RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-02860
BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20081030

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Engineer Equipment Operator, medically separated for “right foot hallux limitus” with a disability rating of 10%.

CI CONTENTION:  Review of all conditions requested. 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 - 20080821	VARD - 20081031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Hallux Limitus	5299-5281	10%	Status Post Surgical Repair Fractured Sesamoid Bone Right Foot with Complex Regional Pain Syndrome	
5299-5281	
10%	
20080821	
Right Foot Complex Regional Pain Syndrome	Cat II					
Chronic Postoperative Pain	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Right Foot Hallux Limitus. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right foot condition began in 2 February 2007 while performing a run in boots. He felt a pop in his right foot that caused pain in the foot that traveled up his leg. He was diagnosed with a medial sesamoid fracture (bone located below the first metatarsal head, involved in motion of the great toe). He underwent surgery to remove the bone on 7 November 2007 without complication. At approximately 6 weeks after surgery, the CI was kicked in the foot

and it caused extreme pain to the foot. The podiatrist noted the degrees of discoloration and high proportion of pain and chronic regional pain syndrome (CRPS) was diagnosed. The CI was treated aggressively for CRPS with a decrease in his symptoms, which initially involved the whole foot, but was reduced to a painful area under the medial aspect of the foot. A 12 March 2008 physical medicine follow-up visit noted mild CRPS and somatic pain with good relief from the hypersensitivity pain with the second lumbar sympathetic nerve block. The CI was “overall doing well.”

The 4 June 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of burning throbbing pain, aggravated by any type of walking. He required the use of a cane for ambulation. Physical examination showed a well healed medial scar of the foot. There was mild to minimal swelling. There was approximately 35 degrees of great toe dorsiflexion (normal 55) before pain at the surgical site. Other ROM of the foot was within normal limits. Neurovascular status was intact and sensation was normal. The CI was unable to walk without a cane due to pain. He had a noticeable limp and walked on the outside of the foot. He could stand without a cane, but he put weight on the outside of the foot. Foot X-rays confirmed removal of the sesamoid bone. The MEB NARSUM examiner commented that interventions had reduced the CI’s symptoms, but he continued to have “low grade amount of discomfort on a daily basis.”

At the 21 August 2008 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported a one year history of CRPS of the right foot. He reported constant pain in a patch on the bottom of his foot which the VA examiner noted as “approximately 4 cm square.” The CI reported he could not bear weight on the right foot or walk without use of a cane. Physical examination showed a normal gait, but also noted the CI used a cane for ambulation. Ankle ROM was entirely within normal limits without pain fatigue, weakness, lack of endurance, or incoordination after repetitive use. There was pain over the great toe and a 4 cm square patch of allodynia (pain which can be triggered by stimuli which normally do not produce pain) on the bottom of the foot. The neurological examination was otherwise normal. There was active motion of the great toe metatarsophalangeal joint (no hallux rigidus). There was no other foot or toe deformity. The CI wore arch supports. There was no neuroma. The CI could not stand on the right foot.

The panel directed attention to its rating recommendation based on the above evidence. The PEB and the VA both rated the right foot hallux limitus condition 10%, coded analogously as 5281 (hallux rigidus, unilateral, severe). The VA based the rating on the C&P examination, citing pain experienced with range of motion maneuvers. The PEB also listed chronic post-operative pain and CRPS right foot conditions as Category II conditions (related to and contribute to the primary unfitting condition). The chronic post-operative pain diagnosis is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed under the same rating. The CRPS diagnosis is not integral to the hallux limitus diagnosis; each of these diagnoses of the right foot can exist independently of the other. However, at separation the disability due to the hallux limitus condition was foot pain and the disability due to CRPS was also foot pain. There was no evidence of any motor or sensory deficit associated with the CRPS which caused separately unfitting impairment and the foot pain cannot be assigned more than one rating under different diagnoses IAW VASRD §4.14.

A 10% rating was supported for hallux limitus and is the only rating available under 5281. The panel next considered alternatively coding and rating the foot condition under 5284 (other foot injury), but agreed the foot injury was no more than moderate, which also provides a 10% rating. The dissenting voter thought that the CI’s impairment due to the foot condition was greater due to the complication of CRPS in addition to the pain and limited motion from the great toe surgery and that a 20% rating was appropriate, coded analogously as 5284. The panel majority agreed there was no higher than a 10% rating supported under any applicable VASRD code. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the

panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the right foot condition.

Contended PEB Conditions: Pain In Joint Involving Ankle And Foot. There was no ankle condition listed on any LIMDU or implicated in the NMA and no ankle condition failed retention standards. The panel presumed in this case the phrase was referring to the CRPS condition, which initially involved the whole right foot. More proximate to separation, the area of CRPS involvement was limited to a patch of the bottom of the right foot. There was no performance-based evidence from the record that the ankle condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel majority agrees it cannot recommend any additional disability rating.

BOARD FINDINGS: In the matter of the right foot condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 20%, coded 5299-5284 and did not elect to submit a minority opinion. In the matter of the contended ankle condition, the panel agrees it cannot recommend it for additional disability rating. 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 20170426, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY   REFER TO,
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 19 Jul 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate  action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.