RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-02604
BRANCH OF SERVICE:  Army	BOARD DATE:  20150123
SEPARATION DATE:  20050201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Care Specialist) medically separated for right foot pain.  This condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “stump neuroma, right foot” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain, right foot” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “This disability affects my current career as a nurse.  I have pain on a daily basis.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

IPEB – Dated 20041214	VA* - (~8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Foot…	5099-5003	10%	…Residuals… Right Foot	5279-7804	10%	20050110	
Other x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050205 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Right Foot Condition.  The narrative summary noted the CI developed right foot pain in 2001 and was diagnosed with Morton’s neuroma (thickening of the tissue around the nerve, most commonly between the third and fourth toes).  Treatment included multiple steroid injections without relief and the CI had a surgical resection on 25 March 2004.  The CI continued to report pain of the right foot following the surgery and was diagnosed with a stump neuroma (bulb shaped thickening during nerve regeneration in the healing phase).  Additional injections provided no relief.  At the MEB examination on 2 November 2004, 3 months prior to separation, the CI reported right foot pain located in the third interspace of the toes of the right foot.  The MEB physical exam noted a mild hypertrophied scar of the third toe, with normal pulses in the foot and normal skin temperature and texture.  There was tenderness of the incision site and squeezing the toes caused pain in the third interspace.  Foot X-rays were normal.  The examiner indicated the CI was unable to run or march due to pain and had difficulty with combat boots, but that pain may be reduced with changes in shoe wear.

At the VA Compensation and Pension (C&P) examination on 10 January 2005, a month prior to separation, the CI reported foot pain treated by activity modification and use of shoe inserts.  The examination noted a normal gait, posture, and balance.  There was a well healed scar noted.  The CI was able to heel and toe walk and stand on one foot without difficulty.  The examiner additionally noted there was no evidence of swelling, weakness, tenderness, deformity, arthritis, painful motion or guarding of movement, or evidence of significant impairment of occupational or recreational activities except aggravation of pain by prolonged standing, walking, or running.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the foot condition 10%, coded 5099-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy.  The VA also rated 10%, coded 5279-7804 (metatarsalgia/Morton’s disease with painful scar).  The Board agreed that the evidence in record supports coding as 5279 IAW §4.71a, and 10% is the only available rating with this code.  The Board reviewed to see if rating as 5284 (other foot injury) would provide a higher evaluation, but the rating for moderate foot injury is 10%, and a higher evaluation of 20% could only be achieved for moderately severe injury.  However, Members agreed that the C&P evidence of a normal foot appearance, pulses, strength, and normal gait did not support characterization of the foot disability as either moderate or moderately severe.  The VA rated based upon criteria of an unstable scar, however, the Board does not recommend rating for scars unless their presence imposes a direct limitation on fitness, which in this case there is not a preponderance of evidence to support such a finding.  As the VA coding achieved a 10% rating this is a moot point in this case.  The Board concluded that there was no path to a higher evaluation than that conferred by the PEB despite the reliance on the USAPDA pain policy, and therefore a recommendation to change the code to be compliant with the VASRD would be of no benefit to the CI.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right foot condition.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right foot condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.
RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131203, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX
President
DoD 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, AR20150008361 (PD201302604)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA