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot was run over by a tractor in March 2001 and he underwent open reduction internal fixation (ORIF) surgery.  In January 2002, left foot X-rays showed evidence of midfoot arthritis. The CI recovered to the extent that he was allowed to return to full duty in June 2003.

The 14 August 2003 MEB NARSUM examination, 12 months prior to separation, documented complaints of left foot pain but no medication use.  The examiner noted that the CI returned to full duty 2 months prior to the NARSUM due to “excellent recovery of power, mobility, and function.” His arch was well maintained and he had custom orthotics for both shoes, however, he could not meet standards for a 3-mile run due to pain.  Physical examination showed well-healed scars with mild keloid formation.  Left foot range of motion (ROM) documented “minimal, if any, loss of subtalar ROM, slight toe flexion loss secondary to scar over the midfoot dorsally.”  Toe flexors were slightly weak, but the foot neurovascularly intact.  Ankle strength was normal.

During the 20 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months before separation, the CI reported left foot pain for which he took medication.  Physical examination showed a dorsal scar and mild to moderate edema.  There was also subjective decreased sensation to the sole of the foot.  

At the February 2004 orthopedic clinic visit, 6 months prior to separation, the CI complained of daily midfoot pain that was somewhat alleviated by medication.  He also had increased morning stiffness and pain, stiffness after prolonged sitting, and pain when walking short distances.  Physical examination showed a slightly antalgic gait, and well-healed scars with keloid formation.  The examiner recorded normal reflexes and sensation with the CI noting some tingling on the left foot plantar surface.  The left arch was slightly lower than the right, and subtalar motion was normal.  Dorsiflexion was 20 degrees (normal) and plantar flexion was 40 degrees (normal 45).  There was tenderness over the fourth and fifth metatarsal heads, as well as over the midfoot.  Toe flexors and extensors had motor strength of 3/5, and posterior tibialis was also 3/5.  

At the 31 August 2004 VA Compensation and Pension (C&P) general evaluation, 10 days after separation, the CI reported multiple issues with his left foot, as well as problems with his left ankle and right foot.  Physical examination showed he was in no acute distress, walked without a limp and used no assistive devices for ambulation.  The foot examination was deferred, but left foot X-rays the same day demonstrated a hallux valgus deformity with degenerative changes of the first metatarsophalangeal joint and the midfoot.

The 9 December 2004 VA Compensation and Pension (C&P) foot evaluation noted the CI was examined on 14 September 2004, 3 weeks after separation.  He reported great difficulty initiating walking, and complained that he had developed callouses due to compensating for his foot.  Physical examination documented good left foot blood circulation, adequate pulses, and intact reflexes.  ROM was recorded as guarded and limited, with pain upon direct palpation.  The examiner diagnosed arthritic s and degenerative changes involving the midfoot. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 20%, coded 5299-5003-5279 (analogous to degenerative arthritis with metatarsalgia, anterior (Morton’s disease), unilateral or bilateral).  The PEB listed “fifth metatarsalgia” and “mid foot arthritis, left” conditions as related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA rated the left foot condition 30%, coded 5284 (foot injuries, other), based on the C&P evaluation 3 weeks after separation, citing severe foot injury.

Under the coding scheme used by the PEB, the fifth metatarsalgia condition was granted a 10% rating under code 5279, and the midfoot arthritis was granted 10% for painful motion and functional loss under code 5003.  The panel agreed that the 10% rating is the highest allowable rating for the metatarsal condition, but that the 20% rating using code 5003 could not be justified since occasional incapacitating exacerbations were not documented.  The panel next considered code 5284, but could not justify a higher 30% rating for “severe” impairment since the CI ambulated without assistive device, demonstrated good healing, had normal subtalar ROM and X-rays were positive only for degenerative changes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left foot condition.  

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160917, 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

	XXXXXXXXXXXXXXXXXX
	Acting