RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02871
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “chronic left toe pain in the area of the metatarsophalangeal” and “chronic left ankle pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

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 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 - 20060427	VARD - 20070220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Toe Pain	5281	10%	Left Toe Hallux Rigidus…	5010-5281	10%	20060607	
Chronic Left Ankle Pain	5024	0%	Status Post [Left] Ankle, Tibia, and Fibula Fracture…	5271	10%		
Paresthesias of Left Leg and Right Hand	Not Unfitting	Left Lower Extremity, Traumatic Peroneal Neuropathy	8521	10%		
		Right Upper Extremity, Partial Denervation of the Medial Nerve	8515	10%		
Profound High Frequency Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	0%		
Chronic Post-Traumatic Stress Disorder (PTSD)	Not Unfitting	PTSD with Depressive Disorder	9434-9411	50%		
Intermittent Low Back Pain	Not Unfitting	Lumbar Strain…	5010-5243	0%		
Ice-Pick Headache	Not Unfitting	Migraine Headaches	8100	30%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Left Toe Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left toe condition began in 1992 during a ruck march while in the Marines, and he was immediately discharged for this condition.  He then enlisted in the Army in 1994, and reinjured the left great toe during a deployment in 1995 after a large canister fell directly on it.  There was no X-ray equipment available at the time, but 2 weeks later a fracture of the first phalanx was identified and treated conservatively.  The CI continued to experience pain, and during a physical therapy evaluation on 21 May 2005, the examiner noted effusion of the left great toe and metatarsophalangeal (MTP) joint dorsiflexion (DF) of 20 degrees and plantar flexion (PF) of 10 degrees compared to DF of 60 degrees and PF of 20 degrees of the right great toe.  

During the 20 October 2005 MEB podiatry consultation, 7 months prior to separation, the CI reported left great toe pain, aggravated by weight bearing activities and physical training.  He was not interested in additional surgery and desired to undergo an MEB for the condition.  Physical examination showed mild swelling and deformity of the toe.  Range of motion (ROM) of the first MTP joint, especially with DF, was decreased and painful.  Toe X-rays showed an old, healed fracture of the mid-proximal phalanx, with degenerative joint disease (DJD) of the first MTP joint and hallux valgus (bunion).  At the 15 March 2006 MEB NARSUM examination, 2 months before separation, the examiner documented tenderness to palpation (TTP) of the left great toe.  

At the 7 June 2006 VA Compensation and Pension (C&P) examination, less than 1 month before separation, the CI reported left great toe pain aggravated by weight bearing.  Physical examination showed a limp, but no use of any assistive device for ambulation.  The foot was normal in appearance with a well-aligned Achilles tendon and no pes planus (flat foot).  Left great toe ROM was limited to DF of 10 degrees and PF of 10 degrees, without painful motion.  Left foot X-rays showed hallux valgus and moderate DJD of the MTP joint.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left great toe condition 10%, coded 5281 (hallux rigidus), citing arthritic changes and some limitation of motion.  The VA also rated the left toe condition 10%, analogously coded 5010-5281 (degenerative arthritis-hallux rigidus), based on the C&P examination, citing painful and limited motion.  Members agreed that a 10% rating for severe hallux rigidus (5281) was appropriate based on X-rays and the MEB and VA examinations.  The panel considered alternative VASRD foot and analogous codes, but all were less applicable or not advantageous to rating.  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 toe condition.

Chronic Left Ankle Pain.  According to the STR and MEB NARSUM, the CI injured his left ankle after slipping on an icy surface during physical training in February 2003.  He underwent open reduction and internal fixation of a bimalleolar fracture the same day.  Surgical hardware was removed in November 2003 when the ankle fracture had healed in the correct position, but he continued to report residual pain.  

At the MEB podiatry consultation, the CI reported left ankle pain, aggravated by weight bearing, physical training, and military footwear.  Physical examination showed mild left ankle swelling and TTP of the lateral and medial aspects of the ankle and painful dorsiflexion.  Left ankle X-rays showed small osseous densities in the soft tissue suggesting un-united fracture fragments or intra-articular bodies.  The MEB NARSUM examination recorded left ankle DF of 8 degrees (normal 20) and PF of 15 degrees (normal 45); painful motion was not addressed.  

At the C&P examination, CI reported constant left ankle pain, aggravated by weight bearing activities, and that he occasionally wore an ankle brace.  Physical examination noted he walked with a limp, but did not use an assistive device.  Dorsiflexion was to 10 degrees and PF to 35 degrees, with painful motion, but no additional ROM loss due to repetition.  Ankle X-rays were normal with the exception of a possible old avulsion fracture at the tip of the medial malleolus.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 0%, coded 5024 (tenosynovitis), citing loss of motion due to pain.  The VA rated the left ankle condition 10%, coded 5271 (ankle, limited motion), based on the C&P examination, citing painful and limited motion.  Members agreed that the ROM examinations proximate to separation were consistent with “moderate” limitation of motion required for a 10% rating under 5271, and were supported by an abnormal gait noted at the C&P examination.  The panel adjudged that the limitation of motion did not reach the threshold for a 20% rating for “marked” limited ROM of the ankle.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable or not advantageous to rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left ankle condition, coded 5271.  

Contended PEB Conditions:  Profound High Frequency Hearing Loss (HFHL), Chronic Post-Traumatic Stress Disorder (PTSD), Intermittent Low Back Pain (LBP), Ice-Pick Headaches (HAs), Paresthesias of Left Leg and Right Hand.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  

HFHL and PTSD.  The HFHL and PTSD conditions were listed on the permanent profile dated 29 March 2006.  However, the CI was referred for MEB due to the left ankle and toe conditions in November 2005.  During the MEB he was referred for a complete audiology evaluation and given an H3 profile.  Regarding PTSD, the CI was seen by behavioral health (BH) at a military treatment facility for the first time on 18 March 2006 and reported he sought evaluation for mental health symptoms at the VA on 9 March 2006.  He was diagnosed with chronic PTSD and the 18 March 2006 MEB BH consultation determined that he fell below retention standards for the condition, and noted that his treatment was in the early stages.  An NCO Evaluation Report for the period October 2004 to August 2005 rated the CI excellent in all categories except physical fitness (he had been on profile for the left lower extremity conditions and had not taken a physical fitness test since February 2003, but still achieved a successful rating).  His overall potential for promotion and/or service in positions of greater responsibility was rated “among the best.”  The 7 November 2005 commander’s statement specifically referred to the CI’s inability to participate in physical training due to ankle pain and noted that he continued “to work hard to be a consummate NCO but is limited by his injuries.”  The commander noted the CI had been under his command for the previous 3 months, and that while he conducted individual level training and showed desire to train r soldiers, he was unable to participate in foot marches or physical training with his section.  For the HFHL and PTSD conditions, IAW DoDI 1332.38, E3.P3.3.3., Adequate Performance Until Referral, “if the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  There was no performance-based evidence from the record that the HFHL or PTSD conditions significantly interfered with satisfactory duty performance prior to initiation of the MEB for the left ankle and toe conditions.  

LBP, HAs, and Paresthesias of the Left Leg and Right Hand.  None of these 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 these conditions 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, and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic left toe pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the chronic left ankle pain condition, the panel recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  In the matter of the contended profound high frequency hearing loss, chronic post-traumatic stress disorder, intermittent low back pain, ice-pick headaches, and paresthesias of left leg and right hand conditions, 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Toe Pain	5281	10%	
Chronic Left Ankle Pain	5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170403, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008787, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure