RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1200262
BRANCH OF SERVICE:  Army	BOARD DATE:  20140212
SEPARATION DATE:  20040504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (42A/Human Resources) medically separated for sarcoidosis involving joints of both great toes.  The CI complained of pain in his feet of unknown cause, in 2001.  Radiographic and lab studies led to a diagnosis of osseous sarcoidosis.  He was treated initially with medication therapy but eventually underwent bilateral surgical fusion of the joints in his great toes.  Despite further treatment and attempts at rehabilitation, the CI could not meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded to the Physical Evaluation Board (PEB): “bilateral great toe fusion” and “osseous sarcoidosis, bilateral first interphalangeal joint” as failing retention standards.  The Informal PEB (IPEB) adjudicated both of the MEB referred conditions as: “sarcoidosis of bone involving the first interphalangeal joints of both toes status post [s/p] bilateral interphalangeal fusion,” unfitting, and rated 20%.  The CI appealed to the Formal PEB (FPEB), which affirmed the IPEB finding and rating.  The CI did not agree with the FPEB findings, and his case was sent to the US Army Physical Disability Agency (USAPDA).  After reviewing the case, USAPDA affirmed the FPEB findings and the CI was medically separated.

CI’s CONTENTION:  “My rating from VA is 70%, have had 4 operations since discharge.  Army rating was not right.”

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting bilateral sarcoidosis condition affecting the CI’s great toes is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records. 

RATING COMPARISON:

Service FPEB – Dated 20040129	VA - (8 Mos. Pre Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sarcoidosis, first interphalangeal joint, bilateral great toes, s/p fusion	5099-5002	20%	Sarcoidosis with Residuals, Right Great Toe	5299-5284	10%	20030829	
			Sarcoidosis with Residuals, Left Great Toe	5299-5284	10%	20030829	
			Scar, s/p Great Toe Interphalangeal Joint, Right	7804	10%	20030829	
			Scar, s/p Great Toe Interphalangeal Joint, Left	7804	10%	20030829	
No Additional MEB/PEB Entries	Other x 0	20030829	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20090226 (most proximate to date of separation [DOS] in evidence).
* D/C 5299-5284 temp increase to 100% presumably post-surgery effective 20050429, then 20% from 20050801.  70% combined rating referenced in CI contention, from 20080801, includes two additional conditions service connected by VA subsequent to separation, and not in scope under purview of PDBR.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Bilateral sarcoidosis of great toes.  In 2001, the CI developed pain in his big toes.  X-rays showed cystic erosions of the interphalangeal (IP) joint of both great toes.  In January 2002, he was seen by rheumatology at Landstuhl Regional Medical Center (LRMC).  Laboratory and X-ray studies led to a diagnosis of sarcoidosis and he was started on anti-arthritis medication.  In spite of treatment, his toe pain persisted.  In September 2002, the CI underwent fusion of the IP joints of both big toes.  After surgery, he continued to have pain and an MEB was initiated.  His first MEB narrative summary was at LRMC dated 24 January 2003.  Physical examination (PE) at that time revealed tenderness at the surgical sites, but the PE was otherwise unremarkable.  In August 2003, the CI had a VA Compensation and Pension exam.  Once again there was tenderness to palpation of the great toes, but PE was otherwise unremarkable.  As noted above, the CI was separated from service in May 2004.

The Board directs attention to its rating recommendation based on the above evidence.  The January 2004 FPEB combined the two toe problems into a single unfitting condition: sarcoidosis of bone involving the interphalangeal joints of both great toes.  The condition was coded 5099-5002 (analogous to rheumatoid arthritis) and rated at 20%.  The February 2009 VARD unbundled the two toe conditions and assigned a rating of 10% to each, resulting in a combined musculoskeletal toe rating of 20%.  The Board evaluated whether or not it was appropriate for the toe problems to be “bundled” together and determined if the PEB’s approach of combining the conditions under a single rating was justified in lieu of separate ratings.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW the VA Schedule for Rating Disabilities (VASRD).  If the Board judges that two or more separate ratings are warranted; however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as separately unfitting.  After due deliberation, the Board determined there was reasonable justification to support a conclusion that either of the painful big toe conditions separately, would have rendered the CI unable to perform his required military duties.  Accordingly, the Board recommends by majority decision (2:1 vote) a separate disability rating for each of the two great toes.  The minority voter believed the PEB considered the overall effect of the bilateral toe condition and adjudicated the condition properly in that regard.

IAW VASRD §4.40 (functional loss) and §4.59 (painful motion), a part of the musculoskeletal system which becomes painful on use must be regarded as disabled.  With any form of arthritis, pain is an important factor of disability. The Board determined that a 10% rating was warranted for each great toe, due to functional loss and painful motion.  The Board tried to find a path to a higher rating, using other codes which could be applied to the toes.  The other VASRD codes that were considered did not result in a higher rating, since the treatment record did not show evidence of a significantly disabling toe abnormality which would justify a rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% for chronic right great toe pain.  In like manner, the Board recommends a rating of 10% for chronic left great toe pain.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right great toe sarcoidosis condition, the Board recommends by majority decision (2:1 vote) a disability rating of 10%, IAW VASRD §4.40, §4.59, and §4.71a.  In the matter of the left great toe sarcoidosis condition, the Board recommends by majority decision (2:1 vote) a disability rating of 10%, IAW VASRD §4.40, §4.59, and §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Sarcoidosis of bone involving the IP joint of right great toe	5299-5280	10%	
Sarcoidosis of bone involving the IP joint of left great toe	5299-5280	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120312, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20140017929 (PD201200262)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability determination without modification of the combined rating or recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA