RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300925
BRANCH OF SERVICE:  Army	BOARD DATE:  20140321
SEPARATION DATE:  20021114

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91Q/Pharmacy Specialist) medically separated on 14 November 2002 for “chronic pain, multiple cites [sic] to include thoracic and lumbar back and bilateral lower extremities.”  The CI reported that she injured her right knee and ankle in late 1999 during physical training; by May 2001, complaints were bilateral lower extremity pain which now included her feet.  The CI also reported that she injured her back in 1999 in a fall, but no records were found in the evidence available for review.  She had a longstanding history of headaches since childhood.  The CI developed mental health (MH) symptoms and sought treatment as early as 2000.  She was followed monthly for medication and had frequent appointments with a behavioral psychologist and eventually dropped out of treatment.  She could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or satisfy physical fitness standards and was referred for a Medical Evaluation Board (MEB).  She was issued an U3L3S1 profile on 8 April 2002.  While in the MEB process, she was admitted to a civilian treatment facility for suicidal ideations from 21 May to 11 June 2002 and her diagnosis at that time was major depressive disorder (MDD), recurrent, panic disorder and posttraumatic stress disorder (PTSD), chronic.  She was re-admitted to a military hospital from 12-17 June 2002 and her discharge diagnosis was adjustment disorder with mixed disturbance of emotion and conduct.  Her psychiatric narrative summary (NARSUM) diagnoses were MDD, mild to moderate, in remission; anxiety disorder, NOS; and adjustment disorder with depressed mood, resolving.  She was issued a permanent U3L3S2 profile on 26 July 2002, after the second hospitalization.  The “chronic pain, multiples cites [sic]” characterized as “mechanical thoracic and lumbar back pain,, “right knee pain,” “right ankle pain,” “right foot sesamoiditis and metatarsalgia,” “left knee pain,” and “left foot and ankle pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (depressive disorder, NOS and migraine) for PEB adjudication.  The Informal PEB adjudicated the bundled “chronic pain, multiple cites to include thoracic and lumbar back and bilateral lower extremities” as unfitting, rated 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting and therefore not rated.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Within six months of being medically discharged from active duty with a rating 10% the Veterans Administration rated me-all my service connected disabilities at 60%.  Shortly thereafter once all my medical records from active duty were evaluated by the Veteran’s Administration I was rated at 100% disabled from service connected medical issues.  I am permanent and TOTAL 100%.  I am a permanent and total 100% disabled veteran.”  

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that she may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service  IPEB – Dated 20020826	VA - (4 Mos. Post-Separation)  effective 20021115	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Multiple cites to include thoracic and lumbar back and bilateral lower extremities
(MEB DX 1-6)	5099-5003	10%	Spondylosis w/strain Lumbar Spine	5003-5292	0%	20030313	
			Spondylosis w/strain Thoracic Spine 	5003-5291	0%	20030313	
			Patellofemoral Syndrome R Knee	5299-5260	0%	20030313	
			Patellofemoral Syndrome L Knee	5299-5260	0%	20030313	
			Chronic Left Ankle Sprain	5299-5271	0%	20030313	
			Chronic Right Ankle Sprain	5299-5271	0%	20030313	
			Pes Planus, Plantar Fasciitis, Bunion R Foot	5299-5276	10%	20030313	
			Pes Planus, Plantar Fasciitis, Bunion L Foot	5299-5276	10%	20030313	
Depressive Disorder NOS	Not Unfitting	Major Depressive Disorder	9434	0%*	20030228	
Migraine	Not Unfitting	Migraine Headaches 	8100	30%	20030313	
No Additional MEB/PEB Entries	Other x 5 		
Rating:  10%	Combined Rating:  60%	
Derived from VA Rating Decision (VARD) dated 20030410 (most proximate to date of separation [DOS]).   *VARD 20030519 increased MDD to 10% effective DOS.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System (DES) has neither the role nor the authority to compensate service 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.

The PEB combined the back and bilateral knee, ankle and foot conditions under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the back, knee, ankle and feet conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Mechanical Thoracic and Lumbar Back Pain. The CI first reported low back pain (LBP) in May 1991 following a strain in basic training.  She was seen two more times in 1991.  There are no further entries the next 10 years.  The commander’s letter was dated 12 October 2001 and noted that she had problems with bending, reaching, walking, lifting and standing.  She did most of her work sitting.  Her MEB physical was on 19 October 2001; she had no spasm, signs of radicular irritation (which would indicate a problem with a nerve root at the spine), or documented impairment of range-of-motion (ROM).  The narrative summary (NARSUM) was dictated 11 March 2002.  The CI reported low and upper back pain since she had fallen in 1999.  The pain was the length of her back and relieved by medications or prolonged standing.  The examiner recorded full ROM, tenderness to palpation over the midline of the thoracic and lower lumbar spine and no signs of radicular irritation.  She was referred to orthopedics on 26 June 2002, but the record is not in evidence.  An addendum was dictated to the NARSUM on 19 July 2002, presumably by orthopedics although this is not clear.  The examination remained unchanged and essentially normal other than pain with full extension.  X-rays were repeated and normal.  At a physical therapy (PT) session on 22 July 2002, it was noted that her LBP had recurred during a recent psychiatric hospitalization when she was in bed for 15 hours a day.  However, she was able to walk 3 miles a day without pain.  She had a normal gait and full flexion without pain while sitting.  A poor sitting posture was noted.  She was issued a U3L3S2.  At the VA Compensation and Pension (C&P) examination performed 4 months after separation, the CI reported increased pain when lying down and then getting up as well as bending.  She denied any radicular symptoms.  She reported no limitations in activities of daily living.  The neurological examination was normal.  The thoracic and lumbar spine was normal; without spasm, tenderness, radiation of pain with movement or limitation of ROM.  The posture and gait were normal.  Painful motion was not recorded and DeLuca criteria were negative.  The Board observed that the CI did have a profile which listed the back and that the commander mentioned difficulties with lifting.  However, the CI was able to walk 3 miles without pain and had minimal contact with the health care system for her back.  Examinations were consistently normal.  The MEB did find the mechanical thoracic and lumbar back pain medically unacceptable, but the PEB bundled the back condition with the other orthopedic conditions.  The Board did not find that the information in evidence supported finding the back conditions as a separately unfitting condition and noted that even if it were, only a 0% could be assigned which provides no advantage to the CI.

Bilateral knee condition. In 1999, the CI was evaluated for right greater than left shin pain with normal X-rays.  She then presented on 25 August 2000 after an injury of the right ankle and knee.  She had a normal examination including ROM other than a positive patellar compression test and was thought to have a mild soft tissue injury.  She was seen again 3 weeks later and thought to have bursitis of the right knee.  She was seen in PT on 3 November 2000 and thought to have right greater than left retro-patellar (kneecap) pain syndrome (RPPS) with normal ROM, but decreased strength.  Ten days later she was thought to have right knee strain by an orthopedist.  A PT note on 8 December 2000 documented that she had not met goals.  A bone scan, as documented on an 8 May 2001 orthopedic appointment, showed bilateral lower extremity (BLE) stress changes with inflammation of the sesamoid bones (small bones in the ball of the great toes).  She was seen again in orthopedics on 2 October 2001.  The right knee was very tender to varus (outward) stress, but not inward and was tender to pressure over the patella (knee cap).  Neither knee showed instability.  The examiner did not document the ROM, swelling, or signs of meniscal irritation implying that these were absent as the examination was otherwise thorough.  She was diagnosed with a foot condition and referred to MEB.  No knee condition was diagnosed at this visit.  The NARSUM was dated 11 March 2002, 8 months prior to separation.  It noted that she had been treated for right ankle and knee pain since a twisting injury in 1999.  The treatment included bracing, immobilization, medications and PT; all without relief of her pain.  She was having problems at work due to pain in the bottom of her feet.  Standing longer than 10-15 minutes caused “exquisite pain” in her right knee, right foot, and back.  She also had pain in the left knee and foot.  On examination, the ROM of both knees was 0-130 degrees.  The knees were stable in all planes and without meniscal signs (the menisci are cartilage cushions in the knee, two each side.)  The right greater than left knee was tender to palpation (patella and medial joint line, respectively) and a patellar grind positive on the right, indicative of a patellar disorder.  Painful motion was not documented.  X-rays were normal for both knees.  A magnetic resonance imaging of the more symptomatic right knee was also normal.  She was diagnosed with right and left knee pain.  The MEB forwarded both right and left knee pain as medically unacceptable.  As noted, the PEB combined all the orthopedic conditions into a single unfitting condition.  At an undated PT appointment after the PEB, the CI continued to report right knee pain with stairs and standing over 10 minutes.  On examination, the gait was non-antalgic and she was able to fully squat, a maneuver which places significant stress on the knees.  She continued to have right patellar pain.  At the VA C&P examination 4 months after separation, the CI reported that she injured both knees the same day in step aerobics.  The next day, she “was made to perform physical training and jogging” and that her knees were swollen and never got better.  No limitations in activities of daily living were noted.  On examination, the ROM was normal as was the appearance.  There was mild crepitus with flexion of each knee, but neither instability nor meniscal signs was present.  DeLuca criteria were absent.  Her gait was normal and no limitation in either standing or walking present.  Painful motion was not documented.  X-rays showed mild, bilateral osteo-arthropathy (degeneration); the action officer opined that this would not be an unusual finding in someone her age.  The diagnosis was bilateral patello-femoral syndrome (PFS) with minimal effect on her function.  A VA primary care note on 28 July 2003 noted that there was no swelling, redness, warmth or crepitus of the knees.  A separate note on 10 September 2003 documented that there was no effusion, laxity, crepitus, or meniscal signs and the ROM was normal.  She was tender in the hips, thighs and shins bilaterally.  The Board observed that the CI did have a profile which listed right and left knee pain, but with five other conditions.  The commander mentioned difficulty with standing.  However, the CI also reported that she was able to walk three miles without pain and had a normal gait on the VA C&P examination.  Examinations were consistently normal other than tenderness and mild crepitus.  The MEB did find the right and left knee pain medically unacceptable, but the PEB bundled the knee condition with the other orthopedic conditions.  The Board did not find that the information in evidence supported finding the knee condition as a separately unfitting condition, separately or combined, and noted that even if it were, only a 0% could be assigned which provides no advantage to the CI.

Bilateral ankle condition.  The CI first presented for right ankle pain on 25 August 2000 when she noted progressive pain since an injury as outlined above.  She was managed conservatively.  At a 2 October 2001 orthopedic visit, she was noted to have ROM reduced on the left 10 degrees in dorsiflexion and 5 degrees in plantar flexion.  On the right, dorsiflexion was normal and plantar flexion also reduced five degrees.  Very mild discomfort was noted with eversion of the right foot.  There were no further visits in evidence until she was entered into the MEB process.  The NARSUM was 8 months prior to separation.  It noted that she had been treated for right ankle and knee pain since a twisting injury in 1999.  The treatment included bracing, immobilization, medications and PT; all without relief of her pain.  She was having problems at work due to pain in the bottom of her feet.  Standing longer than 10-15 minutes caused “exquisite pain” in her right knee, right foot, and back.  She also had pain in the left knee and foot.  On examination, the ROM of both ankles was 10 degrees dorsiflexion (toes up) and 30 degrees plantar flexion (toes down), a reduction of 10 degrees in dorsiflexion and 15 degrees plantar flexion.  She had pain to palpation over the lateral right ankle and with pain in both ankles with internal rotation.  She was thought to have bilateral ankle pain.  The MEB forwarded both right and left ankle pain as medically unacceptable.  As noted, the PEB combined all the orthopedic conditions into a single unfitting condition.  At an undated PT appointment after the PEB, the gait was non-antalgic.  At the VA C&P examination 4 months after separation, the CI reported that she injured both ankles the same day in step aerobics.  Both ankles were painful, but the right was worse.  She denied any functional impairment.  No limitations in activities of daily living were noted.  On examination, the ROM was normal as was the appearance.  DeLuca criteria were absent.  Her gait was normal and no limitation in either standing or walking present.  Painful motion was not documented.  X-rays were normal.  The diagnosis was status post ankle sprain with residual pain.  A VA podiatry care note on 5 November 2003, almost a year after separation, noted pain in the ankle(s), feet, wrist and knees out of proportion (to objective findings).  She noted that her right knee gave out recently in step aerobics and re-injured the right ankle.  X-rays were normal.  The ROM was limited secondary to guarding.  The Board observed that the CI did have a profile which listed right and left ankle pain, but with five other conditions.  The commander mentioned difficulty with standing.  However, the CI also reported that she was able to walk three miles without pain and had a normal gait on the VA C&P examination.  The more proximate VA C&P examination was normal.  The MEB did find the right and left ankle pain medically unacceptable, but the PEB bundled the ankle condition with the other orthopedic conditions.  The Board did not find that the information in evidence supported finding the ankle condition as a separately unfitting condition, separately or combined, and noted that even if it were, only a 0% could be assigned which provides no advantage to the CI.

Bilateral foot condition.  The CI was noted to have asymptomatic flat feet at accession.  The CI was first evaluated for right foot pain on 12 June 2001 in orthopedics and found to have right sesamoiditis.  She was managed conservatively with shoe inserts.  She was next seen on 2 October 2001 in follow-up by the same orthopedist.  She was tender over the distal metatarsal (the foot bone connecting to the toes); right much greater than left, great toe greater than the other four.  She was thought to have sesamoiditis and to be unfit for duty.  There were no further visits in evidence until she was entered into the MEB process.  The NARSUM was 8 months prior to separation.  She had pain in both feet, but reported persistent pain and burning in the bottom of her feet with exquisite right foot pain and some left foot pain.  On examination, she had pain to palpation over the ball of the right great toe on the right, but not the left.  In both feet, she had tenderness over the balls of the second and third toes as well as the sesamoid bones.  Flat feet were noted bilaterally.  She was thought to have right sesamoiditis and metatarsalgia and left foot pain.  The MEB forwarded right foot sesamoiditis and metatarsalgia and left foot (and ankle) pain as medically unacceptable.  As noted, the PEB combined all the orthopedic conditions into a single unfitting condition.  At an undated PT appointment after the PEB, the gait was non-antalgic.  At the VA C&P examination 4 months after separation, the CI reported pain with standing or walking, but no symptoms at rest.  She had been given arch supports.  No limitations in activities of daily living were noted.  On examination, there was some pain to palpation of the heels to the mid foot bilaterally.  Pes planus (flat feet) was noted bilaterally.  Mild hallux valgus (bunion) and hallux rigidus (a stiff great toe from arthritic changes) was noted.  Her gait was normal and no limitation in either standing or walking was present.  X-rays showed moderate bunions, but without stress fracture or heel spurs (an indication of plantar fasciitis.)  The diagnosis was bilateral pes planus with plantar fasciitis and bunion formation.  The functional on occupation and daily activity was minimal.  A VA podiatry care note on 5 November 2003, almost a year after separation, noted pain in the ankle(s), feet, wrist and knees out of proportion (to objective findings.)  She noted that her right knee gave out recently in step aerobics and re-injured the right ankle.  She reported less discomfort in heels than athletic shoes.  X-rays showed a bipartite tibial sesamoid which was thought to be the cause for the pain in the ball of the foot.  The action officer noted that this condition occurs in about 25% of the population and is bilateral 85% of the time.  While this is almost certainly a congenital condition, the CI was asymptomatic at accession.  The Board observed that the CI had been issued a L3 profile for sesamoiditis on 2 October 2001 and that the feet were profiled until separation.  The orthopedist who recommended MEB listed sesamoiditis as the “unfitting” condition.  The commander mentioned difficulty with standing.  However, the CI also reported that she was able to walk three miles without pain and had a normal gait on the VA C&P examination.  Tenderness to palpation was noted on multiple examinations.  The MEB did find the right foot sesamoiditis and metatarsalgia (pain of some of the foot bones) and left foot and ankle pain as medically unacceptable.  The PEB bundled these conditions with the other orthopedic conditions.  The Board found that the information in evidence supported finding the foot condition as a separately unfitting condition.  The Board then considered if each foot was separately unfitting.  It noted that the CI consistently noted the right foot as more symptomatic than the left and that it was tenderer on examination.  The Board determined that the evidence clearly supported the right foot as a separately unfitting condition.  The Board also determined that the left foot, although less symptomatic, was also separately unfitting.  The Board recommends that bilateral metatarsalgia be found to be a separately unfitting condition and rated at 10%, utilizing the 5279 code for metatarsalgia.  The 10% rating is applied whether the condition is unilateral or bilateral.  The Board also noted that the VA rated the feet as analogous to pes planus at 10% each.  While this is a higher rating, it is not as accurate a clinical description.  The CI had pes planus at accession, albeit asymptomatic.  There was no indication of plantar fasciitis except by the C&P examiner.  It was not diagnosed before or after this examination even though evaluated by multiple orthopedists and podiatrists.  Accordingly, the 5276 coding option is not recommended.

