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AF | PDBR | CY2013 | PD-2013-02003
Original file (PD-2013-02003.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02003
BRANCH OF SERVICE: Army  BOARD DATE: 20150224
SEPARATION DATE: 20050923


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Lithographer) medically separated for right toe pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “right hallux rigidus” (stiff great toe), was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded seven other conditions (proteinuria, hypertension, mixed hyperlipidemia, exophthalmos, mild sensorineural hearing loss, congenital pes planus, and patent foramen ovale) for PEB adjudication. The Informal PEB adjudicated his right toe condition as unfitting and rated it at 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his application.


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 20050613
 VA* - (~3 Months Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Hallux Rigidus 5281 10% Right Hallux Rigidus 5281 10% 20051219
Other x 7 (Not In Scope)
 Other x 9
RATING: 10%
 RATING: 30%
* Derived from VA Rating Decision (VA RD ) dated 200 60322 (most proximate to date of separation ( DOS ) ) .



ANALYSIS SUMMARY:

Right Toe Condition. Based on review of the service treatment record, the CI was initially seen on 16 August 2002, more than 7 years after enlistment, for painful bunions, the left greater than the right, but the examination and treatment plan were directed to the symptomatic left toe. However, a note dated 20 August 2002 indicated the CI had right foot pain at the 1st metatarsal phalangeal joint (MTP) for 2 to 3 weeks, which was different than the bunion pain of the left foot. There was no tenderness over the bunion, but there was tenderness on the plantar surface consistent with sesamoiditis (inflammation of small bones on the bottom of the foot just behind the big toe). The CI subsequently underwent a bunionectomy on the left foot and, a note, dated 3 December 2002, indicated the CI was to follow-up at his new duty station for the right bunion. A consultation took place on 14 May 2003 at which time the CI related a history of “throbbing about the bunion deformity since March when he received new boots.” Examination and X-rays confirmed a hallux valgus and treatment with orthotics, a toe spacer, and foot measurement “to ensure wear correct size shoe gear.” The right bunion became more painful with prolonged marching, and the CI was referred to podiatry for excision. A right bunionectomy was carried out on 13 June 2003. Foot measurements were carried out on 12 August 2003 and both feet were size 13½ R. Improvement was slow with rehabilitation while the CI was awaiting the correct size boots for which custom orthotics were eventually fabricated in May 2004. X-rays on 10 August 2004 of the right foot revealed a healed osteotomy with slight lateral plantar angulation of the first metatarsal, pes planus, minimal degenerative changes of the navicular and talus bones of the mid-foot and hind foot respectively, and no fractures. A right foot CAM walker was added to the post-operative treatment regimen, however, the CI’s pain level was still elevated at 6/10 with slight edema noted on 17 August 2004. Dorsiflexion of the big toe was approximately 40-45 degrees (normal 70 degrees) on 31 August 2004. His diagnosis was revised to right hallux rigidus on 13 October 2004. As a result, he was referred to the MEB since he did not recover as well as he did with the left bunionectomy, had an extended convalescence period, was required to do some heavy lifting and bending as part of his MOS, and was seen numerous times by podiatry. A note dated 4 April 2005 indicated the CI had limited right foot MTP joint range-of-motion (ROM) of dorsiflexion to approximately 45 degrees and plantar flexion of approximately 5 degrees (normal 45 degrees). Additionally, there was non-uniform joint space narrowing with subchondral sclerosis (increased bone around the joint) and the 1st metatarsal was shorter and elevated; and the CI was unable to perform a single limb heel rise.

The MEB physical examination performed on 16 November 2004 noted mild hallux valgus, moderate, asymptomatic pes planus, and scars on both feet. The MEB narrative summary, dated 14 March 2005, reviewed the CI’s history and clinic visits and noted pain was dull and constant with a severity of 7/10 at the worst and 2/10 at the best. ROM measurements of the right big toe were extension (dorsiflexion) 4 degrees, 5 degrees, and 6 degrees (normal 70 degrees) limited mechanically and flexion 19 degrees, 17 degrees, and 19 degrees (normal 45 degrees) limited mechanically; while the ROMs of the left foot and ankles were normal. The CI’s condition was exacerbated by prolonged standing along with military and physical training activities. The PEB determined that though the CI’s congenital flat feet condition existed prior to service (EPTS), the toe deformity was aggravated by military service. A permanent L3 profile was issued on 16 May 2005 for hallux rigidus (stiff and painful right big toe) with limitations of military functional activities including rucking, road marching and running for physical training.

At the VA Compensation and Pension (C&P) examination dated 19 December 2005, performed 3 months after separation, the CI noted intermittent pain in the right great toe joint at rest and with standing and walking, but he did not use a cane, brace or other corrective devices. X-rays revealed deformity of both first metatarsals with slight narrowing of the right 1st MTP joints. He had tenderness plus limited painful ROM about the right great toe joint, a right 2nd hammertoe deformity, and a callus dorsally, but he had no functional limitations on standing or walking. Temporally remote VA C&P examinations were reviewed; however, they offered very limited or no probative post-separation evidence of any significant value other than noting the CI underwent additional right foot surgery on the first and second toes in 2008.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating using code 5281 ( Hallux rigidus, unilateral, severe) and noted the condition was service aggravated by repetitive microtrauma. An EPTS component was overcome by the 8-year rule since the CI served more than 10 years at the time of separation. The VA likewise assigned a 10% rating using code 5281. The Board sought a route to a higher rating but was unable to find any other applicable or additional code for the CI’s condition. After due deliberation, and 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 hallux rigidus 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. 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 hallux rigidus condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.


RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131029, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record




XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150011184 (PD201302003)


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


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