RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXX BRANCH OF SERVICE: air force

CASE NUMBER: PD1001176 SEPARATION DATE: 20081110

BOARD DATE: 20110921

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SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (3AO/Information Management Journeyman), medically separated for chronic right foot pain due to Morton’s neuroma. She did not respond adequately to treatment and was unable to perform within her Air Force Specialty (AFS) or meet physical fitness standards. She was issued an L4 profile and underwent a Medical Evaluation Board (MEB). Chronic right foot pain due to Morton’s neuroma was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AFI 48-123. No other conditions appeared on the MEB’s submission. Other conditions included in the Disability Evaluation System (DES) packet will be discussed below. The Informal PEB (IPEB) adjudicated the chronic right foot pain due to Morton’s neuroma condition as unfitting, rated 10%, with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 10% combined disability rating.

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CI CONTENTION: The CI states: “Morton’s Neuroma in both feet that causes permanent chronic pain. This condition was my official diagnosis is not listed on my ratings.” As a matter of policy, all service conditions are reviewed by the Board for their potential contribution to its rating recommendations.

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RATING COMPARISON:

ANALYSIS SUMMARY: The Military Services, by law, can only rate and compensate for those conditions that were found unfitting for continued military service based on the severity of the condition at the time of separation and not based on possible future changes. However, the VA, operating under a different set of laws, can rate and compensate all service connected conditions without regard to their impact on performance of military duties, including conditions developing after separation that are direct complications of a service connected condition. The VA can also increase or decrease ratings based on the changing severity of each condition over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations compared to VASRD standards, as well as the fairness of PEB fitness adjudications at the time of separation.

Chronic Right Foot Pain Condition. The CI was first seen in November 2005 with three weeks of intermittent right foot pain that began during vigorous physical training (warrior week). Bone scanning revealed evidence of stress fractures of the first and fourth metatarsals of the right foot, and a healing stress fracture of the first metatarsal of the left foot. By May 2006, x-rays were consistent with healing of previously noted stress fractures, left foot symptoms were resolved “for the most part”, but the CI reported some occasional residual right forefoot pain. Examination was consistent with a new problem, Morton’s neuroma of the right foot causing pain at the metatarsal heads (metatarsalgia) and a permanent L2 profile was continued limiting running and high impact activity. One year later, June 2007, she presented for care of recurrent right foot pain of the metatarsal region (metatarsalgia) that began while running. Examination findings again suggested pain due to intermetatarsal neuroma (Morton’s neuroma). Despite activity limitation, orthotics and local injection, the CI’s right forefoot foot pain persisted. Magnetic Resonance Imaging (MRI) (February 2008) did not confirm the presence of a neuroma, but evidence of scar tissue or bursitis was shown in the intermetatarsal area of the right foot correlating with the CI’s pain and examination findings. At the time of the MEB narrative summary (NARSUM) examination, 1 July 2008, there was no current complaint with restricted activity (no running, jumping, prolonged standing), pain was 0 on the 10 scale, and there was no tenderness on examination. The NARSUM examiner commented, “appears to be doing well with restrictions in activity…She would not do well in a deployed setting with the reoccurrence and chronicity of her symptoms.” At the time of the VA compensation and pension (C&P) examination, nearly four months after separation, the CI reported pain with activity. On examination, there was tenderness between the second and third metatarsal heads of both feet. The remainder of the examination, including gait, was normal. Weight bearing x-rays for the C&P examination were normal except for presence of pes planus not previously reported by any clinical examiner including podiatry. Bilateral hallux valgus and hammer toes (fifth toes) were noted by podiatry examination in February 2008 however these examination findings were not correlated with any impairment. The C&P examiner four months after separation did not conclude hallux valgus was present but noted the fifth toe deformities. The PEB rated the CI’s metatarsalgia by analogizing to the VASRD code for neuralgia of the posterior tibial nerve (8725). The Board did not agree this code best fit with the CI’s right foot metatarsalgia and the objective evidence of examinations and imaging. The Board concluded the best medical fit was with the VASRD code 5279 for metatarsalgia (Morton’s disease). Under this code, the condition, whether unilateral or bilateral, has only one rating option of 10% providing no additional benefit to the CI. Although there were examination findings of hallux valgus and hammer toes (single toes) there were no symptoms or impairment attributed to these abnormalities that would warrant rating under VASRD codes 5280 or 5282, and, if rated using these codes, would not attain a minimum rating providing no benefit to the CI. The Board considered rating the unfitting right foot condition under codes for malunion or nonunion of metatarsal bones (5283) but the stress fractures had healed, symptoms were not attributed to residuals of stress fractures, and there was no malunion of the metatarsal bones on imaging. The Board also considered rating using the code for other foot injuries (5284), but agreed the mild intermittent symptoms did not approach the minimum rating of moderate for 10%. The VA chose to rate using 5276 for pes planus of both feet, based on C&P weight bearing x-ray findings reporting presence of pes planus. Podiatrist examinations did not document pes planus or symptoms attributed to pes planus. Examinations of the CI’s feet did not show evidence of abnormal weight bearing, abnormal callosities, abnormal Achilles tendon angles or tenderness of the plantar fascia. Board members concluded that the service medical records contained no clear evidence to support a diagnosis of plantar fasciitis or other manifestation of pes planus overshadowing the right foot metatarsalgia condition that would warrant rating using the code for acquired flat feet. Further, rating using this code would result in a rating no greater than the 10% adjudicated by the VA and applies to the condition whether unilateral or bilateral providing no added benefit to the CI. Although the Board disagreed with the diagnosed code used by the PEB and concluded code 5279 for metatarsalgia (Morton’s disease) was the appropriate code for rating the CI’s condition, correcting the code would not result in a change in the rating recommended by the Board. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right foot pain condition.