Contended PEB Conditions. The CI also contended for the not unfitting depressive disorder and migraine headache conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that these conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Migraine Headaches.  The migraine condition was not profiled and was determined to have existed since prior to service (EPTS).  There were no visits for headaches in evidence in the almost 30 months prior to separation.  The neurology evaluation for the MEB on 17 September 2001 did note that she had chronic daily headaches and had had headaches since childhood.  It was also noted that these were disabling and kept her from working 4 days a week; this is not consistent with the lack of visits in the record.  The evidence available for review shows that she was last put on quarters in March 2000, almost 32 months prior to separation and was not seen again for the headache condition until the MEB neurology evaluation 3 months prior to separation.  There were no further visits for the headaches in evidence other than radiological studies in October 2001 which were normal.  The headache condition was not profiled and she held a P1 profile on her final profile.

Depression NOS.  The depression was given a S2 profile.  The MEB psychiatric addendum in July 2002, 4 months prior to separation, noted the CI had issues of abuse since childhood.  She reported a history of trichotillomania (compulsively pulling out body hair) which predated accession.  She was hospitalized twice for depression with suicidal plans and while in the MEB process.  Six months prior to the first admission, the CI had presented to the emergency room with report of domestic partner violence.  While hospitalized, she noted a significant pre-military history of partner abuse and reported traumatic symptoms related to the abuse.  She was diagnosed with MDD and PTSD.  A second psychiatric hospital admission, approximately a month after the first admission, was prompted by suicidal and homicidal ideation; adjustment disorder with disturbance of mood and conduct was diagnosed.  She was diagnosed with an adjustment disorder, rule out bipolar disorder and rule out PTSD.  There were no additional hospitalizations, no recorded subsequent visits to the emergency room and no indication of intensive outpatient MH treatment in the 5 months prior to separation.  Mental status examination (MSE) during the MEB addendum, weeks after the hospitalizations and 4 months prior to separation, was completely normal.  The examiner diagnosed MDD, mild to moderate, in remission and recommended re-evaluation in 6 months.  The psychiatrist opined a 6-month re-evaluation would allow the opportunity to evaluate the condition while remote from military pressure.  The psychiatrist documented the CI reported she was able to be productive in her new job assignment and was making it to work more on time.  The depression was determined to not be an EPTS condition although the anxiety disorder (trichotillomania) was judged to be EPTS.  She was thought to have minimal impairment for duty.  The MEB forwarded the condition of depressive disorder, NOS (although the psychiatry addendum recorded MDD, in remission).  The PEB adjudicated both conditions of depressive disorder, NOS and MDD as not unfitting.  The commander statement, 13 months prior to separation, noted that her personal/emotional problems affected her attendance at work with no mention of performance impact.  However, the commander specifically listed limitations from the orthopedic conditions and opined that she manipulated the sick call system for her benefit to miss work.  Of interest, the VA C&P examiner, 3 months after separation, noted that much of her symptomatology was influenced by issues with the US Army and her supervisors and that it had subsided since separation.  Her MSE was completely normal.  She was thought to be at risk for an exacerbation and continued care consequently recommended.  The CI did continue to have emotional problems and some depressive symptoms after separation and struggled with pre-service trauma; however, she was able to work in a highly stressful environment in human resources.  Review of the VA records showed no evidence that PTSD was diagnosed after separation.  However, she was provisionally diagnosed with bipolar (disorder), NOS on 10 October 2003, 11 months after separation.  The diagnosis was confirmed 3 weeks later, but she retained a Global Assessment of Functioning of 65, indicative of mild symptoms or impairment.

Both conditions were reviewed by the action officer and considered by the Board.  While there was performance based evidence from the record that, at times, both conditions interfered with satisfactory duty performance, neither significantly interfered with duty at the time of separation.  She had not been seen for the headache condition for over 2 years at the time of separation other than an evaluation for the MEB.  The MSEs proximate to the time of separation were normal.  The MEB examiner determined that the MH condition was in remission.  The VA examiner also noted that she was in remission.  The depressive disorder was judged to meet retention standards by the MEB examiner, but was listed by the MEB.  The migraine condition determined to be EPTS without service aggravation.  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 either of the contended conditions and so no additional disability ratings are recommended.  The SRP also considered the appropriateness of the changes in the MH diagnoses and a disability rating recommendation in accordance with VASRD §4.130.  The MEB psychiatrist diagnosed MDD, mild to moderate, in remission and adjustment disorder, NOS.  The MEB forwarded the MH diagnoses of depressive disorder to the PEB for adjudication.  The PEB adjudicated the CI for the diagnoses as noted by the MEB psychiatric examiner.  However, while in the MEB process, she had been hospitalized and the diagnosis of PTSD given.  The Board determined that no MH diagnoses were changed to the applicant's possible disadvantage in the disability evaluation process.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  As the MH condition was determined to be not unfitting, consideration of either VASRD §4.129 or 4.130 is not warranted.  The SRP considered if the diagnosis should be changed to include PTSD, but noted that this was not diagnosed other than at the initial, civilian psychiatric hospitalization.  This was not diagnosed at the second hospitalization, by the MEB psychiatrist, or by the VA examiners in the post-separation period.

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 bundled orthopedic conditions was operant in this case and these conditions were adjudicated independently of that policy by the Board.  In the matter of the bilateral foot conditions, the Board determined that these be unbundled and that a disability rating of 10%, for bilateral metatarsalgia, be adjudicated, coded 5279 IAW VASRD §4.71a.  In the matter of the contended migraine and mental health conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

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

UNFITTING CONDITION	VASRD CODE	RATING	
Bilateral First Metatarsalgia 	5279	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130523, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	

SFMR-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, AR20140011457 (PD201300925)

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 description 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						

CF: 
(  ) DoD PDBR
(  ) DVA