RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02207
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Patriot Fire Control Operator/Maintainer, medically separated for a “painful scar” with a disability rating of 10%.

CI CONTENTION:  “Please review all conditions, including those found in my VA records.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080703	VARD - 20081104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Painful Scar following Amputation of the Left Fifth Toe	7804	10%	Scar, Left Fifth Toe, Secondary to Amputation	7805	0%	20080610	
			Mild Causalgia in the Fifth Digital Nerve, Left Foot	8520	10%	20080610	
Amputation of the Left Fifth Toe	Not Unfitting	Amputation of Left Fifth Toe due to Dry Gangrene	5172	20%	20080610	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Painful Scar following Amputation of the Left Fifth Toe.  According to the service treatment record and MEB narrative summary (NARSUM), the CI was first seen by podiatry for his toe condition in 5 October 2007.  He was diagnosed with inflammation of the left fifth (little) toe and treated with antibiotics.  Devascularization was noted and dry gangrene was diagnosed on 10 October 2007.  Two days later the CI underwent a disarticulation amputation at the level of the left fifth metatarsal phalangeal joint (MTP) due to dry gangrene and dead devitalized left fifth toe.  Wound cultures showed bacterial infection.  After discharge, the CI reported sharp intermittent pain a couple of times during the day and a lot at night.  He was referred to the pain management clinic.   The physical therapy examination on 28 April 2008, showed a mild antalgic left gait without painful motion during ankle motions and mild pain with first MTP motions.  He could heel-toe walk and single leg balance.

The 15 May 2008 MEB podiatry examination, 5 months prior to separation, showed the CI wore tennis shoes and had a normal gait.  He had pain laterally along the distal left fifth metatarsal, transversely from the surgery site across the dorsal MTPs and “sometimes” dorsally up the anterior lower leg as well.  The CI was apprehensive and withdrew his left foot as the provider moved his finger towards the amputation site.  There was a positive response to light touch of the toes and guarding with light touch to the amputation area.  Amputate site scar was irregular in width and about 1.5 cm in length.  There was a positive Tinel test to percussion of the scar (entrapped nerve), which radiated to areas previously noted as locations of pain.  The scar was not mobile with adhesions to the deep tissues.  The 27 May 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic left foot and ankle pain related to the surgical scar.  According to the American Podiatric Medical Association scale, pain was noted to be moderate and chronic.  He had difficulty sleeping due to his pain at night.

At the 10 June 2008 VA Compensation and Pension (C&P) examination, 4 months before separation, the CI reported phantom and nerve pain to the amputation stump and soreness on the lateral side of his left foot.  The stump did not have swelling and redness.  Treatment was Lyrica, Ketagabalido HCL and Pamelor (pain management) before bed.  He reported the inability to stand or walk for long periods of time.  He was able to perform activities of daily living.  He had been moved to a desk job and had difficulty with standing and walking.  Physical examination showed normal gait.  The amputation stump showed no tenderness, neuroma, circulation problems, swelling, or deformity.  The amputation of the left fifth toe was complete and through the MTP.  The level of amputation did not permit a satisfactory prosthesis.  The peripheral nerve examination showed neuralgia of the digital nerve on the left fifth toe and sensory dysfunction by the stump.  Left foot X-ray showed amputation of the left little toe through the MTP.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the scar condition 10%, coded 7804 (scars, unstable or painful).  The VA rated the scar condition 0%, coded 7805 (scars, other), based on the C&P examination, citing that the scar was not painful or unstable nor does it result in a functional limitation.  Additionally, the VA rated amputation of the left fifth toe due to dry gangrene 20%, coded 5172 (amputation of toes, other than great, with removal of metatarsal head); and rated the mild causalgia in the fifth digital nerve, left foot 10%, coded 8520 (mild incomplete paralysis of sciatic nerve).

The panel noted that the MEB NARSUM examination revealed left foot and ankle pain due to the surgical site scar, which was caused by the nerve entrapment noted by the percussion of the surgical scar (positive Tinel test).  Panel members first considered a rating under code 7805, which defaults to code 7804 (scar(s), unstable or painful) rating criteria.  A 10% rating requires one or two scars that are unstable or painful which is warranted by STR and VA evidence.  A 20% rating requires three or four scars that are unstable or painful which was not in evidence.  Panel members next considered a rating based on 8520.  The panel agreed that the STR and VA evidence showed sciatic nerve paralysis which most approximates a mild impairment or 10% rating.  This paralysis manifested as a left fifth toe digital nerve neuralgia with a sensory dysfunction but no motor dysfunction.  The CI was functionally able to walk with a gait within normal limits, perform activities of daily living, walk approximately 2 miles a day, and stand or walk for prolonged periods although in pain.  The panel reiterated that the CI’s left foot and ankle pain were due to the surgical site scar which was caused by a nerve entrapment.  Therefore, the panel concluded that only one 10% rating can be recommended based on code 7804 or 8520 IAW VASRD §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  Lastly, the panel considered a rating under code 5172 and determined based on the operative report that amputation occurred at the level of the left fifth MTP joint; therefore, the metatarsal head was not amputated to support a 20% rating.  After due deliberation, considering all 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 scar condition.

Contended PEB Condition:  Amputation of the Left Fifth Toe:  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. As noted above, the amputation of the toe was due to gangrene of the toe secondary to infections.  The panel considered that the loss of the toe does not prohibit walking or running.  The contended condition was not profiled or implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the scar condition and IAW VASRD §4.118, the panel recommends no change in the PEB adjudication.  In the matter of the contended amputation of the left fifth toe condition, the panel 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 or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170405, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015067, 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