RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-03503
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060424

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Visual Information Equipment Operator, medically separated for “chronic left pain foot, due to sesamoiditis, with bunion and bilateral pes planus” with a disability rating of 10%.  

CI CONTENTION:  No specific contention was made.  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 - 20060329	VARD - 20061221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain…	5099-5003	10%	Bilateral Pes Planus and Status Post Left Foot Sesamoidectomy and Bunionectomy	5276	30%	20060718	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Left Foot Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left foot condition began with increasing pain in the left toe and heel in the absence of obvious trauma during deployment in 2004 or 2005.  At the end of March 2005, the CI complained of left foot swelling and pain with palpation or ambulation occurring for 2 months.  On examination there was a small area of protrusion on the medial side of the distal first metatarsophalangeal joint (MTPJ) with tenderness on the bottom and medial portions of the MTPJ.  There was a hallux valgus of the left first toe.  Treatment consisted of Motrin (a nonsteroidal anti-inflammatory drug), rest, ice, compression, and elevation), and comfortable shoes, along with no running or jumping until cleared by podiatry.  X-rays of the left foot indicated the medial sesamoid appeared bipartitum.  A nuclear scan was recommended.  

At a podiatry clinic visit on 27 April 2005, 12 months prior to separation, the examiner indicated the CI received temporary relief from an injection 2 weeks earlier.  A steroid/anesthetic combination injection was given and an insert was continued. The examiner’s assessment was left tibial sesamoiditis secondary to a distal bunion.  At a physical examination on 1 August 2005, 9 months prior to separation, the second toe of the left foot was overriding the great toe secondary to a bunion at the left great toe.  Sensation and motor examinations were without abnormalities or dysfunction.   An antalgic gait was noted and though heel walking was normal, toe walking was abnormal and could not be performed secondary to pain.  

The 23 September 2005 MEB NARSUM examination, 7 months prior to separation, noted the complaint of sub left foot pain.  Physical examination showed the CI had pain below the left great toe and metatarsal, medially greater than laterally.  There was increased pain with the first MTPJ dorsiflexion. He was intact distally including sensation.  Vascular status was normal.  The feet were warm and there was no edema.  Ankle range of motion (ROM) was less than 55 degrees of dorsiflexion and less than 10 degrees of plantar flexion (probably listed in reverse— normal for dorsiflexion and plantar flexion are 20 and 45 degrees, respectively).  X-rays showed a first metatarsal bipartite tibial sesamoid with an elevated first ray and short second ray.  The examiner’s diagnoses were bilateral pes planus and bunion deformity as well as sesamoiditis, which did exist prior to service, but were significantly permanently service aggravated.  

At a clinic visit on 3 November 2005, 6 months prior to separation, the CI reported daily pain of the left foot, which made it hard to function.  On examination there was no erythema, induration, or tenderness of the medial mid foot.  A bone scan dated 30 March 2006, one month prior to separation, demonstrated non-specific stress-related/post-traumatic changes of both the first MTPJs and calcaneus.  The CI was seen in consultation by a podiatrist on 20 April 2006, 4 days before separation, with the complaint of foot pain, mainly the left foot at the bottom of his first metatarsal head, although there was pain in numerous other areas of the left foot.  On examination he had pain to pressure to the tibial sesamoid of the left foot and to the dorsal fifth metatarsal head.  The left second toe was dorsally contracted with the great toe somewhat underlapping the second toe.  He also had pain to the lateral column and lateral plantar aspect of his left foot.  The examiner’s review of X-rays showed either a bipartite or fractured tibial sesamoid, and a short left second metatarsal, and a contracture of the left second MTPJ.  Different surgical options were discussed.  Two months after separation, on 26 June 2006, the CI subsequently underwent surgery (bunion fixed, sesamoid removed, and the second metatarsal lengthened) on his left foot. 

At the 18 July 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI was 3 weeks post-surgery and reported left foot pain.  Physical examination showed he used crutches and was non-weight bearing.  Examination was deferred due to recent surgery since he still had a surgical fixation device on the foot with postoperative tenderness.  ROM of the left ankle was full.  X-rays showed post-surgical changes of the left first and second metatarsals with metallic hardware in place, and an osteotomy of the proximal shaft of the left second metatarsal was suggested on the lateral view.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, analogously coded as 5003 (degenerative arthritis), citing the U.S. Army Physical Disability Agency pain policy.  The VA rated the left foot condition 30%, coded 5276 (flatfoot, acquired), based on the C&P examination, citing that the evidence supported the disability, primarily with left foot complications which resulted in significantly severe symptoms.  The panel noted the PEB assigned a 10% rating using an analogous code 5099-5003 and the VA used code 5276, based on an examination just 3 weeks after surgery on the left foot.  In fact the CI had symptomatic sesamoiditis, whether bipartite or a result of a fracture, a bunion, a shortened second metatarsal, and bilateral pes planus.  While the conditions existed prior to enlistment, they were service aggravated.  The panel first addressed the bilateral pes planus as a contributing factor to the chronic left foot pain.  Pes planus, neither unilaterally nor bilaterally, was addressed in the permanent profile, nor was the left pes planus condition contended.  There was no performance-based evidence from the record that the left pes planus condition significantly interfered with satisfactory duty performance at separation.  Thus, there was insufficient evidence to find the left pes planus unfitting or to warrant a rating.  

The panel then focused its analysis on the left foot conditions.  First code 5280 (hallux valgus, unilateral) was considered at 10%, but the CI did not have surgery until after separation.  Code 5299-5283 (malunion of, or nonunion of tarsal, or metatarsal bones) was then discussed, but the CI had a shortened second metatarsal and neither malunion nor nonunion prior to separation.  The panel then raised the possible use of code 5276 (flatfoot, acquired) at 0% for mild symptoms or 20% for moderate symptoms.  However, after further deliberation, despite the lack of an obvious traumatic injury and although there were surgical indications, the panel determined that the aggregate of the service aggravated left foot conditions is best coded 5299-5284 (foot injuries, other) for a moderately severe disability with a 20% rating. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left foot condition, coded 5299-5284.  

BOARD FINDINGS:  In the matter of the chronic left foot condition, the panel recommends a disability rating of 20%, coded 5299-5284 IAW VASRD §4.71a.  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 Foot Pain, Due to Sesamoiditis, with Bunion and Bilateral Pes Planus	5299-5284 	20% 	

AR20190008538, 

Dear XXXXXXXXXXXXXXXXXXX:

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.