Contended Left Foot Morton’s Neuroma. A finding of unfit would not result in an additional rating as the VASRD rating for metatarsalgia provides for a single rating of 10% whether the condition is unilateral or bilateral. Regardless, there was no evidence that the left foot metatarsalgia noted following separation was present in service to a degree to be considered unfit for rating. At the C&P examination four months after separation, the CI complained of left forefoot pain and reported tenderness with examination of the metatarsal interspace. However, service treatment records do not show evidence of Morton’s neuroma of the left foot or metatarsalgia. Following May 2006, there were no service treatment record entries for care of left foot pain, and examinations of the left foot documented in podiatry clinic records during 2008 were normal. There was no indication from the record that left foot pain significantly interfered with satisfactory performance of AFS duty requirements. It was determined that there was no left foot condition of any type (metatarsalgia or other condition) that could be argued as unfitting and subject to separation rating.

Remaining Conditions. Other conditions identified in the DES file were anxiety and insomnia treated with medication. The CI had a history of depression and anxiety treated with medication prior to service (entered service on a waiver). She experienced symptoms of depression, anxiety and insomnia while on active duty for which treatment with medication was provided. Mental health clinic encounters reflect no duty limitations and the commander’s statement noted only physical limitations and recommended retention on active duty. Several additional non-acute conditions or medical complaints were also documented (acne, temporomandibular joint syndrome). None of these conditions were clinically or occupationally significant during the MEB period, none carried attached profiles and none were implicated in the commander’s statement. These conditions were reviewed by the action officer and considered by the Board. It was determined that none could be argued as unfitting and subject to separation rating. No other conditions were service connected with a compensable rating by the VA within twelve months of separation or contended by the CI. The Board, therefore, has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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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 foot pain condition, the Board unanimously recommends no recharacterization of the CI’s disability and separation determination. In the matter of left foot condition, depression and anxiety, or any other medical conditions eligible for Board consideration, the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

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RECOMMENDATION: The Board recommends no recharacterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20100407, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

MICHAEL F. LoGRANDE, DAF

President,

Physical Disability Board of Review

SAF/MRB

1500 West Perimeter Road, Suite 3700

Joint Base Andrews MD 20762

Dear XXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-01176.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXX

Director

Air Force Review Boards Agency